2002/001 OFFSHORE TECHNOLOGY REPORT Slips, trips and falls from height offshore

HSE
Health & Safety
Executive
Slips, trips and falls from
height offshore
Prepared by BOMEL Ltd
for the Health and Safety Executive
OFFSHORE TECHNOLOGY REPORT
2002/001
HSE
Health & Safety
Executive
Slips, trips and falls from
height offshore
BOMEL Ltd
Ledger House
Forest Green Road
Fifield, Maidenhead
Berkshire SL6 2NR
United Kingdom
HSE BOOKS
© Crown copyright 2002
Applications for reproduction should be made in writing to:
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First published 2002
ISBN 0 7176 2327 0
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Neither the Executive, nor the contractors concerned
assume any liability for the reports nor do they
necessarily reflect the views or policy of the Executive.
ii
CONTENTS
Page No.
EXECUTIVE SUMMARY
v
1.
INTRODUCTION
1
1.1
BACKGROUND
1
1.2
1.3
AIMS
OVERVIEW OF APPROACH
3
3
1.4
STRUCTURE OF REPORT
5
2.
3.
4.
5.
6.
7.
LITERATURE REVIEW
7
2.1
APPROACH
7
2.2
RESULTS
7
ACCIDENT DATA ANALYSIS
11
3.1
3.2
3.3
11
13
20
DERIVATION OF BASELINE FROM RIDDOR
IDENTIFYING CAUSES FROM RIDDOR
ACCIDENT DATA FROM OFFSHORE COMPANIES
INTERVIEWS WITH HSE INSPECTORS AND TRADE UNION
REPRESENTATIVE
23
4.1
4.2
4.3
23
23
25
OVERALL APPROACH
HSE INSPECTOR RESULTS
TRADE UNION RESULTS
FOCUS GROUPS WITH OIMS AND SAFETY REPS
27
5.1
OVERVIEW
27
5.2
SAFETY REP FOCUS GROUP RESULTS
27
5.3
OIM FOCUS GROUP RESULTS
28
OFFSHORE VISIT
31
6.1
6.2
APPROACH
RESULTS
31
31
6.3
CONCLUSIONS
34
PHASE ONE CONCLUSIONS
35
7.1
7.2
GROUPS AT RISK
RISK BEARING ACTIVITIES
35
36
7.3
7.4
DIRECT CAUSES
INDIRECT CAUSES
37
37
iii
8.
9.
10.
11.
12.
RIN ANALYSIS AS A BASIS FOR INTERVENTION
39
8.1
8.2
39
39
OVERVIEW
RIN METHODOLOGY
CRITICAL FACTORS/PATHS AND RISK CONTROL IN STFS
43
9.1
9.2
OVERVIEW
RESULTS OF RIN ANALYSIS
43
44
9.3
APPLYING RISK CONTROL MEASURES TO STFS
45
BUILDING A STRATEGIC FRAMEWORK
47
10.1
10.2
47
47
DEVELOPMENT OF THE STRATEGY
THE STRATEGY FRAMEWORK
IMPLEMENTING THE STRATEGY: GUIDANCE FOR HSE INSPECTORS
54
11.1
SMS AUDIT GUIDE TO ASSESS STF ARRANGEMENTS
54
11.2
11.3
11.4
AIDE MEMOIRE TO ASSESS STFS OFFSHORE
RIN ASSESSMENT TOOL FOR STFS
TRIAL OF GUIDANCE WITH OFFSHORE OPERATOR
55
55
56
CONCLUSIONS AND RECOMMENDATIONS
APPENDIX A – RISK CONTROL MEASURES FOR STFs
58
60
APPENDIX B - GUIDANCE FOR ASSESSING ARRANGEMENTS
TO CONTROL STFs
64
iv
SLIPS, TRIPS AND FALLS FROM HEIGHT OFFSHORE
FINAL REPORT
EXECUTIVE SUMMARY
Background
BOMEL was contracted by the Health and Safety Executive (HSE) under the HSE
Framework Agreement with the BOMEL Consortium, to assist the Offshore Division (OSD)
in a study of slips, trips and falls from height (STFs) offshore. The study aims to establish
a firm understanding of the causes and possible prevention of STFs offshore and from this
develop a strategic plan for HSE to use to bring about a 15% reduction in these accidents
offshore over a 3 year period. This will feed into the Health and Safety Commission’s
“Revitalising Health and Safety” target of reducing the incidence of fatal and major injury
accidents by 10% by 2010 and to reach half this figure by 2005.
Slips, trips and falls from height make up a considerable number of the offshore accidents
reported under the Reporting of Injuries Diseases and Dangerous Occurrences
Regulations (RIDDOR). In 1999-2000 for example, almost 40% of all reported accidents
were broadly classed as a slip, trip or fall from height with 27% of these being major injury
accidents. Indeed, STFs have accounted for around one third of all RIDDOR accidents
offshore since 1991. Despite the introduction of the safety case regime in 1992 and the
efforts of the industry’s commitment to a Step Change in safety since 1997, the incidence
of STFs offshore has remained at a similar level for the past four years. This concern has
led to the current HSE call for a more robust understanding of the causes and possible
preventions of STFs and a strategy to influence industry to reduce these accidents
offshore. The current work has been commissioned to address these problems with Phase
1 designed to identify causes and prevention options as a basis for strategy development
in Phase 2.
Literature Review
The first stage in Phase 1 involved a detailed literature review using a number of sources
including psychological and ergonomic abstracts, HSE and British library catalogues and
best practice from societies such as the Royal Society for the Prevention of Accidents. The
focus of the review was on the underlying human, hardware and external causes in STFs
and the associated prevention measures. The factors which were identified as most
important in this respect were housekeeping, inspection and maintenance, quality of
hardware, PPE, culture, training and management/supervision. Much of the information in
these areas was gleaned from work on STFs in general, as well as offshore, due to the
lack of specific studies related to the offshore environment. In broad terms it was found
that the hardware and environmental causes are fairly well documented whereas the
human element in STFs has been given less attention.
v
Data Analysis
Data from the Reporting of Injuries Diseases and Dangerous Occurrences Regulations
(RIDDOR) and from offshore companies were analysed in order to discern areas of risk,
consequences and causal trends in STFs. Results from RIDDOR show that the ratio of
over 3 day injury accidents to major injury accidents is about 3:1. However, there is a
greater risk of a major injury accident as a result of a fall from height as compared to a slip
or trip. The main risk areas are identified as: when workers are in transit; during deck
operations; fixed installations for slipping/tripping; mobile installations for falls from height
and inexperience.
Company accident data provided insight as to possible causes within
these risk areas which included slippery/uneven/untidy site, defective tools/equipment
guards and lack of attention/risk perception. RIDDOR data was also used to calculate a
baseline rate of STFs from which progress towards reducing these accidents can be
measured. The baseline rate of STFs for the three year period prior to 31 March 2001 is
415.75 per 100,000 people.
Consultation and Industry Input
A number of stakeholders were consulted in interviews and focus groups to draw on their
experience of STFs offshore and support the establishment of causes and prevention
measures with practical knowledge. This included HSE inspectors, a trade union
representative, OIMs and safety representatives. To supplement this, an offshore visit was
arranged to gain the views of the general workforce and make first hand observations. In
all consultation sessions a structured method was used to collect the data. There was
found to be considerable consensus between the different groups regarding the main
causes and prevention of STFs. The important causes emerged as lack of care/attention,
lack of risk perception, poor housekeeping, inadequate inspection and maintenance, poor
quality of hardware, stress and fatigue. The most effective means of prevention were
thought to be training, campaigning to increase risk awareness and improved culture in
terms of communicating best practice, reporting, taking sufficient time to work safely and
challenging others.
Phase 1 Conclusions
Conclusions from Phase 1 indicate that the most significant factors in STFs can be divided
into 'groups at most risk', 'related activities', 'direct causes' and 'indirect causes'. Groups at
most risk were found to be younger workers (probably related to experience), those
involved in deck operations, people on fixed installations in terms of slips and trips and
people on mobile installations in terms of falls from height. Additionally, those in drilling
and maintenance appear to be at most risk of high falls and therefore the most serious
injuries. Related activities were found to be climbing or descending or walking on the level
(i.e. when in transit) and manual handling. Direct causes were commonly found to be poor
housekeeping, hardware and personal protective equipment (PPE) and extreme weather
conditions. Indirect causes were summarised as inadequate inspection/maintenance, lack
vi
of attention and awareness, mental and physical stress, inadequate management and
supervision, weak safety culture and under-reporting.
Factors Influencing Likelihood of STFs
Due to the different types of installations offshore, the variety of activities which are
undertaken and the limited resources available it is necessary to target efforts to reduce
STFs. Risk Influence Network (RIN) analysis has been used to identify the most important
factors in STFs from those identified in Phase 1. The approach considered STF scenarios
as top events in a network of influences ranging from direct causes such as low risk
perception to remote influences such as that of the regulator. Using this approach it is
possible to identify direct factors which are critical in STFs and trace critical paths of
influence to more remote factors. Factors are critical in that they offer the greatest
potential to influence the likelihood of STFs. The six critical direct factors in STFs have
been identified as housekeeping, inspection/maintenance, quality of hardware, weather,
risk perception and experience of surroundings. These are underpinned by a number of
common influences including culture, the accident/incident feedback loop, training, work
organisation, safety management and market influence. An exercise was carried out to
apply the risk control measures (RCMs) from Phase 1 to the critical factors/paths and
generate new RCMs where there are gaps.
HSE-OSD Strategy Development
From the knowledge of critical factors and paths of influence in STFs and associated risk
control measures, it is necessary to develop a list of actions which can be used to apply
this information with the aim of reducing STFs offshore. These have been developed with
reference to the activities HSE have at their disposal to influence health and safety
performance. The actions have been structured strategically to indicate the level at which
they need to be implemented, how they might relate to other activities and where the
outcome is expected to be. Front line activities are likely to have the most affect and
include STF focus in HSE inspections and detailed investigation of STF accidents. These
are underpinned by a number of vital support activities such as the development of a
database for STF information and the issuing of guidance to HSE inspectors and duty
holders. Background activities such as further research into human factors in STFs and
the review of design standards in relation to these accidents would help to inform the
overall strategy.
Taking the Strategy Forward
In view of the detailed knowledge gained as a result of this project, it was agreed to extend
the work to deliver a number of tools to assist HSE inspectors in implementing the strategy.
The provision of guidance for inspectors to assess duty holder arrangements to control
STFs has been given particular focus. As a result, guidance has been developed for
inspectors to use during discussions with duty holders onshore and offshore. The
guidance is made up of three working documents which inspectors can use to assess an
vii
operators strengths and weaknesses in relation to provisions for STF accidents. These
are:
·
An SMS audit guide and proforma to record audit results
·
An offshore inspection aide memoire and proforma to record inspection results
·
A risk influence network assessment and improvement tool
The guidance is described in detail in Section 11 and a copy can be found in Appendix B.
Recommendations
A number of recommendations are made in order to help apply the work described in this
report:
·
The strategic activities which have been developed to reduce STFs should be
supported by the findings of this work
·
Front line activities should be supported by provisions at the planning level as
indicated in the strategy network in Figure 10.1 in order that they are successful
·
The direct critical factors and paths in STFs identified by this work should be given
priority in programmes to reduce STFs.
·
The guidance document and tools in Appendix B should be disseminated to HSE
inspectors and industry with appropriate training in its use
·
Inspectors and duty holders should be encouraged to use the RIN assessment
tool in the guidance to help diagnose company specific factors in relation to STFs
·
Duty holders may make an assessment of appropriate risk control measures
(RCMs) using the RCM log in Appendix A as a guide
·
With respect to accident reporting and feedback, it is recommended that company
accident reporting systems including direct and underlying causes of accidents
should be standardised and pooled on a joint industry basis.
viii
1.
INTRODUCTION
This report presents the results of a project aimed at developing a strategy to
reduce slips, trips and falls from height (STFs) occurring in the United Kingdom
offshore oil and gas industry. The project forms part of the Health and Safety
Commission's (HSC's) strategy to improve health and safety performance in key
risk areas (Strategic Theme No. 2) and has been initiated by the Offshore Division
(OSD) of the Health and Safety Executive’s (HSE) Hazardous Installations
Directorate.
Under the HSE Framework Agreement with the BOMEL Consortium, BOMEL has
been appointed as the contractor to assist OSD in its study of the risk of slips, trips
and falls from height. BOMEL's remit, in partnership with OSD's Management
Support Group, includes establishing the factors which contribute to STFs and
from this, developing a programme of activities designed to influence the Offshore
Industry to bring about a 15% reduction of slips, trips and falls from a height within
a three year period.
The project forms a part of the ‘Revitalising Health and Safety’ agenda which was
issued jointly by the Deputy Prime Minister and the Chairman of the Health and
Safety Commission at the beginning of June 2000. In the initiative, the
Government commits the 'Health and Safety System' (regulator, duty holders,
workforce and all those who may have influence), inter alia, to reduce the
incidence rate of fatal and major injury accidents by 10% by 2010 and to reach
half this figure by 2005. It is expected that the drive to reduce STFs offshore will
feed into this overall target.
1.1
BACKGROUND
It is now widely accepted that slips and trips, and falls from height are some of the
more common types of incidents in the workplace, often leading to serious injury
and time off work. Under the Reporting of Injuries, Diseases and Dangerous
Occurrences Regulations (RIDDOR) 1995 (HSE, 1996), 30% of all injuries
offshore were broadly classed as a slip, trip or fall from height in 2000/2001
(provisional) although this figure was as high as 40% in the previous year (27%
major injuries or fatalities). Indeed, slips, trips and falls from height offshore have
accounted for around one third of all injuries reported under RIDDOR since 1990.
The annual number of incidents broadly classed as slips, trips and falls has varied
from 95 (1990-1991), peaking at 218 (1992-1993) and reducing to 69 (2000 to
2001). The significance of STF accidents is not confined to the offshore sector
1
but can be observed in many industries such as food processing, ceramics, paper
making, shipbuilding and construction.
Note – STF accident numbers used in this report are from the RIDDOR
classification ‘Broad Incident Type’ as opposed to ‘Accident Kind’, used by HSE in
OTO reports, as the former provides a fuller picture of the STF problem.
The potential losses caused by slips, trips and falls from height offshore to
employers are likely to be significant. These might include direct costs, loss of key
staff, medevac, breaks in operations and a wide range of liabilities. For an
individual who is involved in a slip, trip or fall accident, loss of earnings and
permanent disability are among the more serious consequences. As an example
of the potential losses caused by STFs, it has been estimated that such accidents
cost employers in the food, drink and tobacco industries around £22 million a year.
Employers have a general responsibility to protect workers from hazards that
might cause slips and trips, and falls from height, under the Health and Safety at
Work etc. Act (1974). In addition, this Act places a clear responsibility on
individuals to comply with health and safety requirements and not to act in a way
which might endanger themselves or others. The Management of Health and
Safety at Work Regulations (1992) require that employers carry out risk
assessments including consideration of hazards which might lead to STFs.
The Offshore Installation and Wells (Design and Construction etc.) Regulations
1996 state that outdoor workstations on an offshore installation must as far as
possible be arranged so that workers cannot slip or fall. This includes provisions
to keep the installation clean, prevent dangerous bumps, slopes or holes and
provide adequate lighting.
The Offshore Installations and Pipeline Works
(Management and Administration) Regulations 1995 make it clear that
management must provide information to employees regarding such matters and
that employees must in turn cooperate with management so that the relevant
statutory provisions are complied with.
A comprehensive overview of the
regulations pertaining to STFs is provided in Support Information for STFs
Offshore Final Report BOMEL Reference C919\05\174u.
Despite the introduction of the safety case regime in 1992 and the efforts of the
industry's commitment to a Step Change in safety since 1997, the incidence of
slips, trips and falls offshore has remained at a similar level over the past four
years. Over this period the HSE has issued new guidance dealing with STFs in
the workplace. As a result, HSE are concerned that the incidence of slips, trips
and falls has been on a plateau for such a considerable time.
2
In order to reduce the number of STFs offshore, it is necessary to have a clear
understanding of the direct causes of these accidents and their underlying
contributory factors. Having developed a thorough understanding of the problem,
potential intervention measures can be put forward to help industry prevent STFs.
A baseline measure of the current incidence of STFs needs to be established
which can be used to measure the effectiveness of HSE strategy in influencing
industry to reduce such accidents.
The approach and results of the study to reduce STFs offshore are now
presented. These include the data gathering on the potential causes of STFs and
the interpretation of this information to identify the critical underlying factors which
influence these accidents. From this has come the development of a strategic
network of activities which HSE can use to help the offshore industry reduce STFs
offshore. Part of this has involved the formulation of guidance for HSE inspectors
to use in assessing duty holder arrangements for controlling STFs. Also
described in the report is the establishment of a baseline against which to
measure any reduction in these accidents.
1.2
1.3
AIMS
·
To build a firm understanding of the underlying causes in slips, trips and
falls from height (STFs) and possible prevention methods
·
To develop a strategy for OSD to successfully influence industry to bring
about a 15% reduction over 3 years in the number of accidents reported
as a result of slips, trips or falls from height
·
To develop a programme of activities for OSD to follow
OVERVIEW OF APPROACH
1.3.1
Phase One
The study has been carried out in two main phases.
Phase 1 was aimed at
identifying data and information to provide an understanding of STF accidents
offshore. The following sources were identified in discussions with HSE OSD and
from initial consultations with relevant stakeholders:
·
A review of accident causation and prevention from the literature,
concentrating on slips, trips and falls from height where possible. Part of
this included a review of the regulations pertinent to STFs.
3
·
An analysis of STFs in the Reporting of Injuries, Diseases and Dangerous
Occurrences Regulations (RIDDOR) database, compiled by HSE and
calculation of a baseline against which future performance can be
measured.
·
An analysis of additional STF accident data provided by offshore duty
holders.
·
Interviews with HSE Inspectors.
·
Consultation with key stakeholders including Offshore Installation
Managers (OIMs), Safety Representatives and a Trade Union
representative.
·
An offshore visit to three installations in the Southern sector of the North
Sea to gain first hand experience of STF issues. This included trial use of
an offshore workforce questionnaire to help gather information.
These strands of analysis were chosen to provide a comprehensive understanding
of the causes and prevention of slip, trip and fall from height accidents offshore.
The literature review was undertaken to provide a theoretical basis, and give
pointers regarding the factors which might influence this type of accident. The
review also provides direct evidence from previous studies, existing guidance and
established best practice as to the causes and prevention of slips, trips and falls.
Additionally, it offers the opportunity to use accident theory to suggest possible
causes and prevention in slips, trips and falls where there are gaps in the
literature.
Accident data from RIDDOR was analysed because it provides a record of all
officially reported slips, trips and falls offshore since 1990. This allows the
calculation of a baseline which can be used to measure the success of the
strategy to reduce these accidents. A further reason for undertaking the RIDDOR
analysis was that it provides a broad indication of the factors associated with
accidents, and can be used to assess specific and generic risk. Company
accident data was used to supplement RIDDOR because it provides information
on non-reportable accidents and incidents and underlying causes in STFs.
Various stakeholders from the offshore industry have been consulted as part of
this study including, OIMs, Safety Representatives, a Trade Union representative
and HSE inspectors. This consultation has been carried out for a number of
reasons. Firstly, those involved in the industry are well placed to offer their views
on the factors which influence the causes of STFs but which cannot readily be
extracted from accident data or the literature. Secondly, stakeholders can suggest
4
prevention strategies which are likely to work in the offshore environment and how
such strategies can best be implemented.
An offshore visit by a member of the project team was included as part of the
study to provide an opportunity for interviewing members of the general workforce
who are potentially routinely exposed to STF hazards. Such people are arguably
in the best position to suggest which measures will effectively reduce risk and how
these measures should be implemented. The offshore visit also offered the
chance for a member of the project team to make an informed first-hand
assessment of the factors which are likely to be most relevant to STFs offshore.
1.3.2
Phase Two
The main focus of Phase 2 has been to develop a strategy based on the Phase 1
findings to control and reduce the incidence of STFs offshore. This has involved
the following steps:
1.4
·
Using Risk Influence Network (RIN) methodology to identify and rank the
underlying causes and influences in STFs
·
Understanding the potential for reducing STFs and where measures are
likely to be effective
·
Devising a strategy for HSE to influence industry
·
Developing tools to enable HSE to pursue the strategy
STRUCTURE OF REPORT
The report is structured as follows:
Sections 2 to 6 contain the results of the data collection activities carried out in
Phase 1 of the study designed to identify causes and prevention in STFs offshore.
This includes a literature review, accident data analysis, interviews and focus
groups with key stakeholders and an offshore visit. The Phase 1 conclusions are
contained in Section 7.
Section 8 describes how Risk Influence Network analysis has been used to further
analyse the results from Phase 1. This has involved identifying critical factors and
paths of influence in STFs and applying risk control measures in these areas
which is dealt with in Section 9. Section 10 presents a strategy for reducing STFs
which has been generated from the analyses in Phases 1 and 2 of the work. An
important extension of this has been the development of guidance on STFs for
5
HSE inspectors which is discussed in Section 11. The guidance has been piloted
with an offshore operator in the UK sector of the North Sea and the results of this
are also presented in Section 11.
Section 12 contains the conclusions and recommendations which have been
generated by the study.
It should be noted that, due to the extensive coverage of this work, not all detailed
data or analysis used during the study is contained in this report. Where
appropriate, references are provided for supporting documentation.
6
2.
LITERATURE REVIEW
2.1
APPROACH
A comprehensive review of existing research into workplace STFs has been
carried out, seeking to isolate the factors that contribute to this type of accident
and to understand the approaches that have been developed to prevent them.
The review has been designed to elicit a set of common causal factors in STFs
drawing on best practice from other industries and general accident causation and
prevention theory where there is a lack of STF specific knowledge.
In order to identify as many sources of relevant information as possible, searches
of the ergonomics and psychology literature have been performed using online
search facilities. As well as this, searches have been made on the HSE library
catalogue and through the British Library. Several organisations have been
targeted for relevant information and ideas on best practice. These include; The
Royal Society for the Prevention of Accidents (ROSPA), The Royal National
Institute for the Blind (RNIB), Step Change, the Trade Union Congress, and the
Transport and General Workers Union. A further source of information used is the
Health and Safety Laboratory in Sheffield.
The review is structured around the three broad factors that are known to play an
integral part in all accidents, incidents and ‘near misses’. These are organisational
factors, human factors and design/environmental factors. Organisational factors
encompass aspects such as management and supervision, procedures and
training. Human factors include attitudes, behaviour, culture and communication.
Design/environmental factors include areas such as the design and maintenance
of floors/stairways, the weather and housekeeping.
2.2
RESULTS
The literature review elicited a number of factors that research and past
experience have shown to contribute to STF accidents. These are summarised in
Table 2.1 and enable a set of common causal factors to be derived. These
common causal factors have been used to guide other activities undertaken during
Phase 1 of this project, including the structuring of interview questions and focus
group brainstorming sessions.
7
Category
Organisational
Human
Factor
Ref
Definition
Management and
supervision
(Reason,
1997)
Responsible for instilling priorities into staff e.g. production or safety.
This can result in compromised safety to get job done.
Procedure
(Reason,
1997)
Job Design
(Leamon and
Li, 1991)
Restrictive procedures can mean that tasks can only be completed by
violation of procedure. Results in loss of motivation to adhere to
procedure in future.
e.g. jobs that are designed which require frequent load carrying are
likely to place individuals at greater risk to slips, trips and falls.
Training
(Buckley and
Caple, 1990)
Adequacy, appropriateness and currency of instruction given in relation
to avoidance of slip, trip and fall accidents
Behaviour
(Step Change,
2000; Haslam
and Stubbs,
2000)
(Fennel, 1998;
Hidden, 1989;
Cullen, 1990)
(Kletz, 1994)
Worker behaviour underpins much of the risk of slip, trip and fall.
Modifying this behaviour might reduce their occurrence.
Culture
Communication
Teamwork
Accidents generally do not occur because people take outrageous risks
but because people assume the accident will not occur.
Personal
Protective
Equipment
(Bentley and
Haslam, 1998)
Can increase likelihood of slips, trips and falls e.g. footwear - if doesn’t
support ankles, safety goggles - can obscure vision, harnesses - if
uncomfortable.
Access
(Moore and
Miller, 1998)
Difficult for maintenance, so adopt awkward / unstable positions,
greater risk of slip, trip and fall.
Weather
etc.
(Bentley and
Haslam, 1998)
External factors such as weather and the visual environment.
Error
Workload
Stress
Floors
Stairways
/Handrails
Environmental
Good communication at shift handover is important for slips, trips and
falls. If departing crew become aware of slip, trip and fall hazards but
do not communicate this effectively then members of incoming crew are
more likely to have an accident
The degree of harmony, mutual respect and co-operation between
members of the workforce.
(Reason,
1997;
Rundmo,
1992)
(Mason, 1992;
Wagenaar and
Groeneweg,
1987)
(Paz Barroso,
1999;
Rundmo,
1998; Brown,
1989)
(Sutherland
and Cooper,
1991)
(Miller, 1996;
Leamon,
1992)
(Moore and
Miller, 1998)
Risk
Perception
Design
This shapes workers attitudes / beliefs & behaviours that can in turn
impact the level of any incident on a given installation.
Lapses, mistakes and violations are all likely to increase the possibility
of slips, trips and falls
Mental workload - skill based tasks where work is 'automatic' leave
people more prone to mental lapses. Underload - tasks monotonous,
unstimulating, leading to decreased awareness / vigilance. Physical
workload - working at the limit of physical capability makes one more
prone to slips, trips and falls.
Increased stress is shown to increase accident rates. Stress is high in
offshore industry due to remote working environment, unusual work
schedule, etc.
Gradient, spillage, etc.
Level of handrails, markings of steps, markings of surface, width, height
and depth of steps all contribute to slips, trips and falls.
Table 2.1 Potential Contributory Factors to STF Accidents Offshore
For each of the factors identified in Table 2.1, associated prevention measures
have emerged from the literature review. These are drawn from both general
theory, best practice initiatives across industry, and advice offered by institutions
such as RoSPA. These possible means of prevention are used to inform thinking
in Phase 2 of the study to ensure that a strategy is developed that is both relevant
8
to the offshore industry and built on past experience. The factors in Table 2.1 are
presented with a selection of possible prevention measures in Figure 2.1.
ORGANISATIONAL
FACTORS
MGMT -
HUMAN FACTORS
BEHAVIOUR -BEHAVIOUR
MODIFICATION
PROGRAMMES
E.g TRIPOD - DELTA
PROCEDURES - MGMT
REPORTING CULTURE:
PLANNING/REVIEWING
INFORMED, REPORTING,
JUST
COMMUNICATION-
JOB DESIGN - FOLLOW
GOOD FIT BETWEEN
TRAINING - CONDUCT
TRAINING NEEDS
ANALYSIS
WALKTHROUGHS,
ANTI-SLIP TREADS
SUPERVISED ROUTINE
EVALUTIONS
STAIRS/ HANDRAILS -
RAILS
TEAM WORK
COHESIVE WORKING
GROUPS
VISUAL MARKINGS -
RIGHT HEIGHT, STEPS CLEARLY
ADEQUATE ILLUMINATION,
MARKED, TREADS WIDE &DEEP
CHANGES IN FLOOR COLOUR
ENOUGH, CONSISTENT RISES
WHERE SLIPPERY
FORMAL PROCEDURES
APROACH TO ENSURE
WORKER AND JOB
HOUSEKEEPING -
FLOORS TEXTURED FINISHES,
CULTURE - ENGINEER
INVOLVE WORKERS IN
SAFETY PROCEDURES
ENVIRONMENTAL
DESIGN FACTORS
WEATHER & GUANO PERSONAL PROTECTIVE
EQUIPMENT FOOTWEAR: SUITABILITY &
MAINTENANCE, STRENGTH OF
ANKLE SUPPORT, COMFORT
IMPROVED FOOTWEAR,
TRAINING & POLICY
RISK PERCEPTION WORKERS INFORMED
OF
OF RISKS
ERROR - DESIGN ERROR
TOLERANCE INTO SYSTEM
ACCESS LADDERS/SCAFFOLDS
POOR ACCESS MARKED
WORKLOAD/STRESS JOB ROTATION,
MULTI-SKILLING
REDUCTION IN SLIPS, TRIPS AND
FALLS OFFSHORE
Figure 2.1 Potential prevention methods for STFs from literature review
For the full literature review including reference list see STFs Offshore Phase 1
Report BOMEL Reference C919\05\060R.
9
2.2.1
Conclusions
Although a number of potential causes in STFs have been found, much of the
information is anecdotal in nature. It appears from the review that very little formal
research exists with regards to STFs in general, let alone in the offshore industry.
Furthermore, the bulk of the information which is available is on the contribution of
hardware, environmental and even organisational factors to STFs. There is
comparatively little on how human factors such as culture, risk perception and
behaviour influence these accidents. For this reason is has been necessary to
review research into the general causes and preventions of people-centred
accidents in an attempt to draw out common human factors which can be applied
to STF accidents in the offshore industry.
The factors identified as contributing to STFs are taken forward for further analysis
in Phase 2 of this work.
10
3.
ACCIDENT DATA ANALYSIS
3.1
DERIVATION OF BASELINE FROM RIDDOR
3.1.1
Approach
The number of accidents from RIDDOR can be combined with population data to
calculate accident rates which give an idea of the level of risk for particular groups.
A baseline can be established to monitor how the accident rates change over time.
Targets for accident reduction can be set and performance can be measured
against the baseline to evaluate the success of accident prevention strategies.
The setting of such a baseline is part of the current study to monitor the
effectiveness of the drive to reduce STFs offshore.
The number of STFs over a three year period is taken from RIDDOR and divided
by the associated population figure which comes from data supplied by HSE. This
is multiplied by 100,000 since it is HSE practice to express accident rates per one
hundred thousand people per year (or whatever time period is used). For the
purposes of this study, three year rolling rates of STFs are calculated, shifting at
both yearly and quarterly intervals for the period 1 April 1991 to 31 March 2001.
3.1.2
Results
Figures 3.1 and 3.2 show the rate of STFs declining steadily in the periods up to
1996 from 600 per 100,000 people to around 450 per 100,000 people. There was
a rise back to nearly 500 per 100,000 people at the beginning of 1998. Since then
the rate has remained on a plateau just below this rate with small fluctuations until
2001 when there was a marked fall to the lowest point in the period.
The rate of STFs measured over the three years preceding 31 March 2001 is
415.75 per 100,000 people. The average rate from 1996 to 2001 is 461.35 per
100,000 people. This illustrates that from 1996 the incidence of STFs is fairly
constant but there has been an increase in 2000 due to a significant drop in the
offshore population without a proportionally similar drop in the number of STFs.
However, the rate has fallen in 2001 due to an increase in the population at the
same time as a drop in the number of STFs.
It is worth noting that the nature of a rolling average serves to stabilise the
measurement of safety performance and prevent sudden deviations from
distorting the overall picture. This might make it more difficult to identify marked
improvements as a result of the strategy. In addition, Figures 3.1 and 3.2 illustrate
how the rate of STFs is prone to an element of standard deviation. The
11
separation of this ‘noise’ from changes in the rate due to the strategy may cause
further difficulties.
Rate of STFs per 100,000 people
700.00
600.00
500.00
400.00
300.00
200.00
100.00
0.00
1994
1995
1996
1997
1998
1999
00
01
Years
Figure 3.1 Three year rolling rate of STFs at yearly intervals 1994 to 2001
Rate of STFs per 100,000 people
700.00
600.00
500.00
400.00
300.00
200.00
100.00
0.00
1994
1995
1996
1997
1998
1999
00
Years
Figure 3.2 Three year rolling rate of STFs at quarterly intervals 1994 - 2001
12
01
3.2
IDENTIFYING CAUSES FROM RIDDOR
3.2.1
Approach
The variables which are considered to be important in the analysis of STFs are as
follows:
·
Accident Category
·
Activity at Time of Accident
·
Process Environment
·
Installation Type
·
Age of Injured
·
Time of Accident
·
Time into Shift
·
Time into Tour
·
Installation Age
·
Offshore Experience
·
Employment Status of Injured
These variables have been analysed from 1990 to 1999. In the current report
however, only results from analysis of the first five variables (Accident Category,
Activity, Process Environment, Installation Type, Age of Injured) are presented
from 1996 to 1999. This is from the onset of RIDDOR 95 which came into force
on 1 April 1996. The data from this point onwards are more useful for the current
study since slips and trips can be separated from falls and falls are categorised
into low falls (<2m) and high falls (>2m). A further reason for focusing on data
from 1996 is that the most useful population data for offshore is only available
from around this time onwards. Population data has been obtained according to
process environment, installation type (fixed or mobile), and age. This allows the
normalisation of the RIDDOR data from 1996 for these variables.
Certain assumptions have been made in the use of population data in this study:
namely that population samples are multiplied by a factor of 1.9 to measure the
entire offshore workforce and that data is used to estimate the offshore population
13
from 1 April in a given year to 31 March the following year. Accident rates are
expressed as the number of people in 100,000 over the time period of concern.
For a full breakdown of the RIDDOR analysis results from 1990 onwards covering
all variables see STFs Offshore Phase 1 Report BOMEL Reference
C919\05\060R.
3.2.2
Results
Figure 3.3 shows the total number of accidents over the period 1996 to 1999
classed as either slips/trips or falls from height which illustrates the risks
associated with the different types of accident. Overall, 72% of accidents were
over 3-day injuries, 27% led to major injuries and 1% were fatalities. Closer
examination of the data shows that of all falls, 30% were major injury accidents
which is a similar proportion to the 26% of slips/trips falling into the major accident
category. The only fatality was as a result of a high fall. In fact, 40% of high falls
resulted in either a fatality or a major injury.
250
Number of accidents
200
Fatality
Major
Over 3-days
150
100
50
0
Slip/trip
High fall >2m
Low fall <2m
Fall height not known
Accident kind
Figure 3.3 Accident category against accident kind 1996-1999
14
Figure 3.4 suggests that the activities associated with most risk of slips and trips
are walking on the same level, climbing / descending and manual handling. Slips
and trips while walking on the same level account for the biggest proportion of all
STF accidents at 23%.
140
Number of Accidents
120
100
Broad slip-trip-fall
Fall height unknown
High fall >2m
Low fall <2m
Slip/trip
80
60
40
20
0
m
Cli
bin
c
es
g/d
n
g
el
ing
uip
e ry
2m
ling
tio
din
lev
eq
t>
old
nd
na
hin
en
l s/
gh
aff
mi
me
ac
ha
i
o
/
c
a
a
e
o
m
g
s
x
t
S
h
in
g
/e
nt/
at
lift
ble
on
pla
lkin
al
ng
rta
cti
nu
rki
ing
Wa
po
pe
t
a
o
s
a
g
M
W
In
in
er
Us
Op
r
he
Ot
Activity at time of accident
Figure 3.4 Number of STFs against activity at time of accident 1996-99
Activities associated with the most risk of falling are climbing/descending and
working at height >2m. Falls of some nature while climbing/descending cover
12.5% of all STFs which is the largest proportion of falls observed. There are as
many high falls while working at above 2m as there are during
climbing/descending which indicates particular risk.
15
Figure 3.5 shows that maintenance (26.7%) and drilling/workover (20.4%) are the
process environments where the highest number of STFs have occurred. Out of
all accidents, the highest proportion of slips/trips and falls are during maintenance
(13.7% and 8.6% respectively). Drilling/workover accounts for the next highest
proportion of STFs.
Figure 3.5 also plots the accident rate per 100,000 people employed in the
industry by process environment(for calculation of rates see Section 3.1.1). The
line shows that the rates are broadly similar except for in deck operations where
the rate is almost three times that of any other. This shows that deck operations is
the process environment with the greatest risk of STFs by a considerable margin
i.e. there are more STFs per man in deck operations compared with all other
process environments even though some other process environments have a
higher number of these accidents.
120
1800.0
80
1200.0
1000.0
60
800.0
40
600.0
400.0
20
200.0
0
Broad sliptrip-fall
Fall height
unknown
High fall >2m
Low fall <2m
Slip/trip
Slips, trips,
falls/100,000
people
Tr
an
sp
or
t
od
uc
tio
n
Pr
ai
nt
en
an
ce
M
ov
er
ril
lin
g/
w
or
k
in
g
D
D
iv
D
ec
k
ru
ct
io
n
op
s
0.0
C
on
st
Number of slips, trips and falls
1400.0
Rate of slips, trips, falls per 100,000 people
1600.0
100
Process Environment
Figure 3.5 Number and rate of STFs against process environment 1996-99
Note – Absolute numbers (the histogram) and rates (the line) are on different
scales
16
Figure 3.6 indicates that 68.7% of all STFs were on fixed installations whereas
31.3% were on mobile installations.
Figure 3.6 also shows the rate of STFs on mobile and fixed installations in terms
of the population on each between 1996 and 1999. It can be seen that the
incidence of these accidents is slightly lower (approximately 8%) on mobile
installations than on fixed. This indicates a higher risk of slipping, tripping and
falling overall on fixed installations compared to mobile. More detailed analysis,
however, shows that the rate of slips and trips is higher on fixed installations but
the rate of falls from height is greater on mobile installations.
300
720.0
710.0
Number of slips, trips and falls
700.0
690.0
200
680.0
150
670.0
660.0
100
650.0
640.0
50
Rate of slips, trips and falls per 100,000 people
250
Broad slip-tripfall
Fall height
unknown
High fall >2m
Low fall <2m
Slip/trip
Slips, trips,
falls/100,000
people
630.0
0
620.0
Fixed
Installation type
Mobile
Figure 3.6 Number and rate of STFs against type of installation
17
Figure 3.7 shows that there are no reported STFs in construction, plant/structure
modifications or transport on mobile installations during this period. The absence
of STFs during construction and plant/structure modifications is probably because
these activities happen onshore/inshore for mobile installations and so any
accidents are not picked up by offshore RIDDOR data.
Of the STFs which occur during deck operations, a greater proportion are falls on
mobile installations than on fixed (32% and 6.5% respectively). Similarly, of the
accidents during maintenance, a greater proportion are falls on mobile installations
than on fixed (48.4% compared with 25.7%). Finally, more slips, trips and falls
occur during drilling on mobile installations (11.2% of all accidents) than during
this process on fixed installations (9.2% of all accidents). Perhaps unexpectedly
though, 33.3% of these are falls on fixed installations compared with only 13.6%
on mobile installations.
3000
80
Number of slips, trips and falls
2500
60
2000
50
1500
40
30
1000
20
500
10
Broad sliptrip-fall
Fall height
not known
High fall
>2m
Low fall <2m
Slip/trip
Slips, trips,
falls/100,000
people
0
C
on
st
ru
ct
io
n
C
M
on
O
B
st
ru
ct
io
n
D
FI
ec
X
k
op
s
M
O
D
B
ec
k
op
s
FI
D
X
ril
lin
g
M
O
B
D
r
i
M
llin
ai
g
nt
FI
ai
X
ne
nc
e
M
M
ai
O
nt
B
en
an
ce
Pr
FI
od
X
uc
tio
n
M
Pr
O
od
B
uc
tio
n
Tr
FI
an
X
sp
or
tM
O
Tr
B
an
sp
or
tF
IX
0
Rate of slips, trips and falls per 100,000 people
70
Process environment by installation type
Figure 3.7 – Number and rate of STFs against process environment according to
installation type 1996-99
Figure 3.7 also shows that for several process environments, the incidence of
slips, trips and falls is broadly similar irrespective of whether the installation is fixed
or mobile. Deck operations has a significantly higher rate on both types of
installation although the rate on mobiles is almost double that on fixed
installations. Again this indicates that there is more chance of a STF per man in
these environments compared with others.
18
As well as deck operations,
construction on fixed installations also has a higher rate than other process
environments.
Figure 3.8 shows the number of slips, trips and falls from height according to the
age of the person at the time of the accident. The 31-40 age group had the most
accidents in this period (36%) while the 51-60 age group had the least.
160
600.0
500.0
120
400.0
100
80
300.0
60
200.0
40
100.0
Rate of slips, trips and falls per 100,000 people
Number of slips, trips and falls
140
Broad sliptrip-fall
Fall height
unknown
High fall >2m
Low fall <2m
Slip/trip
Slips, trips,
falls/100,000
people
20
0
0.0
21 - 30
31 - 40
41 - 50
51 - 60
Age group
Figure 3.8 – Number and rate of STFs against age of injured person 1996-99
It can be seen from Figure 3.8 that the rate of STFs among 21-30 year olds is the
highest observed, being slightly greater than the rate for 31-40 year olds which is
the second highest. This suggests that younger age groups are somewhat more
at risk of slips, trips and falls than older age groups.
3.2.3
Conclusions
The following are the principal conclusions concerning contributory factors in slips,
trips and falls from height which have been identified from the RIDDOR data
analysis.
·
There is more chance of a major injury after a fall from height compared
with a slip or trip.
·
Slips, trips and falls from height are more likely when people are in transit
as opposed to engaged in a particular activity.
19
·
There is a greater risk of STFs during deck operations than in any other
process environment regardless of installation type.
·
There is a slightly higher rate of STFs overall on fixed installations
compared to mobile installations. Furthermore, there is a higher rate of
slips and trips alone on fixed compared to mobile installations.
·
Evidence points to their being a higher rate of falls on mobile installations
compared to fixed installations. This is significant because falls account
for more major injury accidents compared with slips and trips.
3.3
·
Deck operations on mobile and fixed installations and construction on
fixed appear significant risk areas for STFs especially falls from height.
·
High falls (>2m) are most likely during drilling or maintenance activities.
·
People in the younger age groups (i.e. aged between 21 and 30 and
between 31 and 40) appear to be at more risk of STFs than older people.
ACCIDENT DATA FROM OFFSHORE COMPANIES
3.3.1
Approach
RIDDOR does not record detailed information defining the causative factors in
STFs (or any accidents). In addition to this, HSE have estimated that in general
only around 47% of reportable incidents are reported (HSC Revitalising Health and
Safety, 2000) although the proportion is likely to be significantly better than this in
the offshore sector. These points raise the issue of the extent to which RIDDOR
provides an accurate reflection of the STF problem. A number of offshore duty
holders supplied more detailed data which enabled BOMEL to assess the level of
under-reporting and obtain more information on non-reportable accidents/incidents
and on the causes of STFs.
A list of contacts was developed for companies principally involved in the offshore
oil and gas industry. Twenty nine companies were contacted to supply data. Of
these, within a short timescale, eight responded positively which was sufficient to
supplement the RIDDOR data for the purposes described above.
A set of common direct causes were identified for all STFs in the company data.
The direct causes were mapped onto the ‘activity at time of accident’ for all
company data where possible.
20
3.3.2
Results
Figure 3.9 shows the results from the checking of accidents in the company data
against the RIDDOR database. The important point to note is that the majority of
accidents (71%) were not reportable under RIDDOR as they were either near
misses or did not lead to a 3 day injury. This gives an indication of the amount of
useful information which is not captured by RIDDOR. In addition, three of the
accidents in company data appeared to be reportable but could not be found in
RIDDOR. This finding indicates a level of under-reporting significantly lower than
for other industrial sectors.
35
Number of accidents
30
25
20
15
10
5
0
Reportable injury in
RIDDOR
Reportable injury NOT Non reportable injury
in RIDDOR
not in RIDDOR
Non reportable injury
in RIDDOR
Near miss - not
reportable
Unable to make
judgement
Status of accidents in relation to RIDDOR
Figure 3.9 Accidents/incidents from company data checked against RIDDOR
From Figure 3.10 it can be seen that walking on the same level and
climbing/descending are the activities associated with the vast majority of the
STFs sampled from company data (67%) which is consistent with findings from
the RIDDOR database. The company data show that for walking on the same
level, the two major causes are either slippery/uneven/untidy site (30%) or
defective
tools/equipment/guards
(44%).
For
climbing
or
descending,
slippery/uneven/untidy site accounts for the most accidents at 30%. The other two
main causes are lack of care/attention/risk perception (25%) and inadequate
protection from the weather (20%).
21
45
Number of slips, trips, falls
40
35
30
25
20
15
10
5
0
n
el
nt
ing
ing
ery
2m
ling
tio
lev
me
nd
t>
old
nd
hin
na
uip
aff
ac
me
mi
igh
sce
/ha
q
c
a
a
e
e
m
g
e
s
/
x
S
/
h
t
/d
n
ls
tin
/e
at
lan
ing
on
l lif
go
too
ng
cti
gp
ua
mb
rki
lkin
ble
tin
pe
an
o
a
a
Cli
s
a
t
r
r
M
n
W
W
I
e
po
Op
ing
Us
r
he
Ot
Activity at time of slip, trip, fall
Lack of care, attention, risk perception
Inadequate illumination
Poor access
Inadequate weather protection
Defective tools, equipment, guards
Inadequate warning system
Slippery, uneven, untidy site
Other
Figure 3.10 – Activity at time of accident with associated direct causes
Additional analysis of company accident data is described in STFs Offshore Phase
1 Report BOMEL reference C919\05\060R.
3.3.3
Conclusions
·
Company accident data should be regarded as a valuable source of
information for helping to understand contributory factors in accidents
which is not available in RIDDOR. Several of the companies sampled
sent records of near misses and accidents which are not reportable and
identify causes within these.
·
Company accident data indicates that for walking on the same level and
climbing/ descending, 30% of accidents were caused by either a slippery,
uneven or untidy site. In addition, the vast majority of STFs during
manual lifting/handling had the same cause. Given these are the
activities associated with the majority of STFs in RIDDOR, it is likely that
poor housekeeping is an important cause of these accidents.
·
Other important causes seem to be lack of care/attention/risk perception
and inadequate protection from the weather while walking on the level
and climbing/descending, and defective hardware while walking on the
level (probably gratings).
22
4.
INTERVIEWS WITH HSE INSPECTORS AND TRADE UNION
REPRESENTATIVE
4.1
OVERALL APPROACH
Consultations with HSE inspectors and a trade union representative (TU rep) were
carried out to help diagnose the organisational causes of STF accidents and to
suggest possible prevention strategies. It is expected that this process is likely to
elicit realistic solutions grounded in first hand experience of the problems. To
draw on a wide variety of experience, eighteen HSE inspectors from varying
specialities have been selected from different HSE offices to cover the Northern
and Southern sectors of the North Sea. Trade union views have been taken into
account from a TU rep who had experience of providing advice to the Oil Industry
Advisory Committee (OIAC).
A structured set of questions was used in the interviews covering areas of risk,
causes and possible preventions of STFs. A copy of the offshore workforce
questionnaire can be found in Support Information for STFs Offshore Final Report
BOMEL Reference C919\05\174U.
4.2
HSE INSPECTOR RESULTS
Initial results from the HSE inspector interviews indicated that workers on the drill
floor or on the deck are thought to have the highest risk of slipping and tripping.
This risk is particularly high when the workers are climbing or descending
stairways and performing manual handling tasks. For falls, again workers are
perceived to be at most risk when on the drill floor and when on the deck. In
addition, construction workers are seen as being at particular risk of falls
especially when working from scaffolding. Climbing and descending as well as
manual handling tasks are both perceived to increase the risk of a fall from height.
23
Within areas of risk, HSE inspectors were asked to comment on what they thought
to be the principal causes of STFs. The main risk from hardware was thought to
come from the design of equipment while the main environmental causes were
attributed to housekeeping and the weather. The question on human causes
elicited the most responses in this area. These are summarised in Figure 4.1.
100%
% of Inspectors Interviewed
90%
80%
70%
60%
Slips/Trips
50%
Falls
40%
30%
20%
10%
0%
Lack of
concentration
Poor
Unsafe Acts Management
/Supervision
Lack of
Control
Culture
Lack of
Distractions/
Awareness
Stress
Age of
Worker
Fatigue
Procedures
& Planning
Slips/Trips
22%
28%
61%
55%
55%
39%
78%
17%
28%
28%
Falls
22%
44%
61%
55%
55%
55%
61%
17%
33%
33%
Types of Responses
Figure 4.1 – HSE inspector perceptions on the main human causes in STFs
The most often quoted human causes for STFs were distractions, stress and
pressure, along with poor management and supervision. Lack of control by
supervisors and organisational culture are also considered to be important, along
with incompetence and lack of awareness. Workers appear at a greater risk of
slipping and tripping if they are distracted or are under pressure, compared to if
they are complacent or fatigued. The age of the worker does not seem to have
any significant impact on the risk of STF according to a majority of the inspectors.
24
HSE inspectors’ views on workable prevention strategies for STFs are presented
in Figure 4.2.
100%
90%
% of Inspectors Interviewed
80%
70%
60%
50%
40%
30%
20%
10%
0%
Slips/Trips & Falls
Employee Focus
Organisational
Focus
Equipment/PPE
44%
22%
22%
Training
Practical Training
Task
(Competency/Pre/
(e.g. video)
Analysis/Structure
Management)
22%
39%
17%
Planning
Campaigns
(Mostly STOP)
17%
33%
Types of Responses
Figure 4.2 – Workable strategies to prevent STFs from inspector interviews
From the strategies presented and discussed it seems that the majority of the
HSE inspectors interviewed believe employee focused strategies to be the most
workable solution to the STF problem offshore. The inspectors also selected
safety campaigns (such as 'STOP') and competency training to be the most
effective.
4.3
TRADE UNION RESULTS
The main locations of risk identified by the TU rep were as follows:
·
Drill floor
·
Catering section
·
Helideck
25
The contributory causes put forward were:
·
Company versus contracted workers – the less contractors there are the
better culture is likely to be with a lower chance of accidents.
·
Commercial pressure – downsizing and multi-tasking have led to more
‘corner cutting’ and so a greater risk of accidents.
·
Personal stress – factors such as shift work, separation from family and
terms and conditions may lead to stress and more accidents.
·
Design – stairways are thought to be one of the main hotspots for STFs.
·
Environment – people who are less familiar with the installation need to
look at signs to see where to go and may not pay enough attention to
where they are going.
·
Equipment – existing equipment and the availability of replacements is
thought to be inadequate.
The following approaches to the prevention of STFs were suggested:
·
Workforce involvement
·
Improvement in safety culture
·
Better housekeeping standards
·
Behavioural modification programmes
·
Tool box talks
In conclusion, the TU rep perceives the issue of most importance to be the culture
in place on a given installation believing that this affects all aspects of safety and
that any contributor to a STF accident is greatly influenced by the organisational
culture. The TU rep also considers reporting to be important to help reduce the
STF problem and feels that currently these accidents are under-reported perhaps
because they are not thought to be serious enough to warrant attention.
The full set of results from inspector and TU rep interviews can be found in STFs
Offshore Phase 1 Report BOMEL Reference C919\05\060R.
26
5.
FOCUS GROUPS WITH OIMs AND SAFETY REPS
5.1
OVERVIEW
In keeping with the philosophy of stakeholder consultation and ownership it was
decided to conduct focus groups with Safety Representatives and Offshore
Installation Managers (OIMs). Both focus groups have been structured around
what is known as a Risk Influence Network (RIN). In essence, a RIN presents
factors which are known to contribute to accidents at four different levels of
influence, from direct causes through organisational and corporate factors to
environmental influences at the most remote level, for example, market influence.
The RIN is firstly customised for a particular top event, in this case the probability
of a STF accident. The network can then be used to quantify risk or simply to
structure ‘brainstorming’ sessions on the wider causes of the top event and
encourage people to think outside of their usual frames of reference. For a more
detailed description of RIN methodology, see Section 8.2.
5.2
SAFETY REP FOCUS GROUP RESULTS
A focus group was held with two Safety Representatives from offshore
installations. Both representatives worked on fixed as opposed to mobile
installations. The focus group was framed around a presentation and subsequent
discussion of the causes and prevention of STFs using the generic Risk Influence
Network to structure thinking.
The main contributory factors to STFs were identified as follows:
·
Experience – this was thought to apply only to falls. Less experienced
people in new technologies have a more cavalier attitude towards their
work which puts them at greater risk of falling.
·
Health/fatigue – stress was thought to contribute to STFs at two levels:
personal stress resulting from separation from friends and family and
company stress from high workload and reduced manning.
·
Working environment – poor housekeeping in particular was thought to
contribute to STFs.
·
Operating conditions – the main concern here was the affect of bad
weather increasing the likelihood of STFs.
27
·
Hardware quality – inadequate boots and gratings were the main factors
flagged here.
·
Inspection/maintenance – this was thought to be one of the main
contributors to STFs due to the neglect of routine maintenance, grating
squads and dedicated cleaners.
Suggested prevention strategies from the safety reps are shown below:
5.3
·
It is important to get people to slow down and to reduce the perceived
pressure to finish quickly.
·
There needs to be an increase in worker’s general risk perception.
·
Although hardware answers are easily identifiable, software (i.e. people)
strategies could be where the answers lie.
·
Suggested that a ‘stop ethic’ needs to be instilled in workers whereby
they challenge each other when they see violations being committed.
OIM FOCUS GROUP RESULTS
A focus group session was held with five Offshore Installation Managers (OIMs).
The managers came from a variety of fixed, mobile and FPSO (floating,
production, storage & off-loading) installations. As with the safety reps, the OIMs
focus group was framed around a presentation of the Risk Influence Network
approach, using the generic RIN to prompt discussion and as a means of
structuring the subsequent brainstorming activity. However, the OIMs focus group
was conducted in a slightly differently way from the safety reps group in that an
element of quantification was sought from the participants as a means of
comparing the relative importance of different factors, and the quality of these
factors.
General causes of STFs were initially put forward as the workforce’s perception of
time pressure on a job and their poor risk perception in relation to these accidents.
Participants were then asked to weight and rate the factors on the RIN in terms of
their influence on STFs. The results of this are now presented.
28
For slip and trip accidents, the following direct level factors were weighted as the
most important with the potential to be of poor quality:
·
Fatigue
·
Equipment operability
·
Distraction
·
Risk perception
The corresponding factors at the organisational level were:
·
Inspection/maintenance
·
Management/supervision
·
Design quality
·
Accident investigation/feedback
·
Safety climate
With respect to falls from a height, the following direct level factors were rated as
potentially having most influence:
·
Fatigue
·
Compliance
·
Equipment operability
·
Distraction
·
Risk perception
·
Age
·
Fitness/agility
·
Hardware quality
29
The most influential factors at the organisational level for falls from height turned
out to be the same as those for slips and trips:
·
Inspection/maintenance
·
Management/supervision
·
Design quality
·
Accident investigation/feedback
·
Safety climate
Finally, towards the end of the OIM focus group session, participants were asked
briefly what prevention strategies might be suitable to tackle the problem of slip,
trip and fall accidents offshore. Each group member had only enough time to
suggest one or two general areas for attention, which are as follows:
·
Design improvements
·
Zero tolerance of violations
·
Tackling the distraction levels with continuous campaigning
·
Compliance with procedures, especially housekeeping
·
Encouraging 100% reporting
The message from the OIM and safety rep focus groups seems to be that
workers’ attitudes and behaviours combined with shortcomings in design/hardware
and difficult operating conditions create an environment in which there is a
considerable risk of STFs. Poor risk perception and distraction are suggested as
contributory factors as well as a strong perception among workers that it is better
to get a job done to time even if this means short cuts which may compromise
safety. Complete write ups from the safety rep and OIM focus groups including
RIN weightings and ratings from the OIM group are contained in STFs Offshore
Phase 1 Report BOMEL Reference C919\05\060R.
30
6.
OFFSHORE VISIT
6.1
APPROACH
To enable a greater understanding of the risk of slips, trips and falls from a height
offshore, it was necessary to get a feel for the safety implications of being offshore
in terms of these accidents. To meet this requirement, an offshore visit was
arranged to various installations in the southern North Sea. This visit allowed a
deeper insight into the physical ergonomics of the installations, the places where
the workers have to work, the accommodation and the overall human factors in
offshore operations.
The offshore visit enabled data gathering to be accomplished in a number of
different ways. Observations of the physical workplace were made on walkrounds when it was also possible to talk informally to members of the crew on
some of the STF issues. As well as this there were semi-structured interviews
with three safety reps (together) and a medic.
The main tool for gathering data offshore was an offshore workforce
questionnaire. The questionnaire was a variation on the one used in the HSE
inspector and TU interviews. The questions which elicited the most responses in
these interviews were chosen for use offshore in order to get the most from the
little time available. Nine offshore workers were given the questionnaire made up
of a field co-ordinator, engineer, two electrical technicians, a plater, production
operator, steward, scaffolder and roustabout. Eight of the questionnaires were
returned completed which happened to be from four contractors and four company
staff.
6.2
RESULTS
A majority of workers thought that people on the deck, drillers and construction
workers were most at risk of slipping, tripping or falling from a height.
Maintenance workers and older workers were also deemed to be at risk of falling
from height. Stairways were thought to present a particular risk along with manual
handling activities and working at night. When workers were asked for the
principle causes in these areas of risk the responses in Figure 6.1 were obtained.
31
6
4
3
2
1
Pressure
Wet Surfaces
Safety Standards
not met
End of Shift/Night
Tiredness
Equipment
Neglect
Incorrect/Quick
Climb/Desc
Housekeeping
Risk Awareness
Conditions
0
Lack of Attention
Number of Workforce
5
Responses Given
Figure 6.1 – Principal causes in STFs from offshore workforce questionnaire
The most frequent cause of slipping, tripping or falling from height was thought to
be due to lack of attention by the worker concerned. The second two most likely
causes were deemed lack of risk awareness and/or poor housekeeping. Poor
conditions were also seen to be causes of such accidents, along with incorrect
climbing or descending (lack of three point contact), quick climbing or descending
(hurried actions), quality of equipment (such as poor slip resistance surfaces),
tiredness, the end of the night or shift, failure to meet safety standards (not
checking environment), wet surfaces or social/work pressures.
The workforce comments on prevention inputs and strategies for STFs are
summarised in Figure 6.2 which shows overall prevention and what the workforce
think OIMs and the HSE should do towards prevention.
32
8
7
Number of Workforce
6
5
PREVENTION Overall
PREVENTION HSE Input
4
PREVENTION OIM Input
3
2
1
0
Procedures
Behavioural Housekeep
Risk
for high risk
Change
ing
Awareness
tasks
Warning
Signs
Move
Communic
Identify
Improve
Reduce
Smart/STO ate Best Areas/Train Maintenanc
Safety
P Courses practice
ing
e
Pressure
PREVENTION Overall
1
2
3
1
1
1
0
0
0
0
PREVENTION HSE Input
0
0
2
1
0
0
4
5
0
0
PREVENTION OIM Input
1
0
5
1
0
1
2
1
2
1
Responses Given
Figure 6.2 – Workforce opinions on prevention of STFs
The most common prevention strategy overall was to increase risk awareness of
STFs, which would in turn reduce the lack of awareness that was seen as the
most common cause of these accidents. In addition to improving risk awareness,
housekeeping was also seen as an area for overall improvement.
The workforce indicated that the HSE should take the course of identifying the
high-risk areas and feeding this into offshore training courses. Also that this
should be communicated as a best practice strategy by both the HSE and the
offshore management in order to improve the overall risk awareness of the
workforce. It was felt that offshore management should generally increase their
focus on highlighting risk areas and subsequently improving the overall risk
awareness of all workers.
For more extensive coverage of results from the offshore visit see STFs Offshore
Phase 1 Report BOMEL Reference C919\05\060R.
33
6.3
CONCLUSIONS
The offshore visit provided a full insight into the environment in which workers
operate, their accommodation, their relationship with management, management's
perspective on safety and the workforce and the overall ergonomics of all three
installations. The comparison of three different installations was instructive, along
with the comparison of day and night environments.
During the overall visit, insights were obtained into the perspectives of both
management and the workforce and issues for consideration were highlighted.
The principal slip, trip and fall from a height causes that arose as a result of the
observations, general conversations, questionnaire responses and discussions
with the medic and safety representatives, are as follows:
·
Workers have lower risk awareness and demonstrate higher risk
behaviours between tasks.
·
Poor ergonomic design,
contributed to accidents.
·
The deck and stairways presented a particular hazard.
·
Construction workers and drillers are at particular risk.
·
Anyone manual handling, climbing or descending are at particular risk.
fabric
maintenance
and
housekeeping
The principal issues were as follows:
·
A barrier exists between the management and non-management grades
of the workforce.
·
Management has an overall effect on reporting and safety culture.
·
There may still be a focus on production over safety.
·
There appears to be a general decline in pressures on the workforce
overall.
·
Safety awareness is prominent, although its effectiveness is not.
·
Prevention strategies should highlight risk areas and focus on increasing
risk awareness
34
7.
PHASE ONE CONCLUSIONS
The strength of the findings from the study is enhanced by the fact that each data
source has offered unique insights which should improve the effectiveness of the
strategy. In particular, the ten year coverage of RIDDOR and some company data
provides a robust risk outline on which to base conclusions. Furthermore, the
wide range of experience from those consulted has provided valuable insight as to
the main causes within areas of risk.
Due to the wide range of data collected in this study it has been necessary to
systematically draw conclusions in a structured manner. For each section of data
gathering, the main findings have been discussed by the project team in order to
establish which are likely to be the most important. The common factors from
across all sections have been identified and listed against their sources. Similar
factors are merged into one category where appropriate. This has allowed
analysis of which factors have the most evidence behind them.
A final list of factors have been categorised in a way which helps to think about the
causes and possible prevention of STFs. These categories are: groups at risk;
related (i.e. risk-bearing) activities; direct causes; and indirect causes. The
conclusions in each of these categories are now presented.
7.1
GROUPS AT RISK
1.
Younger people appear at more risk than older. This is likely to reflect
the effect of experience.
2.
People on a fixed installations are at more risk of slips, trips and falls
taken together and at more risk of slipping or tripping compared to those
on mobile installations. It could be that people are more aware while
negotiating mobile installations due to the movement of the structure and
so are less likely to slip or trip. The nature of tasks on fixed compared to
mobile installations is also likely to be relevant.
3.
People on mobile installations are at more risk of falling from height than
those on fixed installations. This could be because the nature of work on
mobile installations requires people to work at a greater height than those
on fixed installations. The fact that many mobile installations are drilling
rigs perhaps supports this conclusion.
35
4.
Those involved in deck operations are significantly more at risk of slips,
trips and falls compared with those in any other process environment,
especially on mobile installations. Presumably, those involved in deck
operations are involved in lifting and carrying tasks and may be exposed
to heights and contamination of the decks more than others.
5.
With the exception of deck operations, workers involved in construction
on fixed installations are at more risk of slips, trips and falls from height
than those in other process environments. Construction work often
involves people working on temporary structures and with and around
various tools and equipment which may increase risk.
6.
Drilling is perceived as an area which contains a considerable risk of
slips, trips and falls from height. Although this is not prominent in
accident data it may be that many non reportable incidents occur in
drilling due to the nature of the hazards involved.
7.2
RISK BEARING ACTIVITIES
7.
Falls from a height are strongly associated with climbing and descending.
This finding suggests that either the design of stairways/ladders or the
surface of the steps may be inadequate.
8.
Similarly, a considerable number of slips and trips occur whilst walking on
the same level. When considered with climbing and descending, it
seems that many STF accidents occur when people are in transit as
opposed to being engaged in a particular activity.
Lapses in
concentration are more likely when an individual does not have a specific
job to hand and this can only increase the risk of STFs.
9.
Manual lifting/handling is the activity associated with most STFs after
walking on the level and climbing/descending. It is known that lifting and
carrying affect a person’s balance and also affect the frictional force
between the floor and their footwear. It may also affect their line of vision.
All these factors will put an individual at greater risk of a STF.
36
7.3
DIRECT CAUSES
10.
The standard of housekeeping has been identified as extremely important
as a potential cause of STFs. This evidence comes from every data
source used in the project. Housekeeping includes issues such as
cleaning, equipment storage and the like.
7.4
11.
The quality of hardware is an important cause of STFs. This includes
things such as stairs, floors, gratings, guards, and the operability of
equipment.
12.
The standard of personal protective equipment (PPE) has been related to
STFs. Factors such as footwear and safety harnesses are important.
13.
The extreme weather conditions appear to be a cause of STFs. This is
suggested by both the literature review, data analysis and the focus
groups. Strong winds, wet or icy surfaces will all increase the likelihood
of these accidents.
INDIRECT CAUSES
14.
The standard of inspection and maintenance constantly features as an
underlying cause of STFs. Lack of routine maintenance is likely to mean
that equipment is degraded to dangerously low levels. One example of
this is the abolition of the grating squads who used to check the deck
floor regularly.
15.
Lack of attention/awareness is found to be a contributory factor in STFs.
While this may be a direct cause in some circumstances, it is more likely
that this lack of attention/awareness of an individuals environment makes
them increasingly vulnerable to STFs. Risk perception is related to
attention/awareness. Data shows that more than 61% of accidents occur
when individuals are in transit. This may be because when individuals
are not actually focused on specific hazardous tasks their perception of
risk is lowered and as a result they become more vulnerable to STFs.
16.
Safety culture is frequently cited as an important mediator in STFs. Poor
safety culture will have an impact on almost every aspect of an
organisation, from management and levels of incident reporting to worker
behaviours and attitudes. Safety culture also affects the likelihood that a
safety initiative will be effective. Behaviour modification programmes for
37
example have shown to be more effective when run in organisations with
established safety cultures.
17.
The effectiveness of management and supervisors has been found to
indirectly affect the likelihood of STFs. Management and supervisors
need to give the right messages with regard to the balance between
production and safety. They are responsible for engineering the safety
culture. Deficiencies in either are likely to lead to a number of problems
including things such as negative attitudes and stress etc.
18.
Stress and fatigue are suggested as underlying causes in STFs. Stress
relates to mental stress which may result from factors such as the
unusual work environment or strong production pressures. This can lead
to distractions which increase the likelihood of STFs. Fatigue in this
context is associated with physical tiredness which might lead to cornercutting, sloppiness etc. and so increase the chances of these accidents.
19.
Under-reporting of accidents is seen as an indirect contributor to the
number of slips, trips and falls from height. Under-reporting means that
critical information as to the common causes of these accidents does not
reach higher levels of the organisation. This makes it difficult to design
successful prevention strategies grounded in up to date and accurate
knowledge of the situation ‘on the shop floor'. Without the knowledge
provided by high levels of reporting, safety initiatives are more likely to be
out of touch and unhelpful.
The detail, extent and coverage of the data collected in this study can be regarded
as generally good. The information on the causes and prevention of STFs covers
most areas of the offshore industry despite the fact that representatives from all
parts of the industry have not been consulted. It is unlikely that there is significant
information which has not been uncovered. This suggests that the results of the
study can be treated with a high degree of confidence and provide a solid base
from which to develop a strategy to reduce slips, trips and falls from a height.
38
8.
RIN ANALYSIS AS A BASIS FOR INTERVENTION
8.1
OVERVIEW
From the list of important causes in STFs which have been identified in Phase 1, it
is important to focus on those which most influence the likelihood of these
accidents. It will then be possible to attach the potential risk control measures
(RCMs) generated in Phase 1 to the main contributors and formulate strategic
activities designed to implement these controls. This targeted approach offers the
best chance of bringing about a reduction in STFs. The most important causes in
STFs have been identified using Risk Influence Network (RIN) methodology which
is outlined below.
8.2
RIN METHODOLOGY
8.2.1
Theory Behind the Assessment Cycle
Risk Influence Networks are a method of graphically representing the various
factors which influence the occurrence of a particular accidental event. As an
approach to risk assessment it can be used both reactively and proactively which
is an advantage. It has two important aspects.
·
The network can be used qualitatively to model influences upon adverse
outcomes – either assessing contributions to past events or considering
the likelihood of some future event.
·
This qualitative model can then be used to generate quantitative
measures of the influences of various technical, human and
organisational factors on the risks generated by a particular hazardous
technology. Again this can be done reactively in regard to a particular
accident or proactively to gauge the probability of some possible adverse
event occurring in the future.
The influences are structured in a two-dimensional diagram for analysis as shown
in Figure 8.1. The diagram is referred to as a Risk Influence Network (RIN).
39
EVENT
Human
Hardware
External
Direct Level
Competence
Motivation/
Morale
Health
Working
Environment
Operating Conditions
Fatigue
Resource
Availability
Hardware Quality
IMR
Quality
Info/Advice
Commu- Compliance Equipment
Operability
nication
Organisational Level
Recruitment
Training
Equipment
Purchasing
Procedures
Provision of
Information
Inspection/
Maintenance
Management/
Supervision Communications
Work
Organisation
Design
Quality
Corporate Level
Ownership &
Control
Company
Culture
Labour
Relations
Service
Quality
Safety
Management
Financial
Performance
Environmental Level
Political Influence
Regulatory Influence
Market Influence
Social Influence
Figure 8.1 - Risk Influence Network
Figure 8.1 shows the top item or event which is the scenario being assessed (in
this case the likelihood of a STF accident). Below the top event, the principal
causes are classified into human or hardware failure or unforeseen external
events. Below the ‘failure’ level, influences are defined in levels which signify the
domain in which the influence lies, namely direct, organisational, corporate and
environmental domains.
Each influence is characterised in terms of its inherent quality and the significance
of its effect on each of the influences at higher levels. The strength of these links
and the quality of the individual influences (in terms of their best, average and
worst effect) provide the basis for quantification. This hierarchical network of
influences and its potential for the calculation of a single risk index for the entire
network provides a powerful format for gaining insight into the effect of each
influence on the top event and the effect of any change in influence brought about
by improved risk control.
8.2.2
RIN Customisation
Before the quantification process can commence the RIN must first be fully
customised to fit with the context of the specific project. Customisation of a RIN
is two staged. Firstly the top event(s) must be carefully defined. There can be
two or more top events depending on the complexity of the problem.
The next stage in the customisation is a detailed review of the generic influencing
factors that make up the influence network. Some factors may be considered
irrelevant to the top event and removed whilst it may also be necessary to include
40
additional factors felt to be particularly pertinent to the event in question. The
definitions and scales relating to influencing factors may also be reviewed in the
light of the selected top event.
8.2.3
RIN Quantification
The next step is to quantify the customised RIN. This process usually takes place
in a workshop with subject matter experts (SMEs). RIN quantification is two
staged. The first stage in the quantification process is to assess or rate the
current quality of each of the influencing factors. Each factor is rated in isolation
for its quality in relation to the top event. Anchored rating scales are provided for
this purpose ranging from best to worst practice. Secondly, starting at the
environmental level, the SMEs are required to assess the relative influence or
weight of each factor on those at the level above. Such weightings must be
estimated in relation to the top event where this is possible.
8.2.4
Extracting Critical Factors And Paths Of Influence
Critical factors are defined as those which are weighted as being important
influences and are of poor standard (have a low rating). These factors are critical
since improving the quality of them will have the greatest positive influence on the
likelihood of the top event.
Critical paths are established by identifying
connections between such factors on the diagram. The identification of critical
factors and paths is now explained:
8.2.4.1 Identifying Critical Factors
This involves adjusting the rating of each influence individually and then
measuring the effect on the overall risk index. This approach produces a rank
ordered list of influences from greatest to least effect. A spreadsheet program is
used to carry out these calculations which has been designed to include two
slightly different variations of the method. The first analysis improves the rating of
each factor in turn by 0.1. The second repeats the process but this time changing
each factor rating to 0.8 from its original value. The purpose of this analysis is to
demonstrate how much change there might be to the overall risk index if each
influence individually could be improved to the different levels.
To support the spreadsheet calculations, the data is checked manually for factors
with a high weighting on the level above and a low rating. In some cases the
important factors are clear since they have the highest summed weightings and
lowest rating. In other cases, a reasoned judgement needs to be made if, for
example, the highest weighted factor has a medium rating but a middle weighted
factor has a low rating. Ultimately the analyst will arrive at a subset of factors
which are regarded as having a significant influence on the top event.
41
The results of the manual assessment and the calculations can be cross-checked
to show the factors which are perceived to have the greatest contribution to the
risk of the top event. What is not known at this stage is exactly how these factors
come together to increase the risk.
8.2.4.2 Mapping Paths of Influence
Uncovering a path of influence involves the following steps:
Step 1: The critical factors at the direct level are taken to represent the beginning
of a path of influence.
Step 2: For a given direct critical factor, for example D1, it is necessary to identify
the factors at the level below (the organisational level), that are perceived to have
a high weighting on D1.
Step 3: The organisational factors weighting heaviest on D1 are then ranked
according to their rating, lowest first. The organisational factor(s) with the highest
weighting on D1 and lowest rating is then taken to be the second link in the path of
influence.
Step 4: The critical factor(s) identified at the organisational level is then treated in
the same way, i.e. factors at the level below (corporate level) that have a high
weighting on the critical organisational factor(s) are ranked in order of rating, with
the highest weighting and lowest rating factors(s) becoming the third link in the
path.
Step 5: This process is then repeated to find the final link between the corporate
and environmental levels.
42
9.
CRITICAL FACTORS/PATHS AND RISK CONTROL IN STFs
9.1
OVERVIEW
In order to use the RIN to assess the risk of STFs offshore it is first necessary to
customise the diagram in terms of such accidents. The first step involved
mapping the STF causes identified in Phase 1 to the RIN to ensure that they were
all captured on the diagram. The generic factors are either modified or added to in
order to meet this requirement. Factors of little relevance to STFs are removed.
The selection of different risk scenarios as top events was the next consideration.
The main risk scenarios in the current study are associated with different accident
kinds (slips/trips versus falls from height) and installation types (fixed or mobile).
Combinations of accident kind and installation type therefore make up the top
events, meaning that there are four different scenarios:
·
Falls from height on mobile installations
·
Falls from height on fixed installations
·
Slips/trips on mobile installations
·
Slips/trips on fixed installations
The customised RIN is shown in Figure 9.1 with slips and trips on fixed
installations given as an example of a top event.
43
Slips and Trips on Fixed
Installations
Human
Hardware
External
Housekeeping
Inspection/
Maintenance
Quality of
Hardware
Quality of PPE
Fatigue
Mental Health
Physical
Health
Experience
D1
D2
D3
D4
D5
D6
D7
D8
Weather
Motivation
Risk
Perception
D9
D10
D11
Compliance
Availability of
suitable
resources
Communication
Visual
environment
D12
D13
D14
D15
DIRECT LEVEL INFLUENCES
Organisation
of Deck Ops
O1
Organisation
of Drilling Ops
O2
Supervision
Training
O7
O8
Organisation
of
Construction
Accident/Incident
Management Loop
O3
O4
Procedures
Equipment
purchasing
O9
O10
Safety Culture
O5
Inspection &
maintenance
process
O11
Management
O6
Terms &
conditions
O12
ORGANISATIONAL LEVEL INFLUENCES
Company
Profitability
Ownership &
Control
C1
C2
Political
Influence
E1
Company
Culture
Organisational
Structure
C3
C4
CORPORATE LEVEL INFLUENCES
Safety
Management
Labour
Relations
C5
C6
Regulatory
Influence
Market
Influence
Societal
Influence
E2
E3
E4
ENVIRONMENTAL LEVEL INFLUENCES
Figure 9.1 – RIN customised to assess the risk of STFs on fixed installations
An internal RIN workshop was held at BOMEL drawing on in-house experience
and using the diagram in Figure 9.1. The RIN methodology outlined in Sections
8.2.3 and 8.2.4 was followed in order to arrive at a set of critical factors and paths
for STFs. Once these had been identified, risk control measures (RCMs) could be
applied with the aim of reducing the likelihood of the STF scenario being realised.
The complete transcripts from the workshop can be found in Support Information
for STFs Offshore Final Report BOMEL Reference C919\05\174U.
9.2
RESULTS OF RIN ANALYSIS
The factors and paths of influence which have been identified as critical for STFs
offshore are shown in Table 9.1.
The paths for inspection/maintenance,
housekeeping, risk perception, and experience of surroundings turned out to be
identical for all four risk scenarios and so can be applied to slips, trips or falls from
height on any installation. The path for weather is more strongly associated with
mobile installations due to the affects of motion but is likely to have strong
significance on fixed installations as well. Finally, the quality of hardware path
was most prominent for falls from height on fixed installations but in reality is likely
44
to be as relevant for slips and trips and on any type of installation. In order to see
critical factors and paths tabulated for all scenarios, see Support Information for
STFs Offshore Final Report BOMEL Reference C919\05\174U.
CRITICAL DIRECT FACTORS IN STFs
Critical
Factors at
lower levels
Inspection /
maintenance
Housekeeping
Risk
perception
Experience of
surroundings
Weather
Quality of
Hardware
Organisation
Inspection
and
maintenance
process
Safety
culture
( feedback
loop and
supervision
also
important)
Training
(feedback
loop also
important)
Training
(supervision
also
important)
Work
organisation
(supervision
and culture
also
important)
Inspection
and
maintenance
process
(equipment
purchasing
also
important)
Corporate
Company
culture
(safety
management
and company
profitability
also
important)
Company
culture
(safety
managemen
t & company
profitability
also
important)
Company
culture
(safety
managemen
t and
company
profitability
also
important)
Company
culture
(safety
management
and company
profitability
also
important)
Company
culture
(safety
management
and company
profitability
also
important)
Company
culture
(safety
management
and company
profitability
also
important)
Environment
Market
influence
Market
influence
Market
influence
Market
influence
Market
influence
Market
influence
Table 9.1 – Critical factors and paths in STFs offshore
In conclusion, attention to the critical factors and paths shown in bold in Table 9.1
has the greatest potential to reduce the likelihood of slips, trips and falls from
height offshore. However, the associated factors in parenthesis have also been
flagged as important (such as supervision, management, the accident information
feedback loop and safety management) and should also be considered in any
strategy to control STFs.
9.3
APPLYING RISK CONTROL MEASURES TO STFs
The first stage in selecting RCMs was to generate a list of all possible measures
from the Phase 1 data. From this, a practical list of RCMs are filtered out which
are deemed to be applicable to the STFs problem offshore. Where necessary,
generic RCMs are presented in terms of how they apply to STFs. The risk control
measures have been mapped onto the customised RIN and directly compared
with the critical factors which have been identified. A check is made for each
critical factor to determine if there are sufficient items in the RCM list to control the
45
risk. A brainstorming session was held to develop RCMs in areas which were not
adequately covered by those from Phase 1.
The risk control log contains fifty seven RCMs which are applicable to slips, trips
and falls from height offshore. All have been matched to a factor on the
customised risk influence network. The RCMs range from hardware issues such
as providing adequate ladders/platforms to human factor issues such as improving
individual risk perception of STF hazards.
identified for RCMs where applicable.
Performance measures have been
A closer look at the RCM log reveals that many of the measures are related to
inspection and maintenance, housekeeping, hardware, and the visual environment
(26 out of 57). This is not surprising given that most of the work on STFs has
been to do with hardware and the environment. However, there are also a
considerable number of measures associated with human factors such as safety
culture, risk perception and training. Assessment of RCMs against important
causes in STFs shows that RCMs have been identified for all the critical and
associated factors in STFs highlighted by the RIN analysis. The RCM log is
shown in Appendix A with associated performance measures. A breakdown of the
number of RCMs according to their application area is shown in Table 9.2.
Suggestions as to how these RCMs might be further developed and applied are
made in Section 10.
Application Area
No. of RCMs
Management/supervision
5
Housekeeping
7
Quality of hardware
6
Visual environment
7
Inspection/maintenance
6
Work organisation
2
Procedures
3
Weather
2
Risk perception
5
Training
4
Culture
5
PPE
2
Accident/incident loop
2
Motivation
1
Table 9.2 – Number of risk control measures against application area
46
10.
BUILDING A STRATEGIC FRAMEWORK
10.1
DEVELOPMENT OF THE STRATEGY
The strategy to reduce STFs comes from the knowledge gained during the data
gathering and analysis which has been described so far. As a starting point, a risk
profile has been provided from the accident data analysis which shows the main
areas of risk offshore for STFs. This has been refined with knowledge about the
likely causes within the areas of risk from the literature review and consultation
with stakeholders. RIN analysis takes this a step further by identifying the most
important causative factors and strongest influences.
In order to apply the knowledge gained from this study to the offshore industry, a
strategy is required which HSE can use to influence industry and bring about a
reduction in STFs. This requires a number of activities from the regulator and duty
holders which need to be captured within a strategic framework. In broad terms,
the findings from this work can be used to inform these activities in the following
ways:
·
The critical factors and paths identified from RIN analysis can be used to
guide front line activities such as inspections, accident/incident
investigation and duty holder risk assessments. RIN analysis shows
which factors need most attention in these activities in order to effectively
deal with STFs.
·
Once the RIN critical factors in STFs have been assessed, the risk
control measures (RCMs) identified in this study can be used to reduce
the risk of STFs in these areas.
A strategy framework has been designed according to the functions which HSE
have at their disposal to influence health and safety. An assessment of what
these functions are and how they could be used in the strategy has been made.
This has led to the compilation of a set of actions which, when taken together,
make up a 20 point strategy framework which HSE and duty holders can follow
with the aim of reducing STFs offshore.
10.2
THE STRATEGY FRAMEWORK
The elements of the strategy along with the associated HSE function are
summarised in Table 10.1.
Areas where the findings from the current study
47
should be used are indicated in bold.
This is followed by a more detailed
description of each strategy element.
HSE Functions
Strategic Actions
Policy
STF cost benefit analysis (Assess cost
Provide advice to government on health and safety issues
Delivery of health and safety aspects of wider government policies
Deployment of HSE/OSD resources
Policies on risk targets, acceptability, health and safety costs /
benefits, etc
effectiveness of RCMs by using RIN
Regulating
Work within existing Regulations
Maintaining currency of UK H&S law
Instigating, drafting and publishing new regulations/ACOPs
Implementing EU directives relating to H&S
Collaborating with other UK authorities, eg CAA, MCA, EA, etc
Collaborating with other Divisions of HSE
Stakeholder consultation
Use current guidance
Draft new guidance for duty holders
Standard Setting
Review design standards
analysis)
(Base on critical factors/paths from
RIN and include RCMs)
Deploy HSE expertise from other fields
Consultation with offshore industry
Identifying need, and basis, for new or updated standards
Establishing technical and/or operational standards
Collaborating with other UK/industry/international standards bodies
Focus on Regulation 8(a) of Safety Case
Regs
Permissioning
Assessment and acceptance of safety cases
Review/approval of drilling consents
Inspecting
Summarise relevant STF legislation
For compliance with law and regulatory requirements
Workplace and management system inspections
Offshore and onshore
Review of systems and operations against guidance and good
practice
STF focus in HSE Inspections (Use
Investigation
Detailed investigation of STFs
Forensic investigation of accidents/incidents/disasters
Collation / assessment / dissemination of investigation findings
accidents/incidents (Use critical
critical factors/paths from RIN to help
structure STF inspections)
Feedback loop
factors/paths from RIN to guide
investigations)
Issue STF statistics/information
Promoting
Publish BOMEL report
Liaison with industry associations and workforce groups
One-to-one contact with employers’ post holders
One-to-one contact with safety representatives
One-to-one contact with employees
Consultation with stakeholder groups
Communication and dissemination of H&S information
Persuasion of employers, employees, the public
Awareness raising
Issue awareness pack
Disseminate inspector guidance to
duty holders (Include RCM options)
48
Guidance development
Develop STF guidance for inspectors
Internal OSD guidance for inspectors
Contributing to development of industry guidance
(Use critical factors/paths to structure
guidance and provide info on RCMs in
order that inspectors can advise duty
holders)
Research
Assess coefficients of friction
Formulation of research needs in support of other functions
Ad hoc research conducted internally
Procurement and management of research programme
Workforce survey
Study human factors in STFs
Table 10.1 – Summary of strategy actions to help reduce STFs offshore
The strategy elements are described in more detail in the following paragraphs.
These are based on working within current Regulations covering STFs.
STF cost benefit analysis – A cost benefit analysis relative to other offshore
accidents could be undertaken. This has the potential to show that STF controls
can be implemented relatively cheaply to make a significant difference to the level
of risk. This should help to encourage the offshore industry to take action in the
knowledge that there will be a cost benefit. In addition to this, the risk control
measures in Appendix A could be applied to a Risk Influence Network (Section 8)
in order to assess the cost effectiveness of each.
Use current guidance – The offshore industry should be referred to current
guidance on STFs in other industries e.g. food processing since many of the
underlying principles are the same.
Draft new guidance – New guidance could be drafted relating to controlling STF
risk in the offshore oil and gas industry. This would be the equivalent of the
existing guidance for the food processing industry and could be informed partly by
previous guidance.
The critical factors and paths in STFs identified from RIN
analysis should be used to frame the main risks which duty holders need to
address and the RCMs in Appendix A should be presented as potential solutions.
Deploy HSE expertise from other fields - Knowledge could be drawn from other
HSE divisions e.g. FOD where there is experience of STFs. HSE have carried out
work on STFs in ceramics, paper making, food processing and ship building.
Inspectors with such experience could look at the problem offshore.
Consultation with offshore industry – It is well established that stakeholder
involvement is vital for any intervention strategy and this has been reiterated in the
findings of the current work. As such, consultation with industry bodies such as
UKOOA, Step Change, the Unions, Safety Reps, OIAC, OPITO, BROA, OCA, etc
49
should be an important part of the strategy. This could involve describing the
findings and the strategy from this work, making available guidance and holding a
best practice seminar, among other things. A presentation and associated
handout designed to promote awareness of this study are provided in Support
Information for STFs Offshore Final Report BOMEL Reference C919\05\174U.
Review design standards - Appropriate design standards for hardware could be
reviewed such as BSI standards and American Bureau of Shipping guidance.
From such guidance, best practice in the design of stairs, walkways, platforms etc.
could be collated and compared with design offshore or fed into the design
process for new installations. It is likely that fairly simple modifications could make
a significant difference in terms of STFs.
Focus on Regulation 8(a) of Safety Case Regs – The Safety Case Regulations
require that the management system on an installation is adequate to ensure that
the relevant statutory provisions (in respect of matters within the OIM’s control) will
be complied with in relation to the installation (Regulation 8a). This should cover
provisions for STFs in the SMS so cases could be reviewed with emphasis on
aspects pertinent to managing STF risks.
Summarise relevant STF legislation - Extracts from legislation pertaining to STF
have been brought together for the purpose of easy reference e.g. from HASAW
Act, MHASAW Regs, DCR, MAR, etc. This information can be used by duty
holders to satisfy themselves that they comply with all the statutory provisions for
STFs. A summary of this legislation is provided in Support Information for STFs
Offshore Final Report BOMEL Reference C919\05\174U.
STF focus in HSE inspections – There is a need for STFs to be covered in HSE
inspections both onshore and offshore. To aid this process, inspectors would
benefit from guidance on what to look for in terms of the causes of STFs and
measures to control them. Such guidance should be based on the critical factors
and paths in STFs from RIN analysis. This will help inspectors make decisions on
the suitability of a duty holder’s arrangements to control STFs offshore in each of
the main risk areas (see Section 11).
Feedback loop – It is vital that lessons learned during the implementation of
strategy activities are fed back and used to improve the overall strategy. This
feedback should come from the workforce and management at all levels regarding
the progress of different strategy activities. In addition, HSE inspectors should
carefully record all observations from STF inspections and share this with
colleagues as well as the operator concerned. A system should be in place to
capture feedback generated from the strategy activities in this report.
50
Detailed investigation of STFs accidents/incidents - In-depth investigations
beyond RIDDOR’s level of detail should be carried out to determine and learn from
underlying causes in STFs. The critical factors and paths identified from RIN
analysis could be used to help understand how corporate and organisational
influences might contribute to STFs. Incidents should be considered as well as
accidents. Appropriate resources should be assigned (Inspectors / support staff)
to check reports, obtain missing information and ascertain more detail (underlying
causes / influences and final consequences).
Issue STF statistics/information - Quarterly bulletins and details of STF
incidents/accidents could be generated from a combination of RIDDOR and
company input. Such information can only serve to raise the profile of STFs and
efforts to reduce them.
Develop database - A database should be developed to capture STF statistics,
inspection feedback, company feedback and results of accident/incident
investigations. Having all the data in one location will help establish trends and
make decisions as to the best way forward.
Publish BOMEL report - Publish edited BOMEL report as consolidated
background information.
Issue awareness pack – An awareness pack has been developed to present the
results of this work including the influences/causes and risk controls for STFs, the
strategy, and advice on practical assessment of STF risk. The awareness pack
consists of a presentation and associated handout and can be found in Support
Information for STFs Offshore Final Report BOMEL reference C919\05\174u.
Disseminate inspector guidance to duty holders – The HSE inspector
guidance should be made freely available to duty holders / stakeholders as well as
other guidance, video material, etc. Safety managers and OIMs can use the STF
guidance to be proactive in controlling such accidents. The critical factors/paths
can provide guidance for carrying out STF risk assessments. The list of RCMs in
Appendix A can be used to provide practical ideas in relation to STF risks which
are identified.
Inform HSE inspectors – The strategy to reduce STFs and in particular the
guidance which makes up an important part of this needs to be disseminated to
HSE inspectors. The guidance should be explained to inspectors before they are
required to use it. Furthermore, they should be made aware of the importance of
disseminating the findings from such an inspection. Inspectors should be familiar
with the critical factors/paths in STFs and the associated RCMs in order that they
can advise duty holders.
51
Assess coefficients of friction – The Health and Safety Laboratory in Sheffield
could use their expertise to assess coefficients of friction offshore on
deckings/stairs etc. and from this the suitability of floor/stair surfaces and PPE
could be assessed and risk controls identified as required.
Workforce survey – A workforce questionnaire developed by BOMEL could be
used to provide a broader understanding of the causes and preventions for STFs.
The questionnaire has already been piloted and has the potential to indicate areas
within companies or sectors which need particular attention. A copy of the
workforce questionnaire can be found in Support Information for STFs Offshore
Final Report BOMEL Reference C919\05\174U.
Study human factors in STFs – As already noted, the majority of work in the
STF field is in the areas of hardware and the environment. It may be that further
research on human factors in STFs particularly culture, behaviour and risk
perception could provide new insights for the prevention of these accidents.
The strategy actions are organised according to different levels of intervention in a
strategy network diagram in Figure 10.1.
52
Reduction in number of slips, trips and
falls from height (STFs) offshore
FRONT LINE ACTIVITIES
Detailed
investigation of
STF accidents/
incidents
Deploy HSE
expertise from
other fields
STF focus in HSE
inspections
Consultation with
offshore industry
Feedback loop
Disseminate
inspector
guidance to duty
holders
Summarise
relevant STF
legislation
Develop database
Inform HSE
inspectors
Publish BOMEL
report
Issue awareness
pack
Draft new
guidance
Use current
guidance
Issue STF
statistics/
information
Focus on
Regulation 8(a) of
Safety Case Regs
STF cost benefit
analysis
Review design
standards
Asses coefficients
of friction
Workforce survey
Study human
factors in STFs
ORGANISATION /
PLANNING / GUIDANCE
RESEARCH / INFORMATION
GATHERING
Figure 10.1 – Strategy network of actions to reduce STFs offshore
It should be clear that the findings from this study on the critical factors/paths in
STFs and the associated risk control measures can be used to direct many of the
activities shown in Figure 10.1 such as raising awareness, drafting new guidance
and issuing meaningful STF statistics. As already stated, the information can
probably be put to best use in front line activities by aiding the investigation of
STFs, informing duty holder risk assessments and helping HSE inspectors to
focus inspections on these accidents. The latter point is thought to be of particular
importance and has been given specific focus in the current study.
53
11.
IMPLEMENTING THE STRATEGY: GUIDANCE FOR HSE
INSPECTORS
In order to give impetus to implementation of the strategy particularly in respect of
front line activities it was agreed to extend the work of strategy development to
include the development of guidance tools for HSE inspectors. Therefore,
guidance has been produced as an aid for HSE inspectors in examining the
effectiveness of duty holders’ arrangements for controlling STFs offshore. The
guidance contains working documents which an inspector can use to assess an
operator’s arrangements to control STF risks.
follows:
11.1
The guidance is structured as
·
A summary of health and safety legislation relevant to STFs.
·
An audit guide for HSE inspectors to use for assessing the suitability of a
duty holder’s safety management system (SMS) in terms of
arrangements to minimise STFs.
·
An aide memoire for HSE inspectors or industry in carrying out offshore
inspections to assess the suitability of arrangements in place on an
installation to control STF risks.
·
A risk influence network (RIN) diagram to illustrate the factors which have
been identified as important contributors to STFs and how they influence
each other.
SMS AUDIT GUIDE TO ASSESS STF ARRANGEMENTS
Duty holder arrangements to deal with STFs should be reflected throughout their
safety management system (SMS). The HSE identify the following areas which
should be covered in a SMS:
·
Policy
·
Organisation
·
Planning and implementation
·
Measuring/reviewing performance
54
The components within each of these SMS areas which should cover STFs are
structured in the form of an SMS audit guide for these accidents. The guide is
made up of a number of questions within each SMS topic area which an inspector
can use to assess the duty holder’s arrangements to deal with STFs. These
questions are complimented by discussion points and spaces for operator and
inspector comments. A five point rating scale is provided so that each SMS area
can be rated in terms of arrangements for STFs.
The guide is designed for inspectors to use as guidance during discussion with
onshore and offshore management. Although the guide is probably more relevant
to onshore inspections with safety managers, there are parts of it which may be
applicable to discussion with OIMs offshore.
11.2
AIDE MEMOIRE TO ASSESS STFS OFFSHORE
The items in a safety management system intended to deal with STFs should be
reflected in practice on an offshore installation belonging to the operator
concerned. The critical factors identified in Phase 2 which need to be addressed
to control STFs (hardware quality, inspection and maintenance, housekeeping,
weather, risk perception and experience of surroundings) have been used to
structured an aide memoire for assessing STF controls on an offshore installation.
The aide memoire has the same format as the SMS audit guide and is similarly
made up of a series of questions and discussion points which an inspector can
use to gather information on an operator’s arrangements for STFs. A five point
rating scale is provided to measure the quality of each of the critical factors in
STFs. In addition, a cross referencing feature is provided so that findings during
the offshore visit can be checked against the related findings from the onshore
SMS audit.
The aide memoire is primarily for use by HSE inspectors.
However, if the
inspector is short of time, he could give the aide to the safety officer or a safety
rep and then meet with him at the end of the inspection to discuss findings.
Alternatively, the aide could be used by the safety officer or OIM independently of
an HSE inspection.
11.3
RIN ASSESSMENT TOOL FOR STFS
The customised risk influence network (RIN) showing the critical factors and paths
of influence in STFs is provided as part of the guidance. This can be used as a
tool by safety managers and OIMs for assessing their current status in relation to
55
the factors which influence the likelihood of STFs. The RIN diagram can be used
to assess which are the strongest influences on STFs in a particular company or
on a given installation in one or a combination of the following ways:
·
As a framework for structuring workshop sessions on assessing risk
·
To develop questionnaires for risk assessment
·
For identifying risk control measures and for assessing their effectiveness
Definitions for all the factors in the RIN are contained in Support Information for
STFs Offshore Final Report BOMEL Reference C919\05\174U. The guidance
documents for assessing arrangements to control STFs can be found in
Appendix B.
11.4
TRIAL OF GUIDANCE WITH OFFSHORE OPERATOR
Trials of the STF guidance have been carried out with a UK offshore operator.
This involved testing the SMS audit guide with the safety manager (operations)
onshore followed by a visit to one of the operators installations in the Southern
sector of the North Sea to trial the aide memoire. The main objectives of the trials
were as follows:
·
To assess the suitability of the questions and discussion points in the
guidance in terms of their structure and content
·
To ensure the rating scales and cross-referencing aspects of the
guidance were workable
·
To check that the guidance could provide the information required to
assess STF arrangements in a reasonable time frame
11.4.1 Results
In summary, a number of modifications were made to the guidance in light of the
trials. Several questions have been either, modified, moved, added or removed in
order to make the guidance more user friendly and appropriate to the context in
which it will be used. Similarly, the rating scales have been tested and modified
accordingly.
It was found that around 2 hours with the safety manager onshore and 45 minutes
to one hour with the safety officer offshore was enough time to gather an
abundance of information on arrangements in place to control STFs.
56
For
interviews with other crew members offshore it was necessary to develop a subset
of questions from the aide memoire since the entire proforma was not appropriate.
These interviews were conducted with five members of the crew and elicited
useful information in around 20-30 minutes. The interviews offshore were
supplemented by a walk-round on the installation to record observations on the
status of the outside work environment in terms of STF hazards.
11.4.2 CONCLUSIONS
The main findings from the trial of the guidance are as follows:
·
The guide enabled a number of detailed findings to be identified specific
to STFs because of the focused nature of the questions.
·
The guidance allows the collection of information well within the time an
HSE inspector has at his/her disposal during an inspection.
·
Not all the questions in the guidance need be covered in order to gather
useful information.
·
The guidance is most suited for interviews with safety managers either on
or offshore. However, a subset of questions can be generated which are
applicable to any member of crew.
·
Interviews with different crew members present the best chance of
gaining a comprehensive picture of STF arrangements and how they are
applied.
·
It would be of benefit to view the work site with an individual while asking
questions.
·
A walk-round is vital to make use of the Hardware section of the Offshore
Aide Memoire.
·
The questions in the guidance appeared to be well received by those who
took part in the trial.
The finalised guidance document for assessing arrangements to control STFs can
be found in Appendix B.
57
12.
CONCLUSIONS AND RECOMMENDATIONS
1.
There is a lack of information in the literature specifically on STFs
offshore. However, it is possible to apply findings from the general STF
literature to the offshore industry.
2.
The STF literature focuses mainly on hardware and the environment
whereas there is little on how human factors affect STFs. For this reason
it is necessary to apply human factors understanding in general accidents
to STFs.
3.
The baseline rate of STFs from April 1998 to March 2001 has been
calculated as 415.75 per 100,000 people. This should be used as the
mark from which progress towards reducing STFs is measured.
4.
RIDDOR accident data is useful for identifying risk areas for STFs but
poor on the causes (this is true for all accidents). Causes of accidents
should be fed into RIDDOR.
5.
Company accident data provides more detail on the causes in STFs but
the lack of standardisation between company data creates problems for
analysis. An industry organisation such as Step Change should look at
harmonising the way in which companies record accidents and near
misses.
6.
There is a considerable amount of consensus between stakeholders
including HSE inspectors, trade union rep, OIMs, safety reps and the
general workforce on the causes and prevention of STFs.
The
perceptions of these groups tend to agree with the accident data and
literature. This tends to indicate that the causes of STFs and associated
prevention measures identified in this study are robust.
7.
STF intervention offshore should be targeted due to the relatively small
number of these accidents on any one installation and the tightness of
resources. Risk Influence Network (RIN) analysis has effectively shown
which areas require priority for STF prevention by identifying critical
factors and paths of influence. These are generally supported by the
Phase 1 findings. The RIN assessment tool in the guidance to assess
arrangements for STFs should be used by operators to assess company
specific risk factors in STFs.
58
8.
The most important strands from the critical factors and paths of influence
appear to be culture at all levels, the inspection and maintenance regime
and people’s general awareness of STFs. These factors should be given
particular consideration in programmes to reduce STFs.
9.
The risk control log generated in this study should not be regarded as
comprehensive.
Several measures offer direct improvements while
others may only provide the starting point for long term improvement, for
example those relating to training and culture. Specific needs in these
cases are likely to depend on the operator and assessments should be
made accordingly.
10.
The strategy to reduce STFs in this study should be regarded as range of
activities for reducing STFs which can be informed by the results of the
current work.
11.
The frontline strategic activities are likely to have the biggest impact on
the incidence of STFs. However, background activities such as the
setting up of a database to capture STF incident and accident data
should be regarded as vital to support frontline activities.
12.
The trial of the STF guidance for HSE inspectors has indicated the
potential for the documents in gathering detailed information on duty
holder arrangements for STF control. The guidance can be regarded as
a valuable aid not only for HSE inspectors but also for OIMs, safety
managers and safety officers when considering how to deal with STF
accidents. The guidance document should be disseminated to HSE
inspectors and industry with appropriate training in its use.
59
APPENDIX A
RISK CONTROL MEASURES FOR STFs
60
RISK CONTROL MEASURES FOR STFs
Application area
Risk perception
No
1
2
Inspection &
maintenance
3
4
5
6
7
Housekeeping
Experience of
surroundings
Weather
Risk Control Measure
Use STF hazard checklist/aide memoire in risk assessment
Procedure that at shift hand over, any new slip, trip and fall hazards which have developed over course of shift are
passed on
Use ‘buddy’ system. For initial period on platform, inexperienced always accompanied by more experienced
If necessary, wash floors/decks before operations commence
Valve maintenance - properly maintain valves to avoid leaks, dripping etc. When maintenance is not immediately
possible, provide drip trays which should be emptied regularly.
Slip, trip and fall squads. Routine slip, trip and fall inspections using checklist of slip, trip and fall hazards. Should
cover quality of hardware and housekeeping. Carry out follow up inspection at night to check the visibility of
hazards using same checklist. Responsibility for this should be allocated by splitting the installation into zones.
8
9
10
11
12
13
14
15
16
17
Provide information on key areas for inspection and maintenance. This should include hardware, housekeeping
and visual aspects which have been identified in audits.
Procedure to cover cleaning/clearing as you go or where this is not possible at the end of a job.
Keep supply of conveniently accessible absorbent material for soaking up spillages
Strategic placing of small bins around installation for scrap/rubbish - regularly emptied
Ensure spaces for tool kits etc.
Ensure optimal clearance around work areas/equipment
Plans of installation showing designated storage areas
Procedure that materials only taken to site as and when required
Small items stored in appropriate containers - not loose
Safe routing of cables, hoses etc.
For work at height, select people who are familiar with such work (use Vantage card system)
18
Audit of exposed sites which need weather control measures (will assess suitability of factors in RCMs 19 to 21)
19
20
21
22
23
24
25
Permanent wind breaks at exposed sites
Provide adequate drainage
Provision of temporary refuges for work in bad weather
Provision of warm clothing for cold weather especially gloves and socks
Procedure stating that in bad weather, as much work as possible should be prepared under cover.
Blanket policy which covers when activities should be stopped due to bad weather (not necessarily shut down)
Weather forecast check as part of risk assessment for work at exposed sites.
61
Performance Measures
The number of STF checklists
completed in risk assessments
which are returned in relation to the
number of risk assessments
undertaken
Use results of inspections i.e.
number of hazards recorded from
one inspection round to the next.
Results of the audits over time
such as number of defective
controls and number of new
controls which are needed and
implemented
Quality of Hardware
26
Carry out hardware audit according to guidance from American Bureau of Shipping (will assess suitability of factors
in RCMs 27 to 30)
Quality of PPE
27
28
29
30
31
Provide appropriate ladders/platforms to allow adequate reach
Improve floor resistance
Rails at appropriate levels
Consistent rises for stairs
Carry out audit of PPE to ensure appropriate condition, comfort and usability, especially for footwear and harnesses
Visual environment
32
Carry out audit according to guidance from American Bureau of Shipping (will assess suitability of factors in RCMs
33 to 35)
33
Signs and markings to denote slip, trip and fall hazards. Duplication of signs in different formats and different
locations to reinforce message.
Adequate light levels
Change floor colour/texture to indicate different friction coefficients
Describe installation policy on STF in safety induction and point out STF 'black spots' in walk around
Include STF hazard awareness in safety training using either slides or CD-ROM to generate STF hazard
identification exercises
Training
Accident/incident
management loop
34
35
36
37
38
In supervisor/OIM training, highlight factors which can lead to STF with the aim of helping these people combat the
problem at the organisational level. Also, reinforce the wider implications of STF e.g. costs but also that blame
should not be attached
39
40
Design reporting system to include STF hazards and near misses as well as accidents.
Publish personal accounts of slip, trip and fall accidents in newsletters, especially those with serious
consequences.
41
42
43
44
On a company and installation specific basis, look for STF accident/incident trends to help choose controls.
Focus incident/accident reporting/investigation on critical direct level factors, namely, housekeeping, quality of
hardware, inspection and maintenance, weather, risk perception and experience of surroundings
Separate slips and trips in RIDDOR reporting
Feed back results of company and HSE investigations of slip, trip and fall accidents to RIDDOR
45
Publication of ‘safety digest’ similar to MAIB with information on STF accidents
46
Feedback to workers progress of programme to reduce STF on notice boards etc..
62
Results of the audits over time
such as number of deficiencies and
number of control measures
needed and implemented.
Results of audits over time such as
incidence of inadequate PPE and
number of new items ordered.
Results of the audits over time
such as number of deficiencies and
number of control measures
needed and implemented.
The scores on these test could be
compared over time to assess
performance
Frequency of slip, trip, fall articles
in these publications.
Incidence of STF causes in
RIDDOR.
Amount of STF information in such
a publication
Carry out survey among general
work force to measure extent to
which STF information is reaching
the intended audience.
Workforce culture
Offshore management
culture
Company culture
47
‘Flag it’ campaign. One month reporting blitz.
48
49
Reward system e.g. for tidiest work zone in a month.
Prompt action when something is reported to encourage continued reporting. Strict close out dates against all STF
maintenance jobs.
50
Duty holders to consider contractors safety record before hiring. Requirement for safety section in tender with
consideration of slip, trip, fall hazards.
Apply STF policies and procedures throughout entire organisation, not just offshore.
Facilitate transfer of slip, trip, fall information between different parts of organisation including onshore as well as
offshore. This could involve the development of a STF web site.
OIMs carry out slip, trip and fall audits from time to time to demonstrate management commitment.
51
52
Management/Supervision
53
Level of reporting. Initially, this
would be expected to increase but
as effective controls are introduced
the number of hazards/incidents
reported should go down if
progress is being made.
54
Supervisors/team leaders hold debrief sessions after slip, trip or fall accidents and discussion sessions to promote
awareness.
Work Organisation
Equipment purchasing
55
56
Company profitability
57
Provide safety nets around areas where work at height is carried out.
Provide information on what PPE/hardware is available to allow decisions to be made on its suitability in terms of
STF. This could be the creation of a web site for instant access and sharing.
Adopt loss prevention initiatives via, for example, mutual or self insurance
63
Monitoring of the length of time
taken to 'close out' STF hazard
reports.
HSE review duty holders safety
policies for inclusion of this feature.
Number of hits on STF web site.
Number of times manager carries
out such an audit.
Number of sessions held on an
installation against the number of
slip, trip, fall accidents.
APPENDIX B
GUIDANCE FOR ASSESSING ARRANGEMENTS TO CONTROL
STFs:
SMS AUDIT GUIDE
OFFSHORE INSPECTION AIDE MEMOIRE
RIN ASSESSMENT TOOL
64
GUIDANCE FOR ASSESSING ARRANGEMENTS TO CONTROL
STFs
For working copies of any of the three guidance documents, contact Bernard Ogden at
HSE Offshore Division, Bootle, e-mail; <[email protected]>.
SMS AUDIT GUIDE FOR STF ARRANGEMENTS
Pre-visit planning
It is suggested that inspectors undertake the following before an SMS audit for STFs:
·
Scan the audit guide and select relevant topics based on their knowledge of the
operator to form an agenda for the inspection. NOTE: It is not necessary to cover
all elements contained in the audit guide in order to carry out a useful assessment
of STF arrangements.
·
Gather information from recent offshore inspections concerning the operator.
Ideally, this will have been carried out using the aide memoire. Use the crossreferences (Column 5 of the audit guide) to corresponding items on the aide
memoire. This information can help to develop the agenda for the SMS audit.
·
Obtain the available information from the last audit of the duty holder’s SMS and
note any outstanding actions on the duty holder. In addition, be aware of any
previous enforcement action that has been taken.
·
Obtain RIDDOR statistics on STFs for the duty holder to be inspected.
Using the SMS audit guide
The SMS audit guide is made up of a number of questions within each SMS topic area
which an inspector can use to assess the duty holder’s arrangements to deal with STFs.
These questions are complimented by discussion points and spaces for operator and
inspector comments.
After working through the prompts and discussion points for a particular segment of the
SMS, there is a five point rating scale which the inspector can use to estimate the suitability
of that segment in terms of arrangements for STFs. The rating scale can be used to
indicate the suitability of an operator’s SMS arrangements to deal with slips, trips and falls
on a particular visit and to measure performance over time. Once the audit is complete,
the inspector can compare the findings with how components in the SMS are being dealt
with on an offshore installation by again using the cross-references to corresponding items
on the aide memoire document.
65
SEGMENT: POLICY
Ref
TOPIC AREA
1
POLICIES
a
Does the company have any policies which relate directly to STFs?
b
IF NO:
Does the company have policies which are likely to reduce the likelihood of STFs?
DISCUSSION POINTS
These might include:
· general health and safety policy
· policies on work organization relating to manual handling/movement
· times when activities should be stopped due to adverse weather
· maintenance policy such as ‘clear as you go’
· policy for purchasing equipment which will minimise the chances of STFs
Does the company monitor the extent to which policies are implemented and followed?
c
Do people at all levels participate in the forming of policies?
d
Is there a system in place for periodically reviewing policies? Is any consideration given to
how certain policies could help to control STFs?
Are policies authorised and backed by senior management?
e
COMMENTS
Offshore
ref
2c
3a
1a – i
5b
POLICY RATING SCALE
1. Policies do not cover STFs. Any
considerations are unwritten, and
informal, there are no implementation
requirements and dealing with STF is
reactionary.
2. STFs are dealt with depending on
the installation experience of such
accidents. Policies may cover STFs
but these are based on minimum
regulatory standards and these are not
widely known about or implemented.
3. There are a number of policies
which will help control STFs even if
they are not specifically designed for
these accidents. These are well
defined and a review process is in
place. There is limited knowledge of
the actual policies but people generally
know what to do. Management are
accountable and information is
available.
66
4. All necessary policies are in place
to deal with STFs, there is input from
all levels and participation and adoption
of the systems is widespread although
violations do exist.
5. Some policies are developed
specifically to control STFs. These
define minimum standards and best
practice. New requirements are
evaluated and added as required.
SEGMENT: ORGANISATION
Ref
TOPIC AREA
2
ACCOUNTABILITY AND RESPONSIBILITY
a
Is there a clear line of responsibility and accountability regarding slips, trips and falls from
the highest level of management down to all employees and contractors?
DISCUSSION POINTS
· Does a senior figure coordinate and monitor efforts to control STFs?
· Are line managers allocated specific STF related responsibilities?
· Does the OIM carry out regular installation inspections and does this include STF
hazards?
· Are personnel regularly reminded of their individual responsibilities with respect to
both preventing and avoiding STF hazards?
· Are all personnel (e.g. maintenance, cleaning staff, helideck team, deck crews,
drillers, catering staff etc) clear on their responsibilities and the working practices required
to eliminate slip, trip and fall hazards in all areas of the installation?
Are managers and workforce aware of relevant legislation and how have they satisfied
themselves that they are compliant?
b
3
CONTROL
a
b
Do individual job descriptions contain references to STF related responsibilities?
Do management appraisals take into account performance in relation to the control of
STFs? Do they link responsibility to outputs?
COMMENTS
Offshore
ref
1b, f
4e, c
4e
DISCUSSION POINTS
c
This might include:
· Who is responsible: this should give name & position – are there criteria to measure
the competency of responsible people?
· What they are responsible for
· When the work should be done – are there timetables for inspection/maintenance,
housekeeping walkthroughs etc.?
Are there procedures for identifying and acting upon failures of an individual to achieve
adequate health and safety performance? If so, how do these relate to STFs?
4
COMMUNICATION
a
Is it clear how STF issues should be communicated up and down the management line and
laterally across employees?
DISCUSSION POINTS
The following points may help to ensure effective communication of senior management
commitment to the STF strategy:
· Senior management involved in regular STF tours, management use specified safety
topics to assess and review
4b
67
Ref
TOPIC AREA
·
·
·
·
b
c
5
a
COMMENTS
Offshore
ref
Active involvement in investigations of STF accidents and incidents
Organisation statements showing STF related roles and responsibilities
Clearly documented performance standards
Well publicised significant findings from risk assessments and investigations
Lateral communication between employees may be facilitated by consideration of the
following points:
· Planned meetings (team briefings) at which information can be cascaded. These can
include targeting particular groups of workers for STF critical tasks e.g. maintenance staff
· Monthly or weekly ‘toolbox’ talks at which supervisors can discuss STF issues with
their teams, remind them of critical tasks and precautions. Also allow employees to make
their own suggestions e.g. by brainstorming re particular concerns.
Is it clear how STF procedures and associated documentation is to be made available and
how management monitor that such documents are available and understood?
How are the results of accident/incident investigations disseminated?
4c
DISCUSSION POINTS
This could involve
· A web site
· STF articles in magazines
· Publishing of a company safety digest
SAFETY COMMITTEES
Are slips, trips and falls from height an agenda item on the installation safety committee
meetings?
DISCUSSION POINTS
· If STFs have been discussed at previous meetings, what were the topics? Were there
any actions and how were these dealt with?
· If STFs are not discussed at these meetings, is there any forum where they can be
discussed? If not, what happens when there is a STF issue raised?
4b
ORGANISATION RATING SCALE
1. Roles and responsibilities for safety
matters are either absent or ill-defined
and STFs do not feature. Safety
accountability is generally delegated to
a safety representative. The
communication of safety issues
(including STF) is only ever top down
on a need to know basis and is often
viewed with scepticism. Because of
this, individuals are unaware of STFs
as an issue.
2. Written roles and responsibilities
are defined for the major aspects of
safety and some of this covers STFs.
However, these are not always known
about or followed. STF information
shared is timely and begins to have
credibility with the audience. The
information is primarily top down and
focused on results.
3. There are some written roles and
responsibilities for safety which are
specifically related to STFs.
Individuals know and generally follow
the rules. Management work to fulfil
their responsibilities but accountability
for STFs is still very much at the
workforce level. Meaningful discussion
sometimes occurs but there is limited
adoption of two-way communication.
68
4. The organisation has a well
documented safety management
system which sets out clearly roles and
responsibilities for STFs for all
individuals. These are generally
accepted and individuals pay attention
to STF information and frequently pass
it to management.
5. There is a clear line of responsibility
and accountability at all levels in the
organisation with regard to slips, trip
and falls which is embraced by all.
Communication systems are
implemented, documented and
integrated to share STF best practice
across the organisation.
SEGMENT: PLANNING AND IMPLEMENTATION - STANDARDS, PROCEDURES AND SYSTEMS FOR CONTROLLING STF RISK
Ref
TOPIC AREA
6
RISK ASSESSMENTS
a
Does the risk assessment procedure include prompts for slips, trips and falls from height?
DISCUSSION POINTS
A checklist of STF hazards which need to be considered for different jobs could be
developed. Prompts might come from the following areas:
· Access to work sites
· Movement/storage of hardware equipment
· Potential contamination of the floor
· General housekeeping
· Standard of gratings/handrails
· Provision of PPE
· Placing of non-slip material and visual markings
7
a
c
8
INSPECTION AND MAINTENANCE
a
Are slip, trip and fall hazards part of an inspection strategy?
DISCUSSION POINTS
A checklist could be developed to include:
· Deck gratings
· Stairs and handrails
· Ladders
· Work platforms
· Housekeeping
· PPE
· Signs and visual markings
· Access
· Non-slip surfaces
· Storage of liquids
Is there an inspection strategy in place to ensure managers monitor areas under their
control for slip, trip and fall hazards?
b
Offshore
ref
4a
PERMIT TO WORK
Are slips, trips and falls from height included In the criteria to decide which tasks require a
permit to work?
Are locking or tagging facilities used on plant for secure isolation and mobilisation? Does
this include isolation due to unacceptable slip, trip or fall risks?
Is a tidy/clean workplace a requirement before a permit to work is completed?
b
COMMENTS
1h
1a-i
1b
69
Ref
TOPIC AREA
9
CONTROL OF CHANGE
a
Does the control of change procedure provide clear guidance on what constitutes a change
and does this cover STF hazards?
DISCUSSION POINTS
This could include:
· the removal of decking and handrails
· the changing of floor surfaces
· placing or removing of signs or visual markings
· removal of storage space
· positioning of new plant or equipment
· new PPE
· erection of new access scaffolds / platforms, similarly the dismantling of redundant
structures
· any other temporary arrangements used for storage, access and worksites
Are new equipment / hardware, cleaning products and housekeeping practices properly
evaluated before introduction and does this include consideration of how they might affect
the likelihood of a slip, trip or fall?
b
COMMENTS
10
CONTRACTOR MANAGEMENT
a
What are the criteria used for assessing a potential contractors safety record?
DISCUSSION POINTS
Would a potential contractor be asked their policy on slips, trips and falls?
Is it made clear that contractors must follow the same safety requirements as the duty
holder’s employees? Is particular mention made of the essential parts of the SMS? Would
this include mention of STF?
b
11
TRAINING
a
Is there any provision made for slip, trip and fall awareness in company training?
DISCUSSION POINTS
· Fairly simple exercises could be developed which involved the identification of slip, trip
and fall hazards from pictures of offshore scenarios.
· OIMs and supervisors could be briefed on the critical factors and paths that lead to
slips, trips and falls.
Offshore
ref
5b
4a, c, d
PLANNING AND IMPLEMENTATION RATING SCALE
1. The control of slips, trips and
falls is limited to minimising the
consequences. Action is only taken
after incidents occur.
2. Some preparation is undertaken
to limit the chances of slips, trips
and falls but only in the area of
hazard control as and when they are
found - STFs are not covered in
systems of work. Management take
little interest and participation is
limited.
3. There is a formal program to deal
with slips, trips and falls at the level
of hazard elimination but this is not
necessarily reflected in procedures
and systems of work. STFs are
mostly left to the workforce to deal
with.
70
4. STF issues are covered by some
of the systems of work such as risk
assessments. Management are
active in efforts to reduce STF and
often disseminate information on
STF hazards from assessment
which have been made.
5. STFs are covered explicitly in all systems of
work such as risk assessments, maintenance
programmes and permits to work. The workforce
and sometimes management are involved in the
assessments on a regular basis. Actions to deal
with STF hazards are implemented quickly and
effectively. The problem is high on the
management safety agenda.
SEGMENT: MONITORING/REVIEWING PERFORMANCE
Ref
TOPIC AREA
12
PERFORMANCE STANDARDS
a
Are there performance standards pertaining to slips, trips and falls? If so, how are these
set and at which level (company or installation).
DISCUSSION POINTS
Standards may include:
· The number of STF incidents in a given time
· The number of STF hazards found during inspection and maintenance rounds
· The number of STF audits which management/supervisors undertake over a given
time
· The number of violations in relation to STFs
· The number of the workforce who show STF awareness when surveyed
· The number of times STFs are discussed in safety meetings
Do the personnel involved in setting standards understand and accept the health and
safety significance of what they are expected to work towards, for example, are they aware
of the risks associated with STFs?
b
13
AUDITS
a
Do audits include checks for systems of work which will help to minimise STFs?
b
Is there a way of checking if STF control measures are being adopted?
c
Who carries out audits which have STFs within the remit?
d
How are recommendations from audits dealt with especially in respect of STFs?
14
ACCIDENT/INCIDENT INVESTIGATION
a
Are all slip, trip and fall accidents and near misses subject to reporting and investigation?
How is near miss reporting encouraged and captured?
Have those who are responsible for accident investigation been trained in such methods?
b
c
d
e
COMMENTS
Offshore
ref
4b
4b
DISCUSSION POINTS
Are those who investigate accidents familiar with the critical factors/paths in slips, trips and
falls and the associated hazards? Is guidance available?
Are the underlying as well as the direct causes of STFs identified in accident
investigations?
Is there any corporate involvement with accident investigation? Are the results of STF
accident investigations brought to the attention of senior management?
Are accident/incident data analysed in a manner which allows trends in slips, trips and falls
to be discerned?
DISCUSSION POINTS
This could be on a company and installation basis to identify and highlight STF ‘hot spots’
(e.g. drill floor, helideck, accommodation areas etc).
4b
4b
4b
71
Ref
TOPIC AREA
COMMENTS
15
REVIEW AND APPLICATION OF LESSONS
a
Are the results of STF accident/incident investigations and audits periodically reviewed so
that lessons can be applied? If so, what lessons have been learned and what action taken
as a result?
Offshore
ref
MONITORING/REVIEWING PERFORMANCE RATING SCALE
1. Measurement of STF performance
is not possible. The reduction of these
accidents is lost within general
accident reduction to comply with
minimum regulatory requirements.
The level of STF accidents/ incidents is
a poor reflection of performance due to
a substandard reporting system
2. It is possible to attain a rough idea
of the slips, trips and falls problem.
The risk of slips, trips and falls is
looked at in general but there is no
formal documentation for this process.
Accident/incident investigations rarely
focus on STF accidents and only look
at the direct level.
3. Management has responsibility for
measuring slip, trip and fall
performance but this could be looked
at more. Investigation systems are in
place which allow assessment of STFs
but communication of the results
doesn’t always filter through or get
acted upon. As a result, progress is
inhibited.
72
4. Slip, trip and fall performance is
regularly appraised through
accident/incident assessment from a
system which encourages people to
report. Results are widely
disseminated but the improvement
process is mostly a management
activity with little input from the work
force.
5. STF performance measurement is
an integral part of the safety
management system and the
workforce are fully committed to the
programme. The strategy ensures the
involvement of the workforce to secure
an accurate picture of STFs and create
improvement.
AIDE MEMOIRE TO ASSESS STF ARRANGEMENTS DURING
OFFSHORE INSPECTION
Pre-visit planning
As with an SMS audit, inspectors can prepare for an offshore inspection in which the aide
memoire may be used in the following ways:
·
Choosing areas from the aide memoire where they feel STF arrangements may
need particular attention during the visit based on their knowledge of the operator.
NOTE: It is not necessary to cover all topics in the aide memoire for an effective
audit.
·
Gathering information from the corresponding SMS audit on slips, trips and falls, if
one exists, to help select topics for offshore inspection.
·
Obtaining notes from the last offshore inspection to the installation concerned and
note any outstanding actions. Be aware of any previous enforcement actions that
have been taken.
·
Becoming aware of the RIDDOR slip, trip and fall accident statistics for the
installation to be visited.
Using the aide memoire
As with the SMS audit guide, the aide memoire is made up of questions complemented by
discussion points with spaces provided for operator and inspector comments. There is
also a 5 point rating scale for each of the 5 critical areas which contribute to STFs. Again,
inspectors may complete this upon collection of all the necessary information in a particular
area. The rating scores can be used to indicate the current suitability of arrangements on
an installation for controlling STFs and to measure performance over time.
Once the offshore inspection is complete, cross-referencing with the SMS audit guide can
be undertaken so that the corresponding items in the guide can be traced. Again, this
provides a useful check for inspectors on the alignment between policy, procedures and
practice.
73
AIDE MEMOIRE TO ASSESS STFS OFFSHORE
Ref
TOPIC AREA
1
INSPECTION AND MAINTENANCE
a
Are slip, trip and fall inspections carried out
independent of routine inspections so that the
STF hazards are given specific focus?
For the different management zones of the
installation, are responsible people allocated to
carry out the inspections?
Are inspection staff aware of the areas where
STFs are of particular risk and the hazards
involved?
Are the inspections regular but unscheduled?
8a
Is there rotation of inspection teams between the
different management zones to prevent people
becoming desensitised to the STF hazards in a
particular zone?
How are observations from STF inspection
rounds recorded?
Are actions, responsible
people and close out dates a part of this?
Are floors/decks washed/cleared as a matter of
routine before operations commence?
Is a tidy and clean worksite a requirement before
a permit to work is signed off?
Are there specific arrangements for valve checks
and maintenance?
8a
b
c
d
e
f
g
h
i
COMMENTS
SMS Audit
Ref
8b
8a
8a
8a
8a
7c
8a
INSPECTION AND MAINTENANCE RATING SCALE
1. Hardware and equipment are
never inspected or maintained
with slips, trips and falls in mind.
These hazards are not in the
inspection/maintenance
procedures. Inspection teams do
not know to look for these
hazards.
2. There is either a written or
unwritten general intention to
cover STFs in inspection/
maintenance. However, these
hazards are not considered as a
matter of course. No formal
instructions have been given to
staff regarding these hazards
although they are sometimes
picked up.
3. Explicit instructions exist to
the effect that STF hazards must
be covered in inspection/
maintenance. These instructions
are generally followed and the
more obvious STF hazards are
recorded. However, action is not
always taken and staff have not
been given guidance as to the
areas which need scrutiny for
STF hazards.
74
4. STF inspection and
maintenance is carried out
regularly by staff who have
guidance on what to look out for
and where perhaps in the form of
a checklist. Appropriate
resources are made available for
this work. The work is carried
out thoroughly and actions are
closed out in good time despite
limited workforce involvement.
5. Not only is STF inspection
and maintenance carried out by
special teams, but a culture
exists where everyone takes
responsibility to do their bit. In
addition, OIMs and supervisors
are sometimes involved in the
process. The work is carried out
to a high level of quality and as a
result STF hazards are low.
Ref
TOPIC AREA
2
HOUSEKEEPING
a
Are there strategically placed supplies of
conveniently accessible absorbent material for
soaking up spillages?
How are scrap and rubbish managed on the
installation?
How do workers ensure that there is always
enough space around a worksite to move freely?
b
c
d
e
f
COMMENTS
SMS Audit
Ref
1a, 6a
1a, 6a
1a, 6a
DISCUSSION POINTS
Is there a procedure that material is only taken to
site when it is ready to be used?
Are there arrangements to ensure that cables,
hoses etc are either routed to avoid
walkways/stairs or where they must cross
walkways they are always properly bundled and
personnel protected from potential trip hazards?
Has any consideration been given to posting
plans of the installation showing designated
storage areas for materials/equipment?
Where work is being carried out that has the
potential for causing slips, trips or falls (including
routine washdown e.g. accommodation stairs
and corridors) is it planned during ‘quiet
personnel movement times’ and how much
temporary signage is displayed?
1a, 6a
1a, 6a
1a, 6a
HOUSEKEEPING RATING SCALE
1. Housekeeping is not on the
safety agenda. The priority is to
get the job done irrespective of
the mess it causes. There are
no instructions on housekeeping.
Scrap, tools and equipment are
found lying around in several
areas. Spillages are not dealt
with until a convenient break in
the work. Hoses and cables are
trip hazards.
2. There are no formal
instructions on housekeeping
and so it is dependent on
individual supervisors and the
time and resources available.
Getting the work done often
takes priority but there are
usually clear ups after jobs are
finished. Some thought is given
to how things are stored to ease
congestion.
3. Procedures mention
housekeeping and there is a
requirement for a reasonable
standard. Some arrangements
are in place to aid this such as
bins and safe routing of
pipes/hoses. The installation is
generally tidy but there are one
or two areas which are
neglected, often due to busy
periods.
75
4. Clear standards of
housekeeping are set which are
monitored by supervisors. Work
areas are often cleared before as
well as after jobs but seldom
during. Arrangements are in
place to promote tidiness such
as a rubbish management plan.
The standard of housekeeping
observed is generally good.
5. There is a work instruction to
clear/clean as you go to maintain
a high quality of housekeeping.
This is observed irrespective of
the importance of the job. A
culture exists within which people
are tidy as a matter of course
whether in the accommodation or
at a work area. Work is planned
with housekeeping in mind.
Ref
TOPIC AREA
3
WEATHER CONTROLS
a
Have those external operations and activities that
should be significantly curtailed or ceased during
adverse weather been clearly identified in the
Adverse Weather Policy?
b
c
d
COMMENT
SMS Audit
Ref
1a
DISCUSSION POINTS
What other provisions are there in the Adverse
Weather Policy? e.g. preparation of as much
work as possible under cover in times of adverse
weather.
Have areas of the installation which are exposed
to the effects of bad weather been assessed?
DISCUSSION POINTS
Has there been consideration of permanent wind
breaks? (balanced against requirements of gas
dispersion if appropriate)
How are decisions made regarding the need for
erecting temporary refuges in times of adverse
weather?
Is the weather forecast ever checked as part of
the risk assessment for work at exposed sites?
1a
6a
6a
WEATHER CONTROL RATING SCALE
1. There are no controls and no
consideration regarding how bad
weather might affect slips, trips
and falls. Drainage is poor which
may cause excess water on
decks. There are several areas
on the installation exposed to the
elements.
2. Bad weather is only
considered in extreme
circumstances as and when it
happens but not in relation to
STFs. There may be controls
from a retrospective point of
view.
3. The affects of weather on
STFs is not considered per se
but there are measures to limit
the affects of bad weather in
general. There are no formal
written procedures in place.
Wind breaks and temporary
shelters are used at some times.
76
4. Clear procedures exist in
relation to controls for bad
weather and action which must
be taken at such times. Weather
control measures are common
and may be with STFs in mind.
Bad weather is sometimes taken
into account during risk
assessment.
5. As much precaution as
possible has been taken to limit
the affects of bad weather on
STFs. An audit has been carried
out to identify exposed sites.
There are clear procedures for
stopping certain activities in bad
weather. Management are fully
committed to the bad weather
procedures and workers know to
follow them.
Ref
TOPIC AREA
4
RISK PERCEPTION AND
EXPERIENCE OF SURROUNDINGS
a
RISK ASSESSMENTS
· Is there guidance for RA? Does this include
STFs?
· Is there training for RAs?
· Are RA findings closed out in good time?
· Are any RAs monitored or checked by
safety officers?
THE ACCIDENT/INCIDENT MANAGEMENT
LOOP
· Are slip, trip and fall hazards and near
misses accommodated in the installation
reporting system and made clear to the
workforce
and
supervision
in
reporting
instructions/procedures?
· Do workers know to report STF hazards and
near misses?
b
COMMENT
SMS Audit
Ref
6a
4a-b, 14a-e
DISCUSSION POINT
A system whereby STF hazards can be flagged
quickly, easily and anonymously could be
implemented. This could involve the placement
of boxes and STF observation cards at strategic
points around the installation.
·
c
How is the information on slips, trips and
falls gathered on an installation fed back to
safety managers onshore?
· How is STF information fed back to
workers?
Are
they
aware
of
the
installation/company programme to reduce STFs
or about the results of STF investigations?
· Are STFs on safety committee agendas?
THE SAFETY INDUCTION
· Is the installation/company policy on slips,
trips and falls outlined?
· Are people told where they can find
information on STFs?
· On the walkaround, are any slip, trip and fall
5a
11a, 4b
77
Ref
d
e
TOPIC AREA
COMMENT
SMS Audit
Ref
‘blackspots’ pointed out or examples of STF
hazards?
LESS EXPERIENCED WORKERS
Are any provisions made for less experienced
workers for their first time on the installation?
DISCUSSION POINTS
One way to mitigate the effects of lack of
experience is to adopt a ‘buddy system’ i.e. the
pairing of inexperienced staff with experienced
workers for the first few days of a tour.
THE SUPERVISORY AND MANAGEMENT
ROLE
What are the hands on roles of supervisors and
OIMs in the arrangements to control slips, trips
and falls?
DISCUSSION POINTS
Supervisors and OIMs should periodically be
involved in STF inspections/audits.
Debrief
sessions could be held after serious slip, trip or
fall accidents.
There could be discussion
sessions with workers on the installation
programme to reduce slips, trips and falls.
11a
2a
3a-b
RISK PERCEPTION AND EXPERIENCE RATING SCALE
1. People possess poor
awareness of potential STF
hazards and risks. The focus is
on the immediate task in hand
and getting the job done and STF
are not part of the thinking.
There is no STF information
available to allow workers to
become familiar with these
hazards.
2. Some members of the
workforce are aware of the risks
posed by STFs but this is likely
to have come from previous
experience of the hazards as
opposed to from management.
There is only limited interest from
management and any
information which does exist is
not disseminated.
3. Management acknowledge
responsibility for disseminating
STF risk information to the
workforce but this does not
always happen in practice. As a
result, awareness of STF is good
in some areas but patchy in
others. There is basic
consideration of STFs in risk
assessments.
78
4. STF risks are beginning to be
accepted as significant alongside
more well established offshore
risks. Management take action
to promote these accidents to the
workforce who, as a result have
the information to know of the
risks.
5. There is clear recognition of
potential STF hazards, people
have the ability to anticipate a
range of STF risks and plan
appropriately. On the whole, the
workforce are very familiar with
STF hazards and how to avoid
them. Information from
accidents/incidents, risk
assessments etc is widely
available. STF bulletins may
appear on notice boards.
Ref
TOPIC AREA
5
QUALITY OF HARDWARE
a
VERTICAL LADDERS
· What are the arrangements for working off
ladders?
b
c
COMMENT
SMS Audit
Ref
13
DISCUSSION POINTS
If the work requires two hands, a platform should
be provided if possible instead of a vertical ladder
Work items which need to be grasped should be
within convenient reaching distance of ladders
(As an example of good practice, a maximum
distance of 950mm)
· Are ladder rungs covered with non-skid
surfaces to prevent the foot from slipping?
· Are ladders always attached to permanent
fixtures? Do tall ladders have intermediate
landings? (As a guide, those in excess of 9.1m in
height)
PERSONAL PROTECTIVE EQUIPMENT (PPE)
AND EQUIPMENT PURCHASING
· Are boots and harnesses in good condition
without signs of wear and tear?
· Do boots used on potentially contaminated
decks have microcellular urethane or rubber
soles?
· Are the workforce consulted regarding the
comfort and suitability of PPE?
· Is there an approved installation procedure
on the purchasing of PPE and other
equipment/hardware? Are slips, trips and falls
taken into account in equipment purchasing?
· In terms of slips, trips and falls, is
information collected and stored on suitable PPE
and other equipment/hardware? Is this shared
with
other
installations/onshore
safety
managers?
STAIRS
· Are tread depths consistent? (As an
example of good practice, approximately 275mm
and no less than 230mm)
1a
9b
79
Ref
TOPIC AREA
COMMENT
SMS Audit
Ref
·
d
e
f
Are riser heights consistent? (For example,
no greater than 200mm and a maximum of
230mm)
· Are the leading edges taped with slipresistant bright coloured rubber?
HANDRAILS
· Are stairs with three or more steps provided
with handrails?
· Is there always at least a single tier handrail
on the bulkhead side(s) of stairs?
· Is there a two tier handrail on the exposed
side(s) of stairs to prevent falls?
· Are handrails at a convenient height for
grasping? (As a guide, 890mm from the top rail
to the surface of the tread)
WALKWAYS AND WORK PLATFORMS
· Do walkways for one person travel have
enough clearance for easy access? (As an
example of good practice, a width of at least
500mm or 1.1m where the passageway serves
as a required emergency exit)
· Do elevated work platforms have suitable
space for safe work? (As an example, for work
which requires moving around, a width of no less
than 760mm and a depth of at least 920mm; for
standing only work, a width of no less than
390mm and a depth of no less than 460mm)
· Are elevated walkways provided with
suitable handrails and toe boards? (As a guide,
those above 610mm)
VISUAL ENVIRONMENT
· Are there clearly visible signs and markings
to denote slip, trip and fall hazards where
necessary?
· Are signs duplicated in different formats and
different locations to reinforce the message,
without creating a proliferation of signs?
· Are light levels on walkways and stairways
at or around 210 lux (enough light to work
comfortably at a control station say) and 110 lux
13
13
13
80
Ref
TOPIC AREA
COMMENT
SMS Audit
Ref
at the very least (enough light to negotiate stairs
safely)?
· Are stair treads marked so they are visually
distinguishable?
QUALITY OF HARDWARE RATING SCALE
1. Stairs are steep, not always
with suitable handrails and
walkways are uneven in several
places. There is an absence of
visual markings to highlight STF
hazards. The design of most
work areas limits access. The
majority of footwear is unsuitable
for guarding against STFs.
2. Several cases are observed
where the hardware carries a risk
of STF which is unacceptable.
Simple modifications could make
several areas safer either in
terms of physical alterations or
visual markings. Access is often
poor in areas of high activity.
Little thought is given to the
suitability of PPE for the
purposes required.
3. The design of hardware is
suitable to minimise the risk of
STFs across much of the
installation. Very few gratings
are out of place and stairs are
protected in most cases. Visual
markings are present for the
more obvious hazards. PPE is
robust and good for the work but
is often worn. Access is a
problem in some important
areas.
81
4. There are very few noticeable
STF hazards either on walkways
or stairs and where they do exist
they are flagged by signs.
Access is rarely a problem due to
either good design or the way in
which hardware is arranged.
PPE is suitable for guarding
against STF and mostly in good
condition.
5. The installation has been
designed according to ergonomic
principles. This ensures that
access is good and permanent
fixtures carry a low risk of STFs
due to appropriate design and
explicit visual markings. PPE is
maintained at a high quality and
is suited to the risks in particular
jobs.
BOMEL CONSORTIUM
RIN ASSESSMENT TOOL FOR ASSESSING FACTORS IN STFs
Using the RIN assessment tool
The RIN assessment tool may be used by safety managers/officers, and OIMs to assess
their current status in relation to the factors which influence the likelihood of STFs on
their installations, specific to the company situation. The RIN diagram can be used to
assess which are the strongest influences on slips, trips and falls from height in a
particular company in one or a combination of the following ways:
·
As a framework for structuring workshop sessions on assessing risk
·
To develop questionnaires for risk assessment
·
For identifying risk control measures and for assessing their effectiveness
The six most influential direct factors in STFs have each been assigned a different
colour. It is then possible to follow that colour down through the diagram to find the
strongest influences at the lower levels on the direct cause that was the starting point. In
some cases a lower level factor is the most influential at that level for all critical factors at
the level above and so this is reflected in the colour coding.
Definitions for all the factors in the RIN are contained in Support Information for STFs
Offshore Final Report BOMEL reference C919\05\174u. The scales allow an
assessment of the quality of different factors in STFs and so where risk control
measures may be needed.
82
Slips, Trips and Falls
UNDESIRABLE EVENT
Human
DIRECT CAUSES
Hardware
External
Housekeeping
Inspection/
Maintenance
Quality of
Hardware
Quality
of PPE
Fatigue
Attentiveness
Physical
Fitness
Experience
Weather
Motivation
Risk
Perception
Compliance
Availability of
suitable human
resources
Communication
Visual
environment
D1
D2
D3
D4
D5
D6
D7
D8
D9
D10
D11
D12
D13
D14
D15
DIRECT LEVEL INFLUENCES
Work
Organisation
Acc / Incident
mmt loop
Safety Culture
Management
Supervision
Training
Procedures
Equipment
purchasing
Inspection &
maintenance
process
Terms &
conditions
O1
O2
O3
O4
O5
O6
O7
O8
O9
O10
ORGANISATIONAL LEVEL INFLUENCES
Key
Company
Profitability
Ownership &
Control
Company
Culture
Organisational
Structure
Safety
Management
Labour
Relations
C1
C2
C3
C4
C5
C6
CORPORATE LEVEL INFLUENCES
Political
Influence
Regulatory
Influence
Market
Influence
Societal
Influence
E1
E2
E3
E4
ENVIRONMENTAL LEVEL INFLUENCES
Risk perception critical path
Inspection/maintenance critical
path
Housekeeping critical path
Experience critical path
Weather critical path
Quality of hardware criticla path
Influences all critical factors
above
Figure B.1 – Colour coded RIN showing critical factors/paths in STFs
83
Printed and published by the Health and Safety Executive
C0.35
03/02
ISBN 0-7176-2327-0
OTO 2002/001
£25.00
9 780717 623273