This in the official investigation report from my previous post regarding the above fatality case.
- Type of Incident: Fatality
- Business Unit: Offshore Installation
- Date of Incident: 11th June 2006
- Brief Account of Incident:
- The incident took place when a Rigger was buffing piping the end of a pipe at the ready rack (at junction of longitudinal and transverse conveyor) ready in preparation for welding, when another pipe was advanced from a longitudinal conveyor post end-prep operations.
- The Rigger was caught between the pipe moving to the transverse conveyor and one that was already positioned on the transverse conveyor.
- This area contained hatch markings painted on the floor indicating that this was a hazardous area. Hatch markings were visible, but worn.
- An audible and visible alarm was working and operable warning personnel of moving pipe, but would not have been effective to prevent the fatality as it was behind the rigger and with the noise of the buffer and hearing protection would not have been heard.
- Furthermore this area was considered by barge supervision to be a pinch point area and not a regular place to perform buffing, however the practice was tolerated as it was considered by the Riggers as â€œnormalâ€ practiceâ€ to buff pipe in this location.
- What went wrong?
- Immediate / Direct Causes:
- Personnel should not have been buffing pipe the area demarcated with hatch markings.
- Conveyor operators must check the path of travel of any pipes and ensure personnel are well clear before moving them on conveyor systems.
- Barriers and hatch markings must be installed and clearly identified in any possible pinch point areas
- Basic / Underlying Causes:
- There were several contributing causes to this incident:-
- Training of operators involved in the pipe lay process does not clearly out line the production process and quality standards.
- Level II work instructions do not describe the pipe preparation process, work tasks contained within the process, roles and responsibilities etc.
- Barge supervision and other employees were aware that the immediate accident site was a hazardous area but failed to stop employees buffing in the hazard area.
- System Failure
- Inadequate standards and specifications â€“ walk/work areas not maintained
- Inadequate work instructions
- Barge management / supervisory support of HSE systems
- Inadequate initial / refresher training
- Recommended Action:
- Corrective Action (short term):
- Task Risk Assessment to specify exact pinch points that can be encountered.
- Check and repaint all hatch markings and warning chevrons and include location & inspection regime in planned maintenance system.
- Highlight the purpose and definition of hatch markings and warning chevrons to crew.
- Install physical barrier and warning sign at junction of two conveyors.
- Barge management and supervision to make regular inspections and visits to operating areas focussing on unsafe behaviours and correcting such behaviours.
- Install limit switches to prevent movement of pipe from longitudinal to transverse conveyor when transverse conveyor is full.
- Develop a competency standard and assessment tool for pipeline conveyor operators
- Move the audible and visual alarm to eyesight level and label its purpose.
- Consider disciplinary action for individuals involved in incident and also those that do not report incidents affecting quality and near-miss incidents.
- Assign a Team Leader / Leaderman in each process area to monitor unsafe behaviour; foster team work and caution educate employees on unsafe behaviours.
- Preventative Action (long term):
- Monitor compliance to all TRAâ€™s
- Conduct pinch point survey and ensure all pinch points are delineated or guarded and their location and inspection and maintenance criteria added to the PM system.
- Write a Level 3 Work Instruction that includes: identification of hazards of the pipe process areas, the required competencies of the personnel involved in the process and job rotation schedules.
- Barge management / supervision to record in their daily logs results of visits and inspections and document their findings complete with corrective actions.
- Implement disciplinary action process for those employees and supervision that tolerate / condone at risk behaviours or un-safe conditions.
I Myself as an offshoreman would like to remind others to put extra vigilant to similar activity with potential pinching points. And for those who are willing to be part of the oil gas jobs industry, be prepared to face all the challenges in WORK itself, in safety & in MIND!