Lessons Learned

October 4, 2005

Fatality from a fall from the platform access ladder

Incident Description:Incident Description:

The victim along with 3 other scaffold erectors was erecting

scaffold (for steel work modification) at the 33 metre level of

the LNG flare structure. The victim indicated to the remaining

crew that he intended to descend to make use of the toilet

facilities. One of the crew members witnessed the victim

climb on to the ladder and fall. He also confirms that

immediately prior to the fall he observed him with the lanyard

clip in his right hand i.e. unclipped from the permanent

handrail above the ladder. Finally he confirms that no attempt

had been made by the victim to attach to the fall arrestor prior

to stepping off the grating on to the ladder.

The victim appears to have fallen side ways from the ladder

and descended head first through the structure landing some

14 metres below the top of the ladder on to a scaffold

structure at the 19 metre level.

The ladder itself is in good condition and there is no evidence

of any specific deterioration in the rungs, which may have led

to a slipping hazard. The victims work boots are also in good

condition with adequate tread.

Incident Pictures (01): The access ladders

Location of the landing

14 m

Incident Pictures (02):

Photograph showing the temporary access ladder protruding over the landing platform and arrangements of ladder securing.

Photograph showing a similar temporary access ladder protruding over the landing platform and arrangements of ladder securing.

Photograph showing the landing at the bottom of the temporary ladder.

Outcome:

The injuries sustained by the victim: Multi-system blunt trauma of head, chest,

abdomen, brain contusion, fracture of the 6th thoracic vertebra and fracture of the

1st lumbar vertebra are consistent with eyewitness statements that he made

contact with the steel structure during the course of his fall.

Resuscitation attempts were unsuccessful.

Main Causes:1. The temporary access ladder was not built to Project Specifications.

2. The man fell because he lost three-point contact with the ladder, which he was either stepping on to or descending.

3. The man died because he was not tied off at the time he fell either via the lanyards carried on his harness to a fixed point or to the fall arrestor provided. Had the intermediate platform at the bottom of the ladder been constructed to Project standard such may have prevented the fall continuing past that point.

4. The reasons why he chose not to attach to the fall arrestor prior to detaching his lanyard from the handrails either whilst stepping on to the ladder or starting to descend the ladder are unknown. The most likely causes are desire to descend quickly in this instance and/or the difficulty of attaching the fall arrestor given its installed position. It should be noted that there is evidence from a number of sources that individuals using this ladder system did routinely use the fall arrestor.

Underlying causes:1. Access for work at the top of section 2 of the flare structure was not adequately addressed in the initial

work method statement / risk assessment and job safety analysis. 2. Lack of access in block 2 of the flare structure led to a number of ad hoc access solutions being provided

without formal review and updating of the work method statement / risk assessment and job safety analysis.

3. CTSD supervision knowingly allowed subcontractors to carry out tasks (scaffold/ladder erection) for which they were not competent.

4. Nippon Express knowingly carried out tasks (scaffold / ladder erection) not identified in their work scope and for which they were not competent.

5. CTSD supervisory personnel condoned use of access which was not in compliance with basic site standards.

6. CTSD supervisory personnel considered a protection device as an acceptable substitute for provision of safe access.

7. Cape Sakhalin supervisory and HSE staff fully competent in site scaffolding standards condoned the continued use of unsafe access by their own and other personnel.

8. Individuals felt unable or were unaware of how to register concern over unsafe access and continued to utilise unsafe access putting themselves at risk.

9. The system to restrict use of Cape Sakhalin materials (scaffolds) is not in place or not operating correctly, thus allowing unauthorized usage and erection of scaffolds by other companies.

10. The Field Design Modification process does not address the construction methods to be employed.

What we could have done to stop the incident from happening:

• CTSD supervisory personnel:

– Not to authorize Nippon Express to carry out tasks (scaffold/ladder erection) for which they were not competent. Instead task Cape Sakhalin to do so.

– Inspect and stop use of access which was not in compliance with basic site standards.

• Nippon Express:

– Refuse to carry out tasks (scaffold/ladder erection) not identified in their work scope and for which they were not competent.

• Cape Sakhalin supervisory and HSE personnel:

– Execute the right “To Stop Work” and stop using unsafe access.

• Cape Sakhalin scaffolding crew:

– Refuse to work with the unsafe access.

• SEIC and CTSD:

– Identify access issues in the initial work method statement or at the stage when changes were required to continue work.

There was a lot that could have stopped the incident . . .

The result of inaction:

Is another lost lifeIs another lost life

I truly believe that one of the bitter lessons that we learned from this fatality is that those unsafe acts or unsafe conditions that we sometimes go by, tolerate or prefer not to notice however minor they may appear and even simple inaction on our part carries a potential for consequences that will tear your heart apart for the rest of your life and will break hearts of many other people.

Those who assume the role of a supervisor, an HSE inspector or simply a responsible citizen must never underestimate the level of responsibility that comes with this role.

Igor Sayapin, Incident Investigation Leader Sakhalin Energy Investment Company