2019-00118 / Dropped T-bar

in sub-assembly workshop

October 14th 2019

8/7/2020
 Incident Summary

Classification: Near Miss

Location: Shipyard subassembly workshop
Time: 2.15 pm
Date: 14 October 2019

Description:

A T-Bar [Length: 17.28m / Weight: 3T] was dropped accidentally from approx. 0.5m to ground level in shipyard sub-assembly
workshop.
The T-bar was lifted during a trial lift aimed to adjust the rigging before the T-bar could be loaded onto a flatbed trailer.
The T-Bar was being rigged up by using 2 X 5T vertical plate clamps but minimum requirements for gripping length in the throat of
the clamp is 107mm and the T-bar face plate only offer effective gripping length of 64mm.
One clamp became loose resulting the T-Bar to be dropped from this end.
This sudden jerk caused the second clamp at the other end to release its grip on the T-Bar as well.
No one was injured in this incident.
The DROPS calculation showed that this event had the potential to lead to a fatal incident thus leading to a HiPo Near Miss Tier 1
investigation.

Immediate Action Taken:

The work was stopped immediately and the scene was secured by HSSE Dept from buyer and builder.
A Safety stand-down was conducted on October 15th during the morning toolbox talk for all lifting and rigging crews.

On October 15th, 9AM, an incident investigation team was created with representatives of builder and buyer under the direction of
Regional HSSE/QRM Manager.
The objective of the investigation are to:
- Determine the timeline of events leading to the incident
- Determine the missing or broken barriers leading to the event
- Determine and analyze the root causes
- Determine the corrective actions

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 Incident Scene

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 Tap Root® Investigation
Sequence of events

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 Tap Root® Investigation
Sequence of events

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 Investigation Findings

Fact
Causal Factor
 Wrong type of vertical clamps were chosen and used by the rigger during the lifting of this T-Bar.
 Clamps used required at least 107mm of contact point inside the throat of clamps while face plate of T-Bar is only 64mm.
 This activity is not a normal work and is not included in the work plan for that day.
 No evidence of last minute risk assessment conducted for any new work instruction and lead whereby team leader or foreman could define work procedure,
safe work method statement, right tools and equipment as well as PPEs and address to all crew members.

Position

 Rigger used tagline and was controlling the load from 2m away.
 Next personnel (inspectors) were distant 5m away from the lifted load.
 Rigger and workshop gantry crane operator have clear view of each other.

Part

 All lifting gears and devices used in this lifting activity are in good condition.
 Correct types of plate clamps not available at that particular time due to procurement is still on-going.
 Two skips full of defective and sub-standards lifting clamps were previously put out of service following a lifting/rigging audit conducted by project team.

People

 The rigger has at least 11 years working experience as a certified rigger.

 The rigger participated to the morning Toolbox Talk but no risk assessment was carried out after lunch for this new work instruction by his Foreman.
 The rigger assistant was not available during this lifting activity as he was given another task to fetch some documents.
 Foreman and the rigger are aware of past incidents occurred in relation with T-bar fabrication processes.

Paper

 JSA developed for sub-assembly work approved on August 9th, 2019.

 Morning toolbox talk record dated October 14th and signed – 11 workers – content not specific to the work activity.
 Instruction manual for safe use of plate clamp developed by Lifting and Rigging Dept. However, this document is not a controlled official document.
 Pictorial safe use of plate clamps available and displayed in the sub-assembly as additional instructions.

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 SRS Investigation
Root Cause Determination
Possible Immediate Causes
ACTION
 Use of Tools or Equipment > Tools were used for activities which they were not designed for of did not meet the requirement.
 The rigger was using the wrong type of plate clamps.
 Inattention / Lack of Awareness > The situation was wrongly judged and the wrong decision was made.
 The rigger did not ensure the right plate clamps were used when he found that they were not available.

CONDITION
 Tools, Equipment and Vehicles > The tools were not adequate, or the proper tools were not supplied.
 The suitable plate clamps QYW-3A or Horizontal plate clamps were not available during the event.
 Tools, Equipment and Vehicles > The right tools were not prepared before the job.
 No TBT/RA discussed after lunch after new work instruction was given to ensure right tools were prepared.

Possible System Causes

PERSONAL FACTOR
 Poor Judgement > Although the person involved was well trained at the time of the event, the person did not choose an appropriate course of action.
 The rigger did not ensure the right plate clamps were used when he found that they were not available.
 The rigger did not exercised his right to stop the job since he didn’t had the right tools to safely execute the lift.
JOB FACTOR
 Inadequate Work Planning > The work being done was not adequately planned in terms of people, tools or procedures.
 No evidence of work scope preparation by the supervisor.
 No TBT/RA discussed after lunch arranged for the crew ensure proper work planning is addressed including right getting right tools and people
for the job.
 Tools and Equipment > The needed tools or equipment for the job were not available at the job site.
 Only 5T QYW – 5A plate clamps were available at the workshop during the time leading to the event.
 Procurement of the QYW – 3A was still in the process.
 Communication > Inadequate vertical / horizontal communication.
 No TBT or LMRA was conducted to communicate job and safety requirement upon issuance of new work instruction.
 Inadequate Develop of Procedure > Existing PSP did not fully met the needs of the work.
 There were PSP developed for safe use of plate clamps but no specific instruction or design on the type of rigging to be used for the T-Bar
dimension lifted.

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 SRS Investigation
Corrective actions
Proposed corrective actions to address root causes:

1. Issue work instruction to foreman and supervisors to systematically reassess the risks and clarify instructions to workers in case of
change of work program (LMRA – Last Minute Risk Assessment).

2. Extend Front Line Supervision (FLS) training to subcontractors together with guidance note for supervisor / foreman for the type of
task to be perform.

3. Audit the shipyard training process program and verification of competence of supervisors.

4. Audit the shipyard management system for lifting aids and tools.

5. Extend the initiative of Toolbox Talks assessment to the sub-contractors.

6. Assessment of knowledge transfer verification from supervisors to workers.

Additional corrective actions following technical review:

1. Complement the Site HSSE Induction with element related to

Stop Work Policy and develop an entire Stop Work Policy
training/engagement session with the workforce.

2. Review the JSAs on a frequent basis

CORRECT LIFTING METHODOLOGY USING QYH-3 HORIZONTAL CLAMPS

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 SRS Investigation
Corrective actions status

CA1 – Issue work instruction to foreman and supervisors to systematically reassess the risks and clarify instructions to
workers in case of change of work program(LMRA-Last Minute Risk Assessment)

Shipyard completed their own internal investigation and the list of recommendation corrective actions was distributed to all
Department Heads for dissemination. Work Instruction including clear and precise communication on the correct type of
rigging using the predetermined rigging devices.

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 SRS Investigation
Corrective actions status

CA1 – Issue work instruction to foreman and supervisors to systematically reassess the risks and clarify instructions to
workers in case of change of work program.

Shipyard completed TBT refresher training for all the supervisors and foremen on 2nd Nov, special requirements for the LMRA
was highlighted in the training, the record for the LMRA shall be written on the TBT book by foreman/supervisor for all non-
routine or last minute changes work activities.

Non-routine activities

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 SRS Investigation
Corrective actions status

CA2 – Extend Front Line Supervision (FLS) training to subcontractors together with guidance note for supervisor / foreman for
the type of task to be perform.

Shipyard completed an internal Frontline Supervision Training on 02 Nov 2019. See below pictures for the attendees list and
training evaluation forms.

Attendees
List

Evaluation
forms for the
training

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 SRS Investigation
Corrective actions status
CA3 – Audit the shipyard training process program and verification of competence of supervisors
• Training audit was conducted by HSSE, no significant non-compliance found. Project training procedure and matrix had been developed
and approved and being implemented at site according to the plan.
• Trainers are discipline supervisors from shipyard PMT, VOC witnessed by HSSE, the effect of training was good.

Example:
All Rigging and Lifting crew members attending a special refresher training on Safe Lifting and Rigging Practices on 29th October 2019.
This special training was conducted by a 3rd Party service provider J&L who are specialising in supplying lifting and rigging devices to the
Shipyard.

3rd party
training

Project training
matrix

CMHI’s internal
training materials
Attendees Evaluation forms
List for the training
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 SRS Investigation
Corrective actions status

C4 – Audit the shipyard management system for lifting aids and tools

• Audit conducted by HSSE, no significant non-compliance found during the audit, suggested shipyard to post daily inspection record for
the Lifting and Rigging appliances.
• All Lifting and Rigging appliances will be stored at dedicated storage rack instead of kept by subcontractors.
• Weekly Thematic Inspection (joint inspection) on Lifting and Rigging is on-going and the frequency will be conducted on weekly basis.

Monthly
Color coding
scheme

Weekly
Thematic
Inspection

Daily
inspection
record

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 SRS Investigation
Corrective actions status
C4 – Audit the shipyard management system for lifting aids and tools

• Monthly inspection and maintenance conducted by lifting team of hull dept.

• These inspections are performed by competent rigger certified by Chinese State Authority.

Monthly Inspection record Lifting appliances from Subcontractor

(Subassembly Workshop) Inspected by competent rigger from hull dept.
Rigger
certification
issued by
State
Authority

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 Investigation
Corrective actions status

C5 – Extend the initiative of Toolbox Talks assessment to the sub-contractors

Both buyer and builder are performing evaluation and assessment of the daily TBT for all of their Sub-
contractors. HSSE Dept is monitoring this trend on weekly basis.

To date-----TBT Evaluation by weekly

Summary of TBT evaluation

Target score is 80%

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 Investigation
Corrective actions status

C6 – Assessment of knowledge transfer verification from supervisors to workers

Issue the TBT booklet to all the subcontractors, assessment of knowledge transfer via TBT evaluation form by
various Discipline Supervisors.

TBT
TBT booklet evaluation
form

TBT
evaluation
feedback
Main issues:
TBT • Some workers not wearing gloves
evaluation Good findings:
by • 2 ways communication
discipline • Safety, quality and production all
supervisor involved

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