“Taking Safety Into Account”

“On 28 September 2009, at approximately 9:30 -10:00 AM, a four man crew was assigned by their supervisor to replace both the damaged lifting eyes for two of the three pumps inside the pit and to replace the corroded galvanized lifting chains. This activity was to be the last activity to complete the task. The first victim, a Plumbers Assistant, entered the 6.00 meter (19.70 Feet) deep pump pit. He climbed down a fixed ladder inside the pump station, and was wearing personal protective clothing only (protective insulated shield and safety shoes). He started to feel the effects of the hazardous atmosphere at the bottom of the pump pit, and knocked on the pump with a wrench asking for help. One of the plumbers standing outside the lift station threw him a rope to tie to himself, but the victim inside the pit could not hold it as he was already unconscious and laying on his back. The second victim rushed into the pump pit in an attempt to rescue his co-worker, but he was also overcome by the same hazardous atmosphere and lost consciousness. The plumber outside the pump station screamed for help from the fourth plumber, who was at the bathroom changing his clothes to start work. The fourth plumber rushed out to the accident location to assist his co-workers, but the two labourers were pronounced dead after being removed from the pump station.”

Direct Causes:

  • Operating Procedures: Minor task orders were being handled with reduced safety emphasis. No safety supervisor was on site with the crew.
  • Job Practices: The first victim entered a confined space (the pump station) without testing the air for oxygen level or for toxic atmospheres.
  • Personal Protective Equipment: The rescuer entered the confined space without supplied or self-contained air and with no rescue equipment.
  • Chemical and Physical Agents: Toxic materials and insufficient oxygen level lead to the death of the two labourers who entered without following the safety requirements

Indirect Causes:

  • Personal Protective Equipment: The rescuer also entered the confined space without supplied or self-contained air and without the required rescue equipment.
  • Human Factors: The two victims were not supposed to enter the pump station as they were assistants and were not qualified to perform the task.
  • Environmental Factors: Aerobic decay of organic matter likely reduced the oxygen level inside the liftstation. In addition, anaerobic decomposition likely generated methane and carbon dioxide, which displaced additional oxygen and further reduced the oxygen concentration in the pit.

Primary Lessons

  1. The organization failed to ensure that a safe system of work was in place and followed. Even if a third party is given the task, it is imperative that safety standards are enforced.
  1. There is no such thing as a “little” job. We must treat each task as important (REMEMBER THE JANITOR WHO TOLD JOHN F. KENNEDY HE WAS PLAYING A PART IN HELPING TO SEND A MAN TO THE MOON BY KEEPING THE WORK AREA TIDY) and consequently we must appreciate and manage the risks associated with all jobs.

“The willingness to accept responsibility for one’s own life is the source from which self-respect springs.”
—  Joan Didion

Thanks for the share, TO!