Holdfast Training Services Trial Blog

A few weeks ago we had two notifiable incidents occur within 24 hours.  Fortunately, there were no injuries but both were classed as the most severe category (1P) under the John Holland reporting system as they had the potential for workers or the public to be killed.  Details about the two incidents are included at the bottom of the blog but for the timebeing, I want to focus on the procedure to restart works.

What interested me most about the incidents was the Project Director’s response.  After conducting John Holland’s reporting procedure and informing the Client of the incidents he closed the site.  The next working day all directly employed staff attended a meeting where the incidents were discussed in detail.  The bottom line was that safety is always the priority and that these incidents were a ‘free pass’ as no-one was injured but we needed to to do better going forward.  He identified 5 key areas of concern:

1. Services
2. People and Plant Interaction
3. Lifting operations
4. Temporary Works
5. Pubic Interaction and Traffic

Following the meeting all construction managers, engineers and supervisors were tasked with reviewing their procedures, Safe Working Method Statements, Task Risk Assessments and work permits for their respective areas.  The workers arrived mid-morning and were involved in the process.  The afternoon consisted of site health and safety inspections to identify areas for improvement.  This allowed improvements to be made to the existing procedures, method statements and constructions site set-up.  A feedback session was conducted late afternoon for the directly employed staff.   No project productive works were completed that day.

The next working day a ‘soft-start’ was conducted which was a gradual return to works with the identified changes implemented under closer supervision from the supervisors and engineers.  For areas requiring additional time to review their procedures and documentation, the Project Director supported the delaying of the ‘soft-start’ in their area for as long as was required.

What impressed me about the way this was handled?

1. The Project Director was clear where his priorities lay and drove the process.
2. It generated increased involvement and attention from the construction managers and senior engineers that I hadn’t experienced previously on site.
3. The time to pause and review was critical.
4. Input and empowerment of the workers was essential.
5. The Project Director was willing to bear the cost of a non-productive day and liaise with fixed price contractors as required to ensure their buy-in.
6. A re-focus on the basics.  John Holland has a set of Global Mandatory Requirements (GMRs) that are used to manage key construction risks which are used when planning activities.  These headings formed the basis of the review.  On site we have a handy booklet but the GMR sub-headings can be viewed here.

I’m interested to hear if anyone else has experienced anything similar on site.  If so how was it handled and what did you learn from it?

Incident #1:

The first incident was a dropped load from a gantry crane at the pre-cast yard.  A worker was using a gantry crane to turn over a pre-cast mould bulkhead to weld plates on both sides.  There were a number of factors that caused the incident in a ‘swiss cheese’ scenario:

1. The worker operating the gantry crane is a dogman (rigger or slinger in UK/military terminology) but had not been used much in this role previously on site.
2. The worker had not operated the gantry crane before but the supervisor thought he had.  (Following the incident it has not been possible to determine if the individual completed the on-site training from the gantry crane supplier as no record of the training was maintained).
3. The worker was not aware of the designed lifting points on the bulkhead.
4. An engineer was asked about the weight of the lift.  The engineer remembered lifting a bulkhead previously so stated the weight he remembered.  No plans were checked and he estimated the weight incorrectly.
5. The worker decided to use soft-slings to lift the load.  He was aware of the potential for the metal edges to cut into the slings so used rubber to pack the metal edges against the slings.
6. As the load was picked up the rubber packing moved.
7. The soft-slings were cut/snapped on one side of the load resulting in a dropped load onto the foundation slab.

Following the incident works were halted, the load was made safe and the incident scene preserved.  Senior management were informed and external bodies notified.  The senior management team used a technique called 5 Whys? (similar to the combat estimate and asking ‘so what’) to get to the root causes of the incident.  A number of areas were identified that could have prevented the incident from occurring.  Examples include:

• A bespoke and accredited gantry crane operators course.
• Identifying designated gantry crane operators and alternative operators.
• All precast lifts are identified at the morning pre-start and discussed with the team.
• Two engineers are required to check the drawings and calculate the weight of each lift independently.  Their assessments are compared prior to conducting the lift.
• The use of soft slings is now restricted at the precast yard with a permit system adopted.
• More emphasis has been placed on ensuring the correct mix of qualifications and site experience (SQEP) across the work crews.
• Giving nominated personnel responsibility for tasks such as maintaining designated work zone signage.

These have now been incorporated as new processes or procedures at the precast yard with the Safe Work Method Statements and Task Risk Assessments updated accordingly.

Incident #2:

The second incident related to an excavator which hit an elevated LV cable when tracking from one working area to another and pulled it down to ground level.  This was classified as a 1P event as the pylon also had a HV cable which was not disturbed.  Again there were a number of factors that contributed to the incident:

1. In preparation for the weekend site closedown, the excavator operator was instructed to conduct environmental controls in a different area of the site.
2. The excavator driver was guided by a pedestrian spotter under the power cable to access the other area of the site and completed the environmental controls.
3. The excavator operator returned to their original working area but was not guided under the power cables.
4. The operator was aware of the power cables but lost sight of them as he was passing under the cables resulting in contact with the LV cable.

A similar incident review process was carried out and the following root causes identified:

• A change in planned activities (over here they call it Change Management*).  This is considered to be a contributing factor in most site incidents.
• No ‘goal-posts’ or overhead power lines signs were displayed.  The signs would have had little effect as the operator knew about the power lines but the ‘goal-posts’ might have given warning that the excavator’s arm was too high.
• There was no requirement to track the excavator across the top of the embankment.  Traffic barriers have now been installed to prevent access.
• The operator failed to adhere to the project spotter procedures when operating near power lines.

*This is different from the use of the term on Project ANEMOI where it refers to                    the deliberate/planned change of the design following a formal process.