lesson from accidents
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منع وقوع الحوادث من خ�ل الدروس والعبر المستفادة منھا
Incident Prevention Through
Learning from Incidents
July - September, 2012
قسم الصحة والس�مة والبيئة
Health, Safety & Environment Division
1
For further information, comments and suggestions please contact:
Dr. Muhammad. R. Tayab (drtayab@adco.ae) Health, Safety & Environment Division
Tel: 02-6041217; Mobile – 00971 (0) 50 324-3996
ء الم�حظات وا�قتراحات يرجى ا�تصال بـ:للمزيد من المعلومات وإبدا
drtayab@adco.aeعلى البريد ا�لكتروني التالي : محمد ريحان طيب الدكتور قسم الصحة والس�مة والبيئة
6041217رقم الھاتف :
This Booklet is circulated within ADCO organization within the framework of HSEMS. It should only serve as guidance and ADCO shall in no event accept any liability for either the fact described, nor for any reliance on the contents by any third party.
2
During the 3rd Quarter of 2012 we have had 42 injuries of varying nature and in addition, we had 29
transportation, 9 fires, 17 Property damage, 4 Gas releases and 3 spills related incidents. We sadly had 6 Non Accidental Deaths (NAD) involving our colleagues. Incident investigations have revealed deficiencies in effective
supervision and leadership, improper behavior, and inadequate work planning being the root causes.
During this period, we have worked over 38 Million Man-hours and have driven over 47 Million kilometers which
was a great challenge to our drilling, operations, project and support team members as we would like to
enhance operation safety in an environment of expansion. I urge you all to discuss these incidents within our
teams and work groups especially with contractor workforce to ensure that none of us get hurt during our work. We can address our shortcomings with:
• Strong leadership by visibly engaging with workforce • Discouragement of unsafe behavior by rewarding & acknowledging safe behavior
• Risk minimization by involving all levels of workforce in task execution
Let us promote a working environment where safety becomes part of our second nature.
Saleh Aidrous Al Wahedi Senior Vice President (Engineering & Projects)
3
Table of Contents
Damage to Underground Fiber Optic Cable During Excavation 4
Crane Mounted Truck (Hiab) Rollover on Gatch Road 5
Vehicles Collision on Gatch Road 6
Arm Injury Due to Explosion During CAD Welding 7
Fire at Scaffolding Platform Around Stripper Column 8
Foreign Object Entering Eye of a Worker 9
Vehicle Rollover on Gatch Road 10
Crane Mounted Truck (Hiab) Rollover on Gatch Road 11
Vehicles Collision 12
Crane Rollover During Move on Gatch Road 13
Water Tanker Rollover 14
Hand Entrapment Inside Tong 15
Electrical Shock 16
Worker’s Finger Entrapment Between Pipe Flange and Valve Flange 17
Transformer Fire 18
Fire in UPS Unit of Substation 19
Vehicle Drop in Low Lying Area/Depression 20
Breakage of Hook of Wire Rope 21
HSE Performance, Q3, 2012 (YTD) 22
Incident Sub Types Q3 – 2012 (YTD) 23
Asset Wide Incident Sub Types Q3 – 2012 (YTD) 25
Incident Sub Types Asset Wide Q3 – 2012 (YTD) 26
Incident Immediate Cause Analysis Q3-2012 (YTD) 29
Asset Based Incident Immediate Cause Analysis Q3-2012 (YTD) 31
Incident Root Cause Analysis Q3-2012 (YTD) 32
Asset Based Incident Root Cause Analysis Q3-2012 (YTD) 34
Focus Areas Q3-2012 (YTD) 36
4
Damage to Underground Fiber Optic Cable During Excavation
Area Incident Description Causes
BAB Field
08-08-12
A 3rd party contractor was working on a project to lay a new
potable water pipeline to supply GASCO and ADCO with
potable water and the majority of the work was completed in
BAB. The work was performed under ADCO Permit to Work
(PTW) system and an excavation certificate was issued. As
built drawing did not show location of buried fiber optic cables
(which were running parallel to a transfer line) and there were
no physical markers on the ground.
The task was intended for manual excavation and the use of machine was limited to removal of excavated material/debris.
The crew did not have adequate resources (i.e. number of
laborers for manual excavation) to complete the task on
schedule and these resources were not adjusted for work
during the fasting month of Ramadan.
The job performer had started to use mechanical excavator,
after exposing buried line. During the excavation a fiber optic
communication cable was cut and that has resulted in tripping
of Remote Degassing Station (RDS-1) and alarm was sounded
in the control room of Bab Central Degassing Station (BCDS).
• Inadequate Work Planning (The
number of labourers in the crew were
not adequate to manually excavate
the site on time and shorter working
hours in Ramadan were not
considered during work planning)
• Inadequate Implementation of
Procedure (JP was not a member of
Task Risk Assessment (TRA) team and
did not endorse the TRA)
• Inadequate Leadership (Job
Originator was not involved in TRA
and did not ensure availability of
adequate resources for task
execution; As built drawings did not
show location of buried cables)
Lessons Learned
1. Do not use mechanical excavator
in restricted areas.
2. Ensure availability of adequate
resources prior to execution of
tasks
3. Provide updated as built drawings
to support excavation certificate
4. Ensure Job Origionator & Job
Performer/s are part of Task Risk
Assessment (TRA) Team
Immediate Causes
• Violation by Supervisor (The job performer (JP) used a
mechanical excavator in area where manual excavation
was authorized)
• Lack of knowledge of Hazards Present (Location of
buried cable was not known to Job Performer and there
were no surface makers on the ground; Job Performer was
not aware of risks associated with the task)
• Inadequate Guard or Protective Devices (Cable were
buried without any physical protection)
5
Crane Mounted Truck (Hiab) Rollover on Gatch Road
Area Incident Description Root Causes
BAB Field
22-08-12
A crew was involved in civil works in RDS-2
and after the completion of the work, a driver
was driving Hiab Truck (crane mounted truck)
from the work site towards their camp.
The supervisor and job performer (JP) did not
notice that the vehicle had deteriorated tires
and IVMS (In Vehicle Monitoring System) was
not functional. Due to high humidity, the
gatch road surface became slippery.
After driving 8 km from the worksite, while
the driver was maneuvering through holes on
the surface of the gatch and he applied harsh
brakes. A combination of deteriorated tires,
slippery surface, harsh brake and sharp
maneuvering of steering caused the vehicle to
rollover. Outcome: The driver sustained
lower back injuries.
• Inadequate Audit/ Inspection/
Monitoring (Vehicle’s tire fitness was not
checked; Road condition (potholes) were not
assessed prior to the journey; Vehicle IVMS
and driver’s driving behavior reports were not reviewed)
• Inadequate Identification of
Worksite/Job Hazards (Hazards of slippery
surface due to humidity and potholes in gatch
road were not identified and controlled)
Lessons Learned
1. Avoid harsh braking and sharp
maneuvering of steering especially on
gatch roads.
2. Consider hazards of weather conditions
(rain, high humidity etc.) on road/track
conditions in Task Risk Assessment
Immediate Causes
• Improper Decision Making/ Lack of
Judgment (Driver applied harsh brakes
and sharp maneuvering of steering on
slippery road)
• Improperly Prepared Vehicle (The
vehicle had deteriorated tires)
• Storm or Act of Nature (Road surface
became slippery due to high humidity)
6
Vehicles Collision on Gatch Road
Area Incident Description Root Causes
Engineering
& Projects
Asab
09-07-12
Two different contractor (Project & Drilling)
vehicles were approaching from opposite
directions, on a gatch road. There was a
blind spot at a turning and one driver was
driving on the wrong side of the road. Desert
flags mounted on both vehicles were not
visible to other vehicle due to the height of a
pipeline berm. One vehicle (Project) was
driven at a speed not appropriate for road conditions (73 km/Hrs) and the other driver
(Drilling) was driving at the speed of 60
km/Hrs. Both vehicle emerged after ablind
spot and collided head on.
Outcome: Total six passengers in both
vehicle sustained minor injuries and vehicles
were badly damaged.
• Inadequate Identification of Worksite/
Job Hazards (There was no sign or marking
when approaching the blind spot)
• Inadequate Practice of Skill (Project driver
was in haste and over speeding; and he was
driving on the wrong side of the road)
Lessons Learned
1. Always reduce vehicle speed according to road
conditions especially when approaching blind
spots
2. Do not drive in wrong lane even for shorter
period of time
Immediate Causes
• Violation by Individual (The project
vehicle was driven in wrong lane)
• Work or Motion at Improper Speed
(Vehicle speed was not adjusted
according to road condition and presence
of a blind spot)
• Inadequate Warning System (There
were no road signs to alert approaching
drivers)
7
Arm Injury Due to Explosion During CAD Welding
Area Incident Description Causes
Engineering
& Projects
Asab
12-07-12
CAD* Welding of grounding cable outside the control
room building was planned but no specific work permit
was obtained and the work was performed under a
“Green Field” general permit to work. A newly arrived
electrician who was dressing electrical cable inside the building was requested to assist the CAD welding
crew.
The job Performer went to attend another task and
stopped the activity but the crew continued work. The
electrician was not wearing any welding gloves and no
special tool to hold the mold was available.
The electrician held the cable in his hand although it is
held by the mold itself. After the set-up, another
worker ignited the weld powder in the mold using
spark igniter whilst electrician was still holding the
cable. Explosion/backfire through the aperture cover
of the mold occurred. Outcome: It resulted in 2nd
degree burn on the right forearm of the electrician.
• Inadequate Job Placement (An
electrician was assigned on CAD welding
activities without assessment of required
skills)
• Inadequate Assessment of Need &
Risks (CAD welding activity was
performed without necessary tool to hold
the mold)
• Inadequate or Lack of Safety Meeting (Electrician was not subjected to tool box
Talk and crew was not made aware of
hazards of CAD Welding)
Inadequate Audit / Inspection/
Monitoring (Job Performer left the crew
to attend another task without assuring
that work has stopped)
Lessons Learned
1. Always subject all crew members to tool
box talk specific to the task.
2. Ensure assignment of skilled crew
members and availability of all necessary
tools, especially on high risk activities
3. Never leave crew unattended specially
those working on high risk activities
*CAD welding (Exothermic welding) is process for joining
two electrical conductors, that employs superheated
copper alloy to permanently join the conductors.
Immediate Causes
• Violation by Group (The activity was stopped by
the Job Performer but crew continued the work)
• Personnel Protective Equipment (PPE) not
used (Electrician did not use welding gloves; the
right tool to hold the mold was not used/obtained)
• Lack of Knowledge of Hazards Present (The
crew was not aware of hazards of back fire)
• Improper Position or Posture for the Task
(Electrician was holding the cable at the both sides
of the mold)
8
Fire at Scaffolding Platform Around Stripper Column
Area Incident Description Root Causes
Engineering
& Projects
Asab
16-07-12
A welder was welding a pipe on the topmost
platform (35 m high) of stripper column.
After completing the task he lowered his
tools and the portable welding equipment to
a lower level platform and left the site. On
scaffold boards (which were below welding
area) food scarps, plastic bottles, papers etc.
had accumulated and not noticed by crew or
their supervisor. The welding habitat was not
set and the fire blanket was too small for the
task and had holes in it.
Later, workers noticed fire and smoke from
upper level scaffold platforms and raised the
alarm. Outcome: ADCO & GASCO Fire
Teams responded and extinguished the fire.
No personnel injuries and damage to scaffold
boards had occurred.
• Inadequate Audit/Inspection/
Monitoring (Supervisor did not visit the site
before and after the completion of hot work;
accumulation of combustible materials was
not noticed; Fire blanket with holes and
absence of fire habitat were not noticed)
• Inadequate Work Planning or Risk
Assessment Performed (A welder without
any supervision was assigned for the task;
Job Performer (JP) did not go to the top
platform to monitor the work; cleaning of
scaffold sites of accumulated debris was not
considered)
Lesson Learned
1. Maintain housekeeping at work locations.
2. Subject critical activities to continuous
monitoring & supervision
3. Switch off/Disconnect power supply to
portable electrical equipment during breaks
4. Use fir blanket/fire habitat for welding
activities in process areas.
Immediate Causes
• Inattention to footing &
Surroundings (Accumulation of
combustible waste material near welding
area was not noticed)
• Inadequate Guards or Protective
Devices (Fire blanket was not adequate
to isolate welding spatters/ welding
habitat was not set)
• Work Exposure to Temperature
Extreme (Hot summer day with ambient
temperature exceeding 47oC)
9
Foreign Object Entering Eye of a Worker
Area Incident Description Root Causes
Engineering
& Projects
Sahil
26-07-12
A welder was assigned to perform welding task
for the installation of pipe support. After
completing the welding task, while he was
removing welding face shield, he felt a sand
particle had entered his left eye.
He washed his eye with water and felt relieved
and continued his job. Later, at night he felt
pain and irritation in his eye and he visited the
camp clinic the next morning and he was
attended by the Physician and then referred to
a Hospital for the removal of foreign object
from his eye.
Outcome: The foreign object (sand particle)
was removed from his eye.
• Inadequate Identification of
Worksite/Job Hazards (Workers were not
adequately made aware of hazards of working
on a windy day; risks of rubbing eyes when a
foreign body enters eye were not known)
• Inadequate Communication (Lessons from
prior similar incident occurred on 04-05-2012
were not effectively communicated)
Lessons Learned
1. If a foreign object enters eye, do not rub eyes
and seek medical attention
2. Report all incidents (including minor
incidents/injuries) to your supervisor
3. Always use eye wears for protection in
working sites, especially in sandy areas.
Immediate Causes
• Storm or Act of Nature (Blowing wind
carrying particles/dust/light objects)
• Personal Protective Equipment (PPE)
Not Used (Welder removed his welding
face shied after the task and due to blowing
winds sand particle entered his eye)
10
Vehicle Rollover on Gatch Road
Area Incident Description Causes
Engineering
& Projects
BAB
23-08-12
A vendor crew was involved in installing gauges
on multi flow meters and after the completion
of the task, transport was arranged to transfer
them back to Abu Dhabi. The plan was to
collect passengers from Accommodation Camp
and proceed to Abu Dhabi via Madinat Zayed
Road.
An Engineer decided to go to Abu Dhabi with
vendor crew and boarded the vehicle. The
Engineer advised the driver to go through Bab-
Tarif Road and to avoid going through security
check post, the engineer identified a gatch
road. The driver was driving fast (80-90
Km/Hrs) for the road condition and at a bend
he lost control of the vehicle and the vehicle
rolled over. Outcome: No serious injuries to
passengers and the vehicle sustained minor
damage.
• Improper Supervisory Example (The
Engineer changed the journey plan and
advised the driver to take short cuts/gatch
road and did not stop him from over
speeding)
• Inadequate Audit/ Inspection/
Monitoring (Driver’s RAG reports were not
used to coach the driver with history of over
speeding)
• Inadequate Correction of Worksite/ Job
Hazards (Lessons from prior Road Traffic
Accidents were not effectively communicated; No tool Box Talk was
conducted for drivers)
Lesson Learned
Immediate Causes
1. Always drive within posted speed limits and
reduce speed according to rad conditions
2. Conduct Tool Box Talks for drivers and
empower them to not let any passenger to
change journey plan
3. Passenger/s should stop driver from over
speeding, taking short cuts and from driving recklessly.
• Violation by Individual (The driver was
driving fast in excess of posted speed limit)
• Violation by Supervisor (The Engineer
did not stop driver from overspending)
11
Crane Mounted Truck (Hiab) Rollover on Gatch Road Area Incident Description Root Causes
Engineering
& Projects
BAB
28-08-12
A crew consisting of a Rigger & Operator of
Crane Mounted Truck (Hiab) were instructed by
their Engineer drive the truck to work site and
lift pre-cast materials. The crew left their camp
and was proceeding to the location.
They were travelling on a gatch road parallel to
an existing pipeline. This road contained many
pot holes and the surface was wet/ slippery
due to high humidity. The driver was
attempting to drive around potholes and made
a sharp maneuvering of steering followed by harsh brakes.
It resulted in vehicle to get out of control. The
rear end of the vehicle spun around in the
opposite direction and then rolled over on
passenger side against the pipeline berm.
Outcome: The vehicle rolled over to its side on
the berm of the pipeline. Driver and passenger
sustained minor injuries as they were wearing
seat belts.
• Inadequate Audit/ Inspection/
Monitoring (Driver had history of
applying harsh brakes and harsh
acceleration and his driving behavior
reports were not effectively reviewed to
initiate counseling/ coaching on the skill)
• Inadequate Identification of
Worksite/Job Hazards (Hazards
associated with the journey (i.e. gatch
road condition and high humidity) were
not identified)
Lesson Learned
1. Avoid applying harsh brakes and sharp maneuvering of steering when driving off
road.
2. Review drivers’ driving behavior reports
and provide coaching and counseling to
risky drivers
3. Subject drivers to daily tool box talks to
discuss route hazards and to reinforce
safe driving behaviour
Immediate Causes
• Improper Decision Making/Lack of
Judgment (The driver applied harsh brake
and sharp maneuvering of steering to avoid
pot hole on the gatch road)
• Work or Motion at Improper Speed (The
vehicle was driven on gatch road at a speed
between 20 to 45 kph with a sudden
acceleration to approx. 58 kph followed by
a harsh breaks immediately prior to the
incident)
12
Vehicles Collision
Area Incident Description Root Causes
Engineering &
Projects
BAB
04-09-12
A 3rd Party mechanic was working on a broken down
vehicle near the road side a replacement tire was
requested from their base camp in Mussafah. A truck
carrying the replacement tire arrived and stopped on
the road side. The mechanic requested the driver to
move the truck on the opposite side.
A project driver involved was transferring staff to and
from difference locations since morning and was
making a trip to collect three passengers from Bab
Central Degassing Station (BCDS) to their Camp. The
driver was driving 128 km/Hr on a road with a speed
limit of 80 km/Hr.
The project driver was over taking the truck whilst
the truck started to turn left. Outcome: The project
vehicle collided with the front tire of the truck. Two
passenger sustained minor injuries and the vehicle
sustained moderate damage.
• Inadequate Audit / Inspection
/Monitoring (Drivers driving behavior
and driving assignments were not
adequately monitored)
• Improper Performance to save time
(The driver was involved in transferring
passengers to & from different locations
since early morning and was rushing to
the camp for mid-day break)
• Inadequate Identification of
Worksite/Job Hazards (In Vehicle
Monitoring System (IVMS) was
reconfigured so that speeding event
below 130 km/Hr were not recorded as
system violation)
Lessons Learned
1. Always follow the posted speed limits
and do not over speed.
2. Use vehicle signal before maneuvering
vehicles even on a short journey
3. Monitor the driving behavior of
new/inexperience driver more frequently
Immediate Causes
• Violation by individual (The driver was
overspending (128 km/Hr on a road with a speed
limit of 80 km/Hr)
• Improper Decision Making (The truck driver
started to turn left without using indicators/
signal)
13
Crane Rollover During Move on Gatch Road
Area Incident Description Root Causes
Engineering
& Projects
BAB
26-09-12
A 25 Tone Grove Crane, was mobilized on site to load /
offload piping materials from various locations within the
vicinity of RDS-8 Transfer Line area. The crane reached
the site at around 06:30am and started off-loading pipe
supports from the trailer truck. The crane being moved
between locations (approximately 100 meters apart) to lift excess pipe supports. The crane operator was
following the pick-up vehicle (boarded by the Rigging
Foreman) and the trailer truck on gatch road, parallel to
the transfer line.
There was slope between the two gatch roads and the
pick-up and trailer truck managed to drive across the
bank and reached the elevated gatch road.
As the crane tried to ascend on slope (with crane boom
not fully folded), the crane lost the balance causing it to
roll over to its right side. Outcome: The operator
managed to exit the crane cabin safely through the cabin
door and the crane sustained minor damage.
• Inadequate Supervisory Example
(Rigging Forman did not ensure the
suitability of the track)
• Inadequate Audit / Inspection/
Monitoring (Job Performer (JP) was
away supervising another crew and
the crew moved without his
knowledge)
Lesson Learned
1. Do not move heavy equipment from
one location to another location
unless track conditions are inspected
and are found suitable.
2. Ensure Crane boom is fully folded and
hook block secured when moving
crane, to maintain stability of the
equipment
Immediate Causes
• Violation by Individual (The operator did not fully
fold the boom of the crane and did not lock the hook
block while moving the crane)
• Violation by Supervisor (Rigging Foreman did not
assess the road conditions and asked the crane
operator to follow the vehicle)
14
Water Tanker Rollover
Area Incident Description Root Causes
Drilling
21-07-12
For a cementing job, 500 barrels (bbls) of
freshwater delivery was required at the rig site
and an urgent delivery request was sent to water
supply contractor. The contractor assigned
tankers & drivers were not available and therefore
a new driver and a tanker was sent from Musafah
Base to make this delivery. The driver did not
have ADCO Safe Driving Document (ADSD) and
the vehicle was not fitted with In Vehicle
Monitoring System (IVMS).
It was the first day of Ramadan and the driver
missed his Dinner & Sahur and made a delivery of
water. After the delivery he went back to his
camp to refill tanker and then again proceeded to
the rig site for another delivery. The air
conditioning system in driver’s cabin was not
working and it was a hot day and the driver was
working in excess of six hours. During the trip the
driver felt dizzy and lost control of the tanker. It
resulted in tanker to rollover. Outcome: The
driver escaped unhurt and the tanker sustained
minor damage.
• Inadequate Leadership (Knowingly an
untrained driver was assigned on the task)
• Inadequate Work Planning (Request for
supply large quantity of water was made
without ensuring availability of contractor’s
resources)
• Inadequate Audit/ Inspection/
Monitoring (There was no monitoring
system in place to check contractor
compliance with contractual requirements
for the safety of driver and vehicles)
Lessons Learned
1. Assess availability of contractors’ resources
prior to issuing task order.
2. Monitor contractor compliance with
contractual requirements for the safety of
driver and vehicles.
Immediate Causes
• Violation by Supervisor (A new driver,
without ADSD was assigned to the task;
Unauthorized vehicle was used)
• Defective Vehicle (Air conditioning unit in
driver’s cabin was not working)
• Work Exposure to Temperature Extreme
(The driver was fasting, working over 6 hours
during peak summer hours in hot cabin of the
water tanker)
15
Hand Entrapment Inside Tong
Area Incident Description Root Causes
Drilling
NDC Rig 21
03-08-12
While an inexperienced tubular services
operator was working as a tong operator, he
had his left hand at the top of the tong rotary
while the other hand was on the lever
adjusting the tong rotary.
His supervisor left the Rig Floor leaving the
operator alone before completing the job.
When he started to operate the tong, the tong
jumped resulted in slippage of his left hand
which got trapped inside the tong.
Outcome: Tong Operator sustained an open
displaced fracture on his left hand.
• Inadequate Leadership (Senior Operator
left the inexperienced operator at the rig floor
before completing the job; Rig crew did not
stop “Green Hat” – (New or Inexperienced
Worker) from working alone)
• Inadequate Identification of Required
Skill or Competency (Inexperienced
operator was not adequately coached on
required skills to work independently)
Lessons Learned
1. Do not leave in experienced staff (Green Hat)
workers unsupervised at hazardous locations such as Rig Floor
2. Include all sequence of works (such as
operations as well as any repair/
troubleshooting) in Job Safety Analysis (JSA)
Immediate Causes
• Improper Posture/Position for the
Task (The operator had placed his hand on
the top of tong rotary while adjusting the
rotary)
• Lack of Knowledge of Hazards Present
(The Supervisor left the operator working
alone on the rig floor; the operator was not adequately trained to recognize pinch
points on power tongs)
• Work Exposure to Mechanical Hazards
(Power Tong at Rig Floor)
16
Electrical Shock
Area Incident Description Root Causes
Drilling
NDC Rig 55
06-09-12
The electrical panel door of the fire unit fall down
due to broken hinges (caused by the deterioration
of pin in the hinges) resulting in cables
cut/damage inside the panel.
An isolation certificate and permit to work was
issued. The damaged/cut cables were
fixed/replaced by an electrician. After electrical
cables were fixed, the electrician restored the
power supply and started to check cables voltage
using a portable voltmeter. During the process an
electrical spark occurred.
Outcome: It has resulted in a second degree
burn on electrician’s right hand thumb.
• Inadequate Practice of Skills (The electrician
did not systematically check the electrical system
and did not ensure physical protection from
coming in contact with live conductor)
• Excessive Wear & Tear (Due to harsh climatic
conditions and rig move, hinge pins were
deteriorated)
Lessons Learned
1. Always follow systematic way of checking
electrical circuit
2. Stay clear of live conductors when servicing
energized electrical system
3. After each rig move visually check the integrity of
hinge pins
4. Conduct trade relate workshops for experience
electricians to share their knowledge and incident
lessons learned.
Immediate Causes
• Servicing of Energized System (The
Electrician was checking cables voltage using
a portable voltmeter on a live system)
• Improper Decision Making/Lack of
judgement (The Electrician made a physical
contact with a live conductor)
17
Worker’s Finger Entrapment Between Pipe Flange and Valve Flange
Area Incident Description Root Causes
South East
(SE)
Asab Field
08-07-12
Well work-over was completed and a Field
Services crew was working to fix a 2” valve on
bleed-off line. Emergency response plan and PPE
were discussed in Tool Box Talk (TBT) and the
work started.
There was no dedicated banksman and the
Foreman himself was directing the Crane
Operator. The crew included a newly hired
laborer.
The bleed valve with the spool was lifted and the
laborer was holding the T-piece with valve during
alignment. When the load moved, his left hand
index finger got trapped and crushed between the
pipe flange and valve flange.
Outcome: The foreman stopped the operation
and transferred the injured person to RAMS Clinic
for treatment. Laborer sustained fracture to his
finger.
• Inadequate Work Planning or Risk
Assessment Performed (No dedicated banksman was used; & inexperienced
laborer was assigned to assist a crew
involved)
Lessons Learned
1. Do not assign inexperienced laborers on
new activities.
2. Ensure crew members are aware of task
related hazards through effective Tool Box
Talk (TBT).
Immediate Causes
• Improper Position or Posture for the Task
(Inexperienced worker wrongly positioned his
left index finger between the two flanges
during alignment)
• Improper Decision Making/Lack of
Judgment (Foreman was also acting as
Banksman losing focus on supervision)
• Lack of Knowledge of Hazards Present
(An inexperienced and untrained laborer was
assigned to the job)
18
Transformer Fire
Area Incident Description Root Causes
NEB
25-07-12
In oil train 1, at 2nd stage Desalter, flash over
occurred at the transformer (secondary high
voltage) cable located at a height of 12 feet.
The flash-over was detected by the UV/IR
detectors.
Outcome: Control Room Operator (CRO)
alerted electrical team who isolated the cable.
After the isolation fire was extinguished using
CO2 fire extinguisher.
It was the third similar incident in NEB
involving melting of high voltage bushing (or
high voltage cable).
• Inadequate Preventive Maintenance (High
Voltage Busing were not changed as per vendor
recommendations and Desalter oil samples were
not tested)
• Tools & Equipment - Inadequate Availability
(High Voltage Busing and oil tester were not
available)
Lessons Learned
1. Oil samples should to taken from all desalters to
evaluate the condition of High Voltage Bushings
2. Evaluate condition of the HV bushings during the
regular maintenance periods
3. Ensure availability of critical spare parts such as
High Voltage Bushings at all times
Immediate Causes
• Violation by Group (Maintenance
Procedures as per Vendor Instructions were
not fully followed due to non-availability of
oil tester)
• Inadequately Prepared Equipment
(High Voltage Bushing Replacement was
not carried as per vendor
recommendations)
19
Fire in UPS Unit of Substation
Area Incident Description Root Causes
NEB
08-07-12
Dabbiye’a has two substations and each
substation has 2 AC- Uninterrupted Power
Supply (UPS) units. Each UPS unit is equipped
with cooling fan to cools different components
such as capacitors, transformers and power
electronic devices.
Due to frequent voltage fluctuation (from
external power supply source), capacitors’
performance was compromised. After such
voltage fluctuation event, a capacitor burnt and the fire spread within the UPS system and
extended to the major components within the
cabinet. Fire Auxiliary Team responded and
extinguished the fire.
Outcome: It resulted in damage of two power
transformers, static switch module, cooling fans
and few capacitors. The plant was manually
shutdown on Emergency Shut Down-1.
• Engineering Design – Inadequate
Assessment of Potential Failure
(Capacitor surpassed their material life
and were subjected to wear & tear due to
power fluctuation)
• Materials Shelf life Exceeded
(Manufacture identified capacitor’s life
span as 14 Years and after the incident it
was corrected as 7 years)
Lessons Learned
1. Provide adequate spacing and ventilation for
UPS and other electrical devices for cooling
2. Provide adequate spacing for maintenance.
3. Before accepting reliability value of systems,
study proving the calculated reliability to be
submitted.
Immediate Causes
• Inadequate Equipment (Premature
failure of capacitor due to power
fluctuation)
• Inadequate Ventilation (Cabinet units
were stacked close to the wall, not
providing adequate ventilation)
20
Vehicle Drop in Low Lying Area/Depression
Area Incident Description Root Causes
Buhasa Field
(BUH)
22-08-12
A mechanical foreman was returning to the
workshop from a wellsite (CL-29) and he was heading the wrong way. His colleagues
(passengers) in the vehicle advised him to
proceed in the opposite direction. He turned
the vehicle and started to drive in the desrt
to get on the designated track. There was a
low lying area /depression in the sand and
the vehicle slid down and made contact with
the bottom of the dune.
Outcome: The vehicle sustained minor
damage on the front-end bumper.
• Inadequate Practice of Skill
(Driver u-turned into non-
designated route instead of
remaining on track)
Immediate Causes
• Improper decision making/lack of
judgment (The driver did not return
back to original track but tried to go
another way to merge with the main
track)
• Inattention to surroundings (He did
not pay attention to surface conditions
and was focusing to get on the
designated track)
Lesson Learned
1. Always take the designated
to avoid the risk of unstable
ground conditions.
21
Breakage of Hook of Wire Rope
Area Incident Description Root Causes
Buhasa
Field
(BUH)
10-08-12
A Foreman was driving to a well site (BU-559)
and his vehicle got stuck on a sand dune. He
requested assistance from the transport pool.
Transport Pool Driver reached the site and
tried to pull the stuck vehicle using a wire rope with his own vehicle.
While pulling the vehicle from the rear side, the
wire rope's hook broke and struck against the
foreman-vehicle’s rear window. Outcome:
Rear window of the vehicle was completely
smashed.
• In adequate removal/replacement of
tools & equipment (The slings in the older
desert safety boxes were not checked/
replaced)
Lesson Learned
1. Check adequacy of tools available for in
vehicle tool box.
2. Always check if the slings are
certified/checked, and suitable for pulling
the vehicle prior to use.
Immediate Causes
• Inadequate Tools or Equipment (The
sling used was not suitable for the job)
22
HSE Performance, Q3, 2012 (YTD)
Historical Vs Q3 2012 (YTD) HSE Performance
29
27
34
47 5
6
55
44.4
32.3
32.5
57.3
6
118.9
2
123.9
5
0.630.55
0.360.28
0.16 0.160.29
0.12
0.34
0.26 0.090.06
0.700.66
0.800.68
0.550.51
0.81
0.93
1.29
0.78
0.340.50
0
20
40
60
80
100
120
140
0
0.2
0.4
0.6
0.8
1
1.2
1.4
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 YTD2012
Mill
ion
M
an
ho
urs
W
ork
ed
Lo
st
Tim
e In
jury
Fre
qu
en
cy R
ate
/ T
ota
l R
eco
rdab
le In
jury
R
ate
YearManhours Actual LTIF TRIR
23
Incident Sub Types Q3 – 2012 (YTD) (Work & Non-Work Related – 247 Events)
Injury/Illness
47%
Transportation
30%
Onshore Spill
13%
Fire
7%
Gas Release
3%
24
Asset Wide Incident Sub Types Q3 – 2012 (YTD)
25
Asset Wide Incident Sub Types Q3 – 2012 (YTD)
26
Incident Sub Types Asset Wide Q3 – 2012 (YTD)
27
28
Incident Immediate & Root Cause Categories Q3-2012 (YTD)
Immediate Causes
Root Causes
Repetitive Immediate Causes
Cause Repetitiveness
Improper decision making or lack of judgment 9%
Violation by individual 7%
Lack of knowledge of hazards present 7%
Inattention to footing and surroundings 4%
Improper position or posture for the task 3%
Repetitive Root Causes
Case Repetitiveness
Inadequate identification of worksite/job hazards 9 %
Inadequate training 7 %
Poor judgment 7 %
Improper supervisory example 5%
Inadequate work planning 5 %
29
Incident Immediate Cause Analysis Q3-2012 (YTD)
Violation by individual One individual intentionally chose to violate an established safety practice.
Improper position or posture for the task
The person did not follow the human kinetic practices. The person was working on an unsafe, unstable or non-standard work floor or was placing body parts in unsafe positions.
Violation (by supervisor):
A supervisor or other management person either personally violated an established safety practice
Improper decision making or lack of judgment
This cause is the opposite of violations. Unintended human error can consist of perception errors, memory errors, decision errors or action errors. A person’s job performance was affected by their inability to make an appropriate judgment when confronted by an ambiguous situation.
Inattention to surroundings:
The person was not alert to their surroundings and just tripped or ran into something that was clearly visible and obvious.
Routine activity without thought
The person involved was performing a routine activity, without conscious thought, and was exposed to a hazard as a result
30
Lack of
knowledge of
hazards
present
56%
Personal
Protective
Equipment not
used
17%
Equipment or
materials not
secured
16%
Use of Protective Methods
Lack of Knowledge of Hazards Present
The worker was not aware of risks associated with the task performing
PPE Not Used
The equipment or methods necessary in this situation were not used by the person doing the work.
Equipment or Materials not Secured
The tools, material or equipment in use were placed in a position creating a hazard, for example, tools placed overhead fell and struck the person or a truck was parked on a slope and rolled down
31
Asset Based Incident Immediate Cause Analysis Q3-2012 (YTD)
32
Incident Root Cause Analysis Q3-2012 (YTD)
Inadequate audit
/inspection/ monitoring Supervisors did not monitor, inspected or audited the work as planned.
Inadequate Work Planning
The work being done was not planned or was not risk assessed prior to starting that work.
Inadequate preventative maintenance program
The tools or equipment involved in the incident were not covered by a preventative maintenance program, and became unserviceable.
Inadequate identification of
worksite/job hazards
The incident was caused by the failure to perform or properly
respond to a loss exposure study, such as Job Safety
Analysis.
Inadequate Leadership The leaders in an area did not set the right direction or tone
for safety or allowed roles and responsibilities for safety
activities to be unclear or undefined.
Inadequate Supervision
33
Inadequate Training
Some training was conducted, but it did not accomplish the necessary knowledge transfer.
Inadequate Training efforts Training did not accomplish the necessary knowledge transfer, due to such factors as training program design, or poor means to determine if students have indeed mastered the material being taught.
Improper supervisory
example
Supervisors not giving the proper example to the people working in their organizations.
Inadequate Behavior
Employee perceived haste
The incident was caused by the employee’s perception that speed in completing the work was required causing laps in safety considerations.
34
Asset Based Incident Root Cause Analysis Q3-2012 (YTD)
35
Asset Top Two Repetitive Immediate
Causes
Top Two Repetitive Root Causes
BAB Lack of knowledge of hazards
present
Equipment or materials not secured
Inadequate correction of prior
hazard/incident
Improper supervisory example
BUH Improper decision making or lack of
judgment
Inattention to footing and
surroundings
Inadequate vertical communication
between supervisor and person
Inadequate preventive maintenance
E & P Violation by individual
Improper decision making or lack of
judgment
Inadequate training
Inadequate identification of worksite/job
hazards
NEB Violation by individual
Improper decision making or lack of
judgments
Improper supervisory example
Inadequate assessment of potential failure
SE Improper decision making or lack of
judgments
Routine activity without thought
Poor judgments / Lack of coaching on skill
Inadequate work planning
TPO Defective equipment
Inadequate guards or protective
devices
Improper supervisory example
Inadequate identification of worksite/job
hazards
Technical
Services
Lack of knowledge of hazards
present
Improper decision making or lack of
judgments
Inadequate identification of worksite/job
hazards
Inadequate leadership/ Improper
supervisory example
36
Focus Areas Q3-2012 (YTD)
37
Quiz Name:______________________________________________________
Designation: _________________________________________________
Staff No: ____________________________________________________
ADCO Asset or Company Name: _________________________________
Contact Number: ______________________________________________
Incident Title True False
1. Damage to Underground Fiber Optic Cable During Excavation
As built drawing did not show location of buried fiber optic cables.
JP was a member of Task Risk Assessment (TRA)
2. Crane Mounted Truck (Hiab) Rollover on Gatch Road Due to high humidity, the gatch road surface became slippery.
Driver applied harsh brakes and sharp maneuvering of steering on slippery road
3. Vehicles Collision on Gatch Road There was no sign or marking when approaching the blind spot
The project vehicle was driven in wrong lane
4. Arm Injury Due to Explosion During CAD Welding
Electrician was subjected to tool box Talk and crew was made aware of hazards of CAD Welding
The activity was stopped by the Job Performer but crew continued the work
5. Fire at Scaffolding Platform Around Stripper Column Accumulation of combustible waste material near welding area was not noticed
Supervisor did not visit the site before and after the completion of hot work
6. Foreign Object Entering Eye of a Worker
Workers were not adequately made aware of hazards of working on a windy day
Risks of rubbing eyes when a foreign body enters eye were known
7. Vehicle Rollover on Gatch Road The Engineer changed the journey plan and advised the driver to take shortcuts
Driver’s RAG reports were regularly reviewed
8. Crane Mounted Truck (Hiab) Rollover on Gatch Road The road surface had holes and was wet/ slippery due to high humidity
The driver applied harsh brake and sharp maneuvering of steering
38
9. Vehicles Collision Drivers driving behavior and driving assignments were not adequately monitored
The driver was driving 128 km/Hr on a road with a speed limit of 80 km/Hr.
10. Crane Rollover During Move on Gatch Road Rigging Forman did not ensure the suitability of the track
The operator did not fully fold the boom of the crane
11. Water Tanker Rollover
A new driver, without ADSD was assigned to the task
Air conditioning unit in driver’s cabin was working
12. Hand Entrapment Inside Tong The Supervisor left the operator working alone on the rig floor
The operator had placed his hand on the top of tong rotary
13. Electrical Shock The Electrician was checking cables voltage using a portable voltmeter on a live system The Electrician made a physical contact with a live conductor
14. Worker’s Finger Entrapment Between Pipe Flange and Valve Flange
Inexperienced worker placed his index finger between the two flanges during alignment
Foreman was also acting as Banksman
15. Transformer Fire Maintenance Procedures were not fully followed
Desalter oil samples were regularly tested
16. Fire in UPS Unit of Substation Cabinet units were stacked close to the wall
Capacitor were not subjected to wear & tear due to power fluctuation
17. Vehicle Drop in Low Lying Area/Depression The driver did not return back to original track
Driver was driving on non-designated route
18. Breakage of Hook of Wire Rope
While pulling the vehicle from the rear side, the wire rope's hook broke
The sling used was suitable for the job
Please hand in the quiz to your Asset HSE Focal Points for assessment
39
Do Not Compromise on the Safety of Staff & Workers, Protection of the Environment and Integrity of Assets
ABU DHABI COMPANY FOR ONSHORE OIL OPERATIONS
(ADCO)
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