gupco kamose fatality incident toolbox talk lessons pack presenter’s name title department...

GUPCO Kamose Fatality Incident

Toolbox Talk Lessons pack

Presenter’s NameTitle Department

Prepared By Dave Goodwill for Dave Blevins

Background

• Mohi Mohammed Gouda was a Barge Engineer on the EDC rig “Kamose” working for BP’s GUPCO joint venture operation offshore Egypt.

• On 18th June 2001 he was involved in an incident during a lifting operation he was supervising.

• He fell 4m and sustained serious head injuries.

• Several weeks later he died of these injuries having never recovered.

Learn from a fatal error

• This accident would not have happened if existing procedures and good practice had been used

• What will You Learn from Mohi’s death ?

• Could you and your workmates be at risk of a similar incident ?

The Job

Your Task

• Replace the crane engine

Your Procedure

• The job has been done before using the spare crane and another available rig crane

• You’ve identified a better way

• But you’ve never done it this way before

Your PlanYour Equipment

• The other crane• Rigging equipment• An air winch from

another location on the rig welded to the generator room roof

Your Team

• You (supervisor)• Crane driver• Asst crane driver• 2 x Roustabouts

What else do you need to do ?

How it was done

• A permit is not being used

• A JSA has not been carried out

• The welds fixing the winch to the deck have not been tested

• The old engine has been successfully removed using the method.

Would You be happy with this ?

The Incident

He died in hospital of these injuries several weeks later

What happened

• The weld between the winch and the roof failed

• The winch was dragged over the handrail

• Mohi (the supervisor) was first trapped between the air line and the handrail

• He was then forced over the handrail and fell 4m to the deck below sustaining serious head injuries

The Key CausesWhat Do You Think ?

Now that you know what happened:

• What do you think were the key causes ?

• What should have been done here ?

The Key CausesThe Investigation Findings

Three Critical factors identified:

• The weld was inadequate. It was neither designed for the job, carried out by a certified welder or properly tested.

• No permit to work , risk assessment or Safe Job Analysis (JSA) was completed.

• The previous procedure, known to be sound, was not followed

Could something like this happen on your rig ?

Think about it. Do you always:

• Use established and proven procedures ?

• Carry out a thorough risk assessment before using a new procedure ?

• Carry our work like this under the control of a Permit To Work System ?

• Conduct JSA’s and pre job safety meetings ?

• Ensure that load bearing welds are properly designed, inspected and tested ?

If you answer “no” to any of these it could happen to you