While checking site conditions, the construction manager working on the project observed a contractor on the top level of one of the new buildings being constructed. The contractor was an employee of of a mechanical installation contractor. The top level is an open external area. It did not have handrails installed or any temporary fall protection. The fall to ground from the top level is 8.7 meters. The contractor was observed to have no harness on.
The original task involved coordination with a team member working from a MEWP underneath. During the installation there were periods when the other 2 men on the 5.4m level had free time. During the free time the CP (Contractor Person) took it upon himself to install the stair treads leading up to the 8.7m level. After completing the stair treads installation, the CP used the stairs to access the 8.7m level and began with installing the handrail on the top level.
- The contractor made an unsafe act by deciding to install an access to the 8.7m level and then use that access to make installation of handrails that was not planned and not according to agreed methods.
- The contractor had insufficient training for performing the task. The contractor's management were aware of the competency of the CP but did not adequately manage the competencies against the task, similarly Tarmac did not ensure the CP had all training required for the task.
- Supervision by the contractor was deemed inadequate.