Safety Performance Indicators - 2015 Data - Fatal Incident Reports

REPORT JUNE
2015sf 2016
DATA SERIES
Safety performance indicators – 2015 data

– Fatal incident reports
Acknowledgements
IOGP acknowledges the participation of the companies that have
submitted safety performance indicators. This report was produced by
the Safety Committee.
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REPORT JUNE
2015sf 2016
DATA SERIES
Safety performance indicators – 2015 data

– Fatal incident reports
Revision history
VERSION DATE AMENDMENTS
1.0 June 2016 First release

2015 safety data – Fatal incident reports 4
Contents
AFRICA 5
ONSHORE 5
OFFSHORE 9
ASIA/AUSTRALASIA 11
ONSHORE 11
OFFSHORE 15
EUROPE 16
ONSHORE 16
OFFSHORE 19
FSU 20
ONSHORE 20
OFFSHORE 22
MIDDLE EAST 23
ONSHORE 23
OFFSHORE 29
NORTH AMERICA 31
ONSHORE 31
OFFSHORE 33
SOUTH & CENTRAL AMERICA 38

ONSHORE 38
OFFSHORE 39
AFRICA
ONSHORE
DATE: Apr 22 2015

LOCATION: GABON
FUNCTION: Production
NUMBER OF DEATHS: 1
CATEGORY: Caught in, under or between
ACTIVITY: Transport - Land
RULE: Seat belt
Employer: Contractor
Occupation: Manual Labourer
NARRATIVE: On a laterite (dirt) road, rollover of a light utility vehicle, the passenger was ejected
and struck under the vehicle.
WHAT WENT WRONG: Personnel not authorized to use the vehicle, over-speed, dirty road, and
passenger not wearing his safety belt.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Lock of all vehicles, reinforcement of the
driving rules.
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Violation intentional (by individual or group)
PEOPLE (ACTS): Following Procedures: Work or motion at improper speed
PEOPLE (ACTS): Use of Protective Methods: Personal Protective Equipment not used or used
improperly
PROCESS (CONDITIONS): Work Place Hazards: Congestion, clutter or restricted motion
DATE: Feb 22 2015

LOCATION: GABON
NUMBER OF DEATHS: 1
CATEGORY: Struck by
ACTIVITY: Transport - Water, incl. marine activity
RULE: PPE (Including flotation device)
Occupation: Transportation Operator
NARRATIVE: During the river journey of a contracted pusher-boat and barge assembly, while
passing from the pusher-boat to the barge situated at the head of the assembly, the crew
member (open footwear, no life vest) fell into the water between the boat and the barge.
He was drawn underneath the forward-moving boat toward the propellers that caused a fatal injury.
WHAT WENT WRONG: Organization: Absence of technical referential and HSE referential (no
maintenance log of boats and barges), lack of marine competence, absence of training and
exercise for personnel. Contract’s follow-up: Initial call for tender: technical evaluation based
on insufficient scope; absence of pre-qualification. Contract extension: poor technical and HSE
evaluation. Contract execution: absence of follow-up of HSE clauses and equipment (use of a
tugboat as a pusher-boat contrary to the contract). No inspection of floating units. No follow-up
of audit findings.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Pre-qualification of contractors before
the call for tender. Rigorous evaluation of their technical and HSE competencies. Audits and
inspections of equipment, implementation of corrective actions. Regular follow-up by the
responsible of contract execution, who is clearly appointed, that the means and personnel are
in accordance with the contract. Official notification to the contractor of any noticed gap with the
contract. Regular training for transfers.
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Violation unintentional (by individual or group)
improperly
PROCESS (CONDITIONS): Work Place Hazards: Inadequate surfaces, floors, walkways or roads
PROCESS (CONDITIONS): Organizational: Inadequate training/competence
PROCESS (CONDITIONS): Organizational: Inadequate work standards/procedures
PROCESS (CONDITIONS): Organizational: Inadequate supervision
PROCESS (CONDITIONS): Organizational: Poor leadership/organizational culture
DATE: Oct 9 2015

LOCATION: NIGERIA
NUMBER OF DEATHS: 1
CATEGORY: Assault or violent act
ACTIVITY: Production operations
RULE: No appropriate Rule
Occupation: Other
NARRATIVE: At about 0640am on the 9th of October 2015 unknown gun men approached the
Flow station and opened fire on the security personnel at their sentry post. In the exchange of
fire with the security personnel, a station warden was fatally wounded.
CAUSAL FACTORS: <<No Causal Factors Allocated>>
DATE: Apr 7 2015

LOCATION: NIGERIA
NUMBER OF DEATHS: 1
CATEGORY: Other
ACTIVITY: Diving, subsea, ROV
Employer: Company
Occupation: Other
NARRATIVE: A person was undertaking TBOSIET training at when IP was reported to be
unconscious. IP was initially resuscitated at the training centre clinic but was reported dead
en-route retainer clinic.
WHAT WENT WRONG: Investigation in progress
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Investigation in progress
DATE: Nov 22 2015

LOCATION: NIGERIA
NUMBER OF DEATHS: 4
CATEGORY: Pressure release
Occupation: Engineer, Scientist, Technician
NARRATIVE: At about 1500hrs on Sunday 22nd November 2015, during the repair work on an 8”
illegal connection on a 28” Pipeline, a sudden surge of crude oil and gas occurred impacting on
personnel that were within the cofferdam. Five persons were impacted (Four fatally wounded;
one receiving medical care at the Terminal Hospital and in stable condition).
DATE: Sep 23 2015

LOCATION: NIGERIA
FUNCTION: Unspecified
NUMBER OF DEATHS: 1
CATEGORY: Struck by
ACTIVITY: Office, warehouse, accommodation, catering
RULE: Dropped objects
Occupation: Manual Labourer
NARRATIVE: On Wednesday 23/09/15 at about 0745hrs the IP, a contractor staff attached to the
fuel dump and two other of his colleagues, were on a normal daily routine action to open the
entrance steel roller gate (1800 kg) of the fuel dump. Just as the gate was beginning to open,
the second, out of the five, top support/bracket broke-off from the concrete fence, causing the
roller gate to fall off. The IP was stationed at the second handle in the middle of the gate and
was not able to escape, when the entire gate fell on him, while his other two colleagues were
able to escape unhurt. Following the incident, a distress call was received by the Fuel dump and
workers/passers-by that witnessed the incident promptly intervened by assisting to lift the gate
to rescue the deceased. The IP was observed to be unconscious and bleeding around the face
region and he was immediately taken to the Clinic by ambulance. The doctor declared him dead
after attempts to resuscitate him failed.
WHAT WENT WRONG:
1. The ‘as built’ drawings of the gate did not match with the technical drawings of the project.
The gate was very heavy and this resulted in high friction between the components;
2. The incident occurred due to the failure of the second bracket within the first one meter of
gate travel during the opening process;
3. There was no preventive maintenance of the gates. Only corrective on request of user
department;
4. The stoppers on the rail of the gate that fell were long broken off and not replaced. Also no
record of its being reported for replacement;
5. The rail track of the remaining standing gate and its surroundings were filled with sand and
stagnant water, due to the rain, that negated free movement of the gate during opening and
closing operations.
CORRECTIVE ACTIONS AND RECOMMENDATIONS:
1. Ensure that all the gates are in line with the project drawings and in good conditions;
2. Ensure that the rail track is always free from any obstacles material in order to avoid any
further friction;
3. An annual inspection plan covering all the gates has to be in place;
4. A Preventive Maintenance Plan (PMP) has to be applied and updated;
5. A visual inspection whenever the gate is opened/closed and use of the UA/UC Form/Tool to
report any kind of unsafe condition have to be done;
6. To be always careful and vigilant during the opening/closing operation of the gate.
CAUSAL FACTORS:
PROCESS (CONDITIONS): Tools, Equipment, Materials & Products: Inadequate design/
specification/management of change
PROCESS (CONDITIONS): Tools, Equipment, Materials & Products: Inadequate/defective tools/
equipment/materials/products
PROCESS (CONDITIONS): Tools, Equipment, Materials & Products: Inadequate maintenance/
inspection/testing
OFFSHORE
DATE: Jan 18 2015

LOCATION: GABON
NUMBER OF DEATHS: 1
CATEGORY: Struck by
ACTIVITY: Lifting, crane, rigging, deck operations
Employer: Company
Occupation: Foreman, Supervisor
NARRATIVE: A modular mobile crane was installed on a platform to perform the five year
maintenance of the fixed platform crane. The Mobile modular crane was inspected for the
commissioning. While being load tested at 3t (below the maximum design load of 5t), the mobile
crane base assembly failed and caused the structure to collapse backward and hit the crane
operator who subsequently died.
WHAT WENT WRONG: During the fabrication of the crane, a spacer plate was added to
correct a defect in the machining of one part, resulting in decrease of screw penetration and
modification of the effort type applied on the screws. General failure of the quality control over
the construction/certification/receipt process from all parties involved (manufacturer, lifting
contractor, company). No specific risk assessment for crane test.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Documentation to be available before the
installation of a modular crane: detailed crane specifications, factory acceptance test, Load
Test certificate, detailed assembly procedure and structural calculations. Documentation to
be available after the installation of the crane and before its first use: site installation report,
detailed load test plan for the first lift, visual inspection report by a recognized third party.
Control command of the crane shall, wherever possible be positioned in a safe area and not
below the load path. The preparation and the supervision of the works using temporary lifting
needs special attention: analysis of the specific risks and implementation of compensatory
measures. Works must be supervised by competent personnel.
CAUSAL FACTORS:
PEOPLE (ACTS): Use of Tools, Equipment, Materials and Products: Improper use/position of
tools/equipment/materials/products
PROCESS (CONDITIONS): Organizational: Inadequate hazard identification or risk assessment
ASIA/AUSTRALASIA
ONSHORE
DATE: May 16 2015

LOCATION: INDONESIA
FUNCTION: Construction
NUMBER OF DEATHS: 1
CATEGORY: Exposure electrical
ACTIVITY: Construction, commissioning, decommissioning
RULE: Isolation
Occupation: Maintenance, Craftsman
NARRATIVE: Individual contacted live connectors and sustained a 6.6 kV electrical shock
resulting in a fatality.
CAUSAL FACTORS:
PEOPLE (ACTS): Inattention/Lack of Awareness: Improper decision making or lack of judgment
DATE: Aug 20 2015

LOCATION: PAKISTAN
FUNCTION: Exploration
NUMBER OF DEATHS: 1
CATEGORY: Falls from height
ACTIVITY: Seismic / survey operations
RULE: Work at height
Occupation: Other
NARRATIVE: A cable helper employed by the seismic contractor fell approximately 6 metres
from a rock path into a gorge and was fatally injured. The Injured Person was part of a twenty-
eight-man crew, including three foremen, assigned to recover the cable and geophones from a
seismic shoot.
WHAT WENT WRONG: The terrain assessment and classification failed to identify a hazardous
location. Ineffective supervision of work-party moving in rough loose path within 1.5 metres of
a 6–10 metre fall. Training in mountain safety not effective in communicating the process and
intent of area classification (Red, Yellow, Green).
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Carry out a compliance audit of the Terrain
Assessment Guideline. Use clear markings along access routes to show approved access way
use colour coding (Red, Yellow, Green). Green zones should be positively marked to ensure
understanding of the terrain classification. Implement a fatigue management process to strictly
control working days in excess of normal roster. Contractor management programme for land
seismic surveys to identify critical procedures and standards.
CAUSAL FACTORS:
PEOPLE (ACTS): Use of Protective Methods: Failure to warn of hazard
PEOPLE (ACTS): Inattention/Lack of Awareness: Fatigue
PROCESS (CONDITIONS): Protective Systems: Inadequate/defective guards or protective barriers
DATE: Oct 22 2015

LOCATION: PAKISTAN
NUMBER OF DEATHS: 4
CATEGORY: Explosions or burns
ACTIVITY: Drilling, workover, well services
RULE: Gas test
NARRATIVE: At 7:57AM a low energy explosion occurred with a road tanker reversing to the
temporary crude loading bay. The explosion was caused likely by the suffocating engine of the
road tanker inducting hydrocarbon vapours and developing a backfire in its silencer.
The initial blast was followed by a higher energy explosion after ca. 25 seconds, creating a
fireball and static fires of minor crude oil spills. The explosion resulted in serious 2nd and 3rd
grade burn injuries of 4 crew members of two tankers who all passed away during the following
days. The vapours came from the open hatches of one rectangular storage tank and created a
flammable cloud of approximately 15m wide and 35m long covering the tanker and the area in
front of it. The ignition was most probably caused by the helper of the tanker who attempted to
disconnect the battery terminals. Based on his own statement his driver was unable to turn off
the engine with the ignition key and also with the battery master switch after the first explosion.
Then he requested his helper to disconnect the battery to stop the runaway engine. While
the terminals of the batteries were not found disconnected during the inspections, one of the
batteries top plate was badly damaged. Loose and damaged wires were also found and shorting
them with the truck’s metal parts has most likely caused the ignition of the second explosion.
WHAT WENT WRONG:

PC1 PPE requirements were not communicated clearly to the contractor and they were not
enforced either
- Inappropriate on-site training
- Detailed HSE requirements are not part of the contract
- Regulation on required PPE (material of coverall) ambiguous
- Resistance of local contractor against using PPEs (cultural, cost issues)
PC2 Inadequate PTW system and practice
PC3 Simultaneous operations not coordinated - no joint HSE plan
PC4 No site handover applied
PC5 Inadequate/not comprehensive Job Safety Analysis
PC6 Gas detection only optional in PTW
PC7 Personnel (Company and Contractor awareness and competence)
- Inadequate system of evaluation and maintenance of adequate competence level of the
staff
- Overall Contractor HSE Management on remote sites not fully implemented
PC8 Ongoing civil works - lot of people on the site
- Physical barriers and signs inadequate
PC9 Risk awareness weak
- Inadequate procedure/practice for area restriction
- Inappropriate on-site training
PC10 Road tanker technical condition
PC11 Inadequate on-site control of the road tanker
- No clear principles for local contractor involvement
- Failed contractor pre-qualification process
- No technical specification during tendering process
- On-site compliance checklist inadequate/not enforced
PC12 No quality check of SOP from company
PC13 General SOP prepared by Contractor - not for the specific job
PC14 Inadequate gas capacity of gauge tank causing high amount of light HC to storage tank
PC15 Continued operation in unsafe condition without knowing the potential consequences
PC16 Improper vapour management on storage tank
PC17 Congested layout - safe distances not kept
- No systematic approach to establish, control and maintaining SOPs
- Design limitation of equipment under given circumstances
- Risk assessment and awareness
- Inadequate consideration of simultaneous operation
PC18 Non availability of appropriate medical facility for burn cases
- No burn treatment facility near the operation area
- No emergency response scenario in place
- No arrangements for first aid and treatment of burn cases
PC19 Inappropriate management of crisis
CORRECTIVE ACTIONS AND RECOMMENDATIONS: The main learning point of the accident,
that prior any dangerous activity either it is routine activity the proper hazard identification and
risk assessment must be done. On our operation sites the HSE LIFE Saving Rules has to be
complied in 100%, since over the given case more Life Saving Rules were broken.
CAUSAL FACTORS:
improperly
PEOPLE (ACTS): Inattention/Lack of Awareness: Lack of attention/distracted by other concerns/
stress
PROCESS (CONDITIONS): Protective Systems: Inadequate/defective guards or protective barriers
PROCESS (CONDITIONS): Protective Systems: Inadequate/defective Personal Protective
Equipment
PROCESS (CONDITIONS): Protective Systems: Inadequate/defective warning systems/safety
devices
PROCESS (CONDITIONS): Protective Systems: Inadequate security provisions or systems
PROCESS (CONDITIONS): Work Place Hazards: Hazardous atmosphere (explosive/toxic/
asphyxiant)
PROCESS (CONDITIONS): Organizational: Inadequate communication
OFFSHORE
DATE: Jul 14 2015

LOCATION: AUSTRALIA
FUNCTION: Unspecified
NUMBER OF DEATHS: 1
NARRATIVE: Offshore vessel moved to a station location due to weather conditions. While in the
established station keeping area, a wave came over the back deck, cargo moved on deck and a
crew member became trapped suffering fatal injuries.
WHAT WENT WRONG: The potential for fatal injuries to crew undertaking cargo loading and
securing activities offshore on an anchor handling tug and supply vessels have not been
identified by the industry as high risk.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Offshore Cargo handling operations are not
planned with the same rigor as loading operation at the port.
CAUSAL FACTORS:
PEOPLE (ACTS): Use of Protective Methods: Equipment or materials not secured
PROCESS (CONDITIONS): Work Place Hazards: Storms or acts of nature
EUROPE
ONSHORE
DATE: Sep 2 2015

LOCATION: GERMANY
NUMBER OF DEATHS: 1
ACTIVITY: Maintenance, inspection, testing
RULE: Line of fire - safe area
Occupation: Unknown
NARRATIVE: While preparing a temporary gas condensate vessel for cleaning and inspection work
an explosion (deflagration) occurred inside the 20m3 vessel. This event results in a fatality of one
person and injuries of three people who were standing too close to the radiant heat and flying debris.
WHAT WENT WRONG:
• A flammable atmosphere developed due to evaporation of remaining gas-condensate inside
the tank;
• The ignition of the flammable atmosphere was caused by heat from a Pyrophoric Iron
Sulfide chemical reaction: 4FeS + 3O2 => 2Fe2O3 + 4S + HEAT
• The task was assumed to be routine. Therefore the risk awareness was limited. The tank was
assumed to be safe as it appeared that the tank was purged on the day before the incident.
• The victim was submitted to overpressures and temperatures consistent with a probability of
lethality reaching 100%.
• In performing Job Safety Analysis, evaluate all possible options of performing the work and
make sure there are at least always 2 safety barriers in place
• Plan in order to take time to work safely
• Remind the Life Saving Rule (LSR): “Do not perform hot work unless the fire or explosion
risks have been eliminated”.
• Set a philosophy when to replace aged equipment. Implement work instructions to be
followed for installing temporary equipment on site
• Implement work instructions or procedures to illustrate the importance of correct purging
or inerting of equipment
• Reinforce in all assets the implementation of the HSE Management system. Also all
contractors have to be supported in their efforts to comply with the HSE Management System.
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Improper position (in the line of fire)
DATE: Feb 25 2015

LOCATION: ROMANIA
FUNCTION: Drilling
NUMBER OF DEATHS: 1
Employer: Company
Occupation: Other
NARRATIVE: Mechanic climbed on the truck to get a chain sling using the steps on the
sideboard of the truck and grabbed the BOP wheel (which was facing the truck’s headboard).
He slipped on the step and gripped the BOP wheel for balance; the BOP weighing 350 kg shifted
and subsequently toppled over the edge of the truck platform and fell on him.
WHAT WENT WRONG: Lack of housekeeping on the truck. Inadequate design of the BOP frame;
No Management of Change. No detailed standard / guideline regarding correct securing of
loads. Inadequate equipment for properly securing the loads. Certification and inspection of
lifting gear doubtful. Securing of loads not established part of working culture. Safe access to
platforms and securing of loads not appreciated as major risk. Improper load placing practice.
Improper design of steps onto truck platform, inadequate inspection and maintenance.
Improper design of handle for safe access onto platform.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Develop a standard/procedure on adequate
Techniques and Means to Secure Load; train and coach drivers on securing loads. Investigate
suitability, design and placement of steps and hand grips for current trucks. Implement a
standardized equipment by introducing adequate transport containments for loose and bulky
equipment. Develop Hazard Spotting and Risk Awareness training to realize when scope of
work has changed. Load test current side wall steps to determine if adequate and communicate
the acceptable Safe Working Load. Reinforce the adherence to the provisions out of the Lifting
Standard.
CAUSAL FACTORS:
DATE: Feb 28 2015

LOCATION: UK
NUMBER OF DEATHS: 1
CATEGORY: Falls from height
RULE: Work at height
Occupation: Heavy Equipment Operator
NARRATIVE: While installation of a 130 t truck crane, the crane driver had to move on the
trailer side, on a narrow passage. He fell, his head first impacting the tarmac. The trailer, where
he stood, was at 195 cm height. His helmet was broken after the impact.
WHAT WENT WRONG: The design of this brand-new crane truck’s trailer has a narrow passage
to go from the cabin to the rear cabinet, and the handrails are very elevated so difficult to grab.
No warning stickers. His helmet was overdue and painted.
On a truck crane, when someone on the trailer needs to reach another place: step down, and
use a direct side access with a ladder.
CAUSAL FACTORS:
improperly
PROCESS (CONDITIONS): Protective Systems: Inadequate/defective guards or protective
barriers
Equipment
devices
OFFSHORE
DATE: Dec 30 2015

LOCATION: NORWAY
FUNCTION: Drilling
NUMBER OF DEATHS: 1
CATEGORY: Other
ACTIVITY: Unspecified - other
RULE: Insufficient information to assign a Rule
NARRATIVE: A freak wave crashed the cabin window in the living quarter. One person declared
dead in the incident.
WHAT WENT WRONG: Under investigation
Ref ongoing investigation
FSU
ONSHORE
DATE: Mar 19 2015

LOCATION: RUSSIA
NUMBER OF DEATHS: 1
Employer: Company
Occupation: Process/Equipment Operator
NARRATIVE: While the examination of the pump jack in order to find out the source of the noise
operator went inside the barrier of the crank gear of the pump jack and was caught between the
crank gear and the frame of the pump jack.
WHAT WENT WRONG: The cleaning of the equipment was done on the working pump jack, the
barrier did not limit the access to the dangerous zone. The operator opened the barrier door
and entered the unsafe zone.
All the barriers were changed in order to limit the access to the unsafe working zone. Provide
all the moving parts of the equipment with the warning signs.
CAUSAL FACTORS:
PEOPLE (ACTS): Use of Tools, Equipment, Materials and Products: Servicing of energized
equipment/inadequate energy isolation
PEOPLE (ACTS): Use of Protective Methods: Inadequate use of safety systems
DATE: May 22 2015

LOCATION: RUSSIA
FUNCTION: Drilling
NUMBER OF DEATHS: 2
Occupation: Drilling/Well Servicing Operator
NARRATIVE: During a loss of well control event the wrong procedure for the well sealing was
used that caused a spark and ignition. Two contractors got burnt and died.
WHAT WENT WRONG: While shift change the information on the status of the well conditions
and works were not transferred properly, the night shift was not informed about the
displacement of the liquid without the gas from the well. The night shift didn’t have experience
with the well or the location of the shutoff valve. So when the well control was lost the crew took
the measures on the well sealing which caused the spark and ignition.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Toolbox talks held during the change of the
shifts Development of the adequate emergency response procedures for the activities on the
well Trainings done in time Fire resistant PPE
CAUSAL FACTORS:
Equipment
devices
DATE: Nov 21 2015

LOCATION: RUSSIA
NUMBER OF DEATHS: 1
CATEGORY: Exposure electrical
RULE: Overhead power lines
Occupation: Maintenance, Craftsman
NARRATIVE: While construction works of the overhead power line the electrician confused the
line under the construction without the power with the working line under the power, climbed
on the working line pole start working on it and was electrocuted.
WHAT WENT WRONG: There were not warning signs, there no barriers to indicate the working
zone and separate the unsafe zone.
The safe system of works to be implemented, the toolbox talks held, refresh the training on the
warning signs and hazard assessment and risk control.
CAUSAL FACTORS:
OFFSHORE
No offshore fatalities were reported in the FSU region.
MIDDLE EAST
ONSHORE
DATE: Jul 3 2015

LOCATION: IRAQ
NUMBER OF DEATHS: 1
CATEGORY: Struck by
RULE: Journey management
Occupation: Other
NARRATIVE: A road traffic accident occurred approximately at 1315 hrs on 3rd of July 2015. The
driver suffered head injuries resulting in coma. He succumbed to injuries and died 7 days after
the accident. The other IP suffered abdomen injuries and fractured leg.
WHAT WENT WRONG:
1. Poor vehicle Management.
2. Incompliance to Journey Management Plan Guideline.
3. Inadequate compliance to the contractor agreement.
1. Ensure vehicle integrity by identifying vehicle specification, pre-acceptance test and
maintenance record availability.
2. To have a Specialist or SME in road transportation for the Operations that have high road
transportation activities.
3. Manage contractor and sub-contractor compliance to contract requirement.
CAUSAL FACTORS:
DATE: Apr 16 2015

LOCATION: KUWAIT
NUMBER OF DEATHS: 1
CATEGORY: Other
NARRATIVE: At 10.00 hrs one Fatal Motor Vehicle Accident took place, involving one of the
Contractor employee working as a Safety Officer. While driving towards the New Management
Building after crossing the Security Checkpoint, the deceased lost consciousness due to low
blood sugar level, which led to loss of control of his vehicle. As a result, the vehicle drifted
approximately 54 metres towards the right side shoulder area of the road colliding with several
trees and bushes before coming to a halt. The incident led to on the spot fatality of the employee
and total damage of the vehicle. The employee had previously collapsed at site at around 8.00
am on the same day but failed to seek the medical consultation.
WHAT WENT WRONG: No medical consultation pursued in spite of collapse of the employee
on the same day previously. In spite of being a diabetic person the employee had driven the
vehicle without taking the food for more than 12 hours. Severe multiple injury due to the crash
of vehicle (possibly due to loss of control under low sugar initiated coma).
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Review the guideline on ‘Employees Health
Surveillance’ to necessitate periodical medical check for seconded / contractor employees.
Review the guideline on ‘Employees Health Surveillance’ to ensure communication of health
concern of the employee to line supervisor and contractor. Revise Safety Risk Register and
Health Risk Register for Team / Group to include driving in medically unfit condition as a high-
risk activity. Instruct line management to enforce safe behaviour of the employee especially with
regard to fitness for the work. Inform line supervisor to discuss health concern and physical
limitation of employee in their meeting. Encourage line supervisor to apply disciplinary action
(as appropriate) enforcing safety culture and behaviour based safety.
Direct Contractor to promote and enforce safety culture and behaviour based safety among
their employees. Enhance awareness among employees through bilingual health bulletin /
brochure / postmaster message about diabetes and other chronic health risks, its physical
limitation, possible consequence and precautionary measures. Carry out ‘Defensive Driving’
campaign focusing health fitness concern and impact.
Nominate employee with diabetic history to attend the campaign on Diabetes being conducted
time to time by the Hospital. Review the Emergency Rescue dispatch process to improve the
response time.
Control the removal of incident evidence (such as damaged vehicle) in accordance with
procedural requirement. Communicate worker with diabetic history not to carry any passenger
in their vehicle considering physical limitations. Audit the compliance level of Guidelines
for Contractors’ focusing the requirement under Risk Evaluation and Management Direct
contractor to review and update their training program in line with the Training
Matrix as per Contract requirements along with implementation.
CAUSAL FACTORS:
stress
PEOPLE (ACTS): Inattention/Lack of Awareness: Fatigue
DATE: Aug 17 2015

LOCATION: KUWAIT
NUMBER OF DEATHS: 1
RULE: Speeding / phone
Employer: Company
NARRATIVE: Around 13:40 hrs, two company newly appointed field operators were on routine
check of wells. While driving in unpaved road (Rig road), the vehicle overturned and rolled over
resulting in multiple injuries to both employees and subsequent death of the driver at around
16:00 hrs, in hospital. The other person sustained a dislocated and fractured left shoulder, for
which he was treated and discharged on 24th August 2015.
WHAT WENT WRONG: High Speed Driving (exceeding the set limit). The deceased and injured
not wearing seat belt. Poor condition of the rig road used for travel.
• Reinforce company personnel (Management of change MOC) Procedure.
• Defensive Driving Campaign should be conducted addressing of the risks and lesson learned
of motor vehicle accidents.
• Behaviour Based Safety (BBS) Driving is to be established.
• Driving policies/procedures are to be shared and communicated regularly to staff.
• Defensive driving training to include off-road hazards and safe driving.
• Rig road use to be restricted to Rig movement operations only and other uses may be
possible subject to the availability of safe conditions.
• Driving behaviour monitors to be installed in all company vehicles.
• Safety Observation and Conversation (SOC) and Behaviour Based Safety (BBS) to be included
in the generic training for new employees.
• Defensive driving to include theoretical and practical skills with test and refreshing courses.
• Improve monitoring and auditing processes for off-road driving.
• Safe Driving awareness to be conducted at the facility and work locations.
• Communication mechanism shall be developed to ensure all risks including driving are
properly addressed and communicated upon employee rotation / movement.
• Before assigning a vehicle to a new employee a mechanism is required to ensure the vehicle
assignee has read and understood related driving procedure.
• The implementation of Driving safety policy shall be reinforced including off-roads driving.
• Emergency response vehicles to be equipped with Location tracking system. Study
possibility for using personal location identification system for field operators.
• Ensure that all risks related to off-road driving are addressed in safe driving procedure.
• Increase frequency of Audit on compliance to driving procedure.

• Investigate the inadequate usage of radios and ensure sufficient resources, equipment and
training are available.
• Conduct audit on harmonization on communications protocol for all emergency services.
CAUSAL FACTORS:
DATE: Feb 11 2015

LOCATION: KUWAIT
FUNCTION: Drilling
NUMBER OF DEATHS: 1
CATEGORY: Struck by
NARRATIVE: While setting casing slips in E-Section of the wellhead section, the contractor
Engineer observed that the casing slip does not fit into the wellhead section due to off-centre of
casing in the wellhead. Several attempts were made to centre the casing and to install the slips
by various means, e.g., pulling the casing at Rig floor level, pulling and rocking the Blow Out
Preventer (BOP) and BOP hoist, but were unsuccessful. Finally it was decided to simultaneously
shake BOP stack using a forklift and web slings joined by shackles to give jerks (by successive
pulling and releasing) and hoisting the BOP by hoist. In the process of doing this activity, the
web sling attached to the Forklift carriage parted, resulting in the whipping of the shackle along
with the other web sling to strike the victim on his head, who was positioned at the edge of
cellar grating of BOP. The strong hit by the shackle resulted in severe injury to the head leading
to skull fracture and subsequent death.
WHAT WENT WRONG: Bad condition of the Web Sling. No proper inspection/certification of
sling. Excessive and shock loading of Sling exceeding its Safe Working Load capacity. Absence
of a standard procedure to align an off-centre casing in the wellhead. Failure to assess risk
involved in the centering operation (Job Safety Analysis). The location of contractor Engineer in
‘line of fire’. No rigging plan available and actions by different parties on their own.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: To develop a comprehensive procedure
for centering of Casing in the Well Head for installation of Slips. It must include the roles and
responsibilities of all parties involved. The Job Safety Analysis (JSA) shall be done for the Casing
centering procedure and should be endorsed every time it is used, based on the complexity of
particular installation. All activities involving Lifting and pulling using Heavy Equipment, and
utilizing Lifting tackles and tools shall be performed according to Rigging plans and under
supervision of qualified, trained and skilled personnel. The CCTV systems installed at Rigs
should be enhanced to improve the coverage and to be maintained well. Wherever multi-
activities are performed on any job simultaneously, there must be a lead to control and guide
the actions according to a set plan. The inspection and certification of lifting tools and tackles
shall be performed regularly according to the guidelines in HSEMS document and relevant
records should be maintained. Adequate audit plan to be in place.
Ensure compliance to the ‘Permit to Work’ system for performing any activity in the field
according to the HSEMS guidelines. Adequate audit plan to be in place. The ‘Company Man’
at the Rigs shall be offered training courses to enhance his leadership capabilities and HSE
awareness. Training in rigging trade should be imparted to all employees of contractor involved
in such activities. This shall be included in Training Matrix of contractors. Company Ambulance
drivers must be well acquainted with access to the Rigs and knowledgeable in their locations.
Awareness sessions must be held for employees to appreciate the Paramedic role in attending
an injured person (IP). Only trained and certified persons shall take responsibility of handling IP.
The working hours of the Company man should be bench marked with International practices.
CAUSAL FACTORS:
inspection/testing
DATE: Jul 25 2015

LOCATION: KUWAIT
FUNCTION: Drilling
NUMBER OF DEATHS: 1
CATEGORY: Struck by
Occupation: Other
NARRATIVE: On 24th July 2015, 13 3/8” casing and cementing job was completed. On 25th
July 2015, BOP- Blow out preventer (weighting approximately 15 Ton), was lifted using BOP
trolleys for casing slip setting and hook load was released. Job was planned for cut casing and
nipple down BOP to carry out top up job to fill casing annulus. Casing cutting job was carried
out by Rig welder (IP-Injured Person) who was positioned on a ladder placed inside cellar pit.
At around 4:45 am, welder (IP) started cutting the final part of the casing by keeping one foot
on the ladder and other foot on the horizontally laid barrel inside the cellar. Upon completion
of cutting the last section of circumference of casing, due to the unbalance of BOP, it swung
towards the welder (IP) and struck IP’s head which got caught in between the cellar and BOP
adaptor flange, causing serious injuries resulting into fatality.
WHAT WENT WRONG: Casing cutting was started and BOP inclination was not considered. Welder
moved to the BOP inclined location (hazardous spot) and started cutting the final part of the casing
by keeping one foot on the ladder and other foot on the horizontally laid barrel inside the cellar.
• The contractor operations procedure shall include the method for centering the casing on
line with the best practices; modified procedure shall be rolled out and implemented.
• Job Safety Analysis:
-- JSA for all the activities including casing cutting shall be reviewed to capture all the
hazards such as BOP swinging and lifting.
-- After review, JSA shall be rolled out among the rig personnel.
• BOP shall be centered without any deviation prior to casing cutting.
• Suitable mechanism for securing of BOP during casing cutting activity shall be identified and
implemented.
• The Controlling team and the Contractor (HSE) shall ensure effective implementation of
Permit to Work and Job Safety Analysis procedural requirements by carrying out periodic
HSE Inspections / Audits.
• All personnel working in the rigs shall be trained and act on noticing life threatening hazard
(STOP program).
• Casing cutting activity shall be reviewed considering international practices. Appropriate
working platform shall be provided to the welder as per the casing cutting procedure.
• All personnel working in the company shall be trained on ‘Incident Reporting Mechanism’ as
per Incident Reporting Procedure.
• Site specific rig emergency response plans shall be developed, which shall include
emergency response for different emergency scenarios.
• Necessary Personal Protective Equipment shall be used based on identified hazards.
• Following Requirements for Contractor’s ambulance shall be specified in the relevant HSE
MS procedure (Occupational Health and Hygiene procedure):
-- Specification for Contractor’s ambulance (Standard for Automotive Ambulances can be
referred)
-- Approval of Contractor’s ambulance (preferably by Medical group)
• Lessons learnt from this incident shall be shared in all the rigs across the company and
other subsidiaries involved in drilling rig operations.
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Improper lifting or loading
OFFSHORE
DATE: Jun 25 2015

LOCATION: UAE
FUNCTION: Drilling
NUMBER OF DEATHS: 1
CATEGORY: Struck by
NARRATIVE: A floor man was struck by a winch line that was under tension and got suddenly
released when a lead sheave failed. The crew was in the process of laying down a joint of 5-7/8”
HWDP (heavy weight drill pipe) with the use of rig floor tuggers. One tugger suspended the joint,
while the second tugger was secured to the Samson post on one side of the V-door and led
through a lead sheave, which was fixed to the Samson post, on the other side of the V-door. The
tugger wire was being used to pull the joint of the HWDP to the V-door when the lead sheave
failed under load.
WHAT WENT WRONG: The Lead Sheave failed releasing the wire rope. The deceased was
standing on line of fire. The rig drew continued laying down HWDP instead of waiting for the crane.
Task difficulty. No specific operating procedure available for task of laying down the HWDP.
1. Develop rig-specific procedure for Lay-Down of Heavy Weight Drill Pipes and ensure
competency of rig crew.
2. Examine availability of specific procedures for all rig operations, address the gaps and
develop as necessary the relevant procedures.
3. Revise Job Safety Analysis and Risk Assessment Templates to include ‘line of fire’ and
‘stored energy’ factors
4. Provide awareness level (in-house) training on Hazard Identifications (Ex: Line of Fire,
Stored Energy, STOP Card Policy, etc.)
5. Any critical path primary or secondary tool has to undergo full evaluation from initial
design to operation phase to ensure it meets proven standard design (in this case catwalk).
Alternative solutions shall be thoroughly risk assessed for its suitability using design
verification procedure.
CAUSAL FACTORS:
PEOPLE (ACTS): Use of Protective Methods: Inadequate use of safety systems
stress
PROCESS (CONDITIONS): Protective Systems: Inadequate/defective guards or protective

barriers
devices
DATE: Oct 18 2015

LOCATION: YEMEN
NUMBER OF DEATHS: 1
RULE: Speeding / phone
Occupation: Unknown
NARRATIVE: The car rolled over while carrying company and contractor’s employee on the way
to their homes from the site.
WHAT WENT WRONG: Lack of training the driver was overloaded. Inadequate maintenance.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Any road diversion for any reason shall
be driven with the minimum speed limit 30 kph. All vehicles shall be equipped with some
emergency equipment. No transport of dangerous goods with passengers and vehicles.
CAUSAL FACTORS:
inspection/testing
NORTH AMERICA
ONSHORE
DATE: Dec 27 2015

LOCATION: MEXICO
NUMBER OF DEATHS: 1
CATEGORY: Exposure noise, chemical, biological, vibration
Employer: Company
Occupation: Other
NARRATIVE: Death of a worker in the area of storage tanks battery separation.
WHAT WENT WRONG: Misapplication of procedure.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Emphasize proper training of staff carrying
out activities.
CAUSAL FACTORS:
DATE: Dec 22 2015

LOCATION: USA
NUMBER OF DEATHS: 1
RULE: Seat belt
NARRATIVE: A contract lease operator’s (pumper) vehicle was found rolled over on a lease
road. The driver was fatally injured on the scene.
WHAT WENT WRONG: Driver was impaired.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Ensure a robust driving safety policy.
CAUSAL FACTORS:
improperly
DATE: Apr 18 2015

LOCATION: USA
NUMBER OF DEATHS: 1
CATEGORY: Pressure release
RULE: Isolation
Occupation: Other
NARRATIVE: Contractor’s employee was working on a flare header when a compressor injected
air into a plug inserted into the pipe. It was ejected, striking the contractor’s employee.
WHAT WENT WRONG: Over-pressurization occurred and the plug was ejected under high
pressure striking the individual. There was no confirmation that pressure being applied was
venting to prevent the over-pressurization of the flare line.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: LOTO procedure should have been
followed. There was a lack of communication between the contractor’s work crews.
CAUSAL FACTORS:
DATE: Nov 24 2015

LOCATION: USA
NUMBER OF DEATHS: 1
CATEGORY: Struck by
NARRATIVE: A third-party consultant on company business, was driving a personal vehicle on
a public highway. A water hauling truck travelling in the opposite direction lost control, veering
into the consultant’s lane causing a head-on collision. The injuries to the consultant were
immediately fatal.
WHAT WENT WRONG: Water hauling truck driver was inattentive or careless and veered into
oncoming traffic.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Make sure that company drivers are alert
and aware at all times when driving.
CAUSAL FACTORS:
PEOPLE (ACTS): Inattention/Lack of Awareness: Lack of attention/distracted by other concerns/stress
OFFSHORE
DATE: Feb 5 2015

LOCATION: MEXICO
NUMBER OF DEATHS: 1
Occupation: Other
NARRATIVE: During activities and performing movements with a crane, making a turn, a
worker was caught against a support pipe, causing a severe brain damage.
out activities.
DATE: Sep 30 2015

LOCATION: MEXICO
NUMBER OF DEATHS: 1
Occupation: Other
NARRATIVE: A worker was trapped by a rack containing oxyacetylene tanks when resting in a
hammock placed between the rack and a storage tank of 1000 litres of water.
WHAT WENT WRONG: Misapplication of procedure
out activities
DATE: Jan 5 2015

LOCATION: MEXICO
NUMBER OF DEATHS: 1
Occupation: Other
NARRATIVE: During removing work for all the pipe and metal structures remain in a marine
platform section at the acid gas cooler, a flame was presented injuring workers.
out activities.
DATE: May 5 2015

LOCATION: MEXICO
NUMBER OF DEATHS: 2
ACTIVITY: Maintenance, inspection, testing
Occupation: Other
Occupation: Other
NARRATIVE: During the activities of positioning of a jack up, a report of sea water penetration
sudden observing in one leg, causing tilt at starboard.
out activities.
DATE: Aug 26 2015

LOCATION: MEXICO
NUMBER OF DEATHS: 1
Occupation: Other
NARRATIVE: During welding equipment cutting with acetylene an angle, flame occurs due to
the presence of oily water in the vicinity of the work area.
out activities
DATE: Apr 1 2015

LOCATION: MEXICO
NUMBER OF DEATHS: 7
Employer: Company
Occupation: Other
Employer: Company
Occupation: Other
Occupation: Other
Occupation: Other
Occupation: Other
Occupation: Other
Occupation: Other
NARRATIVE: Explosion and fire in the area of marine light crude dehydration.
WHAT WENT WRONG: Lack of application of the procedure Misapplication of procedure.
out activities.
CAUSAL FACTORS:
Equipment
DATE: Jul 27 2015

LOCATION: MEXICO
FUNCTION: Drilling
NUMBER OF DEATHS: 1
CATEGORY: Struck by
Occupation: Other
NARRATIVE: At a marine platform during activities of intervening a well, a contractor was trying
preventers, while at the yard of removing pipeline material a worker stay inside a metal box
when a winch approximately
100 kg falling down at a height of 6 metres when the winch was disarmed in two parts hurting
the worker in the head.
out activities.
DATE: Aug 19 2015

LOCATION: MEXICO
NUMBER OF DEATHS: 1
ACTIVITY: Diving, subsea, ROV
Occupation: Other
NARRATIVE: During diving operations at a depth of approximately 105 metres for opening
clamp for withdrawal of brace stiffener pipeline of product, when the diver remove the last
screw, the same tube stiffener rotate and trapping the diver between two pipelines.
out activities
DATE: Oct 20 2015

LOCATION: USA
FUNCTION: Drilling
NUMBER OF DEATHS: 1
CATEGORY: Struck by
NARRATIVE: In preparation for a jetting operation of a 36” conductor, a drill pipe stand was
being handled by the pipe racking system. The bottom of the drill pipe stand swung free from
the pipe racking system and struck the individual in the head. Onboard medic arrived to scene
and confirmed individual was deceased.
WHAT WENT WRONG: Inadequate instructions: The Spotter (IP) was identified to be their first
day in the new role. Inadequate identification and evaluation of loss exposure: The potential
hazard for stored energy to be accumulated in a stand in this way had not been recognized.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: On a regular and quite frequent basis,
fingerboard latches are prone to be in a closed position when they are expected to be open.
CAUSAL FACTORS:
SOUTH & CENTRAL AMERICA
ONSHORE
DATE: Mar 25 2015

LOCATION: ARGENTINA
FUNCTION: Drilling
NUMBER OF DEATHS: 1
NARRATIVE: While a winch truck was removing a tubular-carrier structure from the site, an
employee of the contractor company, was trapped between the front bumper of the vehicle and
said structure.
WHAT WENT WRONG: Decision to perform a front operation with a fastening chain.
The driver failed to ensure that the helper was standing outside the line of fire.
The helper positioned himself in the line of fire.
• Inform the Company Man before operations are started.
• Carry out the risk assessment before the task is performed, especially if conditions were
modified. Unless all conditions to perform the task safely are adequate, the task MUST BE
STOPPED
• Be knowledgeable and aware of the truck blind spots.
• The driver must make sure that the signalman is ALWAYS at sight, otherwise the task must
be stopped.
• The signalman must make sure he can see the driver’s face. Remember that as long as we
cannot see the driver’s eyes, he cannot see us either.
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Improper lifting or loading
DATE: Aug 20 2015

LOCATION: BOLIVIA
NUMBER OF DEATHS: 1
CATEGORY: Water related, drowning
ACTIVITY: Seismic / survey operations
RULE: PPE (Including flotation device)
NARRATIVE: During geological reconnaissance work surface in a place of difficult access, a
working group of 6 people fell into the water while crossing the river with an inflatable row boat.
A person disappeared from the surface and died.
WHAT WENT WRONG: Carrying capacity of the boat, which was designed to carry three
people, was exceeded - appropriate risk analysis was not performed for river crossings. Poor
Leadership at middle and upper management levels. The boat did not have life jackets for all
passengers.
• Improving contractor management
• Inventory of critical tasks
• Hazard identification and risk analysis for critical tasks
• Assessment of compliance with the set standards
• Change management during project implementation.
CAUSAL FACTORS:
improperly
PROCESS (CONDITIONS): Protective Systems: Inadequate/defective Personal Protective Equipment
PROCESS (CONDITIONS): Organizational: Poor leadership/organizational culture
OFFSHORE
No offshore fatalities were reported in the South & Central America region.
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Safety performance indicators – 2015 data

VERSION DATE AMENDMENTS

1.0 June 2016 First release

SOUTH & CENTRAL AMERICA 38

DATE: Apr 22 2015

DATE: Feb 22 2015

DATE: Oct 9 2015

DATE: Apr 7 2015

DATE: Nov 22 2015

DATE: Sep 23 2015

DATE: Jan 18 2015

DATE: May 16 2015

DATE: Aug 20 2015

DATE: Oct 22 2015

WHAT WENT WRONG:

DATE: Jul 14 2015

DATE: Sep 2 2015

DATE: Feb 25 2015

DATE: Feb 28 2015

DATE: Dec 30 2015

DATE: Mar 19 2015

DATE: May 22 2015

DATE: Nov 21 2015

DATE: Jul 3 2015

DATE: Apr 16 2015

DATE: Aug 17 2015

• Increase frequency of Audit on compliance to driving procedure.

DATE: Feb 11 2015

DATE: Jul 25 2015

DATE: Jun 25 2015

PROCESS (CONDITIONS): Protective Systems: Inadequate/defective guards or protective

DATE: Oct 18 2015

DATE: Dec 27 2015

DATE: Dec 22 2015

DATE: Apr 18 2015

DATE: Nov 24 2015

DATE: Feb 5 2015

DATE: Sep 30 2015

DATE: Jan 5 2015

DATE: May 5 2015

DATE: Aug 26 2015

DATE: Apr 1 2015

DATE: Jul 27 2015

DATE: Aug 19 2015

DATE: Oct 20 2015

SOUTH & CENTRAL AMERICA

DATE: Mar 25 2015

DATE: Aug 20 2015

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