BG Group

Communication Pack

Learning the lessons

ELNG Construction Site Train 2, Idku Egypt - Fatal Incident on 21st March 2005

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Contents

• Incident description

• Findings

• Improvement actions

• Way forward

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• Incident on Train Two 54” stainless steel Ethylene Line from Cold Box involving Aresco subcontractor workers

• Leading activity was welding ethylene line to Cold Box

• Grinder asphyxiated by Argon gas inside pipe during seal weld preparation activities

• Scaffolding supervisor, pipe fitter and 2nd grinder asphyxiated by Argon gas inside pipe during failed rescue operation

ELNG Fatal Incident – 21 March 2005

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ELNG Idku - Location of Incident

Compressor DeckColdBox

ArgonSupply

Scaffolding

35m

FoamSeal

Location Of Weld

4”line

• Argon purge and shield gas being controlled from roof

• Welders complete first two welds on 54” incident pipe

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ELNG Idku Fatalities – 21 March

• Deceased #1 and Welder enter 54” incident pipe at compressor deck with tools and equipment to perform seal weld

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ELNG Idku Fatalities – 21 March

• Deceased #1 dies and Welder exits and raises alarm

• Deceased #2 and #3 enter pipe in rescue attempt

• Deceased #4 enters later

• 4” pipe cut at Cold Box end to allow air into 54” pipe

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Surface Causes

• Asphyxiation assumed to have been caused by Argon gas that accumulated in low point at end of line

• Worker entered confined space with argon gas present

• No permit for confined space entry or work

• Personnel not trained in confined space entry and hazards

• Gaps in supervision, coordination and communication during work

• Delayed notification and uncoordinated emergency response

• Gaps in compliance to project permitting procedure

• Gaps in Supervision of Project HSE Plan

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Contributory Causes

• Inadequate allocation of safety responsibility (in practice, Bechtel’s safety dept is in charge of safety)

• Insufficient supervision level of sub contractors by Bechtel. Minimum control of method statements

• inadequate site-wide hazard identification

• Poor design constructability for 54” line

• Lack of coordination and communication at various levels e.g. Bechtel/sub contractors

• Inappropriate incentives scheme

• Lack of competency assessment in training process (risk specific)

• Limited scope of contractual HSSE obligations to cover full scope of work and limited contractual recourse

• Insufficient resources for effective supervision

• Recognised cultural issues not sufficiently addressed

• Auditing at all levels not sufficient to verify compliance with Project procedures

• Inadequate emergency response planning system

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Main Improvement Actions

• Management & Leadership– Increase the quantity and quality of supervision levels at the work-face– Conduct hazard identification studies of all activities– Review coordination and communication activities– Perform an independent safety management evaluation

• Policies, Standards & Procedures– EPC contractor and ELNG to review Method Statements for all high

risk activities.

• Behaviours / People– Behaviour-Based Safety initiative will be reinforced – BG Egypt and ELNG to review training programme and ensure

competency based testing is implemented

• Work planning– BG Egypt to monitor implementation of audit plan at formal project

review meetings

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Next Steps

• HSSE Away day for GEC on 27th May to review high level implications for BG Group and agree performance step change

• Regional workshops, led by respective EVP & MD’s, discuss implications and way forward for own Region with support from Group HSSE.

• Cascade by AGM’s to own Assets during Town Hall meetings

• Time out for safety and/or stand downs at all BG sites led by line management to review incident findings and discuss implications for own site and/or activities

• Project and Operations managers will formally present, to their Asset Management Teams, arrangements in place to prevent similar disasters

• AGM’s to provide assurance that actions have been taken to assess risks and mitigating measures implemented

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Way Forward

• Consolidation of feedback from:– Safety Meetings led by AGMs– Time Outs For Safety and/or Stand Downs in the Assets– Regional Workshops– GEC Safety Away Day

• Development of an improvement framework and action plan for the next performance step change

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Implications for BG X [Asset name]

• This is an Asset-specific slide where the AGM needs to:

–Flag own risks (e.g. unskilled contracted workforce, land transport, new projects, …)

–Compare with causal factors from fatal incident–Review existing controls–Trigger a debate on the adequacy of controls and

tease out ideas

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Incident Investigation Process

• First BG management visit was on 22nd March. Jorn Berget, Stuart Fysh, Malcolm Brown, Ray Betros visited ELNG site, held discussions with local staff and agreed to a joint stakeholders investigation team (led by Bechtel)

• Frank Chapman appointed Jorn Berget to lead an independent BG team to review findings of the Bechtel-led investigation and to identify high level lessons for the BG Group

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Independent Investigation Team

• Review team (Jorn Berget, Ray Betros, Nebil Younes, Ross Michie, Peter Joyce) visited Egypt from 30th March to 1st April.

• Findings of the Bechtel investigation reviewed and fully supported

• Other causes identified:– Group implication

• Several “Immediate Actions” were discussed and agreed with Bechtel

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Immediate follow up

• Improve physical barriers including Train 1 segregation and security inspectors

• Review of all site permits and procedures and communicate to workforce

• Tighten Safe Work Permit systems (CSE, Hot Work, Live Electricity etc)

• Review the Emergency Response System

• Zero tolerance of major Safety rules violations

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Completed actions

• Stand down (x 2) of ELNG site and presentations of incident facts to ELNG Staff and Board

• Presentation of findings to Frank Chapman, GEC, Board and at senior managers workshop by AGM, Jorn Berget and Head of HSSE

• Guidance on inert gas and confined space entry precautions including best practice and case studies issued by Group HSSE to all BG group Assets

• Letters from Frank Chapman to all staff and to AGMs on progress and requirements

• Communication Pack produced by Group HSSE