Sub-Contractor:

Main-Contractor
:

Detailed Investigation Report

(Lifting Operation Failure ‘’Assembly Works’’)

Document Number:

00 14/12/2017 Information&Approval A.Dogani K.Leka E. Barhani E. Company

REV DATE ISSUED FOR ISSUED BY CHECKED BY MD TD CPM

IEC
□ □ □
Engineer
REJEC
DATE BY APPROVED NA COMMENTS
TED

Present document is property of Owner and it is prohibited any copy and/or convey of its original copy with any means, before the written
confirmation and approval of the Company's legal represents.
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1 TABLE OF CONTENTS
PURPOSE .................................................................................................................................................................4

2 SCOPE .............................................................................................................................................................4

3 INVESTIGATION REFERENCES ..........................................................................................................................4

4 INVESTIGATION OF HEALTH, SAFETY, AND ENVIRONMENT CONSIDERATION .................................................4

4.1 Requirements .................................................................................................................................4

4.1.1 Team Members Trainings .......................................................................................................5

4.1.2 Tools and Equipment..............................................................................................................5

4.1.3 Weather Condition .................................................................................................................6

4.1.4 Housekeeping .........................................................................................................................6

4.1.5 Communication ......................................................................................................................6

4.1.6 First Aid and First Aider ..........................................................................................................6

4.1.7 Investigation of Grounding (Earthing) ....................................................................................6

4.1.8 Investigation of Emergency numbers at Site..........................................................................6

4.1.9 Investigation of Method of Anchoring the Hydraulic Winch for Derrick. ..............................7

4.1.10 Investigation of Method of positioning and anchor points of the Derrick during Incident. ..7

4.1.11 Investigation of Method of Anchoring of the Steel rope and Steel Pulleys on the steel
elements of the Tower during lifting operation. ....................................................................................7

5 MANUUFACTURING AND CE STANDARDS INFORMATION ABOUT (LIFTING MACHINERIES, EQUIPMENT’S

ACCESSORIES......................................................................................................................................................... 11

..............................................................................................................................................................12

..............................................................................................................................................................13

..............................................................................................................................................................14

..............................................................................................................................................................15

..............................................................................................................................................................16

..............................................................................................................................................................18

..............................................................................................................................................................19

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6 DESCRIPTION OF INCIDENT STEP BY STEP ..................................................................................................... 20

..............................................................................................................................................................20

7 CONCLUSION & HS MEASURES ..................................................................................................................... 21

8 CONTRACTOR ORGANIZATION...................................................................................................................... 22

9 APPENDIX B - JOB HAZARD ANALYSIS ........................................................................................................... 23

10 APPENDIX C RISK ASESMENT ........................................................................................................................ 27

11 APPENDIX D - EQUIPMENT LIST .................................................................................................................... 35

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PURPOSE
To prevent measures about health and safety incidents in the feature regarding assembly of erection of
lattice steel towers required for construction of 1x400kV & 2x400kV transmission lines for OHL

2 SCOPE
This Detailed Investigation procedure establishes description and guidelines for investigation of root of
incident after incident about Lifting operation failure. It explains the the consequences of the incident,
Health Safe and Environmental Obligations prior works started., and the the final conclusion about this
incident.

Definitions
IEC – ClientEngineering Construction
CPM – Country Project Manager
TD – Technical Director
Tehno-Control –Authorized HS Company according to Montenegrin Laws

3 INVESTIGATION REFERENCES
COMPANY HSE Plan
QA/QC Plan
EN norms
Methodology Statement s

4 INVESTIGATION OF HEALTH, SAFETY, AND ENVIRONMENT CONSIDERATION

4.1 Requirements
Before Contractor will start performing the tower erection activity there is some requirements that
became completed.
1. All the crew became trained for such activity.
2. Equipment became in good condition and all safety devices functional and active during all the
time.
3. Tools must become in good shape and not damaged or modified.

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4. Visitors or vendors must have permission to get in on site, they must attend a brief about the
HSE rules and sign the attendance sheet.
5. Housekeeping and clean working area.
6. Communication.
7. Working time.
8. Work organization and team coordination.
9. Grounding
10. All the equipment’s will be inspected periodically from HSE Department of COMPANY D.S.D

4.1.1 Team Members Trainings

Team members became trained in different disciplines to perform in this activity.
 General induction training
 Tools and equipment training
 PPE training
 Fall protection training
 Work at height training.
 First aid training
Only this category of workers became working on height at the tower erection, the workers that will
work on level ground are not required to have all this training except general induction training that is
mandatory for everyone.
Worker at Height Ground Worker
General induction training + +
Tools and equipment training + +
PPE training + +
Fall protection training +
Work at height training +
First aid training + +
Rescue Plan Training(Falling from
+ +
heights)
Emergency response training + +

4.1.2 Tools and Equipment

 Tools became in good condition and was free from any damage (Techno-Control Report and
Machineries Documentation regarding the visual inspections.
 Only proper tools became allowed to use in this activity.
 Homemade tools were not present on site.

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 Equipment became in good condition and checked periodically (Techno Control Reports about
Machineries and equipment’s.
 Operator of Hydraulic Winch became use the machineries and to he be shore that the
equipment to be well maintained.
 Lifeline referred to COMPANY HSE Plan became be used for Tower erection only when the half
of the tower will be erected.
 Rescue Plan for falling from heights became everyone was informed about the way of rescue
plan.

4.1.3 Weather Condition

Weather conditions at the moment of incident was Sun and around 12 Degrees.

4.1.4 Housekeeping
On site the working area all the workplace was in good shape. Ground level was flat and free from
holes, mud, and ice. Also materials were stored in the proper way. Timbers, tools or any other material
was being store in order to have batter access and aggress.

4.1.5 Communication
According to witness communication with the team one by one during the activity the communication
became with Hand Signals.

4.1.6 First Aid and First Aider

During working time, first aid kits and box became on site that erection works of towers will be
performed. Also a first aider became present all the time on site.

4.1.7 Investigation of Grounding (Earthing)

During Investigation it was evidenced that Grounding of this Tower was not done.

4.1.8 Investigation of Emergency numbers at Site

- Ambulance
- Police
- Firefighter
- IEC Site Management
- COMPANY Site Management
Notice: Emergency numbers of above-mentioned and of the Site Management of COMPANY was share
at COMPANY Warehouse at Cetinje in order to be visible from all the Employers. And the team that
was present during the incident approve that have also this Emergency Contact on their Vehicles.

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4.1.9 Investigation of Method of Anchoring the Hydraulic Winch for Derrick.

During Site Inspection our Engineers has clearly show the conditions of method according to Hydraulic
Winch as follow;
The Hydraulic Winch was anchored in the form of a Vehicle Type Range Rover that was around 3.000kg
and was used us counterweight, the position of the vehicles.

4.1.10 Investigation of Method of positioning and anchor points of the Derrick during Incident.

During Site Investigation Inspection of our Engineers has clearly show the conditions of method
according to positioning and anchor method of Derrick during Lifting operations at T 91i.
Our Site Engineer has decelerated to HSE Department that Derrick according to witness of Foreman and
workers was fixed to 3 points on the body of the Tower because at this moment the was trying to fix the
Cross arm.

4.1.11 Investigation of Method of Anchoring of the Steel rope and Steel Pulleys on the steel
elements of the Tower during lifting operation.

During Site Investigation Inspection of our Engineers has clearly show the conditions of fixed method
according to positioning of steel ropes and steel pulleys and they decelerate as follow ;

1.The steel rope was cutter at the lever around 18m after of Derrick Hook. Attached Pictures of
Investigation date 05.12.2017.

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2.The body of the Tower near to the cross arm was deformed. Attached photo of the Body of the Tower
91 I at Date 05.12.2017;

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3.The Cross arm was on the ground deformed as a result of the fall;

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4.The hydraulic Winch was anchored to the vehicle and was fixed with Ropes and everything was in
safety conditions. Attached Picture of the Hydraulic Winch date 05.12.2017;

5 MANUUFACTURING AND CE STANDARDS INFORMATION ABOUT

(LIFTING MACHINERIES, EQUIPMENT’S ACCESSORIES

During the Investigation our HSE Department has review and check all the documentation regarding
technical specification of machineries, equipment’s and accessories that are used to site T91 I during the
incident.

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6 DESCRIPTION OF INCIDENT STEP BY STEP

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7 CONCLUSION & HS MEASURES

According to Investigation HSE department conclusion is as follow;
Incident about lifting failure was created by negligence of Foreman, if foreman would provide double
rope to the cross arm in the moment that stack the cross arm would not fall from height.

HS Measures;

All the Foreman of the Teams are informed about this incident and in the feature if they had such
situations during lifting operations they will secure the cross arm with double rope in order to not fall
from height.

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8 CONTRACTOR ORGANIZATION

Counetry Project
Manager

Site Project
Manager

HSE Advisor &Tehno -

Control

Mechanical Engineer

Mechanical
Engineer

Tower Eretion Team I

Tower Eretion Team II

Tower Eretion Team III

Tower Eretion Team IV

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9 APPENDIX B - JOB HAZARD ANALYSIS

Job Description: JHA No.: R-

DOK.07.02.012.0000.A
Tower Erection / Assembly of Towers Revision: 01
Job Location: Sub-Contractor
Name:
Job Hazard Analysis
Prepared/Revised by: Approved by: Date: 09.07.2017
Arber Dogani HSE Edison Barhani
Department Technical Department

SEQUENCE OF JOB POTENTIAL ACCIDENTS

RECOMMENDED SAFE JOB PROCEDURE
STEPS OR HAZARDS
 Improper loading or  Only qualified and trained operators will
unloading participate at this activity
 Overturn of vehicles  Usage of proper equipment for loading and
unloading
 Collapse of materials
 Safe loading of vehicles on the load capacity
 Materials falls during  Secure the loads during transportation using
1.Transportation of
transportation certified rigging equipment and in accordance
materials with boom
with CE standard
truck
 Prevent unauthorized person to access to the
working area







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 Bad positioning of
boom truck
 Overhead power lines
and cables
 Lifting gear failure
 Effects of wind speed
 Anchoring of Hydraulic
Winch
 Bad weather condition
Collapse of the load due
to improper rigging &
2.Transport and slinging
Lifting operation with
Hydraulic Winch or
boom truck  reduced according to manufactures





 Falling from height due
to slips & trips
 Falling from height due
to physical fatigue
 Falling from height due
to negligence of
workers
 Object falling from
height
 Bad weather condition
3. Working at height (rain, thunderstorm)




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 Position of boom truck on solid ground
and minimum 2m from the edge of
foundation
 Extend outriggers to full extent on both
sides when performing a lift operation
 Visual control by the operator before
starting work
 Use warning signs and guide ropes.
 Usage of certified lifting gear and in
accordance with standards
 All lifting gear must be inspected before
being put in use
 When wind velocities are above 40 km/h,
the rated load and boom lengths shall be
specifications Refer of COMPANY HSE
Plan.
 Operators should be able to determine the
weight, centre of gravity and
characteristics of the load.
 Anchoring of Hydraulic winch will be done
by concrete blocks or by vehicle
respecting the counterweight logic.
 Only trained and qualified workers will
participate at this activity
 Worker who will work at height must use
safety harness and other fall arrester
equipment’s like vertical lifeline or fall
arrest block.
 Workers will not work for a long time at
height
 Don’t smoke, eat, drink or use the phone
during working at height.
 Do not throw tools to each other
 Don’t work below the workers who work at
height
 Weather condition shall be regularly
monitored & the work must be stopped
during bad weather condition
DIR
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 Improper equipment.  All equipment must be checked before

 Checked equipment. performing on site
 Defected equipment.  All equipment must be proper for the work
 Homemade tools that will be used
 All equipment’s must be used only from
the authorized operator.
4. Equipment and
 All equipment that is modified must be
tools.
removed from the site.
 Only authorized and non-defected
equipment are allowed to use on site.
 Homemade tools are not allowed to use
on site, only certified CE/EN


 Improper PPE  All PPE must be wear by all the personnel
manual and non-manual, during all the
time that they are performing works on
site. gloves, concrete boots, hard hat,
glasses, high visible vest.
5. PPE  Safety harness must be all the time used
from all the workers that will be working at
height
 Only trained workers will work at height
 Only authorized personnel must take part
in this work activity
 All the workers on site  Each team must have a first aider in case
 Fire fight of accident or incident
 Water flood  All site must have a first aid box and to be
 Wild life placed in a place where everyone has
 Cold and heat stress access
 Emergency numbers must be put in all the
vehicles and visible to the all crew
members
6. First Aid.
 Transportation must be in each location in
(Emergency
case of necessity of transporting the
response)
injured person
 Fire training BUS (ALB)
 To be determines the assembled point for
every possible emergency at site
 First Aid Box for all the equipment’s and
vehicle working on site
 First Aid Personnel should be identified by
a stick on the helmet
 Spill incident such as  Immediately clean up using inert sand or
oil or fuel other suitable materials
 Timbers and wood  Recycle bins at the place of working
7. Housekeeping materials stacked  Accumulation of wastes Waste collector
inappropriately
 Waste of excavated
area, garbage

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10 APPENDIX C RISK ASESMENT

Residual
Degree of
Degree of
Risk
Activity and Risk
Location Hazard and/or Who Person

Risk Degree

Risk Degree
Ref Result Control Measure(s)

Probability

Probability
Responsible for
ClientProject occurring of risk Effected

Severity

Severity
Control Measure(s)
Montenegro

1. Transportation Improper loading Drivers, 5 4 20 High Risks - Qualified and trained operators 3 4 12 Foreman, Site
of materials with or unloading Workers, only Engineer, Site
boom truck Pedestrians - Safe loading of vehicles on the Manager, HSE
load capacity Repres.Techno-
- Using proper equipment for Control
loading and unloading
- Check the loads if had moved
during transportation.
2. Transportation Overturn of Drivers, 4 5 20 High Risks - Qualified operators only 2 5 10 Foreman, Site
of materials with vehicles Operators, - Speed limits on site Engineer, Site
boom truck workers - Safe loading of vehicles on the Manager, HSE
load capacity Repres.Techno-
- Secure the loads during Control
transportation using certified
rigging equipment and in
accordance with CE standard

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3. Transportation Collapse of Operators, 4 5 20 High Risks - Qualified operators only 2 5 10 Foreman, Site
of materials with materials workers, - Secure the loads during Engineer, Site
boom truck pedestrians transportation using cerfitied Manager, HSE
rigging equipment and in Repres.Techno-
accordance with CE standard Control
4. Transportation Materials fall on Operators, 5 5 25 Intolerable - Using proper PPE (hard hats, 3 4 12 Foreman, Site
of materials with personnel Workers, safety shoes, gloves, visible vest) Engineer, Site
Risks
boom truck Pedestrian - Using warning signs on the Manager, HSE
working area Repres.Techno-
- Prevent unauthorized person to Control
access to the working area
5. Lifting operation Effects of wind Drivers, 4 4 16 High Risks - Only trained operator 3 4 12 Foreman, Site
with boom track speed Operators, - When wind velocities are above Engineer, Site
All workers 40 km/h, the rated load and boom Manager, HSE
lengths shall be reduced Repres.Techno-
according to manufactures Control
specifications Refer to HSE plan
6. Lifting operation Bad positioning Drivers, 5 5 25 Intolerable - Trained and qualified operators 2 5 10 Foreman, Site
with boom track of boom track Operators, Risks - Position the boom track on solid Engineer, Site
All workers ground Manager, HSE
- Extending outriggers on both Repres.Techno-
sides when performing a lift Control
operation
7. Lifting operation Overhead power Drivers, 5 5 25 Intolerable - Visual control by the operator 2 5 10 Foreman, Site
with boom track lines and cables Operators, Risks before starting work. Engineer, Site
All workers - Use warning signs. Manager, HSE
Repres.Techno-
Control

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8. Lifting operation Bad weather Operators, 5 5 25 Intolerable - Weather condition shall be 2 5 10 Foreman, Site
with boom track condition workers Risks regularly monitored Engineer, Site
- Work must be stopped during Manager, HSE
bad weather condition Repres.Techno-
- Wear proper PPE Control
9. Lifting operation Lifting gear Drivers, 4 5 20 High Risks - Only trained and qualified 2 5 10 Foreman, Site
with boom track failure Operators, personnel Engineer, Site
All workers - Inspect and determine whether a Manager, HSE
rope or other piece of lifting Repres.Techno-
equipment is damaged or not fit Control
for purpose
- Use certified lifting gear and in
accordance with CE standard
10. Lifting operation Collapse of the Operators, 5 5 15 Intolerable - Only trained and qualified 3 4 12 Foreman, Site
with boom track load due to all workers Risks operators Engineer, Site
improper rigging - Operators should be able to Manager, HSE
& slinging determine the weight, centre of Repres.Techno-
gravity and characteristics of the Control
load.
- Tool Box Talk
11. Lifting operation ,Anchoring of Drivers, 5 5 25 Intolerable - Only trained and qualified 3 4 12 Foreman, Site
with Hydraulic hydraulic winch Operators, Risks operators Engineer, Site
Winch All workers - Tool Box Talk Manager, HSE
-Anchoring of hydraulic winch will Repres.Techno-
be by Concrete blocks of similar Control
solutions as anchoring on the
trees etc.

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12. Working at Falling from All workers 5 5 25 Intolerable - Only trained and qualified 2 5 10 Foreman, Site
height height due to who works at Risks workers Engineer, Site
slips & trips height - Fall arrest methods such as Manager, HSE
lanyards and fall arresters
Repres.Techno-
(Blocks) or vertical lifeline shall be
used. Control

- Wear proper PPE (safety

harness, hard hats, safety shoes,
gloves, visible vest)
- Tool Box Talk & SSC
13. Working at Falling from All workers 5 5 25 Intolerable - Only trained and qualified 2 5 10 Foreman, Site
height height due to who works at Risks workers Engineer, Site
physical fatigue height - Workers will not work for a long Manager, HSE
time at height. Repres.Techno-
-- Fall arrest methods such as Control
lanyards and fall arresters
(Blocks) or vertical lifeline shall be
used.

- Wear proper PPE (safety

harness, hard hats, safety shoes,
gloves, visible vest)
- Tool Box Talk

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14. Working at Falling from All workers 5 5 25 Intolerable - Only trained and qualified 2 5 10 Foreman, Site
height height due to who works at Risks workers Engineer, Site
negligence of height - Don’t smoke, eat, drink or use Manager, HSE
workers the phone during working at Repres.Techno-
height. Control
- Fall arrest methods such as
lanyards and fall arresters
(Blocks) only up of the middle of
Tower

- Do not throw tools to each other

- Wear proper PPE (safety
harness, hard hats, safety shoes,
gloves, visible vest)

15. Working at Object falling All workers 5 5 25 Intolerable - Don’t work below the workers 2 5 10 Foreman, Site
height from height Risks who work at height Engineer, Site
- Barricaded area with white & red Manager, HSE
tape Repres.Techno-
- Wear proper PPE (safety Control
harness, hard hats, safety shoes,
gloves, visible vest)
- Tool Box Talk
16. Working at Bad weather All workers 4 5 20 High Risks - Weather condition shall be 1 5 5 Foreman, Site
height condition (rain, regularly monitored Engineer, Site
thunderstorm) - Work must be stopped during Manager, HSE
bad weather condition Repres.Techno-
Control

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17. Working at Electrical storm All workers 4 5 20 High Risks - Weather condition shall be 1 5 5 Foreman, Site
height regularly monitored. Engineer, Site
-Tower must be grounded before Manager, HSE
start the work. Repres.Techno-
- Work must be stopped during Control
bad weather condition.
-Safety harness will be used
during all the time
-When towers erected in the midel
of the body then all the workers
that are working at heights will use
Lifeline.
18. Working at Improper type of All workers 5 4 20 High Risks - Visual check of the tools before 3 4 12 Foreman, Site
height with tools starting work Engineer, Site
hand-tools - Remove all damaged tools Manager, HSE
- Use proper tools Repres.Techno-
- Wear proper PPE (safety Control
harness, hard hats, safety shoes,
gloves, visible vest)
- Tool Box Talk
19. Working with Improper storage All workers 5 4 20 High Risks - Store all materials & tools in 3 4 12 Foreman, Site
hand-tools of materials & proper place Engineer, Site
tools - Tool Box Talk Manager, HSE
Repres.Techno-
Control
20. Emergency Accident or All workers 5 4 20 High Risks - All the crew must have a first aid 3 4 12 Foreman, Site
response, incident cured on person for any accident or incident Engineer, Site
First Aid team. site case that might be on site. Manager, HSE

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-First Aid Kit available on site Repres.Techno-

- All emergency contacts must be Control
exposed where can be seen from
all the team members.
- Transportation available to
transport the injured peoples in
every working area.
-Rescue Plan falling from heights
will be followed and instructed to
the each formen of groups from
Site engineers or site manager
and they will be ready to follow the
Plan.
21. Housekeeping Spills incident All workers 4 3 12 Medium risks - Immediately clean up using inert 3 3 9 Foreman, Site
such as oil or sand or other suitable materials Engineer, Site
fuel. - All material used to mop up spills Manager, HSE
will be immediately removed to a Repres.Techno-
safe place and stored in closed Control,
containers for safe disposal, till to Environmental
be removed from the site to a Lead
safer area
22. Housekeeping Materials stacked All workers 5 2 10 Medium Risk - Store all materials in proper 3 2 6 Foreman, Site
inappropriately place. Engineer, Site
Manager, HSE
Repres.Techno-
Control
23. Housekeeping Garbage The access 4 3 12 Medium Risk - Recycle bins available on site 3 2 6 Foreman, Site
road - Accumulation to Matej DO waste Engineer, Site

Document Number: IEC-000-TO-00-02_DIR_01 DIR

 Detailed Investigation ISSUING DATE: 14/12/2017

State of issue: 00
Incident Report ‘’ Page 34 of 35

working collector company at Cetinje Manager, HSE

area. Repres.Techno-
Control,Environme
ntal Lead.

PROBABILITY SEVERITY
1 (VERY SMALL) Almost no 1 (VERY LIGHT) No loss of work time, can only be eliminated immediately, requiring first aid
2 (SMALL) Very few (once a year), only abnormal situations, 2 (LIGHT) No loss of working days, outpatient treatment without permanent effect
3 (MEDIUM) Under (a few times a year) 3 (MEDIUM) Slight injury, inpatient treatment / injury
4 (HIGH) Often (once a month) 4 (SERIOUS) Serious injury, long-term therapy, occupational disease
5 (VERY HIGH) Very frequently (once a week, every day), and under 5 (VERY SERIOUS) Death, permanent incapacity
normal operating conditions

RESULT ACTION
Intolerable Risk The work must not be started or ongoing activity must be stopped immediately till
(25) the defined risk is reduced. Although the activities carried out are not possible to
reduce risk, activity must be avoided.
Important Risks The work must not be started or ongoing activity must be stopped immediately till
(15, 16, 20) the defined risk is reduced. The risk relates to continue to work; emergency
measures to be taken and as a result of these measures should be decided to
continue the activity.
Mid-Level Risks The activities should be started for reducing of defined risks. The reduction
(8, 9, 10, 12) measures of risk may take more time.
Acceptable Risks The identified risks may not be necessary to eliminate additional control
(2, 3, 4, 5, 6) processes. However, these controls should be continued and maintained existing
controls be inspected.
Unimportant Planning and control processes carried out to eliminate the risks of identified
Risks activities may not need to keep records.
(1)

Document Number: IEC-000-TO-00-02_DIR_01 DIR

 Detailed Investigation ISSUING DATE: 14/12/2017

State of issue: 00
Incident Report ‘’ Page 35 of 35

11 APPENDIX D - EQUIPMENT LIST

List of Equipment and Tools used for Tower Erection

No. Description (English) Model Brand Qty.
1 Hydraulic winch 101/1/AS Tema 6
- Supplied with steel rope diam 8mm
L=500m
2 Nylon Pilot Rope 22.TR.16.1000 Tema 20
-L=1000m +
- Wound on steel reel 1400mm 062/3
3 Nylon Pilot Rope 22.16.1000 Tema 8
L=1000m +
Wound on steel reel 1400mm Cod. 062/3
062/3
4 Steel Wire Rope Tema 1
- Steel antitwist. Wire 21.12.14.900
- Diam 14mm, L=900m +
Wound on steel reel 1100mm Cod. 062/2
062/2
5 Connector Joint ' U ' Type GF 10 Tema 35
6 Connector Joint ' U ' Type GF 16 Tema 10
7 Snatch Blocks 020/0,5/N/G1 Tema 10
8 Heavby Duty Snatch Blocks 020/1,5/A /G1 Tema 6
9 Heavby Duty Snatch Blocks 020/3,0/A /G1 Tema 6
10 Gin Pole 050/3/12.3 Tema 6
-External rope passage
11 Torques wrenches 050/5/11.F2 Tema 6

Document Number: IEC-000-TO-00-02_DIR_01 DIR