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					  Contractor Crane Topple Incident

PRELIMINARY:   INVESTIGATION ONGOING
 IINCIDENT SUMMARY:

At about 1330hrs on Saturday December 20, 2008, a
70 ton Groove crane toppled whilst it was being
brought into operation for the loading of pipe spools
at xxxxxxxxxxxxx

The crane operator jumped out of his cabin as the
crane fell to the ground and neither he nor other
workers in the vicinity suffered injury
RAM Rating   Actual :            Asset 1
             Potential:   People 4B
                      Carbon Steel Shop


                4               1. Parked position of Crane
Paintin                         2. Rigger in Container hung web sling
g Shop                          3. Crane fall position
                                4. Position of Assistance Rigger Supv &
                                    Piping Engr



          3
                                          2

                                        Container

                            1
              Access Road
                   FALLEN GROOVE CRANE
Position of
Assistant Rigger
Foreman & Piping                    Position of Rigger
Engineer.                           No. 1 /Container that
                                    was being loaded
        CRANE ON GROUND WITH RETRACTED OUTRIGGERS


Piping Engineer &
Rigging
Supervisor’s
Office
Typical Crane with Fully Extended Outrigger
 EVENTS LEADING UP TO INCIDENT:
0703hrs:   Crew had tool box talk

0805hrs:   Crew of an operator, three riggers, one banks man and one flagman
           assigned lifting operation. Assignment was to lift a container
           already loaded with spool onto a truck for despatch to CPF.

0840hrs:   Crew commenced second assignment of loading long pipe spools into
           40ft container

0930hrs:   Supervisor directed that loaded spools be offloaded from container
           as they can loaded directly onto the truck.

0955hrs:   Long spools from container offloaded

1020hrs:   Loading of short spools into open top 40ft container commenced.

1140hrs:   Loading of spool into container still in progress. Crew breaks for
           lunch with assignment yet to be completed.
SEQUENCE OF EVENTS.
1305hrs:   A rigger arrived from lunch

           Piping Manager saw crane key on his desk, expressed concern over
           delay in re-start of work after lunch. He gave the key to his
           piping engineer and instructed crew to resume work.

1320hrs:   Operator arrives along with a second rigger. Operator collects key
           from first rigger and proceed to start the Crane.

1325hrs:   The two riggers available positioned themselves for the spool
           loading activity, one at location of spools for slinging and the
           other inside the container for receiving spools from crane.

           One of the rigger unhooked crane block and gave signal for operator
           to hoist up. Operator telescope crane boom and swung to direction
           of the container. Rigger in container hung web sling.

           Operator hoisted up, swung to the direction where the spools are to
           be loaded. Crane became unbalanced, operator attempted
           unsuccessfully to recover by retracting boom and swinging the boom
           back, raised alarm, jumped out of cabin, crane fell to the ground.
MAIN FINDINGS - 1
1.   Crane toppled because it was brought into operation without outriggers
     extended.
2.   The outriggers were used during the morning operations though the crane
     was shut down and outriggers retracted at lunchtime (normal practice)
     and outriggers not re-extended upon commencement of the afternoon’s
     work
3.   Crane was not on load at time of incident with ground conditions
     stable.
4.   Crew on duty at time of incident was incomplete – Flagman and Banksman
     were absent after lunch
5.   PTW approved for work is with attached JHA and work method statement
     but no Lifting Plan.
6.   Chain of command between the separate Piping and Rigging departments
     became confused. Piping Managers intervention with the crane crew was
     taken as an instruction to commence work.
7.   There was evidence of poor job planning (double handling of long spools
     prevented the activity from being completed before lunch)
8.   Equipment maintenance record indicate regular maintenance of crane.
OTHER FINDINGS


  1.   Crew appeared agitated because of extended duration of work; workers
       expecting that xxxxxxxx would allow them to close early for Christmas
       shopping.
  2.   December payslip was issued to workers the previous day but money was
       yet to be released to bank by xxxxxxxx at time of incident.
  3.   Some of the crew members did not return after lunch, purportedly
       because food vendors were unavailable.
  4.   Crane operator competent, ASME B30.5 certified with relevant Drivers
       License
  5.   Container being loaded was scheduled for despatch to CPF that same
       day (it is unlikely that it could have completed the journey before
       nightfall).
  6.   Minor hydrocarbon spill observed at scene of incident.
  7.   Safety alert to operators and drivers on the need to walk around
       equipment prior to start of work was communicated but not implemented
       in this instance

				
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