REPORT MARCH

2013pfh 2015

DATA SERIES

Safety performance indicators –

Process safety events – 2013 data
Fatal incident and high potential events
Fatal incidents and high potential events that were also process safety events (PSE), and fatal
incidents and high potential events that were PSE-related – 2011, 2012 and 2013
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 REPORT MARCH
2013pfh 2015

DATA SERIES

Safety performance indicators –

Process safety events – 2013 data
Fatal incident and high potential events
Fatal incidents and high potential events that were also process safety events (PSE),
and fatal incidents and high potential events that were PSE-related – 2011, 2012 and 2013

Revision history

VERSION DATE AMENDMENTS

1.0 March 2014 First release

 Process safety events – 2013 data 4

FATAL INCIDENT REPORTS CLASSIFIED AS TIER 1 PROCESS

SAFETY EVENTS – 2013

DATE: Nov 14 2013 LESSONS LEARNED AND RECOMMENDATIONS:

LOCATION: Asia/Australasia, INDONESIA 1. Task Risk Assessment level 2 is mandatory
DATA SET: Contractor Offshore requirement for Bleed Off Pressure and Kill Well Job.
WORK FUNCTION: Drilling
2. Pressure test is mandatory required to bleed off/kill
INCIDENT CATEGORY: Pressure Release
well job and set packer job similar to stimulation,
ACTIVITY: Drilling, Workover, Well Services
gravel pack, TCP, nitrogen job, etc. which to stated
WORKFORCE DEATHS: 1 3RD PARTY DEATHS: 0 in revised SOP.
AGE: 35 EMPLOYER: Contractor 3. Revise the existing SOP-Bleed Off Pressure and Kill
OCCUPATION: Drilling/Well Servicing Operator Well Job. with adding:
NARRATIVE: The ongoing operation was bleed off well • Install safety chain to prevent the hose move
pressure (SICP=700 psi/SITP=Unknown). Killing line had uncontrolled due to hose and connection failure
been installed on X-tree by Day-Shift crews. The victim, • Secure the killing line position to avoid worker
with other co-worker (Night shift crew), slowly opened having direct expose to the line.
the crown valve using 24" pipe wrench since no wheel
4. BU must provide standard X-tree prior to do well
on the valve. Suddenly, the XO (cross over) connected
intervention to avoid any potential hazard to the well
from the X-tree cap to 2" hose came free from the cap
intervention crew.
and hit the victim’s face. As a result he fell down on
his back and the back of his head hit the grating deck. 5. Re-socialize SIMOP Procedure (Well Hand Over)
His co-worker, who was standing behind him, also fell implementation.
down close to him without any injury. The tool pusher 6. Perform routine X-tree maintenance.
came to the site and shut the well in while he called the 7. Re-vitalize STOP and BBS program, especially
Emergency Response Team from the barge to bring up to emphasize awareness of behaviour related to
the stretcher. Immediately, the victim was brought down “Position of People”.
to the clinic, and then to the hospital by chopper. The
CAUSAL FACTORS:
doctor declared that the victim passed away at 09.55
am, ten minutes after arriving at hospital. PEOPLE (ACTS): Following Procedures: Improper
position (in the line of fire)
WHAT WENT WRONG:
1. X-tree has been installed for approximately 30 years PEOPLE (ACTS): Use of Tools, Equipment, Materials and
without any maintenance and no preparation when Products: Improper use/position of tools/equipment/
the well was selected for well intervention. materials/products

2. Crews could not read tubing and casing pressure due PEOPLE (ACTS): Use of Protective Methods: Equipment
to no pressure gauge having been installed. Casing or materials not secured
pressure could be read out only from manifold.
PEOPLE (ACTS): Inattention/Lack of Awareness:
3. The crew installed the killing line without proper Improper decision making or lack of judgment
check X-tree cap box thread condition.
PROCESS (CONDITIONS): Protective Systems:
4. The victim used 24" pipe wrench to open the crown
Inadequate/defective guards or protective barriers
valve due to having no wheel on crown valve.
PROCESS (CONDITIONS): Protective Systems:
5. The position of victim was very close to the installed
Inadequate/defective warning systems/safety devices
killing line.
6. No safety chain installed between X-tree and PROCESS (CONDITIONS): Tools, Equipment, Materials
killing line. & Products: Inadequate/defective tools/equipment/
materials/products
7. No pressure test after connecting the line.
8. SIMOP (simultaneous operations) procedure
(Well Hand Over Form) is not well implemented.
 Fatal incident and high potential events 5

DATE: Apr 27 2013 4. To strengthen risk analysis before the operation

LOCATION: Asia/Australasia, CHINA for the storage tank, especially for storage oil
DATA SET: Contractor Offshore tank sulfur, to pay attention to the risk analysis of
WORK FUNCTION: Production ferrous sulfide self-ignition and control measures,
INCIDENT CATEGORY: Explosions or Burns to improve the system of management, added the
ACTIVITY: Maintenance, Inspection, Testing corresponding management requirements.
WORKFORCE DEATHS: 2 3RD PARTY DEATHS: 0 5. To strengthen the management of personnel
AGE: 47 EMPLOYER: Contractor qualifications. Timely replacement training for
OCCUPATION: Maintenance, Craftsman personnel arrangements, to ensure compliance.
AGE: 44 EMPLOYER: Contractor 6. After completion of elimination danger for Platform
OCCUPATION: Maintenance, Craftsman B, in the process of tissue repair and restore
production, we should consider to increase the inert
NARRATIVE: There was a plan to do a maintenance
gas protection device, ensure that the nature of the
operation by coating the roofs of the crude oil tanks on
crude oil storage tank safety.
a production platform with epoxy resin and Fiberglass
because serious corrosion had been found on the roofs 7. Accident unit should extrapolate, full screen similar
during a patrol inspection. The oil tanks were emptied crude oil storage tank, for screening out hidden
before the day the work was planned. On April 27th, trouble organizing special projects, to prevent major
7:30am, according to the construction scheme, the workplace malignant accidents.
contractor workers got permission for work and had a CAUSAL FACTORS:
safety meeting before the operation. At 8:12AM, an oil tank
exploded when a worker had just reached the top of the oil PEOPLE (ACTS): Following Procedures: Violation
tank. The accident caused two deaths and one injury. unintentional (by individual or group)

WHAT WENT WRONG: PEOPLE (ACTS): Use of Tools, Equipment, Materials and
Products: Servicing of energized equipment/inadequate
1. The ferrous sulphide self-ignition ignited the
energy isolation
combustible gas mixture inside the oil tank, a flash
explosion occurred. PEOPLE (ACTS): Use of Protective Methods: Personal
2. Electrostatic discharge ignited the combustible gas Protective Equipment not used or used improperly
mixture, a steam explosion occurred. PEOPLE (ACTS): Use of Protective Methods: Equipment
LESSONS LEARNED AND RECOMMENDATIONS: or materials not secured

1. To strengthen the antistatic field personnel to use PEOPLE (ACTS): Inattention/Lack of Awareness:
the management of labour insurance supplies, in Improper decision making or lack of judgment
the case of test methods and standards are not PROCESS (CONDITIONS): Protective Systems:
clear, should be forced to replace system, ensure Inadequate/defective guards or protective barriers
the use of anti-static overalls and tools effectively.
PROCESS (CONDITIONS): Protective Systems:
2. To strengthen and anti-static, and ferrous sulfide
Inadequate/defective Personal Protective Equipment
knowledge training, propaganda and education.
Against static electricity and lack of awareness PROCESS (CONDITIONS): Tools, Equipment, Materials
of ferrous sulfide, accidents related unit shall & Products: Inadequate/defective tools/equipment/
immediately organize employee training, strengthen materials/products
the professional knowledge and skill training, to
PROCESS (CONDITIONS): Work Place Hazards:
ensure the safety of site work.
Hazardous atmosphere (explosive/toxic/asphyxiant)
3. Norms and to strengthen the tank (especially
PROCESS (CONDITIONS): Organisational: Inadequate
with longer) detection and cleaning. For related
hazard identification or risk assessment
equipment in strict accordance with industry
standards for testing and evaluation, according to PROCESS (CONDITIONS): Organisational: Poor
the evaluation results, formulate corresponding leadership/organisational culture
measures and equipment management system, and
ensure the compliance, security field integrity and
intrinsically safe equipment and facilities.