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Sub-Contractor:
Main-Contractor
:
Detailed Investigation Report
(Lifting Operation Failure ‘’Assembly Works’’)
Document Number:
00 14/12/2017 Information&Approval A.Dogani K.Leka E. Barhani E. Company
REV DATE ISSUED FOR ISSUED BY CHECKED BY MD TD CPM
IEC
Engineer
□ □ □
DATE BY APPROVED
REJEC
TED
NA COMMENTS
Present document is property of Ow ner and it is prohibited any copy and/or convey of its original copy w ith any means, before the w ritten
confirmation and approvalof the Company's legal represents.
Detailed Investigation
Incident Report ‘’
ISSUING DATE: 14/12/2017
Revision: 00
Page 2 of 35
Document Number: IEC-000-TO-00-02_DIR_01 DIR
1 TABLE OF CONTENTS
PURPOSE.............................................................................................................................................................................................4
2 SCOPE ........................................................................................................................................................................................4
3 INVESTIGATION REFERENCES...............................................................................................................................................4
4 INVESTIGATION OF HEALTH, SAFETY, AND ENVIRONMENT CONSIDERATION..........................................................4
4.1 Requirements...................................................................................................................... 4
4.1.1 Team Members Trainings.............................................................................................. 5
4.1.2 Tools and Equipment .................................................................................................... 5
4.1.3 Weather Condition ....................................................................................................... 6
4.1.4 Housekeeping............................................................................................................... 6
4.1.5 Communication............................................................................................................ 6
4.1.6 First Aid and First Aider................................................................................................. 6
4.1.7 Investigation of Grounding (Earthing)............................................................................. 6
4.1.8 Investigation of Emergency numbers at Site................................................................... 6
4.1.9 Investigation of Method of Anchoring the Hydraulic Winch for Derrick. ........................... 7
4.1.10 Investigation of Method of positioning and anchor points of the Derrick during Incident. . 7
4.1.11 Investigation of Method of Anchoring of the Steel rope and Steel Pulleys on the steel
elements of the Tower during lifting operation.............................................................................. 7
5 MANUUFACTURING AND CE STANDARDS INFORMATION ABOUT (LIFTING MACHINERIES, EQUIPMENT’S
ACCESSORIES ...................................................................................................................................................................................11
..................................................................................................................................................12
..................................................................................................................................................13
..................................................................................................................................................14
..................................................................................................................................................15
..................................................................................................................................................16
..................................................................................................................................................18
..................................................................................................................................................19
Detailed Investigation
Incident Report ‘’
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Document Number: IEC-000-TO-00-02_DIR_01 DIR
6 DESCRIPTION OF INCIDENT STEP BY STEP .......................................................................................................................20
..................................................................................................................................................20
7 CONCLUSION & HS MEASURES..........................................................................................................................................21
8 CONTRACTOR ORGANIZATION ..........................................................................................................................................22
9 APPENDIX B - JOB HAZARD ANALYSIS ..............................................................................................................................23
10 APPENDIX C RISK ASESMENT..............................................................................................................................................27
11 APPENDIX D - EQUIPMENT LIST.........................................................................................................................................35
Detailed Investigation
Incident Report ‘’
ISSUING DATE: 14/12/2017
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Document Number: IEC-000-TO-00-02_DIR_01 DIR
PURPOSE
To preventmeasuresabouthealthandsafetyincidentsinthe feature regardingassemblyof erectionof
lattice steel towers requiredforconstructionof 1x400kV & 2x400kV transmissionlinesforOHL
2 SCOPE
ThisDetailedInvestigationprocedure establishes descriptionand guidelines for investigation of root of
incidentafterincidentaboutLiftingoperationfailure. It explains the the consequences of the incident,
HealthSafe andEnvironmental Obligationspriorworks started., and the the final conclusion about this
incident.
Definitions
IEC – ClientEngineering Construction
CPM– Country Project Manager
TD – Technical Director
Tehno-Control –Authorized HS Company according to Montenegrin Laws
3 INVESTIGATION REFERENCES
COMPANY HSE Plan
QA/QC Plan
EN norms
Methodology Statement s
4 INVESTIGATION OF HEALTH, SAFETY, AND ENVIRONMENT CONSIDERATION
4.1 Requirements
Before Contractor will start performing the tower erection activity there is some requirements that
became completed.
1. All the crew became trained for such activity.
2. Equipmentbecame ingoodconditionandall safety devices functional and active during all the
time.
3. Tools must become in good shape and not damaged or modified.
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4. Visitors or vendors must have permission to get in on site, they must attend a brief about the
HSE rules and sign the attendance sheet.
5. Housekeeping and clean working area.
6. Communication.
7. Working time.
8. Work organization and team coordination.
9. Grounding
10. All the equipment’s will be inspected periodically from HSE Department of COMPANY D.S.D
4.1.1 Team Members Trainings
Team members became trained in different disciplines to perform in this activity.
 General induction training
 Tools and equipment training
 PPE training
 Fall protection training
 Work at height training.
 First aid training
Only this category of workers became working on height at the tower erection, the workers that will
workon level groundare not required to have all this training except general induction training that is
mandatory for everyone.
Worker at Height Ground Worker
General induction training + +
Tools and equipment training + +
PPE training + +
Fall protection training +
Work at height training +
First aid training + +
Rescue PlanTraining(Fallingfrom
heights)
+ +
Emergency response training + +
4.1.2 Tools and Equipment
 Tools became in good condition and was free from any damage (Techno-Control Report and
Machineries Documentation regarding the visual inspections.
 Only proper tools became allowed to use in this activity.
 Homemade tools were not present on site.
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 Equipmentbecame ingoodconditionandcheckedperiodically (Techno Control Reports about
Machineries and equipment’s.
 Operator of Hydraulic Winch became use the machineries and to he be shore that the
equipment to be well maintained.
 Lifelinereferredto COMPANY HSE Planbecame be usedforTowererectiononlywhenthe half
of the tower will be erected.
 Rescue Planfor falling from heights became everyone was informed about the way of rescue
plan.
4.1.3 Weather Condition
Weather conditions at the moment of incident was Sun and around 12 Degrees.
4.1.4 Housekeeping
On site the working area all the workplace was in good shape. Ground level was flat and free from
holes, mud, andice.Also materialswere storedinthe proper way. Timbers, tools or any other material
was being store in order to have batter access and aggress.
4.1.5 Communication
Accordingto witnesscommunication with the team one by one during the activity the communication
became with Hand Signals.
4.1.6 First Aid and First Aider
During working time, first aid kits and box became on site that erection works of towers will be
performed. Also a first aider became present all the time on site.
4.1.7 Investigation of Grounding (Earthing)
During Investigation it was evidenced that Grounding of this Tower was not done.
4.1.8 Investigation of Emergency numbers at Site
- Ambulance
- Police
- Firefighter
- IEC Site Management
- COMPANY Site Management
Notice: Emergency numbers of above-mentioned and of the Site Management of COMPANY was share
at COMPANY Warehouse at Cetinje in order to be visible from all the Employers. And the team that
was present during the incident approve that have also this Emergency Contact on their Vehicles.
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4.1.9 Investigation of Method of Anchoring the Hydraulic Winch for Derrick.
DuringSite Inspectionour Engineers has clearly show the conditions of method according to Hydraulic
Winch as follow;
The HydraulicWinch was anchored in the form of a Vehicle Type Range Rover that was around 3.000kg
and was used us counterweight, the position of the vehicles.
4.1.10 InvestigationofMethod of positioningand anchorpoints oftheDerrickduringIncident.
During Site Investigation Inspection of our Engineers has clearly show the conditions of method
according to positioning and anchor method of Derrick during Lifting operations at T 91i.
Our Site EngineerhasdeceleratedtoHSEDepartmentthatDerrickaccording to witness of Foreman and
workerswasfixedto3 pointson the bodyof the Towerbecause atthismoment the was tryingto fix the
Cross arm.
4.1.11 Investigation of Method of Anchoring of the Steel rope and Steel Pulleys on the steel
elements of the Tower during lifting operation.
During Site Investigation Inspection of our Engineers has clearly show the conditions of fixed method
according to positioning of steel ropes and steel pulleys and they decelerate as follow ;
1.The steel rope was cutter at the lever around 18m after of Derrick Hook. Attached Pictures of
Investigation date 05.12.2017.
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2.The body of the Towernearto the cross arm was deformed.Attachedphotoof the Body of the Tower
91 I at Date 05.12.2017;
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3.The Cross arm was on the ground deformed as a result of the fall;
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4.The hydraulic Winch was anchored to the vehicle and was fixed with Ropes and everything was in
safety conditions. Attached Picture of the Hydraulic Winch date 05.12.2017;
5 MANUUFACTURING AND CE STANDARDS INFORMATION ABOUT
(LIFTING MACHINERIES, EQUIPMENT’S ACCESSORIES
During the Investigation our HSE Department has review and check all the documentation regarding
technical specificationof machineries,equipment’sandaccessoriesthatare usedto site T91 I duringthe
incident.
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6 DESCRIPTION OF INCIDENT STEP BY STEP
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Incident Report ‘’
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7 CONCLUSION & HS MEASURES
According to Investigation HSE department conclusion is as follow;
Incidentaboutlifting failure was created by negligence of Foreman, if foreman would provide double
rope to the cross arm in the moment that stack the cross arm would not fall from height.
HS Measures;
All the Foreman of the Teams are informed about this incident and in the feature if they had such
situationsduring lifting operations they will secure the cross arm with double rope in order to not fall
from height.
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8 CONTRACTOR ORGANIZATION
Counetry Project
Manager
Site Project
Manager
Mechanical Engineer
Mechanical
Engineer
Tower EretionTeam I
Tower EretionTeam II
Tower EretionTeam III
Tower EretionTeam IV
HSEAdvisor &Tehno -
Control
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Incident Report ‘’
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Document Number: IEC-000-TO-00-02_DIR_01 DIR
9 APPENDIX B - JOB HAZARD ANALYSIS
Job Description: JHA No.: R-
DOK.07.02.012.0000.A
Tower Erection / Assembly of Towers Revision: 01
Job Location: Sub-Contractor
Name:
Job Hazard Analysis
Prepared/Revised by:
Arber Dogani HSE
Department
Approved by:
Edison Barhani
Technical Department
Date: 09.07.2017
SEQUENCE OF JOB
STEPS
POTENTIAL ACCIDENTS
OR HAZARDS
RECOMMENDED SAFE JOB PROCEDURE
1.Transportation of
materials with boom
truck
 Improper loading or
unloading
 Overturn of vehicles
 Collapse of materials
 Materials falls during
transportation
 Only qualified and trained operators will
participate at this activity
 Usage ofproper equipmentfor loading and
unloading
 Safe loading ofvehicles on the load capacity
 Secure the loads during transportation using
certified rigging equipmentand in accordance
with CE standard
 Prevent unauthorized person to access to the
working area






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2.Transport and
Lifting operation with
Hydraulic Winch or
boom truck
 Bad positioning of
boom truck
 Overhead power lines
and cables
 Lifting gear failure
 Effects of wind speed
 Anchoring of Hydraulic
Winch
 Bad weather condition
Collapse of the load due
to improper rigging &
slinging

 Position of boom truck on solid ground
and minimum 2m from the edge of
foundation
 Extend outriggers to full extent on both
sides when performing a lift operation
 Visual control by the operator before
starting work
 Use warning signs and guide ropes.
 Usage of certified lifting gear and in
accordance with standards
 All lifting gear must be inspected before
being put in use
 When wind velocities are above 40 km/h,
the rated load and boom lengths shall be
reduced according to manufactures
specifications Refer of COMPANY HSE
Plan.
 Operators should be able to determine the
weight, centre of gravity and
characteristics of the load.
 Anchoring of Hydraulic winch will be done
by concrete blocks or by vehicle
respecting the counterweight logic.





3. Working at height
 Falling from height due
to slips & trips
 Falling from height due
to physical fatigue
 Falling from height due
to negligence of
workers
 Object falling from
height
 Bad weather condition
(rain, thunderstorm)
 Only trained and qualified workers will
participate at this activity
 Worker who will work at height must use
safety harness and other fall arrester
equipment’s like vertical lifeline or fall
arrest block.
 Workers will not work for a long time at
height
 Don’t smoke, eat, drink or use the phone
during working at height.
 Do not throw tools to each other
 Don’t work below the workers who work at
height
 Weather condition shall be regularly
monitored & the work must be stopped
during bad weather condition




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4. Equipment and
tools.
 Improper equipment.
 Checked equipment.
 Defected equipment.
 Homemade tools
 All equipment must be checked before
performing on site
 All equipment must be proper for the work
that will be used
 All equipment’s must be used only from
the authorized operator.
 All equipment that is modified must be
removed from the site.
 Only authorized and non-defected
equipment are allowed to use on site.
 Homemade tools are not allowed to use
on site, only certified CE/EN


5. PPE
 Improper PPE  All PPE must be wear by all the personnel
manual and non-manual, during all the
time that they are performing works on
site. gloves, concrete boots, hard hat,
glasses, high visible vest.
 Safety harness must be all the time used
from all the workers that will be working at
height
 Only trained workers will work at height
 Only authorized personnel must take part
in this work activity
6. First Aid.
(Emergency
response)
 All the workers on site
 Fire fight
 Water flood
 Wild life
 Cold and heat stress
 Each team must have a first aider in case
of accident or incident
 All site must have a first aid box and to be
placed in a place where everyone has
access
 Emergency numbers must be put in all the
vehicles and visible to the all crew
members
 Transportation must be in each location in
case of necessity of transporting the
injured person
 Fire training BUS (ALB)
 To be determines the assembled point for
every possible emergency at site
 First Aid Box for all the equipment’s and
vehicle working on site
 First Aid Personnel should be identified by
a stick on the helmet
7. Housekeeping
 Spill incident such as
oil or fuel
 Timbers and wood
materials stacked
inappropriately
 Waste of excavated
area, garbage
 Immediately clean up using inert sand or
other suitable materials
 Recycle bins at the place of working
 Accumulation of wastes Waste collector
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10 APPENDIX C RISK ASESMENT
Ref
Activity and
Location
ClientProject
Montenegro
Hazard and/or
occurring of risk
Who
Effected
Degree of
Risk
Result Control Measure(s)
Residual
Degree of
Risk
Person
Responsible for
Control Measure(s)
Probability
Severity
RiskDegree
Probability
Severity
RiskDegree
1. Transportation
of materials with
boom truck
Improper loading
or unloading
Drivers,
Workers,
Pedestrians
5 4 20 High Risks - Qualified and trained operators
only
- Safe loading of vehicles on the
load capacity
- Using proper equipment for
loading and unloading
- Check the loads if had moved
during transportation.
3 4 12 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
2. Transportation
of materials with
boom truck
Overturn of
vehicles
Drivers,
Operators,
workers
4 5 20 High Risks - Qualified operators only
- Speed limits on site
- Safe loading of vehicles on the
load capacity
- Secure the loads during
transportation using certified
rigging equipment and in
accordance with CE standard
2 5 10 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
Detailed Investigation
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3. Transportation
of materials with
boom truck
Collapse of
materials
Operators,
workers,
pedestrians
4 5 20 High Risks - Qualified operators only
- Secure the loads during
transportation using cerfitied
rigging equipment and in
accordance with CE standard
2 5 10 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
4. Transportation
of materials with
boom truck
Materials fall on
personnel
Operators,
Workers,
Pedestrian
5 5 25 Intolerable
Risks
- Using proper PPE (hard hats,
safety shoes, gloves, visible vest)
- Using warning signs on the
working area
- Prevent unauthorized person to
access to the working area
3 4 12 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
5. Lifting operation
with boom track
Effects of wind
speed
Drivers,
Operators,
All workers
4 4 16 High Risks - Only trained operator
- When wind velocities are above
40 km/h, the rated load and boom
lengths shall be reduced
according to manufactures
specifications Refer to HSE plan
3 4 12 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
6. Lifting operation
with boom track
Bad positioning
of boom track
Drivers,
Operators,
All workers
5 5 25 Intolerable
Risks
- Trained and qualified operators
- Position the boom track on solid
ground
- Extending outriggers on both
sides when performing a lift
operation
2 5 10 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
7. Lifting operation
with boom track
Overhead power
lines and cables
Drivers,
Operators,
All workers
5 5 25 Intolerable
Risks
- Visual control by the operator
before starting work.
- Use warning signs.
2 5 10 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
Detailed Investigation
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8. Lifting operation
with boom track
Bad weather
condition
Operators,
workers
5 5 25 Intolerable
Risks
- Weather condition shall be
regularly monitored
- Work must be stopped during
bad weather condition
- Wear proper PPE
2 5 10 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
9. Lifting operation
with boom track
Lifting gear
failure
Drivers,
Operators,
All workers
4 5 20 High Risks - Only trained and qualified
personnel
- Inspectand determine whether a
rope or other piece of lifting
equipment is damaged or not fit
for purpose
- Use certified lifting gear and in
accordance with CE standard
2 5 10 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
10. Lifting operation
with boom track
Collapse of the
load due to
improper rigging
& slinging
Operators,
all workers
5 5 15 Intolerable
Risks
- Only trained and qualified
operators
- Operators should be able to
determine the weight, centre of
gravity and characteristics of the
load.
- Tool Box Talk
3 4 12 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
11. Lifting operation
with Hydraulic
Winch
,Anchoring of
hydraulic winch
Drivers,
Operators,
All workers
5 5 25 Intolerable
Risks
- Only trained and qualified
operators
- Tool Box Talk
-Anchoring of hydraulic winch will
be by Concrete blocks of similar
solutions as anchoring on the
trees etc.
3 4 12 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
Detailed Investigation
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12. Working at
height
Falling from
height due to
slips & trips
All workers
who works at
height
5 5 25 Intolerable
Risks
- Only trained and qualified
workers
- Fall arrestmethods such as
lanyards and fall arresters
(Blocks) or vertical lifeline shall be
used.
- Wear proper PPE (safety
harness, hard hats, safety shoes,
gloves, visible vest)
- Tool Box Talk & SSC
2 5 10 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
13. Working at
height
Falling from
height due to
physical fatigue
All workers
who works at
height
5 5 25 Intolerable
Risks
- Only trained and qualified
workers
- Workers will not work for a long
time at height.
-- Fall arrestmethods such as
lanyards and fall arresters
(Blocks) or vertical lifeline shall be
used.
- Wear proper PPE (safety
harness, hard hats, safety shoes,
gloves, visible vest)
- Tool Box Talk
2 5 10 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
Detailed Investigation
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14. Working at
height
Falling from
height due to
negligence of
workers
All workers
who works at
height
5 5 25 Intolerable
Risks
- Only trained and qualified
workers
- Don’t smoke, eat, drink or use
the phone during working at
height.
- Fall arrestmethods such as
lanyards and fall arresters
(Blocks) only up of the middle of
Tower
- Do not throw tools to each other
- Wear proper PPE (safety
harness, hard hats, safety shoes,
gloves, visible vest)
2 5 10 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
15. Working at
height
Object falling
from height
All workers 5 5 25 Intolerable
Risks
- Don’t work below the workers
who work at height
- Barricaded area with white & red
tape
- Wear proper PPE (safety
harness, hard hats, safety shoes,
gloves, visible vest)
- Tool Box Talk
2 5 10 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
16. Working at
height
Bad weather
condition (rain,
thunderstorm)
All workers 4 5 20 High Risks - Weather condition shall be
regularly monitored
- Work must be stopped during
bad weather condition
1 5 5 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
Detailed Investigation
Incident Report ‘’
ISSUING DATE: 14/12/2017
State ofissue: 00
Page 32 of 35
Document Number: IEC-000-TO-00-02_DIR_01 DIR
17. Working at
height
Electrical storm All workers 4 5 20 High Risks - Weather condition shall be
regularly monitored.
-Tower must be grounded before
start the work.
- Work must be stopped during
bad weather condition.
-Safety harness will be used
during all the time
-When towers erected in the midel
of the body then all the workers
that are working at heights will use
Lifeline.
1 5 5 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
18. Working at
height with
hand-tools
Improper type of
tools
All workers 5 4 20 High Risks - Visual check of the tools before
starting work
- Remove all damaged tools
- Use proper tools
- Wear proper PPE (safety
harness, hard hats, safety shoes,
gloves, visible vest)
- Tool Box Talk
3 4 12 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
19. Working with
hand-tools
Improper storage
of materials &
tools
All workers 5 4 20 High Risks - Store all materials & tools in
proper place
- Tool Box Talk
3 4 12 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
20. Emergency
response,
First Aid team.
Accident or
incident cured on
site
All workers 5 4 20 High Risks - All the crew must have a first aid
person for any accidentor incident
case that might be on site.
3 4 12 Foreman, Site
Engineer, Site
Manager, HSE
Detailed Investigation
Incident Report ‘’
ISSUING DATE: 14/12/2017
State ofissue: 00
Page 33 of 35
Document Number: IEC-000-TO-00-02_DIR_01 DIR
-First Aid Kit available on site
- All emergency contacts must be
exposed where can be seen from
all the team members.
- Transportation available to
transport the injured peoples in
every working area.
-Rescue Plan falling from heights
will be followed and instructed to
the each formen of groups from
Site engineers or site manager
and they will be ready to follow the
Plan.
Repres.Techno-
Control
21. Housekeeping Spills incident
such as oil or
fuel.
All workers 4 3 12 Medium risks - Immediatelyclean up using inert
sand or other suitable materials
- All material used to mop up spills
will be immediately removed to a
safe place and stored in closed
containers for safe disposal, till to
be removed from the site to a
safer area
3 3 9 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control,
Environmental
Lead
22. Housekeeping Materials stacked
inappropriately
All workers 5 2 10 Medium Risk - Store all materials in proper
place.
3 2 6 Foreman, Site
Engineer, Site
Manager, HSE
Repres.Techno-
Control
23. Housekeeping Garbage The access
road
4 3 12 Medium Risk - Recycle bins available on site
- Accumulation to Matej DO waste
3 2 6 Foreman, Site
Engineer, Site
Detailed Investigation
Incident Report ‘’
ISSUING DATE: 14/12/2017
State ofissue: 00
Page 34 of 35
Document Number: IEC-000-TO-00-02_DIR_01 DIR
working
area.
collector company at Cetinje Manager, HSE
Repres.Techno-
Control,Environme
ntal Lead.
PROBABILITY SEVERITY
1 (VERY SMALL) Almost no 1 (VERY LIGHT) No loss ofwork time, can only be eliminated immediately, requiring first aid
2 (SMALL) Very few (once a year), only abnormal situations, 2 (LIGHT) No loss of working days, outpatient treatment without permanent effect
3 (MEDIUM) Under (a few times a year) 3 (MEDIUM) Slight injury, inpatient treatment / injury
4 (HIGH) Often (once a month) 4 (SERIOUS) Serious injury, long-term therapy, occupational disease
5 (VERY HIGH) Very frequently (once a week, every day), and under
normal operating conditions
5 (VERY SERIOUS) Death, permanent incapacity
RESULT ACTION
Intolerable Risk
(25)
The work mustnotbe started or ongoing activity mustbe stopped immediately till
the defined risk is reduced. Although the activities carried out are not possible to
reduce risk, activity must be avoided.
Important Risks
(15, 16, 20)
The work mustnotbe started or ongoing activity mustbe stopped immediately till
the defined risk is reduced. The risk relates to continue to work; emergency
measures to be taken and as a result of these measures should be decided to
continue the activity.
Mid-Level Risks
(8, 9, 10, 12)
The activities should be started for reducing of defined risks. The reduction
measures of risk may take more time.
Acceptable Risks
(2, 3, 4, 5, 6)
The identified risks may not be necessary to eliminate additional control
processes.However,these controls should be continued and maintained existing
controls be inspected.
Unimportant
Risks
(1)
Planning and control processes carried out to eliminate the risks of identified
activities may not need to keep records.
Detailed Investigation
Incident Report ‘’
ISSUING DATE: 14/12/2017
State ofissue: 00
Page 35 of 35
Document Number: IEC-000-TO-00-02_DIR_01 DIR
11 APPENDIX D - EQUIPMENT LIST
List of Equipment and Tools used for Tower Erection
No. Description (English) Model Brand Qty.
1 Hydraulic winch
- Supplied with steelrope diam 8mm
L=500m
101/1/AS Tema 6
2 Nylon Pilot Rope
-L=1000m
- Wound on steel reel 1400mm
22.TR.16.1000
+
062/3
Tema 20
3 Nylon Pilot Rope
L=1000m
Wound on steel reel 1400mm Cod.
062/3
22.16.1000
+
062/3
Tema 8
4 Steel Wire Rope
- Steel antitwist. Wire
- Diam 14mm, L=900m
Wound on steel reel 1100mm Cod.
062/2
21.12.14.900
+
062/2
Tema 1
5 Connector Joint ' U ' Type GF 10 Tema 35
6 Connector Joint ' U ' Type GF 16 Tema 10
7 Snatch Blocks 020/0,5/N/G1 Tema 10
8 Heavby Duty Snatch Blocks 020/1,5/A /G1 Tema 6
9 Heavby Duty Snatch Blocks 020/3,0/A /G1 Tema 6
10 Gin Pole
-External rope passage
050/3/12.3 Tema 6
11 Torques wrenches 050/5/11.F2 Tema 6

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Investigation report 05.12.2017 lifting operation failure during tower erection investigatigations by ; arber dogani

  • 1. Sub-Contractor: Main-Contractor : Detailed Investigation Report (Lifting Operation Failure ‘’Assembly Works’’) Document Number: 00 14/12/2017 Information&Approval A.Dogani K.Leka E. Barhani E. Company REV DATE ISSUED FOR ISSUED BY CHECKED BY MD TD CPM IEC Engineer □ □ □ DATE BY APPROVED REJEC TED NA COMMENTS Present document is property of Ow ner and it is prohibited any copy and/or convey of its original copy w ith any means, before the w ritten confirmation and approvalof the Company's legal represents.
  • 2. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 Revision: 00 Page 2 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 1 TABLE OF CONTENTS PURPOSE.............................................................................................................................................................................................4 2 SCOPE ........................................................................................................................................................................................4 3 INVESTIGATION REFERENCES...............................................................................................................................................4 4 INVESTIGATION OF HEALTH, SAFETY, AND ENVIRONMENT CONSIDERATION..........................................................4 4.1 Requirements...................................................................................................................... 4 4.1.1 Team Members Trainings.............................................................................................. 5 4.1.2 Tools and Equipment .................................................................................................... 5 4.1.3 Weather Condition ....................................................................................................... 6 4.1.4 Housekeeping............................................................................................................... 6 4.1.5 Communication............................................................................................................ 6 4.1.6 First Aid and First Aider................................................................................................. 6 4.1.7 Investigation of Grounding (Earthing)............................................................................. 6 4.1.8 Investigation of Emergency numbers at Site................................................................... 6 4.1.9 Investigation of Method of Anchoring the Hydraulic Winch for Derrick. ........................... 7 4.1.10 Investigation of Method of positioning and anchor points of the Derrick during Incident. . 7 4.1.11 Investigation of Method of Anchoring of the Steel rope and Steel Pulleys on the steel elements of the Tower during lifting operation.............................................................................. 7 5 MANUUFACTURING AND CE STANDARDS INFORMATION ABOUT (LIFTING MACHINERIES, EQUIPMENT’S ACCESSORIES ...................................................................................................................................................................................11 ..................................................................................................................................................12 ..................................................................................................................................................13 ..................................................................................................................................................14 ..................................................................................................................................................15 ..................................................................................................................................................16 ..................................................................................................................................................18 ..................................................................................................................................................19
  • 3. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 Revision: 00 Page 3 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 6 DESCRIPTION OF INCIDENT STEP BY STEP .......................................................................................................................20 ..................................................................................................................................................20 7 CONCLUSION & HS MEASURES..........................................................................................................................................21 8 CONTRACTOR ORGANIZATION ..........................................................................................................................................22 9 APPENDIX B - JOB HAZARD ANALYSIS ..............................................................................................................................23 10 APPENDIX C RISK ASESMENT..............................................................................................................................................27 11 APPENDIX D - EQUIPMENT LIST.........................................................................................................................................35
  • 4. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 4 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR PURPOSE To preventmeasuresabouthealthandsafetyincidentsinthe feature regardingassemblyof erectionof lattice steel towers requiredforconstructionof 1x400kV & 2x400kV transmissionlinesforOHL 2 SCOPE ThisDetailedInvestigationprocedure establishes descriptionand guidelines for investigation of root of incidentafterincidentaboutLiftingoperationfailure. It explains the the consequences of the incident, HealthSafe andEnvironmental Obligationspriorworks started., and the the final conclusion about this incident. Definitions IEC – ClientEngineering Construction CPM– Country Project Manager TD – Technical Director Tehno-Control –Authorized HS Company according to Montenegrin Laws 3 INVESTIGATION REFERENCES COMPANY HSE Plan QA/QC Plan EN norms Methodology Statement s 4 INVESTIGATION OF HEALTH, SAFETY, AND ENVIRONMENT CONSIDERATION 4.1 Requirements Before Contractor will start performing the tower erection activity there is some requirements that became completed. 1. All the crew became trained for such activity. 2. Equipmentbecame ingoodconditionandall safety devices functional and active during all the time. 3. Tools must become in good shape and not damaged or modified.
  • 5. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 5 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 4. Visitors or vendors must have permission to get in on site, they must attend a brief about the HSE rules and sign the attendance sheet. 5. Housekeeping and clean working area. 6. Communication. 7. Working time. 8. Work organization and team coordination. 9. Grounding 10. All the equipment’s will be inspected periodically from HSE Department of COMPANY D.S.D 4.1.1 Team Members Trainings Team members became trained in different disciplines to perform in this activity.  General induction training  Tools and equipment training  PPE training  Fall protection training  Work at height training.  First aid training Only this category of workers became working on height at the tower erection, the workers that will workon level groundare not required to have all this training except general induction training that is mandatory for everyone. Worker at Height Ground Worker General induction training + + Tools and equipment training + + PPE training + + Fall protection training + Work at height training + First aid training + + Rescue PlanTraining(Fallingfrom heights) + + Emergency response training + + 4.1.2 Tools and Equipment  Tools became in good condition and was free from any damage (Techno-Control Report and Machineries Documentation regarding the visual inspections.  Only proper tools became allowed to use in this activity.  Homemade tools were not present on site.
  • 6. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 6 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR  Equipmentbecame ingoodconditionandcheckedperiodically (Techno Control Reports about Machineries and equipment’s.  Operator of Hydraulic Winch became use the machineries and to he be shore that the equipment to be well maintained.  Lifelinereferredto COMPANY HSE Planbecame be usedforTowererectiononlywhenthe half of the tower will be erected.  Rescue Planfor falling from heights became everyone was informed about the way of rescue plan. 4.1.3 Weather Condition Weather conditions at the moment of incident was Sun and around 12 Degrees. 4.1.4 Housekeeping On site the working area all the workplace was in good shape. Ground level was flat and free from holes, mud, andice.Also materialswere storedinthe proper way. Timbers, tools or any other material was being store in order to have batter access and aggress. 4.1.5 Communication Accordingto witnesscommunication with the team one by one during the activity the communication became with Hand Signals. 4.1.6 First Aid and First Aider During working time, first aid kits and box became on site that erection works of towers will be performed. Also a first aider became present all the time on site. 4.1.7 Investigation of Grounding (Earthing) During Investigation it was evidenced that Grounding of this Tower was not done. 4.1.8 Investigation of Emergency numbers at Site - Ambulance - Police - Firefighter - IEC Site Management - COMPANY Site Management Notice: Emergency numbers of above-mentioned and of the Site Management of COMPANY was share at COMPANY Warehouse at Cetinje in order to be visible from all the Employers. And the team that was present during the incident approve that have also this Emergency Contact on their Vehicles.
  • 7. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 7 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 4.1.9 Investigation of Method of Anchoring the Hydraulic Winch for Derrick. DuringSite Inspectionour Engineers has clearly show the conditions of method according to Hydraulic Winch as follow; The HydraulicWinch was anchored in the form of a Vehicle Type Range Rover that was around 3.000kg and was used us counterweight, the position of the vehicles. 4.1.10 InvestigationofMethod of positioningand anchorpoints oftheDerrickduringIncident. During Site Investigation Inspection of our Engineers has clearly show the conditions of method according to positioning and anchor method of Derrick during Lifting operations at T 91i. Our Site EngineerhasdeceleratedtoHSEDepartmentthatDerrickaccording to witness of Foreman and workerswasfixedto3 pointson the bodyof the Towerbecause atthismoment the was tryingto fix the Cross arm. 4.1.11 Investigation of Method of Anchoring of the Steel rope and Steel Pulleys on the steel elements of the Tower during lifting operation. During Site Investigation Inspection of our Engineers has clearly show the conditions of fixed method according to positioning of steel ropes and steel pulleys and they decelerate as follow ; 1.The steel rope was cutter at the lever around 18m after of Derrick Hook. Attached Pictures of Investigation date 05.12.2017.
  • 8. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 8 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 2.The body of the Towernearto the cross arm was deformed.Attachedphotoof the Body of the Tower 91 I at Date 05.12.2017;
  • 9. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 9 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR
  • 10. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 10 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 3.The Cross arm was on the ground deformed as a result of the fall;
  • 11. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 11 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 4.The hydraulic Winch was anchored to the vehicle and was fixed with Ropes and everything was in safety conditions. Attached Picture of the Hydraulic Winch date 05.12.2017; 5 MANUUFACTURING AND CE STANDARDS INFORMATION ABOUT (LIFTING MACHINERIES, EQUIPMENT’S ACCESSORIES During the Investigation our HSE Department has review and check all the documentation regarding technical specificationof machineries,equipment’sandaccessoriesthatare usedto site T91 I duringthe incident.
  • 12. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 12 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR
  • 13. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 13 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR
  • 14. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 14 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR
  • 15. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 15 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR
  • 16. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 16 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR
  • 17. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 17 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR
  • 18. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 18 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR
  • 19. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 19 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR
  • 20. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 20 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 6 DESCRIPTION OF INCIDENT STEP BY STEP
  • 21. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 21 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 7 CONCLUSION & HS MEASURES According to Investigation HSE department conclusion is as follow; Incidentaboutlifting failure was created by negligence of Foreman, if foreman would provide double rope to the cross arm in the moment that stack the cross arm would not fall from height. HS Measures; All the Foreman of the Teams are informed about this incident and in the feature if they had such situationsduring lifting operations they will secure the cross arm with double rope in order to not fall from height.
  • 22. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 22 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 8 CONTRACTOR ORGANIZATION Counetry Project Manager Site Project Manager Mechanical Engineer Mechanical Engineer Tower EretionTeam I Tower EretionTeam II Tower EretionTeam III Tower EretionTeam IV HSEAdvisor &Tehno - Control
  • 23. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 23 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 9 APPENDIX B - JOB HAZARD ANALYSIS Job Description: JHA No.: R- DOK.07.02.012.0000.A Tower Erection / Assembly of Towers Revision: 01 Job Location: Sub-Contractor Name: Job Hazard Analysis Prepared/Revised by: Arber Dogani HSE Department Approved by: Edison Barhani Technical Department Date: 09.07.2017 SEQUENCE OF JOB STEPS POTENTIAL ACCIDENTS OR HAZARDS RECOMMENDED SAFE JOB PROCEDURE 1.Transportation of materials with boom truck  Improper loading or unloading  Overturn of vehicles  Collapse of materials  Materials falls during transportation  Only qualified and trained operators will participate at this activity  Usage ofproper equipmentfor loading and unloading  Safe loading ofvehicles on the load capacity  Secure the loads during transportation using certified rigging equipmentand in accordance with CE standard  Prevent unauthorized person to access to the working area      
  • 24. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 24 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 2.Transport and Lifting operation with Hydraulic Winch or boom truck  Bad positioning of boom truck  Overhead power lines and cables  Lifting gear failure  Effects of wind speed  Anchoring of Hydraulic Winch  Bad weather condition Collapse of the load due to improper rigging & slinging   Position of boom truck on solid ground and minimum 2m from the edge of foundation  Extend outriggers to full extent on both sides when performing a lift operation  Visual control by the operator before starting work  Use warning signs and guide ropes.  Usage of certified lifting gear and in accordance with standards  All lifting gear must be inspected before being put in use  When wind velocities are above 40 km/h, the rated load and boom lengths shall be reduced according to manufactures specifications Refer of COMPANY HSE Plan.  Operators should be able to determine the weight, centre of gravity and characteristics of the load.  Anchoring of Hydraulic winch will be done by concrete blocks or by vehicle respecting the counterweight logic.      3. Working at height  Falling from height due to slips & trips  Falling from height due to physical fatigue  Falling from height due to negligence of workers  Object falling from height  Bad weather condition (rain, thunderstorm)  Only trained and qualified workers will participate at this activity  Worker who will work at height must use safety harness and other fall arrester equipment’s like vertical lifeline or fall arrest block.  Workers will not work for a long time at height  Don’t smoke, eat, drink or use the phone during working at height.  Do not throw tools to each other  Don’t work below the workers who work at height  Weather condition shall be regularly monitored & the work must be stopped during bad weather condition    
  • 25. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 25 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 4. Equipment and tools.  Improper equipment.  Checked equipment.  Defected equipment.  Homemade tools  All equipment must be checked before performing on site  All equipment must be proper for the work that will be used  All equipment’s must be used only from the authorized operator.  All equipment that is modified must be removed from the site.  Only authorized and non-defected equipment are allowed to use on site.  Homemade tools are not allowed to use on site, only certified CE/EN   5. PPE  Improper PPE  All PPE must be wear by all the personnel manual and non-manual, during all the time that they are performing works on site. gloves, concrete boots, hard hat, glasses, high visible vest.  Safety harness must be all the time used from all the workers that will be working at height  Only trained workers will work at height  Only authorized personnel must take part in this work activity 6. First Aid. (Emergency response)  All the workers on site  Fire fight  Water flood  Wild life  Cold and heat stress  Each team must have a first aider in case of accident or incident  All site must have a first aid box and to be placed in a place where everyone has access  Emergency numbers must be put in all the vehicles and visible to the all crew members  Transportation must be in each location in case of necessity of transporting the injured person  Fire training BUS (ALB)  To be determines the assembled point for every possible emergency at site  First Aid Box for all the equipment’s and vehicle working on site  First Aid Personnel should be identified by a stick on the helmet 7. Housekeeping  Spill incident such as oil or fuel  Timbers and wood materials stacked inappropriately  Waste of excavated area, garbage  Immediately clean up using inert sand or other suitable materials  Recycle bins at the place of working  Accumulation of wastes Waste collector
  • 26. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 26 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR
  • 27. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 27 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 10 APPENDIX C RISK ASESMENT Ref Activity and Location ClientProject Montenegro Hazard and/or occurring of risk Who Effected Degree of Risk Result Control Measure(s) Residual Degree of Risk Person Responsible for Control Measure(s) Probability Severity RiskDegree Probability Severity RiskDegree 1. Transportation of materials with boom truck Improper loading or unloading Drivers, Workers, Pedestrians 5 4 20 High Risks - Qualified and trained operators only - Safe loading of vehicles on the load capacity - Using proper equipment for loading and unloading - Check the loads if had moved during transportation. 3 4 12 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control 2. Transportation of materials with boom truck Overturn of vehicles Drivers, Operators, workers 4 5 20 High Risks - Qualified operators only - Speed limits on site - Safe loading of vehicles on the load capacity - Secure the loads during transportation using certified rigging equipment and in accordance with CE standard 2 5 10 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control
  • 28. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 28 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 3. Transportation of materials with boom truck Collapse of materials Operators, workers, pedestrians 4 5 20 High Risks - Qualified operators only - Secure the loads during transportation using cerfitied rigging equipment and in accordance with CE standard 2 5 10 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control 4. Transportation of materials with boom truck Materials fall on personnel Operators, Workers, Pedestrian 5 5 25 Intolerable Risks - Using proper PPE (hard hats, safety shoes, gloves, visible vest) - Using warning signs on the working area - Prevent unauthorized person to access to the working area 3 4 12 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control 5. Lifting operation with boom track Effects of wind speed Drivers, Operators, All workers 4 4 16 High Risks - Only trained operator - When wind velocities are above 40 km/h, the rated load and boom lengths shall be reduced according to manufactures specifications Refer to HSE plan 3 4 12 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control 6. Lifting operation with boom track Bad positioning of boom track Drivers, Operators, All workers 5 5 25 Intolerable Risks - Trained and qualified operators - Position the boom track on solid ground - Extending outriggers on both sides when performing a lift operation 2 5 10 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control 7. Lifting operation with boom track Overhead power lines and cables Drivers, Operators, All workers 5 5 25 Intolerable Risks - Visual control by the operator before starting work. - Use warning signs. 2 5 10 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control
  • 29. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 29 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 8. Lifting operation with boom track Bad weather condition Operators, workers 5 5 25 Intolerable Risks - Weather condition shall be regularly monitored - Work must be stopped during bad weather condition - Wear proper PPE 2 5 10 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control 9. Lifting operation with boom track Lifting gear failure Drivers, Operators, All workers 4 5 20 High Risks - Only trained and qualified personnel - Inspectand determine whether a rope or other piece of lifting equipment is damaged or not fit for purpose - Use certified lifting gear and in accordance with CE standard 2 5 10 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control 10. Lifting operation with boom track Collapse of the load due to improper rigging & slinging Operators, all workers 5 5 15 Intolerable Risks - Only trained and qualified operators - Operators should be able to determine the weight, centre of gravity and characteristics of the load. - Tool Box Talk 3 4 12 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control 11. Lifting operation with Hydraulic Winch ,Anchoring of hydraulic winch Drivers, Operators, All workers 5 5 25 Intolerable Risks - Only trained and qualified operators - Tool Box Talk -Anchoring of hydraulic winch will be by Concrete blocks of similar solutions as anchoring on the trees etc. 3 4 12 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control
  • 30. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 30 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 12. Working at height Falling from height due to slips & trips All workers who works at height 5 5 25 Intolerable Risks - Only trained and qualified workers - Fall arrestmethods such as lanyards and fall arresters (Blocks) or vertical lifeline shall be used. - Wear proper PPE (safety harness, hard hats, safety shoes, gloves, visible vest) - Tool Box Talk & SSC 2 5 10 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control 13. Working at height Falling from height due to physical fatigue All workers who works at height 5 5 25 Intolerable Risks - Only trained and qualified workers - Workers will not work for a long time at height. -- Fall arrestmethods such as lanyards and fall arresters (Blocks) or vertical lifeline shall be used. - Wear proper PPE (safety harness, hard hats, safety shoes, gloves, visible vest) - Tool Box Talk 2 5 10 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control
  • 31. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 31 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 14. Working at height Falling from height due to negligence of workers All workers who works at height 5 5 25 Intolerable Risks - Only trained and qualified workers - Don’t smoke, eat, drink or use the phone during working at height. - Fall arrestmethods such as lanyards and fall arresters (Blocks) only up of the middle of Tower - Do not throw tools to each other - Wear proper PPE (safety harness, hard hats, safety shoes, gloves, visible vest) 2 5 10 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control 15. Working at height Object falling from height All workers 5 5 25 Intolerable Risks - Don’t work below the workers who work at height - Barricaded area with white & red tape - Wear proper PPE (safety harness, hard hats, safety shoes, gloves, visible vest) - Tool Box Talk 2 5 10 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control 16. Working at height Bad weather condition (rain, thunderstorm) All workers 4 5 20 High Risks - Weather condition shall be regularly monitored - Work must be stopped during bad weather condition 1 5 5 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control
  • 32. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 32 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 17. Working at height Electrical storm All workers 4 5 20 High Risks - Weather condition shall be regularly monitored. -Tower must be grounded before start the work. - Work must be stopped during bad weather condition. -Safety harness will be used during all the time -When towers erected in the midel of the body then all the workers that are working at heights will use Lifeline. 1 5 5 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control 18. Working at height with hand-tools Improper type of tools All workers 5 4 20 High Risks - Visual check of the tools before starting work - Remove all damaged tools - Use proper tools - Wear proper PPE (safety harness, hard hats, safety shoes, gloves, visible vest) - Tool Box Talk 3 4 12 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control 19. Working with hand-tools Improper storage of materials & tools All workers 5 4 20 High Risks - Store all materials & tools in proper place - Tool Box Talk 3 4 12 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control 20. Emergency response, First Aid team. Accident or incident cured on site All workers 5 4 20 High Risks - All the crew must have a first aid person for any accidentor incident case that might be on site. 3 4 12 Foreman, Site Engineer, Site Manager, HSE
  • 33. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 33 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR -First Aid Kit available on site - All emergency contacts must be exposed where can be seen from all the team members. - Transportation available to transport the injured peoples in every working area. -Rescue Plan falling from heights will be followed and instructed to the each formen of groups from Site engineers or site manager and they will be ready to follow the Plan. Repres.Techno- Control 21. Housekeeping Spills incident such as oil or fuel. All workers 4 3 12 Medium risks - Immediatelyclean up using inert sand or other suitable materials - All material used to mop up spills will be immediately removed to a safe place and stored in closed containers for safe disposal, till to be removed from the site to a safer area 3 3 9 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control, Environmental Lead 22. Housekeeping Materials stacked inappropriately All workers 5 2 10 Medium Risk - Store all materials in proper place. 3 2 6 Foreman, Site Engineer, Site Manager, HSE Repres.Techno- Control 23. Housekeeping Garbage The access road 4 3 12 Medium Risk - Recycle bins available on site - Accumulation to Matej DO waste 3 2 6 Foreman, Site Engineer, Site
  • 34. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 34 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR working area. collector company at Cetinje Manager, HSE Repres.Techno- Control,Environme ntal Lead. PROBABILITY SEVERITY 1 (VERY SMALL) Almost no 1 (VERY LIGHT) No loss ofwork time, can only be eliminated immediately, requiring first aid 2 (SMALL) Very few (once a year), only abnormal situations, 2 (LIGHT) No loss of working days, outpatient treatment without permanent effect 3 (MEDIUM) Under (a few times a year) 3 (MEDIUM) Slight injury, inpatient treatment / injury 4 (HIGH) Often (once a month) 4 (SERIOUS) Serious injury, long-term therapy, occupational disease 5 (VERY HIGH) Very frequently (once a week, every day), and under normal operating conditions 5 (VERY SERIOUS) Death, permanent incapacity RESULT ACTION Intolerable Risk (25) The work mustnotbe started or ongoing activity mustbe stopped immediately till the defined risk is reduced. Although the activities carried out are not possible to reduce risk, activity must be avoided. Important Risks (15, 16, 20) The work mustnotbe started or ongoing activity mustbe stopped immediately till the defined risk is reduced. The risk relates to continue to work; emergency measures to be taken and as a result of these measures should be decided to continue the activity. Mid-Level Risks (8, 9, 10, 12) The activities should be started for reducing of defined risks. The reduction measures of risk may take more time. Acceptable Risks (2, 3, 4, 5, 6) The identified risks may not be necessary to eliminate additional control processes.However,these controls should be continued and maintained existing controls be inspected. Unimportant Risks (1) Planning and control processes carried out to eliminate the risks of identified activities may not need to keep records.
  • 35. Detailed Investigation Incident Report ‘’ ISSUING DATE: 14/12/2017 State ofissue: 00 Page 35 of 35 Document Number: IEC-000-TO-00-02_DIR_01 DIR 11 APPENDIX D - EQUIPMENT LIST List of Equipment and Tools used for Tower Erection No. Description (English) Model Brand Qty. 1 Hydraulic winch - Supplied with steelrope diam 8mm L=500m 101/1/AS Tema 6 2 Nylon Pilot Rope -L=1000m - Wound on steel reel 1400mm 22.TR.16.1000 + 062/3 Tema 20 3 Nylon Pilot Rope L=1000m Wound on steel reel 1400mm Cod. 062/3 22.16.1000 + 062/3 Tema 8 4 Steel Wire Rope - Steel antitwist. Wire - Diam 14mm, L=900m Wound on steel reel 1100mm Cod. 062/2 21.12.14.900 + 062/2 Tema 1 5 Connector Joint ' U ' Type GF 10 Tema 35 6 Connector Joint ' U ' Type GF 16 Tema 10 7 Snatch Blocks 020/0,5/N/G1 Tema 10 8 Heavby Duty Snatch Blocks 020/1,5/A /G1 Tema 6 9 Heavby Duty Snatch Blocks 020/3,0/A /G1 Tema 6 10 Gin Pole -External rope passage 050/3/12.3 Tema 6 11 Torques wrenches 050/5/11.F2 Tema 6