8.0 Most Probable Causes The TSL employees were potentially exposed to asbestos fibers (sic) because they employed oxy-acetylene cutting to remove steelwork coated with Cora-Kote (sic). This method had the potential to disturb asbestos. The work team was not provided with the scope of work by TSL which identified the asbestos hazard associated with the steelwork. TSL did not have management processes that require the scope of work to be used in development of its own JSA / SWI. This represented a failure of TSL to understand, and/or recognize the risks of asbestos hazards and to properly instruct its personnel in relation to those risks. 9.0 Contributing Factors The following factors may have contributed to the incident: 1. Asbestos awareness training is not mandated for contractors 2. The potential asbestos hazard was not identified as a risk in the Authority to Proceed form because it does not contain a prompt to check the Asbestos Register 3. Scope of works that impact on structural steelwork do not include a requirement to consult the Asbestos Register 10.0 Other Safety Issues The investigation identified that some TSL employees continued to undertake cutting of steelwork after they were instructed to cease work. This is considered a violation. 11.0 Corrective Actions to Table 1 for a list of corrective actions that will reduce the likelihood of a reoccurrence of a similar incident. Corrective actions were recommended in the investigation report in relation to contractor management. These included: (a) amending Alcoa’s Authority to Proceed form, with a prompt to require specific consideration of asbestos hazards and to cross-check the Asbestos Register if work is being performed on plant that may potentially contain ACMs; (b) expand the induction process to include reference to examples of ACMs; (c) require asbestos awareness training for contractors”, who are “embedded likely to work on potential ACMs; (d) Transfield be required to introduce management systems that require the of work to be used when developing job safety analysis and safe work instructions with increased supervision; and
8.0 Most Probable Causes The TSL employees were potentially exposed to asbestos fibers (sic) because they employed oxy-acetylene cutting to remove steelwork coated with Cora-Kote (sic). This method had the potential to disturb asbestos. The work team was not provided with the scope of work by TSL which identified the asbestos hazard associated with the steelwork. TSL did not have management processes that require the scope of work to be used in development of its own JSA / SWI. This represented a failure of TSL to understand, and/or recognize the risks of asbestos hazards and to properly instruct its personnel in relation to those risks. 9.0 Contributing Factors The following factors may have contributed to the incident: 1. Asbestos awareness training is not mandated for contractors 2. The potential asbestos hazard was not identified as a risk in the Authority to Proceed form because it does not contain a prompt to check the Asbestos Register 3. Scope of works that impact on structural steelwork do not include a requirement to consult the Asbestos Register 10.0 Other Safety Issues The investigation identified that some TSL employees continued to undertake cutting of steelwork after they were instructed to cease work. This is considered a violation. 11.0 Corrective Actions to Table 1 for a list of corrective actions that will reduce the likelihood of a reoccurrence of a similar incident. Corrective actions were recommended in the investigation report in relation to contractor management. These included: (a) amending Alcoa’s Authority to Proceed form, with a prompt to require specific consideration of asbestos hazards and to cross-check the Asbestos Register if work is being performed on plant that may potentially contain ACMs; (b) expand the induction process to include reference to examples of ACMs; (c) require asbestos awareness training for “embedded contractors”, who are likely to work on potential ACMs; (d) Transfield be required to introduce management systems that require the of work to be used when developing job safety analysis and safe work instructions with increased supervision; and
OSHT-3-2017-201800268.DOCX