Review of Cause of Construction Accidents - HSE rr218 PDF

Health & Safety Executive
HSE
Peer review of analysis of specialist group reports on causes of construction accidents
Prepared by Habilis Ltd for the Health and Safety Executive 2004
RESEARCH REPORT 218
Health & Safety Executive
HSE
Peer review of analysis of specialist group reports on causes of construction accidents
Liz Bennett BSc PGCE CEng MICE MIOSH FRSA Habilis Ltd 3 Market Place Shipston on Stour Warwickshire CV36 4AG
The Construction (Design and Management) Regulations 1994 have introduced new duties for designers. It is argued that early intervention by designers and indeed clients can have a significant impact on construction safety during the main building phase and also during maintenance and demolition of structures. Until the advent of these Regulations the principal blame for any construction site incident was generally laid at the door of the main contractor. The industry has found the cultural changes necessary for proper designer integration difficult to embrace and various projects have been initiated by the Health and Safety Executive to remedy this. It was believed that an analysis of a series of randomly selected incidents might give evidence, or at least an indication, to a reluctant industry that designers can do more to improve safety and health in construction. The initial stage was to develop a methodology for carrying out this analysis. The secondary stage was to peer review and iteratively agree on those findings. This report is a summary of that review. The findings very thoroughly underline the fact that the thinking behind the Regulations is sound and that designers can and so arguably should do more. This report and the work it describes were funded by the Health and Safety Executive (HSE). Its contents, including any opinions and/or conclusions expressed, are those of the authors alone and do not necessarily reflect HSE policy.
HSE BOOKS
Crown copyright 2004 First published 2004 ISBN 0 7176 2836 1 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the copyright owner. Applications for reproduction should be made in writing to: Licensing Division, Her Majesty's Stationery Office, St Clements House, 2-16 Colegate, Norwich NR3 1BQ or by e-mail to hmsolicensing@cabinet-office.x.gsi.gov.uk
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ACKNOWLEDGEMENTS
Acknowledgements are made to Malcolm James whose innovative approach to the analysis of the accidents reviewed in this study was both stimulating and illuminating.
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CONTENTS 1
1.1 1.2 1.3 1.4 1.5
BACKGROUND.....1
Accident Rates..1 Construction (Design and Management) Regulations 1994 CDM...1 CDM Regulation 13 Difficulties for Industry...2 CDM Difficulties for the Health and Safety Executive2 Industry Wide Initiatives3
2
2.1 2.2
PROJECT OBJECTIVES AND WORK PHASES.5

Project Objectives Work Phases
3
3.1 3.2
SOURCE DOCUMENTS..7
Accident Reports 7 Original Research Reports.7
4
4.1 4.2
AUTHORS REMARKS...9
Author Entry View..9 Impact Of Fatal Accident Reports.9
5
5.1 5.2
ASSUMPTIONS AND PROCESSES.11

Processes and Iterations11 Agreed Assumptions..11
6 7 8
FINDINGS13 COMMENTARY.21 RECOMMENDATIONS.25
APPENDIX 1 CATEGORIES27 APPENDIX 2- ACCIDENT ANALYSIS SHEETS.29
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EXECUTIVE SUMMARY
The Health and Safety Executive is committed to making a fundamental reduction in the number of deaths, injuries and cases of ill health in construction. There is a view held by some of the industry and underpinned by Regulations that designers could make a significant difference. The key changes required are for designers to design structures that are safer and healthier to build, maintain and demolish. Clearly operational issues must be considered as well since they have a major effect on maintenance capability. There are many in the industry, and in particular in the design community, who remain unconvinced by the arguments that designers can and should make a difference to the way they work. The purpose of this research package was to analyse actual incidents with respect to designer involvement. As the research evolved various other potentially useful indicators emerged and additional requirements for information collection were identified. This research must therefore be seen as part of an unfolding investigation into the best way to identify some of the key change points for the industry. The author has chosen to track personal views of the research for the reader as this was judged helpful. In particular a certain amount of cynicism towards the arguments for real intervention by designers was in place at the beginning of the programme. Long before the end the author became completely convinced of the enormous importance of the need for radical change amongst the design community. The original research was modified after discussions between the author and the originator of the incident summaries. It is recognised that further improvements could be made to the collection of data and its analysis that could provide significant material for industry. The original review of the incidents was conducted by Malcolm James, who did the development of the methodology for the study and also summarised and analysed the incidents in the first instance. The peer review that is the subject of this report acknowledges the importance of Malcolms work but takes complete responsibility for statements within the report. The Report concludes that almost half of all accidents in construction could have been prevented by designer intervention and that at least 1 in 6 of all incidents are at least partially the responsibility of the lead designer in that opportunities to prevent incidents were not taken. The Report makes no commentary on culpability or the moral and ethical dimensions of designer failings. These must be decided in other places.
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BACKGROUND
1.1
ACCIDENT RATES
The United Kingdom construction industry has one of the lowest accident rates in the world following generally declining rates over recent decades. Latterly, however, a levelling off has been observed and there remain various categories of seemingly intractable accidents. In 2002 there where 80 fatal accidents in construction, which is nearly seven each month. The cost of these deaths to the families and friends of those killed is incalculable. The cost to the industry and the UK at large can more easily be quantified but never accurately assessed. In any case this price is always too high for all concerned. 1.2 CONSTRUCTION (DESIGN AND MANAGEMENT) REGULATIONS 1994 CDM
For some years there has been a belief that early contributions to the construction and building processes from both clients and designers could make a radical improvement to the construction processes during the whole life of a structure. Anecdotal evidence from industry showed that the construction and building industry is capable of delivering safe construction but that it regularly fails to do so. Changing the emphasis of responsibility towards those who commission, scope and design works so that the end result is seen as a team approach to life long safety and health management was expected to deliver benefits. The Temporary and mobile construction sites Directive 89/391/EEC was introduced across the European Economic Community to change the way construction health and safety is managed. In the UK this Directive was implemented as two sets of construction regulations: the Construction (Design and Management) Regulations 1994 CDM - and the Construction (Health, Safety and Welfare) Regulations 1996 - CHSW. CDM put new duties on clients and designers and introduced a new statutory appointment of Planning Supervisor. The concept behind CDM was one of teams of competent appointees providing appropriate information throughout the life of the project for use by those who had the capacity to influence health and safety for good or ill. There was also a requirement to allow for adequate resources in all senses to achieve the same ends. The opportunities presented by CDM would seem to be clearly apparent, based as they are on sound project management philosophy and holistic risk management. The regulations were, however, generally considered by consultants and advisors in their narrowest sense and frequently not read or applied in conjunction with the CHSW or other relevant regulations, without which their application becomes meaningless. Further, the Regulations were not so ordered as to make duty holders duties easily apparent to the vast numbers of those who were obliged to wrestle with legal terminology for the first time. Designers duties are generally encapsulated in Regulation 13, which is often considered as stand alone, though there are significant implied duties for designers embedded in other regulations, mainly to do with competence, communication, co-ordination and co-operation. Regulation 13 has two key aspects to it. Regulation 13 (i) essentially requires designers to
ensure that clients are aware of their duties, allowing the non-expert client to be kept informed by professionals. Regulation 13(ii) can be summarised as a requirement to contribute to the designing out of hazards and risks of downstream contractor processes. 1.3 CDM REGULATION 13 DIFFICULTIES FOR INDUSTRY
The requirements of CDM Regulation 13 have not been effectively managed by some parts of industry. Various reasons for this may exist. The wording of the regulation is insufficiently precise to set standards in relation to legal duties. There has been an assumption that CDM could stand alone without an understanding of building, construction and maintenance processes, including demolition, and of other requirements such as operational constraints. These other factors are often overlooked to the detriment of decision making. Many designers are either unaware of, or not up to date in, modern construction and building processes. For them to make any real contribution to safety and health they clearly need to understand where the challenges are that face those who will construct. There has been an assumption that the regulation demanded risk assessment now commonly referred to as DRA or Design Risk Assessment. Generally the teaching of CDM to the industry has been conducted by health and safety professionals with experience in contractor risk assessments. They have tended to translate this across to the design community. In fact the Regulation makes no reference to risk assessment nor is the Regulation 13 (2) duty best approached by the same methods as contractor risk assessments, being rather a design process. Most DRAs are poorly conducted, retro-fitted, contractor risk assessments. Many of the procurement routes, particularly those facing architects, make early intervention difficult from a commercial perspective. Civil law is at odds with CDM in that case law exists that states that responsibility for safety and health on site is the responsibility for the constructor alone. Such civil law is in place at every contract while the criminal law of health and safety may only present as a challenge to this where there is, for whatever reason, enforcer intervention. The fear of criminal action has resulted in production of excessive paperwork as an attempt to manage liability. In fact such paper trails are generally of poor quality and do little other than add to costs. They do not reduce liability unless they are effective. 1.4 CDM DIFFICULTIES FOR THE HEALTH AND SAFETY EXECUTIVE The HSE cannot visit every site and must select those most appropriate to deliver cultural change to a diverse industry. While large projects are an obvious target the smaller projects, frequently under resourced in terms of competent advice, continue to be the places where many of the accidents happen. HSE field inspectors are experts in the law of health and safety and its enforcement. Design is, however, a complex professional discipline requiring years of training and experience. For inspectors to challenge decisions taken by designers or to ask why alternatives have not been considered is not possible except for those inspectors with a specialist background in the appropriate discipline. Even within the industry there is a considerable range of specialist disciplines at work and the provision of competent inspectors to match every such situation is not tenable. Many of the difficulties that exist for industry also exist for inspectors. A ten year fatal accident high set challenges to the thinking behind CDM. Many questioned whether CDM had done anything but add costs to industry.
1.5
INDUSTRY WIDE INITIATIVES
The Deputy Prime Minister, John Prescott, held a construction health and safety summit where he challenged industry to make commitment to improvement. Several strategic initiatives were launched to bring the construction industry together and improve performance across all aspects of the construction process. Rethinking Construction and its daughter report, Rethinking Health and Safety in Construction were produced. Designers were challenged to make a more positive contribution to health and safety in construction.
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2.1
PROJECT OBJECTIVES AND WORK PHASES
PROJECT OBJECTIVES
The objectives of the whole project were to examine a randomly selected sample of specialist inspector reports to establish: 2.2 2.2.1 Whether the case for CDM can be supported Whether designers are really missing opportunities to contribute to health and safety in construction How HSE can best engage in driving change at field enforcement level
WORK PHASES Phase 1: Initial research by Malcolm James
A random selection of 91 construction specialist inspectors reports were taken and analysed. Those that were clearly not to do with design were set aside but included in the final numerical computations. The categories selected for this analysis were in the first instance iteratively developed by Malcolm James, who also assigned scores to most categories. These categories are listed in Appendix 1. Each report was summarised, assessed according to categories and notes made in relation to such matters as design failings. A table was developed that set the opportunity presented to the designer against the opportunity taken by that designer in relation to intervention to prevent realisation of an incident. Colour coding was used for ease of recognition at the request of the HSE. 2.2.2 Phase 2: Peer review of research by Liz Bennett of Habilis
Each report was reassessed without reference to the initial summaries but using the same categories. The two results were then compared. Where differences occurred the second assessment reconsidered the data and original assessors remarks to gain clearer understanding of the reasons for disparity. Outstanding differences were discussed at a meeting between the two reviewers. One of the difficulties encountered was that in some examples different assumptions had been made. In others more than one designer could have had an influence. Unless reviewers had selected the same designer the opportunity assessment could easily differ. Keywords were a further area of difficulty since these depended on a range of variables. Their use to facilitate later search was however agreed. 2.2.3 Phase 2: Amended review and agreed forward strategy
An agreed forward strategy was developed as follows: A list of standard keywords would be established for selection by assessors. This is seen as important for future analysis of findings in relation to particular work activities or common failings as it will facilitate a general search enquiry.
Almost all the reports predate CDM and focus largely on construction processes. This means that Temporary Works Designers feature in a way that is likely to be disproportionate to the potential contribution to be made by other designers. It was agreed that a separate analysis of each designer should also be made so that temporary works may be selected out to consider other designer aspects or included in if that is more pertinent to the point being made. The analysis was to consider the current project only and not any design or construction for the original works. From time to time where the original design had been a clear contributing factor, say to later maintenance, this would be noted but not scored. It was agreed that in areas of doubt assessors should err in favour of the designer. In certain instances assumption would need to be made and stated about stakeholder competence ie the competence of the designer in specialist design areas. This would allow clearer understanding by readers of the reviewer thought processes. The designer effort assessment can be taken as a rough indicator of designer costs. It was noted that designer effort is frequently a cost centre for designers even when economic benefits accrue to the project. These benefits are generally delivered to the contractor and/or the client unless contractual arrangements also deliver economic benefit to designers. It was agreed that for the third iteration the forms would be redesigned, slightly reordering the existing sections and providing opportunity to assess separately the different designers contributing to a project. It was anticipated that this would be particularly useful for future analysis. It was recognised that what the designer should have done encompasses moral, professional, economic and statutory obligations. It was agreed that the review should concentrate on what the designer could have done set against what was done, without making judgements about duty and responsibility, which, in relation to statutory duties, would be a matter for the courts to decide. It was agreed that while a ten point separation was useful during the analysis phase this should be grouped for the final table into five double sections. The final table is thus presented as 5x5 rather than 10x10 It was agreed that the scales should be more closely prescribed in the introduction to reduce the variation amongst assessors. This is to echo the level of detail given in the accident severity scale. It was accepted that neither assessor had been entirely consistent in considering industry today and had from time to time included industry opportunities. Such comment adds value but assumptions need to be clearly identified. Some of the reports assessed advisory visits. It was agreed that where there was a report there was a potential for harm and inclusion of such reports was thus valid as they described opportunities for all parties to a project. All of the incidents were reassessed in light of the above decisions. Only the final iteratively agreed results are included in the Appendix 1 to avoid confusion. The text describing the incidents is almost entirely that of the original assessor, Malcolm James, with occasional additional remarks by Liz Bennett of Habilis, where it was felt that these added greater clarity or useful comment.
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3.1
SOURCE DOCUMENTS
ACCIDENT REPORTS
When an accident occurs it is usually the local HSE Enforcement Officer who attends in the first instance. If it is likely that specialist construction expertise is required the case or elements of the case may be passed to the construction specialist for additional input to the enquiry. Where the report relates to request for specialist advice, this is referred to an inspector with the necessary competence. All construction specialist reports are stored together, being sorted by type of activity and date. Thus roof work incidents are kept in sequential order. Ground works are similarly sorted. For the purposes of this research handfuls of specialist inspector reports were removed from the store ensuring that there were examples from each general category but otherwise making a random selection of bundles of reports. At first review those reports that clearly did not have anything to do with design were sifted out and set aside. The iterative process described in section 2 above were then applied to the residual majority. It is important to recognise that these incident reports relate to real happenings affecting the lives of many people. Because the documents must remain confidential for legal reasons they are not included in this report except in sanitised summary. Similar incidents to those described happen regularly in construction and readers will often be able to recognise from their own experience incidents that relate closely to those reported. 3.2 ORIGINAL RESEARCH REPORT
The original research conducted by Malcolm James did not reach publication prior to this additional work being conducted because it clearly needed external validation. His preliminary work, however, set the scene for the whole of this report. Malcolm James experience of the construction industry and of the law of health and safety in that industry is clear and his comments and notes form a critical part of the completed document. His development of some ways to assess incidents in a structured manner is very helpful to both industry and enforcer alike as it provides a framework and breakdown of the critical elements to be considered by stakeholders in the design process. Notwithstanding the above, the results presented are only those of the combined iteration as it was agreed that this would be most helpful for industry. Consequently neither of the main source document sets is available for public scrutiny.
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4.1
AUTHORS REMARKS
AUTHOR ENTRY VIEW
The following remarks are provided to give the reader an indication of the mindset of the reviewer and author of this report throughout the process. They are personal commentary and provided to give background information to those who may wish to accept or refute the findings. Construction industry design professionals are generally taught to be backward focussed, dependent on codes, standards and experience of similar projects undertaken successfully. Clearly there are some exceptions to this retrospective approach. Innovation in itself introduces risk and many clients prefer tried and tested methodology. The construction industry spans across a great many levels of competence and a range of sectors and types of activity, some of which have little synergy. No single solution to the continuing high levels of accident and ill health problem suffered as a result of industry activity can fit all work. The author is passionate about reducing harm to at risk groups of people and while convinced that designers can make a contribution to the process of safe and healthy construction was less persuaded that this change was worth seeking given the costs to individuals, industry and society at large. Further, industry wide problems with CDM compliance already experienced seemed to indicate that the chance of delivering significant added value change to the culture of a diverse industry was small. The author was and is also concerned that health and safety professionals still hold the main power base in terms of delivering advice, training and proposing solutions. While their contribution to construction health and safety is clearly essential, the special nature of design means that their lead in this area is likely to devalue the potential contribution designers can make. Standards of training and competence for designers have not been established across industry by those experts in design who could be demonstrating best practice and the added value of this additional effort. Steps are being taken through the Construction Industry Council and its member bodies to remedy this. University courses have not responded to the requirements for educational change in construction and building design to a sufficient level. There are well rehearsed arguments relating to this problem and in any case change is also afoot here. It is clear, however, that undergraduate courses already impose extremely high workloads on staff and students alike. In summary the entry frame of mind was that the research was likely to be interesting but arguably only able to deliver skewed results, set out as a politically correct sop to the requirements of a European Directive.
4.2
IMPACT OF FATAL ACCIDENT REPORTS
Many of the incidents reported were technically interesting. Some did not provide sufficient information to take any but an overview. Most could have resulted in multiple fatalities, including multiple fatalities to members of the public. Some of the projects would have
required highly competent designers to provide creative solutions or the spending of considerable time and therefore cost to deliver solutions. Some of the accidents were simply avoidable. Some of these were fatal or resulted in serious injury. Reading of incidents that have destroyed lives and had a knock on effect to many others associated with the victim in whatever way had a very sobering effect. None of the incidents should have happened. Many could have been prevented very easily. Many could have been prevented by small actions by someone involved. Every attempt was made to absolve designers of responsibility. In particular Temporary Works designers and manufacturers were removed from the main quoted statistics. The final numbers are not just persuasive but absolutely convincing. Designers can do more. Designers need to learn how to do better or else be made to do so by whatever means. The clear message should be one of warning and challenge for the whole design community.
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5.1
ASSUMPTIONS AND PROCESSES
PROCESSES AND ITERATIONS
The process for the research was driven by Malcolm James original work, which was slightly modified in the third iteration. Each incident was sanitised as a summary description from the report. Various measures were given quantitative values from what it is agreed must be inadequate information in many instances. These assessments were validated, however, by peer review and comparison and the close fit gives confidence to the author of the values placed on the findings. Many of the assessments made were not of primary interest to the objectives of the report. These additional values provide some commentary on matters such as design effort/cost, level of specialist knowledge required etc which enrich the central debate. There is also an assessment made of whether a Planning Supervisor appointment could have made a difference to the outcome and likewise whether a site safety supervisor could have prevented the incident. This was done to provide a minor commentary on the future of the coordination role at design and site supervision stages. 5.2 AGREED ASSUMPTIONS
The reports used for the research related to incidents prior to CDM and thus generally made reference to construction products and processes with little reference within those reports to design and planning aspects of construction. Certain assumptions were made for the purposes of the research and are listed here for clarification. Designers were given the benefit of any doubt. The aspects of design considered related to the project in hand. Thus maintenance work referred to designer contribution to that maintenance but not to the original design of the structure. Where poor design had led to difficulties with maintenance this was pointed out in the notes but not given any value in the overall quantitative assessment. Where assumptions about designer competence were critical to the assessment these are stated. Designer effort is judged to be roughly equivalent to designer costs. It should be recognised that no indication of the procurement route or contract arrangements is given in the reports and this can have a significant effect on the ability of designers to contribute effectively. It is here assumed that the designer is appointed prior to any design. In some instances some designers are required to make speculative outline design as part of the tender process. No allowance is made for such factors. No assumptions are made about designer culpability in law, which assessment must be a matter for the courts. Apportionment of responsibility to architects or consulting engineers is in most cases arbitrary since most reports are silent on the nature of the design professionals involved. For the final commentary these two groups have been assessed together as principal designers.
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6.1
FINDINGS
Prior to CDM data collection by HSE specialist inspectors concentrated on the facts at the scene and did not generally detail any significant designer issues except where these related to temporary works or the design of construction products. Identification of procurement routes and contractual relationships was not considered part of the investigation protocol in any the reports considered. The results can only give a general indication of the potential for change but it must be remembered that the assumption was that any doubts should be resolved in the designers favour. In other words, the results are indicative of the level of potential change that could be achieved. The summary table below collects results from all incidents. Tables 2 to 6 select out different groupings that the author judged would add value to the final output so that new targets can be set for activity by the whole industry to effect improvements.
6.2
6.3
6.4 6.5
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Table 1 Summary chart
Architect 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52.
Consultant 4J
TW
Other 8G Contractor 4G M 6G M 6J M
6G 2E 4J 6J 6J 6J 8E 10J 4E 8J 6J 4E 6E 4C 6E 6J 4E 4E 10J 10J 10J Scaffolder 10J 10J 10J Scaffolder 10J 10J 6E 8G Contractor 10J 4J Subcontractor 4C 10J 10J 6E 4C 4E 8J 10G 6E M 2C 4E 8G 6G 2C 10J 8E 4C 2C 6C 10J 8J M 8J M 6G M
8E 10E
4E 10J
10J M 8J M 4G M 10J Contractor
10J
2C
8E
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53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73.
4C M 10G
4E 4E 10J 8J M 6C M 8G 8G 6E 2A 8G 4E M/Transport 8G 10J -
TOTAL TOTAL TOTAL TOTAL TOTAL
10 2 7 2 21
5 5 5 3 18
14 4 5 1 22
13 3 7 0 23
TOTALS 41 13 24 6 84
Notes: 1. 2. There are 73 reports analysed above. In some cases there can be seen to be more than one party with responsibility for design issues. The summary diagram takes several views of the data. It considers the reports and is the source for the following tables: Table 2 All design: worst case only included; Table 3 All design: all contributions to each incident; Table 4 Main design only: worst case only included; Table 5 Temporary works only; and Table 6 Supplier/Manufacturer only. It should be pointed out that it was not always easy to decide who the designer was, an architect or engineer.
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Table 2 Summary of designer intervention All design: Worst case result only taken in each incident
What was necessary Something What designer did Not enough Not nearly enough Nothing
A C E G J
What designers could have done Very little A bit more Major A lot more contribution 0-2 4 6 8 1 0 0 0 2 1 0 0 4 6 2 3 1 5 3 4 0 3 7 5
Critically significant 10 0 0 0 2 18
Summary by category
Rating & total number 5 18 9 39 Recommended consideration Designer not implicated Designer could improve Designer may be implicated Designer prosecution supportable
Notes 1 2 3 4 Total incidents considered in detail Total incidents reported 73 91
The balance were clearly not to do with design but must be taken into sample for comparisons Percentage of incidents likely to be the subject of further investigation of a designer because the designer has failed to take enough action when such action could have made a major contribution to accident prevention is 39/91 x 100 = 43% or almost half of all cases reported. A further 9/91 x 100 = 10% may well be asked to make improvements to their systems and be subject to criticism for taking inadequate steps at the design stage of a project.
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Table 3 Summary of designer intervention All design: All contributions to each incident
A C E G J
What designers could have done Very little A bit more Major contribution 0-2 4 6 1 0 0 4 1 0 0 5 10 2 3 2 6 4 6
A lot more 8 0 0 4 7 6
Summary by category
Notes: 1 2 3 4 Total incidents considered in detail Total incidents reported 73 91
The balance were clearly not to do with design but must be taken into sample for comparisons Percentage of incidents likely to be the subject of further investigation of one or more designers because the designer has failed to take enough action when such action could have made a major contribution to accident prevention expressed as a function of the number of incidents is 42/91 x 100 = 46% or almost half of all cases reported. A further 11/91 x 100 = 12% may well be asked to make improvements to their systems and be subject to criticism for taking inadequate steps at the design stage of a project.
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Table 4 Summary of designer intervention Main design only: Worst case result only taken in each incident
A C E G J
A lot more 8 0 0 3 4 1
Summary by category
The balance were clearly not to do with design but must be taken into sample for comparisons Percentage of incidents likely to be the subject of further investigation of lead designer because that designer has failed to take enough action when such action could have made a major contribution to accident prevention is 15/91 x 100 = 16% or about 1 in 6 cases. A further 7/91 x 100 = 8% may well be asked to make improvements to their systems and be subject to criticism for taking inadequate steps at the design stage of a project.
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Table 5 Summary of designer intervention Temporary works design
A C E G J
A lot more 8 0 0 1 0 1
Summary by category
The balance were clearly not to do with design but must be taken into sample for comparisons Percentage of incidents likely to be the subject of further investigation of a temporary works designer because the designer has failed to take enough action when such action could have made a major contribution to accident prevention is 15/91 x 100 = 16% or about one in six of all cases reported. A further 1/91 x 100 = 1% may well be asked to make improvements to their systems and be subject to criticism for taking inadequate steps at the design stage of a project.
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Table 6 Summary of designer intervention Supplier or manufacturer
A C E G J
A lot more 8 0 0 0 1 4
Summary by category
The balance were clearly not to do with design but must be taken into sample for comparisons Percentage of incidents likely to be the subject of further investigation of a manufacturing designer because the designer has failed to take enough action when such action could have made a major contribution to accident prevention is 8/91 x 100 = 9% or almost 1 in 10 of all cases reported. A further2/91 x 100 = 2% may well be asked to make improvements to their systems and be subject to criticism for taking inadequate steps at the design stage of a manufacturing project.
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7.1
COMMENTARY
It must be remembered that the figures relate not to all projects but only to those that were investigated. This means that the statistics quoted do not indicate that 1 in 6 of initial designs show designer failure to intervene to prevent accidents but that 1 in 6 of those investigated showed this lack. Case law exists that states that consultant engineers and architects should have no involvement in the construction processes even when the methods chosen by the constructor threaten safety. There will need to be greater clarity in relation to legislative changes before designers would be advised to be prescriptive in any great manner. This attitude of separation of responsibilities clearly pervaded the industry throughout the period during which the reported incidents took place. There were some key themes to the incidents themselves. In particular poor communication between parties to a contract was often cited as a root cause of an incident. There would seem to be many incidents where a designer had not taken sufficient notice of existing or adjacent structures nor the likely impact their existence would have on operator behaviour or ability to access the site with plant and materials. In a great many cases the designer had not understood the construction processes nor taken any account of them in the final design. This was standard practice (See 7.2) across the industry and remains so to this day for most projects. It is to be expected that in an industry where the main duties and liabilities rest with the principal contractor that the majority of accident reports would reflect this in their findings. It was for this reason that the incidents that are the responsibility of the Temporary Works designer or manufacturer have been separated out and dealt with as a different industry issue. Table 2 shows that in almost half of reported cases a designer could have taken steps to prevent realisation of an accident but failed to take such steps. There is a clear message here for all of those involved in design, specification and communication of critical information. Table 3 shows much the same as Table 2. It includes multiple responsibility for incident avoidance but does not give results that are very different from Table 2. Table 4 shows the results that are at the heart of this research. It is the number of main designers who could have, but failed to, intervene to prevent accident realisation. In approximately 1 in 6 cases the original designer could have done something to prevent an accident happening but failed to take that opportunity. If this figure is translated across to the annual accident statistics this means that 1/6x80 = 13 deaths a year could be prevented by designer action. Proportionate savings in injury and ill health could presumably be made. This clearly is a significant difference by any measure and well worth setting out a change agenda to achieve. It is particularly telling when it is remembered that this peer review chose to err in favour of the designer in the event of doubt and also the fact that the reports did not generally comment on the original designer activity. Further, maintenance accidents included did not blame the original designer because it was decided to consider only the current project. There are, however, several incidents where the original design made
7.2
7.3
7.4
7.5
7.6
7.7
7.8
7.9
21
maintenance activities difficult and unsafe. It is the view of the author that, because of the reasons cited above, this figure of 1 in 6 is very conservative. 7.10 Table 5 shows the number of incidents where temporary works designers alone failed to take the opportunities presented to intervene effectively to prevent accidents. It is judged likely that this statistic is more accurate since at the time of the reports temporary works design involvement was more often considered by the investigating inspector than principal design. In any case there clearly need to be improvements made by the temporary works community. Common mistakes here included incorrect assumptions, poor communication and not involving expert designers at the appropriate time, even when they were available. Table 6 shows that a significant number of incidents could have been prevented, but were not, by better intervention from the construction products design community. In particular systems scaffolding incorrectly used, systems building units poorly handled or inadequately seated and access systems with inferior failure modes or emergency controls were found to be root causes. Generally the product design community did not give adequate information about the suitability or otherwise of their products for particular situations. Information collection by the Health and Safety Executive (HSE) inspectors rarely enquired about designer involvement in buildability. This was appropriate to the prevailing culture and to the civil law of the time. For the effective delivery of closer understanding of the potential for designer contribution to accident prevention it will be necessary for this strategy to change and for enquiry methodologies to incorporate investigation of complex design processes and decision making. It is likely that this will need a considerable amount of additional research to be carried out as many front line HSE inspectors do not have the technical competence in design to make appropriate enquiry without additional guidance and support. Designers rarely provided adequate information to contractors about significant aspects of their design. There are several reasons for this. Civil law argues that where a contractor takes on a contract to construct a particular design he is making a statement about his capability to do so. An integral part of this capability is his competence and presumably his competence to manage the risks to the safety and health of his workforce. Designers need clearer advice about the relationship between competence of contractors and their own increased liability if they instruct contractors, or may be seen so to do, in methods of building. Clearer information is needed too about the kind of information that would be of use to a contractor. The industry has evolved a methodology for this process usually called design risk assessment. In fact designers usually retrofit poor quality contractor risk assessments to their final design. Many do engage in design decisions that take account of buildability and maintainability but do not recognise these for what they are, which is a correct response to statutory duty. Designers often did not obtain adequate information about existing site conditions or the fabric and condition of existing structures. Their duty to obtain clearer information of sufficient quality to be of use in decision making needs clearer expression in legal and industry standard documents. Designers often did not consider the operational aspects of a structure and the requirement to maintain that structure during user activity. Not to consider such matters where information is available is a failure to provide proper design services even without consideration of the safety aspects of those who will be affected. In particular access to lighting, services and minor fixtures and fittings continues to
7.11
7.12
7.13
7.14
7.15
22
cause real problems. Designers need to develop creative solutions to those requirements. 7.16 The Planning Supervisor potential contribution to accident prevention was also considered. In every case where the Planning Supervisor could have intervened for good it would only have been possible if that Planning Supervisor was highly competent in both design and construction processes and also had the character, authority and opportunity to intervene at the correct time in the project delivery. No general electronic or paper based system frequently used by Planning Supervisors would have been able to pick up on the technical or other potential defects adequately. The Site Safety Supervisor could in some instances have intervened, for example when system scaffold or building units were not being safely used or installed. In many cases, however, technical knowledge beyond that of the general site safety supervisor was needed to make adequate intervention. Procurement routes and the costs to the design community are seen as a real barrier to effective delivery of change. Where health and safety is an early contract requirement designers and constructors alike can deliver high standards. Where designers would need to spend considerable sums of unrecoverable money to deliver change it is no surprise that they fail to take that opportunity. This must be a matter for regulators and government. In many instances contractor design incompetence was a major contributor to an accident. No designer had been involved at all. It may be necessary to put a requirement on certain types of project for such specialist intervention in some manner. It is the Authors very strong conclusion that the case for CDM is made by this analysis and that the design community can do more to reduce the number of deaths and injuries in construction. While health could not be considered in this analysis it is the view of the Author that the case for improvement, through designer intervention, in workforce health is implicit in these findings. There are several opportunities for HSE to improve construction safety through intervention in the design phase of projects. Methodologies for enforcement intervention need to be developed.
7.17
7.18
7.19
7.20
7.21
23
24
8
8.1
RECOMMENDATIONS
The design community needs to learn more about modern methods of construction. How this is achieved is complex and is likely to be a mixture of reward, through clearly better project delivery or reduced Professional Indemnity costs, and penalty through enforcement action. To achieve the latter the revised Regulations or Approved Code of Practice will need to emphasis the requirements on designers in this respect and the HSE will need to develop enquiry methodologies that probe the design process. The manner in which designers can intervene effectively needs to be more clearly expressed in industry standard documentation and training. The culture of acceptance of poor quality design needs to change. It could be extremely helpful to refine this research methodology in the light of new understanding about barriers to change and opportunities for improvement. The best means of making proper enquiry of designers by enforcers without the appropriate depth of technical skills needs to be developed. Engagement with IT data management could begin to generate systems that can provide a rich source of downstream information that can readily be searched for a variety of purposes. The key words need to be further discussed. The purpose of the selection criteria and the impact on the data management capabilities need further development. Significant information could be delivered to the industry, including HSE, through a closer understanding of what initiating factors tend to cause later incidents. For instance procurement routes, time for planning, nature of the client, size of design house, competence of design house etc could be useful to future analysis. Every opportunity needs to be explored to engage Clients. Where Clients demand high qualities of health and safety then procure competent and well resourced suppliers of design and construction, the industry can deliver radical improvement. The issue of designer liability with respect to instructions to contractors to build in a certain manner needs to be further explored. In particular the tension between the civil and criminal law in this matter needs to be resolved. HSE needs to develop better methodologies for inspector investigation and enquiry, not just following an accident but also when making routine site visits. The information so gathered can serve several purposes. It can encourage and require improvement from the design community; it can provide a better source of data for future incident review such as this; it can provide better data for appropriate enforcement action.
8.2
8.3
8.4
8.5
8.6
8.7
25
26
APPENDIX 1 CATEGORIES
Key to categories of incident data and other contributory factors detailed in FCG reports where a design fault may have led to a failure of some description. Job refers to the location or nature of the work being done, where: F O G R A E C W D Steelwork and steel frame erection Roofing General construction including scaffolding Refurbishment Falsework, formwork etc Excavations and foundations etc Cleaning and maintenance Window cleaning Demolition
Incident rating refers in sequential rows to potential for incident then for actual harm done, where: 10 8 6 4 2 0 Most severe. Major disaster with members of the public affected as well. Multiple fatalities to workers on site Single fatality to worker Serious injury to worker Minor injury Non injury report or event
Note that property damage almost always has potential to cause harm to people, so will be picked up in the first listing of incident rating. Could the designer have done more? This refers to an arbitrary view from information available relating to potential for prevention or reduction in probability by the named designer. 10 8 6 4 2 0 Designer could probably have prevented Designer could have done a lot more to prevent Designer could have reduced likelihood significantly Designer had opportunities to reduce likelihood or prevent Designer may have been able to reduce likelihood Designer could not have done anything
Extent of failure to prevent incident. This refers to an arbitrary view of the lost opportunity by the designer. Notes on duty to have intervened are in the main text. J G E C A Complete failure to prevent or reduce probability Failure to make additional efforts using specialist support Failure to research issues and apply them General lack of design contribution/communication opportunity No designer failings
27
Design effort refers to an estimate of the additional effort and consequently resource likely for designer to include a suggested feature. H M L A lot of effort Some effort Very little effort
Degree of specialist knowledge refers to an estimate of whether a designer could be expected to know or to have found out from standard sources, where: 0 1 2 3 4 Should know at basic designer level Generally expected to know to fulfil defined designer role Should easily be able to find out Would need some research to discover this or higher than general competence Would need specialist expert help
Cost implications refers to an estimate of increased cost to the project R L E S Interventions Two additional boxes are included for interest. These relate to external interventions from individuals outside the direct line of design or construction. They are the Planning Supervisor (or equivalent such as Client Advisor) and the Site Safety Advisor/Supervisor. Would such interventions have prevented the incident or potential incident? 0 1 2 3 4 No difference Unlikely Possibly Probably Yes Reduction in cost Little additional cost Some additional cost Significant additional cost
28
APPENDIX 2 ACCIDENT ANALYSIS SHEETS

The following 73 sheets each summarise an incident that was investigated by the Health and Safety Executive (HSE) Construction Specialist Group and assign it categories as listed in Appendix 1. In most cases the HSE reports were made following an incident but in some cases they were as a result of requests for advice or followed on from the serving of notices. All categories were included because it was felt that where HSE had been involved at specialist level there was an implied potential for an incident. Whether the potential was realised or not and the extent of that realisation is captured in the summary sheets but was not transferred to the final analysis. It is certain that industry will be able to argue about the detail of the findings relating to each incident reported in summary but the author is confident that the results are fair because of the very close agreement between the original assessor and the reviewer. Only in a very small number of cases was there a need for final arbitration and significant adjustment. In many cases additional information would have assisted the analysis process considerably and assumptions had to be made.
29
Quick Ref Designer
8F
Contractor
Description of incident An agricultural steel portal framed building collapsed during erection. The columns were not secured to the ground, there was no bracing in the walls and the temporary bracing was of dynamic fibre ropes mainly in the across the bay direction. The structure was intended to be stabilised when complete by having the columns cast into concrete perimeter bund or walls.
Keywords from list Job nature type of activity Incident rating potential Incident rating actual
Collapse/partial collapse; Erecting structures; Steel/rc frame F 8 0
Reference category Designers involved Could the designer have done more? Did the designer miss the opportunity to do more? Design effort
Architect N/A
Engineer N/A
TW Designer N/A
Other (Specify) Contractor 8
Designer specialist knowledge
Cost implications
Could external intervention at design stage (PS) have made a difference? Could site supervision at construction/ site detail have made a difference?
Remarks No consideration appears to have been given to temporary instability problems during construction that could have been within the design remit. The report notes that the structure was to be built similarly to a previous one and that consequently there were no separate drawings or calculations in this case. However there is no information in the report concerning the provisions against collapse in the design for the original structure. The design effort is unlikely to have been any greater than the loss of time experienced on site due to that effort not being made.
HSE Peer review: Ref 4467/R33.115 Case worksheet HAB 01H
30
Quick Ref Designers
4J/4G
Consultant Manufact.
Description of incident A U-shaped [in plan] runway beam was being installed as a new steel framed building was being constructed. This runway beam was in two halves joined at the centre of the U, i.e. each half was Jshaped in plan and was spanning 2 bays of the steel frame. The runway beam halves had approx. 1.5m pedestals bolted to their top flange which were to be the means the beam was to be secured to the rafters. When one half was being lifted a temporary clamp providing a lifting anchorage for the slings apparently slipped and possibly dislodged a steel erector who was about to secure it. The erector was wearing a safety harness but it was not secured. Fall from height; Erecting structures; Keywords from list Steel/rc frame F Job nature type of activity Incident rating potential Incident rating actual 8 6
Architect N/A
Consulting Engineer 4
TW Designer N/A
Other (Specify) Manufacture 4
Cost implications
Remarks While the general lack of enforcement of securing the safety harnesses by the contractor was an important contributing factor. Better design consideration for the need to provide secure lifting positions and means of anchorage for the safety harnesses was also a factor. There could have been a problem with the stability of such an unsymmetrical shape while lifting, although the report notes that when lifted later it hung perfectly. The report does question the suggested slipping of the temporary anchorage point although the beam was possibly basically unstable because of the two pedestals and its plan shape.
HSE Peer review: Ref 4467/R33.115 Case worksheet HAB02H
31
Quick Ref Designers
N/A N/A
Description of incident This is the same incident as HAB 03H but includes the further research into manufacturers capability to intervene. This aspect is incorporated in HAB 02H. This report looks at the clamps used to provide lifting points for the roof trusses. The manufacturers of these would have only been happy with them being used where there was no lateral force being imposed. In this case they should have been used with a lifting beam. Keywords from list Job nature type of activity Incident rating potential Incident rating actual
Architect
Engineer
TW Designer
Other (Specify)
Cost implications
Could external intervention at design stage (PS) have made a difference? Could site supervision at construction/ site detail have made a difference? Remarks There appears to have been a lack of communication between the manufacturer and the user of these clamps. The users appear to have been unaware of the limitations on the use of the clamps which could have been easily dealt with by the use of spreader/lifting beams. This could have been dealt with by attaching a warning to the clamps. While the clamps must have been capable of taking some lateral load the manufacturers did not appear to want to take any responsibility for such use.
32
Quick Ref Designers
6G
Manufact
Description of incident A temporary roof edge barrier blew off the edge of a single storey bridge link between two other buildings. No one was injured. The barrier should have had uprights at no more than 2m centres held down by 30kg sandbag ballast. The uprights had been placed at 4.3m centres and no ballast had been used. However the report comments on the likely possibility that the bridge was in an exposed position and subject to funnelling effects so that ballast weighing 50kg would have been required to give a suitable FOS in this case. Falls from height off edge; Struck by falling object; Roof work; Keywords from list Job nature type of activity Incident rating potential Incident rating actual O 10 0
Architect possibly
Engineer possibly
TW Designer possibly
Other (Specify) Manufact 6
Cost implications
Remarks The designers of the temporary barriers had failed to deal with the possibility that they could have been used in more severe situations than that envisaged. They also failed to appreciate that where a contractor was expected to obtain other equipment (i.e. sandbag ballast) then there was a real possibility that these would be omitted. Part of the answer to the design faults would have been to have provided better advice on the spacing of the uprights and their ballast weights, ideally permanently attached to the equipment. The failure could also possibly have been avoided by having designated ballast weights as part of the kit. Information is only given in the report about system edge protection. It may have been possible for other design professionals to have intervened to the extent that such system protection was not needed. This cannot be presumed, however, so is not included in statistics.
33
Quick Ref Designers
6J
Manufact
Description of incident A prefabricated building was being dismantled and moved to another location. The building was constructed from a series of 2.74m pre-clad portal frames spanning 12m and consisting of two portal frames, which would be bolted to adjacent sections to form the full length of the building. Each section was handled by being slung from two lifting points on the roof requiring the slinger(s) to walk on the roof to attach the lifting slings. Each side of the roof portal had a plastic roof-light that occupied a significant percentage of the total roof area. Falls from height; Lifting Machinery; Roof work Keywords from list Job nature type of activity Incident rating potential Incident rating actual O 6 0
Architect
Engineer
TW Designer
Other (Specify) Manufacturer 6
Cost implications
Remarks While it is possible that the lifting points were at the edge of each section this would still mean that someone would have to go on the roof to remove the slings or reattach them on relocation along at least one edge. In addition someone would have to work along the ridge to install or remove the flashings at this point. Therefore, as it appears, the building was intended to be easily relocated, it would have been reasonable to ensure the whole roof was non-fragile and perhaps even build in facilities for edge protection. The report does not state the nature of the lifting points but it has been assumed that there were 2 on each edge of the sections. The building appears to be one that had been designed to facilitate easy relocation. Therefore, the incidence of someone working over the roof could have been something that frequently occurred. If it was intended to be readily reassembled then ensuring that this could be simply and safely achieved should have been part of the designers brief.
34
Quick Ref Designers
6G
Consultant
Description of incident A fairly standard sandwich skin roof was being installed that had roof-lights in it. The inner skin was being installed ahead of the outer skin and a roofer fell through an unsecured section of the inner skin roof-light.
Falls from height through; Roof work; Commercial building O 6 4
Architect N/A
Engineer 6
TW Designer N/A
Other (Specify) N/A
Cost implications
Remarks The designer could have avoided the separate installation of inner and outer roof skins. In addition The designer could have ensured (at a cost) that each skin was none fragile and that there was provision at the eaves for the installation of edge protection. Finally the designer could have included in the specification for the works a provision for suitable edge protection. While the contractor can provide means to install these types of roof the reliability of any such protective systems would be improved where the designers had planned for safe access or facilitated its provision.
35
Quick Ref Designers
2E
Consultant
Description of incident A roofer fell through an inner lining sheet. This had only been secured by one fixing at its top edge instead of the recommended 3 because a curved ridge/crown sheet was still to be installed requiring the removal of the single fixing. The roofer had walked over the inner liner as an easy way to get to an electrical junction box.
Falls from height through; Roof work; Commercial building O 6 2
Architect N/A
Engineer 2
TW Designer N/A
Other (Specify) N/A
Cost implications
Remarks The sequence of fixing the roof sheets appears to have made some contribution to the accident although the greater part was due to poor site management and a mistake on the part of the roofer. A small contribution to this accident also came from the design. If this had allowed different types of sheets to be fixed independently of others then the accident could have been avoided. Clearer details or sufficient details from the designer could have helped prevent this accident. Properly fixed the inner skin of the roof construction was non-fragile. However, the safety of those installing the roof depended on them keeping off the liner sheets until they were fixed; the planning of the work should have ensured this.
36
Quick Ref Designers
4J
Consultant
Description of incident An accident occurred when two men fell from a steel roof frame while they were unslinging a pack of roof sheets with no means of protection.
Falls from height off edge; Structural erection; Steel frame O 8 8
Architect Unlikely
Engineer 4
TW Designer N/A
Other (Specify) N/A
Cost implications
Remarks While the major contributory factor to this accident was a failure of site management and unreasonable behaviour by the roofers involved, it could have been possible for the designer of the building to have provided some form of anchorage for those carrying out this necessary and foreseeable operation. The designer could have encouraged the use of safety lines or nets in designing suitable anchorages for this type of equipment.
37
Quick Ref Designers
6J
Consultant/ Architect
Description of incident A bricklayer fell through a 1.2m square PVC domed roof-light.
Falls from height through; Refurbishment; Commercial O 6 4
Reference category Designers involved
Architect Possibly in original only 10
Engineer Possibly in site investigation 6
TW Designer N/A
Other (Specify) N/A
Could the designer have done more? Did the designer miss the opportunity to do more? Design effort
Cost implications
Remarks The designer contributed to this accident by specifying the use of a fragile roofing element. The contractor should have been aware of this and could have taken various types of precautions. In addition it is possible that the bricklayer was particularly careless or deliberately stood on the rooflight. Habilis assessment assumes this is refurbishment so not due to architect or engineer as original designer. (Assume err in favour of designer). As a result only engineer as refurbishment designer taken to summary at top of page. Note that this could have been an architect rather than an engineer.
38
Quick Ref Designers
6J
Architect
Description of incident A new church was under construction having steeply pitched roofs to a maximum height of 13m. No provision had been made to safeguard those working on the roof and a PN was issued.
Falls from height off edge; Erecting structure; Access O 6 0
Architect 6
Engineer Possibly
TW Designer N/A
Other (Specify) N/A
Cost implications
Remarks The designer could have included features in his design to support a working platform and/or to provide anchorages for safety lines. The provision of anchors to support a safety line or similar facility could have been done by the designer working alone. However the installation of means to support working platforms would have to be done in consultation with the contractor.
HSE Peer review: Ref 4467/R33.115 Case worksheet HA 10H
39
Quick Ref Designers
6J
Architect
Description of incident A roofer helping to build a new cattle shed adjacent to an older, and 1m lower, cattle shed. The older building was clad with single skin corrugated asbestos sheets while similar new sheets were being installed on the new shed. The roofer stepped down from the higher new roof and fell through the older sheets. The report is not clear whether there was a temporary barrier at the point where the roofer fell.
Falls from height through; Roof work O 6 4
Architect Possibly 6
Engineer Possibly
TW Designer N/A
Other (Specify) N/A
Designer specialist knowledge Cost implications
1 L
Remarks While control of this risk lay chiefly with the contractor, the designer should have flagged up the real risks of someone stepping or falling down onto the old roof. This could have encouraged the construction of effective protective measures. Control of this risk lay chiefly with the contractor. However, designing a building adjoining to a lower one should have flagged up the risks of someone stepping or falling down onto the old roof. It is possible that increased production resulting from a proper edge protection system could have been greater than the original design effort. This was a cattle shed either an architect or an engineer could have been retained. Architect assumed here after discussion. Initial site inspection would have indicated access difficulties that required additional attachments or similar to be included.
40
Quick Ref Designers
8E
Architect
Description of incident An old warehouse was being converted into flats. The roof was completely stripped leaving the old roof trusses. These were of a substantial construction, spanning 13m, standing 5.5m high and weighing an estimated 1.3 tonnes. Some longitudinal 100mm x 50mm timbers had been nailed between the trusses at approx. 1/3 their height using 2 100mm nails at each truss. The masonry against the ends of the trusses was being removed to allow checks to be made on the condition of the timber at the time when a moderate to fresh gale was blowing and 8 trusses fell over. Keywords from list Job nature type of activity Incident rating potential Incident rating actual Partial collapse; Refurbishment O/R 8 4
Architect 8
Engineer N/A
TW Designer N/A
Other (Specify) N/A
Cost implications
Remarks The designer would know that the roof was to be stripped and that effective temporary bracing would be required. Therefore, he should have anticipated that the method of stripping the roof would have left, at some stage, the old trusses standing without covering and perhaps the bracing. He should have provided details of how the trusses should have been stabilised, including the strength of the fixings. Even if the collapse had been avoided, it is probable that the increase in production would have paid for the slightly additional design effort.
41
Quick Ref Designers
10J
Architect
Description of incident A cradle runway was installed on the roof of a hospital for the use of window cleaners. The roof however had only a very low parapet that would not give any protection to anyone using or maintaining the cradles. In addition the cradles were intended to be worked by one man but could only be accessed by this person from the roof. This meant that this person would have to step over the parapet down into the cradle. There was a risk that someone could fall off the roof. Keywords from list Job nature type of activity Incident rating potential Incident rating actual Falls from height off edge; Maintenance; Cradles O 6 0
Architect 10
Engineer
TW Designer
Other (Specify)
Cost implications
Remarks The cradles could have been designed so that they could be landed on the roof of the hospital to allow the window cleaner to gain access and then be driven from inside the cradle over the parapet. A suitable system of protecting persons working on or around the cradle tracks would need to be provided. This is a case where inadequate design resulted not only in a risk of serious falling accidents but also resulted in increased operational costs.
42
Quick Ref Designers
8E/4E
TW/A
Description of incident A proprietary scaffold had been erected completely around the site of a new building, which was to be built from prefabricated timber sections lifted over the scaffold into position, followed by a considerable amount of work for follow-up trades to complete the faade. There were problems with the scaffolding concerning: flexing under load, decking members springing free, unauthorised removal of members and difficulties in maintaining a safe gap between the inner edge of the scaffold and the new building. Keywords from list Job nature type of activity Incident rating potential Incident rating actual Scaffold; Access G 8 4
Architect 4
Engineer N/A
TW Designer 8
Other (Specify) N/A
Cost implications
Remarks With a building design such as this there is an even closer relationship between the building panels and the faade access system if a safe, efficient and effective construction method is to be devised. It was therefore important for the panel design to be linked to the design of the access system being fully integrated by the designer. It is possible that this type of scaffold was not intended for moderate or heavy duties and therefore it had been a poor choice. However the manufacturers/suppliers claims for this equipment would tend to suggest that it could give an economic performance in such applications. Therefore some investigation and consideration would be needed to ensure the job operated properly. Had this been done then the economic benefit would have almost certainly exceeded the additional design effort.
43
Quick Ref
8J(A) 10E(C) 10J(M)

Various
Designers
Description of incident Two 30m long, 44 tonne Y7 bridge beams overturned shortly after being placed. Their lifting arrangement, accepted by the manufacturer, was via end diaphragm holes, which were approx. 200mm lower than the beam centre of gravity. This and the lack of adjustment in the lifting arrangements probably resulted in the beam being set unevenly on its bearings. The temporary propping of the beams was ad-hoc and inadequate and could not stop the beams rolling over. Keywords from list Job nature type of activity Incident rating potential Incident rating actual Erection of structures; Temporary Works; Material handling G 8 6
Architect N/A
Engineer 8
TW Designer 10
Other (Specify) Manufacturer (Consulted) 10
Cost implications
N/A
N/A
Remarks The satisfactory, and safe, handling of such large and ungainly units, particularly when set on sliding bearings, depends very much on the on the proper design followed by proper preparation & planning, on site, of all associated temporary works. There was no reason why the beams could not have been designed with proper lifting hooks so that the centre of gravity was below the lifting sling making the handling of the beams easier and reducing the risk of rotation. In addition, the temporary propping arrangement was inadequate and should have been properly designed. The losses in this case for not doing this almost certainly far outweighed the effort of carrying such a proper design. Even if the beams had not failed the time lost in trying to position the beams and trying to sort out some form of temporary stabilisation would possibly still have been greater than the time required to prepare a proper design.
44
Quick Ref Designers
6J(C) 8J(M)
C&M
Description of incident A workman was levering a pre-cast floor slab into position while standing on the top flange of a steel support beam. The bar he was using slipped and he fell from the exposed edge suffering injuries.
Fall from height from; Erection of structures; Pre-cast units G 6 4
Architect N/A
Engineer 6
TW Designer N/A
Cost implications
Remarks Designers who specify pc units should be aware that they often require levering into position on site. Therefore, they should specify for the manufacturer to design in anchorage points for lanyards. The same applies to the manufacturer. If this was a standard design issue, it would be done as a matter of course. The additional handling described is a feature of the product and failure to build in suitable facilities to support this could be argued that the manufacturers products are not fully complete. It is unlikely that such additions to the slabs would be very expensive and given the large number of units manufactured even small production gains made during erection could make these cost effective.
45
Quick Ref Designers
4E(A/C) 4G(M)
Various
Description of incident A worker stepped or fell off a perimeter scaffold onto a pre-cast beam and block floor and either fell through a hole in the floor or his impact broke out the in-fill blocks so forming a hole through which he fell. The in-fill blocks had poor/minimal seatings in some cases due to slight displacement of the beams and those that fell had virtually no seating at all. In addition the blocks had not been grouted in and were incapable of carrying much load.
Fall from height through; R 8 4
Architect or C 4
Engineer or A 4
TW Designer
Cost implications
N/A
N/A
Remarks The main responsibility for this accident lies with the contractor: he failed to ensure that the pre-cast beams were accurately positioned and that the floors were grouted immediately they were laid. However, as the creator of the hazard, the designer should have informed the Contractor about the residual hazard. Not doing this represented a design failure. The manufacturer has designed a system with an obvious safety deficiency: the risk highlighted by this accident would also exist for the person grouting up. It might have been possible to incorporate or provide a gauge to ensure that the pre-cast beams were correctly placed. It is possible that the provision of a suitable gauge would be cost effective as it could provide a limited production benefit.
46
Quick Ref Designers
6E(C) 10J(T)
Various
Description of incident A sloping rc floor was being cast on profiled metal deck sheeting laid to varying slopes. One area of decking failed and a worker fell through the hole. The framework supporting the decking was at varying slopes therefore, the decking could not always sit properly on its support. In addition, while the concrete being placed did, in some cases, significantly overload the decking. A consulting engineer had had involvement on the site but does not appear to have had complete control over the works. A sub-contractor who may not have understood the structural significance of the deckings limitations carried out the actual choice and installation of the decking in this area. Falls from height through; Pre-cast units Keywords from list Job nature type of activity Incident rating potential Incident rating actual A 8 4
Architect N/A
Engineer 6
TW Designer 10
Other (Specify) See note
Cost implications
Remarks The limitations in the decking could have been dealt with in a variety of ways either by themselves or in combinations. These include using stronger decking, using appropriate wedges to give adequate seating, using temporary supports to back prop the floor until the in-situ concrete had gained sufficient strength, placing additional reinforcement in the thick in-situ concrete. The selection of the most appropriate system should have been done by a suitably competent designer In this case the designer was the sub-contractor who was not competent to appreciate the structural significance of what he was doing. The cost of the failure was clearly far greater than the cost of a competent person carrying out the necessary calculations.
47
Quick Ref Designers
10J(A) 10J(Con)
Various
Description of incident A person was injured when a section of pc flooring together with supporting lintel and block work collapsed. The flooring was being installed and was not grouted in. It was resting at one end on a steel lintel spanning onto the block work reveals at the side of a window opening. The floor was heavily loaded with blocks in the area of the failure. The lintel was grossly under-designed and possibly could not have supported its service load. The block work reveal was also severely overloaded. No calculations had been prepared for this work. Collapse of structure; Pre-cast flooring Keywords from list Job nature type of activity Incident rating potential Incident rating actual G 8 4
Architect 10
Engineer N/A
TW Designer N/A
Other (Specify) Contractor modification 10
Cost implications
Remarks Appropriate calculations by a competent person should have easily prevented this incident. While the pre-cast floor used was a substitute for in-situ concrete on permanent shuttering, this would not have solved the overloading problem although could have resulted in a greater distribution of the loads. The accident could have been avoided by normal (pre CDM) procedures a safety appraisal should have indicated that suitable calculations had not been carried out.
48
Quick Ref Designers
4E
Consultant
Description of incident A design change required a section of a suspended concrete floor to be omitted. The method of work for the installation of ceiling ducts to the upper floor required the use of a mobile access tower and the gap in the floor prevented this tower from being moved along the line of the ducts. Spandecks were laid across the void and a tower was placed on these. Possibly due to either a worker climbing down the outside of the tower or because the tower was being pushed along the Spandeck and perhaps pushed this off its seating, the tower and one Spandeck fell into the void. Falls from height through; Pre-cast flooring; Access Keywords from list Job nature type of activity Incident rating potential Incident rating actual G 6 4
Architect
Engineer C 4
TW Designer
Other (Specify)
Cost implications
Remarks The designer had only a small part in this accident but the incident does illustrate the possible consequences of design changes, especially structural ones. When the change was made the designer should have checked, through the planning supervisor, its impact on the method statements for the work surrounding the new hole and ensured these were revised as necessary. The consequences, both from an accident prevention and a financial point of view, of not following through on the consequences of design changes can be very significant and far outweigh the minimal effort usually required to check these out.
49
Quick Ref Designers
6E
Architect
Description of incident A putlog scaffold was being used to build a cavity wall dividing two roof spaces. The scaffold was up to two lifts high and supported only on one skin of block work. The other skin was to be built separately. Possible wind loading caused the block wall and scaffold to collapse.
Collapse of structure; Scaffold G 8 4
Architect 6
Engineer
TW Designer
Other (Specify)
Cost implications
Remarks Knowledge of the vulnerability of thin block walls to a variety of loads is known equally by contractors and designers. However as the designer created the hazard: lightweight walls, it should have been his responsibility to emphasise the restrictions on progressing one leaf ahead of the other. Was the wall checked for wind loads? Following the same argument by expressly giving such instructions would be a normal means of ensuring the quality and therefore minimising the cost of the project.
50
Quick Ref Designers
8J
Manuf.
Description of incident A roller shutter door previously fitted into a building collapsed killing a person. It was found that the door had been secured by Rawlbolts of the correct size and number. However these had been placed into oversize holes, some into mortar joints only and others penetrating into the voids caused by laying bricks with frogs upside down.
Collapse onto; Building products; C 6 6
Architect
Engineer
TW Designer
Cost implications
Remarks The construction products were too heavy for the fixing available with no means of external inspection. While the supplier of the doors had specified suitable bolts no details appear to have been provided on their installation. Had this been done then possibly the accident would not have occurred. While the size of the bolts is important this cannot be separated from a clear specification of the nature of the anchorage holes and materials. Without the two sets of information a reliable fixing cannot be assured. This means that such a failure could have both economic and safety consequences.
51
Quick Ref Designers
6J
Architect
Description of incident A 3-storey building was being rendered off an external scaffold erected all around the building. There were no ties between the scaffold and the building because of the need to give clear areas for the rendering to proceed. Therefore, the scaffold was generally stabilised by the end returns. The scaffold on one elevation was removed and a section along the return wall where a gin wheel was being used, collapsed.
Scaffold collapse G 8 4
Architect 6
Engineer
TW Designer
Other (Specify)
Cost implications
Remarks The designer specified the render and it should have been clear that the scaffold could not be tied to the building or that ties would have to be moved and not replaced. Therefore, the designer should have provided suitable anchorage points in the faade. While it would not be normal for the designer to get involved with scaffold design and use, in this case the scaffold could have seriously affected work that had been specified. It was therefore in the clients interest for the scaffold to be designed and arranged so as not to impair the harling work.
52
Quick Ref Designers
8G
Manuf.
Description of incident Three men were preparing to install ducting working from suspended ceiling panels. The panels failed; 2 men fell 5.9m. The ceiling sat in 33x33x1.8 aluminium angles. In some cases only two 3mm rivets secured this angle to the wall section. It was found that some of the rivets had been badly placed, were subject to both bending and shear and had in fact sheared or were missing. The rivets connecting the suspended panels to the angles had failed in tension pulling out of the panel. The suspended panels were supported by an inverted top hat section hung by M12 threaded bars from the concrete roof structure. No signs had been posted about the safe working conditions for the panels and the panel manufacturer supplied no fixing instructions on the basis that this was something the installer should deal with. Collapse of access platform; Keywords from list Job nature type of activity Incident rating potential Incident rating actual R 8 4
Architect
Engineer
TW Designer
Cost implications
Remarks There were three major failings: (1) The manufacturers had not calculated the sorts of loads that could be imposed on the fixings that could be used to support their product; (2) They had not provided clear information to the installers or the owners/users of the product on the design and load limitations relevant to it; and (3) They failed to provide typical installation details. As a consequence no one, the manufacturers, installers or owners/users of the product, was aware of how safe the product was when used for access purposes. From the report it appears that their was a variety of fixing arrangements, some quite nominal, which is hardly surprising given the lack of consideration given by the manufacturer.
53
Quick Ref Designers
4E
TW
Description of incident A temporary platform that had been slung under a motorway bridge was being lowered when it broke in two and a scaffolder who was on it fell. The platform was found to have been overloaded with access boards and tubes, was being carried at its extreme ends instead of 2m in as required by the design, and had been manufactured from some materials that were defective. The decision to move the suspension points out was taken by a site foreman, without consulting the designer. Investigations showed that the platform was failed for three reasons: (a) it was overloaded, (b) it was slung incorrectly, which exacerbated (a), and (c) there was a defective [weak] component in the failed joints. Keywords from list Job nature type of activity Incident rating potential Incident rating actual Access; Cradle collapse G 8 6
Architect N/A
Engineer N/A
TW Designer But involved 4 not
Other (Specify)
Cost implications
Remarks The temporary platform would possibly not have failed if any of the three weaknesses had not been present i.e. if it had been properly slung, not been overloaded and not had defective materials in its manufacture. However the possibilities of both overloading and slinging at excessive spans are typical forms of misuse for this type of equipment therefore requiring increased factors of safety. Perhaps the designer could have anticipated misuses (a) and (b). There is a need to ensure that all components in a modular temporary access system are manufactured to a high standard as there can be no guarantee that weak items wont be used in highly stressed positions.
54
Quick Ref Designers
4E
Consultant
Description of incident A temporary work platform had been created by placing 3 floor boards across the stub ends of timber joists which had been left in place after the joists themselves had been removed. Although the stub ends of the joists were built into the wall this was only one brick wide and there was no brickwork above the joist ends, which could have held them down. Three men stood on this platform to move a staging towards a mobile access platform and the stub ends of the joists broke free.
Access collapse R 8 6
Architect
Engineer 4
TW Designer
Other (Specify)
Cost implications
Remarks In refurbishment work unexpected situations occur. While it is largely up to the site staff to deal with these, designers can assist by encouraging the contractor to adopt a safe methodical approach to the work. However it appears that there was a major site supervision failing through first allowing the stub ends of the joists to remain in place once the rest of the joists had been removed and secondly in not preventing the workers using such a hazardous form of access.
55
Quick Ref Designers
10J
TW
Description of incident Work in converting an old chapel built within a row of terraced houses required that the cellar floor should be lowered. This was being done without the use of any shoring and a party wall collapsed.
Collapse of structure; Shoring R 8 0
Architect N/A
Engineer TW aspects of design are key
TW Designer 10
Other (Specify) N/A
Cost implications
Remarks Underpinning work and excavation work adjacent to walls should be carried out to a suitable design that will ensure that the structure will always remain stable. Such a design should have been provided in this case. Underpinning and similar work is a highly skilled job and requires that those involved in it, particularly those managing and supervising it, are experienced, competent and reliable.
56
Quick Ref Designers
10J(T) 1C(A)
Description of incident While a roll of lead was being hauled to a roof by means of a gin wheel attached to a 9m high scaffold, the scaffold partly overturned. The scaffold was tied to the building partly by rakers and partly by reveal ties. However the number and quality of both these types of support was less than that required by the code of practice. In addition the joints in the scaffold tubes were not staggered making the scaffold less able to resist rotating.
Scaffold collapse; Material handling R 8 0
Architect 2
Engineer
TW Designer 10
Other (Specify)
0 L
0 L
Remarks The designer could have detailed secure positions to provide tie anchorage points, especially as the design required to installation of new building materials which would have to be hoisted to the roof of the building. Alternatively other means could have been specified for lifting materials etc. The lifting of new materials to roof level etc, was part of the design which required that effective lateral supports would be required if the access scaffold was to be used to mount lifting equipment.
57
Quick Ref Designers
10J
Scaffolder
Description of incident The taller of two adjacent adjoining buildings needed its exposed gable re-pointing. A narrow access scaffold was erected on the pavement as the local authority would not allow further obstruction. In addition, the owners refused to allow the scaffold to be tied to the building. When ordinary ladder was supported on the working platform on the scaffold and laid up the lower roof i.e. it was not hooked over the ridge the reaction from the ladder pushed the scaffold over.
Access constraints; Scaffold collapse R 8 0
Architect
Engineer
TW Designer
Other (Specify) Scaffolder 10
Cost implications
Remarks Scaffold design has not generally been considered to be part of Reg 13 except where it is temporary works or very substantial but it is a serious matter in most cases. Both the local authority and the owners had taken some responsibility for the design of the scaffold by imposing conditions on its layout.
58
Quick Ref Designers
10J
Architect TW
Description of incident A flat roofed section of corridor was being altered. This required the roof to be lifted higher and the sidewalls, originally of timber framed glass panels, to be replaced by block-work. The original sidewalls had been fixed to the ground cill and portalised with the roof joists, to resist rotational forces. There was nothing in the new design to provide lateral restraint. In addition, the flat roof itself was being used as a working platform. The structure collapsed as the second sidewall was being replaced.
Structural collapse R 10 0
Architect 10
Engineer
TW Designer 10
Other (Specify)
Cost implications
Remarks The new design did not make any allowances for lateral restraint either during the construction phase or after completion. While the method of construction made no provision for supporting any lateral forces, which would be created when working on top of the roof, this only compounded a principle design failure. Therefore even if the builders had used bracing during the refurbishment, the building could still remain unstable to some degree after completion.
59
Quick Ref Designers
10J
Contractor
Description of incident A prefabricated temporary roof was being used which had plastic sheets fixed to aluminium trusses supported at each end by a scaffold. This system would be unlikely to fail under wind loading as the plastic panels would rip open before the loads became so high. However while the suppliers of the equipment recommend that each installation is designed, this was not the case with this structure.
Temporary structure; Collapse R 8 0
Architect N/A
Engineer N/A
TW Designer N/A
Other (Specify) Contractor scaffold design 10
Cost implications
Remarks A full design of each installation is recommended by the manufacturer/supplier and while the structure has a tendency to fail to safety, not carrying out a design check could open the way for problems to occur. Although not mentioned in the report the design of the temporary roof requires the erectors to climb along the roof trusses fixing the plastic sheets. This in itself is a design weakness. Contractor should have designed protective scaffold.
60
Quick Ref Designers
10J
TW
Description of incident A wide, up to 2m, scaffold was erected around a church tower for maintenance and refurbishment. The scaffold was about 24m high and erected around each of the four 12m wide faces of the tower. The scaffold probably had some original faults that were not particularly serious but had then been altered by the contractors carrying out the work as well as increasing the loading on the scaffold. The scaffold was not tied at any point to the tower.
Scaffold; Alterations; Refurbishment R 8 0
Architect
Engineer
TW Designer 10
Other (Specify)
Cost implications
Remarks Scaffolds of this size and configuration, particularly because of being unusually wide and not being tied back to the tower, need to be designed and carefully detailed. Such a design should carefully consider both the self-weight of the scaffold and the maximum imposed loads to ensure that the buckling strength was adequate. The unusual width of the scaffold was something that could have reduced the mutual support provided by each of the standards, increasing their slenderness ratio. The scaffold design therefore needed to be checked by an experienced scaffold designer. This is something that the client or architect should have realised.
61
Quick Ref Designers
10J(A/C)
Consultant
Description of incident Steel beams 305mm deep, to support to roof trusses, were positioned on the top of slender brick columns [215x185] approx. 2.17m high, but were not fixed in place. There were gaps of varying depths between the top of the steel beams and the underside of the trusses. The design intention was for the beams to be trapped under the roof trusses by their increased deflection from the increased deadweight of the roof as it was completed. In one position the beam had apparently been dislodged and fallen onto a person.
Collapse of structure; Erection; Steelwork; Material handling G 6 4
Architect If used rather than Engineer
Engineer 10
TW Designer
Other (Specify)
Cost implications
Remarks The seating of the beams was inadequate, because the design intention ignored the reality of the construction process. Consequently, the beams were vulnerable to movement in a variety of scenarios. Had the beams been designed so that they were securely held in place in their temporary condition then the accident would not have occurred. This could have been achieved by either bolting them onto the brick columns or by using a temporary fixing to the trusses, which would still allow them to deflect. The space between the beam and the truss varied to an extent that it is possible that some of the trusses may not have fully settled onto the beam.
62
Quick Ref Designers
6E
TW
Description of incident A slung scaffold was to be hung over a parapet of a tall office building, surrounded by public rights of way. The scaffold was to be used to remove defective tiles at the top of the building and had 3 working platforms. While the design of the scaffold was acceptable, measures to protect the public below were required.
Falls of objects from height; Scaffolding R 10 0
Architect
Engineer
TW Designer 6
Other (Specify)
Cost implications
Remarks The design for the work should have included all its aspects including full details for protecting the public. While to measures for protecting the public may have been picked up by the contractor when the work commenced not including them in the design could have resulted in omissions or unsatisfactory ad hoc solutions being used
63
Quick Ref Designers
8G
Contractor
Description of incident A Victorian house was being refurbished. Concerns were raised about some temporary & some permanent structural provisions being made in the course of these works. These arrangements appear to have been organised without any comprehensive design work being carried out.
Temporary Works; Structural collapse R 8 0
Architect
Engineer
TW Designer
Other (Specify) Contractor No formal design 8
Cost implications
Remarks The report indicates that the works had not been designed properly. Proper detailing of all permanent structural features should be carried out. Suitable planning of temporary structural requirements should be undertaken relative to the complexity and significance of the loads to be supported. The description of the conditions found strongly suggests that things were getting out of hand and there was little or no effective management/supervision. These problems should have been obvious to the designer of the project on site visits prompting remedial works or a change of contractor.
64
Quick Ref Designers
10J
TW
Description of incident A badly laminated and friable rock face was being stabilised by casting up to 2m thick concrete against it. The formwork being used was held in place by rock anchors drilled into the friable rock at 0.7m centres. While casting the concrete the pressures created by vibrating and placing it caused the anchors to fail pushing over the formwork and adjoining access scaffolding. No attempt seems to have been made to assess the pull-out strengths of the anchors.
Rock face; Formwork; A 8 4
Architect
Engineer
TW Designer 10
Other (Specify)
Cost implications
Remarks Designers are aware that concrete needs to be retained until it has hardened. Tests should have been carried out to check whether the pull-out strengths on the anchors was adequate. Calculations should have been made by a competent person to assess the pressures that could be exerted by the concrete and controls put in place to ensure that such pressures did not become excessive. In this situation the concrete pressure could be affected by the moisture content, the rate of pouring, the amount of vibration used and any surcharges from men or materials. All these are features that could have required control in the design. The nature of the rock surfaces suggests that frequent testing of the rock anchors would be required as the pull-out strengths could be significantly affected depending on the strata the anchors were being drilled into. Again this is a feature that the design should have dealt with.
65
Quick Ref Designers
4J
Subcontr
Description of incident Following a commercial dispute a sub-contractor started to remove the shoring to a buildings faade. This could have become unstable if much of the support offered by the shoring had not been available.
Structural instability; Temporary Works A 10 0
Architect
Engineer
TW Designer
Other (Specify) Sub contractor 4
Cost implications
Remarks No temporary supporting structures should be interfered with while the structures they are supporting have not been strengthened in other ways without careful assessment of the likely consequences of such an action.
66
Quick Ref Designers
10J
TW
Description of incident During its 14th pour the roof section of a reinforced concrete box culvert collapsed. The work was under the direction of a city council acting on behalf of a water authority. The formwork sub-contractor had employed consulting engineers to design the falsework and formwork. The roof slab was 550mm thick x 6m wide. An inspection of similar adjoining falsework revealed a series of inadequacies including no bracing, eccentrically loaded props and missing base plates. The design had been carried out in accordance with the code for the structural use of timber and not that for falsework. The design did not include any horizontal loading usually assumed from placing the concrete. Falsework; Temporary works Keywords from list Job nature type of activity Incident rating potential Incident rating actual A 8 0
Architect
Engineer 4
TW Designer 10
Other (Specify)
1 L
1 L
Remarks There was a serious failure by both the design engineer for the temporary works and the supervising engineer. The temporary works design was not to the appropriate code and suggests the engineer was not experienced in this type of work. The supervising engineer should have been aware of the gross shortcomings in the design and construction of the temporary works. The works probably suffered through the length of the chain of authority both for the client and for work on site. This could have resulted in each level of the construction hierarchy paying little attention to how the others carried out their work. In particular there appears to be a lack of competence as far as the design and construction of the temporary works is concerned. For instance the 3 tiers of support to the formwork seem unnecessary and should have prompted questions by the supervising staff.
67
Quick Ref Designers
10J
TW
Description of incident A 225 thick rc floor slab collapsed as it was being poured. The slab spanned 5.7m between steel beams. The formwork was plywood sheets on telescopic centres, which were carried on the beam shutters and a central 150x75 timber bearer layed on its side, which was carried by telescopic props at 0.75 1.20m centres. The props were not laced or braced and, in some cases, were up to 125 out of plumb. In addition, there were instances of poor foundations to the props. Checks revealed that in places the centre supporting timber and the props were up to 4 times overloaded sufficient to explain the flexural failure of this timber and the buckling of some props. The work had been carried out by a formwork sub-contractor without any design being undertaken. Collapse; Formwork Keywords from list Job nature type of activity Incident rating potential Incident rating actual A 8 0
Architect
Engineer
TW Designer 10
Other (Specify)
1 L
Remarks The failure could have been prevented if a proper design had been undertaken and a suitably competent person had supervised the works. The failings were quite basic and should have raised questions by anyone having a reasonable knowledge of these types of temporary works. Telescopic props are made with a large reserve of strength and the fact that some buckled indicates a serious degree of overloading. However, this large reserve of strength does tend to encourage abuse by incompetent persons as does therefore require proper control.
68
Quick Ref Designers
6E
Description of incident A proprietary falsework system was being dismantled. The materials used to build the non-standard falsework and access ways around the system, were scaffold materials and plywood. This resulted in tripping hazards which compounded the absence of guard rails in some instances. There was a potential for persons to fall over 5m due to the ad hoc nature of the temporary works which had not been dealt with in the design. Keywords from list Job nature type of activity Incident rating potential Incident rating actual Falsework; Access A 8 0
Architect
Engineer
TW Designer 6
Other (Specify)
Cost implications
Remarks Temporary works should be designed so that they are safe to erect, use and then dismantle. The design of this falsework system did not consider the needs for access during each of these stages. This should have been dealt with when arranging the layout of the proprietary equipment and associated make-up areas and formalised in the method statement. The use of proprietary equipment, which incorporates typical solutions for access etc., can lead to a false sense of security. This is because the difficulties that can arise when dealing with the nonstandard areas around the proprietary system can be forgotten, meaning that the contractor must do the best he can. The quality and suitability of the resulting in-fill will then depend on the experience and reliability of those doing the work and on the materials or equipment that is at hand.
69
Quick Ref Designers
4C
T/W
Description of incident A large steel reinforcement cage, approx. 4.25m highx4.1m long backed by a 2.1m wide and 1.6m deep chamber area, was being prefabricated prior to being lifted into an existing sewage tank but collapsed before the work had been completed. No additional bracing or strengthening had been incorporated within the cage either to support it while being prefabricated or when being lifted into position. No access had been provided for the steel fixers who therefore climbed the steel bars and rigged some 100mm wide timbers to stand on. The work was being done by a specialist steelwork and formwork sub-contractor for the main civil engineering sub-contractor who was working for the main contractor. Reinforcement cage; Bracing; Temporary works Keywords from list Job nature type of activity Incident rating potential Incident rating actual G 8 4
Architect
Engineer
TW Designer 4
Other (Specify)
Cost implications
Remarks The re-ordering of the construction sequence by the sub-contractor was a sensible decision but did involve structural issues. The decision to prefabricate the reinforcement was taken by the re- sub-contractor but should have involved a full design review. Additional materials were required over the minimum necessary for the original design which envisaged the reinforcement being erected in place against the formwork wall shutter.
70
Quick Ref Designers
4F
Contractor
Description of incident Steel re- was being placed for a 45m long x 7.3m high x 0.6m thick wall. The work was nearing completion except for the upper 3.3m section at the end 9m of wall. The reinforcement partly collapsed when an access ladder, fixed to it for use by the steel fixers, was removed. A full collapse was probably averted because of the stiffening effect of the starter bars from the concrete kicker and because at one end of the wall the reinforcement returned onto a section of wall that had already been cast. As a result the heavier reinforcement at the lower section of the outside face of the wall remained in place. The reason for such a large length of wall was being worked on was because delivery of water bars had prevented the casting of a shorter length of wall. Keywords from list Job nature type of activity Incident rating potential Incident rating actual Reinforcement; Temporary works G 8 0
Architect
Engineer
TW Designer
Other (Specify) Contractor 4
Cost implications
Remarks The reinforcement cage was a substantial structure in itself and contained over 22 tonnes of steel. The erection of such structures requires proper consideration, particularly when unusual circumstances come into play, and this should have flagged up the need for effective lateral supports. Apparently the reinforcement cage appeared to be quite stable before the collapse and both faces of the cage were well tied together. The collapse was attributed to the removal of a ladder from the uncompleted end which may have pulled on the reinforcement initiating the collapse. There was also a failing on the part of the site supervision that they failed to react and question the stability of such a large structure.
71
Quick Ref Designers
8E(C) 8J(T)
Consultant TW
Description of incident A 12m long x 330mm wide block wall was being used as an external shutter for a 4.7m high mass concrete filling, to be done in 3 lifts. During the pouring of the upper lift the block wall failed and the wet concrete cascaded down onto a railway line below, forcing its temporary closure. The concrete density had been increased without reference to the designer and was also very fluid. However the design had not made proper allowance for the fluidity of the original concrete mix and had not required any temporary supports to the block wall. Keywords from list Job nature type of activity Incident rating potential Incident rating actual Falsework; Concrete; A 8 4
Architect
Engineer 8
TW Designer 8
Other (Specify)
Cost implications
Remarks The design seems to have been carried out by someone who was not sufficiently experienced to temporary works design and who mistakenly assumed that the loads, pressures and situations can be narrowly predicted. Errors or omissions in the original design meant that there was insufficient allowance for the possibility of site variations in concrete pressure, from changes in the density and fluidity of the concrete, instigated on site. However, these changes alone should not have led to failure if the original design had been sound. The consequences of a shutter failure on this site could have been extremely serious. Therefore, the design of the shutter should have been extremely detailed and adhered to.
72
Quick Ref Designers
10G
TW
Description of incident The reinforcement for large 12 15m high walls was being fixed in a 97mx47m building that also had a central spine wall. While some walls in this building had been concreted, most consisted only of the reinforcement cage. The walls were 1.6m wide with 3 layers of vertical re- EF & 3 layers of horizontal re- EF: mostly 32mm diam. bars at 174mm c/c, with frequent laps, which meant that high wind pressures could develop. Generally, the two opposite faces of the cage were tied together, but at one length only the reinforcement to the internal face had been erected. Strong winds blew this reinforcement over which dragged adjoining large areas of the fully erected cage and large sections of access scaffolding. Wind loading; Reinforcement; Stability Keywords from list Job nature type of activity Incident rating potential Incident rating actual G 8 6
Architect
Engineer
TW Designer 10
Other (Specify)
Cost implications
Remarks Even after the event the specialist researchers could not agree the cause of the failure. With such huge areas of free-standing re- it is reasonable to expect design checks to be made on the stability of such structures. This is especially true where only one face of the reinforcement was being erected. It appears that the approach adopted on site was little different from when erecting reinforcement against wall shutters for relatively short lengths, medium height walls and not realising that they had moved into a very different league. There are a variety of provisions that could have been made to reduce the risk of collapse. These include welding the faces of the cages together so ensuring that they acted together, using the access scaffold to prop the reinforcement effectively significantly increasing the overall width of this temporary structure, or by limiting the area of reinforcement that would be exposed to wind loading. This latter provision would include making use of the corners as a strong point, casting these first to provide rigid anchors to hold the adjoining rebar cages.
73
Quick Ref Designers
6E
Manuf
Description of incident A proprietary formwork system consisted of waffle moulds resting on a framework of beams and infiller beams. These were supported by a system of props, lacing tubes and braces. One of the beams had not been correctly fitted into position, possibly because one end had been damaged, and in the same area the bracing to the prop heads had been omitted. This possibly allowed the prop heads to move slightly and allowed the beam to fall.
System formwork; Structural erection G 6 6
Architect
Engineer
TW Designer
Other (Specify) Manuf 6
Cost implications
Remarks The design of proprietary systems should take account of the possibility of erector error and limited component damage. The end fixing for the beams should be designed so that they are either correctly located or cannot be fitted at all. Being able to use a damaged/incorrectly fitted item is a recipe for disaster. Any damage that could be significant but would not be easily recognised presents a serious hazard. Items should be so designed that any defects that could be a problem are easily recognised.
74
Quick Ref Designers
2C
Consultant
Description of incident A proprietary falsework system was being used to support plywood formwork. Areas between the proprietary system were being individually supported on props. The falsework was being stripped without ensuring that the plywood formwork was also removed. In one area a hole for a duct had been formed in the slab although the plywood formwork continuously covered the area. This area of plywood also remained in place after the supporting falsework and props had been removed. A person stood on the plywood that then collapsed. Keywords from list Job nature type of activity Incident rating potential Incident rating actual System falsework A 6 6
Architect
Engineer 2
TW Designer
Other (Specify)
Cost implications
Remarks The main circumstances that contributed to this incident were due to failures by the site management. However had a detailed design procedure been provided it is possible that some of these circumstances would not have occurred.
75
Quick Ref Designers
10J(T) 4E(A)
TW/Arch
Description of incident An existing 3-storey building was being completely stripped for conversion into offices. This work also included excavating in the basement area requiring temporary propping to the ground. The fabrication, standard of construction and design of these earth retaining structures was very suspect, as was the means of access into the ground works and a PN was issued.
Refurbishment; Temporary stability; Ground stability R 8 0
Architect 4
Engineer
TW Designer 10
Other (Specify)
3 E
2 E
Remarks The arrangements required to support ground which is in the vicinity of load bearing walls needs careful assessment and the temporary works necessary to support the ground needs to be designed by an experienced engineer having the relevant competencies in this type of work. No mention is made of the need to fully investigate the loads on the walls being left in place and particularly the depth of their footings in relation to the depth of the excavation.
76
Quick Ref Designers
8G
Consultant
Description of incident A brick wall surrounding a site collapsed after some excavations had taken place close to it. The site area was 2-3m below the adjoining street level and the wall foundation extended another metre below the general site level. An earth embankment formed on its side facing the site supported the wall. This embankment was being modified to form an access way to road level by cutting part of it away and depositing the removed material lower down the ramp. While the wall itself was reasonably sound it had been underpinned at some time with 2-3m concrete. This was in a poor condition with its vertical and horizontal casting joints in a very poor condition. The exposed face of the concrete had been rendered partially hiding the condition of the concrete. Excavations; Structural stability; Adjacent structures Keywords from list Job nature type of activity Incident rating potential Incident rating actual E 10 0
Architect
Engineer 8
TW Designer
Other (Specify)
Cost implications
Remarks When retaining old structures, facades, etc, designers should ensure that their true conditions are known. In this case, the condition of the of the wall should have been checked and measures designed in or information provided, to ensure that it remained stable. Any situation where major forces could occur and especially where some interference will be made to materials that support buildings, roads, railways or major services, should be thoroughly examined before starting work.
77
Quick Ref Designers
10J(T) 6G(A)
TW/Arch
Description of incident An excavation was being carried out beside an existing retaining wall into a sandy soil. The wall was 570mm thick, some 1.2 1.5m above the lower ground level with the u/side of its foundations 1.2 1.5m below lower ground surface. The trench had been excavated to a depth of 0.65 1.2m below the walls foundations. Approx. 7.4m length of wall collapsed into the trench.
Excavation; Collapse of structure E 8 2
Architect 6
Engineer
TW Designer 10
Other (Specify)
Cost implications
Remarks The design required the excavation adjacent to the wall therefore, the effects of this process on the stability of the wall should have been investigated. Effective temporary ground support should have been installed against the wall before excavation started, driven to such a depth so as to prevent the wall collapsing. To be able to do this effectively proper ground investigations should have been carried out. While there was a design failing in not providing information on the nature and depth of the wall those carrying out the excavation work should have realised there could be a potential problem when they first exposed the bottom of the retaining wall.
78
Quick Ref
2C(A) 8E(C) 6C(M)

A/C/M
Designers
Description of incident Excavations were being carried out in clay soil, the upper 1.2m generally being disturbed material: generally, the excs were 1.2m deep but at one location 2.7m. The sides of the trenches were being lined with polystyrene sheets to protect the new structure from clay heave. A person went into the deepest part of the trench to secure these sheets when one side of the excavation partly collapsed.
Excavations; Trench work E 6 2
Architect 2
Engineer 8
TW Designer
2 R
2 R
1 R
Remarks The principal error was by the contractor and the individual.
79
Quick Ref Designers
4C
Consultant
Description of incident A worker was setting up a laser target in a trench approx. 3.1m below ground level [Approx. 1.1m of made up ground overlying a sandy clay] when he was struck by falling earth. The trench had near vertical sides 1.75m high and then battered back at less than 450. A trench box was on site but had not been installed at the time of the accident. Trial pits had been dug in the vicinity of the works that clearly revealed the nature of the ground. The excavation had been opened at least the day before the accident.
Excavation; Trench collapse E 6 4
Architect
Engineer 4
TW Designer
Other (Specify)
Cost implications
Remarks The designer should have highlighted the risk of falling debris in the DRA. This type of ground is well known to be very suspect, particularly as the trench was quite deep. This information was available to the designer even if he did not commission it.
80
Quick Ref Designers
2C
Consultant
Description of incident A labourer was working in a 1.5m trench with near vertical sides. No support was provided to the trench and while the labourer was crouched over his work earth material fell on him causing serious injuries. The ground was formed from a top 600mm layer of made ground overlaying coarse sand and gravel.
Excavation; Trench collapse E 6 4
Architect
Engineer 2
TW Designer
Other (Specify)
Cost implications
Remarks The designer should have highlighted the risk of falling debris in the DRA. Although the ground was not particularly deep its nature made it particularly susceptible to falls. However as the ground was covered by fill material it required trial pits to be dug to investigate the grounds true character.
81
Quick Ref Designers
N/A
Description of incident A light fitting, one of around 200 was being changed in a college dining room with a 6.15m high ceiling. A ladder was being used for access resting on a smooth marble floor area and resting against the side of a polished concrete drop beam. The ladder slipped. After the accident a small portable hydraulic vertical lift access platform was used.
Ladder work; C 6 6
Architect N/A
Engineer N/A
TW Designer N/A
Other (Specify) N/A
Remarks Where there are items that could need maintenance at frequent intervals more permanent access provision should be made than for items that are unlikely to need much or any maintenance. Any systems provided should be appropriate to the likely skills of those who would use them.
82
Quick Ref Designers
4C
Manuf
Description of incident A suspended access platform was being used for repairs on a block of flats when the power supply failed causing the automatic locking system to activate and trap the persons using the equipment on the platform. No means had been provided for the workers to signal for help and they were not aware of how to release the locking mechanism.
Access; Fail safe C 8 0
Architect
Engineer
TW Designer
Cost implications
Remarks It is important that the design of the system, especially the systems of control, is very obvious to the persons who are likely to use those systems. It is common for persons with little or no experience or knowledge of the mechanics of powered suspended access platforms to be expected to use them. The means of using this type of equipment should therefore be very obvious. A large part of this problem was that the occurrence was rare and the workers on the platform had either forgotten or not been told how to deal with it. In addition the initiation of the failure through a damp and loose electrical connector suggests that the maintenance of the access platform was suspect.
83
Quick Ref Designers
10G
Architect
Description of incident A cleaner climbed into a spirally wound overhead ducting to clean it out. A 3m approx. length, which was supported directly at only one end collapsed at a point where an inspection hatch had been installed. The structural supports to the ducting were noted as being completely inadequate.
Cleaning C 6 ?
Architect 10
Engineer
TW Designer
Other (Specify)
2 E
Remarks The designer should have been aware that the ducting would need cleaning from time to time, most likely by someone working inside it The supports to the ducting, and possibly the ducting, were not strong enough to support the weight of the cleaner. This should have been obvious to anyone concerned with the design. Although it is probable that the ducting was designed and installed by someone who would have little appreciation of the cleaning needs of the site, this should have been obvious to the architect.
84
Quick Ref Designers
N/A
Description of incident A 100-year old 33m high building was being repainted. The working platforms for the painters were on a light duty scaffold secured to the building with ring ties. The scaffold had been built in sections and was moved progressively around the building as the work proceeded, with the section of the scaffold being dismantled carried around and stored on an adjoining section prior to rebuilding it. The weight of the stored scaffold materials overloaded the scaffold and it collapsed. Some of the ring ties failed in shear and others pulled out og the buildings faade.
Access; Scaffolding G 10 0
Architect N/A
Engineer N/A
TW Designer N/A
Other (Specify) N/A
Cost implications
Remarks Facilitating routine maintenance by some form of permanent feature(s) will vary in practicality according to both the frequency of the maintenance and the cost effectiveness in supplying the feature. For instance if this is complex and expensive to install then it could be cost effective to make it permanent even if the maintenance frequency was low. On the other hand even a simple, low cost feature required for very regular work could be permanently installed so as to be cost effective. All such measures are likely to be more reliable than temporary ones.
85
Quick Ref Designers
N/A
Description of incident A maintenance worker was looking for the source of a water leak by standing on/crossing over a suspended ceiling. This was only designed for very light use such as carrying insulation material, and it failed. The area above the ceiling contained ducting and air conditioning equipment and there was evidence that occasional access took place over the suspended ceiling.
Access; Maintenance C 6 6
Architect N/A
Engineer N/A
TW Designer N/A
Other (Specify) N/A
Cost implications
Remarks Any ceiling or platform that has any sort of plant/equipment above it and is relatively easily accessed can be almost guaranteed to be used as an access or working place. Consequently the only practical solutions of ensuring persons cannot fall through them is to either make them strong enough or make access impossible.
86
Quick Ref Designers
4E
Architect
Description of incident Scaffold walkways were being installed over the fragile ceiling to a swimming pool. One length of tube fell through the ceiling and hit a swimmer below. The area above the ceiling was a plant room for the pool. The ceiling itself had quite a complex shape which would be a major discouragement for persons to stand directly on it.
Access; Fragile ceiling G 10 4(public)
Architect 4
Engineer
TW Designer
Other (Specify)
Cost implications
Remarks
87
Quick Ref Designers
6E
Architect
Description of incident A building was being refurbished and in the course of this staircase balustrade and handrails had been removed and plastic warning tape placed around the stair well. Upholsters were working on the upper floor in the neighbourhood of the stairs and one fell down the stair. well.
Access; Unprotected edge R 6 4
Architect 6
Engineer
TW Designer
Other (Specify)
Cost implications
Remarks The sequence of installing new balustrading after the removal of the old should have been strictly controlled and suitable temporary barriers should have been installed in the meantime. The more complex the maintenance or refurbishment works the greater the need to plan and design it to minimise errors. This planning and design would clearly require contributions from all those involved.
88
Quick Ref Designers
N/A
Description of incident An electrician was installing cabling on a 5m high cable tray, which rested on a small beam. The floor below was mostly filled by plant and the electrician was using a portable ladder to gain access to the cable tray. There were faults with the ladder feet and the floor was of a sealed concrete making the coefficient between ladder and floor quite low. The ladder apparently slipped while the electrician was on it and he fell.
Ladder access; Original design C 6 6
Architect N/A
Engineer N/A
TW Designer N/A
Other (Specify) N/A
Cost implications
Remarks The problem here was congestion in the area under the cable-tray. Perhaps it could have been installed in an area where access could have been more easily provided. Alternatively hooks could perhaps have been fitted to the tray or supporting beam to allow a ladder to be engaged on them for added security. Using a ladder at this height and in a poor condition would be a gamble which would be made worse by only having the small depth of the supporting beam to rest against. As ladders can only be altered in length by approx. 220mm increments, the opportunities of arranging the ladder in the limited floor space, at a reasonable angle and against the beam would be limited
89
Quick Ref Designers
10J
Architect
Description of incident A new building that partly extended over a motorway had arrangements for the window cleaners where they worked off mesh walkways and were secured by a waist high safety line to which they were attached via lanyards and harnesses. There were no guard-rails or other form of barrier. Little provision had been made, through the use of toe-boards etc, to prevent the fall of materials to the pedestrian areas and motorway below.
Edge protection; Access; Falls of materials W 10 0
Architect 10
Engineer
TW Designer
Other (Specify)
Cost implications
Remarks The designer tried to minimise the visual impact of the access and protective systems for the window cleaners. Although it should have ensured that the window cleaners were safe and that people below were protected from falling objects, it did not. This is an example where a safe system of work can be provided which still does not meet the legal requirements.
90
Quick Ref Designers
8J
Manuf
Description of incident A luffing screw on a window-cleaning cradle broke allowing the cradle jib to drop onto the roof parapet. The screw had become stiff at a fixing position causing a rotational failure.
Equipment failure; Access W 10 4
Architect
Engineer
TW Designer
Cost implications
Remarks No facilities were provided in the design to allow access, for routine inspections, to the area where the failure of a safety-critical item occurred. All surfaces of items that are subject to abrasion, loosening or corrosion should be capable of being properly inspected, serviced and lubricated.
91
Quick Ref Designers
6C
Manuf
Description of incident The roof rig of a permanent window-cleaning cradle became dislodged off the roof runway beam. The problem occurred where a turntable had been installed to allow the rig to be moved off the perimeter runway beam into a parking bay. It was found that the turntable had a guard plate to prevent the rig run off, over the turntable but this was on the wrong side. In addition the rail on the turntable was not correctly aligned with the perimeter rail when the turntable was locked into position ready for use.
System access cradle W 10 0
Architect
Engineer
TW Designer
Cost implications
Remarks While the main part of the fault probably lies with the construction of the rig runway, the design was not as foolproof as such a vulnerable system should be. The cradle rig was fairly simple to use and it is probable that the rig was used previously across the turntable without incident through not going too far. The failure occurred when the rig travelled too far and should have been stopped by guard plate if it had been in the right place. The incorrect alignment of the turntable rail only compounded the problem. An effective inspection after the rig was installed should have revealed the problem.
92
Quick Ref Designers
8G
Architect
Description of incident Advice was given on two window cleaning systems. In the first case cradles were to be slung from a permanent beam fixed at eaves level. The fixings for this beam were to be largely hidden behind a fascia panel making inspection difficult. Advice was given for the inspection to be at more frequent intervals. In the second case a powered gantry was to climb a 300 glass atria roof and the cradle for the cleaners would have to be manhandled to its different faces. It was recommended that some form of trolley should be provided to help with this. Installing the cradle was quite complicated and required the cleaners to be well trained. Keywords from list Job nature type of activity Incident rating potential Incident rating actual Window cleaning system; System access W 10 0
Architect 8
Engineer
TW Designer
Other (Specify)
Cost implications
Remarks The advice given dealt with necessary precautions and these should have been obvious to the designer without requiring the HSE Inspector to intervene. In addition the atria gantry cradle should have been designed to be more easy to use. The decision to provide a relatively complicated mechanical system for use by window cleaners could lead to problems and training costs. Window cleaners regularly change jobs and are often recruited from the bottom of the employment ladder. This could mean that there would be a steady turnover of trained cleaners requiring a continual commitment to train new staff. All fixings for suspended or slung equipment should be readily observable so that any deterioration or damage will be quickly seen.
93
Quick Ref Designers
8G
Architect
Description of incident Suspension wires for overhead tramway cables were to be fixed to a building that had its windows cleaned through the use of a suspended cradle. It was found that the travel of the cradle could not easily interfere with the suspension wires but to be sure projecting stops were fixed to the building to prevent the cradle moving too close to them.
Access equipment W 10 0
Architect 8
Engineer
TW Designer
Other (Specify)
Cost implications
Remarks During the lifetime of most buildings, especially those in busy areas, there will be frequent and numerous demands for alterations and changes. It is part of the designers job to facilitate such changes as simply as possible
94
Quick Ref Designers
8G
Manuf
Description of incident A window-cleaning cradle collapsed when a stainless steel bolt failed. This had been made by welding a head onto the shaft rather than turning it down from larger diameter bar. The manufacturers of the bolt had not been informed of the critical nature of the bolt.
Acc equipment failure; W 10 0
Architect
Engineer
TW Designer
Other (Specify) Manufacturer of cradle, not pin 8
Cost implications
Remarks It is probable that a more structurally reliable component would have been produced if the manufacturers had been aware of its critical nature and how it was to be loaded. The designer had two options that could have helped to avoid this incident. The first was to have provided details on how the bolt was to be used, the second to have provided a detailed specification of how it should be tested. By not doing either the design failed as insufficient information was provided to allow the bolt to be properly manufactured.
95
Quick Ref Designers
6E(A) 10J(T)
A/T
Description of incident The insides of two adjoining buildings were being demolished prior to their renovation. One building had been extensively vandalised and left open to the weather for approx. 2 years causing deterioration to the internal timbers. As the demolition progressed one floor collapsed causing other floors below to fail. Subsequent investigation showed that the joists were rotten and that the structural arrangement of the floors was not as straightforward as could be assumed without detailed investigation. The faade of the buildings was being retained to a design prepared by an engineering consultant. Keywords from list Job nature type of activity Incident rating potential Incident rating actual Structural collapse; Demolition D 8 2
Architect 6
Engineer
TW Designer 10
Other (Specify)
Cost implications
Remarks The state of the buildings should have been carefully surveyed prior to work starting and detailed plans drawn up to ensure the stability of the structural components as each level was removed. Such a survey should have investigated both the structural format of the buildings and the condition of the various structural components. In designing any temporary support work it would be necessary to allow for the accumulation of debris etc. following the removed of upper levels.
96
Quick Ref Designers
N/A N/A
Description of incident Collapse of a series of 48 roof trusses during erection. Bracing had been specified but not fixed in the main and in any case inadequately fixed.
Bracing; Roof truss erection collapse O 8 4
Architect
Engineer
TW Designer
Other (Specify) N/A Contractor management
Cost implications
Remarks While this matter was not designer related in the main it could have been that had additional information been provide on the drawings that the sub-sub-contractor used would have been less likely to make the omissions made. The information may have been in place and benefit is given to the designer in this case.
97
Quick Ref Designers
2A
TW
Description of incident Special pin jointed roof truss installation in difficult site. Report based on prior test of erection method. This summary based on future project as well.
Access; Roof truss erection O 8 0
Architect
Engineer
TW Designer 2
Other (Specify)
Cost implications
Remarks This was a significant project in a public place so additional resources had been applied to manage risk.
98
Quick Ref Designers
N/A
Description of incident Fall through a fragile roof. Crane driver giving advice to contractor regarding slinging of gable end section of a building.
Fall from height through; Fragile roof O 6 4
Architect
Engineer
TW Designer
Other (Specify) Contractor management
Cost implications
Remarks The only moot point here is whether a designer should have provided information to the contractor about the nature of the roof lights. It would however have been just as dangerous for the designer to have established this fact unless a desk study could have provided the information. All roof lights should be assumed to be fragile unless otherwise indicated.
99
Quick Ref Designers
8G
Consultants
Description of incident This report relates to steel work erection requiring tandem lifts due to design.
Structural erection; Lifting operations O 8 0
Architect
Engineer 8
TW Designer
Other (Specify)
Cost implications
Remarks Designers could have designed in such a manner that tandem lifts were not required. Further difficult marrying of two elements required by design introduced unnecessary hazards.
100
Quick Ref Designers
4E
M
Description of incident Failure of pre-cast, pre-stressed floor slab under its own weight. Report states that the units may have been damaged in transit or during erection. No information available to inform in relation to product quality.
Structural failure; Pre-cast units G 8 0
Architect
Engineer
TW Designer
Other (Specify) Manufacturer Handler 4
Cost implications
Remarks Manufacturers of system building products should expect some mishandling in transit and during fabrication. If this is critical to safety and stability of their product, specifiers and users should be alerted to the need for caution.
101
Quick Ref Designers
N/A
Description of incident Collapse of floor slabs during construction of a block of flats. The pre-cast slabs rested on lintels that showed excessive deflection. The slabs were propped with timber which subsequently failed leading to progressive collapse of structural elements. The lintel was a replacement element that had been selected by an individual with no technical training together with a builders merchant. Keywords from list Job nature type of activity Incident rating potential Incident rating actual Structural failure; Pre-cast units G 8 4
Architect
Engineer
TW Designer
Other (Specify) Contractor
Cost implications
Remarks Such on the hoof solutions to problems of supply or construction are very common. Where they succeed in solving a problem they tend to be commended. Where they do not they are roundly criticised. Clearly design input was needed and was not used.
102
Printed and published by the Health and Safety Executive C30 1/98 Printed and published by the Health and Safety Executive C1.10 04/04
ISBN 0-7176-2836-1
RR 218
25.00
9 78071 7 628360

Review of Cause of Construction Accidents - HSE rr218 PDF

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Health & Safety Executive

Peer review of analysis of specialist group reports on causes of construction accidents

RESEARCH REPORT 218

Health & Safety Executive

Peer review of analysis of specialist group reports on causes of construction accidents

PROJECT OBJECTIVES AND WORK PHASES.5

ASSUMPTIONS AND PROCESSES.11

FINDINGS13 COMMENTARY.21 RECOMMENDATIONS.25

APPENDIX 1 CATEGORIES27 APPENDIX 2- ACCIDENT ANALYSIS SHEETS.29

INDUSTRY WIDE INITIATIVES

PROJECT OBJECTIVES AND WORK PHASES

WORK PHASES Phase 1: Initial research by Malcolm James

AUTHOR ENTRY VIEW

IMPACT OF FATAL ACCIDENT REPORTS

ASSUMPTIONS AND PROCESSES

PROCESSES AND ITERATIONS

Table 1 Summary chart

10J M 8J M 4G M 10J Contractor

4E 4E 10J 8J M 6C M 8G 8G 6E 2A 8G 4E M/Transport 8G 10J -

TOTAL TOTAL TOTAL TOTAL TOTAL

Notes 1 2 3 4 Total incidents considered in detail Total incidents reported 73 91

Notes: 1 2 3 4 Total incidents considered in detail Total incidents reported 73 91

Notes: 1 2 3 4 Total incidents considered in detail Total incidents reported 73 91

Table 5 Summary of designer intervention Temporary works design

Notes: 1 2 3 4 Total incidents considered in detail Total incidents reported 73 91

Table 6 Summary of designer intervention Supplier or manufacturer

Notes: 1 2 3 4 Total incidents considered in detail Total incidents reported 73 91

APPENDIX 2 ACCIDENT ANALYSIS SHEETS

Quick Ref Designer

Collapse/partial collapse; Erecting structures; Steel/rc frame F 8 0

Other (Specify) Contractor 8

Designer specialist knowledge

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB 01H

Quick Ref Designers

Other (Specify) Manufacture 4

Designer specialist knowledge

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB02H

Quick Ref Designers

Designer specialist knowledge

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB03H

Quick Ref Designers

Other (Specify) Manufact 6

Designer specialist knowledge

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB04H

Quick Ref Designers

Other (Specify) Manufacturer 6

Designer specialist knowledge

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB05H

Quick Ref Designers

Falls from height through; Roof work; Commercial building O 6 4

Other (Specify) N/A

Designer specialist knowledge

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB 06H

Quick Ref Designers

Falls from height through; Roof work; Commercial building O 6 2

Other (Specify) N/A

Designer specialist knowledge

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB 07H

Quick Ref Designers

Falls from height off edge; Structural erection; Steel frame O 8 8

Other (Specify) N/A

Designer specialist knowledge

HSE Peer review: Ref 4467/R33.115 Case worksheet HAB 08H