an investigation into the root cause of a spill from procuring and handling of lubricants in...

An intermediate

bulk container (IBC)

was punctured dur-

ing its handling, re-

leasing a refined oil

product onto land

at a large construction site in an environmentally

sensitive region of Australia. Understanding and

controlling the risks from fuel, oil, and chemical

spills on the current project was of critical impor-

tance, as part of the project’s overall approval,

and ongoing compliance was dependent upon

the project’s commitment to minimize all chemi-

cal and petroleum hydrocarbon spills everywhere

on the site. The telehandler or forklift did not

pierce the plastic of the IBC directly, as was

expected to be the case; rather, one of the tines

had caught on the underside of the metal base

plate (pallet), despite numerous controls being in

place at the time of spill, revealing a previously

unreported mechanism for a fluid spill from the

handling of petroleum hydrocarbons and related

chemicals.

The investiga-

tion team used a

root cause analysis

(RCA) technique,

based on the fish-

bone or Ishikawa

diagram, which was undertaken in a thorough

manner with 12 expert contributors from the

project to identify the underlying cause: an in-

adequate inspection process. Applying the safety

controls hierarchy to close out the incident,

given that IBCs could not be eliminated from

the project, and two engineering solutions were

put in place to prevent spills from occurring

from piercing by telehandler tines. Administra-

tive controls (i.e., those least effective) applied

included the introduction of quality assurance

checks for the verification of IBC condition at

various stages throughout the chain of custody.

These verification checks were not limited to the

Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 23

© 2015 Wiley Periodicals, Inc.Published online in Wiley Online Library (wileyonlinelibrary.com)DOI: 10.1002/tqem.21401

An Investigation Into the Root Cause of a Spill From Procuring and Handling of Lubricants in Intermediate Bulk Containers

A Case Study on the Practical

Application of Root Cause Analysis

Turlough F. Guerin

24 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin

strong safety culture, with product spills being

no exception. There are numerous federal and

state laws in effect in Australia that govern the

regulation of chemicals and their subsequent

spills from infrastructure, equipment, and plant,

and their migration into air, water, and land.

Consent conditions, which define the environ-

mental guidelines to which construction projects

must comply as part of the approval process, also

define spills as specific environmental impacts

that must be prevented, and if they do occur

they must be managed, and there is considerable

focus on the management of petroleum-based

spills and contamination in the Australian re-

sources sector (Altham & Guerin, 2005; Guerin,

2005, 2008; Guerin, Turner, & Tsiklieris, 2004).

Based on communication with peer environmen-

tal managers in the industry, the author’s own

informal research suggests that more than 50%

of all construction environmental incidents in

Australia involve spills. Therefore, spills can pose

a significant challenge in meeting approval con-

ditions and ongoing compliance requirements.

Safety in the Chemical Supply ChainOne of the environmental aims of a facility

under construction is to ensure that there is no

unintentional loss of containment of oil, refined

petroleum products, or other hazardous materials

used by earthmoving equipment. The supply of

such materials to construction sites presents a risk

as it exposes these sites to the potential for loss of

product containment. Construction in remote lo-

cations requires a flexible, yet secure, logistics sys-

tem for the delivery of such fuel, oil, and chemi-

cals. IBC units are used to hold various types of

liquids, including oils, acids, and concrete ac-

celerants (Exhibit 1). IBCs are ideally suited for

such applications because of their flexibility for

handling and scalability as the construction work

front changes. However, despite the industry’s

best endeavors, loss of containment may occur,

IBC surfaces, but rather included specific checks,

using a flashlight, if necessary, for obstructions

and deformations particularly in the IBC pallet

or belly plate/base.

Implications from this investigation are that

all projects using IBCs and telehandlers or fork-

lifts should assess the risks and manage them

to minimize spills and the environmental and

safety hazards associated with the interaction

between these machines and IBCs, including

eliminating, if possible, and minimizing the han-

dling of these IBCs. The study also revealed the

limitations of the hazard identification (HAZID)

process used as part

of the approvals prior

to the construction

project—and prior to

procurement of full

IBCs onto the site. The

HAZID process did not

identify the handling

of IBCs as a risk. Even

though more than 20

controls were identified in the investigation

related to the activity associated with and lead-

ing to the spill, half of which were in place that

could reasonably have been expected to prevent

the spill, the incident still occurred with result-

ing cost implications. This is the first study of

this type to undertake cost accounting for the

individual elements of a spill and its subsequent

investigation.

IntroductionLeaks and spills of petroleum hydrocarbon

are a major concern in the upstream oil industry,

from both a construction and an operational

perspective (Altham & Guerin, 2005; Guerin,

2000, 2005, 2006; Ismail & Karim, 2013; Ruffin,

2012; Sánchez-Arias, Remolina, & Alvarez-León,

2013; Stevenson, 2012). The petroleum industry

is greatly concerned about safety, and it has a

One of the environmental aims of a facility under construction is to ensure that there is no unintentional loss of containment of oil, refined petroleum products, or other hazardous materials used by earthmoving equipment.

Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 25Root Cause Analysis of a Minor Spill

logistics, and construction projects, which are

customers in these supply chains.

A recent study by the author analyzing all

plant and equipment spills on a large resource

construction project in Australia found that four

root causes were common to 60% of the spill

events reported during the peak period of earth-

works (Guerin, 2014). The majority of the spills

were of hydraulic fluid, and these occurred pre-

dominantly from excavators, loaders, and trucks,

and the failed components were typically hydrau-

lic hose fittings and their connections.

Previous studies, which are relevant to the

current spill event because of the similarity of the

spilled product, have focused on large oil spills

and their causes (Ismail & Karim, 2013), and

there are numerous reports on the causes of large

oil spills, particularly those occurring in sensitive

marine environments (Talley, 1995). The risks of

transporting and storing crude oil and its refined

products by tankers over large distances primarily

concern accidental events. The Oil Spill Intelligence

Report, published by Aspen Publishers, provides

regular industry updates on major oil spill events

and their causes (Anonymous, 2014a). This se-

rial has provided insights into root causes for

large-scale oil spills, including lack of attention

to maintenance of oil lines, poor weather condi-

tions, pipe corrosion, rupture of hydraulic hoses,

and budget pressures on an oil-field operation.

and we need to understand the root causes, con-

sequences, and implications of such events.

The project’s HAZID did not identify the

handling of IBCs as posing a risk to the project.

Rather, it agreed to deploy these as an improved

approach over other options. Given that there

is an underlying requirement in all profession-

ally managed construction projects to ensure

that the design stage of the project identifies

and considers the potential risks (Behm, 2005;

Behm & Culvenor, 2011; Behm, Gambates, &

Toole, 2014; Fortunato III, Hallowell, Behm, &

Dewlaney, 2011; Gambatese, Behm, & Rajendran,

2008), including those from transport and stor-

age of chemicals, the current resource construc-

tion project decided to use IBCs as an enhanced

and preferred method instead of procuring 205

liters (L) or 44 gallon drums strapped to pallets,

or to purchase vessels larger than IBCs, such as

“ISO” or intermodal containers or other large

transportable tanks.

Examining Previous Spill StudiesAlthough there have been a large number

of spills occurring globally from infrastructure,

equipment, and plant failures, many of which

have been written about in the literature available

in the public domain, relatively little has been

published on their root causes or the broader

implications of these spills for transportation,

Exhibit 1. Examples of Chemicals Commonly Transported to and Stored at Resource Construction and Mining SitesEngine lubricant Grease Brake fluid

Gear lubricants Detergents Sealants

Coolants Solvents Acetone

Sodium hydroxide Hydrochloric acid Bleach

Sulfuric acid Dust suppressants Gasoline

Flotation reagents Emulsifiers Diesel

Herbicides Bitumen emulsion Special fuel mixture

Hydraulic fluids Distilled water Other water-soluble chemicals


(HSE) data demands special attention from cor-

porate leaders and shareholders to control such

incidents as an immediate measure, as well as

to prevent their recurrence through strategic or

operational plans (Restrepo, Simonoff, & Zim-

merman, 2009). Furthermore, lessons learned

from spill incidents need to be communicated to

oil and gas operators and their contractors more

broadly across the upstream oil and gas industry

to assist in reducing the incidence and severity

of these events. Unfortunately, there is evidence

that this is not occurring to a sufficient degree on

either a national or an international level (Fraser

& Ellis, 2008; Fraser, Ellis, & Hussain, 2008). To

enable companies to work intelligently toward

reducing spills, both across their operations and

up and down their supply chains, robust data are

required, which, in turn, demand effective and

appropriate analytical tools for determining and

establishing cause.

One of the tools commonly used to investi-

gate these losses of containment, RCA, will lead

investigators to take both short-term, immediate

corrective actions, and to identify the underlying

root causes (latent failures) hidden in the way

work is done that will help avert similar incidents

or spills in the future (Otutu & Agba, 2003). By

identifying actions to correct these underlying

issues, oil and gas and related construction facili-

ties can continuously improve their overall busi-

ness, reducing spills and averting injuries from

loss of containment of manufactured products

(Otutu & Agba, 2003), and minimizing loss of

chemicals or product.

RCA is a class of problem-solving methods

aimed at identifying the underlying (or root)

causes of incidents (Anonymous, 2014b; Garg

& Gokavarapu, 2012). By directing corrective

measures at core or root causes, it is anticipated

that the chances of problem recurrence will be

minimized. Thus, RCA is frequently considered to

be an iterative process, and it is frequently viewed

There are, however, relatively few studies

published that describe the far larger number

of smaller spills and their causal agents, that is,

those tentatively set at equal to, or less than, ap-

proximately 1,000 L in size. Presumably, these

spills are of less interest to researchers and are

more in the domain of the commercial interests

and practitioners handling the refined products.

Such accidents are a cause of major marine

transportation spills of oil (Talley, 1995). The

upstream and midstream oil sectors take steps

to identify potential risks from construction and

operational oil and chemical spills, and numer-

ous examples of such studies from the Northern

Hemisphere have been

conducted (Bjørn-

bom, Hansen, Engen,

& Knudsen, 2012).

In the study of Vin-

nem, Hestad, Kvaloy,

and Skogdalen (2010),

there are significant

correlations between

number of leaks and

safety climate indicators, and, interestingly, their

very extensive study of the Norwegian oil indus-

try showed that leak frequency and equipment

age did not show a positive correlation. The study

of Ruckart and Burgess (2007) of hazardous ma-

terial events in the mining and manufacturing

industries has analyzed the key role that human

error contributes to spill events. In their study,

11.6% of all events in these industries resulted

from human error. Other contributing factors

were commonly caused by improper filling, load-

ing, or packing. Only 2% of events were a result

of forklift puncture, which is of direct relevance

to this study.

Analysis of Spill CausesThe impact of leaks and spills on company

or corporate health, safety, and environment

Lessons learned from spill incidents need to be communicated to oil and gas operators and their contractors more broadly across the upstream oil and gas industry to assist in reducing the incidence and severity of these events.


environmental concerns for end users in their

supply chains.

Method

Description of OperationThe contractor company that was operating

the IBC-handling equipment when the spill oc-

curred was the primary earthworks contractor

engaged to supply services to the oil and gas

company that had land tenure on the island

on which the resources construction project

was being built. The contractor organization

was operating up to 370 plant items, includ-

ing forklifts or tele-

handlers, used for

handling IBCs. A fully

equipped heavy ve-

hicle repair workshop

was established and

operative at the site.

The contractor em-

ployed approximately

400 personnel (across

the entire construction site) at the time of

the spill. The contractor’s operation was large

compared with other projects underway in the

resources sector in Australia at the time, with

total revenues from the works estimated in

Australian dollars (AUD) at AUD 0.5 billion. As

such, it was considered to be representative of

operations where there is a large throughput of

lubricants, hydraulic fluid, and chemicals. The

overall liquid natural gas (LNG) construction

project was valued at more than several billion

Australian dollars.

Site LocationThe incident occurred at an LNG construc-

tion site located offshore from Western Australia

on a remote island classified as a Class A Nature

Reserve. The site where the spill occurred was

as a tool of continuous improvement. RCA, ini-

tially, is a reactive method of problem detection

and solving. This means that the analysis is done

after an incident has occurred. However, by gain-

ing proficiency in RCA, it becomes a proactive

method. RCA is then able to estimate the pos-

sibility of an incident before it occurs.

RCA consists of the following steps:

• Define the problem;

• Analyze the problem; and

• Find the solutions for the problem (Garg &

Gokavarapu, 2012).

These solutions should be both tactical, to

address the immediate needs of the operation,

and strategic, so as to minimize future occur-

rences in the larger organization and industry,

and for the same construction operation as well

as others.

Purpose and Study RationaleThis paper has an overall objective to pro-

vide a practitioner’s approach to applying RCA

to a relatively minor spill event. This study used

RCA methodology to investigate the cause(s) and

contributing factors that led to an oil spill from

a commonly used bulk handling container (IBC)

on a large construction project in a remote and

environmentally sensitive area. Such contain-

ers are now being widely used across numerous

industries, largely because of their convenience

and low unit cost. The lessons learned and

recommendations made from this study have

general application for the handling of IBCs

internationally, including across the general

construction and resource sectors. While this

study involves an incident with a relatively small

volume spill, there is still a need to determine

root causes and contributing factors of such

spills, as they can pose serious implications for

project costing and budgets, as well as safety and

The lessons learned and recommendations made from this

study have general application for the handling of IBCs

internationally, including across the general construction and

resource sectors.


• Where a robust analysis of the root causes and

contributing factors are required; and

• Where results have to be relied upon before

a potentially expensive change to a business

process or system is implemented.

The RCA method is not commonly used for

relatively minor spills such as the one described

in this study, so the findings here are important

given the reliance that can be placed on the out-

put of the method.

The steps of this process were:

1. Formation of the investigation team;

2. Collection of incident data including ma-

chine handler (operator’s) background;

3. Development of the sequence of events;

4. Undertaking a protective systems analysis;

5. Performing RCA analysis using the cause- and-

effect, fishbone model; and

6. Development of appropriate corrective actions.

Exhibit 2 lists the pro forma options for

possible root causes that were used in the devel-

opment of the RCA process. Preselected primary

and secondary root causes were provided as drop-

down boxes in the documentation to determine

the root cause. These preselected options were

deployed to facilitate responses and outcomes

from all spill events that were as consistent and

comparable with each other as far as practical,

across all operations of the contractor and opera-

tor, thus enabling the comparison of spill causes

between operations.

Formation of Investigation TeamAn RCA investigation team was assembled

from persons possessing a range of complemen-

tary skills. This team comprised 12 members

from the contractor company and the oil and gas

company.

located approximately 2 kilometers (km) from

the ocean in the center of the construction works

where the LNG plant was being built. The topog-

raphy where the spill occurred was flat and well-

travelled by project personnel. The IBC involved

in the spill was located approximately 20 meters

(m) from the main workshop entrance.

Management Systems DescriptionsThe contractor operated under a manage-

ment regime comprising an integrated health,

safety, quality, and environmental management

system. Each component of the system was certi-

fied to the relevant International Organisation

for Standardisation (ISO) standard, including

ISO 9001 and 14001. To ensure alignment of

the contractor’s system with that of the oil and

gas operator, this in-

tegrated system was

audited externally by

the operator every six

months. The incident

management compo-

nent of the system was

fully integrated with the contractor’s business

and the operator’s business systems. All contrac-

tor and operator personnel were inducted in the

use of the incumbent management system at the

time that new employees were on-boarded.

Overview of Investigation (RCA) MethodologyThe team conducted the investigation for this

incident in accordance with a fishbone, cause-

and-effect, or Ishikawa-based RCA process (Anon-

ymous, 2014b). The RCA method used in this

study is based on the Ishikawa, or so-called fish-

bone, method of analysis for determining causes

and contributing factors for an event (or more

generally, cause-and-effect theory) (Ishikawa,

1990). RCA is typically used in industry:

• When a significant injury, death, or major

environmental incident has occurred;

The RCA method used in this study is based on the Ishikawa, or so-called fishbone, method of analysis for determining causes and contributing factors for an event.


Exhibit 2. Pro Forma Root Causes of Fluid Spills Used in Investigations on LNG Construction Sitea

Primary root cause Root cause descriptionb

Procedures and safe work practices Accepted to deviate from work routine

Lack of job oversight

Mistake or mental slip

None exists or available

Not complete or accurate

Not enforced, audited, or inspected

Not trained on procedure

Other priorities conflicted

Risk of not following not understood

Willful deviation

Design Design standards inadequate or not used

Did not anticipate the conditions

Did not consider human factors

Inadequate review

Inherent safety design not incorporated

Inspection and quality control No inspection

Quality control needs improvement

Hold point not performed

Inspection not required

No hold point

Foreign material exclusion during work needs improvement

Inspection instructions needs improvement

Inspection technique needs improvement

Training and competency No training

Understanding needs improvement

Decided not to train

Missed required training

No learning objective

Task not analyzed

Continuing training needs improvement

Instruction needs improvement

Learning objective needs improvement

Lesson plan needs improvement

Practice/repetition needs improvement

Testing needs improvement

Misunderstood verbal communication Long message

Noisy environment

Repeat back not used

Standard terminology needs improvement

Standard terminology not used


• The contractor HSE manager,

• The contractor project director,

• The contractor’s national construction gen-

eral manager, and

• The company incident investigation

manager.

Other administration and support staff were

utilized to undertake specific research into the

incident and the resultant communications.

Team members were:

• The company construction director,

• The company area construction manager,

• Two company environmental coordinators,

• The contractor environmental engineer,

• The company environmental superintendent,

• The telehandler operator,

• The health and safety representative (for the

telehandler operator),

Primary root cause Root cause descriptionb

Supervision Preparation

Selection of worker

Supervision during work

Fall protection needs improvement

Lock out/tag out needs improvement

No preparation

Prejob briefing needs improvement

Scheduling needs improvement

Walk-through needs improvement

Work package/permit needs improvement

Fatigued

Not qualified

Substance abuse

Team selection needs improvements

Upset

Inadequate job hazard/safety analysis

Risk management Inadequate process hazard analysis

Individual snap decision (quick decision made without assessing the risk)

Preventive maintenance/repeat failure Equipment parts defective

Preventative/predictive maintenance/not preventative mainte-nance for equipment

No communication or not timely Preventative/predictive maintenance/preventative maintenance for equipment needs improvement

Communication system needs improvement

Late communication

Turnover needs improvement No standard turnover process

Turnover process needs improvement

Turnover process not used

Turnover less than adequateaAll of these root causes were available as drop down options in the spill report forms. Individuals completing the forms were required to use the provided pro forma options, which also included “not applicable” (not listed in this table).bAdditional primary root causes with no further or root cause descriptions (to tabulate): contractor safety, communications, human factors, management of change, incident and near-miss investigation, emergency response, natural phenomenon, auditing, leadership accountability, and prestart up safety review.

Exhibit 2. (Continued)


The most common IBC is the one-time use

cube (OTC) plastic composite IBC. This unit is

a white/translucent plastic container (typically

polyethylene) housed within a tubular stainless

steel cage that is attached to a pallet. IBCs can

be manufactured out of a number of different

materials depending upon the needs of the ship-

per and the legal requirements that must be met.

In addition to the plastic composite IBC, IBCs

are also manufactured out of fiberboard, wood,

heavy gauge plastic, aluminum, carbon steel,

and stainless steel. Heavy gauge plastic IBCs

are made of reinforced

plastic that requires no

steel cage; they have

a pallet molded into

the bottom so the en-

tire unit is manufac-

tured as a single piece

(Anonymous, 2014a).

Communication ProcessesAfter project spill events that are considered

large by the project’s standards (i.e., >1,000 L;

similar to the one described in this study), the

contractor and the operator companies prepared

projectwide communications that are distributed

to all project personnel. These are in the form

of an email and a verbal description of the spill

events, which is read out to all personnel at a pre-

start event (i.e., at the beginning of a shift). “Les-

sons learned” or “safety alerts” from spill events

are shared at the contractor’s toolbox talks, which

are held weekly on the site and provided to all

personnel. This also occurred after the investiga-

tion report was prepared in the current spill.

Results and Discussion

Background InformationSmaller vessels used for handling refined pe-

troleum products on projects such as those in

Collection of Incident DataData collection included one-on-one inter-

views, review of project and procedural docu-

mentation, employee training records, photo-

graphs from the incidents, and procurement

manifests and related documents. It also included

the goods manifests, discussion with suppliers

of the IBC, and licenses. The time of events and

activities surrounding the incident were obtained

and used to compile a timeline.

Identification of Protective Systems in PlaceProtective systems are defined as software,

hardware, or management systems that reduce

the potential for having an incident or reduce

the consequences of an incident. These include

job safety procedures and HAZID documentation.

The most commonly used procedures and docu-

mentation on Australian construction sites are

safe work procedures (SWPs), job hazard analyses

(JHAs), and “Step Back 5×5s” (i.e., a quick prejob

analysis). The investigation team analyzed all of

the protective systems relevant to this event and

those relating to it.

Description of IBCsAn IBC or IBC Tote or Pallet Tank was the type

of vessel from which loss of containment occurred

in the spill event in this study. An IBC is a single-

use container designed for the transport and stor-

age of bulk liquid and granulated substances (e.g.,

oil, chemicals, food ingredients, solvents, pharma-

ceuticals). IBCs are stackable containers mounted

on pallets that are designed to be moved using a

forklift, a pallet jack, or a telehandler. IBCs have a

volume range that is situated between drums and

tanks, hence the term “intermediate.” The most

common sizes are 1,040 L/275 gallons and 1,250

L/330 gallons (the 1,040-L IBCs are often listed as

being 1,000 L). Cube-shaped IBCs give a particu-

larly good utilization of storage capacity compared

with palletized 205 L drums.

IBCs can be manufactured out of a number of different materials

depending upon the needs of the shipper and the legal requirements

that must be met.


northwest coast of Western Australia, Australia.

Much of the island is covered by spinifex grass-

lands, which provide important habitat for a

variety of wildlife. While the main feature of the

island’s geography is the undulating limestone

uplands, the island is surrounded by a mixture of

sandy beaches and rocky shores, low cliffs, dunes,

salt flats, and reefs. The landscape is arid, and the

climate is usually hot and dry. Most of the annual

rainfall occurs during the cyclone season between

November and April and amounts to approxi-

mately 320 millimeters (mm) per year. Because

of its high conservation value, the island was

declared a public reserve for flora and fauna and

has been classified as a “Class A” Nature Reserve

for the past 100 years.

Using process chemicals, such as petroleum

hydrocarbons, on the project in such a sensitive

environment is a high-risk activity in relation to

potential environmental harm in the event of an

uncontrolled release. This sensitivity was of critical

importance in the study, as an important part of

the project’s overall approval was dependent upon

the project, minimizing all chemical and petroleum

hydrocarbon spills anywhere on the site (with the

exception of within secondary containment).

Employee’s (Machine Operator’s) BackgroundThe investigation revealed that the telehan-

dler operator who was involved in the spill event

had more than 10 years of experience in forklift

operation, held the relevant high-risk license,

including successful completion of the verifica-

tion of competency (VOC), and onsite challenge

test training. The operator commenced working

for the contractor on the project in November

2010, almost two years prior to the spill. The

operator conducted various tasks in the course

of employment, and carried out this specific

task of handling IBCs for the workshop site on

previous occasions. There was a JHA for opera-

tion of the telehandler, which was signed onto

this study include ISO containers and IBCs. The

use of IBCs to transport products to construction

sites poses its own risks, including those to safety

or personnel and potential environmental impact

upon rupture. In the current project, up to 50

IBCs per week were entering the site containing

lubricants, various chemicals, and hydraulic fluid.

Based on estimates from several resource projects

in progress, there could be as many as a million

such IBCs in circulation in Australia alone. These

vessels are vulnerable to damage because of in-

tense handling by tined equipment, as their rela-

tively flimsy design can allow easy puncture unless

very specific controls are in place—as the results of

this study later show. It is important to note that

there are no previous

studies in the scientific

literature reporting

spills from IBCs, fur-

ther highlighting the

need to publish the re-

sults of this study.

IBCs have been used on the project since

project commencement to transport various types

of bulk fluids as well as for temporary storage on

the project site. The chain of custody with IBCs

commences from the point of manufacturer to

the supplier(s), continuing to contractor and

company base supply chains (in accordance with

quarantine requirements) prior to arriving on the

project site. IBCs are transported to the project in

unbunded or bermed sea containers. When they

arrive on the project site, the IBCs are kept in the

contractor’s secondary containment area when in

storage, usually in self-bunded or bermed contain-

ers. IBCs are used by the contractor for transport

and storage of various chemicals, and they were

found to be handled by telehandlers or forklifts.

Site DescriptionThe construction site was located on a small

island located approximately 60 km off the

The use of IBCs to transport products to construction sites poses its own risks, including those to safety or personnel and potential environmental impact upon rupture.


before the project was started. This finding

showed that the HAZID process did not pick up

the potential problem of damaging and handling

damaged IBCs on the project. This was critical as

its absence as a potential risk may have diverted

attention away from IBCs as a process safety risk.

In his studies on root causes, Hendershot (2007)

points out the importance of design engineers

considering the impacts of their decisions as

early as possible in a construction project and

to avoid project designers falling in the mind-

set trap of, “it has always been done that way,”

when developing the final construction designs.

The findings from this study, which describe

the risks from IBCs,

which were originally

deployed because of

the perception that

the risks from these

were very low, will

be fed back into the

knowledge base for

other resource project

design engineers in-

volved in developing

remote projects.

As part of the investigation, structural integ-

rity issues were found with a range of other IBCs

across the project (i.e., with other contractors),

with evidence of dents, damage, and obvious

accident occurrences with IBCs also used to

transport lubricants and chemicals to the project.

None of the events that led to this damage was

reported on the project, and the events were first

discovered and reported as part of the investiga-

tion of this study.

Sequence of Events Prior to Spill EventA timeline was constructed to summarize ac-

tivities before, during, and after the event. These

details are presented in Exhibit 4. The timeline

revealed that the operator of the telehandler

by the operator on the day of the spill. The

contractor had a project SWP for telehandler

operations, and he had received the procedural

VOC training for the task delivered by an expert

operator. The operator stated that there were no

time pressures associated with the task or any

other factors that made the task different on

the day of the event. The operator attended the

contractor’s return to work session, as this was

the operator’s first day of swing after returning

to the project site. In summary, the operator was

fit for work.

Implications of the Assessment of the Protective Systems

The investigation team analyzed the protec-

tive systems relevant to this event, and the result-

ing evaluation is summarized in Exhibit 3.

Although there was an extensive array of con-

trols for this activity, this was not uncommon for

work processes on this project. Analysis showed

that there were no inspection requirements in

any of the project documentation in relation to

IBCs or related items in transport or for storage,

particularly inspections to ensure the identi-

fication of vessel integrity. Of the 21 controls

identified and thought to be relevant to the spill

incident and investigation, 10 were deemed to be

ineffective, and five critical controls that should

have been in place were not in place.

Also, of the 21 separate protective systems,

processes, and controls in place at the time of

the spill, it is noteworthy that only five were

categorized as being higher up the safety hier-

archy than “Administrative.” The use of IBCs

on the project is, in fact, a result of early design

considerations that involved substituting pallet-

strapped 205-L drums of lubricant, the latter of

which were considered to pose an unacceptable

risk from a safety and environmental perspec-

tive. A HAZID process was used—as is common

in industry—and that examined potential risks

Structural integrity issues were found with a range of other IBCs

across the project (i.e., with other contractors), with evidence

of dents, damage, and obvious accident occurrences with IBCs

also used to transport lubricants and chemicals to the project.


Exhibit 3. Evaluation of the Protective Systems and Controls Relevant to the Spill IncidentProtective system Type of control based

on hierarchyIn place? (Y/N)

Effective?a (Y/N)

Comments

IBC: Selection and assessment of type, design, and structural integrity

Elimination/ substitution

N N Other IBC units (from another areas, which are currently or had been in use prior to incident on the project) were identified as damaged during the investigation.

Self-bunded sea container

Isolation/engineering N N These containers are not usually used for transport. These containers are typically used for chemical storage on the project.

Spotter Isolation N N JHA referenced use of spotter if required (when handling IBCs with tined equipment). Operator assessed spotter was not required.

Note: The use of spotter may have influenced the outcome.

Work method statement

Administrative N N Not developed for this particular task.

Plant acceptance HSE checklist

Administrative N N No document was available for the investigation.

SWP Administrative Y N SWP for forklift operations is not specific on when a spotter is required. SWP did not identify potential hazard of obstructions on underside of IBC.

JHA Administrative Y N Operator signed onto JHA.

JHA did not specify when a spotter is required.

JHA did not identify potential hazard of obstructions on underside of IBC.

Communication of similar incidents

Administrative Y N Operator not aware of previous related incidents associated with IBC holding an acid (hydrochloric acid spill of similar magnitude, incident on project site on March 19, 2011).

IBC inspection— Prior to lift

Administrative Y N General area around IBC inspected, inspection did not include underside of IBC and metal plate.

Sea container stacking/filling

Isolation Y Y Correct use of strapping.

“Step back 5×5” (i.e., prework risk analysis conducted by all em-ployees on project site)

Administrative Y Y Four step back 5×5s were completed by the operator throughout the day of the incident.

Telehandler prestart check

Administrative Y Y Prestart check was conducted; no issues identified with telehandler.

Inspection of area (sea container) prior to lift

Administrative Y Y Inspection took place, did not include underside of IBC; according to the JHA there was no requirement to do so.

Supervision Administrative Y Y Supervisor on call and involved in step back 5×5s; supervisor not required to be present for each lift.

Communication Administrative Y Y Communication between operator and workshop superintendent in planning the move of the IBCs and the incident response.


Protective system Type of control based on hierarchy

In place? (Y/N)

Effective?a (Y/N)

Comments

Training: JHA, hazard identification, RTWc

Administrative Y Y Personnel developing JHAs receive feedback from HSE advisors.

Hazard identification toolbox April 18, 2012.

Half-day HAZID course.b

RTW training.

Training: Spill response Administrative Y Y Occurs on a six-month basis for all site personnel.

Random drug and alco-hol testing

Administrative Y Y Process in place and effective

Control of spill Administrative/ protective equipment

Y Y Swift and effective control.

Containment Administrative/ protective equipment

Y Y Earthen bund quickly constructed.

Cleanup Administrative/ protective equipment

Y Y Cleanup required inspection after soil excavation

aThe investigation team made an assessment as to whether the control was effective.bHAZID is a hazard identification process involving a cross-section of stakeholders identifying potential hazards prior to project initiation.cRTW, return to work.

Exhibit 3. (Continued)

tines before extending the telescopic boom. The

operator then returned to the telehandler and

commenced extending the telescopic boom into

the IBC pocket (i.e., pallet base/belly) to engage

the lift. (Note that this function is achieved by

the operator holding in the button to extend the

telescopic boom.)

The operator commenced extending the

boom and then heard a “popping” noise and

observed the IBC collapse immediately. The

operator witnessed oil spilling onto the ground.

The IBC had not been lifted off the ground at

this stage. The operator immediately exited the

telehandler and went to the workshop where

he notified the workshop superintendent of the

spill. The workshop superintendent and the op-

erator returned to the location immediately with

two large spill kits. The workshop superintendent

directed the operator to tilt the IBC upward to

prevent any further spilling (the tines were still

placed within the pockets of the IBC). The IBC

was propped by wooden chocks, and telehandler

was removed and parked close by.

was not negatively impacted prior to the inci-

dent. Furthermore, there were no other adverse

conditions impinging on the activity of moving

the IBC in question.

Outcomes From the IncidentOn the day of the incident, the operator had

undertaken various tasks associated with the use

of a telehandler on the construction site. At ap-

proximately 14:45 hours (h), the operator was

called on the ultra high frequency radio to go to

the workshop to unload a sea container. Upon

arrival, the operator went to the workshop of-

fice and obtained direction as to where the items

from the sea container were to be positioned. The

operator removed the first two pallets of heavy

vehicle parts from the sea container and placed

them at the southern end of the workshop. The

operator returned to commence removal of IBCs

from the sea container. The operator commenced

the activity by placing the tines partially into the

pockets of the IBC and then exited the machine

to check the alignment/position of the fork


Exhibit 4. Timeline of Events Related to the Oil Spilla

Timeb Description of events

6:20 Operator returns to work, first day of swing

6:30 Operator attends prestart meeting

7:00 Operator return to work meeting (normal meeting that occurs when personnel returning to project site)

7:45 Assigned task to operate telehandler

7:50 Operator signs onto JHA for activity

7:55 Operator completes Step Back 5×5 for first assigned task

7:55–8:00 Prestart conducted on telehandler by operator

8:00–10:00 Operator moved pallets for plumbers

10:00 Work break

10:45 Operator completes postwork break Step Back 5×5

10:45–12:00 Operator continues performing various lifts with telehandler

12:00 Lunch break

14:15 Operator completes postlunch Step Back 5×5 completed

14:45 Operator was called on radio and directed to unload sea container at workshop

14:50–15:00 Operator assessed contents of sea container and task

15:00 Operator completes Step Back 5×5 at workshop, for unloading the sea container

15:00–15:15 Operator contacted workshop office to ascertain where pallets were to be positioned once removed

15:15 Operator moved two pallets of spare parts from the sea container in front of IBC, and placed in nominated area workshop

15:15–15:25 Operator released straps securing IBCs within sea container

Operator positioned tines of telehandler into pockets of IBC (approximately 20–100 mm in pocket)

Operator exited telehandler to check positioning of tines

Operator reentered telehandler to commence extending boom and tines into IBC pocket

15:25 Operator heard a “popping” sound, saw IBC collapse quickly and witnessed oil spilling onto the ground

15:25–15:30 Operator exited telehandler and immediately notified workshop superintendent of spill

Workshop superintendent and operator immediately returned to location with spill kits to commence control

IBC repositioned by operator using the telehandler as instructed from workshop superintendent to eliminate any further leaking of oil from IBC

15:30 Workshop superintendent notified contractor’s environmental engineer of spill

15:30–15:40 Loader available in the area commences construction of an earthen bund to contain spill

15:40 Contractor’s environmental engineer arrives at the area, reviews and completes spill report

16:15 Company environmental coordinator arrives on scene, earthen bund is in place

16:30 Pooled oil pumped out of low point in earthen bund. This was then disposed of as hazardous waste

17:40 Contractor submitted spill report to company. Spill report contained all factual details of the spill

18:00 Soil placed over area affected by oil spill to assist in containing the spill. All of the impacted soil was excavated and disposed of the following day

18:30 Incident entered into company database and added to other HSE data from the project

19:00 Investigation commencedaDocumentation was collated on the operator’s training attainment dates, other incidents that operator was involved in, and other incidents involving IBCs from prior to the day of the incident.bTime on the date of incident.


from pro forma root cause descriptions that the

company had developed over several decades

(refer to Exhibit 2). The rational for this was that

there was a defect with the IBC, which caused the

path of the fork tines to be obstructed, leading to

tearing of the base plate and subsequent punctur-

ing of the IBC. Furthermore, there was no specific

inspection process during the chain of custody

for personnel to inspect the undersides of IBCs

for faults or deformities in the metal base plate in

which the fork tines could be caught on. A gen-

eral inspection only around the body of the IBC

and around the base was undertaken, and this

was not sufficient to identify the internal damage

to the IBC pallet base plate.

There were two

contributing factors

to the cause of the

incident:

1. The design of the

IBC cage did not

anticipate condi-

tions on the project. The IBC is designed to

be moved a limited number of times. This

was confirmed by a lubricant supplier, who

informed the author that IBCs are often

referred to as “one-trip cubes,” hence the

petroleum industry term OTCs; and

2. The use of a spotter may have prevented the

outcome, as the spotter may have been able to

identify the deformity in the pallet base plate.

The rigor of the inspection required to have

picked up such a deformity in the base plate

of the pallet would have required the use of a

flashlight, and the inspector would have had

to have leaned down and looked into the pal-

let slot and known what to have looked for.

Exhibit 6 illustrates the configuration of

the impacted IBC at the time of the spill. From

the close inspection of the IBC base, deformed

An earthen bund or berm was quickly con-

structed to contain the spill, and pooled oil was

vacuumed out of a low point from the soil surface

using a truck with the capability of vacuuming a

spilled agent. Cleanup of the affected area was

in progress at this time (i.e., 15:30–15:40 h).

The investigation team inspected the area and

observed that the ground condition around the

sea container was flat, and there were no vis-

ible obstructions, which could have affected the

alignment of the tines with the IBC pallet. An in

situ inspection of the telehandler confirmed that

the tines were not skewed or misaligned.

The data summarized in Exhibit 3 were ob-

tained as part of the investigation process. Imme-

diately following the incident, the operator, work-

shop superintendent, and environmental engineer

inspected the site. This team proceeded to gather

evidence for the purpose of the investigation.

Of critical importance in the incident inves-

tigation was the finding that the fork tines had

not pierced the plastic bladder of the IBC directly.

The investigation determined that the fork tines

had caught on the underside of the metal base

plate. The base plate was subsequently distorted

and pushed inward as the telescopic boom of the

telehandler was extended. The distorted metal of

the base plate punctured the IBC causing it to im-

mediately discharge its contents—and causing the

“popping” sound recorded by the operator. The

evidence supported this conclusion (see Exhibit 5)

and is discussed in the following section.

Findings From the RCAThis section reports the detailed and thorough

findings from the RCA, a result of the extensive

collaboration achieved through 12 experts from

the project contributing their efforts to finding

a root cause. The primary root cause of the spill

was determined to be “Inspection/Quality Con-

trol—Inspection and Acceptance Process is Not in

Place or Adequate.” This root cause was selected

Of critical importance in the incident investigation was the

finding that the fork tines had not pierced the plastic bladder of the

IBC directly.


This author’s research on root causes of fluid

spills from plant and equipment has shown that

the underlying reasons for the majority of fluid

spills is the failure of hydraulic systems, par-

ticularly hoses and their fittings (Guerin, 2014).

Other researchers have reported on the causes

of spills that occur during the operation of oil

and gas facilities (Al-Mansouri & Alam, 2008),

although such research is not directly related

to IBCs or small-sized vessels. These researchers

came to the conclusion that the majority (more

metal had caught on the IBC bladder to cause

the spillage. This finding was established only

after the damaged IBC was inverted and closely

inspected. The investigation also revealed that

the tines of the telehandler had sufficient clear-

ance to enter the base of the impacted IBC under

normal conditions where no such metal deforma-

tion is expected (Exhibits 7–9). Through an in-

verted fishbone or Ishikawa diagram, Exhibit 10

graphically describes the outcome from the RCA

used during the incident investigation process.

Exhibit 5. Data Collected to Verify the Cause of the Oil Spill IncidentData description Comments

Authority to operate/inspect/maintain for operator for the telehandler Manitou MT 1440 dated May 16, 2011 and stating one-year experience with the machine

Discussed by investigation team

Operator’s license to perform high-risk work issued on October 6, 2010 expires on October 6, 2015

Discussed by investigation team

VOC for operator May 10, 2011 Discussed by investigation team

Step Back 5×5—7:45 am May 3, 2012 for “operating telehandler” Conducted by operator

Step Back 5×5—10:45 am May 3, 2012 for “loading of truck with roof sheeting and steel…”

Conducted by operator

Step Back 5×5—14:15 pm May 3, 2012 for “driving forklift” Conducted by operator

Step Back 5×5—15:00 pm May 3, 2012 for “unloading sea container” Conducted by operator

OEM’s health and safety procedure “manual forklift trucks and powered pallet movers”

Note

Prestart on telehandler machine Discussed by investigation team

Contractor’s SWP for forklift operations Note

JHA for telehandler April 20, 2012 Signed onto by operator on May 3, 2012

Inspection of pierced IBC Workshop superintendent stated that new IBCs are requested from the supplier

Witness statement of telehandler operator Formal statement obtained

Witness statement of crane supervisor Formal statement obtained

Witness statement of workshop superintendent Formal statement obtained

Witness statement of mechanical supervisor Formal statement obtained

Photographs taken one to two hours following the incident Viewed and discussed by investigation team

Additional photographs taken of incident area and other used IBC units Refer to Exhibits 6 to 15 in this text

Multimodal dangerous goods form, completed for the sea container May 2, 2012, supply base

Confirms that “the goods have been packed/loaded into sea container in accordance with the applicable provisions”

Photographs taken of IBC immediately after it was loaded into the sea container at supply base prior to shipment to quarantine checking

Shows that IBC was handled at supply base as part of quarantine requirements

Logistics notification request DG standard, sea freight May 2, 2012 Note

Contractor quarantine inspection checklist—packaging May 2, 2012 Quarantine-specific checks only, does not include inspection of integrity/condition of IBCs

Sea container manifest Reviewed by investigation team members


The root cause in this study of “inspection in-

adequate” is similar to ineffective quality control

(described in “vi” above). No other studies have

specifically detailed causes of spills from han-

dling of the types of chemical containers (IBCs)

described in this study.

Comparing the RCA Method With the “5 Why” Analysis

The RCA method using the fishbone, cause-

and-effect, or Ishikawa diagram, is used in the

literature for analyzing large spills because the

underlying causes of such incidents can be

than 90%) of these leaks and spills are due to one

or a combination of potential root causes such as:

(i) Aging facilities,

(ii) Equipment failure,

(iii) Construction defect,

(iv) Accidental damage,

(v) Defeat/bypassing of protective system,

(vi) Ineffective quality control,

(vii) Operational deviation,

(viii) Design fault,

(ix) Blow out of oil well, and

(x) Human error.

Exhibit 6. Views of Damaged IBC

Note: Top left: Timber and tines of the telehandler used to hold punctured IBC in tilted position (note bladder has collapsed or on itself). Top right: Underside of IBC showing impact of damaged metal (belly) plate and location in which the tines are inserted. Bottom left: Underside of IBC showing point of puncture/tear on IBC bladder. Bottom right: Undamaged IBC behind damaged IBC (in sea container) for comparison and spill absorbent material in front.


involves asking why, up to five (or even more)

times, a particular event occurred in the series of

events that led to an incident. In simple terms,

once asking the “Why” question yields no fur-

ther reasons for the cause(s) of an incident, then

the root cause is determined and communicated.

This is why, on many commercial construction

and resource projects, the shorter and less in-

volved process of the “5 Why” method is com-

monly used instead of an RCA. The advantage

of the “5 Why” method is that it can be done

using limited resources (usually by an individual

or small team). However, it does rely on profes-

sional judgment or practical experience to ensure

that the line of questioning is appropriate for the

event under investigation. A qualitative com-

parison of these two types of root cause assess-

ments is given in Exhibit 11. In the majority of

cases, this depth of analysis is “fit for purpose,”

enabling the business to learn quickly and keep

determined with a high degree of confidence.

The results from these analyses are more likely to

be trusted (though not always) for implementa-

tion, and, therefore, they are more likely to be

considered to help prevent recurrences of such

incidents in other sites or settings. However, as

in this study, the thoroughness required by the

RCA method means that a relatively large num-

ber of people with a range of in-depth skills must

be brought in on the investigation. Typically,

several experts may be required for several hours.

One of the problems with the application of RCA

methodology is that it is often only applied to

relatively large or major spills. Commercially,

RCA approaches are marketed under various

trade names, such as ICAMM, Taproot, and the

like, and require several days of training to gain

proficiency in the detailed methodology.

A shortened version of the RCA is called the

“5 Why” method (Pojasek, 2000). This method

Exhibit 7. Views of Work Site at Location at the Time of Spill

Note: Top left: Punctured IBC in location at the time of spill with telehandler in proximate location. Top right: Tines of telehandler involved in the spill. Bottom left and right: Dimensions of tines of telehandler indicating that there was sufficient clearance for insertion of tines into IBC base without any damage expected. Distal end on bottom left and load end on bottom right.


thorough RCA approach was used, ensuring

that the needed resources would be employed

to generate sufficient confidence in the result of

the analysis to enable the needed changes to be

made on the project (see the following section on

Development of Corrective Actions).

Cost ImplicationsAlthough the cost of safety model has been

prevalent in the mainstream safety literature

for the past decade or more (Behm, Veltri, &

Kleinsorge, 2004), corporations have not widely

adopted the approach, nor is any form of finan-

cial analysis of safety or spill incidents commonly

going, business as usual, plus locking in the re-

quired prevention strategies.

However, when the “5 Why” method is

used to determine underlying causes, this means

that full analysis and understanding of the root

causes and contributing factors are not always

thoroughly determined. This, in turn, means that

changes that are made as a result of the findings

of a “5 Why” analysis might not provide ad-

equate prevention measures. As a consequence,

the actual root causes are not necessarily properly

identified and communicated as widely as would

be desired to reduce fluid spills. For this reason,

it was important in this study that the more

Exhibit 8. A Side View of the Base of the IBC; Pallet Showing Dimensions Relevant to the Telehandler Interaction

Exhibit 9. Location of IBC Relative to Rest of the Sea Container Contents and the Telehandler in the Delivered Container


Exhibit 10. The Results of the RCA “Why Tree” for the Oil Spill Incident


component contributing to the spill). Given that

on this project, the same contractor had three-

to-four incidents of such magnitude (at the time

the data were collected for this study), total costs

from spill events are estimated conservatively at

AUD 1–2 million when all project contractors—

up to 20 additional and separate entities—are

considered.

Development of Corrective ActionsBased on the findings of the study, numerous

corrective actions were identified and were rec-

ommended to be implemented by the contractor

and the company. The hierarchy of controls was

applied to the corrective actions, and the actions

were numbered from one to six. While effort was

directed at elimination of risks, substitution, and

engineering, the majority of the implemented

controls to control risks from spillages of bulk

lubricants and chemicals were administrative

in nature. As previously mentioned, the deci-

sion to use IBCs stemmed from the early design

stages, where the risks perceived from using 205 L

drums strapped to pallets were considered to be

too high.

practiced. As a result, companies have tended

either to underinvest in preventive and detection

efforts, or to overspend, putting controls in place

that outweigh the risks from failure. No compa-

rable cost breakdown data were available from

the literature for assessing the current incident.

An estimate was compiled for the break-

down of the costs of the current spill and the

subsequent investigation, and these are given in

Exhibit 12. The cleanup of the contaminated

soil and the commitment of time by the contrac-

tor’s environmental engineer were the single larg-

est cost items from the spill incident. The cleanup

involved the rapid deployment of earthmoving

equipment away from other construction jobs

on the project, containment of oil using earthen

bunds (see Exhibit 13), and then removal, and

disposal of the contaminated soil. This was fol-

lowed by reporting of the incident and replace-

ment of the lost product. This cursory analysis

illustrates that the immediate knock-on effects of

such a spill can have a material impact on a proj-

ect’s budget. The analysis also does not attempt

to quantify the lost productivity from equipment

and machinery downtime (impacted by the failed

Exhibit 11. A Qualitative Comparison of the “Why Tree” (RCA) and “5-Why” Process for Determining Root Causesa

RCA “5-Why”

Detailed, time consuming

Requires extensive training for personnel to lead investigation (several days)

High-level, rapid

Short course (one to two hours) required

Thorough, extensive collaboration in decision making, involving a broad range of experts from diverse backgrounds

Brief, with minimum of consultation/collaboration to decide on the causes, designed to be conducted by individuals or small teams

Requires significant level of resources (requires a team of at least five to six)

Can be done using limited resources (can be done by an individual or small team)

Provides a robust analysis of the root causes and contributing factors

Relies on professional judgment to ensure the line of questioning is appropriate for the event

Results can be relied upon to change business process or systems

Limited reliance can put on the results of a single analysis

Is applied in commercial contexts where a significant injury, death, or major environmental incident has occurred

Is applied in commercial contexts as a common method for RCA where an incident investigation is required

aThis comparison has been developed for practitioners and is based on the author’s experience and professional judgment (Ishikawa, 1990).


Exhibit 12. An Estimate of Financial Costs of the Spilla

Cost element Description Value (AUD)

Loss of product 1,000 L of high-quality lubricant 5,000

Time commitment of environmental engineer

60 hours of time committed to remediation, investigation, and close out

9,600

Soil cleanup Operation of a wheel loader (one to two hour) and supervision/disposal of 10 t contaminated soilb

11,000

RCA Preparation, delivery, and review 3,000

Interviews Meeting with all stakeholders involved 640

Engagement of suppliers Discussions regarding IBC and its history 240

Reporting Preparation of entire investigation report and presentation to operator

6,500

Administration Collection of all required documentation, communication of findings

2,000

Total 37,980c

aConservative estimates based on pay rates of approximately AUD 160 per hour for an engineer.bThe cost of disposal of contaminated soil on the project site was approximately $ AUD 1000 per ton.cIt excludes downtime or lost opportunities for the contractor.

Exhibit 13. View of Spill and Cleanup

Note: Top left: Spilled oil migrated out of unbunded sea container to soil around the front of container. Top right: Floor of container showing the absence of internal bunding. Bottom left: Rear of container. Bottom right: Side of container showing earthen bund erected to limit flow of oil, minimizing safety and environmental impacts. All contaminated soil and contaminated absorbent materials were removed and disposed of as contaminated material within 24 h of the spill event occurring.


Exhibit 14. View of Engineering Controls

Note: Top left: Engineering control, that is, IBC cage, put in place as a result of the spill investigation by contractor at the point of receival of IBCs onto project at the supply base. Top right: The second engineered control, a base plate manufactured on site to minimize impacts of tines on IBCs. Middle left: Other IBCs identified on the project site, that is, in the jurisdictions of other contractors, after the investigation, showing damage to top of IBC other IBCs identified on the project site. Middle right: after the investigation showing damage to base. Bottom left: Other IBCs with extensive damage to base. Bottom right: Damage to the side of another IBC from the project.


visual inspection by the spotter, the spotter

will notify the area supervisor to assess and

determine the need for the contents of the

IBC to be decanted into another IBC unit

in good order prior to lifting or moving the

damaged IBC. IBC units that are identified

as damaged were tagged out to prevent the

use of a forklift/telehandler to pick them up.

Several such damaged IBCs were identified

across the project site (Exhibit 14). The im-

plications of this change to the inspection

regime are that it may expose the inspection

personnel (or spotters) to the added risk of

back injury/strain resulting from repetitious

leaning down to inspect pallets, and this risk

will need to be monitored on the project.

4. Numerous other administrative controls were

upgraded on the project as a result of the

investigation. All relevant JHAs and SWPs

within contractor, subcontractors, and con-

tractor offsite and supply bases were updated

to include:

• Mandatory use of spotter for the transfer of

hydrocarbons or hazardous materials;

• Specific reference to detailed inspection of the

bases of IBCs, including the use of a flashlight

to enhance visual inspection of underside of

The corrective actions are:

1. Design, construct, and use of a protection

plate (an engineering control) was employed

to prevent fork tines from puncturing IBC

units as they are handled, particularly on

major projects where there are numerous

points of handling of these vessels. The

design and construction of such a plate are

provided in Exhibits 14 and 15. In addi-

tion, as a result of the incident, the contrac-

tor began trialing the use of a metal cage for

storing IBCs during shipment and transport

(Exhibit 14). A series of such plates were

manufactured on the project site and have

been deployed across the contractor’s opera-

tions wherever IBCs are being handled.

2. Undertake chain-of-custody inspections of

IBCs containing lubricants and other chemi-

cals to identify and reject any damaged IBCs

with metal base frame deformities from

the supplier’s to the contractor’s supply

base.

3. Undertake inspections of all IBCs that are re-

quired to be moved onsite (across the project)

by telehandlers to identify any other potential

metal base frame deformities. When an IBC is

identified as damaged underneath from the

Exhibit 15. Design of Plywood Protection Board (or Base Plate) for Handling IBCs

Notes: 1. Height of the fork lift tine slots not to exceed the height of the IBC frame/skid slots 2. Cut outs for hand holds 3. Tine spacing thickness 400–500 mm


quarantine requirements), it would appear that

their construction is not likely to be suitable

for multiple lifts with a forklift or telehandler.

There are four points of entry in which the fork

tines can be entered into the base of IBCs. Two

of these entry points create potential obstruc-

tions from the protruding support strut under

the metal base plate on which the fork tines

can be caught. It is necessary to check and/

or reject IBC units with damage during chain

of custody, paying particular attention to the

underside/metal base to ensure that there are

no obstructions. Therefore, it is recommended

that quality assurance

checks for verifica-

tion of IBC condition

at the various stages

throughout the chain

of custody should be

implemented.

There is no protec-

tion plate on these IBC

frames to eliminate

fork tines from making contact/puncturing IBC

units (bladders containing product). Also, this

particular type of IBC unit has no self-bunding

to capture spilled product. Other damaged IBCs

around the construction site were identified

and marked as potentially unsafe so as to avoid

similar incidents.

It is also recommended that the use of a

spotter be implemented to further minimize the

risk of future spills. It should not be assumed by

the handlers of these vessels that their lifts will

be restricted to a certain “low” number. Rather,

damage to these IBCs should be expected and

looked for as they arrive into the areas under

the handler’s operational control. Given that the

RCA process can be predictive, this knowledge of

the vulnerability of commonly used IBCs can be

used by IBC handlers to help eliminate the type

of spill reported in this study.

IBC units in sea containers for possible dam-

age to metal base plate;

• Use of a protection plate to prevent tines from

puncturing the IBC unit;

• Prior to lifting or moving IBCs what are iden-

tified as damaged underneath from the visual

inspection by the spotter, the spotter will no-

tify the particular area supervisor to assess and

determine the need for the contents of the

IBC to be decanted into another IBC unit; and

• Identified damaged IBC units will be tagged

out to prevent forklifts/telehandlers from in-

teracting with damaged IBCs.

These changes were incorporated into the

contractor’s HSE systems and wider business.

5. Developed a toolbox talk package for rele-

vant teams within the contractor’s workforce

and communicated the lessons learned from

the incident, including new requirements,

which were added to inspect the underside

of IBCs, and amendments to updated JHAs

and SWPs.

6. Communications were prepared after the

completion of the investigation, and a site-

and project-wide alert was prepared and dis-

tributed.

While these recommendations are specific

to the project site of this study, the implications

for other sites and projects are much broader,

given the popularity of the use of the 1,000-L

IBC for supplying and distribution of lubricants,

chemicals, and other hazardous materials across

resource construction projects.

Conclusions

GeneralIn designing an IBC that is fit for pur-

pose (i.e., of lightweight nature and will meet

In designing an IBC which is fit for purpose (i.e., of lightweight nature and will meet quarantine

requirements), it would appear that their construction is not likely to

be suitable for multiple lifts with a forklift or telehandler.


sustainable development by reducing environ-

mental impact (Guerin, 2009). Engagement with

plant and equipment and chemical suppliers by

oil and gas companies and/or their civil contrac-

tors would be a productive next step. There is

also scope for greater involvement of broader

cross-company (or site) personnel to collaborate

in such investigations.

Similarly, there is an opportunity for compa-

nies to have their HAZID processes or assessments

reviewed by external parties to ensure that these

assessments are not compromised by limited (or

inwardly focused) thought patterns by company

personnel.

More broadly, there are opportunities to reeval-

uate the role of RCA in commercial applications to

undertake spill investigations. In addition, there

are opportunities for industry to consider adopting

improvements to the RCA process to make it less

complicated and more streamlined without losing

its ability to derive actual underlying causes of

incidents, as other safety professionals (Ferjencik,

2014) suggest from their extensive work done on

the improvement of RCA methodology.

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A cursory examination of the costs arising

from the spill suggests that such events are likely

to have a material impact on the costs for the

project. As such, ongoing attention will need to

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Turlough F. Guerin is a professional environmental manager currently managing the approvals and compliance programs for First Solar’s EPC business in Australia, overseeing the construction of several solar PV power stations in Australia. His career has spanned soil and groundwater assessment and remediation for Rio Tinto and Shell, contractor compliance and assurance management for Chevron, managing the sustainability portfolio for Australia’s largest telecommunications company, Telstra, and consulting to Levine-Fricke-Recon, ICF Kaiser Engineers, and Motorola. He received his bachelor’s degree in agriculture and undertook postgraduate studies and research into the degradation of chlorinated pesticides in farming soils, sediments, and waterways.