Key learnings from a High Potential Incident
HPI OSH Alert #491
Date of incident: 13 December 2016
Safety Flash issued: 15 December 2016
An operator was working on a grid mesh
platform (approximately 7 meters high) pulling
a water pressure cleaning lance and hose
(approx 10–15kg) from the ground level with
the aid of a rope. While pulling on the rope, the
operator put his foot on a sheet metal sign
which was lying on the grid mesh platform. The
sign slid and the worker’s foot slipped,
propelling him forward causing his hip to
contact the top rail with considerable force.
As a result, the operator nearly toppled over
the rail and at one stage his body was
momentarily over the rail head first and feet in
the air. His hard hat fell off in the process. Fortunately, the operator managed to stop
himself from going over the guard rail
completely and no injuries were sustained.
Why did this happen?
- This incident was a result of poor housekeeping. The metal sign was left on the platform and used for a
variety of general purposes including providing protection when kneeling on the grid mesh as well as
covering openings at the conveyor.
- Hazard identification and hazard perception of the employees did not foresee the sheet metal
sign placed on the grid mesh as a potential slip hazard.
- There was a lack of cleaning equipment available at different platform levels, which had it
been in place, would have eliminated the need to haul the hoses to upper level platforms in
- There was no development or communication of a task specific JSEA in relation to the job.
What will the business area involved in the incident do to stop this from happening again?
- Install the necessary hardware, at upper level grid mesh platforms within the sludge treatment facility, to
eliminate the need to drag pressure water hoses from the lower ground floor to upper levels.
- Complete critical control point effectiveness and review high risk work activities using Water Corporation
Safety Essentials as well as legislative tools.
- Develop and disseminate toolbox slides to provide further education and awareness for the business
around mandatory safety rules when working at heights, and also the importance of good housekeeping to
minimise risks in the workplace.
- Ensure the Manual Handling Strategy is implemented to minimise risks related to manual tasks, reduce
injuries and identify good practices (including an on-site assessment with a subject matter expert).
- Develop comprehensive JSEAs for high risk activities by undertaking audits and developing actions in
alignment with the Zero Harm Plan and then sharing these through existing communication channels.
What will our organisation do to stop this from happening again?
- Develop a communications plan/strategy to promote the use of the Minor Equipment Purchase (MEP) process which can be used in the event a safety hazard has been identified and an immediate solution is required.
- The plan will also focus on how the process will support us in maintaining pride in our workplace to ensure safety hazards and incidents are avoided and our people maintain the upkeep/housekeeping of a worksite.
What key learnings can you discuss with your team to stop this from happening again?
When discussing this incident with your teams, it’s important to focus on the risk of housekeeping and the need to keep workplaces clear of clutter.
What appears to have been a relatively simple task scenario in the case of this HPI event had the potential to result in a fatality or permanent disabling injury!
Discussions should encompass the following:
- Even the most basic requirement of maintaining good housekeeping is important to eliminate hazards around work areas.
- It is imperative that our people develop comprehensive JSEAs for specific work areas and tasks.
- Always consider the possibility of more effective ways to complete a task. There had been missed opportunities by the operations and maintenance teams onsite to implement alternative hardware so that the pressure water hose could be connected at the upper level platform for cleaning purposes, rather than having to pull hoses from ground level.
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.