05 September 2007

Fall From Height

Safety Incident Topic: Fall From Height
Location of Incident: Construction Site, Taichang China
Date of Incident: 27 January, 2007

Brief Account of Incident
A contract worker fell from a permanent work deck located 6m above the ground. The investigation revealed that on the morning of the incident, a wooden temporary platform was constructed and then positioned 1.2m./4 ft. (horizontally) from the edge of the steel permanent deck and 1m./3.3ft.(vertically) above it. The worker was standing on the wooden temporary platform in order to grind on an over head pipe. While repositioning himself, he stepped off the wooden temporary platform. The 1m fall caused the worker to lose his balance. When he landed on the steel permanent work deck, he rolled toward the edge, fell through an incomplete guardrail (top rail only), and landed on the concrete floor below. Immediately following the incident, the worker was taken to the hospital and released to work without restrictions. The extent of his injuries was a bruised torso.

Immediate Causes
- Lack of knowledge of hazards present- Unprotected height
- Inadequate guards of protective measures

Root Causes
1. Inadequate identification of critical safe behaviour
Following the installation of the guard rail (top rail only) around the blend deck, the on-site contractor and BP personnel did not recognize the requirements for fall protection when a guardrail is missing a mid-rail and toe board. Once enhanced procedures are communicated to site personnel, extensive HSSE auditing would help to identify unsafe conditions or actions.
2. Inadequate identification of work hazards
During the Jan. 27th daily pre-job tool box safety meeting, the pipe work on the steel permanent work deck was not recognized as “working at heights”. Contract supervisors and workers did not identify the increased risk of falling from the temporary work platform and its close proximity to the unprotected edge. They did not understand or recognize that approved fall protection is required when working on an elevated platform with guardrails that are missing mid-rails and toe boards.
3. Inadequate work planning
For more than two weeks prior to the installation of mid-rails and toe boards on the guardrails, extensive construction activity was allowed to be performed on the steel permanent work deck without approved fall protection.
4. Inadequate implementation of 'Policies, Standard and Procedure'
Standards for Working at Heights were in place but the applicability when working on a flat permanent work deck with an incomplete guardrail had not been addressed. Prior to the incident, the standard had been misapplied due to inadequate detail and implementation.

Actions Taken
1- Revise/update written site safety procedures to enhance requirements for work on elevated walking and working surfaces. Procedures should include a requirement for guardrails to be constructed in full (top rail, middle rail, andtoe boards) at the time of initial installation. Communicate revisions to all site personnel.
2- Contractor and BP site personnel should attend additional formal instruction on Risk Assessments and Hazard Identification. The training will include the recognition of potential interactions of simultaneous activities.
3- Contract and BP site personnel should implement an enhanced HSSE audit process including HSSE audit checklists.
4- BP site construction coordinators should attend contractor planning meetings and ensure that work activities are strategically aligned with HSSE requirements.
5- BP site personnel should audit contactors to ensure that documented risk assessments for non-routine and routine permitted work activities are being completed and adequate for the work being performed.6- Communicate the following to all BP and contractor personnel on site. “Everyone must take personal accountability for themselves and for others. Any work viewed as being unsafe must be stopped.”

What Went Well
A Permit to Work for the welding operations and the Daily Risk Assessments had been completed and signed by all contractor employees involved in the task. HSSE Training records for the contract employee were complete and readily available for review.

Lesson Learned
1. Training on Hazard Identification, considering the interactions of location and tasks, needs to be further enhanced.
2. Personal accountability of others to stop work that they viewed as unsafe is critical to safe operations.

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