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Time Out For Safety

BSP/BLNG 25th August 2004 BSRC Ball room

BSP/Contractor fatality Incident Investigation

Slide: 1

BSP/Contractor fatality Incident Investigation Slide: 2 .This gentleman would have celebrated his 31st birthday on 25th August BUT«««..

Fatality Incident on 18 Aug 2004 BSP/Contractor fatality Incident Investigation Slide: 3 .

SEQUENCE OF EVENT CG 2 1 32´ T SPOOL 12/08/04 ± 13/08/04 11/08/04 Primary Support (WEDNESDAY) CG 3 4 16/08/04 UNTIL 16/08/04 UNTIL 5 Tons JACK 16:00HRS 16:00HRS BSP/Contractor fatality Incident Investigation Slide: 4 .

PICTORIAL REPRESENTATION BSP/Contractor fatality Incident Investigation Slide: 5 .

BSP/Contractor fatality Incident Investigation Slide: 6 . y Cascade immediately the preliminary findings to all BSP staff and contractors within the next 48 hours y Implement immediate actions recommended by the investigation team to prevent recurrence Note that this is only the beginning and there are many more areas that we need to work on in more detail.Tee-Piece Fabrication Fatality Time Out 25 Aug 2004 Purpose y To share preliminary findings of the investigation.

‡ Sub-contractor: Zainal Daud Sdn.m. Bhd. ‡ Victim: Mr.30 a. ‡ Survived by: Spouse & 4 years old son. Lee.Fatality Incident on 18 Aug 2004 Incident Details: ‡ At Zainal Daud (ZD) Fabrication Yard (G25) at 7. ‡ Project: Single Buoy Mooring (SBM) Metering (Phase 2) ‡ Main Contractor : Warner & Company Sdn. 31 years old Malaysian working for Chin Wui Heng Welder Enterprise ‡ Occupation : Senior Marker. Bhd. ‡ Sub sub-contractor: Chin Wui Heng Welder Enterprise BSP/Contractor fatality Incident Investigation Slide: 7 . 8 yrs experience ‡ Injury: Death from severe head injuries.

‡ Was supported by 2 primary ground supports. ‡ Chain block and jack were removed after welding of 2 flanges. BSP/Contractor fatality Incident Investigation Slide: 8 . Suspended.3 tons) partially completed (2 flanges welded on). ‡ No further adjustments of the primary supports were made to improve stability. awaiting material. ‡ Deceased was assigned the role of supervisor of the above fabrication activities. ‡ Chain block and 5 tons jack were used whilst fabrication was in progress for alignment purposes.Fatality Incident on 18 Aug 2004 Facts & Findings (1) : ‡ Fabrication Yard Work delayed whilst waiting for Tool Box Talk ‡ 32´ pipe Tee piece 300 # (1.

‡ Since materials were not available. 70 Kg wt) attempted to sit on outer rim of Tee-piece flange. the deceased (ca. ‡ Tee piece slipped & toppled over crushing victim on the head BSP/Contractor fatality Incident Investigation Slide: 9 .Fatality Incident on 18 Aug 2004 Facts & Findings (2): ‡ Initial calculations indicate Tee-piece Centre of Gravity shifted significantly & effectively on the verge of tilting. Two days later. no further work was carried out.

BSP/Contractor fatality Incident Investigation Slide: 10 . the deceased attempted to sit on the vertical flange of the Tee piece 3. 2. The Tee piece became unstable after the installation of the two flanges. 4. The deceased suffered severe head injuries after being crushed by the Tee piece.Findings y Direct Causes 1. For unknown reasons. This action caused the unstable Tee piece to slip and topple over. The centre of gravity had shifted but the primary supports were not adjusted.

Enforcement of Duty to Stop was inadequate. Although a co-worker. The instability of the Tee piece had not been communicated to the others. 3. 5. Lack of barricades and warning signs around hazardous areas. Hazard Identification Plan (HIP) for the contractor fabrication yard was not developed. re-secured the Tee piece on a chain block. chain block and 5 Tons jack used earlier for alignment purposes were removed leaving the Tee piece on the two unadjusted ground supports. No designated rest area BSP/Contractor fatality Incident Investigation Slide: 11 . recognising a hazard. this was subsequently removed. 4.Findings Indirect Causes (1) 1. 7. 2. 6. General lack of hazard awareness of the workforce. The A-Frame.

sub-contractor & subsub-contractor on responsibility for HSE management ‡ The main contractor was required under its contract with BSP to play a leading role in HSE implementation. 10. Lack of effective supervision.Findings Indirect Causes (2) 8.Contract HSE Management: ‡ Lack of clarity between contractor. BSP/Contractor fatality Incident Investigation Slide: 12 . 9. Lack of planning: Work started on the Tee piece before all the materials had arrived. not just the subcontractor ‡ There were early warning signs of a lack of commitment to safety such as not following up on repeated violations identified during site visits.

3. Include HIP in Tool Box Talk. Communicate any unsafe conditions found. both at BSP and the contractor worksites. Rectify where work supports are unsafe or inadequate. Survey work supports at all worksites immediately. Ensure you have a HIP for every stage of your project. 4. including the fabrication stage.Immediate Action (1) Please undertake the following: 1. 2. BSP/Contractor fatality Incident Investigation Slide: 13 . Ensure provision and enforce use of designated rest areas at worksites. even when unattended. Address safety of worksites.

Confirm who is responsible for sub-contractor HSE management.Immediate Action (2) Please undertake the following : 5. Supervisors & contract holders/managers accountability for safety: ± Do you know the full extent of your role? ± Do you know what you are accountable for? ± Are you discharging your responsibility? 6. BSP/Contractor fatality Incident Investigation Slide: 14 .

3. all direct and indirect sub-contractors to demonstrate commitment to HSE by. for example. Consequence Management). We will require contract holders to include all direct and indirect sub contractors in HSE performance reviews.Areas requiring further work 1. We will need to strengthen the culture of intervention (e. We will require senior management of all contractors. Review appropriateness of contracting strategy to ensure HSE responsibilities can be effectively exercised. site visits and mandatory joint HSE meetings. 4. House Rules. BSP/Contractor fatality Incident Investigation Slide: 15 . 2.g. PAKAT.