2018sh PDF

REPORT JUNE
2018sh 2019
DATA SERIES
Safety performance indicators – 2018 data

– High potential event 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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iStockphoto (Back cover)
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REPORT JUNE
2018sh 2019
DATA SERIES
Safety performance indicators – 2018 data

– High potential event reports
Revision history
VERSION DATE AMENDMENTS
1.0 June 2019 First release

2018 safety data – High potential event reports
Contents
AFRICA ONSHORE 5
AFRICA OFFSHORE 12
ASIA/AUSTRALASIA ONSHORE 18
ASIA/AUSTRALASIA OFFSHORE 32
EUROPE ONSHORE 36
EUROPE OFFSHORE 44
MIDDLE EAST ONSHORE 52
MIDDLE EAST OFFSHORE 66
NORTH AMERICA ONSHORE 72
NORTH AMERICA OFFSHORE 79
RUSSIA & CENTRAL ASIA ONSHORE 87
RUSSIA & CENTRAL ASIA OFFSHORE 87
SOUTH & CENTRAL AMERICA ONSHORE 88
SOUTH & CENTRAL AMERICA OFFSHORE 100
4
AFRICA ONSHORE
DATE: Dec 12 2018

LOCATION: ALGERIA
FUNCTION: Production
CATEGORY: Pressure release
ACTIVITY: Production operations
RULE: Energy Isolation
NARRATIVE: While performing a hydrostatic pressure test on a scrubber (2000psi), the employee
walked around the scrubber to check the pressure gauge and check for potential leaks. At this
moment, the plug installed on one instrument connection blew out, hitting the employee on his
upper right leg causing a severe cut on the thigh muscle leading to amputation of the leg.
WHAT WENT WRONG: Inadequate training, Inadequate equipment (plugs). In the line of fire.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Organisation measures, detailed
procedures and training are essential prevention tools to avoid this type of incidents
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Violation unintentional (by individual or group)
PEOPLE (ACTS): Use of Tools, Equipment, Materials and Products: Improper use/position of
tools/equipment/materials/products
PEOPLE (ACTS): Use of Tools, Equipment, Materials and Products: Servicing of energised
equipment/inadequate energy isolation
PROCESS (CONDITIONS): Tools, Equipment, Materials & Products: Inadequate/defective tools/
equipment/materials/products
PROCESS (CONDITIONS): Organisational: Inadequate training/competence
PROCESS (CONDITIONS): Organisational: Inadequate work standards/procedures
DATE: Apr 2 2018

LOCATION: ANGOLA
CATEGORY: Other
RULE: Insufficient information to assign a Rule
NARRATIVE: During an electrical storm, lightning hit a mobile crude oil storage tank and
ignited the gases coming out of its vent, causing a fire. The fire was put out without any serious
damage to the facility. The facility comprised two mobile storage tanks (500 bbls each), placed
one next to the other, without any lightning protection or electrical grounding systems. The
tanks receive oil that comes out of a separator.
WHAT WENT WRONG: Inadequate protective barriers: The storage tanks lacked any kind of
lightning protection or electrical grounding systems. Defective equipment: The separator previous
to the tanks was not performing a correct gas-liquid separation, originating an excessive gas
flow through the vent once the oil was in the tanks. Inadequate hazard identification or risk
assessment: There was no hazard identification or risk assessment performed on the facility.
Inadequate work standards: There is no standard for gas verification at the exit of the separator.
5
AFRICA ONSHORE
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Need to conduct a comprehensive risk

analysis of all the operating facilities in the field. Install lightning protection systems and
electrical grounding in all facilities which currently lack these protections. Improve the oil-gas
separation at the separator and improve the stabilisation process in the storage tanks to reduce
gas emissions. Train personnel in the hazards identification process and management.
CAUSAL FACTORS:
PROCESS (CONDITIONS): Protective Systems: Inadequate/defective guards or protective barriers
PROCESS (CONDITIONS): Work Place Hazards: Storms or acts of nature
PROCESS (CONDITIONS): Organisational: Inadequate hazard identification or risk assessment
DATE: Feb 27 2018

LOCATION: GABON
FUNCTION: Exploration
CATEGORY: Other
ACTIVITY: Office, warehouse, accommodation, catering
RULE: No appropriate Rule
NARRATIVE: A truck carrying two recently refilled helicopter fuel tanks arrived at a jetty. One of
the tank exteriors was wet. The operation was stopped to inspect the potential cause for the wet
exterior and it was determined that the tank had A-1 jet fuel covering the exterior of one side.
Further examination determined that the tank had been shipped from the fuel depot with an
improperly secured cover and that the movement of the tank on-route had caused some of the
contents to escape via the tank fill point.
WHAT WENT WRONG: Inadequate procedures Insufficient training
CORRECTIVE ACTIONS AND RECOMMENDATIONS:
1. Elaboration and implementation of Company Heli-Fuel Tank Refilling Procedure. This
procedure covers:
a) Heli-fuel tank receipt & pre-fill activities
b) Heli-fuel tank refilling activities
c) A1-Fuel Tank Check List
2. Update risk register including the control measures taken
CAUSAL FACTORS:
PEOPLE (ACTS): Use of Protective Methods: Inadequate use of safety systems
PEOPLE (ACTS): Inattention/Lack of Awareness: Improper decision making or lack of judgment
6
AFRICA ONSHORE
DATE: Oct 13 2018

LOCATION: GABON
FUNCTION: Drilling
CATEGORY: Caught in, under or between (excl. dropped objects)
ACTIVITY: Drilling, workover, well services
RULE: Line of fire
NARRATIVE: During a routine running of tubing in the hole with elevator; a piece of 6m tubing
slipped through the elevator from rig floor and fell down close to operator. The operator was
not injured but the tubing was close enough to tear through the crotch of his coveralls. The
operation was stopped for investigation.
WHAT WENT WRONG:
• USE OF INADEQUATE TOOL: The elevator in use was for 3-1/2” IF drill pipe and not for
3-1/2” None upset tubing. The Internal Diameter is larger for drill pipe elevators (3-1/2” IF )
due to the larger upset of the connection. The coupling therefore was able to pass through
the larger elevator allowing it to fall;
• POOR PLANNING/MATERIAL PREPARATION: the driller and assistant driller are normally in
charge to select the adequate tools as per the various sequences;
• WRONG WORK POSITION: the assistant driller stood below the half 3-1/2’’ tubing mule shoe;
• NO COMPLIANCE WITH DROPS &
• RED ZONE RULES: the assistant driller was in a red zone and did not considered the risk of
dropped objects;
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Implement the check list for running and
pulling when changing drill pipe to tubing. Develop and cascade the awareness presentation
related to restricted areas management process (Red, Yellow, Green Zones). Share the incident
lesson learned with all rigs currently in operation.
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Improper position (in the line of fire)
PEOPLE (ACTS): Following Procedures: Improper lifting or loading
PEOPLE (ACTS): Use of Protective Methods: Failure to warn of hazard
PEOPLE (ACTS): Use of Protective Methods: Equipment or materials not secured
PROCESS (CONDITIONS): Protective Systems: Inadequate/defective guards or protective
barriers
PROCESS (CONDITIONS): Organisational: Inadequate supervision
7
AFRICA ONSHORE

DATE: Dec 24 2018
LOCATION: GABON
FUNCTION: Unspecified
CATEGORY: Cut, puncture, scrape
ACTIVITY: Maintenance, inspection, testing
RULE: Line of fire
NARRATIVE: IP was performing cutting and grinding operation underneath a heavy truck. IP
lost control of the angle grinder and dropped it onto his own neck causing slight injury as the
disc was still rotating.
WHAT WENT WRONG: Did not perform adequate risk assessment. Incorrect working position
and selection of equipment.
• Provide or build heavy duty bridge deck work platform, or work pit.
• Use appropriate tool or equipment (grinder with dead-man switch).
• Conduct proper risk assessment of task and implement proper procedure for maintenance.
• Use of a watch man.
• Do not put yourself in line of fire.
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Overexertion or improper position/posture for task
PEOPLE (ACTS): Use of Protective Methods: Personal Protective Equipment not used or used
improperly
PROCESS (CONDITIONS): Protective Systems: Inadequate/defective Personal Protective
Equipment
PROCESS (CONDITIONS): Protective Systems: Inadequate/defective warning systems/safety
devices
8
AFRICA ONSHORE
DATE: Jan 16 2018

LOCATION: GABON
CATEGORY: Other
ACTIVITY: Lifting, crane, rigging, deck operations
RULE: Safe mechanical lifting
NARRATIVE: A 110T crane was lifting an 80kg lamp post, as the crane approached maximum
extension one of the outriggers sank into the ground and the crane toppled. Fortunately,
the crane collapse did not cause any injuries and did not cause any damage to any other
infrastructure or equipment.
WHAT WENT WRONG: Incorrect lifting plan, and correct working method was not followed.
Outriggers were not placed on solid ground. Failure to respond correctly to crane alarms.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Consideration of best tool for the job and
lowest overall level of operational safety risk. Correct supervision and approvals for lifting plans.
Appropriate levels of supervision and control on site.
CAUSAL FACTORS:
PROCESS (CONDITIONS): Tools, Equipment, Materials & Products: Inadequate design/
specification/management of change
DATE: Nov 6 2018

LOCATION: KENYA
CATEGORY: Explosions or burns
RULE: Bypassing Safety Controls
NARRATIVE: A well was opened under natural flow with initial diesel and inhibited water
circulated in the annulus and wellbore. The flare pilot was ignited, surface facilities lined up
to bitutainer no. 3 with the separator bypassed and an operator positioned at the sampling
point checking to determine when the diesel had been circulated out. Immediately the
operator observed crude at the sampling point, flow was then directed to bitutainer no. 2 via
the separator. Bitutainers are provided in the process area as holding tanks for the de-gassed
crude before transfer into the 5000 bbls Crude Storage Tanks (CST). One hour into the start-
up operation, an explosion and flash fire event occurred in bitutainer no. 2. The explosion
overpressure blew open the bitutainer’s manway cover and ejected the manway’s gasket which
9
AFRICA ONSHORE
landed 20 meters away. The bitutainer tank sustained minimal deformity on its roof. There
were no injuries to site personnel or environmental spill. Immediately after the explosion, the
crew manually activated the emergency shutdown (ESD) system and went to muster as per the
emergency response plan (ERP). The crew waited for approximately one hour and then returned
to the process area, closed the wellhead valves, depressurised the separator and isolated valves
associated with it.
WHAT WENT WRONG:
Tools and Equipment - Accumulation of static charges inside the tank during filling of the
bitutainer without an adequate path for dissipation to ground. The inner tank is coated to 280μm
thickness compared with NFPA 77 recommended thickness of less than 50μm for tanks that
store low conductivity fluids. This very thick coating created a barrier to safe dissipation of
accumulated static charges across the inner tank to the external earthing on the outer skin.
Tools and Equipment - The manway cover was not closed tight hence a gap was created that
allowed air ingress into the bitutainer, leading to the formation of a flammable air-vapour
mixture in the tank. The turbine flow meter installed upstream of the bitutainer consistently
gave inaccurate volumetric readings of crude compared to actual dip measurements. Due to
the ineffectiveness of the flow meter, the crew resorted to visual checks of crude level in the
bitutainer, an action that required regular opening of the manway. A sight glass level indicator
is not installed on the bitutainer. Engineering design - Inadequate technical data and/or
information on physical properties of Ngamia crude specifically electrical conductivity and the
associated hazard of static electricity. This technical data was not available at the time when the
EOPS Basis of Design was issued and during both HAZID and HAZOP studies. Without sufficient
information and understanding of the crude’s physical properties a vital opportunity was missed
that would have ensured sound basis for the effective management of static electricity in
relation to the low conductivity of Ngamia crude oil.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: To minimise the potential for static
discharge, follow the guidelines in NFPA 77. This requires that the coating thickness of tanks
used to store low conductivity fluids to be less than 50μm and that the flow velocity of fluids
discharging into a storage tank which can contain flammable atmosphere be no more than 1
m/s until the fill pipe is submerged in the fluid. Detailed technical data and information should
be made available to ensure proper understanding of the physical properties and behaviour
of materials and to enable conduct of suitable and sufficient hazard identification and risk
analysis.
CAUSAL FACTORS:
10
AFRICA ONSHORE
DATE: Mar 9 2018

LOCATION: NIGERIA
CATEGORY: Exposure electrical
NARRATIVE: While the maintenance team were at the electrical panel carrying out tests after
completing an intervention work, at the same time two security guards received electric shocks
while opening the main gate of the club house. The maintenance team immediately switched off
the electrical panel following an alarm raised by other security personnel and the two security
guards were released from the
WHAT WENT WRONG: A burnt 63A circuit breaker in the main panel. Disused cable buried and
abandoned underground. Degraded insulation on terminal of buried disused cable. Disused
cable breaker was on off position before intervention but not formally isolated. Disused cable
breaker was switched on after intervention.
• To carry out electrical audit of all electrical equipment’s in owned and leased company
properties
• To label all circuit breakers in company facility
• Existing Standard Operating Procedure to be reviewed and validated
• General HSE awareness to be conducted for all security personnel’s on all company
operated site
• Preventive maintenance plan to be develop for circuit breakers and panels.
• Check and trace all disused cables, disconnect/isolate/retrieve
CAUSAL FACTORS:
PROCESS (CONDITIONS): Protective Systems: Inadequate security provisions or systems
11
AFRICA OFFSHORE
DATE: Aug 15 2018

LOCATION: ANGOLA
CATEGORY: Confined space
RULE: Confined space
NARRATIVE: Two contractor employees entered a slop tank using positive pressure airline
apparatus (connected to the emergency air supply cylinder). While climbing down the ladders
to the bottom of tank the entrants identified low pressure of the air on the emergency air supply
cylinder. They contacted the Confined Space Entry Attendant and were requested to vacate the
tank. Both entrants didn’t have visible symptoms of oxygen deficiency or asphyxiation when they
left the confined space. Total duration of the entry (from entry until escape) was between 5-10
minutes.
WHAT WENT WRONG: The entry was done under the emergency air supply cylinder (which is
an integral part of the apparatus) without the external air supply hose being connected. The
breathable airline supply hoses were pre-installed inside the tank to provide entrants with air
supply to carry out their task - after entry to the bottom using emergency air supply cylinder.
The manual cleaning of the residual sludge wasn’t properly planned via planning process. The
entry method wasn’t verified by site COW role holders.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Use of the escape cylinder was the
intended method of entry during task design and the tank entrants were trained and instructed
on this method by the personnel who were not trained or experienced in the use of this airline
set with escape cylinder. The selection of escape cylinder for entry was not appropriate. From
the point the sludge was found, the planning of the task was subject to a number of changes
due to changing methodologies to complete the task. This increased the workload to the
offshore team planning and executing this work. No direct breach of COW identified, however
there was ineffective communication and clarity of the job execution which resulted in different
understanding of how entry was going to be conducted.
CAUSAL FACTORS:
improperly
PROCESS (CONDITIONS): Work Place Hazards: Hazardous atmosphere (explosive/toxic/
asphyxiant)
PROCESS (CONDITIONS): Organisational: Inadequate communication
12
AFRICA OFFSHORE
DATE: Feb 11 2018

LOCATION: ANGOLA
CATEGORY: Falls from height
RULE: Work at height
NARRATIVE: While performing the disinfection of the air line distribution in a HVAC workshop,
a technician climbed on the top of the air unit B to investigate the damper default on air unit A.
While on his way to unit B to check the second damper, he did not pay attention to the 40 cm
gap between both the air units. IP lost his balance and bumped unit B structure. This caused a
sharp pain on his left ribs.
WHAT WENT WRONG:
• Absence of risks identification for intervention at this specific location
• Access mean (ladder) for work at height was not used
• Alarms imprecision (tag missing)
• Working at height alone
• Inadequate Supervision
• Application of the Company rules
• Physical protection to prevent passage from a roof unit to another to be installed.
• Mandatory use of ladder secured by a watcher for intervention HVAC roof units.
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Overexertion or improper position/posture for task
PEOPLE (ACTS): Inattention/Lack of Awareness: Lack of attention/distracted by other concerns/
stress
13
AFRICA OFFSHORE
DATE: Sep 17 2018

LOCATION: ANGOLA
NARRATIVE: A work party of three people accessed the Port Upper Riser Balcony to conduct
visual assessment of the Port Lower Riser Balcony. The objective was to look through the
Upper Balcony gratings to understand the extent of grating corrosion in the Lower Balcony by
walking from one end of the balcony to the other. The team spent around 15 minutes for visual
assessment and discussion. While they were leaving the upper balcony, one of the gratings
failed under the weight of a team member and his foot partially went through the grating
located directly above the sea. No injuries were reported, and the team safely returned to main
deck.
WHAT WENT WRONG: The grating failed as its load bearing capacity reduced due to excessive
corrosion not identified during inspections.
• Grating Assessment and Acceptance Criteria: Grating Register was created in response to
North Sea fatality but inappropriate condition assessment criteria was applied.
• Planned Maintenance Routines (PMRs): Port and starboard PMs existed in Maximo for riser
balcony gratings. PM detail was lost during the transition from Maximo to SAP.
CAUSAL FACTORS:
PROCESS (CONDITIONS): Tools, Equipment, Materials & Products: Inadequate maintenance/
inspection/testing
DATE: Apr 1 2018

LOCATION: CONGO
FUNCTION: Drilling
NARRATIVE: While drilling depleted reservoir (100bars overbalance), bottom hole assembly got
differentially stuck at connection, worked string free. Decision was made to pull BHA to surface
in order to remove radioactive source and run back with simplified BHA. At 6070m MD/RT, while
breaking out connection and racking stand, BHA got differentially stuck again: work string for
33 hours: free string but left 113m of BHA in hole. There was no injury to personnel.
WHAT WENT WRONG:
• Insufficient assessment of operational readiness: Excessive time to spot surfactant pill due
to insufficient preparation (offshore & onshore).
14
AFRICA OFFSHORE
• Inadequate design specification: Large contact area between BHA and borehole - Barite
mud system with large & uniform particle size (partial bridging).
• Incorrect, obsolete procedure: Static period while making connection not adapted to
environment prone to differential sticking.
• Insufficient risk assessment: Risks analysis based on previous operations (coring & logging)
showed risk was acceptable.
• BHA design to be adapted to limit the risk of differential sticking and to limit consequences
of a stuck BHA.
• Drilling and tripping procedures to be adapted to mitigate differential sticking risk.
• Mud system to be reviewed.
• Solution to run RA source
• Free BHA to be looked at during Well SOR
CAUSAL FACTORS:
DATE: Apr 22 2018

LOCATION: GHANA
FUNCTION: Drilling
CATEGORY: Dropped objects
NARRATIVE: Whilst moving a marine riser from the rig floor to the riser bay with the riser gantry
crane, a noise was heard while lowering the riser. The outer telescopic mechanism on the forward
end of the Riser Gantry Crane became stuck momentarily, and when it came free it descended
quickly about 1m, then the inner telescopic mechanism collided with the outer mechanism’s end
plate. The end plate weighed 8.5kg and fell about 6m onto the forward end of the crane walkway.
WHAT WENT WRONG:
• Inadequate assessment of potential failure at the design stage.
• No Safety Alerts have been issued regarding a known problem. Therefore the crew was
unaware of the risks and unable to implement remedial measures to prevent the incident.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Remove End Caps on outer telescopic
boxes and seek for an alternative design that cannot be punched out by inner box if such an
incident should occur in the future.
CAUSAL FACTORS:
15
AFRICA OFFSHORE
DATE: Oct 23 2018

LOCATION: GHANA
FUNCTION: Drilling
ACTIVITY: Transport - Air
NARRATIVE: A plastic folding table weighing about 20kg, fell 8.1m from a storage position to
the deck below while a helicopter was on final approach. No one was near the point of impact at
the time of the event.
The potential outcome of the event on the DROPS Consequence Calculator indicates ‘Fatality’.
WHAT WENT WRONG:
• Pre-landing inspections conducted failed to identify the table in a hazardous location or as a
potential flying object.
• Inadequate identification and implementation of lessons learned from similar event
previously experienced by contractor.
• Table was left at a location susceptible to helicopter downdraft for reasons unknown.
• Increased focus needed for helicopter operations and housekeeping
• Increase awareness helicopter downdraft
CAUSAL FACTORS:
DATE: Mar 18 2018

LOCATION: GHANA
NARRATIVE: While changing out a corroded grating on the process deck level, the old grating
section (2m x 0.5m, 64kg) fell through a slot in the supporting structure, falling onto the main
deck 4.8m below. The area below was not barriered off, however it is not a normal access
route and nobody was in the area. There was no injury to personnel or damage to any other
equipment.
WHAT WENT WRONG: The grating replacement work crew lost control of the grating during
change out and the grating was not tethered to prevent the fall. The grating replacement work
crew did not have the correct tools for the manual handling aspects of this task. Inadequate
identification of worksite/job hazards - The Permit to Work and TRA had conflicting information
regarding hazard identification and risk control. Inadequate work planning and supervision -
The supervisor assigned for workscope was on dayshift and also, the work party was split to
work day and night without ensuring adequate competency and familiarity (green hats) is split
between the teams.
16
AFRICA OFFSHORE
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Introduce Site Safety Standards to reduce

the need for ‘cover everything’ in TRA’s. Review the criteria for routine activity classification
(to allow repetitive, low risk activities to be done under routine. Hence reduce the number of
permits issued per day) and update the Facility’s Routine activities list.
CAUSAL FACTORS:
DATE: Oct 4 2018

LOCATION: GHANA
NARRATIVE: In preparation for the galley upgrade activities, power was shut down to the galley
and mess areas. Temporary lighting was set up by the on-board electricians. While destructing
materials a vendor touched a pipe that was in contact with the gland on the temporary lighting
which caused the vendor to come into contact with the electrical supply. The vendor was not
harmed by the incident.
WHAT WENT WRONG: Inadequate technical design - Wire braid in the armoured cable makes
contact with live electrical terminal. The earth core of the extension cable was not connected.
Inadequate guards or protective devices- Powering circuit from a supply not protected by an
RCD. Lack of awareness of construction standards for portable equipment.
CAUSAL FACTORS:
barriers
17
ASIA/AUSTRALASIA ONSHORE
DATE: Dec 26 2018

LOCATION: AUSTRALIA
FUNCTION: Drilling
ACTIVITY: Construction, commissioning, decommissioning
NARRATIVE: Whilst rigging down, a weld failed at the derrick pivot point securing it to the
carrier. This resulted in the derrick falling approximately 0.5m and skewing to the side before
coming to rest on top of the carrier, not in its designed cradle.
WHAT WENT WRONG:
• Design did not anticipate the conditions
• HES Procedures or Safe Work Practices inadequate
Lessons Learnt:
• The weld type used and strength of the weld were not suitable for the application and did not
take into account fatigue related stress caused by the raising and lowering of the derrick.
• The weld design (fillet weld) was not able to be adequately inspected by typical visual and
NDT processes to detect the failure mechanism which initiated on the inner surface.
• Personnel were allowed to remain in the line of fire and immediately adjacent to heavy
moving parts during rig up/down.
Recommendations:
• Review and update rig up/down procedure to isolate personnel from the proximity to the
mast during lowering.
• Provide engineering justification of Mast and Sub-base overall strength and fatigue
performance under anticipated loading.
• Validate proposed repair design to ensure that design has adequately addressed strength,
fatigue and future inspection requirements.
CAUSAL FACTORS:
18
DATE: Oct 22 2018

LOCATION: AUSTRALIA
CATEGORY: Other
NARRATIVE: A high potential incident occurred when an 8kg vertical line packer fell 10 metres
to grade. There were no injuries associated with this incident.
WHAT WENT WRONG: The stitch welds between the vertical packer and the pipe support
experienced crevice corrosion jacking and failed, leading to the dropped object.
Incorrect installation procedures led to the packer being stitch welded instead of full seal
welded. The packer itself showed signs of surface corrosion only, with no obvious visual
indications that the welds were failing (i.e., inspections were unlikely to detect the issue).
Inspection procedures were inadequate as they did not identify the failure.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: A warning sign was that it had exceeded
its original design lift of 20 years (BOD). Stitch welds have a life of 20 years however fully sealed
welds maintain integrity for longer. The importance of QA/QC processes, which should have
picked up the stitch welds during installation. Failure to learn from similar events that have
occurred.
Update engineering standards and global piping and inspection procedures. This to ensure a
mandate for full seal welding of packers and then to specifically identify packers, pipe shoes
and other susceptible items.
CAUSAL FACTORS:
inspection/testing
PROCESS (CONDITIONS): Organisational: Failure to report/learn from events
19
DATE: Nov 2 2018

LOCATION: AUSTRALIA
CATEGORY: Other
RULE: Line of fire
NARRATIVE: Area Authority was conducting routine round when a flange insulation box (700
mm diameter x 450 mm height) weighing about 30 kg was found on the walkway within the
process area. The box was found about 8 m below where it was previously installed.
WHAT WENT WRONG:
1. No engineering drawing detailing how a secure connection between the flexible elastomeric
foam (FEF) outer jacket on the pipe and the metal box would be installed. This resulted in
the work being completed without guidance of an approved drawing and installed without
adequate securing method between the two materials. The weight of the box and plant
vibration ultimately resulted in the securing method failed.
2. The attachment method required to join these two types of insulation was not identified in
the approved Technical Deviation Request or Work Method Statement.
1. Failure to produce detailed engineering drawings on the fit up of the metal valve boxes on
the existing FEF materials suggests that during the installation, the work team did not have
a drawing for reference.
2. Approved engineering drawing and Work Method Statement are required for the flange
junction box installation.
CAUSAL FACTORS:
DATE: Jul 22 2018

LOCATION: AUSTRALIA
NARRATIVE: An operator located near the oily water pit was alerted, by a personal gas detector
alarm, to the presence of hydrocarbon gas. The operator went towards the oily water pit, and
the personal gas detector indicated a 100% LEL flammable atmosphere at 150mm from the oily
water pit. The operator established, through a process of elimination, that the source of gas was
the oily water drain line from the V1 suction scrubber on screw compressor 3 and he proceeded
to shut down the unit and inform his line supervision. The leak rate has been estimated,
through process calculation, to be 88.6kg/h. The total volume of gas to atmosphere is currently
unknown. The previous operator check undertaken the previous evening did not indicate any
20
abnormalities. Therefore, the initiating event likely occurred between these two operator visits
which were approximately 19 hours apart. The worst case scenario is that 1683 kg of gas was
released to the atmosphere. No one was hurt, and no community members were affected by the
incident. This incident was classified as a Tier 2 Process Safety Event.
WHAT WENT WRONG: Mechanical Instrument Failure Concurrent failure of the compressor
scrubber level controller and the low level safeguard resulted in a flow path to the oily water
drain, which is vented to atmosphere.
Lessons Learned:
1. Risk normalisation: The oily water pit was perceived to be a safe release point.
2. Learning from Incidents: An identical gas blow by incident occurred two months prior.
3. Safeguarding: Inadequate (1) proof testing procedure and (2) actual proof testing execution.
Recommendations:
1. Re-engineer the scrubber low level safeguarding function to reduce the likelihood of
dangerous unrevealed failures.
2. Develop specific proof test procedures for the scrubber low level safeguarding function, and
execute them as per CMMS schedule.
3. Implement previously identified H&RA controls. Establish a hard barrier exclusion zone
around the oily water pit. Draft Investigation report and LFI complete, with Operations
manager (investigation sponsor) for review.
CAUSAL FACTORS:
barriers
inspection/testing
21
DATE: Jan 1 2018

LOCATION: AUSTRALIA
FUNCTION: Construction
CATEGORY: Exposure noise, chemical, biological, vibration
RULE: Line of fire
NARRATIVE: Contractor Commissioning team were conducting a failure to ignite test on the
propane refrigerant compressor. As part of the activity testing of a double block and bleed (DBB)
on the fuel gas line downstream of the gas scrubber was conducted. During this test, a release
of fuel gas (methane) occurred through a weep hole on the vent line of the DBB. The personnel
who were conducting the test were not aware of the weep hole location. This gas release caused
the personal gas monitor worn by the Operations personnel working in the vicinity to alarm on
high LEL. The release was estimated last for about 38 seconds.
WHAT WENT WRONG:
1. Inadequate design specification - the weep hole was installed in the vent line at 1.5 m above
the grade/floor. This is not a safe location for a weep hole on hydrocarbon system.
2. Personnel at work front were not aware the vent was going to be used as they were not at
the pre start job briefing. They were also at a different radio channel than the other working
team.
1. Weep hole for hydrocarbon system shall be designed and installed with due consideration
for safe location to personnel working in the area.
2. Job Supervisor must ensure good communication/coordination amongst personnel
(Contractors and Operations)
CAUSAL FACTORS:
22
DATE: Mar 16 2018

LOCATION: AUSTRALIA
CATEGORY: Struck by
RULE: Line of fire
NARRATIVE: A request was made by a Painting Supervisor to telehandler forklift operator
to remove air preparation unit in response to a cyclone tie-down notification. The area was a
Commissioning controlled area and ignition sources must be managed under Permit to Work.
Mobile plant such as telehandler forklift is within the permit scope; a gest test upon entry to
area is a requirement. A call had been made for someone to meet the telehandler at the area
entrance. The Area Supervisor had made his way to the gate to undertake spotting gas testing.
He was met by the IP who had offered to perform the task. No positive communication was done
between IP and telehandler operator beside hand gesture exchanges between both of them. As
IP was escorting the telehandler forklift operator into the commissioning area when contact was
made between the telehandler`s front wheel and IP`s right foot resulting in a serious injury.
WHAT WENT WRONG:
1. Management system - Personnel did not recognise a change in job scope and did
not adequately review Job Hazard Analysis (JHA) and follow Work Method Statement
requirement. IP was not trained on spotting task.
2. Work direction - Telehandler Operator and IP did not follow mobile plant (vehicle) procedure
with regards to ensuring adequate clearance between people and mobile plant.
3. Communication - poor coordination and interaction between IP and telehandler operator.
1. Personnel shall be adequately trained on risk assessment and management of change.
2. Personnel shall be trained on the undertaking tasks.
3. Supervisor shall ensure JHA is amended when there is a change in task and ensure
communication is done to personnel involved in the task.
CAUSAL FACTORS:
stress
23
DATE: Jul 29 2018

LOCATION: CHINA
NARRATIVE: On an offshore processing platform, during the process of trial production, one
wellhead uplift caused a gas leakage under the tree. There were no casualties or environmental
damage.
WHAT WENT WRONG:
1. Well-up - Due to the increase of formation temperature and fluid production, the
temperature of the oil casing increased more than the original design, and the wellhead
was lifted by the thermal stress, and the lifting force exceeded the strength of the flange
connection of 21-1/4 “casing head, causing the flange bolt to pull off and the wellhead was
instantly lifted.
2. Leak - The lift height of the tree exceeds the allowable design value of the hard pipe of
the kill well, which causes the tree to be pulled apart by the hard pipe, causing the lateral
stress of the tree, which causes the two key flanges of the tree to be pulled apart and causes
natural gas leakage.
1. Design:
-- In previous studies (including basic design), the local temperature over 120 degrees C,
wellhead uplift design (changed from the current 150 degrees C to 120 degrees C.
-- Major changes (reservoir allocation, engineering design) should be evaluated during the
design phase;
2. Job production
-- Key nodes of wellhead and tree site construction should be recorded;
-- Production should be carried out in strict accordance with the design. In case of any
change or change in the production process, the departments should communicate with
each other in time and evaluate the rationality and risk of the change;
-- In the production process, the wellhead temperature and rise data should be closely
monitored, and countermeasures should be studied accordingly.
CAUSAL FACTORS: No Causal Factors Allocated
24
DATE: Aug 12 2018

LOCATION: INDONESIA
NARRATIVE: An IT contractor was involved in installation of IT equipment and cable wiring
at the office floor. Work was carried out after office hours and during weekends when no
employees were around. One morning, more than a week after work began, workers arrived
to continue their work but discovered the site had no electricity. Upon checking, the inspecting
personnel found some miniature circuit breakers (MCB) units had dripped material. This
material that had impaired the MCB resulting the power trip was later confirmed as “firestop”
sealant used by the IT installation team. The sealant was found to be expired and was wrongly
applied. The investigation also found out the IT installation work had been carried out without
energy isolation and with minimal safe work practices.
WHAT WENT WRONG:
1. Inadequate communication and coordination between all parties involved in the job.
2. Poor work planning.
3. Lack of effective supervision.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Inadequate communication and
coordination between all parties involved in the job leading to a poor work planning and lack of
safe execution.
CAUSAL FACTORS:
barriers
25
DATE: Aug 3 2018

LOCATION: INDONESIA
RULE: Line of fire
NARRATIVE: A concrete Pump Helper (IP) was setting the chute of a Concrete Mixer Truck to
the hopper of a Concrete Pump Truck in order to transfer concrete. The Concrete Mixer Truck
started to move backward, and the IP was pinched between the Concrete Mixer Truck and the
Concrete Pump Truck. The IP was taken to the Site Clinic where he received First Aid treatment
before being released on the same day.
WHAT WENT WRONG:
Hazard not identified - Hazards related to position of personnel between two Concrete Vehicles were
not identified. The existing Job Safety Analysis (JSAs) only covered activities at the Batching Plant
and didn’t exist for the supply of concrete from the batching plant to each subcontractor work site.
Failure of Communication - There was a misunderstanding between the driver and IP on the
sequence of setting the position of the two trucks.
Fatigue - The Mixer Truck driver has been waiting for 8 hours before being allocated a delivery
that resulted in him losing focus. As a result, he didn’t engage the hand break and did not
realise the foot brake was not fully engaged.
Maintenance - Control (Lever) of hydraulic system to adjust chute of Mixer Truck was reported
broken and had not been repaired. This caused the IP to adjust the chute using a temporary
handle located in the back of Mixer Truck (line of fire).
• Do your existing procedures and JSAs for concrete operations include supply of concrete to
each subcontractor on site?
• Do you consistently use wheel chocks as a hard barrier to prevent inadvertent vehicle movement?
• Do you have a process to tag and quarantine broken and unsafe equipment to ensure they
will not be operated?
• How do you mitigate the risks of mental fatigue associated with executing familiar and
repetitive tasks?
• Have you done enough to make your workforce aware of the potential risks of fatigue, lack of
communication and being in “line of fire”?
• For activities done by “lone workers”, have you considered the use of spotter to provide support?
CAUSAL FACTORS:
PEOPLE (ACTS): Inattention/Lack of Awareness: Fatigue
26
DATE: Aug 10 2018

LOCATION: JAPAN
FUNCTION: Drilling
CATEGORY: Struck by
RULE: Line of fire
NARRATIVE: Whilst pulling out of hole with the DST string, a tyre tied between the TDS
torque track and the mast fell to the rig floor, glancing the front brim of a worker's hard has
causing the hat to come off. The tyre weighed 15.5kg and fell from a height of 9.85m. Using
the DROPS calculator this event registered as having the potential consequence of causing a
fatality. The worker was checked for injury by the on-site medic and was cleared to return to
work. Concurrently, the area was secured, relevant notifications made, a full mast inspection
conducted to identify any further potential hazards and a safety stand down meeting held.
WHAT WENT WRONG:
• Dropped Object Risk Management was not employed when the tyre was rigged in the mast.
The person that rigged the tyre in the mast remains unidentified. As such, it is important
that all people that work at height have specialist knowledge and capability in identifying
Dropped Object risks.
• Alignment of High Arctic Dropped Management Procedure with the recently released The
DROPS Reliable Securing Focus Group work is required to ensure that World's best practice
is employed at all High Arctic sites. In terms of Control and Risk Management, the following
findings are:
• The High Arctic MoC process was not employed at either site when rigging the tyre to the mast.
• A review of the PTWs and JSAs relating to the mast during the period 1-24 Jun are described
as generic.
• There was no Working at Heights Permit or JSA recorded that described the controls
required for how it was to be rigged, nor the secondary retention required.
CAUSAL FACTORS:
devices
PROCESS (CONDITIONS): Organisational: Poor leadership/organisational culture
27
DATE: Sep 13 2018

LOCATION: JAPAN
NARRATIVE: A Crude Oil Transfer Pump (CTOP) B began to exhibit high vibration in the form
of an alarm to the Control Room Operator on the DCS. The area operator was dispatched to to
investigate. Whilst the operator was mobilising, the pump subsequently tripped on low seal oil
pressure. Upon entering the vicinity of the pump, the operator observed a spray of hydrocarbon
approximately 4-5m in radius emanating from the pump location and immediately hit the ESD
hand switch. The spray of Hydrocarbon was from a damaged seal on the non-drive end of the
COTP B. After a technical root cause investigation, the seal damage was found to be caused by
excessive vibration as a result of the failure of the non-drive end bearing.
The bearing failure was in turn due to lack of lubrication by the oil slinging ring, which was
incorrectly oriented (slinging oil out of the bearing) due to the incorrect installation of the
journal sleeve. The focus of this investigation has been to uncover the human factors that
lead to the incorrect installation of the journal sleeve. A month prior to the COTP B loss of
containment, operations had identified that a seal on COTP B had an internal leak (no loss
of containment and no relations to this event) and a Corrective Maintenance work order was
issued for the repair of the seals, which also involved a change of the bearings for the pump.
The work was designated break-in. The parts were sourced, and the work order was issued on
the 27th August.
The repair work was performed during the day shift of the 28th August. The work itself was
performed by a team comprising the single mechanical technician onsite, along with 2 contract
resources and the senior machinery engineer. The work was completed within 12 hours,
therefore not requiring a deviation to be raised for working under a single valve isolation under
the Baseline Isolation Standard.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: The COTP LOPC incident was wholly
preventable. It was the result of a journal sleeve being installed in the incorrect orientation,
which resulted in the failure of the non-drive end bearing, subsequent shaft vibration from
the failure and then damage to the pump seals. Whilst there was initially a degree of urgency
required to respond to the loss of a redundant pump, this was re-calibrated in the ensuing
production meetings and the workorder was scheduled for a full 12 days prior to execution.
There was little evidence to indicate that the timeframe would have been impacted significantly
if the work was to be executed over the standard 48 hrs, using the full complement of all
technicians. A lack of resource availability resulted in the engineer acting as a work team
member, rather than supervising the job. This was compounded by the practice to only use
inspection and test plans in the workshop (not at site), and the work procedure documentation
being largely used for guidance (reassemble as you pulled it apart), with inadequately sized
assembly drawings. Whilst competency could be improved, it was a contributing factor
rather than the root human factors cause. Although there was not necessarily a direct
observation, there appears to be an underlying urgency at a working level that is not evident in
communications or direction being given from management, driving tactical decision making
28
as evidenced by the job duration and proceeding with an undermanned execution team. Further
investigation is warranted into this behavioural and cultural causal factor, utilising skills
outside this investigation team. Other item of note, not directly involved in the incident, was
the response from both the Sydney and Field teams. The root cause analysis and subsequent
recovery work was conducted smoothly and efficiently. Whilst there are some elements which
could be streamlined, the formation of the a multidisciplinary team across maintenance,
site reliability, integrity and maintenance and facilities engineering, allowing simultaneous
multifaceted investigations certainly reduced the time to determine if there was a risk to the
other COTPs and resulting return to production.
CAUSAL FACTORS:
inspection/testing
DATE: Feb 7 2018

LOCATION: PAPUA NEW GUINEA
CATEGORY: Other
ACTIVITY: Transport - Air
NARRATIVE: A technician was planning to drain a generator pump in preparation for transport.
This was completed inside the bund where a drum used to decant Jet-A1 waste fuel drum
was located. The waste drum contained recently tested fuel samples. Just after midday on the
same day, a loadmaster and three assistants went to the refuelling area to refuel two BK117
helicopters (Helo 1 and Helo 2) with Jet-A1 drum fuel. Helo 1 was refuelled first followed by Helo
2. After refuelling, both helicopters departed for their respective work locations. Approximately
15 minutes after departure, one of the personnel involved in draining the generator pump in the
bund returned to the fuel area and realised that the Jet-A1 waste fuel drum had been utilised
to refuel the helicopters. He immediately alerted the other helicopter company loadmaster,
who then informed the site Dispatcher. Helo 1 was heading back to a seismic location and was
advised by the Dispatcher to land and shut down at the location's Pad 1. The Dispatcher relayed
the message to the Lead Pilot via the radio. The Dispatcher then contacted Helo 2 and advised
the pilot to land and shut down at another helipad. Helo 2 landed safely. A helicopter engineer
attended and inspected the helicopter. There was no evidence of contamination. Helo 2 was
approved to return to service. At the seismic location main base, the refuelling pump filter was
removed, checked for contamination and declared clear of contamination. A helicopter engineer
from the contractor organisation checked Helo 1 and there was no evidence of contamination.
Helo 1 was approved to return to service.
29
WHAT WENT WRONG: Drum refuelling was an inappropriate method of refuelling compared
to drum refuelling due to higher risk of fuel contamination and human error. Helicopter
Loadmasters inadvertently fuelled 2 helicopters from a waste fuel drum The fuel arrangements
within the Aviation Task Plan for project did prescribe use of bulk fuel, not drum fuel. Drum fuel
was only to be used for initial activities and not for longer term use. The use of drums in the
interim period was not assessed for appropriate manning levels against planned flying hours.
Fuel drums and waste drums were not adequately labelled to prevent mis-identification. Waste
drums and fuel drums were not adequately segregated.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Drum refuelling is only recommended for
short duration or light usage - bulk refuelling systems should be used to reduce likelihood of
contamination and reduce human error. Labelling of drum /waste fuel must be clearly marked
to differentiate between them and adequate segregation must be in place
CAUSAL FACTORS:
stress
devices
DATE: Aug 10 2018

LOCATION: PAPUA NEW GUINEA
FUNCTION: Drilling
CATEGORY: Other
RULE: Line of fire
NARRATIVE: Whilst pulling out of hole with the drill test string, a tyre that was previously
installed in the mast as a shock absorber between the top drive torque track and the mast, fell
to the rig floor, glancing the front brim of a worker's hard hat. The worker sustained no injuries
however the tyre weighed 15.5 kg and fell from a height of 9.85m. Using the DROPS calculator
this event registers as having the potential consequence of causing a fatality. The area was
secured, relevant notifications made, a full mast inspection conducted to identify any further
potential hazards and a safety stand down meeting held.
WHAT WENT WRONG: A rubber tyre had been installed in the mast some years ago (date
unknown) in an effort to control damage from excessive shock. No management of change was
conducted at the time and the rig crew were unaware of the dropped object hazard. The tyre
was only secured with fibre rope. The dropped object inspection checklist did not contain the
tyre hazard and was not identified during any subsequent inspections.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Full rig inspection and dropped object
management system audit conducted by third party Revise dropped object management training
Contact OEM to review engineering controls to mitigate contact between torque track and mast
30
CAUSAL FACTORS:
devices
DATE: Jan 7 2018

LOCATION: VIETNAM
NARRATIVE: Utility Operator was taking a weekly HP boiler distilled water sample and came
into contact with an exposed live 110v cable
WHAT WENT WRONG: Monitoring of construction not effective and inadequate inspection of
equipment
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Live cable was from the original ship prior
to conversion to an FPSO and had not been used post conversion. Ensure adequate survey in
construction to identify and isolate all unused electric cables
CAUSAL FACTORS:
31
ASIA/AUSTRALASIA OFFSHORE
DATE: Apr 13 2018

LOCATION: AUSTRALIA
CATEGORY: Other
ACTIVITY: Diving, subsea, ROV
RULE: Line of fire
NARRATIVE: A rope was to be removed from the Pipeline End Termination (PLET) as it was a
potential hazard for the ROV system. On removal, the rigger mistakenly cut the retaining strap
instead of the rope which released the PLET’s stabiliser legs from 350m vertical to rest on the
Pipeline Induction Heat Injection Moulded Poly Propylene unit. There were no injuries or loss of
containment sustained from the incident.
WHAT WENT WRONG:
Equipment Design (Specifications) - the equipment relied entirely on a temporary restraining
arrangement & there was no secondary restraint.
Stored energy - The outriggers had been identified in the Task Risk Assessment however the
raised and restrained outriggers / stored energy wasn’t identified.
Update engineering standard to mandate secondary restraint on future designs. Including, the
Contractor Project Risk Management Process and the System Integration Testing to be reviewed
and updated to address gaps in Safety in Design assessment, Human Factors and guidance.
Communication to be improved – Supervisors confirming understanding of allocated tasks with
their workgroups is imperative to safe operations.
Training to be reviewed, updated and provided to Engineers / Field Engineers on Safety in
Design and Human Factors assessment.
CAUSAL FACTORS:
DATE: Apr 1 2018

LOCATION: AUSTRALIA
NARRATIVE: This incident occurred during FPSO commissioning. Contractors were tasked to
remove couplings on Heating Medium Pump C. On completion of the task it was identified that
the work group had inadvertently worked on the incorrect equipment (Cooling Medium Pump),
which was live (not isolated) and was in stand-by status. This means it could have been remotely
started from the Control Room at any time.
32
WHAT WENT WRONG: The Safe System of Work (SOW) Manual on roles and responsibilities
require the Area Authority (AA) to verify that all precautions specified for the work are implemented
by means of an area safety check including the checking of all isolations. By not visiting the
work site and conducting a site check as required, the AA did not follow the required procedure.
1. Area Authority shall always attend to the work site and conduct physical safety check before
approving any work to commence.
2. Approving work on the premise of “mutual trust” to a work party just because they are
seemed “familiar” with the work site and/or equipment is not acceptable.
CAUSAL FACTORS:
DATE: Oct 2 2018

LOCATION: MALAYSIA
NARRATIVE: Three persons were walking on the platform spider deck walkway when suddenly
a floor grating panel broke under the weight of one of them. The person fell into the gap, but
managed to cling to the ladder that he was carrying with another person, which prevented him
from falling into the sea. He was immediately rescued by his colleagues. He received minor
bruises on the left arm. All persons were wearing self-inflatable life jackets during the incident.
WHAT WENT WRONG: The panel had been badly corroded. During a grating inspection by a
contractor in 2017 the inspector had only carried out a visual inspection and assessed a low
level of rust (grade 7-G). No intrusive test was performed. There had been a lack of specification
about rust level assessment for gratings, leading to inspector’s own interpretation. The extent
of the corrosion had also not been verified by company’s expert team as the level of rust had
been rated as low in the final inspection report. Though daily hazard hunts are being performed
by the operations team, the spider deck area was not mapped as part of the site routine hazard
hunt walkabout and is seldom accessed.
• Company expert team to establish calibration of acceptance/failure criteria for grating
assessment and competency criteria (focusing on grating assessment) for inspectors during
topside structure inspection.
• Company expert team to be consulted to review topside structure inspection reports,
especially on the domain of corrosion activity. Develop standard operating procedure for
topside structure inspection and cascade the requirements to relevant disciplines.
33
• Routine hazard hunts and housekeeping to include every part of the platform and not
focusing on places where there are more activities.
• Periodic maintenance and surveillance for the gratings located at the sea deck, spider deck
and boat landing area as these gratings are more exposed to harsh environment condition
(splash zone). Corroded grating to be changed out.
• Practice extra vigilance if personnel would like to access spider deck area; PTW coordinator
to explain risks associated with this area.
CAUSAL FACTORS:
inspection/testing
PROCESS (CONDITIONS): Work Place Hazards: Inadequate surfaces, floors, walkways or roads
DATE: Sep 13 2018

LOCATION: THAILAND
CATEGORY: Other
NARRATIVE: A vessel was requested to support cargo offloading at a platform. The vessel
travelled to the platform at a speed of 8.0 knot (14.8 kph). The handover process from the Chief
Officer (C/O) to Master was performed at an approximate distance of 1.1 km from the platform
(around 600 m. before entering 500 m. zone), but with higher speed than the recommended
safe practice. The vessel speed could not be decreased in the limit time. Master tried to reduce
speed to reach final speed at 0.6 knot (1.1 km/hr), but the vessel could not be stopped or
sufficiently slowed. The master decided to activate reverse steering instead of drift away from
platform. The vessel could not be fully astern and collided with a Platform and caused the
platform label damage, support pipe broken and boat landing corner distorted.
WHAT WENT WRONG:
1. No enforcement to follow the navigational offshore location procedure, i.e., offset distance of
vessel route and offshore platform and not follow 500m. zone entering safety check list
2. Competency of key person. Technical training was not provided to crew.
34

• Conduct a 500m. zone re-entry audit to verify correct safe practices of PF approaching
operation. Quarterly audit is considered. - Capt. Competency and vessel 500m. entering
process shall be assessed and verified. Re-correct practice and process if found & required.
• All Capt. And C/O shall be trained on how to use CPP controlling system and functional.
This shall also including when emergency situation arise - All crews shall be communicated
for the risk of not follow the steering asset / waypoint but not limit to other MAE of vessel
operational. - Vessel owner is required to implement MOC reviews to determine the
adequacy of temporary or permanent changes with respect to their HSE MS;
CAUSAL FACTORS:
35
EUROPE ONSHORE
DATE: Sep 11 2018

LOCATION: AUSTRIA
CATEGORY: Overexertion, strain
RULE: Confined space
NARRATIVE: During work to open a flange (4 inch pipe) on a fitting part in a pit a hydraulic
flange spreader was used. Due to tensioning, the spreader became loose and was expelled
from the flange. Luckily it did not hit a worker or ignite a spark. During opening of the flange an
explosive mixture built in the pit which could have been ignited with a spark. The fitting part with
the flange was damaged.
WHAT WENT WRONG: No supervisor on site. Work was not properly planned. Wrong tools were
used in this kind of atmosphere. Fire officer also did not realise risk and did not stop work.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Prepare work instruction. Checking of
additional isolation methods like defitting of the adapter and using a blind cover. Chancing the
adapter and additional fit a shut-off-plate. Training for employees, contractors and fire officers.
Issue a technical safety alert to spread information.
CAUSAL FACTORS:
barriers
asphyxiant)
36
EUROPE ONSHORE
DATE: Apr 11 2018

LOCATION: GREECE
CATEGORY: Other
ACTIVITY: Seismic/survey operations
RULE: Driving
NARRATIVE: Vehicle rollover. While returning from the Field where the team was performing
surveys, the driver fall asleep and went off the road (to his right side). At the time the passenger
in the front seat was asleep and the passenger in the back was resting (not sleeping but his
eyes were closed). When driver the realised that the vehicle was off road he steered to the left to
get on the road and applied the brakes, and (by his statement) became frightened, oversteered
and then tried to correct it by steering back to the right, again oversteering. At the time the
vehicle had the front wheels on the gravel parking area and it started rolling over. The driver
stated that they rolled three times before they ended up back on the wheels in the parking area.
Driver and both passengers got out of the car on their own. The owner of the restaurant (on
whose car park the vehicle stopped) called the ambulance and the police. Ambulance showed
at the scene approx. 20 minutes after the incident and the all involved persons were taken to the
hospital. The police were on the scene before the ambulance and administrated Alcohol testing
(full report form the police is pending). The IP did not sustain major injuries. The passenger in
the front seat received several stitches to the head (to be confirmed upon receiving Hospital
release letter, passenger at the back bruises, driver bruises).
WHAT WENT WRONG:
• Procedures and control of operations
• Training
1. Additional toolbox talks for safe driving and emergency response
2. Fatigue refresh training with residual knowledge test. Fatigue management training for all
drivers (point out personal factors, recognition of fatigue)
3. Additional Refreshing Training about emergency response during driving for Contractor employees
4. Refreshing training for the accident involved driver prior to return for operation
5. Install Certified Rollover Protection Systems in off-road vehicles
6. Reduce the maintenance of the vehicle from 15000 to 7500 km, set a warning signal on the
IVMS device
7. Avoiding driving directly after lunch time (indicative 60 minutes)
8. Enforce maintenance of pre-shift medical checks records
9. Adaptation of the back-to-back schedule according to the level of fatigue of each person
during operations.
10. Journey Management plan to be updated implementation of the “two hour” rule become one
hour rule – mandatory stop every hour for 15 min.
11. Increase the frequency of driving assessment(s) – set KPI for assessments 10% of all
authorised drivers per month.
37
EUROPE ONSHORE
CAUSAL FACTORS:
barriers
DATE: Feb 16 2018

LOCATION: NORWAY
NARRATIVE: A crane operator and a rigger were preparing the jib on a mobile crane to lock the
angle of the jib at 0 degrees. The crane operator used a ladder to place the bolt in the jib to lock
it at 0 degrees (there are 3 holes to choose from, 0, 20, and 40 degrees, and the crane operator
placed the locking bolt in 40 degrees instead of 0 degrees). Afterwards the crane operator
placed the ladder in front of the jib and went into the crane to lower down the crane boom to
get some slack in the wire to be able to release the wire from the jib. When the crane operator
moved the ladder in front of the jib it seems that the jib was not fully down to 0 degrees, hence
the ladder got stuck under the jib. When the crane wire was pulled out the rigger tried to
remove the ladder, but the ladder was stuck. The crane driver came in front of the jib to help the
rigger to remove the ladder. The crane operator kicked on the bottom of the ladder and this got
the ladder loose but also made the jib slide down. The injured person, having one hand on the
crane wire at that time, was pulled under the jib with one hand stuck between the crane wire
and the lifting block. The IP’s left hand was severely injured.
WHAT WENT WRONG:
The bolt to set the degrees of the jib was mounted into the wrong position
The ladder was placed in front of the jib before the jib was lowered to the end position, hence
becoming the only structure to hold the jib in 0 degrees.
Even if the lifting operation itself is very well planned and coordinated, ongoing risk assessment
and involvement of the parties during change of circumstances are vital."
• The hole for the locking bolt on existing crane jibs must be clearly marked on both sides
• The routines concerning verification of the crane operators’ checklist must be adhered to
• Always ensure that nobody is within the closed-off area when the angle of the crane jib is
changed.
• Correct documentation from engineering would provide better predictability when adjusting
the crane jib angle (Could avoided changing the angle during the work operation)
38
EUROPE ONSHORE
CAUSAL FACTORS:
stress
DATE: Mar 12 2018

LOCATION: NORWAY
RULE: Line of fire
NARRATIVE: During pressure testing of pipe coils with water, a leak occurred. The leak hit an
operator on the face and he had suffered extensive damage. Operator was hit in the face by 315
bar water jet. The accident was caused by a leak under pressure testing of pipe spool.
WHAT WENT WRONG:
Direct cause: VPTG type packing yielded, was deformed and cracked. The operator stood in a
position where he was exposed to the water jet.
Root causes: Damaged/weakened packing, unknown underlying cause as of today.
Operator heard a sound, would do a closer check of the packing. Operator thought he was in a
safe position, he followed normal or “accepted” practice.
Learning:
• Avoid using this type of package.
• Establish Criteria for Job safety Preparation, SJA, toolbox talk, barriers and when to perform
close-up Inspection during pressure testing.
CAUSAL FACTORS:
39
EUROPE ONSHORE

inspection/testing
DATE: Feb 12 2018

LOCATION: ROMANIA
FUNCTION: Drilling
RULE: Line of fire
NARRATIVE: A contractor carried out a backward manoeuvre driving a truck with a trailer
loaded with drilling pipes. The manoeuvre was carried out in the minicamp area of a well
which lead to crossing into the sanitary group barrack from which the injured person (having
roughneck position) came out. The IP was crushed between the door and the barrack wall.
WHAT WENT WRONG:
• Poor supervision and insufficient communication between drilling contractor and
subcontractor representatives
• Improper site design / Incomplete assessment of the worksite before starting jobs
• No proper assessment of site before rig move
• Drilling sites should be assessed and inspected before starting the drilling jobs
• The main camps, especially the ones installed close to public roads, shall be proper
delimited or fenced in order to prevent trespassing by non-authorised personnel or vehicles
CAUSAL FACTORS:
DATE: May 6 2018

LOCATION: ROMANIA
FUNCTION: Drilling
NARRATIVE: When checking the fuel stock (diesel) of the drilling rig, the rig mechanic has
fallen from the ladder of the diesel tank (height of approximately 1.80-2 m).
WHAT WENT WRONG: Inadequate hazard identification or risk assessment Poor equipment
design Inappropriate operation mode
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Ensure that persons working at heights are
wearing harnesses and that lanyards are anchored appropriately Maintain three contact points
throughout the climb, descend and work on the ladders Improve the tank fuel measurement’s
method, using devices which not require working at height
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EUROPE ONSHORE
CAUSAL FACTORS:
improperly
stress
DATE: Jan 15 2018

LOCATION: ROMANIA
NARRATIVE: Pipeline rupture led to an uncontrolled gas release.
WHAT WENT WRONG: External punctual isolated corrosion due to a potential defect of the
external coating.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Continuing replacement of all segments of
this particular gas pipeline.
CAUSAL FACTORS:
inspection/testing
asphyxiant)
DATE: Dec 12 2018

LOCATION: ROMANIA
CATEGORY: Struck by
RULE: Line of fire
NARRATIVE: While the contractor’s team tried to unload 6” pipes from the truck, the crew
leader was on the top of the pipe stack and moved the pipes by using a crowbar. As the worker
removed the truck’s stanchions, the pipes started to move and roll down from the truck and the
worker fell down too. As a result, he suffered injuries.
WHAT WENT WRONG:
Poor contractor safety culture - Shortcuts and poor working practices were applied for
unloading the pipes by the chief of crew.
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EUROPE ONSHORE
Lack of risk awareness/assessment

Limited controls mechanisms for HSSE deviations/performances defined in the contract
Do not shortcut procedures and control measures established by PTW and JSA
Do not climb / stand on moving objects including stack of pipes under any circumstances
Use proper equipment / tools for the job performed
CAUSAL FACTORS:
DATE: Mar 13 2018

LOCATION: UK
CATEGORY: Other
NARRATIVE: Whilst attempting to start exporting hydrocarbons, there was a leak from a
failing valve stem packing on the main oil line export pump recycle flow loop. There was a
loss of primary containment with high potential, resulting in a platform muster, ESD and EPD.
Approximately 82 kg of hydrocarbons were released, resulting in an oil sheen.
WHAT WENT WRONG: Due to high velocities flow, erosive particles (suspected to be sand), high
pressure drop and constant use, the flow control valve was washed out, causing unconstrained
flow through the recycle line. Normally two pumps were in service. One pump had been offline
for a few months due to maintenance. During the start-up both pumps were online to re-
instate the pump that had been offline. The high velocity through the combined recycle line was
transferred to the flow control valve on the second pump, causing already loose gland nuts to
unscrew. These nuts provided the force to energise the packing, creating a leak path for the
fluids to atmosphere. It was believed the nuts were loose when the valve arrived on the platform
and the valve was installed as received.
Issues with flow transmitters (over the past 18 months) had led operators to believe that flow
readings were spurious.
• Review level of surveillance (inspection and monitoring).
• Review quality assurance (QA) checks and define QA expectations from vendors. Consider QA
checklist for offshore crew.
• Review work instruction for gland packing tightening during valve commission and
installation.
• Review instruments are not out of range for current operating condition.
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EUROPE ONSHORE
CAUSAL FACTORS:
devices
inspection/testing
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EUROPE OFFSHORE
DATE: Nov 21 2018

LOCATION: DENMARK
FUNCTION: Drilling
NARRATIVE: While a tool basket was to be lifted off the rig floor using a crane, two persons
were holding one tag line each to control the basket as it was lifted off rig floor. As the basket
was lifted, one of the personnel's leg got entangled in the tag line and he was lifted several feet
from the drill floor.
The crane operator immediately stopped the lift and lowered the load allowing the personnel to
free himself.
WHAT WENT WRONG: Lack of vigilance
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Lifting procedures to be re-emphasised to
the lifting crew and discussed during toolbox prior to work
CAUSAL FACTORS:
PEOPLE (ACTS): Inattention/Lack of Awareness: Lack of attention/distracted by other concerns/stress
DATE: Aug 27 2018

LOCATION: NETHERLANDS
NARRATIVE: Just before de-manning, the OIM from the normally unmanned offshore platform
did his last check round and smelled gas in the room of the gas generator. Approximately 800 kg
of fuel gas had leaked through the air inlet of a gas generator to the enclosure of the generator.
The gas generator had tripped, but the fuel gas to the generator kept flowing in because the two
remote operated valves in the fuel supply line to the gas generator failed to close on demand.
The OIM stopped the fuel supply to the gas generator by closing the hand valve in the supply line.
WHAT WENT WRONG:
Both remote operated shutdown valves in the fuel gas supply did not close on demand as the
actuators of these valves were stuck in the open position. Causes were that instrument air
was wet, resulting in corrosion and particle (corrosion products, absorbent) generation in the
instrument air system (actuators, solenoids).
Additional underlying causes were:
• Failures in design integrity/management of change; incomplete ALARP assessment of the
impact of changing to unmanned operation & incompatibility between the unmanned mode
of operation and the design of the installation.
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EUROPE OFFSHORE
• Failures in technical integrity; the instrument air auto-drain system was not operated/
maintained properly and alarm systems and remote operations were functioning poorly.
• Failures in operating integrity; i.e., alarm management was not effective, earlier failures of
the ROV on the gas generator were not identified despite physical IPF testing being done in
the field.
• Organise multidisciplinary session, revisit ALARP statement and develop criteria (re
instrument air/dryer, checking of actuators/solenoids, cooling capacity/ventilation, SIF
testing, procedures IA system). Work and mature concepts to de-complex platform and bring
systems on location in line with other NUI platforms.
• Dry and ‘clean’ instrument air system, replace faulty/degraded (safety critical) equipment.
Implement performance standard for instrument air. Review maintenance strategy plan.
• Increase knowledge levels on IA systems in NUI team.
CAUSAL FACTORS:
devices
inspection/testing
asphyxiant)
DATE: Jan 9 2018

LOCATION: NORWAY
FUNCTION: Drilling
CATEGORY: Struck by
NARRATIVE: After racking back the Cement head in the setback area, the lid of the cover for
the remote cabinet fell down on drill floor. The weight on the cover was 12.7 kg and fell down
21.3 meter into the red zone. During site post-incident inspection, the pin for the hinge was
found on drill floor, approximately 5 metres from the drop area. Weight of the pin was 180
grams. No personnel present in the red zone area.
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EUROPE OFFSHORE
WHAT WENT WRONG:

1. Risk assessment of the Cement Head design did not identify the hinge as a dropped object
hazard. The equipment was designed in 2013, pre-dating the introduction of Company’s first
global HSE Standard for Dropped Object Prevention Programs, in which dropped object risks
were specifically required to be analysed and controlled according to a hierarchy of control
measures.
2. When the Dropped Object Prevention Standard was revised in March 2017, it included the
requirement for Technology Group to risk assess equipment design for dropped objects and
referenced the external guideline ‘’Reliable Securing’’, as a source of hazard controls. There
was no retrospective risk assessment done on the existing equipment design.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: DROPS Risk Assessment of other
equipment used in height at rig site. Communicate ‘’Reliable Securing’’ (Rev.04) to global
technology group directors for each PSL, to reference when doing risk assessment of designs.
Any modification of equipment will be covered by MOC or Technical Bulletin. Request rental
equipment vendors to perform DROPS risk assessment and secure identified items on 3rd part
cement head/plug container.
CAUSAL FACTORS:
DATE: Oct 26 2018

LOCATION: NORWAY
CATEGORY: Struck by
NARRATIVE: During the night shift, a pipe connection was discovered lying on the gangway by
sack store. Investigation revealed that the pipe connection had come lose from a pipeline to
the Frac room 9 meters up. This is a pipe line in the Frac room that has been removed without
taking the entire line down. The pipe connection has rusted and eventually broken off because
of the weight. Fall energy of 247j.
WHAT WENT WRONG: Missing inspection program. Abandoned equipment corroding.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: All external pipe penetrations that are
wrapped must be inspected. When pipelines are decommissioned all pipes must be removed,
since that pipeline is removed from the maintenance program.
CAUSAL FACTORS:
inspection/testing
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EUROPE OFFSHORE
DATE: Apr 6 2018

LOCATION: NORWAY
ACTIVITY: Unspecified - other
RULE: Work authorisation
NARRATIVE: A vessel was engaged in debris removal along power cable route prior to
cable installation. Unknown objects recovered to deck via subsea basket, turned out to be
ammunition/grenades dumped after World War II. After the basket was recovered to deck, one
of the DO deck crew picked up one ammunition piece and drilled a hole in it on his own initiative.
After consulting with military/navy EOD experts ashore, it was advised to keep UXO out of
sunshine and keep wet by use of fire hose, until all UXO was over-boarded at safe location. An
investigation revealed that two days prior to this incident, a cartridge magazine found close by
was lifted from the seabed by an ROV operator in order to examine closer. At 80m water depth,
the cartridges “went off” and projectiles hits the ROV. The magazine was then dropped back on
seabed.
WHAT WENT WRONG: Area not known as potential dumping area during planning of operation.
Operator misinformed regarding potential dumping areas. Breach of procedures during
operation by bringing unknown objects to deck even if procedures says “no unknown objects to
be recovered to deck” Lack of understanding risk when handling UXO/ammunition on deck.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Case is still under investigation and final
recommendations are not given but the following has been proposed: Perform a magnetic
survey (UXO survey) for these type of route investigations close to shore. Arrange meeting with
Military/Navy to discuss action to ensure correct information is given vi single point of contact
at Military/Navy The responsibility to stop an operation and include new mitigating measures as
the risk level have significantly increased should be strengthened Develop a “UXO handling Best
practice” or “UXO GL document” for use in Company.
CAUSAL FACTORS:
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EUROPE OFFSHORE
DATE: Aug 3 2018

LOCATION: UK
FUNCTION: Drilling
CATEGORY: Other
NARRATIVE: 20” casing collar deformed and slipped partly through the horse-shoe elevator,
where it was caught by the elevator latches, and rested until the casing string was recovered
utilising an Inflatable Service Packer.
WHAT WENT WRONG: Prior to commencing drilling operations, it was identified that as a
consequence of wellhead selection there was no casing hanger or mudline suspension system
for landing and supporting the 20in casing during cementing operations. Consequently,
the casing would need to be suspended from the rig floor until the casing was cemented in
place. Use of the top-drive/casing elevators for suspending the casing during cementing was
infeasible, as the top-drive would be required to run the drill-pipe cement stinger into the stab-
in float. In the event that standard casing slips were used, there would be a risk that once the
cement had cured, there would be insufficient stretch in the remaining uncemented casing to
provide the required space to retrieve the slips. Consequently, after discussion with all parties,
it was planned that the Horseshoe elevators, supported by wooden sleepers positioned directly
onto the rig floor, would be used to suspend the 20in string. The Horseshoe elevators were to
be set on the rig floor atop wooden sleepers to facilitate removal if required, and a false-rotary
table constructed above it for running the drill-pipe cementing stinger. A selection of casing
pups were to be made available to minimise stick-up, which would allow the use of the Iron-
rough neck in making up the Drill-pipe stinger. This was reported as an industry-wide practice
for dealing with this problem. During operations, the final 20” casing Pup selected was overly
long – resulting in a casing stick-up in the region of 1.5m above the rig floor, rather than the
desired 0.5m, and steel beams were used in conjunction with the wooden sleepers to provide
the additional elevation required. However, the additional height meant that the Iron roughneck
could no longer access the drill-pipe, and rig tongs were required for make-up. The force-
vector from the line-pull on the rig tongs had an outward and downward (due to the elevation)
component during make-up, which was transmitted from the false rotary into the casing
collar & horseshoe elevator supporting it, and in turn the wooden sleepers supporting them.
This reportedly caused some minor damage to the collar, and approximately 1½in of uneven
deformation to the sleeper, resulting in the horseshoe elevator no longer being horizontally level.
Primary Lesson Learnt
1. A Mud line suspension, or a wellhead system which incorporates a 20” casing hanger,
should be used to support the casing during cement operations (should procurement lead
times allow). Secondary Lesson Learnt
2. Ensure planned rig-up is clearly communicated and understood by offshore team. Casing
pup selection should be followed explicitly to ensure the correct casing stick-up is achieved.
A higher than planned stick-up of the casing above the rig-floor resulted in the iron-
roughneck not being used to make up the inner cement string. While not a direct cause of
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EUROPE OFFSHORE
the failure, the use of rig tongs to make up the cement stinger connections contributed to
the uneven loading which resulted in the deformation of the wooden supports. (The reasons
for the selection of the casing pup which resulted in high stick is unknown, but is likely the
result of poor communication or miscalculation.)
3. Wooden supports with no design specification should not be used in this instance. Use
of metal I-beams supported by an appropriate jacking device with a suitable design
specification to suspend the weight of the 20” casing is recommended. The jacking device
would sit directly onto the rig floor and would be collapsed and removed after the cement
had set on the 20” casing.
CAUSAL FACTORS:
DATE: Jul 29 2018

LOCATION: UK
CATEGORY: Other
NARRATIVE: During platform routine inspection, a pressurised container was found unmanned
with the doors wedged open. The container housed numerous non-IS equipment that was
energised - resulting in a potential ignition source in a hazardous area. Furthermore, the
control for the cabin's purge fan was found to be in the “Bypass” position.
WHAT WENT WRONG: The root cause of the incident is not known because it was not
established from the investigation how the cabin came to have its doors wedged open and
its safety systems in bypass immediately prior to the incident. Influencing factors Contract
personnel new to platform and/or offshore environment were not supervised and/or monitored.
Lack of Competency Lack of Communication Lack of Supervision
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Identify number of personnel mobilising to
Platforms under Green Hat definition (new to platform and/or offshore environment), to ensure
the controls are in place to manage / monitor whilst offshore. New measures implemented in
planning phase to identify numbers of personnel mobilising who may be new to platform or
offshore to minimise impact on offshore supervision in managing new personnel onboard.
CAUSAL FACTORS:
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EUROPE OFFSHORE
DATE: Jul 5 2018

LOCATION: UK
CATEGORY: Other
NARRATIVE: During Performing Authority acceptance at worksite, low voltage equipment
was identified as not isolated. While carrying out a worksite inspection prior to the electrical
disconnection of Motor Operated Valve, the Performing Authority and the Area Technician
noticed the display light on top of the MOV was still illuminated. The MOV had previously been
confirmed as isolated by an Isolation Authority (IA) and Isolation Verifier (IV), although the
illuminated display indicated the MOV was still receiving power. The work was suspended and
the issue reported to the Responsible Electrical Person (REP) for further investigation.
WHAT WENT WRONG: Insufficient Detail of Work Rules/Policies/Standards/Procedure
Inadequate monitoring/housekeeping
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Lesson: Verification steps within processes
are a key to identifying potential controls not being applied or in place. Procedures to be more
specific around key steps of Control Of Work to ensure personnel check and verify isolations are
applied correctly.
Increased monitoring of COW compliance.
CAUSAL FACTORS:
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EUROPE OFFSHORE
DATE: Feb 18 2018

LOCATION: UK
RULE: Line of fire
NARRATIVE: The Gas Import Manifold was being lined up to the production flow line during
offshore commissioning works. As a valve was opened, the cavity bleed plug at the bottom
of the valve was ejected without warning and with explosive force - driven by a pressure of
approximately 128 Bar.
WHAT WENT WRONG: Inadequate procedures for leak testing of the valve, operator line checks
and gradual introduction of gas across the valve.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Updated procedures to mandate scope of
valve leak testing, gradual introduction of gas and line walks.
CAUSAL FACTORS:
inspection/testing
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MIDDLE EAST ONSHORE
DATE: May 25 2018

LOCATION: IRAQ
FUNCTION: Drilling
NARRATIVE: While preparing to lift a fly camp cabin with a Reach Stacker, a wire sling
became caught on a cabin roof obstruction during installation. In the process of releasing and
repositioning the slings, the cabin was dragged from its wooden foundation blocks by the Reach
Stacker and injured a local national contractor Rigger, trapping him between two cabins.
WHAT WENT WRONG:
• The cabins were not checked for roof obstructions prior to the lift
• There were changes to key lift crew mid-way through the work
• Communication between foreman and RS operator was not clear when the lift plan changed
• The Lift Foreman was not able to see that all riggers were outside the Line of Fire or that all
slings were fully released before giving a signal to the RS Operator
• Wooden blocks had been introduced as cabin foundations which adversely affected the
stability of the cabins
• Communication between foreman and RS operator was not clear
• The wooden blocks used as foundations decreased the stability of the cabins
• The IP did not follow the Line of Fire principles, in that he returned to the position where the
sling and lift point, which was between two cabins
• The Tactical Operations centre was not notified of the incident
• The JSA was not discussed at the TBT prior to the job starting When the lift plan changed,
there was no discussion with the lifting team to communicate changes
• The PTW system had significant gaps
• The lifting team were fatigued due to Ramadan fasting and lack of rest breaks, which was
exaggerated due to the intense heat (45C)
Lessons learned :
• P
erceived or real pressures of time based penalties should be owned by senior management
and deflected from the teams at the rig site
• A
pplication of working in extreme heat during periods of fasting needs to be managed more
robustly
• T
he hazards and controls need to be clearly understood by all those planning and executing
the work
• B
usiness decisions and strategies that end up effecting the operational scope of work need
to be raised immediately
• T
he Tactical Operations centre was not notified of the incident as per MERP protocol –
communication protocol was not clear Recommendations
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MIDDLE EAST ONSHORE
• F
ly camp cabins not to be placed on individual blocks. Cabins to be set directly on ground,
else onto master skids and suitably secured
• U
se Polyester slings which are easier to handle and less prone to releasing and snagging/
catching. Slings can be secured with tape and sling tag line once installed round trunnion lift
point to choke the sling and hold it in position, whilst allowing the rigger to stand at a safe
distance
• R
iggers to stand far enough back from the load so that they are all in direct line of sight of
the Reach Stacker Operator before he operates any function
• A
ssess how mobile office and accommodation cabins in your operation are supported and
secured, and the impact this has on the stability in position and when lifting
• R
each Stacker to be switched off whenever Riggers are required to approach the load to
install/remove the slings
• C
ommunication during lift operations to be clear with single point accountability of the
Person In Charge to provide instructions during lift operations
• W
orking in extreme heat during periods of fasting needs to be managed with minimum work
and rest periods specified
• Review the number of cabins that are required on site, which will reduce loads and exposure
CAUSAL FACTORS:
stress
PROCESS (CONDITIONS): Work Place Hazards: Congestion, clutter or restricted motion
DATE: May 19 2018

LOCATION: QATAR
NARRATIVE: While descending from cleaning windows at elevation, a contractor cleaner fell
from a height of around 2 meters. Operator heard the fall and found the cleaner with a minor
hand injury. FM team stopped the work for the cleaner.
WHAT WENT WRONG: The motorised cradle has not been in service due to maintenance issues
and due to the limited number of people that can use the basket at one time; The IP ignored the
advice of his supervisor and proceeded with the shorter working rope; The IP was not prevented
from proceeding working with one shorter working rope by the supervisor; No supervision was
available from Contractor or from the Company; The IP ignored the supervisors request to
connect to the neighbouring workers safety line.
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MIDDLE EAST ONSHORE

1. Subcontractors cannot be allowed to work unsupervised by Contractor or Company
Subcontractor, Contractor, and Company supervisors and personnel need to be made aware
of the Company’s Stop Work Policy, which states “If you observe an unsafe act or unsafe
condition – Stop the Work”
2. Task Risk Assessments for high risk activities need to specifically list out the steps of work
and identify specific safe guards. Safe guards in the preparation phase of work might not be
the same as same guards during the work execution phase.
3. Documents governing Safe Work Systems need to be reviewed after any changes to
HSESMS, Organisation.
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Violation intentional (by individual or group)
improperly
DATE: Oct 20 2018

LOCATION: QATAR
CATEGORY: Other
NARRATIVE: Inadequate Hydraulic Control Pressure on DHSV during slick line operation. The
Well was handed over to Well Services the previous day and slick line equipment was rigged
up. The DHSV, UHMV and its Hydraulic Jack Controls were hooked up to a Well Intervention
control panel. The Hydraulic connection for DHSV was mistakenly connected to Hydraulic Jack
and Hydraulic jack intended connection was installed on DHSV. The Hydraulic jack operates at
a comparatively lower pressure of 3500 psi, whereas DHSV requires control pressure of 7500
psi. This caused inadequate operating pressure on DHSV resulting it not being fully open during
Slickline Drift Run. The tool string when being pulled up could not pass through the DHSV
and during fault finding the switching over of connections was discovered. The Connections
were properly made and the Slickline tool string was recovered. There was no damage seen to
either Slickline or tool string. The DHSV was inflow tested on 26th October 2018 and was found
working satisfactorily.
WHAT WENT WRONG: Task Risk Assessment did not address the possibility of mistakenly
switching the hydraulic connections; the connection for the DHSV was mistakenly connected to the
hydraulic jack for UHMV; field checks did not identify the mistake in the hydraulic hose connection.
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MIDDLE EAST ONSHORE

Lesson 1 - The Hydraulic connections hook up wherever possible should be equipped with end
connections to avoid the swapping (Already implemented).
Lesson 2 - Operation Check list for Well intervention operations prior to start of each shift to
cross check the set up. (Already implemented).
Lesson 3 - Enhance the shift handover during Well intervention operations with written
handover between shifts (Already implemented)
CAUSAL FACTORS:
stress
DATE: Sep 9 2018

LOCATION: QATAR
CATEGORY: Other
NARRATIVE: Fire alarm activated in the kitchen and the gas supply system shut down.
Company Security turned off the alarm. Gas company was called and investigated, stated a
sensor was faulty and did a calibration. The next day, the Fire alarm activated again and the
gas supply system shut down at 04h00 during food preparation; Security turned the alarm off
again. The gas company was called and investigated stated that catering company had removed
a gas hose without blocking it off which resulted in a gas leak (gas ball valve was closed but not
locked out).
WHAT WENT WRONG: Maintenance work are not controlled by any PTW system; HSE
assessment on whether PTW is required or not based on contractor maintenance work
activities schedule was inaccurately done; Weekly inspection being conducted by contractor
found inadequate. Description of reported issues are either incomplete or unclear.
1. Ensure awareness session is conducted for all catering and facility personnel on PTW and
Emergency process.
2. Study replacement of gas supply system with electrical enforce PTW procedure in the
accommodation.
3. Improve supervision in the accommodation.
4. Review and modify the maintenance program and control frequency of gas supply confirm
the competency and skill of contractors.
CAUSAL FACTORS:
55
MIDDLE EAST ONSHORE
DATE: Oct 22 2018

LOCATION: QATAR
CATEGORY: Other
NARRATIVE: During a routine Area Operator surveillance round, detached and broken PVC/FRP
cable tray cover sheets were found in different locations on the south side of seawater cooling
towers on the ground floor, in a U-ditch, and on top of the cooling tower. It is suspected that
heavy winds during the day caused the cover sheets to become detached and fall from the top
of the cooling towers from a height of approximately 30m. All operation staff were alerted and a
notification was raised.
WHAT WENT WRONG: Object weight approx. 20kg/Dimensions approx. 1m x 2.7m. Object
material: PVC/FRP (marine specification). Clamps are fixed approximately every 2.5m at the
edges of the cable tray cover sheets. Clamps were found to be loose in most of the locations.
Heavy winds were observed on the day of incident.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: The clamps and fixing arrangements were
not robustly designed and performed poorly when high wind conditions caused vibration. The
clamp bolt is a friction hold clamp which does not penetrate the PVC/FRP cover sheet. Friction
hold clamps should not be used with PVC/FRP cover sheets. Each clamp had only one bolt.
The clamp selection was decided by the subcontractor according to manufacture preference.
Be alert to objects being unexpectedly detached and falling to the ground during high winds.
Provide double stainless steel straps, a minimum of 3 per cover sheet, and remove the clamps
to avoid the hazard of Falling Objects. Inspect the Cooling Towers for similar types of covers and
clamps. Specifications are to be updated to include a statement about avoiding use of friction
hold clamps for PVC/FRP cable tray cover sheets.
CAUSAL FACTORS:
DATE: Mar 18 2018

LOCATION: QATAR
CATEGORY: Other
NARRATIVE: One piece of Flue gas stack aluminium cladding, of an approximate weight of
3kgs, in HRSG 8 was detached and fell down, from a height of approximately 13 meters, to the
ground.
WHAT WENT WRONG: Poor workmanship when installing the cladding; There is no formal
process for prioritising maintenance tasks; Maintenance planner did not action on the SAP
notification; Maintenance planner thought the notification was erroneously assigned “urgent”,
as it was not discussed in the daily PTW meetings.
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MIDDLE EAST ONSHORE
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Escalation of risk due to improper

assessment of the risk related to unsafe condition Job prioritisation and scheduling mechanism
to be developed to rank the jobs of same priority category (Urgent).
CAUSAL FACTORS:
inspection/testing
DATE: Sep 21 2018

LOCATION: QATAR
CATEGORY: Other
NARRATIVE: Signs of leaking were observed on the gravity separator PSV line. Dark patch
observed on the 10’’ line on the vertical section of the line U/S of the PSVs.
WHAT WENT WRONG: Report not completed
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Report not completed
DATE: Dec 11 2018

LOCATION: QATAR
CATEGORY: Other
NARRATIVE: A team performed a UT scan on U/S line. When reinstalling the cladding the
worker was unable to align the cladding properly, and tried to make a new hole with the screw.
The worker used a non-IS battery powered drill to force the screw through the cladding. The
cladding was directly in contact with a steam tracing line (steam temp 175C, pressure 7.5barg),
that was exposed without isolation and heavily corroded. The screw penetrated the steam line
and made a pin hole, steam was released through the pinhole.
CAUSAL FACTORS:
57
MIDDLE EAST ONSHORE
DATE: Jul 16 2018

LOCATION: QATAR
CATEGORY: Other
NARRATIVE: At around 13H45, glass shards fell down from the newly constructed building,
which is located on the East side. Traces of broken glass were found scattered around the area
and near some vehicles parked and the main gate. No damaged was recorded.
DATE: Aug 20 2018

LOCATION: QATAR
CATEGORY: Other
NARRATIVE: After removal of PSV top from demethaniser column, valve technician arranging
the tools inside the tool bag, while closing the bag zip the hole bar slipped from bag and fell
down on 30” cold insulated feed gas line. Hole bar fell and pierced into cold insulation of 30”
gas line. The hole bar fell from a height of approximately 45 meters and had a mass of around
1.5kgs.
DATE: Mar 20 2018

LOCATION: QATAR
CATEGORY: Other
NARRATIVE: During a planned Shutdown activity, it was observed that the Electric Overhead
Traveling (EOT) crane gearbox shaft mounting had become detached/broken and the motor was
being supported by the power cable conduit. This observation was made when EOT crane was
not in use.
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MIDDLE EAST ONSHORE
WHAT WENT WRONG: A visual inspection revealed that the gearbox shaft had failed resulting
in the motor becoming detached and hanging. The EOT crane had been used extensively for
the previous 2-3 days before the incident. A metallurgical examination identified that overload
by external obstruction/force was the cause of the EOT crane shaft failure. The most credible
hypothesis for the cause of the overload is obstruction of the crane’s movement by a scaffolding
structure located in the pathway of the EOT crane.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: When installing temporary structures
(scaffolding, etc.) in and around plant areas ensure that moving equipment are not obstructed.
Before using a moving mechanical device ensure the machinery’s travel pathway is free
from any potential obstructions. Communicate the finding to the Shutdown team and field
maintenance to ensure that there is not restriction to the movement of the EOT cranes
(PREVENT). Communicate with crane OEM to get the material standard for the failed shaft, and
replace the recently installed with a new shaft of the recommended shaft (PREVENT).
CAUSAL FACTORS:
DATE: Oct 22 2018

LOCATION: QATAR
CATEGORY: Other
NARRATIVE: A personal vehicle in the employee parking area was observed to have been
damaged. The back and front windshields were damaged, and the vehicle bonnet and fender
were dented due to impact from exterior glass panels and frame debris falling/flying from
heights of adjacent building due to strong winds and rainy conditions that prevailed during
afternoon. Company security front desk was informed immediately and they conducted visual
inspection.
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MIDDLE EAST ONSHORE
DATE: Sep 20 2018

LOCATION: QATAR
NARRATIVE: Pin hole leak in the DSO gravity separator PSV line. At 1425 hrs area operators
informed leak at the DSO Gravity separator.
Condensate flow diverted to RUN DOWN.
WHAT WENT WRONG: As per design, the dome will always have a liquid level which accordingly
indicates that the PSV line will contain some liquid; A top section of the Oxidation Tower and
Gravity Separator given the presence of some acidic and corrosive Off gas loop. The metallurgy
of the 10” PSV line is however Carbon Steel.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Dead legs pose a threat of corrosion
especially in portions made of Carbon Steel
Periodic inspection of the PSV lines for the separator vessels and to be conducted by AI. This
involves external UT scanning for any thickness reductions. This action is added to the “Routine
Onstream Inspection” list owned by AI.
CAUSAL FACTORS:
DATE: Oct 25 2018

LOCATION: UAE
CATEGORY: Exposure noise, chemical, biological, vibration
NARRATIVE: A boiler was being prepared for start-up and deblinding activities were in
progress by mechanical technicians. While deblinding the 1” acid gas flare line from the fuel
gas heater, suddenly fuel gas leaked out of the line and began pooling in the nearby area. The
Technician left the area and alerted the fire crew. Meanwhile, the Operation/Maintenance crew
using nearby fire hydrant monitors started water spray immediately. The fire crew also arrived
at the site; by the time, leaking hydrocarbon was successfully contained by water spray and
subsequently it was fully stopped within minutes by isolating from the upstream valve.
WHAT WENT WRONG: Exposure to H2S.
1. Retrain and reassess the PICWS’s for his PTW roles and responsibilities in Utility Area
2. Retrain and reassess the Shift controllers, Assistants and Field Operators for their PTW
roles and responsibilities in Utility Area
60
MIDDLE EAST ONSHORE
3. Retrain and reassess the Originators / Operation Coordinators / Shift Controllers for their
PTW roles and responsibilities in Utility Area
4. Retrain and reassess the Maintenance Engineers and Supervisors for their PTW roles and
responsibilities in Utility Area PICWS / Supervisor.
5. Create a handover logbook from Operations to/from Maintenance to capture work (permit)
related items.
6. Review working hours for critical functions (maintenance).
7. Apply LSR Consequence Management for violations during the deblinding incident.
8. Issue instruction to Operations to have all High Risk work approved prior to weekends and
holidays; any unplanned High Risk work to be approved by the Duty Manager.
9. Awareness sessions to be conducted for all staff in Utilities Area on risk assessment, with
particular focus on work involving H2S.
10. Train all personnel in Operations and Maintenance on the details of the Process Safety
Fundamentals
11. Conduct sessions at all levels on the lessons learnt from this blinding/de-blinking activity
12. Review & enhance e-PTW Process in terms of Delegation, Authority, Time, Resources and IT
Infrastructure.
13. Phase out the use of all paper based PTW and supporting documents and use e-PTW
instead.
14. Coach Line management for activity planning & priority management to avoid creation of
unwanted job pressure & job handling/follow-up.
15. Rotate staff from area to area after (maximum) 5 years.
16. Operation and maintenance Line Management to conduct rollout sessions for Process Safety
Fundamentals.
CAUSAL FACTORS:
asphyxiant)
61
MIDDLE EAST ONSHORE

DATE: Oct 29 2018
LOCATION: UAE
NARRATIVE: The contractor was working on pipeline for a coating repair job and backfilling
activity. Due to heavy rain at the time of incident, the shovel slipped down hill and operator lost
control. The contractor informed control room that the JCB was stuck due to rain and they are
leaving the site. The mechanical shovel was going down the hill then slipped, hit the side of the
mountain and rotated 180 degree. The next day operation visited the site and confirmed there no
injuries or asset damage reported, except for JCB being on the berm.
WHAT WENT WRONG:
• ROW is blocked due to washout by heavy rain.
• Performing authority wrong decision by choosing the ROW to drive in the steep slope for
demobilising the equipment from the work location without prior permission from the
issuing authority.
• Operator not having experience in driving Backhoe equipment in the steep slope.
• No any warning signboard at both end of the steep slope mentioning not allowed to drive for
any unauthorised vehicle/equipment.
• Driving the Backhoe Equipment in the steep slope is not captured in the Method statement
and TRA.
• ROW is very steep slope, lot of small stones in the row which fall from the side of the cliff.
• Mobilising the Equipment /driving the equipment in the steep slope not identified in the SOW.
1. Capture the task mobilisation of equipment / vehicle (driving) in the ROW steep slope in any
task in ROW.
2. Equipment operator experience in driving in steep slope shall be verified before driving in
steep slope.
3. Equipment capability to drive in the steep slope shall only be used to drive in steep slope.
CAUSAL FACTORS:
62
MIDDLE EAST ONSHORE
DATE: Apr 26 2018

LOCATION: UAE
CATEGORY: Other
ACTIVITY: Transport - Land
RULE: Driving
NARRATIVE: A subcontractor driver was returning to their workshops after dropping
another worker who went to attend an induction at the project site. Whilst heading back
toward workshops on what is typically a busy blacktop road used primarily by company and
subcontractor employees, he lost control of the vehicle. He attempted to regain control, but the
vehicle rolled over, off the road and onto sand dunes, about 4 meters away from the blacktop
road. The driver was uninjured. The vehicle is installed with rollover bars. The police and the
company were informed and they arrived promptly. The driver was taken by police ambulance
to hospital for further check-up and was discharged a few hours later. He resumed work the
following day.
WHAT WENT WRONG: The incident was due to inattention by the driver. He was distracted by
something that he had failed to disclose which caused him to deviate to the wrong side of the
lanes, directly facing oncoming traffic. Further reactions to regain normal lane, caused him to
swerve deeply and lost control.
• Conduct Safety Awareness sessions to communicate the key requirements of the Company
Road Safety Management to all categories of project drivers.
• Measure and validate the effectiveness of previous Road Safety Awareness campaigns and
incidents’ findings recommendations.
• Provide continuous refresher awareness trainings and meeting based on how to identify and
over road surprises and all road safety rules.
• Provide awareness, posters, stickers and sanctions to prohibit the use of mobile phones
while driving.
• Review and provide road safety coordination and management plan that oversees and unifies all
transport and road safety requirements for the project, including the subcontractors systems.
• Provide clear monitoring and control system to track all existing and newly introduced
vehicles and drivers in the project sites and locations.
• Review and provide dedicated position for transport coordinator at the main Contractor level,
overseeing all project’s vehicles and drivers including main and all the subcontractors.
• Carry out regular route survey and assessment of hazards associated with routes used
for the project journey movements in reference with attachment E-Memo to GLT Oct.22nd,
2014 and AGP Road Safety Management Manual, GS-MAN- 003 Section 2.8, page 18/95,
“Identification & Selection of routes to avoid High-Risk Areas in Projects”.
• Provide and regularly review and update the vehicle and equipment movement plan for the
project. This shall include the route survey, associated road and vehicle hazards, and road
conditions and as well as providing, communicating and implementing all relevant control
measures communicating control measures.
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MIDDLE EAST ONSHORE
• Carry out road and route survey as part of induction/re-induction with project drivers at
regular intervals. Survey shall capture and provide joint agreement to avoid all associated
hazards on the routes. Identification, control and marking of bend spots and other hazards
including avoiding heavy duty trucks in the narrow lanes.
• Carry out regular Road Safety Campaigns involving all road users in the project through
practical drive through of the routes, sharing and communicating areas of improvements.
• Update and provide project Equipment and Vehicle movement plans, including all the
project’s routes and ROWs, survey plans and complete assessment and controls for
identified hazards and control measures provided
CAUSAL FACTORS:
stress
DATE: Jul 7 2018

LOCATION: UAE
CATEGORY: Other
NARRATIVE: A contractor was preparing for road work near the plant and was loading and
unloading materials at the plant and worksite. While moving the truck outside the plant, the
truck boom hit the goal post safe guarding the vent line and damaged the goal post. The goal
post is between the fuel gas system and metering skid.
WHAT WENT WRONG:
• Performing Authority PTW Procedure violation.
• Project Engineer instructing his subordinate to conduct non planned, risk assessed nor
authorised activity.
• Assigned banksman was not certified nor trained.
• Lack of attention and/or Poor judgment from the driver/crane operator.
1. PTW Performing Authority qualification to be revoked.
2. A Mandatory awareness session to be conducted to all projects and maintenance contractor
staff assigned to conduct works covered by PTW procedure.
3. An official written warning to be addressed to Project Engineer.
4. Standing Instruction to be issued to all issuing Authorities to ensure assigned banksman
certification prior to issuing any Vehicle Entry Certificate.
5. Concerned Issuing Authority to undergo refresher training.
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MIDDLE EAST ONSHORE
6. Standing Instruction to be addressed to all Issuing Authorities, instructing them to abide

by PTW Procedure rules regarding multiple number of PTW issued to a single Performing
Authority.
7. Overhead vent pipeline protection goal post to be relocated at safe distance.
8. All overhead pipeline/power lines protection goal post to be surveyed to insure proper safe
distance is maintained.
9. Engineering Standard regarding Overhead pipeline/power lines protection goal post
specifications to be developed.
CAUSAL FACTORS:
stress
65
MIDDLE EAST OFFSHORE
DATE: Nov 23 2018

LOCATION: QATAR
FUNCTION: Drilling
NARRATIVE: During lifting operations using a 72-ton Offshore Pedestal Crane, a loud crashing
noise was heard whilst lowering the hook to lift a load. The three Riggers involved in the lift
looked up and saw the crane boom rapidly descending. The boom struck the steel deck of the
Drilling Rig and punctured the deck plate, leaving a 1 meter hole. The boom was badly damaged
requiring a full replacement. No personnel were injured.
WHAT WENT WRONG:
Boom Failure
• Wire failure resulting in boom failure and impact with deck level. Inadequate Leadership and
Supervision
• Inadequate instruction, Orientation and training
• Seadrill Detailed Instructions (DIN) for wire rope/ wedge socket replacement not know. Lack
of competency
• Lack of job knowledge. Onboarding Process/ Training
• Failure to trin Seadrill personnel on relevant SWP and Procedures. Management of Change
• Shortened retention pin was cut but not documented as a temporary modification.
Ensure instructions for wire rope and wedge sockets replacement are up to date, available, and
understood. Ensure personnel are competent to perform assigned tasks. Ensure procedures
for the verification of works are carried out. This incident validates the importance of complying
with Life Saving Rules (never walk under suspended loads), the controlling of work locations,
and preventing non-essential personnel from entering an area.
CAUSAL FACTORS:
66
DATE: Jul 19 2018

LOCATION: QATAR
FUNCTION: Drilling
NARRATIVE: The deck crew were preparing to lower the barite bulk hose from starboard side
station to the supply vessel. Prior to lowering the hose, the crew had to remove the Camlok
Aluminum cap (1.14 kg). Upon opening the Camlok fittings, the cap blew upwards and struck
the starboard crane cabin lower window, no injury to personnel on board.
WHAT WENT WRONG: The combination of the mixing operation in progress, the passing valves
and the weather cap in place at end of bulk hose generated the pressure trapped in the hose
at the time of incident. Missing procedure/work instruction for dry bulk product from/to supply
vessel. Use or not of the weather cap at the end of bulk hose not determined.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Remove all Weather caps on bulk hose
and put plastic protection. Repair valves leaking operations wise. Update the procedure and
issue work instruction for dry bulk transfer product. Making a Preventive maintenance template
report of all valves status with critical valves identified (in between mixing transfer and bulk
transfer).
CAUSAL FACTORS:
inspection/testing
DATE: May 10 2018

LOCATION: QATAR
CATEGORY: Other
ACTIVITY: Transport - Water, incl. marine activity
NARRATIVE: The tugboat had blackout of main engine due water ingress during oil transfer
operations: A vessel was engaged as hold back tug of an export tanker during an offloading
operation in the field. The vessel was facing moderate/rough weather throughout the operation.
During this period a Gale Storm warning was also reported. The vessel experienced an
unpredicted inclement weather condition. The mean wind was blowing 35 knots gusting up
to 50 knots with seas between 2-3 meters. The vessel was experiencing seas being splashed
on her stern deck and water drained through the deck scuppers. During this time the vessel
experienced a blackout and she lost all her power to its thrusters and main propulsion. This
lead to a potential jack-knife situation between FSO and the Export tank.
67
WHAT WENT WRONG: Due to the design of the deck scuppers and routing of drain, which
runs through the fuel day tanks. Also due to corrosion at the Scuppers and deck connection,
splashed water directly went into the Fuel Day Tank. Due to the water ingress (from Scuppers
on the deck) directly into the day Fuel tank, the fuel got contaminated. Contaminated Fuel
choked the Filters and Supply lines to the Main engines which eventually caused a Blackout.
The Vessel’s Safety Management System also had a heavy weather criteria wherein the limit for
all towing operations was 30 knots. However the Vessel continued to do hold back of the export
tanker with winds reaching 35-50 knots.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Design Flaw – vessel to confirm the design
of the scuppers do not penetrate the Fuel Oil Service/Day tanks. Poor Maintenance – Planned
maintenance system to ensure that all equipment is inspected and maintained as required.
Particular attention to be given to tight areas where corrosion can occur. Safety Management
System – Compliance of the Vessel’s Safety Management System (SMS) is a must along with the
Bridging document. Vessel operators to carry out deep dive audits on all chartered vessels to
ensure SMS compliance is being carried out. Company will request Spot Audit reports to check
the effectiveness on the compliance.
CAUSAL FACTORS:
DATE: Aug 14 2018

LOCATION: QATAR
CATEGORY: Other
NARRATIVE: Ampelmann walkway retracted exposing individual to potential fall to sea.
Following the personnel from offshore satellite platform to a vessel with Ampelmann walkway,
the amplemann retracted prematurely exposing individual between the platform and the end of
amplemann gangway with the potential to fall. A worker lost balance at the edge of the platform
and nearly fell into the sea while attempting to recover the life jackets in a bag stored at the end
of the gangway.
Ampelmann operator immediately noticed the presence of a person at the platform gate and
immediately reconnected the gangway. No injuries to the person.
WHAT WENT WRONG:
• Insufficient identification of Ampelmann use and needs
• Deviation from Procedure without triggering the MOC (Management of Change )
• No process to grant the consistency of working documents & their correct
• Communication and Implementation
• Insufficient level of risk awareness
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Re-assess the need and review the management of life jackets for personnel transfer by
Ampelmann.
Manual guide document for personnel transfer operations by Ampelmann shall be produced
and validated.
Induction / speech on management of change shall be delivered on contracted vessels for
Ampelmann operations
Review all the documents issued on Ampelmann operations and ensure their consistency
Gatekeepers shall be designated and formally nominated for each site.
Nominated gatekeepers shall be provided with required induction as per their respective roles
and duties.
CAUSAL FACTORS:
DATE: Nov 5 2018

LOCATION: QATAR
NARRATIVE: A High Pressure Gas Compressor was stopped for LP/IP engine change out. The
fuel gas system was being prepared for Nitrogen Purging. During this preparation, a gas leak
occurred which triggered the F&G system to launch an ESD-2 Trip.
WHAT WENT WRONG:
• Substandard Isolation
• Management of Change Competency/Roles and Responsibilities
• Filter body and cover
• Sealing surfaces
• Pressure visibility on CCR
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Process Isolations to be prepared and
executed. Procedure to be rolled out with adequate level and complexity in examples and
exercises. Proper training to be done. Once training and assessment completed, Isolation
Authority shall be nominated and recorded in the HSE dossier. Filter covers and body to be
surfaced. Evaluate conversions of an existing PI into PT transmitter to provide visibility to CCR.
69
CAUSAL FACTORS:
DATE: Sep 2 2018

LOCATION: QATAR
CATEGORY: Struck by
RULE: Line of fire
NARRATIVE: Standby boat was in the process of mooring. Hawser transfer from FSO stern to
the Export Tanker bow, the Monkey fist (end of heaving line) from the export tanker struck the IP
on the left side of his face resulting in an injury.
WHAT WENT WRONG:
• Risk assessment did not assess the risk of passing/throwing Messenger line
• Monkey fist was found to contain an additional weight (prohibited)
• Crew Resource Management - Bosun distracted with other task
• Throwing of monkey fist deemed a routine task
• Standby boat was closing in on the Export Tanker, following two failed attempts to pass line
Risk assessments to be modified to include the assessment of passing the messenger line.
Bosun to have a single task of overseeing the mooring operation.
Review how messenger line is passed to determine if there is a safer way.
Monkey firsts to become part of the export tools and swapped for bags filled with sand.
Issue safety notification highlighting that the practice of adding additional weights to a
messenger line is not allowed, within Company operations.
CAUSAL FACTORS:
stress
70
DATE: Nov 30 2018

LOCATION: UAE,
CATEGORY: Water related, drowning
NARRATIVE: During personnel transfer, two out of the three mooring lines used to secure
the vessel to the platform ruptured under tension. During the rupture of the mooring line, the
rope impacted the handrail of a ladder going from the sea to the boat landing and ripped it out.
Nobody was injured.
WHAT WENT WRONG:
• Swell from stern starboard side
• Caused tensions on the lines
• Inspection of mooring lines not currently part of the inspection checklist
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Personnel should avoid waiting on the
boat landing during swing rope transfer. Reinforce in the HSE Talk the fact that all personnel
is empowered to say “no” if they assess the swing rope transfer as “unsafe”. Update the
current inspection list in order to add the verification of the mooring lines & their associated
certificates.
CAUSAL FACTORS:
inspection/testing
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NORTH AMERICA ONSHORE
DATE: May 28 2018

LOCATION: CANADA
NARRATIVE: High winds blew a loosened HVAC panel off the HVAC unit and to the ground. Upon
investigation of the panel, it appeared there was only damage to some of the screw holes, and
others showed corrosion, suggesting that not all screws were in place.
WHAT WENT WRONG:
• High winds
• Human error – HVAC panel improperly affixed
CORRECTIVE ACTIONS AND RECOMMENDATIONS: HVAC maintenance service provider will be
completing weekly inspections and will also provide us a report of any findings.
CAUSAL FACTORS:
inspection/testing
DATE: Jul 17 2018

LOCATION: USA
FUNCTION: Drilling
NARRATIVE: An electrician was injured while working to replace a brake resistor fan motor on
a drilling rig. Electrician was working with the toolpusher and motorhand. A JSA meeting was
held and the equipment was locked out. The old fan motor was removed and the new one was
installed. Before fully securing the fan, rotation direction of the fan was tested. After completing
the process of testing the fan rotation direction, the fan motor breaker was locked out again.
The electrician was in the process of securing the fan when the rig ground fault indicator
alarm sounded. The motorhand left the IC and went to VFD House to see what had caused the
alarm. When he returned, he found the IC unresponsive on the ground. AED was deployed on
the IC and AED instructions indicated “No Shock ” was needed and one chest compression was
administered. Electrician became responsive and started to become alert. Emergency services
were contacted and was taken to the Hospital for care and treatment.
WHAT WENT WRONG: HFTE-12 - Procedure/Work Practice not Followed or Sequence of Steps
Done Out of Order (Procedure/Work Practice Correct and Available) - Technician did not apply
his own locks nor verify that the equipment was correctly locked out. - Motorman did not stop
the work and ask the Technician why he did not apply his own locks.
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1. Ensure all personnel involved in task: Verify, Review, & Sign all associated documents
pertaining to work task. (JSA/LOTO etc.).
2. EACH person performing work needs to first ensure the following are completed: Update the
LOTO log, Verify equipment is properly de-energised, Apply a separate lock with tag. Store Key,
Permit, & JSA (copy) at designated location or control station, & notify all affected personnel.
3. All affected personnel need to effectively communicate and secure the work area before
energising any source. Remain physically clear of any equipment having the potential to
shock or endanger personnel. Setup barriers with signs as needed.
4. Complete a Safety Stand down to review and discuss Lessons Learned.
5. Provide refresher training including but not limited to: LOTO, JSA & Permit Requirements, and
use of SWA as needed to address any concerns or observed safety issues before incidents occur.
6. Where needed apply warning signs and labels to affixed equipment.
CAUSAL FACTORS:
DATE: Oct 25 2018

LOCATION: USA
NARRATIVE: The crew was in the process of walking the rig over to the next well. Crew member
was instructed to reposition and secure the electrical cable for the pragma around line backers
during the move. As the crewmember reached down to move the cable, crewmember felt a
tingle (shock) in his right hand after he grabbed the cable. During the investigation, the location
where the crewmember made contact with the electrical cable was found to be damaged. The
insulation and wiring inside the electrical cable was exposed (2 inch cut).
WHAT WENT WRONG:
• Employee was left by his mentor and not directly supervised
• Training does not contain expectations on not handling live electrical lines/cables or use of sash
• JSA did not contain electrical hazard associated with move .
• Linebackers were not installed correctly (mis-aligned)
• Grounding equipment was not installed and/or maintained by a qualified person
• Cable damage was not detected by ground fault system
• Cable was not adequately protected
73

Review contractors electrical inspection criteria.
Conduct on site field verifications of electrical procedures and inspection checklists
Provide a recommended procedure on the installation of current Linebackers and/or design a
suitable alternative for high/heavy traffic areas.
Create and distribute a Safety Flash to specifically address electrical awareness including the
expectation that employees should not come in contact with energised power lines.
Update the JSA for this specific task to specifically address the expectation that employees
should not come in contact with energised power lines.
CAUSAL FACTORS:
barriers
inspection/testing
DATE: Jul 2 2018

LOCATION: USA
CATEGORY: Other
NARRATIVE: During wireline operation, the wellhead threads failed and resulted in a release of
natural gas. It took about 2 minutes to shut in the well and stop the release.
WHAT WENT WRONG: Failure of the pipe threads due to corrosion.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: There was no maintenance routine defined
for this equipment in the CMMS (Computerised Maintenance Management System)
CAUSAL FACTORS:
inspection/testing
74
DATE: May 9 2018

LOCATION: USA
NARRATIVE: During the process of pressure testing casing integrity with nitrogen, the test plug in
the wellhead failed and ejected the 30’ landing joint on top of the test plug from the well. The well
had 2700 psi at the time of failure. The 30’ landing joint landed 155’ from the well service unit.
WHAT WENT WRONG:
• Procedure/Work Practice not Followed or Sequence of Steps Done Out of Order (Procedure/
Work Practice Correct and Available)
• Stand down with all employees of wellhead company.
• Wellhead company reassessing competency for all field techs utilising SME's
• Communicate the incident and findings to all completion and wellwork personnel.
CAUSAL FACTORS:
stress
DATE: Sep 1 2018

LOCATION: USA
NARRATIVE: Contract employees were in the process of removing existing piping (10” pipe 10
ft. long with an offset run of 4ft./Weight-1000 lbs.) from the pipe rack. Crane flagger notified
the contract supervisor that the lift was beyond the reach of the crane. The contract supervisor
wanted to continue use of the crane to help pull the piping out at an angle. The pipe being
removed became bound due to the cranes maximum reach being exceeded along with the side
load that was generated. The contract supervisor along with another contract employee were
trying to free the bound pipe section. When the pipe freed from the bind, it jumped, striking
another pipe and swung in the direction of the employees. The Contract Supervisor fell back
between the piping in the rack. The removed section bounced across the piping on both sides of
him. Other contractors in the area had to quickly react as well to stay clear of the pipe section.
The pipe came to rest approximately 12 ft. from its original location. The pipe was lowered
and re-rigged to ensure safe movement of the load. No one was injured and no property was
damaged during this event.
75
WHAT WENT WRONG: Lack of Hazard Recognition (Crew/Peer)

• Do not use crane and rigging outside of normal operating parameters.
• Stay clear of line of fire.
• Clear the area when moving the sections of pipe.
• Anticipate the movement of piping and use limit straps to limit the movement of the pipe.
• Reinforce the use of LMRA.
• Investigate better methods to train, set expectations and verify knowledge of Life Saving
Actions (LSAs).
CAUSAL FACTORS:
DATE: Sep 27 2018

LOCATION: USA
CATEGORY: Struck by
NARRATIVE: A 16’ scaffold tube fell from an elevated scaffold rack at an elevation of
approximately 30’. The rack was being loaded with 10’ scaffold tubes for ongoing scaffold
erection activities. When another work crew came available, additional workers were integrated
into the existing work scope. To facilitate the additional workers, foreman called down and
requested 8 – 16’ tubes be placed on top of 10’ tubes. A JCB 510 – 56 all terrain forklift was
being used to elevate the scaffold racks to elevation for scaffold erection activities.
WHAT WENT WRONG:
Direct Cause: Behaviour - Risk insufficiently recognised or measures too laborious
Root Cause 1: The 16’ scaffold tubes were placed on top of the 10’ scaffold tubes in order to
avoid a major time delay caused by having to lower the fork boom and relocating forklift closer
to the scaffold.
Root Cause 2: Foreman gave direction to put 8 - 16’ scaffold tubes in rack on top of 10’ tubes.
Causal Factor: The 16’ tubes were flush with 10’ tubes on one end and the other end
cantilevered by 6’ in order to allow the rack to be closer to scaffold for unloading.
Causal Factor: Mixing of scaffold tubes was perceived to be safe
76

New workers apprentices will be identified and their work task will be assigned based upon
their experience levels. Workers crews to remove excess equipment and materials when
possible to minimise distractions and clutter within the area. Better organisation will enhance
overall housekeeping safety.
CAUSAL FACTORS:
DATE: Nov 13 2018

LOCATION: USA
NARRATIVE: While preparing a waterline for a hydrotest, the crew was setting up a pump
and ball valve system to add pressure to the line. While purging air, a worker went to tighten
the union and the ball valve parted, knocking the worker back. The worker hit their head on a
section of 16" HDPE pipe.
WHAT WENT WRONG:
• Management expectations inadequately documented, communicated or enforced
• Inadequate work direction or unclear expectations
• HES Procedures or Safe Work Practices inadequate
Lessons Learnt:
• Inspect equipment prior to use including verification of equipment and material
specifications prior to starting work (e.g., pressure ratings).
• Reinforce expectations to revisit JSA any time job conditions, work scope, or equipment
change.
• Ensure application of engineering standards and appropriate safeguards are in place,
effective and functioning prior to starting work.
Recommendations:
• Confirm roles and responsibilities and communicate expectations between company and
contractor to include identification of proper equipment, pressure ratings, and PRV in
accordance procedures and Hydro Test Plan.
• Reinforce expectations to revisit JSA any time job conditions, work scope, or equipment
changes and include identification of site address or meeting place for emergency response
purposes on JSA.
77
• Business Partner to develop a pre-populated JSA or checklist for hydrotesting to include

verifying components accepted by company in the Hydro Test Plan and execution plan for
sequence of steps.
CAUSAL FACTORS:
78
NORTH AMERICA OFFSHORE
DATE: Mar 1 2018

LOCATION: CANADA
FUNCTION: Drilling
NARRATIVE: Workers were lowering a tool in a bucket when the swivel assembly (weighing 170
kilograms) shot out over the bucket and fell approximately 50 feet.
WHAT WENT WRONG:
• Not recognised as a hazard by the OEM - limitations for horizontal side loading was not
recognised.
• Procedures not adequate - no procedures to identify handling limitations or horizontal load
limitations for the swivel joint.
• Seek knowledge and understanding
• Both the Management and crew did not recognise the limitations for horizontal side loading
and did not identify the proper handling limitations for the swivel joint.
• Expect accountability
• Engineering process should have identified weak link for complete usage for application of
downhole, pickup, laydown and logistics. Use a questioning attitude
• At no point during the assembly, the inspection or the transport of the Wellhead Running
Tool Assembly did anyone question whether the tool was fit for purpose.
CAUSAL FACTORS:
79
DATE: Dec 12 2018

LOCATION: CANADA
NARRATIVE: Work crew had just completed backloading operations to the standby vessel and
the crane operator began the process of setting the crane in the crane rest. Once the crane
entered the rest, a piece of a wood bumper weighing 1.8lbs. dislodged from the rest and fell
56.5ft to the production deck. No injury to personnel, closest employee was approximately
15 feet away. There was no requirement for the installation of drop zone barriers as lifting
operations had been completed
WHAT WENT WRONG:
• Wood became weathered and damaged over time.
• Previously identified cracking of wood not raised as a drop concern.
• Inadequate inspection frequency.
• Post incident, barriers were installed below the crane rest to prevent personnel from
entering the area until further assessment is conducted
• Completed inspection of all other cranes in the field.
• Add crane rest bumper inspection to the crane pre-use checklist.
• Investigate alternate bumper material.
CAUSAL FACTORS:
barriers
inspection/testing
80
DATE: Jun 22 2018

LOCATION: CANADA
NARRATIVE: On the floating production storage offloading vessel, the upper flare tip of the flare
tower was cracked larger than first noticed and the wind deflector was bent away from the flare
tip and the top weld/bracket was broken off.
WHAT WENT WRONG: Current background flaring rates were not considered in the flare
design. The flare is designed to allow safe depressurisation of the plant at maximum blowdown
rates, but not for long term integrity at low rates. Current inspection strategy is not based on
good practice and has not been revisited since last flare replacement. Inspection technique was
inadequate - visual inspection by helicopter does not produce high resolution images.
• We have had several flare tip failures over the lifetime of the facility, yet the flare design has
never had a full design review. Replacement equipment has never been properly specified.
• The planner asked why we were not using drones for inspections offshore. We worked with
all parties to ensure we had all required documentation and approvals and planned a flare
inspection.
• Once the potential risk was identified the team worked with all stakeholders to risk assess
the situation and make the decision to barricade the area and shutdown for repairs prior to
turn around. There were significant collaborative efforts by the turnaround team to get the
flare tip successfully replaced with a short planning window.
CAUSAL FACTORS:
inspection/testing
81
DATE: Apr 20 2018

LOCATION: USA
FUNCTION: Drilling
NARRATIVE: A crane operator was hoisting the fast line up when the travelling block contacted
the bottom of the office platform deck which lifted it from its j-hook anchors and caused it to fall
approximately 8 feet. It came to rest on the skid beam and handrails of the drill floor truss deck
immediately below causing damage to the hand rails and deck grating.
WHAT WENT WRONG:
• Procedures or Safe Work Practices: HES Procedures or Safe Work Practices less than adequate.
• Inadequate verbal communication.
• Design Review failed to uncover inadequacies in design.
• Design did not anticipate the conditions.
Lessons Learnt:
• Rig designs, though meant to be modular, should always include a secondary retention
mechanism.
• Prior to creating drawings for new designs, dimensions from existing drawings should be
verified against “field” measurements.
• Contractor has a fit-for-duty process; however, it does not detail fit-for-duty requirements
for safety critical roles, such as crane operations.
• Contractor did not have an existing management of change process to manage new designs
or engineering changes.
Recommendations:
• Review deck process and develop guidance for safe placement for lifts.
• Implement guidance for safe manoeuvring of crane when in close proximity to structures.
• Develop a formal communication/handover procedure and communicate to workforce.
• Incorporate requirement into the contractor process (Management of Engineering Design
and Construction) to include field validation of measurements and verification of designs for
all structural additions.
• Incorporate requirement into the Nabors process (Management of Engineering Design and
Construction) to include a secondary retention mechanism in all new designs for structural
additions.
CAUSAL FACTORS:
82
DATE: Oct 1 2018

LOCATION: USA
NARRATIVE: Removable I-beam supporting deck grating fell ~55 ft to the deck below.
WHAT WENT WRONG:
• The beam was designed to be removable to allow riser installation
• The riser had been unchained per procedure (so that it could be rigged down), which allowed
for movement of the riser during high sea state. The riser rubbed on the beam causing it to
move.
• A similar incident occurred in 2013, but the beam only dislodged and did not fall.
• Records could not confirm what action was taken at that time.
• Investigation after the recent event identified that some, but not all I-beams have travel
stops. The recent beam that fell did not have a travel stop.
• The I-beam & cradle are as originally installed ~30+ years ago
• Barricaded well bay sections (all decks) until all beams are modified.
• Add travel stops on the bottom of all removable beams at both ends.
CAUSAL FACTORS:
barriers
DATE: May 8 2018

LOCATION: USA
NARRATIVE: A gas release resulted from third-party transmitter connection on the Platform. A
hydrocarbon gas leaking from export sales gas meter was discovered by personnel in the area.
WHAT WENT WRONG: During maintenance work 18 days before the gas release, incorrect
Teflon seals were installed in the meter instead of Viton O-rings.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Identify locations in high pressure gas
service where Teflon seals are used and replace with appropriate seals.
Work being completed by third party equipment owners must be subject to effective oversight.
83
Verify that employees are trained, drilled, and empowered to activate general alarm or
emergency shut down in an emergency.
Assessments and drills for managing emergencies must be rigorous to provide effective
preparation.
CAUSAL FACTORS:
inspection/testing
DATE: Jun 29 2018

LOCATION: USA
CATEGORY: Struck by
NARRATIVE: Two workers were in the process of removing a coupling guard to replace the dry
gas seals from a beam gas compressor using a 3-ton beam trolley (45 lbs), 1.6-ton chain fall
(35 lbs), and a nylon strap (rating 4,960 lbs). The workers were lowering the coupling guard,
using the lifting equipment, to place it out of the working area. As the workers were moving the
coupling guard the trolley slid off the beam. The beam trolley and chain fall descended 13 feet
to the skid and the coupling guard came to rest on top of the compressor gearbox while still
attached to the chain fall and beam trolley. As the trolley and chain fall descended to the skid,
one worker was manipulating the chain fall and the other worker was assisting the coupling
cover to move it out of the way. The worker manipulating the chain fall was holding the chains
as the trolley descended, causing minor bruising to the left thumb. The other worker was
uninjured.
WHAT WENT WRONG: The original permanent trolley had been removed. Fixed stops had been
specified for the original hoist and monorail configuration. A temporary trolley was used. The
temporary trolley was moved along the beam to get cover to the desired location. The temporary
trolley had been visually inspected, but had not been function tested against the stops.
• Carry out a review of runway beam end stops, and identify and replace all end stops that are
not full width and full height of the beam.
• If the use of a runway beam and trolley is required prior to changing out of the end stops, a
temporary appropriately engineered barrier should be installed. The integrity of the barrier
should be confirmed by close visual inspection by a competent person.
• Consider adding a pre-use inspection to check beam trolley will be stopped by the end stops.
Since these particular pieces of equipment are frequently moved around, installed, removed,
and stored, there is a higher risk.
84
CAUSAL FACTORS:
PEOPLE (ACTS): Use of Protective Methods: Disabled or removed guards, warning systems or
safety devices
barriers
inspection/testing
DATE: Oct 2 2018

LOCATION: USA
CATEGORY: Dropped Object
NARRATIVE: While performing a pre-job work site assessment, workers entered the forward
hull column. One worker experienced the counterweight system getting “hung up” while
entering the column. When exiting the hull column, the same worker was attempting to use the
climb assist system when the counterweight fell 80ft (25m) to the bottom of the column. There
were three workers in the bottom of the column at the time of the incident although no one was
struck by the falling, 180lb (81kg) counterweight.
WHAT WENT WRONG:
• Underlying Cause – Inadequate risk assessment prior to activities
• Individual standing in line of fire
• JSA did not specifically address the risk
• Underlying Cause – Inadequate control of competence
• Inadequate training for third party workers using counterweight system
• Develop and implement training for limpet system
• Update the facility orientation to specifically address use of the limpet system for those
entering the hull
• Improve JSA quality through spot check campaign by Titan leadership
• Conduct LEAN workshop to reduce the frequency of hull entry
• Install the limpet climb assist to eliminate the hazard of the counterweight climb assist
• Engineering control providing mechanical climb assist and fall arrest which eliminates all
hazards of the counter weight system
85
CAUSAL FACTORS:
devices
DATE: Feb 17 2018

LOCATION: USA
CATEGORY: Other
NARRATIVE: A subsea production technician conducting line walk downs on the subsea
chemical injection system observed two skillet blinds installed on the relief header. After finding
the skillet blinds, the subsea technician identified a noticeable deformation of the tank.
WHAT WENT WRONG: Before the chemical injection system skid was shipped offshore, the
fabricator installed 27 skillet blinds as a project defined preservation measure. However, 7 of
the skillet blinds were not included in the mechanical completion or commissioning flange
flagging process at any time during the construction or commissioning of the system. Two of
the skillets remained in place during commissioning causing the overpressure and subsequent
deformation of the tank.
The skillets were installed on the chemical tank system but were not entered into any project
work pack or database. There were several opportunities throughout the construction,
commissioning, and handover phases to identify and remove the skillets.
The key learning to share from the incident is that:
1. Blinds installed in a fabrication yard should be integrated into the construction,
commissioning and handover activities.
2. Verification steps, principally during commissioning P&ID walk-downs and throughout the
project phases should be conducted with adequate rigor.
CAUSAL FACTORS:
stress
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RUSSIA & CENTRAL ASIA ONSHORE
DATE: Aug 13 2018

LOCATION: KAZAKHSTAN
RULE: Line of fire
NARRATIVE: A crew was removing a corrosion coupon on an acid gas line when the release of
H2S occurred resulting in personal H2S detector activation and subsequent plant wide alarm.
When personal H2S detectors activated, the crew members donned emergency respirators and
evacuated from the scene to a safe muster area.
WHAT WENT WRONG:
• Inadequate work oversight or enforcement of work standards.
• Inadequate maintenance planning.
• Review design to eliminate need for corrosion coupons.
• Utilise Reliability Threats Prioritisation process in scope development planning phase.
• Add to the IMPACT process a milestone (trackable metric) of the percent of work activities
with isolation plans.
• Develop an estimated number of work permits per shift by area for operations to use as a
PTW resource loading tool.
• Management address the lack of compliance, specifically (but not limited to) isolation
verification to achieve 100% compliance.
CAUSAL FACTORS:
inspection/testing
RUSSIA & CENTRAL ASIA OFFSHORE
No high potential incidents reported
87
SOUTH & CENTRAL AMERICA ONSHORE
DATE: Feb 15 2018

LOCATION: ARGENTINA
FUNCTION: Drilling
RULE: Line of fire
NARRATIVE: An operator descended by the funnel sector of the pipe handler and stepped on
the variable (weight sensor), which triggered closing the funnel, causing Thorax imprisonment.
WHAT WENT WRONG: Unsafe acts.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Ensure to have the necessary elements
to perform the tasks safely (guardrails, stairs, platforms, etc) and must be kept in place and in
good conditions. If not suspend the task and notify to the supervisor.
CAUSAL FACTORS:
barriers
DATE: Jul 16 2018

LOCATION: ARGENTINA
FUNCTION: Drilling
RULE: Line of fire
NARRATIVE: The traveling block, having disengaged from the head of injection, began to
descend slowly, positioning on the working area floor and being supported on mast. No workers
were below the block.
WHAT WENT WRONG:
• The emergency brake system was misused. There is no braking procedure.
• The matrix of competencies for machinists and welders is focused on safety, without
focusing on technical issues.
• Review and update the matrix of technical skills of the staff
• Energy Isolation: Review the energy isolation permit that identifies all points to be blocked
and the dynamic risks
88
DATE: Jan 22 2018

LOCATION: ARGENTINA
RULE: Line of fire
NARRATIVE: During pulling equipment assembly manoeuvre two operators were placing bolts
that link the first section of the mast when the hydraulic platform moves, due to an involuntary
action of the machinist, and squeezes the operators against the mast.
WHAT WENT WRONG:
• The training of the team members didn't include the practical training of the equipment assembly.
• Equipment/Tool with inadequate design. Hydraulic platform command with inverted drive direction.
• Develop a new MOC procedure.
• Development of a theoretical and practical operating training plan.
CAUSAL FACTORS:
DATE: Oct 13 2018

LOCATION: ARGENTINA
RULE: Bypassing Safety Controls
NARRATIVE: Fire in Hot Oil equipment.
WHAT WENT WRONG:
• There is no evidence of training of operations team.
• Safety controls bypassed.
• Ensure operations team training. Perform emergency simulation plan for operations team.
• Audit interlocks involved during startup. Perform a risk analysis of this interlocks.
89
DATE: Jul 26 2018

LOCATION: ARGENTINA
NARRATIVE: A HIGH PRESSURE WATER RELEASE STRUCK A WORKER IN THE FACE.
WHAT WENT WRONG:
• Non-compliance of energy isolation standard. (It was not possible to verify the absence of
pressure between the valve and 8 rotate figure, due to piping configuration).
• The team was not trained on the energy isolation standard.
• Perform audit in the programming and planning of the works.
• Review “rotate figure 8” step according to the task categorisation matrix. Analyse with cases
that do not comply with the energy isolation standard and develop a risk analysis.
• Modify work instructions, communicate and train the teams.
• Review injection manifold piping standard.
CAUSAL FACTORS:
DATE: Feb 28 2018

LOCATION: ARGENTINA
NARRATIVE: Personnel from Contractor A performed maintenance on the valves of a well
production tree and left the well closed. Then, a pneumatic test of the well testing lines was
conducted by Contractor B, which failed due to flaws in the packing of the hammer unions. Given
that there weren't enough spare parts to fix all the flawed unions, the system was depressurised
through the de-sander (BBS) bleed orifice. Production Engineering decided to open the well
through the contingency line during the night while Contractor B finished repairing the flawed
hammer unions. A new shift started with two new workers continuing the repairs works without
performing a task hazard analysis or pre-job meeting. The Operating Company's personnel had
already left the site and retired to the trailer. Although not included in the work plan, the work
men decide to check the filter inside one of the de-sander's spheres. To do this, they needed to
first unscrew the sphere's cap with a “J” wrench. Reportedly, they had previously checked for
pressure build-up by verifying position of the valves that isolated the filter and by checking for
flow or noise when opening one of the system's the needle valves. When they had almost finished
unscrewing the cap, a sudden pressure release occurred that expelled the cap into the air to fall
90
approximately 7m away from the de-sander. Later calculations estimate the pressure build-up at
approximately 850 PSI. Ultimately, none of the work men were injured by the flying cap.
WHAT WENT WRONG: Inadequate work standards/procedures: A proper handover of the task
was not performed during the shift turn. No hazard analysis or pre-job meeting was conducted,
even though applicable procedures requested so. The steps described in Contractor B's
investigation report do not comply with the recommended sequence in the applicable procedure
for de-sander filter cleaning. The planned task only comprised maintenance on the valves
of a well production tree. Verification of the de-sander's filters was not part of the planned
work scope. Inadequate warning devices: There were no pressure gauges installed to allow
pressure verification within the filter spheres. The system layout in the cleaning procedure
did not match with the real layout at the site. Inadequate materials: The valves used to isolate
the de-sander were defective and, although closed, allowed pressure build-up within the de-
sander. Inadequate training/competence: One of the employees involved in the incident had
one month of work experience in the company and had only one verifiable training registry, a
general induction into EHS. The employee did not seem to fully understand what happened in
the event. It was the employee's first work experience at the facility and also his previous work
experience was mainly related to office duties. The other employee involved had 7 months of
work experience in the contractor company and 3 years of experience in well testing activities.
He was not able to detect that the cap thread was too tight when trying to unscrew it. For both
work men there are no registries available to evidence training in the applicable procedures,
such as hazard identification, LOTO, and de-sander cleaning.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: For Contractor B: Incorporate in the field crews
internal trainers with more experience in high pressure gas operations. Develop a training plan for
new employees and a plan for current employees. Review and update applicable procedures for de-
sander cleaning and LOTO. Communicate to all employees. Write a procedure for shift changes and
specify formats to register pre-job meetings along with the Operating Company supervisors.
CAUSAL FACTORS:
PROCESS (CONDITIONS): Protective Systems: Inadequate/defective warning systems/safety devices
91
DATE: Feb 6 2018

LOCATION: ARGENTINA
CATEGORY: Struck by
ACTIVITY: Transport - Land
NARRATIVE: A contractor vehicle was on its way to an oilfield on a provincial road, carrying a
driver and a passenger. While attempting to pass a truck on the single lane two-way road, the
driver saw a vehicle coming his way with its headlights off (transit law requires to have them
turned on at all times). Given that the incoming vehicle was approximately 100m away, the driver
decided to head his vehicle to the road shoulder opposite to the direction he was headed. The
driver in the incoming vehicle copied the same move, since it was the shoulder corresponding
to his drive lane. When the contractor saw the incoming vehicle copy his move he immediately
drove back to the road, although still in the on the lane opposite to his driving direction. The
incoming vehicle again copied the same move, so the contractor drove back to the opposite
shoulder in an attempt to avoid hitting the car, but ended up crashing into the incoming vehicle
when it again mimicked his move.
WHAT WENT WRONG:
• Inadequate use of equipment: The overtaking manoeuvre was attempted without the
sufficient space and at a speed which exceeded the maximum allowed.
• Inadequate following of procedures: Defensive driving procedures were not followed in
regards to: precautionary distance and speed; visibility requirements; “three seconds” rule.
• Lack of judgement and inadequate training: The driver did not properly assess the
overtaking manoeuvre and the risks it involved, given his knowledge of the road he was
driving on, normal traffic at that hour, etc.
• Unintentional Violation: The driver did not keep a safe distance and speed in accordance with
a professional driver's behaviour.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: The contractor company will add vehicle
driving to its list of critical tasks. The contractor company will incorporate a system to evaluate
the effectiveness of its training courses. The contractor company modified its transport system
to maximise group transports in bigger vehicles, so as to reduce the number and frequency of
trips done by trucks (maximum of four people).
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Work or motion at improper speed
92
DATE: Aug 14 2018

LOCATION: ARGENTINA
NARRATIVE: A Backhoe was conditioning terrain when it struck and detached a 2 inches purge
valve connected to the discharge line of a water injection plant (PIAS). As consequence, injection
water (at 1800 psig) was projected to the ground expulsing stones at high speed and breaking
the glass of the excavator machine without injuring people.
WHAT WENT WRONG:
• The work control process is not correctly implemented in operations
• Inadequate communication between the operations supervisor and the machinist about the
existence of pressure in the pipeline.
• Application of working control during operations
• Elaborate a plan for implementing a competency matrix for the contractor, based on working
positions.
DATE: May 20 2018

LOCATION: BOLIVIA
FUNCTION: Drilling
NARRATIVE: While replacing drilling cables, a section of cable broke away from the splice mesh
and fell to the work floor without causing any injuries or damage to property. Work was stopped
while the area was secured and an event analysis performed. There was a fault with the Vibora-
type Snake Grip LSG cable snaps.
WHAT WENT WRONG:
• Incompatible goals
• Maintenance management
• Training
• Conduct training in the installation of the Snake Grip mesh LSGX
• Issue and implement a training program in drilling equipment operating procedures
• Reinforce training in the completion of safe work analysis work permits and certificates
93
• Review, update and issue in Spanish the procedure for using the mesh Snake Grip LSGX
• Keep a physical copy of all procedures in the dog house
• Check if the operative procedures to identify if they have sections in English and if they have
the necessary detail to carry out the activity safely, make the corrections where necessary
• Include in the audit team of the work permit system the Project Leaders (Superintendent
and Project Manager of Company, Operations Manager of the main contractor), issuing a
program and complying with it
• Include the Viper Snake Grip splice in the inspection and maintenance plans of lifting
elements and equipment
CAUSAL FACTORS:
inspection/testing
DATE: Nov 25 2018

LOCATION: BRAZIL
NARRATIVE: During service (reinforcement of excavation shoring), there was a collapse of part
of the excavation slope that was anchored.
WHAT WENT WRONG: The excavation shoring was inadequate (ineffective way of supporting the
slope, nonexistent drainage system).
• Prepare procedures regarding safety in excavations;
• Train the teams in the procedures;
• Analyse existing check lists reading adequate standards and norms.
CAUSAL FACTORS:
barriers
94
DATE: Nov 14 2018

LOCATION: CHILE
NARRATIVE: While contractor personnel were installing a spacer in a Beam Pump, the
equipment brake failed, thus causing the counter weights start to fall slowly, the horse head
rose, and the clamps separated from the polished rod. No one was injured, and the beam pump
was not damaged.
WHAT WENT WRONG: Although the task was carried out with a safe work analysis and a work
permit, the procedure did not contemplate a brake system test prior to starting the task, based
on a methodology validated by the company and with the manufacturer's recommendations. In
addition, the use of the safety lock as an additional measure for the brake was not specified for
the spacers’ installation.
Due to the absence of the brake test and installation of the safety lock in the procedure, the
personnel were not trained in these safety aspects.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: The procedure must be completed with
the braking system test prior to task execution and based on an authorised methodology. In
addition, the use of the security lock will be mandatory for these tasks.
Once the procedures have been updated, all the personnel involved in the task should be
properly trained on the modifications made and the additional security measures included in
the document.
CAUSAL FACTORS:
DATE: Mar 12 2018

LOCATION: COLOMBIA
NARRATIVE: When staff was installing a protective cover for a HPS (Horizontal Pump System)
cable tray and secured it with screws, one of the screws touched a power cable causing an
electric fault. Due to the above, the protections of the inverter was activated, causing a well
stop. No one was injured, and the HSP was not damaged.
WHAT WENT WRONG: The capacity of the cable storage tray was limited, so when the screw
drilled the hole on the cover, it touched a cable that was out of place.
95

Before carrying out a task, staff must follow all the safety rules for electrical activities, detailed
on the company’s SOS (Safety Operational Standard).
• Turn off all voltage sources
• Lock and tag cutting devices
• Verify absence of voltage
• Delimit and identify the work area. The use of screws to secure tray covers with electric
cables inside will be forbidden. A risk analysis should be performed and documented for
tasks that involve contact with electrical energy.
CAUSAL FACTORS:
stress
DATE: Mar 12 2018

LOCATION: PERU
NARRATIVE: Short circuit during insulation tests. During isolation tests in cubicle MMC-001 of
the Electric Room U400, short circuit occurs, activating the clean agent FM200 of the Fire & Gas
System.
WHAT WENT WRONG:
• Communication
• Organisation
• Training
All maintenance personnel and SMA must have a training in Work Permits and LOTO Procedure.
The field manager, together with the electrical maintenance supervisor, will draw up an action
plan to strengthen the SMA leadership (verifying training, suitability of the personnel to cover
the position, competencies of the position, profile of the worker, etc.)
Periodical inspections of the Confipetrol tool warehouse, especially those used in electrical
works.
96
CAUSAL FACTORS:
DATE: Aug 6 2018

LOCATION: PERU
NARRATIVE: During a planned partial maintenance shutdown (two cryogenic towers out of
service), a sudden stop of the remaining three operational cryogenic towers occurred due to
the activation of the High Level (HL) trip in the de-ethaniser towers. The combination of high
pressure in the slug catcher and the "four out of five" voting logic of the train's inlet SDV valve
closure; activated a level 3 shutdown of the entire facility (according to the High Level Shutdown
logic implemented in the SIS). The entrance pressure at the slug catcher rose from 1350psi to
1450psi, originating a major gas leak in a blind flange at a tie-in of a recently installed flowline
(PSVs were set to open at 1800psi). HL in the towers occurred due to a false signal in a low
pressure switch, which closed the towers' discharge valves. The pressure switch had been
recently serviced. Immediate actions: The slug catcher area was depressurised. Safe working
conditions were verified in the area. The blind flange were the leak occurred was intervened.
WHAT WENT WRONG:
PEOPLE FACTORS: Insufficient practice: The contractor involved in the pressure switch
maintenance did not have enough personnel and subcontracted additional laborers dedicated
to other maintenance tasks to complete its work groups. The subcontracted personnel did not
have the required previous experience in the works to be performed.
WORK FACTORS: Inadequate work planning: Delays in work execution caused initially
separate tasks to overlay, meaning that too many people were working in the same place at
the same time, including the same electrical panels and circuits. Some electrical components
were still not fully operational and tested when startup of the facility took place. Inadequate
communication between work groups. There is no evidence that the work groups had received
appropriate directives regarding the newly installed electrical system verification and potential
impact on other existing electrical systems, and plant operation in general. Inadequate work
delegation The contractor in charge of the new tie-in submitted a torque procedure and final
torque verification report, which had been validated by the their QC supervisor, which were
considered as valid without further verification and the facility was freed for startup. Inadequate
monitoring of standards' compliance The contractor's torque check list and procedure do not
allow a proper assurance of the task's realisation.
97
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Adequate to the Corporate Standard, which

states that “Switches shouldn’t be used to detect process trip parameters. Transmitters are
recommended for shutdown functions.” Verify how the HL trips are set in the de-ethanisation
towers, including their alarms, and define them in accordance with the PST. Define a Policy
for alarms modification regarding users and access levels. Reinforce the practice which
requires that work permits related to signal panels have to explicitly include all signals directly
o indirectly involved in the task to be performed. Communicate and verify compliance with
the standard for commissioning of automation and control equipment. Elaborate a procedure
for torque tasks (in relation to the blind flange leak). Include the use of this procedure as an
obligation in all services.
CAUSAL FACTORS:
PROCESS (CONDITIONS): Protective Systems: Inadequate/defective warning systems/safety devices
inspection/testing
DATE: Jul 15 2018

LOCATION: PERU
CATEGORY: Struck by
NARRATIVE: At a well pad, a “Y” section of a gas flowline was being replaced by means of a 40
metric ton crane. Moments later, the crane falls laterally on its right side until its boom comes
to rest on a nearby metallic walkway structure, ending up at an approximately 45° angle. Only
material damage to the walkway occurred and no employee was injured. The crane was non-
operational for 22 hours. The crane service was provided by a contractor company. Reportedly,
the crane operator was a temporary replacement until the full-time operator returned from a
medical leave. The replacement operator had only limited experience in operating this kind of
heavy equipment.
WHAT WENT WRONG: Improper use/position of equipment: The crane was used exceeding its
capacity and located in an improper position for the hoisting task. Inadequate/defective warning
systems/safety devices: The crane's LMI system (Load Moment Indicator) had been bypassed
98
during the operation. For this reason there was no warning of the excessive load. Inadequate/
defective tools/equipment/materials/products: The crane's LMI system (Load Moment Indicator)
was not working properly and had been presenting random flaws before initiating the task. The
crane presented other maintenance issues, such as loose bolts, oil leaks and non-operational
windscreen wipers. Unintentional violation of procedures: Hoisting and Work Control
procedures were in place and applicable, but were not properly followed. For example, a generic
hoist plan was being used and verification check lists were not completed before beginning the
task. Inadequate training/competence: Crane operator and supporting contractor team lacked
the appropriate training to be able to identify the risk associated with the task and follow the
applicable procedures. Inadequate supervision and Poor leadership/organisational culture:
The Operating Company's supervision did not perform appropriate control of the task before
it began and during its execution. There was a clear lack of safety leadership and culture. The
need to finish the task quickly was prioritised at the expense of safety.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: All involved personnel (contractor and
Operating Company) will receive training to strengthen their understanding in the need to
comply with ALL applicable standards and policies. All involved personnel (contractor and
Operating Company) will receive training in hazard identification and risk assessment, and
work control procedures. A Preventive Maintenance Plan will be prepared to secure the
provision of spare parts, especially those associated with SCE's. Review and improve the current
Competency Management framework, especially regarding those positions which require
granting specific permits and their replacement staff. Prepare an audit plan to verify compliance
of the contractor and Company supervision with all applicable standards and procedures.
Review the equipment inspection procedure to ensure the Operating Company conducts
appropriate control before equipment is sent to the field.
CAUSAL FACTORS:
devices
inspection/testing
99
SOUTH & CENTRAL AMERICA OFFSHORE
DATE: Jun 20 2018

LOCATION: ARUBA
FUNCTION: Drilling
NARRATIVE: While pulling the BHA out of hole (POOH BHA), a piece of metal fell to the rig floor.
Upon investigation, it was discovered that the object was one of the casing fingerboard latches
from the upper finger board. The object weighted 2.5 kg and felt from 32 m of height. No one
was injured.
WHAT WENT WRONG:
• Poor or inadequate supervision;
• No system available to provide feedback of finger latch position to the hydraracker operator
• Poor quality view available by derrick mounted cameras available and mounted camera
location at an ineffective place;
• Improper or ineffective positioning of spotter (only 1 spotter looking at both fingerboards)
• Complacency or oversight from supervision in keeping operating with the hydraracker
without a suitable view of the upper fingerboard and without assigning a spotter to assist
• Failure on management of personnel
• Crew inexperienced in relation to drill floor equipment
• Poor or inadequate equipment design and layout
• Improper or inappropriate secondary retention installed, not suitable to withstand the latch
dropped impact load
• Lack of standardisation and guidance for the proper secondary retention to be installed on
the finger latches
• Failure to follow the Risk assessment Directive requirement
• TBRA was not discussed with the crew prior to the task
• TBRA in use was for tripping pipe both in and out of the hole. It was not specific to pulling
out of the hole and racking pipe in the fingerboard with the hydraracker.
• Verify and provide quotation for a fingerboard monitoring system.
• Procedure to be updated to reflect the requirement for observation of finger latch position
by a watchman with radio to watch the lower fingerboard and another to watch the upper
fingerboard if there is not a suitable and clear visibility from the CCTV cameras available.
• Verify the feasibility to apply visibility markers under the finger latches.
• Prepare HSE alert related to this event with all lessons learned for the fleet.
• Apply Accountability Directive on all levels of supervision on the crews that performed such
operations not only in the event but also from the time drilling operations started in Aruba.
• Record of maintenance and inspection/defective finger latches to be kept and updated on
maintenance system.
100
• Formulation of hemisphere technical document or procedure in relation to use of secondary

retention for finger latches.
• TBRA to be amended in order to ensure that there will be always a watchman with radio to
watch the lower fingerboard and another to watch the upper fingerboard if there is not a
suitable and clear visibility from the CCTV cameras available.
CAUSAL FACTORS:
DATE: Apr 23 2018

LOCATION: BRAZIL
FUNCTION: Drilling
NARRATIVE: During the descent of the BOP, the Derrick Drilling Machine (DDM) descended
uncontrollably and collided with riser spider, passing with elevator for approximately 3m below
the drilling floor, and BOP Stack sank into the seabed. No injuries or fatalities were reported in
relation to the incident.
WHAT WENT WRONG: Drilling winch failure due to poor maintenance.
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Review of the Maintenance Plan of the
contractor to follow the recommendations of the manufacturer, in particular regarding the
adjustment of air gaps, the bedding of the pads and visual inspection of the drilling winch.
CAUSAL FACTORS:
inspection/testing
101
DATE: Mar 9 2018

LOCATION: BRAZIL
FUNCTION: Drilling
CATEGORY: Overexertion, strain
RULE: Line of fire
NARRATIVE: During the withdrawal of the BOP, while using the “catarina” for lifting and
simultaneously the cat line to guide the BOP to the pin of the pipe rack, the steel line of the
cat line broke and the hoisted load struck the service platform colliding and damaging the
front guardrail due to the pendulum effect generated by the angle of the load at the moment of
breaking. The area was isolated for movement, with no people in the range of the load.
WHAT WENT WRONG:
• Failure of inspection and maintenance plan of the lifting system
• Operation of defective steel cable
• Inadequate design criteria
• Move and cut five meters of cat line steel cable monthly and insert this determination into
the maintenance procedure Inspect the steel cables and accessories before each use,
making the registration in specific form
• Disseminate the occurrence to the entire workforce (debrief) and pre-shipment meetings
• Maintain isolated lifting area to ensure the absence of people within the radius of action of
loads and steel cables.
CAUSAL FACTORS:
inspection/testing
DATE: May 5 2018

LOCATION: BRAZIL
NARRATIVE: During preventive maintenance of a valve that was giving way, it was in the closed
position (fail close) and had its upper chamber pressurised with a “vinyl” in an attempt to close
the valve completely. After pressurising, the cap of the actuator helmet broke and shot off in the
direction away from the technician, who was unharmed.
102
WHAT WENT WRONG:

1. Air pressure in the actuator body, above the pressure admissible by the equipment;
2. Execution error to work on equipment not covered in the Permit to Work (PTW);
3. During execution of the activity, the list of tasks contained in the Maintenance Order was not
fulfilled;
4. The ID described in the OM/PTW is not the ID of the main equipment, generating doubts in
relation to other equipment of this system.
1. Reinforce for issuers / requesters to release the PW only when there is no doubt as to which
equipment should be performed the intervention.
2. Correct the ID of the main equipment in the maintenance plan, avoiding the placing of IDs of
secondary equipment (sensors).
3. Reinforce maintenance teams to the activities described in the Maintenance Task List.
CAUSAL FACTORS:
DATE: Sep 24 2018

LOCATION: BRAZIL
ACTIVITY: Diving, subsea, ROV
NARRATIVE: Diving activity was interrupted because of H2S detection near SDSV boat.
WHAT WENT WRONG: Failure of hazard identification
CORRECTIVE ACTIONS AND RECOMMENDATIONS: Review of hazard analysis
CAUSAL FACTORS:
asphyxiant)
103
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REPORT JUNE

Safety performance indicators – 2018 data

IOGP welcomes feedback on our reports: publications@iogp.org

These Terms and Conditions shall be governed by and construed in accordance

Safety performance indicators – 2018 data

VERSION DATE AMENDMENTS

1.0 June 2019 First release

MIDDLE EAST ONSHORE 52

MIDDLE EAST OFFSHORE 66

NORTH AMERICA ONSHORE 72

NORTH AMERICA OFFSHORE 79

RUSSIA & CENTRAL ASIA ONSHORE 87

RUSSIA & CENTRAL ASIA OFFSHORE 87

SOUTH & CENTRAL AMERICA ONSHORE 88

SOUTH & CENTRAL AMERICA OFFSHORE 100

DATE: Dec 12 2018

DATE: Apr 2 2018

CORRECTIVE ACTIONS AND RECOMMENDATIONS: Need to conduct a comprehensive risk

DATE: Feb 27 2018

DATE: Oct 13 2018

DATE: Jan 16 2018

DATE: Nov 6 2018

DATE: Mar 9 2018

DATE: Aug 15 2018

DATE: Feb 11 2018

DATE: Sep 17 2018

DATE: Apr 1 2018

DATE: Apr 22 2018

DATE: Oct 23 2018

DATE: Mar 18 2018

CORRECTIVE ACTIONS AND RECOMMENDATIONS: Introduce Site Safety Standards to reduce

DATE: Oct 4 2018

DATE: Dec 26 2018

DATE: Oct 22 2018

DATE: Nov 2 2018

DATE: Jul 22 2018

DATE: Jan 1 2018

DATE: Mar 16 2018

DATE: Jul 29 2018

DATE: Aug 12 2018

DATE: Aug 3 2018

DATE: Aug 10 2018

DATE: Sep 13 2018

DATE: Feb 7 2018

DATE: Aug 10 2018

DATE: Jan 7 2018

DATE: Apr 13 2018

DATE: Apr 1 2018

DATE: Oct 2 2018

DATE: Sep 13 2018

CORRECTIVE ACTIONS AND RECOMMENDATIONS:

DATE: Sep 11 2018

DATE: Apr 11 2018

DATE: Feb 16 2018

DATE: Mar 12 2018

PROCESS (CONDITIONS): Tools, Equipment, Materials & Products: Inadequate maintenance/

DATE: Feb 12 2018

DATE: May 6 2018

DATE: Jan 15 2018

DATE: Dec 12 2018

Lack of risk awareness/assessment

DATE: Mar 13 2018

DATE: Nov 21 2018