1. BSP/BLNG 25th August 2004 BSRC Ball room
Time Out For Safety
BSP/BLNG
25th August 2004
BSRC Ball room

2. This gentleman would have celebrated
his 31st birthday on 25th August BUT………..
On the 18th August 2004 at about 7.30 a.m., an employee of BSP’s sub-contractor sustained a fatal head injury. The incident happened in the contractor’s fabrication yard in Seria. At the time of the incident work activities had not commenced in the fabrication yard. The deceased was attempting to sit at the flange side of a 32” pipe spool Tee-piece, which was resting on two supports. The pipe spool toppled over, resulting in the deceased sustaining a fatal head injury.

3. Fatality Incident on 18 Aug 2004
This is the position of the Tee piece resting on the ground after it slipped and toppled out of the two ground supports and crashing the victim on the head.

4. 4 2 1 3 5 Tons JACK SEQUENCE OF EVENT Primary Support 32” T SPOOLCG 2 1
32” T SPOOL
12/08/04 –
13/08/04
11/08/04
Primary Support
(WEDNESDAY) CG 3 4
16/08/04 UNTIL
16/08/04 UNTIL
5 Tons JACK
16:00HRS
16:00HRS

5. PICTORIAL REPRESENTATION
Based on witnesses accounts, deceased was about to lift himself from the flange of the Tee piece. The Tee piece slided for about 6 inches, touched the ground, toppled over the deceased and crashed him on the head. The Tee piece then came to a rest on the ground.

6. Tee-Piece Fabrication Fatality Time Out 25 Aug 2004
Purpose
To share preliminary findings of the investigation.
Cascade immediately the preliminary findings to all BSP staff and contractors within the next 48 hours
Implement immediate actions recommended by the investigation team to prevent recurrence
Note that this is only the beginning and there are many more areas that we need to work on in more detail.
This incident involved a fatality.
We need to get immediate learning and maximum impact to BSP and contractors from this loss of live.
Hence we need to cascade this important message to address and arrest latent shortcomings existing in other worksites that may potentially cause similar incidents, hence the 48 hours urgency.

7. Fatality Incident on 18 Aug 2004
Incident Details:
At Zainal Daud (ZD) Fabrication Yard (G25) at 7.30 a.m.
Victim: Mr. Lee, 31 years old Malaysian working for Chin Wui Heng Welder Enterprise
Occupation : Senior Marker, 8 yrs experience
Injury: Death from severe head injuries.
Survived by: Spouse & 4 years old son.
Project: Single Buoy Mooring (SBM) Metering (Phase 2)
Main Contractor : Warner & Company Sdn. Bhd.
Sub-contractor: Zainal Daud Sdn. Bhd.
Sub sub-contractor: Chin Wui Heng Welder Enterprise
The main contractor, Warner & Co. was only identified during the detailed investigation. It was initially thought Zainal Daud was the main contractor.

8. Fatality Incident on 18 Aug 2004
Facts & Findings (1) :
Fabrication Yard Work delayed whilst waiting for Tool Box Talk
32” pipe Tee piece 300 # (1.3 tons) partially completed (2 flanges welded on). Suspended, awaiting material.
Was supported by 2 primary ground supports.
Chain block and 5 tons jack were used whilst fabrication was in progress for alignment purposes.
Chain block and jack were removed after welding of 2 flanges.
No further adjustments of the primary supports were made to improve stability.
Deceased was assigned the role of supervisor of the above fabrication activities.

9. Fatality Incident on 18 Aug 2004
Facts & Findings (2):
Initial calculations indicate Tee-piece Centre of Gravity shifted significantly & effectively on the verge of tilting.
Since materials were not available, no further work was carried out. Two days later, the deceased (ca. 70 Kg wt) attempted to sit on outer rim of Tee-piece flange.
Tee piece slipped & toppled over crushing victim on the head

10. Direct Causes Findings
The Tee piece became unstable after the installation of the two flanges. The centre of gravity had shifted but the primary supports were not adjusted.
For unknown reasons, the deceased attempted to sit on the vertical flange of the Tee piece
This action caused the unstable Tee piece to slip and topple over.
The deceased suffered severe head injuries after being crushed by the Tee piece.

11. Findings Indirect Causes (1)
The A-Frame, chain block and 5 Tons jack used earlier for alignment purposes were removed leaving the Tee piece on the two unadjusted ground supports.
Although a co-worker, recognising a hazard, re-secured the Tee piece on a chain block, this was subsequently removed.
The instability of the Tee piece had not been communicated to the others. Enforcement of Duty to Stop was inadequate.
General lack of hazard awareness of the workforce.
Hazard Identification Plan (HIP) for the contractor fabrication yard was not developed.
Lack of barricades and warning signs around hazardous areas.
No designated rest area

12. Findings Indirect Causes (2) Lack of effective supervision.
Lack of planning: Work started on the Tee piece before all the materials had arrived.
Contract HSE Management:
Lack of clarity between contractor, sub-contractor & sub-sub-contractor on responsibility for HSE management
The main contractor was required under its contract with BSP to play a leading role in HSE implementation, not just the subcontractor
There were early warning signs of a lack of commitment to safety such as not following up on repeated violations identified during site visits.

13. Immediate Action (1)
Please undertake the following:
Survey work supports at all worksites immediately. Rectify where work supports are unsafe or inadequate. Communicate any unsafe conditions found.
Ensure you have a HIP for every stage of your project, including the fabrication stage, both at BSP and the contractor worksites.
Include HIP in Tool Box Talk. Address safety of worksites, even when unattended.
Ensure provision and enforce use of designated rest areas at worksites.

14. Immediate Action (2)
Please undertake the following :
Supervisors & contract holders/managers accountability for safety:
Do you know the full extent of your role?
Do you know what you are accountable for?
Are you discharging your responsibility?
Confirm who is responsible for sub-contractor HSE management.

15. Areas requiring further work
We will need to strengthen the culture of intervention (e.g. PAKAT, House Rules, Consequence Management).
We will require senior management of all contractors, all direct and indirect sub-contractors to demonstrate commitment to HSE by, for example, site visits and mandatory joint HSE meetings.
We will require contract holders to include all direct and indirect sub contractors in HSE performance reviews.
Review appropriateness of contracting strategy to ensure HSE responsibilities can be effectively exercised.