This document discusses an investigation into a safety incident at the Zamzama Phase 2 Development civil construction project. It identifies organizational and individual factors that contributed to the incident, including pressure to meet schedules, inadequate planning for simultaneous work, and supervisors not fully embracing a zero harm culture. Corrective actions are proposed, such as reinforcing safety priorities to supervisors, reviewing schedules, and ensuring pre-start safety checks are conducted. The root causes were determined to be a lack of appreciation for safety as the top priority and a willingness of some supervisors to bypass safety procedures to avoid delays. Actions from the investigation will be tracked over time.

1. Zamzama Phase 2 Development
Preparation of JSA’s

2. Slide No. 2
Zamzama Phase 2 – Civil Contract
Preparation of JSA’s
 Issues and Considerations
 Responsibilities
 Execution
 HSE team
 Participants
 Supervisor
 Team members
 HSE
 Techniques
 Visit site
 Visualise in office
 Make the time
 CAREFUL REVIEW

3. Slide No. 3
Zamzama Phase 2 – Civil Contract
Individual /team
Actions
Supervisor believed
OK to work on
unapproved
scaffolding as work
required was minor
Absent/failed
defences
Task/environmental
conditions
Outcomes
Organisational
Factors
Planning of
simultaneous work
activities in same
area
Work front is behind
project schedule
Failure to implement
actions as required
by local HSEC and
Scaffolding
inspector
Failure to follow
working at height
protocols in
switchroom
Working at heights
procedure was not
followed
Area HSEC advice
was not followed
Pressure applied by
Management (BHPB
and Descon) to
complete job quickly
Scaffold Inspector
requirements were
not followed
Only one BHPB
approved scaffold
inspector is on site
Many activities had
to occur
simultaneously
according to plan
Perceived pressure
to commence work
activities due to work
teams sitting idle
waiting for scaffold
to be inspected
Site supervisors
have not been fully
instilled with ‘Zero
Harm’ as a key
measure of success
ICAM Categories and Factors Chart
Summary of Investigation Outcomes leading up to event
(Primary factors highlighted in red)

4. Slide No. 4
Zamzama Phase 2 – Civil Contract
Preventative and Corrective Actions
Organisational Factors Follow up Action Action By
Pressure applied by Management
(BHPB and Descon) to complete job
quickly
Focus to be provided by Descon and BHPB
Management/supervision at all levels that safety will be a better
measure of success than schedule
BHPB/DEL
Planning of simultaneous work
activities in same area
Daily planning to better consider simultaneous operations and
congestion of work activities – particularly in Switch room area.
Time required for inspection and potentially rework associated
with scaffolding installations should also be factored in.
DEL
Only one BHPB approved scaffold
inspector is on site
BHPB to evaluate Descon nominated candidate as Scaffolding
Inspector in limited supporting role.
BHPB
Some field supervisors have not
been fully instilled with ‘Zero Harm’
as a key measure of success
Specific ‘Realignment meeting’ to be presented to all field
supervisors to reinforce that Safety is the primary measure of
success on this project.
DEL
Task/environmental conditions Follow up Action Action By
Work front is behind project
schedule and possibly unrealistic
A review of current schedule for Switch room area and revision if
deemed unrealistic.
BHPB/DEL
Many activities had to occur
simultaneously according to plan
Schedule review to consider reducing simultaneous operations
where SIMOPS issues are potentially more hazardous.
DEL
Perceived pressure to commence
work activities due to work teams
sitting idle waiting for scaffold to be
inspected
Planning to assess potential contingency activities where
unforeseen delays occur in preparatory works (egg scaffolding).
DEL

5. Slide No. 5
Zamzama Phase 2 – Civil Contract
Preventative and Corrective Actions
Individual /team Actions Follow up Action Action By
Supervisor believed OK to
work on unapproved
scaffolding as work required
was minor
Specific ‘Realignment meeting’ to be presented to all field
supervisors to reinforce all mandatory safety requirements on
the project.
Company’s ‘Zero Tolerance’ policy to be reinforced to all senior
field supervisors.
DEL
Failure to implement actions
as required by local HSEC and
Scaffolding inspector
Specific ‘Realignment meeting’ to be presented to all field
supervisors to reinforce that failure to follow up on advice from
Descon field HSEC team will not be tolerated.
DEL
Absent/Failed defences Follow up Action Action By
Working at heights procedure
was not followed
Specific ‘Realignment meeting’ to be presented to all field
supervisors of mandatory nature of all working at height
procedures to be emphasised.
DEL
Area HSEC advice was not
followed
Specific ‘Realignment meeting’ to be presented to all field
supervisors to reinforce that failure to follow up on advice from
Descon field HSEC team will not be tolerated.
DEL
Pre-Start ‘Take Five’ sessions to be conducted for all activities –
involving HSEC member. All issue identified to be addressed
prior to commencing work
DEL
Scaffold inspector
requirements were not
followed
Specific ‘Realignment meeting’ to be presented to all field
supervisors to reinforce that disregarding tagging procedures is
a dismissible offence and will not be tolerated.
DEL

6. Slide No. 6
Zamzama Phase 2 – Civil Contract
Event Outcomes
 Summary and Root Cause Outcomes
 Key root cause outcomes identified relate to the following:
 A lack of appreciation by field supervisors of Safety as the primary
measure of success in completing work activities
 Setting of possibly unrealistic goals for completion of work packages
 A willingness expressed by field supervisors to break Mandatory working
at height procedures and protocols where risk is considered ‘low’ and
exposure to delays in completing scheduled activities is ‘high’.
 Actions from this mini-ICAM will be inserted into the Project Actions Register
and close tracked on a continuous basis.