L04 Near MissDec. 5, 2014, CLS, non-stewardable, a 1.8 ton pipe fell 1.2 meter when thechain hoist failed just above the swivle.
L04 险肇事故：2014年12月5日，中国液化天然气项目，当葫芦的转轴失效时， 一根1.2米高，1.8吨的管子滑下。
Incident Description: 事故描述
Around 3:00 PM onDecember 5, 2014, a group of workers was erecting a 1.78 ton pipe using three2-3ton chain hoists (A, B, C) when suddenly the hook of the third chainhoist(C) failed and the pipe fell 1.2 meter. After the shock loading, the pipewas held in the rigging due to the redundant capacity left in the rigging.However, if one or both of the other chain hoists had failed, the spool couldhave toppled sideways. No one was hurt as workers were out of line of fire!
2014年12月5日下午3点，一组工人使用1个3吨葫芦（C)，2个2吨葫芦（A, B)安装一根1.78吨的管子，突然第三个葫芦(C) 的钩头失效，管子滑落。受到载荷冲击以后，由于其他葫芦的承载，这根管子悬于空中。然而，如果其它的一个或两个葫芦失效，这根管子将向侧面倾倒。由于工人在危险区域外面，没有人受到伤害。
Direct Cause 直接原因
The hook swivel waswelded shut (self-modified), once torsion was applied this hook could notrotate freely as it was designed for, this torsion resulted in the pin beingtwisted out of the side plate.
钩子转轴被焊住（自己修改），所以当钩头受到扭力时，钩头不能按照原先设计的方式自由旋转，扭力导致销子从葫芦的侧面脱出。
Root Cause 根本原因
• No formal process forpipefitting crews to procure rigging equipment, hence they often end up with‘not fit for purpose’ rigging equipment supplied by the production departmentsor subcontractor companies
• 管子安装工人领起重设备没有正式的流程，因此他们经常拿到生产部门或外包队提供的“不适用的”的起重设备。
• Pipefitting crews have norecognised system/criteria in place to change out defective rigging equipment.Self modified/repaired rigging equipment are often used
没有认可的体系/标准可让管子安装人员更换有缺陷的起重设备。经常使用自己修改/修理的 起重设备。
• Pipefitting Crews have no clear records or checklist in place for chainhoist inspection
管子安装人员没有葫芦检查的清晰检查表或记录。
• The forces, in this case torsion, while using chain hoists were notfully understood by users
使用者不完全理解使用葫芦时所受外力，比如这个事故中的扭力。
Follow upActions 跟踪行动
• Service rigging equipment found to be ‘not fit forpurpose’ must be taken out of service and not recycled to other sub-contractors
“不适用”的起重设备必须报废并且不能给其它外包队循环使用。
• Establish chain hoist inspection checklist andorganize training on the safe use of chain hoists
建立葫芦检查表并对如何安全使用葫芦组织培训。
• Conduct thorough check on all chain hoists used onproject
对项目上使用的所有葫芦进行全面检查。
• Tag all chain hoists and conduct quarterly inspectionand use color code to track inspection status
对所有的葫芦进行挂牌，每季度进行检查，使用色标追踪检查情况。
• Discuss the layout of the chain hoists, establish asimple plan and ensure proper JSA was done before job starts
讨论葫芦的布置，建立一个简单的计划并确保工作开始前做好合适的岗位安全分析。
• Remove any support that may obstruct direct lift ofpipes
移开阻挡管子直接起吊的支撑。