Learning from incidents

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Learning from incidents

• Glasgow Caledonian University

• Neal Stone
• Director of Policy Communications
• British Safety Council

• 10 December 2013

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Three ODA award winners 2010 and lessons learnt

• PROJECTS
• Company A International Broadcast Centre/ Main
  Press Centre
• Company B Sewerage system
• Company C New utilities

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Company A International Broadcast Centre/ Main
Press Centre The Background

• Whilst erecting the steel Beams and Columns a
  slinger fitted the piling clamp to a 10 meter
  length column.
• The piling clamp is a propriety lifting
  attachment and is regularly used to lift the
  columns. The slinger failed to ensure the pin had
  secured properly through the hole in the web.
• As the cranes head was directly above the lifting
  point the piling clamp would grip until the angle
  of the column altered enough for the piling clamp
  to slide free.
• This then left the piling clamp suspended on the
  chain and the column falling to the ground.
• Fortunately, an exclusion zone was in place and
  nobody was injured.

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The piling clamp
Company A International Broadcast Centre/ Main
Press Centre
The Real Picture
Poorly positioned clamp
Dawson clamp
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Company A International Broadcast Centre/ Main
Press Centre Lessons learnt

1. Slingers need to ensure that they double check
   that all lifting equipment is attached correctly
   before signalling the crane driver to begin
   lifting.
2. The design of the piling clamp means that you
   rely on the operator to ensure the clamp engages
   in the hole using the spring release. Dawson
   clamps should be used instead of piling clamps to
   lift the columns because there is less of a risk
   of an operational error due to the fact the
   operator must physically install the pin through
   the hole before signalling the crane driver to
   begin lifting.
3. The resulting investigation and near miss report
   was shared across the Park.

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Company B Sewerage system The Background

• On 1 April 2009, an employee suffered multiple
  fractures and a cracked heel to the left foot
  when a concrete shaft segment (approx. 700 kg)
  toppled and fell onto his foot.
• In recent years as developments of concrete shaft
  segment has progressed, the segments have become
  thinner and taller, making them less stable when
  stored upright in their correct position. The
  standard industry practice was to tie the
  segments in a stack which was adequate when the
  segments were not being used.
• The problem arose when a segment was required to
  be removed from the end of the stack for use in
  the construction. When the ties were released,
  the end segment became unstable.

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Company B Sewerage system The Real Picture
Toppled concrete
Segment into frame
Multiple shaft segments into frame
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Company B Sewerage system Lessons learnt

• Key Learning Opportunities
• Sectional ownership reviewed providing slinger
  signallers storage responsibilities
• All existing segment storage sites checked to
  ensure safe storage i.e. provision of segment
  restraints.
• New 'L' bracket and segment buffers designed as
  permanent preventative solution.
• 4 Stage safe segment storage working practice
  document to be introduced and implemented as a
  mandatory requirement.
• New Measures
• Segment buffers available
• New guidance sheets available on safe use of
  segment buffers.
• Ownership is being rolled out to all
  supervisors/site agents.
• System used across the business

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Company C New utilitiesThe Background

• Company C was required to install over 50 salmor
  pits for the 11kv (LVU) installation works. To
  install them the ground has to be excavated to
  the correct depth and wide enough to accept the
  pit.
• During the initial installation works, the teams
  reported that the standard industry practice for
  access and egress was plainly not best practice.
  i.e. two ladders tied and criss-crossed, one on
  the inside and one on the outside of the pit. The
  operative had to access the actual excavation via
  a ladder, then climb another ladder on the
  outside of the pit, then cross over and descend
  into the pit via another ladder on the inside of
  the pit.
• The reason the access arrangements were like this
  was that the excavation when constructed was
  supported by battering the sides to an angle of
  45. Therefore the edge of the excavation was
  always approximately 1 - 1.5 metres away from the
  edge of the salmor pit.

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Company C New utilities The Real Picture
Best practice winners 2010
Access platform
The pit
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Company C New utilitiesLessons learnt

• Something that would span the gap between the
  excavation and the salmor pit was required. It
  would have to be a least 2 metres in length, have
  handrails, wide enough to access a ladder safely
  to enter the pit, light weight (two man lift
  maximum) and robust with stop ends. A quick
  prototype was developed and the solution was
  found to be ideal for the task in hand.
• The access platform eliminated two ladders.
  Handrails provided security when accessing the
  pit over the excavation. The risk of falling into
  the pit during access was eliminated. The
  standards of the ladder accessing the pit were
  secured to the platform providing more security
  for the person. The platform could not slip even
  if the platform had to be placed at angles to
  access the pit.

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Company C New utilitiesLessons learnt

• What was particularly pleasing about this
  innovation was that it did not require a
  committee to decide to do it but from a
  ground/workface demand the team felt empowered to
  go and make it happen.
• Project Director (Company C)

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• Thank you
• Neal Stone
• Director of Policy Communications
• British Safety Council