What happened:
A team of 2 subcontractor workers was installing insulation material on piping in the top slab level inside A60 shaft of LUN-A concrete base structure. It is believed that one of the workers decided that he needed a board to use for cutting or storing of isolation material. The worker saw a 9 mm plywood board laying on the floor, picked it up on one side and started to shake off sandblasting grit from it. As he was lifting the board (approximately 10 kg) he made a step forward and fell into a manhole in the floor that the board he removed was covering. He fell into the 1 m diameter hole, falling about 12 meters down to a concrete floor and hitting some piping on his way down. The worker received fatal injuries and died in the ambulance on the way to hospital.

Immediate causes:
The initial investigation showed that the safety barriers guarding the manhole were removed and not reinstalled in place by previous teams working in the area.

Recommendations:
The investigation of the incident is still ongoing and actions to address immediate and root causes will be communicated as the investigation is concluded. However, some preliminary recommendations can be drawn at this stage:

• Ensure there is a documented and functioning isolation process in place to manage removal and reinstallation of safety barriers.
• Ensure that manholes/openings in the floor have identifiable covers that can be locked in place, where possible.
• Prevent work in bad lighting, STOP the work if you feel that lighting is inadequate.
• Ensure people understand benefits of housekeeping.
• Identify needs for accessing manholes and openings at the design stage and provide built in design safety features.