BP HSE COMMUNICATION – Lessons Learned Report
management did not generate a vibrant safety
Type of Incident: Major Incident – Electrical
Incident: Electrocution and shock/burns
from contact with 3,000+V DC
overhead line
Business/Performance
Unit: Azerbaijan – Oil Exports
Country: Georgia
Region: Europe
Business Stream: Upstream
Location of Incident: Pump Station PSG2, Georgia
Date of Incident: 25 February 2004
Email: ashdowse@bp.com
Brief Account of Incident: A team of four Georgian
labourers and their foreman working for a major sub-
contractor to the BTC Project were erecting steel poles
to form “goal post” style warning markers about 30m
either side of an uncontrolled crossing at a railway line.
Above the line ran 10KV electricity cables on pylons,
and at a lower level the cable carrying the electric
locomotive supply line at approximately 3,000V DC.
The latter was at about 5.7m above ground level. The
work scope involved digging four holes and cementing
in place vertical scaffold poles each 6m in length.
Bunting was to be stretched between them.
Pre-planning of the work by the sub-contractor was very
informal, and the associated job safety analysis and
toolbox talk by the foreman were of limited quality.
Investigation has concluded that because of uncertainty
about the length of the final pole, two of the labourers
raised it to the vertical position almost underneath the
locomotive supply line, presumably to check it was long
enough for its purpose. It touched the live line. They
both suffered electric shock, burns and subsequent
respiratory/cardiac arrest. Both received attention from
their colleagues and one was kept alive until the site
Doctor arrived and took over; it is believed he will make
a full recovery. The other could not be revived and was
pronounced dead at the scene of the incident.
Potential Outcome: This would probably have been a
double fatality but for the skills of the local first-aiders
and Doctor.
What Went Wrong:
• CLC8.2 Inadequate Management Leadership - weak
site “safety climate”. The style and activities of
atmosphere on site in which everyone is aware of the
Project commitment to the highest possible HS
standards and in which they are encouraged and
empowered to challenge and if necessary stop work
• CLC8.2 Inadequate leadership – standards not
enforced. The foreman failed to exercise supervisory
control, and across the whole site there was a shortfall
in competent safety supervision
• CLC8.4 Inadequate identification of worksite hazards.
The team did not understand the likely severity of
contact with the line, nor the likelihood the pole would
touch the line while they were raising it. This reflects
them coming from a culture which is risk tolerant and
where electricity is not well understood
• CLC8.5 Inadequate management of change. The
foreman had been promoted to that role but this
change did not trigger him receiving the necessary
supervisory skills training (also 7.4)
• CLC11.1 Inadequate work planning. The work control
system (permits and JSAs) was not followed.
Furthermore, routine low skill tasks were not
effectively designed planned and resourced leading to
the work team having inadequate information and
materials
Golden Rules:
• General – risk assessment. The JSA did refer to the
cables but it is likely this was not communicated
seriously, if at all, by the foreman to his team. There
was no perceived reason to worry unduly about the
cables which were high in the air and under which site
vehicles were moving regularly
• Permit to Work – no site general work permit was
issued
• Management of Change – promotion of the foreman
did not trigger his additional supervisory skills training
as required by the training programme and contract
Resultant Actions:
• Supervisors are not simply people who have shown
they can do the technical work well – they need to
have leader qualities and accept accountability. The
supervisory training programme is to be adjusted to
focus on the leadership role and will be extended to all
existing supervisors and future recruits and promotees
• In a short-term project using local labour unused to a
disciplined working environment, getting “safety
completely in the line” is unrealistic and must be
supplemented by effective professional supervision.
 The numbers of site safety supervisors will therefore View looking towards crossing. Locomotive supply line
be increased is lowest line above guard hut. In the foreground to the
• Effective planning of work limits uncertainty in the left can be seen one of the erected poles.
work scope and methodology and obviates the need
for additional activity not envisaged or planned and
which may carry unconsidered risks. Planning
processes are to be reviewed to ensure that even
simple tasks have an appropriate method statement
• All work, however simple, needs to have some
permission associated with it to allow an opportunity
for reflection on risks it might carry. The permit
system and JSA process is to be revised to make it
fit for purpose and to inject rigour into its
application
• No amount of commitment to HSE will deliver HSE
excellence unless the entire management team
demonstrates that commitment visibly,
enthusiastically, continuously and consistently to the
workforce. A strategy is to be implemented which
will increase the overall visibility of management
and their desire to pace safety alongside project
schedule

Key Message: In a short-term project environment in

a location having to use local and unskilled labour,
reliance cannot be placed exclusively on “safety in the
line”. It is essential to bolster this with extensive close
specialist safety supervision by personnel who are
willing to intervene in a constructive manner and
whose authority is respected by the workforce and
management alike, the latter giving them their
unqualified support.

View of crossing. Locomotive supply line is above

right hand rail.