An Analysis on Occupational
Fatalities Casebook
Volume 3
Occupational Safety and Health Branch
Labour Department
Occupational Safety and Health Council
46
This publication is prepared by the
Occupational Safety and Health Branch
Labour Department
This edition August 2004
This publication is issued free of charge and can be obtained from offices of the Occupational Safety and Health Branch, Labour Department. It can also be downloaded from website of the Labour Department at http://www.labour.gov.hk/eng/public/os/D/fatalvol3.pdf. Addresses and telephone numbers of the offices can be found in website of the Department at http://www.labour.gov.hk/eng/tele/osh.htm or call 2599 2297.
This publication may be freely reproduced except for advertising, endorsement or commercial purposes. Please acknowledge the source as “An Analysis on Occupational Fatalities – Casebook Volume 3”, published by Labour Department.
An Analysis on Occupational
Fatalities – Casebook Volume 3
CONTENTS
Page Number
Foreword 3
Case 1 A worker was trapped under a toppled formwork panel 4
Case 2 A glass panel installation worker fell through the void of a canopy 8
Case 3 A worker fell from 22/F to the ground floor through the hoistway 12
Case 4 A welder fell from a tilted catch-fan to the ground 18
Case 5 Two electricians sustained fatal injuries when a flashover occurred at a switch 22
panel
Case 6 A site foreman was trapped inside the crushed cabin of a topple excavator 28
Case 7 A labourer fell from a bamboo scaffold while carrying out concreting work at
the external wall of a building 34
Case 8 A worker was electrocuted by a defective fluorescent light panel during fire
services maintenance 38
Case 9 Bales of cotton collapsed and struck a porter leader 42
Enquiry 46
FOREWORD
Workplace accidents are not just causing sufferings to the victims and their families. They also incur costs arising from work stoppages, insurance claims, medical and rehabilitation expenses.
It is recognized that most workplace accidents are preventable. Very often, the scenarios and causes have common phenomena. Unless the causes of workplace accidents are properly understood, lessons will not be learned and suitable improvements will not be made to ensure the future safety and health protection of those who may be affected by a work activity. The responsible persons of workplaces need to understand why events happened, and act to make sure that they do not happen again.
This casebook gathers a collection of fatal accident at work cases edited in a way for experience sharing on accident prevention. It aims at providing precious lessons to those who are exposed to work activities and the management personnel, as well as case studies for safety training institutes.
Occupational Safety and Health Branch
Labour Department
July 2004
Case 1
A worker was trapped under a toppled formwork panel
Scenario
On a construction site, a sub-contractor undertook the construction of a concrete retaining wall. The retaining wall was constructed section by section involving activities of formwork erection, reinforcement-bar fixing, concreting and formwork removal. The formwork of a section consisted of two sets of wooden panels (one large and one small) in straight alignment at the front.
On the day of the accident, a gang of five workers were assigned to remove the formwork after concrete curing. They arrived at the site and removed the vertical walings, bolt anchors and platforms of the small wooden panel. An excavator was arranged to hold the panel through a pair of rope slings. After the timber studs upon which the small panel was resting had been knocked off and the small panel was caused to detach from the concrete wall surface, the large panel suddenly toppled and struck a worker. He was later certified dead in hospital.
Case Analysis
The toppled large panel had a dimension of 2.7m x 6.1m, and weighed 460Kg. Right before the accident, this panel stood freely leaning against the retaining wall without anything to secure it in position.
The workmen did not adopt a proper way to maintain the stability of the large panel, e.g., rigging the panel under a lifting appliance before hammering off the timber studs. There was no training of any kind provided to the team of workers in performing formwork dismantling.
As supported by the findings aforementioned, the accident reflected the inadequacies of the safety management system. There were :
– No planning and documented work methods to guide the workers to work in the correct way.
– No provision of training to enhance the skill and safety consciousness of the workers to carry out formwork dismantling safely.
Lessons to Learn
A safe system of work in formwork dismantling should be provided and maintained to enhance safety at work. The system should include the following major areas :
- Safety planning with risk assessment be conducted.
- Method statement be prepared and safe working procedures developed.
- Safe working procedures be implemented.
- Adequate information, instruction, training be provided to persons engaged in the work.
Case 2
A glass panel installation worker fell through the void of a canopy
Scenario
On a building construction site, a metal canopy with glass panels was to be constructed at the 1/F level of the building. On the day of the accident, a sub-contractor employed a team of workers to install glass panels for the metal canopy. The team was divided into two groups. One group from the team was responsible for the lifting of glass panels to the top of the canopy whereas the other group stood on the canopy for receiving the glass panels and securing them onto the openings of the metal frames. The deceased person (D/P) was among the workers working on the canopy.
In the evening, workers on the canopy were taking a short break. At that moment, while the D/P was walking on the metal frame of the canopy, he suddenly fell through a void of the metal frame to the ground and sustained the fatal injury.
Case analysis
Observations
- The canopy was a cantilever structure with a horizontal length of 34.8 m, extends outwards by 3 m, and was erected at a height of 8.4 m from the ground.
- The canopy was a metal frame structure with voids of different dimensions to be covered by glass panels.
- Only 11 glass panels had been placed in position, leaving 17 voids of dimensions 1 m to 1.4 m by 2.3 m on the canopy.
- There were eight wooden planks resting on the canopy. Three of them were placed together on the canopy to form a platform of size 4 m x 0.7 m. On one side of this platform, there was a void (1.4 m x 2.3 m) on the metal frame. The other side had another void of 2.3 m x 0.5 m.
- A fibre rope of 28.6 m in length and 19mm in diameter was tied to a concrete column at the 1/F. The other end was loosely placed on the floor slab of the 1/F. It was intended to serve as a horizontal independent lifeline for the attachment of safety belts.
- Five general-purpose safety belts were kept in a toolbox on the 1/F. Their lanyards ranged from 1.1 m to 1.3 m.
Factors Contributing to the Fall of the D/P
- Before the accident, the D/P was seen walking on a 0.4m wide metal member of the canopy frame, and then fell through a void beside the platform. He was wearing a general-purpose safety belt but the lanyard of his safety belt was not attached to any anchorage.
- The function of the independent lifeline for anchoring safety belts was also defeated. The rope was intended to mount on two columns and serve as a horizontal independent lifeline. This was not done at that time.
- Furthermore, there were drawbacks on his horizontal lifeline. All workers could not use it at the same time. The length of the lanyard would restrict a worker's movement on such a large canopy of dimension 34.8 m x 3 m.
- The platform placed over the canopy was not a safe one as it had no guardrails and toe-boards.
- There was a method statement specifying the use of a proper working platform for the installation work. A bamboo scaffold had once been erected for this purpose. However, it was dismantled for the purpose of carrying out pavement work underneath. The contractor had not re-assessed the situation, thus reflecting an inadequacy in the safety management system.
Lessons to Learn
1. A safe system of work for the glass panel installation work should be developed, implemented and reviewed from time to time. The safe system of work should include:
i. assessment of the work process involved;
ii. identification of hazards associated with the work processes;
iii. establishment of well-defined safe working methods and procedures;
iv. implementation of the system and monitoring its effectiveness; and
v. reviewing and, if necessary, revising the system with contingency plans to cope with changing environment.
2. Proper working platforms with safe means of access and egress, suitable guardrails and toe- boards should be provided for workers working at height.
Case 3
A worker fell from 22/F to the ground floor through the hoistway
Scenario
On the day of the accident, a sub-contractor undertook the delivery of air-conditioner parts to the upper floors of a building under construction. Nine workmen, including a team leader and a hoist operator, were assigned to do the job. A material hoist installed along the external wall of the building was used to assist in the transportation work. The team leader was responsible for giving instructions to others through two sets of walkie-talkies with independent channels.
The operator stationed at the hoist control room on the ground floor. The other workers were split into Teams A & B. Team A, comprising the deceased person (D/P) and two workers, loaded the air-conditioner parts into the material hoist at lower floors and Team B, comprising four workers, collected them at upper floors. The accident happened while Team A was working at the 22/F. The D/P was standing alone at the hoist landing place, waiting for his team members to transport the air conditioner parts to him. The hoist platform suddenly ascended and trapped the D/P's head. The D/P lost balance. He fell over the unfenced edge of the landing place, through the hoistway and landed on the ground
Case Analysis
The Control System of the Material Hoist
The hoistway frame of the material hoist had been erected from the ground floor to the 48/F level along the external wall of the building. The control system of the hoist was installed inside a shelter on the ground floor, comprising:
i. a main power supply unit
ii. A central control unit
iii. A pendant remote control device
iv. a visual warning panel
v. an audible signalling unit
The Central Control Unit
The circuit of the central control unit governed the upward and downward movements of the hoist platform, the circuit of the interlocking devices of the landing gates, and the monitoring system on the 'open' or 'close' status of gates at landing places.
Movement of the hoist platform between designated floors could be set prior to the hoist operations.
On the control panel of the unit, there were the following features :
'AUTO' button -
by pressing this button, the hoist platform would move to a designated floor. On completing a loading or unloading operation and by pressing this button again, the hoist platform would return to its previous location. A new designated floor could be selected for another operation.
'Jog up / Jog down' button -
pressing them would allow fine adjustment of the alignment between the level of the hoist platform and that of the landing place when the platform reached a designated floor.
'Emergency' button -
pressing it would bring the travelling hoist platform to a stop and deactivate the functions of the 'AUTO' button. Designated floor numbers had to be re-set to resume the hoist operation.
Touch-Screen -
for entering designated floors that the hoist platform would travel in the operation.
Pendent Remote Control Device
It had four buttons provided for 'emergency stop', 'jog up', 'jog down' and 'auto start'. Once connected to the central control unit by a connecting cable, the functions at the central control unit would be overridden by the remote control.
Visual Warning Panel
It was installed near the central control unit and liked with the circuits of the micro-switches in the interlocking system of the landing gates.
A landing gate in open position during hoist operations would disengage the micro-switch of the interlocking system, thus lit a red-light bulb in the panel to alert the operator on gate-open status.
The Landing Place and the Gate of the Hoist
The landing place of the hoist on the 22/F was a platform at the windowsill where loading and unloading were carried out.
The landing gates at the landing place were in the form of two swing doors made of wire-mesh and metal frames. Closing of the gates would activate a micro-switch linking to the circuit of the hoist control system and gates-monitoring system.
The design allowed the hoist platform to ascend of descend only after all gates at each landing place had been completely closed with all the micro-switches fully engaged by the gate latches. Opening of any gate would disengage the related micro-switch and stop the hoist platform from moving. At the same time, the red light at the visual warning panel would turn on and a warning message would appear on the screen of the central control unit.