2018 PFH

REPORT JULY
2018pfh 2019
DATA SERIES
Safety performance indicators –

Process safety events – 2018 data
Fatal incident and high potential event reports
Fatal incidents and high potential events that were also process safety events (PSE),
and fatal incidents and high potential events that were PSE-related – 2018
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REPORT JULY
2018pfh 2019
DATA SERIES
Safety performance indicators –

Process safety events – 2018 data
Fatal incident and high potential
event reports
Fatal incidents and high potential events that were also process safety events (PSE),
and fatal incidents and high potential events that were PSE-related – 2018
Revision history
VERSION DATE AMENDMENTS
1.0 July 2019 First release

Fatal Incident and High Potential Event reports – Process safety events 2018
Contents
FATAL INCIDENT REPORTS CLASSIFIED AS TIER 1

PROCESS SAFETY EVENTS – 2018 5
FATAL INCIDENT REPORTS RELATED TO PROCESS SAFETY

BUT NOT CLASSIFIED AS TIER 1 PROCESS SAFETY EVENTS 2018 7
HIGH POTENTIAL EVENTS CLASSIFIED AS PROCESS

SAFETY EVENTS – 2018 8
HIGH POTENTIAL EVENTS RELATED TO PROCESS SAFETY

BUT NOT CLASSIFIED AS PROCESS SAFETY EVENTS 2018 14
4
FATAL INCIDENT REPORTS CLASSIFIED AS

TIER 1 PROCESS SAFETY EVENTS – 2018
DATE: Aug 12 2018

LOCATION: Africa, NIGERIA
DATA SET: 3rd Party Offshore
WORK FUNCTION: Production
INCIDENT CATEGORY: Struck by
ACTIVITY: Production operations
LIFE SAVING RULE: No appropriate Rule
WORKFORCE DEATHS: 0 3RD PARTY DEATHS: 1
No Victim details
NARRATIVE: A third party self elevating platform was being towed and separated from its tug
during bad weather. The third party self elevating platform ran into a natural gas line, which
ignited on fire. The crew of the third party self elevating platform abandoned the ship, resulting
in a third-party fatality.
WHAT WENT WRONG: Third party ran into offshore platform.
LESSONS LEARNED AND RECOMMENDATIONS: Operating in an uncontrolled environment.
CAUSAL FACTORS:
PROCESS (CONDITIONS): Work Place Hazards: Storms or acts of nature
DATE: May 18 2018

LOCATION: Russia & Central Asia, KAZAKHSTAN
DATA SET: Company Onshore
WORK FUNCTION: Unspecified
INCIDENT CATEGORY: Explosions or burns
ACTIVITY: Drilling, workover, well services
LIFE SAVING RULE: Work authorisation
NARRATIVE: Workover contractor had to replace the ESP, which had tripped because it
reached the high motor temperature set point at a well. A workover program was defined by the
company and the well was handed over from production to the contractor (MT) on 18.05.2018.
The dayshift crew had completed rig up the next day by 90% and handed over to the next shift,
which completed the rig up and spudded the well at 20:00. After reading the casing and tubing
pressures (0 bar), the well was opened and circulation commenced by pumping water down the
tubing taking returns from the annulus. Gas vented up the drain line (flexible hose), which was
pushed through a grill on the drain. A member of the team (driller) was posted to the drain tank
to listen for gas returns entering the tank.
Gas vented into the tank and started to diffuse out of the tank before the driller realized that
gas was present. The gas migrated towards the diesel circulation pump mixed with air and was
drawn into the circulation pump causing the motor to ‘race’. The Toolpusher attempted to turn
the circulation pump off but was unable to as the presence of fuel in the air intake allowed the
motor to run independently. The attempt to shut the valve at the Xmas tree failed. The gas cloud
ignited. As a result, 3 members of the workover crew died after suffering severe burn injuries
5
FATAL INCIDENT REPORTS CLASSIFIED AS TIER 1 PROCESS SAFETY EVENTS
and one other member broke his legs as he attempted to escape. The blast also set fire to the
bleed off tank, rig and pump on fire.
WHAT WENT WRONG:
• Mild wind blowing gas venting from the drain tank to the circulation pump
• Uncontrolled bleeding off (no use of choke manifold, bleed off not vented through a
separator with flare off))
• Insufficient distance between drain tank, rig and circulation pump
• Insufficient gas detection resulting from:
-- Drift to unsafe work practices due to normalization of deviance
-- Violation of contractors own work instructions in equipment layout, set-up and operation
-- Poor supervision, accepting unsafe condition
-- Poor implementation of regulation and processes (e.g. bridging document, safety rules)
-- Insufficient workover resources within Company leading to reduced oversight capacity
-- Inadequate management and governance of a contractor with weak safety management
and culture
-- Inadequate assurance of competences and compliance to standards in field operations
-- Risk management for country specific challenges not properly implemented
-- Lessons learnt from previous accidents remained on a superficial level, systematic
factors from similar incidents not identified and implemented are the main causes of the
incident.
LESSONS LEARNED AND RECOMMENDATIONS:
• Ensure an effective process for oversight of safety critical activities of both own and
contractor work
• Update Well Engineering Technical Standard to include additional information for WO/WI
minimum requirements for preparation and execution of operations worldwide
• Establish formal process for sustained implementation and verification of actions from
incidents group wide
• Fill vacancies and review organization to ensure suitable resources are recruited for planned
work scope
• Improve contractor management by reviewing WO/WI work instructions, identifying gaps and
developing action plan, and
• Develop well site-specific work instruction for preparation and execution of WO/WI
operations (incl. layout, minimum distances, gas monitoring) are the main recommendations
to prevent any re-occurrence.
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Improper position (in the line of fire)
PEOPLE (ACTS): Use of Protective Methods: Failure to warn of hazard
PROCESS (CONDITIONS): Organisational: Inadequate training/competence
PROCESS (CONDITIONS): Organisational: Inadequate hazard identification or risk assessment
PROCESS (CONDITIONS): Organisational: Inadequate supervision
PROCESS (CONDITIONS): Organisational: Failure to report/learn from events
6
FATAL INCIDENT REPORTS CLASSIFIED AS TIER 1 PROCESS SAFETY EVENTS
DATE: May 2 2018

LOCATION: Africa, ALGERIA
DATA SET: Contractor Onshore
ACTIVITY: Drilling, workover, well services
LIFE SAVING RULE: Energy Isolation
NARRATIVE: A jet fire developed at a wellhead site during a Coil Tubing Operation performed by
a CTU Contractor at an injection well. The gas injection manifold had been left under pressure
and isolated via the manual wing valves. A gas leakage occurred due to the ejection of an
instrument plug at the Manual Wing Valve flange from its seat. The damage of the plug was
caused by a shock from external source, presumably caused by the CTU mast moved by an
incoming sand storm, associated with the gas line internal pressure.
The jet fire caused complete destruction of the coil tubing equipment and spread to the adjacent
vehicles. The thermal radiations associated to the jet fire caused a 3rd degree burn for a
contractor helper located in close proximity of the jet fire, who died
WHAT WENT WRONG: Life-saving rule violation (Energy Isolation), procedure followed
incorrectly, the isolation valve at the inlet to the well pad was left open.
LESSONS LEARNED AND RECOMMENDATIONS: Strictly apply the LOTO procedure according to
the outcomes of the Risk Assessed Method Statement for coil tubing operations.
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Violation unintentional (by individual or group)
PEOPLE (ACTS): Use of Tools, Equipment, Materials and Products: Servicing of energized
equipment/inadequate energy isolation
PEOPLE (ACTS): Inattention/Lack of Awareness: Improper decision making or lack of judgment
PROCESS (CONDITIONS): Tools, Equipment, Materials & Products: Inadequate design/
specification/management of change
PROCESS (CONDITIONS): Work Place Hazards: Storms or acts of nature
FATAL INCIDENT REPORTS RELATED TO

PROCESS SAFETY BUT NOT CLASSIFIED AS
TIER 1 PROCESS SAFETY EVENTS 2018
No incident reports
7
HIGH POTENTIAL EVENTS CLASSIFIED

AS PROCESS SAFETY EVENTS – 2018
DATE: Aug 6 2018

LOCATION: South & Central America, PERU
INCIDENT CATEGORY: Pressure release
LIFE SAVING RULE: Insufficient information to assign a Rule
NARRATIVE: During a planned partial maintenance shutdown (two cryogenic towers out of
service), at 21:00:30 hrs a sudden stop of the remaining three operational cryogenic towers
occurred due to the activation of the High Level (HL) trip in the de-ethanizer towers.
The combination of high pressure in the slug catcher and the 4oo5 logic (ZAC) activated a level 3
shutdown of the facility. The entrance pressure at the slug catcher rose from 1350psi to 1450psi,
originating a major gas leak in a blind flange at a tie-in of a recently installed flowline (PSVs
were set to open at 1800psi). HL in the towers occurred due to a false signal in a low pressure
switch, which closed the towers' discharge valves. The pressure switch had been recently
serviced. Immediate actions: The slug catcher area was depressurized. Safe working conditions
were verified in the area. The blind flange were the leak occurred was intervened.
WHAT WENT WRONG:
PEOPLE FACTORS: Insufficient practice: The contractor involved in the pressure switch
maintenance did not have enough personnel and subcontracted additional laborers dedicated
to other maintenance tasks to complete its work groups. The subcontracted personnel did not
have the required previous experience in the works to be performed.
WORK FACTORS: Inadequate work planning: Delays in work execution caused initially separate
tasks to overlay, meaning that too many people were working in the same place at the
same time, including the same electrical panels and circuits. Some electrical components
were still not fully operational and tested when startup of the facility took place. Inadequate
communication between work groups. There is no evidence that the work groups had received
appropriate directives regarding the newly installed electrical system verification and potential
impact on other existing electrical systems, and plant operation in general. Inadequate work
delegation The contractor in charge of the new tie-in submitted a torque procedure and final
torque verification report, which had been validated by the their QC supervisor, which were
considered as valid without further verification and the facility was freed for startup. Inadequate
monitoring of standards' compliance The contractor's torque check list and procedure do not
allow a proper assurance of the task's realization.
LESSONS LEARNED AND RECOMMENDATIONS: Adequate to the Corporate Standard, which
states that “Switches shouldn’t be used to detect process trip parameters. Transmitters are
recommended for shutdown functions.” Verify how the HL trips are set in the de-ethanization
towers, including their alarms, and define them in accordance with the PST. Define a Policy for
alarms modification regarding users and access levels. Reinforce the practice which requires
that work permits related to signal panels have to explicitly include all signals directly or
indirectly involved in the task to be performed. Communicate and verify compliance with the
standard for commissioning of automation and control equipment. Elaborate a procedure
for torque tasks (in relation to the blind flange leak). Include the use of this procedure as an
obligation in all services.

8
HIGH POTENTIAL EVENTS CLASSIFIED AS PROCESS SAFETY EVENTS – 2018
CAUSAL FACTORS:
PEOPLE (ACTS): Use of Protective Methods: Inadequate use of safety systems
PEOPLE (ACTS): Inattention/Lack of Awareness: Improper decision making or lack of judgment
PEOPLE (ACTS): Inattention/Lack of Awareness: Lack of attention/distracted by other concerns/
stress
PROCESS (CONDITIONS): Protective Systems: Inadequate/defective warning systems/safety
devices
PROCESS (CONDITIONS): Protective Systems: Inadequate security provisions or systems
PROCESS (CONDITIONS): Tools, Equipment, Materials & Products: Inadequate maintenance/
inspection/testing
PROCESS (CONDITIONS): Organisational: Inadequate work standards/procedures
PROCESS (CONDITIONS): Organisational: Inadequate communication
PROCESS (CONDITIONS): Organisational: Poor leadership/organisational culture
DATE: Jan 15 2018

LOCATION: Europe, ROMANIA
NARRATIVE: Pipeline rupture led to an uncontrolled gas release
WHAT WENT WRONG: External punctual isolated corrosion due to a potential defect of the
external coating
LESSONS LEARNED AND RECOMMENDATIONS: Continuing replacement of all segments of
this particular gas pipeline
CAUSAL FACTORS:
PEOPLE (ACTS): Use of Protective Methods: Failure to warn of hazard
inspection/testing
PROCESS (CONDITIONS): Work Place Hazards: Hazardous atmosphere (explosive/toxic/
asphyxiant)
PROCESS (CONDITIONS): Organisational: Inadequate communication
PROCESS (CONDITIONS): Organisational: Failure to report/learn from events
9
DATE: Aug 27 2018

LOCATION: Europe, NETHERLANDS
DATA SET: Company Offshore
NARRATIVE: Just before de-manning, the OIM from the normally unmanned offshore platform
did his last check round and smelled gas in the room of the gas generator. Approx 800 kg of fuel
gas had leaked through the air inlet of a gas generator in to the enclosure of the generator. The
gas generator had tripped, but the fuel gas to the generator kept flowing in because the two
remote operated valves in the fuel supply line to the gas generator failed to close on demand.
The OIM stopped the fuel supply to the gas generator by closing the hand valve in the supply line.
WHAT WENT WRONG: Both remote operated shutdown valves in the fuel gas supply did not
close on demand as the actuators of these valves were stuck in the open position. Causes were
that instrument air was wet, resulting in corrosion and particle (corrosion products, absorbent)
generation in the instrument air system (actuators, solenoids).
Additional underlying causes were:
• Failures in design integrity / management of change; incomplete ALARP assessment of the
impact of changing to unmanned operation & incompatibility between the unmanned mode
of operation and the design of the installation.
• Failures in technical integrity; the instrument air auto-drain system was not operated /
maintained properly and alarm systems and remote operations were functioning poorly.
• Failures in operating integrity; i.e. alarm management was not effective, earlier failures of
the ROV on the gas generator were not identified despite physical IPF testing being done in
the field.
• Organise multi-disciplinary session, re-visit ALARP statement and develop criteria (re
instrument air/dryer, checking of actuators/solenoids, cooling capacity/ventilation, SIF
testing, procedures IA system). Work and mature concepts to de-complex platform and bring
systems on location in line with other NUI platforms.
• Dry and ‘clean’ instrument air system, replace faulty/degraded (safety critical) equipment.
Implement performance standard for instrument air. Review maintenance strategy plan.
• Increase knowledge levels on IA systems in NUI team.
CAUSAL FACTORS:
PEOPLE (ACTS): Use of Protective Methods: Inadequate use of safety systems
PROCESS (CONDITIONS): Protective Systems: Inadequate/defective warning systems/safety
devices
10
PROCESS (CONDITIONS): Tools, Equipment, Materials & Products: Inadequate/defective tools/

equipment/materials/products
inspection/testing
PROCESS (CONDITIONS): Work Place Hazards: Hazardous atmosphere (explosive/toxic/
asphyxiant)
DATE: Dec 12 2018

LOCATION: Africa, ALGERIA
LIFE SAVING RULE: Energy Isolation
NARRATIVE: While performing hydrostatic pressure test on a scrubber (2000psi) the employee
walked around the scrubber to check the pressure gauge and check for potential leaks. At this
moment, the plug installed on one instrument connection, blew out hitting the employee on his
upper right leg causing a severe cut on the thigh muscle leading to amputation of the leg
WHAT WENT WRONG: Inadequate training Inadequate equipment (plugs). In the line of fire.
LESSONS LEARNED AND RECOMMENDATIONS: Organization measures, detailed procedures
and training are essential prevention tools to avoid this type of incidents
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Violation unintentional (by individual or group)
PEOPLE (ACTS): Use of Tools, Equipment, Materials and Products: Improper use/position of
tools/equipment/materials/products
PEOPLE (ACTS): Use of Tools, Equipment, Materials and Products: Servicing of energized
equipment/inadequate energy isolation
11
DATE: Feb 18 2018

LOCATION: Europe, UK
DATA SET: Contractor Offshore
ACTIVITY: Construction, commissioning, decommissioning
LIFE SAVING RULE: Line of fire
NARRATIVE: The Gas Import Manifold was being lined up to the production flow line. During
offshore commissioning works. As a valve was opened, the cavity bleed plug at the bottom
of the valve was ejected without warning and with explosive force - driven by a pressure of
approximately 128 Bar.
WHAT WENT WRONG: Inadequate procedures for leak testing of the valve, operator line checks
and gradual introduction of gas across the valve.
LESSONS LEARNED AND RECOMMENDATIONS: Updated procedures to mandate scope of
valve leak testing, gradual introduction of gas and line walks.
CAUSAL FACTORS:
PEOPLE (ACTS): Following Procedures: Improper position (in the line of fire)
inspection/testing
DATE: Jul 22 2018

LOCATION: Asia/Australasia, AUSTRALIA
NARRATIVE: An operator located near the oily water pit was alerted, by a personal gas detector
alarm, to the presence of hydrocarbon gas. The operator went towards the oily water pit, and
the personal gas detector indicated a 100% LEL flammable atmosphere at 150mm from the oily
water pit. The operator established, through a process of elimination, that the source of gas was
the oily water drain line from the V1 suction scrubber on screw compressor 3 and he proceeded
to shut down the unit and inform his line supervision.
12
The leak rate has been estimated, through process calculation, to be 88.6kg/h. The total volume
of gas to atmosphere is currently unknown. The previous operator check undertaken at 19:40
hrs on the 21/07/2018 did not indicate any abnormalities. Therefore, the initiating event likely
occurred between these two operator visits which were approximately 19 hours apart. Worst
case scenario is that 1683 kg of gas was released to the atmosphere. No one was hurt, and no
community members were affected by the incident.
This incident was classified has a Tier 2 Process Safety Event.
WHAT WENT WRONG: Mechanical Instrument Failure Concurrent failure of the compressor
scrubber level controller and the low level safeguard resulted in a flow path to the oily water
drain, which is vented to atmosphere.
Lessons Learned:
1. Risk normalisation: The oily water pit was perceived to be a safe release point.
2. Learning from Incidents: An identical gas blow by incident occurred two months prior.
3. Safeguarding: Inadequate (1) proof testing procedure and (2) actual proof testing execution.
Recommendations:
1. Re-engineer the scrubber low level safeguarding function to reduce the likelihood of
dangerous unrevealed failures.
2. Develop specific proof test procedures for the scrubber low level safeguarding function, and
execute them as per CMMS schedule.
3. Implement previously identified H&RA controls. Establish a hard barrier exclusion zone
around the oily water pit. Draft Investigation report and LFI complete, with Operations
manager (investigation sponsor) for review.
CAUSAL FACTORS:
PROCESS (CONDITIONS): Protective Systems: Inadequate/defective guards or protective
barriers
inspection/testing
13
DATE: May 8 2018

LOCATION: North America, USA
DATA SET: Company Offshore
NARRATIVE: A gas release resulted from third-party transmitter connection on the Platform. A
hydrocarbon gas leaking from export sales gas meter was discovered by personnel in the area.
WHAT WENT WRONG: During maintenance work 18 days before the gas release, incorrect
Teflon seals were installed in the meter instead of Viton O-rings.
• Identify locations in high pressure gas service where Teflon seals are used and replace with
appropriate seals.
• Work being completed by third party equipment owners must be subject to effective
oversight.
• Verify that employees are trained, drilled, and empowered to activate general alarm or
emergency shut down in an emergency. Assessments and drills for managing emergencies
must be rigorous to provide effective preparation.
CAUSAL FACTORS:
inspection/testing
HIGH POTENTIAL EVENTS RELATED TO PROCESS

SAFETY BUT NOT CLASSIFIED AS PROCESS
SAFETY EVENTS 2018
No events
14
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Fatal incidents and high potential

events that were also PSE, and fatal
incidents and high potential events
that were PSE-related – 2018

2018 PFH

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2018 PFH

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REPORT JULY

Safety performance indicators –

IOGP welcomes feedback on our reports: publications@iogp.org

These Terms and Conditions shall be governed by and construed in accordance

Safety performance indicators –

VERSION DATE AMENDMENTS

1.0 July 2019 First release

FATAL INCIDENT REPORTS CLASSIFIED AS TIER 1

FATAL INCIDENT REPORTS RELATED TO PROCESS SAFETY

HIGH POTENTIAL EVENTS CLASSIFIED AS PROCESS

HIGH POTENTIAL EVENTS RELATED TO PROCESS SAFETY

FATAL INCIDENT REPORTS CLASSIFIED AS

DATE: Aug 12 2018

DATE: May 18 2018

FATAL INCIDENT REPORTS CLASSIFIED AS TIER 1 PROCESS SAFETY EVENTS

FATAL INCIDENT REPORTS CLASSIFIED AS TIER 1 PROCESS SAFETY EVENTS

DATE: May 2 2018

FATAL INCIDENT REPORTS RELATED TO

HIGH POTENTIAL EVENTS CLASSIFIED

DATE: Aug 6 2018

HIGH POTENTIAL EVENTS CLASSIFIED AS PROCESS SAFETY EVENTS – 2018

DATE: Jan 15 2018

HIGH POTENTIAL EVENTS CLASSIFIED AS PROCESS SAFETY EVENTS – 2018

DATE: Aug 27 2018

HIGH POTENTIAL EVENTS CLASSIFIED AS PROCESS SAFETY EVENTS – 2018

PROCESS (CONDITIONS): Tools, Equipment, Materials & Products: Inadequate/defective tools/

DATE: Dec 12 2018

HIGH POTENTIAL EVENTS CLASSIFIED AS PROCESS SAFETY EVENTS – 2018

DATE: Feb 18 2018

DATE: Jul 22 2018

HIGH POTENTIAL EVENTS CLASSIFIED AS PROCESS SAFETY EVENTS – 2018

HIGH POTENTIAL EVENTS CLASSIFIED AS PROCESS SAFETY EVENTS – 2018

DATE: May 8 2018

HIGH POTENTIAL EVENTS RELATED TO PROCESS

Fatal incidents and high potential

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