Crane safety in

construction
This report and the work it describes were funded through the Workers Compensation Operational Fund. Its contents, including any
opinions and/or conclusions expressed, are those of the authors alone and does not necessarily reflect SafeWork NSW policy.

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 Prepared by:

Helen Lingard1
Tracy Cooke1
James Harley1
Payam Pirzadeh1
Gregory Zelic 2
Michael Wilczynska2
Ron Wakefield1
Ehsan Gharaie1
November 2019
1
RMIT University
2
Centre for Work Health and Safety, NSW Department of Customer Service

Executive summary
In Australia, 47 workers were killed in incidents involving cranes between 2003 and 2015 (Safe
Work Australia, 2016a). Safe Work Australia (2019) also reports that there are, on average, around
240 serious injury claims arising from crane safety incidents every year.

The aim of this research project was twofold:

1. To identify causes and contributing factors associated with safety incidents involving
cranes in the construction industry.
2. To explore strategies to reduce the risk of crane safety incidents in the construction
industry.

The scope was further limited towards fixed and mobiles cranes used in the construction industry.
In particular, the primary data collection focused on the construction industry in New South
Wales.

Methods
The research was conducted in three parts:

1. a review of national and international academic and ‘grey’ literature (industry-based and
government documents and reports) was undertaken
2. focus groups and interviews were organised with experts and informed workers from the
industry

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 3. SafeWork New South Wales (NSW) data pertaining to crane-related safety activities were
analysed.

Results

Literature review
Causes of crane safety incidents operate at different levels within a work system and include
factors, such as:

• the regulatory environment

• prevailing levels of worker skill and competency

• industry supply issues

• site planning and management issues

• physical worksite conditions

• human errors and equipment failures.

In some instances, latent conditions are reported with the potential to cause serious crane safety
incidents associated with design or manufacturing issues. Although such incidents are relatively
rare, they show that not all crane safety incidents arise as a result of local site-based factors.

A range of different strategies was identified for preventing crane safety incidents in the
construction industry. These relate to:

• the need for greater clarity relating to roles and responsibilities for crane-related activities
at a worksite, and the involvement of suppliers and sub-contractors in equipment selection
and site planning

• opportunities to increase training for people who plan, coordinate and supervise lifting
operations

• licencing systems, and the importance of ensuring crane operators’ competence in using a
particular type or model of crane

• the adoption of new (and emerging) technologies to improve crane safety.

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Focus groups and interviews
Cause-effect diagrams were developed reflecting five areas of crane safety incident causation:
work environment issues, worksite conditions, human factor issues, equipment issues, and
task/activity issues.

Factors and contributing factors were also classified as operating at one of three levels in the
system of work involving the use of cranes in the construction industry: originating influences,
shaping factors, and immediate circumstances.

A crane safety incident causation model was developed which reflects the operation of
causal/contributing factors at these three levels. The model was tested successfully against
documented crane safety incidents. A small number (n=6) of industry experts reviewed the crane
safety incident causation model and confirmed its relevance both for understanding, and for
investigating and preventing, crane safety incidents.

Industry experts consulted in focus groups/interviews also identified strategies that could assist
in preventing safety incidents involving cranes. Suggested strategies fell into seven topic areas,
as follows:

• training and competence

• development of a code of practice for crane operations
• communications and awareness raising
• the role of the regulator
• design and import issues
• technology use
• procurement and the management of commercial relationships.

SafeWork NSW quantitative data analysis

The analysis of the SafeWork NSW quantitative data revealed that:

• most crane safety incidents occur in the construction industry

• dangerous incidents occur most frequently when mobile and tower cranes are involved.
Serious injuries occur most frequently for bridge/gantry cranes and mobile cranes
• the most common mechanism of crane safety incidents is a person being hit by the load
being lifted. For incidents involving mobile cranes, the most common mechanism for
incidents is the collapse of the crane

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 • between 2015 and 2018, there was a sharp increase in the number of dangerous incidents
recorded per tower crane. However, the rate of serious injuries per tower crane was stable
over this period
• when an immediate cause is identified for a crane safety incident, human error is most
frequently cited. Faulty crane equipment is the next most frequent immediate cause
identified
• crane crew experience is a significant risk factor for crane safety incidents. More experienced
crane workers are less likely to be involved in crane safety incidents.

An agenda for preventing crane safety incidents

This research project identified four key areas of work with potential to prevent crane safety
incidents. This agenda emerges from integrating findings from the literature review, focus groups
and interviews with industry experts, and analysis of SafeWork NSW data.

Workforce competence
Human error was a frequently identified cause of crane safety incidents, and weaknesses were
observed in the current High Risk Work training and licensing systems. Inexperience was also
identified as a risk factor for crane safety incidents. Industry experts consulted in focus
groups/interviews made suggestions to improve or better track the competency of the
workforce, be it by recording the crane experience of workers, and/or introducing a tiered
licensing system, and/or ensuring Verification of Competency (VOC) processes reflect machine-
specific competence and/or providing specific training for those who make critical decisions with
the potential to impact the safety of crane operations at construction sites.

Supply arrangements, communication and planning

Time pressures associated with the delivery of construction projects were found to negatively
impact the time available for planning safe lifting activities. Commercial pressures and specific
features of crane hire practices (such as the use of fixed price contracts) were also identified as
risk factors for crane safety incidents. Fixed price contracts encourage work to be performed
quickly, sometimes at the expense of safety, as delays are potentially costly for crane companies.
Overly complex (and heavily paper-based) work health and safety (WHS) management systems
were perceived to be ineffective for communicating site-specific risk factors and/or safe working
practices to workers. Industry experts consulted in focus groups/interviews raised the importance
of pre-deployment site visits to inform collaborative lift planning, as well as the need for standard
clauses establishing safe operating requirements, and roles and responsibilities for safety, in
commercial agreements between principal contractors and crane hire companies.

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Industry and regulatory environment
Features of the industry and regulatory environment, including inspection practices,
internationalisation of construction markets, and subcontracting practices, were identified as
contributing to crane-related safety incidents in the construction industry. In particular, a history
of non-compliance with WHS regulations was identified as a predictor of subsequent crane-
related safety incidents among construction industry person[s] conducting a business or
undertaking (PCBUs). Industry participants suggested safe working practices in using cranes
could be improved through the regulator adopting an increased mentoring role and providing
more detailed guidance on preventing crane safety incidents. Participants also suggested a more
‘aggressive’ inspection and enforcement regime could potentially produce improvements in the
safe use of cranes in the construction industry.

Equipment design, maintenance and use

The operation of substandard cranes and structural/electrical failures were identified as
immediate causal factors in crane safety incidents. These were traced back to deficiencies in
manufacturers’ information, inconsistent maintenance regimes, or modifications made to crane
installations. Industry experts consulted in focus groups/interviews and identified the importance
of third party crane assessment programs and suggested testing requirements should be based
on functional age relative to a crane’s design life (rather than determined by the age of a crane in
years).

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Table of Contents
Executive summary ............................................................................................................................ 1

Methods ................................................................................................................................................................................... 1

Results ..................................................................................................................................................................................... 2

Table of Contents .............................................................................................................................. 6

List of Figures ..................................................................................................................................... 7

List of Tables ....................................................................................................................................... 8

General introduction ....................................................................................................................... 10

Background ......................................................................................................................................................................... 10

Aims of the project ........................................................................................................................................................... 10

Structure of the report ..................................................................................................................................................... 11

Methods .............................................................................................................................................. 12

Literature review ............................................................................................................................................................... 12

Interviews and focus groups .......................................................................................................................................... 13

SafeWork NSW data ......................................................................................................................................................... 18

Results .................................................................................................................................................23

Literature review .............................................................................................................................................................. 23

Focus groups/interviews ............................................................................................................................................... 62

Crane safety incident causation model ..................................................................................................................... 65

Potential strategies/solutions for crane safety incident reduction ................................................................. 69

SafeWork NSW data ........................................................................................................................................................ 78

Discussion ......................................................................................................................................... 103

Workforce competence ................................................................................................................................................. 103

Supply arrangements, communication and planning ......................................................................................... 106

Equipment design, maintenance and use ............................................................................................................... 109

Industry and regulatory environment ......................................................................................................................... 111

Crane safety incident causation and prevention.................................................................................................... 113

Conclusion and key findings ........................................................................................................ 115

Appendices ....................................................................................................................................... 116

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Appendix 1. The Bellevue crane incident .................................................................................................................. 116

Appendix 2. A fatal mobile crane incident ............................................................................................................... 118

Appendix 3. A tower crane incident .......................................................................................................................... 121

Appendix 4. A mobile crane incident ....................................................................................................................... 126

Appendix 5. Crane incident causation analysis table .......................................................................................... 130

Appendix 6. Cause and effect diagrams .................................................................................................................. 164

Appendix 7. Variables included in quantitative analysis .................................................................................... 172

Appendix 8. Definitions of serious injury and dangerous incident.................................................................. 174

Appendix 9. Focus group and semi-structured interview approach .............................................................. 176

References ....................................................................................................................................... 178

List of Figures

Figure 1. Flowchart describing the filtering procedure of the WSMS workplace incident database
for crane safety incidents. ................................................................................................................................................... 21

Figure 2. Main incident types for mobile and tower cranes. Adapted from Milazzo et al. 2016. ... 25

Figure 3. Fatal incidents involving mobile cranes in the US, 1992-2002. Adapted from NIOSH,
2006. ............................................................................................................................................................................................. 38

Figure 4. Crane safety incident causation model................................................................................................... 67

Figure 5. Causal/contributing factors identified in the scenario analysis. ................................................. 68

Figure 6. Proportions of crane and safety incidents and all workplace safety incidents by type of
industry. ....................................................................................................................................................................................... 79

Figure 7. Seriousness of crane safety incidents by type of crane. ................................................................80

Figure 8. Crane safety incidents by incident mechanism. .................................................................................. 81

Figure 9. Time series analysis of crane safety incidents, 2012 to 2018........................................................ 82

Figure 10. Normalised time series analysis of dangerous incidents and serious injuries involving
tower cranes in Sydney. ...................................................................................................................................................... 85

Figure 11. Distribution of the immediate causes of the crane safety incident for all crane safety
incidents (top chart), for crane safety incidents involving tower cranes only (bottom left chart),
and for crane safety incidents involving mobile cranes only (bottom right chart). ............................. 87

Figure 12. Distribution of the immediate causes of crane safety incidents per year............................ 88
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Figure 13. Geographical distribution of fatal injuries due to crane safety incidents as a function of
the immediate cause of the incident. ...........................................................................................................................90

Figure 14. Proportions of HRW licences held by individuals for crane-related activities. .................. 91

Figure 15. Proportion of licenced crane operators as a function of the number of crane operation
licences held (top panel), and as a function of the type of crane operation licence held (bottom
panel). ........................................................................................................................................................................................... 92

Figure 16. Licensed riggers, dogmen, and operators, by age and experience. ....................................... 93

Figure 17. Comparison of age and experience profiles of licensed workers involved in crane safety
incidents compared to all licensed workers. ............................................................................................................ 96

Figure 18. Training and incident experience of licensed workers involved in crane-related activities,
by RTO size. .............................................................................................................................................................................. 99

Figure 19. Proportion of PCBUs owning at least one registered mobile crane (MC) or one
registered tower crane (TC) as a function of the type of cranes owned (mobile crane, tower crane,
or both), and the total number of cranes owned................................................................................................. 100

Figure 20. Proportion of PCBUs as a function of the PCBU’s previous number of notices. ........... 101

Figure 21. The Bellevue crane incident. Based on McDonald et al. 2011. ..................................................... 117

Figure 22. A fatal mobile crane incident. .................................................................................................................. 120

Figure 23. A tower crane incident ................................................................................................................................ 125

Figure 24. A mobile crane incident. .............................................................................................................................129

Figure 25. Work environment issues. ......................................................................................................................... 164

Figure 26. Worksite conditions. .....................................................................................................................................165

Figure 27. Human factor issues. .................................................................................................................................... 166

Figure 28. Equipment issues. ...........................................................................................................................................167

Figure 29. Task/activity issues. ..................................................................................................................................... 168

List of Tables

Table 1. Tower crane safety incident causation (Beavers et al. 2006). ....................................................... 24

Table 2. Tower crane safety incident causation (Isherwood, 2010). ............................................................ 27

Table 3. Dangers when erecting/dismantling tower cranes (Shin, 2015). ................................................. 28

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Table 4. Causal factors for fatal incidents occurring during erection/dismantling of a tower crane,
in descending order of frequency (Shin, 2015). ...................................................................................................... 29

Table 5. Causes of case study incidents involving mobile cranes (adapted from NIOSH, 2006). 38

Table 6. Safety factors associated with tower cranes (Shapira et al. 2012). ............................................ 43

Table 7. Safety enhancing technologies. ..................................................................................................................... 51

Table 8. Tower crane safety incidents normalised by number of tower cranes standing in Sydney
2015-2019. ................................................................................................................................................................................... 83

Table 9. Frequencies per region of incidents resulting in serious injuries (SI) and dangerous
incidents (DI). ........................................................................................................................................................................... 89

Table 10. Licensing status of persons involved in crane safety incidents. ................................................. 95

Table 11. Training experience of workers with HRW licences involved in crane safety incidents. . 98

Table 12. Frequency with which causal/contributing factors were identified as relevant to crane
safety incident scenarios used in the validation. .................................................................................................. 169

Table 13. List of variables and values included in quantitative analysis. .................................................... 172

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General introduction

Background
The construction industry has developed into a highly mechanised working environment in which
there is an increased dependency on mechanical material handling and lifting (Shapira et al.,
2007). The dependence on cranes as the most prominent form of transportation on a construction
site is linked to increasing industrialisation of construction processes and the off site manufacture
of (often large and heavy) modular components (Raviv et al. 2017a). Cranes are therefore a critical
feature of construction operations. They are also assessed as being one of the most dangerous
items of equipment on a construction site (Sertyesilisik et al. 2010). The level of crane activity in
major Australian cities is significant. The Rider Levett Bucknall (RLB) Crane Index measures the
number of tower cranes standing as an indicator of construction activity. In the first quarter of
2019, this count was 310 for Sydney and 220 for Melbourne (RLB, 2019).

In Australia, 47 workers were killed in incidents involving cranes between 2003 and 2015 (Safe
Work Australia, 2016a). Safe Work Australia (2019) also reports that there are, on average, around
240 serious injury claims arising from crane safety incidents every year.

Aims of the project

Safety incidents involving cranes can have dramatic consequences for workers, their families, and
members of the public. Considering the large number of cranes being used in NSW, and Australia
generally, it is critical to gain a better understanding of both the causes of crane safety incidents,
and the solutions that can be successfully implemented to prevent them.

Since past research has shown that the circumstances of an incident likely differ as a function of
the type of crane involved, the present study focused on two types of crane that are commonly
found in mobile temporary workplaces such as construction sites: fixed cranes (tower cranes, self-
erecting), and mobile cranes.

The present research aimed to answer two questions:

• What are the factors that cause or contribute to the occurrence of safety incidents involving
fixed and mobile cranes used in the construction industry?
• What strategies, initiatives and technologies can be developed and implemented to reduce
the risk of crane safety incidents in the construction industry?

A literature review was first conducted to synthesise the available published evidence and provide
a frame of reference for the second and third components of the research. The second component
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was to analyse qualitative primary data relating to crane use and safety in the Australian
construction industry – these data were collected through focus groups/interviews with industry
experts. The third component of the research was to analyse data available to SafeWork NSW;
for instance, crane safety incidents data, operational data, and High Risk Worker training and
licensing data.

Structure of the report

The remainder of this report is structured as follows:

• the ‘Methods’ section presents a description of the research methods used for each of the
three component parts of the work
• the ‘Results’ section presents the results of the analysis of the three component parts of the
work
• the ‘Discussion’ section presents an overarching discussion of the findings of the three
component parts of the work
• the ‘Appendix’ section presents supplementary material. This includes the tabulated focus
group/interview data synthesis, causal maps used to inform the development of the crane
incident causation model, as well as scenario crane incident cases used in the validation of
the causation model
• the ‘References’ section presents a list of reference material used in this project.

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Methods

Literature review
A review was undertaken of national and international academic and ‘grey’ literature (industry-
based and government documents and reports).

The RMIT Library SearchIt database, Google Scholar, and relevant databases and journals, were
searched, including the American Society of Civil Engineers database of conference and journal
articles, Safety Science, and the Journal of Safety Research. Relevant industry websites (for
example, ‘Vertikal’) were also searched, as were sites of international and Australian regulatory
and health and safety policy-making bodies (for example, the UK Health and Safety Executive).

The document search used keywords including ‘crane’, ‘crane accident/s’, ‘crane incident/s, ‘crane
+ statistics’, ‘crane + statistics + construction’, ‘accident/s + approaches’, ‘accident/s + crane +
construction’, ‘accident + construction + statistics’, plus using previous combinations + [specific
country] (US, UK, China, Japan, Asia more broadly).

The websites of the regulators across Australia (excluding SafeWork NSW) were also searched
to develop a broad understanding of the material presented relevant to the subject of crane
incident causation. Search terms included ‘investigation’, ‘evaluation’, ‘cranes’ and ‘construction.’
This search also included the web resources published by SafeWork Australia. The terms ‘mobile’
and ‘fixed’ were added to specify results on cranes. Further search parameters included
‘investigation’ or ‘evaluation’ (in title) and ‘cranes’ (in title) and ‘construction’.

An exclusion criterion was also applied to exclude results relating to crane types outside the scope
of the study, which focused on crane usage in the construction industry (for example, bridge or
gantry cranes not ordinarily used at construction sites were excluded). Other materials excluded
were those identified as being superseded or those that included information duplicated in
multiple documents within the same jurisdiction (such as a news release and a safety alert
referring to the same incident).

Identified materials were read and classified according to the type of information they presented;
that is, whether the authors present an analysis of the causes or factors contributing to crane
safety incidents in the construction industry, and/or the authors present information about
strategies, initiatives or technologies (that were either implemented or recommended) to prevent
crane safety incidents in the construction industry.

Information in the documents was synthesised and documented in the literature review under
these general areas of analysis.
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Interviews and focus groups

Procedure
Eight focus group sessions were organised by RMIT researchers in consultation with the Centre
for Work Health and Safety (the Centre). Seven focus groups took place in Sydney, split between
the Sydney CBD and Parramatta. This included a focus group specifically scheduled for
employees of SafeWork NSW. One focus group was undertaken via Skype for regulator
participants who could not attend a focus group session. The maximum duration of the focus
group sessions was 90 minutes.

The majority of interviews were conducted via the telephone. However, two interviews were
conducted on site at a crane company in Sydney. Interviews lasted for a maximum of 60 minutes.

The recruitment process started with the Centre putting together a contact list of known experts
from the industry, crane workers, RTO representatives, and experts from the WHS regulator. The
Centre then emailed an ‘Eventbrite’ invitation to these contacts. Prospective participants were
able to ‘opt in’ to a focus group session that was convenient for them to attend. A limit of ten
people per focus group was imposed to ensure group sizes remained manageable. For reasons
of confidentiality, names of the registered participants were only known by the RMIT research
team and were not shared with the Centre. The Centre also provided RMIT researchers with the
names of people who could be approached to request an interview. People who were unable to
attend a scheduled focus group session were offered the opportunity to be interviewed. In one
case, a focus group participant introduced the research team to two members of his work team
in order for them to be invited to participate in an interview. In keeping with confidentiality
requirements, the Centre was not advised as to the identity of the individuals who registered and
participated in focus groups or who were interviewed. In total, 35 people participated in a focus
group and nine people participated in interviews.

Focus group/interview participants included crane owners, crane operators, construction

managers, supervisors and workers, consultants, and people from relevant industry associations
and organisations. The focus group sessions were held on 8, 14, 15 and 24 May 2019. One interview
was conducted prior to the commencement of the focus groups due to the participant’s
preference and time constraints. The remaining eight interviews were conducted in the two weeks
after the focus groups.

The focus groups were conducted using a pre-agreed data collection process. Participants were
asked to share their thoughts and experiences relating to the factors causing or contributing to
crane safety incidents in four main areas: site conditions, the work environment, human factors,
and site safety management.
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Participants were first asked to address each of the four areas in relation to the cause of incidents
involving both fixed and mobile cranes. They were then asked to group and rank the top
causal/contributing factors (relating to fixed and mobile cranes). Finally, they were asked to
identify strategies or interventions that could help to reduce the incidence of crane safety
incidents, with particular relevance to the factors they identified. See Appendix 9 for semi-
structured interview questions and focus group approach.

Data collected during the first round of focus groups and interviews were audio-recorded (with
participants’ informed consent) and transcribed verbatim in preparation for analysis (Gale et al.
2013).

Following analysis of the first round of focus group/interview data, five further interviews were
conducted with selected industry representatives to evaluate the validity/usefulness of the
outputs from the initial data analysis (in particular, a crane safety incident causation model). The
purpose of these interviews was to:

• examine whether the crane safety incident causation model developed following the first
round of data collection/analysis is useful in helping to identify causal/contributing factors
in example crane safety incidents
• examine whether the content of the crane safety incident causation model is applicable to
both mobile and fixed (tower) cranes
• elicit industry participants’ views regarding the practical usefulness of the crane safety
incident causation model.

Interview participants were provided with an example case scenario describing either a mobile
crane or a tower crane incident. Participants were randomly assigned to the mobile and tower
crane incident descriptions. The interviews were not sufficiently long enough for both scenarios
to be considered by all participants.

Participants were asked to read through the incident description/scenario and then identify
immediate circumstances, shaping factors, and originating influences, that contributed to the
incidents. For the purposes of this exercise, three groups were provided with the tower crane
scenario and two groups were provided with the mobile crane scenario.

Participants in the second round of consultation (validation) were also asked:

• whether factors in the model reflected their opinion as to the causal/contributing factors in
crane safety incidents, and
• whether they would find the model useful in analysing incidents and/or understanding
crane-related safety risks in their workplaces.
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Data analysis
In total, 444 pages of transcribed data were generated from the initial focus groups/interviews.
These data were analysed using a systematic method of analysis that is well suited to applied
policy research (Gale et al. 2013). The ‘framework method’ of qualitative data analysis is useful
because, while it captures key concepts, ideas and themes from the original accounts and
observations of participants, it is also focused on meeting pre-set aims and objectives of funders
and researchers (Pope et al. 2000). Data collection tends to be more structured compared to
other qualitative research approaches, and the analytical process is made explicit (and is often
informed by) research questions or a priori theoretical positions (Pope et al. 2000).

The framework method can be used for diagnostic and strategic purposes and is designed to
meet specific information requirements in a limited timeframe (Ritchie & Spencer, 1994). In this
case, the information requirements to be met were both diagnostic and strategic, and related to
identifying and understanding two domains: first, the causes of safety incidents involving cranes
(mobile and fixed) in the Australian construction industry (diagnostic); and second, participants’
viewpoints about what could or should be done to prevent crane safety incidents in the
construction industry context (strategic).

The framework method of analysis offers several advantages. It provides a systematic model for
managing and mapping large qualitative datasets. The matrix format used in the framework also
provides a structured overview of summarised data, making it easy to comprehend and interpret.
Finally, the step-by-step process of analysis makes it is suitable for interdisciplinary and
collaborative research projects (Gale et al. 2013).

The steps followed in the framework method of analysis are those prescribed by Ritchie and
Spencer (1994):

1. Familiarisation with data – gaining an overview of the material to be analysed. All the
transcripts were read by one analyst. The analyst did not participate in data collection.

2. Identifying a thematic framework – once familiar with the data, key issues, concepts and
themes could be identified, according to which the data can then be examined in detail
and referenced. In this case, the analyst used a balance of deductive processes (deriving
themes from the theories of incident causation that informed questions posed by the
focus group facilitator/interviewer), and inductive processes (identifying themes
emerging from participants’ discussion). Combining inductive and deductive analytical
processes is accepted practice in qualitative data analysis (Fereday & Muir-Cochrane,
2006). Gale et al. (2013) argue that the framework method can accommodate both
inductive and deductive thematic analysis, or reflect a combination of both approaches.
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 In developing a framework for subsequent coding and classifying data, it is useful to test
the framework for completeness, to ensure it is reasonably inclusive of the data,
reproducible, and credible to the people who provided the data (Patton, 2002). The
construction industry experience of the data analyst was critical in ensuring the thematic
framework developed in this step met these criteria for completeness.

3. Indexing – the framework was applied to the whole dataset in its text form. During this
stage, the analyst read the focus group/interview transcripts in detail and highlighted
core meanings, themes and concepts contained in the narratives and responses of
participants (that is, the transcripts). Content analysis of this type describes ‘qualitative
data reduction and sense-making effort that takes a volume of qualitative material and
attempts to identify core consistencies and meanings’ (Patton, 2002, p. 453). Relevant
themes and concepts identified in the data were systematically cross-referenced with
the framework developed in step 2. By systematically identifying meaning, themes and
patterns, and linking these back to specific quotes or passages in the transcribed data,
the process of indexing is made visible and accessible. This is an important feature of
applied policy research. A portion of the data was also reviewed by two researchers to
test the reliability of the thematic framework and coding process. To ensure the coding
process was consistent and reproducible, disagreements were discussed until consensus
was reached.

4. Charting – relevant portions of data (those illustrative of core meanings, themes and
concepts identified in step 3) were then ‘lifted’ from the original source documents (in
this case transcripts) and incorporated into a matrix/spreadsheet format. This was done
for each focus group transcript, prior to creating an overall table containing all relevant
themes/concepts, their description and example quotations (traceable back to the
transcripts from which they were drawn). This table is presented in Appendix 5 of this
report. The table organises causal factors identified by the focus group/interview
participants into three levels of causation included in the ConAC model: that is,
immediate circumstances, shaping factors, and originating influences.

5. Mapping and interpretation – when all the data has been sifted and incorporated into
the framework according to core themes/concepts, the analyst then interpreted and
mapped the entire dataset. During mapping and interpretation, the meaning of the data
is explored in relation to the research aims, patterns of association, explanations, and
linkages between diagnosed issues and preventive strategies. At this stage, findings are
judged in terms of their substantive significance. This involved considering how coherent
and solid the evidence is in support of the findings, to what extent the findings increase
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 understanding of the phenomena being studied, to what extent the findings are
consistent with other knowledge relating to the phenomena, and to what extent the
findings are useful for their intended purpose (Patton, 2002). The data were then further
examined to identify causal links between factors operating at different levels in the
ConAC causation framework. Cause-effect maps were developed to show the
relationship between factors operating at different levels in the ‘hierarchy’ of causal
factors. These cause-effect diagrams are provided in Appendix 6.

These cause-effect diagrams were developed for five broad areas of crane incident causation:
work environment issues, worksite conditions, human factor issues, equipment issues, and
task/activity issues.

These broad areas referred back to the way in which the focus group questions were posed.
However, due to the richness of data and detailed responses provided, the site management
factor was broken down into two separate cause-effect diagrams (reflecting equipment issues
and task/activity issues). The diagrams can be found in Appendix 6 of this report.

6. In step 5 of the analysis of qualitative data, ‘cause-effect’ trees (logic diagrams) were
developed, representing linkages between contributing factors to crane safety incidents.
These trees are useful in representing knowledge that is subjective and interrelated to
other issues that need to be considered simultaneously, as is the case in understanding
the factors that influence construction WHS (Cooke et al. 2008). The cause-effect trees
represent actual or potential causal pathways between distal and site-level
causes/contributing factors identified by focus group/interview participants. Where
possible, causal inferences (pathways) were developed based upon the explanations
provided by focus group/interview participants. Some of these pathways were explicitly
identified by participants, while others were implied in their comments and explanations
of the causes of crane safety incidents. However, some pathways incorporated into the
trees were inferred by the analyst, drawing on extensive industry knowledge and
experience. The cause-effect tree diagrams provided an understanding of actual or
potential pathways through which managerial/organisational decisions and actions
contribute to unsafe physical conditions, and/or human error, in relation to crane usage.

On the basis of the qualitative data analysis, a crane safety incident causation model was
developed based upon the nodes in the cause-effect diagrams. This model is based on the ConAC
incident causation framework. The ConAC framework was developed by Haslam et al. (2003)
based on a study of 100 construction safety incidents, categorising causal factors as immediate
circumstances, shaping factors and originating influences. In the US, Behm and Schneller (2013)

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used the ConAC framework to analyse the causes of 27 construction safety incidents of varying
degrees of severity. In Australia, Cooke and Lingard (2011) used the same framework to analyse
the causes of fatal incidents in an analysis of coronial investigation reports. The ConAC framework
has been extended and adapted by Harvey et al. (2018). The model is applicable to the
construction industry and useful in facilitating an understanding of the causes of serious (fatal)
incidents, as well as less serious incidents and near misses (Gibb et al. 2014). Consequently, this
model was used as a framework to structure the results of the qualitative focus group/interview
data analysis.

The resulting crane safety incident causation model thus provides an evidence-informed analysis
of the causal/contributing factors, as identified by focus group/interview participants, operating
at each of the three levels of causation: immediate circumstances, shaping factors, and originating
influences.

SafeWork NSW data

The following issues were examined in the quantitative analysis of SafeWork NSW data:

• Crane safety incident rates were compared across industries in NSW. Crane safety incidents
were analysed according to a number of variables, including injuries, near misses, the type
of crane involved, the mechanism by which the incident occurred and the victim type
• time series analysis was performed to understand how the frequency of crane safety
incidents has changed over time
• causal factors that could be extracted from incident reports were analysed
• geographical analysis was performed to map the regions in NSW where crane safety
incidents occur
• licensing and training data for High Risk Work licence holders: that is, operators, riggers and
dogmen, was analysed to identify the population of high-risk workers most at risk of being
involved in a crane safety incident. The characteristics (for example, age and experience
level) of these workers were compared to those of the general population of High-Risk Work
licence holders
• the size of a High-Risk Work training organisation was analysed for its potential as a risk
factor for crane safety incidents
• the person[s] conducting a business or undertaking (PCBU) most at risk of experiencing a
crane safety incident were identified by analysing their WHS compliance history.

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Data sources
Several datasets captured and managed by SafeWork NSW were used to support the quantitative
analysis. These are described below.

The workplace incident database

The workplace incident dataset was extracted from the Workplace Services Management System
(WSMS). It provides details regarding 75,215 workplace incidents that have occurred between
01/01/2002 and 01/02/2019 in NSW. Eighty variables were documented for each incident (for
example, incident date, incident type), and a further 30 quantitative variables were created
relating to crane safety incidents (see Appendix 7 for a list of extracted variables and Section
2.2.3 for the procedure by which they were created).

The High-Risk Work (HRW) Licence database

The HRW Licence database consists of all HRW licences issued between 29/04/1996 and
01/02/2019 by the Government Licensing Service (GLS). It holds details for a total of 151,715
licences across 14 variables which provide details about the licences and licensees (for example,
reference number, licence issue date, licence expiry date, age, class).

The HRW training database

The HRW training database details training records for each individual who has received RTO
training for a HRW Licence. It consists of 75,021 licences active on 1 February 2019. The dataset
includes variables which provide details about licences and licensees (for example, issue date,
expiry date, class, training).

Inspector compliance notices issued to PCBUs

The compliance notice database was extracted from WSMS. It consists of 72,504 notices issued
by inspectors to PCBUs between 1 January 2007 and 1 January 2019. It records 75 variables which
provide information about the circumstances of the notice issued (for example, type of notice,
date issued, status, ABN, name, postcode).

The crane registration database

Crane registration data was extracted from WSMS and consists of registered mobile and tower
cranes in NSW. A total of 3,213 cranes were listed as registered on 1 February 2019, with 14
variables providing information about each registered crane (for example, registration number,
issue date, owner ABN, industry).

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Data cleansing and analysis
Figure 1 illustrates the procedure followed to narrow the WSMS workplace incident dataset down
to crane safety incidents only, and to extract causal information from the accident reports.

Automated data filtering

To identify safety incidents that were crane-related, the WSMS workplace incident dataset was
initially filtered for the keyword ‘crane’ in the ‘Incident Description’ and ‘Action Taken’ fields. The
‘Incident Description’ field describes the incident in question, usually reported by the PCBU. The
‘Action Taken’ field contains a complete SafeWork NSW inspector’s report and was highly likely
to contain the word ‘crane’ for crane safety incidents. The initial screening resulted in 1,461
incidents that contained the word ‘crane’ in either field, out of a total of 10,026 incidents.

Workplace incidents are categorised by SafeWork NSW into several groups: dangerous incident,
serious injury, injury, serious illness, fatal injury, fatal illness, pollution, or other. The crane safety
incidents were further filtered to only include fatal injuries (n = 72), serious injuries (n = 605), and
dangerous incidents (n = 799). Definitions of serious injuries and dangerous incidents are taken
directly from the Work Health and Safety Act 2011, Section 37. Incident type definitions are
provided in Appendix 8.

Manual review
All dangerous incidents, serious injuries and fatal injuries that included the text string ‘crane’ in
the ‘Incident Description’ and ‘Action Taken’ fields were manually reviewed to confirm that the
incidents were in fact crane related. This procedure was required because there are many
instances where the word ‘crane’ is mentioned in the incident database, but a crane was not
directly involved in the incident in question. The ‘Incident Description’ and ‘Action Taken’ fields
were individually reviewed and incidents where a crane was not involved were filtered out. A total
of 1075 crane safety incidents remained after this filtering process was applied, including 15
incidents resulting in a fatality (fatal injuries), 344 incidents resulting in serious injuries, and 731
incidents categorised as dangerous (Figure 1).

Extracting further quantitative information from the workplace incident database

The ‘Incident Description’ and ‘Action Taken’ fields contained additional information in plain text.
A procedure was established to convert the plain text into a set of new quantitative variables. The
procedure taken was as follows. Three analysts reviewed 80 random records. Each analyst
defined a set of quantitative variables they deemed relevant to the analysis of crane safety
incidents. A final set of 30 quantitative variables was settled upon by consensus. These variables
provided information about the crane (for example, type of crane, action of crane at time of

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incident), and further details surrounding the incident (for example, fall from crane, hit by load),
the victim of the incident, weather conditions, causal factors, and many more. A complete list of
all 30 quantitative variables can be found in Appendix 7.

Figure 1. Flowchart describing the filtering procedure of the WSMS workplace incident database for crane
safety incidents.

PCBU crane ownership and compliance notice history

The list of registered cranes was transformed to provide a list of PCBUs currently owning at least
one registered crane. The number and the type(s) of crane owned by each business were
examined, as well as the average and the maximum time a registered crane had been owned. The
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WSMS compliance notice dataset was then used to inform about the history of compliance
notices issued to each PCBU.

HRW licensing and training

• List of licensed HRW involved in crane safety incidents. By combining information collected
from the workplace incident database and from the investigation files, d a list 280 of
identifiable HRW found to be involved in crane safety incidents as riggers, dogmen or crane
operators was created.
• Licensing and training dataset preparation. There are multiple licence types for each of the
three main roles of working with or around a crane (that is, rigger, dogman, operator). The
licence types were categorised under three main roles: rigging (licences for basic,
intermediate, and advanced rigging), dogging (licences for dogging), and operating
(licences for operating: non-slewing mobile cranes greater than 3 tonnes; slewing mobile
cranes up to 20 tonnes, up to 60 tonnes, up to 100 tonnes, and over 100 tonnes; self-erecting
tower cranes; tower cranes; bridge and gantry cranes; and vehicle loading cranes).
• Characteristics of crane crew and PCBUs operating cranes. The extent to which
characteristics of those HRW involved in workplace incidents differ from the population at
large was examined. The populations examined were riggers, dogmen, crane operators, and
PCBUs owning cranes.

Statistical analysis
A chi-squared test was used to determine the independence between two or more groups.
Results are presented as (χ2(a) = b, p < c), where a is the number of degrees of freedom, b is the
value of the test statistic, and c is the p-value. A p-value of <0.05 was deemed to be significant.

Linear models were fitted to time series data to determine trends over time. A F-test was used to
determine the statistical significance of the trend: that is, whether the slope of the linear fit
significantly differed from zero. Results are presented as (Fa,b =c, p < d), where a and b are the of
degrees of freedom, c is the value of the test statistic, and d is the p-value. A p-value of <0.05
was deemed to be significant.

Further analysis examined whether independent trends in the data were significantly different.
The values and errors of the slopes of linear models were compared, creating a z-score and
associated probability (p-value). Results are presented as (z = a, p = b) where a is the z-score and
b is the calculated p-value. A p-value of <0.05 was deemed to be significant.

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Results

Literature review
The literature review is structured to respond to the two research aims. First, the literature relating
to the causes of crane safety incidents in the construction industry is synthesised and discussed.
Second, strategies recommended in the literature for the prevention of crane safety incidents in
the construction industry are described. The literature review is structured as follows:

• information comparing the different types of safety incidents involving fixed and mobile
cranes is presented
• literature examining the causes of tower crane safety incidents is presented
• literature examining the causes of mobile crane safety incidents is presented
• commentary on the role played by human error in crane safety incident causation is
discussed
• the potential for crane safety incidents to be caused by latent conditions is considered
• research undertaken to quantify the risk of crane safety incidents is described
• risk reduction strategies and initiatives (identified in the literature) are described, including
the application of advanced technologies to support crane safety in the construction
industry
• key findings and limitations inherent in the literature review are summarised.

Comparison of incidents involving mobile and fixed cranes

Shepherd et al. (2000) analysed crane fatalities occurring in the US construction industry
between 1985 and 1995, on the basis of the damaging energy involved. The crane type was
specified in 67% of the incident records. Of these 65% of incidents involved mobile cranes, 20%
involved aerial lifts, and 6% involved tower cranes.

The fatal incidents involving cranes were classified depending on whether the fatality occurred as
a result of:

• electrical energy – electrocution (217 cases)

• gravitational energy (268 cases)
• machine energy (34 cases)
• other forms of energy (6 cases).

Each energy form was further subdivided into incident type. For example, gravitational energy
incidents were subdivided into:

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 • falls of objects (144 cases)
• falls of people (88 cases)
• falls of crane – overturning (36 cases).

Where data about the crane type are incorporated into the analysis of crane safety incident data,
the evidence suggests that mobile and fixed cranes are involved in different types of safety
incident (Neitzel et al., 2001) 1. Beavers et al. (2006) analysed 125 cases of crane safety incidents
resulting in 127 fatalities occurring in the US between 1997 and 2003. They report the majority of
these incidents to involve mobile cranes (88%), with 56% involving lattice boom type mobile
cranes.

Beavers et al. (2006) examined proximal causes and contributing factors to the fatal crane
incidents. However, in this analysis, the proximal cause is better described as the incident type
(for example, struck by load, electrocution) and contributing factor describes the immediate
cause of the incident (for example, rigging failure, unbalanced load, boom contact with source of
electricity). The most frequent proximal causes identified are shown in Table 1.

Table 1. Tower crane safety incident causation (Beavers et al. 2006).

Causes Number of cases Percentage

Struck by load (other than failure of boo m/cable) 40 32.0%

Electrocution 34 27.2%

Crushed during assembly/disassembly 15 12.0%

Failure of boom/cable 15 12.0%

Crane tip over 14 11.2%

Struck by cab/counterweight 4 3.2%

Falls 3 2.4%

Total 125 100.0%

Beavers et al. (2006) observe that electrocution and crane tip-over cases exclusively involved
mobile cranes. Electrocutions predominantly involved failure to maintain clearance in relation to
overhead powerlines in accordance with specified guidelines. Tip-over incidents were mainly
caused by overloading, loss of centre of gravity, and/or outrigger failure. While contact with
_____

1 Gantry, overhead and ship-to-shore cargo cranes were excluded from this analysis. Thus fixed cranes refer to tower cranes utilised
at construction sites. These include flat top, high top and luffing jib tower cranes.
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overhead powerlines is found to be a major cause of fatal incidents involving mobile cranes,
Shapira et al. (2008) argue that the presence of power lines has only a moderate impact on safety
in the use of tower cranes.

Differences in incident type between mobile and tower cranes are shown in Figure 2 which is
taken from an analysis of 937 crane safety incidents occurring worldwide from 2011-2015 (Milazzo
et al. 2016).

50
45
40
35
Per cent

30
25
20
15
10
5
0

Incident type

Mobile Tower

Figure 2. Main incident types for mobile and tower cranes. Adapted from Milazzo et al. 2016.

Some writers argue that human error is more likely to be a factor in mobile crane safety incidents
than it is in tower crane safety incidents (Shapiro et al. 2000), potentially because tower crane
operation is more heavily automated than the operation of a mobile crane (Raviv et al. 2017a).
Another factor in this difference may be that tower cranes, once in position, have limited range
of movement and operational parameters do not change to a great extent. However, the
circumstances in which mobile cranes operate are constantly changing and therefore it is much
more difficult to rely on automation and safety instrumentation that may not determine safety-
relevant changes in the operating environment; for example, changing ground conditions (Kan et
al. 2018).

Crane safety incident causes

Some of the literature that examines crane safety incident causation does not differentiate
between factors causing/contributing to safety incidents involving fixed and mobile cranes. For
example, in a study of High Risk Construction Operations (HRCO) conducted in the US, a crane
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safety investigation team found evidence of improper rigging and lifting practices as contributing
to crane safety incidents irrespective of crane type. Improper rigging and lifting practices
observed were:

• hoisting over people

• load insufficiently attached to crane
• danger of losing all or part of the load
• load striking other objects during hoisting
• slings and other rigging instruments in a deteriorated condition.

It is noteworthy that a fatal crane incident that occurred in Melbourne in 2018 was believed to be
caused by the failure or malfunction of the hoist rope termination assembly. A concrete kibble fell
causing fatal injury to a worker working beneath the lift route. WorkSafe Victoria also points out
that work should be planned to avoid lifting of loads over areas at which work is being performed
(WorkSafe Victoria, 2018). In New York, the HRCO investigation team attributed unsafe rigging
practices to human error, reporting that the rigging equipment is generally inspected and within
sufficient load ratings (Smith & Corley, 2009).

In Australia, Gharaie et al. (2015) identified the most frequent types of crane incident in the
National Coroners’ Information System (NCIS) database to be electrocutions and persons being
struck by moving objects. However, they did not specify the types of crane involved in these
incidents. The incidents reported in the NCIS database were reported to be caused mostly by site
layout issues which were traced back to space constraints in the site environment and aspects of
the work design. Site constraints were related to poor risk management and failure to adequately
design construction processes. Work design factors were traced back to inadequate attention to
safety in the design of the product being constructed (that is, the building or structure) and the
processes of construction.

Sertyesilisik et al. (2010) examined the safety of lifting operations at three case study construction
sites in the UK and identified a number of site management issues with the potential to impact
the safety of cranes operations. These included:

• time pressure and tight deadlines which encourage unqualified workers to act as a
slinger/signaller to speed up operations
• construction contractors, particularly smaller firms, using specialist equipment providers as
a way to overlook their safety responsibilities
• construction contractors lack of awareness of their safety responsibilities, believing
(incorrectly) that contract lift hiring removes their responsibility
• too much emphasis on paperwork
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 • a shortage of industry-based inspectors with in- depth knowledge of crane safety issues
• the need for more rigorous requirements and processes for planning lifting operations
• deficiencies in the level of training for lift supervisors and slingers/signallers (Sertyesilisik et
al. 2010).

Safety incidents involving tower cranes

In the UK, the Health and Safety Executive (HSE) commissioned an investigation of tower crane
incidents occurring between 1989 and 2009 worldwide. Isherwood (2010) considered 85 tower
crane incidents and placed each of these into one of seven categories. Twenty-eight incidents
were attributed to an ‘unknown cause’ group 2. Of the remaining 57, the categories and percentage
distributions are shown in Table 2.

Table 2. Tower crane safety incident causation (Isherwood, 2010).

Number of
Categories Percentage
incidents

Erection/dismantling/extending the crane 29 51.0%

Extreme weather 15 26.0%

Foundation issues 2 4.0%

Mechanical/structural issues 4 7.0%

Misuse 6 10.0%

Electrical/control system issues 1 2.0%

Total 57 100.0% 3

Erection/dismantling/extending (climbing) a tower crane was the most common category of the
tower crane incidents considered in the HSE analysis. Isherwood (2010) suggests that the process
of lifting, manoeuvring and fitting together large components at height is physically demanding
and hazardous. Further, workers engaged in this work are often required to work long/non-
standard hours. Shin (2015) similarly identifies that the majority (68.4%) of fatal incidents involving

_____

2 The number of incidents attributed to ‘unknown’ factors is indicative of informational limitations in understanding crane incident
causation, including in large scale international studies.
3 This classification system confounds incident cause (for example, extreme weather, misuse and issues associated with the crane
foundation, mechanical/structural performance or electrical/control systems) with an on-site activity of phase of use (that is, the
erection/dismantling/extension of the crane). These are not necessarily mutually exclusive, for example extreme weather could
combine with misuse in the erection/dismantling/extension of the crane to produce a safety incident. This hypothetical example
highlights the need for a more nuanced way of understanding causation than the use of simple classification systems such as this.

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tower cranes occurring in Korea between 2001 and 2011 occurred during installing/dismantling,
while 18.4% took place during normal operation of the crane.

Focus groups conducted with construction professionals/crane operators in Korea identified

dangers for safety incidents during tower crane installation/dismantling (see Table 3; Shin, 2015).

Table 3. Dangers when erecting/dismantling tower cranes (Shin, 2015).

Activity Risk factors

Erecting Asymmetric load caused by wrong setting of the foundation anchor, which inclined
to one side
Insufficient installation of a telescopic shoe (incomplete of fixing or mounting)
Poor supporting/fastening of a brace/block to a mast
Not using safety belts
Working without a scaffold and work plates

Climbing Imbalance of each jib while telescoping by not using a counterweight 4

Unlocking or missing of fixing pins at both ends of the sides (not clapping and
fastening all bolts)
Insufficient loading conditions in the mast bogie rails
Derailment of a mast from bogie rails
Imbalance due to failure to use a balance mast
Buckling of a telescopic cage
Fracture of clamped bolts supporting a circle ring

Dismantling Unsafe removal of pins on the telescopic supporter

Jib fracture/inappropriate selection of the position for raising the main jib
Fracture of a wire rope during dismantling
Imbalance due to failure to use a balance mast

General Abrasion (wear and tear of components such as bolts, nuts, or pins)
Incorrect stability of the slewing platform by not completing the connection or
omitting bolts on the surrounding circle ring
Inappropriate sling work or operation (incompetence of slingers)
Errors of a crane operation or malfunction of a tower crane

Shin (2015) identified causal factors (see Table 4) for 38 fatal incidents occurring during the
erection/dismantling of a tower crane.

_____

4 This wording is quoted directly from Shin (2015). The use of the word ‘telescoping’ in relation to tower cranes suggests that this
refers to self-erecting tower cranes sometimes used at small to medium building sites (Safe Work Australia, 2016).
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Table 4. Causal factors for fatal incidents occurring during erection/dismantling of a tower crane, in
descending order of frequency (Shin, 2015).

Number of
Causal factors Percentage
incidents

Violation of work procedure 12 31.6%

Insufficient safety procedure 9 23.7%

Lack of inspection or deterioration of components 4 10.5%

Unsafe operation of tower crane 3 7.9%

Signalling error 2 5.3%

Intrusion into a danger zone 2 5.3%

Loosening of fastening objects 2 5.3%

Not wearing fall protection gear 2 5.3%

Excessive action of the worker 2 5.3%

Total 38 100.0%

It is noteworthy that most of these causal factors attribute the incident to human error. Human
error is a frequently identified causal factor in tower crane safety incidents. For example, Tam and
Fung (2011) examined 12 safety incidents involving tower cranes in Hong Kong between 1998 and
2005, concluding that these events largely occurred due to unsafe practices of tower crane
operation which were attributed to:

• ‘indolent’ performance of requirements or responsibilities of practitioners

• inadequate training
• fatigue (p. 208).

However, Shin (2015) acknowledges that behavioural causes of safety incidents involving cranes
can, in most cases, be explained by organisational issues, including poor communication between
principal contractors and crane hire companies, competition and cost pressures inherent in multi-
layered subcontracting, inadequate pre-planning of crane installation activities on site, and
inconsistent maintenance regimes.

Organisational factors have been identified in a number of safety incidents involving tower cranes.
For example, Marquez et al. (2014) examined a tower crane collapse in Argentina and found that
the crane foundation/supporting structure failed because:

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 • information was not transferred between the crane designer/manufacturer and the
construction team (user of the crane), and thus, load conditions considered during design
were not well understood by users
• early warning signs of failure were misinterpreted or ignored, meaning no proper mitigation
measures were taken
• site-based tests were performed but these did not follow pre-established or approved
testing procedures (Marquez et al. 2014).

Marquez et al. (2014) argue that the human errors involved in the incident arose because the
construction company, at whose site the crane was working, did not have a good understanding
of the impact of variable loads and cyclic stresses on crane foundation structures. Involving crane
manufacturers in the design or approval of crane foundation systems was identified as a strategy
that could have prevented the collapse. Questions were also raised about the allocation of
responsibilities in the lease or sale of tower cranes. Marquez et al. (2014) note that crane
manufacturers are required to specify the maximum load and moments the foundation must
sustain. Yet, once a crane is on the market, Marquez et al. (2014) argue there is no systematic
process to capture information about the design of crane foundation systems, including defects
and incidents, so that this can be shared with construction companies.

The case example below provides another example of how communication failure (in this case
between the principal contractor and the designer of the tower crane foundation/support
system) contributed to the collapse of a tower crane in the US.

Case example: Poor communication and change of construction process leads to tower crane
collapse
A communication failure between a crane foundation/support system designer and
the construction contractor was identified as a causal factor in the collapse of a
tower crane in the US in 2006 (McDonald et al. 2011). In this incident a change to the
timing of construction work made by the construction contractor was not
communicated to the structural engineer responsible for designing the tower crane
foundation/support system. As a result, the design relied on a structural tie between
the building core and the crane tower. This tie would have resisted forces due to the
crane’s overturning moment. However, due to the delay of the core construction,
the structural ties were eliminated from the construction plans. This change was not
effectively communicated to the designer with the result that the crane base was
substantially under-designed. When exposed to repeated load reversals due to
operation and winds, fatigue cracks developed, causing a catastrophic collapse
(McDonald et al. 2011). This example shows how immediate mechanical causes (that
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 is, fatigue-related cracking) can be traced back to a poor design decision which, in
turn, can be traced back to a failure in communication between important players
involved in the set-up and operation of the tower crane.

Consistent with the finding of Marquez et al. (2014) factors causing or contributing to safety
incidents in tower cranes have been identified at different levels within a system of work. Zhou et
al. (2018) used a qualitative (AcciMap) technique to identify factors contributing to tower crane
safety incidents (occurring in China) at the following levels:

• the workers involved in crane assembly/dismantling or lifting operations, including individual

workers’ attitudes, competencies and behaviours
• the equipment being used, including the selection of crane type, structural reliability and
safety devices
• the worksite environment, including site supervision, layout and work planning
• environmental conditions, including wind conditions and visibility
• the regulatory environment, including preventive WHS legislation and certification
requirements for crane usage (Zhou et al. 2018) 5.

Fifty-six causal factors were identified by Zhou et al. (2018) following a literature review and
interviews with 12 industry experts. Further interviews with experts were used to identify the level
at which each factor operated, and the causal links with other factors, to develop a model of tower
crane safety incident causation applicable to the construction industry in China. At a
government/regulatory level, Zhou et al. (2018) identify features of the regulatory environment
as contributing to tower crane safety incidents, including deficiencies in safety regulation and
supervision, operator certification, and crane registration requirements.

At the ‘tower crane stakeholder’ level, the attitudes and safety management systems of principal
contractors, manufacturers’ qualifications and subcontractors’ input (defined as
funding/resourcing) into tower crane activities were identified as contributing factors.

At the site management level, communication was identified as a contributing factor, including
the quality of principal contractor and subcontractors’ safety briefings, the principal contractors’
safety knowledge and training of subcontractors’ personnel, the quality of principal and
subcontractor safety management planning, work schedule pressures implicit in project
programs, and crane inspection and maintenance regimes.

_____

5 These levels are ordered in terms of their increasing distance (separation) from the immediate circumstances of the safety incident.
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In relation to the on site tower crane staff, the competence and behaviour of supervisors, crane
operators, and riggers and signallers, were identified as factors that could contribute to safety
incidents involving tower cranes. It was also recognised that behaviours are shaped by the
commitment to safety (particularly of supervisory personnel), workers’ safety values, and job
stress.

At the environment/equipment level, contributory factors identified included features of the

construction site and prevailing environment, including overlapping crane operations, congested
sites with obstructions, and weather conditions (for example, wind). The reliability of the tower
crane components and foundation system, the ergonomic characteristics of the crane cabin, and
availability of operator aids and auxiliary systems, were also identified as potential contributing
factors at this level of analysis.

Importantly, Zhou et al. (2018) report linkages between causal factors within and between the
different levels of the AcciMap model. For example, decisions made by tower crane stakeholders
can affect construction site management practices and aspects of the work environment and
equipment used. More specifically, principal contractors’ selection decisions have the potential to
impact subcontractors’ crane-related safety practices. Principal contractors’ behaviours can
determine the on site safety management practices within which subcontracted crane workers
perform their work. Subcontractors’ safety activities also determine maintenance, which has the
potential to impact safety and the reliability of equipment. The model also showed that factors
related to the regulator’s behaviour have a direct impact on tower crane stakeholders and site
management practices. Regulatory requirements establish responsibilities and obligations for
various tower crane stakeholders in relation to workplace safety, and site safety management
practices are subject to inspection and compliance monitoring.

Subcontracting practices, and in particular the way crane operators are engaged by principal
contractors, are frequently identified as relevant factors contributing to safety standards in tower
crane use in the construction industry (Tam and Fung, 2011; Shin, 205). It is noted that
constructors typically do not own their own tower cranes but lease them from a lessor for the
required duration. Competitive pressures inherent in the subcontracting system (including
awarding work to the lowest bidder) are reported to negatively impact the extent to which
equipment is safely stored, maintained and installed (Shin, 2015). These subcontracting
arrangements also create conditions in which crane operators work across multiple jobs/sites,
experience low levels of control, and have time pressures imposed upon them by principal
contractors’ construction programs/schedules. Shin (2015) also observes that principal
contractors do not always provide appropriately prepared sites to support crane erection and
dismantling activities, increasing the risk of safety incidents. Safe installation/erection requires
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pre-preparation and planning to ensure that issues, such as ground conditions, access roads, and
other controls, are properly considered and implemented. Communication between the principal
contractor and the crane company is of great importance to ensure site preparation and safety.

A forensic analysis of the cause of tower crane incidents in the US revealed that the tower crane
safety incidents investigated were caused by:

• poor lifting practices, specifically the use of soft (nylon) slings, during climbing or ‘jumping’
a crane
• under-design of foundation system (and lack of approval by crane manufacturer)
• poor quality maintenance/repair of crane components
• deficiencies in the inspection regime (Peraza & Travis, 2009).

These causal factors are similar to some of the staff and equipment level factors identified in the
analysis by Zhou et al. (2018), suggesting commonalities in tower crane safety incident causation
in different countries. It is also noteworthy that only one of the causal factors identified by Peraza
and Travis (2009) relates to immediate circumstances of an incident (the use of soft slings). The
other causes identified are separated from the incident in time, as well as level of responsibility of
persons involved (that is, they are regulatory or managerial failures, rather than frontline worker
errors).

Tam and Fung (2011) conducted a survey of construction industry representatives in Hong Kong
to examine causal factors in tower crane safety incidents. Participants to this survey reported the
following causal factors for tower crane safety incidents:

• a widespread failure to comply with an industry Code of Practice relating to the safe use of
tower cranes
• problems inherent in the existing certification system for operators and other workers
involved in the use of tower cranes
• deficiencies in work practices, including ineffective communication between crane operators
and signallers in situations in which the operator has a restricted view of the lift path
• a failure to follow manufacturers’ instructions during erection/dismantling (Tam & Fung,
2011).

These factors also reflect failures related to the operation of regulation, as well as poor site-level
management practices relating to the use of tower cranes.

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Technical failures and tower crane safety

Raviv et al. (2017b) examined the relationship between human errors and technical failures in
tower crane incidents and report that technical failures are present in tower crane safety incidents
linked to the highest levels of risk and outcome severity. Further, an inverse relationship was found
between the incidence of human error failure types (for example, communication failure or
inattention) and the risk potential of a tower crane incident (Raviv et al. 2017b). Thus, tower crane
safety incidents with the most serious consequence potential are likely to involve some form of
technical failure.

Further, the literature review reveals that not all tower crane safety incidents are caused by unsafe
acts, and some incidents are caused by underlying design or technical issues. This observation
draws upon a distinction, made by James Reason (1990), between active errors and latent
conditions. Active errors are most likely to be made by frontline workers and have an immediate
effect; for example, omitting a step in a process or applying a rule incorrectly (Gordon et al, 1998).
Latent conditions are removed from the ‘sharp end’ of work and have a delayed consequence.
Reason states that such conditions ‘arise from decisions made by designers, builders, procedure
writers, and top-level management. Such decisions may be mistaken, but they need not be’
(Reason, 2000, p. 395). Latent conditions can lie dormant for long periods of time until they
combine with other triggers to produce a safety incident opportunity.

According to Reason (2000), latent conditions produce two kinds of undesirable outcome:

• they can create the conditions in which people are more likely to make active errors – for
example, by creating time pressures, fatigue, under-resourcing, or specifying the use of
inappropriate equipment for a task, or
• they can produce deficiencies in system defences – for example, by providing unreliable
warning systems, poorly designed facilities, or unworkable procedures.

The following two case examples reflect situations in which: (i) a tower crane collapse was
attributed to a latent condition; and (ii) the design characteristics and performance of a luffing jib
type tower crane could (under certain circumstances) produce a safety incident, irrespective of
operator behaviour.

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Case example: Latent condition in tower crane incident causation
Swuste (2013) analysed a fatal tower crane collapse that occurred in Rotterdam in
2008. The tower crane was being used in construction of a 24-storey apartment
block when it fell, killing the operator and causing substantial damage. An
investigation conducted by the Dutch Safety Board (OVV) investigated the incident
to determine its cause. The weather was good on the day of the incident and
conditions were favourable for the lifting activity. A balcony slab was being lifted
and, including the balancing device, the total load burden was 12.8 tons. When the
load was in place, workers on the balcony communicated to the crane driver that
the load should be moved inwards after they observed the trolley of the crane
moving outwards towards the end of the jib. The driver replied, denying he had
moved the control command. The load then swayed away from the workers on the
balcony and the crane collapsed. The detailed technical investigation found that the
crane had reached its maximum load for the 27-metre outreach position. However,
the load moment protection device was switched on. Chemical analysis and tensile
tests revealed the steel structure of the crane was built according to design
specifications and fracture surfaces were indicative of overload rather than material
defects. Weather conditions were good and it was unlikely wind would have been a
factor. Neither had there been quick or abrupt movements of the trolley causing the
load to swing. It was considered plausible that the operator did not command the
trolley to move outwards towards the end of the jib immediately prior to the
collapse. Other factors considered were malfunction of the control motor system
impacting the functionality of the electric trolley braking system and bending of the
jib (beyond that estimated by the manufacturer (Swuste, 2013). Swuste argues that
this incident should be considered a ‘normal accident’ (see Perrow, 1984) because
the mass of the load, height of operation, poorly understood dynamics, critically
narrow limits of safety, intrinsic weakness in the safety monitoring and control
system, and unobservable failure process, combined to provide minimal redundancy
and little time for recovery from failure.

The same incident was considered in an analysis of tower crane incidents worldwide.
Isherwood (2010) categorised it as having electrical/control system causes and, in
his report, also identified an example of a similar problem associated with a tower
crane in the UK that did not result in major structural failure of the crane. Isherwood
expresses the view that ‘this scenario has the potential for becoming more
prominent in crane incidents as newer cranes having ever more sophisticated
control systems come on the market and enter service. Much depends on the
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 training/competence of individuals setting up this type of control system during
erection of the crane and replacement of spare parts once the crane is in service to
ensure that the internal settings of all motor drives are correct for the application’
(p. 27).

Case example: The impact of wind loading on the safety of luffing jib type tower crane
Following a crane collapse incident in Liverpool, Isherwood and Richardson (2012)
were commissioned by the UK’s Health and Safety Executive to undertake an
analysis of the effect of wind loading on the operation of luffing type tower cranes.

A luffing type tower crane was acquired, fitted with instrumentation to measure
wind speeds at the outer end of the jib and on top of the crane’s A frame, as well as
tension in the luffing system. The crane was set up in an experimental testing
location. Under testing, the jib of the crane was found to be susceptible to
uncontrolled movement when exposed to wind loading below the maximum in-
service wind speed, and at jib elevations within the normal maximum and minimum
radius specified by the manufacturer. During testing, the jib of the crane was ‘blown
back’ against a spring buffer mounted on the A frame, at which time the luffing
system lost tension and the luffing rope came out of the grooves of one of the A
frame pulleys. Uncontrolled movement of the jib was observed to occur when the
wind speed approached the maximum in-service wind speed specified by the
manufacturer, and when the jib was close to maximum elevation and minimum
radius. In such circumstances, a serious safety incident could occur with little or no
warning, and little opportunity for recovery.

Isherwood and Richardson also note that, because luffing cranes raise and lower
their jibs to place the load on the hook at the required distance from the crane mast,
it is common for the height above ground of the jib to be significantly greater than
the height above ground of the A frame. On the crane used for testing, this
difference could be as great at 33 metres and occasions were found at which wind
speeds measured by instruments positioned on the A frame and the end of the jib
recorded significantly different measurements. It is common for the anemometer (to
measure wind conditions) to be fitted on top of the A frame which can be a concern
if the crane control setting relies on these measurements to determine the safe
working limits of the crane and triggering an alarm or warning. Isherwood and
Richardson note that it is possible that, unknown to an operator, wind speeds in
excess of maximum in-service wind speed could be reached before any warning is
triggered. The examples (and evidence) provided by Isherwood and Richardson
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 (2012) provides further support to the argument that latent conditions (as defined
by Reason) may – in albeit rare conditions – cause serious crane safety incidents.

In relation to wind loading, authors of a High Risk Construction Oversight Study

undertaken in the US recommended that actual wind speeds in urban areas densely
built with many high rise buildings should be monitored to assess the
appropriateness of current crane designs in relation to wind speed (Smith & Corley,
2009).

These examples suggest that not all tower crane safety incidents necessarily involve human error.
Albeit relatively rare, tower crane safety incidents may be caused by latent condition pathways
(for example, associated with design characteristics or technical failures) irrespective of operator
behaviour.

Safety incidents involving mobile cranes

There are many types of mobile crane. Mobile cranes use principles of leverage to lift heavy loads,
with the weight of the crane balanced against the load being hoisted at the tipping point or
tipping axis (NIOSH, 2006). Mobile cranes are able to lift heavy loads, swing them in multiple
directions and raise them overhead. However, these features contribute to the risk of tipping over
if the crane is not set up correctly or the manufacturer’s instructions are not followed.

In the US:

• the North Carolina Department of Labor estimates that one mobile crane tips over during
every 10,000 hours of crane use in the US
• nearly 80% of all mobile crane tip-overs are attributed to operators exceeding the crane’s
operational capacity
• approximately 54% of these incidents are the result of swinging the boom or making a lift
without the outriggers fully extended (NIOSH, 2006).

NIOSH utilised the US Bureau of Labor Statistics’ multi-source database, the Census of Fatal
Occupational Injuries (CFOI), to identify 719 work-related deaths that occurred between 1992 and
2002 and which involved a mobile crane. Of these deaths, 290 (40.3%) involved a construction
worker being struck by falling objects, including an uncontrolled hoisted load or part(s) of a
mobile crane. Of these ‘struck by’ fatalities, 153 (52.8%) occurred in the construction industry. The
breakdown of types of fatal safety incidents involving mobile cranes is provided in Figure 3.

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 Mobile crane safety incident type
Other

Caught in crane moving parts

Transportation (moving crane to/from

site)

Fall from crane structure/cab

Contact with electrical current

Struck by falling or swinging object

0 10 20 30 40 50 60
Per cent

Figure 3. Fatal incidents involving mobile cranes in the US, 1992-2002. Adapted from NIOSH, 2006.

The NIOSH alert also examines several mobile crane safety incidents (all involving over-tipping
and resulting in fatalities). These incidents and their identified causes are summarised in Table 5.

Table 5. Causes of case study incidents involving mobile cranes (adapted from NIOSH, 2006).

Case circumstances Causes/contributing factors

A suspended personnel platform was struck by The crane was found to have tipped as
an uncontrolled load (a roof section) while being a result of the combination of:
lifted by a large mobile crane. The roof section
was being lifted in windy conditions. The roof ● the weight of the hoisted load
section was being lowered into place when the ● side loads from wind
crane began to tip-over and the roof section ● out-of-level ground conditions
collided with the personnel platform, knocking it ● the swinging motion of the hoisted load
to the ground. The three workers in the platform as the crane moved sideways.
were fatally injured as a result of the incident.

A carpenter who was removing formwork was Investigation of the crane

struck by a loaded concrete bucket during a configuration, the distance of the
crane tip-over. Concrete was being hoisted using intended landing site from the crane’s
a crawler-mounted crane. A rooftop spotter was centre pin, and the manufacturer’s
directing the lifting/carrying of concrete. As the load chart indicated that the crane’s
crane operator hoisted the bucket of concrete, recommended capacity had been
swung it over the roof and towards the empty exceeded.
forms, the crane lost stability and tipped. The
concrete bucket struck the worker on the head Prior to the incident, the crane’s LMI
and shoulder. had been reported to indicate false
readings in the past and had not been
repaired/recalibrated.

Thus, the LMI may have provided the

operator with false information.

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 A truck driver was crushed when a crane tipped An investigation showed that the
over and the crane’s boom landed on the cab of a crane’s load lift capacity had been
dump truck. The all-terrain crane was preparing to exceeded for the boom length and
unload components of a tower crane to be angle used.
installed at the construction site. The crane
operator had fully extended the crane’s left
outriggers. The right outriggers were only partially
extended, as they would have blocked truck
access to the site. This set-up was intended to be
temporary. The crane operator began to clear the
area by lifting an empty concrete bucket over the
rear of the crane. The operator swung the bucket
over the right side of the crane. As the crane’s
boom swung to the right, the operator also began
to “boom down” to extend the load radius. When
the bucket reached the area near the dump truck,
the operator lowered it to the ground. The crane
tipped toward the load. The operator was unable
to drop the load to regain stability and the crane’s
boom hit the truck cab.

Kan et al. (2018) used fault tree analysis to understand the causal factors contributing to falling
object incidents in mobile crane use. Using deductive reasoning, and drawing on historical incident
data and experts’ knowledge, falling object incidents were attributed to defective crane parts,
rigging failures, overloading, and environmental factors. Each of these causes was further
decomposed to understand the intermediate and basic events that can create them. Thus, the
use of a crane with defective parts can arise because of poor maintenance and/or a failure to
perform pre-operation checks. Overloading can be caused by load indicator failure and/or
operator error. By tracing back incident causes to understand the lowest level basic events, Kan
et al. (2018) argue that causes/contributing factors can be grouped to determine whether they
predominantly relate to technical/mechanical issues, human factors or managerial issues.

As with tower crane safety incidents, the factors contributing to mobile crane safety incidents
include human error, as well as mechanical/managerial issues. For example, Kan et al (2018)
decompose the causes of overloading of mobile cranes, suggesting that overloading can occur
as a result of human error or the failure of a load indicator device. Further operator error (in
relation to overloading) can be traced back to poor safety management, improper operation,
and/or inadequate pre-planning. The role played by human error in crane safety incident
causation is further discussed below. It is also evident from the case examples provided in Table
2 that environmental conditions can also contribute to safety incidents involving mobile cranes.

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Human error and crane safety incident causation
Human error is often cited as a prominent causal factor in construction safety incidents, including
those involving cranes (Garrett & Teizer, 2009; Milazzo et al. 2016). Milazzo et al. (2016) report
human error to be the most recurring initial cause of crane safety incidents (drawing on a dataset
including mobile, tower and gantry crane incidents). They identify the following errors as
occurring most frequently:

• weight underestimation of the loads being lifted, causing boom buckling or crane
overturning
• over-extension of boom of mobile crane leading to contact with obstacles, such as
powerlines.

Despite the frequency with which crane safety incidents are attributed to human error, the nature
of the error is often not reported, which potentially limits the lessons learned from these analyses.

Reason (1991) categorised errors in terms of whether they are skill-based slips and lapses, rule-
based mistakes or knowledge-based mistakes. This classification system has been adopted in
guidance on human factors and error reduction (HSE, 1999). Violations are distinct from error and
are defined as ‘deliberate departures from rules that describe the safe or approved methods of
performing a particular task or job’ (Lawton, 1998, p. 78).

According to this classification system, skill-based errors can occur when people are distracted
or preoccupied with things other than the task, leading to slips or lapses. Slips and lapses generally
occur when people are performing very familiar tasks (for example, driving a car), which are
carried out without much need for conscious attention. Even very skilled and experienced workers
are prone to slips and lapses if their attention is diverted from the task they are performing.

Slips are ‘actions-not-as-planned’; for example, omitting a step in a work sequence. But lapses
occur when someone forgets to carry out an action, loses their place when performing a task, or
perhaps forgets what they intended to do.

Rule- and knowledge-based errors are also referred to as mistakes. These are deliberate actions
taken by people who do the wrong thing believing it to be right (HSE, 1999). Mistakes differ from
slips and lapses in that they are not necessarily related to inattention or distraction but reflect a
failure in mental processes. A rule-based mistake can occur, for example, when a set of rules is
remembered but wrongly applied to a situation. A knowledge-based mistake occurs when a
problem or situation is unfamiliar, misdiagnosed and the wrong action is applied.

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The underlying reason for human errors depends on the type of error that has occurred. Leah
(2013) points out, in relation to the operation of construction plant and machinery, that different
error/failure types imply the need for different preventive measures. Thus, slips and lapses could
potentially be reduced by modifying the ergonomic design of the crane cabin and man-machine
interface, whereas rule and knowledge-based mistakes may be reduced through improved
training and/or supervision (Leah, 2013). Further investigation to ‘unpack’ and better understand
the kinds of human error involved in crane safety incidents is therefore warranted.

Perhaps a more fundamental problem associated with the attribution of safety incident causation
to human error was observed by Rasmussen (1982), who commented that:

Frequently they (human errors) are identified after the fact: If a system performs less satisfactorily
than it normally does – due to a human act or to a disturbance which could have been
counteracted by a reasonable human act – the cause will very likely be identified as a human error
(Rasmussen, 1982, p. 313).

The premise that ‘What You Look for is What You Find’ has also been observed in incident
investigation; that is, if human errors are sought they will likely be found (Lundberg et al. 2009).

Attributing incidents to human error has been referred to as ‘judgement in hindsight’ (Hollnagel
& Almaberti, 2001). Dekker (2002) is particularly critical of ‘after the fact’ methods for classifying
human errors, arguing that they:

• are highly subject to hindsight bias

• are based on judgement rather than analysis
• do little to explain why people acted as they did, given the circumstances in which they
found themselves (Dekker, 2002).

In relation to the latter point, the circumstances surrounding the error are often much more
complex than error classification systems suggest. They can include, for example:

• competing organisational priorities and conflicting goals

• resource and time constraints
• limitations associated with equipment or technologies
• information overload
• communication breakdowns
• inter-personal or coordination failures among team members.

Previous analyses of crane safety incident causes suggest that many of these underlying factors
are at play. Thus, the underlying reasons for human error made in relation to crane operation may
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lie at deeper levels of an organisational environment or system of work than the immediate
circumstances of an incident.

The need to understand the root cause of crane-related safety incidents in order to improve
prevention activities has been noted (Kan et al. 2018). It is acknowledged that the factors that
cause or contribute to safety incidents in the construction industry operate at different levels
within a system of work or organisational environment and are linked through ‘cause-effect’
chains. Identifying the underlying or root causes of crane safety incidents is valuable as it can
inform the development of effective preventative strategies. Marquez et al. (2014) similarly argue
that it is necessary to look beyond the immediate, visible causes of an incident to identify factors
(events, conditions or exceeded barriers) that created the immediate causal factors, and thus
contributed to crane safety incidents. However, Swuste (2013) argues that the identification of
root causes can only be achieved once the immediate causes of an incident are well understood.

Quantification of safety risk related to crane use

A number of techniques have been used to quantify the risks associated with the use of cranes.
These include:

• cluster analysis based on crane incident stories (Raviv et al., 2017a)

• analytic hierarchy process, which uses experts to order risk factors by their priority or
importance (Shapira & Lyachin, 2009; Raviv et al. 2017b)
• ‘bowtie’ analysis (Aneziris et al. 2008)
• development of risk factor scales with expert weighting to create a crane safety index
(Shapira et al. 2012).

In the Netherlands, the Workgroup Occupational Risk Model project sought to identify dominant
paths to crane safety incidents so that this information could be used to direct risk reduction
activities (Aneziris et al. 2008). Risk logic models were developed starting with a ‘top’ event
representing an adverse consequence of undertaking a work action. This event is decomposed
into simpler events, the probability of which can be quantified. The ‘bowtie’ model positions the
adverse event at the centre. Events to the left of the centre represent causes, or necessary
prerequisites for the event to occur. Events to the right describe mitigation failures and
dose/response factors that contribute to the consequence of the centre event. This technique
was used to model and quantify the risk of crane safety incidents based upon engineering
principles, existing information about crane safety rules and regulations, and historical incident
data. According to Aneziris et al. (2008) the resulting models can be used to determine the
probability of the occurrence of four levels of consequence associated with crane incidents of
particular types (for example, falling loads/loads overturning and collapsing cranes). However,
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the bowtie models developed by Aneziris address single hazards and do not enable an integrated
assessment of crane-related risk associated with construction site operations. This limits their
usefulness to inform site-based risk assessment activities.

New and evidence-informed ways to undertake site-specific risk assessments of crane-related

safety are being developed that have the potential to improve project-level risk management
activities. An example of this is a model developed by Shapira et al. (2012). This model is based
on experts’ identification of risk factors associated with the use of tower cranes and systematic
weighting of the importance of these factors for the likelihood of safety incidents involving tower
cranes (Shapira & Lyachin, 2009). Based on the expert judgements, factors included in the risk
quantification model are shown in Table 6.

Table 6. Safety factors associated with tower cranes (Shapira et al. 2012).

Weighting
Factor family Description Risk
(%)

Project Blind lifts – partial Operator has no line of sight with

conditions view/obstruction of work load Complete reliance on
zone signalperson 5.63

Potential communication failure

Overlapping cranes – work Danger of job, loads or cables

zones shared by more than colliding 7.02
one crane

Length of operator work Long often monotonous work can

shift cause physical/mental fatigue 3.96
and error

Type of load – dimensions, When properly rigged loads

weight, configuration, should not vary in safety risk but
packaging, rigging combined with factors such as
4.69
methods etc make some tight workspaces, winds etc,
loads more hazardous some loads can present increased
risk

Environment Wind – intensity varies Tower cranes are designed to

according to site location, sustain wind up to specified
topography and intensities, but sudden wind gusts
9.50
geography or high winds combined with
other factors (for example, sail-
like loads) can be dangerous.

Human factors Operator proficiency – Operator proficiency can impact

experience and errors, recognising and
competence, training and preventing dangerous situations 12.90
certification. before they develop: ‘feeling the
crane’

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 Weighting
Factor family Description Risk
(%)

Operator character – Argued to have a bearing on

behavioural patterns and chance of safety incidents 6.27
mental capacity

Operator employment Outsourced operators can be

source – on the company discriminated against, experience
permanent payroll or job security etc, that can impact
4.52
outsourced from a staffing their work
company (project duration
only)

Superintendent character – Argued to have a bearing on

behavioural patterns and quality of supervision and chance 9.16
mental capacity of safety incidents

Signalperson experience – Potential untrained/inexperienced

training and experience signalpersons increase chances of
5.98
safety incidents, particularly in
blind lifts

Safety Site safety management – Driven by superintendent. Impact

management actions to increase on crane work and reduces chance
awareness, training, of crane safety incidents
14.18
prevention, monitoring and
compliance with
procedures

Company safety Determine way in which company

management – policy, and manages projects and people
7.41
processes for consultation,
training, planning etc

Maintenance management Underserviced cranes and lifting

– cranes and lifting accessories increase chance of
accessories, resource safety incidents 8.88
allocation, planning and
scheduling maintenance

Each of the factors listed in Table 6 has a weighting (an expression of how important the factor
was considered to be by industry experts), as well as a specified method of measurement. Some
of these measures are objective and easily quantifiable (for example, the length of the work shift),
while others are more subjective and harder to quantify (for example, operator proficiency).
Shapira et al. (2012) acknowledge that some of the measurement methods they developed need
further testing and refinement.

The risk quantification model uses site-specific data relating to each of these factors (which needs
to be input by persons knowledgeable about site-specific conditions and crane operation
arrangements) to create a cumulative weighted risk value for the site. This cumulative weighted

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risk value is the sum of each of the individual weighted risk values for each of the 13 factors in
Table 6.

However, the cumulative weighted risk value is further transformed by multiplying it with other
site-specific values that reflect:

• the extent to which the tower crane activities ‘oversail’ areas beyond the site boundary
(indicating risk exposure to the public)
• the number of workers who will work in the vicinity of the tower crane (indicating on site
risk exposure)
• the extent of the crane use (indicating hours/duration of daily exposure)
• intensiveness of operation (indicating the number of tasks/lifting cycles to be performed in
a given time).

All of these factors are combined to produce a single quantitative site-specific risk rating
associated with the use of tower cranes. This model was developed in the construction industry
in Israel and, therefore, the risk factors and their respective weighting may not apply to other
countries or contexts. However, the approach taken to modelling risk is potentially very useful
because it provides an evidence-informed and integrated method for understanding site-specific
risk factors relating to the use of tower cranes. The use of weighted risk factors based on expert
judgement is likely to produce a more defensible assessment of risk than the types of semi-
quantitative (and highly subjective) risk matrices that are currently in widespread use in the
construction industry. Further, the incorporation of factors that capture exposure in terms of
public safety, numbers of workers, duration and intensity of crane use also add important
elements above and beyond two-dimensional estimations of risk based solely on likelihood and
consequence.

Raviv et al. (2017a) developed a database of incident stories, using construction industry
representatives in Israel to capture data about safety incidents that involved tower cranes, and
resulted in a range of outcomes (from near misses and fatalities).

The circumstances of each incident were coded and incorporated into the database. Incident
characteristics were qualitative in nature but were assigned parallel quantitative descriptors which
enabled cluster analysis to be used to calculate the potential for each incident within a certain
group in the database to produce a given outcome severity level. This provided a statistical basis
for linking groups of incidents with certain characteristics to less severe and more severe
outcomes. Five distinct clusters of incidents were identified. Every incident in the cluster with the
highest risk potential for fatalities or severe injuries involved a technical failure. Technical failure
occurred in 100% of cases in this cluster, but in only 15% of occurrences in the whole database.
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These results indicate that technical failures are typically linked to high severity outcomes in
safety incidents involving tower cranes, highlighting the importance of enforcing daily inspection
of cranes by competent persons, and ensuring effective repair and maintenance procedures are
in place (Raviv et al. 2017b).

Incidents in the high risk cluster for serious safety outcomes also frequently involved falling
objects and tended to happen during normal crane operation, rather than during erection and
dismantling. The latter finding appears to be inconsistent with previous research that suggests
the majority of fatal tower crane safety incidents occur during erection/dismantling (Shin, 2015).
One potential reason for this difference could be the different industry settings in which the
analysis took place. It is possible that the construction industry context in Korea is significantly
different from that of Israel and that these differences reflect this (Raviv et al. 2017a). The potential
for variation between countries also reflects inherent limitations associated with the
generalisability of quantitative risk models to industry contexts other than the context in which
they were developed.

Raviv et al. (2017b) found the cluster of incidents with the highest potential for low severity
outcomes involves a broader range of failure types than the ‘high severity’ incident cluster.
Incidents with high potential for low severity outcomes involved:

• operator error, which occurred in 39% of incidents in this cluster compared with only 13% in
the entire database
• technical failure, which accounted for 30% in this cluster compared with 15% in the entire
database
• other types of failure that were distributed similarly to the distribution across the entire
database.

Incidents in the cluster with high potential for low severity outcomes were divided evenly between
routine work (for example, normal operation of the crane) and non-routine work (for example,
dismantling and erection activities).

Risk reduction strategies and initiatives

Planning, supervision and management of lifting operations

A common theme in the literature is the important role and responsibility of multiple stakeholders
in relation to maintaining crane safety. Responsibilities are borne by designers, manufacturers,
suppliers, principal contractors, and subcontractors.

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In some jurisdictions, specific duties are established for the planning and management of lifting
operations. For example, in the UK, crane-related safety matters are regulated under the Lifting
Operations and Lifting Equipment Regulations (1998). These regulations establish requirements
so that lifting operations be properly planned by a competent person, appropriately supervised,
and carried out in a safe manner.

Effective lift planning, communication and coordination are identified as being critical in the
prevention of crane safety incidents in construction projects (Wiethorn, 2018). Lifting operations
involve a range of people including lift planners/directors, crane operators, supervisors, riggers,
and signal persons.

Weithorn (2018) argues that the roles and responsibilities of all parties need to be clear and well
understood. In accordance with US guidelines developed by the American Society of Mechanical
Engineers (P30.1-2014 Planning for load handling activities) a competent person should be
appointed with responsibility for planning lifting operations at construction projects. Weithorn
(2018) developed a theoretical lift plan document that establishes who should take primary and
secondary responsibility for all activities related to the management of safety in lifting operations.
This is presented in the form of a responsibility matrix and identifies persons responsible for the
following:

• ensuring the crane meets relevant design requirements

• ensuring the crane is inspected and appropriately certified
• identification of site-specific hazards
• provision of ingress and egress of the crane
• development of a lift plan
• determining how a load should be rigged
• determining what rigging is required
• assigning a designated signal person
• providing appropriate crane signals
• load movement and placement.

The role of lift director is formally acknowledged in the responsibility matrix developed by
Weithorn (2018). In the US, the National Commission for the Certification of Crane Operators has
developed a formal training and certification program for lift directors. This certification requires
demonstration of competency in the following areas:

• site control and evaluation

• roles, responsibilities of parties and required qualifications of lifting personnel

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 • lifting operations
• lifting plans
• rigging
• signalling
• load chart content and comprehension
• use of different types of crane.

US guidance also recommends lift directors hold pre-lift meetings with relevant parties to
establish clear roles and responsibilities for a particular lifting task. A list of topics to be covered
at the pre-lift meeting is provided in the American Society of Mechanical Engineers, P30.1-2014
Planning for load handling activities. Wiethorn (2018) analysed 701 crane safety incidents and
determined that a pre-lift meeting did not occur in 62% of these incidents but would have
addressed factors that initiated or contributed to the majority of incidents. Consistent with this
emphasis on consultation and lift planning, Sertyesilisik et al. (2010) report team-based selection
of equipment (involving subcontractors) helps to ensure the most suitable equipment is selected.
Further, at some worksites rigorous planning was undertaken for lifting operations and, every two
weeks, the success of lifting plans and suitability of lifting equipment was reviewed to ensure
continued safety and effectiveness (Sertyesilisik et al. 2010).

In the Australian context, Smith (2018) recommends closer collaboration between crane
companies and principal contractors, particularly when contractors are opting to maximise the
use of pre-fabricated components and designing for efficient and safe on site assembly of these
components. Smith (2018) argues that crane companies can contribute to improved safety in
design and construction outcomes by collaborating with principal contractors (engaged in Design
and Construct projects) in planning for constructability in the design stage of construction
projects.

Operator competency
The question of whether certification is indicative of competency in crane operation is currently
being debated in the US, where a national certification scheme for crane operators has reportedly
stalled due to disagreements as to whether certification should be based on crane type or crane
type and capacity (Vertikal, 2018). In Australia, a person who holds a High Risk Work Licence
(HRWL) can operate a crane. HRWL training is provided by public and private RTOs but industry
reports indicate that the quality of training is not consistent (Lifting Matters, 2018a). Experience
in crane operations is not a mandated requirement. Instead, many construction companies and
projects require Verification of Competency (VOC) in relation to crane operation. However, the
content for VOC has been poorly defined, unregulated and inconsistent. Further, because sites

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have preferred VOC providers, operators are required to complete multiple VOCs relating to the
same crane type for different worksites (Lifting Matters, 2018). The CrewSafe initiative
(implemented by the Crane Industry Council of Australia) sought to increase safety in the use of
cranes by introducing a standardised machine-specific assessment program to confirm and
document individual operators’ competency in the operation of a specific make and model of
crane. Thus, it captures an operator’s understanding of the unique functions of specific crane
types. The CrewSafe assessment is impartial and undertaken by a peer assessor. Operator
assessments are also filmed, documented and accessible on a CrewSafe digital app, providing site
supervisors with easy access to operator competency data (Vertikal, 2018).

Recommended tracking system for major structural or mechanical components

Regular maintenance is important to maintain the safe operation of cranes. Monitoring repairs to
critical components and keeping comprehensive maintenance records was recommended by the
US High Risk Construction Operations Study (HRCOS) (Smith & Cowley, 2009). The HRCOS crane
team also recommended registering and tracking all key crane components (for example, the
boom and tower mast sections, A-frame, turntable, climbing section, machine platform, operator’s
cab, counter jib, and the movable counter mechanism if applicable) throughout their life. A
national registration and tracking system was recommended following the collapse of a tower
crane in New York in 2008. The incident was found to be the result of a weld along the
circumference of the turntable, made as a repair to the crane (Peraza & Travis, 2009). The HRCOS
team also identified a number of websites that sell crane components that are not manufactured
or approved by the Original Equipment Manufacturer (OEM), despite being advertised as such.
These parts may be inferior to OEM parts and component tracking could prevent the purchase
and use of such components (Smith & Crowley, 2009).

Voluntary crane safety assessment programs

The US HROCS crane team also emphasised the importance of annual third party crane
inspections, as well as more regular inspections and maintenance procedures implemented by
crane owners (Smith & Cowley, 2009). However, the HRCOS investigation team noted that an
increase in variety of crane manufacturers and models in use and increasing technological
complexity of crane equipment 6 requires constant training for inspectors. Smith and Cowley

_____

6 For example, most modern large cranes are controlled via Programmable Logic Controller technology (see, for example,
https://www.designworldonline.com/safety-plc-ensures-safe-crane-operation/).

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(2009) also note that the inspector should be impartial (that is, not be employed by entities
owning or operating the crane being inspected).

In Australia, the crane industry has initiated a voluntary third party crane assessment program.
The CraneSafe program was developed by the Crane Industry Council of Australia (CICA) in
consultation with industry stakeholders. The CraneSafe program aims to supplement existing
workplace safety requirements with annual assessments of mobile cranes, providing crane owners
and operators with:

• a process for third party assessment of safety aspects of their cranes

• a common, industry-wide system for assessment of their cranes single method by which
crane operators, owners, manufacturers, suppliers, designers, and importers, can fulfil their
obligations under state WHS legislation.

CraneSafe also publish data relating to the top ten faults identified for each type of crane covered
by their inspection/assessment program (CraneSafe, 2019).

Safety-enhancing technologies
Many safety-enhancing technologies are available and have been adopted by crane and
component manufacturers; for example, slow ‘cut out’ mechanisms that slow down a crane before
stopping when it is approaching the limits of safe operation. Some international research is also
focused on developing additional technologies that have the potential to improve the safe use of
tower cranes and mobile cranes. Many of these technologies are still under development and/or
not yet in widespread use within the construction industry. Some examples are described in Table
7.

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Table 7. Safety enhancing technologies.

Intention of
technology Focus Details Reference
application

Technology to Planning collision- A methodology which applies Han et al. (2015)

support lift planning free mobile crane dynamic graphical description of
operations in three-dimensional (3D)
modular-based (off visualisation to simulate various
site) construction scenarios with different crane
models and types
The methodology helps to select
the most effective and efficient
crane operation and avoid
collisions and spatial conflicts
The methodology also assists
with the design of support
system.

Technology to Developing / Linking simulation/visualisation Al-Hussein et al.

support lift planning approving safe tools with 3D CAD models (2006)
lifting plans The approach allows simulating
tower crane lifting activities to
examine the safety of lifting
operations and approving lifting
plans

Technology to Automated lift An approach to develop plans for Lei et al. (2013)
support lift planning planning for mobile lifting large prefabricated
cranes components into position using
mobile cranes
The process incorporates design
and site layout with mobile crane
capacity and configuration data
(maximum and minimum lift radii)

Technology to A lifting path A robotic tower crane system Lee et al. (2009)
support automated tracking system as equipped with a laser-
lift planning and part of a robotic technology-based lifting path
tracking tower crane system tracking system
for high-rise The system is proposed to
construction improve productivity and resolve
problems with blind spots, long
lifting distance and material swing

Technology to Safe load rotation Under-hook devices: for example, Smith (2018)
support crane and manoeuvring by the Verton R-Series and the
operation tower cranes Buildvation ‘Rigger Assist’ devices
These technologies help the crew
to safely lift and rotate the load
and minimise load swing

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 Intention of
technology Focus Details Reference
application

Technology to Improved visibility, Video-based systems LSM

support crane anti-collision These systems use waterproof, Technologies,
operation monitoring vibration-proof compact cameras (2019)
fitted at one or more locations on
a crane to provide improved
vision to reduce the risk of
collision and help with blind lifts

Technology to Anti-collision SMIE anti-collision system SMIE (2019)

support crane It is a semi-autonomous system
operation that allows a crane operator to
anticipate the risk of collision
between the moving parts of their
crane and those of a
neighbouring crane
The system automatically stops
hazardous movements

Technology to Anti-collision A prototype system combining Fang et al. (2016;

support crane sensors with a game engine to 2018)
operation monitor the safety of mobile
crane lifting operations in real
time
Sensors are used to monitor the
movement of the major crane
parts and the suspended load
The system generates a visual
representation of the crane in
relation to objects in the
surrounding environment
The system sends warnings if the
crane gets too close to
surrounding objects

Technology to Anti-collision A system combining sensors and Lee et al. (2012)

support crane video cameras to collect and
operation represent information about the
location of a tower crane jib and
lifted load
The data is incorporated in a 3D
BIM model of the site to help
seeing the location of a lifted load
in the context of the building and
surroundings in real time during
lifting operations

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 Intention of
technology Focus Details Reference
application

Technology to Design of mobile An automated system to assist in Hasan et al.

support crane crane supporting calculating the mobile crane’s (2010)
operation system support reactions and in
designing the supporting system
This system can generate a 2D
reaction influence chart which
shows the reactions for each
outrigger at varying horizontal
swing angles and vertical boom
angles to the ground

Technology to Vibration control A simple vibration control Kuo & Kang

support crane during fast crane method for fast crane operation (2014)
operation operation The proposed method maintains
a small sway angle in fast crane
operation. It uses piece-wise
acceleration and deceleration to
reduce the sway angle and
vibration frequency
Therefore, the method helps to
achieve higher productivity
(faster operation) while ensuring
safety.

Technology to Monitoring safety A graphical fuzzy-set model to Al-Humaidi & Tan

support crane performance of determine the performance of a (2009)
operation mobile cranes, crane and its operation to avoid
avoiding electrocution
electrocution near The model can be used to
power lines simulate the safety assessment of
a crane operation, especially
when operating near power lines

Technology to Crane safe operation A prototype of advanced tower Lee et al. (2006)
support crane monitoring crane equipped with wireless
operation video control and Radio
Frequency Identification (RFID) –
video sent back from cameras
enables the crane operator to see
the situations around the crane
and under the trolley

Technology to Anti-collision A distance measurement method Lichen et al.

support crane monitoring of tower based on using ultrasonic sensor (2012)
operation crane for tower crane obstacle
Using multiple sensors, the
proposed method enables
monitoring of surrounding
obstacles of tower cranes and
detect accurate distance between
crane and obstacle

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 Intention of
technology Focus Details Reference
application

Technology to Safety training of A game technology-based safety Guo et al. (2012)

support training construction plant training platform to assist in the
operators safety training of operatives
working with construction plant
(mobile cranes, tower cranes and
excavators)
The platform allows trainees to
study and practice the operating
methods or sequences of plant
operations in a virtual
environment

Technology to Crane operation A crane simulator known as Juang et al.

support safety training SimCrane 3D+ (2013)
training The system provides a realistic
simulation with improved depth
perception

Technology to Training of crane A framework for developing as- Fang et al. (2014)
support training operators built virtual environments for
advance training of crane
operators
The framework integrates
Building Information Modelling
(BIM) and real-time location
tracking technology in a virtual
environment
It can be used to construct as-
built work scenarios for assessing
and improving operator skills in a
virtual training environment

Technology to Training of crane An approach for developing a Fang & Teizer

support training crew, improving virtual training environment that (2014)
cooperation allows multiple users to
between crane participate in lifting operations
operators and cooperatively
ground personnel Using a 3D real-time immersive
during blind lifts visualisation interface, users can
perform hands-on tasks such as
operating cranes and directing
blind lifts

Technologies to support lift planning

The use of three-dimensional visualisation tools to analyse different site context-specific lifting
scenarios. Linking simulation/visualisation tools with 3D CAD models allows tower crane lifting
activities to be reproduced digitally in a realistic and detailed way. This information can be used
to examine the safety of lifting operations and as a mechanism for approving a lifting plan (Al-
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Hussein et al. 2006). Automated lift planning processes have also been developed for the use of
mobile cranes in heavy industrial construction projects. These processes incorporate design and
site layout with mobile crane capacity and configuration data (maximum and minimum lift radii)
to develop plans for lifting large pre-fabricated components into position using mobile cranes (Lei
et al. 2013).

Technologies to support crane operation

Crane load indicators and various types of limiting devices are installed in cranes as required by
Australian Standards 7. However, there have been recent developments in the deployment of
technology to make crane operations safer. For example, Smith (2018) describes the development
of under-hook devices, such as the Verton R-Series and the Buildvation ‘Rigger Assist’ devices.
The Verton R-series is a remote-controlled electromechanical under-hook load rotation system.
It uses a gyrocopter, controlled electronically and remotely, to rotate the load suspended under
the crane hook. This allows a load to be rotated without the need for tag lines, held by riggers to
guide a load (see the case example below). Similarly, the Rigger Assist technology is attached to
the crane hook and measures angle deviation from the vertical of the hook in real time. This helps
the operator to ensure that the boom tip is directly over the centre of gravity of the load to reduce
load swing at the point of lifting. The information generated is provided to the operator in the
crane cabin but can also be made available to the rigger via the use of smart glasses.

Under-hook load rotation system

A condenser unit was to be removed and replaced in a hotel in inner city Brisbane.
The work was carried out at a height of 90m and the new unit needed to be placed
in a narrow access point in the roof cavity of the hotel. The location of the hotel, at
a busy CBD intersection, required the work be performed in a tight timeframe to
avoid lengthy road closure. The Verton R-Series enabled the lifting to be performed
without need for taglines, which would have been very difficult to achieve at the
90m height of the work. Using the technology, the load was lifted and placed with
precision, using global satellite positioning coordinates. This prevented workers
from working under the load, as well as leaning out of the workspace at height to
guide the load into place. It also reduced the duration of the lift and the space within
which the road needed to be closed. The shorter lifting cycle time and ease of
placement also reduces operator fatigue.

_____

7 AS 1418.5: Cranes, hoists and winches – Mobile cranes.

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 Lifting Matters, 2018b, p.9

Technologies to support crane operation have included the development of video-based systems
that utilise waterproof, vibration-proof compact cameras fitted at one or more locations on a
crane to provide improved vision to reduce the risks associated with collision of crane
components with workers, equipment, or adjacent structures. One provider of camera-based
systems, LSM Technologies, reports the successful deployment of the technology on luffing
cranes in the Australian construction industry. This technology is claimed to reduce the risks
associated with undertaking ‘blind lifts’ (LSM Technologies, 2019). Camera-based systems provide
operators with raw video which helps operators to make decisions, using their knowledge and
experience. This is in contrast with autonomous monitoring systems (some examples of which are
described below).

Proximity safety management systems have also been developed which use slewing, trolley and
travelling sensors to capture data that is then used to model the crane’s movement using polar
coordinate systems. These movements are then compared with pre-established zones defined by
arcs and lines (Luo et al. 2014). An example of such a system is the SMIE anti-collision system
which is a semi-autonomous system that allows a crane operator to anticipate the risk of collision
between the moving parts of their crane and those of a neighbouring crane. If the risk of collision
is detected, the SMIE system automatically ‘intervenes’ to stop the hazardous movements (SMIE,
2019).

Other technologies deployed (in combination with a variety of sensors) to aid the safe operation
of cranes are game technologies and building information model (BIM) technologies which allow
visualisation of lifting operations. For example, Fang et al. (2016) developed a prototype system
combining sensors with a game engine to monitor the safety of mobile crane lifting operations in
real time. This system combines a system of sensors to monitor the movement of the major crane
parts as well as the suspended load. Data is collected about the physical worksite topography
and site conditions (captured using a terrestrial laser scanner) and game engine technology is
used to create a visual representation of the crane in relation to objects in the surrounding
environment (for example, trees, buildings). These objects are marked as bounding box objects
in the game engine. Proximity thresholds and severity levels can be set for objects and structures
in the work environment. If the movement sensors determine that the mobile crane (or its load)
comes within a pre-determined distance of one of the site obstructions, a visual or auditory
warning is given to the operator. Fang et al. (2018) evaluated the impact of the use of this system
on crane operators’ situation awareness and performance. This assessment involved five crane
operators undertaking two different lifting tasks (of varying levels of complexity) using a
telescopic mobile boom type crane. Situation awareness is defined as ‘a person’s perception of
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the elements of the environment within a volume of time and space, the comprehension of their
meaning and the projection of their status in the near future’ (Endsley, 1988). Situation awareness
is linked to safety in the performance of complex and/or hazardous work tasks (Stanton et al.
2001; Sneddon et al. 2013). Following the field test, Fang et al. (2018) concluded:

• the operator assistance system enhanced operators’ situation awareness in terms of the
timeliness with which they responded to questions about their environment and the
correctness of their responses – the improvement in situation awareness was also more
evident when operators were undertaking demanding lifting tasks
• operators’ situation awareness and their lift performance were positively correlated – that is,
increased situation awareness improved the performance of a lift
• the operator assistance system was more effective in improving safety than in improving
efficiency performance
• the complexity level of a lift task directly affected the operator’s workload, especially in
relation to mental demands – higher workload reduces situation awareness that potentially
compromises safety performance in lifting.

Lee et al. (2012) developed a combined sensor and video system to collect and represent
information about the location of a tower crane jib and lifted load. This system was linked to a
three-dimensional building information model (BIM) representing the physical design and
construction details of the building under construction. Tower crane operators were able to see
the location of a lifted load in the context of the building and surroundings in real time during
lifting operations. The ease of use and usefulness of the BIM-enabled navigation system were
assessed to be high in field trials by tower crane operators, particularly in ‘blind lift’ situations. The
possibility of using localisation technologies, such as global positioning system (GPS) and radio
frequency (RFID), to directly capture crane position data in relation to other objects, equipment
or personnel is also under experimental development. These have advantages in their ability to
capture data relating to objects temporarily located in a position that may block a crane
operator’s field of view (for example, items of mobile plant), and/or in identifying when workers
enter blind spots or exclusion zones during lifting operations (Cheng & Teizer, 2014). However,
error rates associated with the use of GPS and RFID have been reported to impact the
performance of autonomous safety systems reliant on these technologies (Luo et al. 2014; Lee et
al. 2012). Finally, the use of camera-equipped unmanned aerial vehicles (UAVs) and object
detection technologies is being explored as a means of monitoring crane movements and
identifying safety hazards in real time (Roberts et al. 2017).

Smith (2018) argues that the automation of crane operations is inevitable and, in his opinion, will
relieve pressure from crane operators and other field workers enabling them to focus their
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attention on critical lift decisions. Smith comments: ‘We have to approach smart technology and
automation capabilities as an opportunity to improve the way we do things, including our safety
outcomes’ (p.6). For example, he describes the E-Fence technology developed by CAT which
automatically stops an excavator’s movements within defined boundaries beside, below and
above the machine. The opportunity to use similar technology to prevent crane boom collisions
at multi-crane sites, or accidental slewing into power lines, is noted (Smith, 2018).

The extent to which advanced technologies produce improvements in crane safety will, in part,
be affected by the extent to which the technologies are perceived to be useful by crane operators.
To this end, Fang et al. (2017) recommend that these technologies should be rigorously evaluated
to ensure that the safety benefits associated with their use are objectively demonstrated. Also,
because the work of a crane operator requires the simultaneous processing of information from
multiple sources, including environmental changes, crew communication and crane performance
feedback, any new safety systems should be carefully designed to reduce the cognitive load
experienced by operators as a result of their use (Fang et al. 2017).

Ergonomic cabin design for tower cranes

The need to pay attention to human factors in crane design also applies to the design of crane
cabin interiors. Crane operators work long hours (Fang et al. 2017) and spend most of the working
day in the crane cabin. Work is performed in a static, sedentary position with hands held on
operating handles. The work requires frequent bending or body twisting and also involves
exposure to vibration and noise (Brkic et al., 2015). Tam and Fung (2011) report tower crane
operators work in cramped conditions and frequently feel physical and thermal discomfort. Crane
operators are also reported to be a high risk group for low back pain (Burdorf & Zondervan, 1990).
Brkic et al. (2015) considered the design of crane cabins as a feature that could improve working
conditions, reduce fatigue, and improve safety in the construction industry. They suggest that
manufacturers often refer to subjective and arbitrary historical guidelines to inform the design of
crane cabins, rather than use anthropometric data to inform design decisions. Brkic et al. (2015)
developed a method of assessment of the needs of crane operators (in Serbia) based on
anthropometric data and kinematic modelling.

Data logger installation

Singapore has established a legislative requirement to fit cranes with data loggers that are
automatically switched on whenever the crane is in operation. This requirement applied to all
cranes registered with the Singapore Government’s Ministry of Manpower after August 1 2015.
Cranes registered before this date had to be retrofitted with data loggers by 1 August 2018. The
following crane types were included in this requirement:

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 • truck mounted variable boom length type
• truck mounted fixed boom length type
• crawler mounted variable boom length type
• crawler mounted fixed boom length type
• wheel mounted (w/o prime mover) variable boom length type
• wheel mounted (w/o prime mover) fixed boom length type
• tower crane (horizontal boom)
• tower crane (luffing boom).

The data logger is required to:

• detect and record any override key activation for the cranes’ safety devices, including
derricking limiter, over-hoisting limiter, and rated capacity limiter
• detect and record overloading occurrences (that is, when load reaches and exceeds 100%
of the crane’s rated capacity)
• detect and record status of limit switches, including derricking limiter and over-hoisting
limiter
• be equipped with data security and anti-tampering feature
• download recorded data
• generate reports.

The data logger also needs to record the following operational parameters:

• date and time

• crane configuration
• permitted load, actual load, percentage of usage of rated capacity (for main hook and
auxiliary hook)
• radius of load
• slew angle (applicable to cranes with safe working load that varies according to the slewing
angle)
• main boom angle, fly jib angle (if applicable)
• boom length, fly jib length (if applicable)
• sequence of extension (for telescopic cranes)
• status of limit switches
• status of override key activation (for over-derricking limiter, over-hoisting limiter, and rated
capacity limiter).

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Funding was provided by the Singaporean Work Safety and Health Council to fund up to 50% of
the costs of installing data loggers.

The rationale for this requirement was to collect data that can be used to take proactive measures
to prevent unsafe operation of cranes, and also aid in the investigation of crane safety incidents.
In Australia, it has been argued that installing crane data logging systems can help crane owners
comply with Australian Standards (relating to determining the required frequency of Major
Inspections), and can maximise the asset life of cranes (Cranes and Lifting, 2018). Authors of a
HRCOS prepared for the New York City Buildings Commissioner in 2009 observed that the airline
industry has, for many years, recognised the importance of applying stricter maintenance and
repair systems on ageing aircraft. Thus, operational data, including detailed flight information, is
available from which to identify an age threshold at which planes might be at risk. The HRCOS
team observe that similar operational data, which could be used to establish the functional age
of cranes and crane components, is not currently available (Smith & Corley, 2009). In Australia,
CICA argues that ‘crane usage is a more important indicator of potential wear to crane
components than the age of the crane alone’, and ‘the usage of years to define when a crane has
reached its design life is not granular enough to relate to the time of operation.’ CICA recommends
alternative methods for crane condition monitoring, potentially including the use of data logging
(CICA, 2017).

Guidance materials for crane usage in a globalised construction industry

In an increasingly globalised construction industry, Shapira et al. (2012) note the ‘gradual
disappearance of traditional borderlines between equipment cultures’ (p. 1281). Factors
contributing to crane safety incidents can arise as a result of the internationalisation of
construction markets and engagement of resources (equipment as well as personnel) from
different countries. In the European Union, this has been identified as a factor impacting
competition in the markets for cranes and lifting equipment, and increasing the risk of crane-
related safety incidents. In particular, concerns about importation and use of cranes in the
European Union or European Economic Area construction markets led the Committee for
European Construction Equipment (CECE) to collaborate with leading crane manufacturers to
produce a pictorial guide highlighting the most easily recognisable non-compliant elements of a
tower crane (Cranes Today, 2011). The guide identifies the most frequently encountered examples
of non-compliance as being:

• incorrect markings, instructions and documents

• the wrong combination of modular components being used
• excessive noise emission levels

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 • a lack of additional safety equipment, warnings, and correct labelling (CECE, 2011).

In 2013, the European Materials Handling Federation Product Group (Cranes and Lifting
Equipment) developed a similar guide for identifying non-compliant mobile cranes. Both guides
are intended to be early warning tools for crane buyers and users (who may have limited technical
knowledge). If one or more items are out of line with the specified criteria then it is probable that
the crane is non-compliant with European Union standards and regulations (FEM, 2013).

Risk-specific guidance materials

In the UK, specific guidance has been developed for the use of both tower cranes and mobile
cranes alongside railways. This guidance material was developed by the UK Construction Plant-
hire Association’s (CPA) Crane Interest Group and was produced in cooperation with the UK
railway network operator, Network Rail.

The guidance addresses specific risk to railway operations associated with the use of cranes (for
example, if a crane or its load falls onto the track) and establishes good practice measures for risk
elimination and reduction. The guidance provides detailed requirements for crane configuration,
setting up, and lift planning, in close proximity to an operating railway. Sample documents and
pro formas are also provided, for example, a foundation pre-rigging inspection report form
(Vertikal, 2019).

Information limitations
Analysis of the extant literature reveals the absence of a consistent classification
method/taxonomy or framework previously used in the analysis of causal or contributing factors
for crane safety incidents. Analysis of patterns/trends is therefore difficult because factors
involved are inconsistently recorded. Further, in many cases, little information is available upon
which to identify with any certainty causes or contributing factors in crane safety incidents.
Classifying crane incident by type provides some indication of how crane incidents occur.
However, the incident datasets on which this classification is usually based do not adequately
address causation, and do not provide reliable incident data to understand why these incidents
occur (Wiethorn, 2018).

Other limitations to historical analyses of crane safety incidents include a heavy emphasis on fatal
incident data (few studies of crane incidents in construction include non-fatal incident or ‘near
miss’ incident data), and the aggregation of incident data relating to all types of cranes into a
single dataset.

Relatively few crane safety incidents have been subjected to detailed investigation and reporting
that is available in the public domain. Those incidents for which detailed causal information is
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available tend to be very serious incidents. The heavy emphasis on analysing data relating to fatal
incidents ignores a significant component of safety risk associated with crane usage and reduces
opportunities to learn from a much larger body of non-fatal or near miss cases (Raviv et al. 2017a).
Near miss incidents involving cranes may not be fully reported, limiting opportunities to learn
from these events. Also, because high-consequence crane incidents (associated with tower
cranes and large mobile cranes) have a low probability of occurrence, there may also be a low
probability of repetition of cause (especially when considered within a single jurisdiction).

Aggregating crane incident data into a single dataset (without differentiating by crane type)
assumes that the factors associated with safety incidents apply equally to all types of crane, and
limits opportunities to understand important differences relating to the safety risks (and control
measures) relevant to different types of crane.

Focus groups/interviews

Framework analysis
The analysis of the first round of focus group/interview data led to the development of a crane
incident causation table. This table, presented as Appendix 5 to this report, collates factors
identified by participants as causes/contributing factors to crane safety incidents in the Australian
construction industry. Each of these factors was described – drawing on the meanings derived
from participants’ comments or explanations of each factor. Example quotations are also linked
these factors to the focus group/interview transcripts.

The factors extracted were also classified using the ConAC causation framework as a guide.
Factors were grouped according to their proximity to/distance from an incident. Thus, factors
were grouped as originating influences, shaping factors, and immediate circumstances.

Originating influences identified aspects of the general industry and regulatory environment,
including:

• adequacy of regulatory training requirements

• a disconnect between industry standards and regulatory requirements
• an increase in foreign workers in the construction industry
• a resource shortage
• an overheated construction market.

Other originating influences related to the ways in which construction projects are delivered and
managed, including:

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 • client demands and expectations
• the procurement method selected
• poor communication between the principal contractor and crane operator
• a lack of adequate planning by the principal contractor and/or crane operator.

Shaping factors identified as relevant to crane safety incident causation described site
management practices or workforce characteristics that increased the risk of crane safety
incidents. These included:

• long working hours

• workforce fatigue and mental health
• a ‘tick and flick’ approach to safety-related documentation
• inadequate supervision
• site-specific physical constraints and conditions
• the development of safe work method statements (SWMSs) in isolation (not considering
other site activities)
• inadequate/incorrect information provided to crane operators
• poor safety in design or change in work planning/sequencing.

Immediate circumstances identified by participants as causing crane safety incidents in the

construction industry included worker factors, site factors, and material/equipment factors.

Worker factors included:

• failure to follow manufacturers’ instructions and/or SWMSs

• lack of familiarity with crane being used
• overriding safety technology
• lapses in concentration.

Site factors included:

• changes to ground conditions

• inadequate supporting structures
• lighting/visibility
• interaction with adjacent activities/adjoining properties.

Material/equipment factors included:

• loads too heavy for a lift

• crane too small for tasks being performed

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 • use of substandard cranes or lifting equipment
• structural/electrical failures of cranes.

Further details, and the full set of causal/contributing factors identified following analysis of the
first round of focus groups/interviews, are described and evidenced in Appendix 5.

It is important to note that these factors do not occur in isolation and their effects are likely to be
highly interrelated – both between and within levels of causation/contribution. Thus, the
overheated procurement environment (an originating influence), combined with clients’ demands
and expectations (originating influences), could contribute to crane company over-commitments,
long working hours, and fatigue (shaping factors). In turn, these factors could contribute to a
crane being used that is too small for a task being performed, operators taking shortcuts, hazards
not being properly identified, and safety technology being overridden (immediate
circumstances).

Cause-effect trees
Each of the causal/contributing factors identified in steps 1-4 of the framework analysis was then
incorporated into one of five ‘cause-effect’ trees to identify potential pathways of causation
between factors identified at different levels. These trees are reproduced as Appendix 6 to this
report and reflect the following areas of causation:

• work environment issues

• worksite conditions
• human factor issues
• equipment issues
• task/activity issues.

The trees show how immediate circumstances of crane safety incidents can be traced back to
causal/contributing factors in the site, organisational and industry environments. For example, in
the human factors cause-effect tree an operator’s unfamiliarity with the crane/plant being
operated can be traced back to inadequate onboarding and induction of foreign workers,
selection of dry versus wet hire arrangements, transient workforce, and a crane company’s over-
commitment to work. These factors, in turn, can be traced back to an increase in use of foreign
workers in the construction industry due to resource shortages and an overheated procurement
environment. They can also be traced back to crane company management arrangements,
planning and experience.

It is not possible to ‘unpack’ each of the trees in this section of the report as they are very detailed.
However, they are included in Appendix 6 and show interrelationships between
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causal/contributing factors within and between levels within the crane safety incident causation
model that was developed as an output of the framework analysis of focus group/interview data.

Crane safety incident causation model

A crane safety incident causation model was developed as an output of the analysis of focus
group/interview data. This model is presented in Figure 4. The model is based upon the ConAC
model of causation but is specific to crane safety incident causation in the Australian construction
industry. The model arranges causal/contributing factors identified in the framework analysis in a
graphic representation of originating influences, shaping factors, and immediate circumstances,
identified by participants as relevant to crane safety incident causation in the construction
industry. This model presents the synthesis and primary output of the qualitative data analysis
presented in this report. The application of the model taxonomy in identifying causal factors was
indicated in case examples which can be found at Appendix 1-4.

Validation of the crane safety incident causation model

The validity of the crane safety incident causation model was subsequently evaluated in a second
round of industry consultation. This involved applying the model to case study crane safety
incident scenarios. The results of this validation are presented briefly below.

The frequency with which immediate circumstances, shaping factors, and originating influences,
were identified as relevant to the two scenarios (one involving a tower crane safety incident,
another involving a mobile crane safety incident) are presented in Appendix 3 and 4. The
frequency with which causal/contributing factors were identified as relevant to the crane safety
incident scenarios used in the validation can be found in Table 12 at the end of Appendix 6.

While a small number of people/groups participated in this exercise (n=5), this validation round
showed a reasonably high level of consistency between the three experts tasked to identify the
causes involved in the tower crane incident (factors systematically picked are denoted by a grey
bar showing a frequency count of three), and the two experts tasked to identify the causes
involved in the mobile crane incident (factors systematically picked are denoted by a blue bar
showing a frequency count of two). It also showed that the causal/contributing factors identified
at the three levels (immediate circumstances, shaping factors, and originating influences) were
relevant to both mobile and tower crane incidents (as indicated by a spread of grey and blue lines
across all three levels).

A small number of factors not included in the original crane safety incident causation model were
identified by participants in the second round of consultation. These were subsequently included
in an updated model.
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Participants also indicated that the crane incident causation model would be useful in planning
for crane-related activities and in investigating and understanding the causal/contributing factors
in crane safety incidents.

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Figure 4. Crane safety incident causation model.

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 Frequency identified

0
1
2
3

Hazards not identified

Existing soil conditions
Changes to ground to conditions
Crane located above/below
Not following manufacturer’s instructions
Override safety technology
Operator taking shortcuts
Load transfer too far
Load too heavy
No lift plan

Immediate
Lack of hazard awareness
Not following procedure/SEMS
Supporting structure not adequate
Unfamiliar with plant being operated
Negative interaction between adjoining tasks/activities…
Working in unsuitable weather
‘Tick and Flick’ approach to documentation
Lack of standardised processes
No specific requirements for cranes and their design for…
Inadequate/incorrect information provided to crane
Modifications made to the crane
Lack of/poor safety in design
Documentation too generic
Lack of maintenance
SWMS done in isolation
SWMS submitted prior to job commencing
Procedure doesn’t address/cover high risk activities

Figure 5. Causal/contributing factors identified in the scenario analysis.

Complacency/over confident
Lack of competency/experience
Shaping

Inadequate site supervision

Overly onerous documentation
Site constraints
Not recognising /accounting for changing site conditions
Transient workforce
Fatigue
Wet vs Dry hire
Causal/contributing factor

Lack of co-ordination/oversight of documentation and…

Procurement methodology selected
Crane company overcommits
Long working hours
Lack of RTO consistency in training
Training not meeting the needs of industry
Disconnect between industry standards and regulatory…
Crane contractor’s knowledge and experience
Lack of planning by the crane contractor
Lack of planning by the principal
Level of management by the principal sets the tone
Time/budget pressures to keep the project moving
Regulatory training requirements
Authority/regulator’s permit conditions
Client demands and expectations
Overseas imports
Originating

Resource shortage
Overheated procurement environment
Lack of early involvement/consultation with crane
Crane contractor’s expectations on crane operator
Foreign workforce
Lack of communication by the principal
EBA vs Non EBA
Adjoining properties/community expectations and…
Tower
Mobile

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Potential strategies/solutions for crane safety incident reduction
Participants in the initial focus groups/interviews were asked to provide suggestions for
preventing safety incidents involving cranes. All propositions were broadly grouped into seven
topic areas: training and competence, development of a code of practice for crane operations,
communications and awareness raising, the role of the regulator, design and import issues, use of
technology, and procurement and the management of commercial relationships 8.

In the following section of the report, suggestions made under each topic area are ‘unpacked’ to
provide:

• a statement about the problem identified and/or need for preventive strategies
• an explanation of each suggestion made in relation to this problem/need
• a description of what the suggestion might mean in practice
• potential benefits associated with each suggestion
• anticipated outcomes
• possible performance measures related to each suggestion.

Topic area 1: Training and competence

Suggestion 1.1 Implement a tiered licensing system

Problem/need Competence is understood to develop with experience over time. The current
licensing system does not currently reflect ‘gradations’ in workers’ experience
levels. Understanding the site-based work experience level of operators (and
other workers who perform specific crane-related activities) can help employers
to allocate tasks and manage workers more effectively, based on their
experience levels.

Action Introduction of different categories (levels) of licences for dogmen, riggers, and
crane operators.

Description Similar to road vehicle legislation, a specific licence would be required before a
person was allowed to operate a crane or undertake dogman activities. Upon
completing a recognised training course, a person would be issued with a
licence, subject to restrictions during a probationary period.

Key benefits Workers could be assigned tasks commensurate with their level of competency
and experience.
Safe operating capabilities could be better monitored and assessed, particularly
in newcomers to the industry.

Desirable outcomes More consistent approach to developing and managing critical skills required to
operate and work safely with cranes.

_____

8 These topic areas and subsequent suggestions have not been ranked and are presented in the order in which they were raised by
participants, not in order of priority or importance.
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Performance Training records and licences quantify and reflect the progressive development
measures of knowledge, skills and experience related to crane operation, direction of
crane operations, and rigging practices.

Suggestion 1.2 Introduction of ‘logbooks’ documenting crane operation experience

Problem/need Related to Suggestion 1.1, workers’ experience in operating a particular type of

crane is not consistently documented and recorded. Relatively inexperienced
workers could potentially engage in high risk work. Participants identified a need
for improved ‘visibility’ relating to the experience level of crane operators.

Action Introduction of a ‘logbook’ system to record experience operating particular

types of crane. To be linked to licensing (see Suggestion 1.1).

Description Logbooks and record keeping were seen to assist in evaluating and managing
crane operators’ experience in working with particular crane types. They provide
information about their levels of relevant experience to crane operation
companies, and construction contractors who engage crane crews or operators.
Experience data can be recorded using commercially available digital/web-
based tools.

Key benefits Formal recording of work experience provides a record and evidence of work
history in relation to particular crane/equipment types.
Employers and contractors can make selection decisions based on relevance of
prior work experience.
Workers can be assigned tasks better suited to their previous employment
experience.
A more systematic approach to developing skills and competencies linked to
experience could be implemented.

Desirable outcomes If adopted as an industry requirement, this would provide a consistent approach
to managing skill development and experience in relation to crane operations.

Performance Reliable records kept to quantify and evidence workers’ experience related to
measures the operation of different types of crane.

Suggestion 1.3 Periodic testing/assessment for crane operators

Problem/need Experience is an important contributor to operators’ competence. However,

participants also commented that safe working practices may be forgotten over
time, and/or new technology or changes to industry guidelines may require that
training be updated periodically to ensure knowledge, skills and abilities reflect
current ‘best practice.’

Action Participants commented that periodic testing for crane operators could also be
beneficial.

Description These participants observed that operators should keep up to date with new
technologies and legislative changes.

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Key benefits Refresher training was considered a means of ensuring crane operators’
knowledge remains current, and safe operating practices remain ‘front of mind’,
throughout the industry.
Potentially, refresher training could be linked to the logbook suggestion made in
1.1.

Desirable outcomes Refresher training undertaken to ensure currency of knowledge.

Performance Records are retained regarding crane safety refresher training.

measures

Establish Verification of Competence (VOC) requirements related to

Suggestion 1.4
specific crane types

Problem/need Participants observed that current licensing arrangement reflect broad

categories of crane type and capacity. However, crane operating features vary
considerably by make and model. They identified a need to capture machine-
specific competence in industry VOC practices.

Action Participants suggested there is a need to ensure VOC processes more

consistently capture crane operators’ competence in operating specific types
of crane (that is, including make and model).

Description Participants commented that the content of VOCs is ill-defined and can vary
from provider to provider. The goal of VOC is to ensure crane operators are
assessed in terms of their competence to use a particular type of equipment
(CICA, 2018). However, the use of different VOC providers means operators
often have to complete multiple VOCs to work on different sites. A
standardised, machine-specific assessment program, such as the CICA
CrewSafe system, can help to overcome these challenges.

Key benefits Operators are assessed using consistent criteria and through demonstrating
competence in relation to a specific make and model of crane.
Familiarity with unique features of a crane is assessed.

Desirable outcomes More consistent, efficient, verifiable and traceable assessment of competence
to operate a specific crane.

Performance Consistency in VOC assessment requirements and increased crane-specific

measures knowledge.

Establish specific training (and potentially licensing/registration) for other

Suggestion 1.5
workers whose activities could impact the safety of crane operations

Problem/need Participants commented that the safety of crane activities in the construction
industry is affected by the competence of different parties, not just operators,
dogmen, and riggers. Other parties involved in making safety-critical decisions
about planning, managing and coordinating crane activities do not need specific
training in crane-related safety. This represents an important gap in management
of workforce capability.

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 Action Participants suggested two other groups of workers whose activities could
impact the safety of crane operations. These were:
• engineers who oversee work activities involving cranes
• people responsible for coordinating crane-related activities on
construction sites.

Description It was suggested that to be able to carry out their work competently, engineers
who oversee work involving cranes should receive specific training in crane-
related safety issues, and that this be reflected in a registration system.
It was also suggested that a new category of crane worker be established (that
is, a crane activity coordinator). Participants believed people acting in this role
should have specific training, and potentially also be licensed. Prior to initiating
lifting operations, a person filling a crane coordinator role could, for example,
conduct pre-lift meetings to discuss and plan lifting procedures, rigging
methods, signalling systems, load movement and placement, and the
responsibilities and roles of all parties.

Key benefits Greater certainty for crane operators that site personnel have properly analysed,
planned and prepared for lifting activities to take place.

Anticipated More careful and coordinated approach to planning lifting operations in a

outcomes particular worksite context.

Performance Clear allocation of roles and responsibilities for lifting operations.

measures Decisions concerning lift planning and preparation made by people with requisite
knowledge and experience, with decisions communicated to and well
understood by all involved in lifting operations.

Topic area 2: Develop a Code of Practice for crane operations

Suggestion 2.1 Develop a Code of Practice (CoP) for crane activities

Problem/need Participants observed there is a level of inconsistency in knowledge and

adoption of ‘best practices’ in relation to crane-related safety activities in the
construction industry. In NSW there is no specific Code of Practice related to
use of cranes. Participants identified a need for clear and comprehensive
guidance for all relevant industry participants relating to the practices required
for compliance with WHS regulation in relation to crane use at construction
sites.

Action Participants suggested a CoP should be developed for crane activities in NSW.
This could be similar to CoPs in place in Queensland for Tower Cranes (2017)
and Mobile Cranes (2006). The current NSW CoP, ‘Managing the risks of plant
in the workplace code of practice’, is not specific to cranes.

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 Description The CoP would contain guidance on managing risks associated with specific
types of cranes. Topics identified by participants as areas that could potentially
be incorporated into a crane-specific CoP are listed below.
Roles and responsibilities of all participants involved in, or whose actions could
have an impact on, the safety of crane-related activities, including clients,
principal contractors, crane manufacturers, crane owners/operators, site
engineers and crane coordinators (see 1.5), maintenance personnel, riggers,
dogmen, site supervisors, and others.
Providing specific guidance on coordination of lifting activities, as well as
communication and consultation between participants in planning, design, and
conduct of lifting operations.
Nomination of a coordination role to ensure pre-planning is undertaken
effectively before lifting operations commence (see 1.5).
Alignment of training and crane usage requirements with manufacturers’
guidelines.
Establishing testing, inspection, and maintenance, regimes and ensuring these
are aligned with crane manufacturers’ guidelines.
Guidance on ensuring fitness for work of people engaged in operating cranes or
lifting activities. Specific suggestions made in relation to this topic were medical
assessments, drug and alcohol testing, and fatigue management processes.
Specific guidance for identifying hazards in a specific work environment, and
implementation of appropriate controls and parameters for lifting operations in
particular conditions (for example, heat, wind, spatial restrictions,
underground/overhead services, geotechnical conditions, adjacent structures,
roads or railways).
Requirements for the registration of cranes and notification of use at a particular
worksite/location.

Key benefits A detailed set of guidelines specific to crane usage as a reference point for all
parties involved in work involving cranes in the construction industry.

Desirable outcomes More consistent approach to accessing and understanding practical guidance
to help industry participants better meet their legislative responsibilities when
using cranes at construction sites.
Guidance material describing good practice for using cranes at construction
sites.

Performance Code of Practice development and widespread industry use.

measures Increased industry knowledge of good practice in managing crane activities at
construction sites, and compliance with legislative requirements relevant to
crane use and lifting operations.

Topic area 3: Communication and awareness-raising

Suggestion 3.1 Implement more effective communication and awareness raising

Problem/need Related to Suggestion 2.1, participants perceived there is a gap in the

communication of ‘best practice’ information and guidance material
relating to the safe use of cranes in the construction industry.

Action Participants identified several areas in which more effective

communication and awareness-raising activity relating to crane safety
could be implemented.

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 Description Specific areas where information/awareness-raising was identified as
being beneficial are listed below.
To provide timely and detailed information about causation following a
crane incident. Detailed incident investigation data is not widely or readily
available in the public domain, potentially reducing the ability to use
incident investigation findings for prevention. While confidentiality of
information is important during an investigation, releasing certain
information that could be used to inform timely prevention activity was
considered beneficial. The availability of more detailed investigation
reports, once investigations are complete, can also facilitate learning as
these incidents can be used in toolbox meetings etc to communicate
safety risks associated with crane usage. The US Occupational Safety and
Health Administration, for example, produces and makes publicly available
detailed engineering reports describing outcomes of selected significant
incidents involving machinery failures.
To collate and disseminate international best practice information on crane
safety. Examples provided by participants included UK-based practices of
assessing crane drivers’ fitness for work, and ISO standards relating to
crane design, operation, and inspection. Industry organisations, such as
CICA, potentially could play a role in collecting and disseminating safety-
related information about crane use in the construction industry.
To explore the use of social marketing approaches to ‘push out’ important
messages about crane safety to target audiences.
To ensure industry participants are aware of important tools available to
them, such as anonymous reporting ‘hotlines’ for safety-related concerns
or to report instances of non-compliance.

Key benefits Construction organisations, crane operators, and other stakeholders,

would have easy access to the best available information upon which to
manage the safety of crane-related activities.

Desirable outcomes Management of crane-related activities in the construction industry would

be evidence-informed.
All parties would have access to up-to-date information about incident
causation, prevention, and best practice, in the safe use of cranes.

Performance measures Increased knowledge and awareness of crane-related safety issues across
the construction industry.
Better risk management and decision-making in relation to preventing
incidents involving cranes.

Topic area 4: The role of the regulator

Suggestion 4.1 Implement a more proactive inspection approach

Problem/need Participants commented that worksite inspections are sometimes announced

prior to their occurrence and the operations of smaller crane operators
(particularly in the case of mobile cranes) may not be subject to inspection.
Potentially this creates a ‘gap’ in which cases of non-compliance may not be
identified.

Action Increase surveillance and enforcement of crane-related safety requirements.

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Description Participants suggested the level of enforcement of crane-related safety
requirements could be increased. In particular, participants made the
suggestions listed below.
Use more proactive inspection processes, potentially using registration of crane
usage and location information to identify sites for unannounced inspections.
Introduce a campaign for smaller crane operators and sites to ensure the focus
is not always on large companies and construction worksites.
Consider using fines and penalties for operators found to be in breach of safety
regulations, similar to traffic penalties.

Key benefits Participants suggested a proactive enforcement approach could potentially

improve compliance levels.

Desirable outcomes Industry expectation that sites could be visited at any time without prior
notification.

Performance More frequent unannounced inspections.

measures Improved levels of compliance and, in the medium to long term, fewer instances
of non-compliance.

Suggestion 4.2 Provide a strong advisory/mentoring role

Problem/need Participants described inconsistencies in the level of knowledge about safety of

crane operations in the construction industry. The need was identified for a
reliable source of up to date information about crane safety incident causation,
incident prevention, and best practice recommendations.

Action Provide a more comprehensive advisory/mentoring role for crane-related safety

issues.

Description Participants also suggested the regulator could provide more comprehensive
guidance and advisory services to industry on crane safety. Related to this was
an expressed concern about engineering expertise related to crane safety.

Key benefits The regulator can play an important role, both in enforcing safety-related
statutory requirements, and in providing advice and guidance about how to
prevent safety-related incidents involving cranes. The model of crane incident
causation developed in this report – which is based on evidence and opinions
collected from experienced Australian crane industry representatives – is one
mechanism the regulator can potentially use to leverage the advice provided
about the factors to consider when managing risks associated with crane use at
construction sites.

Desirable outcomes Better informed industry stakeholders in relation to managing safety risks
relevant to crane use and lifting operations.

Performance Increased frequency of interactions between regulator and industry in which

measures advice is provided on managing safety risks relating to cranes.
Information sharing in joint investigations of crane safety incidents (including
near miss incidents) using the model of crane incident causation.

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Topic area 5: Design and import issues

Suggestion 5.1 Review design and import requirements for cranes

Problem/need Participants identified difficulties in ensuring compliance of imported cranes and

components with Australian Standards requirements. There is a perceived lack
of ‘visibility’ on testing procedures undertaken, maintenance records, and
quality of information provided by importers and suppliers.

Action Participants commented that, in relation to new or secondhand cranes imported

into Australia from overseas, closer attention could be paid to design and import
requirements for cranes.

Description Current NSW WHS Regulations (2017) (Part 5.1) establish extensive duties for
persons conducting businesses or undertakings that design, manufacture,
import, or supply items of plant. However, participants still perceived WHS
issues associated with the way design and import requirements are currently
monitored.
Concerns were raised, in particular, about maintenance records and the quality
of information provided about cranes that are supplied or imported. The
magnitude of this problem is not known and cannot easily be discerned from
information available to the research team.
However, it is important that imported cranes are reviewed to ensure they
comply with relevant Australian Standards requirements (AS 1418 and AS 2550
sets of standards).

Key benefits Ensuring imported cranes meet design, maintenance and inspection
requirements in accordance with Australian legislation and standards.
Ensuring information provided about imported cranes meets Australian
requirements (for example, load chart content requirements).

Desirable outcomes Industry-level consistency in applying design and import requirements for
imported cranes.

Performance Reduction in safety-related issues/non-conformances associated with imported

measures cranes.

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Topic area 6: Technology

Suggestion 6.1 Incorporate new technology

Problem/need Human error is frequently identified as a causal factor in crane safety incidents.
Technologies are increasingly available that reduce the likelihood (or impact) of
human error. However, participants observed that these are not consistently
fitted by crane manufacturers and are less likely to be in place in older cranes.

Action Incorporate new technologies in cranes to ensure they are equipped with the
latest devices to maximise safe working and prevent incidents.

Description Participants referenced technologies including, limiters, cameras and real time
data logging, monitoring and sensor equipment. Participants were in favour of
remote monitoring of plant (back-to-base) which companies can use to monitor
how plant is being used. The use of existing and emerging technologies to
improve crane safety was extensively described in the literature review section
of this report. Some technologies are now commercially available and in use by
crane manufacture, supply and operation companies. Examples of these are
given in the literature review. Other technologies are still under development.
With advances in sensor technology and autonomous machinery, technology-
based safety systems are likely to grow in use over time.

Key benefits Potential to increase reliability of crane operation and reduce the impact of
human error.

Desirable outcomes Technologies proven to be reliable and effective are adopted for use in mobile
and fixed (tower) cranes.
Crane operators would potentially have objective data to support decisions
taken not to perform unsafe lifting operations.

Performance Potential reduction in crane incidents attributed to human error.

measures Improved accuracy and efficiency of crane operation (load movement and
placement).

Topic area 7: Procurement and the management of commercial relationships

Suggestion 7.1 Improve management of safety in the procurement of crane services

Problem/need Crane contractors (typically subcontracted to principal contractors) may be

subject to commercial pressures arising as a result of competitive practices,
tight project timelines, and their position in the construction industry supply
network. Participants commented that crane supply arrangements can
sometimes have a negative impact upon safety.

Action Participants suggested that actions taken to improve the procurement of crane
services (both wet and dry hire) could be improved by introducing standard
clauses into contract documents relating to providing these services.

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 Description The commercial contracts under which crane services are procured can impact
the way risks and responsibilities for safe operation are borne and experienced
by crane operators, and other workers involved in lifting operations. Clear,
industry-accepted standard agreements were suggested as a means to ensure
crane operators are not subject to pressures to continue working in situations
in which crane operation may not be safe.
In particular, participants made two suggestions.
First, standard clauses be included in contracts between principal contractors
and crane hire companies identifying responsibilities for safe operation of
cranes at a worksite.
Second, crane hire companies establish operating requirements in tender
documents relating to providing crane services. These could include, for
example, requirements related to maintenance and the specification of safe
limits of a crane’s operation. Related to this latter point, participants also
suggested standard templates be developed by which crane operators could
document situations in which work should be ceased (for example, poor
weather). This could also refer to data collected via objective (back-to-base)
monitoring systems which could be used to ensure lifting activities remain
within specified safe parameters for a crane’s operation.

Key benefits Clarity relating to roles and responsibilities for safety of crane operations at a
construction worksite.
Commercial relationships between principal contractors and crane operators
that respect crane operators’ safety responsibilities and knowledge of safe
working practices relating to the use of cranes.

Desirable outcomes Risks and responsibilities are appropriately allocated and commercial
mechanisms are in place, enabling crane operators to establish and maintain
safe working practices at all times.

Performance Standard practices for procurement of crane services that reflect the need for
measures safe operation.

Limitations
The suggestions made by participants reflect the ideas of a relatively small sample of industry
informants who participated in the initial focus groups/interviews. As such, they cannot be read
as being broadly representative of industry views. With this limitation in mind, it is recommended
that participants’ suggestions be considered further within broader industry consultative
processes to determine their feasibility, and the likely benefits they would produce in terms of
improved crane safety and incident reduction.

SafeWork NSW data

Crane safety incidents by industry

Figure 6 shows the two industries with the highest number of crane safety incidents are
construction (59%) and manufacturing (17%) The three industries that exhibit a higher proportion
of crane safety incidents when compared to non-crane safety incidents were construction,

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manufacturing, and transport/storage. A chi-squared analysis showed that the type of industry is
a significant risk factor for crane safety incidents, with the industry most at risk of experiencing
crane safety incidents being construction (χ2(9) = 717.11, p < 0.001).

Figure 6. Proportions of crane and safety incidents and all workplace safety incidents by industry.

Incident type vs. type of crane

The information for the type of crane involved in the incident was missing from a significant
number of records (36%, or 391 records out of 1075). From those records where the type of crane
involved was recorded, the top three crane types involved in safety incidents were mobile cranes
(36%), tower cranes (26%), and gantry cranes (17%).

Figure 7 shows the relationship between crane type and incident type for the five cranes
exhibiting the highest frequency of workplace incidents. Workplace incidents are grouped into
three categories: dangerous incidents, serious injuries, and fatal injuries (see Appendix 8 for
definitions).

Mobile cranes accounted for 67 (or 33%) of all serious injuries. Tower cranes accounted for only
31 (or 15%) of serious injuries.

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Dangerous incidents occurred most frequently for mobile cranes (176 or 37%), tower cranes (146
or 30%), and gantry cranes (60 or 13%).

No fatal injury cases were recorded involving a mobile crane during the seven-year period of
analysis.

Figure 7. Seriousness of crane safety incidents by type of crane.

Mechanism of incident vs. type of crane

General statistics of the mechanism leading to a crane safety incident are presented in Figure 8.
Definitions of each mechanism are provided in Appendix 8.

‘Hit by load’ and ‘Hit by crane’s part’ were the most frequent types of incidents (42% and 19%
respectively) and accounted for a high proportion of incidents for all crane types. However, Figure
8 also illustrates that different crane types (mobile, tower, and other types) have different profiles
of incident mechanism. A chi-squared analysis confirmed the mechanism of the incident varies
significantly by crane type (χ2 (14) = 148.2, p < 0.001). The most common type of incident for
mobile cranes is crane collapse. Tower crane incidents most commonly involve a person being hit
by a crane load or being hit by the crane itself.

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Figure 8. Crane safety incidents by incident mechanism. Top panel – mechanism of incident as a function
of workplace incident frequency for all crane types. Bottom panel – mechanism of incident as a function
of three crane types in addition to dangerous incidents and serious injuries.

A further analysis of information gleaned from the ‘incident details’ field in the WSMS workplace
incident dataset showed that the top three occupations of persons involved in crane safety
incidents resulting in serious injury are general worker (48%), crane operator (25%), and dogman
(12%).

Out of the 530 incidents in which the action of the crane (at the time of the incident) was
specified, 56% of the incidents related to lifting actions, 17% to slewing actions, and 10% to loading
actions.

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Time series analysis

Crane safety incident time series analysis

Figure 9 shows the number of serious injuries, dangerous incidents, and total incidents, that
occurred from 2012 to 2018. The number of crane safety incidents recorded in NSW increased
significantly between 2012 and 2018.

Figure 9. Time series analysis of crane safety incidents, 2012 to 2018.

A Savitzky-Golay filter has been applied to smooth the data and to present the trends as curved
lines.

The number of incidents resulting in serious injury per year was stable from 2012 to 2015. From
2015 to 2018 the number of incidents resulting in serious injury more than doubled. It is noteworthy
that the number of cranes in operation also increased significantly during this period (see next
section for an analysis which normalises for the number of cranes in operation). A similar trend
was apparent for dangerous incidents which were relatively stable in number between 2012 and
2015, but which increased markedly in frequency from 2015 to 2018.

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Linear models were fitted to the time series data displayed in Figure 9 to determine whether there
was a significant increase in incidents resulting in serious injury and/or dangerous incidents
involving tower and mobile cranes between 2012 and 2018.

Of the four linear models generated, only one related to incidents producing serious injury and
involving tower cranes did not exhibit a significantly positive slope (mobile cranes – serious
injuries F1,5 = 9.091, p – 0.030; dangerous incidents F1,5 = 10.660, p = 0.022; tower cranes – serious
injuries F1,5 = 6.265, p = 0.054; dangerous incidents F1,5 = 11.06, p = 0.021). No differences were
found when comparing the trends for mobile or tower cranes incidents leading to serious injuries
(z = 0.908, p = 0.182), or dangerous incidents (z = 0.971, p = 0.166). Thus, safety incidents involving
cranes have increased significantly in recent years, and this is true for both mobile and tower
cranes.

Normalised tower crane time series analysis

As noted in the previous section, to more appropriately understand changes in the incidence of
crane-related safety incidents it is important to consider the frequency of incidents relative to the
amount of crane activity (or number of cranes in use). To consider the relative frequency of
incidents, the incident data was normalised to take into account the total number of standing
tower cranes in Sydney 9. The RLB crane index (RLB, 2019) provided the total number of tower
cranes in operation in the Sydney area each quarter from Q2 2015 to Q4 2018.

The number of serious injuries and dangerous incidents was normalised to reflect incidents per
100 tower cranes in operation in Sydney (see Table 8). Note that the data are only complete for
incidents where the type of crane could be identified in the database records.

Table 8. Tower crane safety incidents normalised by number of tower cranes standing in Sydney 2015-
2019.

Column one shows number of standing tower cranes in Sydney every quarter from Q2 2015 to Q1 2019
(Ncranes). Number of serious injuries (NSI) and number of dangerous incidents (NDI) are shown per quarter,
as are normalised frequencies of serious injuries and dangerous incidents per 100 cranes (SInorm and
DInorm). Data reconstructed from the RLB crane index® 14th edition.

Quarter Ncranes NSI SInorm NDI DInorm

Q2 2015 162 1 0.62 0 0

Q3 2015 187 0 0 0 0

_____

9 Although this index relates only to tower cranes it was the best available proxy measure of crane activity during the period of
analysis. For the purposes of this analysis only incidents that could be identified as involving tower cranes were included.
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 Q4 2015 213 1 0.47 4 1.88

Q1 2016 251 0 0 7 2.79

Q2 2016 289 0 0 2 0.64

Q3 2016 305 3 0.98 5 1.64

Q2 2016 315 1 0.32 3 0.95

Q1 2017 325 0 0 12 3.69

Q2 2017 334 2 0.60 4 1.20

Q3 2017 342 1 0.29 4 1.17

Q4 2017 351 0 0 5 1.42

Q1 2018 347 2 0.58 8 2.31

Q2 2018 342 3 0.88 10 2.92

Q3 2018 321 2 0.62 13 4.05

Q4 2018 316 1 0.32 13 4.11

Figure 10 presents a time series analysis of normalised serious injuries, dangerous incidents, and
total incidents, related to tower cranes in Sydney between Q2 2015 and Q4 2018. The number of
dangerous incidents per tower crane in operation increased steadily since 2012.

Linear models were fitted to the normalised tower crane safety incident data to test whether the
increase in incidents over time was statistically significant. Serious injuries did not exhibit a
significantly positive slope (F1,13 = 0.745, p = 0.404); however, dangerous incidents involving tower
cranes showed a significant upward trend (F1,13 = 11.42, p = 0.005). The datasets analysed do not
provide a clear explanation as to why dangerous incidents involving tower cranes increased
significantly in this period while incidents involving serious injury did not.

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Figure 10. Normalised time series analysis of dangerous incidents and serious injuries involving tower
cranes in Sydney.

Note: incident rates have been normalised for the number of tower cranes standing at three-
month intervals. A Savitzky-Golay filter has been applied to smooth the data and to present the
trends as curved lines.

Causal factors

Causal factors for serious injuries and dangerous incidents

The cause of incident was extracted from the ‘Action Taken’ and ‘Incident Description’ fields of
the WSMS workplace incident database (see section on data cleansing and Figure 1). Causes of
incidents were classified into five major groups:

• human error
• faulty equipment
• weather conditions
• unauthorised access to a crane

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 • medical condition 10.

Causes were only labelled as such if they were easily identifiable and could be confidently
described as the immediate cause of a specific incident. Where an immediate cause was not
readily discernible, no main cause was reflected in the analysis.

Figure 11 shows the distribution of causes for serious injuries, dangerous incidents, and all incidents
involving cranes. Cases in which the immediate cause was identified as human error made up
82.1% of all incidents. This proportion did not differ significantly for serious injuries or dangerous
incidents. Faulty equipment was the second most frequent cause of incidents (12.4%). Together
these two causes accounted for 94.5% of all incidents.

_____

10 Causes listed here refer to immediate causes and do not take into consideration shaping factors or originating influences which
may have contributed to the cause of an incident.

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Figure 11. Distribution of the immediate causes of the crane safety incident for all crane safety incidents
(top chart), for crane safety incidents involving tower cranes only (bottom left chart), and for crane safety
incidents involving mobile cranes only (bottom right chart).

Only incidents occurring after 2012, and where an immediate cause was identified, were included.

Time series analysis of crane safety incident causes

Figure 12 shows a time series analysis of the causes of incidents between 2012 and 2018.
Distribution between causes remained relatively stable over the time period; however, the
proportion of incidents attributed to human error increased significantly from 72% in 2016 to 89%
in 2018. The proportion of incidents attributed to faulty equipment decreased from 21% in 2016 to
11% in 2018.

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Figure 12. Distribution of the immediate causes of crane safety incidents per year.

This graph compares the proportion of immediate causes of incidents for a specific year. An
increase in proportion of one cause of incident from one year to the other (for example, human
error from 2017 to 2018) means there is an increased proportion of incidents for which this
immediate cause has been identified. It does not mean there is an increase of the number of
incidents for which this immediate cause has been identified.

Geographical analysis
Further analysis was undertaken of workplace incidents in NSW by geographical location. For the
purposes of this analysis, NSW was split into regions based on the Australian Statistical
Geography Standard (ABSGS) SA4 statistical areas (ABS, 2016).

Serious injuries and Dangerous incidents

The geographical distribution of both serious injuries (SI) and dangerous incidents (DI) were
found to be similar (see Table 9).

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Most incidents occurred in Sydney (61% and 63% of all SI and DI respectively), followed by
Newcastle and Lake Macquarie, and Illawarra/South East NSW, with 15.7% and 12.4% of all SI and
DI respectively.

Table 9. Frequencies per region of incidents resulting in serious injuries (SI) and dangerous incidents (DI).

N represents the number of incidents, and %SI and %DI represent the proportion of serious injuries
and dangerous incidents in NSW.

Regions NSI %SI NDI %DI

Sydney 205 61.7 444 63.3

Newcastle and Lake Macquarie 37 11.1 77 11.0

Illawarra 26 7.8 32 4.6

Hunter Valley excl. Newcastle 24 7.2 59 8.4

Capital Region 8 2.4 8 1.1

Southern Highlands and Shoalhaven 6 1.8 10 1.4

Riverina 6 1.8 8 1.1

Coffs Harbour – Grafton 5 1.5 17 2.4

Central Coast 5 1.5 21 3.0

Mid North Coast 4 1.2 8 1.1

Central West 3 0.9 6 0.9

Richmond – Tweed 2 0.6 5 0.7

Murray 1 0.3 3 0.4

New England and North West 0 0.0 3 0.4

Total 332 100.0 701 100.0

Fatal injuries
Fatal injuries were also analysed with respect to location and main cause. Of the 15 fatalities that
occurred between 2012 to 2019, immediate causes for eight fatalities could be confidently
determined from the WSMS workplace incident database. Unauthorised public access (that is,
where trespassers climbed onto a crane and fell or were electrocuted) and human error were
reported to be the most frequent causes of fatality (40%, or six of 15 incidents). Figure 13 shows
the main causes and locations of crane-related fatal injuries.

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Figure 13. Geographical distribution of fatal injuries due to crane safety incidents as a function of the
immediate cause of the incident.

Each symbol represents one fatality. The graph includes fatalities that have occurred since 2012
and for which an immediate cause was identified.

High Risk Work (HRW) licensing

HRW licences relevant to crane-related activities

In total, 67,275 workers are currently licensed either for rigging, dogging, or operating a crane. A
large proportion (77.6%) of these workers hold a licence for dogging. About half (48.9%) hold a
licence to operate a crane, and 25.4% hold a licence for rigging.

Figure 14 provides details of workers’ licensing in relation to crane-related activities.

More than half of the workers (57.6%) are licensed to work in only one role: that is, they are
licensed just to undertake rigging, dogging, or operating a crane. The most specialised role is
dogman, with 35.7% of licensed dogmen holding only one licence. Among workers licensed to
operate a crane, 20.5% hold only an operators’ licence. Riggers are relatively less specialised with
only 1.3% of licensed riggers holding a single licence. The majority of riggers (88%) also hold a
licence for dogging.

About one in ten workers (9.4%) holding a HRW Licence relevant to crane activities are licensed
to perform all three roles. Of 33.1% of workers who hold two types of licence, most hold a licence
for dogging (98.1%) in combination with a licence for operating a crane or for rigging.

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Figure 14. Proportions of HRW licences held by individuals for crane-related activities.

‘Rigger + Dogman’ means the individuals have both a rigging and a dogging HRW Licence.

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Figure 15. Proportion of licenced crane operators as a function of the number of crane operation licences
held (top panel), and as a function of the type of crane operation licence held (bottom panel).

The top panel of Figure 15 shows the proportions of crane operators as a function of the number
of different cranes they are licensed to operate. The results indicate that operators are highly
specialised with most holding a licence to operate one type of crane only (82.8%). Fewer have
licences to operate two types of cranes (13%), and very few are licenced to operate three or more
types of crane (4.2%).

The bottom panel of Figure 15 presents the proportions of crane operators as a function of the
type of crane they are licensed to operate. The three most frequent licences held relate to mobile
cranes. In decreasing order, slewing mobile crane (up to 60 tonnes) is the most commonly held
licence with 26.3% of the crane operators holding this type of licence, followed by slewing mobile
crane (up to 20 tonnes) and non-slewing mobile crane (greater than 3 tonnes) which are held by
20.1% and 19.7% of crane operators respectively. Note that these three licences allow the operation
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of the lightest types of mobile cranes (all less than 60 tonnes). The most common types of cranes
which operators are licensed for, after mobile cranes, are bridge and gantry cranes (15.6%),
followed by tower cranes (6.3%).

Age and experience of currently licensed riggers, dogmen and crane operators
The age and the experience of workers who hold High Risk Work licences related to crane
activities (that is, rigging, dogging or crane operation) was examined. The results are presented
in Figure 16.

Figure 16. Licensed riggers, dogmen, and operators, by age and experience.

Experience in a role is calculated as the time period for which a licence in this role has been held.
If more than one licence was held in a role, experience was calculated as the time the oldest
licence had been held. The analysis was performed separately for different types of licences (that
is, if an individual held two licences, such as dogging and operating a crane, this person would be
counted twice in the analysis – once for their age and experience in holding the dogging licence,
and once for their age and experience in holding the operating licence).

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Independently of the role, the results show that between approximately 60% and 70% of the
cohort are over the age of 40. Most workers licensed to engage in HRW related to crane activities
have between 10 and 15 years’ experience in their roles.

Operators are, on average, the most experienced and oldest of the cohort of licensed workers
engaged in crane-related activities, with an average of 49.1 years of age and 9.4 years’ experience.
Riggers are, on average, slightly younger (46 years of age) and less experienced (9.1 years).
Dogmen represent the youngest and least experienced population of licensed workers, at 44.5
years of age and 8.5 years’ experience.

High Risk Work licensing and crane safety incidents

Using the HRW Licence database, individuals involved in crane-related safety incidents were
identified to determine their licencing details at the time of the incident (see Table 10).

Of 280 individuals with a HRW Licence and identified to be involved in crane safety incidents, 68
were not included in this analysis since more than one individual could be identified under the
same name, and therefore a reliable matching of data was not possible.

Eighty-one names could not be found in the licensing database at the time of the recorded
incident. It must be noted that a ‘text string’ search was performed for the HRW Licence-holders’
names, as they appeared in the ‘Incident Description’ field of the WSMS workplace incident
dataset. One possible explanation for these individuals not appearing in the HRW Licence
database might be that their names were incorrectly scribed by inspectors in their reports.

Of the 131 individuals who could be identified in the HRW Licence database, 29 (or 22.1%) were
found to be licensed for another role than the one they were reported performing at the time of
the incident. For example, a worker holding a licence only for rigging at the time of the incident
was reported as being the dogman in one workplace incident. Finally, 102 (77.9%) of HRW Licence
holders involved in crane safety incidents (who could also be identified in the HRW Licence
database) were found to be licensed correctly for the role (dogging, rigging, or operating) they
performed at the time of the incident.

Note that this analysis does not account for the different variations of licence existing under the
same role. For example, ‘operating’ includes all licences related to operating a crane. The present
analysis does not distinguish between the range of licences existing to operate different types or
classifications of crane.

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Table 10. Licensing status of persons involved in crane safety incidents.

Column one describes the role of the individual. Column two describes the number of individuals identified
in crane safety incidents by name. Column three describes whether the individual could be uniquely
identified by their name in the HRW Licence database. Some names were not unique and therefore could
not be matched to a single individual. Column four lists the number of individuals who could not be found
in the HRW Licence database. Column five lists the number of individuals licensed for the wrong role at the
time of the incident. The last column lists the number of individuals licensed for the correct role at the time
they were involved in a crane safety incident.

Licensed for Correctly

Number of No
Non- another role (at licensed (at
Role persons licence
identifiable time of the time of
identified recorded
incident) incident)

Rigger 32 8 12 2 10

Dogman 81 18 19 17 27

Operator 167 42 50 10 65

Total 280 68 81 29 102

A chi-squared test of independence was performed to compare whether the age and experience
of the 102 HRW workers involved in crane safety incidents (and found to hold a valid licence for
their role at the time of the incident) differed significantly from the age and the experience of the
HRWs currently licensed for the same role according to the HRW Licence database.

Age was only found to be a significant risk factor for the occurrence of crane safety incidents for
operators (χ2 (6) = 22.30, p = 0.001). Experience was found to be a significant risk factor for crane
operators (χ2 (3) = 43.27, p < 0.001) and dogmen (χ2 (3) = 34.84, df = 3, p < 0.001). The analysis
revealed that, more than expected, dogmen and operators with less than five years’ experience
in their role were involved in crane safety incidents. In other words, dogmen and operators with
fewer than five years’ experience in their role are more at risk of involvement in crane safety
incidents.

Figure 17 presents a graphic representation of the difference in experience between the general
population of crane riggers, dogmen, and operators, currently licensed compared to those
individuals identified as having been involved in crane safety incidents who were correctly
licensed at the time of the incident. The average experience of the entire population of operators,
dogmen, and riggers, was 9.4 years, 8.5 years and 9.1 years respectively. For operators, dogmen,

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and riggers, who were involved in crane safety incidents, the experience was significantly lower
at 6.5 years, 5.4 years, and 6.7 years respectively.

The results show that workers with less than seven years’ experience (approximately 30% of the
overall group) are, on average, involved in the majority of workplace crane safety incidents. It is
important to note that these workers are not necessarily young workers, as age was only found
to be a significant risk factor for crane operators.

Figure 17. Comparison of age and experience profiles of licensed workers involved in crane safety
incidents compared to all licensed workers.

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Density curves show experience (in years) of HRW Licence holders involved in incidents at the
time of the incident (grey filled), and the experience of all HRW Licence holders currently licensed
(colour filled). The top panel shows the density curves for riggers, the middle panel shows density
curves for dogmen, and the bottom panel shows density curves for operators. The dashed lines
represent the averages of the underlying distributions.

HRW training
The RTO database was examined to check whether workers involved in crane safety incidents
were correctly trained to perform their roles. The results are presented in Table 11.

Of 280 workers identified in crane safety incidents, 212 were omitted from further analysis since
more than one individual could be identified by the same name and therefore a reliable
dentification was not possible.

A total of 13 names could not be found in the training database at the time of the incident. Of 55
individuals who could be identified in the HRW training database, 12 (or 21.8%) were found to have
been trained for a role other than the one they were reported to be engaged in at the time of the
crane safety incident.

A high proportion of HRW Licence holders (43 individuals, or 77.9% of individuals identified in the
HRW Licence database) were found to have been trained correctly for the activity they were
performing at the time of the incident (for example, dogging, rigging, or operating).

It must be noted that this analysis does not account for different variations of training existing
under the same role. That is, a worker with an operators’ licence would be considered (in the
analysis) to be correctly trained for operating a crane, no matter the type of crane involved in the
training.

The top panel of Figure 18 shows the number of RTOs and their size. The middle panel shows the
distribution of trainees by RTO. This shows that a small number of RTOs (n=10, 8.5%) is
responsible for training more than half the workers trained to perform high risk work (n=14,175,
50.2%). In other words, a quarter of the total number of RTOs involved in training of crane-related
HRW is responsible for training 84% of the currently licensed workers engaged in crane-related
HRW.

A chi-squared analysis revealed the RTO’s number of trainees as not a significant risk factor for a
licensed worker to be involved in a crane safety incident (χ2 (2) = 0.05, p = 0.976); that is, a
trainee has the same chance of being involved in a crane safety incident whether they were
trained by a large RTO or a small RTO.

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Table 11. Training experience of workers with HRW licences involved in crane safety incidents.

Results of a search within the training database for the 280 workers with HRW licences found to
be involved in crane safety incidents. Column one describes the role of the individual. Column two
describes the number of individuals identified in crane safety incidents by name. Column three
describes whether the individual could be uniquely identified by their name in the training
database. Some names were not unique and therefore could not be matched to a single individual.
Column four lists the number of individuals who could not be found in the training database.
Column five lists the number of individuals trained for the wrong role at the time of the incident.
The last column lists the number of individuals trained for the correct role at the time they were
involved in a crane safety incident.

Number of Not found in

Non- Trained for Correctly
Role persons training
identifiable another role trained
identified database

Rigger 32 23 1 3 5

Dogman 81 56 4 3 18

Operator 167 133 8 6 20

Total 212 13 12 43

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Figure 18. Training and incident experience of licensed workers involved in crane-related activities, by RTO
size. Proportions and numbers of RTOs (top panel), HRW trained (middle panel), and HRW trained who
were involved in a crane safety incident (bottom panel).

PCBU crane ownership and history of compliance notices

A total of 390 PCBUs was found to own the 2,313 cranes registered in NSW, with an average time
for owning a registered crane of approximately 7.8 years.

Figure 19 presents the number of cranes owned per type of crane. Most PCBUs registered as
crane owners were found to be specialised regarding the type of cranes they owned, rarely
holding registration for both mobile and tower cranes: only 17 PCBUs, or 3.2%, owned both crane
types. Slightly more than half the PCBUs hold registration for one crane only (n=273, 51.3%).

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Figure 19. Proportion of PCBUs owning at least one registered mobile crane (MC) or one registered tower
crane (TC) as a function of the type of cranes owned (mobile crane, tower crane, or both), and the total
number of cranes owned.

The number of notices issued against a PCBU by SafeWork NSW between 1 January 2007 and 1
February 2019 was used as an indicator of the capacity of a PCBU to work in line with WHS
requirements. Note that notices issued for all WHS infringements, not only those that were crane-
related, were included in this analysis.

The top panel of Figure 20 presents the number and distribution of previous compliance notices
issued to PCBUs owning at least one registered crane in NSW as at 1 February 2019. The majority
of crane owning PCBUs have no history of notices (n=388, 63.5%). For the remaining PCBUs, 100
(18.8%) received between 2 and 10 previous notices, and 46 (8.6%) received more than 10 notices
in the period under consideration.

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Figure 20. Proportion of PCBUs as a function of the PCBU’s previous number of notices.

Top panel shows the proportion for PCBUs owning at least one registered tower or mobile crane.
The middle panel shows the proportions for PCBUs that have notified or have been identified in
crane safety incidents. The bottom panel shows the proportions for PCBUs owning at least one
registered tower or mobile crane and that has also been identified in a crane safety incident.

Characteristics of PCBUs involved in crane safety incidents

Finally, the population of PCBUs currently owning at least one crane (Figure 20, top panel) was
compared to those involved in a crane safety incident (although not necessarily owning a crane)
(Figure 20 middle panel).

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The Australian Business Number (ABN) of the PCBU could be identified in 390 (36.2%) of crane
safety incidents reported (36.2%). A chi-squared analysis revealed the history of notices as a
significant risk factor for crane safety incidents (χ2 (7) = 580.94, p < 0.001).

As Figure 20 illustrates, when comparing the distributions in the top and middle panels, PCBUs
with no history of compliance notices are less likely to be involved in subsequent crane safety
incidents (38.2% against 63.5%). In contrast, PCBUs with more than 10 compliance notices are
more likely to be involved in subsequent crane safety incidents (25.1% against 8.6%).

The bottom panel of Figure 20 compares owners of registered cranes only. The 390 PCBUs found
to be involved in crane safety incidents were extracted from the list of 532 PCBUs that own at
least one registered crane. The search resulted in 55 PCBUs that are registered as owning at least
one crane and that were found to have been involved in a crane safety incident between 2012 and
2017. A chi-square analysis revealed a history of notices as a significant risk factor for workplace
incidents (χ2 (7) = 372.89, p < 0.001). An examination of the results showed that PCBUs with no
history of notices are less likely to be involved in crane safety incidents, whereas PCBUs with two
or more notices are more likely to be involved in crane safety incidents.

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Discussion
The research was undertaken in response to the persistent frequency of safety incidents involving
cranes in the Australian construction industry. In Australia, 47 workers were killed in incidents
involving cranes between 2003 and 2015 (Safe Work Australia, 2016a). Safe Work Australia (2019)
also reports that there are, on average, around 240 serious injury claims arising from crane safety
incidents every year.

The aims of this research project were twofold:

1. To identify causes and contributing factors associated with safety incidents involving cranes
in the construction industry.
2. To explore strategies to reduce the risk of crane safety incidents in the construction industry.

The research utilised three different methods. First a review of the extant literature was conducted
to produce a synthesis of previous research analysing the causes of crane safety incidents in the
construction industry and measures identified for the prevention of such incidents. Second, an
analysis of quantitative data collected by SafeWork NSW, pertaining to the occurrence of crane
safety incidents and the licensing of workers in relation to the use of cranes was undertaken. Third,
in-depth qualitative analysis relating to crane safety incident causation and strategies for
prevention was collected from industry stakeholders and subject-matter experts. This qualitative
data was analysed to develop cause-effect trees and a crane safety incident causation model, as
well as to develop themed suggestions as to how crane safety incidents could be prevented in
the Australian construction context.

This following discussion describes key findings from the three component parts of the research.
The discussion identifies four main areas of crane safety incident causation and provides
suggested solutions to address key areas of:

• workforce competence
• supply arrangements, communication and planning
• equipment design, maintenance and use
• The industry and regulatory environment.

Workforce competence
The analysis of Safework NSW data showed that human error is the most frequently identified
causal factor in crane safety incidents in NSW. This result is consistent with findings published in
other parts of the world. This finding may be partially explained by the propensity of most
traditional investigation methods to focus on the immediate causes of an incident, which has led,

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especially in tasks where a human operates a machine, to an increased focus on operator
performance as the primary cause. However, modern safety incident causation models enable the
explanation of wider range of causal factors for safety incidents in the construction industry,
including those involving cranes (for example, work planning, time pressure), rather than
allocating blame solely on the machine operator.

Notwithstanding this, the proportion of crane safety incidents attributed to human error in NSW
found in SafeWork NSW data suggests workforce competence may be a key issue for crane safety
incidents in the NSW construction industry. Industry experts consulted in the research also
identify workforce competence to be a critical factor in the prevention of crane safety incidents.
Industry participants in the interviews and focus groups were critical of the current licensing
system for crane operators (and others who work with cranes), arguing the possession of a HRW
Licence may not reflect that a worker is sufficiently knowledgeable to operate a particular make
or model of crane. The industry participants also perceived a lack of consistency in the training
provided by RTOs, which impacts workforce competence and safety. Interestingly, the analysis
of the SafeWork NSW data revealed that the size of the RTO at which a worker is trained does
not impact their likelihood of being involved in a crane safety incident. Participants also
commented that experience in relation to the use of a particular make or model of crane is an
important factor in safe operation and that, in the absence of a ‘log book’ system, employers and
principal contractors are not easily or universally able to determine or verify an operator’s
competence in using a particular crane.

Focus group/interview participants frequently raised workforce inexperience as having an impact

on safety. The importance of experience was supported by the quantitative analysis of data from
SafeWork NSW which revealed a significantly higher proportion of crane safety incidents than
expected involve operators with fewer than five years’ experience. For the purpose of that
analysis, experience was deemed to be the length of time they had held the relevant High Risk
Work Licence. It did not relate to experience related to a specific make or model of crane. Focus
group and interview participants also perceived it is ‘too easy’ to obtain a licence for crane
operation, dogging, or rigging, which negatively impacts workforce competence and safety when
combined with an overheated construction industry environment and high level of demand.
Inexperience was also reported to be a risk factor for dogmen in the NSW quantitative data
analysis. This is noteworthy because the literature review revealed that improper lifting practices
(such as lifting over people) contributes to crane safety incidents.

Analysis of SafeWork NSW data also revealed that 22.1% of workers licensed to perform High Risk
Work, and who were involved in crane safety incidents, were undertaking work for which they
were not licensed correctly at the time of the incident. This suggests the licensing system is not

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operating in an effective way. The literature reveals that time pressures inherent in work at
construction sites can sometimes create pressures that encourage unqualified workers to perform
certain tasks.

The literature also identifies the competence of persons who plan and coordinate the use of
cranes and lifting operations at a worksite as being critical for the safe use of cranes. Participants
in the focus groups and interviews similarly commented on the fact that site-based decisions with
the potential to impact the safe operation of cranes are often made by people with little
knowledge of crane use or safety, such as site engineers. Participants identified a need for crane
safety to be better incorporated into the education or training of engineers who enter the
construction industry and who are likely to take on project management or supervisory roles.

Suggestions for addressing issues associated with workforce competence

In relation to identified causal/contributing factors relating to workforce competence, a number
of suggestions were made by industry participants in the focus group consultations and
interviews. These are summarised below. First, participants advocated a more stringent licensing
system that would consider the experience of workers, as well as their training records. The formal
recording of experience (in a log book, for example) was deemed important for ensuring workers
have sufficient relevant experience to perform particular tasks. This would also assist employers
and principal contractors to verify the competence of workers to operate a particular make or
model of crane and/or perform a particular task in relation to the use of cranes at a construction
site.

Some participants suggested implementing a tiered licensing system which would reflect a
worker’s level of experience. Thus, workers could potentially have a probationary period
(equivalent to drivers of motor vehicles) during which managers and supervisors would be aware
of their limited experience and be better able to manage this, for example, by managing workload
expectations, allocating appropriate tasks, providing ongoing skills development and mentoring.

The literature review revealed ongoing debate about the relevance of generic training for crane
operators, and the potential need to verify competence specific to the make and model of a crane
to be operated. Such verification methods were considered important, and the CICA CrewSafe
system was identified as a mechanism that supports effective machine-specific VOC processes.

Participants in focus groups/interviews identified the need for specific training for site engineers
and personnel with responsibility for planning for, coordinating, and managing, crane use at a
construction site. This would require engagement with higher and tertiary education providers to
ensure that crane safety is incorporated into programs for people entering engineering and site
managerial roles in the construction industry.
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Supply arrangements, communication and planning
Most contemporary models of safety incident causation recognise the importance of
organisational issues and management actions in contributing to workplace safety incidents.
Analysis of construction accidents reveal that many construction accidents can be attributed to
professional or managerial failures arising well before work commences on site, most notably in
the planning and design stages (Bomel, 2001; HSE, 2003). The project-based and dynamic nature
of construction work present challenges for the improvement of work health and safety, which
needs to be considered in the project planning and design stages, when the potential to positively
influence WHS has been demonstrated to be at its highest (Lingard et al. 2015). Further an
emphasis on ‘lowest price wins’ tendering processes are reported to negatively impact WHS
innovation and improvement (Langdon, 2011).

International studies report that construction contractors sometimes use specialist equipment
providers in an attempt to ‘transfer’ their responsibilities for workplace safety risk, believing
(incorrectly) that their responsibility can be reduced through contract lift hiring practices.
However, principal contractors maintain a responsibility for the management, coordination,
planning and safety of site-based activities. The literature review identified management factors
in the procurement, planning, on site coordination, and directing of crane activities, are important
in maintaining safe crane operations. The industry stakeholders and subject matter experts who
participated in the interviews and focus groups attributed poor or insufficient planning to time
pressures associated with delivering construction projects. These were often traced back to
pressures put on the principal contractor by the client of a project, that are then transferred to
crane operators. This could result in pressures to continue working in adverse weather conditions,
poor light, and/or working long hours resulting in fatigue. Such pressures were identified by
participants in the focus groups and interviews.

Focus group/interview participants also suggested that a ‘fixed price’ payment mechanism for
crane service providers can have negative safety impacts because delays or disruptions impact
upon the ‘bottom line’ for crane companies. Under fixed price payment arrangements, crane
operators may be under greater pressure to work in unsuitable conditions or to work excessive
hours to ‘get a job done,’ enabling the contractor to move to the next job. Participants in focus
groups/interviews suggested engaging crane service suppliers/operators on an hourly rate is
preferable as this mitigates some of the pressures inherent in fixed-price contracts. Focus
group/interview participants also observed crane operators are more likely to experience
pressure to keep working and feel unable to stop work in unsafe operating conditions under
conditions of ‘dry’ compared to ‘wet’ crane hire, as operators tend to be employed under more
flexible (and potentially precarious) terms in such arrangements.

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Site planning and design factors were identified as having the potential to contribute to crane
safety. In particular, effective and early communication between the principal contractor and the
crane services provider is beneficial in terms of safety. The literature highlighted examples of poor
communication between principal contractors and crane companies, particularly related to design
and site management considerations, resulting in serious safety incidents. Participants in the
interviews and focus groups observed that, in the Australian construction context,
communication between principal contractors and crane contractors is often very good.
However, participants also observed that, in other cases, communication can be poor. Given the
experience and expertise of specialist crane contractors, there are important safety benefits to
be gained from involving them early in discussions and decision-making about the type of crane
to be used, site access, site conditions, crane location and lifting methods. In some cases crane
contractors indicated that they are called to work at a particular construction site with little notice
and no opportunity to visit the site beforehand to gauge the requirements and pre-plan for safe
lifting operations.

Finally, participants in focus groups/interviews raised concerns about the operation of WHS
management systems in the construction industry and the impact of these systems on crane-
related safety. In particular, participants commented that Safe Work Method Statements
(SWMSs) are sometimes overly long and contain generic information not specifically relevant to
crane operations at a particular worksite; for example, documenting the requirement for basic
personal protective equipment. Further, participants argued the volume and complexity of safety-
related documentation can discourage workers from reading it. Participants described a ‘tick and
flick’ approach to WHS management in the construction industry as providing a false sense of
security that effective safety arrangements are in place. Importantly, participants in focus
groups/interviews also observed that task-specific SWMSs can be developed in isolation, relating
to activities of one subcontractor or work crew, while crane operations typically affect the whole
worksite. Participants observed that safety issues arising from the interfaces between
subcontractors, work crews or site-based activities are sometimes not identified or effectively
addressed by existing work health and safety management processes, which has the potential to
negatively impact the safety of crane operations.

Suggestions for addressing issues associated with supply arrangements, communication and
planning
The importance of pre-planning lifting operations (with the involvement of the crane operator,
principal contractor, and subcontractors) was identified by focus group/interview participants.
This was also recognised in the literature which identified the need to involve subcontractors in
decisions relating to the best type of crane to use for specific lifting tasks, and the regular (and

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frequent) review of the adequacy of lifting arrangements at construction sites (Sertyesilisik et al.
2010).

Participants in focus groups/interviews recommended that industry-accepted standard

agreements be developed and instigated for the procurement of crane services. These could
include:

• standard clauses identifying responsibilities for safe operation of cranes at a worksite

• clearly articulating in tender documents agreed maintenance requirements and safe
operating parameters for using cranes.

Participants believed that such standard clauses would establish clear responsibilities in relation
to the safe use of cranes, remove ambiguity about the circumstances in which crane operations
should cease in unsafe conditions and ensure that maintenance requirements are understood,
planned for and adhered to.

Participants also suggested developing standard templates so that crane operators could
document situations in which work should be ceased (for example, poor weather).

The literature review also highlighted the opportunity to use technologies, such as ‘back-to-base’
data loggers, to:

• capture important data about crane use

• provide operators with objective data to support decisions made about safe operating
conditions
• potentially reduce operators’ unwillingness to raise concerns or stop work if necessary.

It is important to ensure good communication about design issues, construction processes,

scheduling, and sequencing of operations. International crane safety incidents documented in the
literature review highlight the importance of communicating important information (particularly
when circumstances change) to crane supply companies (see, for example, the incident described
in Appendix 1).

Improvements may also be made to site-specific planning documents regarding safety of crane
operations to ensure the documents:

• contain safety-critical information about hazards and risk control strategies relevant to
crane-related activities
• are easy to read and understand
• address and communicate issues relevant to specific crane use and lifting tasks to be
undertaken at a construction site.
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The literature also emphasises the importance of conducting a pre-lift meeting, including all
relevant parties at a construction site. At these meetings, safe working arrangements for lifting
would be agreed on and each party’s role and responsibility for safety in the lifting operations
would be documented. This idea was supported by comments made by focus group/interview
participants who noted the benefits associated with visiting a construction site before deploying
a crane. Making such a site visit enables site-specific hazards to be identified and planned for;
however, in some instances crane operators indicated contractors’ timelines preclude them from
making a pre-deployment site visit.

Equipment design, maintenance and use

Many parties have responsibilities for crane safety. These include:

• crane designers, manufacturers, importers and/or suppliers

• crane owners and other persons with management or control of the crane or the workplace
where a crane will operate
• competent persons who inspect cranes
• crane operators (SafeWork Australia, 2015).

Thus, crane designers, manufacturers, importers and suppliers have responsibilities to ensure that
the cranes they design, manufacture, import or supply are safe to use. They also have a duty to
ensure that safety-relevant information is communicated from designers, to manufacturers,
importers and suppliers right down to the end user of a crane. Crane owners and persons with
control of a workplace where a crane is being used also have responsibilities for making sure that
the crane is fit for purpose, is used in accordance with manufacturer’s specifications and that
maintenance work and examination/testing requirements are met to avoid technical equipment
failures.

The literature review revealed that technical equipment failure is a causal factor associated with
crane safety incidents with (or with the potential for) the most serious consequences. The analysis
of SafeWork NSW crane safety incident data revealed that, after human error, faulty equipment
is the most common cause of crane safety incidents, although the number of crane safety
incidents caused by faulty equipment fell by almost one half between 2016 and 2018.

Participants in focus groups/interviews identified the standard, reliability and condition of

equipment as a causal/contributing factor for some crane safety incidents. Immediate
circumstances identified by participants (relevant to the quality or condition of equipment)
included the operation of substandard cranes, and structural or electrical failures. The operation
of substandard cranes was traced to design and importation factors, generic or poorly written or

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translated manufacturers’ information about crane use requirements, and inadequate
maintenance of cranes and related equipment. Inadequate maintenance was linked to industry
demand and pressures applied by clients and principal contractors to continue working, which
can make maintaining a maintenance regime challenging for crane contractors/companies. The
quality of maintenance management is also identified in the international literature as a key factor
impacting risk associated with crane use in the construction industry.

Structural or electrical failures of cranes or their components were traced to modifications of

crane installations, as well as perceived deficiencies in the enforcement of WHS regulations,
compliance with Australian Standards and/or registration, inspection regimes for cranes.

Analysis of the international literature revealed that design-related factors are identified – albeit
rarely – as contributing safety incidents involving tower cranes. Equipment design can, therefore,
be considered a latent condition in crane safety incident causation in some circumstances.

Suggestions for addressing issues associated with equipment design, maintenance, and use
Industry participants in focus groups/interviews raised concerns about the quality of information
(for example, maintenance records) provided about cranes supplied or imported from overseas.
The importance was emphasised of checking that imported cranes comply with the relevant
Australian Standards.

The literature review also revealed that modifications to crane installations, including replacing
component parts with parts not supplied by the OEM, is a risk factor in crane safety incidents. In
some jurisdictions, the development of a registering and tracking system for crane components
throughout their life has been recommended. Thus, any modifications, repairs or replacements
would be recorded, enabling them to be carefully checked by a competent person.

Participants in focus groups/interviews suggested more rigorous application and enforcement of

crane safety inspection regimes be implemented. In particular, the literature identified third party
crane assessment programs as important. CICA CraneSafe is an example of such a program in
which crane inspectors are not employed by entities owning or operating the crane being
inspected, so are not subject to commercial pressures to maintain operation. CraneSafe also
publishes data on the most frequently found equipment faults for each type of crane covered by
its inspection/assessment program, which is useful information when purchasing and managing
crane equipment.

Industry stakeholders who participated in interviews raised concerns about the aging fleet of
cranes in use in the Australian construction industry. Consideration of the usage of cranes in
relation to their design life is recommended. Key stakeholders involved in the research pointed

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out that the age of equipment (in years) does not provide a sufficiently granular indicator of their
usage, which would be related to the wear and reliability of components. In the US, for example,
recommendations have been made to collect operational data (potentially via a data logging
system) that could be used to more reliably measure the functional age of a crane relative to its
design life (Smith and Corley, 2009).

Crane components can also be subject to structural or mechanical failure if the crane is used
outside specified safe operating parameters, such as lifting loads too heavy for the crane, and/or
working outside load chart limitations. The literature review revealed technologies that can help
to ensure safe lifting practices are maintained. In particular, the use of ‘back to base’ data logging
technology was advocated by focus group/interview participants.

Industry and regulatory environment

The construction industry is characterised by the use of long (and often complicated) supply
chains, with the majority of site-based construction work performed by subcontractors.
Subcontracting is widely reported to create challenges for the management of WHS (Arditi and
Chotibhongs, 2005). Loosemore and Andonakis (2007) argue that, although trade
subcontractors make up the bulk of the Australian construction industry’s workforce and often
account for over 90 per cent of a project’s value they can “lack the resources, culture and skills”
to manage WHS risks effectively (p.580). Wadick (2010) argues poor communication between
trades and ineffective consultation between workers and managers in relation to work health and
safety increase the dangers associated with subcontracting in construction projects. Further,
‘payment-by-results’ arrangements under which subcontractors are typically engaged can
encourage corner-cutting (Mayhew et al. 1997). The role of the regulator overseeing and
promoting health and safety in this challenging industry environment is critical. The research
revealed a number of areas in which regulators’ actions have the potential to positively impact
the safety of crane operations in the construction industry.

The literature review tended to focus on causal/contributing factors in the immediate

environment, or circumstances of crane safety incidents. However, some studies did consider
industry-level systemic factors as contributing to crane safety incidents. These included
competitive pressures within the industry, the internationalisation of construction markets and
features of the regulatory environment, including inspection/enforcement regimes and
certification requirements for crane use.

Analysis of SafeWork NSW historical incident data also focused on more immediate
circumstances of crane safety incidents. However, the analysis did suggest some systemic issues
at play. For example, PCBUs that own at least one registered crane are significantly more likely

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to be involved in a crane safety incident if they have a history of receiving two or more notices in
SafeWork inspections prior to the incident. Thus, a track record of WHS compliance issues with
WHS legislation is a predictor of future crane safety incidents. This suggests providing additional
support to construction organisations or worksites at which WHS compliance issues are found
may be an effective ‘early intervention’ strategy for preventing crane safety incidents.

Focus group/interview participants made comments about regulatory behaviour, suggesting the
announcement of inspections before the event reduced their effectiveness in ensuring the safety
of crane activities. Participants commented that worksite inspections are sometimes announced
prior to their occurrence and the operations of smaller crane operators (particularly in the case
of mobile cranes) may not be subject to inspection. Potentially this creates an
inspection/enforcement gap in which cases of non-compliance may not be identified.

Participants also commented on the current ‘overheated’ construction industry market as

contributing to long working hours and fatigue: crane companies are put under considerable
pressure by principal contractors who, in turn, are under pressure to meet clients’ construction
project programs. Combined with a shortage of skilled and experienced personnel, this was
perceived to be a ‘perfect storm’ among focus group/interview participants who observed that
less experienced workers are operating under increasing work intensity, in a context in which
equipment maintenance is sometimes deferred and irregularities are overlooked in the interests
of maintaining project progress.

Suggestions for addressing systemic industry factors

Focus group/interview participants suggested the level of enforcement of crane-related safety
requirements should be increased. Using crane registration and location data to inform proactive
(and unannounced) inspections of worksites was suggested. However, in relation to the use of
mobile cranes, a mechanism for capturing the start and finish dates at which cranes would operate
at particular locations would be required.

Participants also suggested the regulator could play a stronger mentoring/advisory role in
providing advice and guidance about how to prevent safety-related incidents involving cranes.
The model of crane incident causation developed in this report is one mechanism the regulator
can potentially use to leverage the advice provided about factors to consider when managing
risks associated with crane use at construction sites. However, given the identified impact of
competitive pressures and the multi-layered system of contracting and subcontracting, targeted
advice should be provided to construction industry participants whose actions (or omissions)
could impact on the safety of crane activities, from clients and principal contractors through to
designers, large subcontractors who use crane services, and crane companies. Improved

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communication and coordination between stakeholders have the potential to improve safety in
crane activities. For example, integrating specialist knowledge about lifting operations into
decisions made during the design stage of a construction project has the potential to reduce WHS
risks at the source, through designing for safe construction.

It is important that all relevant industry stakeholders understand the role they can play in ensuring
safety in crane use and lifting operations at construction sites.

Crane safety incident causation and prevention

Workplace safety improvements are shaped by knowledge and assumptions about how accidents
happen (Gibb et al. 2014). Understanding how accidents occur is important in order to distinguish
between factors that are relevant and require some action, and factors that are unimportant and
can be ignored (Swuste, 2008). However, compensation-based surveillance systems may not
capture sufficient information to be used effectively for prevention purposes. Safety incident
causation models ‘represent, classify and efficiently organize’ safety-related knowledge and
provide a theoretical framework for the investigation of incidents and the identification of hazards
present in a workplace’ (Arboleda and Abraham, pp. 274–5). Hollnagel (2002) argues that incident
causation models can make safety communication and understanding more efficient.

The crane safety incident causation model developed in the qualitative component of the research
provides an evidence-informed taxonomic framework that can support the analysis and
understanding of factors causing or contributing to crane safety incidents in the construction
industry.

The model extends the consideration of causal factors beyond an incident’s immediate
circumstances. It identifies site management issues as shaping factors in crane safety incident
causation, and factors in the broader construction industry and regulatory environments as
originating influences with the potential to contribute to crane safety incidents.

Proposed uses for the crane safety incident causation model

It is proposed that the crane safety incident causation model be used in two ways.

First, the model can be used to guide crane-safety incident investigation and analysis. In providing
a series of prompts and guidewords, the model can be used to identify the immediate
circumstances surrounding a crane safety incident, and trace these immediate circumstances to
the shaping factors and originating influences that lie at their ‘root cause.’ The guidewords and
prompts provided by the model are likely to produce a greater degree of consistency, and reduce
the chance that important factors may be missed in such analysis. They also provide a basis for
the quantification (and potential ranking or weighting) of factors in the future. This could be based
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on a retrospective analysis of incident data or further expert analysis. The use of the crane safety
incident causation model as an investigation tool has the potential to prompt participants to
consider factors operating at deeper levels within the system of work than the immediate
circumstances of an incident (that is, shaping factors and originating influences). It is also likely
to produce greater consistency in the classification of causal/contributing factors 11.

Second, the model could be used to inform an analysis of risk factors inherent in construction
activities in which cranes are to be used. In this way, the model could be used to identify relevant
factors that should be considered when planning for crane use in a particular context.
Understanding these factors, and the ways they can ‘play out’ to impact the safety of crane use,
has the potential to improve the quality and consistency of risk identification and management,
and to ensure appropriate controls are identified for crane-related activities.

_____

11 Over time, and as the model is used, it is likely that new causal/contributing factors will be identified. Thus, the crane safety incident
causation model should be regarded as a ‘living’ document.
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Conclusion and key findings
The research revealed that factors that cause or contribute to crane safety incidents operate at
different levels within the prevailing work system in the construction industry. The literature
review identified the following as causal or contributory factors to crane safety incidents:

• the regulatory environment

• prevailing levels of worker skill and competency
• industry supply issues
• site planning and management issues
• physical worksite conditions
• human errors and equipment failures.

These factors were also identified by Australian construction industry stakeholders and
representatives in the qualitative component of the research.

Data collected from these stakeholders and representatives was subjected to a systematic
analysis process to create cause-effect trees. These trees formed the basis of the development of
a bespoke crane safety incident causation model. It is suggested that this model be used as a
guide to incident investigation, as well as a tool to communicate crane safety issues and inform
risk assessments related to crane operations in the Australian construction industry.

Participants in the focus groups and interviews also identified opportunities to improve crane-
related safety in the Australian construction industry. Industry experts consulted in focus
groups/interviews also identified strategies that could assist in preventing safety incidents
involving cranes. Suggested strategies fell into seven topic areas, as follows:

• training and competence

• development of a code of practice for crane operations
• communications and awareness raising
• the role of the regulator
• design and import issues
• technology use
• procurement and the management of commercial relationships.

It is recommended that these suggestions be explored further, in consultation with a broader

range of stakeholders, to develop short, medium and long-term actionable measures that will
improve the safety of crane use in the Australian construction industry.

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Appendices
Appendix 1. The Bellevue crane incident

In November 2006, a 210ft overhead tower crane overturned at a building construction site in
Bellevue, WA. The incident led to the death of a bystander, injury to one worker, and damage to
three nearby buildings. The crane operator was trapped in the cabin and was eventually rescued
by firefighters. The crane had been in use on site for about 2 months when the incident happened.
At the time of the incident, wind speed was negligible and there was no load on the hook.

Due to site restrictions, a steel frame had been designed for the crane base. The frame comprised
two girders and two beams attached to existing concrete columns which supported the crane
above existing post-tensioned slabs.

Incident investigations concluded the crane base was under-designed. Based on the early
information received from the crane supplier, the designer had used structural ties between the
building core and the crane tower to bear the crane overturning moments. Therefore, these
moments were not considered in the crane base design. The ties were subsequently eliminated
by the contractor due to a delay in the core construction. However, the base design had not been
modified to accommodate this change. This issue was attributed to a major miscommunication
between the contractor and the designer, as well as severe time pressure which led to
simultaneous design and fabrication of the base.

The structural collapse was initiated by fatigue cracking at the connection between one of the
beams and the girder. The designer had used a standard design for the connection. However, due
to space restrictions the beams were coped at both ends, but the web stiffeners on the beams
were truncated and mislocated causing stress concentration at the connection points. This design
issue was combined with the large moments which, with the elimination of the ties between the
crane and the building core, were exerted to the base frame during the crane operation.
Consequently, fatigue cracks developed at connection points. This further compromised the
structural adequacy of the base to resist forces due to crane overturning moments, and eventually
led to structural collapse and crane overturn.

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 Originating Factors

Design of crane base

Design deviations Design included structural ties

between the crane and the
• The coped web stiffener was parking structure to carry
truncated at the vertical edge, overturning moments (as
rather than continuing to the end characterised in an early design
of the beam concept from the crane supplier)
• Small connection plate, not
providing enough space for 8 bolts
spaced at 3 inches

The designer subsequently increased

beam web extension and number and
space between bolts
Time constraint Lack of planning
Design changes
were not received
Design and fabrication
before fabrication
undertaken simultaneously
2.5 inches space between bolts
rather than 3 inches

Shaping Factors Structural ties eliminated in Project / Site constraint

subsequent versions of the Delay in the construction of
construction plans building core
Beam coping at both ends
Lack of coordination /
Site constraints miscommunication between
Bolts abandoned in favour of
designer and contractor
welding angles to the beam web
Changes were not communicated
effectively or acted upon by the
• Truncation and misallocation designer
of the web stiffeners
• Large weld deposit at at the Crane-base under designed
cope re-entrant corner

Immediate Accident
Circumstances Crane base subject to repeated
load reversals due to wind and
crane operation

Supporting structure (crane-base)

not adequate
Components of crane-base were
loaded well beyond yield capacity

Fatigue cracks in both beams’ webs

grew to 12 inches

Structural base not able

to resist overturning
moments

Crane overturn

Figure 21. The Bellevue crane incident. Based on McDonald et al. 2011.

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Appendix 2. A fatal mobile crane incident

A rough terrain hydraulic mobile crane, with a lifting capacity of 20 tonnes, was lifting a section
of a new high-voltage electricity transmission tower. The project had been underway for almost
a year. The tower was made of five sections. The crane had already lifted two sections and had
started lifting the third section. The tower section was made from steel, with a 3m by 3m section
and 10m long. The crane was attempting to stand up the section by lifting one end of the section
while the other end remained on the ground. During the lifting process, when the end of the
section was approximately 5m off the ground, the section unexpectedly fell. One of the crane
crew, who was holding a guide rope and standing directly underneath the load, sustained severe
injuries and died when he was struck by the tower section.

The crane was bought secondhand and imported to Australia. As part of the importation process,
approvals were obtained from various government departments and the crane was inspected to
ensure its compliance with Australian standards. The crane had two winch drums, one to hoist
the main (larger) hook block and the other to hoist an auxiliary (smaller) hook block. At the time
of the incident, the auxiliary winch was in operation.

The crane had been fitted out with a ‘free fall’ system. The free fall mechanism could be engaged
using two toggle switches, one engaging the free fall function on the main winch (denoted by a
‘M’ sign) and the other engaging the free fall function on the auxiliary winch (denoted by a ‘S’
sign). Beside the switches on the controls panel, the signs indicated two positions, ‘Free’ and ‘ON’.
According to the crane manual, the free fall function would be engaged on each of the two
winches when the relevant switch was put into ‘Free’ mode. The ‘ON’ position, on the other hand,
denoted that the free fall mode was disengaged (that is, the winch clutch was engaged). When
the switches were in an ‘ON’ position, a green light indicator would turn on. The winches would
not go into free fall by only putting the switch into ‘Free’ position. Multiple steps were involved
including: lightly pushing down the auxiliary winch brake pedal, putting the switch into ‘Free’
mode, pushing the brake pedal further down until a shudder is felt, and slowly releasing the pedal
until the auxiliary hook goes into free fall.

The Queensland Mobile Crane Code of Practice (2006) requires that free fall function on mobile
cranes be locked out with a ‘keyed lock out’. For this particular crane, a ‘lock out bar’ had been
attached to the control panel, horizontally across the switches, to prevent the free fall toggle
switches moving into the free fall mode. The lock out bar had been screwed to the panel at both
ends. Investigators considered this a simplistic solution in comparison to using a lock out bar
which is more tamper proof than a screw type bar.

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During the incident investigation, it was found that the lock out bar had been attached to the
incorrect side of the toggle switches, actually preventing the free fall function from being
disengaged. The crane operator was unaware the crane was in free fall mode. He had never been
shown how to engage the free fall function, and he had thought it was not operational.

Although the crane had undergone several major and minor repairs, services and inspections since
the lock out bar was installed, the bar’s incorrect position had not been identified.

As post-incident tests revealed, since the switches were already locked into the ‘Free’ position,
an inadvertent push on the brake pedal, which was adjacent to the winch pedal, could get the
auxiliary winch into free fall. In addition, a warning buzzer, which was supposed to go off just
before the free fall, was not heard during the test. Once the crane got into free fall, the operator
would have had inadequate time to brake and stop the free fall.

The incident investigation concluded the incorrect installation of the lock out bar was a
contributor to the incident, although no direct causal relationship was proven. It was
acknowledged that the features on the control panel with the use of words ‘Free’ and ‘ON’ were
confusing. Although, the crane manual explains these words and the process of engaging the free
fall function, the evidence suggested the lock out bar had been installed without any regard for
the manual. Similarly, the crane inspections were undertaken regardless of the crane manual and
it was assumed the free fall function was not operational. The non-functional auxiliary winch light
and warning alarm had perhaps contributed to engagement of the free fall function being
undetected. Furthermore, post-incident inspections concluded there was no mechanical fault to
the winch. Thus, most likely, the winch had gone into free fall due to an inadvertent brush against
the pedal by the operator, while the free fall system had already been engaged and was in a
standby mode due to the incorrect position of the control switches.

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 Originating Factors
Crane imported from overseas

Crane design

Notation on the free Crane featured a Main winch brake pedal and
fall control panel ‘free fall’ function auxiliary winch brake pedal
was confusing were close to each other

Shaping Factors
Modification to crane

Lock out the free fall function to

comply with Australian standards

‘Lock out bar’ Crane manual was

installed incorrectly not referred to

The auxiliary winch Incorrect installation of Major and minor services and
light and alarm were the lock out bar was not inspections did not include the
non-functional detected free fall system.

The crane was in ‘free fall’

mode

Immediate Accident
The operator was unaware that the
Circumstances crane was in ‘free fall’ mode. He Not following
assumed that the ‘free fall’ function manufacturer’s
was not operational. instructions / manual

The operator unintentionally

pushed the auxiliary brake pedal

Free fall function activated, load fell

A crew member was standing

underneath the load

Fatality

Figure 22. A fatal mobile crane incident.

Based on a report produced by the Queensland Office of the State Coroner.

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Appendix 3. A tower crane incident

In March 2008, a luffing tower crane collapsed in New York City, killing seven people. The crane
mast was laterally supported by steel beam ties connected to the building’s structural slabs at the
3rd and the 9th floors. The ties at each floor consisted of three wide flange beams fastened at
one end to the building floors, and at the other end pinned to a square steel collar surrounding
the mast of the crane. The tie beams on the 3rd and the 9th floors were installed using a mobile
crane at the time of the crane’s initial installation. The employees were installing the tie beams on
the 18th floor without using any mobile crane. This was the first time the employees were installing
the tie beams in this manner by using the crane itself.

Workers had increased the height of the crane by inserting four additional tower sections about
an hour before the incident. This had occurred with no problems. The crane was then placed back
in operation. At the time of the incident they were adding another lateral ‘tie-in’ collar to support
the crane tower at the 18th floor level. Connecting the crane mast to the 18th floor slab through
the tie beams to provide lateral support involved the following process:

• Erect a steel collar around the crane mast by suspending it from the mast steel members
above the collar. During this operation, the collar would not be physically connected to the
mast but could have an approximate gap of 2 inches between the collar and the mast.
• Connect the collar to the 18th floor by three tie beams. One end of the tie beams would be
fastened to the structural floor slab, and the other end placed in the collar pocket and pinned.
• Finally, re-plumb the crane to eliminate the gap between the collar and the mast by
tightening the blocks to provide a tight fit. There would be no positive connection between
the collar and the mast. The tie beams were to transfer lateral loads only, and not gravity
loads.

The construction company had approval to raise the crane. The crane had been inspected the
day before the incident with no violations found.

The collar weighed approximately 11,200lbs and came in two halves. The collar was fabricated by
the crane manufacturer two years prior to the incident.

Approximately one hour before the incident, the crane hoisted the first half of the collar, weighing
approximately 5,600lbs, and brought it near the 18th floor. Each half of the collar was equipped
with six lifting lugs from which it could be supported. The crane hoisted the first half of the collar
on the east side of the crane mast. As the hoist approached the crane mast, the employees using
the tag line positioned the collar by hanging it at northeast and southeast corners by two 2-inch
wide polyester slings choked around the column flanges and the steel angles of the K-braces.

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Each sling was attached to a come along which, in turn, was connected to chain fall fastened to
the collar lifting lugs.

In a similar manner, the other half of the collar was then brought by the crane on the west side of
the crane mast, again lifting at lugs. This half of the collar was also hung by two 2-inch wide
polyester slings on the northwest and southwest corners using the same arrangement described
above. When both halves of the collar were levelled and plumbed, the two halves were bolted
together with four bolts on the north side and four bolts on the south side.

There were no reported problems to this point. The employees then began to place tie beams
into the collar. At the northwest end, there were two tie beams to be placed, and on the northeast
side one tie beam was to be placed. At the time of the incident, only the east tie beam, still
supported by the crane, was placed in the pocket of the collar, but the pin was not yet placed
when suddenly the employees heard a popping sound. Then the employees heard another
popping sound followed by a third sound.

The Occupational Safety and Health Administration (OSHA) investigation revealed a sling failed
under load, allowing the unattached collar to slide down the tower and crash into a building ‘tie-
in’ collar at the 9th floor level of the building. The two loose tie-in collars then crashed into the
supporting collar at the 3rd floor level. This was not ripped out but supporting braces were
broken. The lack of lateral ties transformed the crane mast into a free-standing structure with no
lateral support above the 3rd floor. The counterweights of the crane were facing away from the
building and so were effectively pulling the crane away from the building. The loss of the tie-in
supports permitted the mast section to rotate and fall away from the building. The upper tower
sections fell onto a lower neighbouring building. The top of the crane separated from the mast
during this and fell to the ground.

The OSHA report revealed that four synthetic slings were used to support the collar and, if choked
properly and in a good condition, these slings would provide an ultimate failure capacity of
approximately 20,000 pounds. Given the weight of the collar at 11,200 pounds, the four slings, if
all are supporting the collar weight equally, would provide a factor of safety of approximately 7
or more. However, if the slings were not choked properly, and if one of the four slings failed, the
capacity of the remaining slings would be greatly reduced. All four slings failed in the incident,
with each sling shearing in two pieces.

It was also acknowledged that none of the slings were protected against sharp edges of the
column legs and the steel angle legs. OSHA proceeded to determine whether the slings placed in
the V-shaped crotch could have a significantly reduced capacity to support the load.

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OSHA engaged a sling expert to examine the sling remnants and provide an opinion on the failure
of the slings. After microscopic examination of the fractured surfaces of the slings, the tests
indicated that the slings failed at loads significantly lower than their ultimate capacities due to
contact with edges of the wide flanges. OSHA was most interested to determine the load carrying
capacity of the slings when trapped in a V-shaped notch with sharp edges of the crane mast legs
and the steel angles of the braces.

Further tests were undertaken to replicate the actual manner in which the slings were used at the
time of the incident. Twelve slings (made by the same manufacturer as those involved in the
incident) were tested. They were choked around the column flange and trapped in the V shape.
It was concluded that under sustained load, the slings failed at approximately 7,100 pounds,
significantly lower than 20,000 pounds (5,000 pounds x factor of safety of 4.0 = 20,000 pounds).
The failure was also preceded by popping sounds similar to what the employees had described
hearing before the incident. The testing also showed that elongations of the slings was not
consistent suggesting the collar must be levelled by using come alongs as it is being lifted. If the
levelling is not undertaken at all four corners, and if the collar is permitted to dip at one corner
greater than at other corners, then the load of the collar might be taken by only two slings instead
of four. This would double the load on the supporting slings.

Post-incident examination of one of the slings used in the lifting revealed the sling was already
frayed and deteriorated, even before it was used to support the collar. The situation worsened
when the sling was choked around the column, forcing it into a V-shaped groove. Degradation
and damage to the sling was so great the expert suggested it should have been discarded and
not used.

Further, the installation process deviated from the manufacturer’s guidelines. The lifting points
used did not correspond with manufacturer’s instructions. When the collar was positioned around
the crane mast, the employees had no alternative but to suspend the collar in a way that meant
the slings were choked around the column (into a V-shaped groove). This reduced their load
carrying capacity. If the collar had been supported in the manner recommended by the
manufacturer, the slings would have had adequate capacity because they would have been
supported from steel members directly above the collar. Furthermore, according to the
manufacturer, each half of the collar should be supported at four points instead of two. If the
instructions contained in the drawing were followed, the collar would have been supported at
eight locations (rather than four), until the two halves were bolted together.

The City of New York’s Department of Buildings also conducted an investigation and issued a
report one year after the incident. The main findings were as follows:

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The collar section being lifted was suspended from the tower at only four points, contrary to the
manufacturer’s recommendations, which require the use of eight points.

The points on the collar from which it was suspended from the tower were not intended for that
purpose by the manufacturer.

The synthetic slings used to suspend the collar were choked around the tower in a manner that
is not in accordance with industry practice, and which reduces the strength of the slings.
Specifically, the slings were not protected from the sharp edges of the vertical tower members,
and the slings were bunched and edge loaded in a V-shaped area.

One of the four slings was in a deteriorated condition and should not have been used. 12

OSHA’s conclusions in relation to this incident were similar:

The choice of using polyester slings to suspend the collar at four points was questionable as they
are subject to large elongations under tensile loads, creating a need to constantly monitor and
level the collar.

The collar was rigged improperly in that the slings used to suspend the collar were choked around
the vertical legs of the crane mast and was seated in the V-shaped groove between the angle
bracing and the flange of the crane mast leg. This significantly reduced the load carrying capacity
of the slings.

The slings were not protected against sharp edges for cuts and abrasions.

A deteriorated sling, which should have been discarded if proper inspection of the sling was done
prior to its use, was used to suspend the collar.

The crane raised the collar from the ground, hoisting it at locations different from the crane
manufacturer's recommendations. This led the employees to suspend the collar from locations
above which there were no horizontal members. This resulted in choking the slings around the
legs of the crane mast.

Each collar half was suspended at two points instead of at four points as recommended by the
crane manufacturer. 13

_____

12 https://www.ishn.com/articles/87959-report-improper-rigging-operations-caused-fatal-new-york-crane-collapse-3-17
13 https://www.osha.gov/doc/engineering/2008_r_02.html

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 Originating Factors
Lack of planning by contractor/ Crane operator’s knowledge and
operator experience
Poor planning about installing the Employees lacked experience about
lateral tie installing tie beams and collar

Shaping Factors
Site constraints
Lack of experience
Tall building – not able to use a mobile Lack of maintenance
(operator/decision maker)
crane to lift the tie beams and collar

Immediate Accident
Not following Lack of hazard awareness
Circumstances
manufacturer’s instructions

Wrong suspension points Using 4 slings instead of 8

Improper rigging
Not able to suspend the collar from
steel beams of crane structure directly Wrong lifting points
above the collar

Uneven lifting of the load Overloaded slings

Polyester slings choked around

the crane tower
Damaged slings Deteriorated sling
Slings not protected against
sharp edges

Slings failed

The tie-in collar dropped and

ripped out the collar on level 9

Supporting structure not adequate

No other lateral support for the crane

Crane overturned

Damage and fatality

Figure 23. A tower crane incident

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Appendix 4. A mobile crane incident
A 500-ton mobile crane collapsed while repairs were being made to a cathedral building that had
sustained damage in a recent earthquake. The contractor appointed to undertake the repair work
decided to erect a scaffold system on the roof of the cathedral’s centre tower to access damaged
ornamental/decorative components. The centre tower’s roof height was approximately 320ft, so
to build the scaffold system the contractor needed to use a crane to transport scaffold pieces
and structural beams to roof level. A crane company was engaged to assemble the crane and
undertake the lifting operation.

While lifting the scaffold components amid thunderstorms and heavy rain, the mobile crane
collapsed. The crane’s telescopic boom was 152ft and the attached lattice jib’s length was 276ft.

The crane tipped, overturned and fell its full length along a road adjacent to the building. It
damaged three parked vehicles and a historic building. The crane operator sustained non-life-
threatening injuries. The incident had the potential to cause significant loss of life and damage.

The telescopic mobile crane was relatively new at the time. It was a seven-axle mobile crane
equipped with a telescopic boom and a lattice jib. Three months before the incident the crane
had been load tested and certified by a competent person.

Four days before the incident the crane was positioned adjacent to the cathedral. The four
outriggers were extended and the pads were lowered onto the pavement. The rear right outrigger
pad was positioned near a catch basin, 15ft away. This was a masonry structure constructed more
than 100 years ago.

The crane commenced work the day after it was assembled. After a few lifts (of approximately
3,200 pounds) the operator and others observed cracking in the asphalt pavement at the rear
right outrigger pad. Cracking continued the following day, causing a settlement of a quarter of an
inch at the right rear outrigger pad.

The crane company placed two 12-inch thick timber mats, 32ft long and 4ft wide, side by side on
the asphalt, and added an 8ft by 9ft steel pad between the mats and the rear right outrigger pad.
The purpose of the mats and the steel pad was to uniformly spread the load over a larger area
and minimise any additional settlement.

The following day, after performing the daily inspection, the crane operator set the 152ft long
telescopic boom to 82 degrees. The attached lattice jib length was 276ft. A lift was made carrying
3,200 pounds of scaffold components without any problem. The next load was steel I-beams that
weighed 8,600 pounds. The load was rigged and delivered to the roof of the tower (approx. 320ft

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high). As the load was being released on the roof, intense lightning and rain began. The weather
obscured the view of the jib from the operator’s cab.

The load was released and the operator raised up the hook to clear the cathedral tower. The
operator then swung the boom and jib counter-clockwise to the west and began luffing the jib
down to a lower angle to let the storm pass by. The operator argued that, because it takes
approximately 20 minutes to telescope the boom inward due to the crane’s 12-part pulley system,
he decided not to telescope the boom inward. Instead, he lowered the jib to near zero degrees
and lowered the boom to approximately 68 degrees to minimise risks from possible lightning and
thunderstorm activity.

The operator reported feeling a sudden vibration of the crane after which the boom began to fall
and the counterweight rose until it almost stood vertical. The counterweight then rotated, hit the
pavement and the timber mats supporting the outrigger, and pierced through the pavement. The
north counterweights became separated from the crane and fell off. The counterweights on the
south side remained connected.

An OSHA investigation determined that, when the telescopic boom reached an angle of 63
degrees to the horizontal, and when the jib was nearly horizontal, the overturning moment of the
crane was 8,000,000 ft-pounds. The stabilising moment at this position of the crane was
computed to be 7,980,000 ft-pounds, and hence the failure.

The load chart provides the maximum permissible load that can be hoisted at various working
radii. Working radius is defined as the horizontal distance from the centre of the turntable to the
vertical axis of the load being hoisted. Furthermore, the telescopic boom angles at which
permissible loads are provided at different radii are also given. At the time of the collapse the
crane had a working radius of 344 feet. This was beyond the allowable radius provided in the load
chart which did not go beyond 260 feet, with the boom at an angle of 75 degrees. Moreover, in
the load chart applicable to this crane, only two angles for the telescopic boom were provided
(that is, 82 and 75 degrees). So, the boom could only be operated between angles of 82 and 75
degrees. If the boom was at an angle greater than 82 degrees or at an angle lower than 75 degrees,
then the crane would be in violation of the load chart, and a failure could be imminent.

At the time of the collapse, the overturning moment was greater than the balancing moment due
to the larger radius and lower angles of the boom and the jib. Even though the crane was not
hoisting any load at the time of the incident, the weight of the headache ball and the riggings
were enough to create instability at a radius of 344ft, resulting in the crane overturning.

This was verified by data retrieved from the crane’s data logger that provided insight into the
actual configuration: that is, the angle of the boom, the angle of the jib, the crane platform’s
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orientation, the load at the time of the collapse, the utilisation ratio, and the outrigger reactions.
The crane collapsed at approximately 11.00am, which coincided with measurements of the vertical
angle of the boom falling from 70 to 68 degrees, and the vertical angle of the jib falling from 4 to
0 degrees. Shortly prior to the collapse, at 10.44 am, the jib was at an angle of approximately 51
degrees and was then well within the load chart. At 10.52am the crane jib was suddenly lowered,
at which time it was operating outside the load chart. At this stage it appears the crane was
automatically shut off. However, at 10.56am the crane began to operate once more. It is not clear
why this happened but one explanation (denied by the operator) is that the operator by-passed
the crane’s automatic shutdown mechanism. At 11.00am the crane’s data logger shows that the
front-left outrigger pad had lifted. The collapse followed immediately.

The crane operator denied hearing any warning in the cabin, but the data logger suggests he was
able to continue operating the crane for some 8 minutes after it was outside the load chart.

The OSHA analysis revealed that if the operator had maintained the boom at 81 degrees and the
jib at 22 degrees, the incident would not have happened, despite the raging storm.

OSHA concluded that the right rear support of the pad settled approximately 6 inches before the
incident but did not cause the collapse. Its contribution to the collapse was minimal. If the crane
had been operated within the load chart, the collapse would not have occurred despite the
settlement.

Further, OSHA reported the wind speed at the time of the collapse was approximately 15 miles
per hour with no appreciable gusts. Therefore, wind did not cause the collapse.

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 Originating Factors

Crane operator’s knowledge and

experience

Shaping Factors

Inadequate site Lack of experience Site constraints

Proximity to other
supervision (operator/decision maker) Bad weather and ground settlement
buildings/structures

Immediate Accident
Circumstances Not following
manufacturer’s instructions

Operator’s decision
Operator taking to violate the crane
shortcuts load chart Lack of hazard
awarenes

Override safety
technology

Load transfer too

far

The overturning moment

greater than the balancing
moment

Crane collapsed

Damage and injury

Figure 24. A mobile crane incident.

Source: https://www.osha.gov/doc/engineering/2012_r_02.html

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Appendix 5. Crane incident causation analysis table
Level Issue Definition Quote(s)

IMMEDIATE Working in unsuitable Working outside in I think more people being aware of what damage the wind can do,
CAUSES weather conditions conditions that are not especially customers. Understanding how much we can go with the wind.
suitable. Conditions may And the danger… cranes are designed to lift straight up and down, not
include, but are not limited drag sideways and that sort of thing.
to, storms, wind, rain and
excessive heat. So, weather and wind and rain can be horrendous for the guys that are
working outside in it. Especially they get you on site and they say they
want you to wear safety glasses, and the doggies are trying to look after
them, and they’ve got rain come on their safety glasses, and they can’t see
because the portable lights are blinding their eyes, and they’re trying to
plumb the load up… so weather and wind and rain can be horrendous for
the guys that are working outside in it.

Lighting/visibility Adequate lighting and The lights can be a pain because if they’re facing the wrong way, if they’re
visibility are important to the blinding you, sometimes you can’t see.
safety of crane operations.
This issue particularly relates Tower cranes, we don’t like them doing them at night, but you end up
to night work or work in poor running into darkness a lot of the time especially in winter.
lighting.

Not following Crane manufacturer’s Then go to [project name] where the process is that a crane basically is
manufacturer’s instructions contain specific getting dismantled and the processes of following the actual
instructions information about product manufacturer’s guide how to pull it apart wasn’t followed.
specifications, erection and
dismantling instructions, and
maintenance requirements.
Without this information, Not all of them are computerised and have all the gizmos on them to stop
workers may not understand you lifting or whatever. So the technology is not the same on them all, so
how to safely you can have operators that over lift and do things with them that they
assemble/disassemble or shouldn’t do.
operate a crane.

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Level Issue Definition Quote(s)

Hazards not identified Crane activities in a … you always have a visual. If it’s on some sort of concrete slab beside a
construction site context building and you can see cars going around underneath, close, you will go
present a range of safety down and have a quick little look to see what’s under there, you know?
hazards. Being able to
identify these hazards and But it’s like driving across a football field. If you go into a job where you’ve
respond appropriately to got to drive across the Sydney cricket ground, we know, we’ve been in
them is important for safe there before, we can do it. But, if it’s wet, that’s a hard judgement, you’ve
working. got to take that call. Yeah, it’s hard.

I guess from a risk management point of view, the risks are constantly
changing, because no day is ever the same. The environmental risks on site
are always changing and always need to be reassessed.

Lapse of concentration A lapse in concentration can

affect the way in which work
is undertaken. Being
distracted can lead to errors
and safety incidents when
performing high risk work
such as crane operation.

Existing soil conditions Ground conditions vary from Because it’s all a below ground hazard that… unless you get a geotech sign
not considered one workplace to another off on it, it’s a – you might still have those incidents, but at least we’ve
and even within a single done –
workplace. Failure to address
poor ground conditions to People think that just because they did it at the start of the job, that they
ensure a crane is stable can don't have to continually do it. You have to.
cause the crane to overturn.

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Level Issue Definition Quote(s)

Changes to ground Weather conditions can also …the changing ground conditions because we put in project conditions,
conditions when it rains impact ground conditions. but what was there yesterday might be different to what is there today.
The stability can also be
reduced by the soil drying
out due to hot and sunny
weather. Undertake a
suitable and sufficient site
investigation after weather
events to determine the
nature of the ground
conditions. Monitor
groundwater and soil
saturation levels.

Crane position where Contact with overhead So the other thing that occurs on those sorts of sites is that they quite
services are located powerlines can pose a risk of often set up over underground services. Because it’s only short duration
below/above electric shock or work they don’t do ‘dial before you dig.’
electrocution when
operating the crane. It can be They strike power lines regularly because they work in close proximity to
difficult for crane operators power lines. They’re all aware that power lines are a major issue but of
to see powerlines and to course, as I said before, they get a phone call the day before, they turn up
judge distances from them. next morning, they have a quick look, they decide where the set-ups going
Equally important is to to be which is usually somewhere between the footpath and the base
identify underground frame of the building.
services and nearby
excavations.

Supporting structure not Prior to setting up a crane on If it’s on some sort of concrete slab beside a building and you can see cars
adequate site, the structure supporting going around underneath, close, you will go down and have a quick little
the crane should be look to see what’s under there, you know?
reviewed in a risk assessment
process to determine
whether the structure is
suitable.

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Level Issue Definition Quote(s)

Loads being carried too If a crane is overloaded, a What about the lack of availability, so it might not be the right crane for
heavy for the crane structural or mechanical the right job. So, you can’t get the one you want and you’re going to wait
component may fail or the three months but the project’s got the green light so they just whack up a
crane may overturn. The remote control one, without naming brands.
lifting capacities of cranes
are specified on a load chart. … rather than, say, having a 130-tonne crane put here, they need – because
They should not be of their lack of real estate – they need to try and do it for a 60 tonne in the
exceeded, except during corner. It’s not the right crane for the job.
load testing of the crane by a
competent person under
controlled conditions.

Load transfer too far The counterweight, the … if you have to pick up 10 tonnes at 10 metres radius, that may only be 80
away support structure, and the percent of the capacity of the crane. So, you’ve got an extra 20 percent to
stability of the boom are deal with the other swiss cheese variables. But if you order in a 60-tonne
affected by the distance crane, the 60-tonne crane might be cheaper to get there, cheaper to
from the load’s origin point operate, so on and so forth, but that’s 10 tonnes at 10 metres. So, the load
to the base of the crane. The or the position of the crane don’t change, but your capacity, you might be
rated load weight also varies lifting at 90 percent or 95 percent of capacity. So, you’re still within the
based upon the distance capacity of the chart, we’d advocate every day that you are allowed to lift
from the crane’s base to the to the chart, but that reserve that’s left is only five percent not 20 percent.
load at the end of the boom
or jib.

Crane too small for tasks Different crane types suit … rather than, say, having a 130-tonne crane put here, they need – because
being performed different project needs. of their lack of real estate – they need to try and do it for a 60 tonne in the
Choosing carefully will corner. It’s not the right crane for the job.
ensure the right crane for the
job is selected.

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Level Issue Definition Quote(s)

Unfamiliar with plant Workers in control of cranes Going further, too, with that experience is different cranes, different
being operated need to be competent to use operation modes, different procedures.
it safely. This includes having
the correct skills, knowledge,
experience, and risk
awareness. This should be
specific to the crane type,
make and model.

Negative interaction It is common for a number of I was just going to say, it's particularly the layout and this is why you're
between adjoining trades to be performing talking about is it causing you accidents. It's restricting slew, which
tasks/activities on site activities concurrently at a direction, where you can slew, what you can slew over.
worksite. If consideration is
not given to It’s more being landlocked. So if you haven’t got the planning for the radius
interdependencies and to either weathervane or where you can’t weathervane because you’ve got
interrelated safety issues, another building. Or, if you’ve got another crane in a proximity or vicinity
unanticipated hazards can of the crane you’re in.
arise.

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Level Issue Definition Quote(s)

Not following procedures Safety-related procedures We have to break the rules or else you can't get the job done. Breaking
are intended to reduce the the rules then adds risk.
risks of incidents by
informing workers of the Then go to [project name] where the process is that a crane basically is
correct way to perform a getting dismantled and the processes of following the actual
task. Failure to follow manufacturer’s guide how to pull it apart wasn’t followed.
procedures increases the risk
of safety incidents. …now that was a crane that had the latest dynamic LMI in. The guy hit the
override seven times. It timed out seven times…...Like, it was the latest,
latest, latest crane. Had every failsafe in it. EN13000 compliant LMI, and
they still had an accident.

One is, if you have a plan, then you don’t implement it, you can’t assume
the success of the plan is going to be delivered.

Likewise, you can’t just say, “I have a plan therefore, I’m going to go do it”
because the plan may not have been well thought out.

Operators taking short Taking shortcuts to increase Last week I got away with lifting 10% more than the cranes as I can lift,
cuts efficiency or improve today is 12% more. There’s not much more than 10%, so I’m probably okay.
productivity can have serious
safety consequences. We’ve got to do it in a way that’s wrong equipment and wrong lifting gear.
Consequences by the operator, safety margins, money and family and ‘I
think I’ll get away with it’.

Is there a four-hour time or whatever and they don’t want to go back to

the yard and pick up the stuff, so they just do it.

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Level Issue Definition Quote(s)

No lift plan/plan is not Good practice and correct Poor understanding of what you're actually lifting and where you've got to
reflective of the situation lifting methods enable large lift it to. Where you're able to set it up.
objects to be lifted efficiently
and safely. However,
incorrect lifting methods can
result in safety incidents.
Lifting activities should be
carefully planned to ensure
the correct procedure is
followed for a particular
situation.

Override of safety Safety technology includes … now that was a crane that had the latest dynamic LMI in. The guy hit the
technology engineered devices or override seven times. It timed out seven times… Like, it was the latest,
controls (safeguards) latest, latest crane. Had every failsafe in it. EN13000 compliant LMI, and
installed to ensure an activity they still had an accident.
or equipment is operated
within designed safe
operating limits.

A safety override refers to

such mechanisms being
ignored or circumvented (for
example, by being switched
off).

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Level Issue Definition Quote(s)

Structural/electrical Structural failure may include It was bolted down to a mangalloy bar, which are a very high strength
failure of crane the failure of any crane steel bar. They don’t like being welded too. They were welding a concrete,
component, such as the and they tack welded the reo onto the mangalloy bar to hold it in place.
boom, jib, hydraulic rams, or And the mangalloy bar’s snapped and we nearly had a tower crane down
wire rope. in [inner city street name]. It snapped at one corner, and they managed to
tie it down before it snapped the other three.
Electrical failure can be
inherent or related to failure … failure a number of years ago of a luffing wire
to verify electrical supply
and wiring connections in There are holes in some of the manufacturing of the locking system, and
accordance with relevant principally in some of the older stuff where there was a push to reduce
standards. mass of the crane and increase performance. My hotspot is luffing wires
and the evidence shows that it’s problematic out there at the moment.

It was down at [Sydney suburb] where basically the design of a structure

required a crane to be hand levered, yep, and with that process it failed. I
don’t know any of the elements that were basically contributing factors,
but they were looking at the actual section of the actual support for the
tower crane failed. There was talk at that time that might’ve been in our
substandard metals or pins and things like that, so design is now playing a
role.

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Level Issue Definition Quote(s)

Lack of hazard awareness Cranes should be sited Some have built in tech to stop... or gets to assist the operator but at the
where there is clear space same token, those who don't have it and they're relying only on the
available for erection, operator.
operating and dismantling.
Consideration should be … if people aren't aware of what restrictions are in place, then they make
given to proximity hazards wrong judgements of error and can create an issue.
such as overhead electric
lines and conductors, power
cables, radio frequency wave
transmitting towers, nearby
structures and building,
hoists, stacked materials,
other construction works, the
flight paths of airfields, the
route of aerial ropeway and
other cranes, public access
areas including highways and
railways, etc. Omission of
hazard identification can lead
to safety incidents.

Operating substandard Operating reliable equipment … the operator was reporting the wires broke. Wires broke, site manager
crane is critical in delivering a safe was signing it off, was going down to the plant yard. Plant manager was
working environment. receiving it off the fax, put them in a folder, no-one was picking it up.
Ultimately that crane driver should have been able to go in, throw those
Substandard plant or keys on the table and say, ‘that’s it, I’m not operating’.
equipment is a safety hazard.

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Level Issue Definition Quote(s)

SHAPING Working outside Fair Work Australia states … if we do 7.00 until 5.00 every single day, we're used to day shift. Then all
FACTORS standard working hours that a standard working of a sudden, it poses a risk when we're asked to do something at night.
week is 38 hrs, spread How do you manage fatigue?... and that's where that comes into play.
between 7am and 7pm. In
some instances, it may be a
requirement or permit
condition to work outside of
the standard spread of hours
to limit disruption and
impact on the public.

Long working hours Fair Work Australia states … first to arrive, last to leave, with mobile cranes, there's also the setup
that a standard working time, pack-up time that's often not accountable by some persons
week is 38 hrs, spread
between 7am and 7pm. .. with the hours of work by restrictions from [the public road authority]
Research has begun to and council and things like that because then we're forced to do night shift
identify evidence of a and guys have worked all day. And then your body clock doesn't adjust, so
relationship between long you've got fatigue factors coming into play.
working hours and an
increased risk of Then we get, maybe on a six-hour shift, even at night, and we need eight
occupational injuries. to ten hours of sleep.

Shift work/rostering Shift work involves working Well, all your authorities with infrastructure and things like that. They're the
schedule outside the standard working ones that govern when we can and can't go which then poses risks on
hours of 7am to 7pm. It hours of work. And so, you have an understanding, going back on [name’s]
typically involves workers comment, is hours of work; if we do 7.00 until 5.00 every single day, we're
working in ‘relays’. Shift work used to day shift. Then all of a sudden, it poses a risk when we're asked to
(at night) can upset sleep do something at night. How do you manage fatigue, doing... and that's
patterns and has been linked where that comes into play.
to fatigue and human error.

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Crane company In the context of increased They're booked out for four jobs, but don't know how they're going to fit it
overcommits demand for services, and in.
pressures to maintain
business performance,
companies sometimes
overcommit by taking on
more work than can be easily
resourced and managed
within a given timeframe.

Inadequate site Supervision of construction Like checking the oil and that... if I'd have started the crane back in the day
supervision activities is important for without flipping the cover up and actually pulling the dipstick out and
maintaining safety. Typical checking it, I'd have got me arse handed to me.
supervisory functions include
planning and allocating work,
making decisions, monitoring
performance and
compliance, providing
leadership and building
teamwork, and ensuring
workforce involvement.

Lack of competency and Competence is the ability to The first one is that people who are inexperienced – green, if you like – just
experience of crane undertake responsibilities get their licences and they’re then required to do work that only
operator/dogman/ and consistently perform experienced personnel should have.
activities to a required
rigger standard. It combines … they're not allowed to make a decision for themselves.
practical and thinking skills,
knowledge and experience. … that guy was a dogman for two years, but never had sufficient driver
The competence and training.
experience of individuals
working in and around But at the end of the day, they want us as companies, safety people,
cranes is vital. coordinators, allocators, they want us to sign off on people. We don’t give
them the ticket. We can familiarise people, and this is the biggest problem
Competent workers have the industry has today.
good situational awareness
and are able to identify Supply and demand, lack of training, has caused the problem.
hazards in changing

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 circumstances and maintain I think, that there’s areas of improvement for worker competence in just
safe working practices. ages of experience or years of experience. Some aspects of it are in place,
they just need to be followed.

Labour hire’s always an issue for us because whenever we look at

incidents, both with tower cranes and mobiles, they always you know not
always but a lot of the time they come down to operator error.

You know, all the basic stuff. But then once they get in there, and start
doing real intricate lifts, and that’s where the accidents are happening.

Complacency/ Complacency and … usually mobile crane operators in the lower end of the industry are older,
overconfidence can arise they’re highly experienced, they’re used to taking risk. Their perception of
overconfidence from repeated experience of risk is low because they’ve got away with it for a long period of time.
a specific activity or task.
We think we know what we’re doing. But just that one day the wind come
Too much familiarity can from the other direction, and it made it hard. You know? But my
create complacency or experience said we could get it up there, and the other bloke said yeah,
overconfidence, such that and it wasn’t about having to finish that job. But just, we were there and
new or emerging hazards are that’s just how we work. We try to get the job done like everything.
overlooked or the risks they
pose are underestimated. … then you’ve got the other end of the spectrum where they are over
experienced, if you like, because they think they know it all.
Maintaining a sense of
unease and the
understanding that things
can go wrong is important
for safety.

Inadequate/ incorrect Incorrect or inadequate There's a lot of emphasis put on information of weights of loads at Tier 1s.
information provided to provision of information can And as crane, most of the time, weights are not correct that you're given.
crane contractor increase the probability of
operator error, impacting You'll go, just ask any of the crane companies here. You'll go to a Tier 4
safety and productivity. builder at 7 o'clock; he's not even on site. Now you ask the labourer, what
am I doing? I don't know. Then he'll come driving through the traffic going,
‘fuck mate, why isn't the crane lifting?’ I said, ‘well mate, we don't know

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 what we're lifting’. And the workers don't give a shit because they get paid
from 7.00 until 3.30. They don't care mate. They'll sit there all day.

Lack of/poor safety in Poorly designed plant and The structural stability of them cranes, they don’t have ballast weight as a
design equipment, poorly designed footprint because they’ve tried to make them as light as they can to go on
interfaces, and poorly the slabs, and they go into tight areas.
designed activities, can result
in inefficiencies and safety Unfortunately, on one of the lifts, you had a situation where on the soffit of
hazards. Safe design is about the slab, they had a drainage pit. So, they couldn’t put the prop there. So,
integrating hazard they had to come back something like 400, and then they had another, it
identification and risk was a pipe – a fire pipe – that also got in the way. So, they had to come
assessment methods early in back another… so they had to move this thing about 900 times.
the design process, to
eliminate or minimise risks of There were some design issues across all equipment, nothing to do with
injury throughout the life of a tower cranes, which was sort of driven by the Australia Standards, that
project. It also relates to probably needs to be reviewed, and we certainly made changes in how we
considering operational do things relating to material that’s used in cranes…
activities, taking into account
the health and safety of
workers.

Inadequate onboarding Foreign workers have … because the construction industry here in Australia has got so busy now,
and industry induction of specific characteristics, such a lot of foreign workers now. A lot of foreign workers on working visa.
foreign workforce as different cultures, They don't understand our systems. They don't understand procedures.
background, and language,
which distinguish them from
locals.

Induction is a starting point

for an organisation to
introduce a culture norm that
supports health and safety.
Onboarding and industry
inductions should aim to
provide workers with
knowledge of OHS issues

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 and safe work practices
within the Australian context.

Lack of competency and Designing for cranes and … the engineers and some of the project managers who are involved don’t
experience of engineers their associated activities even know what they’re doing, but they dictate the whole scope of the
and decision-makers requires specialised crane.
knowledge and expertise
about crane specifications, They might be good engineers in their right. But a lot of them have got
limitations and operational zero experience with cranes.
requirements. Obtaining
qualifications as an engineer They were out and out told not to use their pads. They were told by
may not be enough to engineering side that the leg of the crane had to go directly over the dry
understand and be shores. If they had had their pads on the ground, it (an incident) wouldn’t
competent to consider all have happened.
that is needed to safely
design crane-related work … the engineers and some of the project managers who are involved don’t
processes. even know what they’re doing, but they dictate the whole scope of the
crane.

I had a job the other week where I knocked it back... where I was lifting the
back of the big gate that opens and closes on the boat, and they put their
other boats inside. And I lifted 40 tonne or something, and I said, I got it a
little way up but I couldn’t get it any more. And I said to the boys, ‘that’s it,
can’t go any further’. I stopped on that job. It’s just not worth it.

… the engineers and some of the project managers who are involved don’t
even know what they’re doing, but they dictate the whole scope of the
crane.

Now, it would be good if SafeWork could put some pressure on Engineers

Australia to raise the issue of how can they tell who’s competent, you
know, if they’re receiving certificates from people, how can they tell

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 whether they have the appropriate competencies to be issuing those
certificates?

... people who are engaging any old person just to do a crane foundation
design and they don’t realise what a true crane engineer does for you is
more than just a little foundation design.

Wet vs dry hire Wet hire includes machinery I know that most reputable companies or reputable crane operators –
and an operator, while dry especially with tower cranes and that – that they keep an eye on the
hire provides the machinery weather and when it gets past a too dangerous level or past the
only. Wet hire operators are manufacturer’s specifications, they do call their staff back in and stop
said to be familiar with the work. I know that. But that’s with reputable companies. And I mean that,
equipment and more because if they’re just dodgy hire people, or a person on body hire is not
cautious, having a vested going to go to the host employer and say they’re not going to do that.
interest in the condition of
their gear. The issue that I see quite a lot is the conflict of interest that the wet hire
crews have.
Dry hire allows for a more
flexible workforce. They will ring and report that to the crane company who employs them
and the crane company says, ‘Mate, I don’t give a fuck; you get back to
work because if that crane is down out of service, we’ll start to get back-
charged for that crane not being in service, you get up there and keep
driving that crane.’

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Documentation is too Information that is not We've got to also look at it when people who don't have the paperwork
generic/not site specific specific to the site or the straight away, they get hold of it, and they start to come as the same, just
particular task which is being with a different header.
carried out.

Lack of coordination/ Construction projects are We do our own checks. We do our own paperwork, but they never come
oversight of known for high risk activities. and indulge themselves with the rest of the site.
documentation and Coordination can be seen as
planning across multiple a process of managing a Quite often because you’ve got different entities working on the same site,
contractors number of activities being it means that they aren’t coordinating between each other and don’t have
undertaken concurrently in someone overwriting them doing the coordination. They’re left to their
an organised manner so that own devices.
a higher degree of
operational efficiency can be You're working in, the probably interaction with other trades and services
achieved for a given project. around, like you say, you've all of a sudden got somebody {next to you},
because they're trying to meet program and keep the project going, I need
A lack of coordination not to dig a trench here.
only negatively affects the
traditional construction
project parameters of cost,
quality and schedule, but the
ability to achieve a safe
working environment.

Requirement to submit Principal contractors Well, to go on a project, you've got to produce that before you actually get
SWMS prior to the job typically require the work.
commencing subcontractors to submit a
SWMS prior to commencing
work on site. Preparing a
SWMS before visiting a site
can prevent a workplace-
specific approach from being
taken and result in generic
SWMSs. This may not
produce the best safety
planning and preparation
outcomes.

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Modifications to crane Alterations or modifications The structural stability of them cranes, they don’t have ballast weight as a
installations are sometimes made to footprint because they’ve tried to make them as light as they can to go on
cranes so they can be used the slabs, and they go into tight areas.
for a specific
purpose/location. These may … it was bolted down to a mangalloy bar, which are a very high strength
not be subject to required steel bar. They don’t like being welded too. They were welding a concrete,
inspection/testing and and they tack welded the reo onto the mangalloy bar to hold it in place.
certification. And the mangalloy bar’s snapped and we nearly had a tower crane down
in [name of street]. It snapped at one corner, and they managed to tie it
Some modifications mean down before it snapped the other three.
that, even though the crane
is certified, it is significantly
restricted in its use.

Lack of maintenance of Regular inspections, … we constantly have a problem with trying to continue the upkeep of
plant and equipment maintenance and repairs are maintenance of cranes based on the fact that the builders want to keep on
to be carried out in building.
accordance with the
manufacturer’s instructions Maintenance is also a major issue on mobile cranes and that’s because they
or those of a competent tend to be going all the time and you really if the crane company’s working
person. Crane maintenance flat out they don’t have time to take a crane out of service so they’ll tend
needs to be factored into to stretch things further and further and then we end up with some rope
any type of crane operation, failure and a few other odds and ends that go on with that.
particularly over extended
timeframes and the type of It’s because they’re designing for a lifecycle period for them to say that
environment it is operating these guys, or are buying mobile or him buying a tower crane, or me to go
in. out and buy a tower crane, they’re going to say to me – and everyone’s
got this 10-year thing. It’s not a 10-year thing, it’s a duty cycle lifecycle.

… the fire that we had, one of the issues that we had there was the client
was not giving us access to the crane to service it at the regular servicing
rules.

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Fatigue Fatigue can result in a lack of If that guy doesn’t get, on his own making, his eight hours' sleep, we can't
alertness, slower reactions to control that. So, there's a certain responsibility on the people who operate
signals or situations, and the equipment that take it serious and adjust their lifestyle accordingly.
affect a worker’s ability to
make good decisions.
Construction workers are at
higher risk for fatigue due to
the nature of the type of
work involved. Factors that
can contribute to fatigue are
prolonged working hours,
physically and mentally
demanding work, and
working in the elements.

Mental health Construction workers are … but it’s the hours we do which is the hard thing, the crazy hours.
susceptible to poor mental
health. This is often People falling asleep and tired. Yeah, for sure.
attributed to long
(sometimes irregular) work But I think fatigue is still out there. I mean, everyone still does some crazy
hours, work-life imbalance hours as much as you try not to, but you still get the days where you’re
and psychosocial risk factors stuck and I live an hour and a half away from here, and then I’ll start at 4
in the workplace. o’clock in the morning.

Site constraints / Site layout and planning has … can we also please put air space in there? It is absolutely ridiculous in the
congestion / layout significant impacts on last 12 months it started, air space. Can't do this, can't do that.
productivity, costs, and
duration of construction. It I was just going to say, it's particularly the layout and this is why you're
also impacts the health and talking about is it causing you accidents. It's restricting slew, which
safety of those working direction, where you can slew, what you can slew over.
within that environment.
Constraints are usually We’ve been condensed, condensed, condensed, condensed. It’s a big
associated with restrictive problem everywhere. Melbourne’s actually the same now. So you’re just
site area where storage, working... your extremely limited square metreage footprint all the time.
transportation, temporary
works, and building activities,

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 are simultaneously
undertaken.

Lack of empowerment of In spite of legislative …that the builders want to keep on building…
crane operators requirements for worker
representation in relation to Look, what happens in tower cranes, they say that the builder. The next
work health and safety, day, they’re not welcome back on site.
workers may feel a lack of
empowerment and be We’ve had so many good operators kicked off site because they stick by
reluctant to ‘voice’ health their guns.
and safety concerns in
certain circumstances. This Yeah, there is this perception that you won't be invited back if you make
situation can be particularly life difficult for someone.
problematic when
subcontracted workers Yeah, they try and hold you to ransom.
perceive their continued
employment would be
jeopardised by raising health
or safety concerns.

‘Tick and flick' approach ‘Tick and flick’ refers to an If you have a 40-page documentation to give out to any of your operators,
to documentation outcome created by I guarantee you that if they've been operating off the same document for
situations of complex the same amount of time, they've been inducted into it properly, they
paperwork, bureaucracy, and know what's in it, you can quiz them on it. Any other guys, they go, ‘I don't
time spent on a process that know what's written in it. I don't care,’ because it's not relevant.
fails to pass on relevant
information in a concise and Don't tick and flick and say, ‘Yeah, it's here.’ Go and inspect where the
succinct manner. It is more equipment is before it comes to the jobsite.
about getting the paperwork
done. I audit management systems every day through all the builders and cos
there’s so much documentation management systems, sometimes the
most important documents are just a ‘tick and flick’ process.

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Procedure doesn’t Informing a workforce on the Well, the documentation will say, before climbing the tower put your
address or cover high risk proper ways to limit risks gloves on, make sure you’ve got good shoes, make sure you’ve got
activities while undertaking a task can sunglasses and a hard hat and a vest, and then it was saying nothing about
be captured in a procedure lifting the loads. It will say nothing about know what weight you’re lifting,
and can greatly reduce the check that on your chart that it will leave that load from the point you have
chances that workers will put to start through the – if it’s a tortured path, it might be halfway through
themselves and others at your tortured path which is actually the worst location for the crane. So the
risk. If risks are ignored or pickup point and a delivery point might be fine, but you’ve got to go
not recognised, then safety around something, and it’s going around something where you trip over.
measure cannot be put into So a lot of the systems talk about all the gloves and the boots and the
place. glasses, but forget about the lifting activity, which is the big high-risk issue.

SWMS done in isolation The primary purpose of a … some of the issues are crane crew does their stuff for the crane, steelies
(doesn’t consider other SWMS is to help supervisors, do stuff for theirs and there's this gap in the middle, the lack of interaction
activities on site) workers and any other between the systems and processes over here and the systems and
persons at the workplace to processes over there. There's a disconnect.
understand the established
requirements for carrying We do our own checks. We do our own paperwork, but they never come
out high risk construction and indulge themselves with the rest of the site.
work in a safe and healthy
manner. We're here for four hours and we won't be here tomorrow, so we don't
worry about it.
Completing a SWMS in
isolation may result in
identifying key risk factors
for the activity, or new or
evolving hazards as a result
of the activity.

Overly onerous The amount of paperwork or … clients say you need to sign onto the job permit and there's a whole,
documentation/too long level of detail in safety then there's an inch and a half of bloody site procedures. And you say, ‘I
and not read documentation should meet haven't read that yet, mate’.
the requirements of the
workplace, but not to the I think the current style of safety management on sites is doomed from the
extent that it becomes a start. We're expecting people [to read] through 20, 30-page documents.
burden to read and
understand.

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 One frustration of It expresses itself in safe work method statements that are 100 pages long
documents that are too long and indirectly they become meaningless because they’re so monotonous.
and overly onerous is that
workers can spend almost as It diminishes the meaningfulness of the content because the crane
much time familiarising operators that are being ear bashed about the SWMS and about the JSA
themselves with the content and about the lift plans, and about the onboarding and inductions, and the
and trying to comply as they white cards so forth, all of a sudden [they] just kind of shut down or turn
do completing the task. off.

…if it’s too long, no one is going to read them. And they just sign the back
of them.

Transient workforce Some organisations have The crane company will usually have a fleet of cranes. The operator for this
what is referred to as multi- one calls in sick today, the one I’m normally driving is sitting in the yard,
teaming—having their people there is no job for it. So I get put into that one.
assigned to multiple projects
simultaneously. And sometimes they’ll have one big crane and a few little Frannas. So
moving from this one to that one is really significant.
Continuously changing
personnel on project can be Some builders might supply their own labour where we might supply a
disruptive and create safety top-up labour or we might supply the whole crane crew, but then,
concerns through issues depending on the availability, if we take someone off a job for two days
such as lack of familiarity because the builder wants to put their own guy in there, he might not then
with the site or plant, etc. be available to go back there.

No specific requirements There is an assumption that We came up with an 80-point checklist drawing all of that stuff out of the
for cranes and their once a crane is certified then standards and manufacturer’s specification. Then came up with a
design for safe it is safe to operate. voluminous document to satisfy each of that criteria. Most of our guys
operations However, the level of detail were gathering the information to say well that’s the crane brake test
can be ambiguous and not certificate. Had some wonderful diagram on it. They don’t know what that
provide clear guidance on means yet they gathered that piece of information.
the limitation of the plant.
If you work a crane that works with saltwater every day of the week, your
manufacturer guidelines wouldn’t be the same as what you should be
doing cos you’ve got another factor.

I think there’s a lack of clarity around the documentation that is required or

needed for a crane through that commissioning process or at the end of

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 that commissioning process. Even with the Crane Safe program, as good a
program as it is, there’s not good transparency as to what that actually
represents. I know if they’ve gone through the Crane Safe program, but
what does that encompass?

Proximity of existing Failure to maintain sufficient … there's certain places you can't slew over because if you drop anything it
structures on site and clearance between other can cause billions of dollars.
adjoining properties plant and structures may
result in a risk of injury from … can we also please put air space in there? It is absolutely ridiculous in the
a collision between the crane last 12 months it started, air space. Can't do this, can't do that.
or its load with other plant or
structures. The risk of injury I was just going to say, it's particularly the layout and this is why you're
from collision is higher when talking about is its causing you accidents. It's restricting slew, which
the regular working zone of a direction, where you can slew, what you can slew over.
crane is next to another
structure. Mobile plant may
present a greater risk of
injury from collision with a
tower crane than a fixed
structure, as its position may
change.

Not recognising The needs of construction The site’s constantly changing. It changes daily.
continuously changing sites change considerably
site conditions and/or from time to time You came in to assess the site and its wrong information by the time you
layout throughout the project. As get back there.
the project progresses, more
areas are occupied by
permanent facilities leaving
less space to place
supporting facilities. The
types and quantities of
material delivered to the site
keep changing throughout
the construction. Thus, areas
needed for storage and
fabrication change
accordingly. Approach roads

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 required during initial phases
of construction may not be
required during later phases,
which generates a necessity
for a dynamic layout.

ORIGINATIN Resource shortage The demand for workers is There’s so much work out there for mobile crane companies, that they can
G fuelled by the high number pick and choose. If we don’t want to be compliant to your site, then fine,
INFLUENCE of construction and we’ll go work for a builder down the road who only wants X, Y, Z off us.
S infrastructure projects
currently underway or … the fact that the crane industry, regardless of whether it's fixed or
planned. mobile, is very incestuous, so you'll have guys that come from... sorry, to
say this, but crane companies that are absolute garbage and then they
want to move up and then they end up getting a company that's quite
well-known, quite good operators and they might... because of the way the
industry is, the guys still have to... we're lacking in any labour at the
moment. We're on a squeeze with skilled labour... and it happens across all
industries.

Supply and demand, lack of training, has caused the problem.

Lot of crane accidents in the last four or five years, because there’s so
much work on, and they’re just struggling for guys.

Overheated procurement An increase in the number of But what comes with complacency over competency is lack of humanoids,
environment active and planned projects lack of labour. We’re in a boom now and it’s going to continue for at least
sees the building and civil another five years, NSW government, they’ve announced when there’s
companies struggling to 89.4 billion on the books, so in the contract now, then there’s another 50
meet the needs of industry. billion every year after for the next five years.
This is placing pressure on
the availability of contractors
to carry out projects, with

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 impacts that range from not
meeting delivery timeframes,
to increased costs and
overall performance.

Client demands and Clients make key decisions … we've done work where as soon as people start working over 60 hours a
expectations concerning project budgets, week, the incident rate just … it just goes exponential, and yet it's been
timelines, objectives and enforced in other projects where they say, ‘Well, you have to work at least
performance criteria. These a 60-hour week, because we're not going to get the job done because of
types of decisions influence the time factors and the pressures put on by the client.’
health and safety both
positively and negatively, It’s quite a big issue where clients assume the position of the principal
directly or indirectly. contractor. Don’t be giving directions on stuff you’re [not] experienced
Indirectly through project with.
documentation, project
schedule, and product
selection, etc. Directly
through imposition of design,
extent of involvement, etc.

Adjoining properties, Owners of adjoining or Look, a lot of people in Sydney do have it [audible alarms], but a lot of
community expectations, nearby properties and the people turn it off to keep the neighbours happy. By instruction of the
and demands broader community can builder. They got constant complaints that there [are] cranes beeping all
influence a project’s scale night. If it’s a windy night, of course it’s going to beep, but residents [are]
and design. In addition, they unhappy about it.
can also be powerful drivers
in how and when on site
activities are undertaken.

Authority/ It is common for local … we might not work at all during the day because some council says we're
authorities (local councils) not allowed to. Which might involve putting the crane up at the last
regulator's permit and other government minute.
conditions bodies to nominate
conditions on permits issued. … it’s the councils who give unrealistic timeframes to set up as well. You
In some instances, these know, the actual regulators yeah the restrictions, just do it between
conditions can directly
impact how and when crane-

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 related activities are midnight and 3.00am. Fucking what? Leave two wheels and a witch’s hat
undertaken or how they are there? You know, it’s thunderbirds go, it’s a bit of a set up.
carried out.
There was a seven-hour – not even a seven-hour window – from start to
finish to put the crane up. So you had to set a 300 tonne crane up, put up
what you could, pack it up, and be off the road, inside seven hours. So how
is that safe?

… council permits forcing us to do it in other ways that have caused issues

in the past.

Well, all your authorities with infrastructure and things like that. They're the
ones that govern when we can and can't go which then poses risks on
hours of work. And so, you have an understanding, going back on [name’s]
comment, is hours of work; if we do 7:00 until 5:00 every single day, we're
used to day shift. Then all of a sudden, it poses a risk when we're asked to
do something at night.

I bring that up because probably an equal amount or greater of our time is

spent trying to get road access more than performing a lift safely.

It’s difficult to have those costs recovered, so they become overheads that
the business wears and the more burdensome these overheads are, maybe
energy is being diverted towards part of the business that could have been
spent on WHS activities. So, it has that indirect impact, I think, especially
when people are spending so much time just trying to get to the job site.

If we’re in the city we’re going in and we’re trying to get a crane together
as fast as we can, to work all night, and then pack it up as fast as we can to
reopen the street.

Yeah, I can’t catch public transport, starting that time of day.

Regulatory training Operating a crane is high risk … one of the things that I find is a major problem is the fact that anyone
requirements work and requires those in who has nothing to do with construction or mobile cranes at this point in
control, as well as those time, they’re making hamburgers for the past 15 years, within one week, if
assisting with crane they’re diligent enough and study hard enough, they can get their open
operations (dogmen and
riggers), to have completed

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 recognised training with an crane ticket for fixed or mobile crane ticket, or tower crane ticket licence
RTO. without any experience.

Lack of consistency in RTO’s training and … unfortunately, there’s a lot of unscrupulous, left-column RTOs, trainers,
RTO training assessment practices, assessors – whatever you want to call them – that people are still buying
including the amount of assessors off.
training they provide, may
vary between providers. As a
result, there is a risk that
training is not sufficient to
enable participants to gain
the competencies required
to safely fulfil the role of
crane operators, dogmen,
and riggers.

Training not meeting the There is an emerging But you can go and get a crane ticket in a week.
needs of industry disparity between current
vocational training for crane … there’s [a] disconnect between the operator training requirements and
operators, dogmen, and what is current best practice.
riggers, and the expectations
of the crane industry. The Your RTOs and training organisations that will tell, ‘This is what you need
curriculum is believed to fall to do, but for the test, you need to say this.’
short in providing the
knowledge, skills and My main thing is I just think the guys are rushing through now. It should be
experience to work safely. a minimum couple of years as a dogman and then a minimum couple of
years as a rigger, and then you progress to being a full time crane driver if
you’ve got the skills and the common sense, more or less.

I don't think you should be able to go out and get your dogman’s and
rigger's ticket and crane driver's ticket in one week.

The first one is that people who are inexperienced – green, if you like – just
get their licences and they’re then required to do work that only
experienced personnel should have.

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 … one of the things that I find is a major problem is the fact that anyone
who has nothing to do with construction or mobile cranes at this point in
time, they’re making hamburgers for the past 15 years, within one week, if
they’re diligent enough and study hard enough, they can get their open
crane ticket for fixed or mobile crane ticket, or tower crane ticket licence
without any experience.

… unfortunately, there’s a lot of unscrupulous, left-column RTOs, trainers,

assessors – whatever you want to call them – that people are still buying
assessors off.

They’re still fraudulently selling tickets and VOC – verification of

competency – as well.

Principal contractor’s Principal contractors I think that comes down to it. I work for builders that are just, ‘push, push,
demands and interpret and apply the push’, and you're working for [name] and we’re not push, push, push with
expectations requirements of the contract that. The guys are saying, ‘No!’, it's no.
to ensure the successful
execution of the project. Yeah, there is this perception that you won't be invited back if you make
Maintaining productivity may life difficult for someone.
also require continual
adjustments to planned Yeah, they try and hold you to ransom.
activities to meet the
requirements of various … make us do all of this paperwork, and say you can’t do this, you can’t do
stakeholders, such as that, you can’t do that. Once everything is in signed, they turn up and say,
adjoining neighbours, local ‘just get the job done’.
council, etc.
But they are tipping a lot of cranes over on these wind farms and stuff with
Meeting and maintaining the wind and their tight schedules and they’re pushing.
project demands flows down
to contractors and workers. Sometimes they’ll send us off to do another little [lift], while you’re here
reach over and grab that.

If it's the project manager or the superintendent, they want to get the
project done. That’s the end of the story.

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 You have to go back to them and say, ‘Mate, I can't do that.’ ‘I don't care.
Just do it,’ and that's what happens.

Crane contractor Contractors bear the Like, we’re doing a tower crane in [regional city] on Thursday and I’ve
knowledge and responsibility of leading their already been down to have a look at the site and told them what area I
experience organisation to achieve need cleared to get the crane in of course, and then the tower crane guys
objectives and stated goals. on site I’ve already told the same thing, what area they need to run the
Their experience, knowledge crane, to put the crane together.
management, and decision-
making strategies, are crucial … we’ll normally go in a couple of days before, get inducted, have a quick
factors in making informed scope of the jobsite, know where to pull up when I get there, I know where
decisions. to pull up and we start setting up.

I think that’s probably one of the biggest concerns is lack of experience in

the industry, definitely on the client’s side but also in a lot of crane
companies too, there’s a lot of new crane companies around which don’t
have a lot of experience.

Impact of EBA vs non- Enterprise Bargaining … we’re undercut by a number of non-EBA companies who can continue to
EBA workforce Agreements may have operate and do whatever they please, I guess on site.
additional conditions not
applicable to those not
working under such
agreements. For example, an
EBA will nominate rostered
days off enabling workers to
have appropriate rest and
recovery opportunity.

Increase in foreign Maintaining the supply of … because the construction industry here in Australia has got so busy now,
workforce workers to accommodate a lot of foreign workers now. A lot of foreign workers on working visas.
demand in the construction They don't understand our systems. They don't understand procedures.
and infrastructure industry
has seen an increasing
reliance on workers from
overseas to meet industry
demands.

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Crane contractor's When focused on tight What about the lack of availability, so it might not be the right crane for
expectations on crane timelines and project the right job. So you can’t get the one you want and you’re going to wait
operators programs, employers may three months but the project’s got the green light so they just whack up a
provide instructions to remote control one, without naming brands.
workers that (explicitly or
implicitly) put them under No planning, no management planning has gone in place, no lift planning
pressure to break safety has gone, you know if they say we’re putting it in tomorrow, they do that.
rules.
So the one thing, the drivers are worried about their boss telling them to
complete and finish the job and you know do everything they can in their
power to ensure but by all means you know they try to put him under
pressure to finish the job.

They simply will try to please the clients by doing everything in their power
to finish the job. So they put a lot of pressure on the drivers to finish the
job. So the drivers then sometimes will override their limits by using the
overriding keys and they’re just working off charts thinking they can finish
the job.

The issue that I see quite a lot is the conflict of interest that the wet hire
crews have.

They will ring and report that to the crane company who employs them
and the crane company says, ‘Mate, I don’t give a fuck; you get back to
work because if that crane is down out of service, we’ll start to get back-
charged for that crane not being in service, you get up there and keep
driving that crane.’

Procurement The contracting strategy It is better to get paid by the hour. I'd love to get paid by the hour
methodology selected defines the roles and sometimes, but we can't. We have a fixed rate.
responsibilities of, as well as
relationships among, the So, the costing becomes the event. The job gets delayed.
client and other parties who
contribute to the project It's a fixed contract, you're in trouble.
(including design
consultants, contractors, and … it's just spur of the moment bookings and come in and this is what we
suppliers). The type of need to do
contract selected also
influences the extent of

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 integration of health and
safety in a project.

Disconnect between Industry I don’t normally gang up on the regulators and say they’re a toothless tiger
industry standards and practices/recommendations, and all that stuff but we can only regulate ourselves to the standards we’ll
regulatory requirements such as those of the IPCC, do accept.
not align with the legal
obligations set out in That’s fine, that works for a little while but then we got really, really busy
relevant acts, regulations and and that gets diluted because the cowboys don’t know what the IPCC
standards. says. They don’t know anything about the protocols and they don’t give a
stuff and it’s not regulated.

… but the interpretation of the Australian standard in what we should be

doing and what’s getting done is two different things.

We’ve got a protocol now for a crane coming into our facility or on our
scope that’s amplified massively over a land-based requirement. I
implemented Marine Order 32 which is the international marine crane and
lifting equipment requirements, so they don’t have ten-year inspections
and annual inspections. They have six monthly inspections.

It’s because they’re designing for a lifecycle period for them to say that
these guys, or are buying mobile or him buying a tower crane, or me to go
out and buy a tower crane, they’re going to say to me – and everyone’s
got this 10-year thing. It’s not a 10-year thing, it’s a duty cycle lifecycle.

There were some design issues across all equipment, nothing to do with
tower cranes, which was sort of driven by the Australia Standards, that
probably needs to be reviewed, and we certainly made changes in how we
do things relating to material that’s used in cranes.

Time/budget pressures Sector competition, low So, that puts pressure on them, forces people to do irrational decisions.
to keep the project contractor margins, tight
moving budgets and pressure to cut
programs and costs can
Page 159 of 186
 encourage corner-cutting But they are tipping a lot of cranes over on these wind farms and stuff with
and impact safety. the wind and their tight schedules and they’re pushing.

Level of management by A principal contractor’s You have to go back to them and say, ‘Mate, I can't do that.’ ‘I don't care.
the principal contractor attitude to safety Just do it,’ and that's what happens.
sets the tone/principal significantly influences
experience behaviour and performance … they're not allowing us anymore to bring the best equipment for the
of subcontractors/suppliers. jobsite on because so many other factors suddenly start to determine.
The principal also determines
the way safety is
incentivised/rewarded within
commercial relationships
with
subcontractors/suppliers.

Lack of early Early involvement of a crane … most of the time they only get a phone call the day before, come and do
involvement/ contractor enables specialist some lifts tomorrow morning.
crane expertise to inform
consultation with crane project planning and Like, we’re doing a tower crane in [regional city] on Thursday and I’ve
contractor decision-making. Site layout already been down to have a look at the site and told them what area I
and construction processes need cleared to get the crane in of course, and then the tower crane guys
can be designed for the safe on site I’ve already told the same thing, what area they need to run the
use of cranes. crane, to put the crane together.

… we’ll normally go in a couple of days before, get inducted, have a quick

scope of the jobsite, know where to pull up when I get there, I know where
to pull up and we start setting up.

But our sites are 90% unknown to the crane crews when they turn up on
site, because they haven’t been there before.

Lack of planning by the Lack of planning leads to If I only have six hours to do a job, the thunderstorm comes through, I
principal contactor inadequate preparation for already have a problem. If I have more than 10 hours, I can say to the boys,
the safe use of cranes at a ‘Take half an hour, the thunderstorm is, we wait.’ So, it is very important
worksite, and can create that we address it, that we get the hours we need to do the work.
unanticipated problems and
negative safety impacts as

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 construction work … it's just spur-of-the-moment bookings and come in and this is what we
progresses. need to do.

… and then we get to a hold point and say the weather’s turned too much
or... We might start putting one up, but you almost reach the point of no
return if you start putting it up, you’ve got to get the certain hold points
before you can then walk away from it and then it’s safe, then you can
come back to it the next day.

So, operating close to the limit by itself wasn’t a problem, operating with a
gust of wind individually wouldn't have been a problem, but the
combination of the two are a problem collectively. So, I think, there’s
definitely areas for improvement in planning.

It’s not necessarily that people want to be more cavalier or cowboy, it’s
just that they don’t take the time because the time’s not often afforded to
them to think something through.

For me, it’s pulling up in a crane and there’s something in the way that has
to be moved and then I’ve got five semi-trailers behind me, of my gear,
that are spaced out every 10 minutes to come in, and then next minute,
they’re all in the street waiting. The client’s going off his head, the traffic
controllers going off their head, because they’re blocking the road, but
there’s nowhere for them to pull up. There’s nowhere for them to park in
the city no more.

Lack of planning by the Lack of planning leads to If I only have six hours to do a job, the thunderstorm comes through, I
crane contractor inadequate preparation for already have a problem. If I have more than 10 hours, I can say to the boys,
safe use of cranes at a ‘Take half an hour, the thunderstorm is, we wait.’ So, it is very important
worksite and can create that we address it, that we get the hours we need to do the work.
unanticipated problems and
negative safety impacts as … it's just spur-of-the-moment bookings and come in and this is what we
construction work need to do.
progresses.
… and then we get to a hold point and say the weather’s turned too much
or... We might start putting one up, but you almost reach the point of no
return if you start putting it up, you’ve got to get the certain hold points

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 before you can then walk away from it and then it’s safe, then you can
come back to it the next day.

So, operating close to the limit by itself wasn’t a problem, operating with a
gust of wind individually wouldn't have been a problem, but the
combination of the two are a problem collectively. So, I think, there’s
definitely areas for improvement in planning.

It’s not necessarily that people want to be more cavalier or cowboy, it’s
just that they don’t take the time because the time’s not often afforded to
them to think something through.

For me, it’s pulling up in a crane and there’s something in the way that has
to be moved and then I’ve got five semi-trailers behind me, of my gear,
that are spaced out every 10 minutes to come in, and then next minute,
they’re all in the street waiting. The client’s going off his head, the traffic
controllers going off their head, because they’re blocking the road, but
there’s nowhere for them to pull up. There’s nowhere for them to park in
the city no more.

Lack of communication Effective communication is I think that comes down to communication. In the strategy is good
by the principal important for project communication. To me, that is vital.
performance, including in
safety. Poor communication … so you prepare for that day with all the subbies that you work with. We
can create confusion and didn’t work with subbies but it would be good to have a meeting in the
send mixed messages morning where you get the supervisor from every area to come, sit down,
relating safety expectations run through your works for the day. So relieved knowing what they’re
to subcontractors and doing, and then you come back in the afternoon and have a second
suppliers. meeting so everyone knows where they’re at, ready for the morning. That
covers what’s changed during the day: we’ve made it across the eastern
face of the building; we’re going to be running whatever direction
tomorrow; this is where we’ll be, what you can expect.

… and they need to be fully engaged with the client.

We’ve got a system which we call the DCR which is document control
register. Before we actually start on the project, we list out all the activities
and all the documentation that we’re going to prepare for those activities

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 that we’re going to provide to the client and all the documentation that we
require from the client to perform our work safely.

I don't think the size of the crane matters, I think it’s again more about how
you plan a job out. If you don’t plan the job out properly then all of a
sudden, the guys who are doing the work don’t necessarily know what’s
going on and the site doesn’t know what’s going on.

Crane registration regime There is limited ability to Now, one of the things that SafeWork can do – and I think they should be
not linked to inspection identify the number of crane able to do very easily, is that every crane that’s in the market has a plant
regime activities and their locations item registration. Now, the plant item registration that belongs to each bit
across the state. Monitoring, of crane equipment.
inspections, and
enforcement activities, may What that does is that highlights to them that cranes that are over 10 years
end up being ad hoc as a old automatically should in their system signal that they should be
result. requesting in addition to plan item registration… the renewal of the plant
item registration, at 10 years, they should also request the major inspection
report that says that ‘This piece of equipment has received its major
inspection’ once it passes 10 years old, otherwise, they won’t renew the
plant item registration.

… and if the plant is over 10 years old, and they go to renew their annual
plant item registration, and they don’t submit a major inspection certificate
with it, then they can’t get their plant item reregistered.

Importation of Substandard imported I don’t know about structural failure but I know tower cranes you used to
substandard equipment equipment can potentially order from Spain… they came out, brand new cranes but they’d go for
put property and lives at risk. crack testing. And the amount of welds that failed through that test, and
Foreign manufacturers often these are brand new cranes.
do not follow the necessary
testing regime to prove their
products meet Australian
safety and reliability
standards.

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Appendix 6. Cause and effect diagrams

IMMEDIATE CAUSES SHAPING FACTORS ORIGINATING INFLUENCES

Complacency/over Lack of consistency in RTO

confident training

Lack of competency and

experience of dogman/ Training not meeting the Regulatory training
crane operator needs of industry requirements

Lack of hazard awareness

Lack of empowerment of
Fatigue
crane operators

Lack of planning by crane

Lack of planning by principal
operator

Adjoining properties/
community expectations and
demands
Mental health

Crane company
overcommits

Authority/regulator’s permit
conditions
Transient workforce

Lapse of concentration
Client demands and
Working outside of standard expectations
working hours

Crane contractor’s
Time/budget pressures to
expectations on crane
keep the project moving
operator
Shift work/rostering
schedule

Principal demands and

expectations
Long working hours

Figure 25. Work environment issues.

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 IMMEDIATE CAUSES SHAPING FACTORS ORIGINATING INFLUENCES

Documentation too
generic

Proximity to existing
structures on site and
adjoining properties Lack of co-ordination/
oversight of
documentation and
SWMS done in isolation planning across multiple
(doesn’t consider other contractors
activities on site)

Requirement to submit
SWMS prior to job Crane contractors
Negative interaction Not recognising
commencing expectations on crane
between adjoining tasks/ continuously changing operator
activities on site site layout

Procedure doesn’t
address/cover high risk
activities

Lack of empowerment of
Working in unsuitable crane operators
weather
Lack of planning by Authority/regulator’s
principal permit conditions

Lighting/visibiity
Shift work/rostering Time/budget pressures to Client demands and
schedule keep the project moving expectations

Existing soil conditions

Lack of competency and
not considered
experience of dogman/
crane operator Crane contractor’s
knowledge and
experience

Changes to ground
conditions Lack of involvement of
crane contractor

Inadequate/incorrect
information provided
Supporting structure not
adequate Lack of planning by crane
operator

Inadequate site
supervision

Crane located where Lack of competency and

services are located experience of engineers/ Level of management by
decision makers Principal demands and
below/above the principal sets the
expectations
tone/principal experience

Lack of/poor safety in

design Training not meeting the
needs of industry

Figure 26. Worksite conditions.

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 IMMEDIATE CAUSES SHAPING FACTORS ORIGINATING INFLUENCES

Inadequate on-boarding and Overheated

Increase in foreign
industry induction of foreign Resource shortage procurement
workforce
workforce environment

Lack of standardised
processes

Client demands and

expectations

Impact of EBA vs non-

Wet vs dry hire EBA workforce
Unfamiliar with plant
being operated
Crane company
overcommits
Crane contractor’s
Transient workforce Lack of planning by
knowledge and
crane operator
experience

Overly onerous
documentation/too long
Not following and not read
procedures Lack of consistency in
RTO training

Documentation too
generic
Crane contractor’s
Not following Training not meeting the Regulatory training
expectations on crane
manufacturer needs of industry requirements
Tick and flick approach operator
instructions to documentation

Complacency/over
confident

Override of safety
technology

Lack of competency and

experience of dogman/ Level of management by
crane operator the principal sets the Lack of planning by Principal demands and
tone/principal Principal expectations
experience

Operators taking
shortcuts
Inadequate site
supervision

Lack of empowerment
of crane operators

Figure 27. Human factor issues.

Page 166 of 186

 IMMEDIATE CAUSES SHAPING FACTORS ORIGINATING INFLUENCES

Procurement methodology
selected
Importation of substandard
equipment

No specific requirements
for cranes and their design
for safe operation Overheated procurement
Operating substandard environment
crane

Crane contractor’s
Crane contractor’s
expectations on crane
knowledge and experience
Lack of/poor safety in operator
design
Lack of empowerment of Client demands and
crane operators expectations

Structural/electrical failure
of crane
Lack of maintenance of
plant and equipment
Lack of planning by crane
operator
Time/budget pressures to Principal demands and
keep the project moving expectations

Level of management by
Unintended modifications
the principal sets the tone/
to crane installations
principal experience
Lack of planning by principal

No crane registration
regime in place Disconnect between
industry standards and
regulatory requirements

Figure 28. Equipment issues.

Page 167 of 186

 IMMEDIATE CAUSES SHAPING FACTORS ORIGINATING INFLUENCES

Lack of competency and

experience of engineers/ Training not meeting the Regulatory training
decision makers needs of industry requirements

No lift plan/plan is not

Time/budget pressures to
reflective of the situation
keep the project moving

Lack of empowerment of
crane operators

Crane contractor
knowledge and
experience

Loads being carried too Lack of competency and

heavy for crane experience of dogman/
crane operator

Crane contractors
Lack of planning by crane Lack of communication by Principal demands and
expectations on crane
operator the principal expectations
operator

Complacency/over
Load transfer too far
confident

Lack of early involvement/

consultation with crane
contractor
Proximity to existing
structures on site and Lack of planning by
adjoining properties principal

Crane too small for tasks

being performed Lack of co-ordination/
oversight of
documentation and
planning across multiple
contractors
Not recognising Adjoining properties/
continuously changing site community expectations
layout and demands

Site constraints Authority/regulator’s

permit conditions

Figure 29. Task/activity issues.

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Crane safety incident causation model validation data
Table 12. Frequency with which causal/contributing factors were identified as relevant to crane safety
incident scenarios used in the validation.

Model Level Issue Tower Mobile

Immediate Hazards not identified 3 1

Existing soil conditions 1

Changes to ground to conditions 1

Crane located above/below 1

Not following manufacturer’s instructions 2 2

Override safety technology 2

Operator taking shortcuts 2 2

Load transfer too far 1 2

Load too heavy 2 2

No lift plan 2 2

Lack of hazard awareness 1 1

Not following procedure/SEMS 1

Supporting structure not adequate 2

Unfamiliar with plant being operated 1

Negative interaction between adjoining tasks/activities 1

on site

Working in unsuitable weather 1

Shaping ‘Tick and flick’ approach to documentation 2 1

Lack of standardised processes 1

No specific requirements for cranes and their design for 1

safe operations

Inadequate/incorrect information provided to crane 2 2

Modifications made to the crane 1

Lack of/poor safety in design 2

Documentation too generic 2 1

Lack of maintenance 1

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 Model Level Issue Tower Mobile

SWMS done in isolation 1

SWMS submitted prior to job commencing 1

Procedure doesn’t address/cover high risk activities 2 2

Complacency/overconfident 3 2

Lack of competency/experience 3

Inadequate site supervision 3 1

Overly onerous documentation 3 1

Site constraints 2 1

Not recognising /accounting for changing site conditions 1

Transient workforce 1

Fatigue 1

Wet vs dry hire 1

Lack of co-ordination/oversight of documentation and 1 1

planning across multiple contractors

Procurement methodology selected 1

Crane company overcommits 1 1

Long working hours 1

Originating Lack of RTO consistency in training 1

Training not meeting the needs of industry 3 1

Disconnect between industry standards and regulatory 2

requirement

Crane contractor’s knowledge and experience 2

Lack of planning by the crane contractor 3 1

Lack of planning by the principal 2 1

Level of management by the principal sets the tone 2 2

Time/budget pressures to keep the project moving 2 2

Regulatory training requirements 1 1

Authority/regulator’s permit conditions 2 1

Client demands and expectations 2 1

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Model Level Issue Tower Mobile

Overseas imports 1

Resource shortage 2

Overheated procurement environment 1 1

Lack of early involvement/consultation with crane 2 1

Crane contractor’s expectations on crane operator 1 1

Foreign workforce 1

Lack of communication by the principal 1 1

EBA vs non-EBA 1

Adjoining properties/community expectations and 1

demands

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Appendix 7. Variables included in quantitative analysis
Table 13. List of variables and values included in quantitative analysis.

Variables List of Values

Incident Type ‘Fatal’ OR ‘Serious Injuries’ OR ‘Dangerous Incident’

Type of Crane ‘Barge Crane’ OR ‘Bridge Crane’ OR ‘Derrick Crane’ OR ‘Gantry Crane’ OR
‘Mobile Crane’ OR ‘Portal Boom Crane’ OR ‘Quay Crane’ OR ‘Tower Crane’
OR ‘Two types of Crane involved’ OR ‘[Crane Type Not Specified]’

Action 'Lifting' OR 'Loading' OR 'Slewing' OR 'Unloading' OR ‘Dismantling’ OR

‘Not Operational’ OR ‘NA'

In Operation ‘Yes’ OR ‘No’ OR ‘NA’

Loaded ‘Yes’ OR ‘No’ OR ‘NA’

Load Type ‘Yes’ OR ‘No’ OR ‘NA’

Work Related ‘Yes’ OR ‘No’ OR ‘NA’

Mechanism of Incident 'Hit by load': Injured party hit by crane load.

'Hit by crane part': Body part struck by crane part or caught in crane
part – for example, body part caught between two sections of crane
outrigger.
'Hit by crane': Crane striking injured party or object – for example, crane
jib making contact with power lines.
'Crane collapse': Crane collapsing – for example, mobile crane toppling
over.
'Crane accident / crane collision': Two cranes colliding.
'Electrocution': Injured party electrocuted by crane.
'Fall / jump from crane': Injured party falling or jumping from crane.
‘Other’ – for example, crane catching fire, mechanical failure,
deformation of crane part.

Incident Consequence- ‘Yes’ OR ‘No’ OR ‘NA’

Crane/property/Powerline

Incident Consequence- ‘Yes’ OR ‘No’ OR ‘NA’

Death

Incident Consequence- ‘Yes’ OR ‘No’ OR ‘NA’

Injury

Is there a human factor ‘Yes’ OR ‘No’ OR ‘NA’

involved?

Faulty Equipment ‘Yes’ OR ‘No’ OR ‘NA’

Weather ‘Wind’ OR ‘NA’

Offsite Environment ‘Yes’ OR ‘No’ OR ‘NA’

Involved

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 Variables List of Values

Main Cause 'Faulty Equipment' OR 'Human Error' OR 'Weather Conditions' OR

'Human Error & Faulty Equipment’ OR 'Maybe Human Error' OR 'Faulty
Equipment’ OR 'NA'

Day of the Week 'Monday' OR 'Tuesday' OR 'Wednesday' OR 'Thursday' OR 'Friday' OR

'Saturday' OR 'Sunday' OR 'NA’

Operator Involved Yes’ OR ‘No’ OR ‘NA’

Operator Name <Name>

Rigger Involved Yes’ OR ‘No’ OR ‘NA’

Rigger Name <Name>

Dogman Involved Yes’ OR ‘No’ OR ‘NA’

Dogman Name <Name>

Notices Issued Yes’ OR ‘No’ OR ‘NA’

State of Investigation ‘Completed’ OR ‘Ongoing’ OR ‘NA’

Compliance Yes’ OR ‘No’ OR ‘NA’

Victim Type ‘Dogman’ OR ‘Operator / Driver’ OR ‘Public’ OR ‘Rigger’ OR ‘Worker’

Operator HRW Licence <HRWXXXXXX>

Number

Dogman HRW Licence <HRWXXXXXX>

Number

Rigger HRW Licence <HRWXXXXXX>

Number

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Appendix 8. Definitions of serious injury and dangerous incident
This appendix describes sections 36 and 37 of the Work Health and Safety Act 2011, providing
definitions of ‘serious injury or illness’ and ‘dangerous incident’.

Section 36 What is a "serious injury or illness"

In this Part, "serious injury or illness of a person" means an injury or illness requiring the person to
have:

a) immediate treatment as an in-patient in a hospital, or

b) immediate treatment for:

1) the amputation of any part of his or her body, or

2) a serious head injury, or
3) a serious eye injury, or
4) a serious burn, or
5) the separation of his or her skin from an underlying tissue (such as degloving or
scalping), or
6) a spinal injury, or
7) the loss of a bodily function, or
8) serious lacerations, or

(c) medical treatment within 48 hours of exposure to a substance,

and includes any other injury or illness prescribed by the regulations but does not include an
illness or injury of a prescribed kind.

Section 37 What is a "dangerous incident"

In this Part, a "dangerous incident" means an incident in relation to a workplace that exposes a
worker or any other person to a serious risk to a person's health or safety emanating from an
immediate or imminent exposure to:

(a) an uncontrolled escape, spillage or leakage of a substance, or

(b) an uncontrolled implosion, explosion or fire, or

(c) an uncontrolled escape of gas or steam, or

(d) an uncontrolled escape of a pressurised substance, or

(e) electric shock, or

(f) the fall or release from a height of any plant, substance or thing, or

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(g) the collapse, overturning, failure or malfunction of, or damage to, any plant that is required
to be authorised for use in accordance with the regulations, or

(h) the collapse or partial collapse of a structure, or

(i) the collapse or failure of an excavation or of any shoring supporting an excavation, or

(j) the inrush of water, mud or gas in workings, in an underground excavation or tunnel, or

(k) the interruption of the main system of ventilation in an underground excavation or tunnel,
or

(l) any other event prescribed by the regulations,

but does not include an incident of a prescribed kind.

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Appendix 9. Focus group and semi-structured interview approach

Focus Group Approach

The approach for focus groups was determined in consultation with the client to encourage the
attendees to develop and identify interventions to causal factors, rather than trying to solve a
problem they may not recognise or have experience with. There was a maximum of 10 attendees
per group with each focus group following the same approach outlined below.

1. Causal Factors

a. The facilitator led the group to address each of the four elements (below). The group
was asked to identify causal factors which were recorded on post-it notes and
placed on a flip chart specific to each of the four elements:

i. Project conditions

ii. Environment

iii. Human factors (including power relations)

iv. Safety Management

b. Once the attendees had reviewed each element, the group was then asked to review
the causal factors and identify the top three for each of the four elements.

2. Strategies and Intervention

The facilitator then led to group to discuss interventions for the prioritised causal factors across
each of the four elements.

3. Influence and Implementation

For each intervention proposed, the group was asked the following:

a. Who is the key person this intervention needs to reach? (operator, manager,
regulator etc)?

b. What about this key person may help or hinder the interventions success?

c. What is the best way to reach this person?

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Interview Approach
Interviews were treated as a way to follow up and triangulate data from the focus groups data.
As such, interviews followed the same approach as the focus groups in asking interviewees to
identify causal factors across the four elements. This was the case for all interviews, except for
the first which took a more open-ended approach to the causal factors. This (first) interview
sought responses to the following:

1. What causes crane accidents in NSW against the following contexts:

a. policy/regulatory?

b. industry/supply chain?

c. project/planning levels?

d. business level?

e. worker/operator level

2. What strategies / programs could prevent incidents across the five levels?

3. Would these strategies / programs be suitable for the NSW context?

4. What would be the barriers/constraints to their effective implementation in NSW?

5. What would need to change in order to address these issues?

6. What could be reasonably achieved within the short, medium and long term to achieve
improved outcomes?

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References
Al-Humaidi, H. M., & Tan, F. H. (2009). Mobile crane safe operation approach to prevent
electrocution using fuzzy-set logic models. Advances in Engineering Software, 40(8), 686-696.

Al-Hussein, M., Niaz, M. A., Yu, H., & Kim, H. (2006). Integrating 3D visualization and simulation for
tower crane operations on construction sites. Automation in Construction, 15(5), 554-562.

Aneziris, O. N., Papazoglou, I. A., Mud, M. L., Damen, M., Kuiper, J., Baksteen, H., ... & Post, J. G.
(2008). Towards risk assessment for crane activities. Safety Science, 46(6), 872-884.

Arboleda, C.A. and Abraham, D.M. (2004) Fatalities in trenching operations: analysis using models
of accident causation. Journal of Construction Engineering and Management, 130(2), 273–80.

Arditi D. and Chotibhongs R. (2005). Issues in Subcontracting Practice, Journal of Construction

Engineering and Management 131(8), 866-876.

Beavers, J. E., Moore, J. R., Rinehart, R., & Schriver, W. R. (2006). Crane-related fatalities in the
construction industry. Journal of Construction Engineering and Management, 132(9), 901-910.

Behm, M. and Schneller, A. (2013). Application of the Loughborough Construction Accident

Causation model: a framework for organizational learning. Construction Management and
Economics, 31(6), 580–95.

Bomel (2001). Contract Research Report 387/2001 Improving Health and Safety in Construction:
Phase 1: Data Collection, Review and Structuring, Health and Safety Executive, London.

Brkić, V. S., Klarin, M. M., & Brkić, A. D. (2015). Ergonomic design of crane cabin interior: The path
to improved safety. Safety Science, 73, 43-51.

Burdorf, A., & Zondervan, H. (1990). An epidemiological study of low-back pain in crane operators.
Ergonomics, 33(8), 981-987.

Cheng, T., & Teizer, J. (2012). Modeling tower crane operator visibility to minimize the risk of
limited situational awareness. Journal of Computing in Civil Engineering, 28(3), 04014004.

CICA, (2017), CICA Guidance Note Crane Major Inspection, The Crane Industry Council of
Australia, Mount Waverly, Australia.

Cooke, T. and Lingard, H. (2011) A retrospective analysis of work-related deaths in the Australian
construction industry, in Egbu, C. and Lou, E.C.W. (eds) Proceedings 27th Annual ARCOM

Page 178 of 186

Conference, Bristol, 5–7 September, Association of Researchers in Construction Management,
Reading, pp. 279–88.

Cooke, T., Lingard, H., Blismas, N., & Stranieri, A. (2008). ToolSHeDTM: the development and
evaluation of a decision support tool for health and safety in construction design. Engineering,
Construction and Architectural Management, 15(4), 336-351.

Committee for European Construction Equipment, (2011), Is this tower crane compliant with
European legislation? Retrieved 25 July 2019 from https://www.fem-eur.com/wp-
content/uploads/2016/01/MktSurv-TowerCrane-UK.pdf

Cranes Today, (2011), Manufacturers back CECE guide tackling illegal tower cranes. Retrieved 25
July 2019 from http://www.cranestodaymagazine.com/news/manufacturers-back-cece-guide-
tackling-illegal-tower-cranes/

Cranes and Lifting, (2018). Retrieved 30 July 2019 from

https://www.cranesandlifting.com.au/raycowylie-making-headway-in-australia/

CraneSafe, (2019). Retrieved 20 July 2019 from http://cranesafe.com.au/

Dekker, S. W. (2002). Reconstructing human contributions to accidents: the new view on error
and performance. Journal of Safety Research, 33(3), 371-385.

Endsley, M. R. (1988, May). Situation awareness global assessment technique (SAGAT). In

Proceedings of the IEEE 1988 National Aerospace and Electronics Conference (pp. 789-795). IEEE.

European Materials Handling Federation (FEM) (2013). A brief guide for identification of non-
compliant mobile cranes - marking of machinery, documents, features. Retrieved 25 July 2019
from https://www.fem-eur.com/wp-content/uploads/2016/03/CLE-5019.pdf

Fang, Y., Cho, Y. K., & Chen, J. (2016). A framework for real-time pro-active safety assistance for
mobile crane lifting operations. Automation in Construction, 72, 367-379.

Fang, Y., Cho, Y. K., Durso, F., & Seo, J. (2018). Assessment of operator's situation awareness for
smart operation of mobile cranes. Automation in Construction, 85, 65-75.

Fang, Y., & Cho, Y. K. (2017). Effectiveness analysis from a cognitive perspective for a real-time
safety assistance system for mobile crane lifting operations. Journal of Construction Engineering
and Management, 143(4), 05016025.

Page 179 of 186

Fang, Y., & Teizer, J. (2014). A multi-user virtual 3D training environment to advance collaboration
among crane operator and ground personnel in blind lifts. In Computing in Civil and Building
Engineering (2014) (pp. 2071-2078).

Fang, Y., Teizer, J., & Marks, E. (2014). A framework for developing an as-built virtual environment
to advance training of crane operators. In Construction Research Congress 2014: Construction in
a Global Network (pp. 31-40).

Fereday, J., & Muir-Cochrane, E. (2006). Demonstrating rigor using thematic analysis: A hybrid
approach of inductive and deductive coding and theme development. International Journal of
Qualitative Methods, 5(1), 80-92.

Gale, N. K., Heath, G., Cameron, E., Rashid, S., & Redwood, S. (2013). Using the framework method
for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research
Methodology, 13(1), 117.

Garrett, J.W. and Teizer, J. (2009). Human factors analysis classification system relating to human
error awareness taxonomy in construction safety. Journal of Construction Engineering and
Management, 135(8), 754-763.

Gharaie, E., Lingard, H., & Cooke, T. (2015). Causes of fatal accidents involving cranes in the
Australian construction industry. Construction Economics and Building, 15(2), 1-12.

Gibb, A., Lingard, H., Behm, M., & Cooke, T. (2014). Construction accident causality: learning from
different countries and differing consequences. Construction Management and Economics, 32(5),
446-459.

Gordon, R.P. (1998). The contribution of human factors to accidents in the offshore oil industry.
Reliability Engineering & System Safety, 61(1-2), 95-108.7(1241), 475-484.

Gu, L., Kou, X., & Jia, J. (2012, August). Distance measurement for tower crane obstacle based on
multi-ultrasonic sensors. In 2012 IEEE International Conference on Automation Science and
Engineering (CASE) (pp. 1028-1032). IEEE.

Guo, H., Li, H., Chan, G., & Skitmore, M. (2012). Using game technologies to improve the safety of
construction plant operations. Accident Analysis & Prevention, 48, 204-213.

Han, S. H., Hasan, S., Bouferguène, A., Al-Hussein, M., & Kosa, J. (2014). Utilization of 3D
visualization of mobile crane operations for modular construction on-site assembly. Journal of
Management in Engineering, 31(5), 04014080.

Page 180 of 186

Hasan, S., Al Hussein, M., Safouhi, & Hermann P., (2010). Interactive and dynamic integrated
module for mobile crane supporting system design. Journal of Construction Engineering and
Management 136 (2), 179–186.

Harvey, E. J., Waterson, P., & Dainty, A. R. (2018). Beyond ConCA: Rethinking causality and
construction accidents. Applied Ergonomics, 73, 108-121.

Haslam, R.A., Hide, S.A., Gibb, A.G.F., Gyi, D.E., Atkinson, S., Pavitt, T.C., Duff, R. and Suraji, A.
(2003). Causal Factors in Construction Accidents, HSE Report RR156, HMSO, Norwich.

Health and Safety Executive (1999). Reducing error and influencing behaviour, HSE Books,
London.

HSE (Health and Safety Executive) (2003), Causal factors in construction accidents, Research
Report 156, HMSO Books, Norwich.

Hollnagel, E. & Amalberti, R. (2001). The emperor’s new clothes: Or whatever happened to “human
error”. In Proceedings of the 4th international workshop on human error, safety and systems
development (pp. 1-18).

Hollnagel, E. (2002) Understanding accidents: from root causes to performance variability. Paper
presented at the 7th IEEE Human Factors Meeting, 15–19 September, Institute of Electrical and
Electronics Engineers, Scottsdale, AZ.

Isherwood, R., (2010). Tower crane incidents worldwide, Health and Safety Executive, Research
Report 820: Norwich

Isherwood, R. & Richardson, R., (2012). The effect of wind loading on the jib of a luffing tower
crane, Health and Safety Executive Research Report 917: Norwich.

Janicak, C. A. (1997). Occupational fatalities caused by contact with overhead power lines in the
construction industry. Journal of Occupational and Environmental Medicine, 39(4), 328-332.

Juang, J. R., Hung, W. H., & Kang, S. C. (2013). SimCrane 3D+: A crane simulator with kinesthetic
and stereoscopic vision. Advanced Engineering Informatics, 27(4), 506-518.

Kan, C., Anumba, C. J., Fang, Y., & Messner, J. I. (2018). Use of analytical tools to mitigate mobile
crane-related failures. In Construction Research Congress 2018, American Society of Civil
Engineers. pp. 184-195.

Kuo, T. Y. T., & Kang, S. C. J. (2014). Control of fast crane operation. Automation in Construction,
42, 25-35.

Page 181 of 186

Langdon D. (2011). Health and safety in public sector construction procurement: A follow-up
study, (Research report for the Health and Safety Executive 2011)
http://www.hse.gov.uk/research/rrhtm/rr556.htm.

Lawton, R. (1998). Not working to rule: Understanding procedural violations at work. Safety
Science, 28, 77-95.

Leah, C., Riley, D., and Jones, A. (2013). Mobile Elevated Work Platform (MEWP) incident analysis,
HSE Books, London.

Lee, G., Cho, J., Ham, S., Lee, T., Lee, G., Yun, S. H., & Yang, H. J. (2012). A BIM-and sensor-based
tower crane navigation system for blind lifts. Automation in Construction, 26, 1-10.

Lee, G., Kim, H. H., Lee, C. J., Ham, S. I., Yun, S. H., Cho, H., ... & Kim, K. (2009). A laser-technology-
based lifting-path tracking system for a robotic tower crane. Automation in Construction, 18(7),
865-874.

Lee, U.-K., K.-I. Kang, et al. (2006). "Improving Tower Crane Productivity Using Wireless
Technology." Computer-Aided Civil and Infrastructure Engineering 21: 594-604.

Lei, Z., Taghaddos, H., Hermann, U., & Al-Hussein, M. (2013). A methodology for mobile crane lift
path checking in heavy industrial projects. Automation in Construction, 31, 41-53.

Li, Y., & Liu, C. (2012). Integrating field data and 3D simulation for tower crane activity monitoring
and alarming. Automation in Construction, 27, 111-119.

Li, H., Chan, G., & Skitmore, M. (2013). Integrating real time positioning systems to improve blind
lifting and loading crane operations. Construction Management and Economics, 31(6), 596-605.

Lifting Matters (2018a). CICA CrewSafe, September 2018, p. 7.

Lifting Matters, (2018b). World-first technology set to revolutionise crane safety, September 2018,
p. 8.

Lingard H., Pirzadeh, P., Blismas, N., Saunders, L., Kleiner, B. and Wakefield, R., (2015). The
relationship between pre-construction decision-making and the quality of risk control: Testing the
time-safety influence curve, Engineering, Construction and Architectural Management, 22 (1), 108-
124.

Loosemore, M., and Andonakis, N. (2007). Barriers to implementing OHS reforms – The
experiences of small subcontractors in the Australian Construction Industry. International Journal
of Project Management,25(6), 579-588.

Page 182 of 186

LSM Technologies (2019). Retrieved 26 July 2019 from
https://www.lsmtechnologies.com.au/news_item.cfm?news_id=237

Lundberg, J., Rollenhagen, C., & Hollnagel, E. (2009). What-you-look-for-is-what you-find: the
consequences of underlying accident models in eight accident investigation manuals. Safety
Science, 47, 1297–311.

Luo, X., Leite, F., & O’Brien, W. J. (2014). Location-aware sensor data error impact on autonomous
crane safety monitoring. Journal of Computing in Civil Engineering, 29(4), B4014010, 1-11

Marquez, A. A., Venturino, P., & Otegui, J. L. (2014). Common root causes in recent failures of
cranes. Engineering Failure Analysis, 39, 55-64.

Mayhew, C., Quinlan, M., & Ferris, R. (1997). The effects of subcontracting/outsourcing on
occupational health and safety: Survey evidence from four Australian industries. Safety Science,
25(1-3), 163-178.

McCann, M., Gittleman, J., & Watters, M. (2009). Crane-related deaths in construction and
recommendations for their prevention. The Center of Construction Research and Training.
Retrieved from http://www.cpwr. com/research/crane-related-deaths-construction-
andrecommendations-their-prevention

McDonald, B., Ross, B., & Carnahan, R. A. (2011). The Bellevue crane disaster. Engineering Failure
Analysis, 18(7), 1621-1636.

Milazzo, M. F., Ancione, G., Brkic, V. S., & Vališ, D. (2016). Investigation of crane operation safety
by analysing main accident causes. In Risk, Reliability and Safety: Innovating Theory and
Practice (pp. 74-80). Taylor & Francis.

Ministry of Manpower, Singapore Government. Retrieved 30 July 2019 from

https://www.mom.gov.sg/workplace-safety-and-health/lifting-equipment/data-loggers-for-
mobile-cranes

National Institute of Occupational Safety and Health, (2006), Preventing Worker Injuries and
Deaths from Mobile Crane Tip-Over, Boom Collapse, and Uncontrolled Hoisted Loads, NIOSH,
Cincinnati, OH.

Neitzel, R. L., Seixas, N. S., & Ren, K. K. (2001). A review of crane safety in the construction industry.
Applied Occupational and Environmental Hygiene, 16(12), 1106-1117.

Patton, M. Q., (2002), Qualitative Research & Evaluation Methods, 3rd Edition, Sage, Thousand
Oaks.
Page 183 of 186
Perrow, C., (1984). Normal Accidents: Living With High-Risk Technologies. Basic, New York.

Peraza, D. B., & Travis, J. A. (2010). Crane safety—An industry in flux. In Forensic Engineering
2009: Pathology of the Built Environment (pp. 556-566).

Pope, C., Ziebland, S., & Mays, N. (2000). Analysing qualitative data. British Medical Journal,
320(7227), 114-116.

Ramli, Liyana, Z. Mohamed, Auwalu M. Abdullahi, H. I. Jaafar, & Izzuddin M. Lazim. (2017), Control
strategies for crane systems: A comprehensive review. Mechanical Systems and Signal Processing
95 (2017): 1-23.

Rasmussen, J. (1982). Human errors. A taxonomy for describing human malfunction in industrial
installations. Journal of Occupational Accidents, 4(2-4), 311-333.

Raviv, G., Fishbain, B., & Shapira, A. (2017a). Analyzing risk factors in crane-related near-miss and
accident reports. Safety Science, 91, 192-205.

Reason, J. (1990). Human error. Cambridge University Press.

Reason, J. (1997). Managing the risks of organisational accidents, Ashgate, Aldershot.

Reason, J. (2000). Safety paradoxes and safety culture. Injury Control and Safety Promotion, 7(1),
3-14.

Rider Levett Bucknall (2019), RLB Crane Index, 14th Edition, Q1, 2009. Retrieved 8 October 2019
from https://s28259.pcdn.co/wp-content/uploads/2019/03/RLB-AUS-Crane-Index_Q1_2019.pdf

Ritchie, J., & Spencer, L. (1994). Qualitative data analysis for applied policy research. In Analyzing
qualitative data, A. Bryman and R. G. Burgess (Eds) Routledge: London. pp. 173-194.

Roberts, D., Bretl, T., & Golparvar-Fard, M. (2017). Detecting and Classifying cranes using camera-
equipped UAVs for monitoring crane-related safety hazards. In Computing in Civil Engineering
2017 (pp. 442-449).

SafeWork Australia (2015). General Guide to Cranes, SafeWork Australia, Canberra.

SafeWork Australia, (2016a). Work related traumatic injury fatalities 2015, SafeWork Australia:
Canberra.

SafeWork Australia, (2016b.Guide to Tower Cranes, SafeWork Australia, Canberra.

Salmon, P. M., Cornelissen, M., & Trotter, M. J. (2012). Systems-based accident analysis methods:
A comparison of Accimap, HFACS, and STAMP. Safety Science, 50(4), 1158-1170.
Page 184 of 186
Sertyesilisik, B., Tunstall, A., & McLouglin, J. (2010). An investigation of lifting operations on UK
construction sites. Safety Science, 48(1), 72-79.

Shapira, A., Lucko, G., & Schexnayder, C. J. (2007). Cranes for building construction projects.
Journal of Construction Engineering and Management, 133(9), 690-700.

Shapira, A., Rosenfeld, Y., & Mizrahi, I. (2008). Vision system for tower cranes. Journal of
Construction Engineering and Management, 134(5), 320-332.

Shapira, A., & Lyachin, B. (2009). Identification and analysis of factors affecting safety on
construction sites with tower cranes. Journal of Construction Engineering and Management,
135(1), 24-33.

Shapira, A., Simcha, M., & Goldenberg, M. (2012). Integrative model for quantitative evaluation of
safety on construction sites with tower cranes. Journal of Construction Engineering and
Management, 138(11), 1281-1293.

Shapiro, H. I., Shapiro, J. P., & Shapiro, L. K. (2000). Cranes and derricks, 3rd edition., McGraw-Hill,
New York.

Shepherd, G. W., Kahler, R. J., & Cross, J. (2000). Crane fatalities—a taxonomic analysis. Safety
Science, 36(2), 83-93.

Shin, I. J. (2015). Factors that affect safety of tower crane installation/dismantling in construction
industry. Safety Science, 72, 379-390.

SMIE (2019). Retrieved 16 July 2019 from https://www.en.smie.com/anticollision

Smith, S. J., & Corley, W. G. (2009). High risk construction oversight study, New York City Dept.
of Buildings, New York.

Smith, A, (2018), Utilising technology to provide safer crane operations, Lifting Matters,
September 2018, 4-6.

Sneddon, A., Mearns, K., & Flin, R. (2013). Stress, fatigue, situation awareness and safety in offshore
drilling crews. Safety Science, 56, 80-88.

Stanton, N. A., Chambers, P. R., & Piggott, J. (2001). Situational awareness and safety. Safety
Science, 39(3), 189-204.

Svedung I & Rasmussen J, (2002). Graphic representation of accident scenarios: mapping system
structure and the causation of accidents. Safety Science, 40, 397-417.

Page 185 of 186

Swuste, P. (2008) ‘You will only see it, if you understand it’ or occupational risk prevention from
a management perspective. Human Factors and Ergonomics in Manufacturing, 18(4), 438–53.

Tam, V. W., & Fung, I. W. (2011). Tower crane safety in the construction industry: A Hong Kong
study. Safety Science, 49(2), 208-215.

Vertikal (2018). CICA launches CrewSafe. Retrieved 31 July 2019 from

https://vertikal.net/en/news/story/30703/cica-launches-crewsafe

Vertikal, (2019). CPA rail crane safety guide. Retrieved 31 July 2019 from
https://vertikal.net/en/news/story/32165/cpa-rail-crane-safety-guide

Wadick, P. (2010). Safety culture among subcontractors in the domestic housing construction
industry. Structural Survey, 28(2), 108-120.

Wiethorn, J. D. (2018). An analytical study of critical factors of lift planning to improve crane safety
based on forensic case studies of crane accidents (Doctoral dissertation). University of Texas at
Austin.

WorkSafe Victoria (2018), Cranes back in action but checks continue. Retrieved 14 September
2018 from https://www.worksafe.vic.gov.au/news/2018-09/cranes-back-action-checks-continue

Zhou, W., Zhao, T., Liu, W., & Tang, J. (2018). Tower crane safety on construction sites: A complex
sociotechnical system perspective. Safety Science, 109, 95-108.

Page 186 of 186