You are on page 1of 26

Incident Prevention Through

Learning from Incidents

October- December, 2011


Health, Safety & Environment Division

For further information, comments and suggestions please contact:


Dr. Muhammad. R. Tayab (drtayab@adco.ae)
Health, Safety & Environment Division
Tel: 02-6042979; Mobile 00971 (0) 50 324-3996

:
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

Damage to Over Head Line (OHL)


Area

Incident Description

Causes

A crew was engaged in preparing gatch road


along BUH fence. Task risk assessment (TRA) was

prepared and Permit to Work (PTW) and


excavation certificates were obtained. While
unloading Gatch approximately 20 meters away
from 33KV Over Head Line (OHL) the tipper truck
driver moved the vehicles towards OHL while

BUH extending tipper bucket, to ensure complete


unloading of gatch material. There was no
banksman/flagman to guide the driver. During the
08-12- process, the vehicle crossed underneath the OHL
and the extended bucket made contact and
11
damaged OHL conductors.

Inadequate Leadership (TRA was not


adequate and was not chaired by ADCO; IA
issued the PTW without ensuring presence
of banksman; availability of adequate
resources (i.e. transportation &
communication with staff))
Inadequate Identification of
Worksite/Job Hazards (Risk of damage
to OHL by tipper truck was not adequately
identified; access and agrees for unloading
not marked/ identified)
Inadequate Work Planning (New Job
Pperformer (JP) was not aware of work
site hazards; No vehicle or telephone was
provided to safety officer hindering him
from site visits)
Lesson Learned

Outcome: Damage to OLH resulting in power


supply disconnection to 10 water clusters.

1. Do not drive tipper truck while bucket is


raised
2. Identify access and egress point for heavy
vehicles.
3. Check for operational readiness and do not
issue PTW in haste

Improper Lifting Causing Damage to Forklift


Area

Incident Description

Causes

During routine operations, the driller requested


a Roustabout to arrange to transfer a landing
joint pipe from tool box basket. The roustabout

noted that rig crane operator was busy assigned


on another task and he requested forklift
operator to remove/lift the joint. A sling was
DD
used to tie the joint end and started to pull
backward and lifting it. The joint swung and
04.11.11 broke through the front screen of the forklift.
Outcome: It resulted in broken cabin glass
protector screen and the operator escaped
unhurt.

Inadequate Leadership (Assistant Rig


Manager (ARM) assigned a task of transferring
drill joint to an inexperienced roustabout
without ensuring availability of resources;
Forklift operator agreed to use the equipment
improperly (i.e. lifting long joint from tool box
basket)
Inadequate Work Planning (Task involving
lifting was assigned to inexperience worker;
cranes availability was not checked properly)

Lessons Learned

1. Use right lifting equipment for the task and do


not take short cuts.
2. Ensure availability of resources (equipment
and skilled staff) when assigning tasks.
3. Effectively empower staff to STOP unsafe
actions.

Loss of Containment During Sand Clearance


Area

Incident Description

Causes

Mile Point 21 is an off site valve station where


BUH crude oil joins NEB/SE/Bab Main Oil Line
(MOL) network point on route to JDA terminal.
This station has manifolds and valves for isolating
or connecting individual pipelines to the MOL
network. Due to sand storms, sand had
accumulated inside the station. The sand
clearance was planned and the work started under

Hot Work Permit using Mechanical Shovel.


TPO

Inadequate Work Planning (Work was


planned using a mechanical shovel in
hazardous area, sand clearance was not
carried at the site since the last two years)
Inadequate Assessment of Work/Job
Hazards (The task was not risk assessed;
assigned staff lacked knowledge of PTW
requirements)
Inadequate Management of Change (A
stub pipe was installed on MOL without
Management of Change (MOC)
documentation)

The job performer and his supervisor who was


acting as Permit Issuing Authority (IA) and Area
Authority (AA) were relatively new staff and were
08.11.11 not fully familiar with all locations utilities. While
the mechanical shovel was used to shift sand a
Lesson Learned
stub pipe extending from MOL1, was struck by the
shovel. Due to dislocation of the stub pipe, oil
1. Obtain excavation certificate for sand
under pressure gushed out and released and
clearance activities in restricted areas as
continued to drain toward low lying catchment
per ADCO PTW requirements (Sec 3.4
areas.
Grading and leveling is considered as
Outcome: Approximately 25,000 Bbl were
excavation and Excavation Certificate must
released before the MOL was completely isolated.
be issued for any excavation activity)

Al Gaith Vehicle Rollover


Area

TPO
21.11.11

Incident Description

Following an oil spill at MP 21 on 08-11-2011, a


contractor crew was assigned on oil recovery
job. On 21st Nov, 2011, after finishing daily
activities, the driver was using a gatch road
from MP 21 toward Abu Dhabi Sila Highway,
driving back to Abu Dhabi with two crew
members. The vehicle was not engaged in 4x4
gears and driven at high speed (107 km/Hr).
The vehicle drifted from the gatch road and the
driver tried to steer it back and applied harsh
brakes. He lost control of the vehicle resulting
in vehicle to roll over.

Causes

Inadequate Identification of Worksite or


Job Hazards (Risks of driving off road by new
driver were not adequately assessed).

Inadequate practice of skill (The driver was


not familiar to drive automatic transmission
vehicle resulting in many harsh brake events).
Per RS RAG report the driver was repeatedly
applying harsh brakes and sharp steering to the
control vehicle when drifted from the gatch road)

Lesson Learned

1. Always adjust vehicle speed according to road


Outcome: Driver and two passengers
condition and engage vehicle in 4x4 mode when
sustained injuries and taken to Mirfa Hospital.
driving off roads
After treatment they were discharged from the
Hospital on the same day. The vehicle was
2. Do not apply harsh brakes & sharp steering to
damaged.
control the vehicle when driving off roads
3. Plan your journeys and do not rush to reach your
destination

Hand Injury During Unloading of Gas Cylinder


Area

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 Management of Change


(Design and location of new cylinder
basket was not risk assessed and not
tested/ inspected for fitness as lifting
boom could not access cylinders due to
design limitations)

Inadequate Identification of
Worksite/ Job Hazards (Untrained staff
were assigned to handle gas cylinders)

Inadequate Procedure (There was no


working procedure in place for lifting and
handling of gas cylinders)

Inadequate Communication (Earlier


incident lessons learned involving gas
cylinders were not effectively
communicated to contractor staff)
Lesson Learned

1. Assign trained staff to handle gas cylinders


2. Develop a working procedure/ instructions
on handling gas cylinders
3. Assess fitness/suitability of equipment
design modifications prior to their use.

Water Tanker Rollover


Area

Incident Description

Causes

During construction activities, a 20 wheeler


water tanker (7000 Gallon capacity) approached

the site. The crew was waiting for permit


Issuing Authority (AI) and the tanker driver
intending to enter the site and park the vehicle
pending offloading the consignment. The there
was an excavated area which was not
E&P
barricaded and there was no banksman to guide
Sahil
the tanker operator. During the maneuvering of
the tanker, the vehicle came close to the
07-10-11 excavation and the ground collapsed resulting
in tanker to loose balance and falling into the
ditch/excavation.

Inadequate Leadership (Job Performer did


not stop the tanker operator from
maneuvering the vehicle in hazardous
conditions)
Inadequate Audit/Inspection/ Monitoring
(Missing barriers around excavated area were
not identified; site supervisors and job
performer did not control access to the site)

Lessons Learned

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

Fall from Elevation


Area

Incident Description

Root Causes

Blasting and painting work was ongoing at a


water storage tank. There were 11 Scaffolders
and they were tasked with the erection of the
scaffold inside the tank. They had reached the
first level, which was at a height of 2.5 Meters
and they had decked out the platform with a

series of scaffold planks to facilitate the


erection of the second level.

Inadequate Leadership (Issuing Authority


issued the permit without checking
scaffolds; Safety professional lacked
knowledge of inspecting scaffold; All three
project management (ADCO, PMC and
SKEC) levels failed to ensure on site
supervision & monitoring)
Inadequate Audit/ Inspection/
Monitoring (There was no mechanism in
place for inspection of scaffold materials;
there was no effective supervision on site)

There were some damaged scaffold boards


which were used in the construction of the
working platforms and there was no prior check
Lesson Learned
27-10-2011 or inspection done to assess fitness of
scaffolds. The scaffolder was not using body
harness. While he was transversing across the
unsupported platform, the scaffold plank
1. Inspect scaffold material prior to erection
snapped at the midpoint and he fell to the
floor. Outcome: He sustained facial injuries
2. Do not use scaffold platform without
(fractured tooth and wound on upper lip).
inspection by a competent inspector
E&P
Bab

3. Use body harness when working at heights


Assign trained safety professional/s to
inspect scaffolds

10

Finger Injuries from Broken Laboratory Glassware


Area

Incident Description

Root Causes

SE
Sahil
28-062011

During normal operation at Asab Laboratory,


crude oil samples were tested and after
completing the test, a new helper/labourer was
assigned to drain the sample and wash the
glassware. The sample had volatile hydrocarbons
and the worker tried to insert a cork in the
sample bottle before taking it to washing area.

Inadequate Identification of Worksite/Job


Hazards (Risks of using untrained labourer in
laboratory environment were not mitigated;
bottles with glass stopper were not used; Sample
was not stabilized prior to handing over to
labourer for draining and cleaning; right PPE was
not selected)
No Training Provided (Labourer was assigned
to work in laboratory without any job specific
training)
Lesson Learned

The labourer was newly assigned to assist staff in


the laboratory and he not aware of hazards of
working with laboratory glassware. When he tried
to insert the cork forcefully, the bottle broke into 1. Prior to assigning any task, ensure
pieces in his hands.
helpers/labourers are trained to perform the task
Outcome: Worker received cut wound on his
2. Use Cut-resistant safety gloves when handling
three fingers.
glassware
3. Use sampling bottles with glass conical stoppers
to avoid pushing or struggling with corks

11

Quiz
Event
1.

True

False

Damage to Over Head Line (OHL)


It is safe to move the topper truck with raised bucket (F)
There were two banksman/flagman to guide the driver (F)

2.

Improper Lifting Causing Damage to Forklift


A sling was used to tie the joint end (T)
Task involving lifting was assigned to an experienced worker (F)

3.

Loss of Containment During Sand Clearance


Work was planned using a mechanical shovel in hazardous area (T)
Assigned staff were not familiar with location of utilities (T)

4.

Al Gaith Vehicle Rollover


The driver was not familiar to drive automatic transmission vehicle resulting in many harsh brake events (T)
The vehicle was not engaged in 4x4 gears and driven at high speed (107 km/Hr) (T)

5.

Hand Injury During Unloading of Gas Cylinder


Untrained staff were assigned to handle gas cylinders (T)
There was a working procedure in place for lifting and handling of gas cylinders) (F)

6.

Water Tanker Rollover


Site supervisors and job performer did not control access to the site (T)
Banksmaen were guiding the tanker driver during maneuvering (F)

7.

Fall from Elevation


Checks were done to assess fitness of scaffold boards (F)
Worker was using body harness when working at heights (F)

8.

Finger Injuries from Broken Laboratory Glassware


Worker was trained for the job (F)
The bottle broke in his hands when he tried to insert the cork forcefully (T)
(F)

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

Million Manhours Worked

120

29

Lost Time Injury Frequency Rate /


Total Recordable Injury Rate

1.2

0.16

0
2001 2002 2003 2004 2005 2006
Year 2007 2008 2009 2010 2011

Manhours

Actual LTIF

TRIR

Historical Vs Q1 2011 HSE Performance

13

Incident Sub Types 2011


(Work & Non-Work Related -265 Events )
BUH

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

Distribution of Incident Sub Types 2011


Fire

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 TPO AUH


5% 3%
DD7%
7%
BUH
10%
SE
24%

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

Incident Immediate & Root Cause Categories

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%

Repetitive Immediate Causes

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%

Repetitive Root Causes

Inattention to footing and surroundings

Inadequate work planning

Improper decision making or lack of judgments

Inadequate identification of worksite/job hazards

Routine activity without though

Inadequate adjustment/repair/maintenance

Violation by individual

Inadequate audit/inspection/monitoring

16

Incident Immediate Cause Analysis 2011


Inattention
Following Procedures
Violation by group
5%

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%

Improper decision making or


lack of judgment
Violation by individual

One individual intentionally chose to violate an established


safety practice.
A supervisor or other management person either personally
violated an established safety practice or directed people
under their supervision to do so.
The person involved was not working at the proper speed,
not taking time to do things safely, e.g., driving too fast,
running or adding chemicals too fast or too slow, etc.

Violation (by supervisor):

Work or motion at improper


speed

25

EMPD, 21
BAB
8%

20
15
10
5
0

DD, 13 SAS, 13

Inattention to surroundings:

Routine activity without


thought:

This cause is the opposite of violations, which are intentional


acts. Unintended human error can consist of perception
errors, memory errors, decision errors or action errors. A
persons job performance was affected by their inability to
make an appropriate judgment when confronted by an
ambiguous situation.
The person was not alert to their surroundings and just
tripped or ran into something that was clearly visible and
obvious.
The person involved was performing a routine activity, such
as walking, sitting down, stepping, etc., without conscious
thought, and was exposed to a hazard as a result.

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

Incident Root Cause Analysis 2011


Work Planning
Inadequate
preventive
maintenance
9%

Management Supervision & Employee Leadership

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

The incident w as caused by the failure to perform or properly


respond to a loss exposure study, such as Job Safety
Analysis.

Inadequate Leadership

The leaders in an area did not set the right direction or tone for
safety or 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%

The tools and equipment provided w ere thought to be right,


but proved to be the w rong tools or equipment, because the
risk associated w ith their use w as incorrectly assessed.
Proper tools and equipment w ere available, but had not been
correctly maintained or repaired

Improper
supervisory
example
23%

Employee perceived haste

The incident w as caused by the employees perception that


speed in completing the w ork was required causing laps in
safety considerations.

Improper supervisory
example

Supervisors not giving the proper example to the people


working in their organizations.

Inadequate reinforcement of
critical behaviors

A supervisor seeing someone not follow ing the safety


procedures and guidelines and not correcting immediately
is an example of inadequate reinforcement of proper
behavior.

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 Based Causes 2011

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%

Tools, Equipment &


Vehicles
9%
Use of Protective
Methods
13%

Following Procedures
19%

Management /
Supervision / Employee
Leadership
16%

Mental State
11%

Behavior
16%

Tools & Equipment


11%

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%

Tools & Equipment


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%

Tools & Equipment


4%
Work Planning
27%

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

Work Place Tools, Equipment &


Environment / Layout Vehicles
4%
Work Exposures 8%
To
8%
Protective Systems
8%

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%

Work Rules / Policies /


Standards / Procedures
11%

Behavior
19%
Work Planning
11%

Tools & Equipment


15%

21

Asset

Immediate Causes

Root Causes

BUH

BUH

Work PlaceTools, Equipment &


Environment / Layout Vehicles
Work Exposures7%
To
3%
Use of Tools
7% or
Equipment
7%
Use of Protective
Methods
13%
Protective Systems
13%

Following Procedures
27%

Work Rules / Policies /


Standards / Procedures
Communication
3%
3%
Behavior
18%

Engineering / Design
9%
Innattention / Lack of
Awareness
23%

Skill Level
16%

Work Planning
13%

Management /
Supervision / Employee
Leadership
16%

Tools & Equipment


16%

DD
DD

Training / Knowledge
Transfer
Engineering / Design
3%
3%

Tools, Equipment &


Protective SystemsVehicles
3%
Work Exposures To 5%
16%

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%

Work Rules / Policies /


Standards / Procedures
20%

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%

Tools & Equipment


8%
Behavior
8%
Skill Level
17%
Work Planning
17%

Management /
Supervision /
Employee
Leadership
50%

23

Causes of Top Two Incident Sub Types, 2011


Immediate Causes

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 Rules / Policies /


Standards / Procedures
11%
Physical Condition
11%
Mental Stress
11%
Work Planning
22%

Work Planning
32%

M anagement /
Supervision / Employee
Leadership
30%

Behavior
23%

Management /
Supervision / Employee
Leadership
22%

Inadequate guards or
protective devices
5%

24

Keep him safe

ABU DHABI COMPANY FOR ONSHORE OIL OPERATIONS


(ADCO)
25

You might also like