Professional Documents
Culture Documents
Health, Safety & Environment Division
:
drtayab@adco.ae :
72 9792606 :
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.
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)
Table of Contents
Damage to Over Head Line (OHL)
Improper Lifting Causing Damage to Forklift
Loss of Containment During Sand Clearance
Al Gaith Vehicle Rollover
Hand Injury During Unloading of Gas Cylinder
Water Tanker Rollover
Fall from Elevation
Finger Injuries from Broken Laboratory Glassware
Quiz
HSE Performance
Incident Sub Types 2011
Distribution of Incident Sub Types 2011
Incident Immediate & Root Cause Categories
Incident Immediate Cause Analysis 2011
Incident Root Cause Analysis 2011
Asset Based Causes 2011
Causes of Top Two Incident Sub Types, 2011
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
20
24
Incident Description
Causes
Incident Description
Causes
Lessons Learned
Incident Description
Causes
TPO
21.11.11
Incident Description
Causes
Lesson Learned
E&P
Asab
12-11-11
Root Causes
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 fitters 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 Identification of
Worksite/ Job Hazards (Untrained staff
were assigned to handle gas cylinders)
Incident Description
Causes
Lessons Learned
Outcome: The driver/operator escaped unhurt 1. Mark and barricade areas around excavations
and the tanker sustained damage.
2. Do not move vehicles without banksman in
construction/congested areas
3. Do not allow drivers/operators in work sites
without site familiarization
Incident Description
Root Causes
10
Incident Description
Root Causes
SE
Sahil
28-062011
11
Quiz
Event
1.
True
False
2.
3.
4.
5.
6.
7.
8.
12
HSE Performance
ADCO & Contractors LTIF & TRIR (YTD) vs Manhours worked
1.4
140
1.29
117
0.93
100
0.80
0.29
0.28
0.16
0.12
0.34
60
57.36
44.4
34
27
0.36
0.34
47
0.55
0.4
0.51
32.5
56
0.63
80
0.81
0.55
0.6
0.2
0.78
0.68
0.66
32.3
0.70
55
0.8
40
0.26
0.09 20
120
29
1.2
0.16
0
2001 2002 2003 2004 2005 2006
Year 2007 2008 2009 2010 2011
Manhours
Actual LTIF
TRIR
13
ADCO
BAB
Gas Release
5%
Fire
6%
Onshore Spill
10%
Onshore Spill
5%
Gas Release
2%
Fire
Property
Damage
16%
Injury/Illness
63%
6%
Injury/ Illness
Injury/Illness
45%
Fire
11%
Gas Release
6%
Property
Damage
15%
37%
Propert y Damage
12%
Transport at ion
18%
Onshore Spill
21%
Transportation
22%
DD
Fire
4%
E&P
Onshore Spill
4%
Property Damage
40%
Transportation
17%
Fire
6%
P ro perty
Damage
17%
Injury/Illness
46%
NEB
Transportation
19%
Transportation
20%
Fire
7%
Injury/Illness
46%
Onshore Spill
27%
Transpo rtatio n
31%
Injury/Illness
35%
Property Damage
10%
Fire
10%
TPO
SE
Gas Release
5%
Gas Release
4%
Property Damage
12%
Injury/Illness
56%
Injury/Illness
24%
Fire
2%
Transportation
29%
Onshore Spill
29%
14
SE
6%
TPO
DD 6%
6%
NEB
12%
BUH
12%
Gas Release
BAB
17%
E&P
28%
AUH
18%
BAB
12%
BUH
33%
Injury
SE
10%
NEB
10%
DD
7%
BUH
11%
E&P
34%
AUH NEB
BAB
5% 5%
8%
BUH
10%
SE
15%
AUH
12%
Transportation
NEB
17%
Property Damage
TPO
6%
BAB
10%
SE
33%
E&P
34%
DD
23%
Onshore Spills
E&P
44%
TPO
15%
BUH
26%
BAB DD
4% 4%
SE
51%
15
Root Causes
Immediate Causes
Communication
5%
Tools, EquipmentUse
& of Tools or
Equipment
Vehicles
Protective Systems
4%
6%
7%
Work Place
Environment / Layout
8%
Work Exposures To
10%
Use of Protective
Methods
16%
Innattention / Lack of
Awareness
25%
Following Procedures
24%
Work Planning
23%
Engineering / Design
5%
Skill Level
7%
Work Rules / Policies
/ Standards /
Procedures
8%
Tools & Equipment
9%
Behavior
14%
Management /
Supervision /
Employee Leadership
22%
Inadequate adjustment/repair/maintenance
Violation by individual
Inadequate audit/inspection/monitoring
16
Routine
activity without
though
16%
Violation by individual
26%
Improper loading
5%
Improper lifting
8%
Improper position or
posture for the task
13%
Distracted by
Failure to warn
other concerns 4%
5%
Inattention to
footing and
surroundings
18%
Violation by supervisor
18%
Work or motion at
improper speed
14%
25
EMPD, 21
BAB
8%
20
15
10
5
0
DD, 13 SAS, 13
Inattention to surroundings:
30
TPO NEB
3% 3%
SE, 24
EP
33%
BUH
13%
BU, 8
Improper
decision
making or lack
of judgement
53%
BAB, 5
25
E P, 20
20
DD
11%
15
JD, 2
NEB, 2
10
SE
20%
DD
20%
BUH, 7
DD, 7
BAB TPONEB
6% 3% 2%
SE
36%
BAB, 4
5
0
TPO, 2
NEB, 1
BUH
11%
EP
31%
17
Inadequate job
placement
6%
Inadequate
management of
change system
4%
Inadequate audit/
inspection/
monitoring
46%
20
15
The work being done was not planned or was not risk
assessed prior to starting that work.
Supervisors did not monitor, inspected or audited the
work as planned.
The tools or equipment involved in the incident were
not covered by a preventative maintenance program,
and became unserviceable.
SE, 12
DD, 10
BUH
7%
10
5
0
Inadequate
identification of
w orksite/job hazards
Inadequate Leadership
The leaders in an area did not set the right direction or tone for
safety or allow ed roles and responsibilities for safety activities
to be unclear or undefined.
E & P, 19
BUH, 4 NEB, 4
Inadequate
identification of
worksite/job
hazards
73%
Inadequate
leadership
17%
Inadequate work
planning
39%
Inadequate Work
Planning
Inadequate audit
/inspection/ monitoring
Inadequate
preventative
maintenance program
Inadequate
correction of prior
hazard/incident
2%
NEB
7%
BAB
6%
TPO
4%
E&P
35%
20
E & P, 16
DD
19%
10
BAB, 6 DD, 6 TPO, 6
SE
22%
5
0
E&P
30%
TPO
12%
SE, 10
TPO, 2
NEB
6%
BUH
10%
15
BAB, 3
BUH, 5
NEB, 3
DD
12%
BAB
12%
SE
18%
18
Behaviour
Tools & Equipment
Inadequate
removal/
replacement of
unsuitable items
Inadequate human
10%
factors/
ergonomics
considerations
10%
Inadequate
assessment of
needs and risks
37%
Inadequate assessment of
needs and risks
Inadequate adjustment
/repair/maintenance
8
6
Improper
performance is
rewarded
16%
Employee
perceived haste
26%
Inadequate
identification or
critical safe
behaviors
19%
Inadequate
adjustment/repair/
maintenance
23%
Inadequate
availability
10%
Inadequate
Behavior
16%
Improper
supervisory
example
23%
Improper supervisory
example
Inadequate reinforcement of
critical behaviors
SE, 7
BUH, 5
BAB, 4
4
2
0
E & P, 3
TPO, 1
NEB, 1
E&P
14%
TPO
5%
12
NEB
5%
SE
33%
8
6
BAB
19%
4
BUH
24%
SE, 10
10
2
0
E & P, 7
BUH, 6
BAB
16%
BAB, 5
DD, 2
JD, 1
BUH
19%
DD
6%
JD
3%
SE
33%
E&P
23%
19
Asset
Immediate Causes
Root Causes
SE
SE
Use of Tools or
Protective SystemsEquipment
Work Exposures To
3%
6%
Work Place7%
Environment / Layout
9%
Innattention / Lack of
Awareness
34%
Work Planning
20%
Engineering / Design
5%
Work Rules / Policies /
Standards / Procedures
5%
Following Procedures
19%
Management /
Supervision / Employee
Leadership
16%
Mental State
11%
Behavior
16%
NEB
Tools, Equipment &
NEB
Vehicles
Innattention / Lack of
10%
Awareness
10%
Following Procedures
20%
Work Exposures To
20%
Management /
Supervision /
Employee
Leadership
33%
Work Planning
45%
Protective Systems
20%
Use of Protective
Methods
20%
Skill Level
11%
20
Asset
Immediate Causes
Root Causes
E&P
E&P
Tools,
Use of Tools
orEquipment &
Equipment Vehicles
Protective Systems
4%
5%
5%
Work Exposures To
10%
Following Procedures
25%
Communication
9%
Use of Protective
Methods
12%
Work Place
Environment / Layout
15%
Innattention / Lack of
Awareness
24%
Work Rules /
Policies /
Standards /
Procedures
9%
Skill Level
10%
Behavior
10%
Management /
Supervision /
Employee
Leadership
23%
BAB
BAB
Use of Tools or
Equipment
16%
Following Procedures
20%
Innattention / Lack of
Awareness
16%
Engineering / Design
11%
Use of Protective
Methods
20%
Skill Level
4%
Management /
Supervision / Employee
Leadership
21%
Behavior
19%
Work Planning
11%
21
Asset
Immediate Causes
Root Causes
BUH
BUH
Following Procedures
27%
Engineering / Design
9%
Innattention / Lack of
Awareness
23%
Skill Level
16%
Work Planning
13%
Management /
Supervision / Employee
Leadership
16%
DD
DD
Training / Knowledge
Transfer
Engineering / Design
3%
3%
Innattention / Lack of
Awareness
18%
Following Procedures
34%
Behavior
6%
Mental State
3%
Work Planning
33%
Communication
13%
Use of Protective
Methods
24%
Management /
Supervision / Employee
Leadership
19%
22
TPO
TPO
Work Exposures To
15%
Tools, Equipment &
Vehicles
15%
Protective Systems
15%
Use of Protective
Methods
24%
Following Procedures
16%
Innattention / Lack of
Awareness
15%
Management /
Supervision /
Employee
Leadership
50%
23
Root Causes
Lack of knowledge of
hazards present
18%
Improper decision
making or lack of
judgement
12%
Injuries
Violation by
supervisor
6%
Routine activity
without though
6%
Mechanical Hazards
6%
Work or motion at
improper speed
6%
Transpor
tation
Violation by supervisor
6%
Violation by individual
6%
Slippery floors or
walkways
6%
Improper position or
posture for the task
9%
Congestion or
restricted motion
Inadequate guards or
6%
protective devices
6%
Improper decision
making or lack of
judgement
21%
Inadequate tools
5%
Routine activity
without though
Inattention to footing Inadequate workplace
6%
layout
and surroundings
6%
6%
Lack of knowledge of
hazards present
10%
Improper use of
equipment
5%
Engineering / Design
4%
Communication
4%
Behavior
Work Rules / Policies /
4%
Standards / Procedures
7%
Training / Knowledge
Transfer
7%
Work Planning
32%
M anagement /
Supervision / Employee
Leadership
30%
Behavior
23%
Management /
Supervision / Employee
Leadership
22%
Inadequate guards or
protective devices
5%
24