ICAM Incident Investigation Report: Rooftop Welding Fall at Mt Jackson Village OHS202
- Subject Code :
OHS202
- University :
others Exam Question Bank is not sponsored or endorsed by this college or university.
- Country :
Australia
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Executive Summary |
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Report Number: |
ABCM009 |
Incident Severity Rating: |
5 |
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Name and Location of Operation/ Project/ Site: |
Rooftop Welding activity at Mt Jackson Village, WA (ABC Minerals Mine Site Village) |
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Date of Incident: |
18/03/2024 |
Date of Report: |
25/03/2024 |
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Time of Incident: |
6:00pm |
Incident Type: |
ICAM Recommended (Medium) Two weeks LTI for concussion rehab |
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Brief Description of Incident: |
Alvin slipped from the top of a linen shed while welding knocked himself unconscious and had a minor cut to his leg. |
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Key Findings and Actions: |
In detail investigation of this incident the following Key finding were identified after analysing the process document of safety and other procedures:- Though The primary contributing factor to the incident was failing to wear fall protection equipment (harnesses) when working at heights But the root cause seems to be <!-- [if !supportLists]--> -
<!--[endif]--> Not following fatigue management policy of ABC Mineral <!-- [if !supportLists]--> -
<!--[endif]--> Stress Worker <!-- [if !supportLists]--> -
<!--[endif]--> No Communication methodology or tool <!-- [if !supportLists]--> -
<!--[endif]--> Leadership is missing in the overall event <!-- [if !supportLists]--> -
<!--[endif]--> Conflict within the team <!-- [if !supportLists]--> -
<!--[endif]--> Working in height without safety equipment All these shows that the process laid down by the ABC mineral is not followed and there are gaps in the process also , because there
is no system of Audit or inspection to check that whether the laid process is being followed by the team or not. There was no access to get the harness because the supervisor took the key with him, and he went home for the day . This infringement of safety procedures directly caused Alvin Jones fall from the rooftop. Upon discussion with the MinRes SME (ABC is under the umbrella of MinRes) the normal process is they must follow the Working at Heights Corporate Procedure whenever they do work at height jobs (Appendix 3). They should be conducted for fitness for work including free from alcohol or illicit drugs, fatigue and physically and mentally fit for duties;
that the person who does the job must be Trained, Competent and Authorised to conduct those tasks, must have a Risk Assessment Requirements such as Job Hazard Analysis- JHA developed for the task and the identified hierarchy of control, must have a Rescue Plan developed, must have Working at height Permit to work procedure, equipment and worksite inspections, barricading and signages, Fall Restrain, Fall Arrest systems, and safe climbing systems (ladder, scaffolding and EWP). In this incident, the organisation has failed to follow the procedure by not conducting physical and mental fitness for work to the IP even though Gina had given him an hour of rest, by failing to look into the JHA and if there were enough control measures in place, by failing to provide direct supervision while the IP was doing the weld and by failing to give access to the PPE. The supervisor was not aware of this five-minute weld to be done outside of working hours as it was not communicated to him before he left work. The strict implementation of the legal requirements for working at heights is critical. <!-- [if !supportLists]--> -
<!--[endif]--> Remember to consider organisational failings the idea of ICAM is to make changes within our organisation to improve rather than blame human behaviour. <!-- [if !supportLists]--> -
<!--[endif]--> Look at the normal process compared to what happened that day for example was the process followed, was a JHA completed, was the supervisor aware of the job, and if not should they have been, if they were not what went wrong. Is it an organisation norm for the process not to be followed. If this is the case what other potential work is being completed outside of the processes that are in place. <!-- [if !supportLists]--> -
<!--[endif]--> Also how is the process followed, how is the process communicated with workers, has consultation on what, when, why, who and how taken place? <!-- [if !supportLists]--> -
<!--[endif]--> Also look at safety culture, if light is fading and the job task is high risk are workers comfortable to stop unsafe work. <!-- [if !supportLists]--> -
<!--[endif]--> Remember the wearing of PPE is the last line of defence, surely this is not the only risk control in place in your organisation. Need to look at all controls and organisational procedural compliance. |
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Report Prepared By: |
Daisy McGowan |
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Investigation carried out as per investigation plan, organisational policies and procedures |
Yes ? |
No ? |
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Review Sign-off |
Name |
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Date |
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Lead Investigator:
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Daisy McGowan |
22/04/2024 |
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Responsible Manager
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Brett Baker |
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22/04/2024 |
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Table of Contents
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SCOPE OF INVESTIGATION
Clarify the boundaries and purpose of the investigation which sites, functions or people will be included?
The scope of this investigation includes an analysis of contributory factors associated with the incident in question. Other relevant findings, which may not have directly contributed to the incident, have also been noted during the investigation. The investigation took place over ABC Minerals camp. The people involved are the Welding department, IP, eyewitnesses, PCBU and the subject matter expert
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INVESTIGATION TEAM MEMBERS
The persons in the following table were directly engaged in the investigation process.
Clearly identify subject matter expert.
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Name |
Position |
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Daisy McGowan |
Team Leader |
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Brad Power |
Subject Matter Expert |
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Oscar Bonilla |
Team Member |
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Jacob Burton |
Team Member |
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Lidiane De Lima |
Team Member |
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Grazeil Calimbo |
Team Member |
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4
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DETAILS OF THOSE INVOLVED
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Duty Holder |
Name/Title/Position |
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PCBU |
ABC Minerals |
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Officer (Relevant to indent) |
Marc Fury |
Workers directly involved
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Name/Contractor |
Position/Service Offering |
Injury(s) Sustained |
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Alvin James |
Welder |
IP |
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Carlos Calvo |
Forklift Driver |
NIL |
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Stacey Poole |
Labourer |
NIL |
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Gina Fox |
Admin and first aider |
NIL |
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Peter Jones |
Supervisor |
NIL |
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EQUIPMENT AND PROPERTY DAMAGE
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Equipment/Property |
Owner |
Damage Details |
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Welding equipment |
ABC Minerals |
Broken |
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6
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ENVIRONMENTAL IMPACT
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Details |
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NIL |
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INCIDENT OVERVIEW
Insert a summary of the incident, including initial response, and key details such as date and specific locations of events. Provide comments on the sufficient and suitable of response and persons consulted as part of the initial response (based on consultation with individual/parties).
ABC Minerals is an iron ore mining company at Windarling, Mt Jackson, WA. The workers work hard for long hours (12 hours) and are under stress to finish their jobs due to their strict schedules. Alvin James, 47, was arguing with Peter (Supervisor) about doing the weld. He always stressed out, shouting at everyone, and some workers refused to weld the rooftop. Alvin was arguing with everybody all day. He had a heated argument with Gina earlier in the day when he refused to take his lunch break. Alvin complained that he was too busy to stop. He was shouting at the Korean workers all day to hurry up and had them running about all over the place.
ABC Minerals has a fatigue management policy
that states that when workers display signs of fatigue and stress, they must stop working and relax for as long as needed before returning to work. The Assistant Manager, Gina, gave Alvin an hour-long fatigue break (3:00- 4:00 pm) to regain his energy. He usually knocks off at 6:00 pm every day. However, due to a heavy workload, he had to extend his hours to finish the job. Alvin was working a 5-minute job
at 3 metres high
. He was welding on the linen shed rooftop of Windarling camp Mt Jackson, WA, on the evening of March 18, 2024. At 6:00 pm, Alvin slipped and knocked himself unconscious and had a minor cut to his leg. He received first aid from Gina, who treated his wound with cleansing wipes, cut saline solution, and wound dressing covered with a crepe bandage. She called an ambulance. Management and the Team Leader consulted the witnesses, and an investigation commenced. Alvin was taken to Royal Perth Hospital by a flying doctor.
This report will examine what happened before the incident, what was done on the site, and what was discovered during the investigation. Insights from interviews with significant participants, such as Carlos (the forklift driver), Stacey (the labourer), Gina (the assistant manager and first aider), and Peter (the maintenance supervisor), will also be included. The diagrams of the incident site are in the Photograph section. Recommendations and corrective actions are supplied at the end of this report.
The Investigation Team:
Daisy McGowan - Team Leader Team Member
Brad Power - Subject Matter Expert Lidiane De Lima - Team Member
Oscar Bonilla- Team Member Grazeil Calimbo - Team Member
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SEQUENCE OF EVENTS
The sequence of events before, during and following (initial response) this incident are described in the following table.
Further information may be required to resolve any gaps in the timeline highlight areas that require more investigation and fill in as the investigation progresses.
Ensure initial response and securing site and/or evidence is captured in sequence of events.
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Event Sequence |
Date |
Approx. Time |
Event Description |
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Before incident |
18/03/2024 |
6:00 am |
Prestart meeting |
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6:30 |
Alvin James, 47, was arguing with Peter (Supervisor) about doing the weld. |
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9:00 |
He was shouting at the Korean workers all day to hurry up and had them running about all over the place. |
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12:00pm |
He had a heated argument with Gina earlier in the day when he refused to take his lunch break. He complained that he was too busy to stop. I will take a break after I finish what I do, he added. The company allows workers to break the set break if they cannot leave the unfinished job. This week, three maintenance people were absent due to a family emergency. The workers were overloaded with jobs and some jobs they had to roll over to the next day. Getting immediate backup workers took much work as they had to do induction processes. Due to the rain, they had to weld the linen shed to prevent water from getting into the linen.
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3:00pm 3:02pm |
He was shouting at the Korean workers all day to hurry up and had them running about all over the place. Gina stepped in and sent him for a break after speaking with him (break 3-4:00pm). |
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During incident |
6:00pm |
Alvin James slipped from the rooftop of the linen shed; as he fell, he grabbed hold of the welding
equipment and bottles, which fell with him. He knocked himself unconscious and had a minor cut on his leg. |
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6:03 p.m. |
Stacey, a labourer who witnessed the incident, called Gina, the assistant manager and the first aid officer, who administered first aid and called an ambulance. |
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6:15 p.m. |
An ambulance arrived. Alvin had regained consciousness before the ambulance arrived. Gina treated his wound with cleaning wipes, cut saline solution, and wound dressing covered with a crepe bandage. |
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6:25 p.m. |
Alvin was taken to Royal Perth Hospital by a flying doctor. |
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After incident |
6:30 p.m. |
The Safety Advisor (is the Lead investigator too) was informed that there had been an incident in the linen shed of ABC Minerals village, and the IP had been taken to Royal Perth Hospital. |
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6:45 p.m. |
Ten workers had stopped working when the Safety Advisor arrived at the linen shed. The advisor immediately secured the site and notified the stakeholders per the incident Investigation procedure. The safety advisor inspected the work area and found that Alvin had not been wearing the fall protection harnesses. Gina explained that there was no time. It is not expected to rush a high-risk job. Workers have to do a risk assessment and properly plan how to do the job safely. There was no time to get the key as the supervisor had taken it with him and left for the day home. In this case, proper planning, a safe system of work, a supervisor, and access to PPE were needed; the job should not have started. |
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7:00 pm
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Interviewed Carlos, and 7:15pm interviewed with Gina. |
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7:30 pm |
Interviewed Stacey |
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13/07/2020 |
8:00am. At 9:00 am, |
Interview Peter the Supervisor.
The return-to-work coordinator has informed the Management that the IP has suffered extensive damage to his head from the fall and will be out of work for two weeks rehabilitating from the effects of the concussion. |
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9
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Data collection
9
.1
Organisational Context
Create a working group (3-6 people) to get a sense of the organisational context/ systematic factors that could have contributed to the incident. The facilitator should be an unbiased third party i.e. no involvement in the incident. The participants can include people who are separate to the Investigation Team.
Participants should include:
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People involved in the event
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Others who perform the same or similar role
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Subject matter experts who can provide insight to the event (e.g. design, procurement, supervisors etc)
Finding from this discussion may assist with the PEEPO Analysis.
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Working Group Participants: |
Workers relative to the incident include: <!-- [if !supportLists]-->
<!--[endif]--> Martin Power - General Manager <!-- [if !supportLists]-->
<!--[endif]--> Gina Fox - Assistant Manager <!-- [if !supportLists]-->
<!--[endif]--> Peter Jones-
Maintenance supervisor <!-- [if !supportLists]-->
<!--[endif]--> A lvin James - Welder (Alvin-injured person) <!-- [if !supportLists]-->
<!--[endif]--> Carlos Calvo -
Forklift driver <!-- [if !supportLists]-->
<!--[endif]--> Stacey Poole - Labourer |
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On a normal day, describe how the process/ task is completed? Consider the information supplied, tools/ equipment used, interactions and people required |
A reputable mining and engineering company called ABC Minerals is situated in a remote area of Western Australia called Mt Jackson, WA. The company is mining iron ore. It has different departments, which implies different scopes of work. ABC Minerals has its own mining accommodation village where people stay during their work roster; some are on 2/1, and some are on 8/6. The workers work 12 hours daily from 6:00 am to 6:00 pm, including two 15-minute and 30-minute lunch breaks. In addition, the business has restricted overtime jobs to accommodate intensified workloads or pressing project deadlines. The organisation employs people in various positions essential to mining and processing. This includes drivers, general labourers, painters, welders, cutters, process operators and machine operators. ABC Minerals contracted South Korean nationals who are fast at work but need more English skills. The organisation had no regular WHS meetings, established safety committees, or HSRs. |
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What parts of the process normally work well? Why? Which controls are normally successful implemented? Why? |
Typically, it works well when workers accommodate additional workloads to finish by at least the deadlines. Normally before they do a job there is risk assessment to be done and plan control measures to put in place to eliminate or minimise hazards by applying the hierarchy of controls. There should have their SWMS, JHS, Take time, Checklist for welding job, a spotter, time, equipment, and PPE. However, in this incident organisation had failed to give safe work environment and safe system of work, and this had led to the Alvins falling from height. Workers should constantly follow all safety protocols, processes, and procedures. It seems that the safety process are not followed in the company, thats why the workers were able to work with harness equipment, when it is clearly mentioned on the Manual MRL-SAF-CRM-PRO-0010 of working on Heights, clause 4.2.1, that worker should be FIT to work on height and there should not be any fatigue but in this case it was violated and workers were allowed to work for more than 12 hours, there was missed lunch break. It shows that in normal time also the company doesnt follow the procedures as per manual. Remember ICAM is designed to identify organisational failings, complacency while it does cause a disaster for workers, the underlying issue is that the organisation allows this. I would like to recall something recorded above The safety advisor inspected the work area and found that the fall protection harnesses had not been worn. Gina explained that there was no time. Are safety protocols, processes, procedures etc, only followed when there is time?? |
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What are the challenges which limit performing this task as per the established plan with all required controls in place? |
They are giving additional workloads to workers when they are already fatigued. Workers performing jobs without supervision. Complacency- not wearing a harness as it was only a five-minute weld. The main challenges are that procedures were followed:- Clauses 4.1.2 Project/Site
Risk Register not completed , because it is kept to maintain that all safety equipments are in place before starting the work Clauses 4.2.1 Fitness to Work , again not followed due to long shifts Clauses 4.2.2 Training and Competency It is clear as per the manual that people working in the height should be properly trained and authorised , because Manager was missing in the welding department Emergency Response guideline There was no rescue plan before starting the work Clauses 4.2.4 Permit to Work No permission was granted All these were violated and process is not followed Not wearing the harness is not complacency when the assistant manager insists there was no time additional workloads on fatigued workers, jobs being performed without supervision or the normal processes being followed and no time allocated for safety controls to be implemented are all organisational safety culture impacts on why this job ended with an event. |
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Would Team Members feel comfortable to raise concerns or ask for more information if there is a lack of clarity? |
Yes, workers raised concerns, and nothing is happening as there is no project manager in the welding department. The ABL Mineral doesnt have Issue or conflict resolution process , which is an HR policy and must be there in these type of situations, which clearly tells what should be done when there is a conflict Does the organisation have an issue resolution process? This is a legal requirement to enable workers with issues to be heard and receive an outcome? Others do not raise concerns due to language barriers. But it is responsibility of Project managers to train and inform all works before the starting the work , as it is part of SOP or procedure manual MRL-SAF-CRM-INP-0010 Working at Height Critical Control Inspection MRL-SAF-CRM-TEM-0002 Critical Risk Activity Corporate Procedure Audits Duty of the management also to get the audit done that weather the manual is being followed or not All PCBUs have an obligation to consult workers, therefore the organisation needs to have a process in place to ensure this happens with all workers regardless of cultural differences or language barriers. |
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What would assist in the successful delivery of the task/ process that is currently not being done? What changes could be explored to improve implementation of the required controls? Consider additional/modified factors, steps or controls.
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Proper scheduling of tasks
Good supervision
Have access to PPE
A project manager should oversee them and monitor job completion.
Workers stick to break time for fatigue management The process of MRL-SAF-CRM-INP-0010 Working at Height Critical Control Inspection is not done, in case an inspection would have been done to check that all other laid down process are followed MRL-SAF-CRM-STD-0010 Working at Height Standard is completely Followed, Emergency rescue system,
MRL-SAF-POL-0001 Health and Safety Policy is adhered then the situation would have different that task would have completed in a successful manner . You need to consider here the lack of time allocated for the worker to access the proper safety equipment essential for this job task <!-- [if !supportLists]-->
<!--[endif]--> Create a policy and procedure for overtime jobs <!-- [if !supportLists]-->
<!--[endif]--> Provide essential storage for workers to access PPE <!-- [if !supportLists]-->
<!--[endif]--> Workers have training on Legislative requirements related to their jobs. |
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.2
PEEPO Analysis
As an investigation team, work through each category below and summarise the findings which contributed to the incident. Interviews must be documented,
Statement
can be used to assist with this process. Site, equipment, and other evidence must be inspected.
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Type |
Information/ Data Collected |
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P |
People <!-- [if !supportLists]-->
<!--[endif]--> Who did what, when, where, how and why? <!-- [if !supportLists]-->
<!--[endif]--> Behaviours which increased/decreased the likelihood of an undesired outcome. Are these behaviours common? <!-- [if !supportLists]-->
<!--[endif]--> Do we have the right people, in the right role, doing the right work? Were they trained? |
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<!--[endif]--> W orkers under stress due to workloads <!-- [if !supportLists]-->
<!--[endif]--> As there was no time so Alvin went for the welding <!-- [if !supportLists]-->
<!--[endif]--> Even though there was 12 hour shift , still there was a time constraint and fatigue for the workers
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<!--[endif]--> Complacency the te constraint seems to be the issue rather than complacency?? <!-- [if !supportLists]-->
<!--[endif]--> Language and numeracy problems <!-- [if !supportLists]-->
<!--[endif]--> Mental, physical stress, aggression, and frustration The company has the Fatigue management policy , which clearly has no worker should be working for more than normal working hours and in case there is fatigue he should be allowed to work, which is not followed what process does the organisation have to eliminate or reduce the risk of workers mental health being impacted by work tasks? <!-- [if !supportLists]-->
<!--[endif]--> Personal issues |
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E |
Environment (Workplace, Weather) Consider the physical environmental factors, e.g. weather, noise, work surface, air, light etc. |
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<!--[endif]--> Extreme temperature <!-- [if !supportLists]-->
<!--[endif]--> Hot surface <!-- [if !supportLists]-->
<!--[endif]--> Uneven surfaces It was sunset time as already 6.00 PM so there was issues of proper lighting in the roof How was the light, was the sun setting, where was the sun in relation to the roof etc? |
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E |
Equipment Consider design, maintenance, whether the equipment is fit for purpose |
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<!--[endif]--> No rescue functions <!-- [if !supportLists]-->
<!--[endif]--> Long term Linen shed Roof maintenance issue ABC have the Clause 4.3.7 maintenance program for Equipment is very much established which says that Working at heights equipment shall be maintained as per OEM specifications and intervals via a Maintenance System. Does the organisation have a maintenance program for their structures? |
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P |
Procedures Review procedure requirements and compare to what occurred. Are procedures readily accessible and well understood? Does training support correct application of the procedures. Consider the context of works performed and risk drift. |
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<!--[endif]--> No emergency preparedness Because the manager was missing why is there not one? <!-- [if !supportLists]-->
<!--[endif]--> No consultation with workers doing the job Because there was language barrier and the was lack of time <!-- [if !supportLists]-->
<!--[endif]--> Why not? <!-- [if !supportLists]-->
<!--[endif]--> No health monitoring Because the health fatigue policy was not followed Why not? <!-- [if !supportLists]-->
<!--[endif]--> No supervision Supervisor were knowing that the worker is working in height but the SOP was not followed Where was the supervisor, did they know about one of their workers carrying out a high risk task past end of shift? <!-- [if !supportLists]-->
<!--[endif]--> No Safe System of Works
Lack of time and there was no System for most of the SOPs Is there not a procedure or work instruction and if not what process should have been followed I am guessing the lack of time allowed did not include conducting an analysis of the job (JHA, JSA, JA)? <!-- [if !supportLists]-->
<!--[endif]--> Shift overloading Normal timing of the shift should be not more than 8 hour a day moreover there should be proper lunch break which was again missing in this case This is definitely worth exploring, why is this happening, what is the organisational trend for this occurrence? <!-- [if !supportLists]-->
<!--[endif]--> Need procedural compliance |
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O |
Organisation Consider evidence of management, leadership and commitment to setting high standards of safety, environment quality and productivity performance. Measurable factors such as documented people management processes, provision and quality of tools and equipment, commercial and operational pressures, planning, community and external environmental values, maintenance of facilities and equipment, communication. |
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<!--[endif]--> Insufficient funds <!-- [if !supportLists]-->
<!--[endif]--> No commitment to Safety standards <!-- [if !supportLists]-->
<!--[endif]--> No leadership <!-- [if !supportLists]-->
<!--[endif]--> No Maintenance communication tool <!-- [if !supportLists]-->
<!--[endif]--> Absence of controls The above two lists (Procedures and Organisation) would be some of your key findings that can be listed on page one of the report, as well as what actions could you assign and to who to make changes so an event like this does not happen again?
I have included some questions to consider, just to get you thinking about the organisational factors rather than the human behaviour of complacency ???? |
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ICAM ANALYSIS
Review the contributing factors to the incident and perform an ICAM analysis to identify effective corrective actions.
The Incident Cause Analysis Method (ICAM) has been applied to identify the absent or failed defences which would prevent the incident occurring or to minimise the consequence of the event after it occurred. These findings are described in the following table.
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Absent or Failed Defences |
Individual/ Team Actions |
Task/ Environment Conditions |
Organisational Factors |
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<!--[endif]--> The direct Supervisor was not present at welding time (DF04) <!-- [if !supportLists]-->
<!--[endif]--> No JHA was completed prior to starting the job (DF01 <!-- [if !supportLists]-->
<!--[endif]--> Failed to detect that individuals are fatigued due to being over worked (DF09) <!-- [if !supportLists]-->
<!--[endif]--> Failure to wear PPE -harness when welding (DF14) |
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<!--[endif]--> Failed to wear a harness (IT 05) <!-- [if !supportLists]-->
<!--[endif]--> IP was stressed and fatigued (IT 14) |
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<!--[endif]--> JHA was not found for the task or any procedures (TE 02). <!-- [if !supportLists]-->
<!--[endif]--> ABC Minerals did not plan properly. They had more jobs and fewer workers to do the job, resulting in workers feeling stressed and fatigued (TE 01) <!-- [if !supportLists]-->
<!--[endif]--> No documented processes, such as take 5 and Job Hazard Analysis, which identifies hazards and controls for the safe completion of tasks (TE 02) <!-- [if !supportLists]-->
<!--[endif]--> Harness was inaccessible as the supervisor left for the day and the key was with him (TE06). <!-- [if !supportLists]-->
<!--[endif]--> Workers complacency of not wearing a harness as it was only a five-minute weld (HF01). Is this correct as the worker could not access the harness according to the above point? Yes it was not workers Complacency , it was supervisors responsibility to make Harness available and without that worker should not have allowed as per the height safety manual of the company |
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<!--[endif]--> Deficiencies in the structure of responsibility that involve co-ordination, supervision, and provision of communication during task execution (OR). <!-- [if !supportLists]-->
<!--[endif]--> The organisation needs to establish a safety culture (OC). <!-- [if !supportLists]-->
<!--[endif]--> The Welding department needs to employ a manager to ensure the operational performance is not compromised (MC). |
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INCIDENT RISK ASSESSMENT
The Actual and Potential risk ratings for this incident are discussed below. Refer to the Risk Matrix for consequence and likelihood risk evaluation details.
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Actual Risk Rating for Incident |
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Consequence |
Likelihood |
Risk Level |
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Major |
Likely |
Catastrophic 16 |
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Rationale for Risk Rating: I have given this rating because the injured person was hospitalised, and there is equipment damaged as he fell with his equipment, and with financial loss as it has a lost time injury. |
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Potential Risk Rating for Incident |
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Consequence |
Likelihood |
Risk Level |
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Catastrophic |
Likely |
Catastrophic 20 |
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Rationale for Risk Rating: I have given this potential risk rating because if the welder has no harness, it is likely that he could fall. The impact is catastrophic if he hits his head badly and could lead to internal bleeding and death, or the IP could have a spinal injury for life. This significantly damages the person and the companys financial loss. |
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Classification of Incident |
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Severity (or Potential Severity) Ranking |
Severity (Category) Rating Level |
Select/ Tick |
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Extreme |
6 |
? |
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Very High |
5 |
? |
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High |
4 |
? |
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Medium |
3 |
? |
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Low |
2 |
N/A |
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Very Low |
1 |
N/A |
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RECOMMENDED CORRECTIVE ACTIONS
The corrective actions in the following table are recommended to prevent the occurrence of similar incidents in the future. Where required, corrective actions will include amendments to bow ties, HAZOPs, CRAWS, FMEA or SWMS.
All agreed actions must be recorded against the incident in HSEQ software program and monitored accordingly.
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Action Required |
Type of Control |
Responsibility |
Completion Date |
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Training session for PPE especially wearing harnesses |
Administration |
H S Manager |
28.03.2024 |
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Create a safe work procedure for working at height Such as SWMS, JHA |
Administration |
S upervisor/safety advisor |
25.03.2024 |
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Breaks policy (Strict implementation of meal breaks) |
Administration |
S upervisor |
25.03.2024 |
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Supervision policy (No task without supervision amendment) |
Administration |
S upervisor |
22.03.2024 |
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E mploy Welding department manager |
Administration |
H R Manager |
15.04.2024 |
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Purchase correct PPE based on AS/NZ standard |
Administration |
Purchasing Manager |
17.04.2024 |
|
Install a cabinet where the keys must be stored and avoid taking home. Company should design and implement the required equipment policy to identify the requirement tools and available tools and technology to safeguard, expedite and automate the work which is risky for the worker Could any engineering controls be implemented to avoid a worker have to climb onto the roof for example an EWP (Elevated work platform?) |
Engineering |
Welding Department Manager/assistant |
17.04.2024 |
13
<!--[endif]-->
CONCLUSIONS
In light of the investigation finding, summarise the key learnings and conclusions. Consider objectivity, confidentiality, validity, and accuracy.
The incident investigation at ABC Minerals, which happened on March 18, 2024, has shed important light on the occurrence involving Alvin James fall from a height. The goal of the investigation was to determine the reasons for and contributing elements of the incident and offer ways to prevent it from happening again. The incidents primary contributing factor was the failure to wear fall protection equipment, especially harnesses when working at heights. This infringement of safety procedures directly caused Alvin James fall from the Linen shed rooftop. The event involving the fall from a height at ABC Minerals highlights how crucial workplace safety and adherence to safety protocols are. The absence of a Welding project manager position in the company was the incidents root cause. The organisation can improve its safety culture, safeguard the welfare of its staff, and stop similar accidents from happening by employing a project manager, addressing the identified causative causes, and putting the recommended actions into practice.
The ABL mineral has many SOP and policy in place but still the incident happened , and by investing all the aspects of the incident it can be concluded that though the policies were there , safety equipments were there with the company but SOPs and policies were not followed , equipments were available when it was required , Inspection was done , Supervision was missing , Audit is not done by Management , Conflict resolution system missing and very important the organisation culture toward humanitarian ground by asking them to work for 12 hours without food is all led to this incident. This could been perhaps avoided by following the fatigue management policy of the company and by proper inspection and audit by management to check that all SOPs are being followed. There is lack of governance and internal control mechanisms at all level for such type of failure
I think this summary can be expanded this event did not only occur due to arrest equipment not being worn, time constraints regarding the job (rush, no time), supervisor gone for the day, therefore no supervision at all etc. All of the absent defences impacted the events occurrence.
14
Investigation Team Sign-Off
All investigation team members to sign off on the investigation.
|
Name |
Sign |
Date |
|
Daisy McGowan-Team Leader |
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22/04/2024 |
|
Oscar Bonilla |
<!-- [if gte vml 1]> <!--[endif]--> |
22/04/2024 |
|
Jacob Burton |
<!-- [if gte vml 1]> <!--[endif]--> |
22/04/2024 |
|
Grazeil Calimbo |
<!-- [if gte vml 1]> <!--[endif]--> |
22/04/2024 |
|
Lidiane Ribeiro De Lima |
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22/04/2024 |
|
Brad Westman Power-SME |
<!-- [if gte vml 1]> <!--[endif]--><!-- [if gte vml 1]> <!--[endif]--> |
22/04/2024 |
15
<!--[endif]-->
management Sign-Off
Manager to sign off on the investigation, confirming details of the incident, acceptance of findings and support for actions to create a safer workplace.
|
Managers close out of incident All corrective actions have been completed, where corrective action have not been fully implemented, the following measure have been out in place to ensure ongoing monitoring until implementation is completed. |
||
|
Name |
Sign |
Date |
|
Brett Baker |
<!-- [if gte vml 1]> |
22/04/2024 |
16
appendix
Insert Graphs/Chart of statistics relevant to the incident (organisational/industry/Safety Regulator/Work Cover)
WORKING AT HEIGHTS CORPORATE PROCEDURE
1
OVERVIEW
Mineral Resources Limited (MRL) have developed a suite of Critical Risk Management standards and corporate procedures as part of its overall Risk Management strategy. This corporate procedure is one of seventeen Critical Risk Management procedures developed to manage the identified high-risk activities.
2
PURPOSE
The purpose of this corporate procedure is to outline the Critical Hazards, Risk Controls and specify the Critical Controls required to minimise the risk of falling from one level to another, through fixed or temporary structures, voids, fixed or mobile plant and equipment, that has the potential to cause serious injury or death.
Throughout this corporate procedure, the critical controls are highlighted and identified with the critical control icon.
The intent of this corporate procedure does not specifically include
MRL-SAF-CRM-PRO-0011
- Working in a Confined Space and
MRL-SAF-CRM-PRO-0001
Excavation and Trenching Activities which are outlined in their own specific Critical Risk Management corporate procedures.
This corporate procedure is intended to support MRL risk management activities with reference to;
4
MRL-SAF-POL-0001
Health and Safety Policy
4
MRL-SAF-STD-0002
Hazard and Risk Management Standard
4
MRL-SAF-CRM-STD-0010
Working at Heights Standard Site Requirements Design Specifications
3 SCOPE
This corporate procedure applies to all personnel who Manage, Supervise or carry out work at heights on MRL Sites / Projects.
|
4 GENERAL REQUIREMENTS Element |
Accountability |
|
New plant and equipment shall be designed with the aim of eliminating the requirement for working at height, or otherwise designed to incorporate engineered working at height controls, and include consideration of relevant requirements and findings from; <!-- [if !supportLists]-->
<!--[endif]--> Working at height risk assessments <!-- [if !supportLists]-->
<!--[endif]--> Site / Project operational experience <!-- [if !supportLists]-->
<!--[endif]--> OEM manuals, engineering documents and maintenance requirements |
Site / Project Manager(s) |
|
All operational Sites / Projects shall have the relevant risks identified in relation to work at heights within the site-specific risk register. |
Site / Project Manager(s) |
