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HSE Health & Safety Executive
HSE
Health & Safety
Executive

Peer review of analysis of specialist group reports on causes of construction accidents

Prepared by Habilis Ltd for the Health and Safety Executive 2004

RESEARCH REPORT 218

HSE Health & Safety Executive
HSE
Health & Safety
Executive

Peer review of analysis of specialist group reports on causes of construction accidents

Liz Bennett BSc PGCE CEng MICE MIOSH FRSA Habilis Ltd 3 Market Place Shipston on Stour Warwickshire CV36 4AG

The Construction (Design and Management) Regulations 1994 have introduced new duties for designers. It is argued that early intervention by designers and indeed clients can have a significant impact on construction safety during the main building phase and also during maintenance and demolition of structures.

Until the advent of these Regulations the principal blame for any construction site incident was generally laid at the door of the main contractor. The industry has found the cultural changes necessary for proper designer integration difficult to embrace and various projects have been initiated by the Health and Safety Executive to remedy this.

It was believed that an analysis of a series of randomly selected incidents might give evidence, or at least an indication, to a reluctant industry that designers can do more to improve safety and health in construction. The initial stage was to develop a methodology for carrying out this analysis. The secondary stage was to peer review and iteratively agree on those findings. This report is a summary of that review.

The findings very thoroughly underline the fact that the thinking behind the Regulations is sound and that designers can and so arguably should do more.

This report and the work it describes were funded by the Health and Safety Executive (HSE). Its contents, including any opinions and/or conclusions expressed, are those of the authors alone and do not necessarily reflect HSE policy.

HSE BOOKS

© Crown copyright 2004

First published 2004

ISBN 0 7176 2836 1

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the copyright owner.

Applications for reproduction should be made in writing to:

Licensing Division, Her Majesty's Stationery Office, St Clements House, 2-16 Colegate, Norwich NR3 1BQ or by e-mail to hmsolicensing@cabinet-office.x.gsi.gov.uk

ACKNOWLEDGEMENTS

Acknowledgements are made to Malcolm James whose innovative approach to the analysis of the accidents reviewed in this study was both stimulating and illuminating.

iii

CONTENTS

1 BACKGROUND……………………………………………

… 1

1.1 Accident Rates……………………………………………………………………… 1

1.2 Construction (Design and Management) Regulations 1994 – CDM……………

1

1.3 CDM Regulation 13 Difficulties for Industry……………………………………

2

1.4 CDM Difficulties for the Health and Safety Executive……………………………2

1.5 Industry Wide Initiatives……………………………………………………………3

2 PROJECT OBJECTIVES AND WORK PHASES…………….5

2.1 Project Objectives

2.2 Work Phases

3 SOURCE DOCUMENTS……………………………………… 7

3.1 Accident Reports…………………………………………………………………… 7

3.2 Original Research Reports………………………………………………………….7

9

4 AUTHOR’S REMARKS………………………………………

4.1 Author Entry View………………………………………………………………… 9

4.2 Impact Of Fatal Accident Reports………………………………………………….9

5 ASSUMPTIONS AND PROCESSES………………………….11

5.1 Processes and Iterations……………………………………………………………11

5.2 Agreed Assumptions……………………………………………………………… 11

6 FINDINGS………………………………………………………13

7 COMMENTARY……………………………………………….21

8 RECOMMENDATIONS……………………………………….25

APPENDIX 1 – CATEGORIES………………………………………27

APPENDIX 2- ACCIDENT ANALYSIS SHEETS………………….29

v

EXECUTIVE SUMMARY

The Health and Safety Executive is committed to making a fundamental reduction in the number of deaths, injuries and cases of ill health in construction. There is a view held by some of the industry and underpinned by Regulations that designers could make a significant difference. The key changes required are for designers to design structures that are safer and healthier to build, maintain and demolish. Clearly operational issues must be considered as well since they have a major effect on maintenance capability.

There are many in the industry, and in particular in the design community, who remain unconvinced by the arguments that designers can and should make a difference to the way they work. The purpose of this research package was to analyse actual incidents with respect to designer involvement.

As the research evolved various other potentially useful indicators emerged and additional requirements for information collection were identified. This research must therefore be seen as part of an unfolding investigation into the best way to identify some of the key change points for the industry.

The author has chosen to track personal views of the research for the reader as this was judged helpful. In particular a certain amount of cynicism towards the arguments for real intervention by designers was in place at the beginning of the programme. Long before the end the author became completely convinced of the enormous importance of the need for radical change amongst the design community.

The original research was modified after discussions between the author and the originator of the incident summaries. It is recognised that further improvements could be made to the collection of data and its analysis that could provide significant material for industry.

The original review of the incidents was conducted by Malcolm James, who did the development of the methodology for the study and also summarised and analysed the incidents in the first instance. The peer review that is the subject of this report acknowledges the importance of Malcolm’s work but takes complete responsibility for statements within the report.

The Report concludes that almost half of all accidents in construction could have been prevented by designer intervention and that at least 1 in 6 of all incidents are at least partially the responsibility of the lead designer in that opportunities to prevent incidents were not taken.

The Report makes no commentary on culpability or the moral and ethical dimensions of designer failings. These must be decided in other places.

vii

1

1.1 ACCIDENT RATES

BACKGROUND

The United Kingdom construction industry has one of the lowest accident rates in the world following generally declining rates over recent decades. Latterly, however, a levelling off has been observed and there remain various categories of seemingly intractable accidents. In 2002 there where 80 fatal accidents in construction, which is nearly seven each month. The cost of these deaths to the families and friends of those killed is incalculable. The cost to the industry and the UK at large can more easily be quantified but never accurately assessed. In any case this price is always too high for all concerned.

1.2 CONSTRUCTION (DESIGN AND MANAGEMENT) REGULATIONS 1994 – CDM

For some years there has been a belief that early contributions to the construction and building processes from both clients and designers could make a radical improvement to the construction processes during the whole life of a structure. Anecdotal evidence from industry showed that the construction and building industry is capable of delivering safe construction but that it regularly fails to do so. Changing the emphasis of responsibility towards those who commission, scope and design works so that the end result is seen as a team approach to life long safety and health management was expected to deliver benefits.

The Temporary and mobile construction sites Directive 89/391/EEC was introduced across the European Economic Community to change the way construction health and safety is managed. In the UK this Directive was implemented as two sets of construction regulations:

the Construction (Design and Management) Regulations 1994 – CDM - and the Construction (Health, Safety and Welfare) Regulations 1996 - CHSW.

CDM put new duties on clients and designers and introduced a new statutory appointment of Planning Supervisor. The concept behind CDM was one of teams of competent appointees providing appropriate information throughout the life of the project for use by those who had the capacity to influence health and safety for good or ill. There was also a requirement to allow for adequate resources in all senses to achieve the same ends.

The opportunities presented by CDM would seem to be clearly apparent, based as they are on sound project management philosophy and holistic risk management.

The regulations were, however, generally considered by consultants and advisors in their narrowest sense and frequently not read or applied in conjunction with the CHSW or other relevant regulations, without which their application becomes meaningless.

Further, the Regulations were not so ordered as to make duty holders’ duties easily apparent to the vast numbers of those who were obliged to wrestle with legal terminology for the first time.

Designers’ duties are generally encapsulated in Regulation 13, which is often considered as stand alone, though there are significant implied duties for designers embedded in other regulations, mainly to do with competence, communication, co-ordination and co-operation. Regulation 13 has two key aspects to it. Regulation 13 (i) essentially requires designers to

1

ensure that clients are aware of their duties, allowing the non-expert client to be kept informed by professionals. Regulation 13(ii) can be summarised as a requirement to contribute to the designing out of hazards and risks of downstream contractor processes.

1.3 CDM REGULATION 13 DIFFICULTIES FOR INDUSTRY

The requirements of CDM Regulation 13 have not been effectively managed by some parts of industry. Various reasons for this may exist. The wording of the regulation is insufficiently precise to set standards in relation to legal duties. There has been an assumption that CDM could stand alone without an understanding of building, construction and maintenance processes, including demolition, and of other requirements such as operational constraints. These other factors are often overlooked to the detriment of decision making. Many designers are either unaware of, or not up to date in, modern construction and building processes. For them to make any real contribution to safety and health they clearly need to understand where the challenges are that face those who will construct. There has been an assumption that the regulation demanded risk assessment now commonly referred to as DRA or Design Risk Assessment. Generally the teaching of CDM to the industry has been conducted by health and safety professionals with experience in contractor risk assessments. They have tended to translate this across to the design community. In fact the Regulation makes no reference to risk assessment nor is the Regulation 13 (2) duty best approached by the same methods as contractor risk assessments, being rather a design process. Most DRAs are poorly conducted, retro-fitted, contractor risk assessments. Many of the procurement routes, particularly those facing architects, make early intervention difficult from a commercial perspective. Civil law is at odds with CDM in that case law exists that states that responsibility for safety and health on site is the responsibility for the constructor alone. Such civil law is in place at every contract while the criminal law of health and safety may only present as a challenge to this where there is, for whatever reason, enforcer intervention. The fear of criminal action has resulted in production of excessive paperwork as an attempt to manage liability. In fact such paper trails are generally of poor quality and do little other than add to costs. They do not reduce liability unless they are effective.

1.4 CDM DIFFICULTIES FOR THE HEALTH AND SAFETY EXECUTIVE

The HSE cannot visit every site and must select those most appropriate to deliver cultural change to a diverse industry. While large projects are an obvious target the smaller projects, frequently under resourced in terms of competent advice, continue to be the places where many of the accidents happen.

HSE field inspectors are experts in the law of health and safety and its enforcement. Design is, however, a complex professional discipline requiring years of training and experience. For inspectors to challenge decisions taken by designers or to ask why alternatives have not been considered is not possible except for those inspectors with

a specialist background in the appropriate discipline. Even within the industry there is

a considerable range of specialist disciplines at work and the provision of competent inspectors to match every such situation is not tenable. Many of the difficulties that exist for industry also exist for inspectors.

A ten year fatal accident high set challenges to the thinking behind CDM. Many questioned whether CDM had done anything but add costs to industry.

2

1.5

INDUSTRY WIDE INITIATIVES

The Deputy Prime Minister, John Prescott, held a construction health and safety summit where he challenged industry to make commitment to improvement. Several strategic initiatives were launched to bring the construction industry together and improve performance across all aspects of the construction process.

Rethinking Construction and its daughter report, Rethinking Health and Safety in Construction were produced.

Designers were challenged to make a more positive contribution to health and safety in construction.

3

2

PROJECT OBJECTIVES AND WORK PHASES

2.1 PROJECT OBJECTIVES

The objectives of the whole project were to examine a randomly selected sample of specialist inspector reports to establish:

Whether the case for CDM can be supported

Whether designers are really missing opportunities to contribute to health and safety

in construction How HSE can best engage in driving change at field enforcement level

2.2

WORK PHASES

2.2.1

Phase 1: Initial research by Malcolm James

A random selection of 91 construction specialist inspectors reports were taken and analysed.

Those that were clearly not to do with design were set aside but included in the final numerical computations. The categories selected for this analysis were in the first instance

iteratively developed by Malcolm James, who also assigned scores to most categories. These categories are listed in Appendix 1.

Each report was summarised, assessed according to categories and notes made in relation to such matters as design failings.

A table was developed that set the opportunity presented to the designer against the opportunity taken by that designer in relation to intervention to prevent realisation of an incident. Colour coding was used for ease of recognition at the request of the HSE.

2.2.2 Phase 2: Peer review of research by Liz Bennett of Habilis

Each report was reassessed without reference to the initial summaries but using the same categories. The two results were then compared. Where differences occurred the second assessment reconsidered the data and original assessor’s remarks to gain clearer understanding of the reasons for disparity.

Outstanding differences were discussed at a meeting between the two reviewers. One of the difficulties encountered was that in some examples different assumptions had been made. In others more than one designer could have had an influence. Unless reviewers had selected the same designer the opportunity assessment could easily differ.

Keywords were a further area of difficulty since these depended on a range of variables. Their use to facilitate later search was however agreed.

2.2.3 Phase 2: Amended review and agreed forward strategy

An agreed forward strategy was developed as follows:

A list of standard keywords would be established for selection by assessors. This is seen as

important for future analysis of findings in relation to particular work activities or common failings as it will facilitate a general search enquiry.

5

Almost all the reports predate CDM and focus largely on construction processes. This means that Temporary Works Designers feature in a way that is likely to be disproportionate to the potential contribution to be made by other designers. It was agreed that a separate analysis of each designer should also be made so that temporary works may be selected out to consider other designer aspects or included in if that is more pertinent to the point being made.

The analysis was to consider the current project only and not any design or construction for the original works. From time to time where the original design had been a clear contributing factor, say to later maintenance, this would be noted but not scored.

It was agreed that in areas of doubt assessors should err in favour of the designer.

In certain instances assumption would need to be made and stated about stakeholder competence ie the competence of the designer in specialist design areas. This would allow clearer understanding by readers of the reviewer thought processes.

The designer effort assessment can be taken as a rough indicator of designer costs. It was noted that designer effort is frequently a cost centre for designers even when economic benefits accrue to the project. These benefits are generally delivered to the contractor and/or the client unless contractual arrangements also deliver economic benefit to designers.

It was agreed that for the third iteration the forms would be redesigned, slightly reordering the existing sections and providing opportunity to assess separately the different designers contributing to a project. It was anticipated that this would be particularly useful for future analysis.

It was recognised that what the designer should have done encompasses moral, professional, economic and statutory obligations. It was agreed that the review should concentrate on what the designer could have done set against what was done, without making judgements about duty and responsibility, which, in relation to statutory duties, would be a matter for the courts to decide.

It was agreed that while a ten point separation was useful during the analysis phase this should be grouped for the final table into five double sections. The final table is thus presented as 5x5 rather than 10x10

It was agreed that the scales should be more closely prescribed in the introduction to reduce the variation amongst assessors. This is to echo the level of detail given in the accident severity scale.

It was accepted that neither assessor had been entirely consistent in considering industry today and had from time to time included industry opportunities. Such comment adds value but assumptions need to be clearly identified.

Some of the reports assessed advisory visits. It was agreed that where there was a report there was a potential for harm and inclusion of such reports was thus valid as they described opportunities for all parties to a project.

All of the incidents were reassessed in light of the above decisions.

Only the final iteratively agreed results are included in the Appendix 1 to avoid confusion. The text describing the incidents is almost entirely that of the original assessor, Malcolm James, with occasional additional remarks by Liz Bennett of Habilis, where it was felt that these added greater clarity or useful comment.

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3 SOURCE DOCUMENTS

3.1 ACCIDENT REPORTS

When an accident occurs it is usually the local HSE Enforcement Officer who attends in the first instance. If it is likely that specialist construction expertise is required the case or elements of the case may be passed to the construction specialist for additional input to the enquiry. Where the report relates to request for specialist advice, this is referred to an inspector with the necessary competence.

All construction specialist reports are stored together, being sorted by type of activity and date. Thus roof work incidents are kept in sequential order. Ground works are similarly sorted.

For the purposes of this research handfuls of specialist inspector reports were removed from the store ensuring that there were examples from each general category but otherwise making a random selection of bundles of reports.

At first review those reports that clearly did not have anything to do with design were sifted out and set aside. The iterative process described in section 2 above were then applied to the residual majority. It is important to recognise that these incident reports relate to real happenings affecting the lives of many people. Because the documents must remain confidential for legal reasons they are not included in this report except in sanitised summary. Similar incidents to those described happen regularly in construction and readers will often be able to recognise from their own experience incidents that relate closely to those reported.

3.2 ORIGINAL RESEARCH REPORT

The original research conducted by Malcolm James did not reach publication prior to this additional work being conducted because it clearly needed external validation. His preliminary work, however, set the scene for the whole of this report.

Malcolm James experience of the construction industry and of the law of health and safety in that industry is clear and his comments and notes form a critical part of the completed document. His development of some ways to assess incidents in a structured manner is very helpful to both industry and enforcer alike as it provides a framework and breakdown of the critical elements to be considered by stakeholders in the design process.

Notwithstanding the above, the results presented are only those of the combined iteration as it was agreed that this would be most helpful for industry. Consequently neither of the main source document sets is available for public scrutiny.

7

4 AUTHOR’S REMARKS

4.1 AUTHOR ENTRY VIEW

The following remarks are provided to give the reader an indication of the mindset of the reviewer and author of this report throughout the process. They are personal commentary and provided to give background information to those who may wish to accept or refute the findings.

Construction industry design professionals are generally taught to be backward focussed, dependent on codes, standards and experience of similar projects undertaken successfully. Clearly there are some exceptions to this retrospective approach.

Innovation in itself introduces risk and many clients prefer tried and tested methodology.

The construction industry spans across a great many levels of competence and a range of sectors and types of activity, some of which have little synergy. No single solution to the continuing high levels of accident and ill health problem suffered as a result of industry activity can fit all work.

The author is passionate about reducing harm to at risk groups of people and while convinced that designers can make a contribution to the process of safe and healthy construction was less persuaded that this change was worth seeking given the costs to individuals, industry and society at large. Further, industry wide problems with CDM compliance already experienced seemed to indicate that the chance of delivering significant added value change to the culture of a diverse industry was small.

The author was and is also concerned that health and safety professionals still hold the main power base in terms of delivering advice, training and proposing solutions. While their contribution to construction health and safety is clearly essential, the special nature of design means that their lead in this area is likely to devalue the potential contribution designers can make.

Standards of training and competence for designers have not been established across industry by those experts in design who could be demonstrating best practice and the added value of this additional effort. Steps are being taken through the Construction Industry Council and its member bodies to remedy this.

University courses have not responded to the requirements for educational change in construction and building design to a sufficient level. There are well rehearsed arguments relating to this problem and in any case change is also afoot here. It is clear, however, that undergraduate courses already impose extremely high workloads on staff and students alike.

In summary the entry frame of mind was that the research was likely to be interesting but arguably only able to deliver skewed results, set out as a politically correct sop to the requirements of a European Directive.

4.2 IMPACT OF FATAL ACCIDENT REPORTS

Many of the incidents reported were technically interesting. Some did not provide sufficient information to take any but an overview. Most could have resulted in multiple fatalities, including multiple fatalities to members of the public. Some of the projects would have

9

required highly competent designers to provide creative solutions or the spending of considerable time and therefore cost to deliver solutions.

Some of the accidents were simply avoidable. Some of these were fatal or resulted in serious injury. Reading of incidents that have destroyed lives and had a knock on effect to many others associated with the victim in whatever way had a very sobering effect.

None of the incidents should have happened. Many could have been prevented very easily. Many could have been prevented by small actions by someone involved.

Every attempt was made to absolve designers of responsibility. In particular Temporary Works designers and manufacturers were removed from the main quoted statistics.

The final numbers are not just persuasive but absolutely convincing. Designers can do more. Designers need to learn how to do better or else be made to do so by whatever means. The clear message should be one of warning and challenge for the whole design community.

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5 ASSUMPTIONS AND PROCESSES

5.1 PROCESSES AND ITERATIONS

The process for the research was driven by Malcolm James’ original work, which was slightly modified in the third iteration.

Each incident was sanitised as a summary description from the report. Various measures were given quantitative values from what it is agreed must be inadequate information in many instances. These assessments were validated, however, by peer review and comparison and the close fit gives confidence to the author of the values placed on the findings.

Many of the assessments made were not of primary interest to the objectives of the report. These additional values provide some commentary on matters such as design effort/cost, level of specialist knowledge required etc which enrich the central debate. There is also an assessment made of whether a Planning Supervisor appointment could have made a difference to the outcome and likewise whether a site safety supervisor could have prevented the incident. This was done to provide a minor commentary on the future of the coordination role at design and site supervision stages.

5.2 AGREED ASSUMPTIONS

The reports used for the research related to incidents prior to CDM and thus generally made reference to construction products and processes with little reference within those reports to design and planning aspects of construction. Certain assumptions were made for the purposes of the research and are listed here for clarification.

The aspects of design considered related to the project in hand. Thus maintenance work referred to designer contribution to that maintenance but not to the original design of the structure. Where poor design had led to difficulties with maintenance this was pointed out in the notes but not given any value in the overall quantitative assessment. Where assumptions about designer competence were critical to the assessment these are stated. Designer effort is judged to be roughly equivalent to designer costs. It should be recognised that no indication of the procurement route or contract arrangements is given in the reports and this can have a significant effect on the ability of designers to contribute effectively. It is here assumed that the designer is appointed prior to any design. In some instances some designers are required to make speculative outline design as part of the tender process. No allowance is made for such factors. No assumptions are made about designer culpability in law, which assessment must be a matter for the courts. Apportionment of responsibility to architects or consulting engineers is in most cases arbitrary since most reports are silent on the nature of the design professionals involved. For the final commentary these two groups have been assessed together as principal designers.

Designers were given the benefit of any doubt.

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6

FINDINGS

6.1 Prior to CDM data collection by HSE specialist inspectors concentrated on the facts at the scene and did not generally detail any significant designer issues except where these related to temporary works or the design of construction products.

6.2 Identification of procurement routes and contractual relationships was not considered part of the investigation protocol in any the reports considered.

6.3 The results can only give a general indication of the potential for change but it must be remembered that the assumption was that any doubts should be resolved in the designers’ favour. In other words, the results are indicative of the level of potential change that could be achieved.

6.4 The summary table below collects results from all incidents.

6.5 Tables 2 to 6 select out different groupings that the author judged would add value to the final output so that new targets can be set for activity by the whole industry to effect improvements.

13

Table 1 Summary chart

 

Architect

Consultant

TW

Other

1.

     

8G Contractor

2.

 

4J

   

3.

     

4G M

4.

     

6G M

5.

     

6J M

6.

 

6G

   

7.

 

2E

   

8.

 

4J

   

9.

 

6J

   

10.

6J

     

11.

6J

     

12.

8E

     

13.

10J

     

14.

4E

 

8E

 

15.

 

8J

10E

10J M

16.

 

6J

 

8J M

17.

4E

4E

 

4G M

18.

 

6E

10J

 

19.

10J

   

10J Contractor

20.

 

4C

   

21.

6E

     

22.

     

8J M

23.

6J

   

8J M

24.

     

6G M

25.

   

4E

 

26.

   

4E

 

27.

   

10J

 

28.

2C

 

10J

 

29.

     

10J Scaffolder

30.

10J

 

10J

 

31.

     

10J Scaffolder

32.

   

10J

 

33.

   

10J

 

34.

   

6E

 

35.

     

8G Contractor

36.

   

10J

 

37.

     

4J Subcontractor

38.

 

4C

10J

 

39.

   

10J

 

40.

   

6E

 

41.

   

4C

 

42.

   

4E

 

43.

 

8E

8J

 

44.

   

10G

 

45.

     

6E M

46.

 

2C

   

47.

4E

 

10J

 

48.

 

8G

   

49.

6G

 

10J

 

50.

2C

8E

 

6C

51.

 

4C

   

52.

 

2C

   

14

53.

       

54.

     

4C M

55.

10G

     

56.

       

57.

       

58.

4E

     

59.

4E

     

60.

       

61.

10J

     

62.

     

8J M

63.

     

6C M

64.

8G

     

65.

8G

     

66.

     

8G

67.

6E

   

10J

68.

     

-

69.

   

2A

 

70.

     

-

71.

 

8G

   

72.

     

4E M/Transport

73.

     

-

 

TOTALS

TOTAL

10

5

14

13

41

TOTAL

2

5

4

3

13

TOTAL

7

5

5

7

24

TOTAL

2

3

1

0

6

TOTAL

21

18

22

23

84

Notes:

1.

There are 73 reports analysed above. In some cases there can be seen to be more than one party with responsibility for design issues.

2.

The summary diagram takes several views of the data. It considers the reports and is the source for the following tables:

Table 2 – All design: worst case only included; Table 3 – All design: all contributions to each incident; Table 4 – Main design only: worst case only included; Table 5 – Temporary works only; and Table 6 – Supplier/Manufacturer only.

3.

It should be pointed out that it was not always easy to decide who the designer was, an architect or engineer.

15

Table 2 Summary of designer intervention

All design: Worst case result only taken in each incident

 

What designers could have done

 

Very little

A bit more

Major

A lot more

Critically

contribution

significant

0-2

4

6

8

10

 

What was

A

1

0

0

0

0

necessary

What designer did

Something

C

2

4

1

0

0

Not enough

E

1

6

5

3

0

Not nearly

G

0

2

3

7

2

enough

Nothing

J

0

3

4

5

18

Summary by category

Rating & total number

Recommended consideration

5

Designer not implicated

18

Designer could improve

9

Designer may be implicated

39

Designer prosecution supportable

Notes

1

Total incidents considered in detail

73

2

Total incidents reported

91

3

The balance were clearly not to do with design but must be taken into sample for comparisons

4

Percentage of incidents likely to be the subject of further investigation of a designer because the designer has failed to take enough action when such action could have made a major contribution to accident prevention is 39/91 x 100 = 43% or almost half of all cases reported.

5

A further 9/91 x 100 = 10% may well be asked to make improvements to their systems and be subject to criticism for taking inadequate steps at the design stage of a project.

16

Table 3 Summary of designer intervention

All design: All contributions to each incident

 

What designers could have done

 

Very little

A bit more

Major

A lot more

Critically

contribution

significant

0-2

4

6

8

10

 

What was

A

1

0

0

0

0

necessary

What designer did

Something

C

4

5

2

0

0

Not enough

E

1

10

6

4

1

Not nearly

G

0

2

4

7

2

enough

Nothing

J

0

3

6

6

20

Summary by category

Rating & total number

Recommended consideration

6

Designer not implicated

25

Designer could improve

11

Designer may be implicated

42

Designer prosecution supportable

Notes:

1

Total incidents considered in detail

73

2

Total incidents reported

91

3

The balance were clearly not to do with design but must be taken into sample for comparisons

4

Percentage of incidents likely to be the subject of further investigation of one or more designers because the designer has failed to take enough action when such action could have made a major contribution to accident prevention expressed as a function of the number of incidents is 42/91 x 100 = 46% or almost half of all cases reported.

5

A further 11/91 x 100 = 12% may well be asked to make improvements to their systems and be subject to criticism for taking inadequate steps at the design stage of a project.

17

Table 4 Summary of designer intervention

Main design only: Worst case result only taken in each incident

 

What designers could have done

 

Very little

A bit more

Major

A lot more

Critically

contribution

significant

0-2

4

6

8

10

 

What was

A

0

0

0

0

0

necessary

What designer did

Something

C

3

3

0

0

0

Not enough

E

1

5

3

3

0

Not nearly

G

0

0

2

4

1

enough

Nothing

J

0

2

5

1

4

Summary by category

Rating & total number

Recommended consideration

4

Designer not implicated

11

Designer could improve

7

Designer may be implicated

15

Designer prosecution supportable

Notes:

1

Total incidents considered in detail

73

2

Total incidents reported

91

3

The balance were clearly not to do with design but must be taken into sample for comparisons

4

Percentage of incidents likely to be the subject of further investigation of lead designer because that designer has failed to take enough action when such action could have made a major contribution to accident prevention is 15/91 x 100 = 16% or about 1 in 6 cases.

5

A further 7/91 x 100 = 8% may well be asked to make improvements to their systems and be subject to criticism for taking inadequate steps at the design stage of a project.

18

Table 5 Summary of designer intervention

Temporary works design

 

What designers could have done

 

Very little

A bit more

Major

A lot more

Critically

contribution

significant

0-2

4

6

8

10

 

What was

A

1

0

0

0

0

necessary

What designer did

Something

C

0

1

0

0

0

Not enough

E

0

3

2

1

1

Not nearly

G

0

0

0

0

1

enough

Nothing

J

0

0

0

1

11

Summary by category

Rating & total number

Recommended consideration

1

Designer not implicated

6

Designer could improve

1

Designer may be implicated

15

Designer prosecution supportable

Notes:

1

Total incidents considered in detail

73

2

Total incidents reported

91

3

The balance were clearly not to do with design but must be taken into sample for comparisons

4

Percentage of incidents likely to be the subject of further investigation of a temporary works designer because the designer has failed to take enough action when such action could have made a major contribution to accident prevention is 15/91 x 100 = 16% or about one in six of all cases reported.

5

A further 1/91 x 100 = 1% may well be asked to make improvements to their systems and be subject to criticism for taking inadequate steps at the design stage of a project.

19

Table 6 Summary of designer intervention

Supplier or manufacturer

 

What designers could have done

 

Very little

A bit more

Major

A lot more

Critically

contribution

significant

0-2

4

6

8

10

 

What was

A

0

0

0

0

0

necessary

What designer did

Something

C

0

1

1

0

0

Not enough

E

0

1

1

0

0

Not nearly

G

0

2

2

1

0

enough

Nothing

J

0

0

1

4

2

Summary by category

Rating & total number

Recommended consideration

0

Designer not implicated

6

Designer could improve

2

Designer may be implicated

8

Designer prosecution supportable

Notes:

1

Total incidents considered in detail

73

2

Total incidents reported

91

3

The balance were clearly not to do with design but must be taken into sample for comparisons

4

Percentage of incidents likely to be the subject of further investigation of a manufacturing designer because the designer has failed to take enough action when such action could have made a major contribution to accident prevention is 8/91 x 100 = 9% or almost 1 in 10 of all cases reported.

5

A further2/91 x 100 = 2% may well be asked to make improvements to their systems and be subject to criticism for taking inadequate steps at the design stage of a manufacturing project.

20

7

COMMENTARY

7.1 It must be remembered that the figures relate not to all projects but only to those that were investigated. This means that the statistics quoted do not indicate that 1 in 6 of initial designs show designer failure to intervene to prevent accidents but that 1 in 6 of those investigated showed this lack.

7.2 Case law exists that states that consultant engineers and architects should have no involvement in the construction processes even when the methods chosen by the constructor threaten safety. There will need to be greater clarity in relation to legislative changes before designers would be advised to be prescriptive in any great manner. This attitude of separation of responsibilities clearly pervaded the industry throughout the period during which the reported incidents took place.

7.3 There were some key themes to the incidents themselves. In particular poor communication between parties to a contract was often cited as a root cause of an incident.

7.4 There would seem to be many incidents where a designer had not taken sufficient notice of existing or adjacent structures nor the likely impact their existence would have on operator behaviour or ability to access the site with plant and materials.

7.5 In a great many cases the designer had not understood the construction processes nor taken any account of them in the final design. This was standard practice (See 7.2) across the industry and remains so to this day for most projects.

7.6 It is to be expected that in an industry where the main duties and liabilities rest with the principal contractor that the majority of accident reports would reflect this in their findings. It was for this reason that the incidents that are the responsibility of the Temporary Works designer or manufacturer have been separated out and dealt with as a different industry issue.

7.7 Table 2 shows that in almost half of reported cases a designer could have taken steps to prevent realisation of an accident but failed to take such steps. There is a clear message here for all of those involved in design, specification and communication of critical information.

7.8 Table 3 shows much the same as Table 2. It includes multiple responsibility for incident avoidance but does not give results that are very different from Table 2.

7.9 Table 4 shows the results that are at the heart of this research. It is the number of main designers who could have, but failed to, intervene to prevent accident realisation. In approximately 1 in 6 cases the original designer could have done something to prevent an accident happening but failed to take that opportunity. If this figure is translated across to the annual accident statistics this means that 1/6x80 = 13 deaths a year could be prevented by designer action. Proportionate savings in injury and ill health could presumably be made. This clearly is a significant difference by any measure and well worth setting out a change agenda to achieve. It is particularly telling when it is remembered that this peer review chose to err in favour of the designer in the event of doubt and also the fact that the reports did not generally comment on the original designer activity. Further, maintenance accidents included did not blame the original designer because it was decided to consider only the current project. There are, however, several incidents where the original design made

21

maintenance activities difficult and unsafe. It is the view of the author that, because

of the reasons cited above, this figure of 1 in 6 is very conservative.

7.10 Table 5 shows the number of incidents where temporary works designers alone failed

to take the opportunities presented to intervene effectively to prevent accidents. It is

judged likely that this statistic is more accurate since at the time of the reports temporary works design involvement was more often considered by the investigating

inspector than principal design. In any case there clearly need to be improvements made by the temporary works community. Common mistakes here included incorrect assumptions, poor communication and not involving expert designers at the appropriate time, even when they were available.

7.11 Table 6 shows that a significant number of incidents could have been prevented, but were not, by better intervention from the construction products design community. In particular systems scaffolding incorrectly used, systems building units poorly handled or inadequately seated and access systems with inferior failure modes or emergency controls were found to be root causes. Generally the product design community did not give adequate information about the suitability or otherwise of their products for particular situations.

7.12 Information collection by the Health and Safety Executive (HSE) inspectors rarely enquired about designer involvement in buildability. This was appropriate to the prevailing culture and to the civil law of the time. For the effective delivery of closer understanding of the potential for designer contribution to accident prevention it will be necessary for this strategy to change and for enquiry methodologies to incorporate investigation of complex design processes and decision making. It is likely that this will need a considerable amount of additional research to be carried out as many front line HSE inspectors do not have the technical competence in design to make appropriate enquiry without additional guidance and support.

7.13 Designers rarely provided adequate information to contractors about significant

aspects of their design. There are several reasons for this. Civil law argues that where

a contractor takes on a contract to construct a particular design he is making a

statement about his capability to do so. An integral part of this capability is his competence and presumably his competence to manage the risks to the safety and health of his workforce. Designers need clearer advice about the relationship between competence of contractors and their own increased liability if they instruct contractors, or may be seen so to do, in methods of building. Clearer information is needed too about the kind of information that would be of use to a contractor. The industry has evolved a methodology for this process usually called design risk assessment. In fact designers usually retrofit poor quality contractor risk assessments to their final design. Many do engage in design decisions that take account of buildability and maintainability but do not recognise these for what they are, which is a correct response to statutory duty.

7.14 Designers often did not obtain adequate information about existing site conditions or the fabric and condition of existing structures. Their duty to obtain clearer information of sufficient quality to be of use in decision making needs clearer expression in legal and industry standard documents.

7.15 Designers often did not consider the operational aspects of a structure and the requirement to maintain that structure during user activity. Not to consider such matters where information is available is a failure to provide proper design services even without consideration of the safety aspects of those who will be affected. In particular access to lighting, services and minor fixtures and fittings continues to

22

cause

requirements.

real

problems.

Designers

need

to

develop

creative

solutions

to

those

7.16 The Planning Supervisor potential contribution to accident prevention was also considered. In every case where the Planning Supervisor could have intervened for good it would only have been possible if that Planning Supervisor was highly competent in both design and construction processes and also had the character, authority and opportunity to intervene at the correct time in the project delivery. No general electronic or paper based system frequently used by Planning Supervisors would have been able to pick up on the technical or other potential defects adequately.

7.17 The Site Safety Supervisor could in some instances have intervened, for example when system scaffold or building units were not being safely used or installed. In many cases, however, technical knowledge beyond that of the general site safety supervisor was needed to make adequate intervention.

7.18 Procurement routes and the costs to the design community are seen as a real barrier to effective delivery of change. Where health and safety is an early contract requirement designers and constructors alike can deliver high standards. Where designers would need to spend considerable sums of unrecoverable money to deliver change it is no surprise that they fail to take that opportunity. This must be a matter for regulators and government.

7.19 In many instances contractor design incompetence was a major contributor to an accident. No designer had been involved at all. It may be necessary to put a requirement on certain types of project for such specialist intervention in some manner.

7.20 It is the Author’s very strong conclusion that the case for CDM is made by this analysis and that the design community can do more to reduce the number of deaths and injuries in construction. While health could not be considered in this analysis it is the view of the Author that the case for improvement, through designer intervention, in workforce health is implicit in these findings.

7.21 There are several opportunities for HSE to improve construction safety through intervention in the design phase of projects. Methodologies for enforcement intervention need to be developed.

23

8

RECOMMENDATIONS

8.1 The design community needs to learn more about modern methods of construction. How this is achieved is complex and is likely to be a mixture of reward, through clearly better project delivery or reduced Professional Indemnity costs, and penalty through enforcement action. To achieve the latter the revised Regulations or Approved Code of Practice will need to emphasis the requirements on designers in this respect and the HSE will need to develop enquiry methodologies that probe the design process.

8.2 The manner in which designers can intervene effectively needs to be more clearly expressed in industry standard documentation and training. The culture of acceptance of poor quality design needs to change.

8.3 It could be extremely helpful to refine this research methodology in the light of new understanding about barriers to change and opportunities for improvement. The best means of making proper enquiry of designers by enforcers without the appropriate depth of technical skills needs to be developed. Engagement with IT data management could begin to generate systems that can provide a rich source of downstream information that can readily be searched for a variety of purposes.

8.4 The key words need to be further discussed. The purpose of the selection criteria and the impact on the data management capabilities need further development. Significant information could be delivered to the industry, including HSE, through a closer understanding of what initiating factors tend to cause later incidents. For instance procurement routes, time for planning, nature of the client, size of design house, competence of design house etc could be useful to future analysis.

8.5 Every opportunity needs to be explored to engage Clients. Where Clients demand high qualities of health and safety then procure competent and well resourced suppliers of design and construction, the industry can deliver radical improvement.

8.6 The issue of designer liability with respect to instructions to contractors to build in a certain manner needs to be further explored. In particular the tension between the civil and criminal law in this matter needs to be resolved.

8.7 HSE needs to develop better methodologies for inspector investigation and enquiry, not just following an accident but also when making routine site visits. The information so gathered can serve several purposes. It can encourage and require improvement from the design community; it can provide a better source of data for future incident review such as this; it can provide better data for appropriate enforcement action.

25

APPENDIX 1 CATEGORIES

Key to categories of incident data and other contributory factors detailed in FCG reports where a design fault may have led to a failure of some description.

Job refers to the location or nature of the work being done, where:

F

Steelwork and steel frame erection

O

Roofing

G

General construction including scaffolding

R

Refurbishment

A

Falsework, formwork etc

E

Excavations and foundations etc

C

Cleaning and maintenance

W

Window cleaning

D

Demolition

Incident rating refers in sequential rows to potential for incident then for actual harm done, where:

10

Most severe. Major disaster with members of the public affected as well.

8

Multiple fatalities to workers on site

6

Single fatality to worker

4

Serious injury to worker

2

Minor injury

0

Non injury report or event

Note that property damage almost always has potential to cause harm to people, so will be picked up in the first listing of incident rating.

Could the designer have done more? This refers to an arbitrary view from information available relating to potential for prevention or reduction in probability by the named designer.

10

Designer could probably have prevented

8

Designer could have done a lot more to prevent

6

Designer could have reduced likelihood significantly

4

Designer had opportunities to reduce likelihood or prevent

2

Designer may have been able to reduce likelihood

0

Designer could not have done anything

Extent of failure to prevent incident. This refers to an arbitrary view of the lost opportunity by the designer. Notes on duty to have intervened are in the main text.

J

Complete failure to prevent or reduce probability

G

Failure to make additional efforts using specialist support

E

Failure to research issues and apply them

C

General lack of design contribution/communication opportunity

A

No designer failings

27

Design effort refers to an estimate of the additional effort and consequently resource likely for designer to include a suggested feature.

H

A lot of effort

M

Some effort

L

Very little effort

Degree of specialist knowledge refers to an estimate of whether a designer could be expected to know or to have found out from standard sources, where:

0 Should know at basic designer level

1 Generally expected to know to fulfil defined designer role

2 Should easily be able to find out

3 Would need some research to discover this or higher than general competence

4 Would need specialist expert help

Cost implications refers to an estimate of increased cost to the project

R

Reduction in cost

L

Little additional cost

E

Some additional cost

S

Significant additional cost

Interventions

Two additional boxes are included for interest. These relate to external interventions from individuals outside the direct line of design or construction. They are the Planning Supervisor (or equivalent such as Client Advisor) and the Site Safety Advisor/Supervisor. Would such interventions have prevented the incident or potential incident?

0 No difference

1 Unlikely

2 Possibly

3 Probably

4 Yes

28

APPENDIX 2 ACCIDENT ANALYSIS SHEETS

The following 73 sheets each summarise an incident that was investigated by the Health and Safety Executive (HSE) Construction Specialist Group and assign it categories as listed in Appendix 1.

In most cases the HSE reports were made following an incident but in some cases they were as a result of requests for advice or followed on from the serving of notices. All categories were included because it was felt that where HSE had been involved at specialist level there was an implied potential for an incident. Whether the potential was realised or not and the extent of that realisation is captured in the summary sheets but was not transferred to the final analysis.

It is certain that industry will be able to argue about the detail of the findings relating to each incident reported in summary but the author is confident that the results are fair because of the very close agreement between the original assessor and the reviewer. Only in a very small number of cases was there a need for final arbitration and significant adjustment.

In many cases additional information would have assisted the analysis process considerably and assumptions had to be made.

29

Quick Ref

8F

Designer

Contractor

Description of incident An agricultural steel portal framed building collapsed during erection. The columns were not secured to the ground, there was no bracing in the walls and the temporary bracing was of dynamic fibre ropes mainly in the across the bay direction. The structure was intended to be stabilised when complete by having the columns cast into concrete perimeter bund or walls.

Keywords from list

Collapse/partial collapse; Erecting structures; Steel/rc frame

 

Job nature – type of activity

F

Incident rating – potential

8

Incident rating – actual

0

Reference category

Architect

Engineer

TW Designer

Other

(Specify)

Designers involved

N/A

N/A

N/A

Contractor

Could the designer have done more?

     

8

Did the designer miss the opportunity to do more?

     

G

Design effort

     

L

Designer specialist knowledge

     

0

Cost implications

     

L

Could external intervention at design stage (PS) have made a difference?

     

4

Could site supervision at construction/ site detail have made a difference?

     

3

Remarks No consideration appears to have been given to temporary instability problems during construction that could have been within the design remit. The report notes that the structure was to be built similarly to a previous one and that consequently there were no separate drawings or calculations in this case. However there is no information in the report concerning the provisions against collapse in the design for the original structure.

The design effort is unlikely to have been any greater than the loss of time experienced on site due to that effort not being made.

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB 01H

30

Quick Ref

4J/4G

Designers

Consultant

Manufact.

Description of incident A U-shaped [in plan] runway beam was being installed as a new steel framed building was being constructed. This runway beam was in two halves joined at the centre of the U, i.e. each half was J- shaped in plan and was spanning 2 bays of the steel frame. The runway beam halves had approx. 1.5m pedestals bolted to their top flange which were to be the means the beam was to be secured to the rafters. When one half was being lifted a temporary clamp providing a lifting anchorage for the slings apparently slipped and possibly dislodged a steel erector who was about to secure it. The erector was wearing a safety harness but it was not secured.

Keywords from list

Fall from height; Erecting structures; Steel/rc frame

 

Job nature – type of activity

F

Incident rating – potential

8

Incident rating – actual

6

Reference category

Architect

Consulting

TW Designer

Other

Engineer

(Specify)

Designers involved

N/A

N/A

Manufacture

Could the designer have done more?

 

4

 

4

Did the designer miss the opportunity to do more?

 

J

 

G

Design effort

 

L

 

L

Designer specialist knowledge

 

2

 

1

Cost implications

 

L

 

L

Could external intervention at design stage (PS) have made a difference?

 

3

 

3

Could site supervision at construction/ site detail have made a difference?

 

1

 

0

Remarks While the general lack of enforcement of securing the safety harnesses by the contractor was an important contributing factor. Better design consideration for the need to provide secure lifting positions and means of anchorage for the safety harnesses was also a factor. There could have been a problem with the stability of such an unsymmetrical shape while lifting, although the report notes that when lifted later it hung perfectly. The report does question the suggested slipping of the temporary anchorage point although the beam was possibly basically unstable because of the two pedestals and its plan shape.

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB02H

31

Quick Ref

N/A

Designers

N/A

Description of incident

This is the same incident as HAB 03H but includes the further research into manufacturers capability to intervene. This aspect is incorporated in HAB 02H. This report looks at the clamps used to provide lifting points for the roof trusses. The manufacturers of these would have only been happy with them being used where there was no lateral force being imposed. In this case they should have been used with a lifting beam.

Keywords from list

 

Job nature – type of activity

 

Incident rating – potential

 

Incident rating – actual

 

Reference category

Architect

Engineer

TW Designer

Other

(Specify)

Designers involved

       

Could the designer have done more?

       

Did the designer miss the opportunity to do more?

       

Design effort

       

Designer specialist knowledge

       

Cost implications

       

Could external intervention at design stage (PS) have made a difference?

       

Could site supervision at construction/ site detail have made a difference?

       

Remarks There appears to have been a lack of communication between the manufacturer and the user of these clamps. The users appear to have been unaware of the limitations on the use of the clamps which could have been easily dealt with by the use of spreader/lifting beams. This could have been dealt with by attaching a warning to the clamps. While the clamps must have been capable of taking some lateral load the manufacturers did not appear to want to take any responsibility for such use.

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB03H

32

Quick Ref

6G

Designers

Manufact

Description of incident A temporary roof edge barrier blew off the edge of a single storey ‘bridge’ link between two other buildings. No one was injured. The barrier should have had uprights at no more than 2m centres held down by 30kg sandbag ballast. The uprights had been placed at 4.3m centres and no ballast had been used. However the report comments on the likely possibility that the ‘bridge’ was in an exposed position and subject to funnelling effects so that ballast weighing 50kg would have been required to give a suitable FOS in this case.

Keywords from list

Falls from height off edge; Struck by falling object; Roof work;

Job nature – type of activity

O

Incident rating – potential

10

Incident rating – actual

0

Reference category

Architect

Engineer

TW Designer

Other

(Specify)

Designers involved

possibly

possibly

possibly

Manufact

Could the designer have done more?

     

6

Did the designer miss the opportunity to do more?

     

G

Design effort

     

M

Designer specialist knowledge

     

2

Cost implications

     

L

Could external intervention at design stage (PS) have made a difference?

     

3

Could site supervision at construction/ site detail have made a difference?

     

4

Remarks The designers of the temporary barriers had failed to deal with the possibility that they could have been used in more severe situations than that envisaged. They also failed to appreciate that where a contractor was expected to obtain other equipment (i.e. sandbag ballast) then there was a real possibility that these would be omitted. Part of the answer to the design faults would have been to have provided better advice on the spacing of the uprights and their ballast weights, ideally permanently attached to the equipment. The failure could also possibly have been avoided by having designated ballast weights as part of the kit. Information is only given in the report about system edge protection. It may have been possible for other design professionals to have intervened to the extent that such system protection was not needed. This cannot be presumed, however, so is not included in statistics.

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB04H

33

Quick Ref

6J

Designers

Manufact

Description of incident A prefabricated building was being dismantled and moved to another location. The building was constructed from a series of 2.74m pre-clad portal frames spanning 12m and consisting of two portal frames, which would be bolted to adjacent sections to form the full length of the building. Each section was handled by being slung from two lifting points on the roof requiring the slinger(s) to walk on the roof to attach the lifting slings. Each side of the roof portal had a plastic roof-light that occupied a significant percentage of the total roof area.

Keywords from list

Falls from height; Lifting Machinery; Roof work

 

Job nature – type of activity

O

Incident rating – potential

6

Incident rating – actual

0

Reference category

Architect

Engineer

TW Designer

Other

(Specify)

Designers involved

     

Manufacturer

Could the designer have done more?

     

6

Did the designer miss the opportunity to do more?

     

J

Design effort

     

L

Designer specialist knowledge

     

2

Cost implications

     

L

Could external intervention at design stage (PS) have made a difference?

     

3

Could site supervision at construction/ site detail have made a difference?

     

1

Remarks While it is possible that the lifting points were at the edge of each section this would still mean that someone would have to go on the roof to remove the slings or reattach them on relocation along at least one edge. In addition someone would have to work along the ridge to install or remove the flashings at this point. Therefore, as it appears, the building was intended to be easily relocated, it would have been reasonable to ensure the whole roof was non-fragile and perhaps even build in facilities for edge protection. The report does not state the nature of the lifting points but it has been assumed that there were 2 on each edge of the sections. The building appears to be one that had been designed to facilitate easy relocation. Therefore, the incidence of someone working over the roof could have been something that frequently occurred. If it was intended to be readily reassembled then ensuring that this could be simply and safely achieved should have been part of the designers brief.

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB05H

34

Quick Ref

6G

Designers

Consultant

Description of incident A fairly standard sandwich skin roof was being installed that had roof-lights in it. The inner skin was being installed ahead of the outer skin and a roofer fell through an unsecured section of the inner skin roof-light.

Keywords from list

Falls from height through; Roof work; Commercial building

Job nature – type of activity

O

Incident rating – potential

6

Incident rating – actual

4

Reference category

Architect

Engineer

TW Designer

Other

(Specify)

Designers involved

N/A

N/A

N/A

Could the designer have done more?

 

6

   

Did the designer miss the opportunity to do more?

 

G

   

Design effort

 

L

   

Designer specialist knowledge

 

2

   

Cost implications

 

L

   

Could external intervention at design stage (PS) have made a difference?

 

3

   

Could site supervision at construction/ site detail have made a difference?

 

4

   

Remarks The designer could have avoided the separate installation of inner and outer roof skins. In addition The designer could have ensured (at a cost) that each skin was none fragile and that there was provision at the eaves for the installation of edge protection. Finally the designer could have included in the specification for the works a provision for suitable edge protection. While the contractor can provide means to install these types of roof the reliability of any such protective systems would be improved where the designers had planned for safe access or facilitated its provision.

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB 06H

35

Quick Ref

2E

Designers

Consultant

Description of incident A roofer fell through an inner lining sheet. This had only been secured by one fixing at its top edge instead of the recommended 3 because a curved ridge/crown sheet was still to be installed requiring the removal of the single fixing. The roofer had walked over the inner liner as an easy way to get to an electrical junction box.

Keywords from list

Falls from height through; Roof work; Commercial building

Job nature – type of activity

O

Incident rating – potential

6

Incident rating – actual

2

Reference category

Architect

Engineer

TW Designer

Other

(Specify)

Designers involved

N/A

N/A

N/A

Could the designer have done more?

 

2

   

Did the designer miss the opportunity to do more?

 

E

   

Design effort

 

L

   

Designer specialist knowledge

 

2

   

Cost implications

 

L

   

Could external intervention at design stage (PS) have made a difference?

 

2

   

Could site supervision at construction/ site detail have made a difference?

 

2

   

Remarks The sequence of fixing the roof sheets appears to have made some contribution to the accident although the greater part was due to poor site management and a ‘mistake’ on the part of the roofer. A small contribution to this accident also came from the design. If this had allowed different types of sheets to be fixed independently of others then the accident could have been avoided. Clearer details or sufficient details from the designer could have helped prevent this accident. Properly fixed the inner skin of the roof construction was non-fragile. However, the safety of those installing the roof depended on them keeping off the liner sheets until they were fixed; the planning of the work should have ensured this.

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB 07H

36

Quick Ref

4J

Designers

Consultant

Description of incident An accident occurred when two men fell from a steel roof frame while they were unslinging a pack of roof sheets with no means of protection.

Keywords from list

Falls from height off edge; Structural erection; Steel frame

Job nature – type of activity

O

Incident rating – potential

8

Incident rating – actual

8

Reference category

Architect

Engineer

TW Designer

Other

(Specify)

Designers involved

Unlikely

N/A

N/A

Could the designer have done more?

 

4

   

Did the designer miss the opportunity to do more?

 

J

   

Design effort

 

L

   

Designer specialist knowledge

 

0

   

Cost implications

 

L

   

Could external intervention at design stage (PS) have made a difference?

 

3

   

Could site supervision at construction/ site detail have made a difference?

 

3

   

Remarks While the major contributory factor to this accident was a failure of site management and unreasonable behaviour by the roofers involved, it could have been possible for the designer of the building to have provided some form of anchorage for those carrying out this necessary and foreseeable operation. The designer could have encouraged the use of safety lines or nets in designing suitable anchorages for this type of equipment.

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB 08H

37

Quick Ref

6J

Designers

Consultant/

Architect

Description of incident A bricklayer fell through a 1.2m square PVC domed roof-light.

 

Keywords from list

Falls from height through; Refurbishment; Commercial

Job nature – type of activity

O

Incident rating – potential

6

Incident rating – actual

4

Reference category

Architect

Engineer

TW Designer

Other

(Specify)

Designers involved

Possibly in original only

Possibly in

N/A

N/A

site

 

investigation

Could the designer have done more?

10

6

   

Did the designer miss the opportunity to do more?

J

J

   

Design effort

L

L

   

Designer specialist knowledge

0

0

   

Cost implications

L

L

   

Could external intervention at design stage (PS) have made a difference?

3

3

   

Could site supervision at construction/ site detail have made a difference?

3

3

   

Remarks The designer contributed to this accident by specifying the use of a fragile roofing element. The contractor should have been aware of this and could have taken various types of precautions. In addition it is possible that the bricklayer was particularly careless or deliberately stood on the roof- light.

Habilis assessment assumes this is refurbishment so not due to architect or engineer as original designer. (Assume err in favour of designer). As a result only engineer as refurbishment designer taken to summary at top of page. Note that this could have been an architect rather than an engineer.

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB 09H

38

Quick Ref

6J

Designers

Architect

Description of incident A new church was under construction having steeply pitched roofs to a maximum height of 13m. No provision had been made to safeguard those working on the roof and a PN was issued.

Keywords from list

Falls from height off edge; Erecting structure; Access

 

Job nature – type of activity

O

Incident rating – potential

6

Incident rating – actual

0

Reference category

Architect

Engineer

TW Designer

Other

(Specify)

Designers involved

Possibly

N/A

N/A

Could the designer have done more?

6

     

Did the designer miss the opportunity to do more?

J

     

Design effort

M

     

Designer specialist knowledge

2

     

Cost implications

E

     

Could external intervention at design stage (PS) have made a difference?

3

     

Could site supervision at construction/ site detail have made a difference?

3

     

Remarks The designer could have included features in his design to support a working platform and/or to provide anchorages for safety lines. The provision of anchors to support a safety line or similar facility could have been done by the designer working alone. However the installation of means to support working platforms would have to be done in consultation with the contractor.

HSE Peer review: Ref 4467/R33.115 Case worksheet HA 10H

39

Quick Ref

6J

Designers

Architect

Description of incident A roofer helping to build a new cattle shed adjacent to an older, and 1m lower, cattle shed. The older building was clad with single skin corrugated asbestos sheets while similar new sheets were being installed on the new shed. The roofer stepped down from the higher new roof and fell through the older sheets. The report is not clear whether there was a temporary barrier at the point where the roofer fell.

Keywords from list

Falls from height through; Roof work

 

Job nature – type of activity

O

Incident rating – potential

6

Incident rating – actual

4

Reference category

Architect

Engineer

TW Designer

Other

(Specify)

Designers involved

Possibly

Possibly

N/A

N/A

Could the designer have done more?

6

     

Did the designer miss the opportunity to do more?

J

     

Design effort

L

     

Designer specialist knowledge

1

     

Cost implications

L

     

Could external intervention at design stage (PS) have made a difference?

2

     

Could site supervision at construction/ site detail have made a difference?

2

     

Remarks While control of this risk lay chiefly with the contractor, the designer should have flagged up the real risks of someone stepping or falling down onto the old roof. This could have encouraged the construction of effective protective measures. Control of this risk lay chiefly with the contractor. However, designing a building adjoining to a lower one should have flagged up the risks of someone stepping or falling down onto the old roof. It is possible that increased production resulting from a proper edge protection system could have been greater than the original design effort. This was a cattle shed either an architect or an engineer could have been retained. Architect assumed here after discussion. Initial site inspection would have indicated access difficulties that required additional attachments or similar to be included.

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB 11H

40

Quick Ref

8E

Designers

Architect

Description of incident An old warehouse was being converted into flats. The roof was completely stripped leaving the old roof trusses. These were of a substantial construction, spanning 13m, standing 5.5m high and weighing an estimated 1.3 tonnes. Some longitudinal 100mm x 50mm timbers had been nailed between the trusses at approx. 1 / 3 their height using 2 – 100mm nails at each truss. The masonry against the ends of the trusses was being removed to allow checks to be made on the condition of the timber at the time when a moderate to fresh gale was blowing and 8 trusses fell over.

Keywords from list

Partial collapse; Refurbishment

 

Job nature – type of activity

O/R

Incident rating – potential

8

Incident rating – actual

4

Reference category

Architect

Engineer

TW Designer

Other

(Specify)

Designers involved

N/A

N/A

N/A

Could the designer have done more?

8

     

Did the designer miss the opportunity to do more?

E

     

Design effort

L

     

Designer specialist knowledge

O

     

Cost implications

L

     

Could external intervention at design stage (PS) have made a difference?

3

     

Could site supervision at construction/ site detail have made a difference?

1

     

Remarks The designer would know that the roof was to be stripped and that effective temporary bracing would be required. Therefore, he should have anticipated that the method of stripping the roof would have left, at some stage, the old trusses standing without covering and perhaps the bracing. He should have provided details of how the trusses should have been stabilised, including the strength of the fixings. Even if the collapse had been avoided, it is probable that the increase in production would have paid for the slightly additional design effort.

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB 12H

41

Quick Ref

10J

Designers

Architect

Description of incident

 

A

cradle runway was installed on the roof of a hospital for the use of window cleaners. The roof

however had only a very low parapet that would not give any protection to anyone using or maintaining

the cradles.

 

In

addition the cradles were intended to be worked by one man but could only be accessed by this

person from the roof. This meant that this person would have to step over the parapet down into the cradle. There was a risk that someone could fall off the roof.

Keywords from list

Falls from height off edge; Maintenance; Cradles

 

Job nature – type of activity

O

Incident rating – potential

6

Incident rating – actual

0

Reference category

Architect

Engineer

TW Designer

Other

(Specify)

Designers involved

     

Could the designer have done more?

10

     

Did the designer miss the opportunity to do more?

J

     

Design effort

M

     

Designer specialist knowledge

3

     

Cost implications

E

     

Could external intervention at design stage (PS) have made a difference?

3

     

Could site supervision at construction/ site detail have made a difference?

1

     

Remarks The cradles could have been designed so that they could be landed on the roof of the hospital to allow the window cleaner to gain access and then be driven from inside the cradle over the parapet.

A suitable system of protecting persons working on or around the cradle tracks would need to be

provided. This is a case where inadequate design resulted not only in a risk of serious falling accidents but also resulted in increased operational costs.

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB 13H

42

Quick Ref

8E/4E

Designers

TW/A

Description of incident

 

A

proprietary scaffold had been erected completely around the site of a new building, which was to be

built from prefabricated timber sections lifted over the scaffold into position, followed by a considerable amount of work for follow-up trades to complete the façade. There were problems with the scaffolding concerning: flexing under load, decking members springing free, unauthorised removal of members and difficulties in maintaining a ‘safe’ gap between the inner edge of the scaffold and the new building.

Keywords from list

Scaffold; Access

Job nature – type of activity

G

Incident rating – potential

8

Incident rating – actual

4

Reference category

Architect

Engineer

TW Designer

Other

(Specify)

Designers involved

N/A

N/A

Could the designer have done more?

4