ACCIDENT INVESTIGATION REPORT

MANUAL TONG HIT THE DRILLER WHEN BREAKING

OUT 8” DRILL COLLAR WITH MANUAL TONG

January 12, 2009 at 12.45 pm.

HPS RIG #05 , KUW North 1

 REPORT OUTLINE
1. Accident Description
2. Accident Photo’s
3. Accident Sketch's
4. Root Cause Analysis and Verification
5. Root Causes and Category
6. Recommendation
 1. Accident Description
On Monday, January 12, 2009 at time: 12.45 pm
while POOH 12 ¼” hole. Driller breaking out 8” Drill
collar with rig manual tong. After connecting manual
tong by Floor man to 8 “ Drill collar, the Driller
(victim) operate manual tong to breakout drill collar
joint, manual tong broken a latch jaw hinge pin. This
caused the found out the broken jaw to hit right flank
and the Driller fall in the rig floor. After that
Toolpusher and all floor man take the stretcher and
go down to the car furthermore to hospital at
Sorong.
2. Accident Photo’s
2. Accident Photo’s
3. Accident Sketch’s

DRILL
COLLAR
LEVER

LATCH
 3. Accident Sketch’s

MAST
DRILLER (VICTIM)

MANUAL TONG

DRILL COLLAR

RIG FLOOR
6. Root Cause Analysis and Verification
Why - Tree Method of Incident Analysis
POOH 12 ¼” hole and breaking
out 8” Drill collar with rig manual EVENT
VERIFICATION
tong.

Nobody check the condition

VISUAL CHECK of equipment before starting HUMAN CAUSE
the job.

INTERVIEW Not following result of NDT

inspection that manual tong
must be replace.

Nobody remind about Driller don’t know

INTERVIEW condition of manual tong maximum tension the
base on NDT inspection manual tong.

Manual tong broken a latch jaw hinge pin and hit Driller
INTERVIEW

Lack of team Lack of JSA & SOP

work communication Implementation
SYSTEM LEVEL and supervision
 7. Root Causes and Categories

No Root Causes Root Cause Category

1 Lack of JSA & SOP Procedure
Implementation

2 Lack of Team Work Procedure

Communication
 8. Recommendation
No Description Corrective Action Due Date PIC Status
1 Lack of SOP Refresh SOP using manual January Rig Supt. & Close
Implemented tong to all crew Rig. 13, 2009 HSE Officer

Socialize to make JSA for January Rig Supt.& Continue

high risk work before 13, 2009 HSE Officer
conducted

Following result of NDT January Rig Manager Close

inspection that manual tong 12, 2009
must be replace with new
one
2 Lack of Team Refresh team work January Rig Close
Work communication to all rig 12, 2009 Manager,
Communication crew, support and service Rig Supt &
company HSE Officer

Inspect all equipment & January Rig Supt., Close

reminding each other if see 12, 2009 HSE Officer
unsafe condition or action. & all crew