Shell Contractor Steering Team 13107

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Shell Contractor Steering Team1/31/07

• South Texas Incident Review

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MMR HSE ALERT
FRACTURED LEFT LEG Description of Incident An
MMR crew was working at a single Gas Well site
located in South Texas. During the course of
their work, a yard maintenance contractor arrived
on location to cut grass. While cutting grass,
the Bush Hog passed over a ½ stainless steel
needle valve which had been partially buried for
an undetermined amount of time. When the valve
was struck by the rotating Bush Hog blades, it
became airborne and flew approximately 35 feet,
striking an MMR employee on the lower left leg.
The impact caused a severe laceration and
multiple fractures. The employee was transported
to the local hospital where he underwent
emergency surgery to repair the damage done to
his leg. This injury will result in lost-time.
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MMR HSE ALERT
Bell Ferguson 5
Tractor Bush Hog
North
Manifold
MMR Employee (Turning to bend towards the North
reaching for tools)
Projectile trajectory (1/2 needle
valve) Distance 35 approx.
Injured MMR Employee
Jackson Road
MMR Employee
Mobile Work Trailer
MMR Supervisor
MMR Employee
Not to Scale
Well
MMR Employee
Chain Link Fence
Front Gate
El Ranch Road
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MMR HSE ALERT
Chains to be installed on Bush Hog
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MMR HSE ALERT

• Root Causes / Contributing Factors
• The crew failed to recognize the potential
  hazards associated with the grass cutting
  operations and did not use Stop Work Authority
  (SWA).
• The grass cutting contractor and the MMR crew
  failed to discuss Simultaneous Operations
  (SIMOPS) and update their JSEAs to address new
  hazards now present at the work site.
• The ½ valve was left on the ground.
• Chains missing from rear of bush hog which may
  have deflected the valve.

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MMR HSE ALERT

• Recommendations
• 1. Employees are urged to recognize hazards and
  use SWA.
• All work crews at the location will be given
  SIMOPS and JSEA refresher training.
• 3. Housekeeping at all well locations to be
  addressed by all.
• 4. Install chains or guard on rear of bush hog
  and perform pre-op inspections on all equipment.

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MMR HSE ALERT

• Key Learnings
• Contract and Facility Employees understanding of
  Stop Work Authority and willingness to implement
  it need improvement.
• Employees understanding of SIMOPS and the
  importance of being aware of other crafts and the
  hazards their tasks present needs improvement.
• Employees understanding of the JSEA process
  needs improvement.
• 4. Housekeeping at all well locations needs
  improvement.
• 5. All equipment must be inspected for condition
  and guards before use.