Cause & Consequence
- Fall from height
- Change management
Description of Process
A rope access work party were installing a clamp on a platform leg in preparation for fitting a replacement section of escape to sea ladder.
Description of Incident
The first section of clamp had been successfully lowered into position below the leg mooring ring.
One team member ascended to the spider deck to prepare the second clamp section for lowering, leaving one over-side team member on the mooring ring.
The first team member partially rearranged one of the ropes to improve access for lowering the second clamp section.
The second team member remained on the mooring ring and positioned himself to access a chain block, changing over ropes to do this.
The second member transferred onto a rope loop, which unravelled when full weight was applied, resulting in an unplanned descent from the mooring ring onto the water surface.
- No injuries were sustained.
- Individual remained connected to ropes at all times during this unplanned descent.
On contact with water his lifejacket activated and he was picked up by the on-scene daughter craft within 2 minutes
Inadequate communication between team members: The temporary change in status of one of the rope systems was not effectively communicated between the team members.
Improper decision making or lack of judgement: Individual connected to a rope which he had not adequately confirmed as having sufficient tension to apply his full weight.
- Inadequate monitoring of ongoing work.
- Standards of performance missing or not enforced.
- Inadequate change management.
Routine activity without thought: Over-reliance or overconfidence using the mooring ring as a working platform.
Good Practice Guidance
- Work suspended and time out for safety prepared and delivered to all crews.
- Equipment quarantined and sent for inspection to identify any potential defects.
- Safety alerts issued to highlight awareness of incident throughout industry.
Communication: Following issue of a work instruction always verify work party understanding.
Complacency: Where structural items provide foot placements that enable rope access personnel to remove some or all of their weight from ropes, it is essential that robust operational discipline is maintained at all times (operational discipline includes maintaining sufficient tension in all rope systems to remove potential for an unplanned descent or shock loading to any part of the system).