learning from incidents

Learning from incidents

Neal StoneDirector of Policy & CommunicationsBritish Safety Council

Glasgow Caledonian University

10 December 2013

Three ODA award winners 2010 and lessons learnt PROJECTS• Company A: International Broadcast Centre/ Main

Press Centre

• Company B: Sewerage system

• Company C: New utilities

Company A: International Broadcast Centre/ Main Press Centre3

Company A: International Broadcast Centre/ Main Press Centre

The Background

• Whilst erecting the steel Beams and Columns a slinger fitted the piling clamp to a 10 meter length column.

• The piling clamp is a propriety lifting attachment and is regularly used to lift the columns. The slinger failed to ensure the pin had secured properly through the hole in the web.

• As the cranes head was directly above the lifting point the piling clamp would grip until the angle of the column altered enough for the piling clamp to slide free.

• This then left the piling clamp suspended

on the chain and the column falling to the ground.

• Fortunately, an exclusion zone was in place and nobody was injured.


Poorly positioned clamp

Dawson clamp

The piling clamp

Company A: International Broadcast Centre/ Main Press Centre The Real Picture


Company A: International Broadcast Centre/ Main Press Centre

Lessons learnt

a) Slingers need to ensure that they double check that all lifting equipment is attached correctly before signalling the crane driver to begin lifting.

b) The design of the piling clamp means that you rely on the operator to ensure the clamp engages in the hole using the spring release. Dawson clamps should be used instead of piling clamps to lift the columns because there is less of a risk of an operational error due to the fact the operator must physically install the pin through the hole before signalling the crane driver to begin lifting.

c) The resulting investigation and near miss report was shared across the Park.

Company B: Sewerage system6

Company B: Sewerage system

The Background

• On 1 April 2009, an employee suffered multiple fractures and a cracked heel to the left foot when a concrete shaft segment (approx. 700 kg) toppled and fell onto his foot.

• In recent years as developments of concrete shaft segment has progressed, the segments have become thinner and taller, making them less stable when stored upright in their correct position. The standard industry practice was to tie the segments in a stack which was adequate when the segments were not being used.

• The problem arose when a segment was required to be removed from the end of the stack for use in the construction. When the ties were released, the end segment became unstable.



The Real Picture

Toppled concrete

Segment into frame

Multiple shaft segments into frame



Lessons learnt

a) Key Learning Opportunities

• Sectional ownership reviewed providing slinger signallers storage responsibilities

• All existing segment storage sites checked to ensure safe storage i.e. provision of segment restraints.

• New 'L' bracket and segment buffers designed as permanent preventative solution.

• 4 Stage safe segment storage working practice document to be introduced and implemented as a mandatory requirement.

b) New Measures

• Segment buffers available• New guidance sheets available on safe use of

segment buffers.• Ownership is being rolled out to all

supervisors/site agents.• System used across the business

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Company C: New utilities

The Background


• Company C was required to install over 50 salmor pits for the 11kv (LVU) installation works. To install them the ground has to be excavated to the correct depth and wide enough to accept the pit.

• During the initial installation works, the teams reported that the standard industry practice for access and egress was plainly not best practice. i.e. two ladders tied and criss-crossed, one on the inside and one on the outside of the pit. The operative had to access the actual excavation via a ladder, then climb another ladder on the outside of the pit, then cross over and descend into the pit via another ladder on the inside of the pit.

• The reason the access arrangements were like this was that the excavation when constructed was supported by battering the sides to an angle of 45°. Therefore the edge of the excavation was always approximately 1 - 1.5 metres away from the edge of the salmor pit.

Company C: New utilities10


The Real Picture

Best practice winners 2010

The pit

Access platform

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Lessons learnt


• Something that would span the gap between the excavation and the salmor pit was required. It would have to be a least 2 metres in length, have handrails, wide enough to access a ladder safely to enter the pit, light weight (two man lift maximum) and robust with stop ends. A quick prototype was developed and the solution was found to be ideal for the task in hand.

• The access platform eliminated two ladders. Handrails provided security when accessing the pit over the excavation. The risk of falling into the pit during access was eliminated. The standards of the ladder accessing the pit were secured to the platform providing more security for the person. The platform could not slip even if the platform had to be placed at angles to access the pit.

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Lessons learnt


“What was particularly pleasing about this innovation was

that it did not require a committee to decide to do it; but

from a ground/workface demand the team felt

empowered to go and make it happen.”

Project Director (Company C)

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Thank you

Neal StoneDirector of Policy & CommunicationsBritish Safety Council

learning from incidents

Documents

piling clamps

end segment

sewerage system6company

segment restraints

segment buffers

framecompany b

sewerage system7

real picturecompany