Description of Incident
4 workers from an external contractor company were performing work to replace the roof gutter of a store. These workers were positioned on the roof wearing harnesses and lifelines. They pulled the central gutter in order to remove it. This motion affected the structure of the false ceiling, resulting in the fall of some elements of the structure and plates of the false ceiling.
Two people were in the store, fortunately, no one was under the false ceiling when it collapsed, 4 people were present on the roof when this occurred.
Why it happened?
The analysis of the event concluded that the fixing rods of the false ceiling structure had remained attached to the gutter despite the observation made during the preliminary site visit.
This visit, part of the preparation phase, was conducted by 2 individuals (service station manager + External company supervisor) without a representative of the subsidiary. Some of the anchored fixing rods were not removed before starting the removal of the gutter: their identification being difficult because of the configuration, the construction, and the difficulty of visual detection. The extraction of the gutter led to the tearing off of a part of the structure and then, the collapse of the false ceiling of the store.
All the investigation elements also highlight failures in the work preparation phase: the SS manager was not informed of the risks associated with the intervention and the risk analysis guide as well as the operating procedures were not filled in (incomplete PDP). Finally, the event analysis identified other failures - HOF (human and organisational factor): work started without work authorisation and specific permit (work at height).
Good Practice Guidance
- Work at height: Carry out an inspection of the site to check the work area and access before the risk analysis (check, as far as possible, the areas under/on the roof (inside/outside the building).
- Carry out a complete risk analysis with the External Company (take into consideration the risks of electrical lines).
- Ensure that the External Company has defined an operating procedure and a risk analysis known to its operators and in compliance with the Company's requirements.