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ستفادة منھاوس والعبر الم الدر لقوع الحوادث من خ منع وIncident Prevention Through Learning from Incidents July - September, 2012 مة والبيئة قسم الصحة والسHealth, Safety & Environment Division

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Page 1: lesson from accidents

منع وقوع الحوادث من خ�ل الدروس والعبر المستفادة منھا

Incident Prevention Through

Learning from Incidents

July - September, 2012

قسم الصحة والس�مة والبيئة

Health, Safety & Environment Division

Page 2: lesson from accidents

1

For further information, comments and suggestions please contact:

Dr. Muhammad. R. Tayab ([email protected]) Health, Safety & Environment Division

Tel: 02-6041217; Mobile – 00971 (0) 50 324-3996

ء الم�حظات وا�قتراحات يرجى ا�تصال بـ:للمزيد من المعلومات وإبدا

[email protected]على البريد ا�لكتروني التالي : محمد ريحان طيب الدكتور قسم الصحة والس�مة والبيئة

6041217رقم الھاتف :

This Booklet is circulated within ADCO organization within the framework of HSEMS. It should only serve as guidance and ADCO shall in no event accept any liability for either the fact described, nor for any reliance on the contents by any third party.

Page 3: lesson from accidents

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During the 3rd Quarter of 2012 we have had 42 injuries of varying nature and in addition, we had 29

transportation, 9 fires, 17 Property damage, 4 Gas releases and 3 spills related incidents. We sadly had 6 Non Accidental Deaths (NAD) involving our colleagues. Incident investigations have revealed deficiencies in effective

supervision and leadership, improper behavior, and inadequate work planning being the root causes.

During this period, we have worked over 38 Million Man-hours and have driven over 47 Million kilometers which

was a great challenge to our drilling, operations, project and support team members as we would like to

enhance operation safety in an environment of expansion. I urge you all to discuss these incidents within our

teams and work groups especially with contractor workforce to ensure that none of us get hurt during our work. We can address our shortcomings with:

• Strong leadership by visibly engaging with workforce • Discouragement of unsafe behavior by rewarding & acknowledging safe behavior

• Risk minimization by involving all levels of workforce in task execution

Let us promote a working environment where safety becomes part of our second nature.

Saleh Aidrous Al Wahedi Senior Vice President (Engineering & Projects)

Page 4: lesson from accidents

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Table of Contents

Damage to Underground Fiber Optic Cable During Excavation 4

Crane Mounted Truck (Hiab) Rollover on Gatch Road 5

Vehicles Collision on Gatch Road 6

Arm Injury Due to Explosion During CAD Welding 7

Fire at Scaffolding Platform Around Stripper Column 8

Foreign Object Entering Eye of a Worker 9

Vehicle Rollover on Gatch Road 10

Crane Mounted Truck (Hiab) Rollover on Gatch Road 11

Vehicles Collision 12

Crane Rollover During Move on Gatch Road 13

Water Tanker Rollover 14

Hand Entrapment Inside Tong 15

Electrical Shock 16

Worker’s Finger Entrapment Between Pipe Flange and Valve Flange 17

Transformer Fire 18

Fire in UPS Unit of Substation 19

Vehicle Drop in Low Lying Area/Depression 20

Breakage of Hook of Wire Rope 21

HSE Performance, Q3, 2012 (YTD) 22

Incident Sub Types Q3 – 2012 (YTD) 23

Asset Wide Incident Sub Types Q3 – 2012 (YTD) 25

Incident Sub Types Asset Wide Q3 – 2012 (YTD) 26

Incident Immediate Cause Analysis Q3-2012 (YTD) 29

Asset Based Incident Immediate Cause Analysis Q3-2012 (YTD) 31

Incident Root Cause Analysis Q3-2012 (YTD) 32

Asset Based Incident Root Cause Analysis Q3-2012 (YTD) 34

Focus Areas Q3-2012 (YTD) 36

Page 5: lesson from accidents

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Damage to Underground Fiber Optic Cable During Excavation

Area Incident Description Causes

BAB Field

08-08-12

A 3rd party contractor was working on a project to lay a new

potable water pipeline to supply GASCO and ADCO with

potable water and the majority of the work was completed in

BAB. The work was performed under ADCO Permit to Work

(PTW) system and an excavation certificate was issued. As

built drawing did not show location of buried fiber optic cables

(which were running parallel to a transfer line) and there were

no physical markers on the ground.

The task was intended for manual excavation and the use of machine was limited to removal of excavated material/debris.

The crew did not have adequate resources (i.e. number of

laborers for manual excavation) to complete the task on

schedule and these resources were not adjusted for work

during the fasting month of Ramadan.

The job performer had started to use mechanical excavator,

after exposing buried line. During the excavation a fiber optic

communication cable was cut and that has resulted in tripping

of Remote Degassing Station (RDS-1) and alarm was sounded

in the control room of Bab Central Degassing Station (BCDS).

• Inadequate Work Planning (The

number of labourers in the crew were

not adequate to manually excavate

the site on time and shorter working

hours in Ramadan were not

considered during work planning)

• Inadequate Implementation of

Procedure (JP was not a member of

Task Risk Assessment (TRA) team and

did not endorse the TRA)

• Inadequate Leadership (Job

Originator was not involved in TRA

and did not ensure availability of

adequate resources for task

execution; As built drawings did not

show location of buried cables)

Lessons Learned

1. Do not use mechanical excavator

in restricted areas.

2. Ensure availability of adequate

resources prior to execution of

tasks

3. Provide updated as built drawings

to support excavation certificate

4. Ensure Job Origionator & Job

Performer/s are part of Task Risk

Assessment (TRA) Team

Immediate Causes

• Violation by Supervisor (The job performer (JP) used a

mechanical excavator in area where manual excavation

was authorized)

• Lack of knowledge of Hazards Present (Location of

buried cable was not known to Job Performer and there

were no surface makers on the ground; Job Performer was

not aware of risks associated with the task)

• Inadequate Guard or Protective Devices (Cable were

buried without any physical protection)

Page 6: lesson from accidents

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Crane Mounted Truck (Hiab) Rollover on Gatch Road

Area Incident Description Root Causes

BAB Field

22-08-12

A crew was involved in civil works in RDS-2

and after the completion of the work, a driver

was driving Hiab Truck (crane mounted truck)

from the work site towards their camp.

The supervisor and job performer (JP) did not

notice that the vehicle had deteriorated tires

and IVMS (In Vehicle Monitoring System) was

not functional. Due to high humidity, the

gatch road surface became slippery.

After driving 8 km from the worksite, while

the driver was maneuvering through holes on

the surface of the gatch and he applied harsh

brakes. A combination of deteriorated tires,

slippery surface, harsh brake and sharp

maneuvering of steering caused the vehicle to

rollover. Outcome: The driver sustained

lower back injuries.

• Inadequate Audit/ Inspection/

Monitoring (Vehicle’s tire fitness was not

checked; Road condition (potholes) were not

assessed prior to the journey; Vehicle IVMS

and driver’s driving behavior reports were not reviewed)

• Inadequate Identification of

Worksite/Job Hazards (Hazards of slippery

surface due to humidity and potholes in gatch

road were not identified and controlled)

Lessons Learned

1. Avoid harsh braking and sharp

maneuvering of steering especially on

gatch roads.

2. Consider hazards of weather conditions

(rain, high humidity etc.) on road/track

conditions in Task Risk Assessment

Immediate Causes

• Improper Decision Making/ Lack of

Judgment (Driver applied harsh brakes

and sharp maneuvering of steering on

slippery road)

• Improperly Prepared Vehicle (The

vehicle had deteriorated tires)

• Storm or Act of Nature (Road surface

became slippery due to high humidity)

Page 7: lesson from accidents

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Vehicles Collision on Gatch Road

Area Incident Description Root Causes

Engineering

& Projects

Asab

09-07-12

Two different contractor (Project & Drilling)

vehicles were approaching from opposite

directions, on a gatch road. There was a

blind spot at a turning and one driver was

driving on the wrong side of the road. Desert

flags mounted on both vehicles were not

visible to other vehicle due to the height of a

pipeline berm. One vehicle (Project) was

driven at a speed not appropriate for road conditions (73 km/Hrs) and the other driver

(Drilling) was driving at the speed of 60

km/Hrs. Both vehicle emerged after ablind

spot and collided head on.

Outcome: Total six passengers in both

vehicle sustained minor injuries and vehicles

were badly damaged.

• Inadequate Identification of Worksite/

Job Hazards (There was no sign or marking

when approaching the blind spot)

• Inadequate Practice of Skill (Project driver

was in haste and over speeding; and he was

driving on the wrong side of the road)

Lessons Learned

1. Always reduce vehicle speed according to road

conditions especially when approaching blind

spots

2. Do not drive in wrong lane even for shorter

period of time

Immediate Causes

• Violation by Individual (The project

vehicle was driven in wrong lane)

• Work or Motion at Improper Speed

(Vehicle speed was not adjusted

according to road condition and presence

of a blind spot)

• Inadequate Warning System (There

were no road signs to alert approaching

drivers)

Page 8: lesson from accidents

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Arm Injury Due to Explosion During CAD Welding

Area Incident Description Causes

Engineering

& Projects

Asab

12-07-12

CAD* Welding of grounding cable outside the control

room building was planned but no specific work permit

was obtained and the work was performed under a

“Green Field” general permit to work. A newly arrived

electrician who was dressing electrical cable inside the building was requested to assist the CAD welding

crew.

The job Performer went to attend another task and

stopped the activity but the crew continued work. The

electrician was not wearing any welding gloves and no

special tool to hold the mold was available.

The electrician held the cable in his hand although it is

held by the mold itself. After the set-up, another

worker ignited the weld powder in the mold using

spark igniter whilst electrician was still holding the

cable. Explosion/backfire through the aperture cover

of the mold occurred. Outcome: It resulted in 2nd

degree burn on the right forearm of the electrician.

• Inadequate Job Placement (An

electrician was assigned on CAD welding

activities without assessment of required

skills)

• Inadequate Assessment of Need &

Risks (CAD welding activity was

performed without necessary tool to hold

the mold)

• Inadequate or Lack of Safety Meeting (Electrician was not subjected to tool box

Talk and crew was not made aware of

hazards of CAD Welding)

Inadequate Audit / Inspection/

Monitoring (Job Performer left the crew

to attend another task without assuring

that work has stopped)

Lessons Learned

1. Always subject all crew members to tool

box talk specific to the task.

2. Ensure assignment of skilled crew

members and availability of all necessary

tools, especially on high risk activities

3. Never leave crew unattended specially

those working on high risk activities

*CAD welding (Exothermic welding) is process for joining

two electrical conductors, that employs superheated

copper alloy to permanently join the conductors.

Immediate Causes

• Violation by Group (The activity was stopped by

the Job Performer but crew continued the work)

• Personnel Protective Equipment (PPE) not

used (Electrician did not use welding gloves; the

right tool to hold the mold was not used/obtained)

• Lack of Knowledge of Hazards Present (The

crew was not aware of hazards of back fire)

• Improper Position or Posture for the Task

(Electrician was holding the cable at the both sides

of the mold)

Page 9: lesson from accidents

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Fire at Scaffolding Platform Around Stripper Column

Area Incident Description Root Causes

Engineering

& Projects

Asab

16-07-12

A welder was welding a pipe on the topmost

platform (35 m high) of stripper column.

After completing the task he lowered his

tools and the portable welding equipment to

a lower level platform and left the site. On

scaffold boards (which were below welding

area) food scarps, plastic bottles, papers etc.

had accumulated and not noticed by crew or

their supervisor. The welding habitat was not

set and the fire blanket was too small for the

task and had holes in it.

Later, workers noticed fire and smoke from

upper level scaffold platforms and raised the

alarm. Outcome: ADCO & GASCO Fire

Teams responded and extinguished the fire.

No personnel injuries and damage to scaffold

boards had occurred.

• Inadequate Audit/Inspection/

Monitoring (Supervisor did not visit the site

before and after the completion of hot work;

accumulation of combustible materials was

not noticed; Fire blanket with holes and

absence of fire habitat were not noticed)

• Inadequate Work Planning or Risk

Assessment Performed (A welder without

any supervision was assigned for the task;

Job Performer (JP) did not go to the top

platform to monitor the work; cleaning of

scaffold sites of accumulated debris was not

considered)

Lesson Learned

1. Maintain housekeeping at work locations.

2. Subject critical activities to continuous

monitoring & supervision

3. Switch off/Disconnect power supply to

portable electrical equipment during breaks

4. Use fir blanket/fire habitat for welding

activities in process areas.

Immediate Causes

• Inattention to footing &

Surroundings (Accumulation of

combustible waste material near welding

area was not noticed)

• Inadequate Guards or Protective

Devices (Fire blanket was not adequate

to isolate welding spatters/ welding

habitat was not set)

• Work Exposure to Temperature

Extreme (Hot summer day with ambient

temperature exceeding 47oC)

Page 10: lesson from accidents

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Foreign Object Entering Eye of a Worker

Area Incident Description Root Causes

Engineering

& Projects

Sahil

26-07-12

A welder was assigned to perform welding task

for the installation of pipe support. After

completing the welding task, while he was

removing welding face shield, he felt a sand

particle had entered his left eye.

He washed his eye with water and felt relieved

and continued his job. Later, at night he felt

pain and irritation in his eye and he visited the

camp clinic the next morning and he was

attended by the Physician and then referred to

a Hospital for the removal of foreign object

from his eye.

Outcome: The foreign object (sand particle)

was removed from his eye.

• Inadequate Identification of

Worksite/Job Hazards (Workers were not

adequately made aware of hazards of working

on a windy day; risks of rubbing eyes when a

foreign body enters eye were not known)

• Inadequate Communication (Lessons from

prior similar incident occurred on 04-05-2012

were not effectively communicated)

Lessons Learned

1. If a foreign object enters eye, do not rub eyes

and seek medical attention

2. Report all incidents (including minor

incidents/injuries) to your supervisor

3. Always use eye wears for protection in

working sites, especially in sandy areas.

Immediate Causes

• Storm or Act of Nature (Blowing wind

carrying particles/dust/light objects)

• Personal Protective Equipment (PPE)

Not Used (Welder removed his welding

face shied after the task and due to blowing

winds sand particle entered his eye)

Page 11: lesson from accidents

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Vehicle Rollover on Gatch Road

Area Incident Description Causes

Engineering

& Projects

BAB

23-08-12

A vendor crew was involved in installing gauges

on multi flow meters and after the completion

of the task, transport was arranged to transfer

them back to Abu Dhabi. The plan was to

collect passengers from Accommodation Camp

and proceed to Abu Dhabi via Madinat Zayed

Road.

An Engineer decided to go to Abu Dhabi with

vendor crew and boarded the vehicle. The

Engineer advised the driver to go through Bab-

Tarif Road and to avoid going through security

check post, the engineer identified a gatch

road. The driver was driving fast (80-90

Km/Hrs) for the road condition and at a bend

he lost control of the vehicle and the vehicle

rolled over. Outcome: No serious injuries to

passengers and the vehicle sustained minor

damage.

• Improper Supervisory Example (The

Engineer changed the journey plan and

advised the driver to take short cuts/gatch

road and did not stop him from over

speeding)

• Inadequate Audit/ Inspection/

Monitoring (Driver’s RAG reports were not

used to coach the driver with history of over

speeding)

• Inadequate Correction of Worksite/ Job

Hazards (Lessons from prior Road Traffic

Accidents were not effectively communicated; No tool Box Talk was

conducted for drivers)

Lesson Learned

Immediate Causes

1. Always drive within posted speed limits and

reduce speed according to rad conditions

2. Conduct Tool Box Talks for drivers and

empower them to not let any passenger to

change journey plan

3. Passenger/s should stop driver from over

speeding, taking short cuts and from driving recklessly.

• Violation by Individual (The driver was

driving fast in excess of posted speed limit)

• Violation by Supervisor (The Engineer

did not stop driver from overspending)

Page 12: lesson from accidents

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Crane Mounted Truck (Hiab) Rollover on Gatch Road Area Incident Description Root Causes

Engineering

& Projects

BAB

28-08-12

A crew consisting of a Rigger & Operator of

Crane Mounted Truck (Hiab) were instructed by

their Engineer drive the truck to work site and

lift pre-cast materials. The crew left their camp

and was proceeding to the location.

They were travelling on a gatch road parallel to

an existing pipeline. This road contained many

pot holes and the surface was wet/ slippery

due to high humidity. The driver was

attempting to drive around potholes and made

a sharp maneuvering of steering followed by harsh brakes.

It resulted in vehicle to get out of control. The

rear end of the vehicle spun around in the

opposite direction and then rolled over on

passenger side against the pipeline berm.

Outcome: The vehicle rolled over to its side on

the berm of the pipeline. Driver and passenger

sustained minor injuries as they were wearing

seat belts.

• Inadequate Audit/ Inspection/

Monitoring (Driver had history of

applying harsh brakes and harsh

acceleration and his driving behavior

reports were not effectively reviewed to

initiate counseling/ coaching on the skill)

• Inadequate Identification of

Worksite/Job Hazards (Hazards

associated with the journey (i.e. gatch

road condition and high humidity) were

not identified)

Lesson Learned

1. Avoid applying harsh brakes and sharp maneuvering of steering when driving off

road.

2. Review drivers’ driving behavior reports

and provide coaching and counseling to

risky drivers

3. Subject drivers to daily tool box talks to

discuss route hazards and to reinforce

safe driving behaviour

Immediate Causes

• Improper Decision Making/Lack of

Judgment (The driver applied harsh brake

and sharp maneuvering of steering to avoid

pot hole on the gatch road)

• Work or Motion at Improper Speed (The

vehicle was driven on gatch road at a speed

between 20 to 45 kph with a sudden

acceleration to approx. 58 kph followed by

a harsh breaks immediately prior to the

incident)

Page 13: lesson from accidents

12

Vehicles Collision

Area Incident Description Root Causes

Engineering &

Projects

BAB

04-09-12

A 3rd Party mechanic was working on a broken down

vehicle near the road side a replacement tire was

requested from their base camp in Mussafah. A truck

carrying the replacement tire arrived and stopped on

the road side. The mechanic requested the driver to

move the truck on the opposite side.

A project driver involved was transferring staff to and

from difference locations since morning and was

making a trip to collect three passengers from Bab

Central Degassing Station (BCDS) to their Camp. The

driver was driving 128 km/Hr on a road with a speed

limit of 80 km/Hr.

The project driver was over taking the truck whilst

the truck started to turn left. Outcome: The project

vehicle collided with the front tire of the truck. Two

passenger sustained minor injuries and the vehicle

sustained moderate damage.

• Inadequate Audit / Inspection

/Monitoring (Drivers driving behavior

and driving assignments were not

adequately monitored)

• Improper Performance to save time

(The driver was involved in transferring

passengers to & from different locations

since early morning and was rushing to

the camp for mid-day break)

• Inadequate Identification of

Worksite/Job Hazards (In Vehicle

Monitoring System (IVMS) was

reconfigured so that speeding event

below 130 km/Hr were not recorded as

system violation)

Lessons Learned

1. Always follow the posted speed limits

and do not over speed.

2. Use vehicle signal before maneuvering

vehicles even on a short journey

3. Monitor the driving behavior of

new/inexperience driver more frequently

Immediate Causes

• Violation by individual (The driver was

overspending (128 km/Hr on a road with a speed

limit of 80 km/Hr)

• Improper Decision Making (The truck driver

started to turn left without using indicators/

signal)

Page 14: lesson from accidents

13

Crane Rollover During Move on Gatch Road

Area Incident Description Root Causes

Engineering

& Projects

BAB

26-09-12

A 25 Tone Grove Crane, was mobilized on site to load /

offload piping materials from various locations within the

vicinity of RDS-8 Transfer Line area. The crane reached

the site at around 06:30am and started off-loading pipe

supports from the trailer truck. The crane being moved

between locations (approximately 100 meters apart) to lift excess pipe supports. The crane operator was

following the pick-up vehicle (boarded by the Rigging

Foreman) and the trailer truck on gatch road, parallel to

the transfer line.

There was slope between the two gatch roads and the

pick-up and trailer truck managed to drive across the

bank and reached the elevated gatch road.

As the crane tried to ascend on slope (with crane boom

not fully folded), the crane lost the balance causing it to

roll over to its right side. Outcome: The operator

managed to exit the crane cabin safely through the cabin

door and the crane sustained minor damage.

• Inadequate Supervisory Example

(Rigging Forman did not ensure the

suitability of the track)

• Inadequate Audit / Inspection/

Monitoring (Job Performer (JP) was

away supervising another crew and

the crew moved without his

knowledge)

Lesson Learned

1. Do not move heavy equipment from

one location to another location

unless track conditions are inspected

and are found suitable.

2. Ensure Crane boom is fully folded and

hook block secured when moving

crane, to maintain stability of the

equipment

Immediate Causes

• Violation by Individual (The operator did not fully

fold the boom of the crane and did not lock the hook

block while moving the crane)

• Violation by Supervisor (Rigging Foreman did not

assess the road conditions and asked the crane

operator to follow the vehicle)

Page 15: lesson from accidents

14

Water Tanker Rollover

Area Incident Description Root Causes

Drilling

21-07-12

For a cementing job, 500 barrels (bbls) of

freshwater delivery was required at the rig site

and an urgent delivery request was sent to water

supply contractor. The contractor assigned

tankers & drivers were not available and therefore

a new driver and a tanker was sent from Musafah

Base to make this delivery. The driver did not

have ADCO Safe Driving Document (ADSD) and

the vehicle was not fitted with In Vehicle

Monitoring System (IVMS).

It was the first day of Ramadan and the driver

missed his Dinner & Sahur and made a delivery of

water. After the delivery he went back to his

camp to refill tanker and then again proceeded to

the rig site for another delivery. The air

conditioning system in driver’s cabin was not

working and it was a hot day and the driver was

working in excess of six hours. During the trip the

driver felt dizzy and lost control of the tanker. It

resulted in tanker to rollover. Outcome: The

driver escaped unhurt and the tanker sustained

minor damage.

• Inadequate Leadership (Knowingly an

untrained driver was assigned on the task)

• Inadequate Work Planning (Request for

supply large quantity of water was made

without ensuring availability of contractor’s

resources)

• Inadequate Audit/ Inspection/

Monitoring (There was no monitoring

system in place to check contractor

compliance with contractual requirements

for the safety of driver and vehicles)

Lessons Learned

1. Assess availability of contractors’ resources

prior to issuing task order.

2. Monitor contractor compliance with

contractual requirements for the safety of

driver and vehicles.

Immediate Causes

• Violation by Supervisor (A new driver,

without ADSD was assigned to the task;

Unauthorized vehicle was used)

• Defective Vehicle (Air conditioning unit in

driver’s cabin was not working)

• Work Exposure to Temperature Extreme

(The driver was fasting, working over 6 hours

during peak summer hours in hot cabin of the

water tanker)

Page 16: lesson from accidents

15

Hand Entrapment Inside Tong

Area Incident Description Root Causes

Drilling

NDC Rig 21

03-08-12

While an inexperienced tubular services

operator was working as a tong operator, he

had his left hand at the top of the tong rotary

while the other hand was on the lever

adjusting the tong rotary.

His supervisor left the Rig Floor leaving the

operator alone before completing the job.

When he started to operate the tong, the tong

jumped resulted in slippage of his left hand

which got trapped inside the tong.

Outcome: Tong Operator sustained an open

displaced fracture on his left hand.

• Inadequate Leadership (Senior Operator

left the inexperienced operator at the rig floor

before completing the job; Rig crew did not

stop “Green Hat” – (New or Inexperienced

Worker) from working alone)

• Inadequate Identification of Required

Skill or Competency (Inexperienced

operator was not adequately coached on

required skills to work independently)

Lessons Learned

1. Do not leave in experienced staff (Green Hat)

workers unsupervised at hazardous locations such as Rig Floor

2. Include all sequence of works (such as

operations as well as any repair/

troubleshooting) in Job Safety Analysis (JSA)

Immediate Causes

• Improper Posture/Position for the

Task (The operator had placed his hand on

the top of tong rotary while adjusting the

rotary)

• Lack of Knowledge of Hazards Present

(The Supervisor left the operator working

alone on the rig floor; the operator was not adequately trained to recognize pinch

points on power tongs)

• Work Exposure to Mechanical Hazards

(Power Tong at Rig Floor)

Page 17: lesson from accidents

16

Electrical Shock

Area Incident Description Root Causes

Drilling

NDC Rig 55

06-09-12

The electrical panel door of the fire unit fall down

due to broken hinges (caused by the deterioration

of pin in the hinges) resulting in cables

cut/damage inside the panel.

An isolation certificate and permit to work was

issued. The damaged/cut cables were

fixed/replaced by an electrician. After electrical

cables were fixed, the electrician restored the

power supply and started to check cables voltage

using a portable voltmeter. During the process an

electrical spark occurred.

Outcome: It has resulted in a second degree

burn on electrician’s right hand thumb.

• Inadequate Practice of Skills (The electrician

did not systematically check the electrical system

and did not ensure physical protection from

coming in contact with live conductor)

• Excessive Wear & Tear (Due to harsh climatic

conditions and rig move, hinge pins were

deteriorated)

Lessons Learned

1. Always follow systematic way of checking

electrical circuit

2. Stay clear of live conductors when servicing

energized electrical system

3. After each rig move visually check the integrity of

hinge pins

4. Conduct trade relate workshops for experience

electricians to share their knowledge and incident

lessons learned.

Immediate Causes

• Servicing of Energized System (The

Electrician was checking cables voltage using

a portable voltmeter on a live system)

• Improper Decision Making/Lack of

judgement (The Electrician made a physical

contact with a live conductor)

Page 18: lesson from accidents

17

Worker’s Finger Entrapment Between Pipe Flange and Valve Flange

Area Incident Description Root Causes

South East

(SE)

Asab Field

08-07-12

Well work-over was completed and a Field

Services crew was working to fix a 2” valve on

bleed-off line. Emergency response plan and PPE

were discussed in Tool Box Talk (TBT) and the

work started.

There was no dedicated banksman and the

Foreman himself was directing the Crane

Operator. The crew included a newly hired

laborer.

The bleed valve with the spool was lifted and the

laborer was holding the T-piece with valve during

alignment. When the load moved, his left hand

index finger got trapped and crushed between the

pipe flange and valve flange.

Outcome: The foreman stopped the operation

and transferred the injured person to RAMS Clinic

for treatment. Laborer sustained fracture to his

finger.

• Inadequate Work Planning or Risk

Assessment Performed (No dedicated banksman was used; & inexperienced

laborer was assigned to assist a crew

involved)

Lessons Learned

1. Do not assign inexperienced laborers on

new activities.

2. Ensure crew members are aware of task

related hazards through effective Tool Box

Talk (TBT).

Immediate Causes

• Improper Position or Posture for the Task

(Inexperienced worker wrongly positioned his

left index finger between the two flanges

during alignment)

• Improper Decision Making/Lack of

Judgment (Foreman was also acting as

Banksman losing focus on supervision)

• Lack of Knowledge of Hazards Present

(An inexperienced and untrained laborer was

assigned to the job)

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Transformer Fire

Area Incident Description Root Causes

NEB

25-07-12

In oil train 1, at 2nd stage Desalter, flash over

occurred at the transformer (secondary high

voltage) cable located at a height of 12 feet.

The flash-over was detected by the UV/IR

detectors.

Outcome: Control Room Operator (CRO)

alerted electrical team who isolated the cable.

After the isolation fire was extinguished using

CO2 fire extinguisher.

It was the third similar incident in NEB

involving melting of high voltage bushing (or

high voltage cable).

• Inadequate Preventive Maintenance (High

Voltage Busing were not changed as per vendor

recommendations and Desalter oil samples were

not tested)

• Tools & Equipment - Inadequate Availability

(High Voltage Busing and oil tester were not

available)

Lessons Learned

1. Oil samples should to taken from all desalters to

evaluate the condition of High Voltage Bushings

2. Evaluate condition of the HV bushings during the

regular maintenance periods

3. Ensure availability of critical spare parts such as

High Voltage Bushings at all times

Immediate Causes

• Violation by Group (Maintenance

Procedures as per Vendor Instructions were

not fully followed due to non-availability of

oil tester)

• Inadequately Prepared Equipment

(High Voltage Bushing Replacement was

not carried as per vendor

recommendations)

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Fire in UPS Unit of Substation

Area Incident Description Root Causes

NEB

08-07-12

Dabbiye’a has two substations and each

substation has 2 AC- Uninterrupted Power

Supply (UPS) units. Each UPS unit is equipped

with cooling fan to cools different components

such as capacitors, transformers and power

electronic devices.

Due to frequent voltage fluctuation (from

external power supply source), capacitors’

performance was compromised. After such

voltage fluctuation event, a capacitor burnt and the fire spread within the UPS system and

extended to the major components within the

cabinet. Fire Auxiliary Team responded and

extinguished the fire.

Outcome: It resulted in damage of two power

transformers, static switch module, cooling fans

and few capacitors. The plant was manually

shutdown on Emergency Shut Down-1.

• Engineering Design – Inadequate

Assessment of Potential Failure

(Capacitor surpassed their material life

and were subjected to wear & tear due to

power fluctuation)

• Materials Shelf life Exceeded

(Manufacture identified capacitor’s life

span as 14 Years and after the incident it

was corrected as 7 years)

Lessons Learned

1. Provide adequate spacing and ventilation for

UPS and other electrical devices for cooling

2. Provide adequate spacing for maintenance.

3. Before accepting reliability value of systems,

study proving the calculated reliability to be

submitted.

Immediate Causes

• Inadequate Equipment (Premature

failure of capacitor due to power

fluctuation)

• Inadequate Ventilation (Cabinet units

were stacked close to the wall, not

providing adequate ventilation)

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Vehicle Drop in Low Lying Area/Depression

Area Incident Description Root Causes

Buhasa Field

(BUH)

22-08-12

A mechanical foreman was returning to the

workshop from a wellsite (CL-29) and he was heading the wrong way. His colleagues

(passengers) in the vehicle advised him to

proceed in the opposite direction. He turned

the vehicle and started to drive in the desrt

to get on the designated track. There was a

low lying area /depression in the sand and

the vehicle slid down and made contact with

the bottom of the dune.

Outcome: The vehicle sustained minor

damage on the front-end bumper.

• Inadequate Practice of Skill

(Driver u-turned into non-

designated route instead of

remaining on track)

Immediate Causes

• Improper decision making/lack of

judgment (The driver did not return

back to original track but tried to go

another way to merge with the main

track)

• Inattention to surroundings (He did

not pay attention to surface conditions

and was focusing to get on the

designated track)

Lesson Learned

1. Always take the designated

to avoid the risk of unstable

ground conditions.

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21

Breakage of Hook of Wire Rope

Area Incident Description Root Causes

Buhasa

Field

(BUH)

10-08-12

A Foreman was driving to a well site (BU-559)

and his vehicle got stuck on a sand dune. He

requested assistance from the transport pool.

Transport Pool Driver reached the site and

tried to pull the stuck vehicle using a wire rope with his own vehicle.

While pulling the vehicle from the rear side, the

wire rope's hook broke and struck against the

foreman-vehicle’s rear window. Outcome:

Rear window of the vehicle was completely

smashed.

• In adequate removal/replacement of

tools & equipment (The slings in the older

desert safety boxes were not checked/

replaced)

Lesson Learned

1. Check adequacy of tools available for in

vehicle tool box.

2. Always check if the slings are

certified/checked, and suitable for pulling

the vehicle prior to use.

Immediate Causes

• Inadequate Tools or Equipment (The

sling used was not suitable for the job)

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22

HSE Performance, Q3, 2012 (YTD)

Historical Vs Q3 2012 (YTD) HSE Performance

29

27

34

47 5

6

55

44.4

32.3

32.5

57.3

6

118.9

2

123.9

5

0.630.55

0.360.28

0.16 0.160.29

0.12

0.34

0.26 0.090.06

0.700.66

0.800.68

0.550.51

0.81

0.93

1.29

0.78

0.340.50

0

20

40

60

80

100

120

140

0

0.2

0.4

0.6

0.8

1

1.2

1.4

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 YTD2012

Mill

ion

M

an

ho

urs

W

ork

ed

Lo

st

Tim

e In

jury

Fre

qu

en

cy R

ate

/ T

ota

l R

eco

rdab

le In

jury

R

ate

YearManhours Actual LTIF TRIR

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23

Incident Sub Types Q3 – 2012 (YTD) (Work & Non-Work Related – 247 Events)

Injury/Illness

47%

Transportation

30%

Onshore Spill

13%

Fire

7%

Gas Release

3%

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Asset Wide Incident Sub Types Q3 – 2012 (YTD)

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25

Asset Wide Incident Sub Types Q3 – 2012 (YTD)

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Incident Sub Types Asset Wide Q3 – 2012 (YTD)

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Page 29: lesson from accidents

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Incident Immediate & Root Cause Categories Q3-2012 (YTD)

Immediate Causes

Root Causes

Repetitive Immediate Causes

Cause Repetitiveness

Improper decision making or lack of judgment 9%

Violation by individual 7%

Lack of knowledge of hazards present 7%

Inattention to footing and surroundings 4%

Improper position or posture for the task 3%

Repetitive Root Causes

Case Repetitiveness

Inadequate identification of worksite/job hazards 9 %

Inadequate training 7 %

Poor judgment 7 %

Improper supervisory example 5%

Inadequate work planning 5 %

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Incident Immediate Cause Analysis Q3-2012 (YTD)

Violation by individual One individual intentionally chose to violate an established safety practice.

Improper position or posture for the task

The person did not follow the human kinetic practices. The person was working on an unsafe, unstable or non-standard work floor or was placing body parts in unsafe positions.

Violation (by supervisor):

A supervisor or other management person either personally violated an established safety practice

Improper decision making or lack of judgment

This cause is the opposite of violations. Unintended human error can consist of perception errors, memory errors, decision errors or action errors. A person’s job performance was affected by their inability to make an appropriate judgment when confronted by an ambiguous situation.

Inattention to surroundings:

The person was not alert to their surroundings and just tripped or ran into something that was clearly visible and obvious.

Routine activity without thought

The person involved was performing a routine activity, without conscious thought, and was exposed to a hazard as a result

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30

Lack of

knowledge of

hazards

present

56%

Personal

Protective

Equipment not

used

17%

Equipment or

materials not

secured

16%

Use of Protective Methods

Lack of Knowledge of Hazards Present

The worker was not aware of risks associated with the task performing

PPE Not Used

The equipment or methods necessary in this situation were not used by the person doing the work.

Equipment or Materials not Secured

The tools, material or equipment in use were placed in a position creating a hazard, for example, tools placed overhead fell and struck the person or a truck was parked on a slope and rolled down

Page 32: lesson from accidents

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Asset Based Incident Immediate Cause Analysis Q3-2012 (YTD)

Page 33: lesson from accidents

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Incident Root Cause Analysis Q3-2012 (YTD)

Inadequate audit

/inspection/ monitoring Supervisors did not monitor, inspected or audited the work as planned.

Inadequate Work Planning

The work being done was not planned or was not risk assessed prior to starting that work.

Inadequate preventative maintenance program

The tools or equipment involved in the incident were not covered by a preventative maintenance program, and became unserviceable.

Inadequate identification of

worksite/job hazards

The incident was caused by the failure to perform or properly

respond to a loss exposure study, such as Job Safety

Analysis.

Inadequate Leadership The leaders in an area did not set the right direction or tone

for safety or allowed roles and responsibilities for safety

activities to be unclear or undefined.

Inadequate Supervision

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Inadequate Training

Some training was conducted, but it did not accomplish the necessary knowledge transfer.

Inadequate Training efforts Training did not accomplish the necessary knowledge transfer, due to such factors as training program design, or poor means to determine if students have indeed mastered the material being taught.

Improper supervisory

example

Supervisors not giving the proper example to the people working in their organizations.

Inadequate Behavior

Employee perceived haste

The incident was caused by the employee’s perception that speed in completing the work was required causing laps in safety considerations.

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Asset Based Incident Root Cause Analysis Q3-2012 (YTD)

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Asset Top Two Repetitive Immediate

Causes

Top Two Repetitive Root Causes

BAB Lack of knowledge of hazards

present

Equipment or materials not secured

Inadequate correction of prior

hazard/incident

Improper supervisory example

BUH Improper decision making or lack of

judgment

Inattention to footing and

surroundings

Inadequate vertical communication

between supervisor and person

Inadequate preventive maintenance

E & P Violation by individual

Improper decision making or lack of

judgment

Inadequate training

Inadequate identification of worksite/job

hazards

NEB Violation by individual

Improper decision making or lack of

judgments

Improper supervisory example

Inadequate assessment of potential failure

SE Improper decision making or lack of

judgments

Routine activity without thought

Poor judgments / Lack of coaching on skill

Inadequate work planning

TPO Defective equipment

Inadequate guards or protective

devices

Improper supervisory example

Inadequate identification of worksite/job

hazards

Technical

Services

Lack of knowledge of hazards

present

Improper decision making or lack of

judgments

Inadequate identification of worksite/job

hazards

Inadequate leadership/ Improper

supervisory example

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Focus Areas Q3-2012 (YTD)

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Quiz Name:______________________________________________________

Designation: _________________________________________________

Staff No: ____________________________________________________

ADCO Asset or Company Name: _________________________________

Contact Number: ______________________________________________

Incident Title True False

1. Damage to Underground Fiber Optic Cable During Excavation

As built drawing did not show location of buried fiber optic cables.

JP was a member of Task Risk Assessment (TRA)

2. Crane Mounted Truck (Hiab) Rollover on Gatch Road Due to high humidity, the gatch road surface became slippery.

Driver applied harsh brakes and sharp maneuvering of steering on slippery road

3. Vehicles Collision on Gatch Road There was no sign or marking when approaching the blind spot

The project vehicle was driven in wrong lane

4. Arm Injury Due to Explosion During CAD Welding

Electrician was subjected to tool box Talk and crew was made aware of hazards of CAD Welding

The activity was stopped by the Job Performer but crew continued the work

5. Fire at Scaffolding Platform Around Stripper Column Accumulation of combustible waste material near welding area was not noticed

Supervisor did not visit the site before and after the completion of hot work

6. Foreign Object Entering Eye of a Worker

Workers were not adequately made aware of hazards of working on a windy day

Risks of rubbing eyes when a foreign body enters eye were known

7. Vehicle Rollover on Gatch Road The Engineer changed the journey plan and advised the driver to take shortcuts

Driver’s RAG reports were regularly reviewed

8. Crane Mounted Truck (Hiab) Rollover on Gatch Road The road surface had holes and was wet/ slippery due to high humidity

The driver applied harsh brake and sharp maneuvering of steering

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9. Vehicles Collision Drivers driving behavior and driving assignments were not adequately monitored

The driver was driving 128 km/Hr on a road with a speed limit of 80 km/Hr.

10. Crane Rollover During Move on Gatch Road Rigging Forman did not ensure the suitability of the track

The operator did not fully fold the boom of the crane

11. Water Tanker Rollover

A new driver, without ADSD was assigned to the task

Air conditioning unit in driver’s cabin was working

12. Hand Entrapment Inside Tong The Supervisor left the operator working alone on the rig floor

The operator had placed his hand on the top of tong rotary

13. Electrical Shock The Electrician was checking cables voltage using a portable voltmeter on a live system The Electrician made a physical contact with a live conductor

14. Worker’s Finger Entrapment Between Pipe Flange and Valve Flange

Inexperienced worker placed his index finger between the two flanges during alignment

Foreman was also acting as Banksman

15. Transformer Fire Maintenance Procedures were not fully followed

Desalter oil samples were regularly tested

16. Fire in UPS Unit of Substation Cabinet units were stacked close to the wall

Capacitor were not subjected to wear & tear due to power fluctuation

17. Vehicle Drop in Low Lying Area/Depression The driver did not return back to original track

Driver was driving on non-designated route

18. Breakage of Hook of Wire Rope

While pulling the vehicle from the rear side, the wire rope's hook broke

The sling used was suitable for the job

Please hand in the quiz to your Asset HSE Focal Points for assessment

Page 40: lesson from accidents

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Do Not Compromise on the Safety of Staff & Workers, Protection of the Environment and Integrity of Assets

ABU DHABI COMPANY FOR ONSHORE OIL OPERATIONS

(ADCO)