2013 SH

SAFETY PERFORMANCE INDICATORS 2013 DATA
High potential events report

Report No. 2013sh
(July 2014)
OGP DATA SERIES
International Association of Oil & Gas Producers

Safety performance indicators2013 data

High potential events report
Report No: 2013sh

July 2014
Revision history
Version Date Amendments
1.1 August 2014 Addition of South and Central America data
1.0 July 2014 First issued
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ii OGP
Safety performance indicators 2013 dataHigh potential events report
Contents
Africa 2
Asia/Australsia 16
Europe 24
FSU 39
Middle East 47
North America 72
South and Central America 83
OGP 1
Africa
Onshore
Algeria
Function: Drilling Category: Caught In, Under or Between Activity: TransportLand
Narrative:
The field ambulance rolled over about 600 m from the rig location on its way from the rig site to the new rig location.
What went wrong:
Driver exceeded speed limit.
Corrective actions and recommendations:
Awareness training for drivers, in particular ambulance drivers - Re-assess the rig roads regarding their topography and
conditions and put more warning signs and speed limit signs in place if necessary.
Causal Factors:
People (acts): Following Procedures: Work or motion at improper speed
Process (conditions): Work Place Hazards: Inadequate surfaces, floors, walkways or roads
Process (conditions): Organisational: Inadequate work standards/procedures
Process (conditions): Organisational: Inadequate communication
Process (conditions): Organisational: Failure to report/learn from events
Algeria
Narrative:
Garbage collecting truck rolled over about 22 km from the rig location on its way from the rig site to the waste
treatment area.
What went wrong:
Failure of management to effectively deal with the drivers previous errant behaviour that allowed him to still be
driving on the day in question having had no impact on his driving behaviour.
Awareness training for drivers.
Equip all cars with a driving monitor system.
Causal factors:
People (acts): Following Procedures: Violation intentional (by individual or group)
People (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgment
People (acts): Inattention/Lack of Awareness: Lack of attention/distracted by other concerns/stress
Algeria
Function: Drilling Category: Caught In, Under or Between Activity: Unspecifiedother
Narrative:
The civil guard tower was buffeted by a gust of extremely high wind and flipped over, completing a 180 degree roll. The
guard was thrown around inside the tower and when it finally came to rest he had sustained an injury to the inside of
his right biceps and a deep cut to his forehead.
2 OGP
Safety performance indicators 2013 dataHigh potential events
What went wrong:

There are 2 conditions for this serious injury to occur:
1. Guard in tower:
Instructions to vacate the tower not followed
Instructions to vacate the tower given by radio
Confirmation of the instruction not established
Guard decided to stay in the tower
No confirmation that he followed the instruction to vacate the tower.
2. The tower toppling over
Exposed location of the tower
Watch tower location to provide optimum visibility and effectiveness
Clearly understanding the limitations of the design of the watch tower
Generic design of watch towers commonly used throughout the industry.
No personnel to be in the watch towers during high winds and sandstorms Empty barite bags will be placed over the
bottom cross members and filled with sand, this will anchor the towers better.
Causal factors:
Process (conditions): Protective Systems: Inadequate/defective warning systems/safety devices
Process (conditions): Work Place Hazards: Storms or acts of nature
Cameroun
Function: Drilling Category: Water related, Drowning Activity: Drilling, Workover, Well Services
Narrative:
A jack up rig blackout caused the main deck to be submerged (1 m) by the tide. No injury, but equipment was washed
out to sea (Drums, hoses) plus damage to electrical motors. Two of three spud cans got deeply stuck in the mud at
the time the blackout occurred.
What went wrong:
Generators stopped due to a lack of fuel because a bleeding valve of a Day Tank had been accidentally left open. Rig
situation was similar to a punch through, but on the other direction. With the rig under water, the full available
buoyancy creates a bending moment on the two stuck legs as the 3rd one is free. This could seriously damage the jacking
system and/or the hull.
Install a level alarm in the diesel Day Tank. Install a Lockout Tagout system To be kept Closed on the valve of the
bleeding line between the Day Tank and the Holding Tank. Improve the water-tightness of the hull below the main
deck especially for the cables/wires ways. Have emergency generator operational at all times.
Causal factors:
People (acts): Following Procedures: Violation unintentional (by individual or group)
Process (conditions): Tools, Equipment, Materials & Products: Inadequate maintenance/inspection/testing
Ethiopia
Function: Exploration Category: Caught In, Under or Between Activity: TransportLand
Narrative:
A pedestrian walked in front of the vehicle - the driver applied the brakes and turned away from the pedestrian, which
eventually resulted in the vehicle overturning.
OGP 3
What went wrong:

Lack of/inadequate policies and procedures. Inadequate management/supervision/leadership. Inadequate skill and/or
knowledge level. Lack of/inadequate policies and procedures. Inadequate communication.
Causal factors:
People (acts): Use of Protective Methods: Inadequate use of safety systems
Process (conditions): Organisational: Inadequate supervision
Ethiopia
Narrative:
Motor vehicle Accident. Three vehicle occupants, (Sub Contractor). Multiple rollover.
What went wrong:
Not following procedure.
No corrective actions or recommendations described.
Causal factors:
Ethiopia
Function: Drilling Category: Exposure Noise, Chemical, Biological, Vibration Activity: Unspecifiedother
Narrative:
IP struck multiple times on safety boot by a Carpet Viper.
What went wrong:
Inattention/lack of awareness. Inadequate tools and equipment.

Causal factors:
Process (conditions): Protective Systems: Inadequate/defective guards or protective barriers
Ethiopia
Function: Drilling Category: Other Activity: Drilling, Workover, Well Services
Narrative:
During a 9 5/8 casing run two lower sections of the fill-up tool fell approximately 16 m to the rig floor. The two pieces,
estimated to be over 40 kg, struck the top rim of a casing pipe held vertically in the elevators, bounced back in the
direction of the draw-works, struck the roof of the drillers console and then fell onto the rig floor.
What went wrong:
Inadequate management/supervision/leadership.
Causal factors:
4 OGP
Gabon
Function: Production Category: Pressure Release Activity: Production Operations
Narrative:
During a night pig reception on the 18 pig receiver, a large volume of paraffin was received and plugged the pig
receiver, leading to pressure increase. The inlet valve of the receiver was closed, and the receiver opened. About 153 m3
of crude oil leaked from the receiver, as the inlet valve had failed to properly close. 150 m3 were recovered, the sand
impregnated with the remaining 3 m3 was collected for treatment.
What went wrong:
Disrespect of procedure for pig recovery. Lack of experience of the team. Regular arrival of paraffin plugging the
by-pass line.
Training and sensitization on operational procedures. Upstream oil treatment review.
Causal factors:
Process (conditions): Organisational: Inadequate training/competence
Kenya
Function: Exploration Category: Other Activity: TransportLand
Narrative:
MarineVehicle travelling between Fly Camp and Line Camp became stuck and had to overnight in the field. With
loss of radio communications.
What went wrong:
Inadequate maintenance. Inadequate management/supervision/leadership. Inadequate communication. Inadequate
work planning. Lack of/inadequate policies and procedures. Inadequate knowledge transfer/training. Inadequate
tools and equipment.
Causal factors:
Kenya
Function: Exploration Category: Water related, Drowning Activity: TransportLand
Narrative:
Near missno injuriessecurity vehicle was washed down stream while attempting to cross a lugger. Vehicle came to a
stop against a tree.
What went wrong:
Lack of/inadequate policies and procedures. Inadequate knowledge transfer/training.
Causal factors:
OGP 5
Mozambique
Function: Production Category: Pressure Release Activity: Construction, Commissioning, Decommissioning
Narrative:
An operator was using a mechanical excavator (TLB) to extend the foundation of a pre excavated foundation at the
manifolds, when the excavator struck the incoming 16 68 bar gas pipeline which was buried underground. The impact
of the excavator on the pipeline resulted in the pipelines polypropylene coating being ripped open at three areas. This
was identified as a high potential incident.
What went wrong:
Failure of Excavation Permit and Incorrect as built drawings.
Corrective actions and recommedations:
Review all Excavation Permit procedures to ensure: All potential services, electrical, instrumentation and production
lines must be identified. The competencies needed to sign an excavation permit are defined and record of authorised
persons kept. Excavation permits are signed off by necessary level of authority. Alternate verification methods such as
visual pilot holes and use of technology (e.g. pipe locator) are used. Excavation permit must consider surface hazards
and take into consideration proximity to roads, buildings and other structures. Excavation Permit must also consider
safe excavation principles, shoring, access etc. Ensure procedures are in place and adhered to for the control of drawings,
updating of drawings and submission of as built drawings.
Ensure that service providers only use sub contractors that meet Company SHE requirements. Ensure that there is a
documented acceptance of accountability for all project/work areas.
Causal factors:
Process (conditions): Tools, Equipment, Materials & Products: Inadequate design/specification/management of
change
Nigeria
Function: Production Category: Exposure Noise, Chemical, Biological, Vibration Activity: Production Operations
Narrative:
Tank roof tilted, allowing liquid pentane to flow onto the roof and down through the normally open roof drain point.
Approximately 50k bbls released into secondary (bundwall) containment. No release of product outside secondary
containment.
What went wrong:
Clogged tank roof drains allowed water to accumulate on roof, causing roof to tilt. Roof foam dam has relatively few
drainage slots and requires frequent cleaning to maintain adequate drainage. Roof had not been cleaned recently to
accommodate heavy rainfall.
Increase frequency of tank roof inspections by unit personnel. Remove debris from roof drain screen regularly. Validate
the adequacy of the roof drains in relation to peak rainfall.
Causal factors:
6 OGP
Tanzania
Function: Drilling Category: Exposure Electrical Activity: Office, Warehouse, Accommodation, Catering
Narrative:
An operational team member was about to use a laminator machine. They unplugged two items which were already
plugged into an extension unit (a Lifepack 15 and a suction unit) before plugging in the laminator, and using it. After
finishing with it they plugged the Lifepack 15 device, and were in the process of plugging the suction unit in when they
received a shock. They described how the shock made their entire body become ridged momentarily plus experiencing
a sharp pain in their hand, which was holding the suction unit plug. No other symptoms followed.
What went wrong:
It was later found that the distribution panel was not fitted with a residual current deviceRCD.
Periodically inspect and tag Portable electrical equipment (PAT); testing should be risk based. RCD should be installed
on all distribution panels. Formally document hand-overs between projects and operations.
Causal factors:
change
Process (conditions): Tools, Equipment, Materials & Products: Inadequate/defective tools/equipment/materials/
products
Tunisia
Function: Production Category: Struck by Activity: Production Operations
Narrative:
During plant start up after Emergency Shut Down, the slug-catcher pressure control valve PCV-01118 was slightly
opened to keep the flare lit. However, the valve failed open resulting in a high flow rate of gas directed to the flare. This
resulted in a flame stabilizer sleeve, weighing approximately 50 kg, to be ejected from the flare tip at a height of 45 m.
The stabiliser sleeve fell to the ground, about 8 m from the flare base within the flare exclusion zone. No asset damage
or personnel injuries were sustained.
What went wrong:
Inadequate Engineering/Design
Inadequate Monitoring of Construction Inadequate Maintenance
Inadequate Preventative Inadequate Work Standards /Procedures
Inadequate Implementation of Work Standards/Procedures
Corrective Actions And recommendations:
Review the inspection plan and frequency of plant flare tip and consider adopting a risk based approach. Develop and
implement a maintenance programme for PCVs. Review the current failure modes of safety critical valves and ensure
they fail as intended.
Causal Factors:
People (acts): Use of Tools, Equipment, Materials and Products: Servicing of energized equipment/inadequate
energy isolation
change
OGP 7
Tunisia
Function: Drilling Category: Caught In, Under or Between Activity: Lifting, Crane, Rigging, Deck operations
Narrative:
During a reversing manoeuvre, a forklift hit a trailer and a worker working at the backside of the trailer was caught
between the two pieces of equipment. He suffered from a sprain on both wrists, a fracture on one finger and a potential
fracture on one finger of the other hand.
What went wrong:
Time pressure on well hook up time. Absence of supervisor. Violation of Rig Move Procedure. Questionable
accountability of philosophy of contractor.
Review and adopt procedure for forklift operation. Force drilling contractor to be accountable for all his contractors
and subcontractors. Develop a standardized cross functional procedure addressing tasks and schedule based on
common agreement. Put Qualification Passport into practice for Company staff.
Causal factors:
People (acts): Following Procedures: Work or motion at improper speed
Tunisia
Narrative:
As part of his normal and daily operational duties, a contractor driver and his helper were transporting potable water
to the Rig site around 5 km from the rig. There is sharp curve uphill where he lost the control on his truck and rolled
over at a speed of 30-40 km/hr. They did not have their safety belts fastened.
What went wrong:
Failure of effective contractor management. Lack of risk management. Lack of management responsibility. Lack of
competency. Poor consequence management.
Develop and communicate Company Driving Rules. Replace or change water truck by proper tankers with
compartments. Revise Speed Limits for driving in the desert and ensure communication to all Contractors and
Employees. Develop access cards (like a passport) that everyone in the field has to carry with them. Ensure usage of
safety belts for all drivers and passengers. Clearly define contract owner and holder for every contractor including
subcontractors. Held periodically SQM/HSSE meetings with contractors. Company representative in contractor
HSSE meetings in the fields to ensure compliance with Company standards. Pre-qualify contractors including staff
competence and equipment before starting any activity in the field. Get all vehicles equipped with GPS.
Causal factors:
8 OGP
Offshore
Angola
Function: Drilling Category: Exposure Noise, Chemical, Biological, Vibration Activity: Drilling, Workover, Well
Services
Narrative:
Discharge valve was inadvertently left open during circulation of synthetic oil based mud. Approximately 285 barrels
were released to reserve pit and the agitator room floor. All spilled materials were recovered and returned to the mud
system. No injuries were reported.
What went wrong:
No description provided.
Causal factors:
No causal factors allocated.
Angola
Narrative:
Rig was performing scheduled rig maintenance in between wells when the vessel suffered a complete loss of power.
There was no pipe or equipment in the water at the time of the event. All personnel were accounted for and no injuries
were reported.
What went wrong:
Causal factors:
Angola
Function: Drilling Category: Struck by Activity: Drilling, Workover, Well Services
Narrative:
While preparing to move the Enhanced Landing String Assembly (ELSA), the fluid return vent hose backed out of a
fitting, which resulted in the hose/ fitting assembly falling to the drill floor. The fitting assembly weighs approximately
1 kg and dropped approximately fifty feet. No injuries were reported. However, two personnel were within two to
three metres of the point where the hose/fitting assembly landed on the rig floor.
What went wrong:
Causal factors:
OGP 9
Angola
Narrative:
While lifting the drill string off the slips with the DP elevators, three back up dies out of the TDS pipe handler fell to
the rig floor. No injuries were reported.
What went wrong:
Causal factors:
Angola
Narrative:
Assistant driller identified a slot on the pipe inventory screen as an open position but when the gates were opened the
slot was occupied by a BHA double stand that had been racked back during the previous tour. The BHA double came
out of the finger slot and fell across the drill floor. No injuries were reported.
What went wrong:
Causal factors:
Angola
Function: Construction Category: Pressure Release Activity: Construction, Commissioning, Decommissioning
Narrative:
During the towing and commissioning of a FPSO, an operational test of the Deluge/Foam was being performed. A
simulation of fire detection was performed to initiate the fire water pump A, which was operated at 14 bar. 4 people
were in charge of this test. Approximately after 1 min of testing, the flow sight glass fragmented under pressure and
the fragments scattered and injured a company operator who was working 4m away, resulting in cut and contusion.
What went wrong:
Fire waterline designed for 14 bar, 10 bar operating when the sight glass was designed for 3.5 bar. Use of wrong P&ID.
Management of documentation Approval and Quality control process prior commissioning operations.
Causal factors:
change
Process (conditions): Organisational: Inadequate hazard identification or risk assessment
10 OGP
Cameroun
Narrative:
At approximately 06:30am on 26th April, during a period of high surface vibration from MWD tool, a 200 g lifting rod
end (from the TDS service tool) fell 28 m to the rig floor below. Red zone precautions were in place and no personnel
were below. The item was identified by a floorhand located outside the red zone, when he saw/heard it land. Operation
was stopped immediately, and checks were started to confirm the provenance of the item.
What went wrong:
No secondary retention were in place/Inadequate awareness of the drilling crew. Nobody found it earlier/monthly
inspection on Topdrive not respected TD installer did not remove the lifting rod end/Inadequate follow up on
procedures
Implement a Dropped Object Prevention Program (DOPP) Crew to be guided in how to perform checks on Topdrive
with increased level of supervision. Contact TD manufacturer to see if picture book check list available to this Topdrive.
Initial derrick survey performed with remedial actions OIM to address the importance of all being aware of potential
dropped objects and dealing with them immediately OIM to investigate cross departmental hazard hunts. Complete
inspection of the Topdrive for potential dropped object to be performed. Create specific checklist for the inspection
on different Topdrive checks. Development of the Dropped Object Prevention Manual Review actual checklists and
document used as guidelines for TDS inspection and modify in order to ensure that they will be fully detailed and
clear to all Contact TD manufacturer to inform of incident and issue Safety bulletin if required.
Causal factors:
People (acts): Use of Tools, Equipment, Materials and Products: Improper use/position of tools/equipment/
materials/products
Egypt
Narrative:
After releasing the casing hanger seal assembly running tool (CHSART) from the hanger, the CHSART jumped
(possibly due to pressure) and fell out of the hanger, striking two floor men. One of the men experienced a fracture
injury.
What went wrong:
Causal factors:
OGP 11
Gabon
Function: Production Category: Explosions or Burns Activity: Production Operations
Narrative:
Fire outbreak while hot work being carried out near to the HC process area on board a production platform. The hot
work was a disk-cutting job to re-size one hole on deck to allow passage for instrument cables. The fire reached a rubber
hose located under a production separator and used to transfer hydrocarbons from closed drains. Personnel on board
mustered and were evacuated. The fire fighting team managed to put the fire out after 10 minutes.
What went wrong:
Use of solvent to clean up decking surface coated with paraffin. Confusion about resulting actions of various emergency
pushbuttons around the platform; SDV (Shut-Down Valve) of LP (Low Pressure) separator did not work properly;
ESDV (Emergency Shut Down Valve) logic (platform isolation)not complying with performance standards.
Management of Change overlooked - Inadequate management of co-activities (SIMOPS context).
Loose Permit To Work System.
Lack of Supervision.
Causal factors:
Morocco
Function: Drilling Category: Caught In, Under or Between Activity: Maintenance, Inspection, Testing
Narrative:
The IP was working on the top of a personnel elevator, with the assistance of a motorman. A 3rd party engineer was
on the outside of the elevator at floor lever, on level one. The IP had placed the elevator in Inspection Mode, and was
manually operating the elevator to move it up and allow the 3rd party engineer access to grease the rollers and tracks
underneath the elevator. The 3rd party engineer was attempting to lift the safety bar on the access door, but was unable
to. The IP shouted down for him to Wait - Wait and he stood back out of the way to keep his hands clear. As the
elevator was being moved up by the IP, in a start - stop - start - stop manner, using the manual controls to position the
elevator to allow the safety bar on the shaft access door to be lifted, the IPs head was forced into the handrails around
the roof of the elevator. The IP suffered a severe cut to her lower lip and chin, and a fractured jaw and tooth roots.
What went wrong:
Poor communication due to language differences and noisy environment. Inadequate barriers. Inadequate work
instructions/procedures. Inadequate hazard identification/risk assessment for the task.
Install physical barrier. Develop and implement a programme to thoroughly review all preventative maintenance
practices including:
1. Clear and fit for purpose procedures and work instructions.
2. Lockout procedures/PTW if appropriate.
3. Fail safe mechanisms.
4. WRA and Tool Box Talk.
5. Number and competence of personnel for task.
6. Access to work area.
7. Communications prior to and during tasks. Assurance process on all preventative maintenance jobs. Develop
a detailed audit programme to assess performance of preventative maintenance activities, to include routine
assessment, HSE advisor support, assurance audits. Assess level of English competence for all personnel who
12 OGP
do not use English as a first language. Ensure company complies with contract requirement that all persons on
board can communicate adequately in English.
Causal factors:
Tunisia
Function: Production Category: Exposure Noise, Chemical, Biological, Vibration Activity: Maintenance,
Inspection, Testing
Narrative:
A project team working on 12,000 level under the crew compressor smell H2S gas. The source of the H2S gas was found
from a blind flange installed on a corroded pipe of a drain pipe connected to the closed drum vessel V2201. The H2S
concentration was around 35 ppm on the lower deck and can reach 180 ppm near the blind flanges.
What went wrong:
Insufficient pipeline material design for H2S action. H2S presence in the oil was not considered.
Ergonomic design of safety & emergency equipment or protective gear inadequate.
Further inspection of Closed Drains System on ASHPF 2. Preparation in CMMS to manage Pipeline Integrity
Management required. Develop WO and Notification Process for Pipeline Inspection Program which will require
close collaboration between Technical Integrity and Maintenance Departments. Revise Hazardous Area study (Safety
Case and RMRI Study). TA empowerment in conjunction with MOC process. Additional personal H2S detectors
should be purchased. Install specific H2S detection, MCP& alarm signal on PFC. Additional Escape SCBA to be
purchased. H2S training to be performed for all crew, project employees and visitors. Ensure grating and deck covers
are secure and or protected scaffold barrier/barrier tape if removed.
Causal factors:
change
Tunisia
Function: Production Category: Other Activity: Maintenance, Inspection, Testing
Narrative:
During the connection of CTF RIG 05 retention tank pumps from the electrical room side, the electrician heard an
alarm from the UPS. When he checked the situation, he found out that both UPS were on bypass mode. It is to
be highlighted that in this mode, the UPS is not ensuring its fundamental role of supplying an uninterrupted power
supply. Actually, the ESD of PF3 is supplied with 220 V from the network. In case of blackout the ESD will be out of
service.
What went wrong:
Leadership and commitment inadequate. Communication of expectations and priorities ineffective. Hazard &
Effects/management of Safety Critical Equipment (SCE). Confusion around roles & responsibilities for managing
SCE.
Establish status of actions from original September 2011 High Potential Event report and reassess in light of subsequent
problems with UPS. Ensure that actions from Sept investigation report are SMART and tracked to completion with
senior management overview. Includes replacement of UPS at earliest opportunity to replace temporary substitute.
Review maintenance strategy for UPS (e.g. annual Preventative Maintenance). Senior Leadership to emphasize that
OGP 13
management of SCE is the number 1 priority. Identify KPIs for SCE management according to Company standards.
Senior Leadership to regularly review new KPIs.
Causal factors:
Process (conditions): Organisational: Poor leadership/organisational culture
Tunisia
Function: Production Category: Pressure Release Activity: Maintenance, Inspection, Testing
Narrative:
During routine surveillance, Project HSE Engineer smelled gas odour. After investigation, he discovered that a pipe
fitter had cut with a pneumatic grinding machine a live HP flare header line. Portable gas and personal H2S detector
were signalling an alarm. Project HSE Engineer immediately instructed to stop all works and informed the relevant
supervisors.
What went wrong:
Lack of job planning. Poor management of Tool Box Talks (TBT). Bridging Documents not fully implemented.
Deficiencies in Permit To Work (PTW) procedure management. Organizational change management not fully
functional. Poor quality of HSE training.
Daily job planning and permits shall be submitted and discussed with OIM one day in advance of planned work
by all teams for brown field activities. Review and improve the company PTW system and associated documents
(LO/TO; JSA; TBT). Improve existing TBT according to bridging document. Train all workforce on updated
procedure (LO/TO; JSA; TBT). Test and qualify contractor personal for performing authorities. Review and update
the Project HSEQ Audit Plan and include audits of Contractor and its subcontractors concerning competence of
employees (both professional and HSE). Re-enforce and clarify supervision Offshore.
Causal factors:
Tunisia
Function: Unspecified Category: Other Activity: TransportAir
Narrative:
Half way through a routine crew change flight to platform, the helicopters right rear passenger door and adjacent body
panel suddenly fell out into the sea. The pilot managed to fly safely back to the airport. None of the total of 10 persons
on board was physically harmed.
What went wrong:
Poor design of the doors sliding system. Channels material subject to vibration and liable to metal fatigue. Channels
maintenance plan covering only visual and dimensional checks.
Check company operations to ensure no N types are in use elsewhere and if so prohibit their use. Prohibit use of
Dauphin N helicopters in project. Adopt OGP guidelines as project/Company minimum standards. Revise incident
response procedures for this type of event. Improve follow up communications and support with directly or indirectly
affected field personnel. Ensure additional relevant recommendations from Manufacturer and TCAA are adopted.
Communicate interim recommendation to Contractor to replace all guide rails on their N models pending Original
Equipment Manufacturer investigation process.
14 OGP
Causal factors:
change
products
Tunisia
Function: Unspecified Category: Struck by Activity: TransportWater, incl. Marine activity
Narrative:
It was noticed from IFRII radar that the N-W standby BUOY changed position due to bad weather conditions. The
drifting distance was around 0.5 miles.
What went wrong:
Procedures about communications structure ineffective. Inadequate specification and design of the stand-by mooring
system because of lack of marine technical authority. Non-preventable unsuitable work conditions not evaluated (bad
weather conditions). Supply system for tools/equipment was ineffective.
An ROV inspection of the flow line and umbilical should be carried out to determine if they have sustained any
damage. A Marine technical authority is required to provide the necessary competence and input into MOC and
risk assessment activities. The vessel risk assessment should be revisited to include DP failure as a possible risk event.
Improvements need to be made to the MOC process and its use to control marine operations. More rigorous close
out of risk assessment actions required before commencing the marine activities to which the risk assessment relates.
Better systems required to manage and document vessel movements in the field clearer assignment of responsibilities
for vessel movement permissions. Integrated field lay-out plan should be developed identifying the location of all
permanent and temporary (e.g. stand-by buoys) facilities.
Causal factors:
OGP 15
Asia/Australasia
Onshore
Australia
Narrative:
Injured party was exposed to well head pressure when opening a valve. The release resulted in fluid being injected under
the skin.
What went wrong:
Under investigation
Pending investigation
Causal factors:
Australia
Narrative:
A drain line on a compressor pulsation damper drum failed, which resulted in a release of hydrocarbon vapour. The
release was isolated locally. No injuries or asset damage.
What went wrong:
Improvement in the management of technical change and in application of procedures associated with design changes.
It is important to ensure that any procedural and technical changes are effectively embedded. Clarify in training
programs the expected responses to hydrocarbon release set out in standards, and build supervisors and management
knowledge.
Causal factors:
Australia
Narrative:
During removal of an LNG loading arm following the completion of ship loading, a piece of ice estimated to be
1-2 kgs fell about 13 m from the apex of the loading arm to the ships loading platform. No personnel were injured.
What went wrong:
A feature of loading LNG is that ice forms on the outside of the loading arms. Once the loading is complete and the
loading arm begins to warm, and/or when its apex moves, the ice loosens, presenting a chance for it to fall away from
the loading arm. Caging is installed around the arms to collect the ice as it disconnects from the arm, however this
caging stops short of the elbows in to the apex. The ice fell from the unprotected elbow at the apex.
Be mindful of surroundings. Engineering out the problem is a far better solution than managing the problem using
procedures. Additional caging mesh to be installed on all loading arm elbows.
16 OGP
Causal factors:
change
Australia
Function: Construction Category: Caught In, Under or Between Activity: Construction, Commissioning, Decommissioning
Narrative:
Prior to completing a golden weld inside a bell-hole, final cleaning activities were occurring on the bevelled end of
two sections of 42 pipe. The work crew believed the cleaning had been satisfactorily completed and the Supervisor
who was acting as the dogman signalled to the side boom operator to commence the lift. One of the Trades Assistant
noticed a small amount of debris remaining inside one of the bevelled edges and moved to remove this debris before the
lifted section of pipe was located to its final position ahead of welding. The trades assistant (IP) was caught between the
fixed section of 42 pipe and the lifted section, sustaining an injury to the upper arm.
What went wrong:
Improper BehaviourImproper Attempt to Save Time or Effort. Inadequate Management Leadership and/or
SupervisionLack of Supervisory/Management. Inadequate Management Leadership and/or SupervisionUnclear or
Conflicting Assignment of Responsibilities.
Ensure all elements of Lifesaver Lifting Operations are fully complied with and apply Accountability Model when
this does not occur. Share learnings from this incident as a means of highlighting consequences of individual at-risk
behaviour.
Causal factors:
Australia
Function: Construction Category: Confined Space Activity: Construction, Commissioning, Decommissioning
Narrative:
A welder was tasked with the job of welding a stainless steel pipe. The welder stated that after a few attempts to weld
the pipe, he realized the purge dam was not fitting correctly, so he asked his co-worker who installed the purge dam
prior to connecting the second pipe, to enter the pipe and re-position the purge dam. Without an approved confined
space permit, the pipe fitter entered the 24 pipe. The welder was standing at the opening, stated that he could hear the
pipe fitter breathing extremely heavy and noticed him not moving, so decided to enter the pipe to rescue the pipe fitter.
The welder stated that he dragged the pipe fitter backwards towards the opening. At the same time a worker who was
working on the adjoining platform noticed the two workers were not on the platform walked over to have a look at the
work area and realized the two were inside the pipe.
What went wrong:
1. The work activity did not include nor authorize a confined space entry. The workers entered the confined space
without advising their foreman of the problem with the purge damn and without authorization.
2. Neither worker received specific confined space training.
3. Neither worker had received training on the dangers of inert gas purging of confined spaces.
Provide specific confined space training to all employees to include the consequences of inert gas purging. Ensure all
workers fully understand the requirement to inform supervisors of any problems during work activity so as to ensure
that the problem is assessed and any changes to the activity are implemented.
OGP 17
Causal factors:
Australia
Function: Construction Category: Falls from Height Activity: Construction, Commissioning, Decommissioning
Narrative:
Two welders entered, and were observed exiting, a 54 pipe without having acquired the necessary project confined
space documentation and implementing adequate safe working at height controls. The welders were executing a weld
to join two sections of pipe, during which time they identified some alignment inconsistencies. Subsequently, post final
weld completion, the welders elected to perform an internal inspection of the root weld. Prior to entering the pipe a
gas monitor was used to sample the pipes internal atmosphere. From the point of entry the pipe runs approximately
3 m and then bends north (right) another 2-3 meters to the weld location. One metre beyond the weld the pipe drops
vertically to ground level, exposing the welders to a potential 10 m free fall hazard. During the entry period the welders
failed to implement any fall from height protection measures.
What went wrong:
Inadequate Training/Knowledge Transfer
Training Not Effective. Inadequate Management Leadership and/or Supervision
Inadequate Reinforcement of Correct Behaviours.
Inadequate Work Standards/Procedures
Inadequate Communication of Standards/Procedures.
Review and identify all, potential and confirmed, confined spaces and sign post accordingly. Revise confined
space training pack to ensure it is specific and aligned with project procedures. Provide more frequent site-wide
communication to reinforce the dangers and requirements associated with confined space entry and working at height.
Revise the confined space Safe Work Method Statement to include the mandatory use of confined space determination
form prior to entry.
Causal factors:
Pakistan
Narrative:
A flow line connecting a producing well to Gas Plant ruptured and resulted in a jet fire at a distance of ~2.5 km from
the plant. In response, the line was isolated which resulted in cessation of the fire.
What went wrong:
Poor Design - Lack of sharing of Data, Knowledge and Experience between facilities operator and owner resulting into
differences in designs and construction of equipment.
Promote proactive joint approach between facilities operator and owner to design, material selection, construction and
handover tasks.
18 OGP
Causal factors:
change
Offshore
Australia
Function: Production Category: Falls from Height Activity: TransportWater, incl. Marine activity
Narrative:
A Floating Production Storage and Offtakes fast rescue craft (FRC) was retrieved to a height of 23 m above sea level
following operational duties. When hoist up control input was given via the davit controls the FRC commenced
an unplanned but gradual descent to the sea. With controls returned to the neutral position the descent continued.
Activation of the emergency stop also did not stop the descent of the FRC. It was concluded that both hoist brakes had
functionally failed and that the only brake arresting the descent was the mechanical centrifugal/inertia brake. Four
persons were aboard the FRC but no injuries were sustained.
What went wrong:
Installation of incorrect hydraulic valve causing pressure lock in hydraulic system (valves nearly identical in appearance
but part numbers differed by one character). Deficiencies in third party testing/certification procedures. Operator
maintenance procedures not fully followed by contractor.
Ensure replacement parts are like for like. System failure modes must be fully understood and clear mitigative
maintenance checks implemented to address those failure modes. Compliance with maintenance procedures, in
particular technical integrity maintenance, is critical. Ensure a full understanding of the maintenance and assurance
tasks that are completed by third parties and that these tasks are clearly defined, documented and compliance with
Operator requirements are verified.
Causal factors:
materials/products
change
products
Process (conditionss): Tools, Equipment, Materials & Products: Inadequate maintenance/inspection/testing
Australia
Narrative:
A gas release was observed during the restart of a platform following a planned shutdown. The platform was immediately
shut down and de-pressured. No personnel were injured during this event.
What went wrong:
Pressure spike in system lifts the Pressure Safety Valve (PSV). PSV failed to reseat because the reseat pressure was lower
than the operating pressure. Extended duration of PSV chatter, led to eventual failure of the system weak point (pipe
support) and the hydrocarbon release.
OGP 19

Consider all conditions in PSV selection during detailed design - Conventional PSV blowdown is ~10%. Under
2-Phase flow conditions this can be as high as 20% and needs to be considered in PSV selection during detailed design.
Causal factors:
Proces (conditions): Tools, Equipment, Materials & Products: Inadequate design/specification/management of
change
Australia
Function: Production Category: Struck by Activity: Lifting, Crane, Rigging, Deck operations
Narrative:
Cargo transfer was taking place between a tug/supply vessel and an offshore support vessel. A deck crew member on
the supply vessel was struck by the stinger from the crane on the support vessel. The injured party has a graze on his
neck. Actual severity first aid case.
What went wrong:
1. Communication on the boat failed during crew and crane operation.
2. Improper the position of injury person.
3. Tag line during cargo transfer.
1. Provide training and competency for cargo transfer.
2. Use this case to remind personnel about good practices for lifting Operations : preparation, information, good
practices for operation, good control and stop work if necessary.
Causal factors:
People (acts): Following Procedures: Improper position (in the line of fire)
People (acts): Following Procedures: Improper lifting or loading
People (acts): Use of Protective Methods: Failure to warn of hazard
India
Function: Drilling Category: Struck by Activity: Lifting, Crane, Rigging, Deck operations
Narrative:
A shackle pin from the BOP Hoist weighing approximately 14 kg accidentally released from the shackle and fell on
Derrick mans (IP) hard hat who came to pick up a rope underneath the BOP Hoist Shackle. The pin fell from a height
of 15 feet while connecting the BOP hoists shackle to the diverter lifting eye.
What went wrong:
Inadequate Hazard and Risk Assessment. Improper Behaviour
Improper Supervisory Example.
Risk assessment/JSA for all Permitted activities should be assessed with each sequential job step. Barricading practices
to be applied for all work at height activities that possess a dropped object risk. Ensure Supervisors do not get involved
in the work.
20 OGP
Causal factors:
change
Indonesia
Function: Production Category: Other Activity: Production Operations
Narrative
Boil off gas at LNG Plant was cold vented from the tank flare system due to flare being temporarily extinguished.
What went wrong:
Causal factors:
Indonesia
Narrative
Five and one half inch drill pipe elevators on top drive system came into contact with monkey board while pulling out
of hole resulting in damage to the elevator, control hose, and monkey board. One stand of pipe fell across derrick. No
injuries were reported.
What went wrong:
Causal factors:
Malaysia
Function: Drilling Category: Pressure Release Activity: Drilling, Workover, Well Services
Narrative:
Gas release on drilling rig during restart of adjacent platform following power failure. Drilling rig vent system had
been tied into the platform blow down system. During platform restart, the automated blow down valve (BDV) was
bypassed and blow down line manually opened as part of restart procedure. Gas from platform flowed back through
the vent connection and discharged on the rig. Blow down stopped manually within 10 minutes.
What went wrong:
Drilling rig vent hose routed into platform blow down system without proper assessment. Did not consider potential
backflow effects of pressure relief or venting from platform - not identified in drilling risk assessment standard.
Enhance the drilling risk assessment process to include consideration of connections to platform relief venting systems.
Review platform design as it relates to BDV and SDV controls. Review other jack-up rig installations to confirm
drilling vent systems are not tied into platform vent header.
OGP 21
Causal factors:
Myanmar
Narrative:
During work on the BOP deck a hammer dropped to the wellhead deck, all barriers where in place, there were no
employees within the area of the drop and of no danger to anyone.
What went wrong:
The equipment and tool was not secured from using.
1. Ensure that all staff working below are reminded that there is no work to be conducted below the BOP area during
nipple up operations.
2. All equipment and tool is secured during working at height.
Causal factors:
People (acts): Use of Protective Methods: Equipment or materials not secured
products
Thailand
Function: Drilling Category: Falls from Height Activity: Lifting, Crane, Rigging, Deck operations
Narrative:
While transferring personal from a support vessel via the use of a personnel basket to the platform a large sea swell
caused the basket to bump against the deck. As a result one of the passengers on the basket lost balance and rolled off
onto the deck of the support vessel sustaining a minor injury.
What went wrong:
Incident still under investigation.
Pending results of the investigation.
Causal factors:
Thailand
Narrative:
Safety pin shears allowing Crane Boom pennant securing pin to work loose. This could still have resulted in a
catastrophic boom failure should sufficient weight being lifted at the time of pin coming free from pennant.
What went wrong:
The crane had not been in use and was in a stationary unmanned position. Due to an electrical failure of the cranes
starter motor.
22 OGP

1. Review Incident investigation at Daily Pre Tour meetings and Weekly Safety Meetings.
2. Investigate whether correct Pin and Safety keeper pin system are in use as standard. Completed Correct pin and
safety keeper in place, checked diameter of keeper pin and requested information from crane manufacturer
Correct pins in place.
3. Daily crane operators Pre Start inspection form to be amended by contractor to include visual inspection of all
pins in cranes.
4. Requested inspection program up and running as soon as possible and ensure quality of inspection is of adequate
standard.
Causal factors:
products
OGP 23
Europe
Onshore
Austria
Narrative:
An uncontrolled gas release from a gas well occurred in the morning. A leakage of about 20 mm at the choke valve led
to a release of gas, water and sand (pressure 50-55 bar). An employee noticed an unexpected noise on his way to work
when he passed nearby in the morning. Due to his excellent knowledge of the place and work experience, he decided to
check the surroundings, detected the gas release, and he immediately reported the leakage by telephone. The employee
also blocked the access to the site until the fire brigade arrived.
What went wrong:
The immediate cause for the uncontrolled gas release was a leakage of the choke valve caused by massive erosion within
a very short period of time. The root cause was a mobilization of sand in the formation caused by increased production
of formation water.
Check all gas wells for liquid and sand production after initial startup or after recompletion via sand trap, and conduct
regular checks on site, especially in situations where the reservoir pressure is significantly below initial conditions;
Install well-head flowing pressure recording device after initial start-up or after re-completion of gas wells for at least
two weeks in order to monitor liquid production; In case of detection of small volumes of sand production, conduct
regular check of choke valve and feedback to reservoir department for advice and further action; Integration of gas well
risk scenario into county wide risk management system.
Causal factors:
Austria
Function: Construction Category: Exposure Electrical Activity: Construction, Commissioning, Decommissioning
Narrative:
On August 29th a truck driver dumped excavation material from the project site to a designated dumping area. Due to
muddy condition at the dumping area he positioned the truck at the only asphalted area which was below a live 20 kV
line. Not being fully aware of the risk the driver gradually tilted the loading platform up to an angle of ~40. At this
point the platform got in contact with the line and a short circuit over the earth occurred. Instinctively the driver did
the right thing to lower the loading platform. No one got injured and no real damages happened to the truck or the
line.
What went wrong:
Communication and interface management to and amongst contractors; Management of change; Limited risk
awareness of truck driver and limited empowerment to stop work.
Visual and clear delimitation of all the dumping areas used by the project, including sign-posting (delimitation,
safety signs, high voltage, surface and subsurface installations, etc.). Conduct risk assessment for respective dumping
area prior to put it in operation again and ensure that any new or changed location is risk assessed and subject to
management of change.
Contractor managementDiscuss HiPo investigation report with Contractor construction management and give
written warning; Risk assess all operational areas underneath high voltage lines and ensure proper action are taken
(signage, barricading, informing staff, etc.).
24 OGP
Causal factors:
Austria
Function: Unspecified Category: Struck by Activity: TransportLand
Narrative:
An empty suction tank truck was on its way from the waste disposal site back to the base camp. The driver wanted to
turn left, because the other street was blocked further on due to the construction of a new plant. The driver reduced
speed in order to prepare for the left turn. He saw a third party truck approaching the crossing and expected him to
stop. When the Contractor driver realised that the other vehicle would not stop, he steered to the right, but a collision
of the two trucks could not be avoided.
What went wrong:
Aggressive driving behaviour of third party driver (e.g. had overrun stop sign and caused damage already some weeks
ago, repeated speeding).
Introduce an additional one day defensive driving course and an update of the bridging documents; Review potential
construction measures in order to reduce the risk at black spot crossing; Implement and enforce a standard for general
transport activities, applicable also to those contractors that provide transportation services as part of their main
activities (e.g. mechanical services, scaffolding, etc.).
Causal factors:
Croatia
Function: Production Category: Falls from Height Activity: Maintenance, Inspection, Testing
Narrative:
During climbing up the ladder the worker of the contractor company fell down and got minor injuries. HSE
representative of the company immediately on site took preventive measures.
What went wrong:
Causal factors:
People (acts): Use of Protective Methods: Personal Protective Equipment not used or used improperly
Croatia
Function: Drilling Category: Assault or Violent act Activity: Office, Warehouse, Accommodation, Catering
Narrative:
Injury of the workers left hand and the right part of the buttocks due to the physical assault by local worker. Worker
received first aid in the infirmary on the facility by the doctor. Worker was sent back to the hospital where his wounds
were treated.
What went wrong:
No description provided
OGP 25
Causal factors:
Croatia
Function: Drilling Category: Explosions or Burns Activity: Drilling, Workover, Well Services
Narrative:
During drilling generator switches ejected due to fire in a generator at position No.2. Night electrician who happened
to be nearby, between PCR and MCC, first heard dull thud near generator, and then saw strong smoke and flame
from the generator at position No.2. Immediately he shut down generator No.2 in the PCR and then generator No.3.
During this time the drilling crew and night mechanic quickly put fire under control and there was no further damage
to the engines and generators. After that drilling crew continued with the usual work.
What went wrong:
Causal factors:
products
Croatia
Function: Drilling Category: Explosions or Burns Activity: Maintenance, Inspection, Testing
Narrative:
During the welding process above the tank No.18 the fire in the tank No.18 occurred. The fire was successfully
extinguished in its initial stage.
What went wrong:
No description provided
Causal factors:
Croatia
Function: Drilling Category: Falls from Height Activity: Lifting, Crane, Rigging, Deck operations
Narrative:
During removal of the tower tread and relocation of the drilling rig a worker fell from a height of approximately
3 m to the ground. When the main mechanic and electrician heard a moan and noticed that worker had fallen down
they retained cables by hand to prevent the platform from falling on the injured man. Other workers removed the
injured man and put the platform to the ground. After that they gave him first aid and transported him by vehicle to
an Emergency Room. Afterwards injured worker was hospitalized. The whole time he was conscious. According to the
first information workers face and hip are injured.
What went wrong:
26 OGP
Causal factors:
Germany
Function: Exploration Category: Struck by Activity: Drilling, Workover, Well Services
Narrative:
Installation of a submersible centrifugal pump was being carried out by two Contractors. While dismantling the
deflection roller (electrical cable duct) it fell towards the windbreak on the rig floor and injured a worker.
What went wrong:
Preconditions: Workover work has a broad spectrum of activities and TKP replacement is an additional one. It is
possible to assemble a cable roller on the mast without specific engineering. Weather conditions were suboptimal (dark,
rain, wind, cold). Two involved persons had limited knowledge of the way of assembly since the other shift did this.
Review of the existing procedure (was actually observed all the activities). Teaching the contractors about pre-task risk
assessment. Competence mapping for employees of workover operations.
Causal factors:
Germany
Function: Production Category: Explosions or Burns Activity: Maintenance, Inspection, Testing
Narrative:
At the inspection round smell of gas was perceived in the heating container. At the analysis the following was started:
A small leakage at a welding of the gas feed line;
Worker smelled the gas before the gas sensor could initiate the safety process (automatic closing of the gas
line) because the concentration was under UEG (explosion) limit.
What went wrong:
Correction action: Sealing the leakage up with a repair clamp. Checking of the functionality of the gas sensor. Training
of the involved contractors shortly after the event.
Method: Revision of the organization Standard for low pressure gas lines in accordance to DVGW G600 worksheet.
Revision of the SCE (safety critical elements) Procedure. Update of the MOC Procedure Human : Training of involved
contractors and employees.
Review of the existing SCE procedure (identification, efficiency). Review of the application of the management of
change (all safety relevant modifications are documented and evaluated).
Causal factors:
Germany
Narrative:
A employee was driving on the L 47 in the direction of Meppen. For unknown reasons the car came to the left about the
roadway middle and collided with an oncoming truck. The vehicle rotated and finally came to a stop at the guard rail.
Despite the air bags, the employee suffered considerable head injuries and bruises, so he was brought into a hospital.
What went wrong:
The investigation identified the following circumstances which probably led to the accident: The employee was not
fully concentrating on the traffic. The vehicle was not equipped with an intelligent security system. There had not been
OGP 27
any compulsory safe-driving training (the last three years) ordered by the company -Pictures of the accident : drivers
side of vehicle ripped open.
Review the need for defensive driving for relevant personal(exposed to driving risk): Observe the traffic well; Refrain
from risky driving manoeuvres; Drive foresighted; Adjust the safety distance in line with actual speed. Control the
vehicle at all times. Recognize dangerous situations early. Minimize the risk of collision by timely braking. Allow
enough time for safe driving. Relate to the Group Rule : Prevention of vehicle risks. Relate to the Live Saving Rule
(LSR).
Causal factors:
Hungary
Function: Production Category: Struck by Activity: TransportLand
Narrative:
The employee was driving towards Miskolc on the Motorway M3. At the stone 134 he started an overtake, but he did
not recognize another car that had started to overtake him in the next lane. Noticing the car he became frightened, and
suddenly turned the wheel and lost control of the vehicle, hit the inside guardrail, and rebounded to the other side, hit
the guardrail and stopped. There was no personal injury or damage other than his car.
What went wrong:
Causal factors:
Romania
Function: Drilling Category: Caught In, Under or Between Activity: Drilling, Workover, Well Services
Narrative:
Rig crew was racking back a stand-off drill collar. A lifting sub was connected to the top of the stand to pull it out
of the hole. As a result the total length of the stand exceeded the normal working height of the monkey board. The
derrick man decided to use the monkey board wind wall frame to climb up and get physically higher, to be able to
open the elevators manually. During this activity the fall arrestor cable, connected below water table, tangled up into
the Top Drive System (TDS). The derrick man opened the elevators and while he was preparing to secure the drill
collar stand, the driller started lowering the elevators without getting the clear signal from the derrick man to do so.
The driller made the assumption that the derrick man was ready and safe. As the fall arrestor cable caught in the TDS
and tightened up, it caused the derrick man to lose his balance, the derrick mans hardhat subsequently fell to the rig
floor. Lowering of the TDS by the driller was stopped because the derrick man shouted from the monkey board, this
prevented more serious consequences.
What went wrong:
1. Rig auditors recommendations were carried out without proper risk assessment. The design of the fall protection
fixing bracket on the crown needs to be re-assessed as the current bracket does not take into account the
retrospectively fitted top drive unit.
2. Lack of implementation of MOC. In the case that the installation of the top drive would impact the safe
operations of the fall arrestor.
1. Change hook up of fall arrestor assembly immediately.
2. Use rope system for opening or closing elevators at a height not reachable from the monkey board level.
28 OGP
3. Driller should only move TDS after receiving signal from the derrick man.
4. Initialize checking the fall arrestor hook up at all rigs.
5. Review the design of the fall arrestor system to ensure maximum efficiency.
6. Improve audio and video communication between derrick man and driller, recommend a headset radio system.
Causal factors:
change
Romania
Narrative:
While bleeding off hydrocarbons from the annulus into the cellar of a well, a flammable gas cloud was ignited by a non-
explosion-proof halogen light. Three persons were hurt (two burns, one leg injury) in the resulting explosion.
What went wrong:
1. Incomplete well intervention work instruction not specifying how to vent or bleed off gas resulting in inadequate
well intervention program.
2. Management of Change not performed when the intervention program was changed from sucker rod replacement
to tubing string replacement. Work program did not recognize new well status (flow line nipple down), and
increased workload and related risks.
3. Lack of hazard identification and risk awareness of the crew members and chief related to the release of flammable
hydrocarbons (no knowledge of well pressure, use of non-explosive-proof lamp, use of non-spark proof tools to
open valves in confined space).
4. Permit To Work considered as necessary paperwork but not as risk assessment and risk mitigation system (night
shift, potential ignition sources, tools, relevant procedures, confined space not considered).
5. Improper maintenance system to properly maintain the well-head and x-mas tree components (valves and support
equipment like lighting in very poor condition).
6. A get the job done mentality of crew resulting in not stopping the work when unable to follow the work program
to measure the pressure of the well.
7. Perceived pressure to cut cost resulting in not starting the generator to minimize fuel consumption and no use of
derrick lights.
8. Organizational changes (restructuring programs) potentially resulting in concerns on job, fears, emotional
disturbance.
9. Key Rules of Contractor (Management of Changes) and Company (Stop work) not followed.
10. Sub optimal work areacellar, well-head/Xmas tree and associated pipe work/valves configuration presented
limited workspace and required workers to enter cellar.
1. Enhance current procedure for bleeding or venting off pressure from tubing or annuli, which should ensure
pressure is monitored before and during the operations and that any hydrocarbons are not allowed to accumulate
in an area where personnel are exposed to the risk of fire or explosion.
2. Perform active roll out and implementation of Company Rules to the entire workforce with special reference
to Stop Work and Management of Change to properly evaluate the risk and implementations of modified
operations.
3. Implement program of preventative planned maintenance to include all active well-sites (covering Safety Critical
Equipment and valves) commencing with any wells on the current workover and intervention schedule.
4. Implement review of all active well-sites with respect to the design and layout of Xmas tree, well-head and
associated pipework and valves, to ensure safe working conditions (minimize entry to cellars, cellar covers).
OGP 29
Causal factors:
change
Romania
Narrative:
During raising the working platform connected to the workover rig from the horizontal to vertical position with the
travelling block during rig down, the sling which was used to move the platform snapped and the working platform fell
down and hit one employee, who was standing below the load.
What went wrong:
1. Inadequate assessment of needs and risks.
2. Inadequate HSEQ hazard identification/ risk evaluation in design.
3. Lack of situational awareness/ risk perception/ risk awareness.
1. Review all rigs in the fleet to identify similar set-ups for platform lifting and ensure practices which prevent that
employees stand below lifted load.
2. Define a permanent solution for proper Platform mounting/dismounting (e.g. auxiliary winch).
3. Rework sling inspection/checking procedureusing colour coding or equivalent (e.g. 6 monthly replacement
program).
Causal factors:
Romania
Function: Construction Category: Struck by Activity: Construction, Commissioning, Decommissioning
Narrative:
A driver operating a forklift used for pipe lifting/laying operations lost control of the equipment due to a break failure.
The forklift hit an existing (provisional) pipeline on its concrete supports, positioned on the side of the forest road, very
close to the pipe construction area. Three concrete supports were hit before the forklift stopped. At that time, a welder
was working in a welding tent placed above a double-joined pipe. The welder was thrown into the trench together with
one concrete pipeline support, the double-joined pipe and the welding tent. The double-joined pipe fell on the welders
leg. The dirt road in this area has a 10% slope with broken stone (gravel) and sand on its surface. The road was dry at
the time of the incident. Visibility was good.
What went wrong:
1. Lack of training of the fork lift operator on this specific forklift by contractor who was a new recruit for this job.
2. Inadequate risk assessment, site specific risk not taken into consideration, no involvement of working crews.
3. Inadequate supervision: project and HSSE supervision.
4. Inadequate management of change: initial method of construction was changed by contractor and did not
consider hazards from adjacent steep road.
30 OGP

1. Ensure that equipment specific training and instructions is carried out on heavy equipment vehicles for
construction works and copies of the required licenses and training certificates of the equipment operators shall
be provided.
2. Potential hazardous activities shall be identified in the weekly construction meetings based on the look ahead for
the construction work and intense supervision and a detailed JSA shall be conducted for these activities.
3. Ensure that all equipment is inspected and maintained by the contractor according to manufacturer and legal
requirements.
4. Reinforce the utilization of MOC standard.
5. Reinforce Companys Company Rules for projects in particular with focus on Stop work.
Causal factors:
change
Romania
Function: Unspecified Category: Caught In, Under or Between Activity: TransportLand
Narrative:
A sub-contractor truck driver made a sudden manoeuvre of the steering wheel while on a left curve, trying to avoid
an agricultural horse carriage coming from the opposite direction, causing the trailer to loose balance and topple over
the entire system (tractor and trailer) in the ditch on the right side of the road. Following this event resulted in total
destruction of the trailer and spreading oil-contaminated soil in roadside ditch. This incident led to environmental
damage and damage to equipment, but did not lead to injuries.
What went wrong:
1. Lack of HSSE requirements stipulated in the contract related to sub-contracting
2. Lack of specific procedures for transport activities with this sub-contractor
3. Lack of evidence on auditing this subcontractor
4. Subcontractor inadequately assessed in pre-qualification phase
5. No defensive driving training program at this sub-contractor
6. Insufficient practice and experience for the driver involved on the incident (about only 2 months experience in this
transport category).
1. To require a system for monitoring and evaluation of driver safety performance at al contractor and its
subcontractors.
2. Improve HSE minimum requirements for transportation contractors.
3. Contractor shall recruit and develop competent and motivated personnel to execute all transport work safely.
Drivers shall have a minimum of 3 years driving experience preferably with the assigned type of vehicle;
4. Contractors and subcontractors must demonstrate the implementation of a consistent fleet management system in
accordance with Companys contractual requirements.
Causal factors:
OGP 31
Romania
Function: Unspecified Category: Explosions or Burns Activity: Maintenance, Inspection, Testing
Narrative:
An explosion occurred in an underground 5 m3 plastic tank for industrial water. Two contractor employees were
repairing a leak of the tank with PU foam. While using the foam cans inside the tank the blowing agent, consisting
of a mixture of flammable gas created an explosive atmosphere which found a source of ignition. When the explosion
occurred both workers (one being in the water tank and the other in the upper tank chamber) suffered burns in face
and hands, eye injuries and lung damage. After receiving medical first aid they were transferred to the Emergency
Hospital of Plastic surgery Reparatory and Burns.
What went wrong:
1. Inadequate assessment of needs and risks.
2. Inadequate monitoring of construction.
3. Inadequate commissioning handover process.
4. Inadequate work/process planning/programming.
5. No adequate control system for sub-contractors on site.
6. Lack of supervisory/management job knowledge.
7. Inadequate experience.
8. Lack of situational awareness/risk perception/risk awareness
1. Contractor-subcontractor Management: Ensure that each contractor manage their sub- and sub subcontractors as
specified in Company standards
2. Establish performance criteria for external QA/QC
3. Handover projectsoperations and commissioning ensure that accountabilities and responsibilities are clearly
defined for all stages.
4. Access Control: only allow qualified and authorized personnel to work on our sites; (including concept for
contractor, sub- and sub-sub contractors).
5. Qualified supervision: each activity must be risk assessed and the right level of supervision provided either by
operations or the contractor (also for contractor, sub and sub-sub contractors).
Causal factors:
materials/products
Process (conditions): Protective Systems: Inadequate security provisions or systems
change
Offshore
Norway
Function: Exploration Category: Other Activity: Lifting, Crane, Rigging, Deck operations
Narrative:
Condition:
32 OGP
Arrestor on lifting beam/h-beam not wide enough to stop trolley.

Potential risk:
Trolley could have dropped on to scaffolding and caused it to collapse with one person on it. Weight 400 kg, height
2 m down to scaffoldingadditional 6 m to deck leveltotal of 8 m.
What went wrong:
Due to excellent observation an incident with high potential was avoided. The person who discovered this had safety
in mind and was aware of potential risks.
Fabricate and install new arrestors.
Check all similar lifting beams/h-beams on the oilfield (total of 307).
Causal factors:
Norway
Function: Production Category: Struck by Activity: Construction, Commissioning, Decommissioning
Narrative:
During trials of the crude offloading system, a loading hose was recovered to the vessel partially filled with water and
pressured to 3.5 Bar. In the final stages of recovery, the end section of the hose (weighing in excess of two tonnes) came
over the top of the hose reel falling onto the deck behind the reel. There were no injuries reported.
What went wrong:
Causal factors:
Norway
Function: Unspecified Category: Caught In, Under or Between Activity: Lifting, Crane, Rigging, Deck operations
Narrative:
Due to weather picking up to about 45 knots wind and 9.5 m maximum wave height, the rig rolled 9,8 and this made
some of the cargo on deck shift position. At the same time a person was exiting an office container placed in this
area, and was hit by two moving containers weighting approximately 8 and 6 metric tons. The person was injured,
but managed to pull himself out onto the escape route and call for help by radio. This incident could under slightly
different circumstances have resulted in a fatality.
What went wrong:
1. The potential risk of container shifting on deck due to rig movement was not understood and communicated.
2. The rig was preparing for adverse weather by sea fastening. The risk of large equipment, containers and baskets
moving was not included in their plan for sea fastening, nor criteria for cargo/deck friction and requirements for
fastening of such cargo.
3. There were no predetermined weather/motion criteria set for preventing entry of work areas on deck.
1. Ensure that containers placed in cargo areas, and equipment which may affect work areas/escape ways are properly
sea fastened/secured, and that uniform standards/methods of sea fastening are established.
2. Establish set criteria for rig motion when access to cargo areas is restricted.
3. Ensure that the requirement to protecting escape routes against shifting cargo/ equipment is always maintained (to
withstand 17 list).
4. Establish a common best practice for sea fastening within the industry.
OGP 33
Causal factors:
Romania
Narrative:
During the lifting of the boat with 2 men on board at approximately 3 m above sea level, the boom of the crane started
to bend, the boat fell in the sea and the cables hit the ceiling of the cabin. No injuries, the two sailors were out of the
cabin, one in the front and the other at the back of the boat. The two sailors went out of the boat on the landing panel
(the boat landed near the panel). The boat was taken out from the hook of that crane and taken over and sustained by
another crane. A weld seam was not accessible for NDT tests, boom drum crank shaft of the crane has failed.
What went wrong:
1. No risk assessment was carried out on the procedure for lowering and lifting of FIC by crane together with boat
crew.
2. No risk-based maintenance system.
3. Aged crane with poor engineering design, e.g. difficult access, no possibility to NDT crank shaft without
breaking/ re-welding in place.
4. Non-comprehensive operational procedures for FIC
5. Crane operations and maintenance outsourced with improvable steering and control.
1. Assess maintenance, event history of every offshore crane.
2. Evaluate feasibility of re-design boom drum crank shaft for integrity, inspection, and monitoring.
3. Evaluate possibility of installing a redundant brake system.
4. Formulate and start implementation of a sound risk-based preventative maintenance and inspection plan.
5. Prohibit the current practice of lifting personnel on lifting loads (e.g. Crew).
6. Explore alternatives to FIC storage on board of platform requiring crane-lifting.
Causal factors:
change
UK
Function: Production Category: Caught In, Under or Between Activity: Lifting, Crane, Rigging, Deck operations
Narrative:
A contractor load handler was struck during deck operations to position a container on the pipe deck. The load handler
was momentarily caught between a waste skip and deck area bump bar and reported some back pain following the
incident.
What went wrong:
Causal factors:
34 OGP
UK
Function: Production Category: Struck by Activity: Maintenance, Inspection, Testing
Narrative:
Crane rope connector failed during maintenance activity. Thirty five metres of 35 mm crane rope fell approximately
35-50 m to the galley landing area. No injuries were reported.
What went wrong:
Causal factors:
UK
Narrative:
The Performing Authority (and Injured Party) for the task and was issued a permit to split a valve and actuator in-situ.
As the last remaining bolt was removed the actuators stored energy was released allowing the actuator to swing rapidly
through approximately 45 degrees, coming into contact with the IPs head. The IP was knocked unconscious for
10-20 seconds and suffered a laceration to his left ear.
What went wrong:
The investigation revealed that the valve had a known defect in that it did not reach its fail-safe position when it was
de-energised and isolated in preparation for the work to commence. The valve was therefore stuck 50% open when the
IP started working. The work site therefore had a significant hazard, not identified on the permit or Risk Assessment.
The task was allocated to a work party that were not competent to perform this task nor equipped to identify the
hazard.
Splitting Actuators and Valves shall be undertaken by a competent person with a permit, a clear method statement and
thorough Level 2 Risk Assessment. Ensure adequate identification and allocation of correct roles and responsibilities
to the correct task. Audit your Tool Box Talks (TBT) - use this to coach and train teams on how to hold a good,
comprehensive TBT challenging the hazards and mitigations.
Causal factors:
UK
Function: Drilling Category: Exposure Noise, Chemical, Biological, Vibration Activity: Drilling, Workover, Well
Services
Narrative:
Flexible coupling on charge pump failed during milling operations discharging 115 barrels of oil based mud into the
lower pump room. No injuries were reported.
What went wrong:
OGP 35
Causal factors:
UK
Narrative:
Following the running and successful pressure test of the well lower completion and Quantum Packer which
incorporated a Formation Isolation Valve (FIV) (Type: 5.5 x 2.94 FIV-II-9X), a dedicated wellbore clean-up
string was run to allow for displacement of the weighted Oil Based Mud (OBM) above the FIV and Quantum
Packer to inhibited sea water.
Following OBM displacement to inhibited sea water a successful inflow test was performed on the FIV and
Quantum Packer.
A Multi-Functional Circulating Tool (MFCT) incorporating a 2 7/8 washing assembly bullnose was run in-hole
to increase fluid flow and improve circulation and subsequent removal of any remaining particulate debris from
within the wellbore and directly above the FIV ball valve. The MFCT is activated by landing the tool on the
Quantum Packer and applying force to overcome the shear pins. This force along with reciprocated cycling up
and down movements functions the tool.
During the subsequent circulation and simultaneous pumping of a 100 bbls wash pill via the cement unit, a
sudden increase in well in-flow was observed and the well was closed in on the BOP annular.
The annulus and the stand pipe pressure increased indicating an influx of gas had entered the well bore. Seawater
was also observed coming through the rotary table during closure of the BOP annular.
What went wrong:
Inadvertent Opening of the FIV
Probable Cause was the Inadvertent Opening of the FIV:
Remaining down-hole particulate material debris in conjunction with the hole angle, tight tolerance and
reciprocation of the washing assembly, combined to inadvertently mechanically function the FIV valve to a
partially open position.
Investigation Key Finding:
Poor FIV/ MFCT Interface Hazard Management
Poor Risk Assessment
Ineffective fluid flow and volume monitoring
Causal factors:
UK
Function: Drilling Category: Other Activity: Lifting, Crane, Rigging, Deck operations
Narrative:
Dropped object in Vessel area.
During ROV launch an umbilical roller guide bar became detached from a two bolt securing arrangement above
the Launch And Recovery System (LARS) umbilical drum mechanism. The umbilical roller guide bar weighing
approximately 20 kg subsequently fell approximately 10 m to the deck area directly below.
At the time of this incident one member of the ROV team was located on deck approximately 2-3 m from point of
impact. ROV launch immediately stopped, ROV safely lowered to deck and operations suspended.
What went wrong:
36 OGP
Causal factors:
UK
Narrative:
During Bottom Hole Assembly (BHA) handling operations on the rig floor, a 5 ton rig floor tugger wire became
snagged by the kelly hose clamp as the top drive descended. The tugger had been used just prior to the incident and
had been hooked off to its parking post and was static. As the top drive descended, an unintended force was applied to
the tugger line and the sheave block (McKissick M491G 14 inch, 12 tonne head fitting) which hangs from the crown,
130 feet above the rig floor. This resulted in the recently installed 95 lb sheave block parting at its swivel and falling
40 feet from the crown before getting hung up in the finger boards below. It is thought that the secondary retention
wire broke under the force of the ejected sheave and tugger wire assembly. Some of the tugger wire descended to the
drill floor, landing approximately 10 feet from where personnel were setting the slips at the time. No personnel were
injured in the incident.
What went wrong:
Inadequate Hazard and Risk Assessment. Inadequate Tools/Equipment/Materials
Inadequate Standards or Specifications.
Review the MBL (Maximum Breaking Load) of each accessory to ensure the tugger wire is the weak link Carry out
review of derrick set up. Review of hanging, snagging, parking points and secondary retention and possible engineering
solutions Review design of sheave system to ensure that they are suitable for inspection.
Causal factors:
change
products
UK
Narrative:
Worker was struck by a valve that had sheared off the overdrive assembly while it was being lowered into position to
latch into a joint liner.
What went wrong:
While being lowered into place the mud saver valve contacted the edge of the liner tool joint rather than locating
within it. This resulted in the valve being sheared off and falling 45 feet and deflecting off a nearby pipe handling
machine and then striking a worker a glancing blow to the lower back.
Causal factors:
change
OGP 37
UK
Narrative:
Five inch drill pipe was being lifted by elevators. When the joint had been raised approximately five feet above the
floor, the elevators opened and the join dropped to the deck, bounced and came to partially rest on the drill floor and
partially on the V door. No injuries were reported.
What went wrong:
Causal factors:
UK
Function: Drilling Category: Struck by Activity: TransportWater, incl. Marine activity
Narrative:
While working on supply vessel, whip line upper limit chandelier (6-8 kg) slid down the whip line (130 ft), struck the
header ball and dropped roughly 15 ft to the deck of the supply vessel. Nearest Deckhand was about 50 ft away as the
load was in the process of been lowered. Vessel pulled away from the rig while the crane was put into the rest position
and the incident investigated.
What went wrong:
Poor design of limit switch arrangement. Original Equipment Manufacturer system does not allow for cable to be
caught.
Contacted manufacturer of the crane and fitted factory approved limit switch system. Ensure Original Equipment
Manufacturer safety system is in place Ensure Preventative maintenance regimes in place for verification.
Causal factors:
products
38 OGP
FSU
Onshore
Kazakhstan
Function: Production Category: Confined Space Activity: Construction, Commissioning, Decommissioning
Narrative:
While hand digging at a depth of 2.5 m a piece of ground collapsed from the opposite side of the trench, pinning the
worker to the wall of the trench. Safety watch and other team members were able to free the worker by hand digging
the worker out.
What went wrong:
While working to slope and step the trench the surround soil became unstable and caved in.
Causal factors:
Kazakhstan
Narrative:
When a worker connected a steam hose to the vessel they noted the drainage hole was plugged. The worker removed
the plug from the drain hole and was then overcome due to a release of sour water from the vessel.
What went wrong:
With the clearing of the drain plug a significant amount of sour water was released overcoming the worker.
Safety stand-down meetings were held immediately after the incident to share the incident information. Also a
simulation video was created which was used at local town-hall meetings for all facility employees and contractors.
Causal factors:
Kazakhstan
Narrative:
When workers were performing operations to increase the spread on a flange in preparation for hydro blasting there
was a release of H2S. All of the workers involved in the operations lost consciousness.
What went wrong:
Prior to work commencing H2S readings indicated no H2S vapor in the space of the flange. Once work began to
increase the spread on the flange there was a release of H2S affecting all involved.
Causal factors:
change
OGP 39
Kazakhstan
Narrative:
A burst of 3rd stage cooler bundle tube of 30-K-510 Compressor occurred. The Operator of Compressor Unit (CU) and
Shift Engineer in Control room heard a sound of burst coming from Compressor and saw a gas cloud around the CU.
After the burst noise CCR operator pressed emergency shut-down bottom of 1st level and CO2 extinguishing system
were activated. All personnel were evacuated immediately to a master pointduring shut-down no injuries or wounds
observed.
What went wrong:
Immediate Route cause: Internal Corrosion reduced wall thickness of 3rd stage cooler tube, that triggered the burst and
gas was released to the atmosphere. Erosion, corrosive environment (wet gas). Insufficient account of process criteria
taken during the design. Insufficient designer-user communication during design or modification phase Inspection
system for tools/equipment was inadequate.
Develop Cleaning and Inspection Procedure for Cooler Tubes. Review current process conditions whether tubes
material is appropriate or additional protection against corrosion is required. Incorporate detailed review of HP
cooling system in next HSSE Case/HAZOP. Communicate causes and lessons learned on this incident Company-
wide to prevent similar incidents. Ensure MoC Process for each Modification during Project Phases.
Causal factors:
change
Kazakhstan
Narrative:
Contractor WO rig was on location to perform re-entry of the well. The Well was drilled in 1985 by another operator
and tested for oil. The well location is in the field which gets flooded by the Caspian sea on a regular basis. Therefore
it is very important to construct well pad and access road in a way that it can withstand the incoming flood. On 31st
October at 7:00 am the ongoing operation was to run in Drill pipes to drill out an expected cement plug. At a depth of
approximately 2700 m WO supervisor at location noticed the laid out foundation near the cellar was not holding the
weight and the rig was sinking around 6-10 cm at one side each time the rig picked up load. He immediately stopped
running in hole operation and circulated the well clean. The decision was made to secure and suspend the well, lower
derrick and move the rig away from the dangerous area.
What went wrong:
Immediate Cause: Weak foundation close to the well cellar that was added to the initial construction works of the well
pad. Root causes:
1. Project Construction Management
2. Design Change not Properly Implemented
3. Construction deficiency
1. Increase competence level of Construction Supervisors on civil work quality control through appropriate training.
2. Improve on Project Ownership: make changes in Project Ownership only after key stages are reached and finished.
3. Implement Technical Authority System in Projects in order to provide technical guidance for the preparation
of SoWs, check/approve the design and to take care of the proper integration of the scope changes and project
integration into existing facilities.
40 OGP
4. Provide support to Contraction Supervisors on site with additional resources of the required qualification to
control Project execution and quality of construction work on site.
5. Management of Change process shall be implemented and introduced in Project Department by Department
Manager.
6. Comply with Legal requirements for the design approval.
Causal factors:
Process (conditions): Work Place Hazards: Inadequate surfaces, floors, walkways or roads
Kazakhstan
Function: Unspecified Category: Explosions or Burns Activity: Office, Warehouse, Accommodation, Catering
Narrative:
An employee, who lives in a 40 foot Container, in Company Camp, saw smoke coming underneath the door of his
room. He opened the door and noticed a strong smoke diffusion in the hall of the container. Considering that the
exit door was not accessible because of the smoke, the employee decided to escape from the container through the
window installed in his living quarter. The heavy smoke was caused by an ignition that took place inside the toilet and
shower room of the container due to the malfunctioning of the ballast of the ceiling fluorescent lamp. At 23:43, the
employee called the Emergency operator and Fire Brigade immediately rushed to the scene of the incident, controlled
and liquidated the ignition.
What went wrong:
Use of fluorescent lamps of poor quality, with plastic cover and plastic base.
Inspection quality probably not exhaustiveto be ascertained, a meeting with contractor is planned.
24 hours operation of fluorescent lamps.
Wrong design of electrical protection switches for the toilet.
No approved Project design for all Living containers (construction, electrical, mechanical) and no Conclusive
Expertise for usage released by Sanitary and Fire Department Authority.
Coreective actions and recommendations:
To repair smoke sensors in Living Container and reconnect it in main Fire Alarm system Plan and implement an
integrated lock system with master keys in the living quarter. To inspect all Company camp buildings and facilities for
installed faulty fluorescent lamps in working areas. To remove all fluorescent type lamps regardless type of ballast and
replace them with new low energy type in living containers on all sites of the Company. Beacon and sound alarm to be
installed also inside the living container and not only outside. After review of fire alarm system consider upgrading in
order to have centralized control panel installed in the Fire Department premises.
Causal factors:
Kazakhstan
Narrative:
A contracted bus and a contracted lorry were in a collision. The bus driver drove out of a road junction at the Processing
plant without seeing the oncoming lorry. When the bus driver realised a lorry was heading towards him he tried
to accelerate across the road to avoid a collision. However the lorry driver had to take evasive action and tried to
manoeuvre around the front of the bus. The result was the truck collided with the bus. 17 passengers were on the bus
OGP 41
at the time. No one was seriously hurt. All passengers and both drivers were taken to hospital for examination. Both
vehicles were damaged. Road Traffic Police Department were called to the scene of the accident.
What went wrong:
Inadequate Training/Knowledge Transfer
Inadequate Instructions, Orientation and/or Training.
Inadequate Work Standards/Procedures
Inadequate Implementation of Work Standards.
Reassess the Defensive Driving instruction and assessment process to ensure more focus on awareness of other road
users Review dangers in the field and at the road junctions and consider improvement of visibility, signs, lighting,
traffic lights, cameras, reflective strips on vehicles, etc. Installation of IVMS in all vehicles to monitor speed/braking/
acceleration in order to encourage good driving habits.
Causal factors:
Russia
Function: Exploration Category: Struck by Activity: TransportLand
Narrative:
A van was moving along from West to North, at 10 km/h, with passengers in cabin. This road has an approximate slope
of 10 degrees. Driver was using brakes to avoid accelerating, when he suddenly felt the failure of the brake system. The
vehicle started increasing its speed and the driver took the decision to change to a lower gear and use the characteristics
of the terrain to stop the car, and then checked the brakes and found brake fluid in the wheels. He then managed to
fix the issue on spot.
What went wrong:
Lack of maintenance.
Toolbox meeting regarding:
Technical condition of the existence machinery, ATVs and Tanks
Detailed technical inspection and check required before work on a regular basis
Reporting of failure and technical issues to management if identified
Following of the traffic rules and regulations
Causal factors:
Russia
Narrative:
A crane was installed near to a well head for a lifting operation. When it started extending its boom the crane tipped
over and brushed the well skid. No injury, well not damaged, damage to the crane. The head of the boom fell near an
unprotected manifold. Outriggers were not used. The well was stopped and de-pressurized.
What went wrong:
Work permit failure: generic. No specific limitations relative to crane location and movements. No lifting operation
description.
42 OGP

Lifting plan to be included in the Permit To Work. Reinforce HSE inductions towards process major risks. HAZID
and Kick-off meetings systematically performed involving both company and contractors before any activity starts on
site. Ensure proper certification of all lifting equipment and personnel.
Causal factors:
materials/products
Russia
Narrative:
On June 26th at 18:55 p.m. the driver of a bus went to work in the transportation of crews. At 21:18 p.m. while driving
on the 41st km of the road, moving at a high speed from the opposite direction a Renault Logan vehicle left a strip of
oncoming traffic and collided with the front part of the bus. After the collision the bus slid into a ditch and rolled
over on its right side. At the time of the accident there were 8 persons in the bus, including 4 Contractor employees;
there were 2 individuals in the Renault Logan vehicle. Upon arrival of the ambulance first aid was rendered to four
passengers of the bus and to the Renault driver and passenger and then they were taken to hospital with injuries of
varying degrees. As a result of the accident the bus and the passenger car Renault Logan had significant mechanical
damage. The bus driver and three passengers were not injured. The bus was moving at a speed of 21 km/h.
What went wrong:
1. The driver of the passenger car violated traffic regulations:
was not chosen the speed of movement which provided possibility of continuous control over the vehicle
movement considering road risks and other unaccounted risks
Road signs Dangerous turn and Overtaking is forbidden were not noticed by the driver and he drove
on a dangerous site of the road at a speed of 110 km/h.
2. The crew bus was not equipped with seat belts, whereupon workers were injured.
3. All possible measures to avoid collision were not taken by the bus driver.
4. Contracting company drivers were not trained in Defensive Safety Training.
1. Inform all Contractor employees on the Causes and circumstances of the accident and make registration in Log
books.
2. Run HSE Stand-downs to inform employees on the circumstances and causes of the incident.
3. Run analysis of means of transportation; determine technical condition and wear factor. Define number of buses
that require installation of safety seat belts.
4. Consider the option of the bus fleet renewal for buses with operational term over 10 years. Develop the schedule
and make suggestion to Contractor Company management.
5. Install seat belts on all buses.
6. Provide training in Defensive Driving for the drivers.
7. Develop temporary measures to reduce road traffic injuries in buses which are not equipped with seatbelts.
OGP 43
Causal factors:
Process (condtions): Organisational: Inadequate training/competence
Russia
Narrative:
A Subcontractor Driver was performing work for a Contractor company under the car lease contract and was driving
a Contractor vehicle on the highway and, while readjusting from the acceleration lane, did not give way to a third
party vehicle moving simultaneously on the main lane which resulted in a collision with Contractor vehicle rolling
onto its left side and the 3rd party vehicle rolling over onto its roof. As a result of the road accident the Subcontractor
driver and 4 Company employees who were in Contractor vehicle suffered traumas of varying severity and were taken
to the nearest hospitals by Ambulance crew. Minor injuries were recorded for 4 Company employees and severe injury
was recorded for driver. The driver of the third party vehicle was given medical help at the place of the incident as
hospitalization was not required. The driver and the front passenger of the Contractor vehicle were wearing seat
belts; the passenger compartment was not equipped with seat belts. The Contractor vehicle was not equipped with an
in-vehicle monitoring system.
What went wrong:
1. Seat belts were not used in accordance with operating instruction; the inertial unit of a seatbelt on a drivers seat
was fixed by a screw.
2. The driver of the car while readjusting from the acceleration lane did not give a way to the vehicle moving
simultaneously on the main lane in the same direction, which violated traffic regulations of Russian Federation.
3. The worker showed no care when making a manoeuvre.
4. The vehicle is not equipped with safety belts in full. Safety belts are available only for the front passenger and
driver seats. No seat belts are available for passengers in the cabin.
5. Determined time of training for the subcontractor drivers and one month driving experience did not provide full
mastering of driving skill.
6. The vehicle was not equipped with in-vehicle monitoring system and does not meet safety specifications.
7. Control was not provided over the organization and the drivers involved in provision of transportation services.
1. In selecting and defining driving experience driver to be guided by employment record in the workbook instead of
date of issue of the drivers license.
2. If driving experience of the employed driver is less than one year, the admission to independent driving of vehicle
has to be allowed only after successful completion of the on-the-job training and Defensive Driving training.
3. In accordance with Company requirements recommend Contractors and Subcontractors to involve for provision
of transportation services only Drivers with driving experience not less than 3 years. Lists of newly assigned
drivers are to be agreed with the general contractor.
4. Contractors to agree on-the-job training program with the customer.
5. General Contractor in case of additional agreements and contracts has to arrange systematic monitoring of HSE
compliance by subcontracting companies.
6. Do not allow to participation in the tendering and procurement of transportation services Contractor companies
which vehicles are not equipped with seat belts.
7. Contractor company which provided subcontracting company which caused road accident, has to audit
subcontract companies on compliance with requirements of Company Standard Transportation Safety.
44 OGP
Causal factors:
People (acts): Use of Protective Methods: Disabled or removed guards, warning systems or safety devices
Process (conditions): Protective Systems: Inadequate/defective Personal Protective Equipment
Offshore
Azerbaijan
Narrative:
An anchor was found within the 500 m zone of the platform having been wet stored approximately 5.5 km from the
platform. The anchor had possibly been dragged during anchor handling operations and could have crossed live gas and
oil export lines and a fibre optic cable en-route to its recovery point where it was resting against an uncommissioned
produced water line. No injuries were reported.
What went wrong:
Causal factors:
Azerbaijan
Narrative:
During crane testing, a walkway grating weighing approximately 22 kg was dislodged and fell approximately 15 m to
area below. No injuries were reported.
What went wrong:
Causal factors:
Azerbaijan
Narrative:
During anchor handling operations on board tug, the chain used to connect the tugger hook to the wire parted. The
injured party was standing on deck and was hit by the wire resulting in cuts and bruising.
What went wrong:
OGP 45

Causal factors:
Azerbaijan
Narrative:
Minibus carrying seven passengers from terminal to office in Baku hit the edge of pavement resulting in roll over into
ditch. Injured passengers were taken to local hospital for examination and observation.
What went wrong:
Causal factors:
46 OGP
Middle East
Onshore
Iraq
Narrative:
During an acid wash job on a well, a liquid/gas mixture was produced to the surface and burned directly in the flare
pit. At this time H2S gas was detected by the Early Well Test (EWT) facility inlet manifold detector @ 20 ppm, some
300 m away from the well. The highest H2S concentration noted was 65 ppm at the EWT inlet manifold.
What went wrong:
Inadequate tools, inadequate assessment. Inadequate change, setting wrong priorities. Insufficient monitoring of initial
operation. Unclear assignment of roles and responsibilities. Inadequate work standards, inadequate risk identification.
Inadequate communication, inadequate transfer of information between sites.
Extra H2S sensor must be installed at EWT facilities, down in valley and to be tested working correctly to alarm at rig.
EWT control room shall be communicated prior to well testing / flowing the well. Flaring only with wind and proper
wind direction especially during unloading the well where larger volumes of treatment fluids are produced. Unloading
operations and restart of flow of the well only during daylight. Check burner for operational set-up if fit for fluids
produced during the test period 15 min. escape sets shall be provided to all personnel of EWT and security personnel.
Assess H2S situation at the other Well locations and rectify as above.
Causal factors:
materials/products
products
Iraq
Narrative:
During POOH with Bottom Hole Assembly (BHA) the first heavy weight drill-pipe (HWDP) stand had been pulled
out of the hole and the driller positioned the TDS with elevator above the monkey board level and tilted the elevator
towards the stand. Derrick man opened the elevator latch secured tugger line and pulled HWDP stand towards the
fingers. After seeing the derrick man cleared with the HWDP stand, the driller started lowering the block down
without activating the floater switch for the link tilt. When driller realized his mistake and applied the brake, the
elevator had already collided against the monkey board resulting in damage to the monkey board and the diving board.
What went wrong:
Inadequate supply chain management-Rig specification.
Inadequate Tools, inadequate assessment.
Inadequate change, setting wrong priorities, inadequate monitoring of initial Operation.
Unclear organizational structure, unclear assignment of role.
Inadequate work standards, inadequate risk identification.
Mental/psychological stress due to emotional overload.
Inadequate communication, inadequate transfer of information between processes.
OGP 47
Corrective actins and recommendations:

Utilize headset communication between driller and derrick man, at all times. Ensure proper supervision as required
by work instructions. Revise all the Job Description for Drilling Department staff. Ensure revision of the JSA for
tripping, includes this hazard. Ensure installation of visual/audible alarm for link tilt function in the drillers cabin.
Once it is recognized that a crew member is under emotional overload, it is strongly recommended not to put such a
person in an workplace where other crew members could be put in unacceptable risk.
Causal factors:
change
Iraq
Function: Unspecified Category: Struck by Activity: Office, Warehouse, Accommodation, Catering
Narrative:
When IP (Trailers Driver) was moving on loaded casing to place the stopper (wooden pad) beside the second layer he
loaded the casing to avoid rolling over. Unfortunately casing started rolling and the person became scared. He came
down from the trailer and fell down on the ground, and then rolling casing was falling down, continued rolling and
hit him on his left leg.
What went wrong:
Lack of competency of fork lift operator. No certified riggers available. No JSA/Risk Assessment conducted for
operations. Lack of contractor management. Due to the time pressure to fulfil contractual obligation with Ministry
of Natural Resources, the focus was on preparation of sites drilling, drilling two wells, one work over and building an
Early Well Test Facility. Hence, the warehouse activities did not receive sufficient management attention.
Immediate, mandatory use of fixed wood stoppers provided by Company for all pipe loading operations. No person
allowed on trailer during any forklift loading operation for casings or pipes. Develop and communicate the Loading
Procedure. Develop a Training Plan for all personnel dedicated to warehouse. Risk Assessment for warehouse activities
to be carried out, with involvement of all concerned parties. Mandatory presence of warehouseman during the whole
process of pipe loading.
Causal factors:
materials/products
48 OGP
Kuwait
Function: Unspecified Category: Other Activity: Drilling, Workover, Well Services
Narrative:
On 26th December, at about 9:30 pm, at one of the drilling rigs, an activity called preparing of EZSV (easy drill
subsurface valve) was in progress. All of a sudden there was total power failure (black out) and as a result all engines
stopped. Two engines were on line #1 & #3 and stopped due to low fuel pressure active alarms on both ECM which
means the main fuel source got restricted somewhere between the fuel day tank and the engines house. A detailed
investigation for the incident has been carried out. The underlying causes have been identified and the necessary
corrective and preventive actions have been taken to avoid recurrence of such incidents.
What went wrong:
Immediate cause: Supply and return valves at engine skid side might be accidentally closed because there were no
protective covers.
Root cause: Human engineeringHuman machine interface label need improvement.
Immediate cause: The mechanical air compressor battery was not maintained as per policy.
Root cause: Management SystemsStandards, Policies, or Admin Controls not used. Enforcement needs
improvement.
Cover, lock out and signage to be on the supply and return valves in the diesel tank. Move the supply and return valves
at engine area to be close to engine skid to be away from the walking area but for short term cover should be in place
until next lines can be moved without shut down of rig operation. Install an audible alarm for low fuel level so that
the Driller/STP/Coy Man can hear if the alarm is actuated. Mechanic and Electrician to follow guidelines for proper
maintenance for the backup air compressor.
Causal factors:
materials/products
energy isolation
products
Oman
Narrative:
While pulling out of hole, operations were paused for the midnight crew handover. Following the handover, the driller
latched the elevators and pulled the first stand. For unknown reason, the blocks ascended to a height beyond normal.
The travelling block broke through the bumper bars and impacted the crown block. No injuries were reported.
What went wrong:
Causal factors:
OGP 49
Oman
Function: Drilling Category: Struck by Activity: TransportLand
Narrative:
Vehicle under contract to the Company was returning to the highway to head back to base when the vehicle was struck
by an 18 wheeler. A first aid injury was reported.
What went wrong:
Causal factors:
Oman
Function: Drilling Category: Water related, Drowning Activity: TransportLand
Narrative:
A 4x4 vehicle was swept off a road by a torrent of flood water and carried approximately fifty metres downstream. A
contractor driver climbed onto the roof of the vehicle and was rescued by civil defence personnel.
What went wrong:
Causal factors:
Qatar
Function: Production Category: Caught In, Under or Between Activity: Maintenance, Inspection, Testing
Narrative:
There was a job on an enriched gas condenser to check the belt condition, tension, and also do the realignment of fan/
motor pulley. (Motor solo-run to be conducted). The fan belt was removed and Permit To Work (PTW) brought back
to SC office with Electrical certificate sanction to test, case signed by electrical technician and energized. The following
day (25th April) a PTW was issued for a solo run test. 16:00 PTW was brought back again to SC office, while enquiring
about the solo run test feedback the Mechanical supervisor reported that the belt had already been installed, so SC
notified him that the Fan was not de-energized to carry out such activity.
What went wrong:
Investigation report is not completed yet.
Causal factors:
50 OGP
Qatar
Function: Production Category: Confined Space Activity: Maintenance, Inspection, Testing
Narrative:
Dedicated safety watch was not provided for confined space job.
What went wrong:
1. Inadequate Initial Instruction.
2. Lack of Coaching.
Causal factors:
Qatar
Function: Production Category: Cut, Puncture, Scrape Activity: Maintenance, Inspection, Testing
Narrative:
Two technicians were called for belt replacement job. One of them was injured during the execution of that job, due to
the sudden movement of the fan. His finger got caught between the pulley and the belt which caused a cut in his left
hand index finger.
What went wrong:
The technicians did not comply with the safe working methods which are: Adherence with the Permit To Works
(PTW) instructions. Switch off the machine and secure the fan prior doing the doing work.
PTW must be followed. Secure any moving parts of machine prior execution of job, JSA to be prepared and understood
prior to commencing the job. Ensure adequate supervision.
Causal factors:
materials/products
Process (conditions): Work Place Hazards: Congestion, clutter or restricted motion
Process (conditions): Work Place Hazards: Hazardous atmosphere (explosive/toxic/asphyxiant)
OGP 51
Qatar
Function: Production Category: Falls from Height Activity: Maintenance, Inspection, Testing
Narrative:
A rigger working on the top of the ablution block loaded on the trailer truck with full body harness, but not tied-off to
anchor points. The rigger was standing at a height of 5.5 m from the ground level.
What went wrong:
1. Standard, Procedure and Admin Control need improvement.
2. Training-Understanding need improvement.
3. Enforcement need improvement.
4. Fall protection need improvement.
5. Communication system need improvement.
6. Accountability need improvement.
1. The Shutdown logistic plan, Road Safety Manual or safe work practice does not provide adequate guidance in
defining oversize loads.
2. Workers did not use hazard identification and risk reduction tool. (No pre-task risk assessment or pre-job briefing
are conducted.)
3. The rigger decided to walk through the top without hooking on the harness, even though he could use the ladder
to reach four corners.
4. JSA failed to address the concern of having to work on the top of ablution block in the absence of the crane.
Causal factors:
Qatar
Narrative:
A 2 inch Common liquid hydrocarbon line was found dislodged from the pipe support. The location of the pipe is
about 10 m from the ground. The pipe was found to be sagging about 1.5 metres from its original position. It is not
known when this pipe became dislodged. Scaffolds were erected to inspect the line and reinstate it to its original
position.
Note: Routine activities on this line are the intermittent draining in two phases:
Manually by F.O. (at least one per shift) for the AGR Feed gas filter to remove accumulated liquid
hydrocarbon
Automatically by level control to remove liquid hydrocarbon from feed drum of U101 and U104.
What went wrong:
Investigation report in not completed yet.
Causal factors:
change
products
52 OGP
Qatar
Function: Production Category: Pressure Release Activity: Maintenance, Inspection, Testing
Narrative:
Pressure Relief Device (PRD) was found to have the wrong PRD setting. Device setting should be have been 16.5 barg
but the installed valve setting was found to be 44 barg. This setting (44 barg) is used for the 2nd stage discharge pressure
not the inter-stage relief pressure. (PSE Tier-3)
What went wrong:
1. Quality ControlNo InspectionNo inspection required.
2. Management SystemStandards, Policy or Administrative Controls (SPAC) Need ImprovementNo SPAC.
3. Quality ControlQuality Control Needs ImprovementInspection Instructions need improvement.
4. Human Machine InterfaceArrangement/Placement
1. The inspection of work not performed because it had not been required butt it should have been because of the
safety or production significance of the work.
2. Other facilities, plants, units, or similar operations have SPAC to control this type of work but there wasnt a
SPAC for this facility.
3. Quality Verification (QV) check sheet contained too little detail.
4. Critical documents not readily available and linked to functional function.
Causal factors:
Qatar
Narrative:
During regeneration of propane treater bed, observed that pressure was increasing in the liquid drain drum. The
pressure in the drum could not be reduced till a flare header valve, which an in situ repair was carried out on 13th June
was opened 10%.
What went wrong:
1. Supervision During WorkNo Supervision.
2. PreparationWalk Thru needs improvement.
3. Communication of Standards, Policy or Administrative Controls (SPAC) enforcement needs improvement.
4. Problem not anticipatedEquipment environment not considered.
Causal factors:
Qatar
Narrative:
A corroded square metal plate approx. 0.6 kg weight fell approximately 18 m from top of an overhead crane.
OGP 53
What went wrong:

1. Failure to check/monitor and follow procedure.
2. Inadequate identification and evaluation (The annual inspection did not pick up the corrosion and anticipate
failure).
Causal factors:
Qatar
Narrative:
During the process of lowering a fire extinguisher (6 kg weight) using a canvas bag and rope, the bag snagged tipping
the extinguisher out. The extinguisher fell approximately 8 m.
What went wrong:
1. Lack of situational awareness.
2. Missunderstood direction.
3. Inadequate practices.
4. Infrequent performance.
5. Lack of coaching.
6. Inadequate reinforcement of behaviour.
7. Inadequate planning or program.
8. Inadequate communication of standards.
9. Procedure/practice/ruleNo specific guideline for manual handling.
1. Substandard/inconsistent compliance with safe practice for lifting and lowering material at elevations.
2. Ineffective implementation of JSA control measure in line with JSA procedure.
3. No provision to secure loose material inside the lifting bag.
Causal factors:
materials/products
Qatar
Narrative:
A piece of concrete fell from one of the support beam of the main pipe rack approximately 25 m to ground level.
What went wrong:
Based on the observation above the fall of fireproofing is suspected due to following:
1. The construction issue, proper care and bondage of fireproofing near joint has not been achieved.
2. No proper compaction due to small sized gap.
3. The fire proofing is subjected to thermal and natural weathering actions (expansion and contraction).
4. Being at a height of 24.0 m above ground and below cooler location, thermal action are more evident.
5. There is probable expansion and contraction at joint due to thermal variations.
54 OGP

Causal factors:
change
Qatar
Narrative:
A piece of concrete fell approximately 25 m from the main pipe rack.
What went wrong:
1. Construction Issue.
2. Natural weathering Action.
3. Thermal Stress.
4. Design and detailing issue.
1. There is no proper compaction of the concrete due to small sized gap.
2. There seems poor quality control during fire proof coating.
3. There is no specific document which clearly measures extent of weathering action. However cracked element can
help formulate repair strategy, inspection strategy. There are structural inspection programs that are already
in-place and are executed periodically, to confirm and locate civil anomalies occurring.
4. Being at a height of 25.0 m above ground and below cooler location, thermal actions are more evident. There is
probable expansion and contraction at joint due to thermal variations.
5. The cooler should have been supported at more distance from the location of expansion joint. The joint should
have been designed for minimizing bending stress. The fireproofing materials should have been adequately
reinforced near expansion joint.
Causal factors:
change
Qatar
Narrative:
In heavy rain accompanied by strong winds the SC with 2 field operators were checking the external call points. They
observed one piece of metal 2 x 1 m that had fallen from the steam turbines hall to the location between two 33 kV
step up transformers.
What went wrong:
Causal factors:
OGP 55
Qatar
Narrative:
Thermal Rx on FG firing Stoichiometric operation for a fuel gas sweeping operation. It was observed there was about
10 to 15 kg of concrete chunk in the pavement. This concrete chunk had fallen down from 15 m above, specifically from
the concrete beam supporting the 2nd Reactor outlet pipe to the Final condenser. Similarly, a piece of concrete was also
observed in the pavement, but of small quantity (less than a kilo) and it is coming from the concrete beam supporting
the 1st Claus Reactor outlet line to the 2nd Sulphur Condenser. It is suspected that there was some unusual movement
of the 48 pipes during the shutting down of SRU-2 causing a chunk of concrete insulation to cracked and fall.
What went wrong:
Causal factors:
Qatar
Function: Production Category: Struck by Activity: TransportLand
Narrative:
After looking on both sides and confirming that there are no vehicles on the road a pedestrian started crossing a facility
road using a pedestrian crossing. When the person was half way across the road an approaching vehicle failed to stop
or slow down narrowly missing the pedestrian.
What went wrong:
1. Available control measures and Road safety aids are inadequate to protect vulnerable road users.
2. Effective traffic management system is not in place to control speed and manage traffic within operating facility.
Causal factors:
Qatar
Narrative:
During construction activities a piece of steel weighing approximately 1.5 kgs fell approximately 16 meters from a
platform to the ground. The object landed 2 metres from a work group.
What went wrong:
Corrective actions and recommendationsS:
Causal factors:
56 OGP
Qatar
Narrative:
The IP, together with his group, was doing fencing work. It was found that his co-worker was using a rebar and the
handle of a pick axe as a lever to pull the cyclone wire for final alignment. Suddenly, all the force transferred to the
rebar causing his co-worker to lose his grip. The rebar flew up and hit the IP (who was standing beside the co-worker)
on his safety glass causing it to break. The impact of the safety glass on his nose and eyes caused the injury to his upper
left cheek near the eye socket.
What went wrong:
Risk was not properly identified
The crew performing the task was using an improper tool (rebar and pick axe handle)
The cyclone wire recoiled causing the tension to be transferred to the rebar causing it to fly up
The co-worker was pulling the rebar in an awkward position, he was fixing the upper part of the fence
IP was standing in the line of fire without protection.
Corrective actions and recomendations:
Do a more detailed risk assessment before the start of each job
Provide the proper tools for each task to be done. In this case, a crowbar is the best tool to be used
A working platform or steps should have been provided so that the co-worker did not have to over-reach
Observe proper body positioning and avoid the line of fire.
Causal factors:
People (acts) : Use of Tools, Equipment, Materials and Products: Improper use/position of tools/equipment/
materials/products
Qatar
Narrative:
A Medical Attendant accidentally hit a pedestrian with a car. The victim sustained (Minor) multiple injuries to the
right thigh, right hand and right lower abdomen. Also noticed during the examination was superficial abrasion of the
right thigh lateral aspect and minor abrasion at right hand, and mild dizziness as verbalized.
What went wrong:
The driver was driving his car without looking in front of him and instead was talking to someone else.
Report to work in good physical and psychological condition.
Before moving any vehicle, especially in a crowded area, make sure that the area is clear and that nobody is a
potential victim when moving your car.
Be attentive and concentrate when driving your car.
OGP 57
Causal factors:
materials/products
UAE
Function: Production Category: Explosions or Burns Activity: Drilling, Workover, Well Services
Narrative:
On 18th April, approximately at 03:45 hours, well testing activities were in progress and a night shift crew member (an
operator) was involved in collecting oil samples and manual filling of diesel fuel to generator which resulted in oil &
diesel splashes on his coverall. There was a change in wind direction and the operator decided to switch the gas flow to
another green burner. He energized the electrical ignition and started propane flow to and then attempted to ignite
pilot of the green burner remotely. The pilot did not ignite due to lack of wind barrier near spark & propane interface &
carbon deposit on the tip of the pilot. He then decided to use a fire stick (long metal rod with diesel soaked rag on one
end) and went near the burner. When he lighted the Fire Stick near the burner, the accumulated propane gas ignited.
It caused his cotton coverall to catch fire.
Outcome: He sustained 2nd & 3rd degree burn injuries on his arm, face, back
What went wrong:
Root Causes
1. Lack of Procedure (There was no formal or standard operating procedure for depressurizing trunk line)
2. Inadequate Preventive Maintenance (There was no specific preventive maintenance schedule for gaskets & valves;
maintenance work orders are not specific to individual valves but it cover the entire area)
3. Inadequate Training Efforts (There is no structured training/familiarization program to assure the competency of
the new staff with respect to the operation of gas gathering & injection facilities)
4. Inadequate Technical Design (The selected valve had no provision for greasing, lack of maintenance philosophy
and no interlock system to prevent using 2 vent valve)
1. Remove all Fire Sticks and other homemade type (banned) tools/ equipment from the site
2. Provide & Use Fire Retardant Coveralls when working in hazardous areas/conditions
3. Test site specific emergency plan for each work location prior to commence operations
Causal factors:
change
58 OGP
UAE
Function: Production Category: Falls from Height Activity: Drilling, Workover, Well Services
Narrative:
On 06th April, approximately at 12:14 hours, running Completion tubing (31/2), using pick up & lay down (PC
machine) machine, was in progress. After running 34th joint, driller picked up the 35th joint from the PC machine after
receiving signal from the assigned floor man to start lifting, then driller started elevating joint to stab & make it up to
the string in hole.
While the joint was about 15 ft. from total 35 ft. the stabber shouted that Safety pin is missing and the single joint
elevator was not holding the tubing joint. Driller applied brake to stop the traveling block and due to momentum of
the traveling block, elevator door opened, which resulted in releasing tubing joint from the elevator and falling down
though the catwalk on the pipe rack area.
Outcome: No Injury or property damage had occurred.
What went wrong:
Root Causes
1. Excessive Wear & Tear (Due to wear & tear latch spring became weak and jaws were worn out)
2. Inadequate Audit/Inspection or monitoring (Integrity of the jaws & latch spring was not assessed prior to start of
the job)
1. Confirm mechanical integrity of all tubular handling equipment before sending to the Job.
2. The pre-job safety meeting with drilling crew to be repeated if situation demand.
Causal factors:
UAE
Function: Production Category: Falls from Height Activity: Drilling, Workover, Well Services
Narrative:
On 23rd February, approximately at 11:00 hours., during pulling out of 6 horizontal hole, a Derrick man was
working at monkey board, racking stands. After unlatching the elevator, the Driller started running the top drive
service downwards to pick the next stand. On its way, downward, the Top Drive Blower Assembly (slightly protruded)
entangled with the extended fall arrestor cable, which was inclined due to heavy wind. Derrickman experienced a
strong downwards pull where he lost his balance and fell on monkey board. The fall arrestor cable broke off from the
side of the safety harness due to extreme tension.
Outcome: The fall arrestor cable broke off from the side of the safety harness due to extreme tension.
What went wrong:
Root Causes
1. Technical Analysis for Risk not Effective (Fall protection Anchor point was 35 feet from the latching point of
Derrick man safety harness, prone to shift during windy conditions)
2. Inadequate Identification of Worksite/ Job Hazards (Job Safety Analysis (JSA) was too generic and did not
address hazards of lowering Top Drive System (TDS) and the required level of communication between Derrick
man & Driller)
1. Driller should not start lowering the TDS Block unless Derrick man gives OK signal
2. Modify/ redesign secondary Self Retracting Line (SRL) anchor point in such a way that the SRL cable does not
entangle or come in contact with TDS at any circumstances
Causal factors:
products
OGP 59
UAE
Function: Production Category: Other Activity: Drilling, Workover, Well Services
Narrative:
On 7th January approximately at 10:00 hours, a wire line crew was mobilized to retrieve valves. The wire line unit crane
was inspected and certified and the last load test for wire rope was conducted 3 years ago. The wire rope was subjected
to wear & tear and corrosion. The crew started to rig up lubricator and BOP assembly (weighing approximately
1.4 tons) by using wire line unit crane with safe working load of approx. 3 tons. While the load was positioned over the
Christmas Tree (X-mas), the wire rope failed near the wedge socket of the whip line block and parted causing the load
to fall down on the Xmas tree.
Outcome: X-mass tree valves handles, hydraulic actuator and a spectacle spade were damaged
What went wrong:
Root Causes:
1. Inadequate Audit/ Inspection/ Monitoring (The wire line unit including lifting equipment were certified
without adequate due diligence as wire rope was not subjected to load test and absence of Advanced Safety Load
Indicator (ASLI))
2. Inadequate Identification of Work site or Job Hazards (Ensuring adequate certification/testing of lifting devices to
eliminate use of uncertified wire rope was not part of Task Risk Assessment (TRA))
Corrective actins and recommendatins:
1. Ensure all lifting devices are duly tested and certified prior to initiating permit to work (PTW).
2. Conduct ad hock quality audit of Lifting Equipment Inspection & Certification Companies (LEICC) and wire
line crews competency
Causal factors:
UAE
Function: Production Category: Pressure Release Activity: Construction, Commissioning, Decommissioning
Narrative:
On 18th April, approximately at 10:30 hours, as a part of an upstream project, high pressure gas (350-370 bars) from the
plant is re-injected into the reservoir through 4 trunk lines. TL-7 is operated at approximately 5000 psi pressure and is
connected to 4 wells including Bb-645. Due to a leak from a gasket at Bb-645, it was planned to depressurize the TL.
An Operations Foreman tried to open 6 isolation valves u/s the choke valve (for depressurizing the trunk line) but the
first main isolation valve got stuck and did not open. The Foreman Control Room Foreman and after discussing the
issue, the Operations Foreman opened 2 vent valve located between Main SDV and Main trunk line manual isolation
valve. It resulted in 2 vent line, between the double block valves, to shear from the flare header and resulted in gas
release and activation of Hydrocarbon Alarm in the Control Room. Company personnel approached the location and
closed the depressurization valve to bring the situation under control that ensured complete isolation of flare header by
insertion of spade on 10 header at the site.
Outcome: It resulted in release of approximately 3.2 MMSCF of gas to atmosphere.
What went wrong:
Root Causes
1. Lack of Procedure (There was no formal or standard operating procedure for depressurizing trunk line)
2. Inadequate Preventive Maintenance (There was no specific preventive maintenance schedule for gaskets & valves;
maintenance work orders are not specific to individual valves but it cover the entire area)
3. Inadequate Training Efforts (There is no structured training/familiarization program to assure the competency of
the new staff with respect to the operation of gas gathering & injection facilities)
4. Inadequate Technical Design (The selected valve had no provision for greasing, lack of maintenance philosophy
and no interlock system to prevent using 2 vent valve)
60 OGP

1. Ensure availability of Standard Operating Procedure (SOP) prior to depressurize trunk lines.
2. Familiarize new staff with site specific operating procedures prior to their assignment.
3. Review & update schedule & scope of preventive maintenance to ensure all critical equipment are effectively
maintained
Causal factors:
UAE
Function: Production Category: Pressure Release Activity: Drilling, Workover, Well Services
Narrative:
On 12th June, approximately at 03:45 hours, a Flow Suction Tank was in service since 2005 with weir height of
1.75 m. The internal GRE lining was provided up to a height of 1 m from the tank floor. The settled water level within
the oil compartment accumulated to levels higher than 1 m (over GRE- internal lining level), and created corrosive
conditions for deterioration of steel. During routine patrolling, a jet of oil from tank shell, near oil outlet nozzle of the
tank about 1.5 m high from the bottom plate, forming a pool of Oil was observed by an Operations Foreman and the
leak was reported to control room.
Outcome: The leaked oil (approximately 130 bbls.) was contained within the secondary containment (bund area).
Input to the tank was isolated and its inventory was pumped out through Main Oil Line (MOL) system. The hole was
plugged and HAZMAT Team was mobilized to recover oil from the secondary containment.
What went wrong:
Root Causes
1. Inadequate Technical Design (The internal lining of the tank was one meter and its adequacy was not reviewed)
2. Inadequate Implementation of Procedure (Tank operating & draining was not implemented to monitor water
level in the tank and periodic water drainage either upstream or downstream the weir)
3. Inadequate Assessment of Required Skill or competency (New Operations staff were not adequately familiarized
with operating procedures and hazards).
1. Implement draining procedures to ensure that water level is monitored and water is drained periodically.
2. Review & Update Tank design specifications to ensure adequacy of internal GRE lining.
3. Develop a mechanism to ensure skills & competency of new staff with respect to site specific procedures & facilities
prior to assignment.
Causal fcators:
Process (conditions): Protective Systems: Inadequate security provisions or systems
change
products
OGP 61
UAE
Narrative:
On 14th March, approximately at 11:00 hours, the well was drilled and completed with 3 completions in the gas
plant reservoir. (H2S content 22% & well shut in pressure 2500 psi). Production Logging operation was planned to
define fluid inflow using Coiled Tubing (CT) logging package. The deployment of the PLT dummy tool string on
the CT BOP had been completed. While conducting pressure equalization across CT Blowout Preventer (BOP), an
uncontrolled hydrocarbon release occurred this resulted in a fire on the CT injector head. The CT operator activated
the shear seal ram and subsequently closed the Christmas Tree valves (Swab & Upper Master) to control the situation.
What went wrong:
Root Causes
1. Inadequate Audit/ Inspection /Monitoring (Inadequate Supervisory Verification of Task Execution)
2. Inadequate Identification of Work Site/Job Hazards (A generic Task Risk Assessment (TRA) template was used
without taking work sequence and well characteristics into consideration)
3. Inadequate Work Planning (There was inadequate availability of supervisory staff)
1. Do not use generic Task Risk Assessment (TRA). Update existing TRAs according to work sequence and work
location.
2. Do not perform high risk activities without effective Company supervision.
3. Ensure integrity of Pressure Control Equipment (PCE) via pressure testing prior to exposure to well head pressure.
4. Ensure double sealing barriers are in place during pressure deployment of logging tools.
5. Pressure Control Equipment (PCE) configuration and pressure test certificate should be countersigned by both
Job Performer and Company Engineer In charge
Causal factors:
change
products
UAE
Narrative:
On 12th January approximately at 18:30 hours, during the operation of pulling out of hole (POH) at a speed of
500 ft/hr. After POH / wipe log 5 stands, it was noticed that well was not taking the proper amount of mud & flowing
at a rate of 30 bbls/hour. The Rig Crew & Drilling supervisor decided to Run In Hole (RIH) back, circulated hole &
flow was checked, found the well flowing. After that informed Office without securing the well. Office informed the
DS to shut the well immediately. Well was killed using driller method with 88 pcf mud weight. Modular Dynamic
Tester (MDT) in the 8 pilot hole confirmed that formation pressure is 4950 psi instead of 5100 psi.Therefore, the
decision was made to lower the mud weight in 6 hole compared with the well program due to one water injector was
near to another which was closed only 2 weeks before the incident. Therefore, the decision was made to lower the
mud weight compared with the well program. This resulted in an under balance between mud weight and formation
pressure, resulting the well to flow.
Outcome: The well was shut & secured and crew evacuated.
What went wrong:
Root Causes:
1. Inadequate Practice of Skill (Drilling Supervisor (DS) reduced the mud weight for the 6 section)
2. Inadequate Communication (DS did not consult drilling team members prior to reducing mud weight)
1. Continuously monitor reservoir pressure update based on injection and faults affect in the area
62 OGP
2. Discuss MDT pressures with team members involved in developing the drilling program
Causal factors:
materials/products
change
products
UAE
Narrative:
On 28th January, approximately at 17:20 hours, in a single oil producer, 8 deviated pilot hole was drilled. The
Modular Dynamic Tester (MDT) recorded 4875 psi pressure Vs 4100 psi predicted reservoir pressure. The 6
horizontal hole was planned but did not cater for updating the pressure and mud weight after recording MDT.
While drilling 6 Horizontal hole across the formation with 71 pcf mud considering the predicted pressure of
4100 psi Vs 4875 psi recorded (775 psi underbalanced), the well started to flow, alarm was activated and 5 bbls gain in
the mud tanks was observed.
Outcome: The well was shut & secured and crew was evacuated.
What went wrong:
Root Causes:
1. Inadequate Work Planning or Risk Assessment Performed (Drilling plan was based on predicted reservoir
pressure and did not require to update reservoir pressure based on MDT).
2. Inadequate Correction of Worksite/Job Hazards (Nearby injection wells were not shut down as requested creating
reservoir pressure uncertainties)
3. In adequate communication (There was no effective communication between Drilling Engineer, Reservoir
Engineer and Petroleum Engineer to discuss reservoir pressures and results of MDT pressure; The driller and
crew were not aware of another well control incident of that occurred on 27th January, 2013
1. The reservoir pressure should be continuously monitored and updated considering injection and faults affect in the
area and the mud weight should adjusted accordingly.
2. Identify and shut down nearby injection wells two weeks before penetrating the reservoir.
3. The new MDT pressure should be reported and communicated directly between all teams and mud weight to be
adjusted accordingly
Causal factors:
change
Yemen
Function: Production Category: Explosions or Burns Activity: Maintenance, Inspection, Testing
Narrative:
A gas leak occurred from an Oxy-Acetylene torch leaking hose and resulted into a small fire when the gas came into
contact with the sparks generated from adjacent grinding work.
OGP 63
What went wrong:

No inspection/Maintenance program of the cutting torch set.
Poor quality of Acetylene hose and compliance to standard.
Personnel Safety Awareness/competency.
Work Co-ordination and Supervision.
A Periodic inspection program of the hoses and cylinders shall be put in place and well recorded.
All workers in charge of hot naked flame activities shall be debriefed about the risk associated with this type of
activities.
A regular constant program shall be developed and implemented.
All concerned entities shall verify that any material or equipment provided by their contractors shall meet and
comply with the International Standard required by the Company.
All contractors shall ensure that all equipment delivered to Company facilities or site comply with the
International standard.
Welder should obtain third party certificate especially those who are working in the plant.
The contractor hydro-test facilities should be audited to verify the reliability of the service.
The certification of the facilities shall be provided.
Causal factors:
products
Yemen
Function: Production Category: Explosions or Burns Activity: Office, Warehouse, Accommodation, Catering
Narrative:
A fire started in one of the porta-cabins near a warehouse due to an electrical extension cord malfunctioning.
What went wrong:
Inspection and preventive maintenance of electrical appliance.
No quality control at purchasing phase
Unknown Supplier
Improve the routine inspection check lists by adding specific check list for each electrical appliance.
Set up regular audits for accommodation maintenance lead by BMMS.
All personnel electrical appliances should be checked and approved by BSS.
Initiate a campaign to remove all unsafe appliance.
All appliances should go through technical evaluation prior approving purchase order.
Causal factors:
materials/products
products
Yemen
Narrative:
Fire started in one of the camp rooms due to an electrical extension cord malfunction.
64 OGP
What went wrong:

Inspection and preventive maintenance of electrical appliance.
Design of fire detection system in CMs.
No quality control at purchasing phaseUnknown Supplier Delay in Purchase Order delivery
Make a study in order to review the fire detection system in the accommodations. Issue modification proposal as per
the recommendation above. Improve the routine inspection check lists by adding specific check list for each electrical
appliance. Set up regular audits for accommodation maintenance lead by BMMS. All personnel electrical appliances
should be checked and approved by BSS. SSI related to the use of personal electrical appliances in the rooms to be
issued. To initiate a campaign to remove all unsafe appliances. All appliances should go through technical evaluation
prior approving purchase order.
Causal factors:
materials/products
products
Yemen
Narrative:
A fire started inside the camp kitchen in the deep fryer cooking oil.
What went wrong:
Quality Assurance/Quality Check of the Preventive Maintenance Program.
Daily maintenance and cleaning program of the kitchen equipment.
Set up a Quality assurance and check of the preventive maintenance program to ensure that the Preventive Maintenance
programs are done properly and by competent personnel. Reinforce the discipline of the kitchen personnel to properly
perform daily maintenance and cleaning program of equipment.
Causal factors:
materials/products
Yemen
Function: Production Category: Other Activity: Office, Warehouse, Accommodation, Catering
Narrative:
A fire started inside the Warehouse cooled room.
What went wrong:
Inadequate electrical works design i.e. no earthing in place.
No preventive maintenance records.
No inspections (electrical installation i.e. bad wiring, bad connection etc.)
Design adequate/dedicated storage area.
Ensure that proper and adequate maintenance program in place.
Electrical installations must be as per specifications/standards.
Emergency response training for related personnel i.e. basic and advance fire training.
OGP 65
Causal factors:
products
Yemen
Narrative:
During disconnection of the loading arm, after uncoupling the loading arm from the ship manifold, the loading arm
targeting cable failed. The situation was controlled by on scene operators.
What went wrong:
Inadequate preventive maintenance procedure and task lists.
Inadequate Inspection procedure.
Undefined role and responsibility.
1. The preventive maintenance task list to be reviewed for adding targeting cable lubrication and frequency of
greasing for the section of cables that is exposed to acquisition winch movement.
2. Review the scope of preventative maintenance check and reduce the frequency of inspection of the targeting cable
to six monthly instead of yearly.
3. Change the methodology of the inspection of targeting cables to include internal corrosion.
4. Implement supplier recommendations for the cable replacement intervals, as defined in supplier manual cable to
be replaced every two years.
5. To define clearly the responsibility for checking the targeting cable before use as recommended by supplier /
develop checklist.
Causal factors:
products
Yemen
Function: Production Category: Other Activity: TransportAir
Narrative:
Beechcraft-1900 Plane collided with ATR-42 Plane at airstrip during parking.
What went wrong:
Bad judgement
Apron approved and grounds marks performed only for two aircraft
Ensure Pilots are familiar with Airstrip procedures. Conduct regular joint tool box talks with both aviation crews and
Company ground staff. Conduct a monthly safety meeting with all airstrip personnel.
Causal factors:
People (acts): Following Procedures: Overexertion or improper position/posture for task
66 OGP
Yemen
Narrative:
When an excavator operator was trying to release a faulty (malfunction) spring lever of a trailer ramp suddenly the
lever released and hit his face causing him serious facial injuries.
What went wrong:
Injured Personsafety awareness. Work Site Supervision. Work Coordination. Inspection/Maintenance Program of
the Trailer Ramps system.
Revise risk assessment to include the correct operation of trailer ramp.
Reinforce work supervision on site.
The competent supervisor/foreman shall be available on site to supervise the work especially for movement and
operation of heavy equipment.
Improve work coordination on site.
Define clearly responsibility of personnel involved and who doing what on each task or job performed on site.
Inspection of all ramp systems of all trailers utilized by EPRS and all related departments using the trailers.
Repair/replace all damage or defective Trailer Ramp System identified by the above inspection.
Set up inspection program of the Trailer Ramp System and to be included into the regular inspection of the trailer.
Causal factors:
People (acts): Following Procedures: Overexertion or improper position/posture for task
materials/products
products
Yemen
Narrative:
While disconnecting a loading arm at the Jetty, the loading arm hit a lighting pole.
What went wrong:
No plan for preventive maintenance for battery, radio remote and the charger. No proper instruction for battery
management.
Implement vendor recommendation regarding preventive maintenance of the remote and battery. Battery management
to be clearly included in the procedure.
Causal factors:
products
OGP 67
Yemen
Narrative:
Crane was working at the pipe racks area picking up the Insert Bushing to the Rig floor, the load was removed from the
Cranes ball hook, and the hand signal was given to the crane operator in order to move the boom out of the rig floor
area. While moving the boom off the rig floor, suddenly the hook spooled to the sheave without operating. Cranes ball
hook hit the sheave and dropped down on the Rig floor which caused deformation to the pipe racking area cover and
damage to on lower bull nose sheave. No one was in the area; no injuries.
What went wrong:
Operating a crane with disabled safety systems. Failure to recognize a safety-critical system malfunction. Failure to
use Stop Work Authority. Miscommunication between Crane operator, Rig Manager, Mechanic and Electrician.
Procedures not known/not followed.
Lack of Competence
Crane computer was not functioning and operation was possible by overriding safety systems: Do not operate non-
functioning equipment! Safety systems need to be enabled during all operations and shall at no point be by-passed!
Use the Stop Work authority!
Causal factors:
Yemen
Function: Unspecified Category: Confined Space Activity: Office, Warehouse, Accommodation, Catering
Narrative:
Workers were carrying out a cleaning job of an underground water tank without taking any safety measures for
confined space entry.
What went wrong:
Lack of awareness of contractor personnel regarding confined space entry procedures. Work Site Supervision. The
current Permit to work procedure was inadequate for such activities.
Reinforce work supervision on site.
The Permit to work procedure is to be updated to cover adequately all applicable activities
Causal factors:
materials/products
products
68 OGP
Yemen
Function: Unspecified Category: Falls from Height Activity: Maintenance, Inspection, Testing
Narrative:
A welder and his assistant cut a worn plate from the top of a tanker with an oxy-acetylene cutter when the tanker shell
burst due to a gas explosion. The welder was thrown off the tanker, fell approx. 3.5 m and suffered a light injury. The
assistant luckily did not fall down.
What went wrong:
Field organization not suited to the task (lack of competences, HSSE supervisor has no back 2 back and as such half
the time he is not in the field; no clear organizational chart and responsibility allocation was produced yet). Although
PTW procedure is implemented by the contractor, this is unreliable and its importance is not understood by those
involved. Failure of effective contractor management by Company - no procedures in place for this type of high risk
work (at Company request contractor replied that it will submit these when ready).
Causal factors:
People (acts): Use of Protective Methods: Disabled or removed guards, warning systems or safety devices
Offshore
Qatar
Narrative:
At around 1115 H of March 27, 2013 a workers left leg below the knee was trapped by a toppled scaffold that was
transferred/lifted to the helideck from LQ Cellar deck. The crane sling had been released from the trolley when the
trolley toppled, trapping the scaffolders left leg against the helideck floor.
What went wrong:
The load was not properly secured (loosely packed) at the trolley, evidenced by slipping off of trolley scaffolding
tubes from the clips at three trolley corner locations after toppling.
The load was unbalanced and the centre of gravity was not established since the caster wheels were loose and
trolley legs were approximately 1.5 feet long including wheel diameters. Also, the scaffolding tubes were longer
than the trolley base and length of the tubes was not centred to bed of trolleys longitudinal board base.
No certified rigger at offloading area.
No lifting to be done without presence of qualified/certified riggers since the root causes identified were all the
Riggers responsibilities.
Proper size of trolleys to be prepared corresponding to length of scaffolding tubes to be loaded.
Work site supervisors to ensure close monitoring of work area.
Tool Box Talk specific to the task should be conducted by work site supervisors to help in preventing untoward
incidents and to avoid over confidence that leads to negligence of safety responsibilities.
Causal factors:
materials/products
OGP 69

products
Qatar
Function: Production Category: Other Activity: Diving, Subsea, ROV
Narrative:
A diving support vessel carried out diving and ROV operations within the 500 m zone of the platform without a BA
cascade system.
What went wrong:
Causal factors:
Qatar
Function: Production Category: Other Activity: Diving, Subsea, ROV
Narrative:
A diving/ROV survey vessel was mobilized to platform for inspection on 28th October. The NFEP and PTW were
approved and the vessel entered the platform 500 m zone on 28th October. ROV and diving activities were launched
and the vessel maintained a safe distance of 25 m to the platform (according to TRA). On 29th October at 09:30 am,
subsea AI was informed that the final Subsea Service Contract awarding process is not yet completed for the final step
of dated signatures so in effect no signed contract was in place. The vessel was instructed to stop the running activities
and depart the 500 m zone at 09:38 am. Diver and ROV were returned to the recovery bells. All subsea personnel
and tools were recovered to the surface and the vessel was moved out and set-up on DP mode outside the 500 m zone.
Contract award signatory process was completed and the vessel was returned to work on 30th October.
Causal factors:
No causal factors allocated
70 OGP
Qatar
Narrative:
The hydraulic direction control valve was stuck in the neutral position. The weight of the tool string caused it to free
wheel into the hole for approx. 30 feet. It was stopped by the brake, then the wire clamped. The fault was recognized
later the same day and rectified. Pulled out of the well without incident.
What went wrong:
Causal factors:
Qatar
Function: Production Category: Struck by Activity: Transport - Water, incl. Marine activity
Narrative:
During night watch of a tug boat, the vessel was steaming up and down near the platform. At 03:00 hrs a Cargo vessel
was approaching close to the platform from the north side. The duty officer immediately made contact with the ships
Captain and informed the Master of the tug. The vessel began to drift due to engine failure. Observing the drifting
vessel heading and bearing reading and the sea state (Current, wind, etc.) the captain of the tug did not call the CCR
as per emergency response plan procedure.
What went wrong:
Causal factors:
OGP 71
North America
Onshore
Canada
Narrative:
While a motorhand was installing grates on the drill floor, the grating that weighed approximately 34 pounds shifted
and fell approximately 13 feet through an opening into the cellar/ substructure. No injuries reported.
What went wrong:
Causal factors:
USA
Narrative:
During the process of purging the NGL (Natural Gas Liquids) meter prover loop of liquid, the hose was not connected
correctly and NGLs were released into the module. Halon was released by the gas detection system upon 60% LEL
(Lower Explosive Limit) detection by separate devices. Approximately five barrels of stabilized NGLs were released
and contained within the module on the floor.
What went wrong:
Causal factors:
USA
Function: Production Category: Exposure Electrical Activity: Drilling, Workover, Well Services
Narrative:
A wireline boom truck contacted overhead power lines trapping the operator inside until lines could be de-energized.
What went wrong:
Boom truck struck live overhead power lines.
Personnel performing work with elevating equipment shall be trained and competent in the use of the Overhead
Power Line policy including use of Look Up and Live flags and use of documented procedures for critical tasks.
Causal factors:
72 OGP
USA
Narrative:
A contractor gauger left a production tank drain valve in the open position. An estimated 259 barrels of fluids
(produced water and hydrocarbons) were released to the metal secondary containment ring surrounding the tank. No
What went wrong:
Causal factors:
USA
Function: Production Category: Other Activity: Construction, Commissioning, Decommissioning
Narrative:
Pipeline strike near miss.
What went wrong:
Did not respond to a one call and pipeline markers were not visible.
Always respond to one calls and mark right of ways visibly.
Causal factors:
Process (conditioins): Protective Systems: Inadequate/defective warning systems/safety devices
USA
Narrative:
While rolling a crane towards its storage location, a wheel dropped into a gap in the floor causing an abrupt stop. The
shift in momentum caused dynamic loads on the structure of the crane and the failure of two fastening bolts. The
horizontal I-beam, trolley and hoist, weighing approximately 600 pounds, dropped fifteen feet to the floor. No injuries
were reported.
What went wrong:
Causal factors:
OGP 73
USA
Narrative:
While tripping pipe in hole out of the derrick, the SRL line that was attached to the derrickman came in contact with
and got caught somewhere on the travelling blocks. Neither the operator nor the derrickman noticed the line making
contact with the blocks. As the blocks continued to move downward, the derrickman was pulled down onto the tubing
board floor. He hit his head and the blow rendered him unconscious for several minutes.
What went wrong:
There were no existing procedures to ensure the SRL line was clear prior to moving the blocks. The boom that holds the
SRL line out was not deployed out allowing the line to contact the travelling blocks in high wind conditions.
Checklist put in place to ensure the boom is deployed prior to commencing pipe tripping operations. SRL lines should
be flagged for easy identification by driller and workers. Better training is needed as all rigs are not set up the same.
Causal factors:
USA
Narrative:
An assistant driller was operating hydraulic controls to rotate the booster wheels in preparation for a rig move. The tyre
rotated, pinning the assistant driller against the hydraulic controls. At the time of the incident, the assistant was being
trained in the operation by an experienced hand. The injured party received medical treatment.
What went wrong:
Causal factors:
USA
Narrative:
Three crew members were tasked with testing tree valve integrity on a well. The crew inadvertently arrived at another
well and began bleeding gas using a metal bucket bonded to the tree. A likely static discharge ignited the gas into a gas
jet fire estimated at seven to nine feet. One crew member jumped approximately thirteen feet from the tree platform
to escape the fire. The fire was extinguished one to two minutes after ignition. The crew member required first aid
treatment.
What went wrong:
Causal factors:
74 OGP
USA
Function: Drilling Category: Exposure Electrical Activity: Maintenance, Inspection, Testing
Narrative:
Contractor received an electrical shock while inspecting a plug on an energized 480V/100A circuit that he thought
had been locked out. After first aid treatment at a local clinic, the contractor was released with a full return to work
authorization.
What went wrong:
Causal factors:
USA
Function: Drilling Category: Falls from Height Activity: Drilling, Workover, Well Services
Narrative:
A snubbing unit work crew was pulling out of the hole laying down the work string. The operator picked up a joint
and, when it was approximately 18 feet up out of the slips, the drill line severed. As a result, the travelling block and
drill line fell, struck and bent a joint of tubing, and came to rest on the snubbing basket. There were two workers in
the snubbing basket at the time of the incident. One worker was struck by falling material and the other worker was
reportedly uninjured. Both individuals were taken to the hospital for further evaluation and the one injured person
received sutures for a head laceration.
What went wrong:
Immediate Causes:
Equipment/toolsUsed defective tools/equipment: The 1 9x40 drill line had numerous square-ended
fatigue wire breaks that existed for a period of time before the failure on February 8.
According to the 3rd party Engineering Report (Wire line failure analysis report), it is likely that this
section of damage (the failed section) was a result of the rope having been in contact with itself while on
the drum at either the step up point or cross over point.
Underlying Causes:
Technical conditions
Inadequate inspection and maintenance programs:
Quality of visual inspection insufficient
According to the third party Engineering Report (wire line failure analysis report), these broken
wires should have been visible upon visual inspection and should have resulted in rope removal and
replacement prior to the rope failure.
Routine maintenance (change out schedule) inadequate: the well service company did not have a
specific required change-out schedule for the drilling line. Based on their perceived quality of drill line
construction, coupled with their internal experience, the visual inspections and associated deficiencies
observed typically led to a drill line change-out that occurred every 8 to 12 months.
Frequency of inspection inadequate: The most recent well service company monthly inspection of the
drill line occurred on January 28th 2013 (10 days prior to the failure) recorded no broken wires, no rope
damage, and no excessive wear.
No Technical useful life calculations performed: The well service company did not perform ton-mile
calculations to measure the cumulative load lifted and the distance lifted or lowered in miles. Since ton-
mileage was not calculated, there was no pre-determined limit in place to slip/cut or replace prior to drill
line fatigue or failure.
Requirements/procedures/guidelines: Incomplete/not suitable/missing. There is a reliance on the
contractor to appropriately inspect and maintain their equipment. No verification of contract company
inspections or maintenance records.
OGP 75

Summary of local actions:
Establish/develop a standard ton-mileage calculator for use on Company locations
Implement a requirement that each applicable contract company will:
Calculate ton/mileage
Establish a safe pre-determined operational threshold limit specific to the drilling line being used
Report the ton-mileage calculation every 24 hours on the daily job log
Lessons learned and key reminders:
Thoroughly inspect working areas and equipment before operation
Properly inspect and maintain equipment in accordance with best management practices
Causal factors:
materials/products
products
USA
Narrative:
While picking up a joint of tubing using manually engaged elevators on the rig floor, a single joint of tubing came free.
The joint fell one foot to the ground and toppled over. One person sustained a leg injury.
What went wrong:
Causal factors:
USA
Narrative:
While performing pressure testing ahead of completion activity, the combined sand and water dump lines system was
over pressured to 5000 psi instead of the intended 1800 psi. The pressure was bled off with no injuries and no damage
reported.
What went wrong:
Causal factors:
76 OGP
USA
Narrative:
High pressured frac stack near miss. Relief valve went off and pump was shut down. Pressure was bled off.
What went wrong:
Closed incorrect valve.
Communicate clearly to personnel involved and stay out of red zone.
Causal factors:
USA
Narrative:
During final tightening of fittings on a manifold over the wellhead, a surface casing valve separated from the nipple
resulting in a release of natural gas and well fluids. Seven contractors were in the vicinity of the well when the release
occurred and four of them received abrasions and lacerations from airborne gravel and debris. They were evaluated at
local hospital and released for full duty.
What went wrong:
Causal factors:
USA
Narrative:
A rig worker (new hire with approximately 7 years of drilling experience) was disconnecting a line from a pressure
washer manifold when he was struck in the mouth/jaw by the metal end of the pressure washer line. The IP was
assigned with his mentor to retrieve the 3000 psi hose so that it could be moved and used to thaw the kelly hose
located on the rig floor. The pump, attached to the rig pressure washer, was not in use or running while it was being
disconnected, but the hose was found to be partially frozen and contained as much as 1800 psi trapped pressure. The
result of this impact caused multiple fractures to the IPS jaw and lacerations requiring sutures.
What went wrong:
The equipment was known to have a bad gauge but was left in service without repair. The employee was a short service
employee and was unaware of the risk. The line was frozen allowing pressure to remain in the system and not be bled
off.
Any time equipment is not functioning properly it needs to be removed from service and flagged until repaired. Short
Service employees should always be assigned a mentor. Preventive maintenance programs need to be in place for all
equipment. Whip checks need to be installed on all pressurized lines.
OGP 77
Causal factors:
energy isolation
USA
Narrative:
While laying down tubing, the driller inadvertently released the elevator release control allowing a single joint of
tubing to drop approximately 18 feet onto the pipe skate. The joint jumped off the pipe skate and slid down the V door
chute coming to rest in the pipe shed. There were four crew members in the vicinity of the dropped tubing joint but no
What went wrong:
Causal factors:
USA
Narrative:
While trying to secure a tubing hanger in the well head, the hanger came out of the top of the BOP and fell to the
ground. The well was immediately secured by closing the BOPs and casing valve. No injuries were reported.
What went wrong:
Causal factors:
USA
Narrative:
Drilling installation of a spacer spool below the Blowout Preventers (BOPs), the rig floor was raised. The rig operator
was lifting a cat line that was in the way of a forklift by pulling it up through the floor. While doing so, a removable
floor plate, weighing approximately 30 pounds, fell 17 feet glancing off a crew members hard hat. Minor injuries
reported.
What went wrong:
78 OGP
Causal factors:
USA
Function: Construction Category: Caught In, Under or Between Activity: TransportLand
Narrative:
Contractor light vehicle left road and rolled over coming to rest on top of the transit lines between drill sites. The
contractor driver was alone and was taken to the medical clinic by ambulance and treated for abrasions to hands and
a sore lower back.
What went wrong:
Causal factors:
USA
Function: Construction Category: Pressure Release Activity: Construction, Commissioning, Decommissioning
Narrative:
Workers for a construction crew were constructing a new Company pad location. While removing topsoil for the
construction of an access road, a dozer struck a 4-inch lateral gas line that was 24-inches below the surface. The gas
line, that serviced two local cities, was shut down and repaired by 6:45 pm. There was no fire or injuries associated with
this incident.
What went wrong:
Immediate Causes:
Undesired BehaviourDid not meet requirements/guidelines/instructions.
The location of the gas transmission line was known and was flagged. There was a hydro-vac machine on
location for specifically for potholing the line to verify its depth. The hydro-vac machine was temporarily
out of service and the project manager specifically told the project supervisor not to have anyone excavate
in the area of the known pipeline until the depth was verified by potholing.
The project supervisor consciously gave instruction to the dozer operator that was contrary to the specific
instruction that had been given to him by the project manager.
In addition, this instruction to excavate was against the construction companys excavation protocol and
contrary to the Company Safe Practices Manual Excavation and Trenching requirements.
Underlying Causes:
Work Supervision and Follow-upHSE Considerations given lower priority than economy and progress: -
The need for HSE precautions was recognized and communicated however these precautions were not
carried out because they were holding up progress on the project.
Work Practices and Accomplishment
The team/entity did not obey rules, procedures or good working practices:
The crew neglected to follow the construction companys excavation policy and the Excavation and
Trenching requirements in the Company Safe Practices Manual.
The project supervisor consciously gave instruction to the dozer operator that was contrary to the specific
instruction that he had been given, contrary to construction companys excavation protocol, and contrary
to the Company Safe Practices Manual requirements.
OGP 79

Lessons Learnt:
If a needed piece of equipment is in need of repair, get it fixed!
Do not proceed to work on tasks that might seem routine, until all gas lines are flagged and the depths are verified.
Stop work and communicate safe working conditions before someone is injured.
Local Actions to Prevent Recurrence:
Conducted a safety stand-down to reinforce Companys HSE expectations with all excavation contractors.
Verified that the construction company had reinforced Company safe work practices with all of their applicable
employees (particularly Excavation, Safe Job Analysis, and Stop Work Authority).
Implemented a local amendment to the Company Safe Practices Manual that requires the use of a Safe Work
Permit when conducting Excavation and Trenching activities in the Business Unit.
Causal factorsrs:
materials/products
products
USA
Narrative:
A five gallon bucket (approximately 21 pounds) containing metal electrical components fell through a space between
the edge of the Module and scaffolding. Falling approximately fourteen feet, it landed on the threshold of the entry
door to the Module.
No injuries reported.
What went wrong:
Causal factors:
80 OGP
Offshore
USA
Narrative:
A beam clamp chain hoist weighing approximately 85 pounds fell thirty feet to the deck floor. A first aid injury from
the falling chain sustained by a technician was reported.
What went wrong:
Causal factors:
USA
Narrative:
Technicians temporarily placed a torque wrench weighing 110 pounds on one of the studs while replacing bolting on
the drilling derrick foundation. The wrench fell three feet landing in close proximity to a technician working on the
desk below. No injuries were reported.
What went wrong:
Causal factors:
USA
Narrative:
While attempting to place drill line onto a pallet on the main deck, the crew placed a nylon sling on the drill line.
After hoisting the length of drill line with the crane, a roustabout manipulated the drill line to coil and secured it to
the pallet.
After approximately seven feet of the drill line had been fastened to the pallet, the line slipped from the sling and fell
to the deck. Two workers were struck by the falling drill line. Both have been released and returned to work.
What went wrong:
Causal factors:
OGP 81
USA
Narrative:
Dropped object.
What went wrong:
Vibration caused failure of retaining cotter pin. Pin was not proper size and was re-used.
Never re-use a cotter pin and only use Original Equipment Manufacturer specified parts.
Causal factors:
materials/products
products
USA
Narrative:
Roustabout was struck in the shoulder/ back by a single joint of drill pipe. Operation at the time of the incident was
laying down drill pipe on the auxiliary side of rig floor while circulating and conditioning mud at the main well centre.
Operations were shut down, location secured. A Lost Work Day Case was reported.
What went wrong:
Causal factors:
82 OGP
South and Central America
Onshore
Argentina
Function: Production Category: Exposure Electrical Activity: Lifting, Crane, Rigging, Deck operations
Narrative:
While a hole drilling truck was making holes to install electric line poles, when driving under the energized line
(13.2kV) being the rig in a vertical position on top of the truck, the wire cut and one of the electric poles bent.
What went wrong:
Lack of judgement: the operator was trained on interferences and had knowledge of the presence of wires at the
site, but decided to transport the rig in a vertical position.
Pressure perceived by the employee: the operator assumed that the speed to finish the job was more important than
safety.
Policies, standards, procedures: the procedure was not fulfilled.
Engineering/Design: the hole drilling truck was not designed to be unable to move when the rig is in a vertical
position.
Placement of a locking device to prevent the truck from travelling with the tower in a vertical position.
Review of the contractors procedures.
Diffusion of the procedure and retrain the excavation crew.
Reinforcement of the stop work authority policy.
Diffusion of the emergency role, emphasizing that it should be applied immediately upon the occurrence of an
incident.
Causal factors:
materials/products
products
Bolivia
Function: Production Category: Caught In, Under or Between Activity: Transport - Land
Narrative:
A tanker truck delivering propane to the plant shut-down went off the road to its right side when the Driver decided
to carry out the manoeuvre to avoid crossing animals. After 30 m driving on the soft shoulder of the road the truck
lost stability and turned over to its right side. As a result of this RTA the Driver received first aid and the tanker truck
suffered minor damage without any loss of propane containment.
What went wrong:
Physical Stress - Fatigue Due to Lack of Rest. Inadequate Purchasing - Inadequate Receiving Inspection and Acceptance.
Logistic R&R are clearly established within the organization and Companys responsibilities are understood when
transporting product and service supplies. Contractors have robust HSSE contractor management processes in place to
ensure Companys HSE requisites are fully cascaded down to subcontractors Contractors and subcontractors comply
with Company Driving Standard including having in place robust Journey Management plans.
Causal factors:
People (acts): Inattention/Lack of Awareness: Fatigue
OGP 83
Ecuador
Function: Production Category: Confined Space Activity: Production Operations
Narrative:
During pipeline mantenance operations inside a trench, two operators became caught due to soil slipping from one of
the walls.
Whate went wrong:
Noncompliance of emergengy response procedure - Noncompliance of operational procedure - Lack of risk awareness
Traning and review of procedures for supervisor and operators
Causal factors:
Uruguay
Function: Exploration Category: Exposure Electrical Activity: Transport - Water, incl. Marine activity
Narrative:
The Chief and Second engineer on board a seismic vessel removed a bulkhead panel in order to fit a cabinet. It was
decided for ease of installation, the panel would be removed and the cabinet and panel then re-fitted back into its
original location. Whilst removing the panel, a loud bang was heard, startling both engineers. On investigation, it was
discovered a previously unidentified coiled 400V energized cable had been positioned behind the panel. This cable
had no function, was not shown on the vessel plans or drawings and had been left in situ from when the vessel was
constructed in the shipyard, some 18 months earlier.
What went wrong:
Inadequate Engineering/DesignInadequate Standards, Specifications and/or Design Criteria.
Inadequate Engineering/DesignIncorrect Technical Design.
Assume all electrical cables or wires are live until proven dead. Ensure that any modifications made to designs are fully
risk assessed.
Causal factors:
Offshore
Trinidad & Tobago
Narrative:
At approximately 10:00, personnel were attempting to change the winches on the Hercules crane with the use of a
mobile crane. The crane operator moved the boom with the winch attached from West to South. As he was about to
lower the winch onto the deck the crane tipped over onto the left side.
What went wrong:
Did not follow procedures, rules and regulations
Incomplete documentation provided as well as duties was not carried out as part of SSOW.
84 OGP

Enforce Action/Consequences program similar to rewards and recognition
Retrain Individuals on SSOW and roles and responsibilities of job position
Causal factors:
Trinidad & Tobago

Narrative:
Swagelok fitting failed during a routine function test, resulting in a loss of primary containment (LOPC) of hydraulic
fluid from the BOP control system and rendering control of the BOPs impossible. No injuries, damage to equipment
or environmental impact were reported.
What went wrong:
Causal factors:
OGP 85
209-215 Blackfriars Road
London SE1 8NL
United Kingdom
Telephone: +44 (0)20 7633 0272
Fax: +44 (0)20 7633 2350
165 Bd du Souverain
4th Floor
B-1160 Brussels, Belgium
Telephone: +32 (0)2 566 9150
International
Fax: +32 (0)2 566 9159
Association
of Oil & Gas Internet site: www.ogp.org.uk
Producers e-mail: reception@ogp.org.uk

2013 SH

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SAFETY PERFORMANCE INDICATORS 2013 DATA

High potential events report

OGP DATA SERIES

International Association of Oil & Gas Producers

Safety performance indicators2013 data

Report No: 2013sh

South and Central America 83

What went wrong:

What went wrong:

No corrective actions or recommendations described.

Corrective actions and recommendations:

Corrective actions and recommendations:

Corrective actions and recommendations:

Arrestor on lifting beam/h-beam not wide enough to stop trolley.

Corrective actions and recommendations:

Corrective actions and recommendations:

Corrective actins and recommendations:

What went wrong:

Corrective actions and recommendations:

Corrective actions and recommendations:

What went wrong:

What went wrong:

People (acts): Use of Protective Methods: Failure to warn of hazard

Corrective actions and recommendations:

Corrective actions and recommendations:

South and Central America

Corrective actions and recommendations:

Trinidad & Tobago

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