White paper on fatal accidents at Hyundai Heavy Industries – 1

Korean Institute of Labor Safety and Health

2021

Ⅰ. Purpose of the study

The labor union of Hyundai Heavy Industries investigated their old newsletters to collect accident records. Until then, even though workers were dying, the labor union did not have any data to answer the question, “How many workers died from work?”

After the labor union announced the numbers of deaths since the beginning of the company, the media spread the news. The number of worker deaths have been updated every year but they remain only as numbers without any other narrative in media reporting. The government also deals with occupational accidents and deaths as numbers. This shows that South Korean society habitually deals with the very problematic issue of occupational accidents and deaths in an insincere manner.

In order to know the reason why the numbers of occupational accidents are not reduced, it is necessary to check the details of accidents in depth before looking into changes in the numbers of deaths and the suitability of preventive measures. There are dynamic and accidental situations in which occupational accidents occur as well as structural causes that result in occupational accidents.

The absence of proper records makes it hard for people to remember. Not remembering makes it difficult to determine the underlying cause of an accident despite repeated occurrence. Therefore, this research aims to record deaths at work as ‘narratives’ not ‘numbers.’ We tried to record every detail of the situation at the time of the accident, and restore all the links to administrative and structural causes.

Through this approach, first we aim to synthesize and reconstruct the situations and causes of each accident in as much detail as possible. Second, measures to prevent recurrence after the accident are summarized. Third, we added researchers’ opinions about some parts that needed to be checked out additionally or other parts that were sufficiently inspected. Fourth, the entire accident investigation was analyzed to reveal causes of major accidents and problems in accident investigations.

The research team tried to use open and transparent communications for accident inspections and prevention of accidents. This included communicating vertically from the main contractor to subcontractors, as well as over time from the past to the present.

We collected records of 35 serious accident cases that occurred since 2014. To supplement the details of the accident situations, we collected 27 written opinions on the accident investigations by the Korea Occupational Safety & Health Agency along with some court decisions.

The reason why the title of this research is “White paper on fatal accidents at Hyundai Heavy Industries – 1” is to show that we recorded the accidents to ensure that we captured the details of each accident rather than analyzing the accidents and proposing solutions. Also, this kind of work should be continued by the labor union or the company (joint work would be even better), and this research is a first try.

Ⅱ. Accident inspection and overall analysis

Analysis of fatal accidents: 2014~2021

An analysis was conducted on 35 fatal accident cases that occurred between 2014 and 2021 at Hyundai Heavy Industries. By type, entrapment was the most common with 7 cases. There were 5 cases due to falls, 3 cases of workers being trapped under heavy objects, 3 cases of falling into the sea, and 3 cases of drowning. By process, shipbuilding was the most common location of fatal accidents with 5 cases. There were 3 cases that occurred during painting, installing necessary components for the ship to sail, and manufacturing support. There were 8 accidents involving main contract workers while 26 cases involved subcontract workers. The main contractors were all regular workers. For subcontract workers, 1 was a short-term contract worker, 6 were not identified, and the other 19 were regular workers of subcontractors.

Work suspension due to an occupational accident was implemented only for some parts of where an accident occurred even though it should be implemented for the whole work site. Also, work suspension was confirmed in only 8 out of 35 cases that we analyzed. The average number of days of work stoppage in six accidents was 24 days, either by order of the Ministry of Employment and Labor or by the company itself.

Accidents were analyzed by dividing them into technical, managerial, and systemic causes. Technical causes are technical, physical, and chemical causes, and violation of safety procedures. Management causes mean systemic reasons by which such technical causes occurred. These include insufficiency or violations in procedures and risk assessments, violations, and non-compliance. Lastly, the term, systemic causes, means a management cause and a condition in which the safety management system could not work properly.

Technical causes

Issues of safety devices and facilities were most common. There were many cases of leaving equipment unlocked that should have been immobilized for safety reasons. There were also cases in which there were no safety devices such as handrails or sensors. There were cases of fires getting bigger or burn injuries due to failure to install ventilation systems in enclosed spaces, lack of monitoring oxygen concentrations, no deployment of fire extinguishers, and the failure to install emergency exits.

There were also accidents in which different types of work was performed in narrow places, or workers got caught in a narrow space. For cranes, there were accidents when cranes were not anchored properly or when an object was not properly fixed to the cranes. At dark working sites workers were strangled, fell from ladders, or fell into the sea. Due to the lack of stop signs or warning signs, while a worker was repairing an excavator, it suddenly started working and the worker died after being hit, or got caught between structures or fell into the sea. Workers work near the sea for shipbuilding, so there is a possibility of falling into the sea. However, there were repeated situations in which it took a while for divers to arrive or it was difficult to find lifesaving equipment.

Managerial causes

There are a lot of dangerous jobs in the shipbuilding industry, so it requires a team of two to do the work safely. Such guidelines need to be included in the standard work manual to effectively prevent serious accidents. For example, repairing excavators or operating a hangar door should be addressed by a team of two people but the company did not require two people to do these jobs. As a result, workers had accidents while working alone in an isolated place and ended up dying because but they were found quite late.

In some cases, the standard work manual was not prepared or it was filled in after the work was started. There were even cases in which false documents were prepared after the accident to make it look like the standard work manual was filled in. There were cases where the standard work guide existed, but the work plan was insufficient. There were also accidents that occurred when a hazardous work permit was not submitted.

Many accidents occurred because they did not follow the standard work manual or risk assessment even though the work was clearly contained in the manual or risk assessment. Working with the jib crane, there was an accident where a sling belt was cut due to carelessness. In the loud shipyard, workers were supposed to communicate by hand signals but they used their voices and eventually an accident occurred. There were also accidents when work was not carried out according to the risk assessment or the work plan.

Systemic causes

It has been constantly pointed out that the multilevel subcontracting system of the shipbuilding industry is the most important factor in accidents. However, this characteristic of the shipbuilding industry remains unchanged and this makes it impossible for the safety management system to work.

Workers from Hyundai Heavy Industries MOS who were not skilled were put into high-risk work. The standard work manual, risk assessment, and work instructions were not the same between Hyundai Heavy Industries MOS, subcontractors and secondary subcontractors. Since some parts of the work were outsourced, there have been repeated accidents related to equipment. Outsourcing also adversely affected communication between company workers and subcontractors and between subcontractors from different companies. Sometimes workers clashed while doing different tasks at the same place and time. The work could not be connected due to lack of communication. Other times, lack of communication between subcontractors resulted in accidents. For example, a worker was killed during the repair of an excavator because another subcontractor tried to operate the machine at the same time.

A working environment where signal operators or supervisors were not deployed became a cause of a major accident. Even at night time, there were times when there were no supervisors. Accidents occurred during aerial work or working on heavy loads because supervisors and signalmen were not deployed.

Work speed is a serious problem. Accidents occurred due to fast, cursory inspection or pushing ahead with work due to a pressure to shorten the work period. Because of insufficient time to complete the job, there was a lack of safety equipment, resulting in an accident. Another example is when lifting heavy loads, workers proceeded even though the load was not balanced and it led to a serious accident.

Work at night time and harsh weather were related to unreasonable work planning. Working at night time and harsh weather to meet the whole work schedule increased the risk of accidents.

Ⅲ. Conclusion and recommendations for proper accident inspection

First, the incident white papers should be published regularly, including the causes of accident cases, measures in place, and the results of carrying out measures shared with supervisors and workers, including subcontracted workers. By publishing and sharing the accident white paper, risks can be revealed and managed. It is important to outline the accident and describe its causes in detail.

Second, the Ministry of Employment and Labor is implementing a ‘review committee to release suspended work’ for a site where there was a fatal incident to allow for work to resume after it has been stopped due to an accident. This committee is composed only of experts outside the company and excludes labor union opinions. Before the review committee, a temporary occupational safety and health committee needs to be held. After the discussion between the company and the labor union in the temporary safety and health committee, the committee needs to decide whether to release or not. The regular safety and health committee is held quarterly between the company and workers (union), and the temporary committee can be held when the chairperson thinks it is necessary.

Third, after inspecting 35 accident cases since 2014, we found 28 deaths of subcontracted workers. Major accident causes were safety and health systems that did not work between the main workers and subcontracted workers. Moreover, another cause was that the analysis and risk evaluation of the subcontractor’s work process was poorly conducted. Even though it is not guaranteed by the law, the joint safety and health committee between main workers and subcontracted workers should be guaranteed by the system.

Fourth, we reviewed the Ministry of Employment and Labor’s disaster investigation statements. Most statements include 1) an overview of the site of the accident, 2) individuals’ information and degree of injury of the victim, 3) circumstances of the accident, 4) investigator’s opinion and accident cause analysis, including measures to prevent recurrence. The disaster investigation statement is not disclosed to bereaved families, coworkers, the labor unions, and the company, so it is not helpful in understanding the causes of the accident in depth. Therefore, the Ministry of Employment and Labor should disclose all disaster investigation statements as soon as possible to ascertain the causes of fatal accidents and develop measures to prevent recurrence.