FALL FROM LADDER INCIDENT DRILLSAFE MELBOURNE 02 DECEMBER, 2010 Presenter: Russell Telford Rig175 HR /HSE Supervisor
WORKING AT HEIGHT EXPECTATIONS WHEN WORKING AT HEIGHTS THE EXPECTATION IS NOBODY FALLS AND TO BRING ABOUT A SIGNIFICANT REDUCTION IN RISK ASSOCIATED WITH WORKING AT HEIGHT. THIS CAN BE ACHIEVED WITH PROPER PLANNING APPROPRIATE TRAINING ESTABLISHING PEOPLES ROLES AND RESPONSIBILITIES CORRECT EQUIPMENT SELECTION: CERTIFICATION, INSPECTION AND MAINTENANCE. SAFE BEHAVIORS PARTNERSHIP APPROACH EMERGENCY RESPONSE PLAN 2
THE INCIDENT OVERVIEW THE DRILL CREW WERE PREPARING TO RUN THE WEARBUSHING ON A STAND OF DRILL PIPE. THE FLOORMAN ASCENDED THE MAST TO RACK BACK A STAND OF DRILL PIPE AT THE CONCLUSION OF SETTING THE WEAR BUSHING. AT THE COMPLETION OF RACKING BACK THE STAND OF DRILL PIPE THE FLOORMAN DESCENDED THE MAST TO ATTEND A JSA FOR THE NEXT OPERATION. DURING THE DESCENT OF THE MAST THE FLOORMAN FELL FROM THE MAST LADDER APPROXIMATLY 14 FEET TO THE RIG FLOOR. 3
R175 RIG FLOOR LAYOUT AT TIME OF INCIDENT Floorman Driller Roust Floorman Roust V-Door 4
THE INVESTIGATION THE INVESTIGATION FOUND THAT DURING THE FLOORMANS DESCENT THE LAD-SAF BRAKING DEVICE (PRIMARY FALL PROTECTION) ENGAGED AT APPROXIMATELY 14FT FROM THE RIG FLOOR. THE FLOORMAN TRIED TO DISENGAGE THE BRAKE BY STEPPING UP ONE RUNG AND HOLDING HIS WEIGHT WITH HIS LEFT FOOT WHILE USING HIS RIGHT HAND TO DISENGAGE THE BRAKE. AT THIS POINT THE FLOORMAN LOST THREE POINT CONTACT WITH THE LADDER. THE FLOORMAN ONLY HAD HIS LEFT HAND AND LEFT FOOT IN CONTACT WITH THE LADDER. 5
THE INVESTIGATION THE FLOORMANS LEFT FOOT SLIPPED ON THE LADDER RUNG SIDEWAYS AND HIS LEG WENT THROUGH THE LADDER CAUSING HIM TO LOSE HIS BALANCE. THIS CAUSED THE FLOORMAN TO GRAB THE BRAKING DEVICE AND THE LAD-SAF CABLE TOGETHER, THEREFORE DISABLING THE BRAKING DEVICE. 6
THE INVESTIGATION APPROXIMATELY 6FT FROM THE RIG FLOOR THE LAD-SAF BRAKING DEVICE ENGAGED. DUE TO THE FLOORMANS MOMENTUM THE KARABINER THAT CONNECTED HIS HARNESS TO THE LAD-SAF SYSTEM ELONGATED AND OPENED UP ALLOWING THE FLOORMAN TO FALL TO THE RIG FLOOR. New Damaged 7
THE INVESTIGATION NO SECONDARY FALL PROTECTION WAS USED BY THE FLOORMAN. ie: INERTIA REEL AS REQUIRED BY POLICY AND THIS WAS IN PLACE FOR USE WHEN ASCENDING AND DESCENDING THE MAST. THE KARABINER SCREW GATE WAS FOUND TO BE IN THE UNLOCKED POSITION WHICH WAS CONFIRMED BY A CERTIFIED THIRD PARTY AUTHORITY. THIS EFFECTED THE INTEGRITY AND THE EFFICIENCY OF THE KARABINER. THUS ALLOWING THE KARABINER TO ELONGATE AND OPEN UP. THE KARIBINERS SWL WHEN IN THE LOCKED POSITION IS 2549 KG, WHEN THE KARABINER IS IN THE UNLOCKED POSITION ITS LOSES 2/3 S OF ITS INTEGRITY. 8
INJURED FLOORMANS STATUS AS A RESULT OF THE FALL THE FLOORMAN SUSTAINED A FRACTURED LEFT FIBULA 2 INCHES ABOVE THE ANKLE AND INJURED HIS L1 & L2 VERTEBRA. 9
DIRECT CAUSES THE FLOORMAN LOST THREE POINT CONTACT WITH THE LADDER WHILE TRYING TO DISENGAGE THE LAD-SAF BRAKING DEVICE. THE SECONDARY FALL ARREST SYSTEM (INERTIA REEL) THAT WAS INPLACE WAS NOT USED AS PER COMPANY POLICY. THE KARABINER SCREW GATE WAS NOT PLACED IN THE LOCKED POSITION. 10
ACTIONS TO PREVENT RECURRENCE A SAFETY STANDDOWN WAS HELD AND ACCESS TO THE MAST SUSPENDED UNTIL FURTHER RISK ASSESSMENT AND JOB SAFETY ANALYSIS WERE CONDUCTED. THE HEIGHT SAFETY EQUIPMENT WAS CHECKED AND VERIFIED TO BE IN GOOD OPERATING CONDITION BY A CERTIFIED THIRD PARTY AUTHORITY. THE CREWS WERE TRAINED ON BASIC LADDER TECHNIQUES. TASK SPECIFIC JSA S AND BUDDY CHECKLISTS WERE DEVELOPED FOR ASCENDING / DESCENDING THE MAST. THIS ENSURES PERSONNEL ACCESSING THE MAST HAVE A BUDDY TO ASSIST WITH THE APPROPRIATE P.P.E. AND GIVE VERFICATION OF CORRECT FITMENT. ADDITIONAL SIGNAGE WAS PLACED AT THE ACCESS POINTS OF ALL THE MAST LADDERS. 11
ACTIONS TO PREVENT RECURRENCE 12
ACTIONS TO PREVENT RECURRENCE 13
VERIFICATION ARE OUR WORKING AT HEIGHTS EXPECTATIONS UNDERSTOOD AND REINFORCED ON A REGULAR BASIS? WHEN WERE CREW MEMBERS LAST TRAINED? HAVE THE RIG CREWS RECEIVED REFRESHER TRAINING? DO CREW MEMBERS UNDERSTAND CORRECT USE OF FALL PROTECTION SYSTEMS? WHAT FALL PROTECTION SYSTEMS ARE AVAILABLE / REQUIRED FOR EACH ASCENDING/DESCENDING LADDER? 14
VERIFICATION WHAT PROCESSES ARE BEING USED FOR EQUIPMENT SELECTION, CERTIFICATION, INSPECTION, MAINTENANCE? IS THE WORKING-AT-HEIGHTS OPERATIONS CHECKLIST BEING USED? FOR WHAT OPERATIONS/ACTIVITIES? ARE PROCESSES DIFFERENT FOR EXPERIENCED VS INEXPERIENCED CREW MEMBERS? DO JSA S FOR ALL ACTIVITIES COVER DIFFERENT WORKING-AT-HEIGHTS HAZARDS? 15