Learning plan from past incidents

8/17/2019 Learning plan from past incidents

1/27


2/27

2 3

Table of Contents

1 Foreword 4

2 Introduction 5

3 Accident Types 6

3.1 Fall from height fatal accident at Plant 27 63.2 Fall from Crane 8

3.3 Dropped object accident at Installations Area 10

3.4 Fall from height during Train 1 Shutdown 12

3.5 Fall from height in ADGAS Main Stores 14

3.6 Injury due to incorrect work practice 16

3.7 Crane Failure Incident – ADGAS Ofce Building 18

3.8 Crush injury due to unsafe work practice 20

3.9 Injury during Maintenance at STOREX Tank Farm 24

3.10 Fire and Equipment Failure 26

3.11 Injury due to incorrect work practice during construction work 28

3.12 Injury during construction work at Train 3 Sub-station #7 323.13 Fall from height injury 34

3.14 Property damage due to crane runaway – Pentane Line 36

3.15 Injury to construction worker due to ying object 38

3.16 H2S Gas release leading to fatal from height 40

3.17 Severe injury to multiple workers due to Electrical Flash 44

4 Learning from our past mistakes 47


3/27

4 5

Abu Dhabi Liquefaction Company

(ADGAS) owns and operates an

LNG Plant at Das Island located

approximately 160 km North West

of Abu Dhabi City. The plant con-

sists of two identical Trains (Trains1 and 2) and a third Train (Train

3) and associated facilities. The

plant was originally commissioned

in 1977 with two Trains and the

third Train was commissioned in

the third quarter of 1994. It is de-signed to liquefy the associated

gas produced from Umm Shaif,

Zakum and Bunduq offshore eldsthat are operated by ADMA-OP-

CO. The associated facilities of

the plant are utilities, tanks and

product loading facilities through

two separate jetties, one for LNG

/ LPG / Parafnic Naphtha and the

other for molten Sulphur.

As such, ADGAS recognize the

need to share safety knowledge inorder to achieve its vision through

the safe and efcient execution of

its operations. ADGAS has a well

established HSE ManagementSystem (HSEMS) in place, which

provides the necessary guidance

on managing HSE aspects of our

operations and therefore provide asafe working environment for all of

us.

Ever since we began operations

on Das there have been number

of incidents over the years, vary-

ing from plant shutdowns to rst

aid cases, to fatalities involving ourcolleagues and friends. Our inci-

dent investigations have identied

that many of these incidents are of

a repetitive nature

The purpose of this booklet is

to further enhance our efforts in

meeting the standards and expec-

tations we have set for ourselves

by learning from our past mistakes,taking the necessary steps to pre-

vent reoccurrence and cascadingthese learning’s to our employees

and contractors.

1. Foreword

The oil and gas industry processes,

stores and exports large quantities

of hazardous substances including

flammable and toxic materials, and

the potential for serious incidents

to evolve is highly probable.The inherent risks associated within all

areas of the industry, from construc-

tion and commissioning, maintenance

and production, and now increasingly

so, decommissioning of assets re-

quires the employment of competent

people who adopt a positive safety

behavioural attitude in their daily lives

and embrace the management proc-

esses and systems to aid us in assur-

ing safe and efcient operations.

When incidents do occur, the result-

ant surveys and investigations have

revealed that human factors, such

as failure to implement procedures

properly, are often a cause. These

failures may in turn be attributable to

root causes such as a lack of training,instruction, communication or under-

standing of either the purpose or prac-

tical application of an organisations

Safety Management System and the

supporting Safe Systems of Work.

Investigations into many other inci-

dents within the industry, from Piper

Alpha to the Sonatrach Skikda plant

in Algeria (2004) and BP’s Texas City

Renery (2005) have revealed that

a third of all accidents were mainte-

nance-related with the largest single

cause being a lack of, or deciency

in the deployment of safe systems of

work, primarily, risk assessment, per-

mit to work and the strict adherence

to such systems. Indeed, here in theUAE, many incident investigations

have revealed failures within these

systems as a root or contributory

cause, including incidents in our plant.

Safe systems of work, together with

the legislation that governs them and

ADNOC Codes of Practices / com-

pany guidelines that guide us in the

development of such systems, associ-

ated training programs and operation

manuals have all evolved over the

years to cope with larger, more com-

plex sites and operations. This has re-

sulted in most systems being regularly

reviewed and revised to form robust

safe systems of work. So why do we

still have incidents occurring?

The kinds of pressure that can com-promise any safe system of work are

all too familiar – the volume of paper-

work such as permits, poor planning,

unrealistic or tight deadlines, inap-

propriate risk assessment and poor

safety behaviour.

Appropriate selection of personnel

with the required competency is also

crucial to assuring safe operations, as

is a deep routed safety culture within

our workforce.

2. Introduction


4/27

6 7

On Sunday 22nd October 1995 a

scaffolder was part of a team erect-

ing a scaffold extension to an exist-

ing structure around the piping ris-

er of LNG Storage Tank 27-D-103

to enable access for painting.

He was working approximately 40

metres above ground level when

he released his safety harness tobend under a handrail extension,

and then as he stepped and turned

on the scaffold extension, the oor

board platform collapsed and he

fell to the ground, rst striking the

piping 3 metres above ground

level.

Despite prompt emergency medi-

cal attention rstly by the on-sit

Safety Ofcer administrating CPR

and then the Das Medical Emer-

gency Team, the casualty died al-

most instantly as a result of the falland was pronounced dead on ar-

rival at the Das Medical Centre.

3. Accident Types

Two root (or essential factors)causes were identied by theinvestigation team:Mechanical failure: The exten-sion bracket became detachedfrom the upright of the mainscaffold structure due to thescaffold team not being familiar

with the Layer system.Incorrect work practice and un-derestimation of hazard: Thesafety harness was not securedto a xed structure and misjudg-ing the risks associated with thistype of activity.

Root Cause

1. All Supervisors and scaffolders are to be reminded of the need to use

safety harnesses attached to xed points at all times.

2. Ensure that all personnel connected with the work attend the Toolbox

Talk and that it adequately addresses the specic task at hand. In this

case it did not address the potential hazards/failings associated with the

locking pin of extension brackets.

3. Conduct refresher training to all scaffolding staff on Layer scaffolding

and maintain training record.

3.1. Fall from height fatal accident at Plant 27

Overview of Incident

The resulting investigation identi-

ed that for a variety of reasons

there were several delays to the

maintenance work being conduct-

ed that resulted in a mixed contrac-

tor workforce being deployed to

complete the works within a speci-

ed time-frame, and with an ex-

tended workscope than originallyplanned. This also resulted in two

different scaffold systems being

utilised, tube and ttings, and the

Layer supplied system scaffolding.

Lessons Learned

Inadequate Leadership or Supervi-

sion: This was very much lacking

particularly with respect to the in-

creased workscope.

Inadequate competency: Some

members of the scaffold team were

not familiar with the Layer system.

Inadequate Toolbox Talk: The

Toolbox Talk did not adequately

address the potential hazards as-

sociated with the Layer system

scaffold.

Contributory Causes

Tube & Fitting Scaffold

Layer Scaffold System


5/27

8 9

Lessons Learned

1. Ensure that all crane operators are familiar with the crane they are

required to operate and reinforce the message that the purpose built ac-

cess routes must always be used whilst conducting routine maintenance

activities on the crane.

2. Large sign to be stencilled on the front windshield ledge ‘NO STEP –

ACCESS FOR CABIN ROOF WINDOW AT REAR OF CABIN’.

3. Warning sign to be posted at a highly visible location within the crane

cabin ‘Access to crane platform is only from front and rear at grade level’.

Root Cause

On Monday the 22nd April 1996 at

approximately 07:20, a crane op-

erator

drove his mobile crane to the South

side of Plant 2, Train 2, where he

parked awaiting permit authorisa-

tion.

Whilst waiting for the required Per-

mit, the crane operator decided toclean the outside of the crane wind-

shield and roof window. He left the

cabin and climbed onto the crane

chassis to clean the windshield

then stepped up onto a ledge (be-

low the windshield) to clean the

roof window however, upon

descending back to chassis level,

he lost his balance. He tried to

grasp the crane front grab rail but

failed to hold on and fell approxi-

mately 2 metres to ground level.

The casualty was given immedi-

ate rst aid treatment before being

carried by stretcher to Marshalling

Point No.3 before being taken byambulance to the Das Medical

Centre for immediate treatment for

a deep laceration of the scalp and

multiple rib fractures, before being

transferred to Abu Dhabi Mafreq

Hospital by helicopter.


Typical Mobile Crane

3.2. Fall from Crane

Hazard underestimated: The

Crane Operators underestimation

of the potential hazards whilst con-

ducting routine maintenance and

losing his balance in the process

was identied as the root cause of

this incident.

Incorrect work practice: The Crane

Operator did not use the desig-

nated access routes, which areprovided with anti-slip pads. The

access to the roof window is also

at the rear of the cab.

Contributory Causes


6/27

10 11

On the morning of Monday the

22nd April 1996 a small team of

scaffolders and labourers were

dismantling scaffolding on the

West side of LNG Tank 27-D-104

following a suspension of the work

to allow inspection activities to take

place to lower sections of the shell.

Two scaffolders were removing a

bracket and pulley wheel assem-

bly from a vertical scaffold pole

at the 13th lift (approx 26 metres

above ground) in preparation for

using it at a lower level of the scaf-

fold structure.

During the process of lowering

the combined pulley wheel and

bracket over the scaffold structure

handrail, the bracket became de-

tached from the pulley wheel and

fell, striking a labourer who was

working at ground level, within the

exclusion area, collecting loose

scaffold ttings.

The labourer suffered severe facial

lacerations and was transferred by

ambulance to Das Medical Centre

for immediate treatment before be-

ing evacuated by helicopter to Abu

Dhabi Mafreq Hospital.

Inadequate Leadership or Super-

vision: The inspection of the work-

site and workscope following the

suspension was not conducted.

Inadequate Leadership or Super-

vision: The inspection of the work-

site and workscope following the

suspension was not conducted.Inadequate procedure, practic-

es or guidelines: There was no

formal procedure in place for low-

ering the combined pulley wheel

and bracket, nor did the contractor

have adequate systems in place to

address the potential hazards for

the task at hand.

Inadequate Toolbox Talk: Thereas no record of a Toolbox Talk be-

ing conducted to address the spe-

cic task at hand.

3.3. Dropped object accident at Storex Area


Root Cause

Dropped objects can be fatal

Lessons Learned

1. Install and use securing devices on all pulley gin wheel support hooks.

2. Develop and issue a formal procedure for lowering pulley arrange-

ments during scaffold activities, addressing aspects of potential hazards.

3. Re-enforce adequate exclusion zones.


Talk and that it adequately addresses the specic task at hand.

5. Establish frequency and scope of site inspections, particularly with

respect to recommencing work following a period of suspension,

Incorrect work practice and haz-

ard underestimated: The lowering

of the combined pulley wheel and

bracket without a securing de-

vice and the fact that a man was

present within the exclusion zone

whist work was in progress over-

head were identied as the root

causes of this incident.

Contributory Causes


7/27

12 13

In the afternoon of the 2nd May

1998, a contract Mechanical Su-

pervisor fell from approximately 7

metres off a rope ladder whilst at-

tempting to exit a Butane Treater

Vessel (9-C-102b) via the top noz-

zle, after completing inspection of

the vessel internals with a third

party inspector.

The Mechanical Supervisor lost

his grip on the rope ladder and as

he was not wearing the prescribed

safety harness (as required by the

PTW) the fall resulted in fractures

to his pelvis, vertebra and right fe-

mur.

Although the Mechanical Supervi-

sor was an experienced contrac-

tor, the resultant investigation into

this incident identied that his age

(57), bulky physique and unt con-

dition may have caused him to

lose his footing on the rope lad-

der due to exhaustion through the

effort of climbing the rope ladder.

He subsequently lost his grip ashe was unable to support his full

weight. If he had been wearing the

safety harness as per the PTW re-

quirements then the severity of this

accident would have been greatly

reduced.

During the incident investigation,

the following also came to light:

• The onsite Safety Advisor did not

have any means to raise the alarm

and entered the conned space to

aid the injured party without due

consideration for his own safety.

• The incident area became con-

gested with Fire and Rescue ve-

hicles, unauthorised Police and

State Security and Medical vehi-

cles. Additionally, these people en-

tered the area without appropriate

PPE.

3.4. Fall from height during Train 1 Shutdown

Incorrect work practice and un-

derestimation of hazard: The

Mechanical Supervisors underes-

timation of the potential hazards

whilst ascending the rope ladder,

coupled with his lack of physical

tness, and the failure to wear a

safety harness were identied as

the root cause of the incident.

Root Cause

1. Due consideration to a persons physical age, size and tness must

be taken into account before assigning him to tasks involving restricted

or difcult access.

2. Suitable safety harnesses must be worn by all persons using rope

ladders.

3. Safety Assistants must be provided with adequate and appropriate

means to raise the alarm in the event of an emergency.

4. Work procedures and associated training programs must address the

roles and responsibilities of Safety Assistants during conned space en-try activities.

5. Site safety induction training should be given periodically to person-

nel who do not normally work within plant areas, for example the Police,

State Security and Medical personnel, to ensure that they are familiar

with the potential site hazards.

6. The Operations Shift Superintendent is responsible for assuming and

maintaining full control of the situation and for directing resources to en-

sure the incident is effectively brought under control.

Lessons Learned

Non adherence to ADGAS PTW

requirements: PTW conditions with

respect to the use of a full body

harness were not followed.


sion: This was very much lacking

in the build-up to the incident and

during the emergency response,

whereby the Police, State Security

and Medical personnel entered the

site without adequate PPE.

Contributory Causes


Butane Treater Vessel


8/27

14 15

On Tuesday 3rd November 1998

at 09:15 a contract rigger fell from

a height of 2 metres whist work-

ing within the ADGAS Main Stores

area and suffered multiple rib frac-

tures as a result of the fall.

On the day of the incident, the rig-

ger was involved in the transfer of

boxes within the stores area. The

boxes were covered with tarpaulinwhich was held in place by wood-

en crates. To remove the wooden

crates the rigger climbed atop the

boxes and during the removal of

the crates, lost his balance when

he stepped unknowingly between

the boxes and fell to the ground.

Although employed as a rigger, the

contractor was not qualied for this

role.

3.5. Fall from height in ADGAS Main Stores

1. Contract documents to clearly specify the requirement of Third Party

Riggers and Rigging Supervisors.

2. Contractors to be instructed that all their personnel must attend the

ADGAS Safety Induction Course before working in industrial and non-

industrial areas of ADGAS facilities on Das Island.

3. The requirements of the ADGAS PTW system must be adhered to atall times.

4. The practice of holding down tarpaulin covers (on top of boxes) by

utilising wooden crates (or similar) should be discontinued.

5. Standing Instructions should be developed and issued for the safe

handling of boxes and containers within the ADGAS Stores and Harbour

areas. This should also be part of the tender and contract documents.

Lessons Learned

NonadherencetoADGASPTWsys-

temrequirements: NoPTWwas-

raisedfor working at height, no risk

assessment was conducted and

therefore the potential hazards

were not addressed and inade-quate work planning was evident.

Lack of Safety Training: The rig-

ger had not attended the ADGAS

Safety Induction Course.


sion: The rigging team were carry-

ing out the activities with no lead-

ership or supervision at site.

Incorrect work practice: The prac-

tice of holding down tarpaulin with

wooden crates is considered sub-standard as it introduces further

risk into the job when it needs to

be removed for whatever reason.

Root Cause

Improper assignment of person-

nel: The rigger was not qualied

or experienced in this type of work

and therefore was not aware of the

potential hazards when conducting

such duties.

Contributory Causes

All falls from height can cause damage to the human body



9/27

16 17

On the morning of the 31st De-

cember 1999, a contractor em-

ployee was assisting six other men

in erecting the steel frame of the

ADGAS Ofce Building signboard,

which comprised 4” carbon steel

pipe weighing 1016 KG.

As a crane was not available, the

site Surveyor and Foreman de-

cided to manually lift the structureonto an ‘Easy Fix’ scaffold platform

at Level 2 with the aid of twenty

(20) labourers. Upon completion of

the welding, the frame was brought

down to Level 1 of the scaffold plat-

form with the aid of six (6) labour-

ers. During this activity, the Welder

(casualty) was asked to assist

by raising the frame by 3” - 4” by

means of a scaffold tube in order to

place packers under the frame so

that the supporting transom could

be removed and the whole struc-

ture lowered by the six labourers

with the aid of ropes. As the welder

was doing this, he lost his balance

and twisted his right foot. However,

he completed the activity but within

30 minutes he complained of pain

in his right ankle and was trans-ferred to Das Clinic for treatment

and later referred to hospital in Abu

Dhabi where it was ascertained

that he had suffered a fractured

bone (distal end of bula).

3.6 Injury due to incorrect work practice Overview of Incident


Incorrect work practice and inad-

equate competency: Neither the

casualty nor the six labourers were

qualied riggers and had no ration-

ale or reasoning to lift the frame

manually.

Root Cause

ADGAS Ofce Building

1. All lifting operations must be conducted using appropriately qualied

riggers.

2. Mechanical lifting equipment to be used for handling heavy/awkward

structures, and conducted under the strict supervision of appropriately

qualied supervision.

3. Method statements to be provided for all heavy lift operations for re-

view by ADGAS HSE Dept.

Inadequate work planning: A meth-

od statement was not submitted by

the contractor and therefore not re-

viewed by the HSE Dept.

Page 14 of 45

Inadequate procedure, practices

or guidelines: The contractor had

no written procedure for the lifting

operation.


sion: Full mobilisation of the con-

tractor had not been completed

and no contractor management

was on site, thereby resulting in no

clear chain of command for execu-

tion of the work activity.

Contributory Causes

Lessons Learned


10/27

18 19

On the morning of the 6th Decem-

ber 2000, a tower crane failed and

dropped its load onto scaffolding,

resulting in damage to the scaf-

fold but fortunately no one was

harmed.

The crane was being utilised in

construction work for the new

ADGAS Ofce Building and the

team comprising Crane Driver,Banksman and Riggers conducted

their work well. An ADGAS Safety

Representative was also in attend-

ance.

The crane was loaded with an

empty steel bucket, having just

been emptied of concrete blocks

on a platform near the top of the

building. On completion of the lift,

the crane driver changed from 2nd

gear to neutral, when the brake

would normally have engaged. It

then slewed anti-clockwise and

travelled the radial bogie inwards.

The crane driver realised some-

thing was wrong but was help-less as the hoist rapidly dropped

uncontrollably, landing on an un-

manned scaffold approximately 3

– 4 metres from the original hoist

position and where two men were

previously standing.

3.7. Crane Failure Incident – ADGAS Ofce Building


Mechanical failure: the cause of

the accident was indentied as the

failure of the splined drive shaft.

Contributory Cause

Incorrect work practice and in-

adequate competency: Although

the Contractor site Mechanic had

serviced the crane previously and

had been instructed to have a look

at the gearbox at regular interval,

it appears he was unaware as to

what he was looking for. Further-

more, there were no recorded de-

tails of previously conducted main-

tenance servicing or indeed, any

proper maintenance procedures.

Root Causes

During the course of the investi-

gation, a number of irregularities

were found, including:

• The crane purchased second

hand in 1995 (manufactured in

1979) and brought to Das in Feb-

ruary 2000. No maintenance man-

ual or drawings were available.

• There was no written mainte-

nance history available. Weekly

checks were made but these were

considered dubious as the exact

wording was used every week.

• The gearbox inspection revealed

excessive play of the internals,

missing lock-washers, heavily

worn gear teeth and the bearing

housing had been welded in two

places, which suggests severe

damage in the past.

Tower Crane dropped load on to scaffolding

Tower Crane

Lessons Learned

1. Future contracts should consider stating a minimum age for cranes

and associated components, and have the service history made avail-

able.

2. Prior to award of a contract, companies must demonstrate that they

have a sound HSE Management System.

3. Mechanics must be adequately trained and assessed as competent.

4. Proper maintenance schedules for the different inspections must be

provided and maintained


11/27

20 21

The scaffold platform around

the exchanger was cleared of

al l non-essential personnel, leav-

ing the:

• Rigging Supervisor, who was in

charge of the lifting operations and

positioned at the North end of the ex-

changer, ready to adjust the two off

chain blocks to level the exchang-

er on the horizontal plane. A single

sling was tted to the South end

of the exchanger and Tirfor lines

were attached to restrain lateral

movement.

• Rigging Foreman was stationed

at the East side of the exchanger

on the same level.

• Banksman was positioned at the

South side, with a clear vision of

the other two and would commu-

3.8. Crush injury due to unsafe work practice


Root Cause

Position of Rigger when he sustained Crush Injury at his left hand

On Thursday 24th May 2001, a third party contractor work team

were preparing to change out a Propane De-superheater Exchang-

er (weighing approx 18 tons), located at the top of the exchanger

bank on Plant 6, approx 7 metres above ground level.

The removal of the leaking exchanger was to be effected by utilising a

32 ton capacity Liebherr mobile crane, together with an arrangement of

chain blocks and ‘Tirfor’ lines to control any lateral movement.

Unsafe work practices: The unsafe act committed by the Banksman in-

dicates a low level of behavioural safety.

nicate with the crane driver by

means of hand signals.

The Rigging Supervisor gave the

instruction to the Banksman to

commence the lift slowly and lift

the exchanger by only 5mm.

The exchanger lifted approximate-

ly 5mm only at the South end and

immediately slewed slowly to the

West, towards the sister exchanger.

In an attempt to restrain the move-

ment, the Banksman, with his left

hand on the outer rim of the ex-

changer suffered severe crush in-

juries when contact between the

two exchangers occurred. He was

escorted from the worksite and

was transported to Das Clinic by

car where he received initial medi-

cal treatment before being trans-

ferred to the Central Hospital in

Abu Dhabi for further treatment to

a severed index nger, crushed

second and third ngers and lac-

erations to the back and palm of

the left hand.

Mobile crane


12/27

22 23

1. Safety behaviour training for all contractors is essential to assuring

safe operations and contractors are to ensure that this type of training

forms an inherent element to their training program.

2.The assigned Banksman must always stand clear of the lift and be

dedicated to to providing the communications link with the crane driver

only, leaving the hands on control of the lift to other members of the rig-ging team.

3. Rigging Procedure / Instructions to indicate correct positioning of all

lifting equipment involved in any lift, with the Rigging Supervisor carrying

out a check that all is in order prior to the lift.

4. Contractors must arrange a joint meeting to discuss critical lifting op-

erations with ADGAS Rigging Supervisor and HSED.

Lessons Learned

Contributory Causes

Incorrect work practices: The

incorrect positioning of the lifting

sling and crane hook not aligned

in a plumb position. Additionally,

there were an insufcient number

of correctly positioned restraining

lashes (Tirfor wires) to prevent lat-

eral movement of the exchanger

during the initial stages of the lift,

with no tag lines secured to con-

trol lateral movement thereafter.

Also, the Banksman should not be

involved in the ‘hands on’ activities

of controlling the lift.

Inadequate work planning: A

critical situation arose late in the

maintenance period which neces-

sitated removal of the exchanger

in a limited time frame, resulting

in the work not being thoroughly

thought through.

Poor safety behaviour: The con-

tractor exercised poor safety be-

haviour during the lifting operation

with regard to their actions.

Poor coordination: Poor co-

ordination and cooperation

between ADGAS/Contractor Rig-

ging Departments prior to the lift-

ing operation was identied as a

contributory factor which formed

the background to the chain of

events leading to the accident.


13/27

24 25

On the 5th November 2001, con-

tract Scaffolders were erecting

platforms to enable overhaul ac-

tivities to be carried out on the

personnel elevators on Tank 27-D-

103 and 27-D-105.

Three PTW’s were issued for work

on 27-D-105, one Cold Work PTW

for scaffolding, one Hot Work PTW

for routine instrument maintenance

on the tank level gauges and oneCold Work PTW for routine me-

chanical work on an air hoist.

During the execution of the works,

ADGAS Mechanical personnel

used the elevator to ascend to the

top of the tank to commence work

on the air hoist and left the elevator

at the top level.

An ADGAS Senior Instrument

Technician, on returning from his

tea-break found the elevator was

at the top level and pressed the call

button for the elevator however, a

scaffolder was working close to the

elevator well and his foot became

trapped between a support struc-ture and the side of the elevator

when it started to descend. The el-

evator emergency brake activated,

securing the elevator and defeat-

ing normal operation.

The alarm was raised, the elevator

electrically isolated and ADGAS

mechanical personnel attempted

to free the scaffolder by levering

the elevator car by means of a

scaffold tube. This proved unsuc-

cessful and they eventually freed

him by cutting through the eleva-

tor structure cross beam using a

hacksaw. The injured scaffolder

was pulled clear and treated at the

scene by medical personnel and

administered a pain killing injection

before being transferred to ground

level by stretcher via the stairs andtransported to Das Clinic.

3.9. Injury during Maintenance at STOREX Tank Farm

Overview of IncidentRoot Cause

Elevator at 27-D-105

Location at the platform where the

scaffolder had his foot trapped

Poor safety behaviour: The

scaffolder exercised poor safety

behaviour by standing on the

elevator structure cross mem-

ber in the knowledge that the

elevator was live. Additionally,

the contractor Safety Ofcer,

who had direct responsibility to

be present at the worksite, was

located at ground level.

storex earea


14/27

26 27

Inappropriate risk assessment:The Risk Assessment was con-ducted by the contractor in AbuDhabi and no site visit was con-ducted. Additionally, the change inthe work process invalidated theRisk Assessment.Poor coordination: There waspoor coordination and cooperationbetween ADGAS and Contractorpersonnel. At the kick-off meeting,most of the attendees were una-

ware of the detailed work area inrelation to the operational elevator,and the Senior Instrument Techni-cian was unaware of the on-goingwork adjacent to the elevator.Inadequate PTW preparation:

The PTW conditions were ambigu-ous, stating “elevator to be rackedout if required”. Also, the PTW wasprepared by the night shift, hadno detailed drawing or associateddocumentation, and no site visitwas conducted prior to approv-al. Additionally, liaison between

ADGAS Mechanical Supervisorand contractor Site Supervisor wasidentied as virtually non-existentwith respect to the PTW.

1. Safety behaviour training for all contractors is essential to assuring

safe operations, with the ADGAS Advanced Safety Awareness scheme

being adopted by contractors.

2. The ADGAS method for Risk Assessments to be adopted with a site

visit being a mandatory requirement.

3. ADGAS to review PTW procedure with respect to specic roles andresponsibilities, and the policy regarding the allowance of accepting Per-

mits by ADGAS personnel for one discipline on behalf of another dis-

cipline. PTW training should also highlight the risks involved in adding

ambiguous precautions to Permits.

4. Review procedures for work on elevator structures and dene when

elevator should be racked out.


Talk and that it adequately addresses the specic task at hand.

Lessons Learned

Contributory Causes


15/27

28 29

Following the completion of

maintenance the pump was

returned to service and re-

streamed following normal op-erational procedures and the

standby pump shutdown.

After approximately 25 minutes

of running, the pump experi-

enced, in quick succession, ab-

normal vibrations, high bearing,

shaft and coupling tempera-

tures, which resulted in a re at

the inboard turbine bearing, fol-

lowed rapidly by a catastrophic

failure of the shaft and coupling.

Although the re was quickly

extinguished using portable re-ghting appliances, attempts to

re-start the standby pump failed

due to an electrical permissive

(design feature) that prevents

the pump from being restarted

within 30 minutes of shutdown.

The rst attempt to restart was

attempted at 26 minutes after

shutdown. The failure to main-

3.10. Fire and Equipment Failure


Component failure: The speed indication probe failure was iden-

tied as the most likely cause of bearing failure.

Incorrect sensor setting: The turbine air purge pressure was setfar in excess of the recommended setting.

Contributory Causes

Inadequate working conditions: The presence of grit blast mate-

rial, prevailing wind conditions and exposed bearings was identi-

ed as a contributing cause of the bearing failure.

Root Cause

On Thursday 31st January 2002, HP Lean Carbonate Pump 2-G-

104A was released for 6-monthly routine maintenance activities

to be carried out, which involved bearing inspections but did not

require uncoupling of the pump.

1. Ensure that maintenance activities and sensor settings strictly

adhere to manufacturers recommendations.

2. Ensure that meticulously clean working areas are maintained

during invasive maintenance activities. The fact that grit blast-ing activities had been recently carried out in the proximity of the

pump, and the high winds experienced during the maintenance

activity would have made it very difcult to keep the bearings clean

during the procedure.

Lessons Learned

tain either pump on-line result-

ed in a plant shutdown and loss

of production.

A fault tree analysis method of

investigation was applied which

identied two root causes with a

contributory cause. However, it

should be noted that the investi-

gation was hampered due to the

large extent of damage caused

by the re and catastrophic me-

chanical failure.

Carbonate Pump


16/27

30 31

On 30th July 2005, a Mechani-

cal Helper was working for the

Boil-off Gas (BOG) project when

he fell from ground level to the

base of a 2.8 metre deep exca-

vated trench. The team was en-

gaged preparatory works asso-

ciated with the rewater tie-ins

for the BOG Plant.

The accident happened when

the injured person was in the

process of moving a PVC con-

duit containing electrical/instru-

ment cables to one side of the

trench so that a section of the

new rewater piping could be

laid within the trench. The PVC

conduit protecting the under-

ground electrical services was

suspended by means of a rope

to a 6 metre long scaffold tube,

which traversed the excavation.

Despite being told to wait at

the worksite until the Foremancould provide him with addi-

tional help to assist with the

task, the Mechanical Helper

proceeded on his own to pull

one end of the scaffold tube to-

wards him. As a result, the op-

posite end of the scaffold tube

dropped into trench and the end

which he was holding swung

upwards and struck him on the

thigh, causing him to lose bal-

ance and fall to the base of the

excavation.

3.11. Injury due to incorrect work practice during construction work


To complicate matters, the in-

jured person was helped from

the trench and then left the

scene of the accident and as-

sisted by colleagues to the

Contractor Site Ofce to see the

Deputy HSE Manager however,

he was not there and it was de-

cided he should go to Das Clin-

ic, whereupon he was admitted

for treatment. The following day

he was transported by helicop-

ter to hospital in Abu Dhabi but

discharged himself later that

day. He was then taken to the

Contractor ofce in Abu Dhabi

and assigned ofce duties.

This pipe was not inside the trench dur-

ing the accident.The injured person was pulling the scaffolding

bar to clear the area for the crane to put the

pipe inside the trench.


17/27

32 33

Non adherence to ADGAS Emergency procedures: No

attempt was made to inform the Shift Superintendent or the Con-

trol Building to request medical assistance, even though the in-

jured person was complaining of lower back pain.

1. Performing Authorities (ADGAS or Contractor) must ensure that

all work is carried out in accordance with ADGAS procedures.

Additionally, all work must stop should conditions change at the

worksite, and a re-assessment of the risks undertaken as per

ADGAS procedures.

2. Ensure that all work party members attend the Toolbox Talk and

that it adequately addresses the specic task at hand, and covers

the topic of the correct actions to take in calling for medical assist-

ance and handling of any casualty.

3. Advanced Safety Audits (ASA) must cover the subject of job

specic Toolbox Talks.

4. The practice of dropping down dismantled scaffold material to

the ground, thereby making the work area an unsafe place is con-

sidered a dangerous and unacceptable activity. These should be

properly handled and deposited into containers or bags to ensure

correct and safe handling procedures.

5. All Contractor Job Ofcers must verify that unskilled employees

have a minimum of one year’s experience in their line of work.

Additionally, Contractor HSE Auditors must also verify this require-

ment.

Lessons LearnedRoot Cause

Incorrect work practice: The arrangement in adopted in secur-

ing the PVC conduit to protect the underground electrical services

was substandard.

Contributory Causes

Lack of communication: Poor communication between Mechan-

ical Helper (injured person), Foreman and Mechanical Supervisor.

Lack of experience: It became

evident that the injured person’s

construction work experience

was extremely limited and thatprior to this particular incident

he was observed working in

the trench alone and was ques-

tioned by the Safety Ofcer,

where it was noted that he was

totally unaware of the inherent

dangers of working alone in aconned space and within close

proximity to a live gas plant.

Non conformance to Task Risk Assessment: Although the Task

Risk Assessment adequately addressed the potential hazards, the

associated control measures were not enforced.

Inadequate Toolbox Talk:

There as no record of a Tool-

box Talk being conducted to ad-

dress the specic task at hand.

Change of worksite condi-

tions: The removal of the cer-

tied walkway across the exca-

vation forced the Contractor to

look at alternatives ways to com-

plete the task and the method

of suspending the conduit by a

length of rope to a scaffold tube

was employed, and later identi-

ed as a major contributory fac-

tor to the incident occurring.


18/27

34 35

The onsite contract Foreman admin-

istered rst aid at the worksite and

utilised a dust mask to dress the in-

jury. The Foreman then contacted

the on site contract Supervisor to

inform him of the incident before

driving the labourer to the contrac-

tor onsite ofce for further medical

treatment. This was conducted by

the ofce boy (who did not hold a

valid rst-aid certicate) by applying

Savlon cream and a cleansing so-

lution to the injured nger. He later

informed his Manager that the injury

was not serious.

The onsite Project Manager then in-

formed the injured labourer to rest in

his room before granting him com-

passionate leave and travel to Abu

Dhabi.

Whilst waiting for his ight at Das

Airport, he was spotted by the Police

covering his left hand with a scarf.

When questioned, the labourer in-

formed the Police of the accident

and he was requested to attend

Das Police Station before being

transferred to Das Clinic for proper

medical treatment. He was detained

overnight and released the following

morning.

3.12. Injury during construction work at Train3 Sub-station#7


Inappropriate method state-

ment and risk assessment:

Although a Method Statement

and Risk Assessment were

conducted, neither addressed

the hazards posed by the U-

shaped reinforced steel barsthat protruded from the ground

during the demolition works.

Inadequate Supervision: Dur-

ing the interview sessions as

part of the incident investigation

it was noted that the contractor

line management were aware of

the potential hazards posed by

the U-shaped reinforced steel

bars and indeed, the mitigation

measures but they did not dis-

seminate this to personnel actu-

ally performing the work.

Inadequate work brieng: Al-though the brieng session cov-

ered general topics such as the

use of PPE and housekeeping,

it did not highlight the specic

risks to the actual task at hand

to those conducting the work.

Root Cause

On the 12th November 2005, a contract Labourer was working with a

pneumatic jack hammer conducting demolition work on a concrete foun-

dation when the hammer drill bit became stuck in the concrete. The la-

bourer managed to forcefully free the drill bit but by applying a rocking

motion and in doing so, his left hand ring nger was jammed between

the jack hammer handle and a U-shaped reinforcement steel bar (Refer

Fig 5), resulting in a minor injury.

1. A more in-depth, detailed Method Statement to be developed

and used as the basis for the Risk Assessment with all potential

hazards addressed.

2. Contractor management and supervision must review the ap-

propriate project plan and become fully conversant with ADGAS

procedures.

3. Conduct daily work brieng sessions that address the specic

task at hand with reference to the associated Method Statement

and Risk Assessment.

4. Ensure that all contractors are aware of the correct actions to

take in the event of any accidents occurring at the worksite.

5. Nominated rst-aiders are to be appropriately trained and a

list of qualied rst aiders displayed at Contractor Ofce notice

boards.

U shaped reinforcement steel bar hazard U shaped reinforcement steel bar hazard

Unsafe work practices: The unsafe use of the pneumatic jack ham-mer by the Labourer indicates a low level of behavioural safety when

using pneumatically operated equipment.

Contributory Causes

Lessons Learned


19/27

36 37

The injured scaffolder along with his

team of 3 persons was engaged in the

dismantling of the scaffold, under a

General Cold Work Permit.

The accident occurred when the in-

jured scaffolder was dismantling the

scaffold at approximately 2.16 me-

tres and was un-doing a Beam Clamp

(Gravelock). During the process, thespanner slipped, he lost balance and

fell backwards and collided with the

1.2 metre high guard rail behind him.

The guard unfortunately had loose t-

tings and the force of the impact dis-

lodged the guard rail from the scaffold

structure and it fell to the ground. Sub-

sequently, with the backwards motion

the injured person fell to the ground,

landing on his back atop the fallen

guard rail and scaffold clamps, which

had previously been removed in the

dismantling process.

The injured scaffolder was immedi-ately transported by ambulance to

Das hospital the later medivac to Abu

Dhabi by helicopter for further medical

treatment.

3.13. Fall from height injury


Inadequate work planning: A specic Toolbox Talk for the activity, out-

lining the potential risks and hazards was not evident.

Non conformance to procedures/standing instructions: CITB certi-

ed scaffolders are a mandatory requirement yet this was compromised

with a parallel process to carry out the certication as soon as possi-

ble. This is a wholly inadequate process and appropriate steps must be

made to ensure this is not repeated.

Non adherence to ADGAS PTW requirements: PTW conditions

with respect to the use of a full body harness were not followed.

Root Cause

Workers on a scaffold structure

Beam Clamp

On 15th April 2008, a scaffolder fell from the scaffold structure located

beneath the Blowdown to Plant 19 Pipe Rack.

1. Engaged scaffolder certication and records are checked and veried

by ADGAS prior to them being mobilised to site.

2. Ensure that all work party members attend the Toolbox Talk and that i t

adequately addresses the specic task at hand.

3. The practice of dropping down dismantled scaffold material to the

ground, thereby making the work area an unsafe place is considered a

dangerous and unacceptable activity. These should be properly handled

and deposited into containers or bags to ensure correct and safe han-

dling procedures.

4. PTW conditions to be adhered to at all times.

Incorrect work practice and un-

derestimation of hazard: The

safety harness was not secured

to a xed structure and misjudging

the risks associated with this type

of activity. Complacency had also

crept into the way the work was

performed.

Additionally, the practice of drop-

ping down dismantled scaffold

material to the ground, thereby

making the work area an unsafe

place is considered a dangerous

and unacceptable activity, which

aggravated the injuries sustained.

Contributory Causes

Lessons Learned


20/27

38 39

The crane operator was instructed to

drive his crane (60 tons) by his banks-

man to Second Street, which was

temporarily designated as a ‘waiting’

area for heavy vehicles due to the nor-

mal heavy vehicle parking areas beingheavily congested. Upon arrival the

crane operator noticed that Second

Street was congested with three other

cranes parked ahead, and the banks-

man was not there to meet him.

The crane operator then left the crane

unattended with the engine run-

ning and without applying the brake

to meet with other crane operators.

He assumed that the crane was bal-

anced and at an equilibrium position

but moments later noticed the crane

roll down the sloped road and hitting

the parafnic naphtha loading line of

Plant 21 pipe rack. Additionally, the

impact of the accident shifted the pipe

to the North side and caused damageto the adjacent access platform and

civil foundation.

It was found that the banksman who

was supposed to be at Second Street

with the crane operator was given an

additional task to submit a Permit to

another trailer driver located in Area

502, which caused a delay for him

getting to Second Street on time to

instruct the crane operator and the

cranes movements.

3.14. Property damage due to crane runaway – Pentane Line


Inappropriate risk assessment: Sec-ond Street was designated as a tem-porary parking area and waiting areafor heavy vehicles for the Turnaroundactivities without conducting an ad-equate risk assessment.Lack of supervision: There was no co-ordinator assigned at Second Streeton the day of the accident to monitorthe movement of heavy vehicles. Additionally, the assigned banksmanwho was supposed to be at SecondStreet with the crane operator wasgiven an additional task which de-

layed his arrival at Second Street toinstruct the crane operator and moni-tor his movement.Lack of training: The crane operatorwas recruited by a Contractor in Octo-ber 2008 but the Contractor providedonly one training certicate and thatwas for HSE and breathing apparatus.Inappropriate property protection: Theimpact of the accident shifted the pipeto the North side and caused damageto the adjacent access platform andcivil foundation as there was no bar-rier protection provided.

Root Cause

On 15th November 2008, an unmanned crane rolled down a sloped

(approx 1.6 degrees) road and hit the parafnic naphtha loading line of

Plant 21 pipe rack, causing damage to the pipe work and ange, which

resulted in a minor leak.

Incorrect work practice and underestimation of hazard: Thecraneoperator

stopped his crane and left the vehicle unattended with the engine running, with-

out securing the crane and without applying the parking brake.

Lessons Learned

1. Third party certication and competency of crane operators, banksmen andriggers must be assessed and assured during the recruitment process. ADGAS

should also be involved in the interviewing and selection process before they

arrive at Das to assure adequate competency of personnel.

2. Ensure that an adequate risk assessment is conducted to ensure that all

work and site hazards have been properly addressed.

3. The assigned banksman should not be given more than one task dur-

ing shutdown activities and an adequate number of banksmen must be avail-

able on site at all times.

4. Removable concrete barriers should be erected at all industrial roads in

ADGAS Plant areas to protect pipe work and civil foundations to mitigate the

potential of collision damage.

Contributory CausesDamage to the Crane loading line & structure

Damage to parafnic naphtha


21/27

40 41

3.15. Injury to construction worker due to yingobject

Overview of IncidentLack of hazard awareness: Al-

though a risk assessment was

completed for the works that iden-

tied and documented the control

measures for this type of work,

they were not communicated at

site nor was it present at the work-

site.

Lack of training: The injured con-

tractor had received no training in

the use of angle grinders.

Inadequate Toolbox Talk: A toolboxtalk was conducted for the activity

ten days prior to the incident and

no reminder or refresher toolbox

talk was conducted for the task at

hand.

Inadequate PPE: Had the contrac-

tor been wearing the proper PPE

then he would not have suffered

injuries to his right jaw.

Use of substandard/inappropriate

tools: There was no evidence that

the angle grinder was purchased

from a known manufacturer or had

been subjected to any form of in-tegrity checks.

Root Causes

Lessons Learned

1. Establish training programs to cover:a. Hazard awareness

b. Effective toolbox talk for supervisorsc. ASA training to supervisorsd. Use of air powered tools, including associated risk and consequencesof failure to all who use them.

2. Ensure that toolbox talks are job specic and effectively communi-cated to all concerned at the start of each shift.

3. All powered tools to be procured from known manufacturers and meet

ADGAS requirements. They must also undergo preventative mainte-

nance checks at regular intervals to assure integrity.

4. Post Safety Flashes and HSE posters at strategic locations through-

out all plant areas. This provides valuable communication of ‘lessons

learned’.

5. ADGAS trained personnel to conduct ASA on regular basis to reinforce

safety messages and ensure that the correct PPE is worn at all times.

6. Introduce a mechanism for measuring and rewarding HSE perform-

ance on project sites in addition to the incentive scheme already in place.

Underestimation of risk: The de-

gree of risk associated with us-

ing the unproven methodology of

smoothing the concrete with inad-

equate machine tools (angle grind-

er) was totally underestimated by

the Foreman on site. The injured

contractor was given a brief famil-

iarisation on the use of the angle

grinder but not the associated risks

he was exposed to.

Contributory Causes

On the 15 March 2008, civil project

work was being conducted by

the assigned contractor and sub-

contractor, which included the

preparation and smoothing of the

concrete surface on the Pre-as-

sembled Rack (PAR) 102 foun-

dation footing. This is done by

the use of a stone cup disc and

pneumatic powered angle grinder

prior to water-proong or protec-tive coating application. As part of

civil works, concrete surfaces must

be smoothed prior to application

of water-proong and protective

coating.

During execution of the works, the

contractor was injured with rotating

ying object from the broken stone

cup disc assembly striking his

lower jaw whilst conducting grind-

ing work on the concrete founda-

tion. The injured contractor was

initially treated at Das Hospital and

then transferred to hospital in AbuDhabi for further treatment.

grinding machine


22/27

42 43

The key activity was to de-spade the

Sour and Liquid Flare and Blow-down

systems, which during streaming

was isolated from Train 1. After de-

spading, the system isolation valves

were to be opened thus making the

system operational, and thereby link-

ing the are systems of Trains 1 and

2. The de- spading was being carried

out on a platform 10 metres long and

accessed via an 8 metres high caged

vertical ladder.

At approximately 05:25 the next day

(Day 31 of the overhaul), a Supervi-

sor and Fitter from the assigned con-

tractor began to de-bolt the spade on

the verge of breaking containment,

they donned their breathing apparatus

while a Safety Assistant and another

Fitter were present without BA. A BA

Technician was also located at ground

level and operated the BA line.

At the same time, and in contravention

of the Operations Procedure, the are

valves were opened whilst the de-

spading activities were taking place.

This resulted in sour gas from Train 1

being admitted to the Train 2 system,

up to the crossover at the de-spading

location.

3.16. H2S Gas release leading to fatality from height


Immediate Causes

Release of high concentration of toxic H2S gas: Acid gas at low pres-

sure from Train 1 Sulphur Plant containing a high concentration of H2S

was released during de-spading activities. The release was a result ofthe decision by ADGAS Night Shift Operations Coordinator to open the

isolation valves before the completion of de-spading activities.

Access ladder De-spading activities on Platform 10 metresabove ground

At the start of the night shift of 21st November 2008, day 30 of the major over-

haul of LNG Train 2, the Maintenance and Operations Teams were preparing

for the last shift of mechanical work and including some hot work, after which

activities related to re-streaming the train for gas-in, was to commence.

This particular incident was thoroughly investigated and the Board of

Enquiry identied that the accident was a result of multi causes and cat-

egorised as follows:

• Immediate cause

• Root causes

• Indirect contributory causes

The BA Technician (at ground level)

smelled gas and observed that one

of the Fitters and the Safety Assist-

ant had started to descend the caged

ladder and at a point of about half-

way down the Fitter suddenly fell to

the ground at the base of the ladder,

immediately followed by the Safety

Assistant, striking his head fatally

against the ladder cage during the fall

and landing atop the Fitter.

The BA Technician at ground level

was initially overcome by H2S before

recovering enough to make his es-

cape. Another Fitter located close-bywas also overcome by H2S and col-

lapsed unconscious.

At 0531, gas alarms were activated by

the escaping gas and then the emer-

gency alarm was raised, Yellow A

alert was instituted, Fire and Rescue

crews mobilised, the deceased Safety

Assistant, injured Fitter (broken leg)

and the two individuals overcome with

H2S where taken to Das Clinic. The

accident site was cordoned off and

the Incident Command Centre (Das)

and Crisis Management Centre (Abu

Dhabi HQ) were manned until the ‘all

clear’ was declared at 10:08.


23/27

44 45

Inadequate wearing of PPE:

Only two of the four contractors

present at the elevated platform

were wearing BA, while the

other two were exposed to high

concentrations of H2S.

Falling from height: The two

contractors exposed to high

concentrations of H2S lost con-

sciousness whilst descending

the caged ladder. This resulted

in them falling, which caused

one fatality and one serious in-

jury.

Non adherence to Operating Procedure: The re-commissioning of the

Flare system was not carried out by the ADGAS Night Shift Operations

Coordinator as per the prescribed procedure.

Non adherence to Safety Procedures: The Contractor Supervisor did

not ensure that the area was prepared as per the requirements of the

PTW.

Lack of hazard awareness: The ADGAS Night Shift Operations Coordi-

nator was not aware that Train 1 Sulphur Plant was not operational and

as a result 15 tons of gas, containing high concentrations of H2S was

being continuously ared.

Non adherence to PTW: The ADGAS Senior Operator (as instructed

by the ADGAS Night Shift Operations Coordinator) signed the PTW al-

lowing work to commence without checking the worksite to ensure site

readiness as per PTW requirements.

Root Causes

1. Review and amend Operational Procedures to address associated

hazards when de-spading activities are taking place.

2. Review and amend the PTW process / procedure so that it is the

Performing Authority that raises the PTW and collates the associated at-

tachments such as the Task Risk Assessment and not Operations as is

the case. The PTW close-out process must also be improved to ensure

that all PTW’s are closed out prior to conducting ‘gas-in’.

3. Revise roles and responsibilities during Turnaround activities.

4. Review and improve H2S Hazard Awareness training.

5. Conduct competency assessment for safety technicians with BA

standby role, including his responsibilities.

6. Key critical operations such as de and re-streaming the process train

to be conducted by ADGAS Maintenance personnel.

7. Conduct a comprehensive review of the Emergency Response Proce-

dure to clearly dene roles and responsibilities.

8. Develop adequate safety training and site hazard awareness pro-

grammes to ensure safety compliance of Contractor safety personnel

prior to site work. Training objectives should be set to ensure that the

training delivers sufcient knowledge transfer to full the training needs

of the organisation and the individual.

Lessons Learned

Lack of H2S awareness: It was

evident from the behaviour of all

Contractor Labour personnel in-

cluding the Safety Assistant that

the potential consequence of H2S

inhalation was not well known to

them.

Pressure to meet Turnaround

completion target: There was

a perceived sense of urgency to

complete the job quickly as ‘gas-in’

had been planned for the next shift

and there appeared to be pressure

on the Operations nightshift crew

to complete all necessary activi-

ties.

Inadequate work practice: Dur-

ing the investigation, it became ev-

ident that this particular contractor

had been the subject of a number

of Near Miss Reports (700), PTW

violations (over 100).

Indirect Contributory Causes


24/27

46 47

Root Cause

On the 2nd March 2009, two Hot

Work Permits were issued to the

Electrical Maintenance Depart-

ment (Electrical Technician and

Electrical Trainee) to carryout rou-

tine maintenance on Substation

6, 3.3 kV switchgear. After part of

the work was completed the per-

mit was extended up to the 10th

March 2009.

Following completion of the rst

motor feeder, the switchgear was

tested but the 110V AC auxiliary

test supply MCB tripped. The Elec-

trical Technician assumed the trip

was due to an inrush of current

and repeated the test several more

times until they noticed smoke

emitting from the switchboard

cubicle, which consequently acti-

vated the smoke detection system.

The testing was halted and the

technician began trouble shooting

along with the Electrical Supervi-

sor, who had at this point, arrived

at the scene.

By mistake, the Electrical Techni-

cian connected the multi-pin plug

in reverse orientation (this was lat-

er identied as a design fault). This

caused a short circuit in the control

wiring, leading to a ow of heavy

current and ultimately burning the

PVC wires and generating a lot of

smoke/soot.

vestigation, the technician reAs

3.17. Severe injury to multiple workers due to Electrical Flash

Overview of Incident Inadequate competence: TheElectrical Supervisor and Elec-

trical Technician were not fully

aware of the bus bar arrange-

ments, which in turn led them to

believe that the bus bar was iso-

lated. Furthermore, they did not

fully realise the consequences

when smoke/soot is generated in

live switchgear.

Switchboard cubical after the the flash

reSwitchboard cubical before flash

re

Effect of the flash re on bus bars

Note:

The Electrical Supervisor and Electrical Technician were given skin

grafting surgery after 48Hours of being admitted to hospital following

sterilisation. The Supervisor was discharged from hospital some 21 days

later. The Technician was discharged after 23 days in hospital. Both re-quired a period of time to attend hospital on a weekly basis for further

consultation treatment.


25/27

48 49

Inadequate design: The control

multi-pin socket in the switchgear

was found to have a design weak-

ness, which caused the unintend-

ed reverse connection in the rst

instance.

Non adherence to safety warn-

ing sign: The Electrical Supervi-

sor and Electrical Technician both

ignored warning signs and opened

the protective barriers/panels,

thereby exposing themselves di-

rectly to the live bus bars.

Lack of hazard awareness: Non

adherence to Electrical and PTW

procedures: These procedures

were not strictly followed. The work

activity was extended out-with the

limit of the PTW without evaluating

the associated risk and communi-

cating this to the concerned Engi-

neer.

1. Review the design of the switchgear and replace with new, safer de-

sign. ADGAS procurement procedures should ensure that adequately

manufactured equipment is sourced, supplied and installed by ade-

quately competent contractors.

2. Fix new warning signs to all removable plates with clear message in

Arabic and English. Work procedures should also clearly warn of the

hazards of removing such panels.

3. Competency of all Electrical Technicians/Supervisors to be re-evalu-

ated. Those supervising work must have the same or higher kV authori-

sation.

4. Review and revise electrical procedures to ensure that they are ap-

propriate.

5. Ensure that toolbox talks are job specic and effectively communi-

cated to all concerned at the start of each shift.

Contributory Causes

Lessons Learned

As you have seen, from the various examples provided in this booklet,

our work activities have resulted in a number of incidents occurring over

the years we have been in operation, all with similar root and contribu-

tory causes.

We now need to ask ourselves, why? Why is it that an incident that oc-

curred last year had similar root and contributory causes to an incident

that occurred 12 years ago for example? Firstly, let’s identify the top six

failings or root causes from the incidents we have highlighted in this

booklet and discuss each one a little more detail. They are:

• Inadequate training

• Inadequate work practices• Non adherence to ADGAS Procedures

• Lack of hazard awareness/Risk Underestimated

• Inadequate work planning including Toolbox Talks

• Inadequate supervision.

4. Learning from our past mistakes

Despite great effort being placed

upon the identication and deliv-

ery of various training programs,

inadequate training is often iden-

tied as either a root or contribu-

tory cause in any incident. How-

ever, many training events fail at

the rst stage by failing to identify

appropriate learning objectives.

Whether the training is conducted

by traditional classroom methods,e- learning or on-the-job-training,

learning objectives must be spe-

cic and measurable as they pro-

vide the means on which to base

the course assessment, which in

turn, helps to determine the ef-

fectiveness of the training and as-

sure that the desired learning out-

come’s, are consistently achieved.

A properly trained and competent

workforce is the rst step in assur-

ing safe operations in any eld but

the word ‘competent’ is often mis-

understood. Competence is the

ability to undertake responsibilities

and to perform activities to a rec-

ognised standard on a regular ba-

sis. Competence is a combination

of practical and thinking skills, ex-

perience and knowledge, and alsoincludes a willingness to undertake

work activities in accordance with

standards, rules and procedures.


26/27

50 51

Inadequate work practices can

be attributed to a lack of ad-

equate training or quite often

due to personnel circumventing

the proper processes or proce-

dures, or indeed, complacency.

We have already addressed the

subject of Training above, so

how do we overcome the prob-

lem of people taking short-cuts

and removing complacency

from the workplace? Education

and continual learning is the

answer, coupled with changing

people’s hearts and minds to

embrace a safety behavioural

attitude.

Our systems and processes are

comprehensive and have been

developed and implemented for

your protection and to guide you

in the correct work practices.

Remember also that a PTW

does not guarantee the job is

safe – it is the attitude of the

individuals concerned that pro-

vide this. As you have seen from reading

this booklet, falling from height

have resulted in many of our

friends and colleagues suffer-

ing major injuries and in some

cases, fatalities have resulted,

which can be easily attributed to

inadequate work practices and

complacency, thinking that it

won’t happen to me but sooner

or later luck runs out.

If people are properly trained

and deemed competent for the

work that they are employed to

do then the non adherence to

ADGAS Procedures is a clear

and blatant disregard to safe

working practices. ADGAS has

dedicated a great deal of ef-

fort over the years in develop-

ing safe systems of work, which

meet international standards,

are continuously reviewed and

updated to reect our continu-

ous learning’s from industry.

ADGAS have also been at the

forefront in implementing safety

initiatives to further improve the

working environment for staff

and contractors alike. In return,

ADGAS expects each and eve-

ry individual to adhere to its poli-

cies and procedures, and adopt

a safety behavioural approach

to the work they do.

Inadequate work planning isalso an area that appears all

too often in our incident reports,

particularly when plant upsets

necessitate prompt actions to

rectify faults and this is often

used as an excuse when things

go wrong. Our systems and

processes are designed to ca-

ter for the unexpected and if you

follow the associated rules and

guidelines you will complete the

job safely.

Pre-job safety meetings or Tool-

box Talks, as they are com-

monly referred to are part of

the planning process and full a

crucial function in ensuring any

task is conducted safely. They

are mandatory requirement for

any work on Das and must be

attended by all persons involved

in the task, and must cover the

specic task at hand. It is equal-

ly important that the supervisor

/ foreman who delivers the tool

box talks is adequately trained

to effectively communicate haz-

ard knowledge and the associ-

ated risk.

A Lack of hazard awareness/

Risk Underestimated is quite

common ndings during in-

cident investigations even

amongst experienced person-

nel. The ability to be aware of

potential hazards and effec-tively assess the risks is directly

related to proper training and

competency.

Competence is a combination

of practical and thinking skills,

experience and knowledge, and

also includes a willingness to

undertake work activities in ac-

cordance with standards, rules

and procedures.

Lastly and most importantly

whether you are a Manager,

Supervisor, Foreman or indeed

the senior person in charge

of a work party, you have cer-

tain responsibilities in provid-

ing leadership and supervision

functions that require good

communication skills to guide

and advice, thus ensuring that

the work is completed to the

required standards. Failure to

achieve this will result in inad-

equate supervision, which al-

ways leads to dangerous situa-

tions arising at the worksite.

Working safely must be para-

mount to everything we do


27/27

Not just a business priority, but rather a high human value

Safety at the workplace is a mandatory business priority for everyorganization, as it ensures the integrity of assets and optimized

hassle-free performance.

For ADGAS, safety is one of the highest human values. It involves the

very life of our most valued asset: our people.

This booklet investigates 17 past incidents to pinpoint their root caus-

es and provide our staff with insights to how they should assimilate

these lessons and enhance their immunity against similar mishaps.

S a f e t y

Documents

Learning plan from past incidents