LEARNING FROM ACCIDENTS OSHI SEMINAR 2017 · Lessons Learnt Risk Assessment •RA should be...

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A Great Workforce A Great Workplace

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Mohamed Haniffa bin IbrahimInvestigations (General Workplaces)

LEARNING FROM ACCIDENTSOSHI SEMINAR 2017



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Overview

Case studies of fatal accidents

Accident Description

Investigation findings

Lessons learnt

1. Fall from height

2. Struck by falling object

3. Caught in/between object



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Case Study 1

Worker died after falling from storage rack



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The Deceased went to the production department to collectfinished products and subsequently brought the finishedproducts to the store area for storage.

The Deceased then proceeded to store the collected finishedproducts to their designated location. A co-worker at the storearea then heard a loud thud and found the Deceased lying onthe floor.

The co-worker rendered first aid and the Deceased wassubsequently conveyed to the hospital but succumbed to hisinjuries on the same day. The certified cause of the death washead injury.



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Location where the Deceased fell

from

Investigation Findings



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Ladders used by Deceased to access 2nd level and 3rd level of storage area



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Modified Stacker



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Had conducted a RA and had established SWP only for theirproduction work activities. Failed to conduct a RA and SWP fortheir warehousing activities.

Failed to establish a safe process of storing and retrieving ofplastic products.

Exposed the workers to the hazard of falling from height.

Failed to conduct any daily toolbox meetings or safety briefingsfor their employees at all.



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Lessons Learnt

Risk Assessment • RA should be conducted for ALL WORK activities with appropriate control measures put in place and effectively communicated

Safe Work Procedure • Establish procedure for the safe storing and retrieving of goods

Awareness • Standing, climbing up or down should never be allowed on the racks

Equipment • All equipment should not be modified (unless approved by manufacturer)



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Case Study 2

Worker died after being struck by a spreader beam



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The Deceased and his supervisor were at the client’s workplaceto carry out pest control works. At the same time, the forklifttruck operator was operating the forklift truck loaded with aspreader beam.

The forks together with the spreader beam were elevated to aheight of 3.5m. The forklift truck then went over a small humpand the unsecured spreader beam slide off the forks, fell andhit the Deceased, who was in close proximity spraying antimosquito chemical, on his head.

The Deceased was subsequently conveyed by ambulance tohospital but succumbed to his injuries on the same day. Thecertified cause of the death was multiple injuries.




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Spreader Beam

Accident ForkliftParked Trailer

Sheltered Workshop

Direction of Forklift




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3.5m (from the forks to the ground)

One end of the spreader beam found lying on the construction materials

The location where the Deceased was struck by the spreader beam

Length of spreader beam 8.4m

The location where the fork was inserted



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A cable was tied to the key and steering column

Tyres were worn off



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Had conducted RA for the use of forklift trucks. However failed toidentify the risk of struck by object.

Failed to establish safe work procedures for the forkliftoperations within the premises.

Did not have a traffic management plan to separate paths forpedestrians and vehicles.

Failed to established a system

• to identify if a person is an appointed forklift truck operator.

• to secure the key of the forklift truck, such that only authorisedoperators, may draw the forklift truck key and operate the forklifttruck.



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Lessons Learnt

Risk Assessment • Identify all possible risk and hazards and implement its appropriate control measures

Safe Work Procedures • Establish procedures to control the access to the forklift truck key

• Establish procedures for the safe lifting and transportation (load to be secured) of materials

Work Environment • Establish a traffic management plan to separate pedestrian and vehicular movement

• Maintain Good Housekeeping

Equipment • Ensure Forklift trucks are periodically maintained



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Case Study 3

Worker died after being caught in/between

collapsed I-beam



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The Deceased was tasked to perform rigging works at a storageyard.

The Deceased was in the process of placing a timber block onthe uneven ground to provide support for I-beams to be placed,when an earlier set of I-beams that were stacked next to himtoppled and trapped him underneath.

The Deceased was pronounced dead at the scene. His certifiedcause of death was determined to be “traumatic asphyxia”.




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Sheet piles and I-beams were stacked to various heights in the storage yard




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No signs of steel platesor supporting structures

Each 12m long andweigh about 868.8kg

Deceased was standing about 11m away while he was placing the timber block before the stack of 8 I-beams fell

The stack of 8 I-beams was lifted and place at this area

A stack of 4 I-beams were to be lifted and placed at this area

X

Stack of 7 I-beams stack in an ‘interlocking’ manner.

Total height was about 1m




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Illustration showing the position of the Deceased before the accident

Illustration of stack of 8 I-beams toppling onto Deceased

The distance between the 7 stack I-beam and the 8 stack I-beam was about 64cm




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Steel plate and timber block Timber block placed by Deceased before the accident



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Poor housekeeping with No proper means of access and egress for the workers



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Failed to conduct Risk Assessment for all work activities.

Failed to establish Safe Work Procedures for all work activities.

Failed to provide a Safe Work Environment.

• No proper means of safe access or egress

• Materials were stored without any height restrictions

• No supports were provided for the I-beams that were stacked

Deceased was not a trained rigger.



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Lessons Learnt

Risk Assessment • Plan and Conduct a comprehensive RA • Identify all possible risk and hazards• Apply appropriate control measures (hierarchy

of hazard control)

Safe Work Procedures • Establish Safe Work Procedures for all work activities under taken in the workplace

• Clearly highlight the roles and responsibilities of competent individuals carrying out the works

Work Environment • Provide access and egress for workers

• Store Materials in an orderly manner

• Always Maintain Good House keeping

Communications • Ensure all identified hazards and risk, control measures are effectively communicated to all workers before any commencement of works



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Summary

Have a Plan before any commencementof works

Have a Competent Team and Conduct aRisk Assessment

Identify all possible risk & hazards Implement appropriate control measures Communicate



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Thank You for

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