What happened? At Approximately 9:40 am the Hoist 51;Welder was conducting minor repair activities to the handrail. The handrail was being balanced on the ground by Welder outside Maintenance workshop, 1m meter away from the lifting basket. Whilst while welder was attempting to remove upper handrail pin using hammer, he lost balance causing him to fall forward with the Handrail towards lifting basket hitting his lower jaw. The fall caused damage and deformity of the teeth. Why it happened/Finding : No clear Procedure of the task Violation of Manual Handling heaving heavy of Monkey Board Handrail’s in order to remove pin Site supervisor’s Inadequate Coordination Welder working alone Welder’s poor judgement Management and Supervisors’ Ineffective Monitoring and Supervision