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7/29/2019 CCGI Forklift Incident - Fatality
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Galkynysh Gas Field Development Project
Yoloten, Mary, Turkmenistan
PIUL Contract: NO.: GKT-29.12/09-02
CCGI Fatality
CCGI Structural Laydown Area
14 January 2013
Investigation
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Summary
Incident Details
Location : CCGI Structural Steel Lay down Area
Date & Time : 14 January 2013; 1520 hrs
Incident Type : Fatality
Contractor : CCGI
Name of Deceased: Aman Gammarov: Married with three children
Nationality : TurkmenAge : May 1981
Nature on injury : Crush Injury
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Summary
One charge hand and five workers were tasked with general housekeeping duties in the laydown yard.
Pre-job meeting for general housekeeping was carried out. During this meeting it was mentioned that
the forklift would not be required. Forklift operator did not attend this meeting. He was informed he
was to work elsewhere after lunch.
Workers were left unsupervised to carry out the clean-up activities. Charge hand left the site to PMV to
check on a crane under repair.
Deceased instructed forklift operator to help move 1750 kg steel beam.
Forklift raises the beam about 60cm off the ground, but the beam is very unstable due to placement ofthe beam on the forks and a piece of timber that was lodged between the beam and the forks.
Deceased worker attempts to manipulate and extract the piece of timber under the beam and in doing
so bends down placing himself at risk under the beam.
Manipulation of the timber causes the beam to fall on the deceased worker causing fatal crush injuries
to head and chest.
Key Facts:
Workers decided to perform a task beyond the original job instruction.
Workers were left unsupervised.
Forklift operator was properly certified in Forklift operations, but no certified riggers were available.
Specific task of lifting beams with forklift was not described in any method statement or task
assessment.
Incorrect usage of equipment to lift the beam.
Peripheral activity to main site works.
Incident Description :
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Incident Sketch
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January 2013Group HSSEIA Performance5
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January 2013Group HSSEIA Performance6
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January 2013Group HSSEIA Performance7
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Root Causes
Operator Error
6.2 Inadequate practice of skills:
a) The operator should have tilted the forks backward to avoid the load tipping forward.
b) The operator should have lowered the load on the ground in order the IP to remove the
timber under the load.
Not Following Instructions
5.3 Inadequate identification of critical safe behaviors: The IP placed himself in line offire, where he should not have been.
11.1 Inadequate work planning: The crew the IP was in deviated from the initial work
planning that they were supplied with, which was manual handling/housekeeping of the
area and ended up using the forklift.
13.10 Improper equipment selection: Usage of Forklift for such materials was notmentioned/identified in the related procedure; the crane should have been used.
14.4 Inadequate enforcement of PSP: The crew which the IP was in was clearly instructed
not to use mechanical means to organize the yard but IP ignored the instruction and
ordered the forklift to be used.
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Action Items
Actions Responsible Party Due Date Status
CCGI to provide full refresher training to alllifting operators.
CCGI 25.01.2013 COMPLETED(25-30.01.2013)
After finalization of the report, full project
size safety stand down should be performed
by senior management endorsement.
PIUL and CCGI 21.02.2013 COMPLETED
13&15&21.01.2013
All subcontractors should initiate a full
thorough inspection on the material stacking
at their current stock yards to correct any
unsafe condition.
PIUL HSE Manager 26.01.2013 COMPLETED
03.02.2013
CCGI to submit JSA/MS for each specific
lifting task.
CCGI 10.02.2013 COMPLETED
06.02.2013
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Action Items
Actions Responsible Party Due Date Status
No lifting/material handling activitiesshould be carried out unless supervised
by competent supervision. No load to
be lifted when the resting position is
not safe.
SubcontractorsSite Managers
Immediate BEING DONE ONDAILY BASIS BY HSSE
DEPARTMENT
The supervision of such activities must
be responsible and accountable and
present at all times in their work
location.
Subcontractors
Site Managers
Immediate BEING DONE ON
DAILY BASIS BY HSSE
DEPARTMENT
All lifting operations related personnel
must be trained in hazard awareness
and related safe working practices.
Subcontractors
Site Managers
Immediate BEING DONE ON
DAILY BASIS BY SITE
MANAGEMENT
All subcontractors to increase frequency
and quality of hands-on training prior to
each start of a new task and those to be
provided to PIUL for attendance and
surveillance.
Subcontractors
Site Managers
Immediate BEING DONE ON
DAILY BASIS BY SITE
MANAGEMENT
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Action Items
Actions Responsible Party Due Date Status
Petrofac Assurance Index to be
expanded to include section on
Peripheral Activities.
ECOM HSSE Immediate COMPLETED
29.01.2013