Watch a video about the investigation of the fall accident at Mongstad on 18 January 2023.
Read the full investigation report: Equinor/Beerenberg – Mongstad – investigation of incident where a person fell from scaffolding
The direct cause of the incident was that a scaffold ledger to which the injured person had attached his fall-arrest safety harness came loose from its attachment to the standard at one end of the scaffolding frame. The person lost his balance on the ledger he was standing on, causing him to fall backwards, and the ledger hook at the other end bent and detached from the standard. The scaffolder sustained very serious injuries and the incident could have had a fatal outcome.
The incident at Mongstad is not the first accident or near-miss involving a fall from scaffolding in recent years. The most serious incident occurred on Oseberg B in 2009 when a scaffolding worker fell 14 metres and died. In the years since, there have been several incidents where scaffolding workers have fallen and sustained minor injuries, due to scaffold ledgers becoming detached.
Background
Work on the day of the incident started with a new scaffolding team being assigned to complete a 30-metre-high frame scaffolding that was to be built around a goods lift. The scaffolding was having to be rebuilt because it was originally erected in the wrong place.
The work was part of a surface and maintenance programme at Mongstad, carried out by Beerenberg Services (BSS). A key framework condition in the framework agreement was the unit rate format, which means that the scaffolding work was priced on an estimate per cubic metre. This had consequences for the planning of the work, because no hours were planned or priced for the new scaffolding. The situational awareness was that this was a routine job requiring a high level of efficiency.
Lack of risk assessment
The work was carried out by a team of three scaffolders from Poland, employed by BSS. No one in the work team had a certificate of apprenticeship for scaffolding, despite Equinor's internal requirement is that at least one member must have one.
BSS also failed to perform the mandatory risk assessment, prepare an assembly plan or assess the need for rescue prior to the actual assembly work.
Framework conditions
In a number of audits, the Petroleum Safety Authority Norway has pointed out that framework conditions stipulated in contracts have consequences for health, safety and the environment. This investigation shows that framework conditions have set expectations for efficient execution and progress, which in turn have influenced decisions and actions related to the planning, organisation and execution of scaffolding work.
Order to BSS
A week after the incident occurred, the Petroleum Safety Authority Norway ordered BSS to stop all installation, dismantling and alteration of scaffolding at Mongstad, until a procedure had been drawn up describing the specific risks of these activities, and all personnel involved in the planning and assembly of scaffolding had been trained in the procedure and had been made aware of the accident and health risks associated with the work. BSS complied with the order on 30 January and was able to resume scaffolding work.
Order to Equinor
When the investigation was complete, the Petroleum Safety Authority Norway also ordered Equinor Mongstad to carry out a comprehensive and systematic overall risk assessment in respect of work at height, to ensure that risk factors associated with the work are followed up by its own organisation and by contractors. The order also includes ensuring that collective safety measures are preferred over measures directed at individuals, and applying learning from similar incidents in risk-reduction activities.
Equinor must also carry out a comprehensive and systematic review of management systems at contractors that perform work at height, to ensure the necessary competence and compliance with the regulations and Equinor's internal requirements.