Contractor Crane Topple Incident PRELIMINARY: INVESTIGATION ONGOING

IINCIDENT SUMMARY: At about 1330hrs on Saturday December 20, 2008, a 70 ton Groove crane toppled whilst it was being brought into operation for the loading of pipe spools at xxxxxxxxxxxxx The crane operator jumped out of his cabin as the crane fell to the ground and neither he nor other workers in the vicinity suffered injury RAM Rating Actual : Asset 1 Potential:People 4B

Parked position of Crane 2. Rigger in Container hung web sling 3. Crane fall position 4. Position of Assistance Rigger Supv & Piping Engr Paintin g Shop Carbon Steel Shop Container Access Road

FALLEN GROOVE CRANE Position of Rigger No. 1 /Container that was being loaded Position of Assistant Rigger Foreman & Piping Engineer.

CRANE ON GROUND WITH RETRACTED OUTRIGGERS Piping Engineer & Rigging Supervisor ’ s Office

Typical Crane with Fully Extended Outrigger

EVENTS LEADING UP TO INCIDENT: 0703hrs: Crew had tool box talk 0805hrs:Crew of an operator, three riggers, one banks man and one flagman assigned lifting operation. Assignment was to lift a container already loaded with spool onto a truck for despatch to CPF. 0840hrs:Crew commenced second assignment of loading long pipe spools into 40ft container 0930hrs: Supervisor directed that loaded spools be offloaded from container as they can loaded directly onto the truck. 0955hrs: Long spools from container offloaded 1020hrs:Loading of short spools into open top 40ft container commenced. 1140hrs:Loading of spool into container still in progress. Crew breaks for lunch with assignment yet to be completed.

SEQUENCE OF EVENTS. 1305hrs:A rigger arrived from lunch Piping Manager saw crane key on his desk, expressed concern over delay in re-start of work after lunch. He gave the key to his piping engineer and instructed crew to resume work. 1320hrs:Operator arrives along with a second rigger. Operator collects key from first rigger and proceed to start the Crane. 1325hrs: The two riggers available positioned themselves for the spool loading activity, one at location of spools for slinging and the other inside the container for receiving spools from crane. One of the rigger unhooked crane block and gave signal for operator to hoist up. Operator telescope crane boom and swung to direction of the container. Rigger in container hung web sling. Operator hoisted up, swung to the direction where the spools are to be loaded. Crane became unbalanced, operator attempted unsuccessfully to recover by retracting boom and swinging the boom back, raised alarm, jumped out of cabin, crane fell to the ground.

MAIN FINDINGS Crane toppled because it was brought into operation without outriggers extended. 2. The outriggers were used during the morning operations though the crane was shut down and outriggers retracted at lunchtime (normal practice) and outriggers not re-extended upon commencement of the afternoon ’ s work 3. Crane was not on load at time of incident with ground conditions stable. 4. Crew on duty at time of incident was incomplete – Flagman and Banksman were absent after lunch 5. PTW approved for work is with attached JHA and work method statement but no Lifting Plan. 6. Chain of command between the separate Piping and Rigging departments became confused. Piping Managers intervention with the crane crew was taken as an instruction to commence work. 7. There was evidence of poor job planning (double handling of long spools prevented the activity from being completed before lunch) 8. Equipment maintenance record indicate regular maintenance of crane. 9. There was no observed damage to the outrigger members and systems.

OTHER FINDINGS 1. Crew appeared agitated because of extended duration of work; workers expecting that xxxxxxxx would allow them to close early for Christmas shopping. 2. December payslip was issued to workers the previous day but money was yet to be released to bank by xxxxxxxx at time of incident. 3. Some of the crew members did not return after lunch, purportedly because food vendors were unavailable. 4. Crane operator competent, ASME B30.5 certified with relevant Drivers License 5. Container being loaded was scheduled for despatch to CPF that same day (it is unlikely that it could have completed the journey before nightfall). 6. Minor hydrocarbon spill observed at scene of incident. 7. Safety alert to operators and drivers on the need to walk around equipment prior to start of work was communicated but not implemented in this instance