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Incident Prevention Through Learning from Incidents

January - December, 2012 Health, Safety & Environment Division

For further information, comments and suggestions please contact: Dr. Muhammad. R. Tayab (drtayab@adco.ae) Health, Safety & Environment Division Tel: 02-6041217; Mobile 00971 (0) 50 324-3996

: drtayab@adco.ae : : 6041217

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.

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)

Table of Contents
Finger Injury Resulting from Using Hand Tools 33-Kv Underground Cable Damage During Sand Clearance Damage to Underground Fiber Optic Cable During Excavation Crane Mounted Truck (Hiab) Rollover on Gatch Road Crane Mounted Truck Rollover on Gatch Road Loss of Containment Rollover of Truck Carrying Gatch Fire at Wooden Electrical Pole Vehicle Drop in Low Lying Area/Depression Breakage of Hook of Wire Rope Injury from Falling Cap of Circulating Head Struck by Swinging Mud Pump During Lifting Fall of Travelling Block with Full String Weight Gas Release From Coil Tubing Vehicle Collision Near A Rig Site Low Bed Trailer Rollover Finger Injury During Entanglement of Wire from Wireline Reel Release of Oil from Xmas Tree Fall of Foreman from Stand Pipe Dropped Object During Lifting Uncontrolled Descend of Travelling Block Power Generator/Engine Fire Trailer Fire at Rig Camp Water Tanker Rollover Hand Entrapment Inside Tong Electrical Shock Arm Injury Due to Fall of Jumbo Bag Falling Object Fire Due to Poor Grounding During Welding Fiber Optic Cable Cut During Excavation Vehicle Collision & Rollover Asphyxiation of Welder Inside A Pipe Man Lift Drove Over Flagmans Foot Vehicle Rollover Vehicle Collision on a Sand Track 9 10 11 12 13 18 19 20 21 22 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 49 50 51 52 53 54 55

Vehicle Drove Over a Berm Cement Mixer Rollover Damage to Overhead Line Ankle Injury During Cable Pulling Vehicles Collision on Gatch Road Arm Injury Due to Explosion During CAD Welding Fire at Scaffolding Platform Around Stripper Column Foreign Object Entering Eye of a Worker Vehicle Rollover on Gatch Road Crane Mounted Truck (Hiab) Rollover on Gatch Road Vehicles Collision Crane Rollover During Move on Gatch Road Vehicle Collision Fatal Fall of Worker from a Moving Vehicle Fall of Mobile Scaffold Platform on a Worker Arm Amputation Inside Foam Concrete Mixer Vehicle Crash During OHL Visual Survey Transformer Fire Fire in UPS Unit of Substation Electrical Flashover Inside Transformer Terminal Box Foreign Object (Metal Particle in Eye) Workers Finger Entrapment Between Pipe Flange and Valve Flange Heat Stress HSE Performance, 2012 Incident Types - 2012 Asset Wise Event Type Distribution - 2012 Incident Immediate & Root Cause Categories 2012 Incident Immediate Cause Analysis -2012 Incident Root Cause Analysis -2012

56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 76 77 78 83 84 85 90 91 92 94 95 96 97

BAB & Gas Asset

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 (0602-2010)

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)

Finger Injury Resulting from Using Hand Tools


Area Incident Description Root Causes 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

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 Bab Field wound management

14-02-12

Immediate Causes 1. Always use right tools for the task and do not take short cuts Improper Position or Posture for the Task (Placing finger/hand near pipe and the 2. During task/work planning identify tool) requirements and availability of right tools Inadequate Equipment (Using a wrench 3. Provide hand tool safety awareness to all with a pipe extension instead of standard Forman, helpers/labourers tools, spanner) Workplace Layout- Congestion or restricted movement

33-Kv Underground Cable Damage During Sand Clearance


Area Incident Description Root Causes 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 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 Bab Field reached at the crossing, it damaged the live 28-04-12 cable. Outcome: The power supply to clusters was disconnected. No personnel injury was reported. 1. Always obtain excavation certificate for sand clearance (leveling/grading) activities (Item No. 3.4, Page No. 17; Item No. 3.13, Page No. Lack of knowledge of Hazards Present 69; Item No. 3.13.2.1 Page No 71 of PTW (Sand clearance crew was not aware of procedure) buried utilities) Immediate Causes 2. Place visual markers to guide sand clearance No Warning Provided (There was no machine operators. markers/warnings identifying buried cable) Inadequate Guards or Protective System (Cable was not protected at the edge of the track)

10

Damage to Underground Fiber Optic Cable During Excavation


Area Incident Description 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. BAB Field The job performer had started to use mechanical excavator, after exposing buried line. During the excavation a fiber optic 08-08-12 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). Causes 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)

11

Crane Mounted Truck (Hiab) Rollover on Gatch Road


Area Incident Description 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 BAB Field brakes. A combination of deteriorated tires, slippery surface, harsh brake and sharp 22-08-12 maneuvering of steering caused the vehicle to rollover. Outcome: The driver sustained lower back injuries. 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) 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 Root Causes

Inadequate Audit/ Inspection/ Monitoring (Vehicles tire fitness was not checked; Road condition (potholes) were not assessed prior to the journey; Vehicle IVMS and drivers driving behavior reports were not reviewed) Inadequate Identification of Worksite/Job Hazards (Hazards of slippery surface due to humidity and potholes in gatch road were not identified and controlled)

Lessons Learned

12

Crane Mounted Truck Rollover on Gatch Road


Area Incident Description 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 (Bb241). 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). Root Causes Inadequate Audit/ Inspection/ Monitoring (Contract focal point did not follow contractors 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)

The gatch road leading to the site (Bb-797) became wet slippery due to fog/humidity 3. Lessons Learned Not Embedded (Lessons overnight. After driving approximately 2 km, from similar incidents (occurred on 22-08the vehicle drifted from the gatch road and 2012 & 28-08-2012) involving rollovers of the driver applied harsh brakes and sharp crane mounted trucks in BAB Field were not BAB Field maneuvering of steering to control the vehicle effectively incorporated into work plan) causing vehicle to over to its side. Outcome: 22-08-12 The driver sustained open wound on his hand Lessons Learned and treated at a hospital. 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)

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)

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Buhasa/Huwaila/Bida Qamzan Asset

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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)

Loss of Containment Resulting in Fatal Vehicle Fire (07-05-2011)

Loss of Containment Resulting in Fatal Vehicle Fire (07-05-2011)

Worker Attacked by an Ostrich (2607-2011)

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)

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17

Loss of Containment
Area Incident Description 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. Causes

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)

The foreman assumed that fitting screws were Buhasa Field fitted back and he proceeded with the Lessons Learned installation. Operation crew opened the well and a release of oil was reported by another crew (BUH) (approximately 2 km away from the well site) from the access assembly. The well was shut in 01-01-12 and the leak subsided. Outcome: Approximately 1 bbl of crude oil was 1. Always assess/inspect readiness of the released/spilled system before installation/operations. 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) 2. Do not assume and when in doubt, check with line supervisors.

Assembly without Screws

Assembly with Screws

18

Rollover of Truck Carrying Gatch


Area Incident Description 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. Root Causes

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)

Buhasa Field Outcome: The driver sustained minor (BUH) injuries on his both hands and forehead. Vehicles windshield, right mirror, right door 03-03-12 were damaged. 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)

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.

19

Fire at Wooden Electrical Pole


Area Incident Description 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. Buhasa Field (BUH) 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. Causes 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

14-04-12 Immediate Causes

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

Inadequate Guards or Protective Devices 3. Use deeper Earthing wells to disperse (Earthing system was not adequate to leakage current. disperse leaking current) Work Exposure to storms or acts of nature (Lightening and light rain.)

20

Vehicle Drop in Low Lying Area/Depression


Area Incident Description Root Causes

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. Buhasa Field Outcome: The vehicle sustained minor damage on the front-end bumper. (BUH)

Inadequate Practice of Skill (Driver took a u-turn and entered into non-designated route instead of remaining on track)

22-08-12 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.

21

Breakage of Hook of Wire Rope


Area Incident Description Root Causes

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-vehicles 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)

Buhasa Field (BUH)

Lesson Learned

10-08-12

Immediate Causes

1. Check adequacy of tools available for in vehicle tool box. Inadequate Tools or Equipment (The sling used was not suitable for the job) 2. Always check if the slings are certified/checked, and suitable for pulling the vehicle prior to use.

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Technical Services Drilling

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Past Incidents

Damage to Hammer Union During Pressure Test (23-11-2010)

OBM Haulage Tanker Rollover (29-102010)

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 Preparation (23-03-2010)

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)

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Injury from Falling Cap of Circulating Head


Area Incident Description Causes

Drilling

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.

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)

Outcome: The hardhat of that floorman flownRig No. 17 off from his head and he sustained scratches due to the impact of sliding of hardhat. 17-01-12 Immediate Causes 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) Lesson Learned 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

27

Struck by Swinging Mud Pump During Lifting


Area Incident Description Root Causes Inadequate Identification of 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

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 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 didnt 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)

Drilling Rig No. 53

20-01-12

28

Fall of Travelling Block with Full String Weight


Area Incident Description Root Causes Inadequate Audit/ Inspection/ 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)

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 electrodynamic (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 Drilling Rig No. 38 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)

Lessons Learned

02-02-12

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.

29

Gas Release From Coil Tubing


Area Incident Description 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 Drilling and the well was killed by bull-heading with 100bbls of brine water (75pcf). Gas leak was Rig No. 22 stopped after pumping 15bbls of the brine into tubing. Outcome: Release of N2 (Nitrogen) and 21-03-12 gas with H2S from coil tubing to the atmosphere. 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) 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 Root Causes 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

30

Vehicle Collision Near A Rig Site


Area Incident Description Root Causes

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. Drilling NDC Rig 25 24-05-12 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) Outcome: Both vehicle sustained minor damaged on their front right sides.

Inadequate Identification of 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.

31

Low Bed Trailer Rollover


Area Incident Description Causes

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

Drilling NDC Rig 9

02-06-12

Immediate Causes Improper Decision making/Lack of Judgment (The operator of low bed trailer 1. Always inspect and identify access route for the attempted to take a U turn on sand movement of equipment bars/humps) 2. Familiarize new drivers/operators with roads and Lack of Knowledge of Hazards Present access routes prior to their assignments (The operator of the trailer was not familiarized with road/access route conditions and hazards associated with the journey)

32

Finger Injury During Entanglement of Wire from Wireline Reel


Area Incident Description Root Causes

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.

Inadequate Identification of Worksite or Job Hazards (The risk of entanglement of wire on reel and trapping of hand/limb during entanglement were not identified)

Lesson Learned Drilling Rig No. 51 15-06-12 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) 1. Stop equipment completely before performing any work on the moving/rotating parts 2. Use line splitter guards on wire line reels

33

Release of Oil from Xmas Tree


Area Incident Description Root Causes

Drilling Rig No. 1

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 XTree 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. 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)

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 Engineers 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

05-06-12

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

34

Fall of Foreman from Stand Pipe


Area Incident Description 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 Drilling his full weight on his left elbow on the compacted sand ground. Outcome: The Labor Foreman NDC Rig 54 sustained fractured elbow. 18-06-12 Immediate Causes 1. Do not stand on stand pipe or other similar structures without fall protection equipment. 2. Stop all unsafe actions effectively Root Causes

Improper Supervisory Example (The Assistant Driller did not effectively stop the Labor Foreman from standing on standpipe). Inadequate Identification of Worksite/ Job Hazards (The Foreman did not realize of risks of standing on standpipe and assisting the crew).

Lessons Learned

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

Improper Decision Making/Lack of Judgment 3. Supervisor should supervise crew and should not participate in execution of (Forman intended to observe his newly assigned tasks. crews and assist them in pulling the hose while standing on the stand pipe).

35

Dropped Object During Lifting


Area Incident Description 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 Drilling double wrap slinging method. The rigger ignored the advised and continued to lift the load and NDC Rig 56 later, the lifting sub slipped and fell down on the V-door causing damage to steps of the V-door 24-06-12 stair then it is slipped down to the ground. Outcome: No injury to personnel and damage to three steps of V door stairs. Immediate Causes Root Causes

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 Violation by Individual (The rigger did not 3. Conduct Tool Box Talk/ Pre Job Safety prior to all tasks especially high risk activities 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)

36

Uncontrolled Descend of Travelling Block


Area Incident Description 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. Drilling NDC Rig 31 28-06-12 Defective Equipment (Joy Stick controlling the brake malfunctioned) 1. After each rig move, verify the integrity of Draw Work (D/W) & anti-collision system. Outcome: It resulted in minor damage to equipment. Immediate Causes Root Causes 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

Improper Decision Making/Unintentional 2. Use Disconnect System/ Variable Frequency Drive Human Error (ARM did not use/activate (EDS/VFD) to stop any free fall of blocks. Emergency Disconnect System (EDS)) 3. Post D/W safe work practices/ guidelines in driller cabin for quick reference

37

Power Generator/Engine Fire


Area Incident Description Root Causes

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)

Drilling NDC Rig 11 02-06-12

Lessons Learned

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)

1. Develop and implement rigorous testing/replacement of fuel lines after each Rig move. 2. Maintain fire watch during the operations of generators.

38

Trailer Fire at Rig Camp


Area Incident Description 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 Drilling the truck. The camp crew responded and extinguished the fire using 3 water tankers and NDC Rig 51 10 fire extinguishers. 06-06-12 Outcome: No personnel injury occurred and the trailer and loaded equipment were damaged. Root Causes

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

Lessons Learned

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) 1. Provide and mark location of designated smoking areas 2. Do not smoke near parked vehicles.

39

Water Tanker Rollover


Area Incident Description 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 Drilling conditioning system in drivers cabin was not working and it was a hot day and the driver was working in excess of six hours. During the trip the 21-07-12 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. 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 drivers 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) Root Causes

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 contractors resources) Inadequate Audit/ Inspection/ 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.

40

Hand Entrapment Inside Tong


Area Incident Description 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. Drilling NDC Rig 21 03-08-12 Improper Posture/Position for the Task (The operator had placed his hand on 1. Do not leave in experienced staff (Green Hat) workers unsupervised at hazardous locations the top of tong rotary while adjusting the such as Rig Floor rotary) Lack of Knowledge of Hazards Present 2. Include all sequence of works (such as operations as well as any repair/ (The Supervisor left the operator working troubleshooting) in Job Safety Analysis (JSA) 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) Immediate Causes Root Causes 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

41

Electrical Shock
Area Incident Description Root Causes

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.

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)

Drilling NDC Rig 55

Lessons Learned

Outcome: It has resulted in a second degree 06-09-12 burn on electricians right hand thumb. Immediate Causes 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.

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)

42

Arm Injury Due to Fall of Jumbo Bag


Area Incident Description 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 NDC Rig 11 out of other strap causing the bag to fall on the arm of the labourer, which was positioned near bag, while attempting to 29-10-12 cut the bottom of suspended bag. Outcome: Worker sustained left forearm fracture. Drilling 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) Root Causes

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

43

Falling Object
Area Incident Description 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. Root Causes Inadequate Identification of 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)

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 NDC Rig 57 from 30 feet height. Drilling 28-10-12

Lessons Learned

Immediate Causes Improper Decision Making/Lack of Judgment (The 1. Establish clear signals between stabber & Driller before start of the job. Stabber gave signal prematurely to Driller to stop the Top Drive System (TDS) and the Driller was lowering the 2. Do not float the TDS links to its original block, at the same time he was floating the links) position while the TDS is in motion. Lack of Knowledge of Hazards Present (Job Safety Analysis (JAS) was generic in nature and did not address the communication signal between Stabber & Driller)

44

Engineering & Projects

45

46

Past Incidents

Cement Mixer Truck Rollover (12-062010)

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 (10-092011)

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)

47

48

Fire Due to Poor Grounding During Welding


Area Incident Description 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 Engineering & adjacent scaffolding plank. The crew stopped the operation Projects and extinguished the fire. Sahil Field 03-01-12 Immediate Causes Violation by Supervisor (Welder did not check the 1. 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 2. Authority (IA) issued the permit without confirming grounding and confirmed adequacy of grounding on the permit) 3. 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) Check and ensure proper Grounding / Earthing of welding stations prior to commence welding Conduct task specific Tool Box Talk (TBT) discussion hazards and control Permit Issuing Authority (IA) & Job Performers (JP) must assess/check system, readiness prior to issuance of permit and start of work Root Causes 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

49

Fiber Optic Cable Cut During Excavation


Area Incident Description 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. Engineering Outcome: Damage to underground Fiber Optic & Projects Cable Shah Field 09-01-12 Immediate Causes 1. Do not use machines for excavation in areas marked for manual excavation Root Causes Inadequate Identification of 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

Violation by Supervisor (Violation of Permit to Work (PTW) Procedure for use for 2. Positively identify locations of underground utilities before commencing excavation machines in hazardous area) 3. Consider communication skill/language No Warning Provided (Location/presence barrier when assigning crew members of Fiber Optic Cable was not identified in Excavation certificate) Improper Decision Making/Lack of Judgment (The Foreman instructed Excavator Operator to excavate in area marked for manual excavation

50

Vehicle Collision & Rollover


Area Incident Description 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 Engineering & pickup vehicle was hit by an oncoming Projects bus. It resulted in pickup vehicle to rollover. Outcome: The driver sustained minor injuries on his hands and the vehicle Bab Field was badly damaged 30-01-12 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) Root Causes 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.

51

Asphyxiation of Welder Inside A Pipe


Area Incident Description 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 Engineering & the pipe and he collapsed inside the pipe and Projects asphyxiated. Outcome: Crew members tried to recover and evacuate the welder to site Clinic and he Sahil Field was pronounced dead by the Physician upon arrival. 06-02-12 Immediate Causes Violation by Individual (The welder made unauthorized confined space entry in pipe; Cowelder 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) Root Causes 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) 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

Lack of Knowledge of Hazards Present 3. Do not leave workers unsupervised at work site (Welders were not aware of asphyxiation hazards especially during high risk activities due to Argon gas escaping from leaking foam pads 4. We all are authorized (by ADCO Chief Executive ; over confidence due to earlier entry into the pipe, Officer) to stop any unsafe action in ADCO work Lessons learned from incidents were not shared areas. with welders; No specific Tool Box Talk (TBT) for 5. Educate yourself with risks associated with your job welders was conducted

52

Man Lift Drove Over Flagmans Foot


Area Incident Description 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 Flagmans right foot. The Flagman was taken to the site clinic and then referred to hospital for further assessment. Root Causes

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))

Engineering & Projects Outcome: Flagman sustained minor foot injury Bab Field Immediate Causes 15-03-12

Lesson Learned

1. Do not move heavy machines/ equipment unless directed by Banksmen/Flagmen. 2. Violation by Individual (Man-lift operator started moving the man-lift without signal from Banksman/ Flagman and did not maintain 3. clear sight of Banksman/ Flagman) Improper Position for the Task (Banksman/ Flagman was standing close to the man-lift) Machine/equipment operators must maintain clear sight of Banksmen/ Flagmen. Conduct task specific Tool Box Talk (TBT) for each crew.

53

Vehicle Rollover
Area Incident Description Root Causes 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 engineers work schedule) Inadequate Inspection & Monitoring (Contractor did not adequately monitor compliance with ADCO Road Safety requirements.) Lesson Learned

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 Engineering vehicle to roll over. Outcome: The driver & Projects sustained shoulder injury and the vehicle was badly damaged. Buhasa Field 19-02-12 Immediate Causes Violation by Supervisors (Allowed the use of private vehicle to travel to fields.)

1. Do not drive private vehicle on ADCO business.

Inattention to footing & Surroundings 2. Only assign trained drivers to drive or provide drivers for staff transit. (Staff was working for the last 11 hours including the 2.5 hrs journey to site and 3. Supervisors should monitor compliance of their did not pay attention to road conditions contractor staff with ADCO Road Safety (sand accumulation) due to fatigue) Requirements.

54

Vehicle Collision on a Sand Track


Area Incident Description Root Causes 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 Engineering sustained minor injuries and the third & Projects passenger sustained head& facial injuries. Both vehicles were damaged Qw badly. 28-02-12 Immediate Causes Violation by Individuals (Bothe drivers were exceeding the posted speed limit, passengers were not wearing seat belts) Improper Decision Making/Lack of 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)

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.

55

Vehicle Drove Over a Berm


Area Incident Description 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 Engineering the berm, jumped over the berm and landed on the front & Projects bumper. Outcome: Three occupant sustained injuries and two Asab Field were discharged after the treatment from the hospital. The third labourer was admitted for three days in the hospital 01-03-12 and then discharged. 1. Root Causes 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) Inadequate Implementation of Policies/ Standards/ Procedures (PSP) (ADCO road safety requirements and Life Protection Rules (LPRs) were not effectively implemented. Lesson Learned Always follow posted speed limits and road traffic warning signs

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

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. Violation by Supervisor (He gave his blue key to the driver and did not stop driver from over speeding) 4. Supervisors should review drivers RAG Improper Decision Making/Lack of Judgment (Driver continued driving during low visibility on an unknown track) (driving behaviour) reports regularly and provide counseling to drivers to reinforce correct driving behaviour.

56

Cement Mixer Rollover


Area Incident Description 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 Engineering & Projects Shah Field 18-04-12 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) Lessons Learned Root Causes 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) Inadequate Audit/ Inspection/ Monitoring (There was no monitoring system in place to check and guide delivery vehicles)

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

57

Damage to Overhead Line


Area Incident Description 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. Engineering & Projects Outcome: The overhead line tripped on earth fault. The operator came out of the excavator BAB Field safely 24-04-12 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) Inadequate Guards or Protective Devices (There no goal post/height level markers was installed at overhead line crossing) 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 Root Causes Inadequate Identification of Worksite/ 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 operators movement) Lesson Learned

(For Illustration Purpose)

58

Ankle Injury During Cable Pulling


Area Incident Description 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 Engineering & corner, moving the sandbags that were supporting it, the roller tipped over and the cable slipped out Projects (dislodged) from the cable roller and struck the right ankle of the Foreman. Outcome: Foreman sustained Asab Field multiple fracture injury on his right ankle. 24-04-12 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) Root Causes Inadequate Identification of Worksite/ 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.

59

Vehicles Collision on Gatch Road


Area Incident Description Root Causes 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 Engineering spot and collided head on. & Projects Outcome: Total six passengers in both Asab 09-07-12 vehicle sustained minor injuries and vehicles were badly damaged. Immediate Causes 1. Always reduce vehicle speed according to road conditions especially when approaching blind spots

Inadequate Identification of Worksite/ 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

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

Work or Motion at Improper Speed 2. Do not drive in wrong lane even for shorter (Vehicle speed was not adjusted period of time according to road condition and presence of a blind spot) Inadequate Warning System (There were no road signs to alert approaching drivers)

60

Arm Injury Due to Explosion During CAD Welding


Area Incident Description 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 Engineering held by the mold itself. After the set-up, another & Projects worker ignited the weld powder in the mold using spark igniter whilst electrician was still holding the cable. Explosion/backfire through the aperture cover Asab of the mold occurred. Outcome: It resulted in 2nd 12-07-12 degree burn on the right forearm of the electrician. Immediate Causes Causes 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.

Violation by Group (The activity was stopped by 2. Ensure assignment of skilled crew members and availability of all necessary the Job Performer but crew continued the work) tools, especially on high risk activities Personnel Protective Equipment (PPE) not used (Electrician did not use welding gloves; the 3. Never leave crew unattended specially those working on high risk activities 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)
*CAD welding (Exothermic welding) is process for joining two electrical conductors, that employs superheated copper alloy to permanently join the conductors.

61

Fire at Scaffolding Platform Around Stripper Column


Area Incident Description 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. Root Causes 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)

Later, workers noticed fire and smoke from upper level scaffold platforms and raised the alarm. Outcome: ADCO & GASCO Fire Lesson Learned Engineering Teams responded and extinguished the fire. & Projects No personnel injuries and damage to scaffold boards had occurred. Asab Immediate Causes 16-07-12 Inattention to footing & 1. Maintain housekeeping at work locations. Surroundings (Accumulation of combustible waste material near welding 2. Subject critical activities to continuous area was not noticed) monitoring & supervision

Inadequate Guards or Protective 3. Switch off/Disconnect power supply to Devices (Fire blanket was not adequate portable electrical equipment during breaks to isolate welding spatters/ welding 4. Use fir blanket/fire habitat for welding habitat was not set) activities in process areas. Work Exposure to Temperature Extreme (Hot summer day with ambient temperature exceeding 47oC)

62

Foreign Object Entering Eye of a Worker


Area Incident Description 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 Engineering from his eye. & Projects Outcome: The foreign object (sand particle) was removed from his eye. Sahil 26-07-12 Immediate Causes 1. If a foreign object enters eye, do not rub eyes and seek medical attention Storm or Act of Nature (Blowing wind carrying particles/dust/light objects) 2. Report all incidents (including minor incidents/injuries) to your supervisor Root Causes

Inadequate Identification of 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

Personal Protective Equipment (PPE) 3. Always use eye wears for protection in Not Used (Welder removed his welding working sites, especially in sandy areas. face shied after the task and due to blowing winds sand particle entered his eye)

63

Vehicle Rollover on Gatch Road


Area Incident Description 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 BabTarif Road and to avoid going through security check post, the engineer identified a gatch Engineering road. The driver was driving fast (80-90 & Projects 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 BAB passengers and the vehicle sustained minor damage. 23-08-12 Immediate Causes 1. Always drive within posted speed limits and reduce speed according to rad conditions 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) 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. Causes

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) Inadequate Audit/ Inspection/ Monitoring (Drivers 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

64

Crane Mounted Truck (Hiab) Rollover on Gatch Road


Area Incident Description 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. Immediate Causes Improper Decision Making/Lack of 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) Root Causes Inadequate Audit/ Inspection/ 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) Inadequate Identification of Worksite/Job Hazards (Hazards associated with the journey (i.e. gatch road condition and high humidity) were not identified) Lesson Learned

Engineering & Projects BAB

28-08-12

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

65

Vehicles Collision
Area Incident Description 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 Engineering & the truck started to turn left. Outcome: The project vehicle collided with the front tire of the truck. Two Projects passenger sustained minor injuries and the vehicle sustained moderate damage. BAB 04-09-12 Immediate Causes Root Causes 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) Inadequate Identification of 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. Violation by individual (The driver was overspending (128 km/Hr on a road with a speed limit of 80 km/Hr) 2. Improper Decision Making (The truck driver started to turn left without using indicators/ 3. signal)

Always follow the posted speed limits and do not over speed. Use vehicle signal before maneuvering vehicles even on a short journey Monitor the driving behavior of new/inexperience driver more frequently

66

Crane Rollover During Move on Gatch Road


Area Incident Description 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. Root Causes

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

Engineering As the crane tried to ascend on slope (with crane boom & Projects not fully folded), the crane lost the balance causing it to roll over to its right side. Outcome: The operator BAB managed to exit the crane cabin safely through the cabin door and the crane sustained minor damage. 26-09-12 4. Do not move heavy equipment from Immediate Causes one location to another location unless track conditions are inspected and are found suitable. 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) 5. Ensure Crane boom is fully folded and hook block secured when moving crane, to maintain stability of the equipment

67

Vehicle Collision
Area Incident Description Root Causes 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 Engineering shoulder, restricting the direct view. The & Projects 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 BAB Junction and crossed the road and the 01-10-12 project vehicle collided on the side of the land cruiser. Outcome: Minor injuries (Bruises) to passengers as they were 1. wearing seatbelts and serious damage to both vehicles.

Inadequate Audit/ Inspection/ 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 (250300 km/day) and his work assignment, journey management and time pressure were not effectively addressed) Lesson Learned

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

Immediate Causes Violation by Individual (The project vehicle (Pickup) was over speeding) Improper Decision Making/Lack of Judgment (ADCO Staff entered the junction without ensuring clearance)

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

68

Fatal Fall of Worker from a Moving Vehicle


Area Incident Description 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 Engineering & Projects Qw 17-11-12 Immediate Causes Causes 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)

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)

Lessons Learned Equipment or Materials not Secured (Fence gates were not secured before 1. Provide coaching to Job Performers (JP) on conducting moving the vehicle) effective tool box talks (TBT) Inadequate Vehicle for the Purpose 2. Develop and publicize an incentive scheme both for (Vehicle was not suitable for workers and their JPs/Foremen to stop & report unsafe transferring oversized fence gates) actions and set a target for each worker. Congestion or Restricted movement 3. Ensure contractor JPs & Foreman have supervisory skills (Narrow access track for the movement prior to their assignment and subject them to regular of vehicle) motivational training to enhance their supervisory skills

69

Fall of Mobile Scaffold Platform on a Worker


Area Incident Description Causes

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 Engineering constructive surgery & Projects Asab 28-11-12 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)

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).

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.

70

Arm Amputation Inside Foam Concrete Mixer


Area Incident Description 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 Engineering the mixer and started washing. Suddenly the mixer & Projects started and is arm was struck by blades inside the mixer. Outcome: Arm of the operator was amputated. Qw Immediate Causes 12-12-12 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) 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. Causes

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)

Inadequate Isolation of Process or Equipment 3. Conduct task specific Tool Box Talks (TBT) Power supply to the mixer was not isolated instead 4. Job Performers should never leave their site power switched was turned in off position). whilst work is ongoing and crew is still present. Inadequate Guards/Protective Devices (Grid 5. Consider mixer washing on site as a part of of the guard was too wide to stop entry/insertion of future Task Risk Assessments (TRA) body parts)

71

North East Bab (NEB) Asset

72

73

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) 74

75

Vehicle Crash During OHL Visual Survey


Area Incident Description 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. Immediate Causes Lesson Learned Improper decision making/lack of judgment (The Foreman decided to drive and visually inspect over head lines 6. Do not drive and get distracted by other activities at the same time whilst a professional driver was seating as a passenger)) 7. Maintain right of way (ROW) near overhead line poles and check adequacy of the track prior to Inattention to surroundings (While commence work focusing on overhead lines the depression was overlooked) Root Causes

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)

North East Bab (NEB)

30-04-12

76

Transformer Fire
Area Incident Description 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). North East Bab (NEB) 25-07-12 Immediate Causes Violation by Group (Maintenance Procedures as per Vendor Instructions were not fully followed due to non-availability of 1. Oil samples should to taken from all desalters to evaluate the condition of High Voltage Bushings oil tester) 2. Evaluate condition of the HV bushings during the Inadequately Prepared Equipment regular maintenance periods (High Voltage Bushing Replacement was not carried as per vendor recommendations) 3. Ensure availability of critical spare parts such as High Voltage Bushings at all times Root Causes 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

77

Fire in UPS Unit of Substation


Area Incident Description Dabbiyea 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 North East extinguished the fire. Bab (NEB) 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. Root Causes 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 capacitors life span as 14 Years and after the incident it was corrected as 7 years)

Lessons Learned

08-07-12

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)

78

South East (SE) Asset

79

80

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 Preparation (16-04-2010)

Carpenters 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)

81

82

Electrical Flashover Inside Transformer Terminal Box


Area Incident Description 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. Root Causes 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

South East (SE) Outcome: An electrical flashover occurred. The fire was self-contained inside the transformer terminal box Asab Field 07-04-12Immediate Causes

Inadequate Equipment (Not using the proper bushing-bus bar terminal lug) Work Exposure to Energized Electrical Systems

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

83

Foreign Object (Metal Particle in Eye)


Area Incident Description Root Causes

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

Immediate Causes 1. Wear eye protection during windy days even when proceeding to worksite 2. Contact medical professional when a foreign object enters into eyes

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)

84

Workers Finger Entrapment Between Pipe Flange and Valve Flange


Area Incident Description 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 South East pipe flange and valve flange. (SE) Outcome: The foreman stopped the operation and transferred the injured person to RAMS Clinic Asab Field for treatment. Laborer sustained fracture to his finger. 08-07-12 Immediate Causes Improper Position or Posture for the Task 1. Do not assign inexperienced laborers on new activities. (Inexperienced worker wrongly positioned his left index finger between the two flanges 2. Ensure crew members are aware of task during alignment) related hazards through effective Tool Box Talk (TBT). Improper Decision Making/Lack of 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) Root Causes

Inadequate Work Planning or Risk Assessment Performed (No dedicated banksman was used; & inexperienced laborer was assigned to assist a crew involved)

Lessons Learned

85

Terminal & Pipelines Operations (TPO) Asset

86

87

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)

Partial Fall of Roof in Accommodation Camp (28-05-2008) Fall of Worker into a Manhole (26-04-2007)

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Heat Stress
Area Incident Description Causes Fatigue (Over exertion of physical capabilities led to fatigue during physical training on a hot and humid day in full fire suit) Inadequate Implementation of Policies/Standards/Procedures (New trainees were enrolled without ensuring medical fitness; ADCO guidelines for heat stress were not implemented)

Abu Dhabi/Jebel Dhanna

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.

Lessons Learned

09-04-12

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).

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.

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HSE Performance, 2012

ADCO & Contractors LTIF & TRIR (YTD) vs Manhours

worked
1.4
1.29

180

Lost Time Injury Frequency Rate / Total Recordable Injury Rate

160.49

1.2 1
0.80 0.81 0.68 0.55 0.51 0.55 0.36 0.28 0.16 0.16 0.29 0.12 0.34 0.26 0.93 0.78 0.70 0.66 0.63

160 140 120 100

0.8 0.6 0.4 0.2

0.47 0.34

80 60 40

44.4

32.3

32.5

29

27

34

47

56

55

0.09 0.08

20 0

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

Year
Manhours Actual LTIF TRIR

Million Manhours Worked

57.36

118.92

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Incident Types - 2012


(Work & Non-Work Related 380 Events)

Gas Release 3% Fire 5% Property Damage 10% Onshore Spill 12% Injury/Illness 42%

Transportation 28%

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Asset Wise Event Type Distribution - 2012

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Incident Immediate & Root Cause Categories 2012

Immediate Causes

Root Causes

Skill Level 5% Mental State 6% Communication 7%

Management / Supervision / Employee Leadership 21% Work Planning 16%

Work Rules / Policies / Standards / Procedures 9%

Training / Knowledge Transfer 10%

Behavior 15%

Repetitive Root Causes Repetitive Immediate Causes


Inadequate work planning Improper decision making or lack of judgments Lack of knowledge of hazards present Violation by individual Violation by supervisor Inadequate identification of worksite/job hazards Inadequate adjustment/repair/maintenance Inadequate audit/inspection/monitoring

95

Incident Immediate Cause Analysis -2012

Improper decision making or lack of judgment Violation by individual Violation (by supervisor): One individual intentionally chose to violate an established safety practice. A supervisor or other management person either personally violated an established safety practice or directed people under their supervision to do so.

Inattention to surroundings:

Improper position or posture for the task

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 persons job performance was affected by their inability to make an appropriate judgment when confronted by an ambiguous situation. The person was not alert to their surroundings and just tripped or ran into something that was clearly visible and obvious.

No warning provided

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Incident Root Cause Analysis -2012

Inadequate Work Planning Inadequate audit /inspection/ monitoring Inadequate preventative maintenance program

The work being done was not planned or was not risk assessed prior to starting that work. Supervisors did not monitor, inspected or audited the work as planned. 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 Inadequate Leadership

The incident was caused by the failure to perform or properly respond to a loss exposure study, such as TRA, JSA. 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. Safety meetings such as effective tool box talks were not conducted

Inadequate /Lack of Safety Meetings

97

Inadequate Training Inadequate Knowledge Transfer No Training Provided

Some training was conducted, but it did not accomplish the objectives of the training A training programme was in place, but it did not transfer the necessary the inability of students to comprehend (material beyond their level, language difficulties), The person was not trained in a specific subject Employee perceived haste Improper supervisory example Inadequate reinforcement of critical behaviors The incident was caused by the employees perception that speed in completing the work was required causing laps in safety considerations. Supervisors not giving the proper example to the people working in their organizations. A supervisor seeing someone not following the safety procedures and guidelines and not correcting immediately is an example of inadequate reinforcement of proper behavior.

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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)

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