The root cause of the incident was that the handrails of the sub-base, either side of the draw works handrail, were left in position when the draw works were moved.

Contributing factors included the lack of suitable guidance documentation, hazard identification and risk analysis, and implementation of safe working practices.

It also appears that documentation capturing, identifying and mitigating the hazards was flawed or absent, and so the hazards and risks associated with the task were not identified in the risk assessment.

• Review the adequacy of documentation relating to safe working practices and guidance material for standard operations.
• Review of adequacy of the material presented at pre-start, toolbox and safety meetings.
• Engineer the activity so that the draw works can be lifted without the need to skid the draw works, or use appropriate equipment such as a hydraulic ram jacking operation to perform the skidding operations.