Safety Performance Indicators

REPORT
2013pfh
MARCH
2015
DATA SERIES
Safety performance indicators

Process safety events 2013 data
Fatal incident and high potential events
Fatal incidents and high potential events that were also process safety events (PSE), and fatal
incidents and high potential events that were PSE-related 2011, 2012 and 2013
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REPORT
2013pfh
MARCH
2015
DATA SERIES
Safety performance indicators

Fatal incidents and high potential events that were also process safety events (PSE),
and fatal incidents and high potential events that were PSE-related 2011, 2012 and 2013
Revision history
VERSION
DATE
AMENDMENTS
1.0
March 2014
First release
FATAL INCIDENT REPORTS CLASSIFIED AS TIER 1 PROCESS

SAFETY EVENTS 2013
DATE: Nov 14 2013
LOCATION: Asia/Australasia, INDONESIA
DATA SET: Contractor Offshore
WORK FUNCTION: Drilling
INCIDENT CATEGORY: Pressure Release
ACTIVITY: Drilling, Workover, Well Services
WORKFORCE DEATHS: 1 3RD PARTY DEATHS: 0
AGE: 35 EMPLOYER: Contractor

OCCUPATION: Drilling/Well Servicing Operator
NARRATIVE: The ongoing operation was bleed off well
pressure (SICP=700 psi/SITP=Unknown). Killing line had
been installed on X-tree by Day-Shift crews. The victim,
with other co-worker (Night shift crew), slowly opened
the crown valve using 24" pipe wrench since no wheel
on the valve. Suddenly, the XO (cross over) connected
from the X-tree cap to 2" hose came free from the cap
and hit the victims face. As a result he fell down on
his back and the back of his head hit the grating deck.
His co-worker, who was standing behind him, also fell
down close to him without any injury. The tool pusher
came to the site and shut the well in while he called the
Emergency Response Team from the barge to bring up
the stretcher. Immediately, the victim was brought down
to the clinic, and then to the hospital by chopper. The
doctor declared that the victim passed away at 09.55
am, ten minutes after arriving at hospital.
WHAT WENT WRONG:
LESSONS LEARNED AND RECOMMENDATIONS:

1. Task Risk Assessment level 2 is mandatory
requirement for Bleed Off Pressure and Kill Well Job.
2. Pressure test is mandatory required to bleed off/kill
well job and set packer job similar to stimulation,
gravel pack, TCP, nitrogen job, etc. which to stated
in revised SOP.
3. Revise the existing SOP-Bleed Off Pressure and Kill
Well Job. with adding:
Install safety chain to prevent the hose move
uncontrolled due to hose and connection failure
Secure the killing line position to avoid worker
having direct expose to the line.
4. BU must provide standard X-tree prior to do well
intervention to avoid any potential hazard to the well
intervention crew.
5. Re-socialize SIMOP Procedure (Well Hand Over)
implementation.
6. Perform routine X-tree maintenance.
7. Re-vitalize STOP and BBS program, especially
to emphasize awareness of behaviour related to
Position of People.
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Improper
position (in the line of fire)
1. X-tree has been installed for approximately 30 years

without any maintenance and no preparation when
the well was selected for well intervention.
PEOPLE (ACTS): Use of Tools, Equipment, Materials and

Products: Improper use/position of tools/equipment/
materials/products
2. Crews could not read tubing and casing pressure due

to no pressure gauge having been installed. Casing
pressure could be read out only from manifold.
PEOPLE (ACTS): Use of Protective Methods: Equipment

or materials not secured
3. The crew installed the killing line without proper

check X-tree cap box thread condition.
4. The victim used 24" pipe wrench to open the crown
valve due to having no wheel on crown valve.
5. The position of victim was very close to the installed
killing line.
6. No safety chain installed between X-tree and
killing line.
7. No pressure test after connecting the line.
8. SIMOP (simultaneous operations) procedure
(Well Hand Over Form) is not well implemented.
PEOPLE (ACTS): Inattention/Lack of Awareness:

Improper decision making or lack of judgment
PROCESS (CONDITIONS): Protective Systems:
Inadequate/defective guards or protective barriers
Inadequate/defective warning systems/safety devices
PROCESS (CONDITIONS): Tools, Equipment, Materials
& Products: Inadequate/defective tools/equipment/
materials/products
DATE: Apr 27 2013

LOCATION: Asia/Australasia, CHINA
WORK FUNCTION: Production
INCIDENT CATEGORY: Explosions or Burns
ACTIVITY: Maintenance, Inspection, Testing
4. To strengthen risk analysis before the operation

for the storage tank, especially for storage oil
tank sulfur, to pay attention to the risk analysis of
ferrous sulfide self-ignition and control measures,
to improve the system of management, added the
corresponding management requirements.

OCCUPATION: Maintenance, Craftsman
5. To strengthen the management of personnel

qualifications. Timely replacement training for
personnel arrangements, to ensure compliance.
NARRATIVE: There was a plan to do a maintenance

operation by coating the roofs of the crude oil tanks on
a production platform with epoxy resin and Fiberglass
because serious corrosion had been found on the roofs
during a patrol inspection. The oil tanks were emptied
before the day the work was planned. On April 27th,
7:30am, according to the construction scheme, the
contractor workers got permission for work and had a
safety meeting before the operation. At 8:12AM, an oil tank
exploded when a worker had just reached the top of the oil
tank. The accident caused two deaths and one injury.
WHAT WENT WRONG:
1. The ferrous sulphide self-ignition ignited the
combustible gas mixture inside the oil tank, a flash
explosion occurred.
2. Electrostatic discharge ignited the combustible gas
mixture, a steam explosion occurred.
1. To strengthen the antistatic field personnel to use
the management of labour insurance supplies, in
the case of test methods and standards are not
clear, should be forced to replace system, ensure
the use of anti-static overalls and tools effectively.
2. To strengthen and anti-static, and ferrous sulfide
knowledge training, propaganda and education.
Against static electricity and lack of awareness
of ferrous sulfide, accidents related unit shall
immediately organize employee training, strengthen
the professional knowledge and skill training, to
ensure the safety of site work.
3. Norms and to strengthen the tank (especially
with longer) detection and cleaning. For related
equipment in strict accordance with industry
standards for testing and evaluation, according to
the evaluation results, formulate corresponding
measures and equipment management system, and
ensure the compliance, security field integrity and
intrinsically safe equipment and facilities.
6. After completion of elimination danger for Platform

B, in the process of tissue repair and restore
production, we should consider to increase the inert
gas protection device, ensure that the nature of the
crude oil storage tank safety.
7. Accident unit should extrapolate, full screen similar
crude oil storage tank, for screening out hidden
trouble organizing special projects, to prevent major
workplace malignant accidents.
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Violation
unintentional (by individual or group)
Products: Servicing of energized equipment/inadequate
energy isolation
PEOPLE (ACTS): Use of Protective Methods: Personal
Protective Equipment not used or used improperly
Inadequate/defective Personal Protective Equipment
materials/products
PROCESS (CONDITIONS): Work Place Hazards:
Hazardous atmosphere (explosive/toxic/asphyxiant)
PROCESS (CONDITIONS): Organisational: Inadequate
hazard identification or risk assessment
PROCESS (CONDITIONS): Organisational: Poor
leadership/organisational culture
DATE: Jul 4 2013

LOCATION: North America, MEXICO
DATE: Mar 18 2013

LOCATION: North America, CANADA
DATA SET: Company Onshore

OCCUPATION: Process/Equipment Operator

AGE: 51 EMPLOYER: Company
NARRATIVE: The worker was operating heavy equipment,

when he impacted a pipeline, causing the explosion.
NARRATIVE: Employee was performing a routine

pigging operation when a severe head injury was
sustained. The injured person was transported to the
hospital for treatment. The injured person succumbed
to the injuries the following day.
WHAT WENT WRONG: Safety analysis failure in during

operations of heavy equipment.
Critical procedures must be correctly communicated
and applied.
CAUSAL FACTORS:
WHAT WENT WRONG:

1. The pig was stuck in the pig trap with trapped
pressure behind it. Wintry conditions at the time
would have increased the likelihood of ice or
hydrates forming around the pig further increasing
its tendencies to stick.

materials/products
2. The injured person was in the line of fire when the

pig released.
PEOPLE (ACTS): Use of Protective Methods: Inadequate

use of safety systems
1. Modify pig trap inspection processes.
PEOPLE (ACTS): Inattention/Lack of Awareness: Lack of

attention/distracted by other concerns/stress
materials/products
work standards/procedures

2. Re-inspect all pig traps to meet any revised
standards and modify as needed.
3. Review QA/QC process for new pig traps with focus
on internal restrictions.
4. Ensure all SOPs and Level 1 procedures
complement each other.
CAUSAL FACTORS:
materials/products
DATE: Jun 14 2013

LOCATION: Europe, NETHERLANDS
AGE: unknown EMPLOYER: Contractor


NARRATIVE: Casualties during leak test of gas cooler.
During leak testing of gas cooler three people were injured.
WHAT WENT WRONG: Searching for leaking tubes in gas
cooler by means of utility air with uncontrolled pressure
(max 14 barg). Gas cooler did not leak at all. At 4.5 barg
tube plate built up greater than 40 T of force and travelled
from cooler housing at explosive speed, crushing the
two people between the tube plate and the cooler head,
hanging some 1.5 metres in front of the cooler.
We have a list of recommendations and actions that is
not yet published outside the company.
CAUSAL FACTORS:
training/competence
FATAL INCIDENT REPORTS RELATED TO PROCESS SAFETY BUT

NOT CLASSIFIED AS TIER 1 PROCESS SAFETY EVENTS 2013
<<No incident reports found>>
HIGH POTENTIAL EVENTS CLASSIFIED AS PROCESS SAFETY

EVENTS 2013
DATE: Jan 26 2013
LOCATION: North America, USA
DATA SET: Contractor Onshore
WORK FUNCTION: Construction
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 Behavior Did not meet requirements/
guidelines/instructions
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.
Lessons Learned:
If a needed piece of equipment is needed, 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.
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.
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).
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.
CAUSAL FACTORS:
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.

materials/products
Underlying Causes: Work Supervision and Follow-up

HSE 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
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.
intentional (by individual or group)

materials/products
The team/entity did not obey rules, procedures or

good working practices:

training/competence
The crew neglected to follow the construction

companys excavation policy and the Excavation
and Trenching requirements in the Company Safe
Practices Manual.

DATE: Feb 19 2013

ACTIVITY: Production Operations
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.
10
DATE: Jul 26 2013

LOCATION: Africa, ANGOLA
INCIDENT CATEGORY: Exposure Noise, Chemical,
Biological, Vibration
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.
<<No Causal Factors Allocated>>
DATE: Nov 27 2013

NARRATIVE: Three crew members were tasked with
testing tree valve integrity on well P1-09. The crew
inadvertently arrived at well P1-20 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 fee. 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.
DATE: Oct 14 2013

DATA SET: Company Offshore
INCIDENT CATEGORY: Other
NARRATIVE: Boil off gas at LNG Plant was cold
vented from the tank flare system due to flare being
temporarily extinguished.
DATE: May 14 2013

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.
DATE: Aug 5 2013

LOCATION: Asia/Australasia, MALAYSIA
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.
CAUSAL FACTORS:
11
DATE: Jul 10 2013

LOCATION: Africa, NIGERIA
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:
& Products: Inadequate maintenance/inspection/testing
DATE: Oct 9 2013

NARRATIVE: A contractor gauger left a production
tank drain valve in the open position. An estimated
259barrels of fluids (produced water and hydrocarbons)
were released to the metal secondary containment ring
surrounding the tank. No injuries were reported.
DATE: Jul 4 2013

LOCATION: Europe, UK
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.
DATE: Sep 1 2013

LOCATION: Africa, GABON
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 cubic metres of crude oil
leaked from the receiver, as the inlet valve had failed to
properly close. 150 cubic metres were recovered, the
sand impregnated with the remaining 3 cubic metres
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:
training/competence
12
DATE: Jun 10 2013

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 resize 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 firefighting 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:
supervision
DATE: Mar 31 2013

LOCATION: Asia/Australasia, 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.
CAUSAL FACTORS:
& Products: Inadequate design/specification/
management of change
communication
13
DATE: Apr 17 2013

LOCATION: Middle East, 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 metres 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.
LESSONS LEARNED AND RECOMMENDATIONS: 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
15min. 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
materials/products
communication
14
DATE: Aug 1 2013

LOCATION: Europe, AUSTRIA
DATE: Jun 20 2013

LOCATION: Asia/Australasia, AUSTRALIA
NARRATIVE: An uncontrolled gas release from a gas

well occurred in the morning. A leakage of about 20mm
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.
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: 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.

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.
LESSONS LEARNED AND RECOMMENDATIONS: 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:
CAUSAL FACTORS:
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.

15
DATE: Jun 12 2013

DATE: Apr 14 2013

LOCATION: FSU, KAZAKHSTAN
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.
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 point during shut-down no injuries or
wounds observed.
WHAT WENT WRONG: Improvement in the management

of technical change and in application of procedures
associated with design changes.
LESSONS LEARNED AND RECOMMENDATIONS: 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:
training/competence
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:
PROCESS (CONDITIONS): Organisational: Failure to
report/learn from events
16
DATE: May 27 2013

LOCATION: Africa, TUNISIA
DATE: Nov 24 2013

LOCATION: Europe, ROMANIA
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.
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: 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:
training/competence
supervision
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 nonexplosive-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 Golden Rules of Contractor (Management of
Changes) and Company (Stop work) not followed.
10. Sub optimal work area cellar, 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
Golden 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, wellhead and associated pipework and valves, to ensure
safe working conditions (minimize entry to cellars,
cellar covers).
CAUSAL FACTORS:
17
DATE: Jun 12 2013

LOCATION: Middle East, UAE
NARRATIVE: HIPO, Leak from Flow Suction Tank On
12th Jun 2013, approximately at 03:45 Hrs., a Flow
Suction Tank was in service since 2005 with weir height
of 1.75 meters. The internal GRE lining was provided up
to a height of 1 meter from the tank floor. The settled
water level within the oil compartment accumulated to
levels higher than 1 meter (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
1.5m 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 FACTORS:
PEOPLE (ACTS): Use of Protective Methods: Failure to
warn of hazard
Inadequate security provisions or systems
materials/products
training/competence
DATE: Oct 24 2013

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:
18
DATE: May 22 2013

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:
training/competence
communication
DATE: May 23 2013

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 vapour 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:
19
20
HIGH POTENTIAL EVENTS RELATED TO PROCESS SAFETY BUT NOT

CLASSIFIED AS PROCESS SAFETY EVENTS 2013
DATE: May 9 2013
LOCATION: Middle East, QATAR
DATE: Jun 26 2013

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 44barg. This setting (44barg) is used for the
2nd stage discharge pressure not the inter-stage relief
pressure. (PSE Tier-3)
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 13 June 2013 was opened 10%.
WHAT WENT WRONG:
1. Supervision During Work No Supervision.
1. Quality Control No Inspection No inspection

required.
2. Preparation Walk Thru needs improvement.
2. Management System Standards, Policy or

Administrative Controls (SPAC) Need Improvement
No SPAC.
3. Quality Control Quality Control Needs
Improvement Inspection Instructions need
improvement.
4. Human Machine Interface Arrangement/
Placement
WHAT WENT WRONG:
3. Communication of Standards, Policy or

Administrative Controls (SPAC) enforcement needs
improvement.
4. Problem not anticipated Equipment environment
not considered.
CAUSAL FACTORS:
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.
DATE: Sep 19 2013

LOCATION: South & Central America, TRINIDAD &
TOBAGO
INCIDENT CATEGORY: Other
3. Quality Verification (QV) check sheet contained too

little detail.
4. Critical documents not readily available and linked
to functional function.
CAUSAL FACTORS:
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.
21
DATE: Nov 19 2013

DATE: May 22 2013

INCIDENT CATEGORY: Struck by
NARRATIVE: High pressured frac stack near miss.

Relief valve went off and pump was shut down. Pressure
was bled off.
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 meters. The
stabiliser sleeve fell to the ground, about 8 meters from
the flare base within the flare exclusion zone. No asset
damage or personnel injuries were sustained.
WHAT WENT WRONG: Closed incorrect valve.

Communicate clearly to personnel involved and stay out
of red zone.
CAUSAL FACTORS:
communication
DATE: Jun 9 2013

LOCATION: Europe, CROATIA
WHAT WENT WRONG: Inadequate Engineering/

Design Inadequate Monitoring of Construction
Inadequate Maintenance Inadequate Preventative
Inadequate Work Standards/Procedures Inadequate
Implementation of Work Standards/Procedures
LESSONS LEARNED 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:
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.

energy isolation
CAUSAL FACTORS:


22

SAFETY EVENTS 2012
DATE: Jun 25 2012
OCCUPATION: Other
NARRATIVE: A temporary pig launcher was overpressured resulting in one fatality, and leaving two
individuals with significant injuries requiring medical
treatment. The incident occurred in connection with
a pipeline inspection programme. Temporary high
pressure nitrogen pumping equipment was being used
to drive the In-Line Inspection (ILI). The operation was
being controlled by a procedure. The team believed the
launcher was open to the pipeline and ready to receive
pressure, so started the nitrogen pumping operation.
They did not know that the Trap Valve between the
pig launcher and the pipeline had been inadvertently
left closed. The pressure was being monitored on two
0-100 psig pressure gauges on the launcher barrel. It is
believed that the gauges over-ranged within seconds of
starting pumping, and appeared to show zero pressure
when the gauge needle was pushed up against the zero
stop. Within minutes the temporary pig launcher was
pressured beyond its mechanical burst pressure.
WHAT WENT WRONG: The pumping equipment was
capable of delivering pressures far in excess of the
design pressure of the launcher. The risk associated
with the High Pressure to Low Pressure (HP/LP)
interface that was created between the nitrogen
pumping equipment and the pig launcher and pipeline
had not been fully recognised by the team; therefore,
the associated risk was not adequately mitigated. The
task relied on human action and procedural controls
to prevent overpressure. The pumping equipment was
fitted with mechanical and instrumented overpressure
device, but these were set to protect the pumping
equipment, which had a much higher design pressure
than the launcher. There was no mechanical or safety
instrumented overpressure protection of the launcher.
LESSONS LEARNED AND RECOMMENDATIONS: During

the design phase for an activity, give early consideration
to avoiding the use of temporary equipment capable of
exceeding the plant safe operating limits. Where this is
not practical, techniques such as HAZOP may be used to
identify mechanical and instrumented systems to reliably
prevent limits from being exceeded. When temporary
equipment has the capacity to exceed the safe operating
limits (e.g., pressure or temperature) of the process plant
to which it is connected, the temporary design should,
where practical, have the same layers of protection you
would consider for permanent plant. In the case where
this is not practical, rigorous risk assessment should
be completed by an engineer and clear risk controls
identified. Procedural controls may be an unreliable
method of preventing safe limits from being exceeded
because of the range of factors that can affect human
decision making and action.
CAUSAL FACTORS:
energy isolation
23
DATE: Feb 16 2012

DATE: Sep 18 2012

WORK FUNCTION: Unspecified

OCCUPATION: Manual Labourer


NARRATIVE: Drill rig exploded.

OCCUPATION: Foreman, Supervisor

Under investigation.
CAUSAL FACTORS:

OCCUPATION: Engineer, Scientist, Technician

OCCUPATION: Other
DATE: Aug 5 2012

LOCATION: Africa, CHAD

NARRATIVE: While reverse circulating wellbore fluids
to an open-top tank (diffuser tank), gas accumulated
and combusted. The source of the ignition was a nearby
vacuum truck.
WHAT WENT WRONG: Gas accumulation. Presence of
ignition source.
LESSONS LEARNED AND RECOMMENDATIONS: Hazard
recognition.

OCCUPATION: Admin, Management, Support Staff

OCCUPATION: Other

OCCUPATION: Other



OCCUPATION: Other

OCCUPATION: Other



OCCUPATION: Other
OCCUPATION: Other
OCCUPATION: Other


AGE: unknown EMPLOYER: Company





NARRATIVE: During a maintenance activities a loss of
mechanical integrity failure at the measurement pipeline
with gas leak and explosion. The result of this event was
the death of 5 company and 26 contractor workers.
WHAT WENT WRONG: Mechanical Integrity Failure and
a pipeline design failure.
Improvement in quality control for material and
equipment acquired.
CAUSAL FACTORS:
24
DATE: Jan 8 2012

NARRATIVE: An offshore well operation was taking
place from a self-elevating workover platform
positioned next to a well platform. The operation
consisted of running Coiled Tubing into the well,
pumping chemicals to clear obstructions and pumping
a nitrogen and diesel mixture to assist the lift of flow
to surface. The returns were flowed to a surface tank
which was emptied by pumping liquid to the flow
station. There was only one liquid pump so it was not
possible to pump diesel and nitrogen when pumping
to the station, only nitrogen was pumped through the
Coiled Tubing. In the process of changing over from
emptying the surface tank, the operator opened the
bleed valve, not noticing that the valve isolating the
nitrogen pressure at 700 psi was open. A loud noise
was heard and the area was engulfed in a mixture of
nitrogen and diesel. The bleed line, attached with a
rope, broke loose and hit the operator in the head. First
Aid was immediately administered but the operator
succumbed to the injuries while in transit to a nearby
accommodation barge to allow medical evacuation.
WHAT WENT WRONG: The full investigation was
undertaken with support of third party and the
investigation revealed all root causes. The main
categories were: a) Insufficient joint approach of complex
and integrated operations b) Insufficient control of
contractors c) Lack of schematic of equipment for
operation showing surface equipment layout
A total of 49 corrective actions were determined and
have been closed out. Main learnings were: Carry out
integrated HAZID and HAZOP between company and its
contractors; Develop a comprehensive and integrated
well intervention procedure; Conduct pre-mobilization
inspection and acceptance of contractors equipment;
Provide communication plan with clear roles and
responsibilities between company and contractors;
Draw up a schematic of equipment for operations.
CAUSAL FACTORS:
materials/products
training/competence
25
DATE: May 27 2012

NARRATIVE: Two Field Operators were tasked to line-up
Liquid Oxygen (LOX) injection. An ignition and flash fire
occurred in which both operators were severely burned
and subsequently died.
WHAT WENT WRONG: Presence of flammable silicon oil
in valves of affected air separation unit. Bearing materials
not suitable for oxygen service at high pressure.
Consider bringing in external SME services to
supplement in-house expertise in high risk activities.
Provide resource for QC (checking specifications) as for
QA (setting specifications) throughout the supply chain.
26

<<No incident reports found>>
27

EVENTS 2012
DATE: May 29 2012
NARRATIVE: While drilling at the depth of 3780m and
when disconnecting the seventh pipe, a manifestation
of the well was observed, so gang proceeded to register
self-contained breathing equipment and continue with
the activities. During this event 3 workers suffered acute
intoxication by gas.
WHAT WENT WRONG: Lack of implementation of
procedures and drilling good practice to not constantly
monitor the presence of gas in the drilling mud.
Perform a constant reinforcement in the training of
personnel dedicated to the drilling of wells.
CAUSAL FACTORS:
training/competence
supervision
public attention was limited (radio, local press). Works

were stopped immediately and work area secured.
The relevant operator was informed immediately
and pipeline stopped, pressure released and sealed
according to regulations. Afterwards the pipeline could
take up into operation again.
WHAT WENT WRONG: In the GIS only the two parallel
running pipelines (A & B) are registered. An unknown
cable (Data cable) was also not recorded in GIS. The
sister company (gas transport) was not contacted and
informed that maintenance work right beside their own
pipeline B was being made. PE-coating on excavated
pipe was seen as confirmation that the correct pipeline
(B) was being excavated (as pipeline A was expected to
have bitumen coating). Pipe thickness gauging showed
12,7 mm, 8 mm were expected for B (assumption was
made that this section of the pipeline was repaired
using 12,7 mm pipe). 60 bar pipeline was drilled with
non suitable (PN 8) drilling equipment.
Information to facility/pipeline operator and approval
of work by operator, even when the work is only close
to their pipeline. Search range with pipeline locator
extended from 5 to 30m. Work clearance: 4-eye
principle on location. Execution control and working
planer will jointly approve work on location. Pipeline
wall thickness check: inconclusive information then
stop of operation. PN of shut-off device: in future, only
ANSI 600 will be used.
CAUSAL FACTORS:
DATE: Feb 15 2012

LOCATION: Europe, AUSTRIA
NARRATIVE: Unplanned drilling maintenance by a
worker crew as instructed but on high pressure gas
pipeline A under pressure instead of low pressure
gas pipeline B. Those two pipeline run parallel to each
other, the high-pressure pipeline belongs to and is
operated by a sister company. Methane was released
under controlled conditions to the environment,

materials/products
communication
28
DATE: Jan 13 2012

DATE: Jan 26 2012

NARRATIVE: An important gas release has been

observed at the exit of gas heat exchanger E3940
(70bar), which was feeding a unit after fracturing of a
3/4' gauge connection.
NARRATIVE: Whilst taking gas sample, opened vent line

of the sample point, to release any remaining pressure
trapped in the line. Attached the flexible hose to the
bomb, checked for tightness and found good. Opened
inlet and outlet bomb for flushing the bomb then slowly
opened the inlet line of the sampling point. Pressure
increased to almost 50BarG and suddenly an abnormal
sound was detected. It was found that there was a gas
leak at the joint of the bomb and flexible hose. The
flexible hose then suddenly detached from the bomb
at a pressure of around 50BarG. The inlet valve of the
sampling point was immediately closed.
WHAT WENT WRONG: Employees had insufficient skills

for emergency ops. or prev. measures. Insufficient
use was made of safety and protective equipment.
Insufficient design provisions made for operating
external environment. Tools or equipment were too
difficult to use.
Planning and co-ordination of maintenance activities
inadequate. Tools or equipment were defective,
no longer in optimal condition. Insufficient design
provisions made for operating external environment.
Tools or equipment worked or were used differently
from expectations. Tools/equipment were wrongfully
used. Tools or equipment were partially or wholly
defective, no longer in optimal condition. Environmental
conditions at time of emergency operations
unfavourable. Detection and alarm system or notices
gave insufficient warning.
Maintenance and Periodical Technical Inspection
Schedule to be carried in time as per manufacturer.
CAUSAL FACTORS:
DATE: Aug 22 2012

NARRATIVE: Two workers were in the process of
conducting scheduled maintenance on a production
tank ground-level man-way. A third individual, a pumper,
was completing unrelated tank-gauging activities on
top of an adjacent production tank. Based on an initial
investigation, flammable vapours were present and these
vapours ignited. The ensuing fire burned both individuals
that were working on the man-way.
WHAT WENT WRONG: Competence of workforce, work
instruction with no detail procedure, design assessment
for operational readiness not effective.
Evaluate oversight of maintenance activities, evaluate
how maintenance and modification work is planned/
scheduled and assigned, evaluate design of future tank
batteries for safety improvements.
CAUSAL FACTORS:
training/competence
DATE: Feb 28 2012

NARRATIVE: While filling water in spent molecularsieve drums during plant turnaround in a non hazardous
area, 94 Area near MV substation corner of the fence,
two workers suddenly overcome with H2S gas. One of
the workers raised the alarm and was administered first
aid by the roadside. The second worker collapsed near
the drums and was rescued by station operators ERT.
Ambulance was called and both workers taken to Clinic
for further treatment. one FAC and other LWC.
29
WHAT WENT WRONG: Improper use of PPE. Inadequate

Safety Supervision.
LESSONS LEARNED AND RECOMMENDATIONS: The
water filling activities for the molecular Sieve continues
with Airline breathing apparatus. Contractors Worksite
Supervisor and Safety Representative on standby at
the site all the time with TMR radio. Continued gas test
carried out by clients Operators.
Clients instruction for next shut-down/scope of work:
Spent catalysts water washing shall be done under
constant safety supervision and with the use of air lines.
CAUSAL FACTORS:
materials/products
warn of hazard
training/competence
supervision
30
DATE: Jul 1 2012

WHAT WENT WRONG: Condensate upset in the fuel

gas scrubber: abnormal flow of condensate upstream
the scrubber due to pigging operations. Level High
alarm inhibited in the scrubber by the control room
and glass level not monitored by the operators
occupied by the restart.
NARRATIVE: From a production platform, operators

observed and smelled the odour of an important
gaseous release from the foot of an unmanned platform
located 1.5 km away. Emergency shutdown on the
production and compression platform as well as on the
unmanned platform, production stopped on satellite
platforms (90% of the field). After leak stopped, a team
went on site to determine its origin and isolate the
perforated line (HP gas riser).
Automatic and manual drain are limited by design:

scrubber manual drain valve locked open at 15% to
avoid fuel gas flow to the closed drain drum. PSDV on
the Fuel Gas feed line to CCVT is passing. Condensate
carry-over to the gas burner inside the CCVT.
Accumulation of un-burned condensate inside the CCVT,
which finally caught fire.

Submarine inspection on risers. Update of maintenance
plan.
LESSONS LEARNED AND RECOMMENDATIONS: To

assess complete CCVT fleet: Fire detection and fire
fighting system. Enclosure type of material. ESD Logic.
Protection against condensate carry over Reinforce
supervision: no by-pass or shortcut from the procedure
should be tolerated. Define and validate bypass forms
and procedure for operators if during start-up they need
to bypass the safety system that not listed in the startup procedure.
CAUSAL FACTORS:
CAUSAL FACTORS:

PEOPLE (ACTS): Use of Protective Methods: Disabled or

removed guards, warning systems or safety devices

materials/products

WHAT WENT WRONG: Former deformation on the riser,

weakened and broke 21 m under sea level, probably due
to a strong swell.

DATE: Apr 19 2012

NARRATIVE: While restarting the platform following an
upset on the fuel gas unit, operators noticed a thick cloud
of smoke and flames coming from the Closed Circuit
Vapour Turbogenerator (CCVT) skid. They informed the
control room and initiated a general platform shut-down.
2 fire-fighting boats were mobilized to extinguish the fire.
Platform safety was restored 2h30 after the alarm was
raised. CCVT is totally burnt.

materials/products
communication
31
DATE: Mar 25 2012

DATE: Aug 1 2012

LOCATION: Asia/Australasia, INDIA
NARRATIVE: Loss of integrity on a well completion

lead to major hydrocarbon release from the conductor
annulus. All personnel were evacuated from the
platform and the rig. Gas release continued for 54 days,
until the well was killed, injecting heavy mud into the
well head, using an extra rig.
NARRATIVE: Hydrocarbon Gas leak from Multipurpose

Flow meter (MPFM) inlet line at PD Platform
WHAT WENT WRONG: Severe loss of well integrity.

The leak was caused by a type of stress corrosion
which was unique to the well and was fed from a so
far non-producing chalk layer located approximately
1,000meters above the original reservoir. Leak to
annulus B via probable production casing rupture
above cement Successive losses of annulus B and C
sealing at mud sea level (mud line suspension) During
intervention on G4 well, poor control of circulated fluids
leading to well instability. Was treated as an annulus
management, not as a well control
LESSONS LEARNED AND RECOMMENDATIONS: Set
up a Remediation Task Force in order to restart the
essential functions on both platform and rig. Perform
thorough investigation, launch a plugging/workover
campaign on all the other wells of the field.
CAUSAL FACTORS:
WHAT WENT WRONG: Equipment Failure. Inadequate

Work Standards/Procedures Inadequate Development
of Standards/Procedures Coordination with Process
Design. Inadequate Work Standards/Procedures
Inadequate Development of Standards/Procedures
Inconsistent Standards/Procedures/Rules. Inadequate
Work Standards/Procedures Inadequate Management
of Change Controls in Place.
Produce a guideline for flange torqueing based on size,
class and Material of construction. Communication
required to all project/ brownfield staff that
Management of change shall be utilised for change of
gasket from approved for construction drawings.
CAUSAL FACTORS:
DATE: Nov 7 2012

LOCATION: Asia/Australasia, INDIA
NARRATIVE: There was a tubing snapping incident at
the platform. " tubing was used to provide gas lift
to #4 well. The tubing connecting between isolation
valve (2" valve) and shutdown valve (1/2") got snapped
from ferrule at shutdown valve connecting end at about
0900hrs. This was an isolated section as both upstream
and downstream valves were closed and nobody was at
the cellar deck location where the incident occurred.
The approximate release of sour gas volume was 0.1scf.
No personal injury due to this incident.
WHAT WENT WRONG: Equipment Failure. Lack of
Knowledge/Skill/Competence Inadequate Competence
Assessment. Inadequate Engineering/Design
Inadequate Evaluation of Changes.
Identify the tubing sections with non-compatible
combination of material for tube and connectors
installed by other vendors and replace with OEM
recommended material on platforms with risk based
approach.
CAUSAL FACTORS:
training/competence
DATE: Feb 7 2012

NARRATIVE: During a preventive maintenance (PM)
task to function test the emergency depressurisation
valve (EDV) from the Propane Accumulator vessel
on LNG Train-1, an unintentional release of propane
vapour to the Dry Flare occurred when the EDV was
stroked open.
32
The release to flare was due to the downstream 10"

gear-operated manual ball isolation valve being placed
in the open position prior to the EDV being stroked open.
Investigation confirmed that the isolation valve had
previously been held in the closed position since plant
start-up, despite being car-sealed open (CSO), with the
position indicator showing open. This situation occurred
as a result of physical dismantling and re-assembly
of the valve-gearbox interface during commissioning
phase to correct a mis-orientation in order to facilitate
operation of the valve. The initial commissioning and
start-up tests were insufficient to reveal this defect, and
the scheduled maintenance program did not call for
physical function-testing until now.
WHAT WENT WRONG: QA/QC during valve reorientation and installation failed to directly prove
correct operation of the valve. Piping System Checklist
did not adequately cover installation, position-indication,
and testing for manual valves.
Current procedures and practices for projects are
inadequate in directly proving the correct orientation,
function, and subsequent position of valves. For critical
service valves the operating position should be verified
by competent personnel familiar with the function and
operation of the specific valve type. Original Equipment
Manufacturers operating instructions must be strictly
adhered to, and post-commissioning changes must be
controlled by formal Management of Change. Operating
position of valves for isolation and/or LO/LC status
should be verified by direct mechanical indications
whenever possible (e.g. x-ray to confirm valve status,
instead of reliance on position indicator).
CAUSAL FACTORS:
materials/products
supervision
33
DATE: Dec 23 2012

LOCATION: FSU, RUSSIA
DATE: May 3 2012

NARRATIVE: A drilling crew of contractor was drilling

through a cement column after cementing the
conductor of well. At 12:45, while starting up a mud
pump of the drilling rig, a sudden pressure surge
occurred breaking a DZU-250 quick release valve off the
manifold line and injuring a contractor mud engineer,
born in 1985. After medical assistance was rendered to
him, the injured person was taken to the Trauma Centre
of City Hospital with a preliminary diagnosis of a roughedged wound of the right thigh and broken left-side ribs
of the thorax.
NARRATIVE: During preparation for a test run of a

transfer pump, a hydrocarbon loss of containment
incident occurred. The source of the release was
identified as being from a screw associated with a vent
plug on a tight shut-off valve. Damage due to galling of
the threads on the vent plug was noticed so the plugs
threads were re-machined and re-ins
WHAT WENT WRONG: Pressure release into the

pipeline system with the shut-off valve closed. Safety
valves broken. Injured person being in an unsafe zone.
LESSONS LEARNED AND RECOMMENDATIONS: Hold
safety Stand-downs communicating information about
the circumstances and causes of the incident to all
Company and contractor employees. Have ad-hoc
briefings on safe operations to the drilling contractor
personnel. Have an unscheduled inspection of safety
valves on pumps and manifold lines of drilling rigs.
CAUSAL FACTORS:
materials/products
WHAT WENT WRONG: Investigation concluded that the

valve was supplied contrary to the design engineering
procurement specifications. The procedures for
conducting leak testing on the valves onsite did not
adequately cover the vent plug.
Strengthening quality assurance and quality control
processes, particularly on new facilities is vital. Improve site
procedures and processes for conducting tests on valves.
CAUSAL FACTORS:
materials/products
34
DATE: Aug 12 2012

DATE: Apr 14 2012

NARRATIVE: Whilst preparing a loading pump for

maintenance, during the process of purging condensate
from the pump into the drain vessel using gaseous
nitrogen, a mist of condensate of no more than 150L
was released to the atmosphere via the atmospheric
vent on the drain vessel. The operator immediately
stopped the activity and contained the leak. There was
no injury of personnel or damage to assets caused by
the incident. The procedure instructed the operator to
crack open the nitrogen valve.
NARRATIVE: Methane Leak from pump body flange in

the Nitrogen Recovery Unit.
WHAT WENT WRONG: The precise requirement of the

term crack open and potential impacts of this action
was not appreciated or clarified. Confirmation was not
sought that the drain vessel level was reducing during
purging. Incorrect configuration of the automatic level
control system on the drain vessel.
Avoid ambiguity in procedural instructions so that the
intended impact of each step is fully understood before
execution. Adequacy of vessel level controls should
be confirmed to reduce the risk of a high level during
draining/purging.
CAUSAL FACTORS:
training/competence
communication
WHAT WENT WRONG: Small gas leak was noticed at

the cryogenic pump while the plant was in total recycle.
Review of QA/QC and factory acceptance test procedure
to include checking of the torque of pumps bolts in
check lists. Review cool down /warm up procedures
and consider introduction of additional measures
particularly post prolonged shut down periods.
Isolation valves around the cryogenic pumps should
be tested Passing valves failing to provide isolation
should be replaced or repaired Review opportunity
and benefits of using Nitrogen/helium mixtures for
leak testing. Organise refreshers for all Operations
personnel on Emergency Response procedures to raise
risk awareness. Issue clear instructions to site main
controllers on actions to take on confirmed gas leaks.
Consider automatic shut down on confirmed flammable
gas detection in NRU and compressors areas.
CAUSAL FACTORS:
materials/products
DATE: Oct 29 2012

NARRATIVE: Amine leak occurred when a lagger drilled
through a pipe as he was installing insulation cladding.
WHAT WENT WRONG: While fixing lagging into the
amine stripper, the worker drilled a hole into aluminium
cladding and continued to drill the pipe causing an
amine leak.
LESSONS LEARNED AND RECOMMENDATIONS: Carry
out check on all similar lagging works to verify the
pipework integrity. Review of current practices for the
application of insulation material on hot pipe and for
the installation, adjustment and fixation of cladding on
process pipework. Identify technical training for the
application of insulation material and include all lagging
operators into it. Application of accountability model.
Coaching in implementing Safe Systems of Work.
DATE: May 24 2012

LOCATION: Africa, EGYPT
NARRATIVE: On 24th May 2012, 09:00 hours an open
valve was discovered leaking condensate onto the
ground in the area of the condensate shipping pumps.
The spill, forming a pool of approximately 8 x 50m, took
place following the removal of isolations that had been
applied so that a routine hydrotest could be performed
on the condensate cooler. An alternative valve had
been used for isolation without updating the work pack
or marking the change onto the isolation P&ID used
with the PTW. Unaware of this change, the alternative
valve was left open, when the isolation was removed
by the technician of the following shift. The volume of
condensate spilled is estimated to exceed 150 bbls.
Remediation works were carried out.
35
WHAT WENT WRONG: Improper Behaviour, Improper

Attempt to Save Time or Effort, lack of Knowledge/Skill/
Competence, inadequate Induction Training, inadequate
Engineering/Design, Inadequate Hazard and Risk
Assessment.
Revise your permit to work system to ensure proper
management of change and retrain relevant personnel
on mechanical isolation procedures. Ensure that
shift handover procedures cover instructions for
formal handovers, required information and physical
documentation to be passed across Revise site
response procedures and develop site specific
emergency response scenarios so that response
exercises can be focussed and tested. Include
specific notification requirements in the site response
procedures.
DATE: Mar 4 2012

NARRATIVE: While welding on 4" choke line flammable
gas was released causing a flash fire that immediately
went out. Two workers were in the vicinity and exposed
to the fire causing 2nd degree burns to face and neck.
WHAT WENT WRONG: No hot work permit and JSA
completed. Procedure to flush the line not followed.
Hazards of gas vapours in the choke line not anticipated
by the welder and DSV. Inadequate job preparation due
to unclear work instructions and poor job planning.
LESSONS LEARNED AND RECOMMENDATIONS: Assure
risk hazards are identified and addressed with proper
JSA process.
CAUSAL FACTORS:
DATE: May 14 2012

NARRATIVE: During BOP testing operations utilizing a
BOP test stand the crossover that was located below
the rotary table blew out of the top of the test stand
when the BOPs were pressured up to 12,500 PSI for the
high pressure test. The crossover assembly had a lift
nubbin in it, and the lift nubbin was connected to one of
the rig floor air tuggers. When the crossover assembly
was blown out of the test assembly, it went up in the air
approximately 30' and the pin end came down close to
the rotary table. The box end that was connected to the
tugger was leaning over towards the set back area. Due
to the box end being connected to the lift nubbin and
suspended by the tugger the only part of the crossover
assembly to make contact with the rig floor was the pin
end, causing the pin end to be damaged. The assembly
also had a pump in sub on top of it. When the crossover
assembly was ejected from the rotary, the fitting was
knocked off of the end of the valve, and the hose fell an
undetermined distance to the rig floor. A rotary hole
cover was also being used to surround the assembly
that was sticking out of the rotary. When the assembly
was ejected from the hole, the hole cover also was
ejected. The hole cover, weighing approximately 10 lbs,
was found on top of the draw works shed. The rig floor
had been cleared of all non-essential personnel. All of
the remaining personnel on the rig floor were standing
in the safe zone behind the drillers console inside of the
draw works machinery shed. Proper precautions had
been taken to mitigate any hazards to personnel as per
the pressure testing JSA.
WHAT WENT WRONG: The pipe that failed was N-80
(not P-110) as stated. 3-1/2" tubing was ordered as a
cement stinger and not for pressure testing use of
wrong equipment. There are no known standards for
using used production tubing for pressure testing, so no
expectations for pipe quality were stated to the provider.
36
LESSONS LEARNED AND RECOMMENDATIONS: Actual

test pressures were higher than the test pressures
stated in the Drilling/Completion program to allow
for the chart recorder to stabilize without going below
the permitted test pressure and causing a NO test
situation according to BSEEs testing standards.
Drilling supervisors should always work with QAQC and
Engineering when working on a BOP test assembly.
Well data should be validated against the program so
that if well conditions are different than anticipated that
the program can be adjusted and a MoC generated. A
lighter weight composite hole cover would lessen the
possibility of a serious injury if it was to fall from height.
CAUSAL FACTORS:
communication
37
DATE: Nov 16 2012

Decommissioning
DATE: Apr 2 2012

NARRATIVE: Hydrocarbon release from well 446 flowline. On 16 November 2012, a construction contractor,
drilled a small hole into a pressurised flow line
releasing hydrocarbons. The flow line from Well 446 was
mistakenly assumed to be the abandoned flow line from
Well 913. Personnel working in the area mustered and
were later safely evacuated. Gas from the release was
detected at EOPS and a level 1 Shutdown was activated.
The well 446 was manually shut down and the flow line
depressurised to allow fitting of the repair clamp. The
estimated sour gas release was 392 m3 and estimated
condensate release was 292 litres.
NARRATIVE: Hydrogen sulphide gas released causing

the activation of fixed Gas detector which was located
around 15 metres away from the leak point. This
incident occurred while assigned work party were in
the process of reinstalling the channel cover to the Hot
Lean/Rich Glycol Heat Exchanger. Immediate actions
were taken by operations personnel by evacuating all
workers from the area and notifying the emergency
response team.
WHAT WENT WRONG: Inadequate Management

Leadership and/or Supervision. Inadequate Work
Planning or Programming. Inadequate Management
Leadership and/or Supervision. Lack of Supervisory/
Management Job Knowledge. Inadequate Engineering/
Design. Inadequate Standards, Specifications and/or
Design Criteria.
Contractor to provide a comprehensive HSE
Improvement Plan, addressing all the safety
deficiencies highlighted by the investigation. Review the
existing contractor management controls and increase
levels of supervision, in particular for remote locations
worksites. Review the existing control measures for
Brown Field area activities to prevent unauthorised
works being carried out. Undertake an audit of the
design control process with specific focus on control
of interfaces with design contractors and the internal
design review process.
CAUSAL FACTORS:
communication
supervision
WHAT WENT WRONG: Procedures Followed

Incorrectly. Inspection instructions need improvement.
Pre-job briefing need improvement. Walk-thru
need improvement. Supervision during work need
improvement. Work package/permit need improvement.
Field Operator to brief the personnel involved in the
process of closing valves pertaining to safe isolation.
Area Operator to verify/make sure positive shut-off
of the valves prior to signing off the isolation list.
Conduct knowledge transfer session (on permitting)
to include the requirement to hold a pre-job briefing
(between Permit Holder/Issuing Authority/Shut-down
Coordinator) to understand the job scope prior to
application of the work permit. Work Management
Team along with the Training Centre to consider adding
a practical session to the existing work management
training program. A safety alert to be generated to
enforce the fact that Isolations is a safe guard.
CAUSAL FACTORS:
energy isolation
training/competence
supervision
DATE: Nov 11 2012

NARRATIVE: A maintenance team was exposed to
Hydrocarbons and hydrogen sulphide which were
released whilst de-blinding a 40" downstream valve. At
the time of incident, the double block & bleed valve was
in closed position and also blinded while in the valve
Inspection checklist shown open. No injuries reported.
WHAT WENT WRONG: Failure to follow Company Work
Management System Procedure (Log out/tag out and
Isolation list). Inadequate work preparation.
Develop and communicate the incident lesson learned
to all operations personnel and also managing V1,2,3,4
valves in a double block and bleed case as part of
isolation certificate and also provide more clarity on
requirement of donning breathing apparatus during
breaking containment.
CAUSAL FACTORS:
warn of hazard
38
DATE: Mar 21 2012

NARRATIVE: Gas Release From Coil Tubing. The well
was drilled as exploratory well and, after the production
test, it was scheduled for work over to perforate and
test Hith Formation and horizontalization. During run
in hole with coil tubing and lifting the well with nitrogen
at depth 370ft from surface, the coil tubing partially
parted (almost 75% from its circle) just 1.5ft before
the mechanical depth indicator of the coil causing big
sound, nitrogen and gas with hydrogen sulphide release
to the atmosphere due to failure of dual check valve in
the Bottom Hole Assembly (BHA). Nitrogen and gas with
Hydrogen Sulphide (1400PMM) was released into the
atmosphere. All the personnel were evacuated and the
well was killed by bull-heading with 100bbls of brine
water (75pcf). Gas leak was stopped after pumping
15bbls of the brine into tubing. Outcome: Release of
nitrogen and gas with hydrogen sulphide from coil
tubing to the atmosphere.
WHAT WENT WRONG: Inadequate Inspection/
Monitoring. Inadequate Assessment of Required Skills
or competency/Inadequate Job Placement. Inadequate
Work Planning.
LESSONS LEARNED AND RECOMMENDATIONS: Do not
exceed recipe exposure time during acid job test. Always
inspect and test coil tubing and double check valve after
acid job. Assign competent staff on high risk jobs.
CAUSAL FACTORS:
supervision
39

DATE: Sep 12 2012
ACTIVITY: Unspecified other
DATE: Apr 2 2012

LOCATION: Europe, ROMANIA
NARRATIVE: Observed C4 rundown line pressure

increasing abruptly causing disc rupture to release
pipeline overpressure. Set pressure is 18 BarG. It was
confirmed that some ongoing maintenance activity was
being carried out involving the switchover of C4 line
from original to spare line. During this operation the
rundown line was closed inadvertently.
NARRATIVE: The cementing crew were testing the

pressure on the pumping line prior to the cement job,
at a testing pressure of 2,800 PSI. A Rock catcher was
mounted in the pumping line between two 2" x 10,000
PSI pup joints. Immediately after pressurizing the
pumping line, the wing nut of the 4 inch hammer union
connecting the two bodies of the Rock Catcher cracked.
About 50 litres of testing fluid (water) spilled on the
ground. The operation stopped and the Rock Catcher
was replaced.
WHAT WENT WRONG: There is no clear technical

specification of Cement Pressure Lines in the company
Historical practices and lack of knowledge regarding
secure pressure lines.
LESSONS LEARNED AND RECOMMENDATIONS: All high
pressure connections shall be as a Standard FIG. 1502
(welded connection ) and secured with clamps, chain or
wire sling. All third party companies shall be required to
use only FIG. 1502 connection and with clamps chain or
wire sling. Rig Inspection training to be provided to all
Drilling Supervisors and Junior Engineers.
CAUSAL FACTORS:
40

SAFETY EVENTS 2011
DATE: Mar 6 2011
DATE: May 28 2011


AGE: 25 EMPLOYER: Company

NARRATIVE: A work party of 2 process operators were
tasked with preparing a caustic soda neutralisation
vessel for maintenance. The level control indicator on
the bridle was not working and the intention was to gasfree the vessel by draining down the sour caustic from
the process to one of the other tanks, purge/blanket the
vessel with nitrogen, then fill the vessel with water to
eliminate all gas. On completion, the vessel would be
confirmed as gas-free then containment broken to fix
the level transmitter. During the water filling process
an unplanned release of H2S gas occurred that resulted
in the incident. The second operator is currently being
treated by medical staff.
CAUSAL FACTORS:
NARRATIVE: During the re-start of the facility, following

a trip of an electrical generator, an amine flash tank
was over pressured. A subsequently closed block
valve effectively shut off the pressure relief outlet from
the amine flash tank. This caused overpressure and
subsequent rupture of the amine flash tank. The failure
of the flash tank and the subsequent pressure release
resulted in the injuries.
WHAT WENT WRONG:
Engineering Design:
1. Engineering design review including HAZOP and
independent verification of process safety design
of amine system and integration of skid into other
process units
2. Verification of the selection and sizing of equipment
items
3. Safety integrity level assessment of design
Operator Competence Verification:

training/competence
1. Develop and implement a customised formal

training programme which includes competency
assessment/verification for operators Good

Operations Practice:

supervision
1. Provide and enforce procedures for Lock Out/Tag

Out, PTW and equipment isolation
2. Report and investigate to closure Near Misses and
High Potential process safety incidents
3. Review single operator practice at facility
CAUSAL FACTORS:
training/competence
supervision
DATE: Apr 26 2011


OCCUPATION: Unknown
NARRATIVE: While increasing the choke valve on the

production well, the upper master valve actuator failed
catastrophically and struck and fatally injured the
individual.
WHAT WENT WRONG: During opening of wells on a
remote platform, a pneumatic actuator for a Xmas tree
valve was over pressured. The housing separated from the
actuator, hitting the operator resulting in fatal injuries.
LESSONS LEARNED AND RECOMMENDATIONS: Verify
that operating and maintenance procedures involving
actuators include maximum operating pressure
rating. Pneumatic actuators should not be exposed to
pressure higher than their rated operating pressure.
Actuators should be operated only with manufacturers
recommended overpressure protection (e.g. relief
41
valves, blowout plugs) installed and functioning. Never

apply excessive force, such as hammers, to an actuator
which is stuck or not working properly. Do not use
jumpers to apply pressure to an actuator without MOC
and pressure regulators in place.
CAUSAL FACTORS:
materials/products
DATE: Sep 9 2011


OCCUPATION: Unknown
NARRATIVE: Contractor struck in the head during

swabbing operations.
DATE: May 7 2011

42

1. Revise flowline design specification; and integrity
assurance practices to consider flowline leaks as an
abnormal occurrence.


OCCUPATION: Unknown

OCCUPATION: Unknown
2. Amend procedures and instructions such that night

operation is considered an abnormal and higher
risk activity.
3. Review design philosophies and over pressure
protection from the well head through RDSs all to
the CDS in view of changing reservoir conditions,
flowline aging and recent enhanced design practice.

OCCUPATION: Transportation Operator
4. Review emergency response procedure to consider

an ESD on the plant as an emergency event.

OCCUPATION: Unknown
5. Review specifications for coveralls with respect to

fire resistance for both company and contractor staff.
NARRATIVE: After the normalization of an emergency

shutdown of the central degassing station at midnight,
the operation teams started to open closed wells. At
01:25 hrs, a fire was observed at Bu-407 flowline (about
200m from the wellhead) and the well was isolated.
Another Operations team (driver and four crew
members) proceeded to RDS-3 to isolate the well from
the station for depressurization. There was an oil leak
from the flowline of Bu-570 covering the main access
track (about 300m from the RDS-3). Upon crossing
the oil pool, the vehicle caught fire and the accident
resulted in four fatalities (1 company 3 contractor). A
crew member sustained minor injuries.
WHAT WENT WRONG:
Management/Supervision/Employee Leadership.
1. Inadequate identification of worksite/job hazards
Work Planning
1. Inadequate preventive maintenance * assessment
of needs
2. Inadequate job placement * use by untrained
people.
Tools & Equipment
1. Inadequate removal/replacement of unsuitable
items
2. Inadequate adjustment/repair/maintenance.
CAUSAL FACTORS:
warn of hazard
materials/products
43

DATE: Nov 3 2011
INCIDENT CATEGORY: Confined Space

NARRATIVE: While a Contractor was cleaning out a
20,000 m3 vertical tank, an explosion of gas-air mixture
occurred with consequent fire which started at remained
sludge in the reservoir. After 3 hours 40 minutes, the fire
was extinguished. As a result, two Oilfield Equipment
Repairmen, who were inside the tank, were lethally
injured. The tank sustained serious damage.
WHAT WENT WRONG:
1. Presence of the source of explosion (spark) with
explosive hydrocarbon concentration inside the tank.
2. People inside the tank at exceeded non-explosive
concentration.
1. General:
Modern unmanned technologies must be
applied for cleaning of tanks and plants where
possible;
Prior to jobs, all risks should be assessed and
all safety issues must be discussed with the
workers involved in operations;
Strict control should be in place to ensure that
contractors comply with safety standards; if any
non-compliance is observed work should be
immediately stopped and contractors may even
be taken off the job.
Where possible testing should take place prior
to high risk work
During accident investigations we must place
special focus on the impact of human factors to
ensure that we understand the root causes of
the behaviour of people.
2. Gas hazardous work (work in confined spaces):

Gas and air should be sampled using
instruments verified for specific conditions and
composition of gases generated in the working
environment (meeting all standards, within
allowable error rates);
Gas and air to be sampled in line with the work
execution plan and in accordance with preapproved sampling procedure. If the sample
exceeds the allowable limit the person in charge
must be informed and the work stopped until
the atmosphere in within allowable limits.
A person responsible for gas dangerous work
should ensure continuous supervision;
Mobile phones and any devices that can cause
ignition shall be prohibited on site;
Put in place the ventilation system that can
activate every time when carbons concentration
exceeds maximum allowable level.
Work that may be dangerously explosive should
be performed with intrinsically safe tools and
equipment; workers should wear proper clothes
and shoes.
Equipment used in operations should be
earthed;
Workers inside oil tanks must necessarily wear
air line respirators;
At least 3 crew members should be assigned for
work inside oil tanks (1 worker and 2 observers).
When doing work in confined space, at least 2
observers should stay outside by the entrance/
exit to ensure safety in case of emergency.
Radio contact with CCR must be maintained the
observers.
CAUSAL FACTORS:
supervision
44

EVENTS 2011
DATE: Feb 15 2011
WORK FUNCTION: Unspecified
Decommissioning
NARRATIVE: Two members of the sites demolition
team accidently cut into a 20 inch pipe containing gas
at 1.7 barg. The pipe was cut on the wrong side of the
isolation, the workscope having been misunderstood
by the contractor. A site procedure relating to marking
of pipes had not been followed. An estimated 162 kg
of gas was released to the atmosphere. The gas was
not ignited and was dispersed in an open area. There
was no injury to personnel. The affected plant was shut
down and depressured. At the time of the incident the
2 members of the demolition work party were
positioned approximately 1m from the locus of the cut in
a cherry picker basket. The 12v electrical control panel
for the cherry picker located in a panel at the rear of
the basket was not EX certified and so represented a
potential source of ignition.
WHAT WENT WRONG:
1. Ineffective communication of work scope
Workscope was communicated verbally during site
visit, and misunderstood by the contractor. The
company work pack defined the scope, but was not
used by the contractor. The contractors work pack
did not define the scope.
2. Lack of marking on pipes Pipework was
labelled as redundant (historical). No physical
marking on the pipework for this work contrary
to the contractors procedure. Live pipework at
air gap not marked as required by current site
decommissioning philosophy.
3. Work control The risk of cutting the pipe in the
wrong position was not recognised in the work
permit, but the control designed to prevent this was
not sufficiently rigorous.
4. Safety leadership The sites earlier practice of
marking or witnessing cuts ceased circa early
2009, despite this being called for in the method
statement. The site auditing process had not
identified this gap.

Ensure there is a rigorous process in place and
followed for marking the location and witnessing any
process pipework cuts.
Ensure sufficient safeguards are in place to
mitigate against the potential for human error or
misunderstanding in communicating safety critical
activities.
Ensure auditing and monitoring processes are
rigorous enough to identify degradation in adherence
to procedures and processes.
CAUSAL FACTORS:
energy isolation
communication
DATE: Apr 5 2011

NARRATIVE: A worker at the well site was transferring
fluids between the produced water and condensate
tanks. In the course of transferring the condensate into
the condensate tank, the worker stated he instinctively
felt that something was wrong. As he was preparing to
shield himself, a blast of condensate knocked him into
the transfer truck and soaked him in condensate. He
ran down wind (eastward) toward the site entrance to
escape the scene and call for aid.
WHAT WENT WRONG:
1. Inadequate grounding during condensate transfer
operation
The incident investigation group concluded that
the ignition source for the internal combustion
explosion was from a static electrical discharge.
The static electrical discharge was made possible
when transport operator connected the ground
clip from the transport truck to the handrail of
the ladder rather than to the ground clip on the
tank as required by contract company procedure.
2. Injection of oxygen into condensate tank during offloading operation.
The Transport operator used air pressure from
the transport truck to transfer the condensate
into the storage tank. Hydrocarbon entrained air
manifests itself in the vapour space of the tank
potentially creating an explosive environment in
the vapour space above the condensate level.
Verification that contract companies have an
established process for training and competency
assessment of their employees and that equipment
provided is appropriately suited for the work. Review
off-loading procedures to ensure they contain sound
engineering practices for handling non-conductive,
flammable, and combustible fluids.
CAUSAL FACTORS:
materials/products
45

training/competence
supervision
DATE: Jun 22 2011

NARRATIVE: A three person corrosion monitoring crew
was in the well house removing a corrosion coupon.
When the coupon plug was removed from the access
fitting, the tool operator heard a hissing sound he
interpreted as a leaking hammer union. In the process
of replacing the coupoon plug, the tool operator
accidently opened the service valve and bleed valve
simultaneously. The bleed valve allowed more gas to
reach the bleed than it could vent, and the can ruptured
into 2 pieces with enough force to propel it across the
well house. The tool operator immediately closed the
bleed valve and re-inserted the coupon plug to isolate
the pressure.
WHAT WENT WRONG:
1. An engineering review was not conducted on the
bleed valve. A correctly engineered bleed valve
would not have passed enough pressure to rupture
the bleed can.
2. The bleed can evolved over more than 20 years of use
without engineering review or MOC. The container
was incapable of safely venting the maximum gas
possible from the upstream equipment.
3. Failure to follow procedure. Despite having
performed it correctly in the past, rushing to relocate
the plug with the union leaking caused the tool
operator to open the valves out of procedural order.

1. Immediately cease use of the bleed can and
temporarily stop all coupon pulling activities.
2. MOC and engineering review for each coupon pull,
until a general design is complete.
3. Review training on the procedures.
4. Re-design the bleed system to ensure that the
valve and can are considered as a system and
appropriately sized to the other components.
5. Ensure that an MOC and engineering evaluation
is performed if either the bleed valve or can are
modified.
CAUSAL FACTORS:
46
DATE: Jan 8 2011

LOCATION: Asia/Australasia, PAKISTAN
NARRATIVE: Mild gas leakage was observed from lower
side glass level gauge (GLG) of inlet filter coalescer
V-590 by shift incharge and area operator during
routine plant round. Upon leakage identification level-1
shutdown was activated at 1227 hrs to stop the leakage.
All emergency response measures were taken by
activating FAT and FFT. GLG was replaced with new
one and plant was again brought into flow at 1528hrs
following cold start-up procedures and using the
already developed plant start-up TRA.
WHAT WENT WRONG: The sealing gasket of the glass
level gauge could not withstand the operating pressure
even it was well within the design range of LG and
eventually led to material failure.
Maintenance schedule shall be revised. There shall be
annual inspection of LGs instead of bi-annual (2 years).
CAUSAL FACTORS:
DATE: Jan 11 2011

LOCATION: Europe, HUNGARY
NARRATIVE: There was a fire on compressor N-708.
The discharge valves cover bolts were broken, the
valve cap, and the valve holding bell; was shot to the
foot-grid, the gas was flowing and ignited. The plantfire brigade in cooperation with the govt fire-brigade
started the cooling. The operators eliminated the
critical sections. Additional problem occurred, when the
CC2-MC2 units emergency shut down, as the gas could
flow back from the flareline through a damaged valve.
Decreasing the field production and started the CC2MC2 units, the supply of the gas could be stopped, the
fire was out and the unit could be cooled down. There
was personal injury ( post-event psychological shock).
The plant-fire brigade in cooperation with the govt firebrigade started the cooling. The operators eliminated
the critical sections. There was a personal injury (postevent psychological shock and a bone in his ear was
broken), 155 000 m3 natural gas was burned (causing
300 tons of CO2 emission).
WHAT WENT WRONG: Cleaning of a piroforic tank
was done without any safety information, proper risk
assessment, trained staff.
LESSONS LEARNED AND RECOMMENDATIONS: New
procedure for handling piroforic equipment Reinforce
PTW system
CAUSAL FACTORS:
materials/products
materials/products
communication
DATE: Sep 17 2011

Decommissioning
NARRATIVE: A contractor crew was dismantling
an inactive pipeline, when, at 15:00, an excavator
involved in earthwork damaged an active oil pipeline
(commissioned in 1994) with its bucket. As a result of
the incident, 0.25 tons of oil-water emulsion were spilt
over an area of 0.33 ha.
47
WHAT WENT WRONG:

Violation of ground disturbance procedure:
performance of work without operation certificate and
hazardous work permit. performance of work using
a mechanical digger in the buffer zone of active oil
pipeline. Absence of underground utility line diagram
and clearance from the owners of the utilities.
Improper decision making or lack of judgment Digger
driver did not know that the inactive pipeline to be
dismantled intersected an active pipeline as there
was no utilities diagram agreed with their owners.
Improper decision making or lack of judgment:
Foreman made an error of judgment when he
instructed the digger driver to start ground
disturbance work thinking that the documentation
for pipeline from well to ZU2 of field referred to the
detected ZU9 GS pipeline.
1. Carry out target audits of operations to dismantle
inactive pipelines for compliance with:
procedure for interaction between the
Customers units and shops;
issuance of permitting documents for the
performance of works (operation certificate
issued to the contractor to perform work at the
Customers sites, work permit, availability of
agreed utilities flow diagram, briefings, etc.).
2. Review and update as needed instructions
and regulations regarding dismantling of
inactive pipelines to ensure that coordination of
accountabilities of unit and shop leaders are in place.
3. Apply penalties to the contractor in accordance with
the contract.
4. Take disciplinary action against persons responsible
for the incident.
5. Carry out cleanup work on the incident site.
CAUSAL FACTORS:
communication
48
DATE: Oct 6 2011

LOCATION: Middle East, OMAN
DATE: Sep 3 2011

LOCATION: Asia/Australasia, THAILAND
NARRATIVE: The plant annual shut down was being

completed. A pipeline PV had been removed for
calibration and not replaced yet. Gas was introduced to
the pipeline from the wellsite and leaked from the open
flange of the removed PV. Leak pressure around 350psi
for a short period. No injuries, no ignition.
NARRATIVE: While drilling the 12 " top hole section

with flow riser (no BOP) at 220m, the drill started to
bounce. Plans were checked for anti-collision and it was
concluded there was still a 5m separation. Cautious
drilling continued. Some 7 minutes later the well kicked.
Mud flowed from the wellbore. Rig crews evacuated
the rig floor. The kick lasted 3-5 minutes then stopped
by itself. During attempts to pump mud into the well
another small kick occurred. The well was eventually
filled with mud again and no further flow occurred.
WHAT WENT WRONG: Failure to follow supervisors

instructions. Inadequate assessment of competence/
skills required. Poor work activities planning.
Inadequate communication between work groups. Poor
Permit to Work control.
Ensure PTW use is enforced. Job Safety Analysis to be
done. Use of mechanical isolations to be extended and
enforced.
CAUSAL FACTORS:
WHAT WENT WRONG: The well being drilled collided

with an adjacent well. Rig ESD was not hooked up at
the time.
LESSONS LEARNED AND RECOMMENDATIONS: Close
attention must be paid to anti-collision procedures
and practices. Pre-spud meeting must be held with
all involved parties to ensure everyone has a clear
understanding.
CAUSAL FACTORS:
supervision
DATE: Oct 2 2011

NARRATIVE: Following a planned shutdown of the
onshore gas plant, a gas release occurred during
re-start activities on Train 5. The loss of containment
resulted when flanges installed in the liquid outlet on
a Column were subjected to excessive load during the
cool down process. This loading occurred because
thermal movement of the pipe allowed it to exceed
the height of the support guides resulting in a single
point of support adjacent to the flanges. This support
created the excessive flange bending moment. The
hydrocarbon release was classified as significant
(RIDDOR Classification).
WHAT WENT WRONG: The root causes from the
major investigation include; engineering process did
not adequately consider piping thermal bowing and
piping quality control did not identify that piping stress
calculations had not been completed for the design
change relative to Train 4.
Lessons learned have been shared with Design
Development Project Teams for future project
designs. Revise project procedures to ensure that
design changes on critical piping are subjected to
reassessment of the piping stress calculations. Develop
an improved process for the cooldown of LNG trains
to minimise the piping thermal gradient and thermal
bowing during the cooldown.
CAUSAL FACTORS:
49
DATE: Oct 7 2011

Decommissioning
NARRATIVE: During the commissioning phase of a
new FPSO a major hydrocarbon release (estimated at
28,000kg) occurred when the pressure vacuum (PV)
breaker protecting the cargo tanks from over and
under pressure released gas to the atmosphere at a
pressure lower than the design intent. The hydrocarbon
release was detected by the gas detection system and
the appropriate actions were initiated, resulting in
shutdown of the facility.
WHAT WENT WRONG: The investigation determined
that the root causes included; incorrect calculation
signed off in design, consequence analysis not
completed for P/V breaker release, P/V breakers not
constructed as per design specification, small margins
between maximum operating pressure and P/V breaker
release and onshore commissioning that never tested
the full functionality of the P/V breaker (re-sealing
arrangement).
LESSONS LEARNED AND RECOMMENDATIONS: PV
breakers designed with an automatic re-sealing system
should be reviewed and if necessary computational
fluid dynamics to demonstrate their viability. Carry out
consequence analysis of PV breaker release (dispersion,
fire and explosion, asphyxiation) and ensure that the
instrumented protective function is suitable for the
hazard. Review design margins between maximum
operating pressure, high pressure trip setting and
PV breaker release. Commissioning and Operating
procedures must ensure that the PV breaker is suitably
commissioned, tested and operated as per design.
CAUSAL FACTORS:
DATE: Aug 16 2011

LOCATION: Middle East, IRAQ
WORK FUNCTION: Exploration
NARRATIVE: After finishing drilling a stand at
2354Meters and reaming down the stand, the RCD
(ROTATING CONTROL DEVICE) seal failed, causing
an unexpected well pressure, H2S gas release to the
atmosphere through the top of the BOP, Reaching
almost the crown and placing H2S gas level up to 1.2 %
in the atmosphere. Night Drilling Supervisor secured
the well.
WHAT WENT WRONG: RCD (ROTATING CONTROL
DEVICE) seal failed
Check the certifications for each equipment prior
the job and ensuring by visual inspection.
Run only slick drill pipe through the RFD seals.
Wellhead pressure; In respect to confirm if the
industry leader in UBD operations has reduced the
dynamic WHP by 20%, and, determine the reason(s)
for doing so, if relevant, adjust the WHP parameters
accordingly.
Improve the gas detection capability at the RFD seals.
Seal material checked for quality or degradation.
This should ideally be carried out by an independent
organization.
ensure that practice drills are as realistic as
practicable and are carried out to the furthest
practicable extent.
CAUSAL FACTORS:
materials/products
materials/products
training/competence
50
DATE: Mar 19 2011

LOCATION: South & Central America, TRINIDAD &
TOBAGO
NARRATIVE: At 15:55hrs on one Offshore Platform, an
alarm both audible and flashing was detected on the Fire
and Gas panel in the control room, identifying Fire on
Pump Deck. The operator observed Shore Line Pump
#04 to be on fire and the alert alarm was activated and
an announcement was immediately made following
which, the Emergency Response Team was activated.
The supply vessel (which was alongside the neighbouring
Platform) was requested to come to the Platform to
provide assistance with extinguishing the fire.
The Emergency Response Team #01 and Operations &
Maintenance personnel responded to the emergency. The
fire was extinguished at approximately 16:15hrs following
which, boundary cooling was applied to the area.
WHAT WENT WRONG: The R-CAT method was used to
conduct the investigation, and demonstrated that the
fire on Shore Line Pump #04 came about as a result of
two events that occurred in series:
1. The Pump was starved for liquid as a result of a
blockage by foreign object
2. Volatile mixture (un-burnt fuel) around/in the turbo
charger.
There were 2 fires each driven by a separate fuel
source:
a. Natural gas driven fire, which was coming from
either the corroded engine fuel gas line to Shore
Line Pump #04 or a build-up of un-burnt fuel in the
turbo charger.
b. The second fire was fed by ignition of leaked/
leaking liquid hydrocarbon coming from the leaking
mechanical seals.

What went well:
There were no fatalities and no injuries to personnel
There was minimal environmental damage
The recently installed Fire & Gas and Fire-Water
systems functioned
The contracted vessel was in the field at the time of
the fire and was able to readily lend assistance in
extinguishing the fire and providing boundary cooling
Opportunities for improvement:
The on-site emergency response procedure for
mustering was not adhered to
51
DATE: Aug 4 2011

WORK FUNCTION: Exploration
ACTIVITY: Seismic/Survey Operations
NARRATIVE: Piercing of condensate pipeline by
bulldozer during seismic operations. During the
construction of the ramp, the pipeline was punctured
by a bulldozer, resulting in a significant release of
pressurized condensate and consequential loss of
production by the owners and operators of the pipeline.
WHAT WENT WRONG:
Critical activities for the inspection of the Shore Line

Pump #04 train were not completed due to logistics
and operations constraints
Insufficient risk assessment for used equipment,

unclear pipe position, lack of supervision. Unclear
presence of pipeline
Critical findings from the inspection of the Shore

Line Pump #04 train was not communicated to
the Maintenance Manager in a timely manner; as
such any opportunity to repair or replace defective
parts, which may have prevented this incident from
occurring were not undertaken
Accurate visual identifications missing
The alarm history log was not available so it was not

possible to ascertain whether safety systems were
indeed functional.
Absence of competent supervision of ramp

construction
A major overhaul was not conducted on the Shore

Line Pump #04 train as per the manufacturers
requirements
Topographer not present, lack of survey by

competent personnel (maps, metal detectors)
Bulldozer used instead of Front End Loader
Missing specific procedure for bulldozer
Nearing end of seismic contract for the company

possible time pressures
Ramp construction considered routine
No PTW or risk assessment for use of bulldozer
CAUSAL FACTORS:
Management of change procedure not applied

Lack of instructions on bulldozer ramp construction

Poor document control system

Provide accurate and visible pipeline locations and

instructions to operators

No visual pipeline markers available

Risk assessment for overall project to be carried

out prior to start up and implemented in contract
(prescriptive)
Ensure full time supervision by both company and
contractor on technical matters and HSSE
Show visible leadership with higher frequency of
MWAs (company and joint)
CAUSAL FACTORS:
materials/products
PEOPLE (ACTS): Inattention/Lack of Awareness: Fatigue
materials/products
training/competence
communication
supervision
52
DATE: Jul 7 2011

LOCATION: Africa, CONGO
NARRATIVE: On 07/07, 6:30 am, oil overflow at the flare
resulting in oil spill fire of about 600 m2. Despite a very
high potential and impressive burning flames (about
50m high), no serious impact on human, environment
and material was recorded. Production was stopped for
2 days. Some immediate actions taken allows to reduce
the fire consequences: closure of the manual valve
on site which prevent from additional overflow, short
delay for firefighting team intervention, no activation of
general mustering alarm. The muster point was located
in a heat exposed area in that case.
WHAT WENT WRONG: Slug catcher was not
operational. Production was not stopped on time:
deviation of level alarms which does not allow a
clear control on capacities, all drums were filled with
hydrocarbons due to intentional system inhibitions,
production was a priority. Tiredness following
complicated night shift operations. Integration of new
installation (slug catcher and new production line) from
other company was not commissioned. Inhibitions
access on panel control was not protected by password.
Partner installation to be commissioned and HAZOP
to be performed. Incorporate flare overflow fire
in emergency scenarios taking into account the
topography (extension of spill). Management of change,
complete review of site configuration integrating each
modification. Replace level alarm by specific level
controllers adapted to new fluid composition. Safety
shall remain a priority in any situation. Hand-over
between night shift and day shift shall be performed
under supervision of management supervisory level.
Management responsibilities to be clearly defined
between day and night shift, week-end and vacations.
Advanced emergency situation training for all members
of site management team.
CAUSAL FACTORS:
warn of hazard
PEOPLE (ACTS): Inattention/Lack of Awareness: Fatigue
materials/products
communication
supervision
53
DATE: Mar 15 2011

LOCATION: Africa, ANGOLA
NARRATIVE: Chlorination unit explosion. On 13/03, the
chlorination unit cell A was isolated from the process
and electrically. On 14/03, the cell was opened to
inspect the plates condition. On 15/03, the electrical
and process isolations were removed and the cell was
refilled with water on manual mode (to the minimum
liquid level of 48%) and then switched to automatic
mode. Some minutes later, the cell exploded damaging
the adjacent cell B.
WHAT WENT WRONG: Lack of start-up procedure:
opening the cell allowed to have air in the system, which
allowed the explosion to occur. There was no procedure
provided by the vendor to remove the air before startup. No respect of operating manual procedures: the
system was flushed once every 2 days while the vendor
manual requests once every day. It is assumed that the
electrolyte plates were not covered with water that could
most likely cause a spark that ignited the explosion.
PSV failed to release the blast pressure.
Respect strictly the operating manual. Perform
HAZOP to ensure that unit design and safety barriers
are compliant with company rules. For start-up
and shutdown of specific units ensure that vendors
procedures are existing and apply them strictly.
CAUSAL FACTORS:
54
DATE: Feb 26 2011

DATE: Apr 24 2011

NARRATIVE: On 26th Feb. 2011 approximately at

22:00hrs., after making up the 20" casing head housing
assembly to the 20" casing string the casing string
was picked-up with the 20 landing joint (P/Up weight
= 550,000 lbs). Circulation was established and the
lowering of the 20 casing string took place (Slack
off weight = 535,000 lbs) aimed for landing the casing
with the casing head housing at the landing ring. After
lowering the casing string (with housing) over a distance
of 25 ft and with the casing head housing below rotary
table whilst centring the casing head housing in the
30" bell nipple, the landing joint disconnected from the
20" casing string (stripped-out). The casing then fell
down over the remaining distance of 35 ft. Until the
casing head housing landed on the 30" landing ring. As
a result of the disconnect of the landing joint, the full
volume of the 20" landing joint was released whilst still
pumping. The pressure release and fluid release from
the landings joint resulted in a high risk event because
people were standing in the vicinity without expecting
this to happen. The worst outcome from such an
incident could have been a fatality.
NARRATIVE: On 24th April, at approximately 12:40 Hrs,

during start-up of train 5, while lining-up the production
header to train 5, a sudden pressure pulsation
(Hydraulic hammer) occurred that caused movement
of the inlet header, resulting in displacement of the
inlet pipe and damage to pipe supports. Due to rupture
of vent and drain lines, gas and approximately 2 bbls
of liquid was released. No other damage or personnel
injuries were reported.
WHAT WENT WRONG:

Work Planning
1. Inadequate work planning Communication
2. Inadequate vertical communication between
supervisor and person
CAUSAL FACTORS:
WHAT WENT WRONG:

Communication
1. Inadequate communication between shifts Work
Planning
2. Inadequate work planning Management/
Supervision/Employee Leadership
3. Inadequate management of change system
1. Ensure plant status is properly recorded in the
shift log books and shifts are properly handed over
particularly during plant start up and shutdown
conditions.
2. Develop and encourage the use of standard
production start-up checklists.
3. Apply Management of Change (MOC) process for
facilities upgrade.
CAUSAL FACTORS:
materials/products
DATE: Feb 16 2011

NARRATIVE: Slight leakage of sour gas from electrical
cables manhole.
WHAT WENT WRONG: Leaking spool piece of an
underground pipeline.
Inspection of whole line and replacement was carried
out as appropriate.
CAUSAL FACTORS:
55
56

DATE: Apr 30 2011
NARRATIVE: During a nitrogen pressure test a test hose
failed as a result of over pressurisation.
WHAT WENT WRONG: Company can remove a
contributing factor from this problem by establishing a
process of controlling goods inward (i.e. ISO Tank detour
and delay to F02 work party). Company can remove
a contributing factor from this problem by balancing
work-rest schedules to allow optimal performance of
Project Supervisors. Company can remove a systematic
root cause from this problem by clearly defining and
communicating Company management responsibility
for contractor safety throughout the organisation.
Contractor can remove a contributing factor from this
problem by enforcing the requirement of a minimum
of two competent personnel present at any pressure/
leak testing work sites, as outlined in their Safe Work
Standard. Company can remove a systemic root cause
from this problem by establishing a Procedure requiring
test packs for all pressure/leak testing. Contractor can
remove a systemic root cause from this problem by
changing the Procedure for multiple gauge monitoring.
Contractor can remove a systemic root cause from this
problem by establishing a standard requiring a suitable
regulator. Contractor can remove a systemic root
cause from this problem by establishing a Standard to
provide approved test packs. Contractor can remove a
systemic root cause from this problem by establishing a
standard requiring PSVs independent of unit under test.
Company can remove a systemic root cause from this
problem by establishing a robust planning process to
enforce adequate notification of work to the appropriate
authorities. This ensures sufficient time for Engineering
and Operations review prior to Permit Issue

Company to define contractor HSSE management
accountabilities across company and clearly
communicate responsibilities to stakeholders. Company
to collaborate on the development of a Procedure
detailing the minimum requirements for a test pack to
be supplied to company project Management prior to
the commencement of any pressure or leak testing. To
establish an effective work planning process to ensure
all proposed work is subject to appropriate Engineering
and Operations review prior to application for Work
Permit/Work Authorisation. To review staffing, PTW
Procedure, and training to ensure the requirement
for Area Authorities, who are competent in the plant/
facility, to review the content of permits is clearly
understood. To review competence of existing Permit
Authorities with detailed examination of their ability to
carry out responsibilities as defined in Permit to Work
Procedure. To establish a training and competence
program for future Permit Authorities based on defined
responsibilities.
CAUSAL FACTORS:
warn of hazard
supervision
DATE: Dec 19 2011

NARRATIVE: The washout exposed the gas pipeline and
created an unsupported span of 51-meters where san
supporting the pipeline was eroded.
WHAT WENT WRONG: A rupture from a neighbouring
water pipeline washed-out the earth supporting our gas
line.
57
CAUSAL FACTORS:
communication

Lessons Learned
1. Future pipelines should not be laid alongside any
GRP pipelines whenever possible
2. Ensure qualified welders are available and
maintained for emergency pipeline repairs.
Recommended Corrective Actions
a. Continue to supply the customers via other
pipelines.
b. keep the current mode of operation under minimal
pressure.
c. maintain items a and b until neighbouring water
pipeline decommissions its GRP pipelines.
d. Expedite the setting-up of the UAE Gas Network
Emergency Repair System (UGNRS) or at least create
as soon as possible a specific Emergency Pipeline
Repair System (EPRS) for similar wash out cases.
e. Management to liaise with neighbouring water
pipeline management to determine the scheduled
decommissioning dates of the GRP pipelines and
future disposition.
f. Determine the critical unsupported spans of all
pipelines in the UAE Gas Network.
g. Create Standard Operating Procedure (SOP) for
Pipeline Depressurization and Stabilization in case
of emergency within the UAE Gas Network such
as unsupported spans due to washout, and natural
disasters including pipeline damage from third
party activity.
DATE: Mar 20 2011

NARRATIVE: Sever vibration (line shaking) was
observed on 160-0G-2352-10"-G48-0 (Recycled Gas
from 2nd Stage Off-Gas Compressor to Unit 100). As a
consequent to that the nearby line (Flare Blow-down
line 14") was observed bouncing on its cantilever
support. It was dissipated completely after 2 hrs.
WHAT WENT WRONG: The report is not finalized
report is not finalized
58
59
Registered Office
Level 5
209215 Blackfriars Rd
London SE1 8NL
United Kingdom
Brussels Office
Bd du Souverain,165
4th Floor
B-1160 Brussels
Belgium
T +44 (0)20 3763 9700

F +44 (0)20 3763 9701
reception@iogp.org
T +32 (0)2 566 9150

F +32 (0)2 566 9159
Fatal incidents and high potential

events that were also PSE, and
fatal incidents and high potential
events that were PSE-related
2011, 2012 and 2013
www.iogp.org

Safety Performance Indicators - Process Safety Events - 2013 Data - Fatal Incident and High Potential Events

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Safety performance indicators

Process safety events 2013 data

FATAL INCIDENT REPORTS CLASSIFIED AS TIER 1 PROCESS

LESSONS LEARNED AND RECOMMENDATIONS:

1. X-tree has been installed for approximately 30 years

PEOPLE (ACTS): Use of Tools, Equipment, Materials and

2. Crews could not read tubing and casing pressure due

PEOPLE (ACTS): Use of Protective Methods: Equipment

3. The crew installed the killing line without proper

PEOPLE (ACTS): Inattention/Lack of Awareness:

Fatal incident and high potential events

DATE: Apr 27 2013

4. To strengthen risk analysis before the operation

WORKFORCE DEATHS: 2 3RD PARTY DEATHS: 0

5. To strengthen the management of personnel

NARRATIVE: There was a plan to do a maintenance

6. After completion of elimination danger for Platform

Process safety events 2013 data

DATE: Jul 4 2013

DATE: Mar 18 2013

WORKFORCE DEATHS: 1 3RD PARTY DEATHS: 0

WORKFORCE DEATHS: 1 3RD PARTY DEATHS: 0

NARRATIVE: The worker was operating heavy equipment,

NARRATIVE: Employee was performing a routine

WHAT WENT WRONG: Safety analysis failure in during

WHAT WENT WRONG:

PEOPLE (ACTS): Use of Tools, Equipment, Materials and

2. The injured person was in the line of fire when the

PEOPLE (ACTS): Use of Protective Methods: Inadequate

1. Modify pig trap inspection processes.

PEOPLE (ACTS): Inattention/Lack of Awareness: Lack of

LESSONS LEARNED AND RECOMMENDATIONS:

Fatal incident and high potential events

DATE: Jun 14 2013

Process safety events 2013 data

FATAL INCIDENT REPORTS RELATED TO PROCESS SAFETY BUT

Fatal incident and high potential events

HIGH POTENTIAL EVENTS CLASSIFIED AS PROCESS SAFETY

The project supervisor consciously gave instruction

The location of the gas transmission line was known

Verified that the construction company had

The project supervisor consciously gave instruction

In addition, this instruction to excavate was against

PEOPLE (ACTS): Use of Tools, Equipment, Materials and

Underlying Causes: Work Supervision and Follow-up

Implemented a local amendment to the Company

PEOPLE (ACTS): Use of Protective Methods: Inadequate

The team/entity did not obey rules, procedures or

PROCESS (CONDITIONS): Organisational: Inadequate

The crew neglected to follow the construction

PROCESS (CONDITIONS): Organisational: Poor

Process safety events 2013 data

DATE: Feb 19 2013

DATE: Jul 26 2013

<<No Causal Factors Allocated>>

DATE: Nov 27 2013

DATE: Oct 14 2013

DATE: May 14 2013

Fatal incident and high potential events

DATE: Aug 5 2013

DATE: Jul 10 2013