An Investigation Into the Root Cause of a Spill From Procuring and Handling of Lubricants in Intermediate Bulk Containers

An intermediate
bulkcontainer(IBC)
was punctured dur-
ing its handling, re-
leasing a refined oil
product onto land
at a large construction site in an environmentally
sensitive region of Australia. Understanding and
controlling the risks from fuel, oil, and chemical
spills on the current project was of critical impor-
tance, as part of the project’s overall approval,
and ongoing compliance was dependent upon
the project’s commitment to minimize all chemi-
cal and petroleum hydrocarbon spills everywhere
on the site. The telehandler or forklift did not
pierce the plastic of the IBC directly, as was
expected to be the case; rather, one of the tines
had caught on the underside of the metal base
plate (pallet), despite numerous controls being in
place at the time of spill, revealing a previously
unreported mechanism for a fluid spill from the
handling of petroleum hydrocarbons and related
chemicals.
The investiga-
tion team used a
root cause analysis
(RCA) technique,
based on the fish-
bone or Ishikawa
diagram, which was undertaken in a thorough
manner with 12 expert contributors from the
project to identify the underlying cause: an in-
adequate inspection process. Applying the safety
controls hierarchy to close out the incident,
given that IBCs could not be eliminated from
the project, and two engineering solutions were
put in place to prevent spills from occurring
from piercing by telehandler tines. Administra-
tive controls (i.e., those least effective) applied
included the introduction of quality assurance
checks for the verification of IBC condition at
various stages throughout the chain of custody.
These verification checks were not limited to the
Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 23
© 2015 Wiley Periodicals, Inc.
Published online in Wiley Online Library (wileyonlinelibrary.com)
DOI: 10.1002/tqem.21401
An Investigation Into
the Root Cause of a
Spill From Procuring and
Handling of Lubricants
in Intermediate Bulk
Containers
A Case Study on the Practical
Application of Root Cause Analysis
Turlough F. Guerin

24 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin
strong safety culture, with product spills being
no exception. There are numerous federal and
state laws in effect in Australia that govern the
regulation of chemicals and their subsequent
spills from infrastructure, equipment, and plant,
and their migration into air, water, and land.
Consent conditions, which define the environ-
mental guidelines to which construction projects
must comply as part of the approval process, also
define spills as specific environmental impacts
that must be prevented, and if they do occur
they must be managed, and there is considerable
focus on the management of petroleum-based
spills and contamination in the Australian re-
sources sector (Altham & Guerin, 2005; Guerin,
2005, 2008; Guerin, Turner, & Tsiklieris, 2004).
Based on communication with peer environmen-
tal managers in the industry, the author’s own
informal research suggests that more than 50%
of all construction environmental incidents in
Australia involve spills. Therefore, spills can pose
a significant challenge in meeting approval con-
ditions and ongoing compliance requirements.
Safety in the Chemical Supply Chain
One of the environmental aims of a facility
under construction is to ensure that there is no
unintentional loss of containment of oil, refined
petroleum products, or other hazardous materials
used by earthmoving equipment. The supply of
such materials to construction sites presents a risk
as it exposes these sites to the potential for loss of
product containment. Construction in remote lo-
cations requires a flexible, yet secure, logistics sys-
tem for the delivery of such fuel, oil, and chemi-
cals. IBC units are used to hold various types of
liquids, including oils, acids, and concrete ac-
celerants (Exhibit 1). IBCs are ideally suited for
such applications because of their flexibility for
handling and scalability as the construction work
front changes. However, despite the industry’s
best endeavors, loss of containment may occur,
IBC surfaces, but rather included specific checks,
using a flashlight, if necessary, for obstructions
and deformations particularly in the IBC pallet
or belly plate/base.
Implications from this investigation are that
all projects using IBCs and telehandlers or fork-
lifts should assess the risks and manage them
to minimize spills and the environmental and
safety hazards associated with the interaction
between these machines and IBCs, including
eliminating, if possible, and minimizing the han-
dling of these IBCs. The study also revealed the
limitations of the hazard identification (HAZID)
process used as part
of the approvals prior
to the construction
project—and prior to
procurement of full
IBCs onto the site. The
HAZID process did not
identify the handling
of IBCs as a risk. Even
though more than 20
controls were identified in the investigation
related to the activity associated with and lead-
ing to the spill, half of which were in place that
could reasonably have been expected to prevent
the spill, the incident still occurred with result-
ing cost implications. This is the first study of
this type to undertake cost accounting for the
individual elements of a spill and its subsequent
investigation.
Introduction
Leaks and spills of petroleum hydrocarbon
are a major concern in the upstream oil industry,
from both a construction and an operational
perspective (Altham & Guerin, 2005; Guerin,
2000, 2005, 2006; Ismail & Karim, 2013; Ruffin,
2012; Sánchez-Arias, Remolina, & Alvarez-León,
2013; Stevenson, 2012). The petroleum industry
is greatly concerned about safety, and it has a
One of the environmental aims
of a facility under construction
is to ensure that there is no
unintentional loss of containment of
oil, refined petroleum products, or
other hazardous materials used by
earthmoving equipment.

Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 25Root Cause Analysis of a Minor Spill
logistics, and construction projects, which are
customers in these supply chains.
A recent study by the author analyzing all
plant and equipment spills on a large resource
construction project in Australia found that four
root causes were common to 60% of the spill
events reported during the peak period of earth-
works (Guerin, 2014). The majority of the spills
were of hydraulic fluid, and these occurred pre-
dominantly from excavators, loaders, and trucks,
and the failed components were typically hydrau-
lic hose fittings and their connections.
Previous studies, which are relevant to the
current spill event because of the similarity of the
spilled product, have focused on large oil spills
and their causes (Ismail & Karim, 2013), and
there are numerous reports on the causes of large
oil spills, particularly those occurring in sensitive
marine environments (Talley, 1995). The risks of
transporting and storing crude oil and its refined
products by tankers over large distances primarily
concern accidental events. The Oil Spill Intelligence
Report, published by Aspen Publishers, provides
regular industry updates on major oil spill events
and their causes (Anonymous, 2014a). This se-
rial has provided insights into root causes for
large-scale oil spills, including lack of attention
to maintenance of oil lines, poor weather condi-
tions, pipe corrosion, rupture of hydraulic hoses,
and budget pressures on an oil-field operation.
and we need to understand the root causes, con-
sequences, and implications of such events.
The project’s HAZID did not identify the
handling of IBCs as posing a risk to the project.
Rather, it agreed to deploy these as an improved
approach over other options. Given that there
is an underlying requirement in all profession-
ally managed construction projects to ensure
that the design stage of the project identifies
and considers the potential risks (Behm, 2005;
Behm & Culvenor, 2011; Behm, Gambates, &
Toole, 2014; Fortunato III, Hallowell, Behm, &
Dewlaney, 2011; Gambatese, Behm, & Rajendran,
2008), including those from transport and stor-
age of chemicals, the current resource construc-
tion project decided to use IBCs as an enhanced
and preferred method instead of procuring 205
liters (L) or 44 gallon drums strapped to pallets,
or to purchase vessels larger than IBCs, such as
“ISO” or intermodal containers or other large
transportable tanks.
Examining Previous Spill Studies
Although there have been a large number
of spills occurring globally from infrastructure,
equipment, and plant failures, many of which
have been written about in the literature available
in the public domain, relatively little has been
published on their root causes or the broader
implications of these spills for transportation,
Exhibit 1. Examples of Chemicals Commonly Transported to and Stored
at Resource Construction and Mining Sites
Engine lubricant Grease Brake fluid
Gear lubricants Detergents Sealants
Coolants Solvents Acetone
Sodium hydroxide Hydrochloric acid Bleach
Sulfuric acid Dust suppressants Gasoline
Flotation reagents Emulsifiers Diesel
Herbicides Bitumen emulsion Special fuel mixture
Hydraulic fluids Distilled water Other water-soluble chemicals

(HSE) data demands special attention from cor-
porate leaders and shareholders to control such
incidents as an immediate measure, as well as
to prevent their recurrence through strategic or
operational plans (Restrepo, Simonoff, & Zim-
merman, 2009). Furthermore, lessons learned
from spill incidents need to be communicated to
oil and gas operators and their contractors more
broadly across the upstream oil and gas industry
to assist in reducing the incidence and severity
of these events. Unfortunately, there is evidence
that this is not occurring to a sufficient degree on
either a national or an international level (Fraser
& Ellis, 2008; Fraser, Ellis, & Hussain, 2008). To
enable companies to work intelligently toward
reducing spills, both across their operations and
up and down their supply chains, robust data are
required, which, in turn, demand effective and
appropriate analytical tools for determining and
establishing cause.
One of the tools commonly used to investi-
gate these losses of containment, RCA, will lead
investigators to take both short-term, immediate
corrective actions, and to identify the underlying
root causes (latent failures) hidden in the way
work is done that will help avert similar incidents
or spills in the future (Otutu & Agba, 2003). By
identifying actions to correct these underlying
issues, oil and gas and related construction facili-
ties can continuously improve their overall busi-
ness, reducing spills and averting injuries from
loss of containment of manufactured products
(Otutu & Agba, 2003), and minimizing loss of
chemicals or product.
RCA is a class of problem-solving methods
aimed at identifying the underlying (or root)
causes of incidents (Anonymous, 2014b; Garg
& Gokavarapu, 2012). By directing corrective
measures at core or root causes, it is anticipated
that the chances of problem recurrence will be
minimized. Thus, RCA is frequently considered to
be an iterative process, and it is frequently viewed
There are, however, relatively few studies
published that describe the far larger number
of smaller spills and their causal agents, that is,
those tentatively set at equal to, or less than, ap-
proximately 1,000 L in size. Presumably, these
spills are of less interest to researchers and are
more in the domain of the commercial interests
and practitioners handling the refined products.
Such accidents are a cause of major marine
transportation spills of oil (Talley, 1995). The
upstream and midstream oil sectors take steps
to identify potential risks from construction and
operational oil and chemical spills, and numer-
ous examples of such studies from the Northern
Hemisphere have been
conducted (Bjørn-
bom, Hansen, Engen,
& Knudsen, 2012).
In the study of Vin-
nem, Hestad, Kvaloy,
and Skogdalen (2010),
there are significant
correlations between
number of leaks and
safety climate indicators, and, interestingly, their
very extensive study of the Norwegian oil indus-
try showed that leak frequency and equipment
age did not show a positive correlation. The study
of Ruckart and Burgess (2007) of hazardous ma-
terial events in the mining and manufacturing
industries has analyzed the key role that human
error contributes to spill events. In their study,
11.6% of all events in these industries resulted
from human error. Other contributing factors
were commonly caused by improper filling, load-
ing, or packing. Only 2% of events were a result
of forklift puncture, which is of direct relevance
to this study.
Analysis of Spill Causes
The impact of leaks and spills on company
or corporate health, safety, and environment
Lessons learned from spill incidents
need to be communicated to oil and
gas operators and their contractors
more broadly across the upstream
oil and gas industry to assist in
reducing the incidence and severity
of these events.

environmental concerns for end users in their
supply chains.
Method
Description of Operation
The contractor company that was operating
the IBC-handling equipment when the spill oc-
curred was the primary earthworks contractor
engaged to supply services to the oil and gas
company that had land tenure on the island
on which the resources construction project
was being built. The contractor organization
was operating up to 370 plant items, includ-
ing forklifts or tele-
handlers, used for
handling IBCs. A fully
equipped heavy ve-
hicle repair workshop
was established and
operative at the site.
The contractor em-
ployed approximately
400 personnel (across
the entire construction site) at the time of
the spill. The contractor’s operation was large
compared with other projects underway in the
resources sector in Australia at the time, with
total revenues from the works estimated in
Australian dollars (AUD) at AUD 0.5 billion. As
such, it was considered to be representative of
operations where there is a large throughput of
lubricants, hydraulic fluid, and chemicals. The
overall liquid natural gas (LNG) construction
project was valued at more than several billion
Australian dollars.
Site Location
The incident occurred at an LNG construc-
tion site located offshore from Western Australia
on a remote island classified as a Class A Nature
Reserve. The site where the spill occurred was
as a tool of continuous improvement. RCA, ini-
tially, is a reactive method of problem detection
and solving. This means that the analysis is done
after an incident has occurred. However, by gain-
ing proficiency in RCA, it becomes a proactive
method. RCA is then able to estimate the pos-
sibility of an incident before it occurs.
RCA consists of the following steps:
• Define the problem;
• Analyze the problem; and
• Find the solutions for the problem (Garg &
Gokavarapu, 2012).
These solutions should be both tactical, to
address the immediate needs of the operation,
and strategic, so as to minimize future occur-
rences in the larger organization and industry,
and for the same construction operation as well
as others.
Purpose and Study Rationale
This paper has an overall objective to pro-
vide a practitioner’s approach to applying RCA
to a relatively minor spill event. This study used
RCA methodology to investigate the cause(s) and
contributing factors that led to an oil spill from
a commonly used bulk handling container (IBC)
on a large construction project in a remote and
environmentally sensitive area. Such contain-
ers are now being widely used across numerous
industries, largely because of their convenience
and low unit cost. The lessons learned and
recommendations made from this study have
general application for the handling of IBCs
internationally, including across the general
construction and resource sectors. While this
study involves an incident with a relatively small
volume spill, there is still a need to determine
root causes and contributing factors of such
spills, as they can pose serious implications for
project costing and budgets, as well as safety and
The lessons learned and
recommendations made from this
study have general application
for the handling of IBCs
internationally, including across
the general construction and
resource sectors.

• Where a robust analysis of the root causes and
contributing factors are required; and
• Where results have to be relied upon before
a potentially expensive change to a business
process or system is implemented.
The RCA method is not commonly used for
relatively minor spills such as the one described
in this study, so the findings here are important
given the reliance that can be placed on the out-
put of the method.
The steps of this process were:
1. Formation of the investigation team;
2. Collection of incident data including ma-
chine handler (operator’s) background;
3. Development of the sequence of events;
4. Undertaking a protective systems analysis;
5. Performing RCA analysis using the cause-and-
effect, fishbone model; and
6. Development of appropriate corrective actions.
Exhibit 2 lists the pro forma options for
possible root causes that were used in the devel-
opment of the RCA process. Preselected primary
and secondary root causes were provided as drop-
down boxes in the documentation to determine
the root cause. These preselected options were
deployed to facilitate responses and outcomes
from all spill events that were as consistent and
comparable with each other as far as practical,
across all operations of the contractor and opera-
tor, thus enabling the comparison of spill causes
between operations.
Formation of Investigation Team
An RCA investigation team was assembled
from persons possessing a range of complemen-
tary skills. This team comprised 12 members
from the contractor company and the oil and gas
company.
located approximately 2 kilometers (km) from
the ocean in the center of the construction works
where the LNG plant was being built. The topog-
raphy where the spill occurred was flat and well-
travelled by project personnel. The IBC involved
in the spill was located approximately 20 meters
(m) from the main workshop entrance.
Management Systems Descriptions
The contractor operated under a manage-
ment regime comprising an integrated health,
safety, quality, and environmental management
system. Each component of the system was certi-
fied to the relevant International Organisation
for Standardisation (ISO) standard, including
ISO 9001 and 14001. To ensure alignment of
the contractor’s system with that of the oil and
gas operator, this in-
tegrated system was
audited externally by
the operator every six
months. The incident
management compo-
nent of the system was
fully integrated with the contractor’s business
and the operator’s business systems. All contrac-
tor and operator personnel were inducted in the
use of the incumbent management system at the
time that new employees were on-boarded.
Overview of Investigation (RCA) Methodology
The team conducted the investigation for this
incident in accordance with a fishbone, cause-
and-effect, or Ishikawa-based RCA process (Anon-
ymous, 2014b). The RCA method used in this
study is based on the Ishikawa, or so-called fish-
bone, method of analysis for determining causes
and contributing factors for an event (or more
generally, cause-and-effect theory) (Ishikawa,
1990). RCA is typically used in industry:
• When a significant injury, death, or major
environmental incident has occurred;
The RCA method used in this
study is based on the Ishikawa,
or so-called fishbone, method of
analysis for determining causes and
contributing factors for an event.

Exhibit 2. Pro Forma Root Causes of Fluid Spills Used in Investigations on LNG Construction Sitea
Primary root cause Root cause descriptionb
Procedures and safe work practices Accepted to deviate from work routine
Lack of job oversight
Mistake or mental slip
None exists or available
Not complete or accurate
Not enforced, audited, or inspected
Not trained on procedure
Other priorities conflicted
Risk of not following not understood
Willful deviation
Design Design standards inadequate or not used
Did not anticipate the conditions
Did not consider human factors
Inadequate review
Inherent safety design not incorporated
Inspection and quality control No inspection
Quality control needs improvement
Hold point not performed
Inspection not required
No hold point
Foreign material exclusion during work needs improvement
Inspection instructions needs improvement
Inspection technique needs improvement
Training and competency No training
Understanding needs improvement
Decided not to train
Missed required training
No learning objective
Task not analyzed
Continuing training needs improvement
Instruction needs improvement
Learning objective needs improvement
Lesson plan needs improvement
Practice/repetition needs improvement
Testing needs improvement
Misunderstood verbal communication Long message
Noisy environment
Repeat back not used
Standard terminology needs improvement
Standard terminology not used

• The contractor HSE manager,
• The contractor project director,
• The contractor’s national construction gen-
eral manager, and
• The company incident investigation
manager.
Other administration and support staff were
utilized to undertake specific research into the
incident and the resultant communications.
Team members were:
• The company construction director,
• The company area construction manager,
• Two company environmental coordinators,
• The contractor environmental engineer,
• The company environmental superintendent,
• The telehandler operator,
• The health and safety representative (for the
telehandler operator),
Primary root cause Root cause descriptionb
Supervision Preparation
Selection of worker
Supervision during work
Fall protection needs improvement
Lock out/tag out needs improvement
No preparation
Prejob briefing needs improvement
Scheduling needs improvement
Walk-through needs improvement
Work package/permit needs improvement
Fatigued
Not qualified
Substance abuse
Team selection needs improvements
Upset
Inadequate job hazard/safety analysis
Risk management Inadequate process hazard analysis
Individual snap decision (quick decision made without assessing
the risk)
Preventive maintenance/repeat failure Equipment parts defective
Preventative/predictive maintenance/not preventative mainte-
nance for equipment
No communication or not timely Preventative/predictive maintenance/preventative maintenance
for equipment needs improvement
Communication system needs improvement
Late communication
Turnover needs improvement No standard turnover process
Turnover process needs improvement
Turnover process not used
Turnover less than adequate
a
All of these root causes were available as drop down options in the spill report forms. Individuals completing the forms were
required to use the provided pro forma options, which also included “not applicable” (not listed in this table).
b
Additional primary root causes with no further or root cause descriptions (to tabulate): contractor safety, communications,
human factors, management of change, incident and near-miss investigation, emergency response, natural phenomenon,
auditing, leadership accountability, and prestart up safety review.
Exhibit 2. (Continued)

The most common IBC is the one-time use
cube (OTC) plastic composite IBC. This unit is
a white/translucent plastic container (typically
polyethylene) housed within a tubular stainless
steel cage that is attached to a pallet. IBCs can
be manufactured out of a number of different
materials depending upon the needs of the ship-
per and the legal requirements that must be met.
In addition to the plastic composite IBC, IBCs
are also manufactured out of fiberboard, wood,
heavy gauge plastic, aluminum, carbon steel,
and stainless steel. Heavy gauge plastic IBCs
are made of reinforced
plastic that requires no
steel cage; they have
a pallet molded into
the bottom so the en-
tire unit is manufac-
tured as a single piece
(Anonymous, 2014a).
Communication Processes
After project spill events that are considered
large by the project’s standards (i.e., >1,000 L;
similar to the one described in this study), the
contractor and the operator companies prepared
projectwide communications that are distributed
to all project personnel. These are in the form
of an email and a verbal description of the spill
events, which is read out to all personnel at a pre-
start event (i.e., at the beginning of a shift). “Les-
sons learned” or “safety alerts” from spill events
are shared at the contractor’s toolbox talks, which
are held weekly on the site and provided to all
personnel. This also occurred after the investiga-
tion report was prepared in the current spill.
Results and Discussion
Background Information
Smaller vessels used for handling refined pe-
troleum products on projects such as those in
Collection of Incident Data
Data collection included one-on-one inter-
views, review of project and procedural docu-
mentation, employee training records, photo-
graphs from the incidents, and procurement
manifests and related documents. It also included
the goods manifests, discussion with suppliers
of the IBC, and licenses. The time of events and
activities surrounding the incident were obtained
and used to compile a timeline.
Identification of Protective Systems in Place
Protective systems are defined as software,
hardware, or management systems that reduce
the potential for having an incident or reduce
the consequences of an incident. These include
job safety procedures and HAZID documentation.
The most commonly used procedures and docu-
mentation on Australian construction sites are
safe work procedures (SWPs), job hazard analyses
(JHAs), and “Step Back 5×5s” (i.e., a quick prejob
analysis). The investigation team analyzed all of
the protective systems relevant to this event and
those relating to it.
Description of IBCs
An IBC or IBC Tote or Pallet Tank was the type
of vessel from which loss of containment occurred
in the spill event in this study. An IBC is a single-
use container designed for the transport and stor-
age of bulk liquid and granulated substances (e.g.,
oil, chemicals, food ingredients, solvents, pharma-
ceuticals). IBCs are stackable containers mounted
on pallets that are designed to be moved using a
forklift, a pallet jack, or a telehandler. IBCs have a
volume range that is situated between drums and
tanks, hence the term “intermediate.” The most
common sizes are 1,040 L/275 gallons and 1,250
L/330 gallons (the 1,040-L IBCs are often listed as
being 1,000 L). Cube-shaped IBCs give a particu-
larly good utilization of storage capacity compared
with palletized 205 L drums.
IBCs can be manufactured out of
a number of different materials
depending upon the needs of the
shipper and the legal requirements
that must be met.

northwest coast of Western Australia, Australia.
Much of the island is covered by spinifex grass-
lands, which provide important habitat for a
variety of wildlife. While the main feature of the
island’s geography is the undulating limestone
uplands, the island is surrounded by a mixture of
sandy beaches and rocky shores, low cliffs, dunes,
salt flats, and reefs. The landscape is arid, and the
climate is usually hot and dry. Most of the annual
rainfall occurs during the cyclone season between
November and April and amounts to approxi-
mately 320 millimeters (mm) per year. Because
of its high conservation value, the island was
declared a public reserve for flora and fauna and
has been classified as a “Class A” Nature Reserve
for the past 100 years.
Using process chemicals, such as petroleum
hydrocarbons, on the project in such a sensitive
environment is a high-risk activity in relation to
potential environmental harm in the event of an
uncontrolled release. This sensitivity was of critical
importance in the study, as an important part of
the project’s overall approval was dependent upon
the project, minimizing all chemical and petroleum
hydrocarbon spills anywhere on the site (with the
exception of within secondary containment).
Employee’s (Machine Operator’s) Background
The investigation revealed that the telehan-
dler operator who was involved in the spill event
had more than 10 years of experience in forklift
operation, held the relevant high-risk license,
including successful completion of the verifica-
tion of competency (VOC), and onsite challenge
test training. The operator commenced working
for the contractor on the project in November
2010, almost two years prior to the spill. The
operator conducted various tasks in the course
of employment, and carried out this specific
task of handling IBCs for the workshop site on
previous occasions. There was a JHA for opera-
tion of the telehandler, which was signed onto
this study include ISO containers and IBCs. The
use of IBCs to transport products to construction
sites poses its own risks, including those to safety
or personnel and potential environmental impact
upon rupture. In the current project, up to 50
IBCs per week were entering the site containing
lubricants, various chemicals, and hydraulic fluid.
Based on estimates from several resource projects
in progress, there could be as many as a million
such IBCs in circulation in Australia alone. These
vessels are vulnerable to damage because of in-
tense handling by tined equipment, as their rela-
tively flimsy design can allow easy puncture unless
very specific controls are in place—as the results of
this study later show. It is important to note that
there are no previous
studies in the scientific
literature reporting
spills from IBCs, fur-
ther highlighting the
need to publish the re-
sults of this study.
IBCs have been used on the project since
project commencement to transport various types
of bulk fluids as well as for temporary storage on
the project site. The chain of custody with IBCs
commences from the point of manufacturer to
the supplier(s), continuing to contractor and
company base supply chains (in accordance with
quarantine requirements) prior to arriving on the
project site. IBCs are transported to the project in
unbunded or bermed sea containers. When they
arrive on the project site, the IBCs are kept in the
contractor’s secondary containment area when in
storage, usually in self-bunded or bermed contain-
ers. IBCs are used by the contractor for transport
and storage of various chemicals, and they were
found to be handled by telehandlers or forklifts.
Site Description
The construction site was located on a small
island located approximately 60 km off the
The use of IBCs to transport
products to construction sites
poses its own risks, including those
to safety or personnel and potential
environmental impact upon rupture.

before the project was started. This finding
showed that the HAZID process did not pick up
the potential problem of damaging and handling
damaged IBCs on the project. This was critical as
its absence as a potential risk may have diverted
attention away from IBCs as a process safety risk.
In his studies on root causes, Hendershot (2007)
points out the importance of design engineers
considering the impacts of their decisions as
early as possible in a construction project and
to avoid project designers falling in the mind-
set trap of, “it has always been done that way,”
when developing the final construction designs.
The findings from this study, which describe
the risks from IBCs,
which were originally
deployed because of
the perception that
the risks from these
were very low, will
be fed back into the
knowledge base for
other resource project
design engineers in-
volved in developing
remote projects.
As part of the investigation, structural integ-
rity issues were found with a range of other IBCs
across the project (i.e., with other contractors),
with evidence of dents, damage, and obvious
accident occurrences with IBCs also used to
transport lubricants and chemicals to the project.
None of the events that led to this damage was
reported on the project, and the events were first
discovered and reported as part of the investiga-
tion of this study.
Sequence of Events Prior to Spill Event
A timeline was constructed to summarize ac-
tivities before, during, and after the event. These
details are presented in Exhibit 4. The timeline
revealed that the operator of the telehandler
by the operator on the day of the spill. The
contractor had a project SWP for telehandler
operations, and he had received the procedural
VOC training for the task delivered by an expert
operator. The operator stated that there were no
time pressures associated with the task or any
other factors that made the task different on
the day of the event. The operator attended the
contractor’s return to work session, as this was
the operator’s first day of swing after returning
to the project site. In summary, the operator was
fit for work.
Implications of the Assessment of the
Protective Systems
The investigation team analyzed the protec-
tive systems relevant to this event, and the result-
ing evaluation is summarized in Exhibit 3.
Although there was an extensive array of con-
trols for this activity, this was not uncommon for
work processes on this project. Analysis showed
that there were no inspection requirements in
any of the project documentation in relation to
IBCs or related items in transport or for storage,
particularly inspections to ensure the identi-
fication of vessel integrity. Of the 21 controls
identified and thought to be relevant to the spill
incident and investigation, 10 were deemed to be
ineffective, and five critical controls that should
have been in place were not in place.
Also, of the 21 separate protective systems,
processes, and controls in place at the time of
the spill, it is noteworthy that only five were
categorized as being higher up the safety hier-
archy than “Administrative.” The use of IBCs
on the project is, in fact, a result of early design
considerations that involved substituting pallet-
strapped 205-L drums of lubricant, the latter of
which were considered to pose an unacceptable
risk from a safety and environmental perspec-
tive. A HAZID process was used—as is common
in industry—and that examined potential risks
Structural integrity issues were
found with a range of other IBCs
across the project (i.e., with
other contractors), with evidence
of dents, damage, and obvious
accident occurrences with IBCs
also used to transport lubricants
and chemicals to the project.

Exhibit 3. Evaluation of the Protective Systems and Controls Relevant to the Spill Incident
Protective system Type of control based
on hierarchy
In place?
(Y/N)
Effective?a
(Y/N)
Comments
IBC: Selection and
assessment of type,
design, and structural
integrity
Elimination/
substitution
N N Other IBC units (from another areas,
which are currently or had been in
use prior to incident on the project)
were identified as damaged during the
investigation.
Self-bunded sea
container
Isolation/engineering N N These containers are not usually
used for transport. These containers
are typically used for chemical storage
on the project.
Spotter Isolation N N JHA referenced use of spotter if
required (when handling IBCs with
tined equipment). Operator assessed
spotter was not required.
Note: The use of spotter may have
influenced the outcome.
Work method
statement
Administrative N N Not developed for this particular task.
Plant acceptance
HSE checklist
Administrative N N No document was available for the
investigation.
SWP Administrative Y N SWP for forklift operations is not
specific on when a spotter is required.
SWP did not identify potential hazard
of obstructions on underside of IBC.
JHA Administrative Y N Operator signed onto JHA.
JHA did not specify when a spotter is
required.
JHA did not identify potential hazard of
obstructions on underside of IBC.
Communication of
similar incidents
Administrative Y N Operator not aware of previous related
incidents associated with IBC holding
an acid (hydrochloric acid spill of similar
magnitude, incident on project site on
March 19, 2011).
IBC inspection—
Prior to lift
Administrative Y N General area around IBC inspected,
inspection did not include underside of
IBC and metal plate.
Sea container stacking/
filling
Isolation Y Y Correct use of strapping.
“Step back 5×5” (i.e.,
prework risk analysis
conducted by all em-
ployees on project site)
Administrative Y Y Four step back 5×5s were completed
by the operator throughout the day of
the incident.
Telehandler prestart
check
Administrative Y Y Prestart check was conducted;
no issues identified with telehandler.
Inspection of area
(sea container)
prior to lift
Administrative Y Y Inspection took place, did not
include underside of IBC; according to
the JHA there was no requirement to
do so.
Supervision Administrative Y Y Supervisor on call and involved in step
back 5×5s; supervisor not required to
be present for each lift.
Communication Administrative Y Y Communication between operator and
workshop superintendent in planning
the move of the IBCs and the incident
response.

Protective system Type of control based
on hierarchy
In place?
(Y/N)
Effective?a
(Y/N)
Comments
Training: JHA, hazard
identification, RTWc
Administrative Y Y Personnel developing JHAs receive
feedback from HSE advisors.
Hazard identification toolbox April 18,
2012.
Half-day HAZID course.b
RTW training.
Training: Spill response Administrative Y Y Occurs on a six-month basis for all site
personnel.
Random drug and alco-
hol testing
Administrative Y Y Process in place and effective
Control of spill Administrative/
protective equipment
Y Y Swift and effective control.
Containment Administrative/
Y Y Earthen bund quickly constructed.
Cleanup Administrative/
Y Y Cleanup required inspection after soil
excavation
a
The investigation team made an assessment as to whether the control was effective.
b
HAZID is a hazard identification process involving a cross-section of stakeholders identifying potential hazards prior to project initiation.
c
RTW, return to work.
Exhibit 3. (Continued)
tines before extending the telescopic boom. The
operator then returned to the telehandler and
commenced extending the telescopic boom into
the IBC pocket (i.e., pallet base/belly) to engage
the lift. (Note that this function is achieved by
the operator holding in the button to extend the
telescopic boom.)
The operator commenced extending the
boom and then heard a “popping” noise and
observed the IBC collapse immediately. The
operator witnessed oil spilling onto the ground.
The IBC had not been lifted off the ground at
this stage. The operator immediately exited the
telehandler and went to the workshop where
he notified the workshop superintendent of the
spill. The workshop superintendent and the op-
erator returned to the location immediately with
two large spill kits. The workshop superintendent
directed the operator to tilt the IBC upward to
prevent any further spilling (the tines were still
placed within the pockets of the IBC). The IBC
was propped by wooden chocks, and telehandler
was removed and parked close by.
was not negatively impacted prior to the inci-
dent. Furthermore, there were no other adverse
conditions impinging on the activity of moving
the IBC in question.
Outcomes From the Incident
On the day of the incident, the operator had
undertaken various tasks associated with the use
of a telehandler on the construction site. At ap-
proximately 14:45 hours (h), the operator was
called on the ultra high frequency radio to go to
the workshop to unload a sea container. Upon
arrival, the operator went to the workshop of-
fice and obtained direction as to where the items
from the sea container were to be positioned. The
operator removed the first two pallets of heavy
vehicle parts from the sea container and placed
them at the southern end of the workshop. The
operator returned to commence removal of IBCs
from the sea container. The operator commenced
the activity by placing the tines partially into the
pockets of the IBC and then exited the machine
to check the alignment/position of the fork

Exhibit 4. Timeline of Events Related to the Oil Spilla
Timeb
Description of events
6:20 Operator returns to work, first day of swing
6:30 Operator attends prestart meeting
7:00 Operator return to work meeting (normal meeting that occurs when personnel returning to
project site)
7:45 Assigned task to operate telehandler
7:50 Operator signs onto JHA for activity
7:55 Operator completes Step Back 5×5 for first assigned task
7:55–8:00 Prestart conducted on telehandler by operator
8:00–10:00 Operator moved pallets for plumbers
10:00 Work break
10:45 Operator completes postwork break Step Back 5×5
10:45–12:00 Operator continues performing various lifts with telehandler
12:00 Lunch break
14:15 Operator completes postlunch Step Back 5×5 completed
14:45 Operator was called on radio and directed to unload sea container at workshop
14:50–15:00 Operator assessed contents of sea container and task
15:00 Operator completes Step Back 5×5 at workshop, for unloading the sea container
15:00–15:15 Operator contacted workshop office to ascertain where pallets were to be positioned once
removed
15:15 Operator moved two pallets of spare parts from the sea container in front of IBC, and placed
in nominated area workshop
15:15–15:25 Operator released straps securing IBCs within sea container
Operator positioned tines of telehandler into pockets of IBC (approximately 20–100 mm
in pocket)
Operator exited telehandler to check positioning of tines
Operator reentered telehandler to commence extending boom and tines into IBC pocket
15:25 Operator heard a “popping” sound, saw IBC collapse quickly and witnessed oil spilling onto the
ground
15:25–15:30 Operator exited telehandler and immediately notified workshop superintendent of spill
Workshop superintendent and operator immediately returned to location with spill kits to
commence control
IBC repositioned by operator using the telehandler as instructed from workshop superintendent
to eliminate any further leaking of oil from IBC
15:30 Workshop superintendent notified contractor’s environmental engineer of spill
15:30–15:40 Loader available in the area commences construction of an earthen bund to contain spill
15:40 Contractor’s environmental engineer arrives at the area, reviews and completes spill report
16:15 Company environmental coordinator arrives on scene, earthen bund is in place
16:30 Pooled oil pumped out of low point in earthen bund. This was then disposed of as hazardous
waste
17:40 Contractor submitted spill report to company. Spill report contained all factual details of the spill
18:00 Soil placed over area affected by oil spill to assist in containing the spill. All of the impacted soil
was excavated and disposed of the following day
18:30 Incident entered into company database and added to other HSE data from the project
19:00 Investigation commenced
a
Documentation was collated on the operator’s training attainment dates, other incidents that operator was involved in, and other
incidents involving IBCs from prior to the day of the incident.
b
Time on the date of incident.

from pro forma root cause descriptions that the
company had developed over several decades
(refer to Exhibit 2). The rational for this was that
there was a defect with the IBC, which caused the
path of the fork tines to be obstructed, leading to
tearing of the base plate and subsequent punctur-
ing of the IBC. Furthermore, there was no specific
inspection process during the chain of custody
for personnel to inspect the undersides of IBCs
for faults or deformities in the metal base plate in
which the fork tines could be caught on. A gen-
eral inspection only around the body of the IBC
and around the base was undertaken, and this
was not sufficient to identify the internal damage
to the IBC pallet base plate.
There were two
contributing factors
to the cause of the
incident:
1. The design of the
IBC cage did not
anticipate condi-
tions on the project. The IBC is designed to
be moved a limited number of times. This
was confirmed by a lubricant supplier, who
informed the author that IBCs are often
referred to as “one-trip cubes,” hence the
petroleum industry term OTCs; and
2. The use of a spotter may have prevented the
outcome, as the spotter may have been able to
identify the deformity in the pallet base plate.
The rigor of the inspection required to have
picked up such a deformity in the base plate
of the pallet would have required the use of a
flashlight, and the inspector would have had
to have leaned down and looked into the pal-
let slot and known what to have looked for.
Exhibit 6 illustrates the configuration of
the impacted IBC at the time of the spill. From
the close inspection of the IBC base, deformed
An earthen bund or berm was quickly con-
structed to contain the spill, and pooled oil was
vacuumed out of a low point from the soil surface
using a truck with the capability of vacuuming a
spilled agent. Cleanup of the affected area was
in progress at this time (i.e., 15:30–15:40 h).
The investigation team inspected the area and
observed that the ground condition around the
sea container was flat, and there were no vis-
ible obstructions, which could have affected the
alignment of the tines with the IBC pallet. An in
situ inspection of the telehandler confirmed that
the tines were not skewed or misaligned.
The data summarized in Exhibit 3 were ob-
tained as part of the investigation process. Imme-
diately following the incident, the operator, work-
shop superintendent, and environmental engineer
inspected the site. This team proceeded to gather
evidence for the purpose of the investigation.
Of critical importance in the incident inves-
tigation was the finding that the fork tines had
not pierced the plastic bladder of the IBC directly.
The investigation determined that the fork tines
had caught on the underside of the metal base
plate. The base plate was subsequently distorted
and pushed inward as the telescopic boom of the
telehandler was extended. The distorted metal of
the base plate punctured the IBC causing it to im-
mediately discharge its contents—and causing the
“popping” sound recorded by the operator. The
evidence supported this conclusion (see Exhibit 5)
and is discussed in the following section.
Findings From the RCA
This section reports the detailed and thorough
findings from the RCA, a result of the extensive
collaboration achieved through 12 experts from
the project contributing their efforts to finding
a root cause. The primary root cause of the spill
was determined to be “Inspection/Quality Con-
trol—Inspection and Acceptance Process is Not in
Place or Adequate.” This root cause was selected
Of critical importance in the
incident investigation was the
finding that the fork tines had not
pierced the plastic bladder of the
IBC directly.

This author’s research on root causes of fluid
spills from plant and equipment has shown that
the underlying reasons for the majority of fluid
spills is the failure of hydraulic systems, par-
ticularly hoses and their fittings (Guerin, 2014).
Other researchers have reported on the causes
of spills that occur during the operation of oil
and gas facilities (Al-Mansouri & Alam, 2008),
although such research is not directly related
to IBCs or small-sized vessels. These researchers
came to the conclusion that the majority (more
metal had caught on the IBC bladder to cause
the spillage. This finding was established only
after the damaged IBC was inverted and closely
inspected. The investigation also revealed that
the tines of the telehandler had sufficient clear-
ance to enter the base of the impacted IBC under
normal conditions where no such metal deforma-
tion is expected (Exhibits 7–9). Through an in-
verted fishbone or Ishikawa diagram, Exhibit 10
graphically describes the outcome from the RCA
used during the incident investigation process.
Exhibit 5. Data Collected to Verify the Cause of the Oil Spill Incident
Data description Comments
Authority to operate/inspect/maintain for operator for the telehandler
Manitou MT 1440 dated May 16, 2011 and stating one-year experience
with the machine
Discussed by investigation team
Operator’s license to perform high-risk work issued on October 6, 2010
expires on October 6, 2015
Discussed by investigation team
VOC for operator May 10, 2011 Discussed by investigation team
Step Back 5×5—7:45 am May 3, 2012 for “operating telehandler” Conducted by operator
Step Back 5×5—10:45 am May 3, 2012 for “loading of truck with roof
sheeting and steel…”
Conducted by operator
Step Back 5×5—14:15 pm May 3, 2012 for “driving forklift” Conducted by operator
Step Back 5×5—15:00 pm May 3, 2012 for “unloading sea container” Conducted by operator
OEM’s health and safety procedure “manual forklift trucks and powered
pallet movers”
Note
Prestart on telehandler machine Discussed by investigation team
Contractor’s SWP for forklift operations Note
JHA for telehandler April 20, 2012 Signed onto by operator on May 3, 2012
Inspection of pierced IBC Workshop superintendent stated that new
IBCs are requested from the supplier
Witness statement of telehandler operator Formal statement obtained
Witness statement of crane supervisor Formal statement obtained
Witness statement of workshop superintendent Formal statement obtained
Witness statement of mechanical supervisor Formal statement obtained
Photographs taken one to two hours following the incident Viewed and discussed by investigation
team
Additional photographs taken of incident area and other used IBC units Refer to Exhibits 6 to 15 in this text
Multimodal dangerous goods form, completed for the sea container
May 2, 2012, supply base
Confirms that “the goods have been
packed/loaded into sea container in
accordance with the applicable provisions”
Photographs taken of IBC immediately after it was loaded into the sea
container at supply base prior to shipment to quarantine checking
Shows that IBC was handled at supply
base as part of quarantine requirements
Logistics notification request DG standard, sea freight May 2, 2012 Note
Contractor quarantine inspection checklist—packaging May 2, 2012 Quarantine-specific checks only, does not
include inspection of integrity/condition of
IBCs
Sea container manifest Reviewed by investigation team members

The root cause in this study of “inspection in-
adequate” is similar to ineffective quality control
(described in “vi” above). No other studies have
specifically detailed causes of spills from han-
dling of the types of chemical containers (IBCs)
described in this study.
Comparing the RCA Method With the
“5 Why” Analysis
The RCA method using the fishbone, cause-
and-effect, or Ishikawa diagram, is used in the
literature for analyzing large spills because the
underlying causes of such incidents can be
than 90%) of these leaks and spills are due to one
or a combination of potential root causes such as:
(i) Aging facilities,
(ii) Equipment failure,
(iii) Construction defect,
(iv) Accidental damage,
(v) Defeat/bypassing of protective system,
(vi) Ineffective quality control,
(vii) Operational deviation,
(viii) Design fault,
(ix) Blow out of oil well, and
(x) Human error.
Exhibit 6. Views of Damaged IBC
Note: Top left: Timber and tines of the telehandler used to hold punctured IBC in tilted position (note bladder has collapsed or on
itself). Top right: Underside of IBC showing impact of damaged metal (belly) plate and location in which the tines are inserted.
Bottom left: Underside of IBC showing point of puncture/tear on IBC bladder. Bottom right: Undamaged IBC behind damaged IBC
(in sea container) for comparison and spill absorbent material in front.

involves asking why, up to five (or even more)
times, a particular event occurred in the series of
events that led to an incident. In simple terms,
once asking the “Why” question yields no fur-
ther reasons for the cause(s) of an incident, then
the root cause is determined and communicated.
This is why, on many commercial construction
and resource projects, the shorter and less in-
volved process of the “5 Why” method is com-
monly used instead of an RCA. The advantage
of the “5 Why” method is that it can be done
using limited resources (usually by an individual
or small team). However, it does rely on profes-
sional judgment or practical experience to ensure
that the line of questioning is appropriate for the
event under investigation. A qualitative com-
parison of these two types of root cause assess-
ments is given in Exhibit 11. In the majority of
cases, this depth of analysis is “fit for purpose,”
enabling the business to learn quickly and keep
determined with a high degree of confidence.
The results from these analyses are more likely to
be trusted (though not always) for implementa-
tion, and, therefore, they are more likely to be
considered to help prevent recurrences of such
incidents in other sites or settings. However, as
in this study, the thoroughness required by the
RCA method means that a relatively large num-
ber of people with a range of in-depth skills must
be brought in on the investigation. Typically,
several experts may be required for several hours.
One of the problems with the application of RCA
methodology is that it is often only applied to
relatively large or major spills. Commercially,
RCA approaches are marketed under various
trade names, such as ICAMM, Taproot, and the
like, and require several days of training to gain
proficiency in the detailed methodology.
A shortened version of the RCA is called the
“5 Why” method (Pojasek, 2000). This method
Exhibit 7. Views of Work Site at Location at the Time of Spill
Note: Top left: Punctured IBC in location at the time of spill with telehandler in proximate location.
Top right: Tines of telehandler involved in the spill. Bottom left and right: Dimensions of tines of
telehandler indicating that there was sufficient clearance for insertion of tines into IBC base without
any damage expected. Distal end on bottom left and load end on bottom right.

thorough RCA approach was used, ensuring
that the needed resources would be employed
to generate sufficient confidence in the result of
the analysis to enable the needed changes to be
made on the project (see the following section on
Development of Corrective Actions).
Cost Implications
Although the cost of safety model has been
prevalent in the mainstream safety literature
for the past decade or more (Behm, Veltri, &
Kleinsorge, 2004), corporations have not widely
adopted the approach, nor is any form of finan-
cial analysis of safety or spill incidents commonly
going, business as usual, plus locking in the re-
quired prevention strategies.
However, when the “5 Why” method is
used to determine underlying causes, this means
that full analysis and understanding of the root
causes and contributing factors are not always
thoroughly determined. This, in turn, means that
changes that are made as a result of the findings
of a “5 Why” analysis might not provide ad-
equate prevention measures. As a consequence,
the actual root causes are not necessarily properly
identified and communicated as widely as would
be desired to reduce fluid spills. For this reason,
it was important in this study that the more
Exhibit 8. A Side View of the Base of the IBC; Pallet Showing Dimensions Relevant to the
Telehandler Interaction
Exhibit 9. Location of IBC Relative to Rest of the Sea Container Contents and the Telehandler in the
Delivered Container

Exhibit 10. The Results of the RCA “Why Tree” for the Oil Spill Incident

component contributing to the spill). Given that
on this project, the same contractor had three-
to-four incidents of such magnitude (at the time
the data were collected for this study), total costs
from spill events are estimated conservatively at
AUD 1–2 million when all project contractors—
up to 20 additional and separate entities—are
considered.
Development of Corrective Actions
Based on the findings of the study, numerous
corrective actions were identified and were rec-
ommended to be implemented by the contractor
and the company. The hierarchy of controls was
applied to the corrective actions, and the actions
were numbered from one to six. While effort was
directed at elimination of risks, substitution, and
engineering, the majority of the implemented
controls to control risks from spillages of bulk
lubricants and chemicals were administrative
in nature. As previously mentioned, the deci-
sion to use IBCs stemmed from the early design
stages, where the risks perceived from using 205 L
drums strapped to pallets were considered to be
too high.
practiced. As a result, companies have tended
either to underinvest in preventive and detection
efforts, or to overspend, putting controls in place
that outweigh the risks from failure. No compa-
rable cost breakdown data were available from
the literature for assessing the current incident.
An estimate was compiled for the break-
down of the costs of the current spill and the
subsequent investigation, and these are given in
Exhibit 12. The cleanup of the contaminated
soil and the commitment of time by the contrac-
tor’s environmental engineer were the single larg-
est cost items from the spill incident. The cleanup
involved the rapid deployment of earthmoving
equipment away from other construction jobs
on the project, containment of oil using earthen
bunds (see Exhibit 13), and then removal, and
disposal of the contaminated soil. This was fol-
lowed by reporting of the incident and replace-
ment of the lost product. This cursory analysis
illustrates that the immediate knock-on effects of
such a spill can have a material impact on a proj-
ect’s budget. The analysis also does not attempt
to quantify the lost productivity from equipment
and machinery downtime (impacted by the failed
Exhibit 11. A Qualitative Comparison of the “Why Tree” (RCA) and “5-Why” Process for Determining
Root Causesa
RCA “5-Why”
Detailed, time consuming
Requires extensive training for personnel to lead
investigation (several days)
High-level, rapid
Short course (one to two hours) required
Thorough, extensive collaboration in decision making,
involving a broad range of experts from diverse
backgrounds
Brief, with minimum of consultation/collaboration to
decide on the causes, designed to be conducted by
individuals or small teams
Requires significant level of resources (requires a
team of at least five to six)
Can be done using limited resources (can be done by
an individual or small team)
Provides a robust analysis of the root causes and
contributing factors
Relies on professional judgment to ensure the line of
questioning is appropriate for the event
Results can be relied upon to change business
process or systems
Limited reliance can put on the results of a single
analysis
Is applied in commercial contexts where a significant
injury, death, or major environmental incident has
occurred
Is applied in commercial contexts as a common
method for RCA where an incident investigation is
required
a
This comparison has been developed for practitioners and is based on the author’s experience and professional judgment
(Ishikawa, 1990).

Exhibit 12. An Estimate of Financial Costs of the Spilla
Cost element Description Value (AUD)
Loss of product 1,000 L of high-quality lubricant 5,000
Time commitment of
environmental engineer
60 hours of time committed to remediation,
investigation, and close out
9,600
Soil cleanup Operation of a wheel loader (one to two hour)
and supervision/disposal of 10 t contaminated soilb
11,000
RCA Preparation, delivery, and review 3,000
Interviews Meeting with all stakeholders involved 640
Engagement of suppliers Discussions regarding IBC and its history 240
Reporting Preparation of entire investigation report and
presentation to operator
6,500
Administration Collection of all required documentation,
communication of findings
2,000
Total 37,980c
a
Conservative estimates based on pay rates of approximately AUD 160 per hour for an engineer.
b
The cost of disposal of contaminated soil on the project site was approximately $ AUD 1000 per ton.
c
It excludes downtime or lost opportunities for the contractor.
Exhibit 13. View of Spill and Cleanup
Note: Top left: Spilled oil migrated out of unbunded sea container to soil around the front of container. Top right: Floor
of container showing the absence of internal bunding. Bottom left: Rear of container. Bottom right: Side of container
showing earthen bund erected to limit flow of oil, minimizing safety and environmental impacts. All contaminated soil and
contaminated absorbent materials were removed and disposed of as contaminated material within 24 h of the spill event
occurring.

Exhibit 14. View of Engineering Controls
Note: Top left: Engineering control, that is, IBC cage, put in place as a result of the spill investigation by contractor at the point of
receival of IBCs onto project at the supply base. Top right: The second engineered control, a base plate manufactured on site to
minimize impacts of tines on IBCs. Middle left: Other IBCs identified on the project site, that is, in the jurisdictions of other contractors,
after the investigation, showing damage to top of IBC other IBCs identified on the project site. Middle right: after the investigation
showing damage to base. Bottom left: Other IBCs with extensive damage to base. Bottom right: Damage to the side of another IBC
from the project.

visual inspection by the spotter, the spotter
will notify the area supervisor to assess and
determine the need for the contents of the
IBC to be decanted into another IBC unit
in good order prior to lifting or moving the
damaged IBC. IBC units that are identified
as damaged were tagged out to prevent the
use of a forklift/telehandler to pick them up.
Several such damaged IBCs were identified
across the project site (Exhibit 14). The im-
plications of this change to the inspection
regime are that it may expose the inspection
personnel (or spotters) to the added risk of
back injury/strain resulting from repetitious
leaning down to inspect pallets, and this risk
will need to be monitored on the project.
4. Numerous other administrative controls were
upgraded on the project as a result of the
investigation. All relevant JHAs and SWPs
within contractor, subcontractors, and con-
tractor offsite and supply bases were updated
to include:
• Mandatory use of spotter for the transfer of
hydrocarbons or hazardous materials;
• Specific reference to detailed inspection of the
bases of IBCs, including the use of a flashlight
to enhance visual inspection of underside of
The corrective actions are:
1. Design, construct, and use of a protection
plate (an engineering control) was employed
to prevent fork tines from puncturing IBC
units as they are handled, particularly on
major projects where there are numerous
points of handling of these vessels. The
design and construction of such a plate are
provided in Exhibits 14 and 15. In addi-
tion, as a result of the incident, the contrac-
tor began trialing the use of a metal cage for
storing IBCs during shipment and transport
(Exhibit 14). A series of such plates were
manufactured on the project site and have
been deployed across the contractor’s opera-
tions wherever IBCs are being handled.
2. Undertake chain-of-custody inspections of
IBCs containing lubricants and other chemi-
cals to identify and reject any damaged IBCs
with metal base frame deformities from
the supplier’s to the contractor’s supply
base.
3. Undertake inspections of all IBCs that are re-
quired to be moved onsite (across the project)
by telehandlers to identify any other potential
metal base frame deformities. When an IBC is
identified as damaged underneath from the
Exhibit 15. Design of Plywood Protection Board (or Base Plate) for Handling IBCs
Notes: 1. Height of the fork lift tine slots not to exceed the height of the IBC frame/skid slots
2. Cut outs for hand holds
3. Tine spacing thickness 400–500 mm

quarantine requirements), it would appear that
their construction is not likely to be suitable
for multiple lifts with a forklift or telehandler.
There are four points of entry in which the fork
tines can be entered into the base of IBCs. Two
of these entry points create potential obstruc-
tions from the protruding support strut under
the metal base plate on which the fork tines
can be caught. It is necessary to check and/
or reject IBC units with damage during chain
of custody, paying particular attention to the
underside/metal base to ensure that there are
no obstructions. Therefore, it is recommended
that quality assurance
checks for verifica-
tion of IBC condition
at the various stages
throughout the chain
of custody should be
implemented.
There is no protec-
tion plate on these IBC
frames to eliminate
fork tines from making contact/puncturing IBC
units (bladders containing product). Also, this
particular type of IBC unit has no self-bunding
to capture spilled product. Other damaged IBCs
around the construction site were identified
and marked as potentially unsafe so as to avoid
similar incidents.
It is also recommended that the use of a
spotter be implemented to further minimize the
risk of future spills. It should not be assumed by
the handlers of these vessels that their lifts will
be restricted to a certain “low” number. Rather,
damage to these IBCs should be expected and
looked for as they arrive into the areas under
the handler’s operational control. Given that the
RCA process can be predictive, this knowledge of
the vulnerability of commonly used IBCs can be
used by IBC handlers to help eliminate the type
of spill reported in this study.
IBC units in sea containers for possible dam-
age to metal base plate;
• Use of a protection plate to prevent tines from
puncturing the IBC unit;
• Prior to lifting or moving IBCs what are iden-
tified as damaged underneath from the visual
inspection by the spotter, the spotter will no-
tify the particular area supervisor to assess and
determine the need for the contents of the
IBC to be decanted into another IBC unit; and
• Identified damaged IBC units will be tagged
out to prevent forklifts/telehandlers from in-
teracting with damaged IBCs.
These changes were incorporated into the
contractor’s HSE systems and wider business.
5. Developed a toolbox talk package for rele-
vant teams within the contractor’s workforce
and communicated the lessons learned from
the incident, including new requirements,
which were added to inspect the underside
of IBCs, and amendments to updated JHAs
and SWPs.
6. Communications were prepared after the
completion of the investigation, and a site-
and project-wide alert was prepared and dis-
tributed.
While these recommendations are specific
to the project site of this study, the implications
for other sites and projects are much broader,
given the popularity of the use of the 1,000-L
IBC for supplying and distribution of lubricants,
chemicals, and other hazardous materials across
resource construction projects.
Conclusions
General
In designing an IBC that is fit for pur-
pose (i.e., of lightweight nature and will meet
In designing an IBC which is fit
for purpose (i.e., of lightweight
nature and will meet quarantine
requirements), it would appear that
their construction is not likely to
be suitable for multiple lifts with a
forklift or telehandler.

sustainable development by reducing environ-
mental impact (Guerin, 2009). Engagement with
plant and equipment and chemical suppliers by
oil and gas companies and/or their civil contrac-
tors would be a productive next step. There is
also scope for greater involvement of broader
cross-company (or site) personnel to collaborate
in such investigations.
Similarly, there is an opportunity for compa-
nies to have their HAZID processes or assessments
reviewed by external parties to ensure that these
assessments are not compromised by limited (or
inwardly focused) thought patterns by company
personnel.
More broadly, there are opportunities to reeval-
uate the role of RCA in commercial applications to
undertake spill investigations. In addition, there
are opportunities for industry to consider adopting
improvements to the RCA process to make it less
complicated and more streamlined without losing
its ability to derive actual underlying causes of
incidents, as other safety professionals (Ferjencik,
2014) suggest from their extensive work done on
the improvement of RCA methodology.
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Turlough F. Guerin is a professional environmental manager currently managing the approvals and compliance programs
for First Solar’s EPC business in Australia, overseeing the construction of several solar PV power stations in Australia.
His career has spanned soil and groundwater assessment and remediation for Rio Tinto and Shell, contractor compliance
and assurance management for Chevron, managing the sustainability portfolio for Australia’s largest telecommunications
company, Telstra, and consulting to Levine-Fricke-Recon, ICF Kaiser Engineers, and Motorola. He received his bachelor’s
degree in agriculture and undertook postgraduate studies and research into the degradation of chlorinated pesticides in
farming soils, sediments, and waterways.

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