A Fatal Fall

This story describes a “Fall from Height” incident at a Queensland construction site

A 30 metre diameter by 13 metre high tank was being fabricated and installed on site.

The slightly dome shaped tank roof consisted of several petal-like sections meeting at the centre of the tank roof.

One roof top section and one section of the side wall was left out to provide ventilation to workers inside the tank

At the time of the event several personnel were inside the tank welding the tank base plate floor seam to the tank walls.

One of the other tasks was to remove all the small lifting lugs and other attachments from the top of the tank roof.

This day shift task was allocated to a boiler maker/welder who had emigrated from Asia – His English was very poor and he behaved in accordance with the social and cultural norms of his home country.

There were no physical barricades in place at the edge of the tank or at the open roof top section to stop a person from falling.

He was wearing a fall arrest harness but was not attached to an anchor point at the time of the incident.

Whilst conducting his work – the employee fell through the opening in the tank roof to the tank base below in front of his work mates.

The fall was approximately 13 metres and resulted in fatal injuries. He died at the scene approximately 10 minutes after the fall.

The investigation.

No physical barricades were in place at any time on the tank roof top.

It was the norm for supervisors and other employees to walk around the roof top without any form of fall arrest being in place. The work supervisor was observed doing this several days prior to the incident. The behaviour had been normalised by the organisation management.

One hour prior to the event, the employee was observed by the contractors’ safety advisor that he was not hooked up to an anchor point. The safety advisor gave direct advice to the employee he must be hooked up to anchor point.

It was subsequently established that this employee had also received five previous verbal warnings over several weeks prior to this event to hook up to an anchor point when working at height.

This was a classic example of “All talk and No action” by this organisation – It was believed that we had discharged our Duty of Care by issuing verbal warnings and nothing else was required. To the employee – there was no consequence to his continuing behaviour to not follow instructions.

It was also established that no real effort was taken to address the employee via an interpreter or other means to ensure that he understood and would follow safety requirements.

It appeared the employee would nod his head to indicate agreement to follow instructions and probably did not understand anything. So everyone was happy

This was now an accident waiting to happen. It just needed the Right Time and Right Place.

The verbal warnings had been recorded and logged.

A pattern of unsafe behaviour clearly been established It was a gross act of negligence by the contractor supervisor/management and safety advisor to have ignored this pattern and rely on the “Feel Good” approach of “He has been warned – it is now up to him to do the right thing.”

The Memorial

A memorial was erected on the site and the employees’ family (wife and three adult children) came to site for the ceremony about six months later.

The ceremony was attended by EPCM Main Contractor (including myself) and the involved Contractor. It was rammed home to all of us to see that family dressed in funeral black and reflect on the fact that real people are left behind who are deeply affected by the loss of a loved on through a workplace accident.

My take on this

Never Forgotten and Never Again