Global Operations HSSE Alert

☐ Inicial | Initial ☒ Final | Final N Alert: HSSE Alert-MdB-MV24-001/2022

Quase Acidente / Near

NOI: IE-2201-0064 Tipo de Formulário | Form Type:
Miss

Quase Acidente / General

Tipo de Incidente | Incident Type: Emitido em | Issued On: 03/25/2022
Near Miss

Título | Title: Rope access activity: Inadequate planning

Descrição do evento | Description of Event
A contractor rope access team was carrying out painting activities on a pipeline in the workshop structure in Module 7P about 3
meters above the ground.

A two-line anchor points were connected to an eyebolt at the top of the workshop structure and the ropes were passed horizontally
along the top of the workshop with simple bypass (with a single point) in an auxiliary structure (guardrail) and deviated at an angle
greater than 90º, vertically to the workplace.

Although the team had two ropes as needed with a solid anchor point, the deviation point was not in line with the practices for rope
access activity and hierarchy of hazards for anchor protection. In the case of a failure on the deviation point, the worker could have
felt.

Por que isso aconteceu? | Why did it happen?

During the investigation, it was found safety-related items that are mentioned in the rope access guide and industry practices and were
incorrectly applied:

• Insufficient and inadequate planning of rope access activity.

• Incorrect selection of the anchor point and misuse of the anchor system, as the deviation point must have the same criteria as
the main anchor.
• The PEAAC (Rope Access Execution Activity Plan) was filled out incorrectly:
o Incorrect completion of item 4 of the PEAAC: It must contain the equipment used in the anchors to be performed. The
MODEC equipment checklist should not be used as a reference in item 4 of the PEAAC, nor should it be described
generically.
o The anchor deviation technique (single or double) and the structure to be fixed were not described in item 5.1 of the
PEAAC.
o There was no photo of the structure where the deviation would be anchored in item 8 of the PEAAC (in this case the
deviation made by the IRATAs should be in the PEAAC due to the fact that it was greater than 90º).
o In the item “location” of the PEAAC, three different areas were mentioned (location: module 5P, 5C, 7P), but in item
8 “anchoring plan” it was not specified which points the images refer to and which type of anchorage (life line, etc) for
each module.
• PEAAC approvers did not observe the mistakes in the documentation.

Life Saving Rules (If applicable)

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☒

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in this file may result in civil and criminal liability. .
 Fotos - Informações de Apoio | Photographs - Supporting Information

Deviation scheme for reference. Not from actual event.

O que podemos fazer para evitar? | What can we do to avoid?

• Share with the rope access teams and PEAAC approvers the event described in this document.
• Reinforce the need to proper select the anchor points and anchor system use.
• Fill in the PEAAC as detailed as possible. Make sure that the plan and anchor points are fully described.
• Disclose with the PEAAC approvers the importance of ensure the correct filling of the document.

Informações adicionais | Additional information

In this case of rope access, this deviation feature is described in the literature and takes into account some important factors such as
nearby hazards and especially the deviation angle (if it is greater or less than 20º) and the distance of the vertical deviation from the
anchorage point (if it is greater or less than 1.5m), as mentioned in the training, evaluation and certification scheme and international
code of practice for industrial rope access, in addition to the schemes used that also limit the use of this technique, which are included
in the manuals from national and international certifiers and also in NBR 15595.

The bypass must be mounted with protection (double bypass):

1. If the deviation angle is ≥ 20°.

2. The distance between the anchor points and the vertical is ≥ 1.5m.
3. There is a risk of equipment failure if there is bulge and impact and structures.

This file (including attachments) contains confidential information which may be legally privileged. If you have received this file in error or you are not the
intended recipient, please immediately notify the sender and delete this file from your system. Unauthorized disclosure and/or use of information contained
in this file may result in civil and criminal liability. .