LESSONS LEARNED

S/N IBRU-Lessons Learned - 6 Issue Part JGC/JMH

Issue Date 2022-01-07 Recipients All Employees in the project

[ Collapse of steel structure during erection]

At 14:30 in China Time today, in Shanghai

Morimatsu module yard, one of module (steel
Incident structure) collapsed by removal of guy wire
detail without confirmation and 2 workers working
on manlift were involved the incident and got
injury.

• MS/JSA was not sufficient detail

• Inadequate communications at the STARRT

Root • Lack of Clear Communications by Language

causes Differences.
• Inconsistent work direction (not following
work direction in the MS and engineering
drawing)

• Review and revise the existing MS/JSA for

steel structure fabrication.
• Conduct a safety stand-down for all module
Corrective erection workers and supervisors.
actions
• A STARRT improvement program shall be
developed to ensure that practical daily
pre-start briefings are conducted with each
work crew.
 LESSONS LEARNED

S/N IBRU-Lessons Learned - 7 Issue Part JGC/JMH.

Issue Date 2022-01-07 Recipients All Employees in the project

[Unsafe Forklift Operation]

On 2nd Jan, 2023, Jintai carried a lifting beam (8m x 4m) for an air cooler with
two 5-ton forklifts facing each other. (one was going front and the other was
N/M detail reversing)
The speed of the two forklifts may not be synchronized and the lifting The beam
would fall.

Corrective • Review and revise the existing MS and JSA for Transporting the material
actions • Consider other safe transportation method

• Forklifts shall be fitted with a Load Capacity Plate showing SWL at different
load centers.
As Per
Procedure • The attachments shall be securely fastened and care taken to ensure that
the attachments or securing device do not foul any part of the mast
structure during raising or lowering of the attachment.
 LESSONS LEARNED

S/N IBRU-Lessons Learned - 8 Issue Part JGC/JMH.

Issue Date 2022-01-07 Recipients All Employees in the project

[Confined Space Entry without PTW ]

Enter from Here

On 3-Jan-23, NCC entered directly into the 40” pipe and for the work, without
N/M detail
applying PTW for confined space entry.

Corrective - Reinforce the HSE organization

actions - HIPO/NM Report will share to management

The Confined space work shall be followed as below procedures

- Confined Space Identification
- Risk Assessment
- Permit to Work
As Per - Entry Controls
Procedure - Pre-Entry Briefing and Check
- Communication
- Atmospheric Monitoring
- Ventilation
- Rescue Plan