JUAN CAMILO ESTRA ORTIZ

WEEK THREE

Part A: Toolbox talk

Learning from Accidents

and Incidents
Have you have ever wondered why we want to investigate all

Injuries, Incidents, Accidents and Near Misses?

The pyramid below may help you understand.

When a worker is injured, even if it is just First Aid we need to look at the cause.
Was the worker using defective tools? Was the material

defective? Was the procedure that was used to do the work inappropriate? Or possibly
the worker needed training. Asking these questions can help us pin point the cause and
prevent another, possibly more serious, injury.

When we have small property damage incidents we need to look at the incident and determine
if there are changes that need to be made. The next property damage incident may include a
worker.
“Near Misses” are serious accidents that didn’t happen. They are incidents that had the potential for causing serious
injury and/or damage but by chance or luck became simply an “Incident”. All Near Misses should be looked at as Near
Hits and steps need to be taken to prevent them from recurring. Near Misses need to be investigated to determine the
cause so steps can be taken to prevent them from happening again, with more serious results.
Meeting Conducted By: Date:

Comments:

Attendees: Print Signature Print Signature

1. 8.

2. 9.

3. 10.

4. 11.

5. 12.

6. 13.

7. 14.
This toolbox talk is in relation to the two men crushed by concrete
blocks at the Eagle Farm project to build new stables
Have you have ever wondered why we want to investigate all Injuries,
Incidents, Accidents and Near Misses?
According to the report prior to the two men being crushed they had a
near miss and avoide being crushed by one of the concrete blocks
When a worker is injured, even if it is just First Aid we need to look at
the cause.
Was the worker using defective tools?
The ladder into the pit was defective
There should have been steel girder supports to prevent the collapse
of the 10tonne concrete blocks
Was the material defective?
The blocks were reported as being too small and unsuitable by the
workers themselves through SMS
The supervisor knew the quality and fit of the blocks were defective
and did not report it to the project manager
Was the procedure that was used to do the work inappropriate?
It was inappropriate as there was no risk management plan or safety
precautions
Or possibly the worker needed training.
Whitecard training in safety was insufficient, the project manager
should encourage direct communication where faulty tools or work
conditions occur in the event that the foreman ignores the
communication from the workers as part of the risk management
Alternately the rules should be implemented on the foreman to relay all
safety communication issues to the project manager immediately
Asking these questions can help us pin point the cause and prevent
another, possibly more serious, injury.
When we have small property damage incidents we need to look at the
incident and determine if there are changes that need to be made. The
next property damage incident may include a worker.
“Near Misses” are serious accidents that didn’t happen. They are
incidents that had the potential for causing serious injury and/or
damage but by chance or luck became simply an “Incident”.

All Near Misses should be looked at as Near Hits and steps need to
be taken to prevent them from recurring.

Near Misses need to be investigated to determine the cause so steps

can be taken to prevent them from happening again, with more serious
results.

Clearly the worksafe regulations under worksafe Queensland were

contravened
Objectives of WHS legislation are:
Ensure that risks to health and safety are identified, assessed,
eliminated or controlled.
Promote and maintain the health, safety and welfare of people at work
against risks in the workplace.

DUTIES OF EMPLOYERS NSW

1) Employees
An employer must ensure the health, safety and welfare at work of all
the employees of the employer.
That duty extends (without limitation) to the following:
 (a) ensuring that any premises controlled by the employer where the
employees work (and the means of access to or exit from the
premises) are safe and without risks to health,

(b) ensuring that any plant or substance provided for use by the
employees at work is safe and without risks to health when properly
used,
(c) ensuring that systems of work and the working environment of the
employees are safe and without risks to health
1

Serious
Injury
Or
Fatality
10 Minor Injuries

Sprained ankle, Contusions, First Aid, etc…1 First

Aid Case a month will get us to 10 in less than a
year

30 Property Damage Incidents

Vehicle, Materials or Equipment Damage

Dings or broken glass on equipment. Damaged material, while handling. Damaged tools due to
mishaps, once a week is over 50 a year.

600 “Near Miss” Incidents

Some one trips and stumbles but recovers. Tools or materials are accidentally dropped off of a scaffold but
no one is hit. A fire starts while refueling a compactor and is put out with out injury.

600 near misses may seem like a lot but these incidents happen frequently on construction projects. 2 or 3
of these incidents a day will add up to 600 in about a year.
 Two construction workers killed at Brisbane's Eagle Farm racecourse
managed to escape one falling concrete wall only to be killed by a
second, police have alleged, after the builder in charge of the site was
arrested at the international airport.

Claudio D'Alessandro, 58, appeared in the Brisbane Magistrates Court

on Wednesday on two counts of manslaughter, after being charged on
Tuesday.

D'Alessandro was arrested at Brisbane international airport, where he

was embarking on a spur-of-the moment, four-day holiday to the
Philippines.
The prosecution conceded D'Alessandro had not broken any law by
attempting to take the trip.
He was granted bail but was required to surrender his passport and
must report to police twice a week as part of his bail conditions.
Ashley Pengana Morris and Humberto Ferraira Leite were killed on
October 6 by a falling concrete slab while they were working on a
major redevelopment of the stables.
The court was told the men were helping to install a four-walled "foul
water settling tank" consisting of four individual walls, each about four
square metres and weighing about 10 tonnes.

The walls were lowered individually onto the floor with a crane, with the
first three walls, once in place, being "tied" to each other across the top
corner by use of adjustable temporary bracing.

Workers 'jumped onto' collapsing wall

A police affidavit stated that the men were working in a "pit" under
D'Alessandro's instructions trying to lower the concrete walls when they
began to collapse.

The pair managed to "ride down" one concrete slab as it fell but were
crushed after the wall's failure caused a second slab to topple forward.
The affidavit stated:
At about 3:40pm, D'Alessandro was in charge of two workers in the pit
and to manually assist the correct positioning of the fourth wall as it
was lowered into position.
The only means of entrance and egress was a steel ladder to the top of
one of the walls (panel 2).
The pit was only slightly larger than the box made by the walls and the
workers had no means of escape other than the ladder.
Panel 2 began to fall forward and the two workers managed to scale
the ladder on that wall and ride down and jumped onto its back as it
fell.
The failure of this wall caused another wall (panel 1) to immediately fall
forward as it was no longer supported.
The two workers were unable to escape the second wall falling and
were crushed to death in between the two panels.

PHOTO: The two men were underneath a concrete slab when it

fell. (ABC News)
Ashley Morris raised issues via text, court hears
The court was told Mr Morris had previously commented on a
construction issue, and it had been discussed with D'Alessandro via
text message.

Police prosecutor Tammy Durre-Bauer said that early in the process of

installing one of the panels, "it was identified by one of the deceased -
Mr Morris - that the panel did not fit on the concrete pads", and that
had been conveyed to D'Alessandro via a text message.

"A series of timber and plastic packers were utilised on top of the
gravel base in an attempt to overcome the inaccuracies on the
concrete levelling pad," Durre-Bauer said.

"The system in fact had no bracing integrity and was not designed or
adopted by an engineer in any manner whatsoever."
The court heard D'Alessandro was an experienced concreter who had
worked across the country and internationally.
The prosecutor said D'Alessandro was the sole person issuing
instructions and protocols on the site.

D'Alessandro 'shocked by the charges'

His lawyer, Michael Purcell, said his client did not intend to flee and
had been free to travel, given he was not under arrest and had been
cooperating with the police investigation.

Outside court, Mr Purcell said D'Alessandro intended to plead not

guilty.

"He's shocked by the charges. We think that they're premature

because the investigation has got a long way to go," he said.
"He's looking forward to getting out on bail and getting back to work."
The case will return to court next month.
PHOTO: The men were working on a multi-million-dollar development
of infield stables. (ABC News)
Topics: murder-and-manslaughter, crime, courts-and-trials, law-crime-
and-justice, eagle-farm-4009, qld, australia, brisbane-4000

Information Source
http://www.abc.net.au/news/2016-11-16/eagle-farm-construction-
deaths-claudio-dalessandro-manslaughter/8029360
1 Directly affected
Not for profit organisations
Federal, state and local council government
Environmental protection authorities
Land titles office
Community- local , native aboriginal community
Local business
Residents
Shareholders
Board of directors
Current water and gas pipeline government departments
1 Indirectly affected
Unions
Employees
Insurance companies
Worksafe NSW
Banks
Project managers
Subcontractors
Engineers

choose 3 stakeholders
1. Residents
Type of information
Require plans , project commencement updates completion,
environmental impact, impact energy disruption, impact energy
costs, impact on traffic and road closures, impact of noise
pollution from work being conducted.
Frequency of relaying information to residents is monthly
communicated through community billboards , email , council and
northwest energy website updates and postal mail, local radio
stations

2.Board of directors
 Require project plan, WBS , budget, time schedule, materials and
quality specifications, Hiring of human resources, hiring of
equipment, risk management plan , contracts, surveyors report,
government regulatory information, community agreements,
WHS, insurance, permits, quotes , IT software costs , training
requirements, progress report.
Frequency is every week through project reports and
presentations from the project manager. Information is to be sent
via email , printed reports, presentations and meetings. Access to
reports and recorded information on the company intranet and
cloud via restricted access.

3.Local Government
Require project plan, WBS , budget, time schedule, materials and
quality specifications, WHS, risk management plan , contracts,
surveyors report, community agreements, insurance, permits,
quotes , IT software , training requirements, environmental
impact report, progress report
Frequency is every week through project reports and
presentations from the project manager. Information is to be sent
via email , printed reports, presentations and meetings.

IV
Board of directors
Surveyors
Project managers
Employees
IT staff
HR staff
Contractors
Engineers
Government representatives
Unions

Require project plan, WBS , budget, time schedule, materials and

quality specifications, WHS, risk management plan , contracts,
surveyors report, community agreements, insurance, permits, quotes ,
IT software , training requirements, environmental impact report,
progress report
Frequency is every week through project reports and presentations
from the project manager. Information is to be sent via email , printed
reports, presentations and meetings.

Plan and electricity grid

Land titles office
Native titles office
Environmental protection authority
Federal government
State government
Local council
Chamber of commerce
Insurance companies for WHS- Work safe NSW
Sewerage and gas pipeline

1Dii
Risk Management
Security management
Current infrastructure protection
Noise pollution
Cyber security
Work Safety
Community safety
Environmental protection
Native animal protection
Garbage disposal
Materials storage
Large equipment storage
Traffic disruption
Energy disruption
Local business disruption
Telecommunications disruption
Extreme weather events
Lack of finance
Lack of qualified employees and contactors
Delay material supply
Lack other resources
Poor communication on the worksite

1Diii
Seek advice based on email request, after initial research on the
government website whereby it gives a form to be filled out and
the requirements for the report.
List of specifications and the general project plan need to be
forwarded in order to give information to the government
department on the project scope.
Requirements will include what the project scope , the different
phases of the project the likely risks and the risk management
plan for each government department
For example the risks for the land titles office is legal action from
residents refusing to sell property that needs to be acquired for
the project. Versus the risk on environmental degradation due to
tree removal and land clearing.

1a i
Project Scope
Project Plan
Project time schedule
WBS- work breakdown structure
Project materials specifications
Employees skills , experience and qualifications
Budget
Risk management plan
IT software to be used
Performance management plan
1Aii
Historical records/ record management
HR files/ HR department
Previous projects completed
Finance department
WHS officer

1Aiii
Project Scope
Project Plan
Project time schedule
WBS- work breakdown structure
Project materials specifications
Employees skills , experience and qualifications
Budget
Risk management plan
IT software to be used
Performance management plan

1Aiv
Time zones
Geographical distance
Communication software
Communication hardware
Internet access
Privacy
Level of responsibility of employee
Confidentiality
Cyber security
Frequency of communication
Level of responsibility
 Urgency and severity of message content

1Av
Whatsapp
Autocad
Viber
Email
Intranet
Internet
Cloud communications
SMS
Printed materials
Sales force .com
CRM

1Av1
Client resources CRM
Microsoft project
Prince II
Sales force .com

http://www.capterra.com/sem-compare/project-management-
software?headline=Top%2010%20Project%20Management%20
Software&gclid=CMqT9eTx-NICFZGXvQod0woI0A

Top 10 Project Management Software

Portfolio
Deploy Collabora Idea Requirements Resource
Product Manage
ment tion Management Management Management
ment
Smartsheet
(151)
dapulse
(340)
 Portfolio
Deploy Collabora Idea Requirements Resource
Product Manage
ment tion Management Management Management
ment
Mavenlink
(155)
Accelo
(2)
ProWorkflo
w
(73)
Freshdesk
(173)
Wrike
(469)
Project
Manager.com
(176)
Flow
(11)
FinancialF
orce Project
Management
(4)
Appendix 1: Skills Matrix

Employee

Fork Lift Fork lift Supervis Carpent

Standard Operating Driver1 Driver 2 or er
Procedure

Learner

Practitioner

Trainer coach

Operator
Legend:

Untrained Employee has no training

Learner Employee cannot perform task independently
Employee can perform task independently with
Practitioner
supervision
Operator Employee can perform task independently
Trainer Employee can train/coach others to perform
/Coach task
Appendix 2: Training Plan

Topic: Eagle Farm

What performance issue does this training session need to address?

Lack Of Work Procedures

Lack of safety equipment
Lack of WHS Training
Key point Bullet points Resources Understanding
(what will you (handouts/phys (how will you
say) ical check for
demonstration/ understanding
slides) –
questions/obs
ervation/discus
sion)
Work No valid work Create new Power point
Procedures procedures visual and and on the job
available written training
procedures

Safety Provide PPE PPE Power point

Equipment and on the job
On the job Visual posters
training
demonstration

WHS Training WHS training by Training Power point

WHS meeting and on the job
representative training
E learning
 Goal Reduce Deaths and Safety Incidents Eagle Farm

Reality Lack of work and building safety equipment likely

cause of deaths

Options Conduct quality checks to ensure all work

completed meets specifications

Based on the death of two workers the WHS

laws have not been upheld the damage to the
work site and supervisor is ongoing in reputation
W Will

Costs associated with the training session:

WHS Representative $2,000

Materials $500

Time off Work $3400

Appendix 3: GROW Model Template