Falls from Height - Workplace Safety and Health Council
Falls from Height - Workplace Safety and Health Council
Falls from Height - Workplace Safety and Health Council
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PREFACE<br />
This compilation of case studies on fatalities in the construction industry<br />
is initiated by the <strong>Workplace</strong> <strong>Safety</strong> <strong>and</strong> <strong>Health</strong> <strong>Council</strong>, <strong>and</strong> put together<br />
by the WSH Construction Committee in collaboration with the Ministry<br />
of Manpower. This booklet depicts how the accidents occurred <strong>and</strong><br />
provides valuable learning points on how they may have been prevented.<br />
This is the first in a series of such booklets to be published.<br />
As much as the next few years promise to be exciting for the construction<br />
industry, they also pose a great challenge to the industry to maintain<br />
workplace safety <strong>and</strong> health. Construction sites have customarily been<br />
viewed as high-risk workplaces, which more often than not have a higher<br />
incidence of workplace fatalities. We must address this perception <strong>and</strong><br />
change the reality. While construction workers strive to complete a building<br />
or facility, it is important that they do not risk life <strong>and</strong> limb. It is crucial<br />
that these workers go home safely after work each day.<br />
This booklet of case studies offers insights to all in the industry on how<br />
these tragic accidents occurred, so that we may glean important, lifesaving<br />
lessons <strong>from</strong> the experience. In learning <strong>from</strong> our past mistakes,<br />
we can <strong>and</strong> must prevent these mishaps <strong>from</strong> happening again. Together<br />
with your help, we can transform construction sites into safe <strong>and</strong> healthy<br />
workplaces for our workers.<br />
Mr Lee Tzu Yang<br />
Chairman<br />
<strong>Workplace</strong> <strong>Safety</strong> <strong>and</strong> <strong>Health</strong> <strong>Council</strong>
CONTENTS<br />
<strong>Falls</strong> <strong>from</strong> <strong>Height</strong><br />
Case 1 Fall through a roof 04<br />
Case 2 Fall <strong>from</strong> a scaffold 06<br />
Case 3 Tripped by an electrical extension 08<br />
Case 4 Fall of formwork 10<br />
Case 5 Fall off a toppling scaffold 12<br />
Case 6 Killed by a plunging hoist 14<br />
Case 7 Fall through an opening 16<br />
Case 8 Fall <strong>from</strong> a scaffold 18<br />
Case 9 Collapse of a platform 20<br />
Case 10 Fall <strong>from</strong> a formwork shoring 23<br />
Case 11 Tipping <strong>and</strong> fall of a table formwork 26<br />
Case 12 Fall of a formwork panel 29<br />
Case 13 Fall through an open side 32<br />
Case 14 Fall <strong>from</strong> a scaffold 35<br />
Case 15 Hit by a rubber hose 38<br />
Case 16 Fall <strong>from</strong> an open side 41<br />
Case 17 Fall off an open platform 44<br />
Case 18 Fall through a skylight 47<br />
Case 19 Fall <strong>from</strong> an attic 49<br />
Case 20 Fall due to an unstable scaffold 51<br />
Case 21 Fall while dismantling a platform 54<br />
Case 22 Fall of a gondola platform 57<br />
Case 23 Fall <strong>from</strong> a scaffold 60
FALLS FROM HEIGHT
CASE 1<br />
FALL THROUGH A ROOF<br />
Description of Accident<br />
A worker was installing lifelines<br />
on a pitched roof at a worksite.<br />
He stepped on one of the roof<br />
tiles which then broke under his<br />
weight. The worker suffered<br />
severe head <strong>and</strong> chest injuries<br />
<strong>and</strong> eventually succumbed to<br />
the injuries.<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
1. Roof tiles removed<br />
• When the worker went up the<br />
roof to install the lifelines,<br />
he had stepped onto the<br />
midsection of the roof tiles<br />
where there was no support<br />
structure. The roof tile hence<br />
broke under his weight.<br />
1<br />
• He fell <strong>from</strong> a height of<br />
4.8m through the roof.<br />
2<br />
1. <strong>Height</strong> of fall = 4.8m<br />
2. Place where the deceased worker l<strong>and</strong>ed<br />
04
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
Immediate cause(s)<br />
Basic cause(s)<br />
Failure of SMS<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
• Improper position for task<br />
• Lack of experience<br />
• Inadequate work st<strong>and</strong>ards<br />
• Inadequate leadership <strong>and</strong>/or supervision<br />
• Hazard analysis <strong>and</strong> risk assessment<br />
Follow-up<br />
A Stop Work Order was issued to stop all work at the premises.<br />
The main contractor was instructed to conduct risk assessment <strong>and</strong><br />
develop safe work procedures for removing roof tiles which<br />
contained asbestos.<br />
Recommendations<br />
Conduct a proper risk assessment prior to the commencement<br />
of a job.<br />
Use a boom lift to send workers to the roof-top to install the lifelines<br />
instead of working directly on a pitched roof.<br />
Use crawl boards or ladders provided on rooftops for safe access<br />
by the workers.<br />
05
CASE 2<br />
FALL FROM A SCAFFOLD<br />
Description of Accident<br />
A worker was intending to paint<br />
the walls adjacent to a ledge. He<br />
tried to climb out of a suspended<br />
scaffold onto the building ledge<br />
but lost his footing <strong>and</strong> fell <strong>from</strong><br />
the nineth storey of the building.<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
• The worker was not wearing<br />
any safety harness or safety belt.<br />
• The suspended scaffold had<br />
last been examined in August<br />
2002, contrary to the legal<br />
requirement which states<br />
that such equipment must be<br />
thoroughly examined <strong>and</strong><br />
certified for use by an approved<br />
person once every 12 months.<br />
1. The deceased l<strong>and</strong>ed here<br />
2. The suspended scaffold was<br />
re-positioned here<br />
3. The position of the suspended scaffold<br />
at the time of the accident<br />
1. The lifeline installed outside the<br />
suspended scaffold<br />
2. A lifeline installed in between the ledges<br />
<strong>and</strong> kitchen area<br />
3. A worker attached the fall arrestor<br />
device to a lifeline<br />
4. One of the cross beams<br />
5. The suspended scaffold installed at<br />
the façade<br />
1<br />
2<br />
3<br />
1<br />
2<br />
3<br />
4<br />
5<br />
06
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
Immediate cause(s)<br />
Basic cause(s)<br />
Failure of SMS<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
• Improper position of worker for task<br />
• Inadequate or improper protective equipment<br />
• Lack of knowledge<br />
• Inadequate leadership <strong>and</strong>/or supervision<br />
• Hazard analysis <strong>and</strong> risk assessment<br />
• WSH rules, permits <strong>and</strong><br />
personal protective equipment<br />
Follow-up<br />
A Stop Work Order was issued which required the occupier to<br />
conduct hazard analyses <strong>and</strong> develop safe work procedures for<br />
the above works.<br />
The occupier was required to engage an approved person to<br />
examine the suspended scaffolds in the worksite.<br />
Recommendations<br />
Provide safe access <strong>and</strong> egress routes for workers.<br />
Install an independent lifeline for anchoring personal fall<br />
protection equipment.<br />
Brief workers on the hazards <strong>and</strong> risks of the job.<br />
07
CASE 3<br />
TRIPPED BY AN ELECTRICAL EXTENSION<br />
Description of Accident<br />
A worker was carrying out drilling<br />
operations at the 33rd level of a<br />
building. While he was searching<br />
for an electrical socket outlet to<br />
connect an electrical tool,<br />
he accidentally tripped on<br />
an electrical extension wire that<br />
he was holding <strong>and</strong> fell through<br />
an opening within a wooden<br />
barricade. He l<strong>and</strong>ed below<br />
on the 32nd level.<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
• The 33rd level floor slab opening<br />
measured approximately 4m in<br />
length <strong>and</strong> 2.7m in width. The<br />
depth <strong>from</strong> the 33rd level to<br />
the 32nd level measured<br />
approximately 4m.<br />
• The floor slab opening was meant<br />
for the staircase before it was<br />
dismantled. It was not guarded<br />
by any effective barrier to<br />
prevent falls.<br />
1. The electrical distribution box<br />
at the corner of the floor slab opening<br />
2. Partition wall beside the floor slab<br />
opening<br />
3. The floor slab opening was meant for<br />
a staircase before it was dismantled<br />
4. The 32nd level worksite below<br />
1. The electrical distribution box at the<br />
corner of the floor slab opening<br />
2. The red-white tape <strong>and</strong> nylon rope<br />
used to barricade the two sides of<br />
the floor slab opening<br />
3. The "Danger No Entry" signage<br />
4. The wooden barricade (guarding<br />
only one side of the opening <strong>and</strong><br />
not the remaining three)<br />
1<br />
2<br />
3<br />
4<br />
1<br />
2<br />
3<br />
4<br />
08
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
Immediate cause(s)<br />
Basic cause(s)<br />
Failure of SMS<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
• Inadequate guards or barriers provided<br />
• Improper placement<br />
• Lack of knowledge<br />
• Communication/group meeting<br />
• WSH training <strong>and</strong> competence<br />
Recommendations<br />
Provide barriers to guard floor openings to prevent falls or cover<br />
floor openings with a cover (if appropriate).<br />
Provide appropriate lighting <strong>and</strong> display suitable warning signs to<br />
warn operators of potential dangers at the work area.<br />
09
CASE 4<br />
FALL OF FORMWORK<br />
Description of Accident<br />
A site supervisor <strong>and</strong> a worker were<br />
killed when a jumpform panel that<br />
they were working on fell off <strong>from</strong><br />
its position to the ground below.<br />
The jumpform was fixed at the<br />
16th storey of a building that was<br />
under construction at the time<br />
of the accident.<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
• The jumpform panel that dropped<br />
was one of the two panels that had<br />
been shifted <strong>from</strong> the 15th storey<br />
of the building using a tower<br />
crane in the morning prior to<br />
the accident.<br />
1. Injured was caught in the net here<br />
below the third storey<br />
• Investigations revealed that the<br />
bracket of the collapsed jumpform<br />
panel was not securely attached<br />
onto its support mechanism. As<br />
a result, the bracket slipped off<br />
<strong>from</strong> its support <strong>and</strong> the entire<br />
panel fell off subsequently.<br />
• Significant changes were noted<br />
during the installation process<br />
of the formwork which<br />
affected its integrity.<br />
1. Jumpform fell off <strong>from</strong> here<br />
10
• The subcontractor did not<br />
conduct hazard analysis or<br />
develop safe work procedures<br />
for the new installation process.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
Immediate cause(s)<br />
Basic cause(s)<br />
Failure of SMS<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
• Failure to secure jumpform<br />
• Lack of skill<br />
• Inadequate leadership <strong>and</strong>/or supervision<br />
• Inadequate monitoring of construction<br />
• Hazard analysis <strong>and</strong> risk assessment<br />
• WSH practices <strong>and</strong> procedures<br />
• WSH training <strong>and</strong> competence<br />
Follow-up<br />
The occupier was instructed to review the design of the formwork<br />
system <strong>and</strong> to revise the safe work procedures for the workers before<br />
work on the jumpform structure was allowed to continue.<br />
<strong>Safety</strong> measures such as additional brackets <strong>and</strong> wire ropes for<br />
securing purposes were also introduced to increase system reliability.<br />
Recommendations<br />
Develop safe work procedures.<br />
Conduct proper supervision of the erection process <strong>and</strong> checking<br />
of the panel support.<br />
Ensure that the bracket hook’s design is such that it can be<br />
checked easily.<br />
11
CASE 5<br />
FALL OFF A TOPPLING SCAFFOLD<br />
Description of Accident<br />
A worker was assigned to service<br />
some roof painting work at a<br />
building. He was erecting a mobile<br />
scaffold along a corridor at the<br />
fourth storey of the building when<br />
the scaffold toppled. As a result,<br />
the worker fell off <strong>from</strong> the scaffold<br />
<strong>and</strong> out of the building onto the<br />
ground 12m below.<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
• The mobile scaffold (with a<br />
cantilevered structure) was not<br />
in a stable position <strong>and</strong> was not<br />
secured to the building structure<br />
or metal railing along the<br />
building corridor at the time<br />
of accident.<br />
1. The fourth storey roof beam<br />
2. The toppled mobile scaffold at<br />
the fourth storey corridor<br />
3. The factory building<br />
4. The location where the deceased<br />
had l<strong>and</strong>ed<br />
5. The driveway<br />
12<br />
• When the worker climbed onto<br />
the mobile scaffold to tie the<br />
metal deckings to the cantilevered<br />
structure, the mobile scaffold<br />
toppled <strong>and</strong> the worker fell off<br />
<strong>from</strong> the scaffold <strong>and</strong> building.<br />
1. The toppled mobile scaffold with the<br />
cantilevered structure<br />
2. The two metal decking which were<br />
to be tied<br />
3. The fourth storey corridor<br />
4. The parapet wall<br />
5. The castor wheels
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
Immediate cause(s)<br />
Basic cause(s)<br />
Failure of SMS<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
• Improper position for task<br />
• Inadequate or improper protective equipment<br />
• Failure to secure scaffold<br />
• Lack of experience<br />
• Inadequate work st<strong>and</strong>ards<br />
• Communication/group meeting<br />
• Hazard analysis <strong>and</strong> risk assessment<br />
• WSH training <strong>and</strong> competence<br />
Follow-up<br />
The main contractor was instructed to conduct a risk assessment<br />
<strong>and</strong> review the safe work procedures for all works at the site.<br />
Recommendations<br />
Conduct risk assessment prior to job commencement.<br />
Use an alternative method of work, or institute safe work<br />
procedures for such work.<br />
Ensure proper safety measures are in place such as securing of<br />
mobile scaffold to the building structure <strong>and</strong> provision of lifelines<br />
for the workers.<br />
13
CASE 6<br />
KILLED BY A PLUNGING HOIST<br />
Description of Accident<br />
A worker, employed as a plasterer,<br />
was seen moving up in the<br />
Passenger <strong>and</strong> Material (PM) hoist.<br />
The PM hoist suddenly plunged to<br />
the ground <strong>and</strong> the worker died<br />
on the spot.<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
1. The control unit<br />
• The PM hoist involved in the<br />
accident had been retrofitted by<br />
the hoist supplier with a machinery<br />
plate with a motor drive unit <strong>and</strong><br />
a safety device.<br />
• The most probable cause of the<br />
accident is the failure of the<br />
mounting bolts of the machinery<br />
plate. The fracture of these<br />
bolts caused the machinery plate<br />
to detach <strong>from</strong> the hoist cage.<br />
• The hoist cage slammed onto<br />
the top of the drive unit, <strong>and</strong><br />
knocked off the machinery plate<br />
with the drive unit <strong>from</strong> the rack,<br />
resulting in the free-falling<br />
of the hoist.<br />
1. The dislodged machinery plate<br />
14
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
Immediate cause(s)<br />
Basic cause(s)<br />
Failure of SMS<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
• Defective tools, equipment or materials<br />
• Inadequate maintenance<br />
• Excessive wear <strong>and</strong> tear<br />
• Maintenance regime of machinery<br />
Follow-up<br />
A Stop Work Order was issued to cease all hoisting operations<br />
installed onsite.<br />
The occupier was instructed to dismantle all hoists <strong>and</strong> replace<br />
them with another br<strong>and</strong> <strong>from</strong> another supplier.<br />
Recommendations<br />
Have a regular maintenance system as per maintenance regime<br />
of CP79.<br />
Replace bolts when installing the PM hoist at a new location.<br />
15
CASE 7<br />
FALL THROUGH AN OPENING<br />
Description of Accident<br />
A worker was to carry out painting<br />
work. While he was getting ready<br />
to paint the wall at the void area,<br />
he fell into the opening at the<br />
10th level <strong>and</strong> l<strong>and</strong>ed about 30m<br />
below on a platform.<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
• Directly above the platform were<br />
openings which were found at<br />
all levels <strong>from</strong> the first level to the<br />
12th level. The opening measured<br />
about 700mm x 900mm.<br />
• The painting supervisor did<br />
not check the work area to<br />
be plastered/painted for<br />
compliance to the safety<br />
requirements listed in the<br />
Permit-to-Work.<br />
• The worker was not wearing a<br />
safety belt/harness. He had been<br />
working on site for two weeks<br />
prior to the accident. Investigations<br />
revealed that the worker had not<br />
attended the <strong>Safety</strong> Orientation<br />
Course (construction).<br />
1. External scaffolding<br />
2. Desceased was found lying at the<br />
platform of the external scaffolding<br />
3. Passenger hoist<br />
1. External scaffolding<br />
2. Guardrail<br />
3. External wall<br />
4. Void area<br />
5. Barricade of wire rope with orange<br />
netting<br />
16
Root Cause Analysis<br />
Evaluation of loss<br />
• One worker killed<br />
Type of contact<br />
• Fall <strong>from</strong> height to lower level<br />
Immediate cause(s) • Improper position for the task<br />
• Inadequate or improper protective equipment<br />
Basic cause(s) • Lack of knowledge<br />
• Inadequate leadership <strong>and</strong>/or supervision<br />
Failure of SMS<br />
• WSH practices <strong>and</strong> procedures<br />
• Hazard analysis <strong>and</strong> risk assessment<br />
• WSH training <strong>and</strong> competence<br />
Follow-up<br />
The occupier was instructed to review the Permit-to-Work system<br />
on site <strong>and</strong> implement it on a daily basis.<br />
The occupier was instructed to only engage painters who have<br />
attended the safety orientation course at the worksite.<br />
Recommendations<br />
Ensure all workers attend the Construction <strong>Safety</strong> Orientation Course.<br />
Implement a safety induction programme on the use of personal<br />
protective equipment prior to starting work.<br />
Supervisors should be responsible to check <strong>and</strong> ensure the use<br />
of appropriate personal protective equipment.<br />
Conduct regular briefings on the dangers of working at heights.<br />
17
CASE 8<br />
FALL FROM A SCAFFOLD<br />
Description of Accident<br />
Worker A <strong>and</strong> his co-workers<br />
were instructed to tidy up metal<br />
scaffolds above a courtyard area<br />
at a worksite. The group took up<br />
their positions on the metal<br />
scaffolds <strong>and</strong> the worker was then<br />
on a scaffold next to the classroom<br />
block. Worker A was to work on<br />
the working platforms at the<br />
fifth lift of the scaffold next to<br />
the classroom block. He fell to<br />
his death <strong>and</strong> was found lying on<br />
the ground at the first storey.<br />
1. The loose frame scaffold that was to be<br />
removed by the deceased<br />
2. A patched wall tie hole where the<br />
cement was still wet<br />
3. The working platform at the fifth lift of<br />
the scaffold where the deceased had<br />
stood on when working on the scaffold<br />
18<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
• The location that Worker A<br />
l<strong>and</strong>ed was right below the<br />
scaffold that he was working on<br />
<strong>and</strong> the ground was scattered<br />
with damaged cross bracings,<br />
metal decking, scaffold frames<br />
<strong>and</strong> metal pipes.<br />
• The group of workers wore<br />
safety belts but there was no<br />
lifeline found on the scaffolds for<br />
them to anchor their safety belts.<br />
1. The deceased was working on the working<br />
platform laid on the fifth lift of the scaffold<br />
2. The corridor where the dismantled<br />
scaffolding items were stored<br />
3. A wall tie at the second lift of the scaffold<br />
4. The deceased had l<strong>and</strong>ed here where<br />
the scaffolding items had scattered
• The workers were not trained<br />
scaffold erectors <strong>and</strong> had not<br />
undergone any course for<br />
scaffold erection.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
Immediate cause(s) • Improper use of personal protective equipment<br />
Basic cause(s)<br />
Failure of SMS<br />
• Lack of knowledge<br />
• Lack of skill<br />
• WSH training <strong>and</strong> competence<br />
• Hazard analysis <strong>and</strong> risk assessment<br />
Follow-up<br />
The occupier was issued with a Stop Work Order to install lifelines<br />
on the scaffold <strong>and</strong> to engage trained scaffold erectors to dismantle<br />
the scaffolds.<br />
Recommendations<br />
Install independent lifelines.<br />
Supervisors should be responsible to check <strong>and</strong> ensure the use of<br />
appropriate personal protective equipment.<br />
Conduct regular briefings on the dangers of working at heights.<br />
19
CASE 9<br />
COLLAPSE OF A PLATFORM<br />
Description of Accident<br />
Three workers were carrying out<br />
installation of a clothes drying rack<br />
at the 10th level of an HDB flat. The<br />
installation was done <strong>from</strong> a mast<br />
climbing platform in the worksite.<br />
Upon completion of the work, they<br />
were about to descend when the<br />
platform suddenly came down.<br />
All three workers fell; two of them<br />
died while the other was injured.<br />
1. The platform had split open after<br />
the incident<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
• The bottom motor of the drive<br />
unit of the platform was not<br />
the original motor fitted to<br />
the platform.<br />
• The gearboxes of both the top<br />
<strong>and</strong> bottom motors were<br />
produced by the same<br />
manufacturer, but were of<br />
different type.<br />
• The top motor was a two stage<br />
gearbox while the bottom motor<br />
was a three stage gearbox. Use of<br />
these two gearboxes with different<br />
output speed induces great stress<br />
within the gears in the gearboxes.<br />
1. Top motor<br />
2. Bottom motor<br />
20
• The moment the gearboxes<br />
failed, the platform<br />
descended suddenly <strong>and</strong><br />
crashed to the ground.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
• Two workers killed <strong>and</strong> one injured<br />
• Fall <strong>from</strong> height to lower level<br />
Immediate cause(s) • Defective tools, equipment or materials<br />
Basic cause(s)<br />
Failure of SMS<br />
• Inadequate maintenance<br />
• Inadequate replacement of unsuitable<br />
materials<br />
• Maintenance regime<br />
• WSH practices <strong>and</strong> procedures<br />
Follow-up<br />
A Stop Work Order was issued.<br />
The occupier was instructed to stop using all mast climbing work<br />
platforms (MCWP) at the worksite.<br />
The occupier was also instructed to carry out the following:<br />
• To inspect all MCWPs <strong>and</strong> make good any defect found.<br />
• To inspect that all motors in each drive unit of every MCWP used<br />
at the worksite were of the same type.<br />
• To have the MCWP inspected, examined <strong>and</strong> certified by an<br />
approved person prior to the start of work.<br />
21
Recommendations<br />
Conduct functional checks, regularly, <strong>and</strong> before use.<br />
Ensure that the specifications of the different units of any<br />
equipment are compatible.<br />
Have fall protection equipment as an additional safety measure.<br />
22
CASE 10<br />
FALL FROM A FORMWORK SHORING<br />
Description of Accident<br />
Worker A <strong>and</strong> his co-worker were<br />
involved in the transfer of three<br />
units of formwork shoring <strong>from</strong> the<br />
third storey to the second storey<br />
of the building that was under<br />
construction.<br />
They were climbing up the frame<br />
of a unit of the formwork shoring<br />
on the third storey so as to attach<br />
the hooks of the chain slings<br />
<strong>from</strong> the tower crane when the<br />
formwork shoring suddenly<br />
tilted <strong>and</strong> toppled to the floor.<br />
Worker A fell <strong>from</strong> the shoring<br />
<strong>and</strong> l<strong>and</strong>ed on the third storey.<br />
He sustained serious head<br />
injuries <strong>from</strong> the fall <strong>and</strong> died<br />
on the spot. The other worker<br />
suffered minor scratches as he<br />
managed to jump to the floor<br />
as the shoring toppled.<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
1. The deceased l<strong>and</strong>ed here<br />
2. The toppled formwork shoring<br />
1. The toppled formwork shoring<br />
2. Width: 1.2m<br />
3. The inner props<br />
• Worker A was st<strong>and</strong>ing on<br />
a formwork frame about 4.28m<br />
<strong>from</strong> the floor when the<br />
shoring toppled.<br />
23
• The ratio of the height of the<br />
shoring against its width was<br />
about 4.74m. It was tall<br />
<strong>and</strong> slim <strong>and</strong> hence prone<br />
to toppling.<br />
• There was no outrigger<br />
installed on the shoring to<br />
ensure the stability of the<br />
shoring. It was thus unsafe<br />
for workers to work on<br />
the shoring.<br />
• The worker who was to rig up<br />
the shoring had not attended<br />
the Rigging Operation Course<br />
<strong>and</strong> he was not an appointed<br />
rigger. There was no lifting<br />
supervisor appointed for the<br />
transfer of shoring using the<br />
tower crane.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
Immediate cause(s)<br />
Basic cause(s)<br />
Failure of SMS<br />
• One worker killed <strong>and</strong> one injured<br />
• Fall <strong>from</strong> height to lower level<br />
• Failure to secure shoring<br />
• Lack of knowledge<br />
• Inadequate work st<strong>and</strong>ards<br />
• Inadequate leadership <strong>and</strong>/or supervision<br />
• Hazard analysis <strong>and</strong> risk assessment<br />
• WSH training <strong>and</strong> competence<br />
24
Follow-up<br />
To prevent recurrence, the factory occupier was instructed to<br />
implement the following safety measures:<br />
• Provide ladders on the shoring or riggers to gain access to a<br />
higher level for rigging up the shoring.<br />
• Provide working platform of at least 635mm width as foothold<br />
on the shoring for the riggers.<br />
• Appoint a qualified lifting supervisor to co-ordinate the<br />
lifting of the shoring before the commencement of work.<br />
• Appoint qualified riggers to carry out the rigging work.<br />
Recommendations<br />
A safe width to height ratio must be ensured.<br />
Proper access such as a monkey ladder should be provided.<br />
25
CASE 11<br />
TIPPING AND FALL OF A TABLE FORMWORK<br />
Description of Accident<br />
Worker A <strong>and</strong> his co-worker were<br />
working on a table form<br />
(formwork) that was partially set<br />
up on the eighth level. The table<br />
form tipped towards the edge of<br />
the building <strong>and</strong> fell to the ground.<br />
Worker A fell together with the<br />
table form <strong>and</strong> l<strong>and</strong>ed on the<br />
ground. He died on the spot.<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
1. The metal frames of the table form that<br />
fell <strong>from</strong> the eighth level<br />
• The table form was not set<br />
up on the eighth level in<br />
accordance with the design of<br />
the professional engineer.<br />
• The formwork subcontractor<br />
claimed that due to space<br />
constraints, the position of the<br />
front props for the table form<br />
could not be put up according<br />
to the design of the professional<br />
engineer. However, the<br />
subcontractor did not request<br />
the professional engineer to<br />
redesign the table form to suit<br />
the actual site situation.<br />
1. The rear corner props<br />
2. The intermediate props<br />
3. The front corner props<br />
26
• According to the design, while<br />
setting up the table form,<br />
four props at the four corners<br />
were to be put up first followed<br />
by two intermediate props.<br />
However at the time of<br />
accident, the table form<br />
was supported by two<br />
props at the rear corners<br />
<strong>and</strong> two placed at intermediate<br />
positions.<br />
• The position of Worker A<br />
<strong>and</strong> his co-worker were outside<br />
the four supporting points<br />
<strong>and</strong> the combined weight<br />
caused the table form to tip<br />
over <strong>and</strong> fall over the edge<br />
of the building.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
Immediate cause(s)<br />
Basic cause(s)<br />
Failure of SMS<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
• Improper placement of table form<br />
• Inadequate evaluation of changes<br />
• Hazard analysis <strong>and</strong> risk assessment<br />
27
Follow-up<br />
A Stop Work Order was issued to stop work on the table form.<br />
The occupier <strong>and</strong> subcontractor were instructed to implement<br />
the following safety measures:<br />
• To redesign the table form using a professional engineer.<br />
The revised design should enable it to be supported by<br />
four props at the four corners.<br />
• To ensure that a formwork supervisor is present to supervise<br />
the erection of the formwork at the site.<br />
• To conduct safety training to instruct the supervisors <strong>and</strong><br />
workers on the proper way to set up the table forms.<br />
Recommendations<br />
Ensure that a table form is fully supported by all necessary<br />
props at all times.<br />
Ensure formwork supervisor is present at all times to supervise<br />
the proper erection of the formwork at the site.<br />
Conduct safety training to instruct supervisors <strong>and</strong> workers on the<br />
proper way to set up the table forms.<br />
28
CASE 12<br />
FALL OF A FORMWORK PANEL<br />
Description of Accident<br />
A worker was involved in the<br />
dismantling of metal formwork<br />
panels. He was st<strong>and</strong>ing on the<br />
working platform of a metal<br />
formwork panel when the panel<br />
gave way. He fell about 6m<br />
together with the panel <strong>and</strong><br />
it l<strong>and</strong>ed on him. He died on<br />
the spot.<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
1. Working platform at the top section<br />
2. Modular formwork panels<br />
• Investigations revealed that<br />
the day prior to the accident,<br />
the tie rods at the top section<br />
of the formwork structure had<br />
been removed. The stability of<br />
the formwork structure was<br />
compromised as a result.<br />
• The foreman had noticed this<br />
but he did not proceed to<br />
check the tie rods at the top<br />
section of the other panels of<br />
the formwork structure,<br />
although he was aware that<br />
something was amiss.<br />
1. Connecting brackets between internal<br />
<strong>and</strong> external formwork panels<br />
2. Deceased was st<strong>and</strong>ing around this<br />
position on the working platform of the<br />
formwork panel prior to the incident<br />
3. The formwork panel had “peeled” off,<br />
exposing the concrete wall<br />
4. The deceased fell about 6m to the<br />
first level. The formwork panel also<br />
came down <strong>and</strong> l<strong>and</strong>ed on him<br />
29
• As the worker was st<strong>and</strong>ing<br />
on one end of the working<br />
platform of the formwork<br />
panel, the formwork panel<br />
peeled off <strong>from</strong> the concrete<br />
wall structure. The worker<br />
lost his balance <strong>and</strong> fell <strong>from</strong><br />
the working platform. The<br />
formwork panel also came<br />
down <strong>and</strong> l<strong>and</strong>ed on him.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
Immediate cause(s)<br />
Basic cause(s)<br />
Failure of SMS<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
• Failure to secure formwork<br />
• Inadequate work st<strong>and</strong>ards<br />
• WSH practices <strong>and</strong> procedures<br />
30
Follow-up<br />
The occupier was instructed to implement the following<br />
improvements/measures at the worksite:<br />
• A written work procedure on the installation <strong>and</strong> dismantling of<br />
the formwork system to be instituted <strong>and</strong> implemented at their<br />
worksites.<br />
• Warning signages to be installed at the top section of the<br />
formwork structure to remind workers not to remove the tie rods<br />
at the top section prior to hoisting by a tower crane.<br />
Recommendations<br />
Ensure that the formwork supervisor closely supervises the work.<br />
Check <strong>and</strong> secure all formwork at all times.<br />
Use written work procedures <strong>and</strong> signage to remind workers not<br />
to remove tie rods.<br />
31
CASE 13<br />
FALL THROUGH AN OPEN SIDE<br />
Description of Accident<br />
Worker A <strong>and</strong> his co-worker<br />
were getting ready to carry out<br />
plastering work to a column<br />
on the fifth level of a building<br />
at a worksite.<br />
Subsequently Worker A was<br />
seen falling through the open<br />
side next to the column to be<br />
plastered. He l<strong>and</strong>ed on the<br />
ground level 15m below <strong>and</strong><br />
died subsequently.<br />
1. Fifth level<br />
2. Open side<br />
3. The deceased was found here<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
• The open side where the worker<br />
fell off was not barricaded.<br />
• There was a lot of building<br />
materials, wooden pallets,<br />
formwork materials <strong>and</strong> other<br />
materials placed on the floor<br />
on the fifth level. These materials<br />
were placed haphazardly <strong>and</strong><br />
obstructed access. Worker A<br />
had to maneuver his way<br />
through these materials to<br />
his workplace.<br />
1. Column to be plastered<br />
2. Open sides<br />
3. Scaffold<br />
32
• Worker A was last seen<br />
st<strong>and</strong>ing at the column near<br />
the open side, holding his<br />
safety belt in his h<strong>and</strong>. He was<br />
seen falling off the edge.<br />
• The accident probably<br />
occurred when Worker A was<br />
inspecting the column located<br />
next to the open side. He may<br />
have tripped on some object<br />
on the ground <strong>and</strong> lost his<br />
balance.<br />
• A similar accident had<br />
happened three months ago.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
Immediate cause(s) • Inadequate guards or barriers<br />
Basic cause(s)<br />
Failure of SMS<br />
• Inadequate work st<strong>and</strong>ards<br />
• Inadequate storage of materials<br />
• Poor housekeeping<br />
• WSH practices <strong>and</strong> procedures<br />
Follow-up<br />
The occupier was instructed to carry out the following:<br />
• To cover all openings <strong>and</strong> put up barricades for open<br />
sides on site.<br />
• To place materials properly so as not to obstruct the passageway.<br />
• To carry out housekeeping regularly on site.<br />
33
Recommendations<br />
Provide barricades with rigid materials for all open sides <strong>and</strong><br />
secure at both ends.<br />
Stack materials properly.<br />
Clear debris frequently.<br />
Ensure close supervision so that personal protective equipment<br />
are used correctly.<br />
34
CASE 14<br />
FALL FROM A SCAFFOLD<br />
Description of Accident<br />
Worker A <strong>and</strong> his two co-workers<br />
were involved in the dismantling<br />
of an external scaffolding of a<br />
block. One of the co-workers<br />
descended <strong>from</strong> the scaffold <strong>and</strong><br />
called out to Worker A <strong>and</strong> another<br />
co-worker to come down <strong>from</strong><br />
the scaffold for lunch.<br />
As the co-worker was waiting at<br />
the foot of the block, Worker A<br />
fell <strong>from</strong> the scaffold <strong>and</strong> hit him.<br />
Worker A was seen bleeding <strong>from</strong><br />
the back of his head <strong>and</strong> was<br />
sent to the hospital where he<br />
subsequently passed away.<br />
1. Block 10<br />
2. External scaffolding being dismantled<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
• The scaffold supervisor was<br />
not with the worker when the<br />
dismantling work was in<br />
progress. He had left the<br />
worksite to buy lunch for his<br />
workers.<br />
1. External scaffolding<br />
2. The deceased was found here<br />
• Worker A was found with<br />
his safety harness on his waist<br />
after the accident.<br />
35
• There were no eye-witness<br />
accounts as to how Worker A<br />
fell <strong>from</strong> the scaffold. Upon<br />
hearing his co-worker’s call to<br />
come down, the worker might<br />
have detached his safety<br />
harness <strong>from</strong> the lifeline.<br />
The accident probably<br />
happened when he was<br />
descending <strong>from</strong> the scaffold,<br />
<strong>and</strong> lost his footing. When he<br />
fell, he hit the scaffold along<br />
the path of his fall <strong>and</strong> hit the<br />
worker who was waiting at the<br />
foot of the block.<br />
• Worker A <strong>and</strong> one of the<br />
co-workers involved in the<br />
dismantling work had not<br />
undergone any training course<br />
for the work. The safety<br />
manager <strong>and</strong> the scaffold<br />
supervisor were aware that<br />
the two workers did not have<br />
scaffold erectors certificates.<br />
It was reported that the<br />
workers were scaffold<br />
assistants <strong>and</strong> were expected<br />
to be stationed on the<br />
ground, not on the scaffold.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
Immediate cause(s) • Making safety devices inoperative<br />
Basic cause(s)<br />
Failure of SMS<br />
• Lack of knowledge<br />
• Lack of skill<br />
• Inadequate supervision<br />
• WSH training <strong>and</strong> competence<br />
36
Follow-up<br />
The occupier was instructed to engage only trained scaffolders to<br />
carry out the scaffolding work on site.<br />
Recommendations<br />
Assign only certified erectors to carry out dismantling work.<br />
Provide proper training.<br />
37
CASE 15<br />
HIT BY A RUBBER HOSE<br />
Description of Accident<br />
A concrete pump operator <strong>and</strong><br />
his co-workers were carrying out<br />
cleaning work on a platform which<br />
was erected about 10m above<br />
the bottom of the shaft.<br />
The cleaning work was carried out<br />
by means of inserting a sponge<br />
ball into one end of the pipeline<br />
<strong>and</strong> feeding the pipeline with<br />
compressed air. The other end<br />
of the pipeline was equipped<br />
with a rubber hose to discharge<br />
the leftover concrete into a<br />
container. The workers were<br />
gripping the rubber hose while<br />
the pump operator held down<br />
the rubber hose with a steel tube.<br />
When the sponge ball was<br />
forced out <strong>from</strong> the rubber hose,<br />
the hose swung suddenly <strong>and</strong><br />
hit the pump operator. He was<br />
flung off the platform <strong>and</strong><br />
l<strong>and</strong>ed on the bottom of the<br />
shaft. He died on the spot.<br />
1. Concrete pump<br />
2. Rubber hose<br />
3. Timbers on the platform<br />
4. Scaffold frame<br />
1. Deceased was st<strong>and</strong>ing here prior<br />
to the accident<br />
2. Rubber hose was placed on a<br />
scaffold frame<br />
38
Causes <strong>and</strong> Contributing<br />
Factors<br />
• There were some pieces of<br />
timber placed on the platform<br />
where the cleaning work<br />
was carried out. Workers<br />
mentioned that it had, to some<br />
extent, hampered their work.<br />
• Investigations revealed that<br />
the rubber hose was not<br />
secured in position to prevent<br />
it <strong>from</strong> moving during the<br />
cleaning operation.<br />
• Towards the end of the<br />
cleaning operation, particularly<br />
at the time when the sponge<br />
ball was forced out <strong>from</strong> the<br />
hose, the sudden release of the<br />
compressed air probably<br />
created some lateral forces. This<br />
caused the hose to swing <strong>and</strong><br />
resulted in the workers losing<br />
their grip on the hose.<br />
• The hose swung <strong>and</strong> hit the<br />
pump operator, pushing him<br />
over the guardrail.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
• One worker killed<br />
Type of contact<br />
• Fall <strong>from</strong> height to lower level<br />
Immediate cause(s) • Failure to secure the rubber hose<br />
• Poor housekeeping<br />
Basic cause(s) • Improper storage of materials<br />
• Inadequate work st<strong>and</strong>ards<br />
Failure of SMS<br />
• WSH practices <strong>and</strong> procedures<br />
• Hazard analysis <strong>and</strong> risk assessment<br />
39
Follow-up<br />
The occupier was instructed to submit safe work procedures (SWP)<br />
for pipeline cleaning work involving compressed air <strong>and</strong> to<br />
implement <strong>and</strong> ensure that all the workers adhered to<br />
the SWP.<br />
Recommendations<br />
Ensure at least two tag lines to hold the end of the rubber hose<br />
in position.<br />
Workers should be provided with <strong>and</strong> trained in the use of fall<br />
protection equipment.<br />
Ensure close <strong>and</strong> continuous supervision of such hazardous<br />
operations.<br />
40
CASE 16<br />
FALL FROM AN OPEN SIDE<br />
Description of Accident<br />
A subcontractor was engaged<br />
to carry out block-laying <strong>and</strong><br />
plastering works at Blocks A <strong>and</strong><br />
B of a building site. The foreman<br />
had given instructions to a worker<br />
at Block A to clear some wooden<br />
palette at the workplace after<br />
which he walked towards Block B.<br />
About five minutes later, the<br />
foreman was seen sitting on top<br />
of a pile of debris at the second<br />
storey of Blk B. He was bleeding<br />
on the left side of his head <strong>and</strong><br />
was pronounced dead by the<br />
ambulance officer.<br />
1. Open side<br />
2. Debris<br />
3. Precast concrete components<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
• A wooden pallet was found<br />
broken among the pile of debris<br />
at Block B. There were fresh blood<br />
stains on the pallet. A worker<br />
confirmed that he found the<br />
foreman on the broken palette.<br />
• The pile of debris was situated<br />
right below a side of the building<br />
with a series of open sides.<br />
1. The deceased was found here<br />
41
• Investigations revealed that<br />
the open sides at the seventh<br />
storey were barricaded. All<br />
the other open sides at<br />
Block B, i.e. first to sixth storey<br />
<strong>and</strong> the eighth storey were<br />
not barricaded.<br />
• Debris was also seen placed<br />
close to the edge of an<br />
open side on the seventh<br />
storey of Block B. The debris<br />
could fall <strong>and</strong> potentially<br />
hit a person st<strong>and</strong>ing below.<br />
• The foreman was believed<br />
to have fallen <strong>from</strong> one of<br />
the open sides. He might have<br />
lost his footing when he was<br />
working near an unbarricaded<br />
open side at Block B. He may<br />
have fallen <strong>and</strong> l<strong>and</strong>ed on the<br />
pile of debris at the second<br />
storey of Block B.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
• One worker killed<br />
Type of contact<br />
• Fall <strong>from</strong> height to lower level<br />
Immediate cause(s) • Inadequate guards or barriers at open sides<br />
• Poor housekeeping<br />
Basic cause(s)<br />
Failure of SMS<br />
• Inadequate work st<strong>and</strong>ards<br />
• WSH practices <strong>and</strong> procedures<br />
42
Follow-up<br />
The occupier was instructed to undertake the following<br />
improvements to the work practices/conditions at the site:<br />
• Cover openings/put up barricades to open sides on site.<br />
• Remove loose materials <strong>from</strong> the edge of the buildings.<br />
• Carry out proper housekeeping on site.<br />
Recommendations<br />
Provide barricades with rigid materials to all open sides <strong>and</strong> secure<br />
at both ends.<br />
Develop proper method statements on putting up barricades.<br />
Stack materials properly.<br />
Debris to be cleared frequently.<br />
There should be close supervision to ensure that personal protective<br />
equipment are used properly.<br />
43
CASE 17<br />
FALL OFF AN OPEN PLATFORM<br />
Description of Accident<br />
A worker was engaged to carry<br />
out painting work in a school<br />
building. He was assigned to paint<br />
the roof purlins <strong>and</strong> the supporting<br />
metal frames for a featured roof<br />
located above the staircase roof<br />
slab of a six-storey building. He<br />
was later found lying at the foot<br />
of the building with serious injuries<br />
<strong>and</strong> was pronounced dead by<br />
ambulance officers.<br />
1. Purlin near the edge of the featured roof<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
• Investigations revealed that a<br />
scaffold with a working platform<br />
had been erected below the part<br />
of the featured roof that was<br />
protruding beyond the staircase<br />
roof slab.<br />
• There was no guardrail erected<br />
on the open side of the working<br />
platform to prevent falls. There<br />
was also no ladder provided on<br />
the scaffold for access to the<br />
working platform.<br />
1. The featured roof<br />
2. Purlin near the edge of the featured roof<br />
3. Working platform on the scaffold<br />
4. The staircase roof slab<br />
5. Roof slab above the sixth storey<br />
3<br />
44
• It is probable that prior to the<br />
accident, the worker had gone<br />
up to the working platform<br />
on the scaffold to paint the<br />
purlin that was located near<br />
the edge of the featured roof.<br />
While painting the purlin,<br />
he may have fallen over the<br />
open side of the working<br />
platform <strong>and</strong> l<strong>and</strong>ed at the<br />
foot of the building.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
Immediate cause(s)<br />
Basic cause(s)<br />
Failure of SMS<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
• Inadequate guard or barrier<br />
• Inadequate engineering<br />
(inadequate assessment of loss exposures)<br />
• WSH practices <strong>and</strong> procedures<br />
45
Follow-up<br />
Occupier was instructed to implement the following safety<br />
measures:<br />
• The scaffold should be properly erected <strong>and</strong> used for painting<br />
the purlin <strong>and</strong> metal frames located near the edge of the roof.<br />
• Guardrails of at least 1.1m height should be erected on the open<br />
sides of the working platform <strong>and</strong> the staircase roof slab, to<br />
prevent fall of persons working there.<br />
• Access ladders should be provided for the workers to reach the<br />
working platform.<br />
• Painters should anchor their safety belts while working on the<br />
working platform.<br />
Recommendations<br />
Provide lifeline for all work at heights.<br />
Brief workers regularly on the use of personal protective equipment<br />
<strong>and</strong> fall protection measures.<br />
Erect scaffolds with proper access <strong>and</strong> guardrails.<br />
46
CASE 18<br />
FALL THROUGH A SKYLIGHT<br />
Description of Accident<br />
Worker A <strong>and</strong> three other<br />
co-workers, each carried a pail<br />
containing waterproofing material<br />
up a roof in preparation for the<br />
coating of the skylight of a roof.<br />
While they were on the roof,<br />
one of the co-workers heard a<br />
breaking sound coming <strong>from</strong><br />
the roof sheets. He turned his<br />
head <strong>and</strong> saw a broken skylight.<br />
Worker A had fallen through the<br />
skylight of the roof (at a height<br />
of 8m) <strong>and</strong> l<strong>and</strong>ed on the ground.<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
1. This row of skylight was to be<br />
waterproofed<br />
2. Location where the deceased fell<br />
through the skylight<br />
• Investigations revealed that prior<br />
to starting work, the site supervisor<br />
had briefed the workers not to<br />
step on the skylight.<br />
• Investigations revealed that<br />
no safety measures such as<br />
crawling boards or planks had<br />
been provided as foothold for<br />
the workers to st<strong>and</strong> on while<br />
working on the roof.<br />
1. The deceased fell about 8m <strong>and</strong><br />
l<strong>and</strong>ed here<br />
47
• According to the workers,<br />
the site supervisor told them<br />
that there were no anchorage<br />
points on the roof <strong>and</strong> hence<br />
they would not be able to<br />
use their safety belts while<br />
working on the roof.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
Immediate cause(s)<br />
Basic cause(s)<br />
Failure of SMS<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
• Inadequate or improper protective equipment<br />
• Inadequate work st<strong>and</strong>ards<br />
• WSH practices <strong>and</strong> procedures<br />
• WSH training <strong>and</strong> competence<br />
Follow-up<br />
The occupier was instructed to implement a written safe work<br />
procedure immediately.<br />
The employer was instructed to provide suitable crawling boards<br />
or planks <strong>and</strong> to install suitable <strong>and</strong> sufficient anchorage points/<br />
lifelines on the roof.<br />
Recommendations<br />
Install appropriate lifelines <strong>and</strong> anchorages.<br />
Provide crawling boards, planks or ladders as a foothold for<br />
workers working on the roof.<br />
48
CASE 19<br />
FALL FROM AN ATTIC<br />
Description of Accident<br />
Worker A, seven other co-workers<br />
<strong>and</strong> a signalman were doing<br />
concreting work on the roof beams<br />
of a building at a worksite.<br />
While waiting for a truckload of<br />
concrete, Worker A was seen resting<br />
on the staircase at the attic. Moments<br />
later, Worker A was found on the<br />
ground bleeding <strong>from</strong> his head.<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
• The workers confirmed that<br />
they were not wearing safety<br />
belts while carrying out the<br />
concreting work. Even if they<br />
had worn their safety belts,<br />
there was no anchorage point<br />
for them to secure their<br />
safety belts.<br />
• There were no working<br />
platforms provided for the<br />
workers for the concreting<br />
of the roof beams.<br />
• Worker A was seen sitting on<br />
the plywood placed on some<br />
timbers at the opening of<br />
the attic.<br />
1. Roof beams<br />
2. Attic level<br />
3. The deceased was found at the fifth level<br />
1. Deceased was seen resting here<br />
2. Plywood<br />
3. Opening<br />
49
• The accident could have<br />
occurred when Worker A was<br />
resting on the plywood. The<br />
plywood could have broken<br />
<strong>and</strong> Worker A may have lost<br />
his footing <strong>and</strong> fallen through<br />
the opening. His head would<br />
have hit the concrete floor<br />
<strong>and</strong> the head injury could<br />
have caused his death.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
Immediate cause(s) • Inadequate guards or barriers<br />
• Inadequate or improper protective equipment<br />
Basic cause(s)<br />
Failure of SMS<br />
• Improper motivation<br />
• Lack of supervisory/management<br />
job knowledge<br />
• WSH practices <strong>and</strong> procedures<br />
• WSH training <strong>and</strong> competence<br />
Follow-up<br />
The occupier was instructed to provide working platforms for<br />
the workers for the concreting work at the roof.<br />
Recommendations<br />
Provide proper working platform.<br />
Provide proper personal protective equipment.<br />
Provide proper training.<br />
50
CASE 20<br />
FALL DUE TO AN UNSTABLE SCAFFOLD<br />
Description of Accident<br />
A worker was instructed to install<br />
a special fixture called “bonding<br />
bars” at the service duct area on<br />
the fourth storey of a building<br />
under construction.<br />
An hour later, he was found to<br />
have fallen together with a mobile<br />
scaffold <strong>from</strong> the corridor of the<br />
fourth storey of the building.<br />
He l<strong>and</strong>ed on the ground floor.<br />
He was sent to the hospital <strong>and</strong><br />
died on the same day.<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
1. Tower scaffold at service duct area<br />
2. Mobile scaffold<br />
3. Parapet wall<br />
4. Two caster wheels found on the<br />
fourth storey<br />
5. Uneven floor<br />
• There were no eye-witnesses<br />
to the accident. The worker<br />
was probably using the<br />
mobile scaffold when he<br />
fell together with the scaffold<br />
<strong>from</strong> the fourth storey to<br />
the ground floor.<br />
1. Tower scaffold<br />
2. Unsecured decking<br />
3. Bonding bars<br />
51
• The following factors could<br />
have contributed to the<br />
accident:<br />
i. The mobile scaffold erected<br />
was not tied to the building<br />
or other structures despite<br />
the fact that its height (3.47m)<br />
was more than three times<br />
the lesser dimension of the<br />
base (0.8m). In addition, it was<br />
placed on an uneven floor.<br />
The mobile scaffold would<br />
have been unstable on such<br />
a floor <strong>and</strong> any person using<br />
it could cause it to topple.<br />
ii. The mobile scaffold was<br />
erected without any<br />
supervision <strong>from</strong> a scaffold<br />
supervisor to ensure that<br />
it was properly erected<br />
<strong>and</strong> stable.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
Immediate cause<br />
Basic cause(s)<br />
Failure of SMS<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
• Inadequate or improper protective equipment<br />
• Inadequate leadership <strong>and</strong>/or supervision<br />
• WSH practices <strong>and</strong> procedures<br />
52
Follow-up<br />
The occupier was instructed to implement a Permit-to-Work system<br />
to control the use of tower <strong>and</strong> mobile scaffolds at the site.<br />
Recommendations<br />
Ensure proper inspection by a trained scaffold supervisor.<br />
Secure mobile scaffold using ties if the scaffold is greater than<br />
4m in height <strong>and</strong> is close to an opening.<br />
Protect workers working close to an opening at a height greater<br />
than 4m with fall arrest equipment.<br />
53
CASE 21<br />
FALL WHILE DISMANTLING A PLATFORM<br />
Description of Accident<br />
Worker A <strong>and</strong> his co-workers<br />
were to dismantle a metal<br />
platform erected on a scaffold<br />
support. For this, they would have<br />
to remove the clips that held the<br />
pieces of metal formwork together<br />
so as to take them apart.<br />
Worker A was later found lying<br />
on the ground beside the<br />
scaffold support. He was taken<br />
to the hospital where he passed<br />
away on the same day.<br />
1. The underside of the metal platform<br />
that was to be dismantled<br />
2. The metal clip holding adjacent pieces<br />
of metal formwork together<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
• The metal platform was about<br />
4.5m above the ground.<br />
• Worker A was last seen by the<br />
foreman 7 to 8 minutes<br />
prior to the accident. He was<br />
doing some work on the ground<br />
below the metal platform that<br />
was to be dismantled.<br />
1. The metal platform that was to<br />
be dismantled<br />
2. The scaffold support<br />
3. The deceased was found lying here<br />
after the accident<br />
54
• Investigations revealed that<br />
on the day of the accident,<br />
a safe means of access or egress<br />
<strong>from</strong> the metal platform,<br />
such as a ladder ramp was not<br />
provided on the scaffold.<br />
• The accident probably<br />
happened when Worker A<br />
climbed up the scaffold<br />
support to dismantle the metal<br />
platform <strong>and</strong> lost his grip on<br />
the scaffold frame <strong>and</strong> fell to<br />
the ground.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
Immediate cause(s) • Inadequate or improper protective equipment<br />
Basic cause(s)<br />
Failure of SMS<br />
• Inadequate engineering<br />
• Inadequate work st<strong>and</strong>ards<br />
• Hazard analysis <strong>and</strong> risk assessment<br />
55
Follow-up<br />
The occupier was instructed to implement the following safety<br />
measures:<br />
• Provide a working platform of at least 635cm width for use as<br />
footing by workers dismantling the metal platforms.<br />
• Provide a safe means of access, such as a ladder or an access ramp<br />
with h<strong>and</strong>rails for workers to gain access to the working platform<br />
on the scaffold support.<br />
• Workers must st<strong>and</strong> on the working platform <strong>and</strong> anchor<br />
their safety belts to the scaffold frames while dismantling the<br />
metal platform.<br />
• The supervisor-in-charge is to brief the workers on the safety<br />
aspects involved in the dismantling of the platform prior to the<br />
commencement of work.<br />
Recommendations<br />
Provide proper access to the formwork level.<br />
Develop <strong>and</strong> implement safe work procedures.<br />
Ensure that the formwork supervisor is present during the<br />
dismantling of formwork <strong>and</strong> its components.<br />
Provide lifelines <strong>and</strong> fall protection for all work at heights.<br />
Brief the workers on the safety aspects of working at heights prior<br />
to the commencement of work. This should be done by the<br />
supervisor-in-charge.<br />
56
CASE 22<br />
FALL OF A GONDOLA PLATFORM<br />
Description of Accident<br />
In the early morning, two workers<br />
had started on the external<br />
window <strong>and</strong> façade cleaning of<br />
a building, using a permanent<br />
gondola located at the rooftop<br />
of the building.<br />
About an hour later, the gondola<br />
became jammed <strong>and</strong> the two<br />
workers were left str<strong>and</strong>ed in the<br />
gondola between the 31st <strong>and</strong><br />
28th storey of the building.<br />
About three hours later, the service<br />
technicians <strong>from</strong> the gondola<br />
supplier arrived on site. While<br />
rectifying the fault, the platform of<br />
the gondola together with the two<br />
workers suddenly plummeted <strong>and</strong><br />
crashed onto the rooftop of the<br />
podium at the fifth floor. One<br />
worker died on the spot.<br />
1. The gondola<br />
1. The rooftop where the gondola crashed<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
• The platform together with<br />
the two workers plummeted<br />
due to the fracturing of the<br />
gearbox shaft holding the<br />
emergency safety brake.<br />
57
• The safety devices, hydraulic<br />
pressure switch <strong>and</strong> electrical<br />
thermal relay for the hoisting<br />
motor were also found to be<br />
incorrectly set. The wrong<br />
setting allowed the gondola<br />
to operate in an overloaded<br />
condition without the power<br />
being automatically cut off.<br />
• Investigations revealed<br />
that the gondola had earlier<br />
experienced numerous<br />
repetitive defects <strong>and</strong><br />
failures that resulted in the<br />
non-functioning of the gondola.<br />
However the gondola supplier<br />
had not taken any measures<br />
to establish the causes for the<br />
recurring fault <strong>and</strong> rectify them.<br />
• Whenever the technicians <strong>from</strong><br />
the gondola supplier were<br />
called in, they would rectify by<br />
resetting the over-speed device<br />
<strong>and</strong> pumping the pressure up<br />
so as to release the safety<br />
brakes <strong>and</strong> render the gondola<br />
mobile. This practice is contrary<br />
to the instructions given by the<br />
manufacturer. The system thus<br />
deteriorated until the day of<br />
the fatal accident.<br />
• The occupier had not<br />
registered the premises as a<br />
factory even though the<br />
external cleaning of windows<br />
<strong>and</strong> façade was for a term<br />
contract of two years <strong>and</strong> they<br />
had been working for more<br />
than two months.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
Immediate cause(s) • Defective tools, equipment or materials<br />
Basic cause(s)<br />
Failure of SMS<br />
• Inadequate maintenance<br />
• Inadequate tools <strong>and</strong> equipment<br />
• Maintenance regime<br />
58
Recommendations<br />
Plan regular maintenance for the gondola.<br />
Ensure the regular inspection of the mechanical <strong>and</strong> electrical<br />
equipment by competent persons.<br />
Ensure emergency <strong>and</strong> rescue procedures are strictly followed.<br />
Avoid overloading equipment.<br />
59
CASE 23<br />
FALL FROM A SCAFFOLD<br />
Description of Accident<br />
60<br />
Worker A <strong>and</strong> his co-workers were<br />
working on a working platform on<br />
a metal scaffold on the fourth<br />
storey of a building. They were<br />
preparing a beam for skim coating.<br />
Worker A was wetting the beam<br />
with a pail <strong>and</strong> was seen walking<br />
backward while wetting the beam.<br />
A few minutes later, Worker A was<br />
found lying on the floor beside the<br />
metal scaffold. He was taken to the<br />
hospital where he passed away a<br />
few days later.<br />
Causes <strong>and</strong> Contributing<br />
Factors<br />
• Guardrails were provided on<br />
the open sides of the working<br />
platform. However guardrails<br />
on both the left <strong>and</strong> right ends<br />
of the working platform were<br />
only secured on one side.<br />
It was done this way so that the<br />
guardrails could be swung open<br />
for workers to get onto the<br />
working platform when they<br />
went up there to work.<br />
1. The deceased was wetting this beam<br />
prior to the accident<br />
2. The guardrail on the right end of<br />
the scaffold<br />
3. The deceased probably fell <strong>from</strong> here<br />
4. The working platform<br />
5. The deceased l<strong>and</strong>ed here after<br />
the accident<br />
1. The deceased was wetting this beam<br />
prior to the accident<br />
2. The scaffold<br />
3. The deceased l<strong>and</strong>ed here after<br />
the accident
• No ladders or steps were<br />
provided for workers to gain<br />
access to the working platform.<br />
• Both Worker A <strong>and</strong> the<br />
co-worker who erected the<br />
scaffold had not undergone<br />
a training for scaffold erection.<br />
The erection of the scaffold<br />
was also not performed under<br />
the supervision of a scaffold<br />
supervisor.<br />
• Worker A got up <strong>from</strong> one side<br />
of the working platform. It is<br />
probable that as he was walking<br />
backwards while wetting the<br />
beam, he failed to stop at the<br />
end of the platform <strong>and</strong> fell to<br />
the floor.<br />
• It is also possible that the<br />
deceased, after having finished<br />
wetting the beam, was climbing<br />
down the scaffold when he fell<br />
to the floor.<br />
Root Cause Analysis<br />
Evaluation of loss<br />
Type of contact<br />
• One worker killed<br />
• Fall <strong>from</strong> height to lower level<br />
Immediate cause(s) • Inadequate guards or barriers<br />
Basic cause(s)<br />
Failure of SMS<br />
• Inadequate leadership <strong>and</strong>/or supervision<br />
• Hazard analysis <strong>and</strong> risk management<br />
61
Follow-up<br />
The occupier was instructed to implement the following safety<br />
measures:<br />
• All guardrails on the working platform to be secured.<br />
• Steps must be provided on the scaffold for access to the working<br />
platform or different levels of the scaffold.<br />
• The erection of the scaffold is to be done by workers who have<br />
undergone a course of training approved by the Chief Inspector.<br />
• The erection must be supervised by a scaffold supervisor.<br />
Recommendations<br />
Secure end guardrails similar to the longitudinal guardrails.<br />
Provide proper access such as ladders or steps.<br />
62
Published in June 2008 by the<br />
<strong>Workplace</strong> <strong>Safety</strong> <strong>and</strong> <strong>Health</strong><br />
<strong>Council</strong> in collaboration with<br />
the Ministry of Manpower.<br />
All rights reserved. This<br />
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reproduced or transmitted in<br />
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in whole or in part, without prior<br />
written permission. The<br />
information provided in this<br />
publication is accurate as at time<br />
of printing. All cases shared in this<br />
publication are meant for learning<br />
purposes only. The learning points<br />
for each case are not exhaustive<br />
<strong>and</strong> should not be taken to<br />
encapsulate all the responsibilities<br />
<strong>and</strong> obligations of the user of this<br />
publication under the law. The<br />
<strong>Workplace</strong> <strong>Safety</strong> <strong>and</strong> <strong>Health</strong><br />
<strong>Council</strong> does not accept any<br />
liability or responsibility to any<br />
party for losses or damage arising<br />
<strong>from</strong> following this publication.