Lessons Learned

1
Lessons Learned

• May 29, 2005
• Fatality from a fall into a manhole

2
Incident Description
Two sub contract painters were working in shaft
A60 installing thermal insulation on the risers.
One of the men wanted to use a piece of plywood
that was lying on the floor for cutting isolation
material or as a storage board for their tools
and materials. He picked up the edge of the wood
without realizing that there was an open manhole
underneath. As he lifted the board, he stepped
forward to raise the wood vertical and fell down
the open manhole, falling some 12 meters to the
floor of the cell beneath.
3
Schematics of the incident
Scaffold Tower
3. The deceased carried the materials and tools
to this location to store them. Assumption is
that he required a clean place, lifted the
plywood to clean it, walked forward and fell down
the manhole
1. Painters were working here when asked to leave
the shaft by the watchman
Access
Open ROV access holes with barriers
Plywood Board
Single 1,500 watt lamp, casting light
P
Point of accident
P
Only one 1,500 watt lamp was installed on the
floor. There was no other light in the area and
in the base of the structure immediately under
the manhole
2. One painter stayed at the work location
cleaning the area
KEY
Rise pipes being worked on by painters ROV
access holes with barriers 1,500w Lamp
P
4
Incident Pictures (01)
Photograph showing poor lighting, black sand and
unprotected plywood over manhole
Photograph showing manhole with plywood removed
5
Incident Pictures (02)
Photograph view looking down, showing cell
beneath with pipes where worker fell
Photograph showing manhole with barricade and toe
boards restored
6
Outcome
The casualty received severe head injuries and
was transported to the site clinic and then onto
Nakhodka hospital. Despite efforts to stabilize
the casualty in the site clinic and ambulance his
condition deteriorated and he was pronounced dead
upon arrival at the hospital.
The deceased was only 28 year old.
7
Main Causes

• The barricade had been removed from the manhole
  and had not been replaced.
• The plywood covering the manhole was not marked
  or secured.
• No inspection by the shaft watchman had taken
  place during the days leading up to the incident
  due to the shaft being closed during sand
  blasting.
• Lack of housekeeping had left several plywood
  sheets on the base of the shaft covered with a
  substantial layer of dark grey blasting sand.
• The lighting in the shaft was barely adequate.

8
Underlying Causes

• Lack of permanent barriers/covers/hazard
  identification.
• Time and schedules pressure resulting in
  priority on schedule vs. safety.
• Inadequate management of change from
  construction phase to marine/demobilisation
  phase, resulting in reduced supervision and
  attention.

9
Things we learned (01)
Watchmen are used to check the shafts but the
manning levels were low as the construction job
was nearly at an end and crew demobilisation had
started. The watchmens office had recently
moved from the shaft to a position about 20
minutes walk away. Manning levels to be improved
to provide one man per shaft with responsibility
for basic safety of shaft including barricades,
electric cables, lighting, housekeeping hoses
over walkways, etc.
10
Things we learned (02)
Manhole covers shall be clearly identifiable and
all manholes should have a cover. Safety
barriers and manhole covers should not be removed
from the installed location without proper
authorization.
11
Things we learned (03)
Change management of HSE through to the end of
the shaft construction job had not been fully
thought through. Attention had switched to the
next (marine) phase of the job. Reinforce
message to supervisors and workforce that if
conditions are unsafe (bad lighting, bad
housekeeping), then all people have authority to
stop the work. Management talk to supervisors to
reinforce their Safety Responsibilities to be
held.
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CONCLUSION
. . . what worries me most is the inadequacy of
supervision and the fact that work colleagues
effectively created circumstances, which were
undetected by supervisors, that led to the death
of their colleagues . . . We must manage the
beginnings of activities, changes and deviations
to activities that we have started, and endings
to activities. These beginnings, changes,
endings may be on a large scale from
construction to commissioning or on a smaller
scale - any change to any activity in the midst
of its execution may actually require a
completely new method statement. We need to be
active in predicting and dealing with them all.
Please remember to finish whatever activity you
start and to never leave potentially dangerous
situations unattended that have the potential to
harm or kill others. The job and safety
management should never end before the job is
over.
From the letter of David Greer, Sakhalin 2
Project Director to all SEIC staff