Accident Case Studies on Lifting Equipment

Presented by: Dr Goh Yang Miang Assistant Director, Investigations Branch, OSH Inspectorate, OSHD, MOM

Purpose and Scope of Presentation To share accident case studies so as to: highlight possible hazards and incident sequences; highlight reasonably practicable measures that could have been done to prevent the accidents
These case studies are presented for learning and educational purposes. The case studies must not be used in any legal proceedings.

Some common types of incidents during lifting operations

Lifting Machine Lifting gear

Load

Not drawn to scale

Some common types of incidents during lifting operations

Lifting machine collapse/ overturn/ failure

Person struck by falling object

Not drawn to scale

Some common types of incidents during lifting operations

Load fall from height

Person struck by falling object

Not drawn to scale

Some common types of incidents during lifting operations

Person caught in-between lifting machine and other objects Or struck by lifting machine

Not drawn to scale

Some common types of incidents during lifting operations

Person struck by object

Load struck object

Not drawn to scale

Common Incident Sequences Situation Lifting Operation

Load struck object Lifting machine overturn

Load fall off

Object fall off

Struck persons/ properties

Struck persons/ Struck persons/ properties properties Severity Minor Moderate Major

Person hit by lifting machine/ load (no overturn)

Case Studies
Case Study 1 Truck-mounted crane overturned Case Study 2 Crawler crane overturned Case Study 3 Load fall from height Case Study 4 Person caught in-between

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Fly jib = 16m at 5 to boom Load = 1.2-1.3 ton Initial boom angle = 60 Crane collapsed when boom angle = 50 to 52

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Right rear outrigger

Right front outrigger

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Accident Analysis
Situation Lifting of debris using mobile crane Incident Sequence Possible Direct Causes

Overloaded Ground failure

Breakdown Event (BE)

Crane overturn

Why?

Hoist rope failure Sudden dynamic load

Wind Lifting gear failure Improper maneuvering

ConseQuences (CSQ)

Crane struck property

Boom structure failure Load entangled

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Boom Angle

16m jib 5 tilt

Actual load = 1.2-1.3 ton

Initial angle 60 Just before collapse 53 Allowable load = 1.06 ton Allowable load = 0.55 ton

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Rear quadrant usually has higher Factor of Safety for stability than side quadrants

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Accident Analysis
Situation Lifting of debris using mobile crane Incident Sequence Causation
Operator continued operation even though overload alarm sounded
Why?

Breakdown Event (BE)

Crane overturn

Why?

Overloaded
Why? Why?

Why?

No lifting plan/ dry rehearsal

ConseQuences (CSQ)

Crane struck property

Moment limiter did not perform as expected

Why?

Operator overrelied on moment limiter

Why?

Unsafe habit not identified and corrected

Actual Moment condition limiter not deviated from properly calibration calibrated condition, e.g. (?) out-of-level (?)

Why? Momentum too high No system to cut-off too identify and correct unsafe late (?) habit 17

Possible Risk Controls

Situation Lifting of debris using mobile crane Incident Sequence

Employer/ Principal

Personsat-work

Occupier

Crane overturn

Why?

Overloaded

Require pre-lifting risk assessment and planning (run through key lifting parameters) Conduct briefing, additional test or onthe-job observations to ensure operator is competent and has safe habits Conduct frequent check on crane condition (incl. safety devices)

Crane struck property

Please note that the risk control measures mentioned here are provided for the benefit of enhancing workplace safety and health. Stakeholders should review their own workplace and determine what measures need to be taken.

Supplier/ Manufacturer
Highlight limitations of safety devices to users Assist users in basic maintenance of 18 crane

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Vertical Main Boom = 33m Luffing jib = 25m

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Deceased was struck by the boom here

Precast staircase = 6900kg Hook Block = 250kg Total Load = 7,150kg Safe working load based on load chart = 7,600kg
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Precast staircase that was lifted

3 Steel plates provided to ensure level and stable ground

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Crawler was moved out of the steel plate

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Initial condition Boom Truss

Cabin

Steel plates

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Before Accident Boom Truss

Cabin

Fulcrum shifted

Steel plates

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Accident Analysis
Situation Lifting of staircase using crawler crane Incident Sequence
Crawler moved out of steel plate
Why?

Causation

Breakdown Event (BE)

Crane overturn

Why?

Why?

Crane moved to gain better view

Why?

Contact Event (CE)

Crane struck worker

Operator unaware
Why?

Signaller not available (walking to position)

Why? Why?

No alarm or demarcation to alert operator

Why?

ConseQuences (CSQ)

Crane struck worker

Operator failed to wait

Why?

Work pressure?

No risk assessment & lifting plan

Reckless? Negligent?

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Possible Risk Controls

Situation
Lifting of staircase using crawler crane
Please note that the risk control measures mentioned here are provided for the benefit of enhancing workplace safety and health. Stakeholders should review their own workplace and determine what measures need to be taken.

Incident Sequence

Employer/ Principal

Occupier

Breakdown Event (BE)

Crane overturn

Require pre-lifting risk assessment and planning Ensure that crane are on stable grounds e.g. simple flag markers to highlight to operator edge of steel plate

Contact Event (CE)

Crane struck worker

Supplier/ Manufacturer

Highlight common causes of overturning to users Engineering Control - Develop new devices to control risk of overturning (ground condition detector? Edge detector?)

ConseQuences (CSQ)

Crane struck worker

Personsat-work

Follow SWPs and highlight hazards to employers Participate in identifying risk 27 controls

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Scrap DB (119kg) Chain slings

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Gap widened

With safety latch

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Chain sling becomes vertical during lifting

Hook can come out easily

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Accident Analysis
Situation Lifting of scrap DB using lorry crane and chain sling Incident Sequence
Breakdown Event (BE)

No maintenance regime
Why?

Causation

Object fall from height

Why?

Chain sling unhooked

Why?

Why?

Gap of hook too wide (no latch)

Lack of maintenance and check by Authorised Examiner (AE)

Why?

Contact Event (CE)

Object struck worker

Gap of hook facing the wrong side

Why? Why?

Decision to use defective lifting gear

Why?

Lack of supervision

Lack of competency
Why?

Lack of training
ConseQuences (CSQ)

Fatality + commercial losses

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Accident Analysis
Situation Lifting of scrap DB using lorry crane and chain sling Incident Sequence
Breakdown Event (BE)

Causation

Object fall from height

Contact Event (CE)

Object struck worker

Why?

Worker too near to load

Failure to clear away during lifting

ConseQuences (CSQ)

Fatality + commercial losses

Lack of training & supervision

Why?
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Possible Risk Controls

Situation Lifting of scrap DB using lorry crane and chain sling Incident Sequence
Breakdown Event (BE)

Employer/ Principal
Provide training to workers that are expected to be involved in lifting work (rigger, signaller etc) Ensure that the training is effective and worker practise what they are taught on-going supervision and briefing Ensure that all lifting gears are

Object fall from height

Occupier individually identified and checked

by AE
Contact Event (CE)

Object struck worker

Supplier/ Manufacturer Personsat-work

Recommend basic checks to determine if lifting gear is serviceable Practise according to SWP or training

ConseQuences (CSQ)

Fatality + commercial losses

Please note that the risk control measures mentioned here are provided for 34 the benefit of enhancing workplace safety and health. Stakeholders should to review their own workplace and determine what measures need to be taken.

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Motor housing Steel mould

Deceased caught inbetween here (gap of about 5mm) 36

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Emergency button cover not present Investigation revealed that button still working Operator should have clear view of deceased

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Accident Analysis
Situation Operating gantry crane in precast yard Causation Incident Sequence

Contact Event (CE)

Worker caught inbetween motor and mould

Why?

Worker working too near to motor and mould

Why?

Why?

Clearance between motor and mould too small

Why?

Operator failed to stop crane

Why?

No risk assessment Poor risk perception (?)

Why?

ConseQuences (CSQ)

Fatality + commercial losses

Operator reckless/ negligent

Why?

No measures to improve risk perception 38

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Possible Risk Controls

Situation Operating gantry crane in precast yard Incident Sequence

Employer/ Principal

Occupier

Contact Event (CE)

Worker caught inbetween motor and mould

Conduct risk assessment Erect barrier to ensure no one gets near to motor Yellow line to demarcate stacking zone Inspection by supervisors Briefing and training on possible hazards

Supplier/ Manufacturer Personsat-work

Highlight inherent hazards of crane components recommend clearance from motor housing

Dont take chances Look, Think, Do

ConseQuences (CSQ)

Fatality + commercial losses

Please note that the risk control measures mentioned here are provided for 39 the benefit of enhancing workplace safety and health. Stakeholders should to review their own workplace and determine what measures need to be taken.

Common Issues with Lifting Equipment Accidents

Altering of accident scene is an offence!! Poor planning
Inadequate knowledge of hazards poor risk assessment No lifting plan/ dry rehearsal Inadequate supervision of lifting works Competency/ habits of operators Over-reliance on overload alarm Unable to read load chart (load chart in foreign language)
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Conclusion
an Su ufa pp c t u lie re rs rs / Pe rs on s at w or k
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pl oy ed em Se lfPr in

pi er

oy er

Em pl

cc u

ci p

al s

Duty to take, so far as is reasonably practicable, such measures as are necessary to ensure workplace safety and health
Workplace Safety and Health Act

All stakeholders should use risk management as the basic tool to help improve safety and health at workplaces.

Thank You!

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