Context: A boilermaker was requested to remove a fan and a steel plate (cover) welded beside the roof opening of a 50-foot high reservoir. The goal was to allow a crane to reach 5 other fans installed on the floating roof 40 feet below.
Event reconstitution
The worker performed the task as required by cutting the welds and raising the cover which forced him to move to the side. Unfortunately, he didn’t know the plate covered a 2’x2’ opening, so when he sidestepped, he fell into the hole.
This event could have turned into a tragedy. Fortunately, the worker was wearing his harness and was secured, but it resulted in the following situation:
When the worker stumbled into the hole, his fall into the reservoir was absorbed by his personal fall arrest system at approximately 8 feet. The worker was hanging about 40 feet above the floating roof. He then grabbed the cable from the nearby crane. Less than a minute later, the crane operator raised the hook and the worker was rescued. Conclusion, the worker was shaken but unhurt.
What were the causes of the incident?
First, it should be noted that among the 5 fans installed on the roof, none had an opening with a 2’x2’ key. The fan was the only one with an opening allowing material to exit the reservoir.
The cause was the opening underneath the plate that had not been identified with a “Warning Hole” signage. Also, the worker was not informed of the opening before performing the task. Finally, the opening was not identified in the AST.
How to prevent this type of incident from occurring in the future?
In addition to always using a personal fall arrest system and ensure to be correctly secured, two preventive actions were identified in relation to the incident:
1. All covers must now be labelled with a “Warning Hole” sign.
2. A barricade must be installed 6 feet around the openings.
After the incident…
It is still important to hold a health and safety general meeting when the workers come back. An update and reminders on the procedures to be followed and implemented are always important elements in order to avoid risks of casualties in the future. Thanks to his excellent health and safety behaviour, Benoît McInnis knew how to react during the incident.
