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GUPCO Kamose Fatality Incident
Toolbox Talk Lessons pack
Presenter’s NameTitle Department
Prepared By Dave Goodwill for Dave Blevins
Background
• Mohi Mohammed Gouda was a Barge Engineer on the EDC rig “Kamose” working for BP’s GUPCO joint venture operation offshore Egypt.
• On 18th June 2001 he was involved in an incident during a lifting operation he was supervising.
• He fell 4m and sustained serious head injuries.
• Several weeks later he died of these injuries having never recovered.
Learn from a fatal error
• This accident would not have happened if existing procedures and good practice had been used
• What will You Learn from Mohi’s death ?
• Could you and your workmates be at risk of a similar incident ?
The Job
Your Task
• Replace the crane engine
Your Procedure
• The job has been done before using the spare crane and another available rig crane
• You’ve identified a better way
• But you’ve never done it this way before
Your PlanYour Equipment
• The other crane• Rigging equipment• An air winch from
another location on the rig welded to the generator room roof
Your Team
• You (supervisor)• Crane driver• Asst crane driver• 2 x Roustabouts
What else do you need to do ?
How it was done
• A permit is not being used
• A JSA has not been carried out
• The welds fixing the winch to the deck have not been tested
• The old engine has been successfully removed using the method.
Would You be happy with this ?
The Incident
He died in hospital of these injuries several weeks later
What happened
• The weld between the winch and the roof failed
• The winch was dragged over the handrail
• Mohi (the supervisor) was first trapped between the air line and the handrail
• He was then forced over the handrail and fell 4m to the deck below sustaining serious head injuries
The Key CausesWhat Do You Think ?
Now that you know what happened:
• What do you think were the key causes ?
• What should have been done here ?
The Key CausesThe Investigation Findings
Three Critical factors identified:
• The weld was inadequate. It was neither designed for the job, carried out by a certified welder or properly tested.
• No permit to work , risk assessment or Safe Job Analysis (JSA) was completed.
• The previous procedure, known to be sound, was not followed
Could something like this happen on your rig ?
Think about it. Do you always:
• Use established and proven procedures ?
• Carry out a thorough risk assessment before using a new procedure ?
• Carry our work like this under the control of a Permit To Work System ?
• Conduct JSA’s and pre job safety meetings ?
• Ensure that load bearing welds are properly designed, inspected and tested ?
If you answer “no” to any of these it could happen to you