BG Group

Communication Pack

Learning the lessons

ELNG Construction Site Train 2, Idku Egypt - Fatal Incident on 21st March 2005

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Contents

• Incident description

• Findings

• Improvement actions

• Way forward

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• Incident on Train Two 54” stainless steel Ethylene Line from Cold Box involving Aresco subcontractor workers

• Leading activity was welding ethylene line to Cold Box

• Grinder asphyxiated by Argon gas inside pipe during seal weld preparation activities

• Scaffolding supervisor, pipe fitter and 2nd grinder asphyxiated by Argon gas inside pipe during failed rescue operation

ELNG Fatal Incident – 21 March 2005

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ELNG Idku - Location of Incident

Compressor DeckColdBox

ArgonSupply

Scaffolding

35m

FoamSeal

Location Of Weld

4”line

• Argon purge and shield gas being controlled from roof

• Welders complete first two welds on 54” incident pipe

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ELNG Idku Fatalities – 21 March• Deceased #1 and

Welder enter 54” incident pipe at compressor deck with tools and equipment to perform seal weld

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ELNG Idku Fatalities – 21 March

• Deceased #1 dies and Welder exits and raises alarm

• Deceased #2 and #3 enter pipe in rescue attempt

• Deceased #4 enters later

• 4” pipe cut at Cold Box end to allow air into 54” pipe

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Surface Causes

• Asphyxiation assumed to have been caused by Argon gas that accumulated in low point at end of line

• Worker entered confined space with argon gas present• No permit for confined space entry or work• Personnel not trained in confined space entry and hazards• Gaps in supervision, coordination and communication during

work• Delayed notification and uncoordinated emergency response• Gaps in compliance to project permitting procedure• Gaps in Supervision of Project HSE Plan

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Contributory Causes

• Inadequate allocation of safety responsibility (in practice, Bechtel’s safety dept is in charge of safety)

• Insufficient supervision level of sub contractors by Bechtel. Minimum control of method statements

• inadequate site-wide hazard identification • Poor design constructability for 54” line• Lack of coordination and communication at various levels e.g. Bechtel/sub contractors• Inappropriate incentives scheme• Lack of competency assessment in training process (risk specific)• Limited scope of contractual HSSE obligations to cover full scope of work and limited

contractual recourse• Insufficient resources for effective supervision • Recognised cultural issues not sufficiently addressed• Auditing at all levels not sufficient to verify compliance with Project procedures• Inadequate emergency response planning system

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Main Improvement Actions• Management & Leadership

– Increase the quantity and quality of supervision levels at the work-face– Conduct hazard identification studies of all activities– Review coordination and communication activities– Perform an independent safety management evaluation

• Policies, Standards & Procedures– EPC contractor and ELNG to review Method Statements for all high risk

activities.

• Behaviours / People– Behaviour-Based Safety initiative will be reinforced – BG Egypt and ELNG to review training programme and ensure

competency based testing is implemented

• Work planning– BG Egypt to monitor implementation of audit plan at formal project

review meetings

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Next Steps

• HSSE Away day for GEC on 27th May to review high level implications for BG Group and agree performance step change

• Regional workshops, led by respective EVP & MD’s, discuss implications and way forward for own Region with support from Group HSSE.

• Cascade by AGM’s to own Assets during Town Hall meetings• Time out for safety and/or stand downs at all BG sites led by line

management to review incident findings and discuss implications for own site and/or activities

• Project and Operations managers will formally present, to their Asset Management Teams, arrangements in place to prevent similar disasters

• AGM’s to provide assurance that actions have been taken to assess risks and mitigating measures implemented

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Way Forward

• Consolidation of feedback from:– Safety Meetings led by AGMs– Time Outs For Safety and/or Stand Downs in the Assets– Regional Workshops– GEC Safety Away Day

• Development of an improvement framework and action plan for the next performance step change

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Implications for BG X [Asset name]

• This is an Asset-specific slide where the AGM needs to:–Flag own risks (e.g. unskilled contracted workforce,

land transport, new projects, …) –Compare with causal factors from fatal incident–Review existing controls–Trigger a debate on the adequacy of controls and

tease out ideas

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Incident Investigation Process

• First BG management visit was on 22nd March. Jorn Berget, Stuart Fysh, Malcolm Brown, Ray Betros visited ELNG site, held discussions with local staff and agreed to a joint stakeholders investigation team (led by Bechtel)

• Frank Chapman appointed Jorn Berget to lead an independent BG team to review findings of the Bechtel-led investigation and to identify high level lessons for the BG Group

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Independent Investigation Team

• Review team (Jorn Berget, Ray Betros, Nebil Younes, Ross Michie, Peter Joyce) visited Egypt from 30th March to 1st April.

• Findings of the Bechtel investigation reviewed and fully supported

• Other causes identified:– Group implication

• Several “Immediate Actions” were discussed and agreed with Bechtel

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Immediate follow up

• Improve physical barriers including Train 1 segregation and security inspectors

• Review of all site permits and procedures and communicate to workforce

• Tighten Safe Work Permit systems (CSE, Hot Work, Live Electricity etc)

• Review the Emergency Response System

• Zero tolerance of major Safety rules violations

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Completed actions• Stand down (x 2) of ELNG site and presentations of

incident facts to ELNG Staff and Board• Presentation of findings to Frank Chapman, GEC,

Board and at senior managers workshop by AGM, Jorn Berget and Head of HSSE

• Guidance on inert gas and confined space entry precautions including best practice and case studies issued by Group HSSE to all BG group Assets

• Letters from Frank Chapman to all staff and to AGMs on progress and requirements

• Communication Pack produced by Group HSSE