All Areas Access has been an IRATA OPERATOR member company since 2013, and an IRATA TRAINER member company since 2016. IRATA is the only international association governing industrial rope access ensuring the highest standards in safety, operations and training. Rope access technicians who have been IRATA trained and certified have the benefit of having their qualification recognised world-wide.

Our first priority is to deliver what we promise with uncompromising safety and ZERO harm to people, property and the environment. All Areas Access proudly boast ZERO lost time or recordable injuries in four years of operation.

All Areas Access working with IRATA to keep our industry, and your workplace, safe and incident free.

1. The incident as reported by the Operating Member Company (OMC)

“While carrying out cleaning works on a tall skyscraper the wind suddenly picked up and blew the technicians whom were window cleaning into the building, resulting in minor injuries to the hand and abrasion to the nose. “ “A traditional rescue was not possible due to the high winds and a window was removed and the technicians retrieved safely through the window.”

2. Incident analysis as reported by the OMC

“All necessary precautions were taken prior to the incident such as briefings, toolbox talk checks and wind readings with the addition to a senior level 3 on site and radio communication. All safe systems of work were implemented fully and correctly.” “The weather suddenly and dramatically picked up resulting in a couple of technicians being blown into the building and receiving minor injuries.” Root cause: “High-unexpected wind.”

3. Control measures implemented by the OMC

“Additional wind readings are now taken and recorded throughout the day. During the day when weather is generally poor or adverse the work is done at a different time. The incident was briefed out to the rest of the company and the risk assessment was changed to implement further measures to prevent such incidents occurring in future, such as if there is any doubt that the wind or weather is forecast to be poor the site technicians will consult with a senior IRATA Manager to see if it is safe to work. The site technicians are instructed to be extra vigilant for weather changes and to stop work if there is any doubt of inclement weather either before starting or during the shift.”

4. Health and Safety Committee - Recommendations for further control measures

It is important to gain a local weather forecast prior to starting a rope access task, having regular updates and understanding how the weather behaves in the given area when comparing to that forecast e.g. sudden turbulence. Local knowledge may prove useful information also when assessing this. Adverse weather should be considered when carrying out a risk assessment for a given task where the hazard exists, this assessment should be ongoing as well as initial and take in to account the changing environmental conditions such as wind speed and temperatures. ICOP 4.2.7.3 provides information on the UK Work at height regulations (WAHR) where under the WAHR; work at height has to be properly planned, appropriately supervised and carried out in a safe manner. This includes the need to plan for emergencies and rescue. In addition, employers are required to ensure that work at height is only carried out when the weather conditions do not jeopardize the health and safety of persons involved in the work (see Regulation 4).

When considering emergency rescue and evacuation consider rigging for rescue and including a pre- installed lowering / lifting device (e.g. certain descender devices have the capacity to lift and lower in certain configurations, always consult the manufactures product instructions for the given device to ensure suitability) to each anchor line so that technicians working in areas where such a hazard exists can be lowered or lifted remotely, safely and efficiently.

5. Health and Safety Committee - Recommendations for further reading

* For further information on identifying hazards and measuring risk reference ICOP 2.2.4 & Annex A – Risk assessment;

* For further information on safe execution of sequence of procedure reference ICOP Annex B – Safety method statements;

* Information on Emergency procedures reference ICOP 1.4.2.7 & 2.11.11;

* Keep a look out on www.irata.org for revised IRATA ICOP Annex O, this annex is currently being reviewed by the ICOP development and review panel (provisionally retitled Protecting against environmental conditions) and will include guidance and information on the effects of working in windy environments. Expected release December 2015.

1. Summary

Member companies continue to submit incident reports regarding dropped objects from height, see selection below as reported by the Operating Member Companies (OMC). The H&S Committee would like to re-enforce the message from SB 28 and SB 35, highlight again, the need to treat this issue with the respect it deserves, considering the severity of consequences a dropped object can pose.

Incident 1: “Technician tried to place rope clamp on their rope, the rope clamp slipped out of their hand and fell to the ground.”

Incident 2: “Technician handed an unsecured crowbar to another technician. The crowbar fell from height and landed on a balcony below. No damage was reported.”

Incident 3: “While performing window cleaning by utilizing rope access, the wiper fell down on the ground, inside the barricaded area.”

Incident 4: “Technician used a karabiner to attach a 4 in 1 gas multi meter to him; he clipped through the ring of the multi meter and attached it to his harness. Whilst working, the ring of the multi meter where the karabiner clipped through had broken resulting in the multi meter falling from height.”

2. Incident analysis

The responsible rope access team employing tools and equipment at height must ensure the suitability and fitness for service of the equipment.

3. Health and safety committee - Recommendations for further control measures

* Conduct thorough pre-use checks of items/tools/equipment used at height regarding its structural integrity and suitability for use in a tethered configuration.

* Consider also using proprietary tool tethers to secure hand tools to prevent dropping, depending on the weight of the tool can be secured to the technician, having larger heavy or cumbersome tools and equipment attached to a separate hauling/lowering system.

* Rope access equipment itself can become a dropped object if not handled carefully.

* A pre-use check consisting of a visual, tactile and function check should be carried out before each use. Operators should continue to monitor the safety of the system during use.

* Consider the use of catch nets, bags with large openings etc. when removing fragile and brittle objects or substances to prevent them from falling. In some cases overhead protection of sensitive equipment below or the coverage of thoroughfares might become essential.

4. Health and safety committee - Recommendations for further reading

* For further information on identifying hazards and measuring risk reference ICOP 2.2.4 & Annex A – Risk assessment;

* For further information on safe execution of sequence of procedure reference ICOP Annex B – Safety method statements;

* For further information on securing tools see ICOP 2.11.8.2.2;

* For further information on exclusion zones reference ICOP 1.4.2.6 & 2.11.8 - Exclusion zones.

* For further information on tool attachment methods reference ICOP Annex M - Use of tools and other work equipment.

All Areas Access rope access maintenance crews simultaneously carried out calcification rectification works and electrical upgrade works during a high profile scheduled rail shutdown in Western Australia.

All works were completed ahead of schedule with ZERO incidents or injuries.

IRATA Safety Notice- keeping our industry safe

1. The incident

On 04 February 2015, in a shipyard on board a vessel, rope access work was in progress. Working space was barricaded with red/white tape, according to the procedures. NDT specialist, technician 1 (Tech 1) was performing work to the top structure (davit) of a lifeboat. He was nearly finished.

The rope access supervisor (Tech 2) for the task was preparing the rigging with beam clamps in order to inspect the next welding spot. To gain proper access to the welding spot and to properly perform a rescue if necessary, walkway grating (see Figure 4, point B) was removed by Tech 2 and Tech 3 and placed out of the way. During this action, Tech 2 had secured himself with a lanyard to the top of the handrail (see Figure 4, point C).

Tech 3 was secured with ropes from the rigging attached to beam clamps (see Figure 3, point A and Figure 4, point D).

Tech 2 was facing point C (Figure 4). Tech 2 asks Tech 3 to hand him a set of ropes for the new rigging. Tech 1 had finished the inspection on top of the lifeboat and was climbing down.

Tech 2 noticed that Tech 1 had his leg near the lifeboat control panel. His intention was to warn Tech 1 to be aware of the control panel. In order to warn Tech 1, Tech 2 turned himself 90 degrees to the right in order to face Tech 1. Now Tech 2 is facing the hole in the grating. At the same time Tech 2 intended to take a different position on the grating, in the direction of Tech 1. Taking a different position, Tech 2, removed with his left hand lanyard from point C (see Figure 4), made a step with his left foot and intended to secure himself to point E (see Figure 4) with the lanyard in his right hand.

While doing these multiple maneuvers, for a split second Tech 2 was unsecured and stepped into the hole of the grating. As a result, Tech 2 fell through the opening in the walkway grating and into the water from 14 meters high. Tech 2 fell with his feet downwards into the water. When coming back to the surface the lifejacket started to inflate.

At the same time, Tech 3 communicated with the Control Room that there was a man overboard. Tech 1 was shouting man overboard. Lifeboat 2 was launched into the water.

Tech 2 was swimming to a pontoon nearby to get out of the water and kept communicating with vessel crew.

The crew inside the lifeboat pulls Tech 2 out of the water and immediately removed all gear and clothes and put him in a thermos-blanket.

The vessel crew handed over Tech 2 to firefighters of the shipyard and was taken to HSE office in order to check any injuries and to warm up. It was reported that Tech 2 suffered no injuries.

2. Incident analysis by the Operating Member Company (OMC)

Root cause:

- Human error

- lack of concentration / attention

Conclusion by OMC

Investigation has led to the fact that all OMCs procedure was followed and that all paperwork and permits were in accordance with procedure from client and site. Multiple maneuvers were performed in a short time, which led to this human error from a very experienced rope access technician.

In case a lifeline / safety-line was in place, the necessity for unhooking when changing of position was not necessary and highly likely would have prevented this accident. OMC has already been in contact several times with Tech 2, to check the physical and mental conditions. As far as we can judge, all is well. Tech 2 will not be disciplinary penalized. He is more than willing to support OMC by supporting us in this investigation and in presentations to all involved.

3. Control measures implemented by the OMC

Although procedures were followed, this accident could happen. We have carefully read our procedures and taken in count all the facts, which led to this accident. This resulted in the following point of improvement:

> will adjust Toolbox form stating what to do with unstable or open surfaces and/or grating.

> will adjust tickbox form with additional line stating: Tensioned line in place? YES or NO

> will adjust RA-OPS (Rope Access procedure) with an additional paragraph explaining the procedure what to do with unstable or open surfaces and/or grating. In detail will be explained that in case of open surfaces, lifelines / safety-lines will be placed along the open surfaces. Lifeline / safety-line will be fastened to proper anchor points. In case a lifeline / safety-line will be in place, the necessity for unhooking yourself when changing of position in case necessary, is limited.

4. Recommendations

A number of fundamental principles failed to be applied essentially being:

1. The technician was not attached whilst working at height;

2. The removal of walk way grating creating the unprotected edge was done without proper planning, protection or notice;

3. The worksite was potentially congested and not planned in an agreed sequence;

4. Communication was inadequate;

5. The fall protection system either personal and/or collective did not fully suit the work scope.

Human error and momentary lapse of concentration appears to be the immediate if not root cause. It is essential that the rope access teams are aware of the hazards associated with the task to be carried out including hazards created by the team itself namely falls from height. A suitable exclusion zone is required to protect not only third parties from the rope access task being carried out but also from the rope access team themselves so that the team are not exposed to the hazard when moving around at height and concentrating on other tasks in hand. The use of barrier tape to prevent third party access was totally inadequate bearing in mind the removal of walkway grating and creating an exposed edge. This may have contributed to the overall approach to the jobsite as with signed & hard barriers in place would have meant access and egress require a more controlled action and a sense of the exposure beyond them considerably higher. There are various ways to control falls from height when working near to exposed areas including but not limited to the following:

 Barricading off the affected area from third party access using signed and hard barriers (in this case barrier tape had been an implemented control measure and was not the immediate cause);

 Implement a Work Restraint system so that it is impossible to reach the affected area;

 The use of a barrier system around an opening as an automatic default action if any grating in a walkway is to be removed;

 Only remove walkway grating when absolutely necessary i.e. when accessing the work area to carry out the task and then installing the walkway grating as soon as the task is complete and technicians have egressed the work area therefore minimizing the exposure time to the hazard;

 If selecting fall arrest as a method of access whilst moving around the affected area then 100% attachment at all times must apply and an appropriate system selected to reflect this.

For further guidance and information on applying a safe system of work please refer to the IRATA International Code of Practice (ICOP) - http://irata.associationhouse.org.uk/default.php?cmd=215&doc_id=4336

IRATA Safety Notice- keeping our industry safe

1. The incident

The incident occurred in a shipyard on board a drilling vessel. A team consisting of four members was on their task to drill m18 hole for the support at the starboard side of the derrick at level 7. The team comprised:

 Employee #1 is on top of the drilling area to lube the drilling bit;

 Employee #2 is on rope doing the drilling from the bottom towards the upper level;

 Employee #3 is holding the safety line for the magnetic drill;

 Employee #4 is stand by at the edge of the platform to hand over equipment.

Employee #1 is holding the cutting oil attached to a lanyard, which is connected to his cow’s tail, while Employee #2 is doing the drilling. Employee #1 repeatedly lubricated the drilling bit by pouring the oil directly from the container and keeping a distance around 10mm. At one point the lanyard of the cutting oil container made contact with the drill bit which caused Employee #1 left little finger to become caught and crushed in between the lanyard and the drilling bit.

2. Incident analysis

Root cause:

- Human error

- lack of concentration / attention;

- ‘Moving parts’ hazard was not identified and highlighted.

3. Control measures implemented

Safety meetings to be held with all crew to raise awareness of concentration and attention during all operation.

Safety meetings to be held with all crews to raise awareness of hazard identifying involved in all tasks.

4. Recommendations for further control measures

 Conduct thorough pre-use checks of items/tools/equipment used at height regarding its suitability for use in a tethered configuration;

 Where appropriate choose auto feed lubrication systems over manual feed;

 Use extended nozzles so that an increased distance between lubricator and machine is maintained;

 Use elasticated or retractable tool tethers/lanyards to reduce unnecessary slack coming into contact with moving machinery thus reducing the entanglement risk.

5. Recommendations for further reading

 For further information on identifying hazards and measuring risk reference ICOP Annex A – Risk assessment;

 For further information on safe execution of sequence of procedure reference ICOP Annex B – Safety method statements;

 For further information on using work equipment from anchor lines reference ICOP Annex M - Use of tools and other work equipment.

IRATA Safety Notice- keeping our industry safe

1. The Incident

On 30 July 2014, a high-potential near miss incident took place on board a semisubmersible drilling platform (could have resulted in a fatality)

During derrick inspection activities whilst using rope access, both ropes of a team member where destroyed caused by accidental activation of the derrick elevator. All moving derrick equipment had been isolated electrically before start of the activities correctly and in accordance with the project’s risk assessment (except for the elevator).

The person involved promptly acted upon noticing that the elevator started to move, which enabled him to stand on a nearby support beam and secure himself to the cable tray directly next to him.

2. Circumstances

Arrangements were made that no persons outside the rope access crew itself (team of 12) could use/activate the elevator from the bottom position (intermediate stops halfway up the derrick and at the crown). The rig floor and surrounding area had also been barrier off.

A team of 2 RA technicians from the team of 12 were working together on the derrick’s corner leg adjacent to the elevator support tracks, but around the corner.

After completion of their inspection descent, one team member climbed back up on the ropes towards the crown to guide torque tools suspended from a light winch along the same route upwards.

Before ascending the ropes were released from the railing to which they were tied down (to prevent them being blown sideways).

Even though agreements were made to ask permission via radio before using the elevator, a RA tech belonging to a second team (next to the one asking the permission) accidentally pressed the elevator call button on the control panel.

A safety alert was raised among company personnel and shared with the client.

3. Lessons Learned

 Task Risk Assessment for use of the elevator (and when changing procedures) with a RA team nearby should have been carried out with the whole team and formally recorded on paper;

 All moving machinery should be isolated when carrying out RA work (even when arrangements are made to keep third parties away from control points);

 Make proper arrangements to prevent ropes getting moved by wind / caught by moving parts (rigging, rope bags, etc.);

 (Radio) Communication procedures should be clearly agreed with the entire team (transfer & verbally confirm all information);

 To have a clear description of / policy on a Level 3’s role in projects with large team sizes.

4. Conclusions

The Operating Member Company (OMC) has implemented additional control measures including: training of employees regarding communication; updating guidance on project risk assessments; adding ‘Confirm isolation of all moving machinery’ to pre-shift meeting checklist.

Furthermore the OMC has cooperated with several clients to issue a standing order to an entire fleet of one drilling contractor which prohibits the use of rope access in active derricks and to confirm complete isolation of moving machinery (also elevators) in derricks. The OMC is also communicating this message across to other drilling contractors & clients.

5. Recommendationsfor further reading from the ICOP

 Refer to Annex A - Risk Assessment for guidelines and principles of the risk assessment process, which can and should be applied to all work situations, see also 2.2.4.5 The hazard identification and risk assessment should be site specific. They should be documented and should cover all aspects of the work to be undertaken. The document(s) should be available to personnel working on-site and should be regularly reviewed formally by them during the course of the work, to take account of changing circumstances, e.g. weather conditions and other work being carried out. Operations such as oil platforms, refineries, power stations and railways have a formal written permit-to-work system to address hazards, by requiring certain precautions to be taken. Examples are: electrical isolations; restriction of other work; communication requirements; specified personal protective equipment

 Refer to 1.4 - Principles and controls for the essential elements of a safe system of work including 1.4.2.5.6An efficient communication system should be established between all rope access technicians in the team and, where necessary, third parties, e.g. the control room, if offshore.

 Refer to Annex P – Recommended actions for the protection of anchor lines, see also 2.11.3 – Use of anchor lines which contains 2.11.3.1.6The effects of wind on the free end of anchor lines should be taken into account. Care should be taken to ensure that the tail end of anchor lines cannot snag on dangerous objects, such as working machinery, power lines or a moving vehicle. This could lead to the need for additional monitoring.

 Refer to 2.11.7 - Pre work checking.

 Refer to 2.11.8 - Exclusion zones.

 Refer to 2.11.9 - Communication which contains 2.11.9.1 An efficient communication system should be established between all rope access technicians and, where necessary, to third parties (e.g. sentries or the control room, if offshore). This should be agreed and set up before work starts and should remain effective for the whole of the time that people are at work.

IRATA Safety Notice- keeping our industry safe

1. Summary

Incident 1:Beam used to hoist a banner got stuck. When released, it hit an employee in the face. Technician had a bleeding nose.

Incident 2:While welding a length of chain onto a cross member, the technician used a gloved hand to initially place the chain. During the welding process a piece of welding slag lodged on a recess of the glove, burnt through the glove which resulted in a first aid treatable burn to the finger. The burn was treated with a tropical burn cream and the technician returned to work. The technician should have used a clamp to hold the chain in place while welding, instead of a gloved hand.

Incident 3: Due to welding above our worksite, weld spatters rained on our equipment resulting in a waste bag catching fire.

2. Conclusions

While the above examples are related to trades specific tasks – rigging and welding - safework principles apply to all working at heights and rope access situations. These cases highlight the need to take care with unfamiliar tasks and the arising risks and hazards requiring pre-execution identification to prepare safe operation. The responsible IRATA site safety supervisor, although experienced in his trade of rope access, must consult with the specialist trades person, engineer, inspector etc. and all team members at large to appropriately plan and execute the task as outlined in the scope, utilising the correct techniques, tools and PPE.

3. Recommendations

 Refer to ICOP Annex A - Risk Assessment for guidelines and principles of the risk assessment process, which can and should be applied to all work situations.

 Refer to ICOP Annex M - M.5 Hot work and M.4 Bulky, awkward or heavy equipment in particular, regarding the above examples.

 Refer to ICOP 2.11.9 - Communication. Rigging and lifting activities on ropes, for example, shall follow the same principle as operations on ground level. Where spotters are necessary to closely monitor a load in motion, ensure the technician is adequately trained and briefed on the task and the commands used during the operation. Ensure alternative communication is available to the team in case one method fails during operation (e.g. failure of radio communication, excess noise inhibit clear conversations etc).

 When planning activities, consider the bigger picture, not only those hazards affecting the immediate vicinity and the technicians performing the work but anticipate the whole area where affected works may possibly reach. Welding splatters may drain away from the immediate job location setting waste on fire however, this could have severe consequences if the resulting fire is cutting off/inhibiting your escape and retrieval routes.

 There may be occasions where PPE worn to access and egress a work place may differ to the PPE required to carry out a given task (e.g. gloves), for further information refer to ICOP 2.7.14 – clothing and protective equipment.

IRATA Safety Notice- keeping our industry safe

1. Summary

Member companies continue to submit incident reports regarding dropped objects from height, see selection below. The H&S Committee would like to re-enforce the message from SB 28, highlight again, the need to treat this issue with the respect it deserves, considering the severity of consequences a dropped object can pose.

Incident 1:Karabiner was carried open on the side of the harness, resulting in a drop of the karabiner. Nothing was hit, karabiner remained within barrier area.

Incident 2:the attachment point of a Makita hand drill broke (without a clear reason, no shock load), resulting in a fall of the Makita from 60m. Only the battery drill was damaged, remaining within the barricaded area.

2. Conclusions

The responsible rope access team employing tools and equipment at height must ensure the suitability and fitness for service of the equipment. The example involving a dropped battery drill in particular shows the importance and value of exclusion zones.

3. Recommendations

 Conduct thorough pre-use checks of items/tools/equipment used at height regarding its structural integrity and suitability for use in a tethered configuration.

 For further information on exclusion zones reference ICOP 1.4.2.6 & 2.11.8 - Exclusion zones.

 For further information on tool attachment methods reference ICOP Annex M - Use of tools and other work equipment.

 Consider having larger, heavy or cumbersome tools and equipment attached to a separate hauling/lowering system

 The above precautions and requirement for inspection and suitability also apply when using retractable lanyard style equipment/tool attachment devices.

 Rope access equipment itself can become a dropped object if not handled carefully and/or malfunctioning.

 A pre-use check consisting of a visual, tactile and function check should be carried out before each use. Operators should continue to monitor the safety of the system during use.

 Consider the use of catch nets, bags with large openings etc. when removing fragile and brittle objects or substances to prevent them from falling. In some cases overhead protection of sensitive equipment below or the coverage of thoroughfares might become essential. Information refer to ICOP 2.7.14 – clothing and protective eg.

IRATA Safety Notice- keeping our industry safe

1. The Incident

Incident occurred on 16 July 2014 at 10.30am at an indoor training area operated by a Trainer Member Company (TMC).

The affected person was a Level 1 candidate (IP1) on the first day of a two-day IRATA Level 1 revalidation course. IP1 had over 6 years experience at IRATA Level 1 with 400 hours in his logbook.

There were three TMC staff on site at the time of incident:

L3T1 = IRATA Level 3T trainer on duty;

L3T2 = TMC director, teaching theory in classroom;

OM= TMC Office Manager, in office.

There were seven trainees on site at the time of incident:

Four Level 1 candidates including IP1 in training area with L3T1;

One L3 candidate and two L2 candidates in classroom with L3T2;

The other three L1s had been with the TMC since Monday.

Two were experienced technicians revalidating and one was new to the industry. All were progressing well with training allowing L3T1 to initially focus his attention on IP1.

After assembling equipment, L3T1 took IP1 through some initial manoeuvres: ascent and descent with ascenders; then up with ascenders and change to descender and descend; this was carried out twice.

With IP1s prior experience and performance on these initial exercises L3T1 was happy to move onto more complex manoeuvres, starting with a rope-to-rope transfer. IP1 completed the first half of the exercise successfully, changing from ascent to descent, connecting to the new ropes with chest ascender and knot, and lowering across. L3T1 advised IP1 of the remaining steps to complete the exercise and turned his attention to the other L1 candidates. A short time later IP1 fell the short distance (approximately 2m) to the floor clutching ropes, burning his right hand and landing hard on his left leg, hurting his ankle. IP1s handled ascender and foot loop were still on the rope, but he had no connections to the ropes. IP1 said he thought he had put his descender on the rope before removing his chest ascender, but it was evident he had not. Likewise his back-up device was not connected, he had untied the knot and had not connected to his handled ascender.

NB: the initial report in the TMC accident book suggests the back-up did not engage due to insufficient height. Further discussion with L3T1 and IP1 suggests the back-up had in fact been disconnected.

2. Incident analysis

Although IP1 considered the accident his own fault, it could have been prevented through closer supervision. Supervision was at the TMCs normal level (4:1), and is lower than IRATA’s maximum candidate/trainer ratio of 6:1. IP1s experience and initial performance were not indicative of him requiring special attention or a higher level of supervision.

Whilst the potential for such accidents is always present when training it is not possible to watch everyone 100% of the time, but a quick check to confirm at least one good connection had been made would have been sufficient to prevent the fall.

The incident required IP1 to make all of a series of mistakes:

 Not re-attaching his descender,

 Not re-connecting his back-up,

 Not disconnecting from the knot,

 Not making a connection to his handled ascender,

 Not checking all of the previous before disconnecting his chest ascender.

The avoidance of any one of these mistakes would have prevented the accident.

Equipment selection was not considered to be a factor here.

This is the first time any of the TMCs trainers have witnessed such an incident in many years experience and it is considered to be very unusual. IRATA’s accident statistics confirm that such occurrences are very rare.

The TMC report that the only unusual factor present was that IP1 was attempting to revalidate in 3 days and perhaps therefore felt pressure to ‘catch-up’ with the other L1 candidates who had been present since Monday.

3. Control measures implemented

IP1 was advised by the TMC to have at least a day’s rest. As this would leave him unable to complete the course the same week it was agreed to reschedule on the 4 August, for a full four days (which became mandatory in the intervening period with the release of the Training Assessment and Certification Scheme on 01 August) of training. The TMC noted that in light of this incident it would seem prudent to insist all candidates attend the 5-day course; coincidentally IRATA introduced this as a requirement in the same period.

The TMC held a toolbox talk with all trainers to discuss how the accident could have been prevented. The incident affirmed the worth of keeping an attachment to the handled ascender, which although not mandatory the TMC teach as good practice.

4. Postscript

IP1 re-attended training without further incident, and was successfully assessed and recertified at IRATA L1 for 3 years.

5. Further Reading

Further reading for candidates attending training courses can be found in IRATAs Training, Assessment and Certification Scheme (TACS) in section 4. - Guidance for candidates.

Further reading for trainers and trainer member companies can be found in TACS section 7. -Requirements and guidance for trainers and trainer member companies.

A link to TACS can be found here - http://irata.associationhouse.org.uk/default.php?cmd=215&doc_id=4193

IRATA Safety Notice- keeping our industry safe

1. The Incident

At around 10h30 on 11 October 2014 a Rope Access Technician Level 1 (IP1) fell from a building roof level to the 2nd floor level of the seven-storey building. All team members and eyewitnesses who were on the scene of the incident were interviewed.

The incident took place after the team had completed their first section of work, during the time that the ropes were being shifted to the next section, but prior to the completion of the rigging. The Level 3 Supervisor (L3S) was responsible for the rigging and was at the ground level on the north elevation busy with rigging and being assisted by a Ground Support Technician (GST1). GST1 was responsible for establishing the exclusion zone and for radio communication with Rope Access Technician Level 2 (RATL2) who was team leader on the rooftop and all communication was done in their mother tongue, to avoid confusion. RATL2 was responsible for communication on the roof and for all rigging assistance and safety measures on location.

At approximately 10h25, RATL2 received information from L3S that the rigging of three sets out of five (1, 2 & 5) are complete and that the team should get ready to start their work on the south elevation. Once the information was received, RATL2 instructed two technicians to start attaching to their ropes in location 1 and 2. At this point one of these technicians requested additional rope protectors from RATL2, who then left to another part of the roof to collect the items.

During the absence of RATL2 two technicians, IP1 and Rope Access Technician 1 (RAT1) proceeded to attach themselves to their individual sets of rope (3 & 4) and positioning themselves on the parapet wall without receiving instruction to do so from the team leader or supervisor. At approximately 10h30, IP1 proceeded to lower himself off the parapet wall and onto his working ropes, but as he let go of the parapet wall committing his entire weight to the ropes the ropes started slipping. IP1 fell two floors where he hit a ledge of approximately 1 meter wide. He rolled off the ledge and proceeded falling the further three floors to the landscaped area on level 2 of the building.

At this point security responded to the sound of the impact and rushed to assist IP1. They released him from his ropes and removed his harness. IP1 was then assisted to go inside the building where he was made comfortable inside the security room on the floor and the security phoned the ambulance service. At the same time on the roof RAT1 informed RATL2 of the incident and RATL2 immediately let L3S know by radio. All technicians went to level 2 to assist IP1, but were prevented access to him by building security until the ambulance arrived and took him to hospital at 11h20.

Detail of injury noted as bruises, bone fracture and ligament damage.

Parts of injury damage noted as left little finger, right foot and right hip. Cause of accident noted as human error/procedure not correct/carelessness. Injury agent noted as concrete slab and loose stone landscaped area.

2. Incident Analysis

Corrective action request taken to prevent re-occurrence or eliminate hazard: An immediate investigation was carried out by the QHSE Manager of the Operating Member Company (OMC) assisted by OMC Safety Officer and in collaboration with the building Associate Director Public Safety, Building Facility Project Manager, Site HSE Manager and site security. All site personnel were interviewed on site excluding L3S who was taken by the police and interviewed at a later stage after his release, on the same day. IP1 was interviewed in the hospital while awaiting the results of his CT scans and x-rays.

A close door emergency meeting was called by OMC Head of Division and attended by division management, operations management, assistant managers involved and site management and supervision. During the meeting all documentation was examined, all procedures where discussed and analysed and corrective actions where determined.

Root cause: - Human error - Poor communication

3. Control Measures Implemented

When rigging activities are carried out that are not in line of site of the technician from where he will access the system then no one will be allowed to transfer onto the ropes until the Level 3 supervisor has checked the rigging and is back on the roof or access level to give personal approval for technicians to access the system.

When rigging activities are carried out that are not in the line of site of the technician from where he will access the system then all access ropes are to be positioned on the roof or access level and not lowered over the building edge until the Level 3 Supervisor has checked the rigging and returned to the access level and gives all technicians the approval to access the ropes.

A green tag system will be implemented where the Level 3 supervisor responsible for the rigging will have to do a green tag on a daily basis for each set of ropes. The tag will contain the following information – supervisor name, date and signature.

Immediate meetings were held with all OMC Supervisors explaining the incident and discussing root cause with preventative measures.

Scheduled meetings are being held with all OMC personnel over the course of the next week to discuss the incident, root cause and the preventative measures emphasising the fact that safety is everyone’s personal responsibility first.

Method statement templates are amended to provide a place for signatures by assistant managers and supervisors (every supervisor who gets to the site – even as a replacement for another need to sign a new method statement document with the site assistant manager) of OMC to assure procedures are explained, understood and handed over.

IRATA Safety Notice- keeping our industry safe

1. Summary

Incidents have been reported to IRATA where technicians have not followed the clients or employing companies’ procedures;

“A worksite visit was being carried out and it was noticed that one of the Abseil team was not wearing a life jacket whilst working overboard. The job was stopped and work party came back in board. Discussions followed with team leader and manager. L3 and team brought in for investigation.”

“A team needed to lift a 900mm C-Beam (3kg) from roof deck to the 8th floor of the derrick. When lifting commenced, the beam jerked due to the ropes rebound and slipped out, falling down 3m. No barriers or signs were put up during the task. Nobody got hurt when the beam fell. The site manager immediately stopped all ongoing task on the derrick and barricaded the location. Investigation carried out found improper rigging methods were used.”

“The technician was abseiling down the rock face, carrying a hedge cutter on his harness to pass it to a competent person to use. The hedge trimmer was hooked on to the IPs harness and hanging at his side. During transportation it bounced on a rock and swung round making impact with his left hand. The technician was fairly inexperienced (level 1 with only 5 months experience), the hedge cutter was being carried incorrectly allowing the hedge trimmer to bounce of the off the rock.

The hedge trimmer should either have been lowered on a rope, raised to the operator on a rope or hang from a lanyard below the operative carrying it down the slope in accordance with the IRATA Code of Practice.”

2. Recommendations

The IRATA ICOP makes clear reference to the requirement for suitable procedures to be in place to help protect personnel and property (A.1.2). Employers and technicians should ensure they fully understand the contents of procedures prior to commencing any task (A.2.1.4.2). Detailed information relevant to the task should be available prior to the task commencing (B.2) and toolbox talks should be used to confirm that technicians understand what is required of them from the safety method statement (annex B) and if they identify that they do not have the correct equipment or PPE (B.2.2.e) or are not suitably qualified (2.2.5.1) to carry out the task then the work should not go ahead until all the correct resources have been found.

Exclusion zones with adequate signage should be set up prior to tasks commencing (1.4.2.6 & 2.11.8) and prior to any work commencing proper pre site planning (1.4.2.1) should be carried out including hazard identification during the risk assessment phase (annex A) and any safety method statements (procedures) should be strictly adhered to during the task and may not be deviated from.

If technicians are unable to comply with any requirement of the procedure or do not understand the procedure then they should not commence the task without reporting the issue to their supervisor or employer. They must not recommence the task until they clearly understand what is required or until the issue has been adequately addressed.

IRATA Safety Notice- keeping our industry safe

1. Summary of incident reports

A few incidents have been reported to IRATA relating to technicians suffering strain injuries;

“While bristle blasting the underside of the pipework, the technician felt a pulling sensation in their left shoulder when applying pressure. Technician came down and reported to medic.”

No rescue required.

“Technician was climbing after lunch, between pipes and experienced pain in his shoulder. He was safe and sitting on pipes and alerted his team mates. A rescue was initiated where the supervisor climbed to him, prior to attaching a 3:1 system to the technician and hauling him to safety. The technician was stripped of his harness and walked away escorted to the medic.”

The shoulder was found to be dislocated causing significant pain.

“While performing rigging work, technician felt pain in his groin after repositioning and evacuated to surface. After resting, the pain was still present so technician reported to rig medic who evacuated him to hospital for inspection/diagnosis. Technician had passed a full medical examination and had been working without problems since then.”

No rescue was required.

All the scenarios above describe qualified rope access technicians who had passed medicals to work in the environment they were operating in, however these medicals do not take into account their current physical strength and fitness as they are usually carried out on a two yearly cycle.

2. Conclusions

According to the IRATA ICOP, rope access technicians should be physically fit to carry out rope access activities at height.

“1.4.2.2 Training and competence

Rope access technicians should be:

b) sufficiently physically fit and free from any disability that might prevent them from working safely at height;”

The trigger mechanism for these incidents appears to be related to poor body positioning, overexertion or lack of access and egress consideration.

3. Recommendations

Rope access work can be strenuous and it is strongly recommended to carry out suitable warm up exercises prior to commencing any rope access activities, especially after prolonged periods of rest.Use rope access equipment for its intended purpose and ensure the most ergonomic body position in relation to the task and worksite.If any discomfort is being experienced, whilst carrying out the task, stop the job and reposition prior to commencing the task. If the task cannot be carried out safely it should not be carried out at all. Technicians should take the time to be mindful of their comfort whilst fitting their appropriately sized rope access harness as per the manufacturer’s instructions and use suitable clothing to maintain a comfortable temperature while working.

“2.3.1.6 Rope access technicians should be given the opportunity not to work at height if they do not feel fit enough to do so. (IRATA ICOP)”

IRATA Safety Notice- keeping our industry safe

1. Summary

An incident has been reported to IRATA relating to a work party not correctly identifying all the hazards associated with their task at the planning or job implementation phase;

“Operators were not informed by the client or had not noticed low voltage electrical bird protection on the structure themselves.

Operator touched the bird protection & received electrical shock to their left hand.

All work ceased until electrical bird protection powered off & isolated. Operators briefed to be aware of these types of protection in the future.”

2. Recommendations

As referenced in the IRATA ICOP, proper hazard identification during the risk assessment process, whilst planning for the job, may have helped identify this hazard correctly and allowed for the necessary steps to be taken to isolate the low voltage electrical bird proofing. It could be beneficial to talk to building managers and/or area authorities and use open questioning techniques during discussions as they may have more knowledge of hazards onsite and in conclusion may help provide for a more comprehensive risk assessment.

2.2.4 Risk assessment

2.2.4.1 Once it has been decided that rope access is a suitable method to carry out the intended task, employers should review carefully the procedures to be followed for carrying out the work. They should identify any hazards and examine how they can be removed or, if this is not possible, how the risk can be reduced to an acceptable level. This is determined by carrying out a risk assessment, which is also known as a job safety analysis (JSA). For more information on risk assessment, see Part 3, Annex A.

2.2.4.3 Hazard identification should comprise identification of anything with the potential to cause harm, for example:

a) power cables, which could pose a high risk of electric shock; …

2.2.4.5 The hazard identification and risk assessment should be site specific. They should be documented and should cover all aspects of the work to be undertaken. The document(s) should be available to personnel working on-site and should be regularly reviewed formally by them during the course of the work, to take account of changing circumstances, e.g. weather conditions and other work being carried out. Operations such as oil platforms, refineries, power stations and railways have a formal written permit-to-work system to address hazards, by requiring certain precautions to be taken. Examples are: electrical isolations; restriction of other work; communication requirements; specified personal protective equipment

2.11.7 Pre-work checking

2.11.7.1 If a permit to work is required, this should already have been obtained and checked. Permits to work are an effective method of isolating a hazard before work starts and to ensure that it remains isolated while work is in progress and until everyone is clear of the danger area.

See IRATA Safety Bulletin number 26 which highlights how important it is to identify all the hazards associated with a task during the planning and risk assessment phase of the project.

NOTE Permit to work systems are not fool proof and technicians must be aware of other site operations

IRATA Safety Notice- keeping our industry safe

1. Summary

“While performing a rigging and rope systems check, one of our techs found one of our lifelines to be cut. This rope was clearly cut intentionally by someone else. It looked as if it has been cut to possibly be used as a haul or tag line. There is probably a 50-75 ft. section of the rope missing. It was not in the way of anyone or another ongoing job. The rope was intact yesterday when it was last used. These ropes have to be left up overnight due to the lengthy rigging process versus the little amount of actual time we are able to spend in the field.”

It goes without saying that rope access equipment represents the safety of human life therefore we must look after our equipment and be aware who is potentially tampering with it. Understandably we can only use reasonable precautions to ensure that no other work parties will cross our barriers and enter our work site to tamper with rope access equipment. It is not unheard of for third parties to interfere and / or damage rigged rope access equipment while technicians are on breaks or off shift. From the example above we can see the importance of pre use equipment inspections and of suitable exclusion zones with clear signage.

2. Recommendations

Although it is nearly impossible to stop third parties from entering, tampering or damaging rope access equipment whilst off shift or on breaks, by following the IRATA ICOP recommendations below it may help to deter these actions from happening;

2.10.1.4 It is essential that all load-bearing equipment is given a visual and tactile inspection by the user before each use to ensure that it is in a safe condition…”

2.11.8.3 Anchor area exclusion zone

2.11.8.3.1 An anchor area exclusion zone (also known as a rope access controlled area) should be cordoned off at anchor level with suitable barriers and warning signs. The anchor area exclusion zone should usually be large enough to include anchor points and to provide safe access to the working edge.

2.11.8.3.2 Only members of the rope access team should be allowed in the anchor area exclusion zone, unless under close supervision.”

2.11.8.2.3 Exclusion zones…People should be discouraged or prevented from entering the exclusion zone or interfering with the rigging by posting suitable notices, providing warning signs, erecting appropriate barriers or installing alarms….

2.11.7.5 At the beginning of each working day and at other times as appropriate, e.g. when the anchor lines are relocated during the day, the rope access safety supervisor should carry out a pre-use check to ensure that all the anchors and anchor lines (wire and textile), and the structure or natural feature to which they are attached, are satisfactory. This pre-use check should include any points on the anchor lines where abrasion or other damage, e.g. caused by hot surfaces, could occur. The rope access safety supervisor should also take responsibility for checking anchor lines for length and that, where appropriate, termination stopper knots are in place and secure.

Another consideration could be the use of bag tags with a unique security seal threaded through the eyelets of the rope bag to prevent unauthorised tampering with rope access equipment. It may be necessary to have an additional person as sentry or guard to prevent unauthorised tampering with suspension equipment.

IRATA Safety Notice- keeping our industry safe

NOV Tuboscope, Singapore has reported the death of an Rope Access Technician during their normal working operations on a Drill Ship in South Korea on 13th Oct 2013 as a result of falling from height.Preliminary investigations are still ongoing with NOV Tuboscope and the local Health & Safety authorities.Further information will only made available to the Association and its members once a full investigation has been completed.

All Areas Access work with State-run and Government facilities, construction companies and property management companies providing site audits, risk assessments, consultation, installation, inspection and re-certification of height safety and fall protection systems.

Our trained, qualified and competent height safety personnel ensure Australian Standards are met throughout the whole process from planning to completion. Our clients are informed of the latest local Standards and assisted in management of existing systems, and any new systems which may be installed.

All Areas Access took part in Kingpost and pad-eye water bag load testing, pre and post load test NDT services on an offshore facility in Western Australia.

A combination of rope access services, rigging, lifting, load testing and NDT inspection techniques resulted in successful operations well within time and budget.

IRATA Safety Notice- keeping our industry safe

Two serious incidents occurred on the Gold Coast due to the incorrect selection and use of rope access systems.

In one incident the working line was severed and the worker fell several floors before the rope grab on the second (safety) line locked onto the rope. As the worker fell he repeatedly struck the building and was injured.

In the other incident the worker was injured when he swung down and along the return face of a building due to the pendulum effect.

All Areas Access rope access inspection personnel are able to carry out most forms of Non-Destructive Testing on in-service plant, equipment and structures. This saves the client time and money, and often eliminates the need for costly shutdowns.

SAFE, QUICK & COST-EFFECTIVE.

All Areas Access rope access and EWP operator personnel were involved in maintenance works of the 20 shade sails scattered around the Metropol Hotel in the Crown Casiono, Perth WA. Careful planning, combined with advanced rigging and rescue systems set in place by our experienced IRATA Level 3 Safety Supervisors, enabled our rope access technicians to complete the tasks with zero incidents or accidents, zero damage to property and little to no disruption to the busy restaurants trading below.

Safety, Quality, Time, Cost.

All Areas Access Group has been involved in successful projects across all states of Australia and across all industries. Our Gallery is regularly updated with dynamic pictures of our rope access and specialist personnel in full swing and demonstrates our innovative ability in providing solutions to Safety, Access, Maintenance, Construction, Engineering & Integrity.

IRATA Safety Notice- keeping our industry safe

1. The incident

A rope access technician carrying out work at height positioned himself and his equipment to a new location while still at height. When the equipment was set up at his new work site, he leaned back to check that the equipment was aligned correctly. By leaning back the path of his ropes changed and his ropes came into contact with unidentified cyclic pipework which had increased in temperature from ambient temperature (about 25 degrees) to greater than 250 degrees. The supervising Level 3, watching the operator, saw that the outer sheath of the working line had become damaged and the inner core seriously compromised whilst in contact with the cyclic pipework. The level 3 immediately called the technician and advised him to return to his original position and to secure himself to the structure. The level 3 rigged and lowered a replacement set of ropes to the technician and the technician descended safely to the ground, unharmed. All work was ceased immediately.

2. Incident analysis

2.1 Rope access team was working in an area with unidentified cyclic pipework.

2.2 Rope access team was unfamiliar with cyclic pipe work and its location/function.

2.3 Area Authority issuing the permit to work did not identify the potential hazard of cyclic

pipework to the performing authority and the rope access team prior to the task

commencing.

2.4 Onsite, vigilant supervision by the level 3 allowed for the technician to be advised of

the incident thus preventing further damage to the technician’s ropes and possible

injury to the technician.

3. Control measures

The sites permit to work system was updated to highlight location of cyclic lines to all

operatives.

Any work sites which are in areas of known cyclic pipework are now discussed in

detail with the Area Operators and team prior to issuing the permit to work.

All works in and around cyclic lines are now considered as working at maximum

temperature and as such all risk assessments and controls made to that effect.

All Ropes will be deviated away and protected from cyclic lines.

(See ICOP reference 2.7.10.1, 2.11.3.1 & Annex P)

All new operatives will be mentored highlighting dangers of cyclic linesToolbox Talks now revised to include cyclic lines and prompt operators to safeguard

ropes from hidden dangers.

4. See also Safety Bulletin 20 ‘Near Miss’ Rope melted by heat from a lamp relating to

situations where failure of both anchor lines caused by a heat source is possible.

http://www.irata.org/safety_notices.php

IRATA Safety Notice- keeping our industry safe

1. The incident A team was performing a potential dropped objects inspection on the forward side of a derrick, from the top of the derrick to midway down using double rope access techniques. A level 1 technician was positioned on his ropes under the crown waiting for his colleague to pass him a tool. At this point the level 1, while still waiting for the tool, felt his main working rope being tensioned towards the bow of the ship, causing him to be pulled away from the derrick in the opposite directions of his two anchors. The tension rope caused his descending device to fail catastrophically (the broken descender device was found more than 50m away from the base of the derrick) and the main rope, that his descending device was on, then snapped at the source of the tension below, causing the technician to swing back in towards the derrick on his back up line. The Level 3 immediately contacted the drill floor, via radio, calling for all activities on the drill floor to be stopped. The level 1 secured himself to the derrick structure and a second set of ropes were deployed by the level 3 who abseiled down to the level 1, once satisfied that the level 1could abseil down without any assistance, the level 3 gave another descending device to the level 1, the level 3 then abseiled down to the next safe level and was soon followed by the level 1, on the new set of rigged ropes, to the same level. All work at height was stopped until further notice. During the incident the snapping rope “whipped” up hitting the top of the level 1’s left leg and knee causing abrasions and severe bruising. Upon investigation of the incident it was found that a member of the drill crew had requested a basket to be lifted by the deck crew but no one had gained authorisation to do this lift. The port forward crane was used to carry out this lift. As the crane moved to carry out the unauthorised lift, the level 1’s rope ends became entangled in the crane boom causing the tension in the lines which led to the incident.

2. Incident analysis 2.1 The deck crew ignored the rope access teams’ barriers and signs and operated the crane without any authorisation from their supervisor. The deck foremen was aware of the rope access activities but he wasn’t consulted about the crane lift over to the drill floor. A sentry in the exclusion zone could have helped prevent this incident. (See ICOP Ref 2.11.8) 2.2 The driller should have been contacted before anyone entered the drill floor; this rule was disregarded by the deck crew carrying out the unauthorised lift. 2.3 Wind direction assisted with the snagging of the ropes. 2.4 There wouldn’t have been any conflict with the crane, even if it did cross the barriers as the rope access work was only supposed to be carried out from the top of the derrick down to the monkey board level (inside the wind wall onto a walkway). The level 3 and team did not recognise the potential hazard of rigging the ropes over the wind wall to deck level. 2.5 The rope access company’s procedures requires rope ends to be kept in bags if there is a risk of them coming into contact with cranes, tugger winches, etc. There was no control of rope ends, by the rope access team, in accordance with company procedures.

3. Control measures implemented

Create a standing Instruction for simultaneous operations, to guarantee that all lifting ops

must be authorised by the deck foreman, that considers crane use while working in derricks

The addition of regular training in company procedures will be implemented.

IRATA Safety Notice- keeping our industry safe

Two cases have been noted in IRATA assessments where a Barrel knot also known as a Scaffold knot has been incorrectly tied around a karabiner to terminate a cow’s tail. If incorrectly tied, it is dangerous because it will slip undone if loaded and especially in a pre-tied knot it is very difficult to tell that it is not a standard Barrel / Scaffold knot by just looking at it. The Lyon Equipment report (2001)* for HSE noted that the Barrel knot was the best knot to tie in the end of a cow’s tail for energy absorption.

PLEASE FOLLOW THE LINK TO READ THIS NOTICE IN FULL, AND SEE SUPPORTING PICTURES. IT COULD SAVE A LIFE !

All Areas Access is committed to hiring only the best talent in the industry. Our team of rope access technicians, inspectors, riggers, scaffolders, engineers and service and trade persons are carefully selected from all over Australia and internationally, and are well vetted to ensure that your project is in good, professional hands.

IRATA Safety Notice- keeping our industry safe

An ACC built in 2008 (first generation) was in April 2013 involved in an accident in Australia . The ascender had not undergone annual inspection nor been upgraded due to our instructions -it was equipped with a superseded rope cover. The operator seriously injured his left hand fingers. The index finger was treated for severe rope burn and nail bed reconstruction and the middle finger and the ring finger tip was amputated at the first joint. The predominant contributing factor for this incident was that the ACC I powered ascender was fitted with a superseded rope cover. The design of the rope cover was changed early 2009, and this particular machine was not modified. Though ActSafe took the correct actions and sent a safety alert to all of their importers and distributors, however the independent Australian distributor at the time did not pass on the information and the replacement part to all users. ActSafe also offered the replacement part at no cost to the end user. The Safety Alert sent out by ActSafe in March 2009 can be viewed here: March 2009 Safety Alert ACC The full report issued by High Point Access and Rescue can be found under "Related files and documents" below. Background At the time of the incident, the Rope Access Supervisor was working approximately 50m above ground level. While ascending with the powered ascender, the rope spooled abnormally out of the device. The operator noticed a loop (approximately 200mm long) had formed between the rope grab and the rope guide. The operator immediately stopped ascending. While attempting to rectify the issue, the device came off the rope and the loop pulled through the rope guide. It is assumed that the loop of rope was wrapped around 3 of the operators fingers at the time, pulling them through the rope guide. The operator fell a short distance onto the safety system. After confirming the integrity of the rope and the ascender, the operator was able to install the rope back into the ascender, reset the safety device and ascend to the walkway above.

Contributing factors 1. Abnormal spooling of the rope out between the rope grab and the rope guide.

The powered ascender had a superseded rope cover fitted.It is assumed that the tail of rope exiting the device was blocked, causing the rope to spool abnormally.

2. Rope coming off the rope grab allowing the device to fall.

The device was not supported / suspended by an alternate system while rectifying the abnormal spooling.The manual / emergency descent pin was left in the receptacle as it was being used for descent to preserve battery life (Note, this will not preserve the battery life).It is assumed that another rope (used to hoist equipment) caught on the manual / emergency descent pin, engaging the manual descent and allowing the rope grab to rotate. This would have wound the rope off the rope grab allowing the device to fall.

Remedial actions

Notify end users of the incident details.End users to inspect their equipment to identify if their unit has a superseded rope cover. This applies to ACC 1 models manufactured prior to Mars 2009If a unit is found to have a superseded rope cover, it must be immediately removed from service and the user contact the Manufacturer.All devices to be sent to the authorized service agent at least annually for inspection.Users to only insert the emergency descent pin when necessary for emergency descent and to remove the pin at all other times. The emergency descent manually disengages the brake, and will function even when the electrical system is isolated.