H2S Workshop

Silent Killer
24th May 2009

Abdul Munim Saif Al

Kindy
General Manager,

The Tragic Incident on 3rd Feb. 2009

Shah Field

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12 ft

ft

Corrosion Coupon Pit

8f

Background
Asab GASCO plant shutdown was planned from 25th Jan. to
11th Feb. 2009. This resulted in a complete ADCO production
shutdown.
Shutdown provided window of opportunities to carry out key
maintenance activities across Asab, Sahil & Shah Fields.
In Shah, the planned key maintenance activities included
partial replacement of transfer line and removal of two stuck
corrosion coupons retrieval tools at KM-58 and KM-68 pits.
At KM-68, removal of stuck corrosion coupon retrieval tool was
successfully carried out with drainage of approx. 200 barrels
crude from the transfer line.
At KM-58, removal of stuck corrosion coupon retrieval tool
necessitated drainage of approx. 1600 barrels of crude from
the transfer line.
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Events of the tragic Day

A Foreman and five laborers proceeded to work involving draining of a
transfer line inside a corrosion coupon pit (confined space) (without
obtaining work permit)

One laborer entered the pit to reattach the rope to the drain valve. While
trying to exit the pit he fell back, hanging upside down and his leg trapped
inside the ladder.

Foreman entered the pit to rescue the laborer and asked a second laborer to
close the valve and help him with the rescue.
The second laborer entered and started helping, but foreman collapsed and
soon after the second laborer collapsed and sustained a head injury by
hitting an object (he survived).
The third laborer entered the pit to rescue his colleagues and collapsed
The two laborers standing outside the pit sought help from Shah control
room.
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Immediate Causes
Violation of Procedure (PTW & Confined Space Entry)
Procedure for draining the Transfer Line not available
& method of statement less than adequate.
Personal Protective Equipment (BAs) not used
Exposure to Hazardous Conditions (H2S,
hydrocarbons)

Root Causes
Inadequate hazards identification
/perception
Inadequate reinforcement of procedures
Inadequate reinforcement of safe
behavior, not implementing stop policy.
Complacency and overconfidence
Inadequate consequence management
Not acceptable and Inadequate
MANAGEMENT
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Recommendations
Ensure PTW is issued based on task risk assessment (TRA) and the TRA has been
endorsed by a safety professional (Safety & Loss Prevention Engineer (SLPE) as
minimum).
Confined space entries cannot be made unless a SLPE is present and he has reviewed
the emergency plan
Empower laborers/workers to STOP unsafe activities and initiate contractual
arrangements to protect/encourage individuals exercising ADCO STOP Policy.
Provide personal H2S detectors to all personnel including laborers working in H2S
exposed areas.
Ensure all helper/laborers members are fully trained for performing their assigned tasks.

Include practical element (step test) and confined space entry in H2S/BA training course
and for all operation/ production and HSE staff.
Establish Access Control on all confined spaces with effective markings, signs &
tagging; and locking, where applicable.
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Post Shah Incident

Comprehensive Respiratory Protection Programme
H2S area classifications and zoning
Facial Hair policy implementation
PPE (escape set
and H2S monitor/per employee( ADCO&
contractors) in restricted areas.
Identification of requirements forH2S warning signs and sign boards
Enhanced &simplify H2S training (multi lingual) for contractor labours
Focused High profile tours theme on the high risk activities( H2S , PTW)
Task Risk Assessment - TRA
Developed TRA for high risk activities, raised the approval level and linked to
PTW
Clearly defined requirements for formal TRA
Initiated training on TRA

Initiated enhancement in HSE communications

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Thank You

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