TABLE OF CONTENTS SECTION TITLE PAGE NUMBER

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1 SCAFFOLDER FALLS INTO UNCOVERED DUCT RECEIVING FATAL HEAD INJURIES Type of Incident: Fatal Date of Incident: December 01, 2010

2 TABLE OF CONTENTS SECTION TITLE PAGE NUMBER 1.0 DATE AND TIME OF INCIDENT NAME & ADDRESS OF PRINCIPAL PARTIES Owner Prime Contractor Employer(s) Worker DESCRIPTION OF PRINCIPAL PARTIES Owner/Prime Contractor Employer Worker LOCATION OF INCIDENT EQUIPMENT, MATERIAL AND OBSERVATIONS Equipment and Material Observations NARRATIVE DESCRIPTION OF INCIDENT ANALYSIS Direct Cause Contributing Factors FOLLOW-UP/ ACTION TAKEN Occupational Health and Safety Industry Additional Measures SIGNATURES ATTACHMENTS 10 2 Alberta Employment and Immigration, Occupational Health and Safety September 16, 2011

3 SECTION 1.0 DATE AND TIME OF INCIDENT 1.1 The incident occurred on December 01, 2010 at the Syncrude Canada Ltd. worksite approximately 40 km north of Fort McMurray at the Sulphur Emissions Reduction Construction Project. SECTION Owner Syncrude Canada Ltd. Bag 4009 Fort McMurray, Alberta T9H 3L1 2.2 Prime Contractor Syncrude Canada Ltd. Bag 4009 Fort McMurray, Alberta T9H 3L1 2.3 Employer Jacobs Industrial Services Ltd. 205 Quarry Park Blvd S.E. Calgary, AB T2C 3E7 2.4 Worker Scaffolder #1 NAME AND ADDRESS OF PRINCIPAL PARTIES SECTION 3.0 DESCRIPTION OF PRINCIPAL PARTIES 3.1 Owner/Prime Contractor Syncrude Canada Ltd. is the owner and prime contractor. Syncrude Canada Ltd. is a joint venture company undertaking mines and processes oil sands in the Athabasca Oil Sands Region to produce synthetic crude oil. Syncrude Canada Ltd. s Mildred Lake mine and processing facility are located 40 km north of Fort McMurray. Syncrude Canada Ltd. was the owner and prime contractor for the Sulphur Emission Reduction Project s (SERP) Flue Gas Desulphurization (FGD) building where the incident occurred 3 Alberta Employment and Immigration, Occupational Health and Safety September 16, 2011

4 3.2 Employer Jacobs Industrial Services Ltd. is a large, multi-national company that provides fullservice engineering, design, construction, modular fabrication, maintenance, and construction management services to clients in the upstream areas of exploration and production. Jacobs Industrial Services Ltd. was contracted by Syncrude Canada Ltd. to provide a construction workforce, equipment and materials to support Syncrude Canada Ltd. s SERP construction project. 3.3 Worker Scaffolder #1( ) was an experienced Journeyman Scaffolder with more than 20 years experience in the scaffolding industry. Scaffolder #1 ( ) was employed with Jacobs Industrial Services Ltd. as a scaffolder at the SERP project at the Syncrude Canada Ltd. worksite since July SECTION 4.0 LOCATION OF INCIDENT 4.1 Sulphur Emission Reduction Project at the Syncrude Canada Ltd. worksite. (Refer to Attachment A Map). SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 5.1 Equipment and Material Vertical Ventilation Duct and fan assembly (Attachment C Photograph #1) Round galvanized steel duct measuring approximately 91 cm diameter and 3 m in length. The vertical ventilation duct was part of the air intake for the heating and ventilation system in the FGD building in the SERP project. A fan assembly for the air intake system was mounted at the bottom of the ventilation duct Ledger Ledgers are part of a scaffolding system used to connect the vertical load bearing supports (standards). The ledger that was lifted over the handrail prior to the incident was approximately 1 m in length and weighed approximately 4.5 kg. (Attachment C- Photograph #2) 5.2 Observations Occupational Health and Safety was notified by Syncrude Canada Ltd. of a fatality at their Sulphur Emission Reduction Project worksite at 12:28 p.m. on December 1, Occupational Health and Safety attended the worksite on December 1, 2010 to commence its investigation. A Stop Work Order was verbally issued to Syncrude 4 Alberta Employment and Immigration, Occupational Health and Safety September 16, 2011

5 Canada Ltd. at 12:54 p.m. on December 1, 2010 at the specific incident site to allow Occupational Health and Safety to conduct its investigation. When Occupational Health and Safety arrived at the worksite, the area surrounding the incident had been cordoned off, and all work had ceased at the construction site. SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT 6.1 On December 1, 2010 at approximately 7:30 a.m., Scaffolder #1 ( ) started his work day. Scaffolder #1 ( ) was assigned to work with a four-man crew in the FGD building at the Sulphur Emission Reduction Project. 6.2 At approximately 8:45 a.m., the Supervisor ( ) completed an SPA card (Safe Plan of Action) at a pre-job meeting with his three man crew at the 127 elevation jobsite. In attendance were Apprentice #1( ), Journeyman #2( ) and Apprentice #2( ). The Supervisor ( ) left the 127 elevation, and the crew started working. 6.3 Shortly after, the Superintendant ( ) advised the Supervisor ( ) that work priorities had changed, and work on the 147 elevation was to take precedence over the 127 elevation work. The Supervisor ( ) went to the 127 elevation, and told the three man 127 crew that they were to start work on the 147 elevation. He then proceeded to the 147 elevation with the three man crew. The 147 elevation work involved constructing a 3 m by 2 m scaffold to facilitate the installation of a 91 cm vertical ventilation duct. There was one section of the duct already installed, and scaffolding was to be built up and around so that another contractor could install a second 10 foot section of the ductwork. 6.4 The Supervisor ( ) discussed the scope of work to be done on elevation 147 with Scaffolder #2( ). The Supervisor ( ) told Scaffolder #2( ) that he would get Scaffolder #1 ( ) to come and help with the work, as this was a bigger job and required more scaffolders than the previous assignment. 6.5 The Supervisor ( went to the Hot Roof job, and told Scaffolder #1( that he had to move to the 147 elevation to work with Scaffolder #2(. Scaffolder #1( ) proceeded to the 147 elevation and met with the three other workers. At approximately 10:00 a.m., all four workers went for a coffee break. 6.6 After the coffee break, Scaffolder #1( ) met with the three other members of the crew at the bottom of the 147 elevation. The crew assessed the work they were doing and realized that they needed more 3 m double scaffold ledgers to do the job. Scaffolder #2( and Apprentice #1 ( ) left the 5 Alberta Employment and Immigration, Occupational Health and Safety September 16, 2011

6 147 elevation to go to the laydown yard next to Bldg #51 to get the necessary materials. 6.7 At approximately 11:00 a.m., the Supervisor ( ) went to the 147 elevation, and met with Apprentice #1( ) and Scaffolder #1( ). He went through the SPA card with Scaffolder #1( ) and had him sign it. 6.8 After the Supervisor ( ) left, Scaffolder #1( ) told Apprentice #2 ( ) that he was going up on the 147 elevation to start moving material up onto the scaffold decks (Attachment C-Photograph #3), as there were four 1 m ledgers that needed to be brought up. 6.9 At approximately 11:15 a.m., Scaffolder #1( ) lowered a rope with a hook over the side of the scaffold to Apprentice #2( ). (Apprentice #2( ) attached a 1 m ledger to the hook, and Scaffolder #1( hoisted the 1 m ledger with the rope hoist, grabbed the ledger, and pulled it over the handrail. (Attachment C-Photograph #4) 6.10 Scaffolder #1( ) moved away from the guardrail, and fell headfirst into the 91 cm diameter 3 m long duct, striking his head on the fan assembly at the bottom of the ductwork At the same time, the Beta Hoist Operator ( ), working nearby, heard a call for help, and immediately went towards the 147 elevation. On his way, he met Scaffolder #2( ) and Apprentice #1 ( ) and told them that he heard a cry for help Scaffolder #2( ) and Apprentice #1( ) raced up the scaffolding ladder to the fourth deck. They looked down the vertical ventilation duct and saw Scaffolder #1( ) at the bottom of the duct. They then went down to the third level and saw an arm hanging out at the bottom of the duct. Apprentice #1( ) immediately went to Scaffolder #1( ) to check for a response, but was unable to find any At 11:18 a.m., a Fuller Austin Inc. General Foreman ( ) was climbing a permanent ladder nearby and heard workers yelling Man Down. The Fuller Austin General Foreman ( ) switched his hand held radio to the emergency services station to summon Emergency Response. The Fuller Austin General Foreman ( ) went to the forth deck on the 147 elevation and started hitting the side of the duct and yelling out to Scaffolder #1( ). Shortly after, the Jacobs Industrial Services Ltd. Safety Advisor ( ) joined him at the duct opening, also hitting the sides of the duct and calling out to Scaffolder #1(. 6 Alberta Employment and Immigration, Occupational Health and Safety September 16, 2011

7 6.14 Syncrude s Emergency Response Services arrived at the incident site at 11:21a.m. and started a response effort. Syncrude s Emergency Responder #1( ) climbed the scaffold and accessed the second deck and assessed Scaffolder #1( ) for vital signs, but was unable to find any. Other members of the Emergency Response Team went above to the fourth deck, and Emergency Response Captain ( ) coordinated the recovery effort with members of the Emergency Response Team and Jacobs Industrial Services Ltd. safety staff At 12:17 p.m., Syncrude s Emergency Response Services extricated Scaffolder #1( ) out of the duct by attaching a rope system onto the fall protection harness that Scaffolder #1( ) was wearing. Scaffolder #1( ) was placed into a stretcher and was lowered to ground level where members of the Regional municipality of Wood Buffalo Emergency Response team were waiting The Fort McMurray Emergency Response team worked on Scaffolder #1(, but were unable to revive him and pronounced him dead at 12:30 p.m. SECTION 7.0 ANALYSIS 7.1 Direct Cause Scaffolder #1( ) received fatal head injuries when he fell headfirst down into a 3 m vertical ventilation duct striking a fan assembly. 7.2 Contributing Factors Although Scaffolder #1( ) was wearing a fall protection harness with a double lanyard, he was not tied off to an anchor point when he fell through the vertical ventilation duct. When Scaffolder #1( ) was lifted out of the vertical ventilation duct by the Syncrude Canada Ltd. Emergency Response team, they attached the rope to the dorsal ring on his fall protection harness. Interviews with members of the Emergency Response Team indicated that the harness that Scaffolder #1( ) was wearing was in good condition and was donned and fastened appropriately. Syncrude Canada Ltd. and Jacobs Industrial Services Ltd. both had fall protection plans that required that all workers be required to be tied off when a fall hazard existed greater than 2 m for this worksite. 100% tie-off was required for scaffolders when working on red tagged scaffolding. It was confirmed through documentation review and interviews that Scaffolder #1( ) had been trained to this standard, and that the Fall Protection Standard was wellcommunicated to all workers at the Sulphur Emission Reduction Project. The scaffold that Scaffolder #1( ) was working on at the time of the incident had a red tag affixed at the bottom of the ladder that the Scaffolder #1( ) used to access the scaffold. (Attachment C- Photograph # 6) 7 Alberta Employment and Immigration, Occupational Health and Safety September 16, 2011

8 7.2.2 There was a 91 cm open hole that extended approximately 20 cm above the deck of the scaffold. While there was metal grating placed around the duct to cover the openings between the duct and the decking, there was nothing placed over the duct opening itself. Syncrude Canada Ltd. and Jacobs Industrial Services Ltd. both had open hole policies that required that an opening be covered, however this policy did not apply to open holes during the erection of scaffolding. At the time of the incident, there was a red tag affixed at the bottom entrance to the 147 elevation which required that all scaffolders accessing the scaffold were to be tied off while working on the scaffold. All workers interviewed indicated that a red tagged scaffold required 100% tie off when accessing the scaffold. SECTION 8.0 FOLLOW-UP/ ACTION TAKEN 8.1 Alberta Employment and Immigration; Occupational Health and Safety Alberta Occupational Health and Safety attended the Syncrude Canada Ltd. worksite on December 1, 2010 to investigate the incident. Interviews and a site survey were conducted on December 1-2, A stop work order was issued to Syncrude Canada Ltd. for the area where the incident occurred so that Occupational Health and Safety could conduct its investigation Occupational Health and Safety issued Notices to Produce to Syncrude Canada Ltd. and Jacobs Industrial Services Ltd. to provide information related to the incident Occupational Health and Safety issued a Notice to Produce to Syncrude Canada Ltd. to provide Occupational Health and Safety with a copy of its investigation report into the incident Occupational Health and Safety issued an order to Jacobs Industrial Services Ltd. to ensure that all covered openings through which workers can fall are provided with adequate protection to prevent a fall. 8.2 Industry Syncrude Canada Ltd. held the incident scene and cordoned off the incident area until Occupational Health and Safety arrived. Syncrude Canada Ltd. provided Occupational Health and Safety with all information required as part of its investigation Syncrude Canada Ltd. conducted an investigation into the incident, and provided a copy to Occupational Health and Safety for its review Jacobs Industrial Services Ltd. cooperated with Occupational Health and Safety fully during its investigation, and provided all information required for Occupational Health and Safety s investigation. 8 Alberta Employment and Immigration, Occupational Health and Safety September 16, 2011

9 8.2.4 Jacobs Industrial Services Ltd. provided Occupational Health and Safety with its revised scaffolding plan for the remaining scaffolding to be erected for the installation of the vertical ventilation ducts so that workers would not be exposed to the hazard of open holes during scaffolding erection. 8.3 Additional Measures No additional measures were required SECTION 9.0 SIGNATURES Cherie Whelan, Lead Investigator Jasmine Lee, Investigator Gerry Wagner, Manager Joanne Garton, Regional Director, Central Date Date Date Date SECTION 10.0 Attachment A Attachment B Attachment C ATTACHMENTS: Map not applicable Photographs 9 Alberta Employment and Immigration, Occupational Health and Safety September 16, 2011

10 Attachment A Map Showing Incident Location Incident Location Incident Location The incident occurred at Syncrude Canada Ltd. s worksite at the Sulphur Emissions Reduction Project approximately 40 km north of Fort McMurray, AB. Alberta Employment and Immigration, Occupational Health and Safety

11 Attachment C Page 1 of 6 Photograph #1 Main photo shows a 3 m vertical high, 91 cm diameter ventilation duct similar to the one involved in the incident. The upper left insert shows the top of the duct that extended above the decking of the fourth scaffolding deck approximately 20 cm. The bottom insert shows the ventilation fan assembly that was mounted at the bottom of the duct work above the floor of the second deck. Alberta Employment and Immigration, Occupational Health and Safety

12 Attachment C Page 2 of 6 Photograph #2 Shows the 1m ledger that Scaffolder #1 lifted up over the edge of the scaffolding prior to his fall. The arrow is pointing to the rope and hook that was attached to hoist the ledger over the side. Alberta Employment and Immigration, Occupational Health and Safety

13 Attachment C Page 3 of 6 Photograph #3 Main photograph shows Deck #1 and Deck #2 of Elevation 146 scaffold. The scaffolding was being erected around the vertical duct that is seen on deck #2 in the main photo. The 3 m vertical duct started at the second deck and extended up to the fourth deck where it extended approximately 20 cm above the floor of the fourth deck. The insert shows the fourth deck where Scaffolder #1 was standing when he hoisted the materials over the guardrail of the scaffold deck Alberta Employment and Immigration, Occupational Health and Safety

14 Attachment C Page 4 of 6 Photograph #4 Shows the ledger on the hook and rope on the floor of the fourth deck on the scaffold. The red arrow is pointing to the approximate position that Scaffolder #1 was standing when he was hoisting materials over the guardrail. Alberta Employment and Immigration, Occupational Health and Safety

15 Attachment C Page 5 of 6 Grating placed around ductwork and scaffold floor. Photograph #5 Main photograph shows the fourth deck of the scaffold. The red arrow is pointing to the indentation on the ductwork. The top left insert is a closeup of the indentation. The top right insert is looking down the ventilation duct where Scaffolder #1 fell. The distance from the top of the duct to the fan assembly at the bottom was approximately 3.4 m. Alberta Employment and Immigration, Occupational Health and Safety

16 Attachment C Page 6 of 6 Photograph #6 Main photograph shows the ladder at the bottom of the 147 elevation scaffold. The top left insert is a close-up of the red tag affixed to the scaffold ladder. It signed by the Supervisor and dated November 30, Alberta Employment and Immigration, Occupational Health and Safety