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Lessons Learned. May 29, 2005 Fatality from a fall into a manhole. Shaft A 60 and the location of the incident. UNLIT AREA. Fall of 12 metres. X. Incident Description:.

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lessons learned

Lessons Learned

May 29, 2005

Fatality from a fall into a manhole

incident description

Shaft A 60 and the location of the incident


Fall of 12 metres


Incident Description:

Two sub contract painters were working in shaft A60 installing thermal insulation on the risers. One of the men wanted to use a piece of plywood that was lying on the floor for cutting isolation material or as a storage board for their tools and materials. He picked up the edge of the wood without realizing that there was an open manhole underneath.

As he lifted the board, he stepped forward to raise the wood vertical and fell down the open manhole, falling some 12 meters to the floor of the cell beneath.

schematics of the incident
Schematics of the incident

Scaffold Tower

3. The deceased carried the materials and tools to this location to store them. Assumption is that he required a clean place, lifted the plywood to clean it, walked forward and fell down the manhole

1. Painters were working here when asked to leave the shaft by the watchman


Open ROV access holes with barriers

Plywood Board

Single 1,500 watt lamp, casting light


Point of accident


Only one 1,500 watt lamp was installed on the floor. There was no other light in the area and in the base of the structure immediately under the manhole

2. One painter stayed at the work location cleaning the area


Rise pipes being worked on by painters

ROV access holes with barriers

1,500w Lamp


incident pictures 01
Incident Pictures (01):

Photograph showing poor lighting, black sand and unprotected plywood over manhole

Photograph showing manhole with plywood removed

incident pictures 02
Incident Pictures (02):

Photograph view looking down, showing cell beneath with pipes where worker fell

Photograph showing manhole with barricade and toe boards restored


The casualty received severe head injuries and was transported to the site clinic and then onto Nakhodka hospital. Despite efforts to stabilize the casualty in the site clinic and ambulance his condition deteriorated and he was pronounced dead upon arrival at the hospital.

The deceased was only 28 year old.

main causes
Main Causes:
  • The barricade had been removed from the manhole and had not been replaced.
  • The plywood covering the manhole was not marked or secured.
  • No inspection by the shaft watchman had taken place during the days leading up to the incident due to the shaft being closed during sand blasting.
  • Lack of housekeeping had left several plywood sheets on the base of the shaft covered with a substantial layer of dark grey blasting sand.
  • The lighting in the shaft was barely adequate.
underlying causes
Underlying Causes:
  • Lack of permanent barriers/covers/hazard identification.
  • Time and schedules pressure resulting in priority on schedule vs. safety.
  • Inadequate management of change from construction phase to marine/demobilisation phase, resulting in reduced supervision and attention.
things we learned 01
Things we learned (01):

Watchmen are used to check the shafts but the manning levels were low as the construction job was nearly at an end and crew demobilisation had started. The watchmen’s office had recently moved from the shaft to a position about 20 minutes walk away.

Manning levels to be improved to provide one man per shaft with responsibility for basic safety of shaft including barricades, electric cables, lighting, housekeeping hoses over walkways, etc.

things we learned 02
Things we learned (02):

Manhole covers shall be clearly identifiable and all manholes should have a cover.

Safety barriers and manhole covers should not be removed from the installed location without proper authorization.

things we learned 03
Things we learned (03):

Change management of HSE through to the end of the shaft construction job had not been fully thought through. Attention had switched to the next (marine) phase of the job.

Reinforce message to supervisors and workforce that if conditions are unsafe (bad lighting, bad housekeeping), then all people have authority to stop the work. Management talk to supervisors to reinforce their Safety Responsibilities to be held.


“. . . what worries me most is the inadequacy of supervision and the fact that work colleagues effectively created circumstances, which were undetected by supervisors, that led to the death of their colleagues . . . We must manage the beginnings of activities, changes and deviations to activities that we have started, and endings to activities. These beginnings, changes, endings may be on a large scale – from construction to commissioning or on a smaller scale - any change to any activity in the midst of its execution may actually require a completely new method statement. We need to be active in predicting and dealing with them all.

Please remember to finish whatever activity you start and to never leave potentially dangerous situations unattended that have the potential to harm or kill others. The job and safety management should never end before the job is over.“

From the letter of David Greer,

Sakhalin 2 Project Director to all SEIC staff