Weekly HSE Lateral Learning 130605

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Weekly HSE Lateral Learning 13/06/05
Slide 1/3
31/05/05 NDSC Fatality B4P
B4P Rig-88, Ahmed along with several members of
the Rig 88 night shift crew were preparing the
rig to commence drilling operations after
completing a rig move. Part of this task is to
set back the mast lifting line equalising yoke.
This requires working at a height of 35 meters
above the rig floor. It was planned to be done
with one man in the mast itself and one man on a
man-riding winch, both assisting in tying the
yoke back. During this operation the cable
supporting Ahmed fell off the snatch block hung
underneath the crown block. Ahmed and his
supporting cable fell the 35 meters to the rig
floor, first hitting the travelling block. Ahmed
was declared dead at 0945 on the same day. He
died of cardio repertory arrest due to severe
head injury and multiple injuries to his chest
abdomen and arms. LEARNINGS The mobile cheek
plate on the snatch block supporting Ahmed was
found open and the static cheek plate found
deformed. It was discovered that a safety pin was
omitted from the retainer bolt during rig-up. The
block had been subject to many activities during
the preceding 8 hours which may have contributed
to the backing out of the bolt. The deformed
static cheek plate had been, sometime in the 8
hours preceding the incident subject to a load
much greater than man-ridding alone. Observations
on the power of the winch indicated a stall pull
could be powerful enough to deform this plate.
The rig had pulled out master-bushings preceding
this incident. Ahmed was probably lifted too
high. He was suspended on a 10m tail chain. At
the height he was supposed to be lifted to, this
would have put the interface between chain and
cable at the block point. No secondary fall
device was fitted. The incorrect winch was used.
The utility winch was used to lift Ahmed instead
of the man ridding winch. No hazard awareness or
control. The PTW system was disregarded. No
meaningful TBT or Job instructions. A climbing
belt was used, not a man-riding harness.
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Weekly HSE Lateral Learning 13/06/05
Slide 2/3

• Aimed at PDO DSVs Some simple checks on your
  rig to prevent a similar occurrence
• Check what kind of man-riding procedures are in
  place on your unit, review them and highlight
  violations.  To which height is man-riding
  allowed, are there any jobs that will require
  breaking this height rule?
• Are all man-riding activities controlled with a
  PTW. Have a look back at the PTW record does it
  match with the activities undertaken
• Is there a secondary fall device installed below
  the sheave. In its simplest form this is a wire
  sling suspended independently such that if there
  is a catastrophic failure of the sheave the wire
  will be caught
• Are man riding belts in use and what type, the
  photo show a climbing belts not a man riding
  belt, familiarise yourself with what constitutes
  a man riding belt
• Is there a dedicated Man riding winch, does it
  meet the requirements for a man riding winch,
  check with contractor, is it used for any other
  purpose. What is the pulling power of this winch?
  Use the manufactures stall load, unless you know
  the actual pull
• What types of shackles are used to connect the
  snatch blocks to the respective pad eyes.
• Do they have a dedicated number and are they part
  of the Lifting equipment register
• Conduct a mast inspection together with the Rig
  Manager and assure your self that
• all sheaves/snatch blocks are properly secured
• right type of shackles are in use ( see
  attached 2003 HSE info note next slide)
• all shackles are secured with the right safety
  pin (no welding wire).
• Check your findings against the latest Mast
  inspection check list of your unit and
  investigate major deficiencies. 
• Before such activities that ensure that hazard
  awareness controls are in place e.g. a JSA, check
  quality TBTs are carried out
• Use the Rig HSE File

This is a climbing belt not a man riding belt
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Weekly HSE Lateral Learning 13/06/05
Slide 3/3
Simple Guide to Shackle Use
4 types of shackle available
2/ Round Pin Bow Shackle
1/ Screw Pin Bow Shackle

• Single Lifts, no vibration or significant
  movement
• 2. Permanent fixture, not regularly opened and
  closed
• 3. For used with chains
• 4. For use on moving items (and vibration) or
  items out of sight

4/ Safety Type Bow Shackle
3/ Screw Pin D Shackle
Type 4 shackle will be used for suspending
sheaves in mast
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Weekly HSE Lateral Learning 18/05/05
20/02/05 Dalma NM 1A
B3P Rig 53 While pressurising to set 9
5/8 whipstock the mud pump pressure increased
to 12000 kpa and stopped. The pump stroke gauge
read zero. The supervisors suspected that the
pump had tripped. The Chief Electrician checked
and reported everything was OK. While this check
was ongoing TP opened up test pump to apply final
test pressure, the test pump Pressure gauge
indicated 29000 kpa!
LEARNING In fact 29000 kPa had been applied to
system by the mud pumps, the pumps had stalled
due to pressure and the pop off valve had failed.
Investigations observed that the stand pipe
manifold pressure gauge hose had ruptured causing
the sensor diaphragm to fail.. The gauge of
remote choke panel was also connected to same
sensor. (MULTIPLE GAUGES ON ONE SENSOR) The
relief valves did not function even at 29000 kPa.
Mud pumps relief valves were set tested to
19000 kPa on 31.1.05, The relief valves were
found stuck as dried out mud was found to have
hardened on top of piston, mud was allowed to
accumulate against the valve because of the
backward slope of the pipe
Picture 2
ACTIONS 1. Check on your rig the piping
arrangement from the pressure relief valves to
the tank, this piping needs to be - Sloping
downward to prevent mud settling and drying
against the valve - Be straight, no bends - Be
anchored securely at the tank end - Be made of
piping rated equal to the system pipework 2. All
gauges must have a separate sensor, with the
exception of monitoring devices such as
geolographs 3. Have pressure gauges (analog
type) installed on standpipe manifold, visible
for the driller and crew
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Weekly HSE Lateral Learning 29/04/05
15/04/05 ODE LTI 3P
C4P RIG-40, During a routine interwell
rig move, the rig carrier sustained a flat tyre.
The rig carrier was raised off the ground and the
surrounding sandy area was leveled. The bolts
holding the wheel retaining wedges where
loosened and some of the retaining wedges were
removed. The plan was to move the forklift into
position to support the wheel prior to removing
the last of the retaining wedges. As the wheel
was slowly turned by hand, it came off the hub
and fell over. The Junior Mechanic and Derrickman
tried to jump clear but their legs were hit by
the falling wheel. The Derrickman sustained a
broken leg. The Junior Mechanic had bruising to
his wrist and leg.
LEARNING The job appeared to have been reasonably
well planned and supervised. A ToolBox Talk was
held, although the operational aspects were well
covered safety aspects were not, no procedures
were in place, the area was prepared and the
right tools were being used. Previous experience
of all involved was that these wheels are tight
on their hubs and require a lot of effort to
remove, this time it fell off unexpectedly Always
Expect the Unexpectedand Plan for it.

• ACTIONS
• A quality TBT/JSA prior to such a job is vital.
  Ask the what ifsWhat if the wheel falls, what
  escape route does the team haveWhat is different
  now, is the wheel hot?
• It is apparent now that this very hazardous job,
  no procedures were in place or JSA done. This is
  a 2.8 ton wheel, the removal of which requires
  men to stand in front of it while loosening its
  retaining bolts. Work such as this needs in depth
  planning, but firstly the rigsite teams need to
  be able to recognize what constitutes a hazardous
  job. It is the responsibility of the senior
  personal on site to be able to recognize such
  hazards, and protect their workers
• Although the medivac went well, The Thuraiya
  belonging to the DSV failed to operate during
  this emergency. All rigs to check their emergency
  contact systems weekly, you never know when you
  need them

The Senior Mechanic, standing directly in front
of the wheel and turning it. when the wheel fell
off he was able to duck through the center hole.
he was very fortunate to escape unharmed. The
wheel passed over him!
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Weekly HSE Lateral Learning 06/04/05
30/03/05 Schlum (Reda) PDO 2P C3P
WPH-15, While preparing to connect lifting
chains to ESP motor clamp, the motor rolled
slightly and pinched the technicians left index
finger at the 3rd digit. Although employee was
wearing proper PPE gloves, the pinch resulted in
a cut approximately ½ inch in length and required
6 stitches
LEARNING The technician was working alone,
attempting to move a heavy load sufficiently to
secure a lifting device. This was made all the
more difficult by the grove in the catwalk. The
grove had trapped the ESP pump, the lifting lugs
made it difficult to turn. Thought should have
gone into how this pump was going to be handled
on a catwalk with a large grove in the middle,
rollers are used at the other end Was a Toolbox
talk held for this job was it effective? Is their
procedures for handling pumps?

• ACTIONS
• Do you have a similar catwalk with large grove,
  what additional problems does this cause you?
  how do you manage this hazard? It needs thought
  about before you start to place large heavy
  objects on it, not after youve hurt someone
• The step by step approach to handing a large item
  such as an ESP pump should have been detailed in
  the toolbox talk,
• Ask for assistance, when manoeuvring difficult
  objects first look at mechanical means, if this
  is not possible do it as a coordinated team