Fatality Investigation Report Fatal head injury at contractor

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Fatality Investigation ReportFatal head injury
at contractors fabrication yard
Summary Details The incident happened in the
contractors fabrication yard in Seria. At the
time of the incident work activities had not
commenced in the fabrication yard. The deceased
was attempting to sit at the flange side of a 32
pipe spool Tee-piece, which was resting on two
supports. The pipe spool toppled over, resulting
in the deceased sustaining a fatal head injury.
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Fatality Incident on 18 Aug 2004

• Incident Details
• At Zainal Daud (ZD) Fabrication Yard (G25) at
  7.30 a.m.
• Victim Mr. Lee, 31 years old Malaysian working
  for Chin Wui Heng Welder Enterprise
• Occupation Senior Marker, 8 yrs experience
• Injury Death from severe head injuries.
• Survived by Spouse 4 years old son.
• Project Single Buoy Mooring (SBM) Metering
  (Phase 2)
• Main Contractor Warner Company Sdn. Bhd.
• Sub-contractor Zainal Daud Sdn. Bhd.
• Sub sub-contractor Chin Wui Heng Welder
  Enterprise

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Fatality Incident on 18 Aug 2004
This is the position of the Tee piece resting on
the ground after it slipped and toppled out of
the two ground supports and crashing the victim
on the head.
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PICTORIAL REPRESENTATION
Based on witnesses accounts, deceased was about
to lift himself from the flange of the Tee piece.
The Tee piece slided for about 6 inches, touched
the ground, toppled over the deceased and crashed
him on the head. The Tee piece then came to a
rest on the ground.
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Fatality Incident on 18 Aug 2004

• Facts Findings (1)
• Fabrication Yard Work delayed whilst waiting for
  Tool Box Talk
• 32 pipe Tee piece 300 (1.3 tons) partially
  completed (2 flanges welded on). Suspended,
  awaiting material.
• Was supported by 2 primary ground supports.
• Chain block and 5 tons jack were used whilst
  fabrication was in progress for alignment
  purposes.
• Chain block and jack were removed after welding
  of 2 flanges.
• No further adjustments of the primary supports
  were made to improve stability.
• Deceased was assigned the role of supervisor of
  the above fabrication activities.

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Fatality Incident on 18 Aug 2004

• Facts Findings (2)
• Initial calculations indicate Tee-piece Centre of
  Gravity shifted significantly effectively on
  the verge of tilting.
• Since materials were not available, no further
  work was carried out. Two days later, the
  deceased (ca. 70 Kg wt) attempted to sit on outer
  rim of Tee-piece flange.
• Tee piece slipped toppled over crushing victim
  on the head

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Findings

• Direct Causes
• The Tee piece became unstable after the
  installation of the two flanges. The centre of
  gravity had shifted but the primary supports were
  not adjusted.
• For unknown reasons, the deceased attempted to
  sit on the vertical flange of the Tee piece
• This action caused the unstable Tee piece to slip
  and topple over.
• The deceased suffered severe head injuries after
  being crushed by the Tee piece.

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Findings

• Indirect Causes (1)
• The A-Frame, chain block and 5 Tons jack used
  earlier for alignment purposes were removed
  leaving the Tee piece on the two unadjusted
  ground supports.
• Although a co-worker, recognising a hazard,
  re-secured the Tee piece on a chain block, this
  was subsequently removed.
• The instability of the Tee piece had not been
  communicated to the others. Enforcement of Duty
  to Stop was inadequate.
• General lack of hazard awareness of the
  workforce.
• Hazard Identification Plan (HIP) for the
  contractor fabrication yard was not developed.
• Lack of barricades and warning signs around
  hazardous areas.
• No designated rest area

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Findings

• Indirect Causes (2)
• Lack of effective supervision.
• Lack of planning Work started on the Tee piece
  before all the materials had arrived.
• Contract HSE Management
• Lack of clarity between contractor,
  sub-contractor sub-sub-contractor on
  responsibility for HSE management
• The main contractor was required under its
  contract with BSP to play a leading role in HSE
  implementation, not just the subcontractor
• There were early warning signs of a lack of
  commitment to safety such as not following up on
  repeated violations identified during site
  visits.

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Immediate Action (1)

• Please undertake the following
• Survey work supports at all worksites
  immediately. Rectify where work supports are
  unsafe or inadequate. Communicate any unsafe
  conditions found.
• Ensure you have a HIP for every stage of your
  project, including the fabrication stage, both at
  BSP and the contractor worksites.
• Include HIP in Tool Box Talk. Address safety of
  worksites, even when unattended.
• Ensure provision and enforce use of designated
  rest areas at worksites.

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Immediate Action (2)

• Please undertake the following
• Supervisors contract holders/managers
  accountability for safety
• Do you know the full extent of your role?
• Do you know what you are accountable for?
• Are you discharging your responsibility?
• Confirm who is responsible for sub-contractor HSE
  management.

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Areas requiring further work

• We will need to strengthen the culture of
  intervention (e.g. PAKAT, House Rules,
  Consequence Management).
• We will require senior management of all
  contractors, all direct and indirect
  sub-contractors to demonstrate commitment to HSE
  by, for example, site visits and mandatory joint
  HSE meetings.
• We will require contract holders to include all
  direct and indirect sub contractors in HSE
  performance reviews.
• Review appropriateness of contracting strategy to
  ensure HSE responsibilities can be effectively
  exercised.