ACCIDENT / NEAR MISS REPORT

AND INVESTIGATION FORM

INVESTIGATION REPORT NUMBER : G O S / 0 1 / ? ? ? ?
(to be filled in by worksite) Worksite Year Number

1.0 SUMMARY
Date of Event : /?? /???? Time : ??:?? Onshore:
Offshore:
Work Site : October Complex

Event Type : Injury Environmental Pollution

Hydrocarbon Release Dropped Object
Accident Fire Property Loss / Damage
Near Miss Vehicle Accident Business Loss
Reporting Area :
Production & Maintenance Drilling Construction Other
Short Description of Event (10-15 words) :
PSVs were removed on the October Complex without using the Permit To Work System as
outlined in the GOS Safety Management System Safety Procedures.

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2.0 GENERAL INFORMATION RELATING TO EVENT
Module / area : Exact Location :
????? ?????
Controlling Company:
GUPCO Contractor (specify) : ?????
Reports Completed :
GUPCO Incident Announcement GOS Incident Announcement
High Potential Announcement
Major Incident Announcement None Other: Near Miss Report
Operation: Construction/Modification Off-Duty Production/Process
Transport Catering/Domestic Deck Operations Maintenance
Diving Drilling/Workover Office/Clerical Walkabout

3.0 DESCRIPTION AND POTENTIAL SEVERITY

Full Description of Event :

Seven PSVs were removed at various locations on the glycol dehydration equipment package at
the October Complex (See attached P&ID, removed PSVs circled). These PSVs were removed
without the use of the Permit to Work System.

The equipment in question, although new, was certainly tied-in to the October complex and
therefore part of the live process system. The Gas-Glycol Contactor had been static tested to
1200 psi with hydrocarbon gas prior to the removal of the PSVs. The removal of the PSVs
occurred just prior to initial start-up (final electrical tie-ins for the glycol pumps were not
complete).

The PSVs were removed and replaced without incident, but a near miss was reported because of
the: 1) Non-compliance with GUPCO Permit to Work System and 2) Unnecessary exposure of the
October Complex to significant risk.

Interviews conducted with personnel onsite during the removal of the PSVs, including the Area
Authority for the subject work, all admitted that no Cold Work Permit, Isolation Confirmation
Certificate, or Task Risk Assessment had been issued or completed for the PSV removal.

What might have been the worst probable outcome of this event?
Uncontrolled gas venting and ignition. Death or injury to personnel and damage to equipment or
October Complex.

Potential Severity: Select one relevant box to indicate probable outcome according to potential severity
and one box according to potential recurrence
Onshore Spill Offshore Spill People Cost Recurrence
>100 bbls A >1000 bbls A Fatality A A
>$1Million <1 in 5 years 1
10-100 bbls B 100-1000 bbls B Pmt. Disability B 100k-1M B <1 per Qtr 2
1-10 bbls C 10-100 bbls C LTI C 25k-100k C >1 per Qtr 3
0.1-1 bbls D 1-10 bbls D NLTI D 5k-25k D
<0.1bblsE <1 bbls E Simple First Aid E <5k E
Event Keywords:

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4.0 INVESTIGATION AND COMMENTS
Team Leader: Ezzat Title
Team Member #1: Bruce Abbuhl Title: Central Area Asst Gen Mgr, Dist Eng
Team Member #2: Title:
Team Member #3: Title:
Team Member #4: Title
Investigation :

Personnel on the October Complex involved in the job to remove the PSVs, including the Area
Supervisor A/Rachman, admitted the work had been performed without a Cold Work Permit,
Isolation Confirmation Certificate, and/or Task Risk Assessment. The reason given by the Area
Supervisor for non-compliance with the GUPCO Permit to Work System was that the glycol
dehydration equipment package was new and that no pressure existed in the system. Therefore the
non-compliance was due to a lack of knowledge of the GUPCO PTW System and Isolation
Procedures and not a circumventing of the system for the perception of speeding the completion of
the PSV removal task.

An additional area of concern was that the Performing Authority for the job, and for that matter,
anyone else associated with the job did not raise a concern that the job was being performed
without a Cold Work Permit, Isolation Conformation Certificate, and/or Task Risk Assessment.
Training in the PTW System and Isolation Practice must be better cascaded throughout the
workforce.

Management Comments:

5.0 CORRECTIVE ACTIONS

No. Corrective Action Person Priority Target Completion
responsible (L /M / H) Date Date
and location
1 A/Rachman to attend PTW and Isolation HSE H ASAP
Training before being allowed to assume
OIM responsibility offshore.
2 A/Rachman and the Performing Authority HSE H ASAP
(Need Name of E&I person) for the PSV
removal to meet with the HSE Gen Mgr to
review the PTW system and Isolation
Policy as it pertained to this job.
3 Develop a policy that no person be HSE H 1/12/01
allowed to assume OIM position offshore
without first attending PTW and Isolation
Training Courses.
4 Ensure that all personnel that will possibly HSE H 1/1/01
be a Performing Authority within the
Permit to Work System has attended PTW
and Isolation Training.
6.0 REPORT APPROVAL
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Approval of Event Report:
Investigation Team Leader / HSE Date: Originator: Date
Gen. Mgr.: ????? ????? ?????
?????

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7.0 CAUSATION ANALYSIS
Preliminary Causation Analysis:
What did people do that may have contributed to the event?
1) Area Authority does not poses full understanding of GUPCO Permit to Work System and Isolation Practice.
2) Performing Authority performed the job without a Cold Work Permit.
Why did they do this?
Lack of knowledge of the PTW System and Isolation Practice
What was defective about the equipment / conditions?
PSV set pressures needed checked
Why were the equipment / conditions defective?
NA
IMMEDIATE CAUSES
ACTIONS
1. Following Procedures : 2. Use of Tools or Equipment :
Violation by Group
Violation by Supervisor
3. Use of Protective Methods : 3. Inattention / Lack of Awareness :
Did not understand the risks
CONDITIONS
5. Protective Systems : 6. Tools, Equipment and Vehicles :

7. Work Exposures to : 8. Work Place Environment / Layout :

SYSTEM CAUSES
PERSONAL FACTORS
1. Physical Capacity : 2. Physical Condition : 3. Mental State :

4. Mental Stress : 3. Behaviour : 4. Skill Level :
Inadequate Training for the job
JOB FACTORS
7. Training / Knowledge Transfer : 8. Management / Supervision / Employee Leadership :
Inadequate Knowledge
8. Contractor Selection and Oversight : 9. Engineering / Design : 11. Work Planning :
Task Risk Assessment not
completed
9. Purchasing, Material Handling & Material Control : 13. Tools and Equipment :

10. Work rules / Policies / Standards / Procedures (PSP) : 10. Communication :

BROAD EVENT TYPE ACTUAL ACTIVITY LEADING TO EVENT
Loss of containment Use of machinery Manual lifting / handling Cleaning
Handling goods / materials Contact with harmful Using portable tools / equipment Handling hazardous
substances materials
Air transport Diving related Operating plant / material Diving
Sea transport Electrical Driving / piloting Electrical work
Slips / trips / falls Structural/Foundation Working at height (>2m) Handling drilling tools
Falling objects Mooring Climbing / descending Drilling
Fire / explosion Land Transport Walking on same level Workover
Lifting / crane operations Use of office equipment Erect / dismantling scaffolding Inspection / examination
Use of hand tools Other Welding / burning Other

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