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Fatality from a fall from the platform access ladder (04-Oct-05)
The victim along with 3 other scaffold erectors was erecting scaffold (for steel work modification) at the 33 metre level of the LNG flare structure. The victim indicated to the remaining crew that he intended to descend to make use of the toilet facilities. One of the crew members witnessed the victim climb on to the ladder and fall. He also confirms that immediately prior to the fall he observed him with the lanyard clip in his right hand i.e. unclipped from the permanent handrail above the ladder. Finally he confirms that no attempt had been made by the victim to attach to the fall arrestor prior to stepping off the grating on to the ladder.

The victim appears to have fallen side ways from the ladder and descended head first through the structure landing some 14 metres below the top of the ladder on to a scaffold structure at the 19 metre level.

The ladder itself is in good condition and there is no evidence of any specific deterioration in the rungs, which may have led to a slipping hazard. The victims work boots are also in good condition with adequate tread.

Those unsafe acts or unsafe conditions that we sometimes go by, tolerate or prefer not to notice however minor they may appear and even simple inaction on our part carries a potential for consequences that will tear your heart apart for the rest of your life and will break hearts of many other people.

Those who assume the role of a supervisor, an HSE inspector or simply a responsible citizen must never underestimate the level of responsibility that comes with this role.

  • Access for work at the top of section 2 of the flare structure was not adequately addressed in the initial work method statement / risk assessment and job safety analysis.
  • Lack of access in block 2 of the flare structure led to a number of ad hoc access solutions being provided without formal review and updating of the work method statement / risk assessment and job safety analysis.
  • CTSD supervision knowingly allowed subcontractors to carry out tasks (scaffold/ladder erection) for which they were not competent.
  • Nippon Express knowingly carried out tasks (scaffold / ladder erection) not identified in their work scope and for which they were not competent.
  • CTSD supervisory personnel condoned use of access which was not in compliance with basic site standards.
  • CTSD supervisory personnel considered a protection device as an acceptable substitute for provision of safe access.
  • Cape Sakhalin supervisory and HSE staff fully competent in site scaffolding standards condoned the continued use of unsafe access by their own and other personnel.
  • Individuals felt unable or were unaware of how to register concern over unsafe access and continued to utilise unsafe access putting themselves at risk.
  • The system to restrict use of Cape Sakhalin materials (scaffolds) is not in place or not operating correctly, thus allowing unauthorized usage and erection of scaffolds by other companies.
  • The Field Design Modification process does not address the construction methods to be employed.

Category:Safety AlertsDocument Type:Safety
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