BP HSE COMMUNICATION – Lessons Learned Report

• 3.5 Equipment or materials not secured - no brace or

Type of Incident: Major Incident - mechanical support. If secured with mechanical brace
Mechanical/Pressure it could not have fallen on deceased
Incident: Dump truck accident resulting • 4.1 Improper decision making – decided to proceed
in a fatality without bracing dump bed
Business/Performance • 6.7 Defective vehicle – working on the brakes
Unit: Algeria – In Salah PU
Country: Algeria System causes:
Region: Africa • 3.1 Poor judgement – trained – chose inappropriate
Business Stream: Upstream act. Did not recognize need to install a brace. Poor
Location of Incident: Krechba management involvement over the activity
Date of Incident: 2 February 2003 • 6.1 Inadequate assessment of required skills – hazard
Report submitted by: Sharon E Ashdown of going into pinch point not recognized. Sub-
Email: ginnj1@bp.com contractor competencies did not meet main project
Telephone: +44 (0) 1932 756575 contractors requirements
• 8.2 Inadequate leadership – tolerated lower standards
Brief Account of Incident: A driver working for a sub- from sub-contractors. Sub-contractor did not take
contractor in a yard located in the In Salah Gas Krechba responsibility for their sub-contractors
site was carrying out repairs to the pneumatic brake • 8.4 Identification of workplace hazards – no Total
system on a dumper truck. To facilitate this, he raised Safety Task Instruction reviewed
the bed of the truck with the engine running, and then • 11.1 Inadequate work planning – no risk assessment.
shut the engine off. He began working to repair the Should have had energy isolated
pneumatic brake system, under the raised bed without • 11.2 Inadequate preventative maintenance – allowed
having a mechanical brace or block to prevent the bed air leaks
descending; ie the bed was held in the raised position • 11.6 Inadequate audit/inspection – did not identify
only by the pressure in the hydraulic lines. truck conditions

One or more air leaks in the pneumatic system led to a
slow depressurization of the pneumatic system. This
resulted in the release of the actuator on the bypass valve
in the hydraulic line to the bed tipping mechanism. The
bed then descended under gravity crushing Mr Loubar as
he became trapped between the chassis and the bed of
the truck.
Outcome: Fatality due to being crushed by the dumper
bucket.
What Went Wrong:
Immediate causes:
• 1.1 Violation by individual - No Total Safety Task
Instruction (TSTI) (work assessment process). Did
not obey warning on truck
• 1.2 Violation by Group - sub-contractor did not
advise main project contractor of personnel or
maintenance activities
• 1.5 Improper positioning for task - under bed of
truck. Could have worked on ground – out of danger
• 3.1 Lack of knowledge of hazards present - did not
consider risk of bed descending
Golden Rule: Energy Isolation - the truck bed was raised
and no mechanical bracing was used to ensure that gravity
could not cause the bed to unexpectedly descend.
Resultant Actions:
• The job was shut down. Maintenance area was
secured. All construction activities were immediately
suspended to attend a “town hall” safety briefing
• Dumper truck maintenance work and field usage was
suspended until remaining trucks were inspected
• Establish an immediate investigation team and formed
an external investigation team jointly between the
Joint Venture and the main project contractor
• Preliminary action items generated from the initial
investigation were implemented immediately
• Address equipment issues
• Improve effectiveness of the risk assessment process
• Ensure sub-contractor controls are in place and
enforced
• Share lesson learned within and external to the BU
Key Message: SH/BP Joint Venture project
management must assure all JV, contractors and their
sub-contractor personnel are properly managed,
trained and will implement established safety
procedures, ie risk assessment, TSTI system, energy
isolation procedures prior to commencing a job. The
JV and main project contractor must continually
reinforce the message that it is everyone’s obligation
to review the job scope, obtain proper authorization
and follow set procedures even in camp/fabrication
yards including routine maintenance activities.

Truck with bed fully elevated under own hydraulic

pressure. Blocks added for investigation team