1. Dropped Panel Fatal Incident
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Dropped Panel
Fatal Incident

2. Terms of Reference
To investigate issues associated with and leading up to the fatality that occurred during works being carried out on substation The investigation is to be as wide ranging as possible but limited within the management influences of CTJV, QG2 project and the 3LNG Management teams.

6. What Happened?
A large, heavy, transom blanking panel, from an installed steel blast door assembly, fell from height during an unplanned task.

9. Urgent panel removal required to allow access for switch gear
Immediate Cause 1.
Urgent panel removal required to
allow access for switch gear

10. Loss of control of heavy blast proof door transom panel
Immediate Cause 2.
Loss of control of heavy blast proof door transom panel

11. Four men standing on trestle
Immediate Cause 3.
Four men standing on trestle

12. Underlying Causes 1 Concerning Urgent Requirement
Request from electrical group to bring forward installation.
Resulted in a perceived operational pressure on civil group.
Driven by requirement to advance a milestone for group morale reasons.
No consideration of implications on other groups.
Design, installation & acceptance process resulted in a pre-ordained requirement to dismantle a heavy assembly, subject of an un-answered TQ and with no JSA.

13. Underlying Causes 1
Early installation of door driven by perceived manufacturer’s requirement.
Building design and possible financial implications apparent.
Departmental liaison issues.

14. Underlying Causes 2 Concerning Loss of Control of Panel
Job was not planned.
Construction Manager was unaware.
Weight of panel was unknown.
Assertive Charge-hand assumed lighter weight and ignored protests, including Safety Officer!
Junior Engineer did not exercise direct supervision.
Usual Foreman absent on leave.

15. Underlying Causes 2 Issues of dominant cultures.
Resulting issues of operating above competence levels.
Poor manpower management & coordination.
Indications of poor Change Management.

16. Underlying Causes 3 Concerning Men on Platform
Because of chosen method.
Driven by perceived pressure.
No JSA in place in spite of clear TQ on drawing.
Poor coordination and feedback/audit within management structure.

17. ROOT CAUSES Poor Interface Management within Joint Venture.
Management Commitment not focussed.

18. RECOMMENDATION 1
Verify that all influencing organisations have the correct level of resource, organisation and structure in place to support the current phase of the project.

19. RECOMMENDATION 2
Establish through audit the Terms and Conditions that will attract the highest calibre management and supervisory personnel including HSE to manage the verified structure; and allocate necessary resource.

20. RECOMMENDATION 3
Establish a programme to ensure a project wide climate that truly empowers any worker to stop work for safety reasons without negative response.

21. RECOMMENDATION 4
Create & Implement an Interface document which confirms responsibilities & accountabilities, processes & procedures used to manage the project.

22. RECOMMENDATION 5
Validate or create a process that links different group, safety critical work procedures, to prevent conflicting targets

23. RECOMMENDATION 6
Establish a labour allocation process to align workforce to prevent dominant behaviour through cultural differences.

24. RECOMMENDATION 7
To establish a competent, integrated project HSE management audit and review programme.