Fatality Review

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Fatality Review
The illustrations in this presentation are
explanatory aids and should not be regarded as
graphically exact technical representations. The
questions (reflections) are designed to prompt
discussion and may not be in any way related to
contributing factors to these fatalities.
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Between 2000 2002 there were 11 Fatalities on
Offshore Installations in the UK, Norway and
Holland. These were our friends and colleagues
We need to work together to make sure that we
have no more deaths in our industry
How will you be making your next trip home?
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(No Transcript)
4
No 1
Jan 2000
A
B

• Reflections
• This is how the joint was slung. How do you sling
  pipe?
• If you saw this, what would you do?
• Would you be happy to stand under this (or any)
  load during a lift?

C
The Event Man struck by joint of casing The
sling slipped up the pipe A, the casing swung
down and outward B, hit the deck, bounced and
struck a man standing on the deck C. This
fatality involved lifting.
5
No 2
May 2000

• The Event Man struck by a 3Ton bundle of pipe as
  it was moved onto catwalk. This fatality
  involved lifting.
• Normal practice was to remain in the
  bus-shelter (yellow area) as loads were moved.
• The crane driver had just been relieved for a
  meal by the assistant.
• A tool-box talk was held at the start of shift
  but not for this changeover.

• Reflections
• This is a routine task some of our routine
  tasks carry significant risk why?
• Do you get comfortable with routine tasks eg
  crossing a busy road?. Perhaps we are far less
  at risk in unfamiliar operations where our guard
  is up?.
• Do you have enough safeguard built in to allow a
  momentary lapse of concentration?
• What is the quality and frequency of your
  toolbox-talks?

6
No 3
Oct 2000

• The Event Man Crushed.
• A man was working on the control hoses for the
  diverter under the drill floor suspended on a
  man-riding winch. During the operation, the man
  was raised too far and crushed against the bottom
  of the rig floor.
• The man operating the winch on the drill floor
  was unable to see the man in the riding belt. A
  radio was in use between the man on the winch and
  a banksman on the BOP deck below.
• There was no safeguard against the communication
  failure.
• The manriding winch was capable of generating
  large loads.

• Reflections
• Do you carry out manriding operations?
• Do you use the Step Change guidelines and
  signals? If not, are your own systems as good or
  better?.
• Manriding is a bit like flying if you or your
  family are in the air what expectations do you
  have of the pilot (winchman), air traffic control
  (banksman) and passengers (the man in the belt)?.
• Do you carry out operations that rely on radio
  contact how to you ensure that radio failure
  does not lead to death or injury?

7
No 4
Dec 2000
The Event Man struck by bundle of drillpipe Two
men (blue basket) asked the crane driver to lift
out a tool move the basket. The deck had a
blind spot (see drawing), caused by the pipe
shuttle. The crane driver went to do the lift and
realised that he needed to move pipe to make room
for the basket. In the meantime, unknown to him,
two different men came into a nearby basket.
While lifting the bundle of pipe (without
taglines or a banksman) the bundle started to
rotate and was set down next to the blue
container in the belief that the two men visible
were those who had requested the lift (ie that
the blind spot was clear). One of the men
managed to jump to safety, the other was killed.
This fatality involved lifting.

• Reflections
• What rigorous precautions do you take for blind
  lifts?.
• What lifts can you carry out without a banksman?
• On your installation, are banksman duties clear?
• Is this a routine task (routine usual, common,
  regularly carried out ). If so does that make
  it safer?
• Could this happen on your installation?

8
No 5
Mar 2001
The Event Man fell through hole to lower deck. A
jack-up was working over a small platform. The
normal solid hatch had been replaced 10 days
before with a drilling hatch with a 42 hole.
This was covered with a plate, 5 sleepers and
surrounded by a scaffold barrier. The crew
reached the stage where access to the well was
needed. Three crew members had removed the
sleepers and were removing the plate when one
crew member stepped in the hole and fell to the
deck below.

• Reflections
• How do you protect such openings on your rig?
• How does that protection stretch across shifts or
  crew changes?
• If this accident were to almost happen on your
  installation, would you report it?
• If you were to report it would you class it as
  high potential (ie a very serious near-miss)?

9
No 6
Jul 2001

• Reflections
• Is this a routine task and if so what dangers
  does it pose?
• What protection have you got against this type of
  event?
• Do those who routinely perform this task consider
  it routine and perhaps trivial?
• Where will the drillers focus be in an operation
  like this rotary or elevators?

The Event Man crushed by descending equipment.
Picking up and running pipe on the drill floor.
As each joint was added to the string a stabbing
guide was used on the pipe to protect the thread
as the next joint was being added. On this
occasion, the top-drive descended considerably
more than required this coincided with
installing the stabbing guide. Is this a lifting
operation?.
10
No 7
Nov 2001
The Event Man fell 37m. A barge supervisor was
carried out maintenance on a personnel lift (to
change out the rope that raises/lowers the lift).
The lift was suspended on slings supported on a
piece of pipe placed across the aperture of the
winch housing floor. The man was standing on top
of the lift, when the pipe supporting the lift
moved and the elevator plunged to the bottom of
the shaft.

• Reflections
• Do you know how lifts on your installation are
  maintained?
• Is this a routine operation? How would you plan
  for an operation like this?
• What secondary measures would you take to protect
  yourself and others?
• This is working at height what are your
  procedures for such work?
• If you dont have lifts what operations on your
  installation bear similarities to this one? How
  are they managed?.

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No 8
Jan 2002

• The Event Man fell overboard.
• The task was to secure the diverter (red item) on
  the cart - a small platform over open water. One
  chain was secure, a cheater bar was needed for
  the other.
• The terms of the permit to work regarding life
  vests, securing the harness and calling in the
  standby boat had not been carried out by the
  supervisor.
• A Time-Out was called for but not taken.
• The cheater bar was thrown to the man on the cart
  (the supervisor), he did not catch it cleanly,
  rolled over and fell into the sea. He was not
  found.

• Reflections
• Supervisors need to care for themselves as well
  as their people.
• Supervisors need to demonstrate the very best
  safety behaviours.
• How rigorously do you observe the terms of the
  permit to work on your installation?.
• If a time-out was called, under what
  circumstances would you not take it?.

Some handrails etc have been removed from this
drawing for simplification.
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No 9
Mar 2002
The Event Man Crushed by basket. Offloading a
supply vessel. The task was to stack one basket
on top of another (dissimilar) basket. The
basket was hanging unevenly one end was higher
than the other when suspended. Dunnage (timber)
was used to support the upper basket. The
banksman went into the bay where the baskets were
being stacked with a view (it is believed) to
re-positioning the dunnage. While there the
basket slipped and the banksman was crushed. This
fatality involved lifting.

• Reflections
• If you stack baskets, are they suitable for it?
• Do you use timber as a structural member?
• What is the role of the banksman is it crystal
  clear on your installation?
• Have you ever been asked to act as banksman are
  you qualified?
• How should one read the risk in this operation
  and when should one say STOP?.

Views looking Aft
View looking Forard
13
No 10
Apr 2002
The Event Man hit by dropped object. A design
engineer was working on a landing frame on the
lower deck area (moon-pool) of a drilling rig.
He was a visitor to the rig not part of any
normal crew. Normal operations were proceeding
on the rig floor using the catwalk trolley. A
crossover sub (large piece of pipe) fell through
the mousehole opening and hit the engineer below.

• Reflections
• How do control work below on your installation?
• How do you manage/control day visitors and their
  activity?
• If you remove hatches, how do you protect people
  on other levels?
• When you remove such hatches do you immediately
  think in terms of a risk created?

Mousehole.
Trolley
Landing Frame
Crossover Sub
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No 11
Nov 2002
The Event Man crushed by falling tank (chemical
pod). Two pods had been stacked and were to be
un-stacked. On request the crane driver lowered
the crane pendant it came down too far and
fouled between tank and frame. The banksman,
while standing on the ladder of the upper tank,
made a radio request to the crane driver to pick
up 20cm. On doing so (with the ferrule fouled),
the tank lifted, slewed sideways trapping and
crushing the banksman against an adjoining
container. This fatality involved lifting.

• Reflections
• How do you communicate with the crane driver?
• What else are you doing at the same time?
• Can you reach lifting equip. on your installation
  from the deck?
• Do you separate the duties of banksman from those
  who touch (or stand on) the load?.
• How well protected is your lifting equipment from
  fouling on the load?

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Common threads identified in the report were

• Mistaking routine for safe.
• Supervisors not spending (or unable to spend)
  sufficient time on site setting expectations.
• Workers vulnerable because they do not perceive
  risk.
• Established Procedures ignored.
• Ignoring of Procedure is observed but
  tolerated.
• Risk assessment cumbersome and not used at the
  coal-face.
• Lifting Operations.
• Banksmen involving themselves in the actual
  movement of the load.
• Some hardware issues e.g. manriding procedures
  kit, cargo baskets.
• High Potential near misses are occurring we
  need to address them.

Read the booklet Fatality Report for more
detail.
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In conclusion These fatalities all occurred on
drilling rigs. However all Hi-potential near
misses are not restricted to drilling. Consider
these fatalities in the context of you own
installation and bear the following in mind If
we were to address even a few of the common
threads effectively (notably lifting operations
and the activity of banksmen) the impact would be
profound !
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Further information is available in the booklet
Fatality Report and in the accompanying CD.
Copies of the booklet and CD can be obtained from
Step Change in Safety contact details on the
web at www.stepchangeinsafety.net or e-mail
info_at_stepchangeinsafety.net