Bechtel identifies 7 things that contributed to Port Arthur LNG tragedy

Instead, the report has identified seven factors that together contributed to the accident.

The report came after Reginald Magee, Felipe Mendez, and Felix Lopez Sr. lost their lives and two of their colleagues were injured at the LNG facility in Texas on 29 April. The five-person crew was performing tank work at elevation when the climbing formwork system on which they were standing gave way.

The crew had to lift the multilayered formwork system, including the platform on which they were standing, resetting it higher on the tank each time to tie the reinforcing steel and pour the next elevation of a concrete wall. They had successfully jumped and set eight sections during their shift and were setting the last section at the time of the incident.

The Port Arthur LNG Phase 1 project, worth $10.5 billion, is currently under construction and consists of trains 1 and 2, as well as two LNG storage tanks and associated facilities. The planned commercial operation dates for train 1 and train 2 are 2027 and 2028, respectively.

Among the seven contributory factors the internal investigation identified were:

1) Improperly secured connection bracket

The investigation found that during installation of the final formwork section, the left-side bracket was not properly attached to the cone screw - a steel bolt with an integrated washer fixed into an embed in the concrete tank wall. Instead of resting on the shaft, the bracket sat on top of the washer or bolt head, leaving the formwork unstable, something crew was unaware of. When the crew instructed the crane operator to release the rigging, the unsecured bracket slipped off, causing the formwork to tilt and the crew to fall.

Bechtel said that in response it has implemented a documented triple-verification process across every project that uses this formwork system. A suspension of all formwork jumping at night, which makes verification more difficult, will continue indefinitely.

2) Use of fall protection

All five crew members involved in the formwork jumping were wearing project-provided personal fall arrest system equipment. When the formwork rotated, the three people killed did not appear to have their fall arrest lanyards attached to an approved anchorage point. The two who were injured had attached their lanyards to an approved anchorage point and experienced an arrested fall. All five crew members had received fall protection training.

Bechtel said it has updated its requirements so that when a foreman and general foreman supervise crews working at height and they must also attend fall protection training to strengthen their ability to apply requirements. The company has also updated training for jumping formwork to included clearer, more visual guidance, and it is strengthening its fall protection training as well as increasing oversight across all projects. Meanwhile it is suspending disciplinary action when its Life Critical Rules are violated if they are identified and corrected within the crew, to encourage a peer-to-peer intervention culture.

3) Inadequate training

All five crew members were recent hires who had limited or no prior experience in jumping formwork. They had completed general fall protection training and received on-the-job training jumping formwork but had not received the 30-minute classroom training prepared by supervision of the formwork jumping system they were using.

Bechtel suspended all formwork jumping across the company after the incident and inspected all formwork systems. It has also developed a Climbing Formwork Training and Qualification Program, retrained all personnel involved with formwork jumping, and has implemented a multipoint verification system for supervisors to verify that workers have completed relevant training.

4) Absence of an experience crewmember

A foreman and leading hand assigned to the crew were experienced and knowledgeable but weren’t present on the formwork at the time of the incident, having been called away to assist elsewhere shortly before the incident.

Bechtel said it has now mandated for all projects involving formwork jumping for the foreman and leading hand to have been trained in formwork jumping as well to have received additional training to identify and correct hazards. The foreman (or leading hand in the foreman’s absence) will have to be present for and directly supervise formwork jumping activities until the system has been triple-verified as engaged and secured.

5) Non-compliance with Bechtel’s monitoring process

Bechtel has a four-week mentoring process for newly hired craft professionals but in this case there was no 1:1 buddy pairing between crew members and more veteran colleagues. Bechtel said it would reinforce the process with weekly check-ins conducted by a supervisor. It has also set a requirement where no more than half of a work crew may consist of members who have been on site for less than three months. There will also be secondary training for the first three months on site, which includes monthly employee check-ins and additional life-critical training.

6) High-risk work on night shift

The high-risk formwork jumping was taking place at night when darkness, fatigue, and reduced supervision increase the potential for incidents. Bechtel has set a requirement for each project to complete an assessment of the tasks to be performed at night, with projects documenting the specific measures that will be taken to manage the risks of that work. High-risk activities on a night-shift have to be approved by a series of managers.

7) Safety culture

The investigation found that Bechtel’s strong safety culture “was not applied consistently” on this project. It said it was launching a company-wide, long-term programme aimed at eliminating microcultures that can develop within a large organisation.

In a message to colleagues, Craig Albert, president and chief operating officer & Paul Marsden, president, Energy, said, “One of the most important takeaways from our review is the role that safety culture played - and, in some cases, failed to play. Safety culture isn’t the same everywhere. It can shift from project to project, crew to crew, and even task to task. In reviewing the incident, we found breakdowns in oversight and supervision, where moments to step in and take corrective action were missed.

“It is up to our leaders to stay connected to and continually assess the health of our safety culture across every level of the organization, and to take deliberate action to intervene and ensure Bechtel’s strong, company-wide safety values are consistently adopted and reinforced across the business. In doing so, we can strengthen the proactive identification of life-critical risks by work crews and front-line supervisors during daily work planning. We can also promote strict adherence to life-critical safety processes by encouraging real-time, peer-to-peer interventions - prompting crews to pause and reset, seek necessary input, and correct unsafe conditions.”