Key learnings from a High Potential Incident
HPI OSH Alert #492
Date of incident: 23 February 2017
Safety Flash issued: 24 February 2017
Two subcontractors were observed working in a shaft approximately 3.9 meters deep without a fall injury prevention system.
A concrete block containing a davit mount was at the work location but no davit was set up for the works.
The temporary handrail at the top had a gap of 500mm which could have allowed a person to fall into the excavation. The shaft was located within a fenced construction site and a secured ladder was being used for access.
Why did this happen?
- There was insufficient hardware available (there were not enough davit arms).
- Both the leading hand and the workers chose to proceed with the task despite knowing that the davit system had not been installed.
- The ladder was perceived by the workers as an adequate control for the risk of falling.
- There was a lack of understanding of when height rules apply e.g. temporary vs permanent works and fixed vs portable ladders.
- The Safe Work Method Statement (SWMS) did not accurately reflect the task requirements.
What will the business area involved in the incident do to stop this from happening again?
- The contractors SWMS that addresses the falls from height risk, has been updated to require the use of a fall arrest system on ladder access whenever the fall risk is greater than 3m. These changes have been reinforced in a toolbox meeting held on all sites.
- Additional davit systems and harnesses are to be sourced for all sites to ensure sufficient resources are available for all scopes of works and at all heights/depths.
- Additional training is to be provided on the safe selection and use of height safety equipment, as well as emergency considerations and first aid in the event a fall from height occurs.
What will our organisation do to stop this from happening again?
- Trigger the Contractor’s pre-qualification within twelve weeks to assess adequate HSE management system.
- Review the Contractor's SWMS associated with all safety essentials and share any learnings at the Contractor Forum.
- Detail Water Corporation’s expectations for portable vs. fixed ladders, and temporary vs. permanent works and ensure inclusion to the tracking register of Safety Essential documentation.
- Project Management Branch (PMB) to issue notice to all Contractors on the use of a fall arrest system on all ladders whenever the fall risk is greater than 3m.
What key learnings can you discuss with your team to stop this from happening again?
Construction and temporary works access by ladders is a frequent activity on contractor and Water Corporation sites. It is important to provide clear consistent minimum standards for people to follow when it comes to fall protection on ladders as follows:
- Critical controls must be clearly defined and checked regularly in the field to ensure works are being completed to the required standards.
- When work is being planned and allocated, the competency of operators, availability of equipment, and the level of supervision required must be considered
- Documentation must clearly define the minimum expectations and key considerations for the process.
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.