PIL-HSSE-LL-2021-02

Date: 01 March 2021

FATALITY – WORKER STRUCK BY DISLODGED RC SLEEVE

Region: Sriracha, Thailand

Location: Thai Oil CFP Project
Date: 19 January 2021
Life Saving Rule breached: N/A

Summary: On 19 January 2021, at approximately 13:50 hours, a Subcontractor crew was performing manual excavation
around cast in-situ piles to prepare for further foundation activities. Two workers were inside the 1.8m deep excavation
when one of the pile heads (with a reinforced concrete sleeve placed on top to protect the U/G utilities) toppled over and
struck one of the workers, resulting in fatal injuries. The injured party was evacuated to the nearest hospital and
pronounced dead shortly after arrival.

Outcome: IP sustained critical head injuries.

Incident Classification: Fatality

Root causes and contributory factors Lessons learned
ROOT CAUSES
➢ Not following procedure • Ensure Quality assurance processes are in place to
• Concrete was not poured up to the top of reinforced prevent deviation from approved method
Concrete (RC) sleeve as per the method statement statements and QC procedures
• Actual pile bore depth was not adequately verified • Ensure pile boring and all subsequent activities are
➢ Inadequate Supervision adequately supervised
No proper guidance or oversight to ensure concrete • Formal Management of change procedure should
was poured up to the top level as per the Method be in place and applied to address any changes
Statement made to agreed processes or methodologies during
➢ Improper decision making project execution
Crew poured insufficient quantity of concrete into the • A proper sequence of manual excavation around
pile thus creating a void for soil to fill the concrete the piles to be implemented using phased approach
sleeve which made the concrete sleeve unstable to avoid deep excavations and perform subsequent
activities such as breaking concrete at lower depths
➢ Inadequate Management of Change (MOC) process
to reduce the risk
Formal MOC process was not in place when RC
• Revisit existing quality control procedures and
sleeve was introduced
processes to ensure all checks and balances are in
place and involve multiple stakeholders, if required.
CONTRIBUTORY FACTORS
➢ Inadequate procedure
• Work sequence - Due to work arrangements and
sequencing, the concrete pile (including RC sleeve)
was left free-standing inside the excavation
• QC inspection criteria –Concrete pouring to the top
level did not require re-verification by multiple
stakeholders other than the work performer / sub-
contractor

Have you thought about the above lessons learned to avoid similar incidents on your work location?
More information and details can be found on Synergi, case 25908