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Leasehand Crushed Between Mud Tank and Shale Bin Type of Incident: Fatality Date of Incident: October 10, 2008

2008 Fatality Report - Leasehand Crushed Between Mud Tank … · 2018. 1. 16. · mud tank, and decided that the shale bin needed to be moved away from the mud tank in order to get

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Page 1: 2008 Fatality Report - Leasehand Crushed Between Mud Tank … · 2018. 1. 16. · mud tank, and decided that the shale bin needed to be moved away from the mud tank in order to get

Leasehand Crushed Between Mud Tank and Shale Bin Type of Incident: Fatality Date of Incident: October 10, 2008

Page 2: 2008 Fatality Report - Leasehand Crushed Between Mud Tank … · 2018. 1. 16. · mud tank, and decided that the shale bin needed to be moved away from the mud tank in order to get

File: F-372407

TABLE OF CONTENTS

SECTION TITLE PAGE NUMBER

1.0 DATE AND TIME OF INCIDENT 3

2.0 NAME& ADDRESS OF PRINCIPAL PARTIES 3

2.1 Owner 3

2.2 Employer(s) 3

2.3 Worker 3

3.0 DESCRIPTION OF PRINCIPAL PARTIES 4

3.1 Employers 4

3.2 Worker 4

4.0 LOCATION OF INCIDENT 4

5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 4

5.1 Equipment and Material 4

5.2 Observations 5

6.0 NARRATIVE DESCRIPTION OF INCIDENT 5

7.0 ANALYSIS 6

7.1 Direct Cause 6

7.2 Contributing Factors 6

8.0 FOLLOW-UP/ ACTION TAKEN 7

8.1 Workplace Health and Safety Compliance 7

8.2 Industry 7

8.3 Additional Measures 7

9.0 SIGNATURES 8

10.0 ATTACHMENTS 8

2 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

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SECTION 1.0 DATE AND TIME OF INCIDENT 1.1 The incident occurred on October 10, 2008 at approximately 3:15 p.m. SECTION 2.0 NAME AND ADDRESS OF PRINCIPAL PARTIES

2.1 Owner(s) 2.1.1 Husky Energy Inc.

707-8 Avenue SW, Box 6525 Station D, Calgary, Alberta T2P 3G7 2.2 Prime Contractor 2.2.1 Husky Energy Inc. 707-8 Avenue SE, Box 6525 Station D, Calgary, Alberta T2P 3G7 2.3 Employer(s) 2.3.1 Trinidad Drilling Ltd. 3059-4 Street, Nisku, Alberta T9E 8L1 2.4 Contractor 2.4.1 Not applicable 2.5 Supplier 2.5.1 Not applicable 2.6 Worker 2.6.1 The Leasehand (Names and personal details were removed before distribution of this report) 2.7 Others 2.7.1 Not applicable

3 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

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SECTION 3.0 DESCRIPTION OF PRINCIPAL PARTIES 3.1.1 Husky Energy Inc. is one of Canada’s largest energy and energy-related companies,

with operations globally. The company has upstream, midstream and retail oil and gas operations.

3.1.2 Trinidad Drilling Ltd. has divisions operating in the drilling, well servicing and barge

drilling sectors. With the completion of current rig construction orders the company will have 126 drilling rigs, ranging in depth from 1,000 to 6,000 m.

SECTION 4.0 LOCATION OF INCIDENT 4.1 Husky Energy oil drilling lease, 4-33-74-9-W6, approximately 30 km northeast of

Beaverlodge, Alberta. (Attachment A – Map) SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 5.1 Equipment and Material

5.1.1 The Drilling Rig Trinidad Rig 24 is a TSM 7000A heavy double drilling rig, capable of drilling to a depth of 3,200 m. Rig 24 had been moved to the lease on October 6, 2008 to drill for oil. The oil was located in a narrow formation and the drill bore was being drilled vertically then curved to run horizontally through the oil-bearing formation. (Attachment “C”, Photograph #1)

5.1.2 The Mud Tank and Shale Bin The mud tank provides storage for drilling fluid (mud) that is circulated down the

well bore during drilling. The shale shaker mounted on top of the mud tank separates drill cuttings from the drilling fluid. The shale slide takes the separated cuttings (shale) from the shale shaker to a shale bin mounted close to the mud tank. The shale bin is a large steel container to store cuttings from the well. The shale bin was rented from Apex Rentals in Grande Prairie.

A 114mm steel pipe is located on the side of the mud tank between the mud tank and the shale bin. The pipe runs horizontally and is installed to connect the choke manifold to the degasser located on the mud tank. Energy Resources Conservation Board (ERCB) Regulations require this pipe to be installed on the outside of the mud tank.

(Attachment “B”, Sketch #1) (Attachment “C”, Photograph #2) 4 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

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5.1.3 The Front-End Loader The front-end loader was a 2005 Komatsu Model WA250-5L, serial number A74205, VIN number KMTWA055T57A74205. The front-end loader was checked by SMS Equipment Ltd. after the incident and found to be operating properly. (Attachment “C”, Photograph #3)

5.2 Observations 5.2.1 Weather conditions data from Environment Canada at Grande Prairie on October 10,

2008 recorded a temperature of 7.1 degrees Celsius at 3:00 p.m. Wind was light, 9 km/hr from the north-northeast. Conditions were mostly cloudy.

SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT 6.1 On October 10, 2008 Trinidad Rig #24 was drilling ahead from a depth of 564m to

755m. Shale from the shale-shaker on top of the mud tank was falling down the shale slide into the shale bin. The shale slide was fixed at the top end by chains, and the bottom end of the shale slide was resting over the edge of the shale bin. During the afternoon the Motor Hand was emptying the shale bin, using the front-end loader. To carry out this task the shale bin gate was dropped down and the front-end loader was driven into the shale bin to scoop out the shale. The wheel width of the front-end loader was 2.35 m, and the shale bin entry was 2.95 m wide, so there was a small clearance and limited room to maneuver the front-end loader inside the shale bin. While raising the bucket of the front-end loader, the Motor Hand caught the shale slide with the bucket, knocking it out of position so that it was hanging down between the shale bin and the mud tank. The shale was now falling between the shale bin and the mud tank instead of into the shale bin. (Attachment “C”, Photographs #6, #7)

6.2 The Motor Hand saw that the shale slide was caught between the shale bin and the

mud tank, and decided that the shale bin needed to be moved away from the mud tank in order to get the shale slide out from between the mud tank and the shale bin. (Attachment “A”, Photograph #7) The Motor Hand went to the Doghouse to seek assistance and found the Leasehand, to help him.

6.3 The Motor Hand installed forks on the front-end loader and used the forks to lift the

open end of the shale bin and slide the shale bin a small distance away from the mud tank. The Leasehand went into the gap between the mud tank and the shale bin. The Leasehand held the shale slide up with one hand and used his free hand to signal to the Motor Hand to use the front-end loader to push the shale bin towards the mud tank. (Attachment “C”, Photographs #3, #4)

5 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

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6.4 The Motor Hand started to push the shale bin towards the mud tank. The Motor Hand was watching the Leasehand as he was pushing the shale tank. The Leasehand was signaling the Motor Hand to move towards him. Suddenly the Leasehand gave a stop signal and then went limp. The Motor Hand went to the Leasehand and saw that he was trapped between a pipe on the mud tank and the shale bin. The Motor Hand went back to the front-end loader and moved the shale bin away from the mud tank. The Leasehand collapsed to the ground. (Attachment “B”, Sketch #2) (Attachment “C”, Photographs #5, #7, #8, #9)

6.5 The Motor Hand ran to the doghouse for help. The rig crew moved the Leasehand out

from between the mud tank and the shale bin. First aid was provided and the Leasehand was airlifted by STARS to hospital in Grande Prairie. The Leasehand died in the hospital later that evening as a result of injuries sustained in the incident.

SECTION 7.0 ANALYSIS

7.1 Direct Cause 7.1.1 The Leasehand was in a position of danger in a pinch point between a fixed mud tank

and a moving shale bin. The Motor Hand operated a front-end loader to move the shale bin towards the mud tank. The Leasehand was caught and crushed between the shale bin and a pipe on the mud tank, receiving injuries that were eventually fatal.

7.2 Contributing Factors 7.2.1 The Leasehand and the Motor Hand, discussed how to retrieve and reposition the

shale slide before the incident, but no effective hazard assessment was carried out. The workers were not concerned about the Leasehand standing between the moving shale bin and the fixed mud tank.

7.2.2 A length of chain was found on the mud tank catwalk above the shale bin. There were

locations in the shale slide to permit chains to be attached to the bottom end of the shale slide from the mud tank. The chain would have allowed workers to move and adjust the position of the shale slide from a safe position on the catwalk. The chain had not been installed at this location.

7.2.3 The mud tank, shale shaker and shale slide are all parts of the rig, and travel with the

rig from location to location. Ancillary items, including the shale bin, are rented locally at each location. The set-up of the mud tank and shale tank is therefore not the same at each site, and the rig components need to be adjusted or re-rigged at each new location, to allow locally rented components to mate with rig components.

6 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

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7.2.4 It was found that the front-end loader was in good operating condition and that the Motor Hand was trained and competent to operate the front-end loader.

SECTION 8.0 FOLLOW-UP/ ACTION TAKEN

8.1 Employment and Immigration; Workplace Health and Safety Compliance 8.1.2 Workplace Health and Safety Compliance issued a stop use order to secure the

incident scene during the on-site investigation. After measurements and photographs were taken the scene was released to Husky Energy Inc. and a stop work order was issued to Trinidad Drilling Ltd. requiring a hazard assessment and a safe work procedure for the process of adjusting or repositioning the shale slide.

8.2 Industry 8.2.1 Husky Energy Inc. carried out an incident investigation and produced an investigation

report. 8.2.2 Trinidad Drilling Ltd. stopped drilling after the incident, and maintained the rig and

drill string in a standby mode during the on-site investigation to allow the investigation to proceed.

8.2.3 Trinidad Drilling Ltd. carried out a hazard assessment and reviewed their procedures

for rig outs and rig moves. Trinidad Drilling Ltd. carried out a Job Safety Analysis (JSA) for moving equipment with a loader and for installing the shale slide to the shale bin. Trinidad Drilling Ltd. issued a safety alert through ENFORM to inform the industry of the incident and the measures taken to prevent a recurrence.

8.3 Additional Measures

8.3.1 No additional measures were required. 7 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

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8 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

SECTION 9.0 SIGNATURES Original Report Signed_______ _____________________ Lead Investigator Date Original Report Signed_______ _____________________ Investigator Date Original Report Signed_______ _____________________ Manager Date Original Report Signed_______ _____________________ Regional Senior Manager North Date SECTION 10.0 ATTACHMENTS: Attachment A Map Attachment B Sketch 1 Sketch 2 Attachment C Photographs

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Report File No. F-372407 Attachment “A” Map

Scale 1:300,000

Incident Location

9 June 19, 2009

Alberta Employment and Immigration, Occupational Health and Safety

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10 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

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11 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

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File: F-372407 Attachment “C”

Page 1 of 9

Photograph #1 Shows the lease site looking east.

12 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

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File: F-372407 Attachment “C”

Page 2 of 9

Photograph #2 Shows the incident site looking east. White arrow indicates the front-end loader. Yellow arrow indicates the shale bin. Red arrow indicates the mud tank.

13 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

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File: F-372407 Attachment “C”

Page 3 of 9

Photograph #3 Shows the front-end loader fitted with forks, with the forks under the open end of the shale bin.

14 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

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File: F-372407 Attachment “C”

Page 4 of 9

Photograph #4 Shows a close-up view of the front-end loader forks under the open end of the shale bin. Arrow indicates one of the forks.

15 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

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Attachment “C” Page 5 of 9

Photograph #5 Shows the view from the driver’s seat of the front-end loader.

16 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

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File: F-372407 Attachment “C”

Page 6 of 9

Photograph #6 Shows the top of the mud tank. White arrow indicates the shale shaker, yellow arrow indicates the shale slide.

17 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

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File: F-372407 Attachment “C”

Page 7 of 9

Photograph # 7 Shows the gap between the mud tank and the shale bin looking north, after the the shale bin had been moved to release the worker. White arrow indicates the 114 mm diameter pipe that the worker was crushed against. Yellow arrow indicates the direction that the shale bin was moving. Red arrow indicates shale falling from the shale slide into the gap between the mud tank and the shale bin. Blue arrow indicates the shale slide.

18 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

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Page 8 of 9

Photograph #8 Shows the gap between the mud tank and the shale bin looking south.

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20 June 19, 2009 Alberta Employment and Immigration, Occupational Health and Safety

File: F-372407 Attachment “C”

Page 9 of 9

Photograph #9 Shows a close-up of the gap between the mud tank and the shale bin. The shale bin has been moved away from the mud tank following the incident.