Network Rail The Quadrant: MK, Elder Gate, Milton Keynes, MK9 1EN.

Date: 10th September 2012

No: IGS 265

Infrastructure Group Safety Bulletin

Lifting Operation: Failure to Secure Loads. Borough Viaduct Project

This bulletin is for the attention of: Infrastructure Projects; Network Operations; Asset Management, NDS and Contractors.

Background An incident occurred on 23rd August 2012 when an individual working on site was struck on their hard hat by a scaffold storage frame, sometimes referred to as a stillage, when it became detached from a load whilst being lifted. The frame formed part of a load that consisted of a number of 5ft scaffold tubes. As it was being lifted the load struck part of the scaffold it was being lifted onto, resulting in one part of the storage frame becoming detached from the load. The frame fell approximately 20ft striking the individual with a glancing blow on his hard hat. The individual suffered no serious injury.

Load was secured with strops in between It was believed that the frame did not need to be secured 2 unconnected scaffold storage frames to the load via the strop as it was held in place by the scaffold tubes. Investigation The investigation established that it was practice (both on this and other Thameslink sites) to lift with the storage frames unsecured to the load. The diagram above right indicates how the frame remains stable under normal conditions, despite being unsecured. Subsequent enquires with both the onsite scaffold company and the supplier of the storage frame/stillage have clarified that this is not the correct methodology for lifting of this equipment, however this had not been documented prior to the incident, and the investigation indicates that this had not been effectively communicated to the operatives on this site (and it would seem to other sites also). Action Those employees and contractors whose work activity involves planning or undertaking lifting activities involving scaffold tubes and storage frames, or related lifting brackets, on Network Rail sites are to review lifting activities involving this equipment to check that all component parts of the overall load are properly secured before lifting and specifically that the storage frame is secured to the load.

If you have any safety concerns, work should be stopped immediately and your concerns reported.

Issued on behalf of: Chris Thomas: Director of S&SD (Acting); Infrastructure Projects

The frames at the site in question now employ a ‘figure of 8’ slinging technique around the frame/stillage and the tubes. This means that the stillage is tied in to the overall load and cannot become detached in the event of an impact – which should be the case for all lifts

Learning Event – Esholt

Communication Method (Tick as appropriate)

TBT Notice Boards H,S & E Bulletins Cascade Briefing

Others please specify

Which People Should Receive This Communication?

All MGJV People

Operational Staff

Operatives Subcontractors Equipment Suppliers

Clients/Contract Partners

Please find details of a recent accident which occurred on the Esholt THP site together with details of the learning from the incident. Incident Summary A steel fixer was working on fixing wall starter bars, this entailed regular movement across the slab mat to collect tie wires etc. Whilst walking over the steels the IP slipped or tripped falling onto the mat, as the IP placed his hand down to prevent the fall his arm came into contact with a sharp cut end of a tie wire on the mat. This resulted in a serious cut to the IP’s left forearm. First aid was administered and the IP was taken to hospital where ten stiches were administered to the wound. The most likely immediate cause of the accident was that the IP stood on a reinforcing bar which sagged and allowed his foot to slip through the mat. Following the accident a Root Cause Analysis was undertaken, the results of which are recorded below; There were a number of areas for improvement which are categorised into Improvements to RAMS and Changes in Working Practice. A breakdown of these is included below; Improvements to RAMS

Where reasonably practicable walkway boards should be provided. Thoughts/decisions on their provision should be documented in the RAMS and should be reviewed regularly.

Where boards are not provided walking on the mat should only be allowed in a direction perpendicular to the main T1 bars, this should be included in the RAMS and reiterated at a tool box talk.

Working Practice

Ties should be knocked down after the final cut.

Additional rest periods should be considered when working from uncomfortable posture positions and in hot temperatures.

Where possible edge shutters should not be placed until all wall starter bars have been fixed.

Knee pads should be made available to ensure that when fixers are kneeling for long periods they have a more comfortable working environment and their legs are less likely to become stiff when standing again.

Electrical Near Miss - Sutton on the Forest WwTW

Communication Method (Tick as appropriate)

TBT Notice Boards H,S & E Bulletins Cascade Briefing

Others please specify

Which People Should Receive This Communication?

All MGJV People

Operational Staff

Operatives Subcontractors Equipment Suppliers

Clients/Contract Partners

Incident YWS operative arrived on the Sutton site in order to reconnect a drum thickener which had been away for repair. A near miss was recorded as the electrical feed into the panel had been disconnected and left energised with terminal blocks in place on the cable ends. Review of incident The near miss has been investigated by the MGJV Framework M & E Manager; The investigation concluded that the electrical installation had been left in a safe condition, however there were a number of areas for review and learning. A summary of the investigation is below; The MGJV Electrical Appointed Person for the Batch met on site and discussed the provision of a temporary supply to feed two temporary submersible pumps required to re-seed the stone media filter bed, it was agreed at site level that the power could be taken from the drum thickener control panel as it was out of commission at the time (nothing was recorded about this decision). After removal of the temporary pumps the power supply was removed and the cable was left in what was deemed to be a safe condition (with terminal blocks on the cable ends) in the drum thickener panel and the circuit re-energised. All work had been completed by an Electrical AP. Learning

Formal Handover /Handback of the electrical installation – Site handover includes handover of the electrical installation, however pre-existing isolations should be dealt with by specific transfer from named person to named person. All handed over areas should be noted and suitable demarcation be in place.

Procedures for Access to Equipment isolated by others – If there is a need to remove a pre-existing isolation more effort must be made to contact the person responsible. If this is not possible or is proving problematic then a safe working procedure should be developed to remove the isolation. A suitable record (including photos) should be maintained and upon completion this should be provided to the person responsible for the site/installation.

MGJV have completed a briefing to all M & E Project Managers with the following content;

Tighten up on YWS Handover / Handback Procedures

Ensure Learning from recent Near Misses is passed on

Manage Change in Circumstances

Build Trust and confidence with YWS

Reinforce Electrical Safety Rules

Reinforce Process Impact Plan Requirements

Figure 1 - Crawler crane position within sulphur pit after incident

PTP-AC201201 Projects and Technology – Major Projects March 2012

Crane Operator Fataly Injured

Target audience for this alert ¡ Project Managers

¡ Project Engineers

¡ Turnaround Managers

¡ Authorised Persons – Lifting and Hoisting

What happened During construction work on the BUGIS project at the Pulau Bukom Site - Singapore, a crane operator used a crawler crane to position a steel H-beam for piling with a vibro-hammer in an excavated pit. In the process, the crane fell into the excavation pit and the operator was fatally injured. No other persons were injured.

Why it happened ¡ The 50 ton crane was being used to position two H-

beams using a vibro-hammer. The total load (vibro hammer and beam) has been established to be 8.7tons. The load was assumed at the time of the incident to be 7.5 tons.

¡ The safe working radius for a 9.0 ton load was 12m according to the manufacturers load charts. The toppling radius would have been 14m.

¡ The first H-Beam was successfully put in position at a 10.15m working radius which was within the crane manufacturer’s 12m safe working radius.

¡ The intended final position for the second H-Beam, at 14.6m, was outside the safe working radius. The second beam was to be ‘parked’ temporarily, close to the first beam (at a radius of 11.15m), to allow the crane to be moved to a new location. See Figure 2.

Figure 2 – showing the layout of job, the intended parking

position for second H-beam and the safe working radius of the

crane

¡ The operator was instructed to lower the H-beam (wire down) at its temporary position. He responded by lowering the crane boom rather than by ’wiring down’ and did not respond to instructions to stop lowering the boom.

¡ The boom continued to be lowered past the tipping point of the crane (14m), passing both the intended temporary, and final locations for the H-Beam. The final impact point of the H-Beam was found to be at a radius of16.35m.

On further investigation it was found that:

¡ The work was being carried out under a generic method statement for the sheet piling. The positioning of the H beams and the safe working distances were not mentioned in the method statement. The lift was treated as a Low Risk Routine lift when in fact it was High Risk lift as the crane was required to move with the load.

¡ The Lifting and Hoisting SME appointed by the Project Management Contractor was not fully aware of the Bukom lift procedures and requirements.

¡ The underestimation of the load weight meant that the safe working radius and tipping point were over estimated by 2m.

¡ The safety devices on the crane failed to prevent the crane from toppling. The most likely explanation is that the safeguarding was functioning correctly and triggered an auto-cutoff when overload conditions were reached but the momentum of the boom and load being rapidly lowered caused the crane to topple into the excavated pit.

¡ The deceased was an experienced crane operator and had worked at Bukom in the past. He had not been passed as ‘Fit to Work’ as a crane operator but he had been passed as fit to work as a foreman.

Underlying causes on why the operator continued to lower the boom and why he failed to respond to instructions are unknown.

Lessons learned For this type of operation, the quality of the risk assessment and method statements is critical and adequate time and resources needs to be given to developing the work plan and communicating it to the lifting crew. The Contractor treated sheet piling as a routine activity with routine lifting and consequently did not develop a lifting plan.

Interviews with other operators found that vibrations from a vibro-hammer can be transmitted to the boom causing nuisance trips of the safeguarding system. Consequently safety devices are frequently overridden by operators. A safer alternative is to use an excavator with a long arm and vibro-hammer fitted.

For safety critical positions, such as crane operators, sites need to ensure that they cross reference the Fitness to Work information provided by contractors against the actual activities that their employees will carry out.

Figure 3 - Second H-beam was lowered using boom and passed

the tipping point

SHEQ Alert

Communication: Toolbox Talks / briefings � Notice boards � Safe and Sustainable

update �

Circulation List: To all of Morgan Sindall � Supply Chain � Morgan Sindall Plant Hire Desk � Morgan Sindall Group �

SHEQ Alert No: 004— 2012

Learning Event – Lifting chain failure

On one of our water framework projects , two lifting accessory

chain failures were reported associated with the attempt to lift2 different mixer pumps out of a shaft. Post investigation it was found that the immediate cause of the lifting chains failing was

a) because the chains installed were 24M in length and b) because the excess chain length had not been hooked up

at the top of the 21M shaft. This caused the excess chain to be drawn in by the mixer pumps operating at the time withinthe shaft.

The underlying root causes of this incident were:

A) The team installing the new mixer pumps, guide rails & chains completed the installation and in the absence of hooks to secure excess chain up at top of the shaft used rope; B) Hooks had not been procured as part of pump supplier package of equipment, although it was assumed was); C)

there was 2-3week order time delay before hooks could be supplied; D) meanwhile the storm tank and mixer pumps were commissioned . E) A number of parties stated that post installation of new

mixer pumps, due to blockages they had been taken in and out of the shaft a number of times. It was not established at what point the excess chain connected to the pumps had been left at the base of the shaft instead of tied off at the top. F) The chains procured were too long (24M) for a 21M

shaft, but the extra allowance was agreed between Morgan Sindall and installer/supplier. The design drawing detail only showed measurements from the base of shaft to shaft top and did not detail

measurements between mixer pump handle to shaft top and where hooks for chain were going to be located. F) The Client design manual does not provide guidance on mixer pump installation, consideration of measures for pump sizes and chain length measurements or points where hooks

for excess chain to be positioned at top of shafts or tanks when designing installations.

If you have any queries regarding the content of this bulletin please contact in first instance your business SHEQ Team Leader

Learning

Installer of lifting chains, pumps and mixers to develop a pre/post installation

checklist to improve quality control covering works they are undertaking.

Develop a Supplier handover checklist covering Mechanical installation works.

Recommend to Mechanical installation management that all designers need to

produce an inventory of materials/equipment/ancillary items associated with M&E design.

Contact and write to our Designer, supplying them with a copy of the learning event

bulletin, & highlight issues re lack of design detail in drawings and of the need for a call off list of key items and of critical measurements needed to execute design.

Bring to the attention of our client that design manual they provide Framework

suppliers need more detail in them concerning mixer pump installation.

Action taken by management

None applicable Applicable (please state below)

Share the contents of this bulletin with: teams on site; Mechanical

electrical suppliers/installers & with other Water Framework contractors.

Advise designers to provide more detailed drawings on critical

measurements & positions of all equipment, adding advisory comments e.g. when procuring lifting chain for pump/s to ensure measurement

between pump handle and where hooks should be for holding any excess chain to be positioned to avoid potential risk of chain being too long. Advise provision of an inventory list of items needed for design and it’s

successful execution.

Advise contractors on the importance of materials and equipment pre/post

installation checks as part of inspection and test plans.

Advise Client of learning event findings requesting update to their design

manual.

Display until: 31-12-12