ADCO 2012 Learning From Incidents- HSE

منع وقوع الحوادث من خ�ل الدروس والعبر المستفادة منھا

Incident Prevention Through

Learning from Incidents

January - December, 2012

قسم الصحة والس�مة والبيئة

Health, Safety & Environment Division

1

For further information, comments and suggestions please contact:

Dr. Muhammad. R. Tayab ([email protected])

Health, Safety & Environment Division Tel: 02-6041217; Mobile – 00971 (0) 50 324-3996

للمزيد من المعلومات وإبداء الم�حظات واقتراحات يرجى اتصال بـ:

[email protected]على البريد الكتروني التالي : محمد ريحان طيب الدكتور قسم الصحة والس�مة والبيئة

6041217رقم الھاتف :

This Booklet is circulated within ADCO organization within the framework of HSEMS. It should only serve as guidance and ADCO shall in no event accept any liability for either the fact described, nor for any reliance on the contents by any third party.

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ADCO regards safety of both ADCO & Contractor staff as well as protection of the environment and integrity of its assets high and I reiterate ADCO commitment to create a safe working environmental for every member of ADCO Community. We have achieved very challenging production and operations targets during 2012 with high focus on personnel and process safety. During the 2012, ADCO has recorded over 160 Million Manhours worked by 52,000 ADCO & Contractor staff; and we have driven approximately 200 Million Kilometers. Regrettably, we have had 2 work related fatalities, 20 Non Accidental Deaths (NAD) and over 75 serious injuries. In addition we had 24 vehicle crashes and 8 oil spills events. Incident investigations highlighted deficiencies in work planning, supervision and behaviour. Key gaps included:

• Task related risks were not adequately identified

• Workers were not made aware of risks and were not effectively supervised.

• Lessons from prior incidents not embedded

• Tasks were not planned adequately (due to lack of competent human resources and non-availability of right tools) ADCO safe system of work (e.g. Task Risk Assessment (TRA), Permit to Work (PTW), Tool Box Talks (TBT) etc.) is designed to save lives and should be respected. It is not mere a paper exercise, it is workers’ life line. I request all ADCO team members to take diligent review of work planning at grass root levels and effectively address these deficiencies. I am sure it will create a positive change and enhance safety at work. I would like every member of ADCO community to review this collection of incidents and what lessons can be learned and then their work activities so that these incidents are not repeated. You are requested never to compromise on the safety of staff & worker, protection of the environment and integrity of our assets. I am fully committed to provide you all the support and resources that you may require to create a safer working environment to all.

Abdul Munim Saif Al Kindy

Chief Executive Officer (CEO)

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Table of Contents

Finger Injury Resulting from Using Hand Tools 9

33-Kv Underground Cable Damage During Sand Clearance 10

Damage to Underground Fiber Optic Cable During Excavation 11

Crane Mounted Truck (Hiab) Rollover on Gatch Road 12

Crane Mounted Truck Rollover on Gatch Road 13

Loss of Containment 18

Rollover of Truck Carrying Gatch 19

Fire at Wooden Electrical Pole 20

Vehicle Drop in Low Lying Area/Depression 21

Breakage of Hook of Wire Rope 22

Injury from Falling Cap of Circulating Head 27

Struck by Swinging Mud Pump During Lifting 28

Fall of Travelling Block with Full String Weight 29

Gas Release From Coil Tubing 30

Vehicle Collision Near A Rig Site 31

Low Bed Trailer Rollover 32

Finger Injury During Entanglement of Wire from Wireline Reel 33

Release of Oil from Xmas Tree 34

Fall of Foreman from Stand Pipe 35

Dropped Object During Lifting 36

Uncontrolled Descend of Travelling Block 37

Power Generator/Engine Fire 38

Trailer Fire at Rig Camp 39

Water Tanker Rollover 40

Hand Entrapment Inside Tong 41

Electrical Shock 42

Arm Injury Due to Fall of Jumbo Bag 43

Falling Object 44

Fire Due to Poor Grounding During Welding 49

Fiber Optic Cable Cut During Excavation 50

Vehicle Collision & Rollover 51

Asphyxiation of Welder Inside A Pipe 52

Man Lift Drove Over Flagman’s Foot 53

Vehicle Rollover 54

Vehicle Collision on a Sand Track 55

4

Vehicle Drove Over a Berm 56

Cement Mixer Rollover 57

Damage to Overhead Line 58

Ankle Injury During Cable Pulling 59

Vehicles Collision on Gatch Road 60

Arm Injury Due to Explosion During CAD Welding 61

Fire at Scaffolding Platform Around Stripper Column 62

Foreign Object Entering Eye of a Worker 63

Vehicle Rollover on Gatch Road 64

Crane Mounted Truck (Hiab) Rollover on Gatch Road 65

Vehicles Collision 66

Crane Rollover During Move on Gatch Road 67

Vehicle Collision 68

Fatal Fall of Worker from a Moving Vehicle 69

Fall of Mobile Scaffold Platform on a Worker 70

Arm Amputation Inside Foam Concrete Mixer 71

Vehicle Crash During OHL Visual Survey 76

Transformer Fire 77

Fire in UPS Unit of Substation 78

Electrical Flashover Inside Transformer Terminal Box 83

Foreign Object (Metal Particle in Eye) 84

Worker’s Finger Entrapment Between Pipe Flange and Valve Flange 85

Heat Stress 90

HSE Performance, 2012 91

Incident Types - 2012 92

Asset Wise Event Type Distribution - 2012 94

Incident Immediate & Root Cause Categories 2012 95

Incident Immediate Cause Analysis -2012 96

Incident Root Cause Analysis -2012 97

5

BAB & Gas Asset

6

7

Past Incidents

Wireline Truck Rollover

(04-0-7-10)

Loss of Containment near RDS5

(20-11-2010)

Fatal Vehicle Rollover

(01-08-2010)

Fire at Disposal Water Pump

(09-03-2011)

H2S Release from Common Drain

Header (09-06-2010)

Eye Injury Due to Acid Splash (06-

02-2010)

Production Header Leak

(24-04-2011)

Finger Injury Due to Slippage of Cylinder (16-06-2011)

Finger Injury During Bolting of Flange

(29-01-2010)

Gas Release From X-Mas Tree

(16-01-2010)

H2S Release from Water Supply Well (16-05-2010)

H2S Release from Oil Well

(20-11-2012)

8

9

Finger Injury Resulting from Using Hand Tools

Area Incident Description Root Causes

Bab Field

14-02-12

A degasser was under off-stream inspection and after the inspection, a labourer/helper was

tightening bolts of Pressure Control Valve (PCV). He was using a pipe to extend the handle of pipe wrench and during the process

his finger was trapped between the pipe and the wrench. The labor was sent to RAMS Clinic and later to Madinat Zayed Hospital.

Outcome: The labourer/helper sustained finger

crush injury and required stitches & subsequent wound management

• Improper Supervisory Example

(Foreman provided inadequate tools to labourer)

• Inadequate Training Efforts (A newly

hired/appointed labourer was not given adequate training on use of hand tools)

• Inadequate Correction of Worksite/

Job Hazards (Hazards of using inadequate

tools for tightening bolts were not controlled)

• Inadequate Assessment of Needs &

Risks (Availability of right tools was not ensured and workers were using home made type tools)

Lessons Learned

1. Always use right tools for the task and do not

take short cuts

2. During task/work planning identify requirements and availability of right tools

3. Provide hand tool safety awareness to all Forman, helpers/labourers

Immediate Causes

• Improper Position or Posture for the

Task (Placing finger/hand near pipe and the tool)

• Inadequate Equipment (Using a wrench

with a pipe extension instead of standard tools, spanner)

• Workplace Layout- Congestion or restricted movement

10

33-Kv Underground Cable Damage During Sand Clearance


Bab Field 28-04-12

Field Services Engineer requested sand

clearance at the main track and a sand clearance crew was mobilized. Sand clearance from existing track is generally considered

routine activities and not subjected to requirements of Permit to Work (PTW). The track had a high voltage (33Kv) line buried at a crossing. The cable was laid as prevailing

engineering standards but at the side of the track the cable was near the surface.

The crew was not aware of any buried cable

and not site markers were placed. The crew was using mechanical grader and when reached at the crossing, it damaged the live cable.

Outcome: The power supply to clusters was disconnected. No personnel injury was reported.

• Inadequate Identification of

Worksite/Job Hazards (Risk associated with grading and leveling near buried cables were not assessed)

• Incorrect Supervisory Example (Sand clearance activity for main access track with buried utilities (high voltage cable) was initiated without PTW; No Tool Box Talk was

conducted for Machine operator)

• Inadequate Communication of Procedure (Requirements of Excavation Certificate were

not understood by staff)

Lessons Learned

1. Always obtain excavation certificate for sand clearance (leveling/grading) activities (Item No. 3.4, Page No. 17; Item No. 3.13, Page No.

69; Item No. 3.13.2.1 Page No 71 of PTW procedure)

2. Place visual markers to guide sand clearance machine operators.

Immediate Causes

• Lack of knowledge of Hazards Present

(Sand clearance crew was not aware of buried utilities)

• No Warning Provided (There was no markers/warnings identifying buried cable)

• Inadequate Guards or Protective

System (Cable was not protected at the edge of the track)

11

Damage to Underground Fiber Optic Cable During Excavation

Area Incident Description Causes

BAB Field

08-08-12

A 3rd party contractor was working on a project to lay a new potable water pipeline to supply GASCO and ADCO with potable water and the majority of the work was completed in BAB. The work was performed under ADCO Permit to Work (PTW) system and an excavation certificate was issued. As built drawing did not show location of buried fiber optic cables

(which were running parallel to a transfer line) and there were no physical markers on the ground.

The task was intended for manual excavation and the use of machine was limited to removal of excavated material/debris.

The crew did not have adequate resources (i.e. number of laborers for manual excavation) to complete the task on schedule and these resources were not adjusted for work during the fasting month of Ramadan.

The job performer had started to use mechanical excavator, after exposing buried line. During the excavation a fiber optic communication cable was cut and that has resulted in tripping of Remote Degassing Station (RDS-1) and alarm was sounded in the control room of Bab Central Degassing Station (BCDS).

• Inadequate Work Planning (The

number of labourers in the crew were not adequate to manually excavate the site on time and shorter working

hours in Ramadan were not considered during work planning)

• Inadequate Implementation of

Procedure (JP was not a member of Task Risk Assessment (TRA) team and did not endorse the TRA)

• Inadequate Leadership (Job

Originator was not involved in TRA and did not ensure availability of adequate resources for task execution; As built drawings did not

show location of buried cables)

Lessons Learned

1. Do not use mechanical excavator in restricted areas.

2. Ensure availability of adequate

resources prior to execution of tasks

3. Provide updated as built drawings

to support excavation certificate

4. Ensure Job Originator & Job Performer/s are part of Task Risk Assessment (TRA) Team

Immediate Causes

• Violation by Supervisor (The job performer (JP) used a

mechanical excavator in area where manual excavation was authorized)

• Lack of knowledge of Hazards Present (Location of buried cable was not known to Job Performer and there

were no surface makers on the ground; Job Performer was not aware of risks associated with the task)

• Inadequate Guard or Protective Devices (Cable were

buried without any physical protection)

12

Crane Mounted Truck (Hiab) Rollover on Gatch Road


BAB Field

22-08-12

A crew was involved in civil works in RDS-2

and after the completion of the work, a driver was driving Hiab Truck (crane mounted truck) from the work site towards their camp.

The supervisor and job performer (JP) did not notice that the vehicle had deteriorated tires and IVMS (In Vehicle Monitoring System) was not functional. Due to high humidity, the

gatch road surface became slippery.

After driving 8 km from the worksite, while the driver was maneuvering through holes on

the surface of the gatch and he applied harsh brakes. A combination of deteriorated tires, slippery surface, harsh brake and sharp maneuvering of steering caused the vehicle to

rollover. Outcome: The driver sustained lower back injuries.

• Inadequate Audit/ Inspection/

Monitoring (Vehicle’s tire fitness was not

checked; Road condition (potholes) were not assessed prior to the journey; Vehicle IVMS and driver’s driving behavior reports were not reviewed)


Worksite/Job Hazards (Hazards of slippery surface due to humidity and potholes in gatch road were not identified and controlled)

Lessons Learned

1. Avoid harsh braking and sharp

maneuvering of steering especially on gatch roads.

2. Consider hazards of weather conditions (rain, high humidity etc.) on road/track

conditions in Task Risk Assessment

Immediate Causes

• Improper Decision Making/ Lack of

Judgment (Driver applied harsh brakes and sharp maneuvering of steering on slippery road)

• Improperly Prepared Vehicle (The

vehicle had deteriorated tires)

• Storm or Act of Nature (Road surface became slippery due to high humidity)

13

Crane Mounted Truck Rollover on Gatch Road


BAB Field

22-08-12

The Coiled Tubing (CT) work was completed at a well site (Bb-797) and a crane mounted

truck was dispatched from Abu Dhabi to Bab Field to shift martials to another location (Bb-241). The mobilization and demobilization was not considered in overall Task Risk

Assessment (TRA) and there was no permit to work was in place for work at another location (Bb-241).

The gatch road leading to the site (Bb-797) became wet slippery due to fog/humidity overnight. After driving approximately 2 km, the vehicle drifted from the gatch road and

the driver applied harsh brakes and sharp maneuvering of steering to control the vehicle causing vehicle to over to its side. Outcome: The driver sustained open wound on his hand

and treated at a hospital.


Monitoring (Contract focal point did not follow contractor’s work schedule and contractors activities without PTW were not

detected)

• Inadequate Identification of Worksite/

Job Hazards (Task Risk Assessment (TRA) did not include mobilization & Demobilization and

therefore hazards of slippery surface due to humidity were not identified)

3. Lessons Learned Not Embedded (Lessons

from similar incidents (occurred on 22-08-2012 & 28-08-2012) involving rollovers of crane mounted trucks in BAB Field were not effectively incorporated into work plan)

Lessons Learned

1. Avoid applying harsh brakes and sharp maneuvering of steering when driving off road.

2. Subject drivers to daily tool box talks to

discuss route hazards and to reinforce safe driving behaviour

3. Consider hazards of weather conditions (rain, high humidity etc.) as a part of site mobilization/demobilization in Task Risk Assessment (TRA)

Immediate Causes

• Storm or Act of Nature (Road surface became slippery due to high humidity)

• Improper Decision Making/ Lack of

Judgment (Driver applied harsh brakes

and sharp maneuvering of steering on slippery road to control the vehicle)

• Violation by Supervisor (Work started

without PTW and driver was not subjected to Tool Box Talk (TBT) or made aware of hazards at work site)

14

Buhasa/Huwaila/Bida Qamzan Asset

15

16

Past Incidents

Damage to Flowline During Sand

Clearance (23-11-2010)

Piping Connection Failure During Well

Killing (06-09-2010)

Damage to Flowline During Site

Preparation (17-06-2010)

Flasover Inside Switchgear Room

(23-01-2011)

Loss of Containment Resulting in Fatal

Vehicle Fire (07-05-2011)





Worker Attacked by an Ostrich (26-

07-2011)

Electrical Flashover (10-04-2011)

Vehicle Stuck in Sand and Caught

Fire (21-07-2011)

Private Vehicle rollover (06-04-2010)

Fall from Ladder (17-05-2010)

17

18

Loss of Containment


Buhasa Field

(BUH)

01-01-12

Work was planned to install corrosion coupon retrieval access fitting on a flow line. Due to

hazardous nature of welding the fitting on site, a cold cut was performed followed by welding the access fitting in the workshop. Before

welding the access fittings screws were removed and after the welding, the welder forgot to fit the screws and a cap was installed on to the fittings.

The foreman assumed that fitting screws were fitted back and he proceeded with the installation. Operation crew opened the well and a release of oil was reported by another crew (approximately 2 km away from the well site) from the access assembly. The well was shut in

and the leak subsided. Outcome: Approximately 1 bbl of crude oil was released/spilled

• Inadequate Inspection & Monitoring (Foreman did not check the fitness of the assembly prior to its installation)

• Inadequate Communication (Welding Foreman did not communicate with the Corrosion & Inspection (C & I) crews to carry out inspection on the fittings)

Assembly without Screws

Assembly with Screws

Lessons Learned

1. Always assess/inspect readiness of the

system before installation/operations.

2. Do not assume and when in doubt, check with line supervisors.

Immediate Causes

• Defective Equipment (Access fitting was capped without fitting screws)

• Unintentional Human Error (Welder did not fix crews before placing the cap of access assembly)

19

Rollover of Truck Carrying Gatch


Buhasa Field (BUH)

03-03-12

An Engineer requested delivery of gatch materials to the site. A transport Foreman conducted a site survey to assess the

condition of the access track and he identified certain areas where soft sand had accumulated. The Field Services crew cleared the sand from the track. The transport Foreman gave instructions to tipper truck driver for the delivery. There were two access tracks to the location and

the driver selected the track which was not prepared. On the track, the driver noticed sand accumulation but he continued to drive. The started to skid and rolled over

to its right side.

Outcome: The driver sustained minor injuries on his both hands and forehead.

Vehicle’s windshield, right mirror, right door were damaged.

• Inadequate Communication (The Foreman did not identify the right/cleared access track for the journey)

• Inadequate Work Planning or risk

Assessment (The journey was not adequately planned and route selection,

journey risks and tool box talk not performed)

Lesson Learned

1. Always identify route before commencing journeys

2. Do not drive over soft sand especially when transporting heavy loads

3. Conduct Tool Box Talk (TBT) for drivers prior to dispatching on assignments.

Immediate Causes

• Lack of Knowledge of Hazards

Present (The driver was not aware of sand accumulation on the track and upon noticing the sand he under

estimated the extent of sand accumulation)

• No Warning Provided (The foreman did not identify the exact route for the

journey)

20

Fire at Wooden Electrical Pole


Buhasa Field

(BUH)

14-04-12

Electrical wooden poles are in use within ADCO concession areas and some of these poles are old and deteriorated, lost their chemical (fire retardant) coating. Typically pole hardware are

visually inspected and if there any abnormality noticed then physical checks are conducted. ADCO requires Over Head Line (OHL) resistance minimum of 4 Ohms and an earthing rod is driven

to 3 m depth.

During a heavy thunderstorm and light rain, a wooden pole caught fire as a result of current

passing from OHL conductor to earth conductor with high resistance.

Outcome: Power to RDS-3, Huwaila, and a few surrounding clusters was disrupted.

• Excessive Wear and Tear (The wooden

poles have been in service for many years and are reaching the end of their service life)

• Inadequate Preventive Maintenance

(Deteriorated wooden electrical poles were not replaced; integrity of fire

retardant chemical coating was not maintained; effectiveness of earthing system not checked)

Lessons Learned

1. Over Head Line (OHL) should be checked regularly for proper tightness.

2. Wood to metal interfaces at king bolt

should be fitted with good electrical contact surfaces to dispense leakage current

3. Use deeper Earthing wells to disperse

leakage current.

Immediate Causes

• Inadequate Guards or Protective Devices (Earthing system was not adequate to disperse leaking current)

• Work Exposure to storms or acts of

nature (Lightening and light rain.)

21

Vehicle Drop in Low Lying Area/Depression


Buhasa Field

(BUH)

22-08-12

A mechanical foreman was returning to the workshop from a wellsite (CL-29) and he was heading the wrong way. His colleagues

(passengers) in the vehicle advised him to proceed in the opposite direction. He turned the vehicle and started to drive in the desrt to get on the designated track. There was a

low lying area /depression in the sand and the vehicle slid down and made contact with the bottom of the dune.

Outcome: The vehicle sustained minor damage on the front-end bumper.

• Inadequate Practice of Skill

(Driver took a u-turn and

entered into non-designated route instead of remaining on track)

Immediate Causes

• Improper decision making/lack of

judgment (The driver did not return back to original track but tried to go another way to merge with the main

track)

• Inattention to surroundings (He did not pay attention to surface conditions

and was focusing to get on the designated track)

Lesson Learned

1. Always take the designated

route to avoid hazards of unstable ground conditions.

22

Breakage of Hook of Wire Rope


Buhasa Field

(BUH)

10-08-12

A Foreman was driving to a well site (BU-559) and his vehicle got stuck on a sand dune. He requested assistance from the transport pool.

Transport Pool Driver reached the site and tried to pull the stuck vehicle using a wire rope with his own vehicle.

While pulling the vehicle from the rear side, the

wire rope's hook broke and struck against the foreman-vehicle’s rear window. Outcome: Rear window of the vehicle was completely

smashed.

• In adequate removal/replacement of

tools & equipment (The slings in the older

desert safety boxes were not checked/ replaced)

Lesson Learned

1. Check adequacy of tools available for in vehicle tool box.

2. Always check if the slings are certified/checked, and suitable for pulling the vehicle prior to use.

Immediate Causes

• Inadequate Tools or Equipment (The sling used was not suitable for the job)

23

Technical Services – Drilling

24

25

Past Incidents

Damage to Hammer Union During Pressure

Test (23-11-2010)

OBM Haulage Tanker Rollover (29-10-

2010)

Fatal Fire & Explosion of OBM Haulage

Tanker (24-02-2012)

Finger Injury During Rigging up

(02-07-2010)

Well Control Incident

(08-04-2010)

Fatal Fall from Height

(18-01-2010)

Damage to Flowline During Site


Uncontrolled Descent of Drilling

Assembly (28-05-2011)

Super Kenworth Rollover

(13-12-2010)

Slippage on Mud Tank

(30-06-2010)

Spillage of OBM

(16-06-2010)

Face Injury From Tong line

(26-01-2010)

26

27

Injury from Falling Cap of Circulating Head


Drilling

Rig No. 17

17-01-12

During normal drilling operations (installation of wearing busing), an Assistant Driller (AD) opened the cap of circulating head on the rig

floor. The cap (weighting approximately 2.5 kg) slipped, hitting on the substructure cross beam and after rebounding fell down in cellar

area. A floorman was working (tightening the chain boomer) in the cellar 32 feet below the rig floor) and the cap struck on his helmet.

Outcome: The hardhat of that floorman flown-

off from his head and he sustained scratches due to the impact of sliding of hardhat.

• Inadequate Identification of Worksite/Job

Hazards (Hazards of falling of circulatory cap due to close location of circulating head to rig floor hand rail and improper adjustment of toe

plate of handrail)

Lesson Learned

Immediate Causes 1. Ensure hand/work gloves are dried & free from oil & grease before handling tools & equipment.

2. Adjust toe plate of handrail to prevent dropping of objects

3. Always use mandatory PPE (Personal Protective Equipment) at Rig Site at all times

• Congestion or Restricted Movement

(The circulating head was located close to rig floor handrail)

• Lack of Judgment/ Unintentional

Human Error (Opening of circulation head with oily/greasy hand gloves)

28

Struck by Swinging Mud Pump During Lifting Area Incident Description Root Causes

Drilling

Rig No. 53

20-01-12

Cracks in housing of mud pump occurred because the mud pump blower and motor assembly structure were not supported properly and the center of gravity was outside of the structure. Rig Electrician and Asst.

Electrician planned to remove the blower unit of Mud pump to weld and repair cracks.

The Electrician instructed the Assistant Electrician to detach, electrical cables from the blower motor and hook up the blower housing with the crane hook by using shackles. While Assistant Electrician was placing the 1st

shackle, suddenly the blower unit tilted, due to the weight of the blower motor, and the whole blower unit (≈115 Kg.) fell down /swung towards the Electrician and hit on his left shoulder, and pushing him down; and the

blower unit rested on the mud pump skid. The electrician fell down on the mud pump skid. Outcome: Electrician sustained fractures on the left two ribs


Worksite/Job Hazards (There was no Job Safety Analysis (JSA) was available to remove and fix back the mud pump blower unit)

• Inadequate Work Planning (Adequate resources were not obtained (i.e. Electrician was working with Assistant

Electrician with no one to supervise the task)

• Inadequate Preventive Maintenance (Earlier inspections did not identify lack

of support to mud pump blower and motor assembly structure)

Lesson Learned

1. Always follow safe lifting procedure by ensuring hooking up the load before

removing the fixing studs

2. Ensure your safe position while lifting operation and keep away from the

loading area

Immediate Causes

• Improper Position (Electrician was standing too close to mud pump during lifting)

• Improper Lifting (Fixing studs were removed before hooking up the load)

• Lack of Knowledge of Hazards Present

(Electrician didn’t put into his consideration the imbalance when he removes the studs the blower unit will tilt from its place due to the center of gravity

of the blower motor)

29

Fall of Travelling Block with Full String Weight


Drilling

Rig No. 38

02-02-12

The rig was conducting work-over operations on a well (BB-282)

and had been on location for approximately one week While

running in hole with a wash-over assembly, the driller picked up the string out of the slips and started to lower the stand, controlling running speed using the electro-

dynamic (eddy-current or Elamgco) auxiliary break. Either from the time of picking up the string or during running of this stand, with approximately 80,000lbs hook-load, breaking force from the Elmagco was lost and the blocks

began to free-fall. The driller attempted to apply the main, mechanical, break but was unable to stop the draw-works sufficiently to prevent the elevators from impacting with

the rotary table. The travelling block also fell to the floor. Outcome: No personnel were injured


Monitoring (Regular inspection of the

linkage is not conducted and no recent maintenance had been performed on the mechanism)

• Inadequate Adjustment/ Repair/

Maintenance (An unathorised part was

used in Elmagco clutch shifting mechanism)

Lessons Learned

1. Always use spares & part as

recommended by original equipment manufacturer (OEM)

2. Examine all auxiliary brake clutch linkage systems for correct

specification fittings

3. Regularly test Elmagco clutch mechanism.

Immediate Causes

• Violation by Group (During commissioning of the rig, the auxiliary brake unit was changed and a substandard part was incorporated)

• Defective Guards or Protective Devices (The Elmagco clutch shifting mechanism failed allowing the Elmagco to disengage)

• Work Exposure to Mechanical Hazards (With

approximately 80,000lbs string weight the elevators impacted with the rotary table, the travelling block landed on the rig floor and the drill-line parted)

30

Gas Release From Coil Tubing


Drilling

Rig No. 22

21-03-12

The well was drilled as exploratory well and after the production test, it was scheduled for work

over to perforate and test Hith Formation and horizontalization.

During run in hole with coil tubing and lifting the well with nitrogen at depth 370ft from surface,

the coil tubing partially parted (almost 75% from its circle) just 1.5ft before the mechanical depth indicator of the coil causing big sound, nitrogen &

gas with H2S (Hydrogen Sulphide) release to the atmosphere due to failure of dual check valve in the Bottom Hole Assembly (BHA). N2 (Nitrogen) and gas with H2S (1400PMM) was released into

the atmosphere. All the personnel were evacuated and the well was killed by bull-heading with 100bbls of brine water (75pcf). Gas leak was stopped after pumping 15bbls of the brine into

tubing. Outcome: Release of N2 (Nitrogen) and gas with H2S from coil tubing to the atmosphere.

• Inadequate Inspection/Monitoring (Rigless

Supervisor and Drilling Supervisor did not monitor the exposure time; Dual check valve installed with coil tubing BHA and coil tubing reel was not inspected or

tested after acid job and prior lifting job)

• Inadequate Assessment of Required Skills or

competency/Inadequate Job Placement (The assigned Drilling Supervisor lacked experience in acid

treatment job and it was the first time to attend gas production test; Rigless supervisor was shifted to this job just before acid job without adequate handover)

• Inadequate Work Planning (There was no detailed acid program from town and no formal job order for the execution of job from Rigless & Drilling Supervisors to Service Providers on site)

Lessons Learned

1. Do not exceed recipe exposure time during acid job test.

2. Always inspect & test coil tubing & double check valve after acid job

3. Assign competent staff on high risk jobs

Immediate Causes

• Violation by Supervisor (Rigless crew exceeded acid recipe time duration)

• Defective Equipment (Coil tubing lost 70% from its material thickness and partially parted; Double check valve was severely

damaged due to long exposure time for acid 28% during acid treatment).

• Work Exposure to Energized System (Exposure to high pressure sour gas in gas

well)

31

Vehicle Collision Near A Rig Site


Drilling

NDC Rig 25

24-05-12

Unspool drilling line operation was ongoing and the Drilling Supervisor (DS) decided to go to camp after finishing his tasks at the rig site. He called for his driver and he was on the way to the rig camp using the designated rig road. Rig Crew change vehicle

was approaching the rig site from rig camp at the same time. Both vehicle approached from opposite directions and collided at a

slope.

Outcome: Both vehicle sustained minor damaged on their front right sides.


Worksite/Job Hazards (Rig access track design did not mitigate risks of driving on slopes in low visibilities (e.g night driving).

• Inadequate Monitoring (Access track was adequately maintained resulting in sand accumulation at places)

Lesson Learned

1. Avoid driving at night time/low visibility conditions between rig site and rig camp.

2. Regularly maintain access tracks to avoid

accumulation of sand on tracks causing drivers to move towards middle of the track or on the wrong side of the track.

Immediate Causes

• Violation by Individual (Driver of Rig

Crew Move vehicle was driving on the wrong side of the track)

• Lack of Knowledge of Hazards

Present (Drivers were not aware of approaching vehicles due to low visibility and road layout- Slopes)

32

Low Bed Trailer Rollover


Drilling

NDC Rig 9

02-06-12

Shifting of a crane from one location to another (Well site No. Sa-220 to Sa231) and was loaded on a low bed trailer. The trailer operator was not aware of the access route to the new location and was travelling in wrong direction. When he realized the error he tried to take a U Turn to return back. Due to sand

accumulation/soft humps and lack of space for turning, the trailer with the crane rolled over. Outcome: The trailed 5th Wheel was damaged and the crane was moved by another crew.

• Improper Supervisory Example (A new & inexperience operator was assigned to transfer the load and the route was not defined/identified)

• Inadequate Assessment of the required

Skill or Competency The driver had only one week experience on low bed trailer and his

competency to operate the trailer with heavy load in field conditions was not assessed and was inadequate)

• Inadequate Communication (The supervisor did not properly identify the route)

Lesson Learned

Immediate Causes

1. Always inspect and identify access route for the

movement of equipment

2. Familiarize new drivers/operators with roads and access routes prior to their assignments

• Improper Decision making/Lack of

Judgment (The operator of low bed trailer

attempted to take a U turn on sand bars/humps)

• Lack of Knowledge of Hazards Present

(The operator of the trailer was not

familiarized with road/access route conditions and hazards associated with the journey)

33

Finger Injury During Entanglement of Wire from Wireline Reel Area Incident Description Root Causes

Drilling

Rig No. 51

15-06-12

Run in Hole (RIH) operation with Gyro was ongoing. During the process the wire got crossed out of the wire line reel and the operator was trying to turn back the wire to its position. When

he returned it, his left thumb got trapped between the wire and the reel.

Outcome: He received the First Aid at Rig Clinic and then taken to Hospital where he was diagnosed with fractured thumb and discharged after treatment. He was assigned on restricted

work.


Worksite or Job Hazards (The risk of entanglement of wire on reel and trapping of hand/limb during

entanglement were not identified)

Lesson Learned

1. Stop equipment completely before performing any work on the moving/rotating parts

2. Use line splitter guards on wire line reels

Immediate Causes

• Servicing of Energised Equipment (The wire line reel was not isolated prior to adjusting the wire)

• Lack of Knowledge of Hazards Present (The operator did not anticipate trapping of his limbs due to low risk perception)

• Inadequate Guards/Protective System

(The reel was not fitted with line splitter guard)

34

Release of Oil from Xmas Tree Area Incident Description Root Causes

Drilling

Rig No. 1

05-06-12

A Water Alternating Gas (WAG) well was drilled, and after the rig move X- mas tree was installed by a Wellhead Engineer & set Non Return Valve (NRV- in place but NRV was passing and all X-mas

tree valves were in open position. X-mass tree installation job was not witnessed by Drilling Supervisor or the Rig Manager and the Wellhead

Engineer was not on the list of approved wellhead Engineers. The well location was under preparation prior to well handover for operations. During the location preparation the well was

found flowing from X-mas tree top needle valve. The DS reported the incident and closed all X-Tree valves to secure the well. Outcome: It had resulted in release of well fluid and gases.

Contaminated soil/sand was removed and sent to treatment facility.

• Inadequate Leadership (Unapproved Wellhead Engineer was assigned to install X-mass Tree and the installation was not witnessed by Rig Management)

• Inadequate Planning or Risk

Assessment Performed (Wellhead

Engineer’s competency was not assured and high risk activity was not supervised)

• Lack of Procedure for the Task (There

was no formal well securing procedure in place)

Lesson Learned

1. Drilling Supervisor should witness installation of X-mas Tree and securing

well.

2. Assure Wellhead Engineers’ competency prior to their assignment on high risk

activities

Immediate Causes

• Violation by Individual (The wellhead Engineer did not close Xmas Tree Valves and NRV installation procedure was not followed)

• Violation by Supervisor (Drilling Supervisor did not witness the installation & securing of X-mas Tree)

• Defective Guards or Protective Devices

(NRV was passing)

35

Fall of Foreman from Stand Pipe


Drilling

NDC Rig 54

18-06-12

Work was planned to connect 2” High Pressure Hose between reverse line and chock manifold and an

Assistant Driller with three roustabouts was moving the hose. A labor foreman, who was not involved in the task (but he was the supervisor of these newly assigned roustabouts – green hats), stepped over the

horizontal section of the stand pipe to observe and assist in pulling the hose.

The Assistant Driller asked him not to stand on the stand pipe but he stayed there for a moment and then he lost his balance resulting in his fall back with his full weight on his left elbow on the compacted sand ground. Outcome: The Labor Foreman

sustained fractured elbow.

• Improper Supervisory Example (The Assistant Driller did not effectively stop the Labor Foreman from standing on standpipe).


Worksite/ Job Hazards (The Foreman did not realize of risks of standing on

standpipe and assisting the crew).

Lessons Learned

1. Do not stand on stand pipe or other

similar structures without fall protection equipment.

2. Stop all unsafe actions effectively

3. Supervisor should supervise crew and should not participate in execution of tasks.

Immediate Causes

• Improper Position or Posture for the Task (The Foreman was standing on the standpipe).

• Improper Decision Making/Lack of Judgment

(Forman intended to observe his newly assigned crews and assist them in pulling the hose while standing on the stand pipe).

36

Dropped Object During Lifting


Drilling

NDC Rig 56

24-06-12

During normal drilling operations at the rig site, a task of removing lifting-sub and crossover

(weighting approximately 250 kg) from rig floor to the ground (33 feet down).

An inexperienced rigger without effective supervision was assigned the task of rigging the

load. Prior to the task, no tool box talk (TBT) or pre job safety meeting was conducted. The rigger used the wire rope sling to attach it to the load by single wrap only and then load was lifted by crane from the rig floor, at height 33ft, to cross over box on the ground. A floor-man noticed that the load was unstable and he requested the rigger to

stop the lifting and advised to secure it through double wrap slinging method. The rigger ignored the advised and continued to lift the load and later, the lifting sub slipped and fell down on the

V-door causing damage to steps of the V-door stair then it is slipped down to the ground. Outcome: No injury to personnel and damage to

three steps of V door stairs.

• Improper Supervisory Example (An inexperienced rigger, without supervision was assigned the rigging task)

• Inadequate Coaching on the Skill (New Rigger was not effectively coached/ mentored by experienced rigger or supervisors prior to the assignment of the task)

• Inadequate /Lack of Safety Meetings (Prior to

the task, no tool box talk (TBT) or pre job safety meeting was conducted)

Lessons Learned

1. Ensure adequate supervision during lifting operations.

2. Attach new riggers with experienced riggers prior to assigning them task independently

3. Conduct Tool Box Talk/ Pre Job Safety prior to all tasks especially high risk activities

Immediate Causes

• Violation by Individual (The rigger did not follow the requirements for safe lifting/rigging

and the load was not secured)

• Improper Lifting (The rigger used one wrap of sling around the load instead of two wraps)

37

Uncontrolled Descend of Travelling Block


Drilling

NDC Rig 31

28-06-12

During Run In Hole (RIH) operations with fishing assembly, the block with top drive started

descending. Assistant Rig Manager, who was running the operations, attempted to stop but failed when applied brakes with joy stick neutral (Auto Park) position. He then applied the parking

brake, meanwhile the Top Drive (T/D) saver sub pin engaged in Drill Pipe (D/P) box which was stab in and avoided further lowering of Top Drive (T/D), but the block continue descending towards off driller side resulting in drilling lines became loose in mast hoisting system.

Outcome: It resulted in minor damage to

equipment.

• Inadequate adjustment/ repair/

maintenance (Integrity of Draw Work (D/W) & anti-collision system was not assured through

regular maintenance regime)

• Inadequate Practice of Skill (When joy stick controlled brake failed, ARM did not use EDS/VFD)

• Inadequate Procedure for the Task (No

written D/W safe work practices/ guidelines were available in driller cabin

Lessons Learned

1. After each rig move, verify the integrity of Draw Work (D/W) & anti-collision system.

2. Use Disconnect System/ Variable Frequency Drive

(EDS/VFD) to stop any free fall of blocks.

3. Post D/W safe work practices/ guidelines in driller cabin for quick reference

Immediate Causes

• Defective Equipment (Joy Stick controlling the brake malfunctioned)

• Improper Decision Making/Unintentional

Human Error (ARM did not use/activate Emergency Disconnect System (EDS))

38

Power Generator/Engine Fire


Drilling

NDC Rig 11

02-06-12

During normal drilling operations, two labourers noticed fire at a diesel driven generator and they informed the night shift Assistant Mechanic. The

Mechanic closed the diesel supply line and shut down the engine then labourers used fire extinguishers to extinguish the fire.

Outcome: Minor damage to the engine fuel supply line

• Inadequate Correction of Worksite/Job

Hazards (Similar incident had occurred on 21st

October, 2007, 25th of August, 2009 & 17th May, 2010 at NDC Rig 25, NDC Rig No.2 & NDC Rig No. 17 respectively)

• Inadequate Preventive Maintenance

(Daily/weekly visual checks and Preventive Maintenance programme was not robust enough to identify deteriorated fuel line)

Lessons Learned

1. Develop and implement rigorous testing/replacement of fuel lines after each

Rig move.

2. Maintain fire watch during the operations of generators.

Immediate Causes

• Defective Equipment (Diesel hose line was leaking due to material fatigue/deterioration

and vibration)

• Work Exposure to Extreme Temperature (High temperature at diesel engine surface)

39

Trailer Fire at Rig Camp


Drilling

NDC Rig 51

06-06-12

After the completion of Rigless operation, equipment (high pressure pump, air compressor,

transfer pump and pipe basket) were loaded on a trailer and the trailer departed from the rig location (Mandar Field) for Abu Dhabi. The driver stopped at Rig Camp (5 km from the Rig for lunch

break), parked the vehicle and went to Mess Hall.

Shortly after, the camp staff observed fire of trailers tires and raised the alarm. The driver separated the truck from the trailer and moved the truck. The camp crew responded and extinguished the fire using 3 water tankers and 10 fire extinguishers.

Outcome: No personnel injury occurred and the trailer and loaded equipment were damaged.

Inadequate Communication Between

Work Groups (Hazards of smoking near parked vehicles were not effectively communicated)

Lessons Learned

1. Provide and mark location of

designated smoking areas

2. Do not smoke near parked vehicles.

Immediate Causes

Violation by Individual (Smoking cigarette in non-smoking areas)

Lack of knowledge of Hazards Present

(Smoker was not aware of hazards of smoking near truck)

40

Water Tanker Rollover


Drilling

21-07-12

For a cementing job, 500 barrels (bbls) of freshwater delivery was required at the rig site

and an urgent delivery request was sent to water supply contractor. The contractor assigned tankers & drivers were not available and therefore a new driver and a tanker was sent from Musafah

Base to make this delivery. The driver did not have ADCO Safe Driving Document (ADSD) and the vehicle was not fitted with In Vehicle Monitoring System (IVMS).

It was the first day of Ramadan and the driver missed his Dinner & Sahur and made a delivery of water. After the delivery he went back to his

camp to refill tanker and then again proceeded to the rig site for another delivery. The air conditioning system in driver’s cabin was not working and it was a hot day and the driver was

working in excess of six hours. During the trip the driver felt dizzy and lost control of the tanker. It resulted in tanker to rollover. Outcome: The

driver escaped unhurt and the tanker sustained minor damage.

• Inadequate Leadership (Knowingly an untrained driver was assigned on the task)

• Inadequate Work Planning (Request for supply large quantity of water was made

without ensuring availability of contractor’s resources)


Monitoring (There was no monitoring

system in place to check contractor compliance with contractual requirements for the safety of driver and vehicles)

Lessons Learned

1. Assess availability of contractors’ resources prior to issuing task order.

2. Monitor contractor compliance with

contractual requirements for the safety of driver and vehicles.

Immediate Causes

• Violation by Supervisor (A new driver, without ADSD was assigned to the task; Unauthorized vehicle was used)

• Defective Vehicle (Air conditioning unit in driver’s cabin was not working)

• Work Exposure to Temperature Extreme (The driver was fasting, working over 6 hours

during peak summer hours in hot cabin of the water tanker)

41

Hand Entrapment Inside Tong


Drilling

NDC Rig 21

03-08-12

While an inexperienced tubular services operator was working as a tong operator, he

had his left hand at the top of the tong rotary while the other hand was on the lever adjusting the tong rotary.

His supervisor left the Rig Floor leaving the

operator alone before completing the job. When he started to operate the tong, the tong jumped resulted in slippage of his left hand which got trapped inside the tong.

Outcome: Tong Operator sustained an open displaced fracture on his left hand.

• Inadequate Leadership (Senior Operator left the inexperienced operator at the rig floor before completing the job; Rig crew did not

stop “Green Hat” – (New or Inexperienced Worker) from working alone)

• Inadequate Identification of Required

Skill or Competency (Inexperienced

operator was not adequately coached on required skills to work independently)

Lessons Learned

1. Do not leave in experienced staff (Green Hat) workers unsupervised at hazardous locations such as Rig Floor

2. Include all sequence of works (such as operations as well as any repair/ troubleshooting) in Job Safety Analysis (JSA)

Immediate Causes

• Improper Posture/Position for the

Task (The operator had placed his hand on the top of tong rotary while adjusting the rotary)

• Lack of Knowledge of Hazards Present (The Supervisor left the operator working alone on the rig floor; the operator was not adequately trained to recognize pinch

points on power tongs)

• Work Exposure to Mechanical Hazards

(Power Tong at Rig Floor)

42

Electrical Shock


Drilling

NDC Rig 55

06-09-12

The electrical panel door of the fire unit fall down due to broken hinges (caused by the deterioration of pin in the hinges) resulting in cables

cut/damage inside the panel.

An isolation certificate and permit to work was issued. The damaged/cut cables were fixed/replaced by an electrician. After electrical cables were fixed, the electrician restored the power supply and started to check cables voltage using a portable voltmeter. During the process an

electrical spark occurred.

Outcome: It has resulted in a second degree burn on electrician’s right hand thumb.

• Inadequate Practice of Skills (The electrician did not systematically check the electrical system and did not ensure physical protection from coming in contact with live conductor)

• Excessive Wear & Tear (Due to harsh climatic conditions and rig move, hinge pins were deteriorated)

Lessons Learned

1. Always follow systematic way of checking

electrical circuit

2. Stay clear of live conductors when servicing energized electrical system

3. After each rig move visually check the integrity of hinge pins

4. Conduct trade relate workshops for experience electricians to share their knowledge and incident

lessons learned.

Immediate Causes

• Servicing of Energized System (The Electrician was checking cables voltage using a portable voltmeter on a live system)

• Improper Decision Making/Lack of

judgement (The Electrician made a physical contact with a live conductor)

43

Arm Injury Due to Fall of Jumbo Bag


Drilling

NDC Rig 11

29-10-12

During mud mixing, at the mud hopper, jumbo bag (weighting 1.5 Tons) containing baryte was being lifted and

suspended over the hopper by crane, utilizing a four legged wire rope sling. A worker was assigned to cut the bag, once positioned over the hopper to discharge baryte.

The procedure required to use jumbo bag stand when mixing

over the hopper but it was not used. It was required that jumbo bag straps be stitched but the consignment was accepted where straps were not stitched accordingly. When the material delivered at the store, it was not inspected and accepted.

The derrick man, supervising the job, left the hopper area and an inexperienced (“green Hat”) started to cut the bag.

Sudden tilt of bag caused it to roll to failed strap side and roll out of other strap causing the bag to fall on the arm of the labourer, which was positioned near bag, while attempting to cut the bottom of suspended bag. Outcome: Worker

sustained left forearm fracture.

• Inadequate Material Packaging (Jumbo

Bag straps were not stitched)

• Inadequate Supervisory Example (Derrikman left the inexperience labourer

unsupervised; Jumbo Bag Stand was not used to save time & efforts)

Lessons Learned

1. Do not leave inexperience (Green Hat) staff unsupervised at rig site

2. Always assess compliance of received materials with contractual requirements for packaging.

3. Whenever emptying jumbo bags at mud

hopper, use Jumbo Bag Stand

Immediate Causes

• Violation by supervisor (Derrickman left the site leaving “Green Hat” labourer unattended/ unsupervised; Material conformance with ADCO requirement was not assured)

• Lack of knowledge of Hazards Present (The labourer was not made aware of worksite/Job Hazards)

• Equipment or not Secured (Jumbo bag stand was not used)

44

Falling Object


Drilling

NDC Rig 57

28-10-12

While running completion tubing, the driller picked up a joint, after stabbing & making the joint in rotary, Stabber

flagged the Driller to slack down. It was first time for Driller to run completion assembly. The Driller was coming down with the block, at the same time he was tilting the elevator links. Suddenly, the stabber flagged driller to stop and float

the links. Before the driller could stop, the elevator guide hit the box end of the made-up tubing joint in rotary.

Outcome: The Impact resulted in shearing of holding bolts of elevator guide & whole guide assembly (8 pcs/biggest piece weighing 7 kg.) to fall down on Rig floor approximately from 30 feet height.


Worksite/ Job Hazards (Job Safety Analysis (JAS) did not include communication signals and hazards of was lowering the block, at the same time he

was tilting the links)

• Inadequate Audit/Inspection/ Monitoring (It was first time for Driller to run completion assembly and there was

no monitoring on his performance and coaching on the skill)

Lessons Learned

1. Establish clear signals between stabber &

Driller before start of the job.

2. Do not float the TDS links to its original position while the TDS is in motion.

Immediate Causes

• Improper Decision Making/Lack of Judgment (The Stabber gave signal prematurely to Driller to stop the Top Drive System (TDS) and the Driller was lowering the

block, at the same time he was floating the links)

• Lack of Knowledge of Hazards Present (Job Safety Analysis (JAS) was generic in nature and did not address

the communication signal between Stabber & Driller)

45

Engineering & Projects

46

47

Past Incidents

Cement Mixer Truck Rollover (12-06-

2010)

Head on Collision (03-03-2010)

Tipper Truck Rollover 28-04-2010)

Leg Trap in Potable Cement Mixer

(17-07-2011)

Worker Ran Over by Water Tanker

02-08-2011)

Flagman Ran Over by Wheel dozer

(17-08-2011)

Fall of Worker from Height (10-09-

2011)

Hand Injury During Cable Pulling

(17-04-2010)

Vehicle Rollover (18-01-2011)

Fatal Injuries to Rigger (22-01-2011)

Tipper Truck rollover (14-02-2011)

Death of a Worker from Heat Stress (24-08-2010)

48

49

Fire Due to Poor Grounding During Welding



Sahil Field

03-01-12

Welding job at a pipe rack was planned and Permit to Work (PTW) issued. The task risk assessment (TRA) identified the risk and need for proper grounding was identified. The

work was in progress and the welder assigned a helper to set up the welding station and during the set up, the helper connected the grounding clamp to an incorrect spool. The helper placed the grounding clamp on another

spool because there was no place available to place grounding clamp of the spool the welding job was being carried. The clamp was in contact with a scaffolding (wooden) plank.

Outcome: During the welding job, current passed through

the grounding clamp, warming it up causing smoldering in adjacent scaffolding plank. The crew stopped the operation and extinguished the fire.

• Inadequate Audit/Inspection

/Monitoring (Job Performer as well as the welder did not inspect the set up of

welding station (as highlighted in Task Risk Assessment) prior to start of welding)

• Inadequate Leadership (Permit issuing

authority did not ensure adequate grounding prior to issuing the permit; (Job Performer did not discuss task related hazards with his crew)

• Lack of Procedure for the Task (There was no formal work procedure or checklist available)

Lessons Learned

1. Check and ensure proper Grounding /

Earthing of welding stations prior to commence welding

2. Conduct task specific Tool Box Talk (TBT) discussion hazards and control

3. Permit Issuing Authority (IA) & Job Performers (JP) must assess/check system, readiness prior to issuance of

permit and start of work

Immediate Causes

• Violation by Supervisor (Welder did not check the

adequacy of grounding prior to starting welding; Job Performer (JP) did not supervise welding operations and did not conduct specific tool box talk; PTW Issuing

Authority (IA) issued the permit without confirming grounding and confirmed adequacy of grounding on the permit)

• Improper Placement of Tools/ Equipment

(Grounding clamp was placed on wrong spool which was contacting a wooden plank)

• Congestion or Restricted Movement (The work location did not provide clear location for grounding)

50

Fiber Optic Cable Cut During Excavation



Shah Field

09-01-12

A combination of manual and mechanical

excavation was planned for preparation of existing line crossing. In preparation for the work, site scanning survey was done however

the location of underground fiber optic cable was not known. Permit to Work (PTW) was issued.

The Foreman instructed the operator to

excavate in an area marked for manual excavation. The Job Performer (JP) signaled the foreman to stop but the foreman continued

the mechanical excavation.

Outcome: Damage to underground Fiber Optic Cable


Worksite/Job Hazards (Site scanning survey and excavation certificate did not identify location/presence of fiber optic cable)

• Inadequate Job Placement (The Job Performer (JP) and crew members had language barriers and were not able to communicate effectively)

Lesson Learned

1. Do not use machines for excavation in areas

marked for manual excavation

2. Positively identify locations of underground utilities before commencing excavation

3. Consider communication skill/language

barrier when assigning crew members

Immediate Causes

• Violation by Supervisor (Violation of Permit to Work (PTW) Procedure for use for

machines in hazardous area)

• No Warning Provided (Location/presence of Fiber Optic Cable was not identified in Excavation certificate)


Judgment (The Foreman instructed Excavator Operator to excavate in area marked for manual excavation

51

Vehicle Collision & Rollover



Bab Field

30-01-12

Due to pre commissioning of Gas Compression Station No. 2, there were increased activities and working hours were extended to meet the schedule. A project driver pick up driver was supporting crew and staff movement

between offices and work sites and over the last one week the driver was working between upto 15 Hrs a day with irregular breaks/rest.

The driver was proceeding to Gas Compressor Station to collect staff. When he entered Habshan –Buhasa Road, his

pickup vehicle was hit by an oncoming bus. It resulted in pickup vehicle to rollover. Outcome: The driver sustained minor injuries on his hands and the vehicle

was badly damaged

• Inadequate Inspection & Monitoring (There was no monitoring system in

place to monitor drivers working conditions)

• Inadequate Implementation of PSP

(Procedure/ Standards/Policy)

(Drivers RAG (Driving Behaviour) Reports were not adequately reviewed)

• Inadequate Work Planning (Due to pre commissioning activities working hours were increased without sourcing additional manpower; Night time driving request form did not include assessment

of risks)

Lesson Learned

1. Monitor drivers working conditions and review RAG (deriving behaviour) reports regularly

2. Conduct Risk Assessment prior to approving night time driving request.

Immediate Causes

• Inattention to Footing &

Surroundings (Driver misjudge the speed of approaching vehicle and

started to cross the road)

• Overexertion of Physical

Capabilities (The driver was working

upto 15 Hrs a day with irregular breaks/rest resulting in loss of concentration and fatigue)

• Violation by Supervisor (Night time

driving approval was not subjected to risk assessment)

52

Asphyxiation of Welder Inside A Pipe



Sahil Field

06-02-12

Piping erection work was in progress and a welding crew was engaged in welding of 30 Inch diameter pipe joint. Due to leakage of Argon gas from argon dam foam pads, welding could not proceed further as it

could have oxidized welds and compromised the quality of welding.

To fix the problem, pipe joint needed to be cut and then Argon Purge Dam Pads adjusted. This process

could have resulted in 1-2 days delay. The crew resolved the issue in about an hour (Foremen sent a welder inside the pipe (without confined space entry certificate) to adjust foam pads) and welders

proceeded with the rest of the welding. The next day, after completing welding, the same welder went inside the pipe and he collapsed inside the pipe and asphyxiated. Outcome: Crew members tried to recover and evacuate the welder to site Clinic and he was pronounced dead by the Physician upon arrival.

• Inadequate Assessment of Needs & Risks (Home-made type Argon Gas Dam foam pads were used resulting in leakage instead of using inflatable or other type of dam pads)

• Inadequate Supervisory Example (Conflicting roles & responsibilities of JPs and foremen created

an environment where no one felt accountable/responsible, Supervisor exposed workers to risks for the sake of meeting time line)

• Inadequate Audit/Inspection/ Monitoring (For this welding crew audit/ inspection/ monitoring of PTW & TBT and safe work flow was inadequate for welders, there was no monitoring system to assess

quality of TRA prepared)

• Inadequate Training (Contractor Job Performer and Foreman were not trained in conducting Tool

Box Talk (TBT; Welders were subjected to intensive HSE training without effective feed-back to assess their knowledge; Confined space training was inadequate to all members of the welding crew)

Immediate Causes

• Violation by Individual (The welder made unauthorized confined space entry in pipe; Co-welder did not stop welder entering the pipe; Job Performer (JP) and welding supervisor were not supervising welders after welding task was

completed and left them at the site unattended)

• Lack of Knowledge of Hazards Present (Welders were not aware of asphyxiation hazards

due to Argon gas escaping from leaking foam pads ; over confidence due to earlier entry into the pipe, Lessons learned from incidents were not shared with welders; No specific Tool Box Talk (TBT) for

welders was conducted

Lesson Learned

1. Do not use any sub-standard or home-made type

tool/equipment at work site

2. Do not enter pipes or other confined spaces unless confined space entry permits are obtained

3. Do not leave workers unsupervised at work site

especially during high risk activities

4. We all are authorized (by ADCO Chief Executive Officer) to stop any unsafe action in ADCO work

areas.

5. Educate yourself with risks associated with your job

53

Man Lift Drove Over Flagman’s Foot



Bab Field

15-03-12

A crew (Man Lift Operator & Banksman/ Flagman) was relocating man-lift from one location to another for a paint touch-up work. On the way, a forklift was approaching from the opposite

direction and Flagman signaled to the man-lift operator to stop, allowing the forklift to pass.

The Flagman stepped towards the man-lift to get out of the way of the passing forklift. When the forklift had passed, the man-lift Operator started to move the man-lift without any signal from the flagman or confirming his location. The operator

drove the man lift over Flagman’s right foot. The Flagman was taken to the site clinic and then referred to hospital for further assessment.

Outcome: Flagman sustained minor foot injury

• Inadequate Practice of Skill (Man-lift operator started moving the man-lift without

taking a signal from the Banksman/ Flagman)

• Inadequate Safety Meetings (No specific TBT was conducted for machinery/ equipments

operators & Banksmen/ Flagmen)

• Inadequate Communication Between Work

Groups (Simultaneous operations were taking place at the same area without any

coordination within Job Performers (JPs))

Lesson Learned

1. Do not move heavy machines/ equipment

unless directed by Banksmen/Flagmen.

2. Machine/equipment operators must maintain clear sight of Banksmen/ Flagmen.

3. Conduct task specific Tool Box Talk (TBT) for

each crew.

Immediate Causes

• Violation by Individual (Man-lift operator started moving the man-lift without signal from Banksman/ Flagman and did not maintain clear sight of Banksman/ Flagman)

• Improper Position for the Task (Banksman/

Flagman was standing close to the man-lift)

54

Vehicle Rollover



Buhasa Field

19-02-12

An instrument commissioning Engineer was involved in integration communication system in Central Degassing Station (CDS). The engineer was based in Mussafah and travelled

to Bu Hasa in a private vehicle and he did not have ADCO Safe Driving Document (ADSD). After finishing his tasks (approximately at 17:30 Hrs) he was on his way back to Abu

Dhabi. Earlier, there was a sand storm resulting in sand accumulation (sand bars) on the road and when he drove over sand bars,

he lost control of the vehicle, resulting in the vehicle to roll over. Outcome: The driver sustained shoulder injury and the vehicle was badly damaged.

• Inadequate Communication of Policies,

Standards and Procedures (ADCO Road

Safety requirements were not adequately communicated to the subcontractor/vendor)

• Inadequate Supervisory Example (Supervisors did not arrange for company

vehicle and/or trained driver for the journey)

• Inadequate Work Planning (Supervisor did not monitor the commissioning engineer’s work schedule)

• Inadequate Inspection & Monitoring (Contractor did not adequately monitor compliance with ADCO Road Safety

requirements.)

Lesson Learned

1. Do not drive private vehicle on ADCO business.

2. Only assign trained drivers to drive or provide drivers for staff transit.

3. Supervisors should monitor compliance of their contractor staff with ADCO Road Safety Requirements.

Immediate Causes

• Violation by Supervisors (Allowed the use of private vehicle to travel to fields.)

• Inattention to footing & Surroundings

(Staff was working for the last 11 hours including the 2.5 hrs journey to site and did not pay attention to road conditions

(sand accumulation) due to fatigue)

55

Vehicle Collision on a Sand Track



Qw

28-02-12

Two vehicles were approaching a hill top from opposite directions on a gatch

road with a posted speed limit of 30 km/hr. Vehicles were driven at a speed of 45 km and 35 Km/hr respectively. One vehicle was carrying three

passengers in rear seats and they were not wearing seatbelts. Both vehicles were travelling in the middle of the track

and drivers did not see the other approaching vehicle (although fitted with desert flags) and their vehicles collided (head-on) on top of the dune

and their air bags inflated. Outcome: Both drivers and two passengers sustained minor injuries and the third passenger sustained head& facial

injuries. Both vehicles were damaged badly.

• Inadequate Preventive Maintenance (The track had sand accumulated on sides and was not adequately maintained)

• Inadequate Inspection / Monitoring (Drivers’

RAG (driving behaviour) reports were not effectively monitored)

• Inadequate/Lack of Safety Meetings (Drivers were not subjected to specific tool box talks (TBT))

Lesson Learned

1. Always follow posted speed limits and road traffic warning signs

2. Do not drive in the middle of tracks, especially when

approaching blind spots (e.g. ascending dunes)

3. All passengers including those on rear seats must wear seat belts

4. Transport Foremen/Supervisor should conduct Tool

Box Talks (TBT) for drivers focusing on hazards associated with their journeys.

5. Regularly inspect & maintain sand track /gatch roads especially after sand storms and windy conditions.

Immediate Causes

• Violation by Individuals (Bothe drivers were exceeding the posted speed limit, passengers were not

wearing seat belts)


Judgment (drivers were driving their

vehicles in the middle of the track)

• Inattention to footing & Surroundings (Drivers did not spot other approaching vehicles, fitted with

desert flags)

56

Vehicle Drove Over a Berm



Asab Field

01-03-12

A crew consisting of a driver, Foreman and three labourers were proceeding to MOL MP-24 location in a double cabin

pickup. The purpose of the trip was to retrieve Permit to Work (PTW) papers from a bus which was stuck in sand and was immobilized a day before. The driver was using the blue key of the Foreman (sitting next him). The driver

did not engage vehicle into 4x4 mode and driving at a speed of 105 km/hr. There was low visibility due to early hours and hazy conditions. One of the labourers, sitting in the rear middle seat did not fasten his seatbelt.

The driver was not familiar with the access track and he did not notice the pipe line crossing ahead of them. He drove over pipe line berm. As an impact; the vehicle hit

the berm, jumped over the berm and landed on the front bumper.

Outcome: Three occupant sustained injuries and two were discharged after the treatment from the hospital. The

third labourer was admitted for three days in the hospital and then discharged.

• Inadequate Supervisory Example

(Supervisor reinforced incorrect behaviour of the driver)

• Inadequate/Lack of Safety Meetings (Drivers were not subjected to specific tool box talks (TBT))

• Inadequate Inspection / Monitoring (Drivers’ RAG (driving behaviour) reports were not effectively monitored)


Policies/ Standards/ Procedures (PSP) (ADCO road safety requirements and Life Protection Rules (LPRs) were not effectively implemented.

Lesson Learned

1. Always follow posted speed limits and road traffic warning signs

2. All passengers including those on rear seats must wear seat belts

3. Transport Foremen/Supervisor should

conduct Tool Box Talks (TBT) for drivers focusing on hazards associated with their journeys.

4. Supervisors should review drivers’ RAG

(driving behaviour) reports regularly and provide counseling to drivers to reinforce correct driving behaviour.

Immediate Causes

• Violation by Individual (The driver was over speeding, did not engage vehicle in 4x4 mode)

• Violation by Supervisor (He gave his blue key to the driver and did not stop driver from over speeding)

• Improper Decision Making/Lack of Judgment

(Driver continued driving during low visibility on an unknown track)

57

Cement Mixer Rollover



Shah Field

18-04-12

A Cement mixer was heading from cement batching plant to Shah -2 to deliver a consignment of cement.

The driver was shifted from another location to Shah Field approximately 10 days before and he was not aware of access route to the destination. He was not subjected to any Tool Box Talk (TBT) and there was

no banksman with him. Upon reaching RDS Gate No 2 he was diverted to Gate No. 1. He drove uphill and found that access track was closed and he was reversing the mixer without any banksman and the mixer came off the track and rolled over. Outcome: The driver escaped

unhurt and the vehicle sustained minor damage

• Inadequate Supervisory Example (The supervisor assigned the task to

a new project driver without HSE induction, Tool Box Talk (TBT and providing a banksman)

• Lessons Learned not Embedded

(Lessons from some of prior incidents to conduct TBT for drivers not effective)


Monitoring (There was no monitoring system in place to check and guide delivery vehicles)

•

Lessons Learned

1. Conduct Site HSE Induction to all

new staff including those involved in making deliveries.

2. Conduct daily specific Tool Box Talk (TBT) for drivers.

3. Specify/mark routes for delivery vehicles within project areas

Immediate Causes

• Violation by Individual (The mixer driver was reversing the vehicle on a narrow track without banksman/ flagman)

• Violation by Group (Site crew did not stop driver reversing heavy vehicle without banksman)

• Lack of Knowledge of Hazards Present (Supervisor did not conduct any Tool Box Talk

(TBT) & Site Familiarization/ HSE Induction). • No Warning Provided (There was no warning sign nor site staff informed driver of the closure

of access track)

58

Damage to Overhead Line


Engineering

& Projects

BAB Field

24-04-12

A contractor crew was involved in stringing, welding and support installation of a new flowline and an excavator operator was hired

from a sub-contractor. The operator was mobilized to the site without any HSE Induction and he was not included in Tool Box Talk

(TBT). Piping Foreman was preparing the site and requested Excavator Operator to move the excavator closer to the work site. The

excavator driver mover the excavator with his boom in extended position and struck against 33KV overhead line conductors.

Outcome: The overhead line tripped on earth fault. The operator came out of the excavator safely


Job Hazards (The Task Risk Assessment (TRA) did not identify the hazard)

• Inadequate Training Efforts (TRA team was not adequately trained in conducting

TRAs; Excavator operator was not subjected to site HSE induction and was not included in Tool Box Talk (TBT))

• Inadequate Monitoring (Foreman or Job

Performer did not monitor excavator operator’s movement)

(For Illustration Purpose)

Lesson Learned

1. Install goal posts at crossing under over head line conductors prior to initiating site works involving movement of equipment.

2. Include vehicle/equipment operators in Tool Box Talks (TBT)

3. Do not operate equipment/machinery when

emotionally disturbed or stressed

Immediate Causes

• Unintentional Human Error (Excavator

Operator moved the equipment with the boom in elevated position)

• Distracted by Other Concerns (The operator was emotionally stressed due to

personal issues)


Devices (There no goal post/height level markers was installed at overhead line crossing)

59

Ankle Injury During Cable Pulling



Asab Field

24-04-12

Instrument cables were being pulled (900 meter run) in cable trench. The crew was using a single

assembly of corner cable roller instead of using multiple interconnecting rollers to allow stability. The foreman was standing inside the radius of bending cables talking to another supervisor while

approximately 16 workers were manually pulling the cable. The cable slack ran out on the upstream side of the corner roller and the cable tightened up against the corner roller.

This resulted in the cable pushing back into the corner, moving the sandbags that were supporting it, the roller tipped over and the cable slipped out

(dislodged) from the cable roller and struck the right ankle of the Foreman. Outcome: Foreman sustained multiple fracture injury on his right ankle.


Job Hazards (Risks of less numbers of cable

rollers resulting in cable release under tension were not adequately assessed/controlled)

• Inadequate Supervisory Example (The

Supervisor/Foreman positioned himself inside the bending radius of cable under tension)

Lesson Learned

3. Maintain adequate communication

between workers and Foreman while the cable is being pulled

4. Use adequate numbers of interconnecting corner rollers to ensure

stability during cable pulling

5. Do not stand inside the bend radius of cable and roller while cables are being

pulled.

Immediate Causes

• Improper position or posture for the task

(IP positioned himself in the line of fire; inside radius of bending cable in case of sudden

tension/tightening of cable)

• Improper placement of roller (Crew was using a single assembly of corner cable roller instead of using at least three interconnecting rollers

supported with sandbags to allow stability)

• Distracted by other concerns (Foreman was talking to another supervisor while approximately

16 workers were manually pulling the cable)

60

Vehicles Collision on Gatch Road



Asab

09-07-12

Two different contractor (Project & Drilling)

vehicles were approaching from opposite directions, on a gatch road. There was a blind spot at a turning and one driver was

driving on the wrong side of the road. Desert flags mounted on both vehicles were not visible to other vehicle due to the height of a pipeline berm. One vehicle (Project) was

driven at a speed not appropriate for road conditions (73 km/Hrs) and the other driver (Drilling) was driving at the speed of 60

km/Hrs. Both vehicle emerged after ablind spot and collided head on.

Outcome: Total six passengers in both vehicle sustained minor injuries and vehicles

were badly damaged.


Job Hazards (There was no sign or marking when approaching the blind spot)

• Inadequate Practice of Skill (Project driver

was in haste and over speeding; and he was driving on the wrong side of the road)

Lessons Learned

1. Always reduce vehicle speed according to road conditions especially when approaching blind spots

2. Do not drive in wrong lane even for shorter period of time

Immediate Causes

• Violation by Individual (The project vehicle was driven in wrong lane)

• Work or Motion at Improper Speed (Vehicle speed was not adjusted according to road condition and presence of a blind spot)

• Inadequate Warning System (There were no road signs to alert approaching drivers)

61

Arm Injury Due to Explosion During CAD Welding



Asab

12-07-12

CAD* Welding of grounding cable outside the control room building was planned but no specific work permit was obtained and the work was performed under a

“Green Field” general permit to work. A newly arrived electrician who was dressing electrical cable inside the building was requested to assist the CAD welding crew.

The job Performer went to attend another task and stopped the activity but the crew continued work. The electrician was not wearing any welding gloves and no

special tool to hold the mold was available.

The electrician held the cable in his hand although it is held by the mold itself. After the set-up, another worker ignited the weld powder in the mold using

spark igniter whilst electrician was still holding the cable. Explosion/backfire through the aperture cover of the mold occurred. Outcome: It resulted in 2nd degree burn on the right forearm of the electrician.

• Inadequate Job Placement (An

electrician was assigned on CAD welding activities without assessment of required skills)

• Inadequate Assessment of Need &

Risks (CAD welding activity was performed without necessary tool to hold the mold)

• Inadequate or Lack of Safety Meeting (Electrician was not subjected to tool box Talk and crew was not made aware of

hazards of CAD Welding) Inadequate Audit / Inspection/

Monitoring (Job Performer left the crew to attend another task without assuring

that work has stopped)

Lessons Learned

1. Always subject all crew members to tool box talk specific to the task.

2. Ensure assignment of skilled crew members and availability of all necessary

tools, especially on high risk activities

3. Never leave crew unattended specially those working on high risk activities

*CAD welding (Exothermic welding) is process for joining

two electrical conductors, that employs superheated

copper alloy to permanently join the conductors.

Immediate Causes

• Violation by Group (The activity was stopped by the Job Performer but crew continued the work)

• Personnel Protective Equipment (PPE) not

used (Electrician did not use welding gloves; the right tool to hold the mold was not used/obtained)

• Lack of Knowledge of Hazards Present (The crew was not aware of hazards of back fire)

• Improper Position or Posture for the Task (Electrician was holding the cable at the both sides of the mold)

62

Fire at Scaffolding Platform Around Stripper Column



Asab

16-07-12

A welder was welding a pipe on the topmost platform (35 m high) of stripper column.

After completing the task he lowered his tools and the portable welding equipment to a lower level platform and left the site. On scaffold boards (which were below welding

area) food scarps, plastic bottles, papers etc. had accumulated and not noticed by crew or their supervisor. The welding habitat was not set and the fire blanket was too small for the task and had holes in it.

Later, workers noticed fire and smoke from upper level scaffold platforms and raised the

alarm. Outcome: ADCO & GASCO Fire Teams responded and extinguished the fire. No personnel injuries and damage to scaffold boards had occurred.

• Inadequate Audit/Inspection/

Monitoring (Supervisor did not visit the site before and after the completion of hot work; accumulation of combustible materials was not noticed; Fire blanket with holes and absence of fire habitat were not noticed)

• Inadequate Work Planning or Risk

Assessment Performed (A welder without

any supervision was assigned for the task; Job Performer (JP) did not go to the top platform to monitor the work; cleaning of scaffold sites of accumulated debris was not

considered)

Lesson Learned

1. Maintain housekeeping at work locations.

2. Subject critical activities to continuous

monitoring & supervision

3. Switch off/Disconnect power supply to portable electrical equipment during breaks

4. Use fir blanket/fire habitat for welding activities in process areas.

Immediate Causes

• Inattention to footing &

Surroundings (Accumulation of combustible waste material near welding area was not noticed)


Devices (Fire blanket was not adequate to isolate welding spatters/ welding habitat was not set)

• Work Exposure to Temperature

Extreme (Hot summer day with ambient temperature exceeding 47oC)

63

Foreign Object Entering Eye of a Worker



Sahil

26-07-12

A welder was assigned to perform welding task for the installation of pipe support. After

completing the welding task, while he was removing welding face shield, he felt a sand particle had entered his left eye.

He washed his eye with water and felt relieved

and continued his job. Later, at night he felt pain and irritation in his eye and he visited the camp clinic the next morning and he was attended by the Physician and then referred to a Hospital for the removal of foreign object from his eye.

Outcome: The foreign object (sand particle)

was removed from his eye.


Worksite/Job Hazards (Workers were not adequately made aware of hazards of working

on a windy day; risks of rubbing eyes when a foreign body enters eye were not known)

• Inadequate Communication (Lessons from prior similar incident occurred on 04-05-2012

were not effectively communicated)

Lessons Learned

1. If a foreign object enters eye, do not rub eyes and seek medical attention

2. Report all incidents (including minor incidents/injuries) to your supervisor

3. Always use eye wears for protection in working sites, especially in sandy areas.

Immediate Causes

• Storm or Act of Nature (Blowing wind carrying particles/dust/light objects)

• Personal Protective Equipment (PPE)

Not Used (Welder removed his welding face shied after the task and due to blowing

winds sand particle entered his eye)

64

Vehicle Rollover on Gatch Road



BAB

23-08-12

A vendor crew was involved in installing gauges on multi flow meters and after the completion

of the task, transport was arranged to transfer them back to Abu Dhabi. The plan was to collect passengers from Accommodation Camp and proceed to Abu Dhabi via Madinat Zayed

Road.

An Engineer decided to go to Abu Dhabi with vendor crew and boarded the vehicle. The Engineer advised the driver to go through Bab-Tarif Road and to avoid going through security check post, the engineer identified a gatch road. The driver was driving fast (80-90

Km/Hrs) for the road condition and at a bend he lost control of the vehicle and the vehicle rolled over. Outcome: No serious injuries to passengers and the vehicle sustained minor

damage.

• Improper Supervisory Example (The Engineer changed the journey plan and advised the driver to take short cuts/gatch road and did not stop him from over

speeding)


Monitoring (Driver’s RAG reports were not used to coach the driver with history of over

speeding)

• Inadequate Correction of Worksite/ Job

Hazards (Lessons from prior Road Traffic

Accidents were not effectively communicated; No tool Box Talk was conducted for drivers)

Lesson Learned

Immediate Causes

1. Always drive within posted speed limits and reduce speed according to rad conditions

2. Conduct Tool Box Talks for drivers and empower them to not let any passenger to change journey plan

3. Passenger/s should stop driver from over speeding, taking short cuts and from driving recklessly.

• Violation by Individual (The driver was driving fast in excess of posted speed limit)

• Violation by Supervisor (The Engineer

did not stop driver from overspending)

65

Crane Mounted Truck (Hiab) Rollover on Gatch Road Area Incident Description Root Causes

Engineering

& Projects

BAB

28-08-12

A crew consisting of a Rigger & Operator of

Crane Mounted Truck (Hiab) were instructed by their Engineer drive the truck to work site and lift pre-cast materials. The crew left their camp and was proceeding to the location.

They were travelling on a gatch road parallel to an existing pipeline. This road contained many pot holes and the surface was wet/ slippery

due to high humidity. The driver was attempting to drive around potholes and made a sharp maneuvering of steering followed by harsh brakes.

It resulted in vehicle to get out of control. The rear end of the vehicle spun around in the opposite direction and then rolled over on passenger side against the pipeline berm.

Outcome: The vehicle rolled over to its side on the berm of the pipeline. Driver and passenger sustained minor injuries as they were wearing

seat belts.


Monitoring (Driver had history of applying harsh brakes and harsh acceleration and his driving behavior reports were not effectively reviewed to

initiate counseling/ coaching on the skill)


Worksite/Job Hazards (Hazards

associated with the journey (i.e. gatch road condition and high humidity) were not identified)

Lesson Learned

1. Avoid applying harsh brakes and sharp maneuvering of steering when driving off road.

2. Review drivers’ driving behavior reports and provide coaching and counseling to risky drivers

3. Subject drivers to daily tool box talks to discuss route hazards and to reinforce safe driving behaviour

Immediate Causes


Judgment (The driver applied harsh brake and sharp maneuvering of steering to avoid pot hole on the gatch road)

• Work or Motion at Improper Speed (The

vehicle was driven on gatch road at a speed between 20 to 45 kph with a sudden acceleration to approx. 58 kph followed by

a harsh breaks immediately prior to the incident)

66

Vehicles Collision


Engineering &

Projects

BAB

04-09-12

A 3rd Party mechanic was working on a broken down vehicle near the road side a replacement tire was

requested from their base camp in Mussafah. A truck carrying the replacement tire arrived and stopped on the road side. The mechanic requested the driver to move the truck on the opposite side.

A project driver involved was transferring staff to and from difference locations since morning and was making a trip to collect three passengers from Bab Central Degassing Station (BCDS) to their Camp. The driver was driving 128 km/Hr on a road with a speed limit of 80 km/Hr.

The project driver was over taking the truck whilst

the truck started to turn left. Outcome: The project vehicle collided with the front tire of the truck. Two passenger sustained minor injuries and the vehicle sustained moderate damage.

• Inadequate Audit / Inspection

/Monitoring (Drivers driving behavior

and driving assignments were not adequately monitored)

• Improper Performance to save time (The driver was involved in transferring

passengers to & from different locations since early morning and was rushing to the camp for mid-day break)


Worksite/Job Hazards (In Vehicle Monitoring System (IVMS) was reconfigured so that speeding event

below 130 km/Hr were not recorded as system violation)

Lessons Learned

1. Always follow the posted speed limits

and do not over speed.

2. Use vehicle signal before maneuvering vehicles even on a short journey

3. Monitor the driving behavior of new/inexperience driver more frequently

Immediate Causes

• Violation by individual (The driver was overspending (128 km/Hr on a road with a speed limit of 80 km/Hr)

• Improper Decision Making (The truck driver started to turn left without using indicators/ signal)

67

Crane Rollover During Move on Gatch Road



BAB

26-09-12

A 25 Tone Grove Crane, was mobilized on site to load /

offload piping materials from various locations within the vicinity of RDS-8 Transfer Line area. The crane reached the site at around 06:30am and started off-loading pipe supports from the trailer truck. The crane being moved

between locations (approximately 100 meters apart) to lift excess pipe supports. The crane operator was following the pick-up vehicle (boarded by the Rigging Foreman) and the trailer truck on gatch road, parallel to

the transfer line.

There was slope between the two gatch roads and the pick-up and trailer truck managed to drive across the

bank and reached the elevated gatch road.

As the crane tried to ascend on slope (with crane boom not fully folded), the crane lost the balance causing it to roll over to its right side. Outcome: The operator

managed to exit the crane cabin safely through the cabin door and the crane sustained minor damage.

• Inadequate Supervisory Example (Rigging Forman did not ensure the

suitability of the track)

• Inadequate Audit / Inspection/

Monitoring (Job Performer (JP) was away supervising another crew and the crew moved without his knowledge)

Lesson Learned

4. Do not move heavy equipment from one location to another location unless track conditions are inspected

and are found suitable.

5. Ensure Crane boom is fully folded and hook block secured when moving crane, to maintain stability of the equipment

Immediate Causes

• Violation by Individual (The operator did not fully fold the boom of the crane and did not lock the hook

block while moving the crane)

• Violation by Supervisor (Rigging Foreman did not assess the road conditions and asked the crane operator to follow the vehicle)

68

Vehicle Collision


Engineering

& Projects

BAB

01-10-12

A project vehicle (Double Cabin Pickup) was returning back from their project site (RDS

8) to their camp store for the collection of materials. He was in mostly in Red and Yellow categories as per his driving behavior report (RAG Report) over the last one month

and there was no effective review of RAG reports in place to provide coaching/ counseling to the driver. An ADCO staff was coming from Ghayathi to BAB in his private vehicle (Land Cruiser) after his rest period and he stopped by a shop in Al Dhafra camp and then proceeded to BAB Accommodation

Camp. There was a long trailer on the hard shoulder, restricting the direct view. The project vehicle was driver at a speed of 121 km/hr on the road with posted speed limit of

80 km/Hr. ADCO staff vehicle entered the T Junction and crossed the road and the project vehicle collided on the side of the

land cruiser. Outcome: Minor injuries (Bruises) to passengers as they were wearing seatbelts and serious damage to both vehicles.


Monitoring (Drivers driving behavior reports were not effectively reviewed and the driver did not receive any coaching or counseling to develop safe driving skills)

• Inadequate Identification of Critical

Safe Behaviour (The project driver drove

considerable long distances with BAB (250-300 km/day) and his work assignment, journey management and time pressure were not effectively addressed)

Lesson Learned

1. Regularly review drivers’ driving behavior(RAG) reports and provide counseling to risky drivers

2. Review drivers’ driving hours and work assignments to reduce time pressure.

Immediate Causes

• Violation by Individual (The project vehicle (Pickup) was over speeding)


Judgment (ADCO Staff entered the

junction without ensuring clearance)

69

Fatal Fall of Worker from a Moving Vehicle



Qw

17-11-12

While two Workers were involved in manually offloading of fence gates from a pickup truck, the site Foreman instructed

the driver to move the vehicle to another location nearby (while two workers were still in the back of pickup). Workers sat down on stacked fence gates which were unsecured. At a sharp turn, the load slipped and workers fell down from the moving vehicle. Outcome: One worker escaped

unhurt whilst the other sustained head injuries and later he died in the hospital

• Inadequate Leadership (HSE site inspections/visits to sites for less than 20 workers were suspended; effective inspection/monitoring system was not in place to identify

this change)

• Inadequate Identification of Worksite or Job

Hazards (Risk associated with transfer & loading/offloading of fencing material were not identified

and there was no Task Risk Assessment (TRA) available for fencing work)

• Improper Supervisory Example (Foreman sent workers to another location to load fence gates into the pickup,

unsupervised and transfer the load; Job Performer did not effectively conduct tool box talk (TBT); After offloading a few gates, Foreman instructed the driver to move the

vehicle while two workers were on the back of the pickup)

• Inadequate Work Planning (Crane mounted truck was not made available for the transfer of wide fence gates therefore the crew used a smaller vehicle for the task)

• Inadequate Enforcement of Policy/ Procedure/Plan

(Contractor staff did not feel empowered to stop unsafe actions due to fear of losing job)

Immediate Causes

• Violation by Supervisor (Foreman

advised the driver to move the vehicle while two workers were in the cargo area of the vehicle; The Foreman & the driver did not ensure that the load was

secured)

• Equipment or Materials not Secured

(Fence gates were not secured before

moving the vehicle)

• Inadequate Vehicle for the Purpose

(Vehicle was not suitable for transferring oversized fence gates)

• Congestion or Restricted movement

(Narrow access track for the movement of vehicle)

Lessons Learned

1. Provide coaching to Job Performers (JP) on conducting

effective tool box talks (TBT) 2. Develop and publicize an incentive scheme both for

workers and their JPs/Foremen to stop & report unsafe actions and set a target for each worker.

3. Ensure contractor JPs & Foreman have supervisory skills prior to their assignment and subject them to regular motivational training to enhance their supervisory skills

70

Fall of Mobile Scaffold Platform on a Worker



Asab

28-11-12

An electrical crew was assigned to cable pulling, dressing and installation of cable tray cover. The crew was using a mobile

scaffold platform. The platform was not subjected to any checks/inspections and its caster wheels were not secured. During the

work, while crew was pushing the platform, over a wooden plant (used as a bridge to cross over a gap), the platform fell down, hitting on the right leg of a worker.

Outcome: The worker sustained compound fracture on his right leg and he underwent constructive surgery

• Inadequate Supervisory Example (The work was started without PTW; JP was not on site and workers were working unsupervised)

• Inadequate Audit/ Inspection/ Monitoring (The mobile platform was not checked/ inspected prior to its use)

• Inadequate Identification of Worksite/Job Hazards (Use of mobile scaffold platform in the area was not risk assessed and workers created inadequate crossing over a gap).

Immediate Causes

• Violation by Supervisor (The work was not subjected to Permit to Work (PTW) and the Job Performer was not supervising the crew at the location)

• Lack of knowledge of Hazards

Present (A narrow wooden plank was used as a bridge for crossing of the

mobile platform)

• Defective Equipment (The mobile platform wheels had no locking mechanism)

Lessons Learned

1. Always inspect mobile equipment and tools to assess

fitness prior to their use.

2. Identify worksite hazards and do not take short cuts.

71

Arm Amputation Inside Foam Concrete Mixer



Qw

12-12-12

At a building construction site, membrane water proofing works was ongoing and a crew consisting of portable foam concrete mixer operator and two

helpers were operating the machine. During the lunch break, the job performer left the site leaving the crew onsite to clean the machine. The mixer was washed,

twice a day, by the operator using a water hose.

The operator of the machine was operating the machine for the last six months and he did not receive any training or coaching on the safe operations of the

mixer. The mixer was not subjected to routine checks/maintenance. The operator switched of the mixer and inserted his hand holding the hose inside the mixer and started washing. Suddenly the mixer

started and is arm was struck by blades inside the mixer. Outcome: Arm of the operator was amputated.

• Inadequate Identification of Worksite or

Job Hazards (Hazards of washing of equipment on site were not identified in Task Risk Assessment (TRA))

• Inadequate Leadership (Job originator did not ensure competency/training of the operator; Operator was not subjected to any training on safe operations of the mixer; Job Performer left the site whilst workers were engaged in washing the mixer; JP did not conduct tool Box Talk (TBS) specific to hazards

of operating the mixer)

• Inadequate Preventive Maintenance (The mixer was not subjected to any checks or

preventive maintenance)

Immediate Causes

• Violation by individual (Job Performer did not implement hazard control barriers as per the task risk assessment)

• Improper position or posture for the task

(Operator inserted his arm inside the mixer while cleaning the mixer)

• Inadequate Isolation of Process or Equipment Power supply to the mixer was not isolated instead

power switched was turned in off position).

• Inadequate Guards/Protective Devices (Grid of the guard was too wide to stop entry/insertion of

body parts)

Lessons Learned

1. Ensure workers/operators are adequately trained in their trade prior to their assignment.

2. Assess fitness and safety feature of the equipment prior to their acceptance at site.

3. Conduct task specific Tool Box Talks (TBT)

4. Job Performers should never leave their site whilst work is ongoing and crew is still present.

5. Consider mixer washing on site as a part of future Task Risk Assessments (TRA)

72

North East Bab (NEB) Asset

73

74

Past Incidents

Gas Release From Closed Drain

Vessel (18-09-2010)

Vehicle Collision with Road Side

Barrier (02-08-2010)

Fire In Rumaith Central Processing

Plant (24-08-2011)

Injuries Due breakage of Valve of a

Pressurized Cylinder (03-09-2011)

Oil & Gas Release at Cluster D

(03-10-2010)

Cable Cut During San Clearance

(07-07-2009)

Shovel Rollover

(01-03-2008)

Arm Crush Injury at Cluster A

(08-11-2007)

Dead Dugong (26-12-2011)

Dead Turtle (17-09-2011)

Finger Injury (06-09-2011)

Vehicle Rollover (28-03-2011)

75

76

Vehicle Crash During OHL Visual Survey


North East Bab (NEB)

30-04-12

As a part of routine inspection of over head line (OHL, visual inspections was ongoing.

There is no access track along the overhead line network. A foreman and a driver were travelling in a vehicle and the Foreman

decided to drive the vehicle himself and the driver was seating in passenger seat. The Foreman inspected one pole and was driving towards the next one to do the same

inspection. Suddenly the vehicle fell down as there was a sharp slop formed by sand dune. Outcome: The foreman and the

driver felt back pain and the car front bumper was damaged (estimated to be $1500). The Foreman was assigned on light duties for one week.

• Inadequate Preventive Maintenance (The right of way was not maintained and resulting in formation of sand dunes beside over-head lines)

• Improper Supervisory Example (The

Foreman decided to drive himself and carry our visual inspection at the same time; and a professional driver was not used for driving)

Immediate Causes

• Improper decision making/lack of judgment (The Foreman decided to drive and visually inspect over head lines

at the same time whilst a professional driver was seating as a passenger))

• Inattention to surroundings (While focusing on overhead lines the

depression was overlooked)

Lesson Learned

6. Do not drive and get distracted by other activities 7. Maintain right of way (ROW) near overhead line

poles and check adequacy of the track prior to commence work

77

Transformer Fire



25-07-12

In oil train 1, at 2nd stage Desalter, flash over occurred at the transformer (secondary high

voltage) cable located at a height of 12 feet. The flash-over was detected by the UV/IR detectors.

Outcome: Control Room Operator (CRO)

alerted electrical team who isolated the cable. After the isolation fire was extinguished using CO2 fire extinguisher.

It was the third similar incident in NEB involving melting of high voltage bushing (or high voltage cable).

• Inadequate Preventive Maintenance (High Voltage Busing were not changed as per vendor recommendations and Desalter oil samples were

not tested)

• Tools & Equipment - Inadequate Availability (High Voltage Busing and oil tester were not available)

Lessons Learned

1. Oil samples should to taken from all desalters to evaluate the condition of High Voltage Bushings

2. Evaluate condition of the HV bushings during the

regular maintenance periods

3. Ensure availability of critical spare parts such as High Voltage Bushings at all times

Immediate Causes

• Violation by Group (Maintenance

Procedures as per Vendor Instructions were not fully followed due to non-availability of oil tester)

• Inadequately Prepared Equipment

(High Voltage Bushing Replacement was not carried as per vendor recommendations)

78

Fire in UPS Unit of Substation



08-07-12

Dabbiye’a has two substations and each

substation has 2 AC- Uninterrupted Power Supply (UPS) units. Each UPS unit is equipped with cooling fan to cools different components such as capacitors, transformers and power

electronic devices.

Due to frequent voltage fluctuation (from

external power supply source), capacitors’ performance was compromised. After such voltage fluctuation event, a capacitor burnt and the fire spread within the UPS system and

extended to the major components within the cabinet. Fire Auxiliary Team responded and extinguished the fire.

Outcome: It resulted in damage of two power transformers, static switch module, cooling fans and few capacitors. The plant was manually shutdown on Emergency Shut Down-1.

• Engineering Design – Inadequate

Assessment of Potential Failure

(Capacitor surpassed their material life and were subjected to wear & tear due to power fluctuation)

• Materials Shelf life Exceeded

(Manufacture identified capacitor’s life span as 14 Years and after the incident it was corrected as 7 years)

Lessons Learned

1. Provide adequate spacing and ventilation for

UPS and other electrical devices for cooling

2. Provide adequate spacing for maintenance.

3. Before accepting reliability value of systems, study proving the calculated reliability to be submitted.

Immediate Causes

• Inadequate Equipment (Premature failure of capacitor due to power fluctuation)

• Inadequate Ventilation (Cabinet units were stacked close to the wall, not

providing adequate ventilation)

79

South East (SE) Asset

80

81

Past Incidents

Multiple Fatalities Due to H2S Release in Shah (03-02-2009)

Multiple Fatalities Due to Vehicle

Collision –Sahil (07-09-2009)

Loss of Containment During

Replacement of Corrosion Coupon (23-10-2010)

Buried Cable Cut During Site


Carpenter’s Finger Injury

(10-02-2011)

Fall of Worker in Wellhead Celler

(24-03-2011)

Wireline Crew Vehicle Rollover

(03-08-2011)

Vehicle Tire Disengagement

(03-08-2011)

Finger Injury during Unplugging of

Drain (14-08-2010)

Scorpion Sting During Sand

Clearance (25-05-2010)

Wrong Flow Line Tie in

(07-04-2011)

Vehicle Rollover

(24-03-2011)

82

83

Electrical Flashover Inside Transformer Terminal Box


South East (SE)

Asab Field

07-04-12-

The 3-yearly preventive maintenance of 33kV OHL(Over Head Line) was completed and the OHL was energized followed by re-energizing of the associated

WI (Water Injection ) clusters. During starting of Water Supply Well (Sb-55 WSW) surface pump, heavy black smoke was noticed with arcing sound from the (3.45KV) surface pump transformer cable box.

Immediately operation foremen stopped the motor, opened 33KV gantry isolating power switches, and applied earth switches.

Outcome: – An electrical flashover occurred. The fire was self-contained inside the transformer terminal box

• Inadequate implementation of Standards: (The

vendor used bus-bar with terminals not suitable for the application. Consequently, the starting current (around 1500 Amps) induces electromechanical forces allowing the physical movement of the

unsecured transition bus-bar between cable terminal and transformer bushing)

• Inadequate adjustment: (Poor Techniques securing transition bus-bar to transformer bushing)

• Inadequate monitoring of work during

construction (All the above root causes were not captured during the construction and mechanical completion phase.

Lesson Learned

1. Use Flat 4- Hole Bolt Terminal in place of Standard Straight Bolt Terminals

Immediate Causes

• Inadequate Equipment (Not using the proper bushing-bus bar terminal lug)

• Work Exposure to Energized Electrical

Systems

84

Foreign Object (Metal Particle in Eye)


South East (SE)

Asab Field

07-04-12-

On a windy day, a foreman was proceeding for preventive maintenance job on potable electrical

booster pump near welding workshop. When he reached the site he felt dust in his eye and he went to wash room to wash his eyes. He completed his task and later he kept rubbing his eyes. The following day,

he woke up with red & swollen eyes and went to clinic for treatment. He was referred to a hospital where a foreign object was removed from his eye.

• Inadequate Identification of Worksite/Job

Hazards (Workers were not made aware of

hazards on a windy day; risks of rubbing eyes when a foreign body enters eye were not known)

Lesson Learned

1. Wear eye protection during windy days even when

proceeding to worksite

2. Contact medical professional when a foreign object enters into eyes

Immediate Causes

• PPE not used (Worker was proceeding to work area and was intending to wear his goggles when starting the job)

• Lack of Knowledge of Hazard Present (Risk of sand/dust particles entering into eye was not adequately identified)

85

Worker’s Finger Entrapment Between Pipe Flange and Valve Flange


South East (SE)

Asab Field

08-07-12

Well work-over was completed and a Field Services crew was working to fix a 2” valve on

bleed-off line. Emergency response plan and PPE were discussed in Tool Box Talk (TBT) and the work started.

There was no dedicated banksman and the

Foreman himself was directing the Crane Operator. The crew included a newly hired laborer.

The bleed valve with the spool was lifted and the laborer was holding the T-piece with valve during alignment. When the load moved, his left hand index finger got trapped and crushed between the

pipe flange and valve flange.

Outcome: The foreman stopped the operation and transferred the injured person to RAMS Clinic for treatment. Laborer sustained fracture to his

finger.

• Inadequate Work Planning or Risk

Assessment Performed (No dedicated banksman was used; & inexperienced

laborer was assigned to assist a crew involved)

Lessons Learned

1. Do not assign inexperienced laborers on new activities.

2. Ensure crew members are aware of task related hazards through effective Tool Box Talk (TBT).

Immediate Causes

• Improper Position or Posture for the Task (Inexperienced worker wrongly positioned his left index finger between the two flanges during alignment)


Judgment (Foreman was also acting as

Banksman losing focus on supervision)

• Lack of Knowledge of Hazards Present (An inexperienced and untrained laborer was assigned to the job)

86

Terminal & Pipelines Operations (TPO) Asset

87

88

Past Incidents

Shovel Falling Into a Ditch

(09-04-2010)

Loss of Containment Due to Rupture of

Hose (26-09-2011)

Loss of Containment Due to Rupture of

Hose (26-09-2011)

Loss of Containment at MP 21

(08-11-2011)

Loss of Containment at MP 21

(08-11-2011)

Vehicle Rollover

(21-11-2011)

Fall of Worker into a Manhole (26-04-2007)

Partial Fall of Roof in Accommodation

Camp (28-05-2008)

89

90

Heat Stress


Abu Dhabi/Jebel Dhanna

09-04-12

A newly recruited team of trainee firefighters were attending a fire drill and it was their first

day of training in full fire suites. During this training two trainee firefighters were over exerted and one trainee stopped the training and went

under the shaded area to rest and later another trainee collapsed and became unresponsive. They were taken to RAMS Clinic in Jebel Dhanna and later transferred to Ruwais Hospital. Outcome:

They were treated for heat stress and later discharged from the Hospital.

• Fatigue (Over exertion of physical capabilities led to fatigue during physical training on a hot and humid day in full fire suit)


Policies/Standards/Procedures (New trainees were enrolled without ensuring medical fitness; ADCO guidelines for heat stress were not implemented)

Lessons Learned

1. Include ADCO heat stress guidelines in HSE induction for training

instructors and new trainees to identify signs and symptoms of fatigue, heat stress etc.

2. Ensure that all Fire Training

Instructors are trained and certified as First Aiders.

Immediate Causes

• Over exertion of Physical Capabilities (New recruits were involved in extended physical i.e. physical training exercise, fire drill)

• Temperature Extremes (27oC with 82%

humidity in full fire suite).

91

HSE Performance, 2012

29

27

34

47

56

55

44.4

32.3

32.5

57.3

6

118.9

2

160.4

9

0.630.55 0.36

0.28

0.16 0.16

0.29

0.12

0.340.26

0.09 0.08

0.700.66

0.80

0.68

0.550.51

0.81

0.93

1.29

0.78

0.34

0.47

0

20

40

60

80

100

120

140

160

180

0

0.2

0.4

0.6

0.8

1

1.2

1.4

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Mill

ion

M

an

ho

urs

W

ork

ed

Lo

st

Tim

e In

jury

Fre

qu

en

cy R

ate

/ T

ota

l R

eco

rdab

le In

jury

R

ate

Year

ADCO & Contractors LTIF & TRIR (YTD) vs Manhours worked

Manhours Actual LTIF TRIR

92

Incident Types - 2012 (Work & Non-Work Related 380 Events)

Injury/Illness

42%

Transportation

28%

Onshore Spill

12%

Property Damage

10%

Fire

5%

Gas Release

3%

93

94

Asset Wise Event Type Distribution - 2012

95

Incident Immediate & Root Cause Categories 2012

Immediate Causes

Root Causes

Management /

Supervision /

Employee

Leadership

21%

Work Planning

16%

Behavior

15%

Training /

Knowledge

Transfer

10%

Work Rules /

Policies /

Standards /

Procedures

9%

Communication

7%

Mental State

6%

Skill Level

5%

Repetitive Immediate Causes

Improper decision making or lack of judgments

Lack of knowledge of hazards present

Violation by individual

Violation by supervisor

Repetitive Root Causes

Inadequate work planning

Inadequate identification of worksite/job hazards

Inadequate adjustment/repair/maintenance

Inadequate audit/inspection/monitoring

96

Incident Immediate Cause Analysis -2012

Violation by individual One individual intentionally chose to violate an established

safety practice.

Violation (by supervisor):

A supervisor or other management person either personally violated an established safety practice or directed people under their supervision to do so.

Improper position or posture for the task

Improper decision making or lack of judgment

This cause is the opposite of violations, which are intentional acts. Unintended human error can consist of perception errors, memory errors, decision errors or action errors. A person’s job performance was affected by their inability to make an appropriate judgment when confronted by an ambiguous situation.

Inattention to surroundings:

The person was not alert to their surroundings and just tripped or ran into something that was clearly visible and obvious.

No warning provided

97

Incident Root Cause Analysis -2012

Inadequate Work Planning

The work being done was not planned or was not risk assessed prior to starting that work.

Inadequate audit /inspection/ monitoring

Supervisors did not monitor, inspected or audited the work as planned.

Inadequate preventative maintenance program

The tools or equipment involved in the incident were not covered by a preventative maintenance program, and became unserviceable.

Inadequate identification

of worksite/job hazards

The incident was caused by the failure to perform or properly

respond to a loss exposure study, such as TRA, JSA.

Inadequate Leadership The leaders in an area did not set the right direction or tone for

safety or allowed roles and responsibilities for safety activities to be

unclear or undefined.

Inadequate /Lack of

Safety Meetings

Safety meetings such as effective tool box talks were not

conducted

98

Inadequate Training Some training was conducted, but it did not accomplish the objectives of the training

Inadequate Knowledge Transfer A training programme was in place, but it did not transfer the necessarythe inability of students to comprehend (material beyond their level, language difficulties),

No Training Provided The person was not trained in a specific subject

Employee perceived haste

The incident was caused by the employee’s perception that speed in completing the work was required causing laps in safety considerations.

Improper supervisory

example

Supervisors not giving the proper example to the people working in their organizations.

Inadequate reinforcement of

critical behaviors

A supervisor seeing someone not following the safety procedures and guidelines and not correcting immediately is an example of inadequate reinforcement of proper behavior.

99

Do Not Compromise on the Safety of Staff & Workers, Protection of the Environment and Integrity of our assets

ABU DHABI COMPANY FOR ONSHORE OIL OPERATIONS

(ADCO)

Documents

ADCO 2012 Learning From Incidents- HSE