Level 2 – Derrick man dies from 30m fall

Date & time of incident 31-May-2005, 07:05 Hours

Region, EP Company, asset team, location EPM, Petroleum Development Oman, Well Engineering, Harweel Area
Proposed classification at time of writing Actual: 4(P) Potential: C4(P)

Incident description 4. Be aware of the maximum pull your rig floor

Ahmed along with several members of the Rig 88 tugger can exert on the sheaves and shackles.
Remember it is a pulley system, the pull is doubled.
night shift crew were preparing the rig to commence
Assume the manufactures stall out pull unless you
drilling operations after completing a rig move. Part
know its actual pull.
of this task is to set back the mast lifting line
5. Use the correct man-ridding winch and an approved
equalising yoke. This requires working at a height of man-ridding (not climbing) harness.
35 meters above the rig floor. It was planned to be 6. Have a proper TBT.
done with one man in the mast itself and one man on
a man-riding winch, both assisting in tying the yoke
back.
During this operation the cable supporting Ahmed fell
off the snatch block hung underneath the crown
block. Ahmed and the supporting cable fell 35m to
the rig floor.
Outcome
Ahmed, 22 year old, suffered multiple injuries and
died on the spot.
Immediate causes
1. The retaining bolt securing the cheek plate on the
snatch block backed out. The safety pin had not
been installed. The block had been subject to many
activities during the preceding 8 hours which may
have contributed to the backing out of the bolt.
2. The deformed cheek plate had been, subject to a
load much greater than man-ridding alone. A stall
pull with the winch would be powerful enough to
deform this plate. The rig had pulled out master-
bushings preceding this incident.
3. Ahmed was lifted too high. He was suspended on a
10m tail chain. At the height he was supposed to be
lifted to, this would have put the interface between
chain and cable at the block point.
4. No secondary fall device was fitted. This secondary
device in its simplest form is a wire sling below the
snatch block to catch the cable in the event of a
catastrophic failure.
5. The utility winch instead of the man ridding winch
was used to lift Ahmed.
6. A climbing belt was used instead of a man-riding
harness. No secondary fall device was used on this
belt.
7. No hazard awareness or control. The PTW system
was disregarded. No meaningful TBT was hel or
Job instructions was given.

Lessons learned
1. Ensure a secondary fall device is fitted on all crown
block sheaves.
2. Review the PTW system. Is it really being used or a
paper exercise?
3. Rigging up safety critical equipment is a PTW
activity, at least check that a second pair of eyes
looks at all critical equipment.
Level 3 – Derrick man dies from 35m fall
Date & time of incident 31-May-2005, 07:05 Hours
Region, EP Company, asset team, location EPM, Petroleum Development Oman, Well Engineering, Harweel Area
Proposed classification at time of writing Actual: 4(P)
Incident description
A derrick man and several members of the Rig 88
night shift crew were preparing the rig to commence
drilling operations after completing a rig move. Part
of this task is to set back the mast lifting line
equalising yoke. This requires working at a height of
35 meters above the rig floor. It was planned to be
done with one man in the mast itself and one man on
a man-riding winch, both assisting in tying the yoke
back.
During this operation the cable supporting the derrick
man fell off the snatch block hung underneath the
crown block. The derrick man and the supporting
cable fell 35m to the rig floor.
Outcome
The 22-year-old derrick man, suffered multiple
injuries and died on the spot.
Immediate causes
1. The retaining bolt securing the cheek plate on the
snatch block backed out. The safety pin had not
been installed. The block had been subject to
many activities during the preceding 8 hours
which may have contributed to the backing out of
the bolt
2. The deformed cheek plate had been, subjected to
a load much greater than man-riding alone. The
same air winch had pulled out the master-
bushings preceding this incident.
3. The derrick man was lifted too high. He was
suspended on a 10m tail chain, this caused the
tail chain to roll off the open snatch block
4. No fall device was fitted below the snatch block
5. The utility winch instead of the man riding winch
was used to lift the derrick man.
6. A climbing belt was used instead of a man-riding
harness. No secondary fall device was used on
this belt.
7. No hazard awareness or control. The PTW
system was disregarded. No meaningful TBT
was held or Job instructions were given.
Immediate actions:
1. All rig and hoist contractors have submitted a
statement of fact regarding how they manage
their man-riding operations.
2. Operational practices are now being updated on
all units in the PDO fleet
3. NDSC are revising their HSE on-boarding
process. No individual will start work without a
good understanding of their basic HSE
requirements
Potential: C4(P)
4. NDSC will review their man-riding requirements
and make them realistic and controlled to the
work that is required
Underlying causes:
1. Failure of the NDSC HSE-MS. Many of the rules
and procedures present in the NDSC-MS were
openly violated on Rig-88. A culture of
progressing work, supported by the senior staff
on the rig, at the cost of safety was present
2. Failure of the NDSC new start selection and
induction process
3. The competence of Rig-88 staff, at all levels, to
recognise, rig up and verify safety critical
equipment.
4. Empowerment to Stop an unsafe act was not
active on Rig-88
5. Equipment standards generally across the PDO
fleet had deteriorated
6. The competence of Supervisors and HSE leaders
across the PDO fleet had deteriorated
Senior Management Actions to Address
Underlying Causes
1. NDSC management are to review how their HSE
MS is interpreted on each unit. All procedures
are to be reviewed for effectiveness and accuracy
2. NDSC to roll out safety critical tasks to all
employees, verification of understanding is to be
undertaken
3. PDO Well Engineering to undertake a 3rd party
review of standards and competencies across the
fleet and subsequently act upon findings and
place resources in the field to maintain standards
4. PDO WE to modify the HSE Case slinging and
lifting section in line with findings from this
incident
5. PDO WE to modify the ROHM File (Rig
Operational Hazard Management) in line with
findings from this incident
6. PDO WE will take an in depth look at equipment
standards, competence and HSE
attitude/leadership across its fleet, resources will
be made available to correct any deficiencies
noted
7. All PDO WE contractors are to introduce
dedicated (not dual purpose) man-riding winches,
on all drilling units
8. All PDO WE contractors will critically review
means to phase out man-riding by Dec 2006