CEMENT – JUNE 2009

LESSONS LEARNED FROM A FATAL ACCIDENT

DEATH OF 2 CONTRACTORS FALLING FROM HEIGHT
ALSAFWA CEMENT, SAUDI ARABIA

On 1st March 2009, Ibrahim Ahmed Ibrahim, 36 years-old married with two daughters and Ali Mohamed
Sayed Said, 25 years old single both employees of the main contractor OCI-Saudi Arabia, fell from 95
meters to their death.

What happened:

A team of 5 contractors including Ibrahim and Ali was
working inside the main chimney on a movable platform.

The 5 slings that were supposed to be used were not
readily available and therefore they hung the platform
by 3 wires only.

The man-basket lifted Ibrahim (welder) and Ali (fitter)
inside the chimney. They had to remove the supports
below the platform (while it is connected to the tower
-
crane) preparing for lifting it to a higher position inside
the chimney.

While the crane was lifting the platform, it got stuck in a
bracket welded on the chimney’s wall. Because of the
rigging, the two men had to use their weights to keep
the platform stable.

When they managed to remove the welded bracket, the
platform suddenly tipped and they fell off the platform.

Principal causes identified:

- Time pressure: as the use of the tower crane is critical, it
was decided to carry out this job during the lunch timeas
the crane was not available after words.
- Poor safety management system in place (policies,
rules, clear responsibilities, specific objectives per
function &/per person, work force involvement,
communication, management review & follow-up, etc.) -

- Lack of awareness and training: no pre-start site

meeting
- Lack of written work procedures and method
Platform which was
statements. Neither risk assessment nor work permits
used inside the Chimney
for job were made
- Very poor supervision at different levels in terms of
rules, responsibilities and awareness
- Poor job planning: shortage in materials and tools as
well as poor quality (wires, brackets) although sufficient
certified tools were available in the store
- Lack of alertness: Lack of reaction as workers became
complacent
Group Communications – to Sr Management, BU managers, Health & Safety & Communications networks for posting and discussion at all sites
 CEMENT – JUNE 2009

LESSONS LEARNED FROM A FATAL ACCIDENT

DEATH OF 2 CONTRACTORS FALLING FROM HEIGHT
ALSAFWA CEMENT, SAUDI ARABIA

Key lessons learned for all sites:

- No risky job should begin without a proper risk assessment and a work procedure.
- Job planning and a pre-start meeting must be carried out for high risk and complex jobs to ensure
risks are identified, discussed and mitigated. This is also an opportunity to ensure workers are
trained to do the job safely according to standards and requirements.
- Time pressure should never be a reason to compromise safety. At the end of the day, doing a job
safely will save time.
- No work during the brakes (nor the night) should be carried out on site without getting a special
permit from site manager -

- We should never hesitate to stop a job that is deemed unsafe. It should be started again only when
all the deficiencies have been addressed and proper tools in place.
- On-site safety supervision must be sufficient on project sites. A rule of thumb is one resource per 40
contractor workers

Group Communications – to Sr Management, BU managers, Health & Safety & Communications networks for posting and discussion at all sites