H2S Workshop Silent Killer

24th May 2009

Abdul Munim Saif Al Kindy General Manager, ADCO

The Tragic Incident on 3rd Feb. 2009 Shah Field

Corrosion Coupon Pit

12 ft

Background
Asab GASCO plant shutdown was planned from 25th Jan. to 11th Feb. 2009. This resulted in a complete ADCO production shutdown. Shutdown provided window of opportunities to carry out key maintenance activities across Asab, Sahil & Shah Fields. In Shah, the planned key maintenance activities included partial replacement of transfer line and removal of two stuck corrosion coupons retrieval tools at KM-58 and KM-68 pits. At KM-68, removal of stuck corrosion coupon retrieval tool was successfully carried out with drainage of approx. 200 barrels crude from the transfer line. At KM-58, removal of stuck corrosion coupon retrieval tool necessitated drainage of approx. 1600 barrels of crude from the transfer line.
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Events of the tragic Day

A Foreman and five laborers proceeded to work involving draining of a transfer line inside a corrosion coupon pit (confined space) (without obtaining work permit)
One laborer entered the pit to reattach the rope to the drain valve. While trying to exit the pit he fell back, hanging upside down and his leg trapped inside the ladder. Foreman entered the pit to rescue the laborer and asked a second laborer to close the valve and help him with the rescue. The second laborer entered and started helping, but foreman collapsed and soon after the second laborer collapsed and sustained a head injury by hitting an object (he survived). The third laborer entered the pit to rescue his colleagues and collapsed The two laborers standing outside the pit sought help from Shah control room.

Immediate Causes
Violation of Procedure (PTW & Confined Space Entry) Procedure for draining the Transfer Line not available & method of statement less than adequate.

Personal Protective Equipment (BAs) not used Exposure to Hazardous Conditions (H2S, hydrocarbons)

Root Causes
Inadequate hazards identification /perception Inadequate reinforcement of procedures Inadequate reinforcement of safe behavior, not implementing stop policy. Complacency and overconfidence Inadequate consequence management Not acceptable and Inadequate MANAGEMENT
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Recommendations
Ensure PTW is issued based on task risk assessment (TRA) and the TRA has been endorsed by a safety professional (Safety & Loss Prevention Engineer (SLPE) as minimum).
Confined space entries cannot be made unless a SLPE is present and he has reviewed the emergency plan

Empower laborers/workers to STOP unsafe activities and initiate contractual arrangements to protect/encourage individuals exercising ADCO STOP Policy.
Provide personal H2S detectors to all personnel including laborers working in H2S exposed areas. Ensure all helper/laborers members are fully trained for performing their assigned tasks.

Include practical element (step test) and confined space entry in H2S/BA training course and for all operation/ production and HSE staff.

Establish Access Control on all confined spaces with effective markings, signs & tagging; and locking, where applicable.
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Post Shah Incident

Comprehensive Respiratory Protection Programme H2S area classifications and zoning Facial Hair policy implementation PPE (escape set and H2S monitor/per employee( ADCO& contractors) in restricted areas. Identification of requirements forH2S warning signs and sign boards Enhanced &simplify H2S training (multi lingual) for contractor labours Focused High profile tours theme on the high risk activities( H2S , PTW) Task Risk Assessment - TRA
Developed TRA for high risk activities, raised the approval level and linked to PTW Clearly defined requirements for formal TRA Initiated training on TRA

Initiated enhancement in HSE communications

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Thank You

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