Projects and Engineering

SHE Learning

Learning number SPRC200

Operating Entity Sasol Energy Operations & Technology (EO&T), Projects & Engineering (P&E)

Date of incident 26 January 2023

Occupational Product Equipment

Process Safety Environment Health Security PSF
Incident type Safety Transportation Damage
X

Relevant Life
Saving Rules
X

Relevant
Process Safety
Fundamentals

Key Undesirable Event Not Applicable

Description of the incident
A team of scaffolders was erecting a scaffold (protective gantry cover) outside the cooling tower shell.
Three scaffolders were busy levelling the inclined modular beam to the required position, while the scaffold
protection gantry was under construction. The injured person was winding down (lowering) the jack with a
swivel into the upright sleeve. However, the jack with a swivel did not lower into the upright as expected,
he attempted to alert his team members about this anomaly, but suddenly, the jack with a swivel lowered
into an upright sleeve, his right hand middle finger was subsequently pinched between the scaffold upright
sleeve and the jack with a swivel lever.

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Underlying and root causes
Key learning and control
improvement recommendations
Identification of standard or
good practice related to the
incident
To prevent future incidents, it is recommended that this incident learning is appropriately shared and implemented by relevant
persons in your Operating Model Entity, where applicable.
Underlying causes:
UC1 - Inadequate task identification and analysis:
The Pre-Task Risk Assessment (PTRA) and Job Safety Assessment (JSA) do not specifically address
possible pinch points which can be created by components (e.g., jack with a swivel) when erecting sloped
protection gantries. Due to the nature of erecting the gantry, awareness of the hazard specifically
presented by the jack with a swivel was not emphasised, as this type of scaffold and erection method is
considered to be non-routine tasks performed on site.
UC2 – Potential scenarios not covered:
The safe work procedures for manual handling activities and scaffold erection do not adequately address
potential hazards and mitigation measures for pinch points or the placement of hands and fingers in the
line of fire.
Root Cause:
RC - Technical error / missing steps:
The scaffold safe work procedures and site-specific method statement for special scaffolds do not specify
the correct method for levelling or adjusting the protection gantry cover, roof type structures, or similar
applications into incline or decline positions while using the jack with a swivel or similar components.
• A task-specific method statement must be developed and implemented whenever non-routine
scaffolding is erected, such as safety protection gantry covers, roofs, hanging scaffolds, and other
special scaffolding.
• The scaffolding safe work procedure must address all potential risks and hazards present when
erecting, modifying, or dismantling a non-routine special scaffolding.
• The task-specific method statements should address any potential manual handling risks and hazards
presented by unique, irregular, or infrequently used scaffold applications that involve high potential
pinch point activities.
None that would provide context.
Together towards ZERO HARM and SUSTAINABILITY