LEARNING FROM INCIDENTS

Shell Global Solutions International B.V.

SGSI GSGH
Process

DATE: February 2008

Collect
LFI Action

ALERT No. 2008AW04 (HSE)

RAM RATING: Act.P3 - Pot.P-4C

Aerial Lift Incident

LFI Focus Area:

This Alert is applicable to all Manufacturing sites that use aerial lifts (mobile elevated work
platforms).

Summary:
The workers in the platform (basket) of the aerial lift sustained injuries as a result of the reaction
forces that impacted on their bodies during the jolting. Additionally, one of the workers fell out of
the platform to a grating that was approximately 2 meters (6.5 feet) below. Both workers had on
fall protection devices.

(MEWP)

LFI Alert_2008AW04_-_Toppled_platform_on_aerial_lift.doc
Here’s what happened:
Two workers were in the basket of a contractor provided aerial lift that was being used to install
support beams in a new structure. The beams were raised into position by a mobile crane and
bolted into place from the aerial lift. Their aerial lift was at a height of 22.3 meters (73 ft) when the
incident occurred. Both workers had on fall protection.

After finishing the connections on the east side of the structure, the workers began the process of
relocating to the west side of the structure. The aerial lift’s platform (basket) was situated in the
steel structure. The construction beams and process vessel had been previously installed, so to
reach the new position, the hydraulically operated mast first had to be retracted. (See picture
above).
When retracting the mast, the cable track1, fitted at right angles to the longitudinal line of the mast,
snagged on a flange on a vertical construction beam. Both installation workers realized that the
mast had come into contact with the structure but did not fully understand the extent of the
problem (aerial lift rising off ground-see diagram 1 below). The aerial lift operator continued
retracting the mast because no stability alarms had been sounded in the aerial lift. The aerial lift
workers view of the aerial lift’s base was obstructed by the structure. Because of the reaction
forces building up as a result of the mast snagging, the base of the aerial lift was raised by about
300 mm or 12 inches (See diagram 1 below). This aerial lift had a stability alarm that was set to
sound at an angle of 4.5° (approx 310 mm in height).
A rigger and a mobile crane operator observed the base of the aerial lift had tilted by about 300
mm or 12 inches. Attempts to notify the aerial lift workers of the tipping of the base of the lift
were unsuccessful. The workers in the platform were wearing hearing protection, there was some
background noise, and the radio had been placed on the floor of the platform. The cable track
support bent, allowing the mast of the aerial lift to break free of the structure. The aerial lift’s base
fell back to the ground again (see diagram 2 below). This jolted the platform 1.5 meters (5 feet)
upwards, striking a horizontally mounted construction beam
Impact with the beam broke the platform’s suspension, allowing the platform to tip over 90°, (See
diagram 3 below). One of the workmen fell onto the construction floor already installed and one
managed to hold on to the aerial lift’s platform.

1
The cable track conceals the electronic and hydraulic cables and hoses
LFI Alert_2008AW04_-_Toppled_platform_on_aerial_lift.doc
Diagram 1 Diagram 2

Diagram 1 Aerial lift gets snagged on

flange of steel structure.

Diagram 2 Aerial lift jolts upwards as a

result of continued maneuvering
and its platform hits horizontal
construction beam.

Diagram 3 Aerial lift platform snaps owing

to instantaneous overload.

Diagram 3

LFI Alert_2008AW04_-_Toppled_platform_on_aerial_lift.doc
How Did This Happen (Causes of incident):

The physical/mechanical causes of the incident include the following:

• The arm of the aerial lift got stuck behind the structural beam flange. The force exerted by
the reverse motion of the mast as the attempt was made to dislodge the lift resulted in the
base of the aerial lift being raised by approximately 300 mm.
• Because of the rapidly increasing forces on the arm of the aerial lift, a support on the cable
track became so buckled that the mast came loose. The arm and the platform were jerked
upwards by 1.5 metres (5 ft) at an acceleration of 5g (see note 2 for reference) and hit a
horizontal construction beam. The impact force resulted in the pivoting point between the
platform and the mast breaking free.
The workers sustained injuries as a result of the reaction forces that impacted on their bodies
during the jolting. Additionally, one of the workers fell out of the platform and to grating that was
approximately 2 meters (6.5 feet) below. Fall protection is designed to restrict falls greater than 2
meters.

Underlying issues:
The following underlying causes were identified:

• The operator of the aerial lift was moving in a congested area and out of line of site with
the base of the unit. The aerial lift operator could not see all movements of the mast.

• Communications with personnel on the ground was difficult due to noise and radio contact
not being maintained (radio was on floor of platform at the time of the lift tipping).

• The contractor’s JHA did not identify the potential hazard of the mast snagging or the
control in place to avoid/minimize snagging.

• The contractor’s training for the aerial lift operator did not include operational emergency
situations. When the cable track snagged, the aerial platform operator had no contingency
plan for what to do in this situation. Both workers in the platform assumed that as long as
no alarm came up on the control panel, they could continue their work safely.

Key Learning:

Aerial lifts are a useful tool in executing maintenance/construction work. Key learnings from this
incident are as follows:
• Training for aerial lift operators needs to include emergency situations (hazards, potential
consequences, precautions for and recovery from unsafe situations).
• Job Hazard Analysis (JHA) teams need to include persons with full operating knowledge of
the aerial lift equipment and the task concerned.

2
Roller coasters are normally designed for 1.5 g’s. Humans are prone to black out at 5g's.

LFI Alert_2008AW04_-_Toppled_platform_on_aerial_lift.doc
 • The checklist used in the JHA was primarily focused on hazards associated with the
process unit and not the task of manuevering the aerial lift inside the structure and
associated potential hazards.
• Prior to starting jobs involving aerial lifts, it is important to consider potential need for a
maneuvering watch (banksman) and a communication protocol. Include “what if” scenarios
for emergencies and changes in manoeuvrability during progression of work.

Serious injuries and fatalities associated with the use of aerial lifts have occurred in the industry.
For example, in 2006 at BP Texas City Refinery, a contractor pipefitter maneuvering an aerial lift
basket was crushed between an I-beam structure and the manlift. The pipefitter had leaned over
the platform controls placing him between the beam and the manlift. The equipment operator then
engaged the man lift controls at a speed and direction that pushed him into the I-Beam.

More Information and Data Sources:

The information and data sources listed below are provided to assist you if more information is
desired or needed regarding the subject of this alert:
* 2006 BP Texas City Refinery Aerial Lift Incident – HSS Operating Experience Summary
• Shell UK Onshore Safety Regulations – Temporary Access Equipment and Working at Height.
• UK Health and Safety Executive - HSE Information Sheet MISC614 – Preventing Falls from
boom type mobile elevating work platforms.
http://www.hse.gov.uk/pubns/misc614.pdf
• Shell Global Solutions - GSGH
• SGSI Manufacturing Learning from Incidents Coordinator

This LFI Alert/Standard is made available to you ('Recipient') pursuant to the relevant agreement between Shell Global Solutions International
and/or affiliates of Shell ('Shell Global Solutions'), and your company, and is written for intended Shell use and not tailored for non-Shell use,
including Recipient's company. Although the LFI’s represent Shell Global Solutions’ good faith judgment of the matters dealt with, they are merely
provided for information only and for Recipient’s use by its qualified professionals, and should not be relied upon as authoritative guidance in any
particular situation. When relevant, Recipient shall seek advice from its own technical advisors and the vendors of their specific equipment. Shell
Global Solutions makes no representations or warranties, express or implied, concerning the accuracy, sufficiency or completeness of the
information contained in any LFI Alert. Shell Global Solutions accepts no liability whatsoever for any loss or damage arising out or in connection
with the contents of this LFI Alert.

Copyright 2008 All Rights Reserved, Shell Oil Company

Copyright 2008 All Rights Reserved, Shell Internationale Research Maatschappij B.V.

LFI Alert_2008AW04_-_Toppled_platform_on_aerial_lift.doc