Investigation Lessons Learned Summary

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Investigation Lessons Learned Summary

safety sharingtheexperience

Title:
East London HiPO Contractor Injury

Investigation Lessons Learned Summary

Incident: East London HiPO injury
Type of Incident: Injury on Duty
Business Unit: Logistics - SAFVC.
Location of Incident: East London
Country: South Africa
Tr@ction No: 3515156.
Date of Incident: 3 June 2010.
MIA/HiPo Notification Date: 4 June 2010.



Brief Account of Incident:

East London terminal consists of 3 sites, the main terminal, site 2 where no operations take place and site 3 contains the 8000m3 capacity tank of HFO and a gantry to support working at heights equipment.
The duties to load HFO at site 3 remain with the Bulk vehicle driver and the security guard.


On the morning of 3rd June the contractor BVO arrived at site 3 to load HFO for a customer in Port Elizabeth.
The Security Guard prepared the load documentation and the driver prepared the vehicle for the load.
The security guard climbed the bulk vehicle using the working at heights equipment to check the truck for emptiness. Once this task was completed, the security guard descended from the bulk vehicle and began the load.
Once the load was complete, the security guard printed the load documents and handed them to the driver.
The driver prepared the vehicle for departure; this was when the security guard noticed that the dome covers were still opened and climbed the vehicle to close the domes without informing the bulk vehicle driver.


The security guard felt the truck move slowly, he panicked and held onto the inertia reel and continued to pull the inertia reel hoping that the reel gear would engage to keep him suspended but he continued to pull the reel as he moved with the slow moving truck beneath him.
The truck then drove off and the security guard fell to the ground hitting his right knee and the back of his head on the ground.

What Went Wrong (Critical Factors):


1.
The security Guard climbed the truck to close the dome covers after handing the loading documents to the bulk vehicle driver

2.
Bulk Vehicle driver drove off from the gantry whilst the security guard was on top of the tanker

3.
The inertia reel did not engage to restrain the security guard from hitting the ground.
Summary of Immediate Factors:
·
Procedure not available - Although the procedure is available the security guard had to rely on memory on the step by step procedure
·
Unintentional Human Error - The Unitrans driver moved the vehicle without any knowledge that the security guard was on top of the vehicle.

·
Incorrect use of personal protective equipment or methods - a harness with lanyard was worn and attached to an inertia reel. Consideration of safety height from ground and the height of the individual was not considered when choosing the correct equipment for working at heights.


Summary of System / Systemic Causes:
·
Antecedent not present in the form of a STOP sign and unclear procedures
·
No training provided for security guards on the use of the equipment or the procedures.
·
Job oversight not effective – security supervisor and depot manager did not conduct task observations at the site
·
Communication not received by the driver when the security guard shouted and whistled
·
Monitoring/ auditing of safety process not effective – the process of checking equipment and task observations were not effective
·
Risk Analysis or tolerance not effective in terms of the working at heights activities at site 3, risks around working at heights was not foreseeable.
·
No work planning or risk assessment performed for the task at site 3 – no available risk assessment for the task.
·
Development of SPP not effective – the SPP for working at heights did not include important step by step information
·
Communication between different organisations not effective during the task, conversations between driver and security guard appear to be scarce.
·
Lack of SPP for the task for the use of the working at heights safety equipment
Summary of Local Action
·
A checklist was developed and shared amongst the depots across the SAFVC.
The checklist asked for assurances around training of working at heights equipment; procedures are specific to the task, the calculation of the safety factor height between the individual and the ground when the individual is restrained by the arrest system.
And general compliance to the SAFVC working at Heights standard.
Those depots that did not comply ceased operations and investigated methods to repair the restraints systems.
·
Based on the findings above – the SAFVC working at Heights standard to be amended to ensure constituency of the equipment and processes used for working at heights.

Lessons Learned.
·
Working at Heights procedure to be reviewed to include Stop signs, ensure clarity in the step by step activities in the procedure, clear responsibilities and training for the security guard and the bulk vehicle driver.
·
Regular task observations conducted by management or supervisors would identify gaps in the procedure
·
Where there is more than one contractor involved in a particular task, the task procedure must be congruent and both parties should be aware of the procedures.
·
The Business Security Representative (BSR) to ensure that security procedures are valid and reflect the actual activity.
Task observations to be included in the Security Managers or supervisors job descriptions
·
Include the security guard operational activities that fall out of the scope of security services, in the site security contract.
Ensure that these tasks are risk assessed and task procedures are aligned to the activities and necessary training provided.
·
Training security guards on the use of the inertia reel and working at heights equipment.
Keep records of training.
·
Ensure that the Working at Heights procedure includes the recovery of suspended individuals in the event of a fall.

Investigation Corrective Actions address:
·
Site specific task procedures that have been risk assessed and takes into account all parties involved in the task.
·
Frequent task observations conducted by BP and contractor management and supervisors

·
BSR’s to conduct frequent observations of security related tasks.
·
A standard for the use of working at heights in terms of equipment, competence individuals conducting the task and competence of individuals testing and checking working at heights equipment.
Consistent approach for the regular inspections of working at heights equipment.
·
The recovery of suspended individuals in the event of a fall.
To be included in the Emergency response plan.