Incident alert

LOCATION:
READYMIX OR MORTAR PLANT
ACTIVITY:
LIFTING
SUB ACTIVITY:
NO SUB ACTIVITY AVAILABLE
ALERT STATUS:
Normal
DATE ISSUED:
12/09/2019 19:42:46
INCIDENT No:
01527

TITLE
Contractor looses 4 fingers during lifting operation - £400K fine for company
COUNTRY OF ORIGIN
ACCIDENT / INCIDENT DETAILS

A site maintenance manager instructed a contractor to fabricate three new gates for some waste material bays at a readymix plant. The contractor and a colleague were fabricating the 3rd of the 3 gates at the plant (see pictures below). Whilst trying to flip the metal gate over using a fork lift truck and lifting chains, the metal gate slipped and trapped one of the contractor’s fingers on his right hand.

The contractor was immediately taken to hospital and was prepared for emergency surgery. Due to blood loss he received 6 units of blood during his operation. During 18 hours of surgery, the surgeon attempted to replant his fingers, sadly this was not successful. The contractor lost the majority of the four fingers on his right hand.

The company was prosecuted under the Lifting Operation and Lifting Equipment Regulations 1998 and fined £400,000 plus expenses. A review of the incident identified that there were 7 opportunities for this accident to have been avoided.

First opportunity to stop this incident                The company required that all contractors were prequalified via the Avetta national contractor data base. Neither of the contractors were Avetta approved.  The plant supervisor appeared not to have access to the Avetta platform to check when contractors arrived, therefore no check was attempted.

Second opportunity to stop this incident           The companies policy was that any contractor working on any of their sites must have completed a Site Specific Induction .  Re-induction should occur every two years or if there is substantial change to the workplace at sites. Both the contractors had been through the site induction at the site the previous year, so both had valid site specific inductions. However, the investigation revealed that  this did not include any form of competency check.

Third opportunity to stop this incident                  All contractors must be issued with a completed Permission to Proceed (P2P) form whilst working on site. Where work continues for more than one day the Permission to Proceed will be reviewed, updated and/or reissued daily.

The responsible person, or nominated person on site should only issue a P2P if they are satisfied with the risk assessment and safe system of work for the task to be undertaken. Certain High Risk activities identified on the P2P by a * will require an additional Permit to Work. Only trained and persons authorised to issue P2P must issue P2P to contractors.

The investigation revealed that the risk assessment and safe system of work used were generic, and did not provide any specific detail relating to the task of fabricating the muck gates. Significantly, No lift plan was provided for the lifting and slinging element of this task by the contractors. Regardless of the above, a P2P was issued for the task. The P2P had  identified that lifting and slinging would be undertaken.

Fourth opportunity to stop this incident Depending on the type of work, the designated contact person for the company  MUST check that H&S management processes are being implemented, such as risk assessment controls are implemented, use of any additional PPE and correct equipment is being used for the task. Whilst on site, the contractors were left unsupervised.

There was no evidence of any company management / supervision to check that the contractors were working in line with the company’s H&S standards / risk assessment/ safe system of work / induction.

Fifth opportunity to stop this incident                  All Lifting operations need a lift plan. The type of lift will determine the lifting plan details and any required competencies. Basic lift – A simple lifting operation where there are no hazards in the working area, the weight of the load is known and simple slinging arrangements are utilised. For example FLT moving pallets around a workshop.

All basic lifting operations MUST have a suitable and sufficient risk assessment and safe system of work in place before any lifting operation commences with the safe system of work recorded on the company form and the records kept. For routine activities on sites, these might be generic documents which are reviewed as per requirements. These can be completed by someone with a basic LOLER competency, for example lifting and slinging.

Standard lift – There are hazards in the working area and / or the proposed route and landing area but they are controlled. The load may be an unusual shape or size and the slinging operation may require more thought. These lifts may be routine operations conducted daily or weekly. For example – lifting a generator from the site of a silt lagoon using a telehandler.

All standard lifting operations MUST have a suitable and sufficient risk assessment and safe system of work in place before any lifting operation commences with the safe system of work recorded for example on UKCP12.F1 and records kept. For routine activities on sites, these might be generic documents which are reviewed as per requirements. These can be completed by someone with a basic LOLER competency, for example lifting and slinging. Where a standard lift involves a mobile crane, a lifting plan completed by an appointed person must be completed.

Complex lift – An operation that requires more than one crane or vehicle to conduct the lift (tandem lift). The lift may be taking place in a hazardous location (near power lines, busy workplace traffic route) and require in-depth planning. These would be contracted to approved contract lifting companies. For example - moving a screen with more than one mobile crane, or removal of a silo.

Appointed person – This person is responsible for the planning of lifting operations mainly for mobile cranes, however, lorry loaders and tracked excavators may need to have lifts planned by an appointed person if the lift is deemed to be complex. There must be an appointed person for all complex lifts and lifts involving a mobile crane.

Sixth opportunity to stop this incident                 All lifting operations MUST have a Lift Plan which details any lifting attachment required. The investigation revealed the following; That no lift plan had been completed for the lifting operations to flip the muck gate over. As a result of this, the correct equipment was not selected for the lifting and slinging of the muck gate. One of the contractors was a trained lifting and slinging operator. The P2P identified lifting and slinging, but the absence of the lift plan was not challenged when issuing the P2P. Inappropriate lifting equipment was used to sling the muck gate, using chains with no FLT slinging attachment. The lifting chains where attached to the FLT forks (see picture below) which allowed the muck gate to slip when the forks were lifted.

Seventh opportunity to stop this incident         Only trained, competent and authorised personnel MUST drive any mobile plant on the company’s operations. Access to all mobile plant must be controlled to prevent unauthorised access. The fork lift truck at the ready mix site was accessed via a 4 digit pin code. During the investigation it became apparent that several employees and contractors knew this code, and accessed the FLT, without the authorisation of the plant supervisor. Neither of the contractors  were competent to drive a FLT.

ACCIDENT / INCIDENT IMAGES
Click image to enlarge



LEARNING POINTS / ACTIONS TAKEN

  • Do all your responsible managers check contractors approval on Avetta as part of the control of contractor site induction? https://app.avetta.com/login?referral=https://app.avetta.com/

  • Do all your responsible managers have access to the Avetta platform?

  • Complete a spot check - do all contractors working on site have a valid site induction and is there evidence of this in their SHE Handbook & Passport which needs to be completed and issued?

  • Are all persons on site who issue a P2P trained in the procedure?

  • Complete a random audit of the last 5 P2P issued for works on your site. Do the risk assessments and SSOW for these P2Ps provide sufficient details of the task, risks and controls measures required?

  • Have any permit to works been issued?

  • Have any recent tasks involved lifting and slinging operations? – If yes, is there clear evidence of a lift plan available for the task?

  • Ensure contractors are actively supervised when on site. This may be completed via a safety conversation, ‘quarry time’. Contractors working on our sites should be visited by the responsible person / company point of contact during their work activities.

  • All lifting operations MUST have a documented lift plan. The type of lift will determine the lifting plan details and any required competencies.

  • All basic and standard lifting operations MUST have a suitable and sufficient risk assessment and safe system of work in place before any lifting operation commences with the safe system of work recorded.

  • Do you have a form that provides a template for this to be recorded on? These need to be completed by someone with a basic LOLER competency, for example lifting and slinging.

  • Does your site have a basic lift plan for all FLTs/Telehandlers on site?

  • Check you have sufficient competencies on site to ensure lifting and singling operations can be completed.

  • Ensure attachment (picture example below) is used when using slings or chains on FLT to prevent the load from moving.

  • Ensure there are clear procedures / processes on site to prevent unauthorised access to mobile plant. Where contractors are required to use items of mobile plant, a copy of their competencies MUST be held seen on induction.


LEARNING POINTS / ACTIONS IMAGES
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Correct lifting device
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Lifting device used in incident
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