Learning from Incident

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Loren Haynes
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1 Fatality: Fall from conveyor at Twistdraai Export Plant Objective of this report Learning from Incident This document is a brief account of the incident and extraction of the most important actions, learning s and reminders for communication. It is not intended as any part of the official record or investigation into the incident and does take legal precedence over the latter, which is managed by line managers in the business concerned. Incident Fall from conveyor Location Twistdraai Export Plant Date 27 February 2007 Report by W Uys Sasol Mining Incident description KISME Engineering was awarded the contract to dismantle a conveyor installation that had to be repositioned at the Export Plant discard dump. KISME Engineering requested a mobile crane from Sasol Mining to assist, and Sasol Mining contracted Marlboro Crane Hire to do the lifting work with a mobile crane with a 20 tonne lifting capacity. Marlboro Crane Hire dispatched the crane to the site with a Rigger, Mr Isaiah Modise, a Rigger with seven years experience at various Sasol Secunda sites, although not all with Marlboro Crane Hire. It was Mr Modise s task to lift the jib section away from the drive section with a mobile crane with a 20 tonne lifting capacity. This was to happen after KISME Engineering personnel had cut the bolts that held the two sections together. Mr Modise climbed onto the roof of the jib section and anchored the lifting chains to the lugs that were on top of the jib section. Mr Modise remained on top of the jib section whilst personnel from KISME Engineering cut the bolts that joined the jib section to the drive section. Once the holding bolts were cut Mr Modise signaled to the Crane Operator, also from Marlboro Crane Hire, to lift the jib section. The crane s overweight safety device tripped, possibly as a result of the jib section being too heavy. The Crane Operator then suggested that the crane be repositioned closer to the load so as to move the crane boom to a more vertical position and by doing so increase the lifting capacity of the crane. Mr Modise then instructed the Crane Operator to lower the crane hook in order to unhook the lifting chains. KISME Engineering personnel shouted to Mr Modise, that were still on top of the jib section, that the holding bolts had been cut. Almost immediately, whilst slackening the chains, the jib section fell over, suddenly dropping Mr Modise over the 7m highwall. He fell in an uncontrolled manner, and on striking the ground he sustained head and neck injuries, and died at the scene. Mr Modise was not wearing a safety harness at the time of the incident.

2 Root Cause Analysis (RCA) 1. Mr Modise climbed onto the equipment that was being lifted which is against safe lifting procedures. 2. A safety harness was not worn as is Sasol and Sasol Mining s standard when working at heights. Contributory factors 1. The competency of Mr Modise is questioned as a check of his qualifications raised concerns about the legitimacy of his Certificate of Competency as Rigger. 2. Clear definition of responsibilities between the Service Provider (KISME Engineering), their Service Provider (Marlboro Crane Hire) and Sasol Mining. 3. Inadequate supervision by the Project Manager. Shortcomings included proper Project Planning, Project Responsibility for the work (including statutory appointments) and a comprehensive Risk Assessment on high potential risks ( Working at Heights, Rigging and Lifting, Cutting and Welding ). Learning, reminders and associated actions: 1. Continuous enforcement of the adherence to Fatal Risks and the required behaviour associated with Sasol s Life Saving Behaviours. (see RCA points 1 and 2) 2. Ensure sound Project Management that includes proper Project Planning, Project Responsibility (Statutory appointments) and comprehensive Risk Assessments (see Contributory factors point 2 and 3) 3. Ensure that qualifications of own and/or Service Provider employee Certificates of Competency are properly verified (see Contributory factors point 1) W Uys R K Fraser

3 Photograph 1 Scene where the incident occurred Crane Alleged position of deceased before fall Conveyor jib section High wall 7 meters Grid guards Deceased position after fall Photograph 2 Positioning of the crane and the conveyor structure

4 Photograph 3 Illustration of the position of the crane. Note the overextension of the boom. Photograph 4 View of the conveyor jib section

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