HSE Lesson Learnt Fall From Height
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Transcript of HSE Lesson Learnt Fall From Height
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7/24/2019 HSE Lesson Learnt Fall From Height
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REF: GHSED/IN-LL/2013-04
HSE IncidentLessons Learnt
Group HSE Division
Important Notice: This report is not intended to provide confirmatory or definitive report on the cause of the incident. The findings and lessons
learnt contained in this report are a product of the sites analysis of the incident and not meant to represent PETRONAS official view on the
topics
Type of Incident:Fall from Height
Location of Incident:Offshore Platform
Date of Incident:August 2013
Summary of the Incident:
An engineer (IP)supervising during Turnaround, fell
through floor opening to an emergency escape
ladder. The incident occurred after he gained access
to the landing space of the Galley deck emergency
escape route for viewing of an ongoing job on the
upper deck. Refer to Figure1.
While giving his full attention to the task overhead (in
a face up position), he stepped his foot backward onto
the opening for the emergency escape ladder that
caused him to fall down through the partially caged
ladder of 7m height. Refer to Figure 2 (Illustration of
the incident).
Outcome:
IP sustained laceration wound and bruises at occipital
of head (7x1); and fracture 1/3 distal right ulna.
Active Failure:
Inadequate warning or barrier to preventpersonnel from crossing the hazardous area.
Key Findings:
Non-compliance to working at height procedures
i.e : not using personal fall protection device.
IP did not attend Toolbox Talk for the work.
Emergency Use only or appropriate warningsignage was not posted at the emergency escape
route.
Lessons Learnt:
1. Enforce the requirement to use full body harness
for working at height including on the galley deck.
2. All personnel who are involve in the work,
including the supervisor, shall attend task specific
Toolbox Talk and ensure hazards are well
communicated.
3. Fall potential floor opening(s) shall be covered
with appropriate fall restraints such as rails or
cages as per PTS 18.5207 Working at Height
(refer item 7.7).
Figure 1: Floor opening to escape ladder
Figure 2: Illustration of the incident
Contact Person for this Lessons Learnt:
Morris Kho, Custodian, Operations Safety, GHSED:
mailto:[email protected]:[email protected]:[email protected]
