Lessons Learned

1. Lessons Learned SHI Cable Installer Fall from Scaffolding– 28 September 2005

2. Incident Description: This incident occurred in the Samsung Heavy Industry (SHI) shipyard in Geoje, So. Korea, where the Lunskoye-A topsides are being constructed. The project is in the final stages of construction and mechanical completion prior to handover to commissioning. As part of the final electrical work, heat tracing cable is being installed. An E&I subcontractor was performing final cable installation and termination in the Mud Pump Room on deck UD22. A worker had completed tie-wrapping a heat tracing cable on a cable rack 2.9 m. above a steel deck. While egressing towards a temporary installed vertical ladder to take a break he fell to the steel deck. He suffered fractures of left skull and right thumb. Emergency response was very good. Shipyard emergency response personnel arrived within 10 minutes of the incident, stabilized the worker, and fitted a neck brace. The worker was transferred to local hospital by ambulance with the SHI clinic doctor and nurse and given a CAT scan and X-rays. The worker was then transferred to Masan Samsung Hospital by helicopter for detailed examination. The worker was moved from critical care to general care on 4th Oct. He is expected to remain in the hospital for a month and should make a full recovery.

3. Incident Pictures Re-creation of IP step to access ladder. Note – scaffolding (red x) installed after incident Looking down on incident location after IP transported to hospital Note – there were no witnesses to the incident. Description of incident is based on co-worker’s statement and re-creation of the event by the investigation team

4. Things we learned (01): • Cable trays often appear as ideal work platforms; however, they are not necessarily designed to support a worker. Stainless steel material also makes them more slippery than wood or normal steel surfaces. • SEIC specification prohibit working in a cable tray. Lunskoye cable trays are not design for a worker. • SHI sees working in cable trays as standard practice and has not included such a restriction in their HSE procedures. • it is generally impractical to build scaffolding for all cable installation activities due to the geometry of cable trays. Often, work must be done from ladders.

5. Things we learned (02): • Safe and reasonably convenient access to the work location must be provided to prevent worker from taking the “easy way down” that might not be as safe. • There was a safe access route to the work location, but it was not very convenient and required climbing through handrail. • Worker probably did such climbing every day and didn’t see it as dangerous. • At 2.9 m, investigation team didn’t feel that the maneuver was particularly hazardous. However, if surface is slippery or one would lose concentration, it would become more dangerous, and such a fall onto a steel deck could be deadly.

6. Things we learned (03): • Hazard recognition by both the worker and his supervisor(s) is critical and should include not just the work location but access/egress routes. • The worker’s immediate supervisor (Group Leader) and the group’s foreman had walked the route before starting work. Neither had spotted the hazard of lack of safe access/egress. • SHI procedures for working at height do not address access/egress to scaffolding or other work areas.

7. Things we learned (04): • Although not deemed to be an immediate cause of the incident, SHI equipment and working at height procedures, which meet Korean regulations, are not in line with best practices. • Safety belt will cause back injury in case of a fall while tied off vs. the better protection of a body harness. • Single lanyard does not allow 100% tie-off for difficult maneuvers. • Small hooks make it difficult to connect, and very often will result in improper connection, i.e., looping lanyard around support and clipping lanyard

8. CONCLUSIONS: • This incident reinforces the critical HSE themes that were identified at the last SEIC EPLT workshop: • Supervisor / foreman training is critical to get their ownership of worker and worksite safety. • Hazard identification is still weak at both the worker and supervisor / foreman level. • The fact that these issues continue to surface and incidents continue to happen is also a reflection of the challenges in moving to a behaviour based safety culture in a large Korean shipyard.