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INCIDENT: While IP was descending permanent stairway of column C-6101 Gas Dew

INCIDENT: While IP was descending permanent stairway of column C-6101 Gas Dew pointing area (ISBL) after completing a painting touch-up Job, he stepped off the bottom stair to grade catching his foot on the support plinth, resulting in twisting his ankle and falling heavily. CAUSES:

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INCIDENT: While IP was descending permanent stairway of column C-6101 Gas Dew

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  1. INCIDENT: While IP was descending permanent stairway of column C-6101 Gas Dew pointing area (ISBL) after completing a painting touch-up Job, he stepped off the bottom stair to grade catching his foot on the support plinth, resulting in twisting his ankle and falling heavily. CAUSES: Dimensions of landing base / plinth at base of stair creates a Trip / Fall hazard. Base extends from structure, but is not wide enough to adequately place one’s full foot. LEARNINGS: Construction crew not recognizing the hazard created by constructing plinths of different configuration from approved design drawings Construction Supervision and QA/QC did not recognize the safety impacts from deviating with approved design drawings. No formal risk assessment performed by responsible personnel to determine impacts of the design change. Management of Change Procedure not fully developed at Site. No formal guidelines for personnel to implement Site design changes. Recommended Actions: Discuss this alert in toolbox talks and HSE meetings and Distribute to all contractors Post on HSE notice boards Include in site HSE induction Management of Change Procedure to be fully developed in order to assure proper implementation by responsible personnel Contact MSE511 for further information or visit HSE website Reference: LTI No. 36 Alert No. 12 August 2010

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