learning plan from past incidents
Post on 06-Jul-2018
218 Views
Preview:
TRANSCRIPT
-
8/17/2019 Learning plan from past incidents
1/27
-
8/17/2019 Learning plan from past incidents
2/27
2 3
Table of Contents
1 Foreword 4
2 Introduction 5
3 Accident Types 6
3.1 Fall from height fatal accident at Plant 27 63.2 Fall from Crane 8
3.3 Dropped object accident at Installations Area 10
3.4 Fall from height during Train 1 Shutdown 12
3.5 Fall from height in ADGAS Main Stores 14
3.6 Injury due to incorrect work practice 16
3.7 Crane Failure Incident – ADGAS Ofce Building 18
3.8 Crush injury due to unsafe work practice 20
3.9 Injury during Maintenance at STOREX Tank Farm 24
3.10 Fire and Equipment Failure 26
3.11 Injury due to incorrect work practice during construction work 28
3.12 Injury during construction work at Train 3 Sub-station #7 323.13 Fall from height injury 34
3.14 Property damage due to crane runaway – Pentane Line 36
3.15 Injury to construction worker due to ying object 38
3.16 H2S Gas release leading to fatal from height 40
3.17 Severe injury to multiple workers due to Electrical Flash 44
4 Learning from our past mistakes 47
-
8/17/2019 Learning plan from past incidents
3/27
4 5
Abu Dhabi Liquefaction Company
(ADGAS) owns and operates an
LNG Plant at Das Island located
approximately 160 km North West
of Abu Dhabi City. The plant con-
sists of two identical Trains (Trains1 and 2) and a third Train (Train
3) and associated facilities. The
plant was originally commissioned
in 1977 with two Trains and the
third Train was commissioned in
the third quarter of 1994. It is de-signed to liquefy the associated
gas produced from Umm Shaif,
Zakum and Bunduq offshore eldsthat are operated by ADMA-OP-
CO. The associated facilities of
the plant are utilities, tanks and
product loading facilities through
two separate jetties, one for LNG
/ LPG / Parafnic Naphtha and the
other for molten Sulphur.
As such, ADGAS recognize the
need to share safety knowledge inorder to achieve its vision through
the safe and efcient execution of
its operations. ADGAS has a well
established HSE ManagementSystem (HSEMS) in place, which
provides the necessary guidance
on managing HSE aspects of our
operations and therefore provide asafe working environment for all of
us.
Ever since we began operations
on Das there have been number
of incidents over the years, vary-
ing from plant shutdowns to rst
aid cases, to fatalities involving ourcolleagues and friends. Our inci-
dent investigations have identied
that many of these incidents are of
a repetitive nature
The purpose of this booklet is
to further enhance our efforts in
meeting the standards and expec-
tations we have set for ourselves
by learning from our past mistakes,taking the necessary steps to pre-
vent reoccurrence and cascadingthese learning’s to our employees
and contractors.
1. Foreword
The oil and gas industry processes,
stores and exports large quantities
of hazardous substances including
flammable and toxic materials, and
the potential for serious incidents
to evolve is highly probable.The inherent risks associated within all
areas of the industry, from construc-
tion and commissioning, maintenance
and production, and now increasingly
so, decommissioning of assets re-
quires the employment of competent
people who adopt a positive safety
behavioural attitude in their daily lives
and embrace the management proc-
esses and systems to aid us in assur-
ing safe and efcient operations.
When incidents do occur, the result-
ant surveys and investigations have
revealed that human factors, such
as failure to implement procedures
properly, are often a cause. These
failures may in turn be attributable to
root causes such as a lack of training,instruction, communication or under-
standing of either the purpose or prac-
tical application of an organisations
Safety Management System and the
supporting Safe Systems of Work.
Investigations into many other inci-
dents within the industry, from Piper
Alpha to the Sonatrach Skikda plant
in Algeria (2004) and BP’s Texas City
Renery (2005) have revealed that
a third of all accidents were mainte-
nance-related with the largest single
cause being a lack of, or deciency
in the deployment of safe systems of
work, primarily, risk assessment, per-
mit to work and the strict adherence
to such systems. Indeed, here in theUAE, many incident investigations
have revealed failures within these
systems as a root or contributory
cause, including incidents in our plant.
Safe systems of work, together with
the legislation that governs them and
ADNOC Codes of Practices / com-
pany guidelines that guide us in the
development of such systems, associ-
ated training programs and operation
manuals have all evolved over the
years to cope with larger, more com-
plex sites and operations. This has re-
sulted in most systems being regularly
reviewed and revised to form robust
safe systems of work. So why do we
still have incidents occurring?
The kinds of pressure that can com-promise any safe system of work are
all too familiar – the volume of paper-
work such as permits, poor planning,
unrealistic or tight deadlines, inap-
propriate risk assessment and poor
safety behaviour.
Appropriate selection of personnel
with the required competency is also
crucial to assuring safe operations, as
is a deep routed safety culture within
our workforce.
2. Introduction
-
8/17/2019 Learning plan from past incidents
4/27
6 7
On Sunday 22nd October 1995 a
scaffolder was part of a team erect-
ing a scaffold extension to an exist-
ing structure around the piping ris-
er of LNG Storage Tank 27-D-103
to enable access for painting.
He was working approximately 40
metres above ground level when
he released his safety harness tobend under a handrail extension,
and then as he stepped and turned
on the scaffold extension, the oor
board platform collapsed and he
fell to the ground, rst striking the
piping 3 metres above ground
level.
Despite prompt emergency medi-
cal attention rstly by the on-sit
Safety Ofcer administrating CPR
and then the Das Medical Emer-
gency Team, the casualty died al-
most instantly as a result of the falland was pronounced dead on ar-
rival at the Das Medical Centre.
3. Accident Types
Two root (or essential factors)causes were identied by theinvestigation team:Mechanical failure: The exten-sion bracket became detachedfrom the upright of the mainscaffold structure due to thescaffold team not being familiar
with the Layer system.Incorrect work practice and un-derestimation of hazard: Thesafety harness was not securedto a xed structure and misjudg-ing the risks associated with thistype of activity.
Root Cause
1. All Supervisors and scaffolders are to be reminded of the need to use
safety harnesses attached to xed points at all times.
2. Ensure that all personnel connected with the work attend the Toolbox
Talk and that it adequately addresses the specic task at hand. In this
case it did not address the potential hazards/failings associated with the
locking pin of extension brackets.
3. Conduct refresher training to all scaffolding staff on Layer scaffolding
and maintain training record.
3.1. Fall from height fatal accident at Plant 27
Overview of Incident
The resulting investigation identi-
ed that for a variety of reasons
there were several delays to the
maintenance work being conduct-
ed that resulted in a mixed contrac-
tor workforce being deployed to
complete the works within a speci-
ed time-frame, and with an ex-
tended workscope than originallyplanned. This also resulted in two
different scaffold systems being
utilised, tube and ttings, and the
Layer supplied system scaffolding.
Lessons Learned
Inadequate Leadership or Supervi-
sion: This was very much lacking
particularly with respect to the in-
creased workscope.
Inadequate competency: Some
members of the scaffold team were
not familiar with the Layer system.
Inadequate Toolbox Talk: The
Toolbox Talk did not adequately
address the potential hazards as-
sociated with the Layer system
scaffold.
Contributory Causes
Tube & Fitting Scaffold
Layer Scaffold System
-
8/17/2019 Learning plan from past incidents
5/27
8 9
Lessons Learned
1. Ensure that all crane operators are familiar with the crane they are
required to operate and reinforce the message that the purpose built ac-
cess routes must always be used whilst conducting routine maintenance
activities on the crane.
2. Large sign to be stencilled on the front windshield ledge ‘NO STEP –
ACCESS FOR CABIN ROOF WINDOW AT REAR OF CABIN’.
3. Warning sign to be posted at a highly visible location within the crane
cabin ‘Access to crane platform is only from front and rear at grade level’.
Root Cause
On Monday the 22nd April 1996 at
approximately 07:20, a crane op-
erator
drove his mobile crane to the South
side of Plant 2, Train 2, where he
parked awaiting permit authorisa-
tion.
Whilst waiting for the required Per-
mit, the crane operator decided toclean the outside of the crane wind-
shield and roof window. He left the
cabin and climbed onto the crane
chassis to clean the windshield
then stepped up onto a ledge (be-
low the windshield) to clean the
roof window however, upon
descending back to chassis level,
he lost his balance. He tried to
grasp the crane front grab rail but
failed to hold on and fell approxi-
mately 2 metres to ground level.
The casualty was given immedi-
ate rst aid treatment before being
carried by stretcher to Marshalling
Point No.3 before being taken byambulance to the Das Medical
Centre for immediate treatment for
a deep laceration of the scalp and
multiple rib fractures, before being
transferred to Abu Dhabi Mafreq
Hospital by helicopter.
Overview of Incident
Typical Mobile Crane
3.2. Fall from Crane
Hazard underestimated: The
Crane Operators underestimation
of the potential hazards whilst con-
ducting routine maintenance and
losing his balance in the process
was identied as the root cause of
this incident.
Incorrect work practice: The Crane
Operator did not use the desig-
nated access routes, which areprovided with anti-slip pads. The
access to the roof window is also
at the rear of the cab.
Contributory Causes
-
8/17/2019 Learning plan from past incidents
6/27
10 11
On the morning of Monday the
22nd April 1996 a small team of
scaffolders and labourers were
dismantling scaffolding on the
West side of LNG Tank 27-D-104
following a suspension of the work
to allow inspection activities to take
place to lower sections of the shell.
Two scaffolders were removing a
bracket and pulley wheel assem-
bly from a vertical scaffold pole
at the 13th lift (approx 26 metres
above ground) in preparation for
using it at a lower level of the scaf-
fold structure.
During the process of lowering
the combined pulley wheel and
bracket over the scaffold structure
handrail, the bracket became de-
tached from the pulley wheel and
fell, striking a labourer who was
working at ground level, within the
exclusion area, collecting loose
scaffold ttings.
The labourer suffered severe facial
lacerations and was transferred by
ambulance to Das Medical Centre
for immediate treatment before be-
ing evacuated by helicopter to Abu
Dhabi Mafreq Hospital.
Inadequate Leadership or Super-
vision: The inspection of the work-
site and workscope following the
suspension was not conducted.
Inadequate Leadership or Super-
vision: The inspection of the work-
site and workscope following the
suspension was not conducted.Inadequate procedure, practic-
es or guidelines: There was no
formal procedure in place for low-
ering the combined pulley wheel
and bracket, nor did the contractor
have adequate systems in place to
address the potential hazards for
the task at hand.
Inadequate Toolbox Talk: Thereas no record of a Toolbox Talk be-
ing conducted to address the spe-
cic task at hand.
3.3. Dropped object accident at Storex Area
Overview of Incident
Root Cause
Dropped objects can be fatal
Lessons Learned
1. Install and use securing devices on all pulley gin wheel support hooks.
2. Develop and issue a formal procedure for lowering pulley arrange-
ments during scaffold activities, addressing aspects of potential hazards.
3. Re-enforce adequate exclusion zones.
4. Ensure that all personnel connected with the work attend the Toolbox
Talk and that it adequately addresses the specic task at hand.
5. Establish frequency and scope of site inspections, particularly with
respect to recommencing work following a period of suspension,
Incorrect work practice and haz-
ard underestimated: The lowering
of the combined pulley wheel and
bracket without a securing de-
vice and the fact that a man was
present within the exclusion zone
whist work was in progress over-
head were identied as the root
causes of this incident.
Contributory Causes
-
8/17/2019 Learning plan from past incidents
7/27
12 13
In the afternoon of the 2nd May
1998, a contract Mechanical Su-
pervisor fell from approximately 7
metres off a rope ladder whilst at-
tempting to exit a Butane Treater
Vessel (9-C-102b) via the top noz-
zle, after completing inspection of
the vessel internals with a third
party inspector.
The Mechanical Supervisor lost
his grip on the rope ladder and as
he was not wearing the prescribed
safety harness (as required by the
PTW) the fall resulted in fractures
to his pelvis, vertebra and right fe-
mur.
Although the Mechanical Supervi-
sor was an experienced contrac-
tor, the resultant investigation into
this incident identied that his age
(57), bulky physique and unt con-
dition may have caused him to
lose his footing on the rope lad-
der due to exhaustion through the
effort of climbing the rope ladder.
He subsequently lost his grip ashe was unable to support his full
weight. If he had been wearing the
safety harness as per the PTW re-
quirements then the severity of this
accident would have been greatly
reduced.
During the incident investigation,
the following also came to light:
• The onsite Safety Advisor did not
have any means to raise the alarm
and entered the conned space to
aid the injured party without due
consideration for his own safety.
• The incident area became con-
gested with Fire and Rescue ve-
hicles, unauthorised Police and
State Security and Medical vehi-
cles. Additionally, these people en-
tered the area without appropriate
PPE.
3.4. Fall from height during Train 1 Shutdown
Incorrect work practice and un-
derestimation of hazard: The
Mechanical Supervisors underes-
timation of the potential hazards
whilst ascending the rope ladder,
coupled with his lack of physical
tness, and the failure to wear a
safety harness were identied as
the root cause of the incident.
Root Cause
1. Due consideration to a persons physical age, size and tness must
be taken into account before assigning him to tasks involving restricted
or difcult access.
2. Suitable safety harnesses must be worn by all persons using rope
ladders.
3. Safety Assistants must be provided with adequate and appropriate
means to raise the alarm in the event of an emergency.
4. Work procedures and associated training programs must address the
roles and responsibilities of Safety Assistants during conned space en-try activities.
5. Site safety induction training should be given periodically to person-
nel who do not normally work within plant areas, for example the Police,
State Security and Medical personnel, to ensure that they are familiar
with the potential site hazards.
6. The Operations Shift Superintendent is responsible for assuming and
maintaining full control of the situation and for directing resources to en-
sure the incident is effectively brought under control.
Lessons Learned
Non adherence to ADGAS PTW
requirements: PTW conditions with
respect to the use of a full body
harness were not followed.
Inadequate Leadership or Supervi-
sion: This was very much lacking
in the build-up to the incident and
during the emergency response,
whereby the Police, State Security
and Medical personnel entered the
site without adequate PPE.
Contributory Causes
Overview of Incident
Butane Treater Vessel
-
8/17/2019 Learning plan from past incidents
8/27
14 15
On Tuesday 3rd November 1998
at 09:15 a contract rigger fell from
a height of 2 metres whist work-
ing within the ADGAS Main Stores
area and suffered multiple rib frac-
tures as a result of the fall.
On the day of the incident, the rig-
ger was involved in the transfer of
boxes within the stores area. The
boxes were covered with tarpaulinwhich was held in place by wood-
en crates. To remove the wooden
crates the rigger climbed atop the
boxes and during the removal of
the crates, lost his balance when
he stepped unknowingly between
the boxes and fell to the ground.
Although employed as a rigger, the
contractor was not qualied for this
role.
3.5. Fall from height in ADGAS Main Stores
1. Contract documents to clearly specify the requirement of Third Party
Riggers and Rigging Supervisors.
2. Contractors to be instructed that all their personnel must attend the
ADGAS Safety Induction Course before working in industrial and non-
industrial areas of ADGAS facilities on Das Island.
3. The requirements of the ADGAS PTW system must be adhered to atall times.
4. The practice of holding down tarpaulin covers (on top of boxes) by
utilising wooden crates (or similar) should be discontinued.
5. Standing Instructions should be developed and issued for the safe
handling of boxes and containers within the ADGAS Stores and Harbour
areas. This should also be part of the tender and contract documents.
Lessons Learned
NonadherencetoADGASPTWsys-
temrequirements: NoPTWwas-
raisedfor working at height, no risk
assessment was conducted and
therefore the potential hazards
were not addressed and inade-quate work planning was evident.
Lack of Safety Training: The rig-
ger had not attended the ADGAS
Safety Induction Course.
Inadequate Leadership or Supervi-
sion: The rigging team were carry-
ing out the activities with no lead-
ership or supervision at site.
Incorrect work practice: The prac-
tice of holding down tarpaulin with
wooden crates is considered sub-standard as it introduces further
risk into the job when it needs to
be removed for whatever reason.
Root Cause
Improper assignment of person-
nel: The rigger was not qualied
or experienced in this type of work
and therefore was not aware of the
potential hazards when conducting
such duties.
Contributory Causes
All falls from height can cause damage to the human body
Overview of Incident
-
8/17/2019 Learning plan from past incidents
9/27
16 17
On the morning of the 31st De-
cember 1999, a contractor em-
ployee was assisting six other men
in erecting the steel frame of the
ADGAS Ofce Building signboard,
which comprised 4” carbon steel
pipe weighing 1016 KG.
As a crane was not available, the
site Surveyor and Foreman de-
cided to manually lift the structureonto an ‘Easy Fix’ scaffold platform
at Level 2 with the aid of twenty
(20) labourers. Upon completion of
the welding, the frame was brought
down to Level 1 of the scaffold plat-
form with the aid of six (6) labour-
ers. During this activity, the Welder
(casualty) was asked to assist
by raising the frame by 3” - 4” by
means of a scaffold tube in order to
place packers under the frame so
that the supporting transom could
be removed and the whole struc-
ture lowered by the six labourers
with the aid of ropes. As the welder
was doing this, he lost his balance
and twisted his right foot. However,
he completed the activity but within
30 minutes he complained of pain
in his right ankle and was trans-ferred to Das Clinic for treatment
and later referred to hospital in Abu
Dhabi where it was ascertained
that he had suffered a fractured
bone (distal end of bula).
3.6 Injury due to incorrect work practice Overview of Incident
Overview of Incident
Incorrect work practice and inad-
equate competency: Neither the
casualty nor the six labourers were
qualied riggers and had no ration-
ale or reasoning to lift the frame
manually.
Root Cause
ADGAS Ofce Building
1. All lifting operations must be conducted using appropriately qualied
riggers.
2. Mechanical lifting equipment to be used for handling heavy/awkward
structures, and conducted under the strict supervision of appropriately
qualied supervision.
3. Method statements to be provided for all heavy lift operations for re-
view by ADGAS HSE Dept.
Inadequate work planning: A meth-
od statement was not submitted by
the contractor and therefore not re-
viewed by the HSE Dept.
Page 14 of 45
Inadequate procedure, practices
or guidelines: The contractor had
no written procedure for the lifting
operation.
Inadequate Leadership or Supervi-
sion: Full mobilisation of the con-
tractor had not been completed
and no contractor management
was on site, thereby resulting in no
clear chain of command for execu-
tion of the work activity.
Contributory Causes
Lessons Learned
-
8/17/2019 Learning plan from past incidents
10/27
18 19
On the morning of the 6th Decem-
ber 2000, a tower crane failed and
dropped its load onto scaffolding,
resulting in damage to the scaf-
fold but fortunately no one was
harmed.
The crane was being utilised in
construction work for the new
ADGAS Ofce Building and the
team comprising Crane Driver,Banksman and Riggers conducted
their work well. An ADGAS Safety
Representative was also in attend-
ance.
The crane was loaded with an
empty steel bucket, having just
been emptied of concrete blocks
on a platform near the top of the
building. On completion of the lift,
the crane driver changed from 2nd
gear to neutral, when the brake
would normally have engaged. It
then slewed anti-clockwise and
travelled the radial bogie inwards.
The crane driver realised some-
thing was wrong but was help-less as the hoist rapidly dropped
uncontrollably, landing on an un-
manned scaffold approximately 3
– 4 metres from the original hoist
position and where two men were
previously standing.
3.7. Crane Failure Incident – ADGAS Ofce Building
Overview of Incident
Mechanical failure: the cause of
the accident was indentied as the
failure of the splined drive shaft.
Contributory Cause
Incorrect work practice and in-
adequate competency: Although
the Contractor site Mechanic had
serviced the crane previously and
had been instructed to have a look
at the gearbox at regular interval,
it appears he was unaware as to
what he was looking for. Further-
more, there were no recorded de-
tails of previously conducted main-
tenance servicing or indeed, any
proper maintenance procedures.
Root Causes
During the course of the investi-
gation, a number of irregularities
were found, including:
• The crane purchased second
hand in 1995 (manufactured in
1979) and brought to Das in Feb-
ruary 2000. No maintenance man-
ual or drawings were available.
• There was no written mainte-
nance history available. Weekly
checks were made but these were
considered dubious as the exact
wording was used every week.
• The gearbox inspection revealed
excessive play of the internals,
missing lock-washers, heavily
worn gear teeth and the bearing
housing had been welded in two
places, which suggests severe
damage in the past.
Tower Crane dropped load on to scaffolding
Tower Crane
Lessons Learned
1. Future contracts should consider stating a minimum age for cranes
and associated components, and have the service history made avail-
able.
2. Prior to award of a contract, companies must demonstrate that they
have a sound HSE Management System.
3. Mechanics must be adequately trained and assessed as competent.
4. Proper maintenance schedules for the different inspections must be
provided and maintained
-
8/17/2019 Learning plan from past incidents
11/27
20 21
The scaffold platform around
the exchanger was cleared of
al l non-essential personnel, leav-
ing the:
• Rigging Supervisor, who was in
charge of the lifting operations and
positioned at the North end of the ex-
changer, ready to adjust the two off
chain blocks to level the exchang-
er on the horizontal plane. A single
sling was tted to the South end
of the exchanger and Tirfor lines
were attached to restrain lateral
movement.
• Rigging Foreman was stationed
at the East side of the exchanger
on the same level.
• Banksman was positioned at the
South side, with a clear vision of
the other two and would commu-
3.8. Crush injury due to unsafe work practice
Overview of Incident
Root Cause
Position of Rigger when he sustained Crush Injury at his left hand
On Thursday 24th May 2001, a third party contractor work team
were preparing to change out a Propane De-superheater Exchang-
er (weighing approx 18 tons), located at the top of the exchanger
bank on Plant 6, approx 7 metres above ground level.
The removal of the leaking exchanger was to be effected by utilising a
32 ton capacity Liebherr mobile crane, together with an arrangement of
chain blocks and ‘Tirfor’ lines to control any lateral movement.
Unsafe work practices: The unsafe act committed by the Banksman in-
dicates a low level of behavioural safety.
nicate with the crane driver by
means of hand signals.
The Rigging Supervisor gave the
instruction to the Banksman to
commence the lift slowly and lift
the exchanger by only 5mm.
The exchanger lifted approximate-
ly 5mm only at the South end and
immediately slewed slowly to the
West, towards the sister exchanger.
In an attempt to restrain the move-
ment, the Banksman, with his left
hand on the outer rim of the ex-
changer suffered severe crush in-
juries when contact between the
two exchangers occurred. He was
escorted from the worksite and
was transported to Das Clinic by
car where he received initial medi-
cal treatment before being trans-
ferred to the Central Hospital in
Abu Dhabi for further treatment to
a severed index nger, crushed
second and third ngers and lac-
erations to the back and palm of
the left hand.
Mobile crane
-
8/17/2019 Learning plan from past incidents
12/27
22 23
1. Safety behaviour training for all contractors is essential to assuring
safe operations and contractors are to ensure that this type of training
forms an inherent element to their training program.
2.The assigned Banksman must always stand clear of the lift and be
dedicated to to providing the communications link with the crane driver
only, leaving the hands on control of the lift to other members of the rig-ging team.
3. Rigging Procedure / Instructions to indicate correct positioning of all
lifting equipment involved in any lift, with the Rigging Supervisor carrying
out a check that all is in order prior to the lift.
4. Contractors must arrange a joint meeting to discuss critical lifting op-
erations with ADGAS Rigging Supervisor and HSED.
Lessons Learned
Contributory Causes
Incorrect work practices: The
incorrect positioning of the lifting
sling and crane hook not aligned
in a plumb position. Additionally,
there were an insufcient number
of correctly positioned restraining
lashes (Tirfor wires) to prevent lat-
eral movement of the exchanger
during the initial stages of the lift,
with no tag lines secured to con-
trol lateral movement thereafter.
Also, the Banksman should not be
involved in the ‘hands on’ activities
of controlling the lift.
Inadequate work planning: A
critical situation arose late in the
maintenance period which neces-
sitated removal of the exchanger
in a limited time frame, resulting
in the work not being thoroughly
thought through.
Poor safety behaviour: The con-
tractor exercised poor safety be-
haviour during the lifting operation
with regard to their actions.
Poor coordination: Poor co-
ordination and cooperation
between ADGAS/Contractor Rig-
ging Departments prior to the lift-
ing operation was identied as a
contributory factor which formed
the background to the chain of
events leading to the accident.
-
8/17/2019 Learning plan from past incidents
13/27
24 25
On the 5th November 2001, con-
tract Scaffolders were erecting
platforms to enable overhaul ac-
tivities to be carried out on the
personnel elevators on Tank 27-D-
103 and 27-D-105.
Three PTW’s were issued for work
on 27-D-105, one Cold Work PTW
for scaffolding, one Hot Work PTW
for routine instrument maintenance
on the tank level gauges and oneCold Work PTW for routine me-
chanical work on an air hoist.
During the execution of the works,
ADGAS Mechanical personnel
used the elevator to ascend to the
top of the tank to commence work
on the air hoist and left the elevator
at the top level.
An ADGAS Senior Instrument
Technician, on returning from his
tea-break found the elevator was
at the top level and pressed the call
button for the elevator however, a
scaffolder was working close to the
elevator well and his foot became
trapped between a support struc-ture and the side of the elevator
when it started to descend. The el-
evator emergency brake activated,
securing the elevator and defeat-
ing normal operation.
The alarm was raised, the elevator
electrically isolated and ADGAS
mechanical personnel attempted
to free the scaffolder by levering
the elevator car by means of a
scaffold tube. This proved unsuc-
cessful and they eventually freed
him by cutting through the eleva-
tor structure cross beam using a
hacksaw. The injured scaffolder
was pulled clear and treated at the
scene by medical personnel and
administered a pain killing injection
before being transferred to ground
level by stretcher via the stairs andtransported to Das Clinic.
3.9. Injury during Maintenance at STOREX Tank Farm
Overview of IncidentRoot Cause
Elevator at 27-D-105
Location at the platform where the
scaffolder had his foot trapped
Poor safety behaviour: The
scaffolder exercised poor safety
behaviour by standing on the
elevator structure cross mem-
ber in the knowledge that the
elevator was live. Additionally,
the contractor Safety Ofcer,
who had direct responsibility to
be present at the worksite, was
located at ground level.
storex earea
-
8/17/2019 Learning plan from past incidents
14/27
26 27
Inappropriate risk assessment:The Risk Assessment was con-ducted by the contractor in AbuDhabi and no site visit was con-ducted. Additionally, the change inthe work process invalidated theRisk Assessment.Poor coordination: There waspoor coordination and cooperationbetween ADGAS and Contractorpersonnel. At the kick-off meeting,most of the attendees were una-
ware of the detailed work area inrelation to the operational elevator,and the Senior Instrument Techni-cian was unaware of the on-goingwork adjacent to the elevator.Inadequate PTW preparation:
The PTW conditions were ambigu-ous, stating “elevator to be rackedout if required”. Also, the PTW wasprepared by the night shift, hadno detailed drawing or associateddocumentation, and no site visitwas conducted prior to approv-al. Additionally, liaison between
ADGAS Mechanical Supervisorand contractor Site Supervisor wasidentied as virtually non-existentwith respect to the PTW.
1. Safety behaviour training for all contractors is essential to assuring
safe operations, with the ADGAS Advanced Safety Awareness scheme
being adopted by contractors.
2. The ADGAS method for Risk Assessments to be adopted with a site
visit being a mandatory requirement.
3. ADGAS to review PTW procedure with respect to specic roles andresponsibilities, and the policy regarding the allowance of accepting Per-
mits by ADGAS personnel for one discipline on behalf of another dis-
cipline. PTW training should also highlight the risks involved in adding
ambiguous precautions to Permits.
4. Review procedures for work on elevator structures and dene when
elevator should be racked out.
5. Ensure that all personnel connected with the work attend the Toolbox
Talk and that it adequately addresses the specic task at hand.
Lessons Learned
Contributory Causes
-
8/17/2019 Learning plan from past incidents
15/27
28 29
Following the completion of
maintenance the pump was
returned to service and re-
streamed following normal op-erational procedures and the
standby pump shutdown.
After approximately 25 minutes
of running, the pump experi-
enced, in quick succession, ab-
normal vibrations, high bearing,
shaft and coupling tempera-
tures, which resulted in a re at
the inboard turbine bearing, fol-
lowed rapidly by a catastrophic
failure of the shaft and coupling.
Although the re was quickly
extinguished using portable re-ghting appliances, attempts to
re-start the standby pump failed
due to an electrical permissive
(design feature) that prevents
the pump from being restarted
within 30 minutes of shutdown.
The rst attempt to restart was
attempted at 26 minutes after
shutdown. The failure to main-
3.10. Fire and Equipment Failure
Overview of Incident
Component failure: The speed indication probe failure was iden-
tied as the most likely cause of bearing failure.
Incorrect sensor setting: The turbine air purge pressure was setfar in excess of the recommended setting.
Contributory Causes
Inadequate working conditions: The presence of grit blast mate-
rial, prevailing wind conditions and exposed bearings was identi-
ed as a contributing cause of the bearing failure.
Root Cause
On Thursday 31st January 2002, HP Lean Carbonate Pump 2-G-
104A was released for 6-monthly routine maintenance activities
to be carried out, which involved bearing inspections but did not
require uncoupling of the pump.
1. Ensure that maintenance activities and sensor settings strictly
adhere to manufacturers recommendations.
2. Ensure that meticulously clean working areas are maintained
during invasive maintenance activities. The fact that grit blast-ing activities had been recently carried out in the proximity of the
pump, and the high winds experienced during the maintenance
activity would have made it very difcult to keep the bearings clean
during the procedure.
Lessons Learned
tain either pump on-line result-
ed in a plant shutdown and loss
of production.
A fault tree analysis method of
investigation was applied which
identied two root causes with a
contributory cause. However, it
should be noted that the investi-
gation was hampered due to the
large extent of damage caused
by the re and catastrophic me-
chanical failure.
Carbonate Pump
-
8/17/2019 Learning plan from past incidents
16/27
30 31
On 30th July 2005, a Mechani-
cal Helper was working for the
Boil-off Gas (BOG) project when
he fell from ground level to the
base of a 2.8 metre deep exca-
vated trench. The team was en-
gaged preparatory works asso-
ciated with the rewater tie-ins
for the BOG Plant.
The accident happened when
the injured person was in the
process of moving a PVC con-
duit containing electrical/instru-
ment cables to one side of the
trench so that a section of the
new rewater piping could be
laid within the trench. The PVC
conduit protecting the under-
ground electrical services was
suspended by means of a rope
to a 6 metre long scaffold tube,
which traversed the excavation.
Despite being told to wait at
the worksite until the Foremancould provide him with addi-
tional help to assist with the
task, the Mechanical Helper
proceeded on his own to pull
one end of the scaffold tube to-
wards him. As a result, the op-
posite end of the scaffold tube
dropped into trench and the end
which he was holding swung
upwards and struck him on the
thigh, causing him to lose bal-
ance and fall to the base of the
excavation.
3.11. Injury due to incorrect work practice during construction work
Overview of Incident
To complicate matters, the in-
jured person was helped from
the trench and then left the
scene of the accident and as-
sisted by colleagues to the
Contractor Site Ofce to see the
Deputy HSE Manager however,
he was not there and it was de-
cided he should go to Das Clin-
ic, whereupon he was admitted
for treatment. The following day
he was transported by helicop-
ter to hospital in Abu Dhabi but
discharged himself later that
day. He was then taken to the
Contractor ofce in Abu Dhabi
and assigned ofce duties.
This pipe was not inside the trench dur-
ing the accident.The injured person was pulling the scaffolding
bar to clear the area for the crane to put the
pipe inside the trench.
-
8/17/2019 Learning plan from past incidents
17/27
32 33
Non adherence to ADGAS Emergency procedures: No
attempt was made to inform the Shift Superintendent or the Con-
trol Building to request medical assistance, even though the in-
jured person was complaining of lower back pain.
1. Performing Authorities (ADGAS or Contractor) must ensure that
all work is carried out in accordance with ADGAS procedures.
Additionally, all work must stop should conditions change at the
worksite, and a re-assessment of the risks undertaken as per
ADGAS procedures.
2. Ensure that all work party members attend the Toolbox Talk and
that it adequately addresses the specic task at hand, and covers
the topic of the correct actions to take in calling for medical assist-
ance and handling of any casualty.
3. Advanced Safety Audits (ASA) must cover the subject of job
specic Toolbox Talks.
4. The practice of dropping down dismantled scaffold material to
the ground, thereby making the work area an unsafe place is con-
sidered a dangerous and unacceptable activity. These should be
properly handled and deposited into containers or bags to ensure
correct and safe handling procedures.
5. All Contractor Job Ofcers must verify that unskilled employees
have a minimum of one year’s experience in their line of work.
Additionally, Contractor HSE Auditors must also verify this require-
ment.
Lessons LearnedRoot Cause
Incorrect work practice: The arrangement in adopted in secur-
ing the PVC conduit to protect the underground electrical services
was substandard.
Contributory Causes
Lack of communication: Poor communication between Mechan-
ical Helper (injured person), Foreman and Mechanical Supervisor.
Lack of experience: It became
evident that the injured person’s
construction work experience
was extremely limited and thatprior to this particular incident
he was observed working in
the trench alone and was ques-
tioned by the Safety Ofcer,
where it was noted that he was
totally unaware of the inherent
dangers of working alone in aconned space and within close
proximity to a live gas plant.
Non conformance to Task Risk Assessment: Although the Task
Risk Assessment adequately addressed the potential hazards, the
associated control measures were not enforced.
Inadequate Toolbox Talk:
There as no record of a Tool-
box Talk being conducted to ad-
dress the specic task at hand.
Change of worksite condi-
tions: The removal of the cer-
tied walkway across the exca-
vation forced the Contractor to
look at alternatives ways to com-
plete the task and the method
of suspending the conduit by a
length of rope to a scaffold tube
was employed, and later identi-
ed as a major contributory fac-
tor to the incident occurring.
-
8/17/2019 Learning plan from past incidents
18/27
34 35
The onsite contract Foreman admin-
istered rst aid at the worksite and
utilised a dust mask to dress the in-
jury. The Foreman then contacted
the on site contract Supervisor to
inform him of the incident before
driving the labourer to the contrac-
tor onsite ofce for further medical
treatment. This was conducted by
the ofce boy (who did not hold a
valid rst-aid certicate) by applying
Savlon cream and a cleansing so-
lution to the injured nger. He later
informed his Manager that the injury
was not serious.
The onsite Project Manager then in-
formed the injured labourer to rest in
his room before granting him com-
passionate leave and travel to Abu
Dhabi.
Whilst waiting for his ight at Das
Airport, he was spotted by the Police
covering his left hand with a scarf.
When questioned, the labourer in-
formed the Police of the accident
and he was requested to attend
Das Police Station before being
transferred to Das Clinic for proper
medical treatment. He was detained
overnight and released the following
morning.
3.12. Injury during construction work at Train3 Sub-station#7
Overview of Incident
Inappropriate method state-
ment and risk assessment:
Although a Method Statement
and Risk Assessment were
conducted, neither addressed
the hazards posed by the U-
shaped reinforced steel barsthat protruded from the ground
during the demolition works.
Inadequate Supervision: Dur-
ing the interview sessions as
part of the incident investigation
it was noted that the contractor
line management were aware of
the potential hazards posed by
the U-shaped reinforced steel
bars and indeed, the mitigation
measures but they did not dis-
seminate this to personnel actu-
ally performing the work.
Inadequate work brieng: Al-though the brieng session cov-
ered general topics such as the
use of PPE and housekeeping,
it did not highlight the specic
risks to the actual task at hand
to those conducting the work.
Root Cause
On the 12th November 2005, a contract Labourer was working with a
pneumatic jack hammer conducting demolition work on a concrete foun-
dation when the hammer drill bit became stuck in the concrete. The la-
bourer managed to forcefully free the drill bit but by applying a rocking
motion and in doing so, his left hand ring nger was jammed between
the jack hammer handle and a U-shaped reinforcement steel bar (Refer
Fig 5), resulting in a minor injury.
1. A more in-depth, detailed Method Statement to be developed
and used as the basis for the Risk Assessment with all potential
hazards addressed.
2. Contractor management and supervision must review the ap-
propriate project plan and become fully conversant with ADGAS
procedures.
3. Conduct daily work brieng sessions that address the specic
task at hand with reference to the associated Method Statement
and Risk Assessment.
4. Ensure that all contractors are aware of the correct actions to
take in the event of any accidents occurring at the worksite.
5. Nominated rst-aiders are to be appropriately trained and a
list of qualied rst aiders displayed at Contractor Ofce notice
boards.
U shaped reinforcement steel bar hazard U shaped reinforcement steel bar hazard
Unsafe work practices: The unsafe use of the pneumatic jack ham-mer by the Labourer indicates a low level of behavioural safety when
using pneumatically operated equipment.
Contributory Causes
Lessons Learned
-
8/17/2019 Learning plan from past incidents
19/27
36 37
The injured scaffolder along with his
team of 3 persons was engaged in the
dismantling of the scaffold, under a
General Cold Work Permit.
The accident occurred when the in-
jured scaffolder was dismantling the
scaffold at approximately 2.16 me-
tres and was un-doing a Beam Clamp
(Gravelock). During the process, thespanner slipped, he lost balance and
fell backwards and collided with the
1.2 metre high guard rail behind him.
The guard unfortunately had loose t-
tings and the force of the impact dis-
lodged the guard rail from the scaffold
structure and it fell to the ground. Sub-
sequently, with the backwards motion
the injured person fell to the ground,
landing on his back atop the fallen
guard rail and scaffold clamps, which
had previously been removed in the
dismantling process.
The injured scaffolder was immedi-ately transported by ambulance to
Das hospital the later medivac to Abu
Dhabi by helicopter for further medical
treatment.
3.13. Fall from height injury
Overview of Incident
Inadequate work planning: A specic Toolbox Talk for the activity, out-
lining the potential risks and hazards was not evident.
Non conformance to procedures/standing instructions: CITB certi-
ed scaffolders are a mandatory requirement yet this was compromised
with a parallel process to carry out the certication as soon as possi-
ble. This is a wholly inadequate process and appropriate steps must be
made to ensure this is not repeated.
Non adherence to ADGAS PTW requirements: PTW conditions
with respect to the use of a full body harness were not followed.
Root Cause
Workers on a scaffold structure
Beam Clamp
On 15th April 2008, a scaffolder fell from the scaffold structure located
beneath the Blowdown to Plant 19 Pipe Rack.
1. Engaged scaffolder certication and records are checked and veried
by ADGAS prior to them being mobilised to site.
2. Ensure that all work party members attend the Toolbox Talk and that i t
adequately addresses the specic task at hand.
3. The practice of dropping down dismantled scaffold material to the
ground, thereby making the work area an unsafe place is considered a
dangerous and unacceptable activity. These should be properly handled
and deposited into containers or bags to ensure correct and safe han-
dling procedures.
4. PTW conditions to be adhered to at all times.
Incorrect work practice and un-
derestimation of hazard: The
safety harness was not secured
to a xed structure and misjudging
the risks associated with this type
of activity. Complacency had also
crept into the way the work was
performed.
Additionally, the practice of drop-
ping down dismantled scaffold
material to the ground, thereby
making the work area an unsafe
place is considered a dangerous
and unacceptable activity, which
aggravated the injuries sustained.
Contributory Causes
Lessons Learned
-
8/17/2019 Learning plan from past incidents
20/27
38 39
The crane operator was instructed to
drive his crane (60 tons) by his banks-
man to Second Street, which was
temporarily designated as a ‘waiting’
area for heavy vehicles due to the nor-
mal heavy vehicle parking areas beingheavily congested. Upon arrival the
crane operator noticed that Second
Street was congested with three other
cranes parked ahead, and the banks-
man was not there to meet him.
The crane operator then left the crane
unattended with the engine run-
ning and without applying the brake
to meet with other crane operators.
He assumed that the crane was bal-
anced and at an equilibrium position
but moments later noticed the crane
roll down the sloped road and hitting
the parafnic naphtha loading line of
Plant 21 pipe rack. Additionally, the
impact of the accident shifted the pipe
to the North side and caused damageto the adjacent access platform and
civil foundation.
It was found that the banksman who
was supposed to be at Second Street
with the crane operator was given an
additional task to submit a Permit to
another trailer driver located in Area
502, which caused a delay for him
getting to Second Street on time to
instruct the crane operator and the
cranes movements.
3.14. Property damage due to crane runaway – Pentane Line
Overview of Incident
Inappropriate risk assessment: Sec-ond Street was designated as a tem-porary parking area and waiting areafor heavy vehicles for the Turnaroundactivities without conducting an ad-equate risk assessment.Lack of supervision: There was no co-ordinator assigned at Second Streeton the day of the accident to monitorthe movement of heavy vehicles. Additionally, the assigned banksmanwho was supposed to be at SecondStreet with the crane operator wasgiven an additional task which de-
layed his arrival at Second Street toinstruct the crane operator and moni-tor his movement.Lack of training: The crane operatorwas recruited by a Contractor in Octo-ber 2008 but the Contractor providedonly one training certicate and thatwas for HSE and breathing apparatus.Inappropriate property protection: Theimpact of the accident shifted the pipeto the North side and caused damageto the adjacent access platform andcivil foundation as there was no bar-rier protection provided.
Root Cause
On 15th November 2008, an unmanned crane rolled down a sloped
(approx 1.6 degrees) road and hit the parafnic naphtha loading line of
Plant 21 pipe rack, causing damage to the pipe work and ange, which
resulted in a minor leak.
Incorrect work practice and underestimation of hazard: Thecraneoperator
stopped his crane and left the vehicle unattended with the engine running, with-
out securing the crane and without applying the parking brake.
Lessons Learned
1. Third party certication and competency of crane operators, banksmen andriggers must be assessed and assured during the recruitment process. ADGAS
should also be involved in the interviewing and selection process before they
arrive at Das to assure adequate competency of personnel.
2. Ensure that an adequate risk assessment is conducted to ensure that all
work and site hazards have been properly addressed.
3. The assigned banksman should not be given more than one task dur-
ing shutdown activities and an adequate number of banksmen must be avail-
able on site at all times.
4. Removable concrete barriers should be erected at all industrial roads in
ADGAS Plant areas to protect pipe work and civil foundations to mitigate the
potential of collision damage.
Contributory CausesDamage to the Crane loading line & structure
Damage to parafnic naphtha
-
8/17/2019 Learning plan from past incidents
21/27
40 41
3.15. Injury to construction worker due to yingobject
Overview of IncidentLack of hazard awareness: Al-
though a risk assessment was
completed for the works that iden-
tied and documented the control
measures for this type of work,
they were not communicated at
site nor was it present at the work-
site.
Lack of training: The injured con-
tractor had received no training in
the use of angle grinders.
Inadequate Toolbox Talk: A toolboxtalk was conducted for the activity
ten days prior to the incident and
no reminder or refresher toolbox
talk was conducted for the task at
hand.
Inadequate PPE: Had the contrac-
tor been wearing the proper PPE
then he would not have suffered
injuries to his right jaw.
Use of substandard/inappropriate
tools: There was no evidence that
the angle grinder was purchased
from a known manufacturer or had
been subjected to any form of in-tegrity checks.
Root Causes
Lessons Learned
1. Establish training programs to cover:a. Hazard awareness
b. Effective toolbox talk for supervisorsc. ASA training to supervisorsd. Use of air powered tools, including associated risk and consequencesof failure to all who use them.
2. Ensure that toolbox talks are job specic and effectively communi-cated to all concerned at the start of each shift.
3. All powered tools to be procured from known manufacturers and meet
ADGAS requirements. They must also undergo preventative mainte-
nance checks at regular intervals to assure integrity.
4. Post Safety Flashes and HSE posters at strategic locations through-
out all plant areas. This provides valuable communication of ‘lessons
learned’.
5. ADGAS trained personnel to conduct ASA on regular basis to reinforce
safety messages and ensure that the correct PPE is worn at all times.
6. Introduce a mechanism for measuring and rewarding HSE perform-
ance on project sites in addition to the incentive scheme already in place.
Underestimation of risk: The de-
gree of risk associated with us-
ing the unproven methodology of
smoothing the concrete with inad-
equate machine tools (angle grind-
er) was totally underestimated by
the Foreman on site. The injured
contractor was given a brief famil-
iarisation on the use of the angle
grinder but not the associated risks
he was exposed to.
Contributory Causes
On the 15 March 2008, civil project
work was being conducted by
the assigned contractor and sub-
contractor, which included the
preparation and smoothing of the
concrete surface on the Pre-as-
sembled Rack (PAR) 102 foun-
dation footing. This is done by
the use of a stone cup disc and
pneumatic powered angle grinder
prior to water-proong or protec-tive coating application. As part of
civil works, concrete surfaces must
be smoothed prior to application
of water-proong and protective
coating.
During execution of the works, the
contractor was injured with rotating
ying object from the broken stone
cup disc assembly striking his
lower jaw whilst conducting grind-
ing work on the concrete founda-
tion. The injured contractor was
initially treated at Das Hospital and
then transferred to hospital in AbuDhabi for further treatment.
grinding machine
-
8/17/2019 Learning plan from past incidents
22/27
42 43
The key activity was to de-spade the
Sour and Liquid Flare and Blow-down
systems, which during streaming
was isolated from Train 1. After de-
spading, the system isolation valves
were to be opened thus making the
system operational, and thereby link-
ing the are systems of Trains 1 and
2. The de- spading was being carried
out on a platform 10 metres long and
accessed via an 8 metres high caged
vertical ladder.
At approximately 05:25 the next day
(Day 31 of the overhaul), a Supervi-
sor and Fitter from the assigned con-
tractor began to de-bolt the spade on
the verge of breaking containment,
they donned their breathing apparatus
while a Safety Assistant and another
Fitter were present without BA. A BA
Technician was also located at ground
level and operated the BA line.
At the same time, and in contravention
of the Operations Procedure, the are
valves were opened whilst the de-
spading activities were taking place.
This resulted in sour gas from Train 1
being admitted to the Train 2 system,
up to the crossover at the de-spading
location.
3.16. H2S Gas release leading to fatality from height
Overview of Incident
Immediate Causes
Release of high concentration of toxic H2S gas: Acid gas at low pres-
sure from Train 1 Sulphur Plant containing a high concentration of H2S
was released during de-spading activities. The release was a result ofthe decision by ADGAS Night Shift Operations Coordinator to open the
isolation valves before the completion of de-spading activities.
Access ladder De-spading activities on Platform 10 metresabove ground
At the start of the night shift of 21st November 2008, day 30 of the major over-
haul of LNG Train 2, the Maintenance and Operations Teams were preparing
for the last shift of mechanical work and including some hot work, after which
activities related to re-streaming the train for gas-in, was to commence.
This particular incident was thoroughly investigated and the Board of
Enquiry identied that the accident was a result of multi causes and cat-
egorised as follows:
• Immediate cause
• Root causes
• Indirect contributory causes
The BA Technician (at ground level)
smelled gas and observed that one
of the Fitters and the Safety Assist-
ant had started to descend the caged
ladder and at a point of about half-
way down the Fitter suddenly fell to
the ground at the base of the ladder,
immediately followed by the Safety
Assistant, striking his head fatally
against the ladder cage during the fall
and landing atop the Fitter.
The BA Technician at ground level
was initially overcome by H2S before
recovering enough to make his es-
cape. Another Fitter located close-bywas also overcome by H2S and col-
lapsed unconscious.
At 0531, gas alarms were activated by
the escaping gas and then the emer-
gency alarm was raised, Yellow A
alert was instituted, Fire and Rescue
crews mobilised, the deceased Safety
Assistant, injured Fitter (broken leg)
and the two individuals overcome with
H2S where taken to Das Clinic. The
accident site was cordoned off and
the Incident Command Centre (Das)
and Crisis Management Centre (Abu
Dhabi HQ) were manned until the ‘all
clear’ was declared at 10:08.
-
8/17/2019 Learning plan from past incidents
23/27
44 45
Inadequate wearing of PPE:
Only two of the four contractors
present at the elevated platform
were wearing BA, while the
other two were exposed to high
concentrations of H2S.
Falling from height: The two
contractors exposed to high
concentrations of H2S lost con-
sciousness whilst descending
the caged ladder. This resulted
in them falling, which caused
one fatality and one serious in-
jury.
Non adherence to Operating Procedure: The re-commissioning of the
Flare system was not carried out by the ADGAS Night Shift Operations
Coordinator as per the prescribed procedure.
Non adherence to Safety Procedures: The Contractor Supervisor did
not ensure that the area was prepared as per the requirements of the
PTW.
Lack of hazard awareness: The ADGAS Night Shift Operations Coordi-
nator was not aware that Train 1 Sulphur Plant was not operational and
as a result 15 tons of gas, containing high concentrations of H2S was
being continuously ared.
Non adherence to PTW: The ADGAS Senior Operator (as instructed
by the ADGAS Night Shift Operations Coordinator) signed the PTW al-
lowing work to commence without checking the worksite to ensure site
readiness as per PTW requirements.
Root Causes
1. Review and amend Operational Procedures to address associated
hazards when de-spading activities are taking place.
2. Review and amend the PTW process / procedure so that it is the
Performing Authority that raises the PTW and collates the associated at-
tachments such as the Task Risk Assessment and not Operations as is
the case. The PTW close-out process must also be improved to ensure
that all PTW’s are closed out prior to conducting ‘gas-in’.
3. Revise roles and responsibilities during Turnaround activities.
4. Review and improve H2S Hazard Awareness training.
5. Conduct competency assessment for safety technicians with BA
standby role, including his responsibilities.
6. Key critical operations such as de and re-streaming the process train
to be conducted by ADGAS Maintenance personnel.
7. Conduct a comprehensive review of the Emergency Response Proce-
dure to clearly dene roles and responsibilities.
8. Develop adequate safety training and site hazard awareness pro-
grammes to ensure safety compliance of Contractor safety personnel
prior to site work. Training objectives should be set to ensure that the
training delivers sufcient knowledge transfer to full the training needs
of the organisation and the individual.
Lessons Learned
Lack of H2S awareness: It was
evident from the behaviour of all
Contractor Labour personnel in-
cluding the Safety Assistant that
the potential consequence of H2S
inhalation was not well known to
them.
Pressure to meet Turnaround
completion target: There was
a perceived sense of urgency to
complete the job quickly as ‘gas-in’
had been planned for the next shift
and there appeared to be pressure
on the Operations nightshift crew
to complete all necessary activi-
ties.
Inadequate work practice: Dur-
ing the investigation, it became ev-
ident that this particular contractor
had been the subject of a number
of Near Miss Reports (700), PTW
violations (over 100).
Indirect Contributory Causes
-
8/17/2019 Learning plan from past incidents
24/27
46 47
Root Cause
On the 2nd March 2009, two Hot
Work Permits were issued to the
Electrical Maintenance Depart-
ment (Electrical Technician and
Electrical Trainee) to carryout rou-
tine maintenance on Substation
6, 3.3 kV switchgear. After part of
the work was completed the per-
mit was extended up to the 10th
March 2009.
Following completion of the rst
motor feeder, the switchgear was
tested but the 110V AC auxiliary
test supply MCB tripped. The Elec-
trical Technician assumed the trip
was due to an inrush of current
and repeated the test several more
times until they noticed smoke
emitting from the switchboard
cubicle, which consequently acti-
vated the smoke detection system.
The testing was halted and the
technician began trouble shooting
along with the Electrical Supervi-
sor, who had at this point, arrived
at the scene.
By mistake, the Electrical Techni-
cian connected the multi-pin plug
in reverse orientation (this was lat-
er identied as a design fault). This
caused a short circuit in the control
wiring, leading to a ow of heavy
current and ultimately burning the
PVC wires and generating a lot of
smoke/soot.
vestigation, the technician reAs
3.17. Severe injury to multiple workers due to Electrical Flash
Overview of Incident Inadequate competence: TheElectrical Supervisor and Elec-
trical Technician were not fully
aware of the bus bar arrange-
ments, which in turn led them to
believe that the bus bar was iso-
lated. Furthermore, they did not
fully realise the consequences
when smoke/soot is generated in
live switchgear.
Switchboard cubical after the the flash
reSwitchboard cubical before flash
re
Effect of the flash re on bus bars
Note:
The Electrical Supervisor and Electrical Technician were given skin
grafting surgery after 48Hours of being admitted to hospital following
sterilisation. The Supervisor was discharged from hospital some 21 days
later. The Technician was discharged after 23 days in hospital. Both re-quired a period of time to attend hospital on a weekly basis for further
consultation treatment.
-
8/17/2019 Learning plan from past incidents
25/27
48 49
Inadequate design: The control
multi-pin socket in the switchgear
was found to have a design weak-
ness, which caused the unintend-
ed reverse connection in the rst
instance.
Non adherence to safety warn-
ing sign: The Electrical Supervi-
sor and Electrical Technician both
ignored warning signs and opened
the protective barriers/panels,
thereby exposing themselves di-
rectly to the live bus bars.
Lack of hazard awareness: Non
adherence to Electrical and PTW
procedures: These procedures
were not strictly followed. The work
activity was extended out-with the
limit of the PTW without evaluating
the associated risk and communi-
cating this to the concerned Engi-
neer.
1. Review the design of the switchgear and replace with new, safer de-
sign. ADGAS procurement procedures should ensure that adequately
manufactured equipment is sourced, supplied and installed by ade-
quately competent contractors.
2. Fix new warning signs to all removable plates with clear message in
Arabic and English. Work procedures should also clearly warn of the
hazards of removing such panels.
3. Competency of all Electrical Technicians/Supervisors to be re-evalu-
ated. Those supervising work must have the same or higher kV authori-
sation.
4. Review and revise electrical procedures to ensure that they are ap-
propriate.
5. Ensure that toolbox talks are job specic and effectively communi-
cated to all concerned at the start of each shift.
Contributory Causes
Lessons Learned
As you have seen, from the various examples provided in this booklet,
our work activities have resulted in a number of incidents occurring over
the years we have been in operation, all with similar root and contribu-
tory causes.
We now need to ask ourselves, why? Why is it that an incident that oc-
curred last year had similar root and contributory causes to an incident
that occurred 12 years ago for example? Firstly, let’s identify the top six
failings or root causes from the incidents we have highlighted in this
booklet and discuss each one a little more detail. They are:
• Inadequate training
• Inadequate work practices• Non adherence to ADGAS Procedures
• Lack of hazard awareness/Risk Underestimated
• Inadequate work planning including Toolbox Talks
• Inadequate supervision.
4. Learning from our past mistakes
Despite great effort being placed
upon the identication and deliv-
ery of various training programs,
inadequate training is often iden-
tied as either a root or contribu-
tory cause in any incident. How-
ever, many training events fail at
the rst stage by failing to identify
appropriate learning objectives.
Whether the training is conducted
by traditional classroom methods,e- learning or on-the-job-training,
learning objectives must be spe-
cic and measurable as they pro-
vide the means on which to base
the course assessment, which in
turn, helps to determine the ef-
fectiveness of the training and as-
sure that the desired learning out-
come’s, are consistently achieved.
A properly trained and competent
workforce is the rst step in assur-
ing safe operations in any eld but
the word ‘competent’ is often mis-
understood. Competence is the
ability to undertake responsibilities
and to perform activities to a rec-
ognised standard on a regular ba-
sis. Competence is a combination
of practical and thinking skills, ex-
perience and knowledge, and alsoincludes a willingness to undertake
work activities in accordance with
standards, rules and procedures.
-
8/17/2019 Learning plan from past incidents
26/27
50 51
Inadequate work practices can
be attributed to a lack of ad-
equate training or quite often
due to personnel circumventing
the proper processes or proce-
dures, or indeed, complacency.
We have already addressed the
subject of Training above, so
how do we overcome the prob-
lem of people taking short-cuts
and removing complacency
from the workplace? Education
and continual learning is the
answer, coupled with changing
people’s hearts and minds to
embrace a safety behavioural
attitude.
Our systems and processes are
comprehensive and have been
developed and implemented for
your protection and to guide you
in the correct work practices.
Remember also that a PTW
does not guarantee the job is
safe – it is the attitude of the
individuals concerned that pro-
vide this. As you have seen from reading
this booklet, falling from height
have resulted in many of our
friends and colleagues suffer-
ing major injuries and in some
cases, fatalities have resulted,
which can be easily attributed to
inadequate work practices and
complacency, thinking that it
won’t happen to me but sooner
or later luck runs out.
If people are properly trained
and deemed competent for the
work that they are employed to
do then the non adherence to
ADGAS Procedures is a clear
and blatant disregard to safe
working practices. ADGAS has
dedicated a great deal of ef-
fort over the years in develop-
ing safe systems of work, which
meet international standards,
are continuously reviewed and
updated to reect our continu-
ous learning’s from industry.
ADGAS have also been at the
forefront in implementing safety
initiatives to further improve the
working environment for staff
and contractors alike. In return,
ADGAS expects each and eve-
ry individual to adhere to its poli-
cies and procedures, and adopt
a safety behavioural approach
to the work they do.
Inadequate work planning isalso an area that appears all
too often in our incident reports,
particularly when plant upsets
necessitate prompt actions to
rectify faults and this is often
used as an excuse when things
go wrong. Our systems and
processes are designed to ca-
ter for the unexpected and if you
follow the associated rules and
guidelines you will complete the
job safely.
Pre-job safety meetings or Tool-
box Talks, as they are com-
monly referred to are part of
the planning process and full a
crucial function in ensuring any
task is conducted safely. They
are mandatory requirement for
any work on Das and must be
attended by all persons involved
in the task, and must cover the
specic task at hand. It is equal-
ly important that the supervisor
/ foreman who delivers the tool
box talks is adequately trained
to effectively communicate haz-
ard knowledge and the associ-
ated risk.
A Lack of hazard awareness/
Risk Underestimated is quite
common ndings during in-
cident investigations even
amongst experienced person-
nel. The ability to be aware of
potential hazards and effec-tively assess the risks is directly
related to proper training and
competency.
Competence is a combination
of practical and thinking skills,
experience and knowledge, and
also includes a willingness to
undertake work activities in ac-
cordance with standards, rules
and procedures.
Lastly and most importantly
whether you are a Manager,
Supervisor, Foreman or indeed
the senior person in charge
of a work party, you have cer-
tain responsibilities in provid-
ing leadership and supervision
functions that require good
communication skills to guide
and advice, thus ensuring that
the work is completed to the
required standards. Failure to
achieve this will result in inad-
equate supervision, which al-
ways leads to dangerous situa-
tions arising at the worksite.
Working safely must be para-
mount to everything we do
-
8/17/2019 Learning plan from past incidents
27/27
Not just a business priority, but rather a high human value
Safety at the workplace is a mandatory business priority for everyorganization, as it ensures the integrity of assets and optimized
hassle-free performance.
For ADGAS, safety is one of the highest human values. It involves the
very life of our most valued asset: our people.
This booklet investigates 17 past incidents to pinpoint their root caus-
es and provide our staff with insights to how they should assimilate
these lessons and enhance their immunity against similar mishaps.
S a f e t y
top related