OSH alert - Confined space breach (December 2016)

Key learnings from a High Potential Incident

OSH Alert Confined SpaceHPI OSH Alert #488

Date of Incident: 16 December 2016

OSH Alert Issued: 7 February 2017

What happened? Confined space entry breach

 A welding sub-contractor was observed exiting a confined space involving a 1 metre deep access point and 3 metre long pipe reducer. There were a number of breaches to the confined space process observed, including:

  • the worker was not wearing a harness at the time of the incident
  • atmospheric testing equipment was not in place
  • the confined entry permit was not authorised.

 Why did this happen?

  • The contractor had made a design change to the pipework installation which created the high risk activity of Confined Space Entry (CSE), but did not update the Contract Risk Register.
  • The welding sub-contractor was not briefed on the contractor’s CSE Safe Work Method Statement (SWMS)
  • The welding sub-contractor entered the confined space on his own accord. Two of the contractor’s workers who were on site at the time, did not stop the works, although one of the workers did try to raise a concern with the Supervisor.
  • The Supervisor was pre-occupied with other instructions crucial to project completion, and disregarded the concern raised regarding the CSE requirements.

What will the contractor involved in the incident do to stop this from happening again?

  • Advise all employees and sub-contractors on the importance of not rushing and taking short cuts, especially during high-risk activities. In addition, all workers will be reminded at toolbox meetings of the importance of stopping unsafe acts / activities regardless of how minor it may be, or their position within the organisation.
  • Review all high risk tasks identified in SWMS to identify opportunities to review competency of employees, training and accreditation in undertaking the high risk activities.
  • Formal written warning issued by contractor and requirement for the welder to re-sit Confined Space Entry Course. Note the Welder is prohibited from undertaking further CSE works until he is deemed competent by the contractor.
  • Communicate across the company on the requirements for Management of Change and the identification and management of high risk works.

What will our organisation do to stop this from happening again?

  • Ensure contract specifications for Design and Construct contracts include requirements for notification and subsequent Principal review and approval of high risk works arising from scope/design changes.
  • Review how sub-contractor safety performance (including panel members) is included and assessed in future Water Corporation works.


What key learnings can you discuss with your team to stop this from happening again?

1. Ensure all personnel involved with confined space entry works are trained and competent

  • Do team members who will be undertaking CSE work have current CSE qualifications?
  • What is the authorisation process that needs to be followed for CSE work?
  • Do we understand the relevant procedures for CSE works (S466 Confined space entry, S476 Atmospheric Testing and Monitoring)?

2. Ensure that contractors have appropriate change management processes to deal with any variations that may arise from working in brownfield sites.

  • What needs to occur if there have been any scope/design changes during the execution of Design and Construct contracts?
  • How do we know whether contractors have an effective change management process to deal with any variations that arise?
  • What tools can we use to check that subcontractors work in accordance with Lead Contractor Safety policies, SWMS and site specific JSEAs?

Further information

If you would like further information about anything included in this HPI OSH Alert, please contact Charis Neumann, Snr OSH Analyst Incidents on (08) 6330 6629.