Learning points:

• Construction crew not recognizing the hazard created by constructing plinths of different configuration from approved design drawings
• Construction Supervision and QA/QC did not recognize the safety impacts from deviating with approved design drawings.
• No formal risk assessment performed by responsible personnel to determine impacts of the design change.
• Management of Change Procedure not fully developed at Site. No formal guidelines for personnel to implement Site design changes.

Recommended Actions:

• Discuss this alert in toolbox talks and HSE meetings and
• Distribute to all contractors
• Post on HSE notice boards
• Include in site HSE induction