Safety alert 03/2018 Worker fatally injured during plant change process

WorkSafe is investigating an incident in which an employee was fatally injured. He was struck by a section of pipe at a wastewater treatment plant during pipe modification works. Preliminary investigations indicate that immediately prior to the incident, air pressure was introduced to the modified system and a failure occurred. A section of pipe broke free and struck the worker.

Possible contributing factors in incidents of this type

  • Hazards relating to modification of the system are not adequately identified
  • Thorough risk assessment in relation to the proposed change is not conducted
  • System is not constructed to the required standard
  • Workers are unaware of the potential hazards of modifying and commissioning the system

Managing hazards and risks

When planning to alter plant, the physical environment or processes at a workplace:

  • Clearly define the proposed change
  • Identify the hazards and assess the risks
    • Involve competent persons, who have training and experience relevant to the issue, including technical specialists, supervisors, workers and safety and health representatives
    • Identify which existing risks may change, and any new hazards and risks which may be introduced
    • Consider the longer term risks that will result from the change, for example changes required in inspection or maintenance
    • Assess whether the changed workplace remains compliant with laws and standards
  • Ensure the change proposal minimises risks as far as practicable
    • Revise the proposal if the risks are elevated - consider a different approach or further controls
  • Communicate all changes in relation to risk to affected workers
  • Provide any necessary instruction, training or supervision
  • Monitor the effectiveness of the controls
  • Ensure there is ongoing monitoring to identify gradual changes
  • Document changes and make the documents available to workers

The above information is based on WorkSafe’s preliminary investigation and further investigation is continuing.

Further information

The Department of Energy, Mines, Industry Regulation and Safety.  What is change management and why is it important?

Last updated 04 Dec 2023

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