Assessment 5 Part B Confined Space Entry Incident 5th December 1215hrs
Assessment 5 Part B Confined Space Entry Incident 5th December 1215hrs
Scenario Additional information
On 5th December 2020, Contractor services had been engaged by ABC Steel to carry out general metalwork duties as work has been very busy and the company are understaffed. The contractors are all South Korean nationals who are fast at their work but have little to no English language skills. They have had a 15-minute induction session that was delivered in English. None of the workers has signed off to state they understood what was discussed in the induction though. James the induction trainer said he believed they understood what he was talking about as they were giving him a thumbs up occasionally.
It is worth noting that the company does not carry out regular meetings for WHS and there are no elected HSRs or established WHS committee. On the day of the incident (05/12/20), the crews in factory 1 started at 0600hrs as they were behind in their job tasks and one job (the silo manhole) in particular had to be finished by the end of the day. They had a quick 5min prestart meeting (0605hrs) to reiterate the need to get the work finished on time.
As mentioned, the task that needed the most attention was a manhole entrance and cover which needed to be cut and fitted to a silo that has been sitting on the back of a truck in factory 2 for the last day. The 6m high silo was brought into the building and placed vertically(1000hrs). The morning tea break siren sounded at 1000hrs. Kim Lee was assigned the task (1005hrs) with one other Korean worker (Jin). The two workers collected their materials for the job from Peter who is the factory 1 supervisor at 1010hrs. Kim Lee entered the silo through a small space (1025hrs) with cutting equipment and began to cut the manhole access. It was noticed by one worker (Sarah) that there was a lot of fumes starting to build up in the area she mentioned her concern to Jin (1155hrs). At 1200hrs the lunch siren sounded. Jin then went to the bathroom.
At 1215hrs, Kim Lee was still working alone, moving, cutting and welding the manhole inside the silo.
After finishing the welding Kim Lee applies a chemical to descale the piece of metal. It has been noted he was not wearing safety goggles, a face mask, gloves or hearing protection. The area was quite dark and noisy and at times temperatures can get above 45 degrees Celsius. He was also working unsupervised as it was lunchtime and the supervisor Peter was having lunch while the worker worked through to make up time on the job task.
While carrying out the finishing task, the chemical fumes have built up in the area and the contractor has collapsed due to toxic fumes. One of the other Korean workers (Jin) who heard the collapse, runs to the scene (1216hrs) to help but he has not been trained in first aid. He waved to Gina the first aid officer to attend. It is relayed to Jin that Kim needs medical help and an ambulance is called (1217hrs). Gina prepared for a confined space entry rescue (entered at 1222hrs) and provided first aid by cleaning Kims face with cold water and placing an oxygen mask over Kims face. She noticed that Kim had sustained a small cut to his forearm which she bandaged with a gauze dressing and antiseptic cream. The ambulance arrived quickly on the scene (1235hrs). Kim was unconscious and the ambulance crew provided first aid (1240hrs). After Kim was then taken to the hospital (1250hrs) and a workplace meeting is called (1300hrs) by the factory manager to find out what has happened. You arrive at the incident site at 12.55 pm. Everyone seems confused as to what to do next. All have stopped work. You immediately take control of the incident as per the requirements of the Incident Investigation Procedure. It is decided that a factory inspection should be carried out (1330hrs) to note any other areas where unsafe situations may be occurring.
On closer inspection certain items are of concern to management and an investigation has been initiated. These concerns include;Signage not in place during operations
Absence of PPE
Lack of training and induction
Language issues
Scheduling of work
Supervision of works
It has been relayed to the workplace by hospital staff that Kim had regained consciousness and had suffered a collapse due to restrictions to his breathing. This was most likely caused by a lack of oxygen in the confined space due to overwhelming welding and chemical fumes. He will be recuperating for some time and the return to work officer is notified that Kim is likely to be away from work for at least six weeks.
You have been provided with the following documents
ABC Steel WHS Policy
ABC Steel WHS Policy (Korean)
ABC Steel Incident Investigation Procedure
ABC Steel First Aid Register
ABC Steel Injury Register
ABC Steel Induction Checklist
ABC Steel Take 5 Checklist
Meeting Minutes from the day
SWMS Welding
COP For Confined Space
SDS Proweld Pickling Gel
Guide to Working in Heat
ABC Work Schedule (for that week)
AS 1885 Measurement of OHS Performance
You are also required to obtain copies of your states relevant health and safety Act and Regulations.
Brief interview transcripts are provided below.
You are required to lead an investigation into this incident, advise internal personnel, notify WorkSafe, compile a first aid register and complete an injury and disease register. A causative analysis will need to be carried out using a Five Whys process identifying contributory factors as well as direct and root causes. Your findings are to then be recorded into an official Incident Investigation Report which will be submitted to management along with a plan for corrective actions. You are also required to alert the workers of ONE major issue regarding this incident with the creation of a workplace poster.
Interview transcripts - December 5th, 2020
Interview transcripts (Use the transcripts below to help identify potential causes of the fall from height at ABC Steel)
-146050303530Can you describe how the induction session was delivered for the Korean workers? It was a quick session. The guys were fresh to the facility and keen to get going. I read through the induction book and asked if they had any questions from time to time. They would generally look at each other and just nod and give me the thumbs up.
In your own words what was their level of English comprehension on the day? I couldnt say as I didnt really have any conversations with them.
Could you provide me with a description of the PPE fitting that was required?As with all the workers I state why the PPE is necessary and then I fit it myself to give them a demonstration on how it is to be worn.
And did, in your opinion the Korean workers find the fitting of PPE easy? Look as I said we were really busy and behind schedule and as I wasnt getting much of a response. I assumed from their body language they were happy to start work.
00Can you describe how the induction session was delivered for the Korean workers? It was a quick session. The guys were fresh to the facility and keen to get going. I read through the induction book and asked if they had any questions from time to time. They would generally look at each other and just nod and give me the thumbs up.
In your own words what was their level of English comprehension on the day? I couldnt say as I didnt really have any conversations with them.
Could you provide me with a description of the PPE fitting that was required?As with all the workers I state why the PPE is necessary and then I fit it myself to give them a demonstration on how it is to be worn.
And did, in your opinion the Korean workers find the fitting of PPE easy? Look as I said we were really busy and behind schedule and as I wasnt getting much of a response. I assumed from their body language they were happy to start work.
James-Induction trainer
-361950319405When the incident occurred, can you please describe what you saw?I didnt see Kim as he was working inside the silo. I believe Jin was supposed to be his spotter for the job task. The first I knew he was injured is when everyone started running around screaming for a medic.
Who else was at the incident scene? Obviously, Jin was there, and the first aider turned up, Gina I think his name is. We were looking for the supervisor but he was having his lunch. Its ok for him, the rest of us were still working to finish this damn job. Weve been behind schedule for days.
In your own words, what communication took place between worker and others prior to the incident?The Korean workers are nice guys, always smiling and nodding to us, but they stick to themselves. They obviously talk to each other, but I have no idea about what. I saw Peter shouting at them earlier to hurry up, they thought it was hilarious!
What previous near misses or similar incidents have occurred? Ahhh, I shouldnt really say to be honest. I refuse to go into confined space until they get us the correct breathing apps. Lets just say, its dangerous work.
00When the incident occurred, can you please describe what you saw?I didnt see Kim as he was working inside the silo. I believe Jin was supposed to be his spotter for the job task. The first I knew he was injured is when everyone started running around screaming for a medic.
Who else was at the incident scene? Obviously, Jin was there, and the first aider turned up, Gina I think his name is. We were looking for the supervisor but he was having his lunch. Its ok for him, the rest of us were still working to finish this damn job. Weve been behind schedule for days.
In your own words, what communication took place between worker and others prior to the incident?The Korean workers are nice guys, always smiling and nodding to us, but they stick to themselves. They obviously talk to each other, but I have no idea about what. I saw Peter shouting at them earlier to hurry up, they thought it was hilarious!
What previous near misses or similar incidents have occurred? Ahhh, I shouldnt really say to be honest. I refuse to go into confined space until they get us the correct breathing apps. Lets just say, its dangerous work.
Sarah- Labourer
-184150292100When the incident occurred, can you please describe what you saw?Here we go again! As with all these situations, I turn up when the damage has been done. I didnt see the incident. I did see Jin trying to climb in the silo though we had to grab him by his feet! The silo hadnt been purged and I was quickly putting on a respirator before jumping in.
Describe the rescue situation? Luckily, I have been trained in confined space rescue, so I knew not to go in unless I had the breathing apps on. None of the other first aiders have had that training so it was lucky I was here. As there were chemicals involved, I also made sure I had the correct gloves on. I grabbed a first aid kit and Sarah helped me into the hole. Jin waited on the edge. He can speak a little English I thought we could use him when Kim comes too to relay what was going on.
Can you explain what other activities happened while you were delivering the first aidI believe a group of workers assembled from the lunchroom basically to see what was going on. Sarah asked them to leave and one of the workers did turn the welding equipment off as it was still live.
00When the incident occurred, can you please describe what you saw?Here we go again! As with all these situations, I turn up when the damage has been done. I didnt see the incident. I did see Jin trying to climb in the silo though we had to grab him by his feet! The silo hadnt been purged and I was quickly putting on a respirator before jumping in.
Describe the rescue situation? Luckily, I have been trained in confined space rescue, so I knew not to go in unless I had the breathing apps on. None of the other first aiders have had that training so it was lucky I was here. As there were chemicals involved, I also made sure I had the correct gloves on. I grabbed a first aid kit and Sarah helped me into the hole. Jin waited on the edge. He can speak a little English I thought we could use him when Kim comes too to relay what was going on.
Can you explain what other activities happened while you were delivering the first aidI believe a group of workers assembled from the lunchroom basically to see what was going on. Sarah asked them to leave and one of the workers did turn the welding equipment off as it was still live.
Gina Assistant Manager (first aider)
0282575When the incident occurred, can you please describe what you saw?I didnt see the incident as I was in the lunchroom having lunch.
Who else was at the incident scene? I believe that Gina, Sara and Jin were at the incident at the time. We all went out though and had a look to see what the commotion was. It was pretty chaotic.
In your own words, can you describe the events leading up to the incident?This job had been on hold for some reason, you would have to ask management why. We tried to get everyone in early as we needed it finished. The regular guys didnt want to start early though as they had all worked until 10pm the previous night. The Koreans also worked until 10 pm yesterday but they didnt mind coming in early to get some extra overtime. The job was explained to them and they got on with it. They are great like that, no questions, just get it done.
Can you clarify which procedures for this job task were being used by the work crew?Im pretty sure there is a SWMS for welding, not sure if its being used though. We did get the OHS Policy translated into Korean which is on the notice board.
00When the incident occurred, can you please describe what you saw?I didnt see the incident as I was in the lunchroom having lunch.
Who else was at the incident scene? I believe that Gina, Sara and Jin were at the incident at the time. We all went out though and had a look to see what the commotion was. It was pretty chaotic.
In your own words, can you describe the events leading up to the incident?This job had been on hold for some reason, you would have to ask management why. We tried to get everyone in early as we needed it finished. The regular guys didnt want to start early though as they had all worked until 10pm the previous night. The Koreans also worked until 10 pm yesterday but they didnt mind coming in early to get some extra overtime. The job was explained to them and they got on with it. They are great like that, no questions, just get it done.
Can you clarify which procedures for this job task were being used by the work crew?Im pretty sure there is a SWMS for welding, not sure if its being used though. We did get the OHS Policy translated into Korean which is on the notice board.
Peter- Factory supervisor
5.29 You are to compile an objective, ethical and unbiased written Investigation Report from the information provided above following the style described within ABC Steel House Style.pdf The report should include:
Title page
Table of contents
Introduction - (including who is on the investigative team)
Organisational background - including descriptions of the premise, personnel and
working conditions
Incident details - the sequence of events leading up to the incident and the actual
Incident
Evidence including descriptions of the following:
site inspections
witnesss accounts and interviews
documentation x 10
photographs & sketches
specialist advice x 3
potential samples
Causative factors including:
timeline of events (with recognised intervention points)
contributing factors
direct causes of the incident
root cause of the incident
Conclusion with Recommendations -
including preventative measures (note the level of the hierarchy of controls next to each preventative measure), suggested improved safety specific tasks for workers, supervisors and managers and the most effective ways to communicate the report to individuals and parties as appropriate). Your recommendations should also include references to which policies and procedures could be updated that support hazard identification, risk management, fire, emergency and evacuation, incident investigation and reporting regarding this incident.)
This must be a comprehensive report as it represents the culmination of all your research of the investigation of the incident at ABC Steel. This report will then be presented to management for approval of suggested recommendations. Your answers need to be in sentences.
Your answers need to be in sentences.
Use the template provided on the next page as a guide for your report expectations.
Title page (separate page)
Table of contents (separate page)
Introduction (minimum of 150 words)
Organisational background (minimum 150 words)
Incident details (minimum 150 words)
Evidence (minimum 100 words)
Causative factors (minimum 300 words)
Conclusion (minimum 200 words)
Recommendations (separate page)
