1

The task: The task:

Salvaging Salvaging Operation. Operation. Included Included cutting and cutting and removal of removal of equipment equipment from sitefrom site

WELDER FATALITY WELDER FATALITY August 2003August 2003

2

Who is likely to carry out a similar Task?Who is likely to carry out a similar Task?

What are the Hazards involved in such a task?What are the Hazards involved in such a task?

What could go wrong?What could go wrong?

What type of controls are required to be in place to completeWhat type of controls are required to be in place to completethis Task Safely?this Task Safely?

DISCUSS WITH YOUR TEAMDISCUSS WITH YOUR TEAM

3

WHAT HAPPENEDWHAT HAPPENED

The contractor Welder was The contractor Welder was torch cutting a purged and torch cutting a purged and cleaned filter vessel from inside cleaned filter vessel from inside the skirt. This was the second the skirt. This was the second of three filter vessels scheduled of three filter vessels scheduled for salvagingfor salvaging . .

The Welder was pinned down The Welder was pinned down between the ground and the between the ground and the vessel, when remaining vessel vessel, when remaining vessel portion toppled once skirt was portion toppled once skirt was weakened from heat/cutting, weakened from heat/cutting, pinning the welder down to his pinning the welder down to his deathdeath

Deceased

One of the vessels still intact

Collapsed portion of the cut vessel

4

WHAT/HOW DID IT HAPPENED?WHAT/HOW DID IT HAPPENED?

# 1

# 2

# 3

# 4

PROCEDURE/SEQUENCE USED IN DISASSEMBLING VESSEL #2

V. M

ed

ia F

ilter V

es

se

l

Horizontal View of Vessel

DeceasedMan way section is cut out in

front along w/ horizontal cut on opposite side

Cutting Sequence

Upper body of vessel is cut after

dome removal

Cement

Remaining vessel portion topples once

skirt is weakened from heat/cutting

Weight of upper tank body no longer counter-balances

cement in tank

6

WHY THIS INCIDENT HAD HAPPENED?WHY THIS INCIDENT HAD HAPPENED?

IMMEDIATE CAUSES

•Work crew perceived the Job is routine

•Work crew did not pre-plan the Job adequately

•Failed to recognize hazards

•No Job HSE analysis carried out

•Work crew did not comply with the Permit to Work issued for the Job

•Lack of Supervision

5

WHY DID THIS INCIDENT HAPPEN?WHY DID THIS INCIDENT HAPPEN?UNDERLYING CAUSES

•Involved Personnel lacked sufficient training & knowledge of the Applicable HSE standards and procedures

•Contractor crew, including deceased, was not assessed as required per The Contractor HSE Management Process

•Role & responsibilities were unclear and as a result supervision was Not effectively provided for the Job

•The level of risk involved was underestimated, resulting in lower emphasis being placed on hazard management at work site

7

HOW CAN THIS JOB BE DONE SAFELY?HOW CAN THIS JOB BE DONE SAFELY?

• Assess contractor competency for the Job prior to commencement of operation

• Evaluate critical activities to ensure HSE risks are properly managed

• Pre-plan the Job and carry out Job Safety analysis

• Communicate Hazard and controls required for the task to all concerned parties and adhere to Permit to Work System where applicable

• Never underestimate the risks, even if the Job has been done before