SAFETY PERFORMANCE INDICATORS – 2013 DATA Fatal …

SAFETY PERFORMANCE INDICATORS – 2013 DATAFatal incidents reportReport No. 2013sf (July 2014)

OGP DATA SERIES

I n t e r n a t i o n a l A s s o c i a t i o n o f O i l & G a s P r o d u c e r s

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International Association of Oil & Gas Producers

©OGP

Revision history

Version Date Amendments

1.1 August 2014 Addition of South and Central America data

1.0 July 2014 First issued

DisclaimerWhilst every effort has been made to ensure the accuracy of the information contained in this publication, neither OGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.

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Safety performance indicators–2013 data Fatal incidents report

Report No: 2013sf

July 2014

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Safety performance indicators 2013 data–Fatal incidents reports

© OGP

Contents

Africa 2

Asia/Australsia 7

Europe 12

FSU 15

Middle East 19

North America 23

South and Central America 28

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Africa

Onshore

Algeria Production Jan 16 2013Number of deaths: 9 Category: Assault or Violent act Activity: Production Operations

Age: Unknown Employer: Company Occupation: UnknownAge: Unknown Employer: Company Occupation: UnknownAge: Unknown Employer: Company Occupation: UnknownAge: Unknown Employer: Company Occupation: UnknownAge: Unknown Employer: Company Occupation: UnknownAge: Unknown Employer: Company Occupation: UnknownAge: Unknown Employer: Company Occupation: UnknownAge: Unknown Employer: Company Occupation: UnknownAge: Unknown Employer: Company Occupation: Unknown

Narrative:

Terror attack on In Amenas.

What went wrong:

The sum of security measures failed to protect people at the site from the attack on In Amenas on 16th January. Neither the Company nor the joint venture could have prevented the attack, but there is reason to question the extent of their reliance on Algerian military protection.

Corrective actions and recommendations:

19 recommendations in 5 areas Security at In Amenas. Improve the joint venture’s ability to detect, delay and stop potential attacks. Organisation and capabilities: Develop a clearly defined ambition for the company’s security capability – strengthen security organisation. Risk management systems: Develop a dynamic, fit-for-purpose and action oriented security risk management system. Emergency preparedness and response: Coordinate and standardise emergency response planning consistent with the principles in the Incident command system (ICS). Collaboration and networks: Broaden and deepen cooperation with relevant government agencies and organisations, reinforce networks and institutional relationships.

Causal factors:

• People (acts): Following Procedures: Violation unintentional (by individual or group)• Process (conditions): Protective Systems: Inadequate/defective guards or protective barriers

Algeria Production Jan 1 2013Number of deaths: 1 Category: Other Activity: Unspecified–other

Age: Unknown Employer: Contractor Occupation: Unknown

Narrative:

Details not available.

Causal factors:

No causal factors allocated.

Gabon Drilling Nov 18 2013Number of deaths: 1 Category: Caught In, Under or Between Activity: Lifting, Crane, Rigging, Deck operations

Age: 30 Employer: Contractor Occupation: Manual Labourer

Narrative:

Contractor helper working at the shore based pipe yard was fatally injured during a lifting operation when he got caught between 36″ tubular stacked before transportation.

What went wrong:

Inadequate Standards, Deviation from Safe Practices

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Safety performance indicators 2013 data–Fatal incidents report

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Work planning/Job safety analysis, method statement and toolbox talk which must be physically undertaken/reviewed at the work site to identify potential shortcomings in the planned work scope. Line supervisor to challenge unsafe behaviour and intervene where required.

Causal factors:

• People (acts): Following Procedures: Improper position (in the line of fire)• People (acts): Following Procedures: Improper lifting or loading• People (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgment• Process (conditions): Organisational: Inadequate work standards/procedures• Process (conditions): Organisational: Inadequate supervision

Nigeria Unspecified Oct 11 2013Number of deaths: 1 Category: Struck by Activity: Maintenance, Inspection, Testion

Age: Unknown Employer: Company Occupation: Maintenance, Craftsman

Narrative:

Details pending.

What went wrong:

Details pending.


Details pending.

Causal factors:

No causal factor allocated.

Tanzania Unspecified Dec 7 2013Number of deaths: 1 Category: Struck by Activity: Transport–Land

Age: 36 Employer: Contractor Occupation: Foreman, Supervisor

Narrative:

On the morning of Saturday 7th December 2013, a contract maintenance supervisor was undertaking scheduled general maintenance of the compound accommodation. The compound’s generator failed to start. Unable to fix the generator, the IP got a lift on the back of a motorcycle, driven by a friend, to get a specialist tool, despite a company-provided vehicle being available. The motorcycle subsequently collided with a third party vehicle and the IP died of the injuries he sustained.

What went wrong:

If the IP had been travelling in a 4 wheel vehicle, it is highly unlikely that his injuries would have been severe. Company standards prohibited the use of motorcycles except in exceptional circumstances. However, locally there were no clear instructions regarding the use of motorcycles for work.


Contractual obligations to meet company standards and company expectations on safety to be reinforced with third party contractors. More rigorous Management of Change assessments of contracts. Review arrangements for emergency medical treatment in remote locations.

Causal factors:

• People (acts): Inattention/Lack of Awereness: Improper decision making or lack of judgement• Process (conditions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate supervision

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Offshore

Angola Drilling Jan 9 2013Number of deaths: 1 Category: Pressure release Activity: Drilling, Workover, Well Services

Age: 40 Employer: Contractor Occupation: Drilling/Well Servicing Operator

Narrative:

During an IBOP (Internal Blow Out Preventer) high pressure test, the HP pipe of HP water pump ruptured at a welded joint and fatally wounded the IP.

What went wrong:

Work instruction for a High Pressure Test not followed (no communication devices, no so secure connection with whip chain devices.) Work instruction too general and outdated. Permit To Work and Job Safety Analysis not followed. Test equipment not adapted (High Pressure/High Volume water test pump for High Pressure/Low Volume test). Inadequate engineering design and deficiency of inspection program (High Pressure piping not certified and rating unknown). Management of personnel.


High pressure test to be performed under Permit To Work. Dedicated High pressure test work instruction. Include High Pressure pipes in preventive maintenance system, maximum working pressure to be indicated.

Causal factors:

• People (acts): Use of protective methods: Equipment or materials not secured• Process (conditions): Protective Systems: Inadequate/defective warning systems/safety devices• Process (conditions): Tools, Equipment, Materials & Products: Inadequate/defective tools/equipment/materials/

product• Process (conditions): Tools, Equipment, Materials & Products: Inadequate maintenance/inspection/testing• Process (conditions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate communication• Process (conditions): Organisational: Inadequate supervision

Angola Drilling Jul 1 2013Number of deaths: 1 Category: Water related, Drowning Activity: Drilling, Workover, Well Services


Narrative:

While pre-loading the rig suffered a sudden and violent tilting. As the rig shifted it hit an adjacent platform and suffered further leg damage, which resulted in the rig eventually capsizing and sinking the following day. Resulted in one contractor fatality, one contractor DAFW, and four contractor recordable injuries.

What went wrong:

During pre-loading operations, the maximum specified air gap was exceeded and the single-leg pre-loading procedure was not followed. The starboard leg punched through causing the rig to suddenly list. Planned response vessel was not yet on location. The rig worker who was lost over board made the decision to enter the water without donning a personal floatation device.


Investigation results pending.

Causal factors:


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Cameroun Drilling Nov 9 2013Number of deaths: 1 Category: Struck by Activity: Drilling, Workover, Well Services


Narrative:

On the 9th of November 2013 at 13:00 a fatal incident occurred on board the MODU carrying out drilling activities. The drilling crew was nippling up a BOP and in the process of installing the choke line Coflex hose on a production platform. The choke line was lifted using a tugger line and a flatbraided sling to allow installation of scaffolding around the BOP. The first attempt at installing the choke line was unsuccessful as the tugger was caught in the rig structure. While the sling was shortened, the scaffolders returned to work. The choke line was again lifted towards its position when the sling parted and the choke line fell to the platform floor hitting one of the two scaffolders. All operations were stopped and the injured scaffolder was attended to by the rig doctor. A medevac was immediately arranged and the injured scaffolder was transported to hospital where the doctor confirmed the fatality.

What went wrong:

Immediate Causes: • The sling used to lift the coflex hose and choke line parted under the load. • The scaffolders were working below the load.Root Causes: The incident has been investigated using Tripod Beta methodology. There were twenty underlying (root) causes identified and the most relevant factors are regarded to be: • Contractor unable of assigning competent and motivated personnel in key positions leading to poor supervision of

operations; insufficient equipment maintenance and testing; and lack of compliance to established procedures. • Safety Systems are managed as an administrative tool and not as an operational one, leading to ineffective

application of e.g. Permit To Work; intervention culture insufficiently implemented; and specific risks not assessed for rig cantilever position.

• Contract terms insufficient to enforce HSSE compliance.


The corrective actions address all root causes identified. The most significant ones are: • Personnel leading the work execution process–e.g. PTW, SJA, TBT and Isolations, must demonstrate competence • Improve visible Leadership of Supervisors & Management and encourage Time Out For Safety • Improve competence through refresher training of Banksmen & Slinger’s, including supervisors • Improve lifting equipment storage, maintenance and certification • Conduct “Hazard Hunt” on lifting equipment • Conduct Work Permit Audit & training• Implement revised design for upper Kill and Choke lines, thus reducing needs for lifting• Strengthen Contractual terms and conditions on HSSE management

Causal factors:

• People (acts): Following Procedures: Improper lifting or loading• People (acts): Use of Protective Methods: Failue to warn of hazard• People (acts): Inattention/Lack of Awereness: Improper decision making or lack of judgement• Process (conditions): Tools, Equipment, Materials & Products: Inadequate maintenance/inspection/testing• Process (conditions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate hazard identification or risk assessment• Process (conditions): Organisational: Inadequate supervision• Procees (conditions): Organisational: Poor leadership/organisational culture• Process (conditions): Organisational: Failure to report/learn from events

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Nigeria Production May 26 2013Number of deaths: 11 Category: Water related, Drowning Activity: Transport–Water, Inc. Marine activity

Age: Unknown Employer: Contractor Occupation: UnknownAge: Unknown Employer: Contractor Occupation: UnknownAge: Unknown Employer: Contractor Occupation: UnknownAge: Unknown Employer: Contractor Occupation: UnknownAge: Unknown Employer: Contractor Occupation: UnknownAge: Unknown Employer: Contractor Occupation: UnknownAge: Unknown Employer: Contractor Occupation: UnknownAge: Unknown Employer: Contractor Occupation: UnknownAge: Unknown Employer: Contractor Occupation: UnknownAge: Unknown Employer: Contractor Occupation: UnknownAge: Unknown Employer: Contractor Occupation: Unknown

Narrative:

Tug was performing static tow operations to an export tanker that was loading. Tug declared an emergency on board and shortly after all contact with the tug was lost. It was later confirm that the tug had capsized.

What went wrong:

Still under investigation.


Pending investigation.

Causal factors:

• People (acts): USe of Protective Methods: Personal Protective Equipment not used or used improperly• People (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgement• Process (conditions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate work standards/procedures• Process (conditions): Organisational: Inadequate communication• Process (conditions): Organisational: Inadequate supervision

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Asia/Australasia

Onshore

China Construction May 25 2013Number of deaths: 1 Category: Struck by Activity: Construction, Commissioning, Decommissioning

Age: 32 Employer: Contractor Occupation: Engineer, Scientist, Technician

Narrative:

On the 25th of May 2013 at 9:00 am, at a land-based plant which was under construction, workers were preparing the pigging operation of a gas pipeline’s onshore section which was 1.8 km length. At 10:00 am, the pigging was plugging at the collecting pig area, and the pig receiver’s quick-opening closure has been opened during the whole operation. An employee worker was trying to visually check where the pig was through the pigger receiver’s opened closure. At this time, the pigger flew out and hit the IP’s head, stopping at a position 70 metres away from the pig receiver. The IP did not survive in the hospital.

What went wrong:

The worker did not obey the pigging procedure to operate and had not properly closed the closure of the pig receiver during the operation.


Initiated a Training Program for employee and contractor focus on strictly followed the producer to operate. Review field organisational arrangements. Implement more structured management of change process, including covering organisational changes at Ventures and Company level.

Causal factors:

• People (acts): Following Procedures: Improper position (in the line of fire)• People (acts): Use of Tools, Equipment, Materials and Products: Improper use/position of tools/equipment/

materials/products• People (acts): Use of Tools, Equipment, Materials and Products: Servicing of energized equipment/inadequate

energy isolation• People (acts): Use of Protective Methods: Inadequate use of safety systems• People (acts): Use of Protective Methods: Equipment or materials not secured• People (acts): Use of Protective Methods: Disabled or removed guards, warning systems or safety devices• People (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgment• Process (consitions): Protective Systems: Inadequate/defective warning systems/safety devices• Process (conditions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate hazard identification or risk assessment• Process (conditions): Organisational: Inadequate communication• Process (conditions): Organisational: Inadequate supervision• Process (conditions): Organisational: Poor leadership/organisational culture

Malaysia Construction May 16 2013Number of deaths: 1 Category: Struck by Activity: Construction, Commissioning, Decommissioning

Age: unknwon Employer: Contractor Occupation: Engineer, Scientist, Technician

Narrative:

Text pending.

What went wrong:

Text pending.


Text pending.

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Causal factors:


Pakistan Production Mar 17 2013Number of deaths: 1 Category: Explosions or Burns Activity: Transport–Land

Age: 22 Employer: Contractor Occupation: Transportation Operator

Narrative:

Condensate tanker (hired vehicle and driver) carrying approx. 30 000 litres of condensate had a front tyre burst, tipped over and caught fire on the Banu-Kohat road while en route to the Crude Decanting Facility. The fire was successfully extinguished by the Company fire fighting team which had reached the location with a team from the Company’s joint venture partner. Tanker driver sustained serious burn injuries and after necessary initial treatment in hospital he was brought to a burn centre in Islamabad. Unfortunately three weeks later the tanker driver passed away in the hospital.

What went wrong:

Front tyre burst.


• Drivers should perform proper mechanical checks daily/as and when required• Loading crew should properly inspect tankers as per prescribed form• Transport contractor has to ensure 3rd parties/sub-contractors are complying with HSE requirements;• All tanker drivers must be fully trained in vehicle inspection and driving safety• Proper HAZMAT Road Transportation Management System has to be implemented by affected Company

subsidiaries.

Causal factors:

• People (acts): Use of Protective Methods: Equipment or materials not secured• Process (conditions): Tools, Equipment, Materials & Products: Inadequate maintenance/inspection/testing• Process (conditions): Organisational: Inadequate training/competence

Papua New Guinea Construction Jul 9 2013Number of deaths: 1 Category: Caught In, Under or Between Activity: Construction, Commissioning, Decommissioning

Age: Unknown Employer: Contractor Occupation: Other

Narrative:

The IP was one of eight experienced crew members engaged in the pipe tie-in activity. Five personnel were in the trench box supporting fit-up. The crew recognized that the hydraulic pipe clamp was damaged. The free pipe being suspended by the sidebooms then moved, causing the damaged clamp to be placed under strain which then released the pipe. The free pipe crushed the IP against the trench box wall. The IP was taken to the clinic and stabilized, received x-rays, and was sedated prior to suffering two cardiac events and passing away.

What went wrong:

Worker was in line of fire of the free pipe while inside the trench box. Sideboom movement was not isolated allowing energy to be introduced into the free pipe. Crew did not recognise the change in working conditions and the introduction of new hazards.


Always consider crushing points in your JSA/JHA. Consider all potential energy sources and the potential impact if they are not controlled electrical, mechanical, pressure, gravitational, etc.). Stop and reassess the work when conditions change to address new hazards which may be introduced.

Causal factors:

• People (acts): Following Procedures: Improper position (in the line of fire)• People (acts): Use of Tools, Equipment, Materials and Products: Servicing of energized equipment/inadequate

energy isolation

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Offshore

China Production April 27 2013Number of deaths: 2 Category: Explosions or Burns Activity: Maintenance, Inspections, Testing

Age: 47 Employer: Contractor Occupation: Maintenance, CraftsmanAge: 44 Employer: Contractor Occupation: Maintenance, Craftsman

Narrative:

There was a plan to do a maintenance operation by coating the roofs of the crude oil tanks on a production platform with epoxy resin and Fiberglass because serious corrosion had been found on the roofs during a patrol inspection. The oil tanks were emptied before the day the work was planned. On April 27th, 7:30 am, according to the construction scheme, the contractor workers got permission for work and had a safety meeting before the operation. At 8:12 am, an oil tank exploded when a worker had just reached the top of the oil tank. The accident caused two deaths and one injury.

What went wrong:

1. The ferrous sulphide self-ignition ignited the combustible gas mixture inside the oil tank, a flash explosion occurred.

2. Electrostatic discharge ignited the combustible gas mixture, a steam explosion occurred.


1. To strengthen the antistatic field personnel to use the management of labour insurance supplies, in the case of test methods and standards are not clear, should be forced to replace system, ensure the use of anti-static overalls and tools effectively.

2. To strengthen and anti-static, and ferrous sulfide knowledge training, propaganda and education. Against static electricity and lack of awareness of ferrous sulfide, accidents related unit shall immediately organise employee training, strengthen the professional knowledge and skill training, to ensure the safety of site work.

3. Norms and to strengthen the tank (especially with longer) detection and cleaning. For related equipment in strict accordance with industry standards for testing and evaluation, according to the evaluation results, formulate corresponding measures and equipment management system, and ensure the compliance, security field integrity and intrinsically safe equipment and facilities.

4. To strengthen risk analysis before the operation for the storage tank, especially for storage oil tank sulfur, to pay attention to the risk analysis of ferrous sulfide self-ignition and control measures, to improve the system of management, added the corresponding management requirements.

5. To strengthen the management of personnel qualifications. Timely replacement training for personnel arrangements, to ensure compliance.

6. After completion of elimination danger for Platform B, in the process of tissue repair and restore production, we should consider to increase the inert gas protection device, ensure that the nature of the crude oil storage tank safety.

7. Accident unit should extrapolate, full screen similar crude oil storage tank, for screening out hidden trouble organizing special projects, to prevent major workplace malignant accidents.

Causal factors:

• People (acts): Following Procedures: Violation unintentional (by individual or group)• People (acts): Use of Tools, Equipment, Materials and Products: Servicing of energized equipment/inadequate

energy isolation• People (acts): Use of Protective Methods: Personal Protective Equipment not used or used improperly• People (acts): Use of Protective Methods: Equipment or materials not secured• People (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgment• Process (conditions): Protective Systems: Inadequate/defective guards or protective barriers• Process (conditions): Protective Systems: Inadequate/defective Personal Protective Equipment• Process (conditions): Tools, Equipment, Materials & Products: Inadequate/defective tools/equipment/materials/

products

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• Process (conditions): Work Place Hazards: Hazardous atmosphere (explosive/toxic/asphyxiant)• Process (conditions): Organisational: Inadequate hazard identification or risk assessment• Process (conditions): Organisational: Poor leadership/organisational culture

Indonesia Drilling Nov 14 2013Number of deaths: 1 Category: Pressure Release Activity: Drilling, Workover, Well Services


Narrative:

The ongoing operation was bleed off well pressure (SICP=700 psi / SITP=Unknown). Killing line had been installed on X-tree by Day-Shift crews. The victim, with other co-worker (Night-Shift crew), slowly opened the crown valve using 24″ pipe wrench since no wheel on the valve. Suddenly, the XO (cross over) connected from the X-tree cap to 2″ hose came free from the cap and hit the victim’s face. As a result he fell down on his back and the back of his head hit the grating deck. His co-worker, who was standing behind him, also fell down close to him without any injury. The tool pusher came to the site and shut the well in while he called the Emergency Response Team from the barge to bring up the stretcher. Immediately, the victim was brought down to the clinic, and then to the hospital by chopper. The doctor declared that the victim passed away at 09.55 am, ten minutes after arriving at hospital.

What went wrong:

1. X-tree has been installed for approximately 30 years without any maintenance and no preparation when the well was selected for well intervention.

2. Crews could not read tubing and casing pressure due to no pressure gauge having been installed. Casing pressure could be read out only from manifold.

3. The crew installed the killing line without proper check X-tree cap box thread condition. 4. The victim used 24″ pipe wrench to open the crown valve due to having no wheel on crown valve.5. The position of victim was very close to the installed killing line. 6. No safety chain installed between X-tree and killing line. 7. No pressure test after connecting the line.8. SIMOP (simultaneous operations) procedure (Well Hand Over Form) is not well implemented.


1. Task Risk Assessment level 2 is mandatory requirement for Bleed Off Pressure and Kill Well Job. 2. Pressure test is mandatory required to bleed off/kill well job and set packer job similar to stimulation, gravel pack,

TCP, nitrogen job, etc. which to stated in revised SOP. 3. Revise the existing SOP-Bleed Off Pressure and Kill Well Job. with adding :• Install safety chain to prevent the hose move uncontrolled due to hose and connection failure. -

– Secure the killing line position to avoid worker having direct expose to the line. 4. BU must provide standard X-tree prior to do well intervention to avoid any potential hazard to the well

intervention crew. 5. Re-socialize SIMOP Procedure (Well Hand Over) implementation. 6. Perform routine X-tree maintenance.7. Re-vitalize STOP and BBS program, especially to emphasise awareness of behaviour related to “Position of

People”.

Causal Factors:


materials/products• People (acts): Use of Protective Methods: Equipment or materials not secured• People (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgment• Process (conditions): Protective Systems: Inadequate/defective guards or protective barriers• Process (conditions): Protective Systems: Inadequate/defective warning systems/safety devices• Process (conditions): Tools, Equipment, Materials & Products: Inadequate/defective tools/equipment/materials/

products

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Myanmar Drilling Jun 30 2013Number of deaths: 1 Category: Water related, Drowning Activity: Drilling, Workover, Well Services

Age: 38 Employer: Contractor Occupation: Other

Narrative:

Mud logger was walking down the access ramp to the tender barge to check his instrumentation. At the end of the ramp, he fell off into the sea. Rescue boats were immediately searching, but the body was found two hours later.

Whate went wrong:

The Injury person jolted in position and caused the two crew to lose their balance and the IP fell forward of the end in between the Injury person and the Company’s contractor. He was next seen floating face down in the water motionless.


1. Risk assessment for work place and review all poor design to prevent re-occurrence of incident. 2. Incident sharing for all employee. 3. Pre-job meeting. 4. Provide training and competency.5. Redesign poor equipment.

Causal Factors:

• People (acts): Following Procedures: Work or motion at improper speed• People (acts): Following Procedures: Improper lifting or loading• People (acts): Use of Tools, Equipment, Materials and Products: Improper use/position of tools/equipment/

materials/products• People (acts): Use of Protective Methods: Failure to warn of hazard• People (acts): Use of Protective Methods: Inadequate use of safety systems• People (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgment• Process (conditions): Protective Systems: Inadequate/defective guards or protective barriers• Process (conditions): Protective Systems: Inadequate/defective warning systems/safety devices• Process (conditions): Tools, Equipment, Materials & Products: Inadequate/defective tools/equipment/materials/

products • Process (conditons): Tools, Equipment, Materials & Products: Inadequate maintenance/inspection/testing• Process (conditions): Work Place Hazards: Storms or acts of nature• Process (condtions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate work standards/procedures• Process (conditions): Organisational: Inadequate hazard identification or risk assessment• Process (conditions): Organisational: Inadequate supervision• Process (conditions): Organisational: Poor leadership/organisational culture

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Europe

Onshore

Ireland Construction Sep 8 2013Number of deaths: 1 Category: Struck by Activity: Construction, Comissioning, Decommissioning


Narrative:

Details pending.

What went wrong:

Details pending.


Details pending.

Causal factors:


Romania Drilling Dec 6 2013Number of deaths: 1 Category: Caught in, Under or Between Activity: Drilling, Workover, Well Services

Age: Unknown Employer: Company Occupation: Drilling/Well Servicing Operator

Narrative:

During the positioning of a workover rig truck, an employee was fatally crushed between a container and the rig truck when the truck moved suddenly and unexpectedly. It remains unknown why the victim was between the unit and the tank at the time.

What went wrong:

• The design of the workover unit, without interlocks, permits the unit to be driven forwards from the driller s cabin.

• Absence of, or lapse of, training on the operation of workover pulling units in the last 3 years. • Inadequate (smooth, round) gravel was used for grading the site. • Well site dimension was below the minimum requirement of 900 square metres. • The Human Machine Interface (HMI)(dashboard), has not been maintained to a standard allowing safe and

correct use of the equipment. • Inadequate training and coaching on the identification of potential “Caught Between” hazards (pinch points).• Absence of sufficient risk assessment prior to, and during the job, to take account of inherent and dynamic risks.


• Develop a new standard on the “Specification and Verification of Mobile Workover Units” (or similar).• Design, test and implement a proper design of chocks for mobile WO/WI units. • Produce a comprehensive but user-friendly check list for mobile plant and equipment for safety critical operations

such as operation of the transfer block. • Develop or adapt and implement a “Situational Awareness Training” program for WO/WI staff (or across

the Company) program to include Risk awareness/assessment including inherent and dynamic risks, Unsafe conditions, Unsafe acts.

• Implement an Audit Program of applicable standards to WO/WI.

Causal Factors:

• Process (condtions): Tools, Equipment, Materials & Products: Inadequate design/specification/management of change

• Process (conditions): Work Place Hazards: Inadequate surfaces, floors, walkways or roads• Process (conditions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate hazard identification or risk assessment

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Romania Drilling May 16 2013Number of deaths: 1 Category: Exposure Noise, Chemical, Biological, Vibration Activity: Drilling, Workover, Well

Services

Age: Unknown Employer: Company Occupation: Drilling/Well Servicing Operator

Narrative:

An employee suffered a fatal heart attack caused by hypocalcaemia from coming into contact with highly concentrated hydrofluoric acid. A small amount of acid spilled on his arm when the cap of an almost empty drum came off while he was manually placing the drum onto a truck.

What went wrong:

Lack of training. Lack of hazard awareness. NO MSDS / Procedure. The “Storage, handling and transport of hazardous goods” procedure was not followed. Lack of oversight and leadership. Lack of end to end process for use of HF. Lack of an overall response plan for hazardous substances used by the Company clearly owned and linked to activities. Lack of change management when increasing the concentration of HF from 38% to 70% (38% is much less aggressive).

Corrective actions and recommendations

Ban the use of HF with concentration of 50% or more and develop alternatives for stimulation operations. Ensure a process in place for immediate removal of hazard substances from well location to proper storage area. Train and test the competency of individuals dealing with hazardous chemicals–including contractors and re-enforce hazardous substance standard and procedures. Provide the Clinic with a complete Hazardous Substance Register and quarterly update the register or whenever a new substance is introduced.Develop a cooperation with local hospitals with regard to medical response plan. Conduct an Independent Audit of all own and outsourced storage areas and perform a gap analysis of the areas to propose an improvement plan. Find an alternative for containment design, loading, offloading and transportation of hazardous substances based on a detailed risk assessment and bench mark against international best practices.

Causal Factors:

• People (acts): Following Procedures: Improper lifting or loading• People (acts): Use of Protective Methods: Personal Protective Equipment not used or used improperly• Process (conditions): Work Place Hazards: Hazardous atmosphere (explosive/toxic/asphyxiant)• Process (conditions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate hazard identification or risk assessment

Offshore

Netherlands Production Jun 14 2013Number of deaths: 2 Category: Pressure release Activity: Tmaintenance, Inspection, Testing

Age: Unknown Employer: Contractor Occupation: Maintenance, CraftsmanAge: Unknown Employer: Contractor Occupation: Maintenance, Craftsman

Narrative:

Casualties during leak test of gas cooler. During leak testing of gas cooler three people were injured.

What went wrong:

Searching for leaking tubes in gas cooler by means of utility air with uncontrolled pressure (max 14 barg). Gas cooler did not leak at all. At 4.5 barg tube plate built up greater than 40 T of force and travelled from cooler housing at explosive speed, crushing the two people between the tube plate and the cooler head, hanging some 1.5 metres in front of the cooler.


We have a list of recommendations and actions that is not yet published outside the company.

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Causal factors:

• People (acts): Following Procedures: Improper position (in the line of fire)• People (acts): Use of Protective Methods: Equipment or materials not secured• People (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgment• Process (conditions): Protective Systems: Inadequate/defective guards or protective barriers• Process (conditions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate hazard identification or risk assessment• Process (conditions): Organisational: Poor leadership/organisational culture

UK Production Aug 23 2013Number of deaths: 4 Category: Other Activity: Transport–Air

Age: 57 Employer: Contractor Occupation: UnknownAge: 46 Employer: Contractor Occupation: UnknownAge: 59 Employer: Contractor Occupation: UnknownAge: 45 Employer: Contractor Occupation: Unknown

Narrative:

A Super Puma AS 332 L2 helicopter G-WNSB (16 pax and 2 pilots) flying to Sumburgh airport for refuelling ditched in the sea 2 nautical miles from Sumburgh. Rescue operations started immediately after the loss of radio contact: 3 helicopters and 2 rescue boats were sent to the scene by coastguards and RAF. 4 fatalities, 14 survivors. AAIB investigation in progress.

What went wrong:

Investigation still in progress by AAIB.


Investigation still in progress by AAIB.

Causal factors:


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FSU

Onshore

Russia Exploration Mar 25 2013Number of deaths: 1 Category: Struck by Activity: Seismic / Survey Operations

Age: Unknown Employer: Contractor Occupation: Drilling/Well Servicing Operator

Narrative:

The incident occurred at 00:55 am while seismic operations were being carried out with explosives. During a well explosion a release of soil occurred. As a result, a frozen soil fragment flying from the well hit the door of an all-terrain vehicle, located 50 metres away from the well, and by ricochet hit the shooter’s back who was coming out of the rover. Around 01:30 am the injured unconscious shooter was brought to the field camp for medical care, at 02:10 am the worker died.

What went wrong:

• The casualty was in the danger zone.• Boundaries of the danger zone were not identified.• The wellhead was not inspected after shooting by the shooter.• Wires of precinct line were not cut at the wellhead immediately after the explosion.• The nature of the borehole destruction was not reported to the operator, the danger zone fencing signs were not

removed. • Inadequate depth of the charge.• The shooter did not escape the explosion in the cockpit of the rover.• Lack of control over the proper execution of works.• Lack of communication between the employees. The emergence of a potentially dangerous situation is not

reflected in the Safety Work instructions for the shooter.• Risk assessment was not done.


• Conduct unscheduled briefings on safety measures during explosive works by seismic crews.• Establish unscheduled inspection of knowledge of safety requirements during explosive works by a special

commission.• Revise safety instructions for Blasters and add all possible dangerous situations during blasting.• Set up requirements for all contractors who conduct seismic work: the organization of explosive activities has to

include measures to ensure and verify the correct laying depth of charges on each point of excitation.• Develop a Standard which defines the procedure for controlling the depth of the hole in the tab charge. Provide

depth control bookmark charge into the well.• Develop rational and ensure safety routines on the processes of charging and shooting; based on their design

performance and necessary production capacities.• Based on the results of the technical experiment oblige all contractors performing seismic survey to increase the

safety distance (danger zone) for shooting of wells.• Develop a regulatory document prescribing the procedure for monitoring the accountable executive for carrying

out blasting charge and shooting well.• Make changes to the internal documents regulating the blasting; ban wells shooting from open side (shooting to

be performed from vehicle cab).• Following an investigation issue an order to attract those responsible for the accident to justice in due course.• Develop a methodology for risk assessment and conduct a risk assessment.• Develop a Plan for emergency medical response and calling in air ambulance for accidents at work sites.

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Causal factors


materials/products• People (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgment• Process (conditions): Protective Systems: Inadequate security provisions or systems• Process (conditions): Organisational: Inadequate communication• Process (conditions): Organisational: Inadequate supervision

Russia Production Jul 12 2013Number of deaths: 1 Category: Struck by Activity: Transport - Land

Age: Unknown Employer: Company Occupation: Engineer, Scientist, Technician

Narrative:

At 6:48 am on July 12th 2013 a vehicle driven by a Contractor Driver based on the request left for commodity-material values pick up from the central warehouse. At 7:25 am. the driver stopped at the appointed place and took the Company employee in charge of wealth and continued to move along the route. At 9:20 am KAMAZ vehicle was being driven on the highway at a speed of 60 km/h and made a head-on collision with the left rear of the semi-trailer vehicle MAN, standing on the edge of the road. As a result of the accident, KAMAZ cab was crushed and an employee was clamped in the cabin. The employee, who was at the time of the accident in the KAMAZ sleeping compartment, died from his injuries at the scene. Medical aid was rendered to KAMAZ driver at the incident scene; third party driver was not injured. Contractor truck KAMAZ was not equipped with in-vehicle monitoring system (IVMS). Kamaz driver was wearing a seat belt.

What went wrong:

• KAMAZ was moving with irrelevant speed in relation to vehicle standing on the edge of the road, and the driver did not provide a continuous monitoring of the vehicle movement.

• Underestimation by the Contractor driver of unaccounted road risks.• Poor visibility due to counter exposure of sunlight.• The Company has no criteria for the selection of contractors for the provision of transport services.• Inadequate identification by the Driver of Hazards in the workplace and their risk levels.• Contractor management was not trained on road safety and safety driving, labour protection, First Aid and fire-

technical minimum.• Contractor driver was not properly trained. • Driver had lack of driving practice due to a rare performance of the driver works.


• Inform Company and Contractor personnel on the causes and circumstances of the accident• Conduct HSE Stand Downs with Company transportation personnel & Contractor drivers, stress on the

vigilance increase on the road, the choice of speed according to road and weather conditions, readiness to take actions to avoid collision of the vehicle in relation to other risks unaccounted risks on the roads.

• Provide a comprehensive review of all transport contractors for compliance to make vehicles ready for service (vehicles inspections and drivers medical check-ups) and for compliance with the requirements of Transportation Standard with issue of non-compliance notices. In case of violations send claim letters directly to counter-parties.

• Prohibit use of beds in all vehicles while driving.• Provide Defensive Driving Training for drivers on the basis of specialized training centres.• Develop criteria for admission of contractors to provide transportation services.• Oblige heads of the contracting companies to provide appropriate training of drivers.• Oblige contractor management to install In-vehicle monitoring system on all vehicles providing transportation for

Company.• Provide monthly monitoring of speeding, providing information on the violators and the measures taken.• Oblige Contractor management to provide and conduct pre-and-post-shift medical examinations of drivers by

licensed medical facility.

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• Contractor management to ensure drivers to have at least 3 years working experience for the operating vehicle type.

• Prohibit admission of Contractor drivers who have caused a fatal accident from providing transportation service for Company.

• Ensure provision and fulfilment of maintenance schedule, seasonal maintenance of vehicles (spring -winter).• Provide traineeship for drivers. • Ensure use of tested and approved by the state breathalysers (included in the state register of measuring

instruments) to conduct medical examinations.• Ensure development of regulations on labour protection for all occupations and types of work.

Causal factors:

People (acts): Following Procedures: Work or motion at improper speedPeople (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgmentProcess (conditions): Organisational: Inadequate training/competenceProcess (conditions): Organisational: Inadequate hazard identification or risk assessmentProcess (conditions): Organisational: Inadequate supervision

Russia Drilling Jan 5 2013Number of deaths: 1 Category: Caught In, Under or Between Activity: Drilling, Workover, Well Services


Narrative:

A crew performed well washing in the field. The vacuum unit AKN -10 came to site for pumping fluid from the gutter technological capacity, which was installed at the site with a 6° slope towards the gutter capacity, at a distance of 1.5 metres from the vessel. The driver did not apply the parking brake and set wheel chocks. When pumping liquids the driller stood on the landing between the vacuum unit and gutter capacity, watching it emptying. When filling the tank, the unit began spontaneously roll down the slope towards the gutter capacity. The driver ran into the cabin for an emergency stop unit. When he climbed into the cockpit, he felt the back of the car hitting an obstacle. He drove the car forward and put it on the hand brake, and then the driver ran back and saw the driller bent over and holding his stomach. The driver ran into the booth, the engineer reported the incident and called an ambulance, then returned to the driller. Crew members tried to resuscitate the driller. Ambulance arrived at 01:10 and the driller’s death was stated by the ambulance team.

What went wrong:

• Vacuum unit was installed on an unprepared site having an inclination. Handbrake was not activated and chocks were not installed.

• The casualty was in the danger zone between the moving unit and gutter capacity.• The Vacuum unit driver had no special training and had no experience working with such type of vehicle.• Risk assessment was not done prior to the work start.• Contractor selection was done without HSE pre-qualification.• Selection of contracting company which does not meet Company requirements.• The existing system of controls over the production of works did not ensure safe operation and performance.• Work instructions do not cover all production operations performed by work-over crew members.• Emergency medical response system failed to provide prompt and timely medical assistance.


• Reduced attention to the source of danger poses a direct threat to the life and health of the personnel.• Detailed risk assessment is required for all activities considering all factors in the production of works.• Conduct “HSE Stand down” for employees and contractors with highlight of the incident causes and outcome.• Conduct unscheduled briefings for Company employees and contractors involved in work with the use of means

of transport. Drivers and employees who are personally responsible for the preparation of working platforms and access roads are to be given special attention.

• Conduct site inspections of Contracting companies’ vehicles and implementation of Transportation Safety measures.

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• Run site inspections of production areas where transportation is being used, with the focus on the scheme of equipment and transport vehicles arrangement, work sites preparation for the installation of transport equipment, training and knowledge of drivers of road safety rules and instructions for the safe operation of vehicles, Parking brake equipment serviceability and if the vehicles are being equipped with under ride guards (chocks) by manufacturer.

• Develop requirements for the process to identify, assess and minimize HSE risks.• Create a list of activities where employees may be exposed to adverse effects of machines and mechanisms. Revise

work instructions by type of activity based on the results of the analysis.• Develop an Action Plan to improve emergency medical response system at the Company’s facilities.• Review the system of First Aid Training provision, providing involvement of specialized organizations, increase in

practical and refresher training.• Develop instructions for the safe operation of all types of vehicles carrying out work at the Company facilities.

Causal Factors:


materials/products• Process (conditions): Work Place Hazards: Inadequate surfaces, floors, walkways or roads• Process (conditions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate hazard identification or risk assessment• Process (conditions): Organisational: Poor leadership/organisational culture

OffshoreNo fatalaties reported in 2013.

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Middle East

Onshore

Kuwait Exploration Aug 28 2013Number of deaths: 1 Category: Caught In, Under or Between Activity: Transport–Land


Narrative:

On 28th August 2013 at about 06.50 am, one of the contractor employee was hit by a truck that has resulted in the fatality of the contractor employee. The involved vehicle was used for transporting and serving water to group of workers who were engaged in the Seismic Survey-UXO Spotting job. On 28th morning, at about 04.50 am the driver left the camp (60 km from work site) with 16 passengers (14 workers and 2 foremen). At about 05.50 am the driver dropped 8 passengers (7 workers and 1 foremen) at the work site. After dropping the 1st work crew, the driver reached another work site(3 km from 1st work site) and dropped the remaining 8 passengers (7 workers and 1 foremen). Then the driver came back to the 1st work site at about 06.30 am. Truck was parked near to the work site. Driver did not get down and the engine was in running condition. 1st work crew stopped the work for break and started to take water from the truck. All the workers including foreman came to the truck to take water from the truck. Drinking water tap was located on the driver’s side of the truck). 6 workers and foremen returned to the work location to resume their work. Meanwhile 7th worker who is an UXO spotter collected the sand bags from the truck and went to front right tyre and was preparing the sand bags. The driver did not notice the UXO spotter sitting near the front tyre, due to blind spot and he took the truck without carrying out any preliminary safety check, by going around the truck before moving ahead. In the process, the front right tyre ran over the UXO spotter. It resulted in head crush injury and fatality of the contractor employee (UXO spotter). The incident has been investigated by a committee to address the root causes and avoid recurrence of such incidents in future.

What went wrong:

1. Incorrect judgement of the Hazards: The worker (UXO spotter) was sitting close to the truck’s front tyre (while the engine was running) without identifying the hazard.

2. Enforcement of Standard practices and procedures was not effective: The driver was given defensive driving training. But he did not stop the truck during the break time. He did not apply wheel chocks. He did not go around the truck prior to moving it from that location. The driver of the truck did not notice the worker who was sitting in front of the vehicle’s right tyre and working there.

3. Lack of supervision: The foreman did not notice the worker who was sitting close to the front tyre of the truck and working.

4. No job oversight process: Driver’s activities were not monitored/audited. The foreman at work site, should have taken the head count and allowed the truck to leave the spot. However it was not done.

5. Technical Design of the vehicle used to transport passengers was not correct: Side mirrors were not able to cover the person sitting in front of the truck, as old model truck was being used as passenger vehicle. Whereas latest model trucks have special mirrors to cover even the blind spots at front.


All workers shall be trained on various hazards involved in their activities, including the safety while working near vehicles. Key Safety Instructions (e.g. Stop, Check, Walk around and Start) to drivers must be displayed inside their vehicles. The contractor shall establish enforcement measures to ensure that the drivers are following and implementing the good practices as prescribed. Audits shall be conducted to ensure that the drivers practice defensive driving techniques. The design of the truck for transporting passengers needs to be reviewed. Passenger carrying vehicles shall not be more than 5 years old.

Causal factors:

• People (acts): Following Procedures: Violation unintentional (by individual or group)• People (acts): Following Procedures: Improper position (in the line of fire)• People (acts): Use of Protective Methods: Failure to warn of hazard• People (acts): Use of Protective Methods: Inadequate use of safety systems• People (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgment

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• Process (conditions): Tools, Equipment, Materials & Products: Inadequate design/specification/management of change

• Process (conditions): Organisational: Inadequate training/competence• Process (condtions): Organisational: Inadequate work standards/procedures• Process (conditions): Organisational: Inadequate hazard identification or risk assessment• Process (conditions): Organisational: Inadequate supervision

Kuwait Drilling Aug 12 2013Number of deaths: 1 Category: Overexertion, Strain Activity: Drilling, Workover, Well Services


Narrative:

During completion activities on a well an H2S alarm sounded triggering a rig muster. While the rig crew evacuated to the muster area, a derrick man located on the tubing board was descending the 50 foot derrick ladder. The derrick man was later found deceased on the rig floor with the Emergency Life Support Apparatus (ELSA) hood on. Automatic air flow to the hood was prevented because the ELSA was not stored in a manner to function properly in an emergency (D-Ring activation strap was not attached to the firing pin).

What went wrong:

ELSA pack was not prepared in a ready state per manufacturer’s procedure. Emergency Response “Personnel on Board” process (headcount) was not conducted. Sweep of the rig site to determine if someone was missing was not performed. Training had not occurred consistently for all personnel concerning the use, inspection and maintenance of the ELSA pack. H2S Emergency Response drills were not being performed according to procedure.


A safety device can become a hazard if not properly prepared for use. It is critical to account for all personnel in an evacuation, even if the perceived hazard does not materialiSe. All personnel that may use Emergency Life Support Apparatus must be trained and be familiar with their use. Regular drills are important to maintaining emergency preparedness.

Causal factors:

• People (acts): Following Procedures: Violation unintentional (by individual or group)• People (acts): Use of Protective Methods: Personal Protective Equipment not used or used improperly• People (acts): Use of Protective Methods: Disabled or removed guards, warning systems or safety devices• Process (conditions): Tools, Equipment, Materials & Products: Inadequate maintenance/inspection/testing• Process (conditions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate work standards/procedures• Process (conditions): Organisational: Inadequate hazard identification or risk assessment

Kuwait Drilling Oct 10 2013Number of deaths: 1 Category: Struck by Activity: Drilling, Workover, Well Services

Age: Unknown Employer: Contractor Occupation: Maintenance, Craftsman

Narrative:

Contractor crew were pulling out the pump from a water well for shifting the pump and tubing to the next water well. Two double joints of 3 ¼ tubing (approx. 60 feet) were pulled out and laid down using a crane. The pipe joints were pulled out directly by connecting the auxiliary hook of crane with the lifting sub on the pipe joint and then laid down. As the bottom side was placed on ground and while the top portion which was connected to hook was being lowered to ground; suddenly, the lifting sub with tubing got disconnected from the crane hook and the pipe had a free fall towards the water well side. The tubing joint directly fell on the head of a contractor employee who was standing and connecting another lifting sub to the tubing joint inside well. The impact resulted in the immediate death of the contractor employee.

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What went wrong:

1. No Job oversight process.2. Technical Analysis of Risk not effective.3. Poor Coordination or reaction time. 4. Improper Supervisory example.5. Vertical Communication between supervisor and workers not effective.6. No inspection/Auditing of activities being carried out.7. Testing of plant, tools or equipment not performed.8. No relevant risk assessment carried out.9. Required permit not obtained.10. Job specific JSA not available.11. No company approved standard operating procedure.12. Enforcement of standards/practices/procedures not effective.


1. Contractor to develop a procedure for ESP lifting operations as per the standard practices as per company HSE requirements and obtain the approval for necessary implementation.

2. To explore advanced safer techniques and equipment for lifting of pipes and removal of ESPs from water wells.3. Dedicated Competent supervisor and rigger including safety officer should be provided all the time for every

activity.4. Job specific HSE training and competency to be developed.5. Security gate passes shall be provided to heavy equipment only after checking of third party certification as per

company HSEMS Mobile equipment Procedure 6. Permit to work should be implemented effectively.7. HSE induction training should be provided to contractor employees.

Causal factors:

• People (acts): Following Procedures: Improper position (in the line of fire)• People (acts): Use of Protective Methods: Failure to warn of hazard• People (acts): Use of Protective Methods: Inadequate use of safety systems• Process (conditions): Tools, Equipment, Materials & Products: Inadequate/defective tools/equipment/materials/

products • Process (conditions): Tools, Equipment, Materials & Products: Inadequate maintenance/inspection/testing• Process (conditions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate work standards/procedures• Process (conditions): Organisational: Inadequate communication• Process (conditions): Organisational: Inadequate supervision

Qatar Drilling Sep 25 2013Number of deaths: 1 Category: Caught In, Under or Between Activity: Transport–Land

Age: 34 Employer: Contractor Occupation: Engineer, Scientist, Technician

Narrative:

On the day of the accident, the rig driver was instructed to take the Rig Medic and Chief Mechanic from the rig to the camp to join the crew change vehicle that was arranged to convey them to the airport. At approx. 13:40 hours, the driver left with the Pick-up after completing and approving the journey management form. At the time of the accident both the driver and the Rig Medic (front seat passenger) had their seatbelts fastened while it is believed that the Chief Mechanic, who was seated in the back, had no seatbelt on. As they were approaching the Interchange, the driver suddenly lost control and veered off the road to the right, then to the left across the road, smashing the steel barriers between the highways and skidded on the passenger’s side before coming to rest. The Chief Mechanic was thrown out of the vehicle before it finally came to rest. The rig was immediately informed by one of the passengers (Rig Medic) at 14:28 hours before they were all evacuated to the Hospital by the client Emergency Team and the Police for treatment.

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The Chief Mechanic died later in the hospital while the Rig Medic and driver were admitted. The Rig Medic was transferred later the same day to the Intensive Care Unit at the Hospital in the city due to head injury and trauma. The driver was discharged at about 12:00 hours the next day. He was detained by the Police for further investigation.

What went wrong:

1. Over speeding and lack of attention by driver. 2. Non compliance with seatbelt policy: Driver moved vehicle without waiting for all passengers to fasten their

seatbelts.3. Lack of training: No defensive driving course. 4. Lack of monitoring and perception of risk. 5. Driver’s competency was not assessed before he was assigned to the rig.


1. Contractor shall develop and use standard check list to ensure drivers have the required training and competence prior to assignment to rigs and have HSEO sign off at rig.

2. Contractor shall review rig induction process to ensure drivers understand and are conversant with their roles in journey management and road accident prevention.

3. Contractor shall review and monitor road safety requirements are implemented immediately.4. Contractor to carry out assessment for vehicles and drivers to ensure they meet safety and contractual

requirements prior to assignment to rigs.5. Contractor to develop and implement a plan on speed control and monitoring.6. Incident shall be cascaded through HSE alert to all employees and other contractors.

Causal factors:

• People (acts): Following Procedures: Violation unintentional (by individual or group)• People (acts): Use of Tools, Equipment, Materials and Products: Improper use/position of tools/equipment/

materials/products• People (acts): Use of Protective Methods: Failure to warn of hazard• People (acts): Use of Protective Methods: Personal Protective Equipment not used or used improperly• People (acts): Inattention/Lack of Awareness: Lack of attention/distracted by other concerns/stress• Process (conditions): Protective Systems: Inadequate/defective Personal Protective Equipment• Process (conditions): Organisational: Inadequate training/competence

OffshoreNo fatalaties reported in 2013.

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North America

Onshore

Canada Production Jul 30 2013Number of deaths: 1 Category: Other Activity: Transport–Land


Narrative:

All Terrain Vehicle (ATV) accident on lease road.

What went wrong:

No additional information at this time–pending litigation.


No additional information at this time–pending litigation.

Causal factors:


Canada Production Mar 18 2013Number of deaths: 1 Category: Pressure Release Activity: Maintenance, Inspection, Testing

Age: 51 Employer: Company Occupation: Process/Equipment Operator

Narrative:

Employee was performing a routine pigging operation when a severe head injury was sustained. The injured person was transported to the hospital for treatment. The injured person succumbed to the injuries the following day.

What went wrong:

1. The pig was stuck in the pig trap with trapped pressure behind it. Wintry conditions at the time would have increased the likelihood of ice or hydrates forming around the pig further increasing its tendencies to stick.

2. The injured person was in the line of fire when the pig released.


1. Modify pig trap inspection processes.2. Re-inspect all pig traps to meet any revised standards and modify as needed.3. Review QA/QC process for new pig traps with focus on internal restrictions.4. Ensure all SOPs and Level 1 procedures complement each other.

Causal factors:

• People (acts): Following Procedures: Violation unintentional (by individual or group)• People (acts): Following Procedures: Improper position (in the line of fire)• Process (conditions): Protective Systems: Inadequate/defective guards or protective barriers• Process (conditions): Tools, Equipment, Materials & Products: Inadequate/defective tools/equipment/materials/

products • Process (conditions): Organisational: Inadequate work standards/procedures

Canada Production Jul 16 2013Number of deaths: 1 Category: Struck by Activity: Construction, Commissioning, Decommissioning

Age: unknown Employer: Contractor Occupation: Unknown

Narrative:

Detail pending.

What went wrong:

Detail pending.

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Detail pending.

Causal factors:


USA Production Jan 1 2013Number of deaths: 2 Category: Other Activity: Unspecified–other

Age: unknown Employer: Contractor Occupation: UnknownAge: unknown Employer: Contractor Occupation: Unknown

Narrative:

Details not available.

Causal factors:


USA Drilling Jun 20 2013Number of deaths: 1 Category: Caught In, Under or Between Activity: Drilling, Workover, Well Services


Narrative:

A drill line slack event occurred during the final stages of running 5½″ casing when the casing stopped downward motion and excess line became slack on the drum. The incident occurred when the drill line crew surveyed the slack drill line problem at the drawworks and while attempting to manually manipulate the drill line into the correct grooves on the drawworks drum, a crew member placed himself in a caught-between situation. The 5½″ casing after being static suddenly moved downward, causing the drill line to go tight and trapping the crew member between the drill line and the turn back roller. A rescue operation was initiated. The injured person was taken to a medical facility where it was later reported the he passed away.

What went wrong:

1. The drawworks cover was removed by crew members and work was initiated without implementation of Contractor’s Lockout-Tagout and Try (LOTO) procedure.

2. The individuals working on the drawworks failed to recognize the hazard and the associated risk of the stored energy in the un-landed casing string.

3. The Driller and Night Drilling Supervisor were initially on the rig floor assessing the change in work conditions and potential hazards that could be associated with the slack drill line, while the activity at the drawworks proceeded beyond the assessment phase without their knowledge.

4. Colleagues failed to enact their authority to stop work upon witnessing a co-worker performing an unsafe act.5. Training processes were conducted for crews, but in this case the training did not adequately affect the

identification and mitigation of hazards for this specific scenario.


1. Contractor will establish a job specific Job Safety Analysis (JSA) to deal with slack drill line scenarios, including requirements for LOTO, steps for securing stored energy hanging from the hoisting equipment, such as casing or drill pipe, and the removal of protective guards before work begins.

2. Implement a stop work authority campaign with onsite drills or exercises to test and teach stop work and hazard recognition culture. Audit to ensure work stoppage practices are being applied.

3. Produce an HSE Alert to effectively communicate the learnings of this incident, raising awareness of hazards due to change in job scope or conditions and the need to stop work to reassess hazards.

Causal factors:

• People (acts): Following Procedures: Violation unintentional (by individual or group)• People (acts): Following Procedures: Improper position (in the line of fire)• People (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgment• Process (conditions): Organisational: Inadequate supervision

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Offshore

Mexico Production Jul 4 2013Number of deaths: 1 Category: Explosions or Burns Activity: Maintenance, Inspection, Testing

Age: 35 Employer: Contractor Occupation: Process/Equipment Operator

Narrative:

The worker was operating heavy equipment, when he impacted a pipeline, causing the explosion.

What went wrong:

Safety analysis failure in during operations of heavy equipment.


Critical procedures must be correctly communicated and applied.

Causal factors:


materials/products• People (acts): Use of Protective Methods: Inadequate use of safety systems• People (acts): Inattention/Lack of Awareness: Lack of attention/distracted by other concerns/stress• Process (conditions): Protective Systems: Inadequate/defective guards or protective barriers• Process (conditions): Tools, Equipment, Materials & Products: Inadequate/defective tools/equipment/materials/

products • Process (conditions): Organisational: Inadequate work standards/procedures

Mexico Production Sep 5 2013Number of deaths: 1 Category: Exposure Electrical Activity: Lifting, Crane, Rigging, Deck operations

Age: 26 Employer: Company Occupation: Maintenance, Craftsman

Narrative:

While moving the crane, it made contact with an energized line causing electric shock and death of the operator.

What went wrong:

Wrong manoeuvre and lack of job safety analysis.


Training in critical procedures during movement and correct job safety analysis process.

Causal factors:

• People (acts): Following Procedures: Violation unintentional (by individual or group)• People (acts): Use of Protective Methods: Failure to warn of hazard• People (acts): Inattention/Lack of Awareness: Lack of attention/distracted by other concerns/stress• Process (conditions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate hazard identification or risk assessment

Mexico Production Jan 8 2013Number of deaths: 1 Category: Falls from Height Activity: Transport - Water, incl. Marine activity

Age: 43 Employer: Company Occupation: Manual Labourer

Narrative:

During crew transportation manoeuvres from ship to rig, the worker fell from a height of 10 metres, landing over the ship. First aid was conducted, but he died 40 minutes later from multiple contusions from the fall.

What went wrong:

Deficient and improper straps.

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Crew transport standards must be changed.

Causal factors:


materials/products• People (acts): Use of Protective Methods: Inadequate use of safety systems• People (acts): Use of Protective Methods: Equipment or materials not secured• People (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgment• Process (conditions): Protective Systems: Inadequate/defective guards or protective barriers• Process (conditions): Tools, Equipment, Materials & Products: Inadequate design/specification/management of

change• Process (conditions): Work Place Hazards: Inadequate surfaces, floors, walkways or roads• Process (conditions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate work standards/procedures

Mexico Production Aug 26 2013Number of deaths: 1 Category: Pressure Release Activity: Maintenance, Inspection, Testing

Age: 44 Employer: Contractor Occupation: Maintenance, Craftsman

Narrative:

During cleaning activities with nitrogen, the tube pressure measure equipment went wrong and broke injuring the worker.

What went wrong

Equipment: maintenance failure.


Preventive Maintenance programs for critical equipment.

Causal factors:


materials/products• People (acts): Use of Protective Methods: Equipment or materials not secured• People (acts): Inattention/Lack of Awareness: Lack of attention/distracted by other concerns/stress• Process (conditions): Protective Systems: Inadequate/defective Personal Protective Equipment• Process (conditions): Tools, Equipment, Materials & Products: Inadequate/defective tools/equipment/materials/

products • Process (conditions): Tools, Equipment, Materials & Products: Inadequate maintenance/inspection/testing• Process (conditions): Organisational: Inadequate work standards/procedures• Process (conditions): Organisational: Inadequate hazard identification or risk assessment

Mexico Production Jun 13 2013Number of deaths: 2 Category: Water related, Drowning Activity: Maintenance, Inspection, Testing

Age: 33 Employer: Contractor Occupation: OtherAge: 38 Employer: Contractor Occupation: Other

Narrative:

During water inspection, the boat with 4 workers crashed and sank. Two of them were killed.

What went wrong:

Severe weather.

Corrective actions and recommedations:

Procedures must be followed during adverse weather conditions.

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Causal factors:


materials/products• People (acts): Use of Protective Methods: Inadequate use of safety systems• People (acts): Use of Protective Methods: Disabled or removed guards, warning systems or safety devices• People (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgment• Process (conditions): Protective Systems: Inadequate/defective warning systems/safety devices• Process (conditions): Tools, Equipment, Materials & Products: Inadequate maintenance/inspection/testing• Process (conditions): Work Place Hazards: Storms or acts of nature• Process (conditions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate work standards/procedures

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South & Central America

Onshore

Peru Construction Apr 7 2013Number of deaths: 13 Category: Other Activity: Transport - Air

Age: unknown Employer: Contractor Occupation: Transportation OperatorAge: unknown Employer: Contractor Occupation: Transportation OperatorAge: unknown Employer: Contractor Occupation: Transportation OperatorAge: unknown Employer: Contractor Occupation: Transportation OperatorAge: unknown Employer: Contractor Occupation: Engineer, Scientist, TechnicianAge: unknown Employer: Contractor Occupation: Engineer, Scientist, TechnicianAge: unknown Employer: Contractor Occupation: Engineer, Scientist, TechnicianAge: unknown Employer: Contractor Occupation: Engineer, Scientist, TechnicianAge: unknown Employer: Contractor Occupation: Admin, Management, Support StaffAge: unknown Employer: Contractor Occupation: Admin, Management, Support StaffAge: unknown Employer: Contractor Occupation: Admin, Management, Support StaffAge: unknown Employer: Contractor Occupation: Admin, Management, Support StaffAge: unknown Employer: Contractor Occupation: Admin, Management, Support Staff

Narrative:

Helicopter crash in rainforest. All personnel on board perished (4 crews and 9 passenger).

What went wrong:

Dramatic failure of helicopter. Possible pilot error.


Prohibit crew change with MI8-MI17 helicopter. Hire Aircraft Manager to follow up recommendations from audits of Air Services providers.

Causal Factors:

• Process (conditions): Tools, Equipment, Materials & Products: Inadequate/defective tools/equipment/materials/products

• Process (conditions): Tools, Equipment, Materials & Products: Inadequate maintenance/inspection/testing

Peru Construction Aug 30 2013Number of deaths: 1 Category: Water related, Drowning Activity: Construction, Commissioning, Decommissioning

Age: unknown Employer: Contractor Occupation: Engineer, Scientist, Technician

Narrative:

One member of technician team tasked to erect telecom tower drowned in the river.

What went wrong:

Individual bathing in river. Absence of sanitary facilities. Inadequate supervision of marginal/remote activities.


Mandatory wearing of PFD (life jacket) in proximity of water bodies.

Causal Factors:

• People (acts): Following Procedures: Violation intentional (by individual or group)• People (acts): Use of Protective Methods: Personal Protective Equipment not used or used improperly• People (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgment• Process (conditions): Organisational: Inadequate work standards/procedures• Process (conditions): Organisational: Inadequate supervision

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© OGP

Offshore

Brazil Drilling May 15 2013Number of deaths: 1 Category: Falls from Height Activity: Drilling, Workover, Well Services


Narrative:

In an offshore drilling rig an operation of running casing into the well was in progress. A Derrick Hand was at a height of 7 metres above the drill floor, inside a Casing Stabbing Basket (mobile hydraulic basket), in order to manually crank the lift of the Spider, when the Top Drive collided with the basket. The connection of the basket with the drilling derrick broke and the movement of the Top Drive caused the basket to fall to the drill floor. The Derrick Hand was fatally injured in the fall.

What went wrong:

Incomplete Procedure: The procedure did not consider the operation with the use of the casing stabbing basket or the conditions for viewing its correct position in relation to the Top Drive. Communication failure: Failure in communication between the Derrick Hand and the Driller allowed the descent of the Top Drive before the basket was away from its path. Failure to attend a legal requirement: Absence of a lifeline for work at height, as well as the proper training for the worker, as required by Safety and Health at Work Regulations. Failure in management of change: The operation was performed with the anti-collision system for protect the Casing Stabbing Basket off (with bypass) without the due precautions for control of this condition.


• Restrict the use of Casing Stabbing Basket in running casing into the well operations, prioritizing the use of lifts with remote control.

• In case of timely need for use of Casing Stabbing Basket, it will be required the use of a hands free radio communication (two channels) between the worker inside the basket and the Driller (leader of the operation).

• Review of operational procedures, including effective requirements for work at height, including worker training, formal communication processes, prohibition of bypassing the anti-collision safety devices of drilling system (top drive , hydraulic wrenches, iron roughneck etc.) when using hydraulic baskets for workers.

• Give focus on requirements for work at height and management of change when carrying out internal audits.

Causal Factors:

• Process (conditions): Protective Systems: Inadequate/defective guards or protective barriers• Process (conditions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate work standards/procedures• Process (conditions): Organisational: Inadequate communication

Brazil Drilling May 18 2013Number of deaths: 1 Category: Falls from Height Activity: Drilling, Workover, Well Services


Narrative:

In an offshore drilling rig an operation of running casing into the well was in progress. The Derrick Hand was working on a Man-Rider, opening and closing elevator Spider at a height of 25 meters above the level of the rotary table. When a malfunction prevented the slip of the Spider to open, the Derrick Hand continued grabbing at the Spider while talking to the Driller. At this point, due to an improper interpretation of signals, the hydraulic drive operator started screwing the casing. As the Derrick Hand was grabbing the Spider and the Spider was still connected to the casing tube, the Derrick Hand was moved around the tube. This caused the steel wire of the Man-Rider to be caught by the Pipehandler, leading to the rupture of the Man-Rider wire causing the Derrick Hand to fall to the floor of the Moonpool.

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What went wrong:

• Breach of procedures: The operation was not being performed according to the procedures, which stipulated that the Derrick Hand should move away from the casing tube and stand at a safe place during the screwing torque operation.

• Communication failure: Failure in communication process enabled the hydraulic drive operator to begin turning of casing tube before the slips of the spider were open.

• Failure to attend a legal requirement: Absence of a lifeline for work at height, as required by Safety and Health at Work Regulations. This situation was not identified in the internal audits performed at the rig.

• Failure in safety management: There was no evidence that the operational teams had been trained in the existing procedures.


• Restrict the use of Man-Rider in running casing into the well operations, prioritizing the use of lifts with remote controls.

• In case of timely need for use of Man-Rider, the use of a hands free radio communication (two channels) will be required between the suspended worker and the driller (leader of the operation).

• Review of operational procedures, including effective requirements for work at height, including worker training, formal communication processes and interlocks. The procedures shall be available in the rig and before the operation, written both in Portuguese and English.

• Give focus on requirements for work at height and management of change when carrying out internal audits.

Causal Factors:

• Process (conditions): Protective Systems: Inadequate/defective guards or protective barriers• Process (conditions): Organisational: Inadequate training/competence• Process (conditions): Organisational: Inadequate work standards/procedures• Process (conditions): Organisational: Inadequate communication

Uruguay Exploration Apr 12 2013Number of deaths: 1 Category: Water related, Drowning Activity: Seismic / Survey Operations


Narrative:

On board a seismic vessel, during recovering operation of tangled streamers, a team of 7 person was working on the streamer deck. 2 unexpected waves hit the vessel on her starboard stern, flooding the entire deck. The Vessel listed on starboard by about 20 degrees. 3 persons were injured and 1 man overboard. Search and rescue operations were not successful.

What went wrong:

Lack of perception of risks: exposure of the crew at stern, occurrence of a big wave, possibility of a man over board from the streamer deck. Too ambitious pattern design versus vessel power and weather conditions. Heavy work load, fatigue and stress.


Dedicated risk assessment for recovery operations during bad weather conditions, with formal risk assessment meeting. Dedicated recovery entangled steamers procedure. Personal Floating Devices mandatory on every open deck, including streamer deck. Operations management and management of change/abnormal situation.

Causal Factors:

• People (acts): Following Procedures: Improper position (in the line of fire)• People (acts): Use of Protective Methods: Personal Protective Equipment not used or used improperly• Process (conditions): Protective Systems: Inadequate/defective Personal Protective Equipment• Process (conditions): Tools, Equipment, Materials & Products: Inadequate design/specification/management of

change• Process (conditions): Organisational: Inadequate work standards/procedures• Process (conditions): Organisational: Inadequate communication• Process (conditions): Organisational: Inadequate supervision

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© OGP

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Internet site: www.ogp.org.uke-mail: [email protected]

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