13 May 2006

Fatality By The Carrydeck Crane

Safety Incident Topic: Fatality By The Carrydeck Crane
Location Of Incident: Australia
Date Of Incident: 29th June, 2005

Brief Account Of Incident
A fan impeller and shaft assembly was being transported from the Potroom workshop to be installed at the Gas Treatment Centre #1 (GTC1) using a 8.5 tonne Carrydeck Crane. The Carrydeck driver had restricted vision in front of him. He approached the GTC1 worksite and hooted the hone.

At approximately 1030am Johannes Du Plessis was supervising the installation of the fan at the GTC1, had completed a call on his cell phone and stepped backwards from between the structure column onto the roadway looking upwards, apparently to have a cigarette. Johannes did not respond to the approaching Carrydeck. The driver did not see johannes and the Carrydeck struck and passed over him impacting fatal injuries. He died at the scene within minutes despite efforts by the paramedics.

What Went Wrong
. The impeller was loaded onto the carry deck in such a way that forward vision was significantly imfacted.
. The risk of driving the crane with impacted vision was recognised but the job proceeded without additional controls.

Contributing Factors
. The work area was not adequately barricaded from passing traffic.
. The ambient noise of the GTC1 area masked the noise of the approaching crane.
. No escort was used to control the risk of restricted forward vision of the crane driver.
. There was no systematic demarcation of pedestrians from vehicle traffic in the GTC1 area.
. Johannes may have been distracted by his early knock off and the pending arrival of his wife.
. He may have been fatigued due to the protracted hours he had worked in the preceding days
. He walked backwards onto the road.

Lesson Learned
. Implementation of identified controls post risk assessment are often not fully implemented.
. Management of subtle change is not well understood and carried out.
. Contractors are often not fully integrated into the management, operation and culture of the site.
. Effective implementation of the fatal Risk Control Protocols would have prevented accidents such as this one.

. Empower and encourage employee s and contractors to STOP the JOB whenever they feel unsafe
. Review and improve change management process and training to ensure the potential risks from small changes are considered (eg impeller loading method was changed).
. Clarify reporting change of command and ensure all are concerned are fully aware of this.
. Ensure rigorous implementation of the newly developed Fatigue Management Plan to all staff and contractors.
. The risk associated with travelling with loads on Carrydeck cranes must be included in training modules.

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