1. 1 The task: Salvaging Operation. Included cutting and removal of equipment from site WELDER FATALITY August 2003

2. 2 Who is likely to carry out a similar Task? What are the Hazards involved in such a task? What could go wrong? What type of controls are required to be in place to complete this Task Safely? DISCUSS WITH YOUR TEAM

3. 3 WHAT HAPPENED The contractor Welder was torch cutting a purged and cleaned filter vessel from inside the skirt. This was the second of three filter vessels scheduled for salvaging. The Welder was pinned down between the ground and the vessel, when remaining vessel portion toppled once skirt was weakened from heat/cutting, pinning the welder down to his death Deceased One of the vessels still intact Collapsed portion of the cut vessel

4. 4 WHAT/HOW DID IT HAPPENED? # 1# 1 # 2# 2 # 3# 3 # 4# 4 PROCEDURE/SEQUENCE USED IN DISASSEMBLING VESSEL #2 V. Media Filter Vessel Horizontal View of Vessel Deceased Man way section is cut out in front along w/ horizontal cut on opposite side Cutting Sequence Upper body of vessel is cut after dome removal Cement Remaining vessel portion topples once skirt is weakened from heat/cutting Weight of upper tank body no longer counter-balances cement in tank

5. 6 WHY THIS INCIDENT HAD HAPPENED? IMMEDIATE CAUSES Work crew perceived the Job is routine Work crew did not pre-plan the Job adequately Failed to recognize hazards No Job HSE analysis carried out Work crew did not comply with the Permit to Work issued for the Job Lack of Supervision

6. 5 WHY DID THIS INCIDENT HAPPEN? UNDERLYING CAUSES Involved Personnel lacked sufficient training & knowledge of the Applicable HSE standards and procedures Contractor crew, including deceased, was not assessed as required per The Contractor HSE Management Process Role & responsibilities were unclear and as a result supervision was Not effectively provided for the Job The level of risk involved was underestimated, resulting in lower emphasis being placed on hazard management at work site

7. 7 HOW CAN THIS JOB BE DONE SAFELY? Assess contractor competency for the Job prior to commencement of operation Evaluate critical activities to ensure HSE risks are properly managed Pre-plan the Job and carry out Job Safety analysis Communicate Hazard and controls required for the task to all concerned parties and adhere to Permit to Work System where applicable Never underestimate the risks, even if the Job has been done before