F-09-01

Incident Summary and corrective action recommendation

Type of incident: Near Miss Accident # Injury

Risk Value:

Probability (3) X Severity () = Time: 2:00 PM Shift Order: 08 A 42 RTG 05 1st

Date of Incident: 03-January-2014 Shift: Orange - Day Location of Incident: Equipment(s) involved: Details

While RTG 05 operator was trying to handle 40 container for loading in bay 08 A 42; the operator tried to catch a container from Raw Charlie (2nd tier) but the spreader wasnt well-landed on the container so he made a hoist up followed by hoist down on the same container resulting in an over slack on the hoist wire from the right/land-side that wasnt noticed by the operator so after repeating hoist ing up the operator noticed abnormal spreader pose from the land-side then stopped working at once and informed his direct S.V. If Injury Please state nature of injury: NA

If Asset Damage Please state nature of the asset damage: right/landside hoist wire rope damaged. If a permit to work was required, was it issued: Summary of statements Involved Person: Name: Hany Helaly Mostafa Department: Operations Experience: 2 years ID: Position: 1369 RTG Operator YES # NO

I got instructions to move gantry toward 08 A 42, and i was adjusting spreader position on the container needed to be loaded and made a hoist down twice on the container till the spreader position became correctly adjusted on the container but unfortunately the spreader wasnt well -landed so i tried to hoist down three times on the same container but in the 3rd time i noticed the spreader was listed toward seaside. Did you made hoist down in over speed in the 3rd time? I hoisted up for a slight height and adjusted my position by gantry to the right & left sides then made hoist down. Did you face any previous problems regarding spreader landing during your working hours? No, i was working for 1 hour on the RTG and it was the first time facing such problem, as I handled 5 containers before without any defects noticed. Issue #: 02 issue date: 01/07/2011 Revision: R002 Revision date: 29/04/2012

 Are you sure the spreader was completely rested on the container you wanted to handle? I wasnt quite sure, as I feel that the spreader was landed on the container but I didnt check visually. Did you notice any wire slack after the last hoist down movement you made? Yes, the wire was slaked. Then, what you should do if you noticed any wire slack? If I noticed any wire slack i made hoist up normally and continue working. After slack happened, did the spreader stop working or not? No, hoist up and down functions worked normally after slack happened without any fault appeared. Did you receive a pre-shift safety talk: Did you receive training in how to do the task involved: Are you aware of the rules / procedures related to this work: If required, were you wearing the correct PPE: Did you receive supervision in the last 1hr of your work:

YES

NO NO NO NO NO

* YES * YES * YES * YES

How do you think this incident could be avoided in future? If i noticed any over slack in wires that looks more than normal; i have to stop working at once and inform engineering team. Direct Supervisor: Name: Ahmed Essam Department: Operation ID: 881 Position: Yard Supervisor

Did he/she give a pre-shift safety talk: Technical Advise/Report: Name: Mohamed Abd El-Aziz Department: Engineering

* YES

NO

ID: 1096 Position: First mechanical engineer

Comment: We made a simulation on the same RTG after hoist wire replacement in order to discover the real reason behind that incident and discover that: several conditions should be in place in order to let it happen: 1. RTG operator should made hoist down in over speed. 2. Spreader should be improperly landed on the container. 3. Wire slacking direction (uncontrolled/rarely happened) should be closed to protruded part of the head block. Immediate causes Hoist wire (right/land-side) on RTG 05 damaged after being strained around a protruded part on the spreader head block. Underline causes 1. RTG operator should made hoist down in over speed. Issue #: 02 issue date: 01/07/2011 Revision: R002 Revision date: 29/04/2012

2. Spreader was improperly landed on the container. 3. Wire slacking resulted in wire wrapping around protruded part of the head block. Root Cause People cause/Lack of attention: Although RTG operator noticed wire slacking, but he didnt observe that it became outside the pulley and wire wrapped around & strained on a protruded part of the head block. Corrective actions taken Live RTG 05 became out of order for hoist wire replacement. Comments and Recommendations by the Investigation committee on how this could be avoided in future # Corrective action Add this case in the daily TBT for all RTG operators, regarding: all RTG operators should keep an eye on the hoist wires upon handling containers for both loading/discharging and report immediately for any over slack observed to their direct S.V and didnt make any further movement till wires being checked by CHE. Engineering team. Deadline Ownership

26-01-2014

Operations

General Manager Comments:

To fill this part in case of high severity near misses & all LTIs and to be signed off by the GM

_______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ GM signature: Date:

HOD Comments: To fill this part _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ HOD signature: Date:

Shift Manager: Salah Abd El-Aziz Investigation completed by: Operations: Mohamed Adel HSE: Mohamed Atef Issue #: 02 issue date: 01/07/2011 Engineering: Mohamed Abd El-Aziz

Revision: R002

Revision date: 29/04/2012