AMEC Bryanston

INCIDENT REVIEW PANEL

Presented by : Colin Kubank (Managing Director - Johannesburg office)

Husab Project Joint Venture (Namibia) 4 February 2014

Classification [HI-PO Near Miss]

Potential
[C5]
Safety Essential Category

Always Take Care

Follow the Rules

Do a Risk Assessment

You Must Intervene

Overview of Incident
Events Leading up to the Incident
04 FEBRUARY 2014

7h00

Tool Box talk conducted for employees. JSTA discussed.

7h30
7h35

Work commenced.
Crane operator and 2x rigger assistants were relocating Batch plant components.

11h30

11h33
11h34

The crane operator lifted the Batch plant mixer (1.6 ton) and slew it into position.
Whilst load was suspended, crane operator instructed the riggers to position dunnage under
the load.
The riggers refused to position themselves under the suspended load.
The riggers instructed the crane operator to slew the load away to enable them to correctly position the
dunnage.

11h38
11h40

11h41

The crane operator refused. The operator left the cab of the crane (still idling) and load suspended.
The crane operator and supervisor then positioned themselves under the suspended load and
moved the dunnage into place.
The riggers instructed the operator and supervisor to remove themselves from under the suspended
load. Both ignored the instruction and continued working. (rigger assistant took the attached photo)

Events Post Incident

04 FEBRUARY 2014

2x Rigger Assistants failed to report the incident to HPJV - They felt that they did not have the authority and feared losing
their job.
06 FEBRUARY 2014

12H00 Rigger Assistant casually informed HPJV Civil Supervisor of the incident during a Tool Box talk.

14H00 HPJV Civil Supervisor informed HPJV management.

14H30 SINOHYDRO crane operator and foreman were removed from site.
07 FEBRUARY 2014

7H30 SINOHYDRO conducted an Incident recall with the workforce.

8H00 HPJV issued the First Alert
10 FEBRUARY 2014

HPJV conducted a stand down presentation regarding the incident with SINOHYDRO

HPJV together with SINOHYDRO launched a full investigation.

Incident investigation report issued.
12 FEBRUARY 2014

Formal incident investigation was complete by HPJV management

Overview of Findings

Rigger Assistants have 4 years experience (Namibian) Sub contractors

Crane operator has 20 years experience (Chinese)
Supervisor has 5 years experience
(Chinese)

Relationship between Assistant Riggers and Operator/Supervisor was amicable. No issue with
communication/language.
Task specific Crew Talk done that morning.

Incident occurred before lunch break

Crane operator and the supervisor were in a rush to complete the lift to get to lunch.
Contractor behind schedule and under pressure to get the work done.

Dunnage was positioned prior to the activity commencing.

The crane operator disembarked from his crane and left it idling with the load suspended
The two rigger assistants tried to prevent the crane operator and the supervisor from entering underneath the
suspended load.

The crane operator and the supervisor ignored riggers` instruction.

The crane operator and supervisor positioned themselves under the suspended load to reposition the dunnage.
Crane operator and supervisor understood their actions to be acceptable behaviour to get the job done.

2x Assistant Riggers failed to report the incident as they were afraid of the consequences

Supporting Information

Foreman under
suspended load

Crane Operator left crane

unattended and still idling and
placed himself under
suspended load

Incident Causes

Underlying Cause(s)

First level (Personal factors) M Behaviour

M4 Inadequate reinforcement of safe behaviour Accepted behaviour by the crane operator and the supervisor.

M7 Poor Supervisory Example Supervisor participated in the unsafe act.

Ignored riggers instruction

Assistant Riggers feared the consequences of reporting. (They would lose their job)

Second level (Job Factors) P Safety leadership

Contributory Cause(s)

First level(Job Factors) ) P Safety leadership

P5 Poor personal example The supervisor failed to set an example to his subordinates as he positioned himself
under the suspended load.

Supervisor failed to lead by example.

X Risk Management

X-1 Inadequate Hazard Identification Supervisor and crane operator ignored the risk of workers being under the
suspended load..

Q Contractor selection and engagement

Q-6 Other Pre-qualification process and adjudication to have much stronger emphasis on HSSE requirements.

Root Cause(s)

First level (Acts or Omissions) D Human Action

D7 Other, The crane operator and supervisor knowingly violated the non-negotiable lifting safety rule. Accepted
behaviour by the crane operator and the supervisor.

Ignored riggers instruction

Element of fear from assistant riggers to be outspoken when communicating with supervisor and operator.

Learning for the Business

Intensive change in safety culture to be addressed throughout the project Award scheme to be introduced to incentivise positive HSE behaviour.

Competent Supervisors understanding project procedures, roles and responsibilities is critical.

Communication reporting of incidents must be encouraged, regardless of project standing on the project.

Pre-qualification process and adjudication to have much stronger emphasis on HSSE requirements.

Multi cultural site with challenges around Chinese management attitudes and the Namibian workforce. Need to avoid
creating an atmosphere of fear.

Investigation Critique
Management of Incident
What went well?

What are the opportunities for improvement?

Incident investigation successfully executed

Two responsible employees were removed from the

project.
Contractor Incident Re-call was conducted.
Non-negotiable rules were discussed .
All relevant supporting documentation is in place
Corporate management participation in investigation
to raise the profile of HSSE importance on site.

ALL relevant persons are to be made available during

an investigation. (Two relevant employees were not
available)
Action plan to incorporate open communication and
emphasise importance of reporting without fear of
retribution.
Continual inspections by HPJV and Sinohydro safety
to ensure compliance with rigging activities.
Promotion of a positive safety culture based on the Six
Safety Essentials. HPJV to make available, stickers for
hard hats and handouts for all project employees.
Continual training of supervisors and personnel to
ensure implementation of procedures are adhered to
and shortcomings discussed.
Focus on safety leadership improvement.
Incentive program to reward positive safety behaviour