Page 78 - Xmo Strata - Bulletin Archive

2/7/2019 Page 2 of 3

Shot left > shows the direction the
employee was walking and the area
in which he tripped.

WHY?
The employee did not firmly locate his foot on the path and tripped as a result. If we use LMRA (Last minute risk
assessment) on a continuous basis and not just at set up it will help identify additional potential risks as you
conduct maintenance and repair operations on site.

CONTRIBUTING FACTORS:
We looked at weather and ground conditions and these were fine and dry so no obvious influence from these
areas contributed to the trip. It would appear to be a simple misplaced step on the kerb which resulted on the
incident. The investigation also highlighted a number of non conformances to WCP in that the employee did not
wear a hi-vis vest or hard hat while on site. These did not contribute to the trip but could have contributed to a
much more serious injury.

ROOT CAUSE
The investigation concludes the root causes responsible for this incident and the non conformances to WCP are:
• cause #3 short cutting procedure, did not wear vest or hat
• cause #4 In the past did not follow procedures, relates to trip LMRA should be used all the time
RECOMMENDATIONS – COMMENTS
1. Recommend that contractor conducts refresher training in WCP (Work Control Procedures) This item
has already been addressed by the*company and closed out on the 6 Nov 2006.
th
2. Recommend that employee receives toolbox talk on site safety by his management, already completed
th
on the 6 Nov 2006.
3. Recommend that employee received refresher training in the use of LMRA.
4. Recommend employee completes the 3Q/2006 self assessment questionnaire, completed on the 6 Nov
th
2006.
5. Recommend improvement of timeliness of reporting incidents, ABB local PE or OM must be advised
within one hour.

6. Comment: The Company’s management response to the investigation is a model to others in the
industry it was swift and detailed and involved all senior management. Actions they determined as
necessary have already been completed. This is not be confused with item 5 which refers to initial notification of the
incident.

“let’s make sure that we continue to make our sites THE SAFEST by helping ourselves, our colleagues,
our customers and even our competitors by improving training, helping where necessary and
addressing any issues of concern there and then”

If you have any queries regarding the Safety Bulletin content or require further information please
contact any staff member of Xmo Strata Ltd.