Incident Prevention Through Learning from Incidents
January - December, 2012
Health, Safety & Environment Division
For further information, comments and suggestions please contact: Dr. Muhammad. R. Tayab (
[email protected]) Health, Safety & Environment Division Tel: 02-6041217; Mobile – 00971 (0) 50 324-3996
:
[email protected] :
: 6041217
This Booklet is circulated within ADCO organization within the framework of HSEMS. It should only serve as guidance and ADCO shall in no event accept any liability for either the fact described, nor for any reliance on the contents by any third party.
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ADCO regards safety of both ADCO & Contractor staff as well as protection of the environment and integrity of its assets high and I reiterate ADCO commitment to create a safe working environmental for every member of ADCO Community. We have achieved verychallenging production and operations targets during 2012 with high focus on personnel and process safety. During the 2012, ADCO has recorded over 160 Million Manhours worked by 52,000 ADCO & Contractor staff; and we have driven approximately 200 Million Kilometers. Regrettably, we have had2 work related fatalities, 20 Non Accidental Deaths (NAD) and over75 serious injuries. In addition we had24 vehicle crashes and 8 oil spills events. Incident investigations highlighted deficiencies in work planning, supervision and behaviour. Key gaps included: • • • •
Task related risks were not adequately identified Workers were not made aware of risks and were not effectively supervised. Lessons from prior incidents not embedded Tasks were not planned adequately (due to lack of competent human resources and non-availability of right tools)
ADCO safe system of work (e.g. Task Risk Assessment (TRA), Permit to Work (PTW), Tool Box Talks (TBT) etc.) is designed to save lives and should be respected. It is not mere a paper exercise, it is workers’ life line. I request all ADCO team members to take diligent review of work planning at grass root levels and effectively address these deficiencies. I am sure it will create a positive change and enhance safety at work. I would like every member of ADCO community to review this collection of incidents and what lessons can be learned and then their work activities so that these incidents are not repeated. You are requested never to compromise on the safety of staff & worker, protection of the environment and integrity of our assets. I am fully committed to provide you all the support and resources that you may require to create a safer working environment to all.
Abdul Munim Saif Al Kindy Chief Executive Officer (CEO)
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Table of Contents Finger Injury Resulting from Using Hand Tools 33-Kv Underground Cable Damage During Sand Clearance Damage to Underground Fiber Optic Cable During Excavation Crane Mounted Truck (Hiab) Rollover on Gatch Road Crane Mounted Truck Rollover on Gatch Road Loss of Containment Rollover of Truck Carrying Gatch Fire at Wooden Electrical Pole Vehicle Drop in Low Lying Area/Depression
9 10 11 12 13 18 19 20 21
Breakage Hook of Wire Rope Injury fromofFalling Cap of Circulating Head Struck by Swinging Mud Pump During Lifting Fall of Travelling Block with Full String Weight Gas Release From Coil Tubing Vehicle Collision Near A Rig Site Low Bed Trailer Rollover Finger Injury During Entanglement of Wire from Wireline Reel Release of Oil from Xmas Tree Fall of Foreman from Stand Pipe Dropped Object During Lifting Uncontrolled Descend of Travelling Block Power Generator/Engine Fire Trailer Fire at Rig Camp Water Tanker Rollover Hand Entrapment Inside Tong Electrical Shock Arm Injury Due to Fall of Jumbo Bag Falling Object Fire Due to Poor Grounding During Welding Fiber Optic Cable Cut During Excavation Vehicle Collision & Rollover Asphyxiation of Welder Inside A Pipe Man Lift Drove Over Flagman’s Foot Vehicle Rollover Vehicle Collision on a Sand Track
22 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 49 50 51 52 53 54 55
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Vehicle Drove Over a Berm Cement Mixer Rollover Damage to Overhead Line Ankle Injury During Cable Pulling Vehicles Collision on Gatch Road Arm Injury Due to Explosion During CAD Welding Fire at Scaffolding Platform Around Stripper Column Foreign Object Entering Eye of a Worker Vehicle Rollover on Gatch Road Crane Mounted Truck (Hiab) Rollover on Gatch Road Vehicles Collision Crane Rollover During Move on Gatch Road Vehicle Collision Fatal Fall of Worker from a Moving Vehicle
56 57 58 59 60 61 62 63 64 65 66 67 68 69
Fall Mobile Scaffold on a Worker Armof Amputation InsidePlatform Foam Concrete Mixer Vehicle Crash During OHL Visual Survey Transformer Fire Fire in UPS Unit of Substation Electrical Flashover Inside Transformer Terminal Box Foreign Object (Metal Particle in Eye) Worker’s Finger Entrapment Between Pipe Flange and Valve Flange Heat Stress HSE Performance, 2012 Incident Types - 2012 Asset Wise Event Type Distribution - 2012 Incident Immediate & Root Cause Categories 2012 Incident Immediate Cause Analysis -2012 Incident Root Cause Analysis -2012
70 71 76 77 78 83 84 85 90 91 92 94 95 96 97
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BAB & Gas Asset
5
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Past Incidents
Wireline Truck Rollover
Fire at Disposal Water Pump (09-03-2011)
Loss of Containment near RDS5 (20-11-2010)
Fatal Vehicle Rollover (01-08-2010)
Eye Injury Due to Acid Splash (0602-2010)
Production Header Leak (24-04-2011)
Finger Injury Due to Slippage of Cylinder (16-06-2011)
H2S Release from Water Supply Well (16-05-2010)
H2S Release from Oil Well (20-11-2012)
(04-0-7-10)
H2S Release from Common Drain Header (09-06-2010)
Finger Injury During Bolting of Flange (29-01-2010)
Gas Release From X-Mas Tree (16-01-2010)
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Finger Injury Resulting from Using Hand Tools Area
Incident Description
Root Causes •
A degasser was under off-stream inspection and after the inspection, a labourer/helper was tightening bolts of Pressure Control Valve (PCV). He was using a pipe to extend the handle of pipe wrench and during the process his finger was trapped between the pipe and the wrench. The labor was sent to RAMS Clinic and later to Madinat Zayed Hospital. Outcome: The labourer/helper sustained finger crush injury and required stitches & subsequent Bab Field wound management
14-02-12
•
•
•
Improper Supervisory Example (Foreman provided inadequate tools to labourer) Inadequate Training Efforts (A newly hired/appointed labourer was not given adequate training on use of hand tools) Inadequate of Worksite/ Job HazardsCorrection (Hazards of using inadequate tools for tightening bolts were not controlled) Inadequate Assessment of Needs & Risks (Availability of right tools was not ensured and workers were using home made type tools) Lessons Learned
Immediate Causes •
•
•
1. Always use right tools for the task and do not take short cuts Improper Position or Posture for the Task (Placing finger/hand near pipe and the 2. During task/work planning identify tool) requirements and availability of right tools Inadequate Equipment (Using a wrench with a pipe extension instead of standard tools, spanner)
3. Provide tool safety awareness to all Forman,hand helpers/labourers
Workplace Layout- Congestionor restricted movement
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33-Kv Underground Cable Damage During Sand Clearance Area
Incident Description Field Services Engineer requested sand clearance at the main track and a sand clearance crew was mobilized. Sand clearance from existing track is generally considered routine activities and not subjected to requirements of Permit to Work (PTW). The track had a high voltage (33Kv) line buried at a crossing. The cable was laid as prevailing
Root Causes •
•
engineering standards but at surface. the side of the track the cable was near the The crew was not aware of any buried cable and not site markers were placed. The crew was using mechanical grader and when Bab Field reached at the crossing, it damaged the live 28-04-12 cable.
Inadequate Identification of Worksite/Job Hazards (Risk associated with grading and leveling near buried cables were not assessed) Incorrect Supervisory Example(Sand clearance activity for main access track with buried utilities (high voltage cable) was initiated without PTW; No Tool Box Talk was conducted for Machine operator)
•
Inadequate Communication of Procedure (Requirements of Excavation Certificate were not understood by staff) Lessons Learned
Outcome: The power supply to cl usters was disconnected. No personnel injury was reported. 1. Always obtain excavation certificate for sand clearance (leveling/grading) activities (Item No. 3.4, Page No. 17; Item No. 3.13, Page No. Lack of knowledge of Hazards Present 69; Item No. 3.13.2.1 Page No 71 of PTW (Sand clearance crew was not aware of procedure) buried utilities) 2. Place visual markers to guide sand clearance No Warning Provided (There was no machine operators. markers/warnings identifying buried cable) Immediate Causes
•
•
•
Inadequate Guards or Protective System (Cable was not protected at t he edge of the track)
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Damage to Underground Fiber Optic C able During Excavation Area
Incident Description A 3rd party contractor was working o n a project to lay a new potable water pipeline to supply GASCO and ADCO with potable water and the majority of the work was completed in BAB. The work was performed under ADCO Permit to Work (PTW) system and an excavation certificate was issued. As built drawing did not show location of buried fiber optic cables (which were running parallel to a transfer line) and there were no physical markers on the ground. The task was intended for manual excavation and the use of machine was limited to removal of excavated material/debris. The crew did not have adequate resources (i.e. number of laborers for manual excavation) to complete the task on schedule and these resources were not adjusted for work during the fasting month of Ramadan.
BAB Field The job performer had started to use mechanical excavator, after exposing buried line. During the excavation a fiber optic 08-08-12 communication cable was cut and that has resulted in tripping of Remote Degassing Station (RDS-1) and alarm was sounded in the control room of Bab Central Degassing Station (BCDS).
Immediate Causes •
•
•
Violation by Supervisor(The job performer (JP) used a mechanical excavator in area where manual excavation was authorized) Lack of knowledge of Hazards Present(Location of buried cable was not known to Job Performer and there were no surface makers on the ground; Job Performer was not aware of risks associated with the task)
Causes •
•
•
Inadequate Work Planning (The number of labourers in the crew were not adequate to manually excavate the site on time and shorter working hours in Ramadan were not considered during work planning) Inadequate Implementation of Procedure (JP was not a member of Task Risk Assessment (TRA) team and did not endorse the TRA) Inadequate Leadership (Job Originator was not involved in TRA and did not ensure availability of adequate resources for task execution; As built drawings did not show location of buried cables) Lessons Learned 1. Do not use mechanical excavator in restricted areas. 2. Ensure availability of adequate resources prior to execution of tasks 3. Provide updated as built drawings to support excavation certificate 4. Ensure Job Originator Job Risk Performer/s are part of& Task Assessment (TRA) Team
Inadequate Guard or Protective Devices(Cable were buried without any physical protection)
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Crane Mounted Truck (Hiab) Rollover on Gatch Road Area
Incident Description A crew was involved in civil works in RDS-2 and after the completion of the work, a driver was driving Hiab Truck (crane mounted truck) from the work site towards their camp. The supervisor and job performer (JP) did not notice that the vehicle had deteriorated tires and IVMS (In Vehicle Monitoring System) was not functional. Due to high humidity, the gatch road surface became slippery.
After driving 8 km from the worksite, while the driver was maneuvering through holes on the surface of the gatch and he applied harsh BAB Field brakes. A combination of deteriorated tires, slippery surface, harsh brake and sharp 22-08-12 maneuvering of steering caused the vehicle to rollover. Outcome: The driver sustained lower back injuries.
Root Causes
•
•
Inadequate Audit/ Inspection/ Monitoring (Vehicle’s tire fitness was not checked; Road condition (potholes) were not assessed prior to the journey; Vehicle IVMS and driver’s driving behavior reports were not reviewed) Inadequate Identification of of slippery Worksite/Job Hazards (Hazards surface due to humidity and potholes in gatch road were not identified and controlled)
Lessons Learned
Immediate Causes •
•
•
Improper Decision Making/ Lack of Judgment (Driver applied harsh brakes and sharp maneuvering of steering on slippery road) Improperly Prepared Vehicle(The vehicle had deteriorated tires)
1. Avoid harsh braking and sharp maneuvering of steering especially on gatch roads. 2. Consider hazards of weather conditions (rain, high humidity etc.) on road/track conditions in Task Risk Assessment
Storm or Act of Nature (Road surface became slippery due to high humidity)
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Crane Mounted Truck Rollover on Gatch Road Area
Incident Description The Coiled Tubing (CT) work was completed at a well site (Bb-797) and a crane mounted truck was dispatched from Abu Dhabi to Bab Field to shift martials to another location (Bb241). The mobilization and demobilization was not considered in overall Task Risk Assessment (TRA) and there was no permit to work was in place for work at another location
Root Causes •
•
Inadequate Audit/ Inspection/ Monitoring (Contract focal point did not follow contractor’s work schedule and contractors activities without PTW were not detected) Inadequate Identification of Worksite/ Job Hazards (Task Risk Assessment (TRA) did not include mobilization & Demobilization and
(Bb-241). therefore hazards of slippery surface due to humidity were not identified) The gatch road leading to the site (Bb-797) became wet slippery due to fog/humidity 3. Lessons Learned Not Embedded(Lessons overnight. After driving approximately 2 km, from similar incidents (occurred on 22-08the vehicle drifted from the gatch road and 2012 & 28-08-2012) involving rollovers of the driver applied harsh brakes and sharp crane mounted trucks in BAB Field were not BAB Field maneuvering of steering to control the vehicle effectively incorporated into work plan) causing vehicle to over to its side. Outcome: 22-08-12 The driver sustained open wound on his hand Lessons Learned and treated at a hospital. Immediate Causes •
•
•
Storm or Act of Nature (Road surface became slippery due to high humidity)
1. Avoid applying harsh brakes and sharp maneuvering of steering when driving off road.
Improper Decision Making/ Lack of Judgment (Driver applied harsh brakes and sharp maneuvering of steering on
2. Subject drivers to daily tool box talks to discuss route hazards and to reinforce safe driving behaviour
slippery road to control the vehicle)
3. Consider hazards of weather conditions (rain, high humidity etc.) as a part of site mobilization/demobilization in Task Risk Assessment (TRA)
Violation by Supervisor (Work started without PTW and driver was not subjected to Tool Box Talk (TBT) or made aware of hazards at work site)
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Buhasa/Huwaila/Bida Qamzan Asset
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Past Incidents
Damage to Flowline During Sand Clearance (23-11-2010)
Piping Connection Failure During Well Killing (06-09-2010)
Loss of Containment Resulting in Fatal Loss of Containment Resulting in Fatal Vehicle Fire (07-05-2011) Vehicle Fire (07-05-2011)
Electrical Flashover (10-04-2011)
Vehicle Stuck in Sand and Caught Fire (21-07-2011)
Damage to Flowline During Site Preparation (17-06-2010)
Flasover Inside Switchgear Room (23-01-2011)
Loss of Containment Resulting in Fatal Worker Attacked by an Ostrich (2607-2011) Vehicle Fire (07-05-2011)
Private Vehicle rollover (06-04-2010)
Fall from Ladder (17-05-2010)
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Loss of Containment Area
Incident Description Work was planned to install corrosion coupon retrieval access fitting on a flow line. Due to hazardous nature of welding the fitting on site, a cold cut was performed followed by welding the access fitting in the workshop. Before welding the access fittings screws were removed and after the welding, the welder forgot to fit the screws and a cap was installed on to the fittings.
Buhasa Field (BUH) 01-01-12
Causes
•
•
Inadequate Inspection & Monitoring (Foreman did not check the fitness of the assembly prior to its installation) Inadequate Communication(Welding Foreman did not communicate with the Corrosion & Inspection (C & I) crews to carry out inspection on the fittings)
The foreman assumed that fitting screws were fitted back and he proceeded with the Lessons Learned installation. Operation crew opened the well and a release of oil was reported by another crew (approximately 2 km away from the well site) from the access assembly. The well was shut in and the leak subsided. Outcome: Approximately 1 bbl of crude oil was 1. Always assess/inspect readiness of the released/spilled system before installation/operations. Immediate Causes •
•
2. Do not assume and when in doubt, check with line supervisors.
Assembly without Screws
Assembly with Screws
Defective Equipment (Access fitting was capped without fitting screws) Unintentional Human Error(Welder did not fix crews before placing the cap of access assembly)
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Rollover of Truck Carr ying Gatch Area
Incident Description An Engineer requested delivery of gatch materials to the site. A transport Foreman conducted a site survey to assess the condition of the access track and he identified certain areas where soft sand had accumulated. The Field Services crew cleared the sand from the track. The transport Foreman gave instructions to tipper truck driver for the delivery. There were two access tracks to the location and the driver selected the track which was not prepared. On the track, the driver noticed sand accumulation but he continued to drive. The started to skid and rolled over to its right side.
Buhasa Field Outcome: The driver sustained minor (BUH) injuries on his both hands and forehead. Vehicle’s windshield, right mirror, right door 03-03-12 were damaged. Immediate Causes •
•
Lack of Knowledge of Hazards Present (The driver was not aware of sand accumulation on the track and upon noticing the sand he under estimated the extent of sand accumulation)
Root Causes
•
•
Inadequate Communication (The Foreman did not identify the right/cleared access track for the journey) Inadequate Work Planning or risk Assessment (The journey was not adequately planned and route selection, journey risks and tool box talk not performed)
Lesson Learned
1. Always identify route before commencing journeys 2. Do not drive over soft sand especially when transporting heavy loads 3. Conduct Tool Box Talk (TBT) for drivers prior to dispatching on assignments.
No Warning Provided (The foreman did not identify the exact route for the journey)
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Fire at Wooden Electrical Pole Area
Incident Description
Causes •
Electrical wooden poles are in use within ADCO concession areas and some of these poles are old and deteriorated, lost their c hemical (fire retardant) coating. Typically pole hardware are visually inspected and if there any abnormality noticed then physical checks are conducted. ADCO requires Over Head Line (OHL) rod resistance minimum of 4 Ohms and an earthing is driven to 3 m depth. Buhasa Field (BUH)
During a heavy thunderstorm and light rain, a wooden pole caught fire as a result of current passing from OHL conductor to earth conductor with high resistance. Outcome: Power to RDS-3, Huwaila, and a few surrounding clusters was disrupted.
14-04-12 Immediate Causes
•
•
•
Excessive Wear and Tear(The wooden poles have been in service for many years and are reaching the end of their service life) Inadequate Preventive Maintenance (Deteriorated wooden electrical poles were not replaced; integrity of fire retardant chemical coating was not maintained; effectiveness of earthing system not checked) Lessons Learned
1. Over Head Line (OHL) should be checked regularly for proper tightness. 2. Wood to metal interfaces at king bolt should be fitted with good electrical contact surfaces to dispense leakage current
Inadequate Guards or Protective Devices 3. Use deeper Earthing wells to disperse (Earthing system was not adequate to leakage current. disperse leaking current) Work Exposure to storms or acts of nature (Lightening and light rain.)
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Vehicle Drop in Low Lying Area/Depression Area
Incident Description
A mechanical foreman was returning to the workshop from a wellsite (CL-29) and he was heading the wrong way. His colleagues (passengers) in the vehicle advised him to proceed in the opposite direction. He turned the vehicle and started to drive in the desrt to get on the designated track. There was a low lying area /depression in the sand and the vehicle slid down and made contact with the bottom of the dune.
Root Causes
•
Inadequate Practice of Skill (Driver took a u-turn and entered into non-designated route instead of remaining on track)
Buhasa Field Outcome: The vehicle sustained minor damage on the front-end bumper. (BUH)
22-08-12 Immediate Causes •
•
Improper decision making/lack of judgment (The driver did not return back to srcinal track but tried to go another way to merge with the main track) Inattention to surroundings (He did not pay attention to surface conditions and was focusing to get on the designated track)
Lesson Learned
1. Always take the designated route to avoid hazards of unstable ground conditions.
21
Breakage of Hook of Wire Rope Area
Incident Description
Root Causes
A Foreman was driving to a well site (BU-559) and his vehicle got stuck on a sand dune. He requested assistance from the transport pool. •
Transport Pool Driver reached the site and tried to pull the stuck vehicle using a wire rope with his own vehicle.
Buhasa Field
In adequate removal/replacement of tools & equipment (The slings in the older desert safety boxes were not checked/ replaced)
While pulling the vehicle from the rear side, the wire rope's hook broke and struck against the foreman-vehicle’s rear window. Outcome: Rear window of the vehicle was completely smashed. Lesson Learned
(BUH) Immediate Causes
10-08-12
1. Check adequacy of tools available for in vehicle tool box.
•
Inadequate Tools or Equipment(The sling used was not suitable for the job)
2. Always check if the slings are certified/checked, and suitable for pulling the vehicle prior to use.
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Technical Services – Drilling
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Past Incidents
Damage to Hammer Union During Pressure Test (23-11-2010)
OBM Haulage Tanker Rollover (29-102010)
Fatal Fire & Explosion of OBM Haulage Tanker (24-02-2012)
Finger Injury During Rigging up (02-07-2010)
Well Control Incident (08-04-2010)
Fatal Fall from Height (18-01-2010)
Damage to Flowline During Site Preparation (23-03-2010)
Uncontrolled Descent of Drilling Assembly (28-05-2011)
Super Kenworth Rollover (13-12-2010)
Slippage on Mud Tank (30-06-2010)
Spillage of OBM (16-06-2010)
Face Injury From Tong line (26-01-2010)
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Injury from Falling Cap of Circulating Head Area
Incident Description
During normal drilling operations (installation of wearing busing), an Assistant Driller (AD) opened the cap of circulating head on the rig floor. The cap (weighting approximately 2.5 kg) slipped, hitting on the substructure cross beam and after rebounding fell down in cellar area. A floorman was working (tightening the Drilling
chain boomer) in the cellar 32 feet below the rig floor) and the cap struck on his helmet.
Causes
•
Inadequate Identification of Worksite/Job Hazards (Hazards of falling of circulatory cap due to close location of circulating head to rig floor hand rail and improper adjustment of toe plate of handrail)
Outcome: The hardhat of that floorman flownRig No. 17 off from his head and he sustained scratches due to the impact of sliding of hardhat. 17-01-12
Lesson Learned Immediate Causes •
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Congestion or Restricted Movement (The circulating head was located close to rig floor handrail) Lack of Judgment/ Unintentional Human Error (Opening of circulation head with oily/greasy hand gloves)
1. Ensure hand/work gloves are dried & free from oil & grease before handling tools & equipment. 2. Adjust toe plate of handrail to prevent dropping of objects 3. Always use mandatory PPE (Personal Protective Equipment) at Rig Site at all times
27
Struck by Swinging Mud Pump During Lifting Area
Incident Description
Cracks in housing of mud pump occurred because the mud pump blower and motor assembly structure were not supported properly and the center of gravity was outside of the structure. Rig Electrician and Asst. Electrician planned to remove the blower unit of Mud pump to weld and repair cracks.
Root Causes •
•
The Electrician instructed the Assistant Electrician to
Drilling Rig No. 53
detach, electrical cables from the blower motor and hook up the blower housing with the crane hook by using shackles. While Assistant Electrician was placing the 1st shackle, suddenly the blower unit tilted, due to the weight of the blower motor, and the whole blower unit (≈115 Kg.) fell down /swung towards the Electrician and hit on his left shoulder, and pushing him down; and the blower unit rested on the mud pump skid. The electrician fell down on the mud pump skid. Outcome: Electrician sustained fractures on the left two ribs
20-01-12
Immediate Causes •
•
•
Improper Position (Electrician was standing too close to mud pump during lifting) Improper Lifting (Fixing studs were removed before hooking up the load)
Inadequate Identification of Worksite/Job Hazards (There was no Job Safety Analysis (JSA) was available to remove and fix back the mud pump blower unit) Inadequate Work Planning (Adequate resources were not obtained (i.e. Electrician was working with Assistant Electrician with no one to supervise the task)
•
Inadequate Preventive Maintenance (Earlier inspections did not identify lack of support to mud pump blower and motor assembly structure) Lesson Learned
1. Always follow safe lifting procedure by ensuring hooking up the load before removing the fixing studs 2. Ensure your safe position while lifting operation and keep away from the loading area
Lack of Knowledge of Hazards Present (Electrician didn’t put into his consideration the imbalance when he removes the studs the blower unit will tilt from its place due to the center of gravity of the blower motor)
28
Fall of Travelling Block w ith Full String Weight Area
Incident Description
( 282) While running in hole with a wash-over assembly, the driller picked up the string out of the slips and started to lower the stand, controlling running speed using the electrodynamic (eddy-current or Elamgco) auxiliary break. Either from the time of picking up the string or during running of this stand, with approximately 80,000lbs hook-load, breaking force from the Elmagco was lost and the blocks began to free-fall. The driller attempted to apply the main, mechanical, break but was unable to stop the draw-works sufficiently to prevent the elevators from impacting with the rotary table. The travelling block also fell to the floor. Outcome: No personnel were injured
38
•
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Inadequate Audit/ Inspection/ Monitoring (Regular inspection of the linkage is not conducted and no recent maintenance had been performed on the mechanism) Inadequate Adjustment/ Repair/ Maintenance (An unathorised part was used in )
Lessons Learned
Immediate Causes
Drilling Rig No.
Root Causes
•
02-02-12 •
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Violation by Group (During commissioning of the rig, the auxiliary brake unit was changed and a substandard part was incorporated) Defective Guards or Protective Devices ( The Elmagco clutch shifting mechanism failed allowing the Elmagco to disengage) Work Exposure to Mechanical Hazards ( With approximately 80,000lbs string weight the elevators impacted with the rotary table, the travelling block landed on the rig floor and the drill-line parted)
1. Always use spares & part as recommended by srcinal equipment manufacturer (OEM) 2. Examine all auxiliary brake clutch linkage systems for correct specification fittings 3. Regularly test Elmagco clutch mechanism.
29
Gas Release From Coil Tubing Area
Incident Description The well was drilled as exploratory well and after the production test, it was scheduled for work over to perforate and test Hith Formation and horizontalization. During run in hole with coil tubing and lifting the well with nitrogen at depth 370ft from surface, the coil tubing partially parted (almost 75% from its circle) just 1.5ft before the mechanical depth indicator of the coil causing big sound, nitrogen &
gas with H2S (Hydrogen Sulphide) release to the atmosphere due to failure of dual check valve in the Bottom Hole Assembly (BHA). N2 (Nitrogen) and gas with H2S (1400PMM) was released into the atmosphere. All the personnel were evacuated Drilling and the well was killed by bull-heading with 100bbls of brine water (75pcf). Gas leak was Rig No. 22 stopped after pumping 15bbls of the brine into tubing. Outcome: Release of N2 (Nitrogen) and 21-03-12 gas with H2S from coil tubing to the atmosphere.
Root Causes •
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Inadequate Inspection/Monitoring(Rigless Supervisor and Drilling Supervisor did not monitor the exposure time; Dual check valve installed with coil tubing BHA and coil tubing reel was not inspected or tested after acid job and prior lifting job) Inadequate Assessment of Required Skills or competency/Inadequate Job Placement(The assigned Drilling Supervisor lacked experience in acid treatment job and it was the first time to attend gas production test; Rigless supervisor was shifted to this job just before acid job without adequate handover)
•
Inadequate Work Planning(There was no detailed acid program from town and no formal job order for the execution of job from Rigless & Drilling Supervisors to Service Providers on site)
Lessons Learned
Immediate Causes •
•
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Violation by Supervisor(Rigless crew exceeded acid recipe time duration) Defective Equipment (Coil tubing lost 70% from its material thickness and partially parted; Double check valve was severely damaged due to long exposure time for acid 28% during acid treatment).
1. Do not exceed recipe exposure time during acid job test. 2. Always inspect & test coil tubing & double check valve after acid job 3. Assign competent staff on high risk jobs
Work Exposure to Energized System (Exposure to high pressure sour gas in gas well)
30
Vehicle Collision Near A Rig Site Area
Incident Description
Unspool drilling line operation was ongoing and the Drilling Supervisor (DS) decided to go to camp after finishing his tasks at the rig site. He called for his driver and he was on the way to the rig camp using the designated rig road. Rig Crew change vehicle
Root Causes
•
Inadequate Identification of Worksite/Job Hazards (Rig access track design did not mitigate risks of driving on slopes in low visibilities (e.g night driving).
•
was approaching the rig site from rig camp at the same time. Both vehicle approached from opposite directions and collided at a slope. Drilling
Inadequate Monitoring (Accessintrack adequately maintained resulting sandwas accumulation at places)
Outcome: Both vehicle sustained minor damaged on their front right sides.
NDC Rig 25
Lesson Learned
24-05-12 Immediate Causes •
•
Violation by Individual(Driver of Rig Crew Move vehicle was driving on the wrong side of the track) Lack of Knowledge of Hazards Present (Drivers were not aware of approaching vehicles due to low visibility and road layout- Slopes)
1. Avoid driving at night time/low visibility conditions between rig site and rig camp. 2. Regularly maintain access tracks to avoid accumulation of sand on tracks causing drivers to move towards middle of the track or on the wrong side of the track.
31
Low Bed Trailer Rollover Area
Incident Description
Causes
•
Shifting of a crane from one location to another (Well site No. Sa-220 to Sa231) and was loaded on a low bed trailer. The trailer operator was not aware of the access route to the new location and was travelling in wrong direction.
Drilling
When he realized the error he tried to take a U Turn to return back. Due to sand accumulation/soft humps and lack of space for turning, the trailer with the crane rolled over. Outcome: The trailed 5th Wheel was damaged and the crane was moved by another crew.
NDC Rig 9
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Improper Supervisory Example(A new & inexperience operator was assigned to transfer the load and the route was not defined/identified) Inadequate Assessment of the required Skill or Competency The driver had only one week experience on low bed trailer and his competency to operate the trailer with heavy load in field conditions was not assessed and was inadequate) Inadequate Communication(The supervisor did not properly identify the route) Lesson Learned
02-06-12
Immediate Causes •
•
Improper Decision making/Lack of Judgment (The operator of low bed trailer 1. Always inspect and identify access route for the attempted to take a U turn on sand movement of equipment bars/humps) 2. Familiarize new drivers/operators with roads and Lack of Knowledge of Hazards Present access routes prior to their assignments (The operator of the trailer was not familiarized with road/access route conditions journey) and hazards associated with the
32
Finger Injury During Entanglement of Wire from Wireline Reel Area
Incident Description
Run in Hole (RIH) operation with Gyro was ongoing. During the process the wire got crossed out of the wire line reel and the operator was trying to turn back the wire to its position. When he returned it, his left thumb got trapped between the wire and the reel.
Root Causes
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Inadequate Identification of Worksite or Job Hazards(The risk of entanglement of wire on reel and trapping of hand/limb during entanglement were not identified)
Outcome: He received the First Aid at Rig Clinic and then taken to Hospital where he was diagnosed with fractured thumb and discharged after treatment. He was assigned on restricted work. Lesson Learned Drilling Immediate Causes
Rig No. 51 •
15-06-12 •
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Servicing of Energised Equipment(The wire line reel was not isolated prior to adjusting the wire)
1. Stop equipment completely before performing any work on the moving/rotating parts
Lack of Knowledge of Hazards Present (The operator did not anticipate trapping of his limbs due to low risk perception)
2. Use line splitter guards on wire line reels
Inadequate Guards/Protective System (The reel was not fitted with line splitter guard)
33
Release of Oil from Xmas Tree Area
Drilling Rig No. 1
Incident Description
A Water Alternating Gas (WAG) well was drilled, and after the rig move X- mas tree was installed by a Wellhead Engineer & set Non Return Valve (NRV- in place but NRV was passing and all X-mas tree valves were in open position. X-mass tree installation job was not witnessed by Drilling Supervisor or the Rig Manager and the Wellhead Engineer was not on the list of approved wellhead Engineers. The well location was under preparation prior to well handover for operations. During the location preparation the well was found flowing from X-mas tree top needle valve. The DS reported the incident and closed all XTree valves to secure the well. Outcome: It had resulted in release of well fluid and gases. Contaminated soil/sand was removed and sent to treatment facility.
Root Causes
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•
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Inadequate Leadership (Unapproved Wellhead Engineer was assigned to install X-mass Tree and the installation was not witnessed by Rig Management) Inadequate Planning or Risk Assessment Performed(Wellhead Engineer’s competency was not assured and high risk activity was not supervised) Lack of Procedure for the Task(There was no formal well securing procedure in place)
Lesson Learned
Immediate Causes
05-06-12 •
•
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Violation by Individual(The wellhead Engineer did not close Xmas Tree Valves and NRV installation procedure was not followed)
1. Drilling Supervisor should witness installation of X-mas Tree and securing well.
Violation by Supervisor(Drilling Supervisor did not witness the installation & securing of X-mas Tree)
2. Assure Wellhead Engineers’ competency prior to their assignment on high risk activities
Defective Guards or Protective Devices (NRV was passing)
34
Fall of Foreman from Stand Pipe Area
Incident Description Work was planned to connect 2” High Pressure Hose between reverse line and chock manifold and an Assistant Driller with three roustabouts was moving the hose. A labor foreman, who was not involved in the task (but he was the supervisor of these newly assigned roustabouts – green hats), stepped over the horizontal section of the stand pipe to observe and assist in pulling the hose.
The Assistant Driller asked him not to stand on the stand pipe but he stayed there for a moment and then he lost his balance resulting in his fall back with Drilling his full weight on his left elbow on the compacted sand ground. Outcome: The Labor Foreman NDC Rig 54 sustained fractured elbow.
Root Causes
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Improper Supervisory Example(The Assistant Driller did not effectively stop the Labor Foreman from standing on standpipe). Inadequate Identification of Worksite/ Job Hazards(The Foreman did not realize of risks of standing on standpipe and assisting the crew).
Lessons Learned
18-06-12 Immediate Causes
•
•
Improper Position or Posture for the Task (The Foreman was standing on the standpipe).
1. Do not stand on stand pipe or other similar structures without fall protection equipment. 2. Stop all unsafe actions effectively
Improper Decision Making/Lack of Judgment3. Supervisor should supervise crew and should not participate in execution of (Forman intended to observe his newly assigned tasks. crews and assist them in pulling the hose while standing on the stand pipe).
35
Dropped Object During Lifting Area
Incident Description During normal drilling operations at the rig site, a task of removing lifting-sub and crossover (weighting approximately 250 kg) from rig floor to the ground (33 feet down). An inexperienced rigger without effective supervision was assigned the task of rigging the load. Prior to the task, no tool box talk (TBT) or pre job safety meeting was conducted. The rigger
used the wire rope sling to attach it to the load by single wrap only and then load was lifted by crane from the rig floor, at height 33ft, to cross over box on the ground. A floor-man noticed that the load was unstable and he requested the rigger to stop the lifting and advised to secure it through double wrap slinging method. The rigger ignored Drilling the advised and continued to lift the load and later, the lifting sub slipped and fell down on the NDC Rig 56 V-door causing damage to steps of the V-door stair then it is slipped down to the ground. 24-06-12 Outcome: No injury to personnel and damage t o three steps of V door stairs.
Root Causes
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Improper Supervisory Example(An inexperienced rigger, without supervision was assigned the rigging task) Inadequate Coaching on the Skill(New Rigger was not effectively coached/ mentored by experienced rigger or supervisors prior to the assignment of the task) Inadequate /Lack of Safety Meetings(Prior to the task, no tool box talk (TBT) or pre job safety meeting was conducted)
Lessons Learned
1. Ensure adequate supervision during lifting operations. 2. Attach new riggers with experienced riggers prior to assigning them task independently Violation by Individual (The rigger did not 3. Conduct Tool Box Talk/ Pre Job Safety prior to all tasks especially high risk activities follow the requirements for safe lifting/rigging and the load was not secured) Immediate Causes
•
•
Improper Lifting (The rigger used one wrap of sling around the load instead of two wraps)
36
Uncontrolled Descend of Travelling Block Area
Incident Description During Run In Hole (RIH) operations with fishing assembly, the block with top drive started descending. Assistant Rig Manager, who was running the operations, attempted to stop but failed when applied brakes with joy stick neutral (Auto Park) position. He then applied the parking brake, meanwhile the Top Drive (T/D) saver sub pin engaged in Drill Pipe (D/P) box which was stab in but andthe avoided lowering of Top Drive (T/D), block further continue descending towards off driller side resulting in drilling lines became loose in mast hoisting system.
Drilling
Outcome: It resulted in minor damage t o equipment.
NDC Rig 31
Root Causes •
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Inadequate adjustment/ repair/ maintenance (Integrity of Draw Work (D/W) & anti-collision system was not assured through regular maintenance regime) Inadequate Practice of Skill(When joy stick controlled brake failed, ARM did not use EDS/VFD) Inadequate Procedure for the Task(No written D/W safe work practices/ guidelines were available in driller cabin
Lessons Learned
Immediate Causes
28-06-12 •
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Defective Equipment (Joy Stick controlling the brake malfunctioned)
1. After each rig move, verify the integrity of Draw Work (D/W) & anti-collision system.
Improper Decision Making/Unintentional 2. Use Disconnect System/ Variable Frequency Drive Human Error (ARM did not use/activate (EDS/VFD) to stop any free fall of blocks. Emergency Disconnect System (EDS)) 3. Post D/W safe work practices/ guidelines in driller cabin for quick reference
37
Power Generator/Engine Fire Area
Incident Description
Root Causes
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During normal drilling operations, two labourers noticed fire at a diesel driven generator and they informed the night shift Assistant Mechanic. The Mechanic closed the diesel supply line and shut down the engine then labourers used fire extinguishers to extinguish the fire.
Drilling
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Inadequate Correction of Worksite/Job Hazards (Similar incident had occurred on 21st October, 2007, 25th of August, 2009 & 17th May, 2010 at NDC Rig 25, NDC Rig No.2 & NDC Rig No. 17 respectively) Inadequate Preventive Maintenance (Daily/weekly visual checks and Preventive Maintenance programme was not robust enough to identify deteriorated fuel line)
Outcome: Minor damage to the engine fuel supply line
NDC Rig 11
Lessons Learned
02-06-12 Immediate Causes
•
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Defective Equipment (Diesel hose line was leaking due to material fatigue/deterioration and vibration)
1. Develop and implement rigorous testing/replacement of fuel lines after each Rig move.
Work Exposure to Extreme Temperature 2. Maintain fire watch during the operations of generators. (High temperature at diesel engine surface)
38
Trailer Fire at Rig Camp Area
Incident Description After the completion of Rigless operation, equipment (high pressure pump, air compressor, transfer pump and pipe basket) were loaded on a trailer and the trailer departed from the rig location (Mandar Field) for Abu Dhabi. The driver stopped at Rig Camp (5 km from the Rig for lunch break), parked the vehicle and went to Mess Hall. Shortly after, the camp staff observed fire of
trailers tires and raised the alarm. The driver separated the truck from the trailer and moved Drilling the truck. The camp crew responded and extinguished the fire using 3 water tankers and NDC Rig 51 10 fire extinguishers. 06-06-12
Outcome: No personnel injury occurred and the trailer and loaded equipment were damaged.
Root Causes
Inadequate Communication Between Work Groups (Hazards of smoking near parked vehicles were not effectively communicated)
Lessons Learned
Immediate Causes Violation by Individual(Smoking cigarette in non-smoking areas) Lack of knowledge of Hazards Present (Smoker was not aware of hazards of smoking near truck)
1. Provide and mark location of designated smoking areas 2. Do not smoke near parked vehicles.
39
Water Tanker Rollover Area
Incident Description For a cementing job, 500 barrels (bbls) of freshwater delivery was required at the rig site and an urgent delivery request was sent to water supply contractor. The contractor assigned tankers & drivers were not available and therefore a new driver and a tanker was sent from Musafah Base to make this delivery. The driver did not have ADCO Safe Driving Document (ADSD) and the vehicle System was not (IVMS). fitted with In Vehicle Monitoring
It was the first day of Ramadan and the driver missed his Dinner & Sahur and made a delivery of water. After the delivery he went back to his camp to refill tanker and then again proceeded to the rig site for another delivery. The air Drilling conditioning system in driver’s cabin was not working and it was a hot day and the driver was working in excess of six hours. During the trip the 21-07-12 driver felt dizzy and lost control of the tanker. It resulted in tanker to rollover. Outcome: The driver escaped unhurt and the tanker sustained minor damage. Immediate Causes •
•
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Violation by Supervisor(A new driver, without ADSD was assigned to the task; Unauthorized vehicle was used)
Root Causes
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•
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Inadequate Leadership (Knowingly an untrained driver was assigned on the task) Inadequate Work Planning(Request for supply large quantity of water was made without ensuring availability of contractor’s resources) Inadequate Audit/ Inspection/ Monitoring (There was no monitoring system in place to check contractor compliance with contractual requirements for the safety of driver and vehicles) Lessons Learned
1. Assess availability of contractors’ resources prior to issuing task order. 2. Monitor contractor compliance with contractual requirements for the safety of driver and vehicles.
Defective Vehicle (Air conditioning unit in driver’s cabin was not working) Work Exposure to Temperature Extreme (The driver was fasting, working over 6 hours during peak summer hours in hot cabin of the water tanker)
40
Hand Entrapment Inside Tong Area
Incident Description While an inexperienced tubular services operator was working as a tong operator, he had his left hand at the top of the tong rotary while the other hand was on the lever adjusting the tong rotary. His supervisor left the Rig Floor leaving the operator alone before completing the job. When he started to operate the tong, the tong jumped resulted in slippage of his left hand which got trapped inside the tong. Outcome: Tong Operator sustained an open displaced fracture on his left hand.
Drilling NDC Rig 21
Root Causes
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Inadequate Leadership(Senior Operator left the inexperienced operator at the rig floor before completing the job; Rig crew did not stop “Green Hat” – (New or Inexperienced Worker) from working alone) Inadequate Identification of Required Skill or Competency(I nexperienced operator was not adequately coached on required skills to work independently)
Lessons Learned
Immediate Causes
03-08-12 •
•
•
Improper Posture/Position for the Task (The operator had placed his hand on 1. Do not leave in experienced staff (Green Hat) workers unsupervised at hazardous locations the top of tong rotary while adjusting the such as Rig Floor rotary) Lack of Knowledge of Hazards Present 2. Include all sequence of works (such as operations as well as any repair/ (The Supervisor left the operator working troubleshooting) in Job Safety Analysis (JSA) alone on the rig floor; the operator was not adequately trained to recognize pinch points on power tongs) Work Exposure to Mechanical Hazards (Power Tong at Rig Floor)
41
Electrical Shock Area
Incident Description
Root Causes
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The electrical panel door of the fire unit fall down due to broken hinges (caused by the deterioration of pin in the hinges) resulting in cables cut/damage inside the panel.
Drilling
An isolation certificate and permit to work was issued. The damaged/cut cables were fixed/replaced by an electrician. After electrical cables were fixed, the electrician restored the power supply and started to check cables voltage using a portable voltmeter. During the process an electrical spark occurred.
•
Inadequate Practice of Skills(The electrician did not systematically check the electrical system and did not ensure physical protection from coming in contact with live conductor) Excessive Wear & Tear (Due to harsh climatic conditions and rig move, hinge pins were deteriorated)
Lessons Learned
NDC Rig 55
Outcome: It has resulted in a second degree 06-09-12 burn on electrician’s right hand thumb. Immediate Causes
•
•
Servicing of Energized System(The Electrician was checking cables voltage using a portable voltmeter on a live system) Improper Decision Making/Lack of judgement (The Electrician made a physical contact with a live conductor)
1. Always follow systematic way of checking electrical circuit 2. Stay clear of live conductors when servicing energized electrical system 3. After each rig move visually check the integrity of hinge pins 4. Conduct trade relate workshops for experience electricians to share their knowledge and incident lessons learned.
42
Arm Injury Due to Fall of Jumbo Bag Area
Incident Description During mud mixing, at the mud hopper, jumbo bag (weighting 1.5 Tons) containing baryte was being lifted and suspended over the hopper by crane, utilizing a four legged wire rope sling. A worker was assigned to cut the bag, once positioned over the hopper to discharge baryte. The procedure required to use jumbo bag stand when mixing over the hopper but it was not used. It was required that jumbo bag straps be stitched but the consignment was accepted where straps were not stitched accordingly. When the material delivered at the store, it was not inspected and accepted.
The derrick man, supervising the job, left the hopper area and an inexperienced (“green Hat”) started to cut the bag. Sudden tilt of bag caused it to roll to failed strap side and roll NDC Rig 11 out of other strap causing the bag to fall on the arm of the labourer, which was positioned near bag, while attempting to 29-10-12 cut the bottom of suspended bag. Outcome: Worker sustained left forearm fracture.
Root Causes
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•
Inadequate Material Packaging(Jumbo Bag straps were not stitched) Inadequate Supervisory Example (Derrikman left the inexperience labourer unsupervised; Jumbo Bag Stand was not used to save time & efforts)
Drilling
Immediate Causes •
•
•
Violation by supervisor(Derrickman left the site leaving “Green Hat” labourer unattended/ unsupervised; Material conformance with ADCO requirement was not assured) Lack of knowledge of Hazards Present(The labourer
Lessons Learned
1. Do not leave inexperience (Green Hat) staff unsupervised at rig site 2. Always assess compliance of received materials with contractual requirements for packaging. 3. Whenever emptying jumbo bags at mud hopper, use Jumbo Bag Stand
was not made aware of worksite/Job Hazards) Equipment or not Secured(Jumbo bag stand was not used)
43
Falling Object Area
Incident Description While running completion tubing, the driller picked up a joint, after stabbing & making the joint in rotary, Stabber flagged the Driller to slack down. It was first time for Driller to run completion assembly. The Driller was coming down with the block, at the same time he was tilting the elevator links. Suddenly, the stabber flagged driller to stop and float the links. Before the driller could stop, the elevator guide hit the box end of the made-up tubing joint in rotary.
Outcome: The Impact resulted in shearing of holding b olts of elevator guide & whole guide assembly (8 pcs/biggest piece weighing 7 kg.) to fall down on Rig floor approximately NDC Rig 57 from 30 feet height. Drilling
28-10-12
Root Causes •
•
Inadequate Identification of Worksite/ Job Hazards (Job Safety Analysis (JAS) did not include communication signals and hazards of was lowering the block, at the same time he was tilting the links) Inadequate Audit/Inspection/ Monitoring (It was first time for Driller to run completion assembly and there was no monitoring on his performance and coaching on the skill)
Lessons Learned
Immediate Causes •
•
1. Establish clear signals between stabber & Improper Decision Making/Lack of Judgment(The Driller before start of the job. Stabber gave signal prematurely to Driller to stop the Top Drive System (TDS) and the Driller was lowering the 2. Do not float the TDS links to its srcinal block, at the same time he was floating the links) position while the TDS is in motion. Lack of Knowledge of Hazards Present(Job Safety Analysis (JAS) was generic in nature and did not address the communication signal between Stabber & Driller)
44
Engineering & Projects
45
46
Past Incidents
Cement Mixer Truck Rollover (12-062010)
Head on Collision (03-03-2010)
Tipper Truck Rollover 28-04-2010)
Leg Trap in Potable Cement Mixer (17-07-2011)
Worker Ran Over by Water Tanker 02-08-2011)
Flagman Ran Over by Wheel dozer (17-08-2011)
Fall of Worker from Height (10-092011)
Hand Injury During Cable Pulling (17-04-2010)
Vehicle Rollover (18-01-2011)
Fatal Injuries to Rigger (22-01-2011)
Tipper Truck rollover (14-02-2011)
Death of a Worker from Heat Stress (24-08-2010)
47
48
Fire Due to Poor Grounding During Welding Area
Incident Description Welding job at a pipe rack was planned and Permit to Work (PTW) issued. The task risk assessment (TRA) identified the risk and need for proper grounding was identified. The work was in progress and the welder assigned a helper to set up the welding station and during the set up, the helper connected the grounding clamp to an incorrect spool. The helper placed the grounding clamp on another spool because there was no place available to place grounding clamp of the spool the welding job was being carried. The clamp was in contact with a scaffolding (wooden) plank.
Outcome: During the welding job, current passed through the grounding clamp, warming it up causing smoldering in Engineering & adjacent scaffolding plank. The crew stopped the operation Projects and extinguished the fire.
Root Causes •
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Inadequate Audit/Inspection /Monitoring (Job Performer as well as the welder did not inspect the set up of welding station (as highlighted in Task Risk Assessment) prior to start of welding) Inadequate Leadership (Permit issuing authority did not ensure adequate grounding prior did to issuing the permit; (Job Performer not discuss task related hazards with his crew)
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Lack of Procedure for the Task(There was no formal work procedure or checklist available) Lessons Learned
Sahil Field Immediate Causes
03-01-12 •
•
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Violation by Supervisor(Welder did not check the 1. Check and ensure proper Grounding / adequacy of grounding prior to starting welding; Job Earthing of welding stations prior to Performer (JP) did not supervise welding operations commence welding and did not conduct specific tool box talk; PTW Issuing 2. Conduct task specific Tool Box Talk (TBT) Authority (IA) issued the permit without confirming discussion hazards and control grounding and confirmed adequacy of grounding on the permit) 3. Permit Issuing Authority (IA) & Job Performers (JP) must assess/check Improper Placement of Tools/ Equipment (Grounding clamp was placed on wrong spool which system, readiness prior to issuance of permit and start of work was contacting a wooden plank) Congestion or Restricted Movement(The work location did not provide c lear location for grounding)
49
Fiber Optic Cable Cut During Excavation Area
Incident Description
Root Causes •
A combination of manual and mechanical excavation was planned for preparation of existing line crossing. In preparation for the work, site scanning survey was done however the location of underground fiber optic cable was not known. Permit to Work (PTW) was issued. The Foreman the operator to excavate in aninstructed area marked for manual excavation. The Job Performer (JP) signaled the foreman to stop but the foreman continued the mechanical excavation.
•
Inadequate Identification of Worksite/Job Hazards (Site scanning survey and excavation certificate did not identify location/presence of fiber optic cable) Inadequate Job Placement(The Job Performer (JP) and crew members had language barriers and were not able to communicate effectively)
Lesson Learned
Engineering Outcome: Damage to underground Fiber Optic & Projects Cable Shah Field 09-01-12 Immediate Causes •
•
•
1. Do not use machines for excavation in areas marked for manual excavation
Violation by Supervisor(Violation of Permit to Work (PTW) Procedure for use for 2. Positively identify locations of underground utilities before commencing excavation machines in hazardous area) 3. Consider communication skill/language No Warning Provided (Location/presence barrier when assigning crew members of Fiber Optic Cable was not identified in Excavation certificate) Improper Decision Making/Lack of Judgment (The Foreman instructed Excavator Operator to excavate in area marked for manual excavation
50
Vehicle Collision & Rollover Area
Incident Description Due to pre commissioning of Gas Compression Station No. 2, there were increased activities and working hours were extended to meet the schedule. A project driver pick up driver was supporting crew and staff movement between offices and work sites and over the last one week the driver was working between upto 15 Hrs a day with irregular breaks/rest.
The driver was proceeding to Gas Compressor Station to collect staff. When he entered Habshan –Buhasa Road, his Engineering & pickup vehicle was hit by an oncoming Projects bus. It resulted in pickup vehicle to rollover. Outcome: The driver sustained minor injuries on his hands and the vehicle Bab Field was badly damaged 30-01-12
Root Causes •
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Inadequate Inspection & Monitoring (There was no monitoring system in place to monitor drivers working conditions) Inadequate Implementation of PSP (Procedure/ Standards/Policy) (Drivers RAG (Driving Behaviour) Reports were not adequately reviewed) Inadequate Work Planning(Due to pre commissioning activities working hours were increased without sourcing additional manpower; Night time driving request form did not include assessment of risks)
Lesson Learned
Immediate Causes •
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Inattention to Footing & Surroundings (Driver misjudge the speed of approaching vehicle and started to cross the road) Overexertion of Physical Capabilities (The driver was working upto 15 Hrs a day with irregular breaks/rest resulting in loss of concentration and fatigue)
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1. Monitor drivers working conditions and review RAG (deriving behaviour) reports regularly 2. Conduct Risk Assessment prior to approving night time driving request.
Violation by Supervisor (Night time driving approval was not subjected to risk assessment)
51
Man Lift Drove Over Flagman’s Foot Area
Incident Description A crew (Man Lift Operator & Banksman/ Flagman) was relocating man-lift from one location to another for a paint touch-up work. On the way, a forklift was approaching from the opposite direction and Flagman signaled to the man-lift operator to stop, allowing the forklift to pass. The Flagman stepped towards the man-lift to get out of the way of the passing forklift. When the forklift had passed, the man-lift Operator started to move the man-lift without any signal from the flagman or confirming his location. The operator drove the man lift over Flagman’s right foot. The Flagman was taken to the site clinic and t hen referred to hospital for further assessment.
Root Causes
•
•
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Inadequate Practice of Skill(Man-lift operator started moving the man-lift without taking a signal from the Banksman/ Flagman) Inadequate Safety Meetings(No specific TBT was conducted for machinery/ equipments operators & Banksmen/ Flagmen) Inadequate Communication Between Work operations were taking Groups (Simultaneous place at the same area without any coordination within Job Performers (JPs))
Lesson Learned
Engineering & Projects Outcome: Flagman sustained minor foot injury Bab Field Immediate Causes 15-03-12
1. Do not move heavy machines/ equipment unless directed by Banksmen/Flagmen. •
•
2. Violation by Individual(Man-lift operator started moving the man-lift without signal from Banksman/ Flagman and did not maintain 3. clear sight of Banksman/ Flagman)
Machine/equipment operators must maintain clear sight of Banksmen/ Flagmen. Conduct task specific Tool Box Talk (TBT) for each crew.
Improper Position for the Task(Banksman/ Flagman was standing close to the man-lift)
53
Vehicle Rollover Area
Incident Description
Root Causes •
An instrument commissioning Engineer was involved in integration communication system in Central Degassing Station (CDS). The engineer was based in Mussafah and travelled to Bu Hasa in a private vehicle and he did not have ADCO Safe Driving Document (ADSD). After finishing his tasks (approximately at 17:30 Hrs) he was on his way back to Abu Dhabi. Earlier, there was a sand storm resulting in sand accumulation (sand bars) on the road and when he drove over sand bars, he lost control of the vehicle, resulting in the Engineering vehicle to roll over. Outcome: The driver & Projects sustained shoulder injury and the vehicle was badly damaged. Buhasa Field
•
•
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Inadequate Communication of Policies, Standards and Procedures (ADCO Road Safety requirements were not adequately communicated to the subcontractor/vendor) Inadequate Supervisory Example (Supervisors did not arrange for company vehicle and/or trained driver for the journey) Inadequate Work Planning(Supervisor did not monitor the commissioning engineer’s work schedule) Inadequate Inspection & Monitoring (Contractor did not adequately monitor compliance with ADCO Road Safety requirements.) Lesson Learned
Immediate Causes
19-02-12 •
•
Violation by Supervisors(Allowed the use of private vehicle to travel to fields.)
1. Do not drive private vehicle on ADCO business.
2. Only assign trained drivers to drive or provide Inattention to footing & Surroundings drivers for staff transit. (Staff was working for the last 11 hours including the 2.5 hrs journey to site and 3. Supervisors should monitor compliance of their did not pay attention to road conditions contractor staff with ADCO Road Safety (sand accumulation) due to fatigue)
Requirements.
54
Vehicle Collision on a Sand Track Area
Incident Description Two vehicles were approaching a hill top from opposite directions on a gatch road with a posted speed limit of 30 km/hr. Vehicles were driven at a speed of 45 km and 35 Km/hr respectively. One vehicle was carrying three passengers in rear seats and they were not wearing seatbelts. Both vehicles were travelling in the middle of the track and drivers did not see the other
approaching vehicle (although fitted with desert flags) and their vehicles collided (head-on) on top of the dune and their air bags inflated. Outcome: Both drivers and two passengers Engineering sustained minor injuries and the third & Projects passenger sustained head& facial injuries. Both vehicles were damaged Qw badly. 28-02-12
Immediate Causes •
•
•
Violation by Individuals(Bothe drivers were exceeding the posted speed limit, passengers were not wearing seat belts) Improper Decision Making/Lack of Judgment (drivers were driving their vehicles in the middle of the track)
Root Causes
•
•
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Inadequate Preventive Maintenance(The track had sand accumulated on sides and was not adequately maintained) Inadequate Inspection / Monitoring (Drivers’ RAG (driving behaviour) reports were not effectively monitored) Inadequate/Lack of Safety Meetings(Drivers were not subjected to specific tool box talks (TBT))
Lesson Learned 1. Always follow posted speed limits and road traffic warning signs 2. Do not drive in the middle of tracks, especially when approaching blind spots (e.g. ascending dunes) 3. All passengers including those on rear seats must wear seat belts 4. Transport Foremen/Supervisor should conduct Tool Box Talks (TBT) for drivers focusing on hazards associated with their journeys.
5. Regularly inspect & maintain sand track /gatch roads Inattention to footing & especially after sand storms and windy conditions. Surroundings (Drivers did not spot other approaching vehicles, fitted with desert flags)
55
Vehicle Drove Over a Berm Area
Incident Description A crew consisting of a driver, Foreman and three labourers were proceeding to MOL MP-24 location in a double cabin pickup. The purpose of the trip was to retrieve Permit to Work (PTW) papers from a bus which was stuck in sand and was immobilized a day before. The driver was using the blue key of the Foreman (sitting next him). The driver did not engage vehicle into 4x4 mode and driving at a speed of 105 km/hr. There was low visibility due to early
Root Causes •
•
•
hours and hazy conditions. of the the rear middle seat did notOne fasten his labourers, seatbelt. sitting in •
•
•
•
Inadequate/Lack of Safety Meetings (Drivers were not subjected to specific tool box talks (TBT)) Inadequate Inspection / Monitoring (Drivers’ (driving behaviour) reports were not RAG effectively monitored)
The driver was not familiar with the access track and he did not notice the pipe line crossing ahead of them. He drove over pipe line berm. As an impact; the vehicle hit Engineering the berm, jumped over the berm and landed on the front & Projects bumper. Outcome: Three occupant sustained injuries and two Asab Field were discharged after the treatment from t he hospital. The third labourer was admitted for three days in the hospital 01-03-12 and then discharged. 1.
Immediate Causes
Inadequate Supervisory Example (Supervisor reinforced incorrect behaviour of the driver)
Inadequate Implementation of Policies/ Standards/ Procedures (PSP) (ADCO road safety requirements and Life Protection Rules (LPRs) were not effectively implemented. Lesson Learned Always follow posted speed limits and road traffic warning signs
2. All passengers including those on rear seats must wear seat belts
3. Transport Foremen/Supervisor should conduct Tool Box Talks (TBT) for drivers focusing on hazards associated with their journeys. Violation by Supervisor(He gave his blue key t o the driver and did not stop driver from over speeding) 4. Supervisors should review drivers’ RAG Violation by Individual(The driver was over speeding, did not engage vehicle in 4x4 mode)
Improper Decision Making/Lack of Judgment (Driver continued driving during low visibility on an unknown track)
(driving behaviour) reports regularly and provide counseling to drivers to reinforce correct driving behaviour.
56
Cement Mixer Rollover Area
Incident Description A Cement mixer was heading from cement batching plant to Shah -2 to deliver a consignment of cement. The driver was shifted from another location to Shah Field approximately 10 days before and he was not aware of access route to the destination. He was not subjected to any Tool Box Talk (TBT) and there was no banksman with him.
Root Causes •
•
Upon reaching RDS Gate No 2 he was diverted to Gate No. 1. He drove uphill and found that access track was closed and he was reversing the mixer without any banksman and the mixer came off the track and rolled over. Outcome: The driver escaped unhurt and the vehicle sustained minor damage Engineering & Projects
Inadequate Supervisory Example (The supervisor assigned the task to a new project driver without HSE induction, Tool Box Talk (TBT and providing a banksman) Lessons Learned not Embedded (Lessons from some of prior incidents to conduct TBT for drivers not effective)
•
Inadequate Audit/ Inspection/ Monitoring (There was no monitoring system in place to check and guide delivery vehicles)
•
Lessons Learned
Shah Field 18-04-12 •
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•
•
Immediate Causes Violation by Individual(The mixer driver was reversing the vehicle on a narrow track without banksman/ flagman) Violation by Group (Site crew did not stop driver reversing heavy vehicle without banksman) Lack of Knowledge of Hazards Present (Supervisor did not conduct any Tool Box Talk (TBT) & Site Familiarization/ HSE Induction).
1. Conduct Site HSE Induction to all new staff including those involved in making deliveries. 2. Conduct daily specific Tool Box Talk (TBT) for drivers. 3. Specify/mark routes for delivery vehicles within project areas
No Warning Provided (There was no warning sign nor site staff informed driver of the closure of access track)
57
Damage to Overhead Line Area
Incident Description
Root Causes •
A contractor crew was involved in stringing, welding and support installation of a new flowline and an excavator operator was hired from a sub-contractor. The operator was mobilized to the site without any HSE Induction and he was not included in Tool Box Talk (TBT). Piping Foreman was preparing the site and requested Excavator Operator to move the excavator closer to the work site. The excavator driver mover the excavator with his boom in extended position and struck against 33KV overhead line conductors. Engineering & Projects Outcome: The overhead line tripped on earth fault. The operator came out of the excavator BAB Field safely
•
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Inadequate Identification of Worksite/ Job Hazards (The Task Risk Assessment (TRA) did not identify the hazard) Inadequate Training Efforts(TRA team was not adequately trained in conducting TRAs; Excavator operator was not subjected to site HSE induction and was not included in Tool Box Talk (TBT)) Inadequate Monitoring (Foreman or Job Performer did not monitor excavator operator’s movement) Lesson Learned
24-04-12 Immediate Causes •
•
•
Unintentional Human Error(Excavator Operator moved the equipment with the boom in elevated position) Distracted by Other Concerns(The operator was emotionally stressed due to personal issues)
1. Install goal posts at crossing under over head line conductors prior to initiating site works involving movement of equipment.
(For Illustration Purpose)
2. Include vehicle/equipment operators in Tool Box Talks (TBT) 3. Do not operate equipment/machinery when emotionally disturbed or stressed
Inadequate Guards or Protective Devices (There no goal post/height level markers was installed at overhead line crossing)
58
Ankle Injury During Cable Pulling Area
Incident Description Instrument cables were being pulled (900 meter run) in cable trench. The crew was using a single assembly of corner cable roller instead of using multiple interconnecting rollers to allow stability. The foreman was standing inside the radius of bending cables talking to another supervisor while approximately 16 workers were manually pulling the cable. The cable slack ran out on the upstream side of the corner roller roller. and the cable tightened up against the corner
This resulted in the cable pushing back into the Engineering & corner, moving the sandbags that were supporting it, the roller tipped over and the cable slipped out Projects (dislodged) from the cable roller and struck the right ankle of the Foreman. Outcome: Foreman sustained Asab Field multiple fracture injury on his right ankle. Immediate Causes
24-04-12 •
•
•
Improper position or posture for the task (IP positioned himself in the line of fire; inside radius of bending cable in case of sudden tension/tightening of cable) Improper placement of roller(Crew was using a single assembly of corner cable roller instead of using at least three interconnecting rollers supported with sandbags to allow stability)
Root Causes •
•
Inadequate Identification of Worksite/ Job Hazards (Risks of less numbers of cable rollers resulting in cable release under tension were not adequately assessed/controlled) Inadequate Supervisory Example(The Supervisor/Foreman positioned himself inside the bending radius of cable under tension)
Lesson Learned
3. Maintain adequate communication between workers and Foreman while the cable is being pulled 4. Use adequate numbers of interconnecting corner rollers to ensure stability during cable pulling 5. Do not stand inside the bend radius of cable and roller while cables are being pulled.
Distracted by other concerns(Foreman was talking to another supervisor while approximately 16 workers were manually pulling the cable)
59
Vehicles Collision on Gatch Road Area
Incident Description Two different contractor (Project & Drilling) vehicles were approaching from opposite directions, on a gatch road. There was a blind spot at a turning and one driver was driving on the wrong side of the road. Desert flags mounted on both vehicles were not visible to other vehicle due to the height of a pipeline berm. One vehicle (Project) was
driven at a(73 speed not appropriate for road conditions km/Hrs) and the other driver (Drilling) was driving at the speed of 60 km/Hrs. Both vehicle emerged after ablind Engineering spot and collided head on. & Projects Outcome: Total six passengers in both Asab
Root Causes
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Inadequate Identification of Worksite/ Job Hazards (There was no sign or marking when approaching the blind spot) Inadequate Practice of Skill(Project driver was in haste and over speeding; and he was driving on the wrong side of the road)
Lessons Learned
vehicle sustained minor injuries and vehicles were badly damaged.
09-07-12
Immediate Causes
•
•
•
Violation by Individual(The project vehicle was driven in wrong lane)
1. Always reduce vehicle speed according to road conditions especially when approaching blind spots
Work or Motion at Improper Speed 2. Do not drive in wrong lane even for shorter (Vehicle speed was not adjusted period of time according to road condition and presence of a blind spot) Inadequate Warning System (There were no road signs to alert approaching drivers)
60
Arm Injury Due to Explosion During C AD Welding Area
Incident Description
Causes •
CAD* Welding of grounding cable outside the control room building was planned but no specific work permit was obtained and the work was performed under a “Green Field” general permit to work. A newly arrived electrician who was dressing electrical cable inside the building was requested to assist the CAD welding crew. The job Performer went to attend another task and stopped the activity but the crew continued work. The electrician was not wearing any welding gloves and no special tool to hold the mold was available. The electrician held the cable in his hand although it is Engineering held by the mold itself. After the set-up, another & Projects worker ignited the weld powder in the mold using spark igniter whilst electrician was still holding t he cable. Explosion/backfire through the aperture cover Asab of the mold occurred. Outcome: It resulted in 2nd 12-07-12 degree burn on the right forearm of the electrician. Immediate Causes •
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•
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Inadequate Assessment of Need & Risks (CAD welding activity was performed without necessary tool to hold the mold) Inadequate or Lack of Safety Meeting (Electrician was not subjected to tool box Talk and crew was not made aware of hazards of CAD Welding) Inadequate Audit / Inspection/ Monitoring (Job Performer left the crew to attend another task without assuring that work has stopped) Lessons Learned
1. Always subject all crew members to tool box talk specific to the task.
Violation by Group (The activity was stopped by 2. Ensure assignment of skilled crew members and availability of all necessary the Job Performer but crew continued the work) tools, especially on high risk activities Personnel Protective Equipment (PPE) not used (Electrician did not use welding gloves; the 3. Never leave crew unattended specially right tool to hold the mold was not used/obtained)
•
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Inadequate Job Placement (An electrician was assigned on CAD welding activities without assessment of required skills)
Lack of Knowledge of Hazards Present(The crew was not aware of hazards of back fire)
those working on high risk activities *CAD welding (Exothermic welding) is process for joi ning two electrical conductors, that employs superheated
Improper Position or Posture for the Task copper alloy to permanently join the conductors. (Electrician was holding the cable at the both sides of the mold)
61
Fire at Scaffolding Platform Around Stripper Column Area
Incident Description A welder was welding a pipe on the topmost platform (35 m high) of stripper column. After completing the task he lowered his tools and the portable welding equipment to a lower level platform and left the site. On scaffold boards (which were below welding area) food scarps, plastic bottles, papers etc. had accumulated and not noticed by crew or their supervisor. The welding habitat not set and the fire blanket was too smallwas for the task and had holes in it.
Root Causes •
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Inadequate Audit/Inspection/ Monitoring (Supervisor did not visit the site before and after the completion of hot work; accumulation of combustible materials was not noticed; Fire blanket with holes and absence of fire habitat were not noticed) Inadequate Work Planning or Risk Assessment Performed (A welder without any supervision was assigned for the task; Job Performer (JP) did not go to the top platform to monitor the work; cleaning of scaffold sites of accumulated debris was not considered)
Later, workers noticed fire and smoke from upper level scaffold platforms and raised the alarm. Outcome: ADCO & GASCO Fire Lesson Learned Engineering Teams responded and extinguished the fire. & Projects No personnel injuries and damage to scaffold boards had occurred. Asab Immediate Causes 16-07-12 Inattention to footing & 1. Maintain housekeeping at work locations. Surroundings (Accumulation of combustible waste material near welding 2. Subject critical activities to continuous area was not noticed) monitoring & supervision •
•
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Inadequate Guards or Protective 3. Switch off/Disconnect power supply to Devices (Fire blanket was not adequate portable electrical equipment during breaks to isolate welding spatters/ welding 4. Use fir blanket/fire habitat for welding habitat was not set) activities in process areas. Work Exposure to Temperature Extreme (Hot summer day with ambient temperature exceeding 47oC)
62
Foreign Object Entering Eye of a Worker Area
Incident Description A welder was assigned to perform welding task for the installation of pipe support. After completing the welding task, while he was removing welding face shield, he felt a sand particle had entered his left eye. He washed his eye with water and felt relieved and continued his job. Later, at night he felt pain and irritation in his eye and he visited the
camp clinic the next morning and he was attended by the Physician and then referred to a Hospital for the removal of foreign object Engineering from his eye. & Projects Outcome: The foreign object (sand particle) was removed from his eye. Sahil
Root Causes
•
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Inadequate Identification of Worksite/Job Hazards (Workers were not adequately made aware of hazards of working on a windy day; risks of rubbing eyes when a foreign body enters eye were not known) Inadequate Communication(Lessons from prior similar incident occurred on 04-05-2012 were not effectively communicated)
Lessons Learned
26-07-12 Immediate Causes 1. If a foreign object enters eye, do not rub eyes and seek medical attention •
•
Storm or Act of Nature (Blowing wind carrying particles/dust/light objects)
2. Report all incidents (including minor incidents/injuries) to your supervisor
Personal Protective Equipment (PPE) 3. Always use eye wears for protection in Not Used (Welder removed his welding working sites, especially in sandy areas. face shied after the task and due to blowing winds sand particle entered his eye)
63
Vehicle Rollover on Gatch Road Area
Incident Description A vendor crew was involved in installing gauges on multi flow meters and after the completion of the task, transport was arranged to t ransfer them back to Abu Dhabi. The plan was to collect passengers from Accommodation Camp and proceed to Abu Dhabi via Madinat Zayed Road. An Engineer decided to go to Abu Dhabi with
vendor crew and boarded the vehicle. The Engineer advised the driver to go through BabTarif Road and to avoid going through security check post, the engineer identified a gatch Engineering road. The driver was driving fast (80-90 & Projects Km/Hrs) for the road condition and at a b end he lost control of the vehicle and the vehicle rolled over. Outcome: No serious injuries to BAB passengers and the vehicle sustained minor damage. 23-08-12
Causes
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Improper Supervisory Example(The Engineer changed the journey plan and advised the driver to take short cuts/gatch road and did not stop him from over speeding) Inadequate Audit/ Inspection/ Monitoring (Driver’s RAG reports were not used to coach the driver with history of over speeding)
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Inadequate Correction of Worksite/ Job Hazards (Lessons from prior Road Traffic Accidents were not effectively communicated; No tool Box Talk was conducted for drivers) Lesson Learned
Immediate Causes 1. Always drive within posted speed limits and reduce speed according to rad conditions •
•
Violation by Individual(The driver was driving fast in excess of posted speed limit) Violation by Supervisor(The Engineer did not stop driver from overspending)
2. Conduct Tool Box Talks for drivers and empower them to not let any passenger to change journey plan 3. Passenger/s should stop driver from over speeding, taking short cuts and from driving recklessly.
64
Crane Mounted Truck (Hiab) Rollover on Gatch Road Area
Incident Description A crew consisting of a Rigger & Operator of Crane Mounted Truck (Hiab) were instructed by their Engineer drive the truck to work site and lift pre-cast materials. The crew left their camp and was proceeding to the location. They were travelling on a gatch road parallel to an existing pipeline. This road contained many pot holes and the surface was wet/ slippery
Engineering & Projects BAB
28-08-12
Root Causes •
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Inadequate Audit/ Inspection/ Monitoring (Driver had history of applying harsh brakes and harsh acceleration and his driving behavior reports were not effectively reviewed to initiate counseling/ coaching on the skill) Inadequate Identification of Worksite/Job Hazards (Hazards
due to high humidity. The driver was attempting to drive around potholes and made a sharp maneuvering of steering followed by harsh brakes.
associated with the journey (i.e. gatch road condition and high humidity) were not identified)
It resulted in vehicle to get out of control. The rear end of the vehicle spun around in the opposite direction and then rolled over on passenger side against the pipeline berm. Outcome: The vehicle rolled over to its sid e on the berm of the pipeline. Driver and passenger sustained minor injuries as they were wearing seat belts.
Lesson Learned
Immediate Causes •
•
Improper Decision Making/Lack of Judgment (The driver applied harsh b rake and sharp maneuvering of steering to avoid pot hole on the gatch road) Work or Motion at Improper Speed(The vehicle was driven on gatch road at a speed between 20 to 45 kph with a sudden acceleration to approx. 58 kph followed by a harsh breaks immediately prior to the incident)
1. Avoid applying harsh brakes and sharp maneuvering of steering when driving off road. 2. Review drivers’ driving behavior reports and provide coaching and counseling to risky drivers 3. Subject drivers to daily tool box talks to discuss route hazards and to reinforce safe driving behaviour
65
Vehicles Collision Area
Incident Description A 3rd Party mechanic was working on a b roken down vehicle near the road side a replacement tire was requested from their base camp in Mussafah. A truck carrying the replacement tire arrived and stopped on the road side. The mechanic requested the driver to move the truck on the opposite side.
Root Causes •
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A project driver involved was transferring staff to and from difference locations since morning and was making a trip to collect three passengers from Bab Central Degassing Station (BCDS) to their Camp. The driver was driving 128 km/Hr on a road with a speed limit of 80 km/Hr.
Improper Performance to save time (The driver was involved in transferring passengers to & from different locations since early morning and was rushing to the camp for mid-day break)
•
The project driver was over taking the truck whilst Engineering & the truck started to turn left. Outcome: The project vehicle collided with the front tire of the truck. Two Projects passenger sustained minor injuries and the vehicle sustained moderate damage. BAB 04-09-12
Inadequate Audit / Inspection /Monitoring (Drivers driving behavior and driving assignments were not adequately monitored)
Inadequate Identification of Worksite/Job Hazards (In Vehicle Monitoring System (IVMS) was reconfigured so that speeding event below 130 km/Hr were not recorded as system violation) Lessons Learned
Immediate Causes
•
•
1. Violation by individual(The driver was overspending (128 km/Hr on a road with a speed limit of 80 km/Hr) 2. Improper Decision Making(The truck driver started to turn left without using indicators/ 3. signal)
Always follow the posted speed limits and do not over speed. Use vehicle signal before maneuvering vehicles even on a short journey Monitor the driving behavior of new/inexperience driver more frequently
66
Crane Rollover During Move on Gatch Road Area
Incident Description A 25 Tone Grove Crane, was mobilized on site to load / offload piping materials from various locations within the vicinity of RDS-8 Transfer Line area. The crane reached the site at around 06:30am and started off-loading pipe supports from the trailer truck. The crane being moved between locations (approximately 100 meters apart) to lift excess pipe supports. The crane operator was following the pick-up vehicle (boarded by the Rigging Foreman) and the trailer truck on gatch road, p arallel to the transfer line. There was slope between the two gatch roads and the pick-up and trailer truck managed to drive across the bank and reached the elevated gatch road.
Root Causes
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Inadequate Supervisory Example (Rigging Forman did not ensure the suitability of the track) Inadequate Audit / Inspection/ Monitoring (Job Performer (JP) was away supervising another crew and the crew moved without his knowledge) Lesson Learned
Engineering As the crane tried to ascend on slope (with crane boom & Projects not fully folded), the crane lost the balance causing it to roll over to its right side. Outcome: The operator BAB managed to exit the crane cabin safely through the cabin door and the crane sustained minor damage. 26-09-12 4. Do not move heavy equipment from Immediate Causes one location to another location unless track conditions are inspected and are found suitable. •
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Violation by Individual(The operator did not fully 5. Ensure Crane boom is fully folded and hook block secured when moving fold the boom of the crane and did not lock the hook crane, to maintain stability of the block while moving the crane) equipment Violation by Supervisor(Rigging Foreman did not assess the conditions and asked the crane operator toroad follow the vehicle)
67
Vehicle Collision Area
Incident Description A project vehicle (Double Cabin Pickup) was returning back from their project site (RDS 8) to their camp store for the collection of materials. He was in mostly in Red and Yellow categories as per his driving behavior report (RAG Report) over the last one month and there was no effective review of RAG reports in place to provide coaching/
Root Causes
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Inadequate Audit/ Inspection/ Monitoring (Drivers driving behavior reports were not effectively reviewed and the driver did not receive any coaching or counseling to develop safe driving skills) Inadequate Identification of Critical Safe Behaviour (The project driver drove considerable long distances with BAB (250300 km/day) and his work assignment, journey management and time pressure were not effectively addressed)
counseling toGhayathi the driver. ADCO was coming from to An BAB in hisstaff private vehicle (Land Cruiser) after his rest period and he stopped by a shop in Al Dhafra camp and then proceeded to BAB Accommodation Camp. There was a long trailer on the hard Lesson Learned Engineering shoulder, restricting the direct view. The & Projects project vehicle was driver at a speed of 121 km/hr on the road with posted speed limit of 80 km/Hr. ADCO staff vehicle entered the T BAB Junction and crossed the road and the 01-10-12 project vehicle collided on the side of the land cruiser. Outcome: Minor injuries (Bruises) to passengers as they were 1. Regularly review drivers’ driving wearing seatbelts and serious damage to both vehicles. behavior(RAG) reports and provide counseling to risky drivers Immediate Causes •
•
2. Review drivers’ driving hours and work assignments to reduce time pressure.
Violation by Individual(The project vehicle (Pickup) was over speeding) Improper Decision Making/Lack of Judgment (ADCO Staff entered the junction without ensuring clearance)
68
Fall of Mobile S caffold Platform on a Worker Area
Incident Description
An electrical crew was assigned to cable pulling, dressing and installation of cable tray cover. The crew was using a mobile scaffold platform. The platform was not subjected to any checks/inspections and its caster wheels were not secured. During the work, while crew was pushing the platform, over a wooden plant (used as a bridge to cross over a gap), the platform fell down, hitting on the right leg of a worker. Outcome: The worker sustained compound fracture on his right leg and he underwent Engineering constructive surgery & Projects Asab
Immediate Causes
28-11-12 •
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Causes
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•
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Inadequate Supervisory Example(The work was started without PTW; JP was not on s ite and workers were working unsupervised) Inadequate Audit/ Inspection/ Monitoring(The mobile platform was not checked/ inspected prior to its use) Inadequate Identification of Worksite/Job Hazards (Use of mobile scaffold platform in the area was not risk assessed and workers created inadequate crossing over a gap).
Violation by Supervisor(The work was not subjected to Permit to Work (PTW) and the Job Performer was not supervising the crew at the location) Lack of knowledge of Hazards Present (A narrow wooden plank was used as a bridge for crossing of the mobile platform)
Lessons Learned
Defective Equipment (The mobile
1. Always inspect mobile equipment and tools to assess fitness prior to their use.
platform wheels had no locking mechanism)
2. Identify worksite hazards and do not take short cuts.
70
Arm Amputation Inside Foam Concrete Mixer Area
Incident Description At a building construction site, membrane water proofing works was ongoing and a crew consisting of portable foam concrete mixer operator and two helpers were operating the machine. During t he lunch break, the job performer left the site leaving the crew onsite to clean the machine. The mixer was washed, twice a day, by the operator using a water hose.
The operator of the machine was operating the machine for the last six months and he did not receive any training or coaching on the safe operations of the mixer. The mixer was not subjected to routine checks/maintenance. The operator switched of the mixer and inserted his hand holding the hose inside Engineering the mixer and started washing. Suddenly the mixer & Projects started and is arm was struck by blades inside the mixer. Outcome: Arm of the operator was amputated. Qw Immediate Causes
Causes
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Inadequate Identification of Worksite or Job Hazards (Hazards of washing of equipment on site were not identified in Task Risk Assessment (TRA)) Inadequate Leadership (Job srcinator did not ensure competency/training of the operator; Operator was not subjected to any training on safe operations of the mixer; Job Performer left the site whilst workers were engaged in washing the mixer; JP did not conduct tool Box Talk (TBS) specific to hazards of operating the mixer) Inadequate Preventive Maintenance(The mixer was not subjected to any checks or preventive maintenance)
12-12-12 •
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Violation by individual (Job Performer did not implement hazard control barriers as per the task risk assessment) Improper position or posture for the task (Operator inserted his arm inside the mixer while cleaning the mixer)
Lessons Learned 1. Ensure workers/operators are adequately trained in their trade prior to their assignment. 2. Assess fitness and safety feature of the equipment prior to their acceptance at site.
Inadequate Isolation of Process or Equipment3. Conduct task specific Tool Box Talks (TBT) Power supply to the mixer was not isolated instead 4. Job Performers should never leave their site power switched was turned in off position). whilst work is ongoing and crew is still present. Inadequate Guards/Protective Devices(Grid 5. Consider mixer washing on site as a part of of the guard was too wide to stop entry/insertion of future Task Risk Assessments (TRA) body parts)
71
North East Bab (NEB) Asset
72
73
Past Incidents
Gas Release From Closed Drain Vessel (18-09-2010)
Vehicle Collision with Road Side Barrier (02-08-2010)
Oil & Gas Release at Cluster D (03-10-2010)
Cable Cut During San Clearance (07-07-2009)
Dead Dugong (26-12-2011)
Dead Turtle (17-09-2011)
Fire In Rumaith Central Processing Plant (24-08-2011)
Injuries Due breakage of Valve of a Pressurized Cylinder (03-09-2011)
Shovel Rollover (01-03-2008)
Arm Crush Injury at Cluster A (08-11-2007)
Finger Injury (06-09-2011)
Vehicle Rollover (28-03-2011) 74
75
Vehicle Crash During OHL Visual Survey Area
North East Bab (NEB)
Incident Description As a part of routine inspection of over head line (OHL, visual inspections was ongoing. There is no access track along the overhead line network. A foreman and a driver were travelling in a vehicle and the Foreman decided to drive the vehicle himself and the driver was seating in passenger seat. The Foreman inspected one pole and was driving towards the next one to do the same inspection. Suddenly the vehicle fell down as there was a sharp slop formed by sand dune. Outcome: The foreman and the driver felt back pain and the car front bumper was damaged (estimated to be $1500). The Foreman was assigned on light duties for one week.
Root Causes
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Inadequate Preventive Maintenance(The right of way was not maintained and resulting in formation of sand dunes beside over-head lines) Improper Supervisory Example(The Foreman decided to drive himself and carry our visual inspection at the same time; and a professional driver was not used for driving)
30-04-12 Immediate Causes •
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Lesson Learned Improper decision making/lack of judgment (The Foreman decided to drive and visually inspect over head lines 6. Do not drive and get distracted by other activitie at the same time whilst a professional driver was seating as a passenger)) 7. Maintain right of way (ROW) near overhead line poles and check adequacy of the track prior to Inattention to surroundings (While commence work focusing on overhead lines the depression was overlooked)
76
Transformer Fire Area
Incident Description In oil train 1, at 2nd stage Desalter, flash over occurred at the transformer (secondary high voltage) cable located at a height of 12 feet. The flash-over was detected by the UV/IR detectors. Outcome: Control Room Operator (CRO) alerted electrical team who isolated the cable. After the isolation fire was extinguished using CO2 fire extinguisher. It was the third similar incident in NEB involving melting of high voltage bushing (or high voltage cable).
North East Bab (NEB)
Root Causes •
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Inadequate Preventive Maintenance(High Voltage Busing were not changed as per vendor recommendations and Desalter oil samples were not tested) Tools & Equipment - Inadequate Availability (High Voltage Busing and oil tester were not available)
Lessons Learned
Immediate Causes •
25-07-12
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Violation by Group (Maintenance Procedures as per Vendor Instructions were not fully followed due to non-availability of 1. Oil samples should to taken from all desalters to evaluate the condition of High Voltage Bushings oil tester) 2. Evaluate condition of the HV bushings during the Inadequately Prepared Equipment regular maintenance periods (High Voltage Bushing Replacement was not carried as per vendor recommendations)
3. Ensure availability of critical spare parts such as High Voltage Bushings at all times
77
Fire in UPS Unit of Substation Area
Incident Description Dabbiye’a has two substations and each substation has 2 AC- Uninterrupted Power Supply (UPS) units. Each UPS unit is equipped with cooling fan to cools different components such as capacitors, transformers and power electronic devices. Due to frequent voltage fluctuation (from external power supply source), capacitors’
performance was compromised. After such voltage fluctuation event, a capacitor burnt and the fire spread within the UPS system and extended to the major components within the cabinet. Fire Auxiliary Team responded and North East extinguished the fire. Bab (NEB)
08-07-12
Outcome: It resulted in damage of two power transformers, static switch module, cooling fans and few capacitors. The plant was manually shutdown on Emergency Shut Down-1.
Immediate Causes •
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Inadequate Equipment(Premature failure of capacitor due to power fluctuation)
Root Causes •
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Engineering Design – Inadequate Assessment of Potential Failure (Capacitor surpassed their material life and were subjected to wear & tear due to power fluctuation) Materials Shelf life Exceeded (Manufacture identified capacitor’s life span as 14 Years and after the incident it was corrected as 7 years)
Lessons Learned
1. Provide adequate spacing and ventilation for UPS and other electrical devices for cooling 2. Provide adequate spacing for maintenance. 3. Before accepting reliability value of systems, study proving the calculated reliability to b e submitted.
Inadequate Ventilation(Cabinet units were stacked close to the wall, not providing adequate ventilation)
78
South East (SE) Asset
79
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Past Incidents
Multiple Fatalities Due to H2S Release in Shah (03-02-2009)
Multiple Fatalities Due to Vehicle Collision –Sahil (07-09-2009)
Loss of Containment During Replacement of Corrosion Coupon (23-10-2010)
Buried Cable Cut During Site Preparation (16-04-2010)
Carpenter’s Finger Injury (10-02-2011)
Fall of Worker in Wellhead Celler (24-03-2011)
Wireline Crew Vehicle Rollover (03-08-2011)
Vehicle Tire Disengagement (03-08-2011)
Finger Injury during Unplugging of Drain (14-08-2010)
Scorpion Sting During Sand Clearance (25-05-2010)
Wrong Flow Line Tie in (07-04-2011)
Vehicle Rollover (24-03-2011)
81
82
Electrical Flashover Inside Transformer Terminal Box Area
Incident Description
Root Causes •
The 3-yearly preventive maintenance of 33kV OHL(Over Head Line) was completed and the OHL was energized followed by re-energizing of the associated WI (Water Injection ) clusters. During starting of Water Supply Well (Sb-55 WSW) surface pump, heavy black smoke was noticed with arcing sound from the (3.45KV) surface pump transformer cable box. Immediately operation foremen stopped the motor, opened 33KV gantry isolating power switches, and applied earth switches.
South East (SE) Outcome: – An electrical flashover occurred. The fire was self-contained inside the transformer terminal box Asab Field
•
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Inadequate implementation of Standards:(The vendor used bus-bar with terminals not suitable for the application. Consequently, the starting current (around 1500 Amps) induces electromechanical forces allowing the physical movement of the unsecured transition bus-bar between cable terminal and transformer bushing) Inadequate adjustment:(Poor Techniques securing transition bus-bar to transformer bushing) Inadequate monitoring of work during construction (All the above root causes were not captured during the construction and mechanical completion phase. Lesson Learned
07-04-12Immediate Causes
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•
Inadequate Equipment (Not using the proper bushing-bus bar terminal lug)
1. Use Flat 4- Hole Bolt Terminal in place of Standard Straight Bolt Terminals
Work Exposure to Energized Electrical Systems
83
Foreign Object (Metal Particle in Eye) Area
Incident Description
On a windy day, a foreman was proceeding for preventive maintenance job on potable electrical booster pump near welding workshop. When he reached the site he felt dust in his eye and he went to wash room to wash his eyes. He completed his task
South East (SE)
Root Causes
•
Inadequate Identification of Worksite/Job Hazards (Workers were not made aware of hazards on a windy day; risks of rubbing eyes when a foreign body enters eye were not known)
and laterup he with keptred rubbing his eyes. day, he woke & swollen eyesThe andfollowing went to clinic for treatment. He was referred to a hospital where a foreign object was removed from his eye.
Asab Field
Lesson Learned
07-04-12Immediate Causes
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•
PPE not used (Worker was proceeding to work area and was intending to wear his goggles when starting the job) Lack of Knowledge of Hazard Present(Risk of sand/dust particles entering into eye was not adequately identified)
1. Wear eye protection during windy days even when proceeding to worksite 2. Contact medical professional when a foreign object enters into eyes
84
Worker’s Finger Entrapment Between Pipe Flange and Valve Flange Area
Incident Description Well work-over was completed and a Field Services crew was working to fix a 2” valve on bleed-off line. Emergency response plan and PPE were discussed in Tool Box Talk (TBT) and the work started.
Root Causes
•
There was no dedicated banksman and the Foreman himself was directing the Crane Operator. The crew included a newly hired laborer.
Inadequate Work Planning or Risk Assessment Performed (No dedicated banksman was used; & inexperienced laborer was assigned to assist a crew involved)
The bleed valve with the spool was lifted and the laborer was holding the T-piece with valve during alignment. When the load moved, his left hand index finger got trapped and crushed between the South East pipe flange and valve flange. (SE) Outcome: The foreman stopped the operation and transferred the injured person to RAMS Clinic Asab Field for treatment. Laborer sustained fracture to his finger. 08-07-12
Lessons Learned
Immediate Causes •
•
•
Improper Position or Posture for the Task1. (Inexperienced worker wrongly positioned his left index finger between the two flanges 2. during alignment) Improper Decision Making/Lack of Judgment (Foreman was also acting as Banksman losing focus on supervision)
Do not assign inexperienced laborers on new activities. Ensure crew members are aware of task related hazards through effective Tool Box Talk (TBT).
Lack of Knowledge of Hazards Present (An inexperienced and untrained laborer was assigned to the job)
85
Terminal & Pipelines Operations (TPO) Asset
86
87
Past Incidents
Shovel Falling Into a Ditch (09-04-2010)
Loss of Containment Due to Rupture of Hose (26-09-2011)
Loss of Containment at MP 21 (08-11-2011)
Loss of Containment at MP 21 (08-11-2011)
Loss of Containment Due to Rupture of Hose (26-09-2011)
Vehicle Rollover (21-11-2011)
Partial Fall of Roof in Accommodation Camp (28-05-2008) Fall of Worker into a Manhole (26-04-2007)
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Heat Stress Area
Incident Description
Causes
•
A newly recruited team of trainee firefighters were attending a fire drill and it was their first day of training in full fire suites. During this training two trainee firefighters were over exerted and one trainee stopped the training and went
Abu Dhabi/Jebel Dhanna
under the shaded area to rest and later another trainee collapsed and became unresponsive. They were taken to RAMS Clinic in Jebel Dhanna and later transferred to Ruwais Hospital. Outcome: They were treated for heat stress and later discharged from the Hospital.
Immediate Causes
09-04-12
•
•
Over exertion of Physical Capabilities (New recruits were involved in extended physical i.e. physical training exercise, fire drill)
•
Fatigue (Over exertion of physical capabilities led to fatigue during physical training on a hot and humid day in full fire suit) Inadequate Implementation of Policies/Standards/Procedures (New trainees were enrolled without ensuring medical fitness; ADCO guidelines for heat stress were not implemented)
Lessons Learned
1. Include ADCO heat stress guidelines in HSE induction for training instructors and new trainees to identify signs and symptoms of fatigue, heat stress etc. 2. Ensure that all Fire Training Instructors are trained and certified as First Aiders.
o
Temperature humidity in full Extremes fire suite). (27 C with 82%
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HSE Performance, 2012
ADCO & Contractors LTIF & TRIR ( YTD) vs M anhours
worked 1.4 l ta o T /e t e a t R a y R c y n r e u u jn q I e r le F b a y r d u j ro n I c e e R im T t s o L
180
1.29
9 .4 0 6 1
1.2 0.93
1 0.81
0.80
0.8 0.6
0.70
0.55 0.63
0.4 0.2 0
0.55
0.36 0 . 16 0 . 16
7 2
4 3
7 4
6 5
5 5
100 0.47
0.29 0.12 4 . .3 4 2 4 3
0.34
0.34 0.26
.5 2 3
140 120
2 9 . 8 1 1
0.51
0.28
9 2
0.78
0.68
0.66
160
6 .3 0.09 0.08 7 5
80 60 40 20 0
d e k r o W s r u o h n a M n o lili M
2001 20 02 20 03 2004 2005 2006 2007 2008 20 09 20 10 2011 2012
Year Manhours
ActualLTIF
TRIR
91
Incident Types - 2012 (Work & Non-Work Related 380 Events)
3%
5% 10% / 42% 12%
28%
92
93
Asset Wise Event Type Distribution - 2012
94
Incident Immediate & Root Cause Categories 2012
Immediate Causes
Root Causes
/ / 5% 6%
21%
7%
/
16%
/
/
/ %
10%
15%
Repetitive Root Causes Repetitive Immediate Causes Inadequate work planning Improper decision making or lack of judgments
Inadequate identification of worksite/job hazards
Lack of knowledge of hazards present
Inadequate adjustment/repair/maintenance
Violation by individual
Inadequate audit/inspection/monitoring
Violation by supervisor
95
Incident Immediate Cause Analysis -2012
Violation by individual
One individual intentionally chose to violate an established safety practice.
Violation (by supervisor):
A supervisor or other management person either personally violated an established safety practice or directed people under their supervision to do so.
Improper position or posture for the task
Improper decision making or lack of judgment
This cause is the opposite of violations, which are intentional acts. Unintended human error can consist of perception errors, memory errors, decision errors or action errors. A person’s job performance was affected by their inability to make an appropriate judgment when confronted by an
Inattention to surroundings:
ambiguous The personsituation. was not alert to their surroundings and just tripped or ran into something that was clearly visible and obvious.
No warning provided
96
Incident Root Cause Analysis -2012
Inadequate Work Planning Inadequate audit /inspection/ monitoring Inadequate
The work being done was not planned or was not risk assessed prior to starting that work. Supervisors did not monitor, inspected or audited the work as planned. The tools or equipment involved in the incident were not
preventative maintenance program
covered by a preventative maintenance program, and became unserviceable.
Inadequate identification
The incident was caused by the failure to perform or properly
of worksite/job hazards
respond to a loss exposure study, such as TRA, JSA.
Inadequate Leadership
The leaders in an area did not set the right direction or tone for safety or allowed roles and responsibilities for safety activities to be unclear or undefined.
Inadequate /Lack of Safety Meetings
Safety meetings such as effective tool box talks were not conducted
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Inadequate Training
Some training was conducted, but it did not accomplish the
Inadequate Knowledge Transfer
A training programme was in place, but it did not transfer th the inability of students to comprehend (material beyond th
No Training Provided
The person was not trained in a specific subject Employee perceived haste Improper supervisory example Inadequate reinforcement of critical behaviors
The incident was caused by the employee’s perception that speed in completing the work was required causing laps in safety considerations. Supervisors not giving the proper example to the people working in their organizations. A supervisor seeing someone not foll owing the safety procedures and guidelines and not correcting immediately is an example of inadequate reinforcement of proper behavior.
98
Do Not Compromise on the Safety of Staff & Workers, Protection of the Environment and Integrity of our assets
ABU DHABI COMPANY FOR ONSHORE OIL OPERATIONS (ADCO)
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