FP fatality review. Safety initiative involving all Personnel

Transcription

1 FP fatality review Safety initiative involving all Personnel

2 16 Fatalities over the period (including 3 road accidents) Algeria / Enafor 21 / fall of rack Qatar / Key Hawaï / hit by side entry sub Libya / BD1 / fall of stabbing board Argentina / Aguada Pichana / line whipping (2) Nigeria / Jack Ryan / fall during crane load test Gabon / SMP 102 / struck by flare line Nigeria / MG Hulme / fall of samson post Iran / Kharg / truck accident Libya / supply vessel / hit by venting hose Gabon / truck accident UAE / Gus Androes / hit by pressurized carter Yemen / truck accident Nigeria / Sedco 700 / fall thru elevator UK / GSF Magellan / man riding accident Nigeria / Jack Ryan / fall of tea-cosy

3 Common causes at origin If we exclude the road accidents, there were 13 fatalities directly linked to our metier. These accidents are of different nature, nevertheless we can find some recurrent causes: Operations were wrongly considered as Routine Hazards were not thoroughly evaluated Some basic procedures were not respected Preparation was incomplete Fall from Height 15% Categories of fatal accidents ( ) Man Riding 8% Dropped Objects 31% Hidden Energy 46% The following review of each accident allows to identify major weaknesses 3 - FP Fatality review -

4 UK GSF Magellan 09/10/2000 Man riding accident Man rider was crushed to death inside the mouse hole housing. Man rider not in direct view of tugger operator BOP area man riding tugger not used as in bad position and not rigged up JSA and PJM not properly conducted. Man riding to be done only when no other solutions exist. Special care to be applied in job preparation (JSA & PJM) Rig Contractor Supervision to be present Under Rig Floor (URF) operations to be managed from URF. 4 - FP Fatality review October 2010

5 Nigeria Transocean MG Hulme 18/03/2003 Samson post failure The Assistant Driller was found on the deck with severe head injuries. Alongside him was a Samson Post (pipe rack post) which had fallen from its vertical position. Fixation of post to deck not appropriate and not inspected (failure of the circumferential weld at base of Post) Crack in post weld was noticed before accident but no action was initiated Posts are receiving repeated shock impacts but are not included in PMS for inspection. Posts strengthening / fixation to deck to be designed and adapted to supported efforts Posts to be included in PMS Use of Anomaly reporting program (eg. STOP cards) Hazard not evaluated Reporting system not effective 5 - FP Fatality review October 2010

6 Libya Al Jurf NICO Raysut supply vessel 01/08/2003 Venting hose whiplash A 4 hose was lowered over the side of the vessel into the sea to prevent dust clouds during venting. To keep the hose submerged, extra weight had been secured to its outboard end. Pressure was suddenly released causing hose to whip out of the sea onto the deck. A crewman was struck at head by weight. Poor working practices No detailed written procedures and no JSA conducted Previous incidents of hoses whipping reported in the fleet but not acted on by management Lack of safety awareness among the crew Poor communications, level of supervision and management of operations onboard. Hose venting procedures to be detailed (validated by JSA) and followed Crew training program to be provided to develop safety awareness Hose laid overboard Hose after it whipped back onto the deck Details of weight attached to hose Approx. position of man when struck by hose Poor level of supervision Procedures not prepared 6 - FP Fatality review October 2010

7 Algeria ENAFOR 21 21/03/2004 Rack fall over A storage rack had been placed on its side for repair. While maneuvering, a forklift truck hit the rack which toppled over and struck a Floorman. Storage rack Placement of rack in a vertical position without securing it Maneuvering a large forklift with limited visibility Personnel not trained to drive forklift Organization of work on site not controlled Safety awareness, qualification and training of personnel deficient. Gas cylinders Position of roughneck Forklift to be operated only by qualified drivers Enforce culture of job preparation (Risk Analysis / Permit to Work / Pre-Job Meeting) Promote use of Anomalies reporting Implement effective site supervision and daily site inspection. Workshop container 7 - FP Fatality review October 2010 No job preparation No anomalies / UAC reporting No effective Supervision

8 Qatar GSF Key Hawaii 05/07/2004 Side Entry Sub accident A Side Entry Sub (SES) was made up to test string and test assembly connected. The back up tong placed above the SES could not grip. When applying torque with TDS the SES quickly rotated and test assembly struck the Floorman who was holding the tong. Reconstruction Lack of job preparation (Testing procedure incomplete, JSA only generic / JSA process not fully understood / PJM with crew not done / Supervision and organization deficient) Lack of risk awareness Difficult communication within the crew members. No attachment of testing assembly to SES until all string connections are made up to full torque Promote safety and risk awareness Call for Time Out for Safety in doubt During PJM Supervisors to ensure instructions are understood and JSA used as support to highlight hazards. 8 - FP Fatality review October 2010

9 Libya Saipem AZ /10/2004 Fall of casing board While running casing the stabbing board dropped and fell some 14 m on the floor hitting the Driller. No JSA conducted / no PTW issued No respect of procedures / no basic safety precautions applied Use of non certified lifting equipment Stabbing board and Safety devices not included in rig's PMS. Back-up anti-fall device is recommended to prevent board fall Safety dogs to be inspected / tested as per PMS Adequate training to use the board to be given & recorded JSA & PTW to be carried out before job Stabber safety line to be attached to derrick structure (not to stabbing board) Derrick track stops to be installed and able to support impact of falling board. Hazard not evaluated Lack of job preparation Non respect of procedures 9 - FP Fatality review October 2010

10 UAE Noble Gus Androes 10/10/2006 Pressurized gear box failure The objective was to partially drain a gear box in order to move its level sight glass to a lower position. A scaffolding was erected to allow Roustabout to monitor the oil level drop. Suddenly, a huge bang was heard. Roustabout was found unconscious on the scaffolding and died soon after. Victim was unaware of pressure hazard and took an uncontrolled initiative (use of 8 bar rig air supply to speed-up gear box draining) Lack of direct supervision PTW & JSA did not cover draining task considered as non-hazardous Poor understanding of safety messages due to language issue on rig. Procedure not respected Role of Supervisors critical in ensuring their teams are working safely Supervisors to conduct PJM to ensure instructions are clear and JSA used to highlight job hazards to the team FP Fatality review October 2010

11 Nigeria Transocean Jack Ryan 05/10/2008 Dropped Object from Xmas Tree While landing a Xmas tree (XT) on trolley, the crane main hoist hydraulic motor failed. The 50 ton XT free fell on trolley and tea cosy bounced off its pedestal. Toolpusher was struck by the tea cosy. Tea Cosy pedestal White circle : Tea Cosy : - in crane control: Main motor replaced by an incorrectly sized motor a week before No deep investigation done following first failure. - in operational control: Tea cosy not fully secured on pedestal as not considered necessary Sudden shock due to XT free fall not identified as a hazard and XT free fall not considered in JSA. PMS spare traceability to be audited to detect failures Design process of XT not only to focus on final use of product, but also on packaging, fastening, lifting, transportation and installation conditions & hazards Tea Cosy final position Position of victim 11 - FP Fatality review October 2010

12 Nigeria Transocean Sedco /09/2009 Fall through hatch The Night Barge Master entered column elevator to access to ballast pump room and stepped inside the elevator. He fell through the hatch down to the bottom of the elevator shaft (40 m high) Poor visibility inside elevator cabin Hatch not identified as a critical part in elevator inspection program Elevator not certified Access to column was a routine task Anomaly reporting procedure not effective (hatch cover hinges were previously broken and failures had not been reported) Elevators to be certified by Contractor approved 3 rd Party and specific maintenance & inspection standards to be defined and applied Any hatch on rig to have a Contractor approved design Column Entry Procedure to be respected Incident / Anomaly Reporting Program to be in force A Corrective Action Tracking System to be implemented to address unsafe acts or conditions. Hazard & Criticality of equipment not evaluated Access considered as routine Hatch opening 12 - FP Fatality review -

13 Argentina Aguada Pichana Field 26/01/2010 Temporary line whiplash / 2 victims A wireline team was trying to retrieve gauges without success. It was decided to vent the well to free the tool. During the flaring process through a temporary line, a strong blast occurred and the temporary line suddenly whipped out of control and hit 2 operators. Temporary line not anchored and not properly connected to wellhead No means to immediately and remotely stop the flow due to the absence of a Surface Safety Valve. Poor Risk Analysis performed Non respect of operations working procedures (temporary line not secured) Non respect of Work Permit procedures Lack of Safety awareness from the wireline team. Excess of confidence of team. Hazard not evaluated Operation considered as Routine 13 - FP Fatality review -

14 Nigeria Transocean Jack Ryan 31/07/2010 Crane failure during load tests During a dynamic load test on Crane the crane boom collapsed overboard tearing out the crane cabin & causing the fall overboard of 3 personnel. 2 injured personnel were rescued but the surveyor was reported missing. Poor Risk Appreciation Lack of Supervision / Management Control Crane Operator required for another job and replaced by Deck Pusher without proper handover Test performed under field conditions with static values. Criticality of load test activity underestimated: Preparation and Supervision not adapted Dynamic charts should always be used for lifts from / to vessels Crane load tests not to be done in open seas but in sheltered waters or harbor conditions RCI calibration to be done regularly and verified before load tests are conducted. Criticality of job underestimated Preparation & Supervision inadequate 14 - FP Fatality review -

15 Gabon SMP /09/2010 Company Man hit by flare line Drilling Supervisor was walking beside a truck to show to the driver where to offload equipment. The truck crossed a flare line, temporarily laid, but trailer wheels could not pass over pipe and dragged it. The Supervisor was hit from behind and fell. The pipe was dragged by the truck over his body. Work overload for the Supervisor (supervision of Civil Works and Logistics operations in addition to his standard duties) Simultaneous works conducted on Site Lack of safety awareness of truck driver Pipe laid and not buried without any indication of restricted access. Reconstruction Platform location to be ready prior rig arrival and formally handed over to drilling crew Specific supervision to be assigned to non drilling operations Operations in progress must be completed prior access is given to area Everybody has the right (and the duty) to stop an operation when the level of safety observed is considered insufficient. Position of Supervisor when hit 15 - FP Fatality review -

16 Synthesis All main findings were classified in 3 categories corresponding to 3 major Steps of a job: Evaluation / Preparation / Realization, in order to draw main Guidelines for each Step Common findings Step 1 - Evaluation Job considered as routine Hazards not evaluated Step 2 - Preparation Procedures not implemented / respected Preparation & Supervision inadequate Step 3 - Realization UAC Reporting system ineffective TOFS not implemented 16 - FP Fatality review -

17 Questions / Answers To apply the previous lessons, we decided to use the question/answer format to involve all Personnel, help them to understand our concerns and improve individual behaviour 1- What is the most important part of Job Evaluation? Answer: An analysis of the associated Risks 2- What are the most important parts of Job Preparation? Answer: Work Permit and Pre Job Safety Meeting 3- What must you do if the Job does not go as Planned? Answer: Stop and reevaluate the Risks The objective by mid-year 2011 is that all Personnel on Sites are able to answer correctly to the above 3 questions FP Fatality review -

18 18 - FP Fatality review - Drilling & Wells Division thanks you for your attention and your cooperation in building a safe environment