ccgi forklift incident - fatality

7/29/2019 CCGI Forklift Incident - Fatality

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Galkynysh Gas Field Development Project

Yoloten, Mary, Turkmenistan

PIUL Contract: NO.: GKT-29.12/09-02

CCGI Fatality

CCGI Structural Laydown Area

14 January 2013

Investigation


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Summary

Incident Details

Location : CCGI Structural Steel Lay down Area

Date & Time : 14 January 2013; 1520 hrs

Incident Type : Fatality

Contractor : CCGI

Name of Deceased: Aman Gammarov: Married with three children

Nationality : TurkmenAge : May 1981

Nature on injury : Crush Injury


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Summary

One charge hand and five workers were tasked with general housekeeping duties in the laydown yard.

Pre-job meeting for general housekeeping was carried out. During this meeting it was mentioned that

the forklift would not be required. Forklift operator did not attend this meeting. He was informed he

was to work elsewhere after lunch.

Workers were left unsupervised to carry out the clean-up activities. Charge hand left the site to PMV to

check on a crane under repair.

Deceased instructed forklift operator to help move 1750 kg steel beam.

Forklift raises the beam about 60cm off the ground, but the beam is very unstable due to placement ofthe beam on the forks and a piece of timber that was lodged between the beam and the forks.

Deceased worker attempts to manipulate and extract the piece of timber under the beam and in doing

so bends down placing himself at risk under the beam.

Manipulation of the timber causes the beam to fall on the deceased worker causing fatal crush injuries

to head and chest.

Key Facts:

Workers decided to perform a task beyond the original job instruction.

Workers were left unsupervised.

Forklift operator was properly certified in Forklift operations, but no certified riggers were available.

Specific task of lifting beams with forklift was not described in any method statement or task

assessment.

Incorrect usage of equipment to lift the beam.

Peripheral activity to main site works.

Incident Description :


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Incident Sketch


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January 2013Group HSSEIA Performance5


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Root Causes

Operator Error

6.2 Inadequate practice of skills:

a) The operator should have tilted the forks backward to avoid the load tipping forward.

b) The operator should have lowered the load on the ground in order the IP to remove the

timber under the load.

Not Following Instructions

5.3 Inadequate identification of critical safe behaviors: The IP placed himself in line offire, where he should not have been.

11.1 Inadequate work planning: The crew the IP was in deviated from the initial work

planning that they were supplied with, which was manual handling/housekeeping of the

area and ended up using the forklift.

13.10 Improper equipment selection: Usage of Forklift for such materials was notmentioned/identified in the related procedure; the crane should have been used.

14.4 Inadequate enforcement of PSP: The crew which the IP was in was clearly instructed

not to use mechanical means to organize the yard but IP ignored the instruction and

ordered the forklift to be used.


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Action Items

Actions Responsible Party Due Date Status

CCGI to provide full refresher training to alllifting operators.

CCGI 25.01.2013 COMPLETED(25-30.01.2013)

After finalization of the report, full project

size safety stand down should be performed

by senior management endorsement.

PIUL and CCGI 21.02.2013 COMPLETED

13&15&21.01.2013

All subcontractors should initiate a full

thorough inspection on the material stacking

at their current stock yards to correct any

unsafe condition.

PIUL HSE Manager 26.01.2013 COMPLETED

03.02.2013

CCGI to submit JSA/MS for each specific

lifting task.

CCGI 10.02.2013 COMPLETED

06.02.2013


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Action Items


No lifting/material handling activitiesshould be carried out unless supervised

by competent supervision. No load to

be lifted when the resting position is

not safe.

SubcontractorsSite Managers

Immediate BEING DONE ONDAILY BASIS BY HSSE

DEPARTMENT

The supervision of such activities must

be responsible and accountable and

present at all times in their work

location.

Subcontractors

Site Managers

Immediate BEING DONE ON

DAILY BASIS BY HSSE

DEPARTMENT

All lifting operations related personnel

must be trained in hazard awareness

and related safe working practices.

Subcontractors

Site Managers


DAILY BASIS BY SITE

MANAGEMENT

All subcontractors to increase frequency

and quality of hands-on training prior to

each start of a new task and those to be

provided to PIUL for attendance and

surveillance.

Subcontractors

Site Managers


DAILY BASIS BY SITE

MANAGEMENT


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Action Items


Petrofac Assurance Index to be

expanded to include section on

Peripheral Activities.

ECOM HSSE Immediate COMPLETED

29.01.2013

ccgi forklift incident - fatality

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