Flash : Fatality due to loose grating - MRM

1 Flash : Fatality due to loose grating . Brief Description Work was in hand to position new panels of steel grating on the 5th level of a process train (See photo). Several supporting cross beams had been located incorrectly. Hence the gratings did not fit properly as designed. However the decision was made to lay down all the gratings and to tie those necessary in place temporary by using thin wire. The contractor fixing the gratings placed wooden planks down over the unsecured gratings to assist him in carrying out safe operations. During the morning of the accident these wooden planks were removed to assist in the operation. The contractor did not expect any other work to be performed at this level during the same day. At lunch time the site was left without the wooden planks being replaced and without any warning signs or tapes. In the late morning some welders requested that a scaffold platform be installed. During the lunch break the scaffolding supervisor went up to the 5th level to review the need for scaffolding.

2 He walked along ontop of the grating unaware that some of the gratings were unsecured. When he put his weight ontop of the grating in question, the wire broke and he and the grating fell down through the platform and he hit his head on a scaffold pole. He died 9 hours later in hospital. Pictures Immediate / Direct Cause(s). The main cause was an unsecured panel of grating . The man unfortunately died several hours later from head injuries. Classification Fatality Immediate Action(s) Taken Stop work & send victim to hospital. Investigation. Review Procedure Lesson Learnt & Recommendations Review the current situation of gratings on all sites (construction and operational) to identify if any are unsecured or in an unsafe condition corroded. The inspection of gratings and fixings is to be part of the routine inspection program. Any unsecured or unsafe gratings should be regulated by using the Scafftag system or equivalent to prevent unauthorised use.

3 During any break (lunch, etc.) or if the work location is to be left in a unsafe condition, warning signs and barriers or tapes are to be (re)installed. The work location is also to be left in a safe condition at the end of the day or shift even if no work is to be carried out until the following morning. For offshore platforms, control mechanisms need to be in place before descending to the lower levels, especially after a storm. Precautions may include use of a buddy-system , fall arrest protection and implementation of the work permit system for entry to lower levels.