P.H.R.C.

INTERNAL MEMORANDUM To: DM SAFETY Ref: Date: 854 3RD August 2011 From: Safety Investigation Officer

INCIDENT REPORT OF ACCIDENT AT THE WELDING WORKSHOP INVOLVING MR. OKWUNA IFEANYI ON 18th JULY 2011. INCIDENT:- There was a report of an accident at the welding workshop, involving Mr.Okwuna Ifeanyi a sub- contractor (welder) to Vengomo (Nigeria) limited, from the Safety Operations Superintendent, through the refinery plant clinic. I was informed about the incident and told to investigate the cause of the incident at about 1055 hrs, on Monday 18 July 2011. ACTION TAKEN: - Mr. Okwuna Ifeanyi (accident victim) was rushed to the plant clinic for wounds sustained during a supposed pre-qualification welding test from a grinding machine by PHRC welders at the Maintenance workshop at about 1045 hrs on the same day. BACKGROUND INFORMATION : Pre-qualification welding tests are statutory professional tests conducted for thirdparties contracted to weld in the refinery, by certified PHRC welders and plant inspection officers. The accident victim was to undergo a test to qualify him to weld for Vengomo (Nigeria) limited, during the rehabilitation of tank 52-TK-59G.

INVESTIGATIONS CONDUCTED:The PHRC plant inspector (Mr. E. F. Akinbola) who was supposed to have conducted the pre-qualification test was interviewed. The site engineer and works supervisor for Vengomo (Nigeria) limited respectively, were contacted and interviewed. The accident victim was contacted and brought to the refinery ten working days after the incident for interview. The Plant inspector (Mr. E. F. Akinbola, ETSD) said he personally took Mr. Okwuna Ifeanyi to the welding workshop for the test, but told Mr. Ifeanyi to wait for him to come back from the plant Clinic(since he had pains in the ribs & lungs requiring urgent medical attention) before the test would commence. Mr. Akinbola was referred to waterlines Clinic to see a thoracic surgeon that same morning because of the critical nature of his ailment. Mr.Okwuna Ifeanyi said he is the managing director of Ifeanco Enterprises, a subcontractor to Vengomo (Nigeria) limited. He was in the refinery for a prequalification welding test at the Maintenance workshop. He said that his examiner had to leave for clinic because of excruciating pains at the ribs and lungs, and told him to wait for his return before the test would commence. Ifeanyi said he decided on his own accord to prepare the objects for the prequalification test at the welding workshop without the knowledge and supervision of his examiner. He decided on his own initiative to use the grinding machine to smoothen the edges on the groove of the pipes that were to be used for prequalification test. He decided to prepare the groves of the pipe so as to ensure deep weld penetration after the test. He had to squat by the vice on the workshop bench which was just three feet from the ground, to use the grinder to dress the edge of the groove. He said that as he powered the grinding machine, the test pipe to be cut whose groove he was dressing held on to the grinding machine, and in that squatting position he attempted freeing the grinding machine from the grip of the pipe. He said that he switched the grinder on manual use, he lost grip of the grinder and in that instance he was hit on the face by the grinding machine. He said he wore no face shield, but used plastic welding goggles which the grinder hit

before falling to the ground, and the left side of his face near the mouth was cut and blood started gushing out. When asked if his examiner instructed him to carry out any preparation in his absence, he said NO. HE was also asked if any of the experienced PHRC welders at the workshop was detailed to assist his examiner in his absence, he said NO. He said the personnel protective gear he used were coveralls, safety boot, hand gloves and plastic welding goggles. He said that the particular grinding machine he used that day had part of the handle which he was to have gripped removed. HE was asked if he went through safety briefing on 1st July 2011, with other workers of Vengomo (Nigeria) limited working on the rehabilitation of 52-TK59G, he answered NO. Okwuna Ifeanyi admitted that he knew he ought not to have used a grinder with missing handle for effective grip, but decided to do so, in order to save time by carrying out unauthorized test preparations in the welding workshop which was a gross safety breach. When asked if he knew he ought to have asked any of the PHRC welders for a grinding machine with handles he answered YES. The site supervisor for Vengomo (Nigeria) limited, Mr. Sonny Firima was asked if any work permit form was filled for such a test bearing in mind the hazardous nature of the pre-qualification test and since the work place and instruments to be used ought to have been certified safe before the test. He answered NO. The site supervisor also said that the reason the victim was not brought in for safety briefing was that his company planned to outsource the services of this welder at a latter stage of the rehabilitation of 52-TK-59G. They were corrected and told that this welder ought to have attended the safety brief. He was told that bringing such a contractor into the refinery for such a test without undergoing a safety brief was an UNSAFE ACT and serious violation of refinery safety regulations.

OBSERVATIONS/ FINDINGS Third party (sub-contractor) was brought into the refinery to carry out welding jobs without safety brief. Sub contracted welder decided to carry out welding qualification test preparations on his own initiative at the welding workshop without supervision. None of the experienced PHRC welders at the scene of the incident challenged the sub-contractor who started grinding and smoothen the grooves of pipes without authorization. The welder did not use his own grinder, it was the grinder given to him at the workshop, without full complement of handles for effective grip of such a tool. None of the PHRC welders at the workshop considered the use of a grinder without handle as an UNSAFE ACT. The inspection & testing section of ETSD, did not verify if the welder had undergone safety briefing before agreeing with the contractor to use him for welding within the PHRC premises. No one at the welding workshop cared to stop the contractor and move him out of the workshop telling him to wait for his examiner. None of our PHRC welders present at the workshop demonstrated the observance of safety regulations by caring for the safety of this subcontractor (third-party) who also has a stake in the refinery. No incident report was written by the superintendent of the welding workshop in whose facility the incident occurred. No incident report was written by the job officer and the contractor in charge of rehabilitation of 52-TK-59G.

CONCLUSION There is a very dire need to vigorously carry out safety sensitization campaigns And trainings for PHRC operational staff and other stake holders to erase the non-chalant attitude of affected staff and contractors to enforcement of safety rules and regulations. RECOMMENDATIONS The non-chalant attitude of affected welders and plant inspectors calls for urgent action and should be looked into. The management of Vengomo (Nigeria) limited should be informed and reprimanded. Effective Safety Awareness programmes should immediately be embarked upon in PHRC in order to avert a potential disaster in the near future judging from the attitude of maintenance staff present at the scene of the incident, who need to be bought in to the new health and safety culture. R.A. O. SOARES. Safety Investigation Officer.