FIELD OPERATOR OVERCOME BY HYDROGEN SULPHIDE Date of Incident: March 7, 2008 Type of Incident: Fatality

File: F-415458

2 June 24, 2009 Alberta Employment and Immigration, Occupational Health and Safety

TABLE OF CONTENTS

SECTION TITLE PAGE NUMBER

1.0 DATE AND TIME OF INCIDENT 3 2.0 NAME& ADDRESS OF PRINCIPAL PARTIES 3 2.1 Owner 3 2.2 Prime Contractor 3 2.3 Contractor 3 2.4 Employer 3 2.5 Worker 3 3.0 DESCRIPTION OF PRINCIPAL PARTIES 3 4.0 LOCATION OF INCIDENT 4 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 4 5.1 Equipment and Material 4 5.2 Observations 6 6.0 NARRATIVE DESCRIPTION OF INCIDENT 7 7.0 ANALYSIS 9 7.1 Direct Cause 9 7.2 Contributing Factors 9 8.0 FOLLOW-UP/ ACTION TAKEN 10 8.1 Occupational Health and Safety 10 8.2 Industry 10 8.3 Additional Measures 11 9.0 SIGNATURES 11 10.0 ATTACHMENTS 12

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3.2 E.L.H. Enterprises Ltd. is a company based in Whitecourt, Alberta that provides oil and gas field operation services. The company employs approximately 6-8 full time field operators. E.L.H. Enterprises Ltd. has been contracting to Orleans Energy Ltd. since June 1, 2006.

3.3 The Field Operator had been employed by E.L.H. Enterprises Ltd. since

July 16, 2007. The Field Operator had worked in the oil and gas industry for over 10 years but did not have any previous field operating experience.

SECTION 4.0 LOCATION OF INCIDENT 4.1 The incident took place in the Orleans Energy Ltd.’s group separator building located

at 10-22-60-19-W5M which is approximately 25 km southeast of Fox Creek, Alberta (Attachment A, Map).

SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 5.1 Equipment and Material 5.1.1 Group Separator 5.1.1.1 The group separator was commissioned in December, 2007. The group separator and

the associated equipment were located inside a building positioned on a skid. The entire skid package was leased by Orleans Energy Ltd. from Bullmoose Capital Ltd. The building measured 3.65 m wide by 7.31 m long and contained an inlet separator vessel and metering equipment. The building could be accessed by two doors, one located at the west end and the other located along the south side of the building (Attachment B, Photograph 1).

5.1.1.2 The group separator is a gas gathering system that receives production from at least 8

Orleans Energy Ltd’s producing well sites. As the production flows through the inlet separator, it is separated into gas, condensate and produced water. The total amount of production and the separated volumes are measured in the metering systems housed inside the group separator. The production flowing into the group separator has a H2S concentration of 1600 ppm or 0.16 %.

5.1.2 Gas Metering System 5.1.2.2 The total amount of production flowing into the group separator is measured through

a metering system. The group separator was equipped with a Daniel Senior Orifice Fitting which is an orifice plate holding device used in the flow measurement system

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(Attachment B, Photograph 2). An orifice plate is a thin calibrated plate with a hole in the middle (Attachment B, Photograph 3). The orifice plate is positioned horizontally inside a 20.3 cm pipe with production flow. As the production flows through the pipe, it has a certain velocity and pressure. When the flow reaches the orifice plate, it is forced to flow through the smaller 10.2 cm hole in the middle. This causes a change in the velocity and the pressure of the flow. By measuring the difference in the pressure before and after flowing through the orifice plate, a volumetric flow measurement can be obtained by using the differential pressure readings.

5.1.2.3 The Daniel Senior Orifice Fitting uses a dual chamber design (Attachment C,

Diagram 1 & 2). One chamber is used for measuring the differential pressure and holds the orifice plate in the flow of production fluid/gas. The second chamber is a temporary holding chamber for the orifice plate and is used when removing or installing the orifice plate. The two chambers are separated by a slide valve. This design allows one to remove or install the orifice plate without interrupting the flow of production.

5.1.3 Gas Monitor 5.1.3.1 Make: Industrial Scientific Model: M-40 Serial Number: 0707062-424 5.1.3.2 The portable gas monitor was programmed to measure the following parameters:

(* The Alberta OHS Occupational Exposure Limits (OEL) were included for reference only) (** Note the low alarm setting for Carbon Monoxide was set 10 ppm above the Alberta OHS 8-hour Occupational Exposure Limit)

Gas

*Alberta OHS Exposure

Limits

Maximum

Concentration

Minimum

Concentration

Low

Alarm

High

Alarm Carbon

Monoxide 25 ppm 8-hour OEL

1000 ppm 0 ppm 35 ppm ** 70 ppm

Hydrogen Sulphide

(H2S)

10 ppm 8-hour OEL 12 ppm

Ceiling

1000 ppm 0 ppm 10 ppm 20 ppm

Oxygen <19.5% or >23 %

21.8 % 0.1 % 19.5 % 23.5 %

Lower Explosive

Limit (L.E.L.)

< 20 %

1000 %

0%

10 %

20 %

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5.1.3.3 The Field Operator was using the gas detection monitor at the time of the incident. The monitor had the ability to store data and recorded gas measurements in one minute average intervals. The gas monitor was last calibrated on March 4, 2008.

5.2 Observations 5.2.1 Occupational Health and Safety (OH&S) Investigators arrived at the scene on March

8, 2008. The scene had been secured and the group separator had been isolated. OH&S Compliance Investigators retained Tarpon Energy Services Ltd. to deem the group separator safe for entry, provide a preliminary report on the position of the gas metering equipment and to interpret the production data retrieved from the electronic metering program.

5.2.2 While under self contained breathing apparatus, upon entry into the group separator

building, the Instrumentation Technician with Tarpon Energy Services Ltd. encountered low levels of combustible gases. As the Instrumentation Technician approached the gas metering equipment, high levels of H2S and combustible gases were encountered. The Daniel Senior Orifice Fitting was examined and the equipment was found to be in a state of disassembly (Attachment B, Photograph’s 4 and 5). Given the position of the equipment, the Instrumentation Technician concluded that the Daniel Senior Orifice Fitting was not dismantled in accordance with the manufacturer’s specifications. The Instrumentation Technician reported that gas was released when the slide bars located on the front of the second chamber of the Daniel Senior Orifice Fitting were opened while the slide valve used to isolate the first and second chamber was not completely closed.

5.2.3 It could not be determined why the slide valve had not been completely closed

however, the Instrumentation Technician noted that while testing the slide valve handle, it hung up and he felt some resistance before it completely closed. The Instrumentation Technician also noted that the orifice plate was still located in the first chamber.

5.2.4 It was noted that there were maintenance instructions on how to remove an orifice

plate located on the top of the Daniel Senior Orifice Fitting. These instructions were located 2.0 m above floor level and could not be viewed at eye level. The manufacturer’s specifications for the Daniel Senior Orifice Fitting were found in a clear plastic bag sitting next to the Daniel Senior Orifice Fitting (Attachment B, Photograph 2).

5.2.5 Occupational Health and Safety Investigators were informed by Orleans Energy

Ltd.’s representatives that the group separator metering system was not measuring accurately and was showing more production than the sum of all the producing wells

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7.2 Contributing Factors 7.2.1 The Field Operator did not use self contained breathing apparatus while

working in an area that had the potential of releasing lethal concentrations of hydrogen sulfide gas and creating an oxygen deficient atmosphere due to displacement of air with hydrocarbon gases.

7.2.2 This was the first time the Field Operator attempted to remove an

orifice plate from a Daniel Senior Orifice Fitting. Normally, when conducting this task in the appropriate sequence as specified by the manufacturer, there should not be any gas released in the vicinity of the work area. The Field Operator was not competent in this task and was not under the direct supervision of a competent worker.

7.2.3 Orleans Energy Ltd. had a written practice for changing orifice plates and a site

specific hazard assessment form to be completed for the task of removing an orifice plate in sour (greater than 10 ppm H2S) service. The E.L.H. Enterprise Ltd.’s Supervisor did not ensure that the Field Operator completed this assessment prior to conducting the task and did not have any documentation to demonstrate the Field Operator was aware of this requirement or practice.

SECTION 8.0 FOLLOW-UP/ ACTION TAKEN 8.1 Employment and Immigration; Occupational Health and Safety 8.1.1 Occupational Health and Safety Investigators conducted an investigation into the

circumstances surrounding the incident. Two orders were issued to Orleans Energy Ltd. with respect to conducting an investigation and contractor obligations. A stop use order was placed on the Daniel Senior Orifice Fitting until it was inspected by a qualified technician and repaired in accordance with the manufacturer’s specifications.

8.1.2 Occupational Health and Safety Investigators issued orders to E.L.H. Enterprises Ltd.

respecting hazard assessment, worker competence, safety training and following manufacturer’s specifications.

8.2 Industry 8.2.1 Orleans Energy Ltd. conducted an investigation and implemented several

preventative measures. A safety consultant was retained to conduct a gap analysis of the Orleans Energy Ltd.’s health and safety program. An orientation, documentation and tracking system was developed and implemented throughout Orleans Energy Ltd.’s operation and drilling departments. A worker competency program was also developed to ensure workers are trained in accordance with Orleans Energy Ltd.’s

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safe work procedures and have gained sufficient experience to conduct the tasks in a safe manner. A vendor/contractor selection process was implemented to ensure that contractors follow a health and safety program and have documentation to demonstrate the programs are implemented, evaluated and enforced.

8.2.2 Orleans Energy Ltd. had the Daniel Senior Orifice Fitting inspected by Ber-Mac

Electrical Instrumentation Ltd. The inspection revealed that the slide valve used to isolate the first and second chamber inside the orifice fitting could not maintain an adequate seal. The slide valve and grease injector were replaced and the equalizing valve was repacked. Upon pressuring up the system, it was determined that these repairs allowed the Daniel Senior Orifice Fitting to function as required.

8.2.3 E.L.H. Enterprises Ltd. complied with the orders by conducting hazards assessments

at the work sites where routine work is conducted. In addition to a routine work hazard assessment, any time the scope of work or the process changes, E.L.H. Enterprises Ltd. required the hazard assessment to be updated and reviewed with all workers affected by it. E.L.H. Enterprises Ltd. initiated a system to track the documentation associated with the hazard assessment process. E.L.H. Enterprises Ltd. also established a worker competency/training program which included documentation to demonstrate when workers have achieved a specific competency level based on verbal and visual assessment criteria.

8.3 Additional Measures 8.3.1 There were no additional measures. SECTION 9.0 SIGNATURES ____________________________ _____________________ Lead Investigator Date ____________________________ _____________________ Investigator Date ____________________________ _____________________ Manager Date ____________________________ _____________________ Regional Senior Manager, North Date

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SECTION 10.0 ATTACHMENTS: Attachment A Map Attachment B Photographs Attachment C Diagrams

ATTACHMENT A

File: F-415458 Attachment A

Page 1 of 1

Map 1

The green star shows the approximate location of the Orleans Energy Ltd. well site 10-22-60-19W5M where the incident took place.

ATTACHMENT B

File: F-415458 Attachment B Page 1 of 5

Photograph 1 Shows the Orleans Energy Ltd.’s group separator building. The doors are not equipped to stay in the open position and required a means to prop them open as shown.

West end door

South side door

Stick used to hold door open

File: F-415458 Attachment B Page 2 of 5

Photograph 2 Shows the equipment located inside the Orleans Energy Ltd.’s group separator building. The yellow star shows where the Supervisor

found the unconscious Field Operator .

The Daniel Senior Orifice Fitting used to measure differential pressure

Manufacturer’s Specifications for the Daniel Senior Orifice Fitting

The inlet separator

File: F-415458 Attachment B Page 3 of 5

Photograph 3 Shows the orifice plate with its gasket to the left which sits in the holder located to the right. The orifice plate and holder fit inside the Daniel Senior Orifice Fitting and the serrated edges on the holder are used to move the holder between the two chambers with manually operated gears that are located on the outside of the Daniel Senior Orifice Fitting (See Attachment C, Diagram 1 and 2).

Serated edges

File: F-415458 Attachment B Page 4 of 5

Photograph 4 Shows the front of the Daniel Senior Orifice Fitting. When the clamping bar and the sealing bar were moved over to the left, the second chamber was opened to atmosphere. Since the slide valve was not completely closed and the second chamber was not isolated from the first chamber, there was a release of gas through the opening. The black lines on the front of the Daniel Senior Orifice Fitting show where the clamping bar and sealing bar were positioned when the equipment was examined by the Instrumentation Technician .

Position of the red sealing bar

Position of the blue clamping bar

Opening to access the inside of the second chamber

Photograph 5

Shows the position the equipment was found by the Instrumentation Technician

. The slide valve was not completely closed and the Instrumentation Technician estimated that the slide valve would have been approximately 75 % closed. The orifice plate was located in the first chamber or the measurement chamber and the bleeder valve was in the open position.

File: F-415458 Attachment B Page 5 of 5

Bleeder valve

Slide valve

First chamber where orifice plate was located

ATTACHMENT C

Attachment C Diagram 1 of 2 File: F-415458

Diagram 1 Top View Partial Cross Section of the Daniel Senior Orifice Fitting

First Chamber or production measurement chamber with orifice

l

Second chamber or temporary orifice chamber used when installing or removing the orifice plate

Clamping bar secured with bolts. When removing orifice plate from the second chamber, the bolts are loosened off and the clamping bar and sealing bar are removed to access the orifice plate

Slide valve handle

Slide valve mechanism used to isolate the first chamber from the second chamber

Orifice Plate

Diagram 2 – Side View Cross Section of the Daniel Senior Orifice Plate Fitting

The orifice plate positioned in the production flow located in the first chamber

Grease gun port used to inject grease sticks to maintain a seal on the slide valve which isolates the first chamber from the second chamber

The area where the orifice plate would be positioned when in the second chamber

Sealing bar

Clamping bar secured with 7 screws

The bleeder valve used to bleed off gas from the second chamber. The valve is opened prior to removing the slide plate and gas is vented outside of the building through tubing

The plate carrier gears used to move the orifice plate from the first chamber to the second chamber

Attachment C Diagram 1 of 2 File: F-415458

To remove the orifice plate from the Daniel Senior Orifice Fitting: - the equalizer valve must be opened to balance the pressure between the first and second chamber - the slide valve is then rotated to the open position - the plate carrier is then turned to move the orifice plate out of the first chamber - a second plate carrier is then turned that lifts the orifice plate out of the first chamber and into the second chamber. This shaft

is rotated until the orifice plate stops against the seal bar - the slide valve is then turned to the closed position - the equalizer valve is closed - the bleeder valve is opened - the screws are loosened two turns and the clamping bar and sealing bar are removed to expose the interior of the second

chamber - the second chamber plate carrier shaft is then rotated to move the orifice plate out of chamber.

The Daniel Senior Orifice Fitting was found in the following position: - the equalizer valve was closed - the slide valve was approximately 75 % closed - the bleeder valve was open - the screws were loosened 2.5 turns and the clamping and sealing bar were moved to the left, exposing approximately 25 mm

of the interior of the second chamber