Page 103 - Xmo Strata - Bulletin Archive

Page 2 of 3

Helmet had no chin
strap, should be
Two people considered for use.
on job, both
should have
removed
ladder

Tri pod obstructing
ladder movement, this
should have been
removed.

SIMULATION SHOT ONLY

RISK POTENTIAL
Serious injury to operator. Lost time incident as the incident was not reported until the following day,

WHY?
Operator did not fully assess the activity and should have conducted a LMRA to ensure he identified potential
risks to himself or others. By removing the ladder alone and the fact it was long at 4m and difficult to handle
although it was not exceptionally heavy at 11kg. This is a classic example of shortcutting and not conducting a
continuous LMRA. And not reporting to ABB/Esso within one hour. It was called in next day this could have led
to an LTI (Loss Time Incident).

CONTRIBUTING FACTORS:
Shortcutting the exercise, no LMRA, lack of procedures, JSA did not mention handling of equipment, incorrect
number of people on this part of the job, late reporting, and inadequate PPE (helmet no straps).

ROOT CAUSE
The investigation team concludes that several root causes are responsible for this incident. They are:
• cause # 2 correct way takes too long
• cause # 3 shortcutting procedures
• cause # 5 lack of operational procedures or working standards
• cause # 6 inadequate communications of expectations re procedures or standards
• cause # 7 inadequate tools or equipment i.e helmet