2011 q4 learning from incidents
DESCRIPTION
Learning From IncidentsTRANSCRIPT
المستفادة منها عبرالدروس وال منع وقوع الحوادث من خالل
Incident Prevention Through
Learning from Incidents
October- December, 2011
قسم الصحة والسالمة والبيئة
Health, Safety & Environment Division
1
For further information, comments and suggestions please contact:
Dr. Muhammad. R. Tayab ([email protected])
Health, Safety & Environment Division
Tel: 02-6042979; Mobile – 00971 (0) 50 324-3996
معلومات وإبداء المالحظات واالقتراحات يرجى االتصال بـ:للمزيد من ال
[email protected]على البريد االلكتروني التالي : محمد ريحان طيب الدكتور قسم الصحة والسالمة والبيئة
72 9792606رقم الهاتف :
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.
2
During the 4th Quarter of 2011 we have had 47 injuries ranging from lost
time injury to first aid cases; 4 spills including a major spill and 17 vehicle
accidents. Incident investigations highlighted deficiencies in work planning,
supervision; and inadequate behaviour. These cause categories are similar
to findings of earlier quarters of 2011.
I request all ADCO including leadership team members to take diligently
review of work planning at grass root levels and effectively address
these deficiencies. You can be the catalyst to create a positive change
and improve safety culture at work.
Brad Kerr Senior Vice President (Technical Services)
3
Table of Contents
Damage to Over Head Line (OHL) 4
Improper Lifting Causing Damage to Forklift 5
Loss of Containment During Sand Clearance 6
Al Gaith Vehicle Rollover 7
Hand Injury During Unloading of Gas Cylinder 8
Water Tanker Rollover 9
Fall from Elevation 10
Finger Injuries from Broken Laboratory Glassware 11
Quiz 12
HSE Performance 13
Incident Sub Types 2011 14
Distribution of Incident Sub Types 2011 15
Incident Immediate & Root Cause Categories 16
Incident Immediate Cause Analysis 2011 17
Incident Root Cause Analysis 2011 18
Asset Based Causes 2011 20
Causes of Top Two Incident Sub Types, 2011 24
4
Damage to Over Head Line (OHL)
Area Incident Description Causes
BUH
08-12-
11
A crew was engaged in preparing gatch road
along BUH fence. Task risk assessment (TRA) was
prepared and Permit to Work (PTW) and
excavation certificates were obtained. While
unloading Gatch approximately 20 meters away
from 33KV Over Head Line (OHL) the tipper truck
driver moved the vehicles towards OHL while
extending tipper bucket, to ensure complete
unloading of gatch material. There was no
banksman/flagman to guide the driver. During the
process, the vehicle crossed underneath the OHL
and the extended bucket made contact and
damaged OHL conductors.
Outcome: Damage to OLH resulting in power
supply disconnection to 10 water clusters.
Inadequate Leadership (TRA was not
adequate and was not chaired by ADCO; IA
issued the PTW without ensuring presence
of banksman; availability of adequate
resources (i.e. transportation &
communication with staff))
Inadequate Identification of
Worksite/Job Hazards (Risk of damage
to OHL by tipper truck was not adequately
identified; access and agrees for unloading
not marked/ identified)
Inadequate Work Planning (New Job
Pperformer (JP) was not aware of work
site hazards; No vehicle or telephone was
provided to safety officer hindering him
from site visits)
Lesson Learned
1. Do not drive tipper truck while bucket is
raised
2. Identify access and egress point for heavy
vehicles.
3. Check for operational readiness and do not
issue PTW in haste
5
Improper Lifting Causing Damage to Forklift
Area Incident Description Causes
DD
04.11.11
During routine operations, the driller requested
a Roustabout to arrange to transfer a landing
joint pipe from tool box basket. The roustabout
noted that rig crane operator was busy assigned
on another task and he requested forklift
operator to remove/lift the joint. A sling was
used to tie the joint end and started to pull
backward and lifting it. The joint swung and
broke through the front screen of the forklift.
Outcome: It resulted in broken cabin glass
protector screen and the operator escaped
unhurt.
Inadequate Leadership (Assistant Rig
Manager (ARM) assigned a task of transferring
drill joint to an inexperienced roustabout
without ensuring availability of resources;
Forklift operator agreed to use the equipment
improperly (i.e. lifting long joint from tool box
basket)
Inadequate Work Planning (Task involving
lifting was assigned to inexperience worker;
crane’s availability was not checked properly)
Lessons Learned
1. Use right lifting equipment for the task and do
not take short cuts.
2. Ensure availability of resources (equipment
and skilled staff) when assigning tasks.
3. Effectively empower staff to STOP unsafe
actions.
6
Loss of Containment During Sand Clearance
Area Incident Description Causes
TPO
08.11.11
Mile Point 21 is an off site valve station where
BUH crude oil joins NEB/SE/Bab Main Oil Line
(MOL) network point on route to JDA terminal.
This station has manifolds and valves for isolating
or connecting individual pipelines to the MOL
network. Due to sand storms, sand had
accumulated inside the station. The sand
clearance was planned and the work started under
Hot Work Permit using Mechanical Shovel.
The job performer and his supervisor who was
acting as Permit Issuing Authority (IA) and Area
Authority (AA) were relatively new staff and were
not fully familiar with all location’s utilities. While
the mechanical shovel was used to shift sand a
stub pipe extending from MOL1, was struck by the
shovel. Due to dislocation of the stub pipe, oil
under pressure gushed out and released and
continued to drain toward low lying catchment
areas.
Outcome: Approximately 25,000 Bbl were
released before the MOL was completely isolated.
Inadequate Work Planning (Work was
planned using a mechanical shovel in
hazardous area, sand clearance was not
carried at the site since the last two years)
Inadequate Assessment of Work/Job
Hazards (The task was not risk assessed;
assigned staff lacked knowledge of PTW
requirements)
Inadequate Management of Change (A
stub pipe was installed on MOL without
Management of Change (MOC)
documentation)
Lesson Learned
1. Obtain excavation certificate for sand
clearance activities in restricted areas as
per ADCO PTW requirements (Sec 3.4
Grading and leveling is considered as
excavation and Excavation Certificate must
be issued for any excavation activity)
7
Al Gaith Vehicle Rollover
Area Incident Description Causes
TPO
21.11.11
Following an oil spill at MP 21 on 08-11-2011, a
contractor crew was assigned on oil recovery
job. On 21st Nov, 2011, after finishing daily
activities, the driver was using a gatch road
from MP 21 toward Abu Dhabi – Sila Highway,
driving back to Abu Dhabi with two crew
members. The vehicle was not engaged in 4x4
gears and driven at high speed (107 km/Hr).
The vehicle drifted from the gatch road and the
driver tried to steer it back and applied harsh
brakes. He lost control of the vehicle resulting
in vehicle to roll over.
Outcome: Driver and two passengers
sustained injuries and taken to Mirfa Hospital.
After treatment they were discharged from the
Hospital on the same day. The vehicle was
damaged.
Inadequate Identification of Worksite or
Job Hazards (Risks of driving off road by new
driver were not adequately assessed).
Inadequate practice of skill (The driver was
not familiar to drive automatic transmission
vehicle resulting in many harsh brake events).
Per RS RAG report the driver was repeatedly
applying harsh brakes and sharp steering to the
control vehicle when drifted from the gatch road)
Lesson Learned
1. Always adjust vehicle speed according to road
condition and engage vehicle in 4x4 mode when
driving off roads
2. Do not apply harsh brakes & sharp steering to
control the vehicle when driving off roads
3. Plan your journeys and do not rush to reach your
destination
8
Hand Injury During Unloading of Gas Cylinder Area Root Causes
E & P
Asab
12-11-11
A pipe fitter and one helper were trying to
manually unload a propane gas cylinder
(weighting approximately 70 kg) from a crane
mounted truck (Hiab/boom truck). Cylinders
were secured with a guard rail in a modified
basket on the back of the truck. This
modification was done based on earlier incident
where a loaded compressor caught fire and it
was decided to keep cylinders away from the
main carriage in a separated basked/partition.
While the crew unbolted the guard rail and
started offloading the first cylinder the second
cylinder fell down from the basket onto the
ground trapping pipe fitter’s left hand between
cylinders.
Outcome: Pipe Fitter sustained crush wound
injuries on his two left hand fingers and he was
assigned on light duties for 5 days.
Inadequate Management of Change
(Design and location of new cylinder
basket was not risk assessed and not
tested/ inspected for fitness as lifting
boom could not access cylinders due to
design limitations)
Inadequate Identification of
Worksite/ Job Hazards (Untrained staff
were assigned to handle gas cylinders)
Inadequate Procedure (There was no
working procedure in place for lifting and
handling of gas cylinders)
Inadequate Communication (Earlier
incident lessons learned involving gas
cylinders were not effectively
communicated to contractor staff)
Lesson Learned
1. Assign trained staff to handle gas cylinders
2. Develop a working procedure/ instructions
on handling gas cylinders
3. Assess fitness/suitability of equipment
design modifications prior to their use.
9
Water Tanker Rollover
Area Incident Description Causes
E & P
Sahil
07-10-11
During construction activities, a 20 wheeler
water tanker (7000 Gallon capacity) approached
the site. The crew was waiting for permit
Issuing Authority (AI) and the tanker driver
intending to enter the site and park the vehicle
pending offloading the consignment. The there
was an excavated area which was not
barricaded and there was no banksman to guide
the tanker operator. During the maneuvering of
the tanker, the vehicle came close to the
excavation and the ground collapsed resulting
in tanker to loose balance and falling into the
ditch/excavation.
Outcome: The driver/operator escaped unhurt
and the tanker sustained damage.
Inadequate Leadership (Job Performer did
not stop the tanker operator from
maneuvering the vehicle in hazardous
conditions)
Inadequate Audit/Inspection/ Monitoring
(Missing barriers around excavated area were
not identified; site supervisors and job
performer did not control access to the site)
Lessons Learned
1. Mark and barricade areas around excavations
2. Do not move vehicles without banksman in
construction/congested areas
3. Do not allow drivers/operators in work sites
without site familiarization
10
Fall from Elevation
Area Incident Description Root Causes
E & P
Bab
27-10-2011
Blasting and painting work was ongoing at a
water storage tank. There were 11 Scaffolders
and they were tasked with the erection of the
scaffold inside the tank. They had reached the
first level, which was at a height of 2.5 Meters
and they had decked out the platform with a
series of scaffold planks to facilitate the
erection of the second level.
There were some damaged scaffold boards
which were used in the construction of the
working platforms and there was no prior check
or inspection done to assess fitness of
scaffolds. The scaffolder was not using body
harness. While he was transversing across the
unsupported platform, the scaffold plank
snapped at the midpoint and he fell to the
floor. Outcome: He sustained facial injuries
(fractured tooth and wound on upper lip).
Inadequate Leadership (Issuing Authority
issued the permit without checking
scaffolds; Safety professional lacked
knowledge of inspecting scaffold; All three
project management (ADCO, PMC and
SKEC) levels failed to ensure on site
supervision & monitoring)
Inadequate Audit/ Inspection/
Monitoring (There was no mechanism in
place for inspection of scaffold materials;
there was no effective supervision on site)
Lesson Learned
1. Inspect scaffold material prior to erection
2. Do not use scaffold platform without
inspection by a competent inspector
3. Use body harness when working at heights
Assign trained safety professional/s to
inspect scaffolds
11
Finger Injuries from Broken Laboratory Glassware
Area Incident Description Root Causes
SE
Sahil
28-06-
2011
During normal operation at Asab Laboratory,
crude oil samples were tested and after
completing the test, a new helper/labourer was
assigned to drain the sample and wash the
glassware. The sample had volatile hydrocarbons
and the worker tried to insert a cork in the
sample bottle before taking it to washing area.
The labourer was newly assigned to assist staff in
the laboratory and he not aware of hazards of
working with laboratory glassware. When he tried
to insert the cork forcefully, the bottle broke into
pieces in his hands.
Outcome: Worker received cut wound on his
three fingers.
Inadequate Identification of Worksite/Job
Hazards (Risks of using untrained labourer in
laboratory environment were not mitigated;
bottles with glass stopper were not used; Sample
was not stabilized prior to handing over to
labourer for draining and cleaning; right PPE was
not selected)
No Training Provided (Labourer was assigned
to work in laboratory without any job specific
training)
Lesson Learned
1. Prior to assigning any task, ensure
helpers/labourers are trained to perform the task
2. Use Cut-resistant safety gloves when handling
glassware
3. Use sampling bottles with glass conical stoppers
to avoid pushing or struggling with corks
12
Quiz Event True False
1. Damage to Over Head Line (OHL) It is safe to move the topper truck with raised bucket (F)
There were two banksman/flagman to guide the driver (F)
2. Improper Lifting Causing Damage to Forklift A sling was used to tie the joint end (T)
Task involving lifting was assigned to an experienced worker (F)
3. Loss of Containment During Sand Clearance
Work was planned using a mechanical shovel in hazardous area (T)
Assigned staff were not familiar with location of utilities (T)
4. Al Gaith Vehicle Rollover The driver was not familiar to drive automatic transmission vehicle resulting in many harsh brake events (T)
The vehicle was not engaged in 4x4 gears and driven at high speed (107 km/Hr) (T)
5. Hand Injury During Unloading of Gas Cylinder
Untrained staff were assigned to handle gas cylinders (T)
There was a working procedure in place for lifting and handling of gas cylinders) (F)
6. Water Tanker Rollover Site supervisors and job performer did not control access to the site (T)
Banksmaen were guiding the tanker driver during maneuvering (F)
7. Fall from Elevation
Checks were done to assess fitness of scaffold boards (F)
Worker was using body harness when working at heights (F)
8. Finger Injuries from Broken Laboratory Glassware Worker was trained for the job (F)
The bottle broke in his hands when he tried to insert the cork forcefully (T)
(F)
13
HSE Performance
Historical Vs Q1 2011 HSE Performance
ADCO & Contractors LTIF & TRIR (YTD) vs Manhours worked
56
55
57
.36
11
7
32
.3
32
.5
2729
44
.434 4
7
0.28
0.16
0.29
0.70
0.80
0.550.51
0.26 0.090.34
0.63
0.12
0.55
0.36
0.16
0.34
0.78
1.29
0.93
0.810.66 0.68
0
0.2
0.4
0.6
0.8
1
1.2
1.4
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Year
Lo
st
Tim
e In
jury
Fre
qu
en
cy R
ate
/
To
tal R
eco
rdab
le In
jury
Rate
0
20
40
60
80
100
120
140
Millio
n M
an
ho
urs
Wo
rked
Manhours Actual LTIF TRIR
14
Incident Sub Types 2011 (Work & Non-Work Related -265 Events )
BAB
Injury/Illness
63%
Onshore Spill
5%Gas Release
5%
Fire
11%
Property
Damage
16%
ADCO
Gas Release
2%
Fire
6%Onshore Spill
10%
Property
Damage
15%
Transportation
22%
Injury/Illness
45%
BUH
Injury/ Illness
37%
Onshore Spill
21%
Transport at ion
18%
Propert y Damage
12%
Gas Release
6%Fire
6%
DD
Property Damage
40%
Injury/Illness
35%
Transportation
17%
Onshore Spill
4%
Fire
4%
E & P
Fire
6%Property
Damage
17%
Transportation
31%
Injury/Illness
46%
TPO
Injury/Illness
46%
Onshore Spill
27%
Transportat ion
20%
Fire
7%
NEB
Injury/Illness
56%Transportation
19%
Fire
10%
Property Damage
10%
Gas Release
5%
SE
Transportation
29%
Onshore Spill
29%
Injury/Illness
24%
Fire
2%Gas Release
4%
Property Damage
12%
15
Distribution of Incident Sub Types 2011
Fire
E & P
28%
AUH
18%BAB
12%
BUH
12%
NEB
12%
DD
6%
TPO
6%
SE
6%
Gas Release
SE
33%
NEB
17%
BUH
33%
BAB
17%
Injury
E & P
34%
AUH
12%BUH
11%
BAB
10%
NEB
10%
SE
10%
DD
7%
TPO
6%
Property Damage
E & P
34%
DD
23%
SE
15%
BUH
10%
BAB
8%
AUH
5%
NEB
5%
Transportation
E & P
44%
SE
24%
BUH
10%
DD
7%
NEB
7%
TPO
5%
AUH
3%
Onshore Spills
SE
51%BUH
26%
TPO
15%
BAB
4%
DD
4%
16
Incident Immediate & Root Cause Categories
Immediate Causes
Innattention / Lack of
Awareness
25%
Following Procedures
24%Use of Protective
Methods
16%
Work Exposures To
10%
Work Place
Environment / Layout
8%
Protective Systems
7%
Tools, Equipment &
Vehicles
6%
Use of Tools or
Equipment
4%
Root Causes
Work Planning
23%
Management /
Supervision /
Employee Leadership
22%Behavior
14%Tools & Equipment
9%
Work Rules / Policies
/ Standards /
Procedures
8%
Engineering / Design
5%
Skill Level
7%
Communication
5%
Repetitive Immediate Causes
Inattention to footing and surroundings
Improper decision making or lack of judgments
Routine activity without though
Violation by individual
Repetitive Root Causes
Inadequate work planning
Inadequate identification of worksite/job hazards
Inadequate adjustment/repair/maintenance
Inadequate audit/inspection/monitoring
17
Incident Immediate Cause Analysis 2011
Following Procedures
Violation by supervisor
18%
Violation by individual
26%
Work or motion at
improper speed
14%
Improper position or
posture for the task
13%
Violation by group
5%
Improper loading
5%
Improper lifting
8%
Violation by individual One individual intentionally chose to violate an established
safety practice.
Violation (by supervisor):
A supervisor or other management person either personally violated an established safety practice or directed people under their supervision to do so.
Work or motion at improper speed
The person involved was not working at the proper speed, not taking time to do things safely, e.g., driving too fast, running or adding chemicals too fast or too slow, etc.
EMPD, 21
DD, 13 SAS, 13
BU, 8
BAB, 5
JD, 2 NEB, 2
0
5
10
15
20
25
E P
33%
DD
20%
SE
20%
BUH
13%
BAB
8%
TPO
3%
NEB
3%
Inattention
Failure to warn
4%
Distracted by
other concerns
5%Routine
activity without
though
16%
Inattention to
footing and
surroundings
18%
Improper
decision
making or lack
of judgement
53%
Improper decision making or lack of judgment
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 person’s job performance was affected by their inability to make an appropriate judgment when confronted by an ambiguous situation.
Inattention to surroundings:
The person was not alert to their surroundings and just tripped or ran into something that was clearly visible and obvious.
Routine activity without thought:
The person involved was performing a routine activity, such as walking, sitting down, stepping, etc., without conscious thought, and was exposed to a hazard as a result.
SE, 24
E P, 20
BUH, 7 DD, 7
BAB, 4TPO, 2
NEB, 1
0
5
10
15
20
25
30
SE
36%
E P
31%
BUH
11%
DD
11%
BAB
6%
TPO
3%
NEB
2%
18
Incident Root Cause Analysis 2011
Work Planning
Inadequate audit/
inspection/
monitoring
46%
Inadequate work
planning
39%
Inadequate
preventive
maintenance
9%
Inadequate job
placement
6%
Inadequate Work Planning
The work being done was not planned or was not risk assessed prior to starting that work.
Inadequate audit /inspection/ monitoring
Supervisors did not monitor, inspected or audited the work as planned.
Inadequate preventative maintenance program
The tools or equipment involved in the incident were not covered by a preventative maintenance program, and became unserviceable.
E & P, 19
SE, 12DD, 10
BUH, 4 NEB, 4BAB, 3
TPO, 2
0
5
10
15
20
E & P
35%
SE
22%
DD
19%
BUH
7%
NEB
7%
BAB
6%
TPO
4%
Management Supervision & Employee Leadership
Inadequate
identification of
worksite/job
hazards
73%
Inadequate
management of
change system
4%
Inadequate
correction of prior
hazard/incident
2%
Inadequate
leadership
17%
Inadequate
identification of
worksite/job hazards
The incident was caused by the failure to perform or properly
respond to a loss exposure study, such as Job Safety
Analysis.
Inadequate Leadership 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.
E & P, 16
SE, 10
BAB, 6 DD, 6 TPO, 6BUH, 5
NEB, 3
0
5
10
15
20
E & P
30%
SE
18%BAB
12%
DD
12%
TPO
12%
BUH
10%
NEB
6%
19
Tools & Equipment
Inadequate
assessment of
needs and risks
37%
Inadequate
adjustment/repair/
maintenance
23%
Inadequate
availability
10%
Inadequate human
factors/
ergonomics
considerations
10%
Inadequate
removal/
replacement of
unsuitable items
10%
SE, 7
BUH, 5
BAB, 4
E & P, 3
TPO, 1 NEB, 1
0
2
4
6
8
SE
33%
BUH
24%
BAB
19%
E & P
14%
TPO
5%
NEB
5%
Inadequate assessment of
needs and risks
The tools and equipment provided were thought to be right,
but proved to be the wrong tools or equipment, because the
risk associated with their use was incorrectly assessed.
Inadequate adjustment
/repair/maintenance
Proper tools and equipment were available, but had not been
correctly maintained or repaired
Behaviour
Improper
supervisory
example
23%
Employee
perceived haste
26%
Inadequate
identification or
critical safe
behaviors
19%
Inadequate
Behavior
16%Improper
performance is
rewarded
16%
Employee perceived haste
The incident was caused by the employee’s perception that
speed in completing the work was required causing laps in
safety considerations.
Improper supervisory
example
Supervisors not giving the proper example to the people working in their organizations.
Inadequate reinforcement of
critical behaviors
A supervisor seeing someone not following the safety
procedures and guidelines and not correcting immediately
is an example of inadequate reinforcement of proper
behavior.
SE, 10
E & P, 7BUH, 6
BAB, 5
DD, 2JD, 1
0
2
4
6
8
10
12
SE
33%
E & P
23%
BUH
19%
BAB
16%
DD
6%
JD
3%
20
Asset Based Causes 2011
Asset Immediate Causes
Root Causes
SE
Innattention / Lack of
Awareness
34%
Following Procedures
19%
Use of Protective
Methods
13%
Tools, Equipment &
Vehicles
9%
Work Place
Environment / Layout
9%
Work Exposures To
7%
Protective Systems
6%
Use of Tools or
Equipment
3%
SE
Behavior
16%
Work Planning
20%
Management /
Supervision / Employee
Leadership
16%
Tools & Equipment
11%
Mental State
11%
Engineering / Design
5%
Work Rules / Policies /
Standards / Procedures
5%
NEB
Following Procedures
20%
Protective Systems
20%
Use of Protective
Methods
20%
Work Exposures To
20%
Innattention / Lack of
Awareness
10%
Tools, Equipment &
Vehicles
10%
NEB
Management /
Supervision /
Employee
Leadership
33%
Skill Level
11% Tools & Equipment
11%
Work Planning
45%
21
Asset Immediate Causes
Root Causes
E & P
Following Procedures
25%
Innattention / Lack of
Awareness
24%
Work Place
Environment / Layout
15%
Use of Protective
Methods
12%
Work Exposures To
10%
Protective Systems
5%
Use of Tools or
Equipment
5%
Tools, Equipment &
Vehicles
4%
E & P
Work Planning
27%Communication
9%
Management /
Supervision /
Employee
Leadership
23%
Behavior
10%
Work Rules /
Policies /
Standards /
Procedures
9%
Skill Level
10%
Tools & Equipment
4%
BAB
Following Procedures
20%
Use of Protective
Methods
20%Innattention / Lack of
Awareness
16%
Use of Tools or
Equipment
16%
Protective Systems
8%
Work Exposures To
8%
Work Place
Environment / Layout
8%
Tools, Equipment &
Vehicles
4%
BAB
Skill Level
4%Engineering / Design
11%
Work Rules / Policies /
Standards / Procedures
11%
Work Planning
11%
Tools & Equipment
15%
Behavior
19%
Management /
Supervision / Employee
Leadership
21%
22
Asset Immediate Causes
Root Causes
BUH
Following Procedures
27%
Innattention / Lack of
Awareness
23%
Protective Systems
13%
Use of Protective
Methods
13%
Use of Tools or
Equipment
7%
Work Exposures To
7%
Work Place
Environment / Layout
7%
Tools, Equipment &
Vehicles
3%
BUH
Behavior
18%
Skill Level
16%
Work Rules / Policies /
Standards / Procedures
3%Communication
3%
Engineering / Design
9%
Work Planning
13%
Tools & Equipment
16%
Management /
Supervision / Employee
Leadership
16%
DD Following Procedures
34%
Use of Protective
Methods
24%
Innattention / Lack of
Awareness
18%
Work Exposures To
16%
Protective Systems
5%
Tools, Equipment &
Vehicles
3%
DD
Work Planning
33%
Work Rules / Policies /
Standards / Procedures
20%
Management /
Supervision / Employee
Leadership
19%
Mental State
3%
Communication
13%
Training / Knowledge
Transfer
3%
Engineering / Design
3%
Behavior
6%
23
TPO
Use of Protective
Methods
24%
Following Procedures
16%
Innattention / Lack of
Awareness
15%
Protective Systems
15%
Tools, Equipment &
Vehicles
15%
Work Exposures To
15%
TPO
Management /
Supervision /
Employee
Leadership
50%Work Planning
17%
Skill Level
17%
Tools & Equipment
8%Behavior
8%
24
Causes of Top Two Incident Sub Types, 2011
Immediate Causes
Root Causes
Injuries
Violation by
supervisor
6%
Routine activity
without though
6% Mechanical Hazards
6%
Inadequate guards or
protective devices
6%
Congestion or
restricted motion
6%
Improper position or
posture for the task
9%
Improper decision
making or lack of
judgement
12%
Lack of knowledge of
hazards present
18%
Work Planning
32%
M anagement /
Supervision / Employee
Leadership
30%
Work Rules / Policies /
Standards / Procedures
7%
Training / Knowledge
Transfer
7%
Engineering / Design
4%
Communicat ion
4%Behavior
4%
Transpor
tation
Improper decision
making or lack of
judgement
21%
Inadequate tools
5%
Violation by supervisor
6%
Work or motion at
improper speed
6%
Violation by individual
6%
Slippery floors or
walkways
6%
Routine activity
without though
6% Inattention to footing
and surroundings
6%
Inadequate workplace
layout
6%
Lack of knowledge of
hazards present
10%
Inadequate guards or
protective devices
5%
Improper use of
equipment
5%
Behavior
23%
Management /
Supervision / Employee
Leadership
22%
Work Planning
22%
Mental Stress
11%
Physical Condition
11%
Work Rules / Policies /
Standards / Procedures
11%
25
Keep him safe
ABU DHABI COMPANY FOR ONSHORE OIL OPERATIONS
(ADCO)