Accident During Lifting

CVO Poly BD Contractor FatalityCVO Poly BD Contractor Fatality

Final ReportFinal Report

Event Chronology (8/12/2006 in PolyBD at CVO) A night contract crew consisting of a supervisor, a crane operator and two multi

craft persons worked to finish piping on an exchanger.

Prior to starting the job, the crew: Discussed the job and assignments were given Signed work permit and EID (Energy Isolation Device) lockout form The two multicraftpersons filled out JSA (Job Safety Analysis) but did not

review with supervisor or crane operator Crane operator completed a lift form and did not review with crew

Multicraftperson 1 was the only crewmember to go to the 3rd level to assess the needs of the job.

Crew supervisor rigged the spool piece on the ground for the two multicraft persons on the exchanger deck.

Event Chronology(8/12/2006 in PolyBD at CVO)

The supervisor and crane operator were blind to the final location. All communications were by radio.

As the spool piece was lowered, a structural member obstructed the rigging and the spool piece could not be set in place.

A decision was made by the multicraftpersons on the deck to adjust the rigging by setting the spool piece on the exchanger shell. This was not communicated to the crane operator or crew supervisor.

The pipe was to be secured by putting an aligning bar in the spool piece bolt hole and through the exchanger flange bolt hole.

Simulation of Piping Spool Location Simulation of Piping Spool Location

Aligning bar installed to secure the piping spool

Piping spool was lowered to the exchanger shell to allow the slings to be moved by the multicraft persons

Event Chronology(8/12/2006 in PolyBD at CVO)

The spool piece was lowered to the exchanger shell, the L shaped piece lifted its flange away from the exchanger flange. This left the spool piece being held by the tapered end of the bar.

As multicraftperson 1 walked back towards the exchanger flange, the crane end of the spool piece slid down his side of the exchanger. This dropped the end more and released the tapered bar from the exchanger flange.

The spool piece then traveled down the north side of the exchanger and struck multicraftperson 1 resulting in a fatal injury.

Structural member interference during the lift

Fatally injured contractorwas struck

Causal Factors

Contractor Expectations

Contractor did not enforce requirements for JSA

No training program for riggers and competent persons

The contractor did not have a rigging training program for employees.

Lift plan guideline

The Lyondell lifting guideline does not specifically address rigging and lift path issues.

Structure not fully removed during demolition

The overhead crane structure was only partially demolished and the remaining structure can provide an obstruction when installing the exchanger piping

1. Contract company is required to present a plan to CVO/Lyondell to cover corrective actions regarding training, JSA improvements and safe work practices accountability.

2. Establish contract requirements for rigger and competent person.

3. Develop an OE crane and rigging procedure that includes the appropriate elements of above and below the hook guidelines (EG 1016 and EG 1017).

4. Evaluate the removal of overhead structure.

5. Put a process in place to document key learnings from lifting activities into safe job plans for future.

Recommendation(s) / Corrective Actions

Incident Incident

Basic Design

Safety systems(Permits, JSA,

etc…)

Individual jobknowledge

Deficiencies (holes)Deficiencies (holes) in the layers of in the layers of

protection that prevent protection that prevent an incidentan incident

Decisionmaking

Key Learning

Safety Culture

Safety Culture

Hazards

Hazards

“Swiss-cheese” Model For Layers of Protection

Media & Community Response

Media interest high, actual coverage was sparse

Company response was quick and accurate

Media statements updated regularly

Message disseminated to key stakeholders

Plant telephone information hotline updated

Minimal interest from local residents

Leadership Key Decisions

Multiple HRGs responded to man the EOC

EAP contacted

Determined amount of counselors

Identified EAP location

Split resources to have HR support in EOC and field

Provided EAP support to StarCon workers

Provided EAP resources to the site

Visible Leadership