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ZamzamaPhase2DevelopmentPreparationofJSA’sPreparationofJSA’sIssuesandConsiderationsResponsibilitiesExecutionHSEteamParticipantsSupervisorTeammembersHSETechniquesVisitsiteVisualiseinofficeMakethetimeCAREFULREVIEW2ZamzamaPhase2–CivilContractIndividual/teamActionsSupervisorbelievedOKtoworkonunapprovedscaffoldingasworkrequiredwasminorAbsent/faileddefencesTask/environmentalconditionsOutcomesOrganisationalFactorsPlanningofsimultaneousworkactivitiesinsameareaWorkfrontisbehindprojectscheduleFailuretoimplementactionsasrequiredbylocalHSECandScaffoldinginspectorFailuretofollowworkingatheightprotocolsinswitchroomWorkingatheightsprocedurewasnotfollowedAreaHSECadvicewasnotfollowedPressureappliedbyManagement(BHPBandDescon)tocompletejobquicklyScaffoldInspectorrequirementswerenotfollowedOnlyoneBHPBapprovedscaffoldinspectorisonsiteManyactivitieshadtooccursimultaneouslyaccordingtoplanPerceivedpressuretocommenceworkactivitiesduetoworkteamssittingidlewaitingforscaffoldtobeinspectedSitesupervisorshavenotbeenfullyinstilledwith‘ZeroHarm’asakeymeasureofsuccessICAMCategoriesandFactorsChartSummaryofInvestigationOutcomesleadinguptoevent(Primaryfactorshighlightedinred)(Primaryfactorshighlightedinred)3ZamzamaPhase2–CivilContractPreventativeandCorrectiveActionsOrganisationalFactorsFollowupActionActionByPressureappliedbyManagement(BHPBandDescon)tocompletejobquicklyFocustobeprovidedbyDesconandBHPBManagement/supervisionatalllevelsthatsafetywillbeabettermeasureofsuccessthanscheduleBHPB/DELPlanningofsimultaneousworkactivitiesinsameareaDailyplanningtobetterconsidersimultaneousoperationsandcongestionofworkactivities–particularlyinSwitchroomarea.Timerequiredforinspectionandpotentiallyreworkassociatedwithscaffoldinginstallationsshouldalsobefactoredin.DELOnlyoneBHPBapprovedscaffoldinspectorisonsiteBHPBtoevaluateDesconnominatedcandidateasScaffoldingInspectorinlimitedsupportingrole.BHPBSomefieldsupervisorshavenotbeenfullyinstilledwith‘ZeroHarm’asakeymeasureofsuccessSpecific‘Realignmentmeeting’tobepresentedtoallfieldsupervisorstoreinforcethatSafetyistheprimarymeasureofsuccessonthisproject.DELTask/environmentalconditionsFollowupActionActionByWorkfrontisbehindprojectscheduleandpossiblyunrealisticAreviewofcurrentscheduleforSwitchroomareaandrevisionifdeemedunrealistic.BHPB/DELManyactivitieshadtooccursimultaneouslyaccordingtoplanSchedulereviewtoconsiderreducingsimultaneousoperationswhereSIMOPSissuesarepotentiallymorehazardous.DELPerceivedpressuretocommenceworkactivitiesduetoworkteamssittingidlewaitingforscaffoldtobeinspectedPlanningtoassesspotentialcontingencyactivitieswhereunforeseendelaysoccurinpreparatoryworks(eggscaffolding).DEL4ZamzamaPhase2–CivilContractPreventativeandCorrectiveActionsIndividual/teamActionsFollowupActionActionBySupervisorbelievedOKtoworkonunapprovedscaffoldingasworkrequiredwasminorSpecific‘Realignmentmeeting’tobepresentedtoallfieldsupervisorstoreinforceallmandatorysafetyrequirementsontheproject.Company’s‘ZeroTolerance’policytobereinforcedtoallseniorfieldsupervisors.DELFailuretoimplementactionsasrequiredbylocalHSECandScaffoldinginspectorSpecific‘Realignmentmeeting’tobepresentedtoallfieldsupervisorstoreinforcethatfailuretofollowuponadvicefromDesconfieldHSECteamwillnotbetolerated.DELAbsent/FaileddefencesFollowupActionActionByWorkingatheightsprocedurewasnotfollowedSpecific‘Realignmentmeeting’tobepresentedtoallfieldsupervisorsofmandatorynatureofallworkingatheightprocedurestobeemphasised.DELAreaHSECadvicewasnotfollowedSpecific‘Realignmentmeeting’tobepresentedtoallfieldsupervisorstoreinforcethatfailuretofollowuponadvicefromDesconfieldHSECteamwillnotbetolerated.DELPre-Start‘TakeFive’sessionstobeconductedforallactivities–involvingHSECmember.AllissueidentifiedtobeaddressedpriortocommencingworkDELScaffoldinspectorrequirementswerenotfollowedSpecific‘Realignmentmeeting’tobepresentedtoallfieldsupervisorstoreinforcethatdisregardingtaggingproceduresisadismissibleoffenceandwillnotbetolerated.DEL5ZamzamaPhase2–CivilContractEventOutcomesSummaryandRootCauseOutcomesKeyrootcauseoutcomesidentifiedrelatetothefollowing:AlackofappreciationbyfieldsupervisorsofSafetyastheprimarymeasureofsuccessincompletingworkactivitiesSettingofpossiblyunrealisticgoalsforcompletionofworkpackagesAwillingnessexpressedbyfieldsupervisorstobreakMandatoryworkingatheightproceduresandprotocolswhereriskisconsidered‘low’andexposuretodelaysincompletingscheduledactivitiesis‘high’.Actionsfromthismini-ICAMwillbeinsertedintotheProjectActionsRegisterandclosetrackedonacontinuousbasis.6ZamzamaPhase2–CivilContract