Scribd Logo
Upload

Welcome to Scribd!

  • 5Why-RWC - Australia - Ver 25-May V3

    Uploaded by

    孔超
    22 views3 pages
    An incident occurred at the Jandakot facility where an individual (IP) tripped and fell while carrying a logging tool (CCL), weighing 18.8kg, on their shoulder. As the IP backed away from the container rack where the tool was stored, their left leg became entangled in a tool stand on the ground, causing them to lose balance and fall. Upon falling, the tool fell from the IP's shoulder and struck their right hand, resulting in a severe laceration to their middle finger requiring five stitches. The investigation found the root causes were deficiencies in management systems around enforcement of safety procedures and gaps in the IP's training regarding hazard identification and risk awareness. Corrective actions

    Original Description:

    Original Title

    5Why-RWC_Australia_Ver 25-May V3.pptx

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    An incident occurred at the Jandakot facility where an individual (IP) tripped and fell while carrying a logging tool (CCL), weighing 18.8kg, on their shoulder. As the IP backed away from the container rack where the tool was stored, their left leg became entangled in a tool stand on the ground, causing them to lose balance and fall. Upon falling, the tool fell from the IP's shoulder and struck their right hand, resulting in a severe laceration to their middle finger requiring five stitches. The investigation found the root causes were deficiencies in management systems around enforcement of safety procedures and gaps in the IP's training regarding hazard identification and risk awareness. Corrective actions

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    22 views3 pages

    5Why-RWC - Australia - Ver 25-May V3

    Uploaded by

    孔超
    An incident occurred at the Jandakot facility where an individual (IP) tripped and fell while carrying a logging tool (CCL), weighing 18.8kg, on their shoulder. As the IP backed away from the container rack where the tool was stored, their left leg became entangled in a tool stand on the ground, causing them to lose balance and fall. Upon falling, the tool fell from the IP's shoulder and struck their right hand, resulting in a severe laceration to their middle finger requiring five stitches. The investigation found the root causes were deficiencies in management systems around enforcement of safety procedures and gaps in the IP's training regarding hazard identification and risk awareness. Corrective actions

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 3

    Wireline & Perforating

    Medical Treatment Case


    #Q038.HS.051920.00246018

    WP – Jandakot
    19-May-2020

    FOR INTERNAL USE ONLY


    Incident Investigation – RWC, WP, Australasia
    Location: Australia, Jandakot Facility Date &Time: 19th May 2020, 3.45PM Status: Investigation Completed
    PSL: Wireline & Perforating (Well Monitoring) Event ID#: #Q038.HS.051920.00246018
    Customer: not applicable

    Incident Details Lines of Defense


    IP was removing 3-3/8” CCL tool from container rack. After removing IP placed tool upon ST-GL-HAL-HSE-0801 -Ergonomics and Manual Handling. Failure
    shoulder (tool weight 18.8kg). IP backed away from container and it was at this point, IP to adhere to requirements regarding Manual Handling of Materials and
    left leg became entangled with tool stand on ground. IP lost balance, tripped and fell to Objects: Obstacles in the route of travel; choose a new route or
    ground. Upon impact with ground, IP arms/hands (palms down) were placed in front to remove obstacles
    protect from impact. It was at this point the dislodged CCL fell and struck the IP on the
    right hand, resulting in severe laceration to side of middle finger requiring five stitches. IP
    was wearing impact gloves at time of incident.

    Investigation Details Corrective and Preventive Actions


    Primary Causal Factor: Struck by falling object after tripping and falling Local Corrective Action:
    Why? – IP was carrying logging tool (CCL) on shoulder  PSL and Area (all PSL) Safety Stand Down – communicate
    Why? – IP moving backwards from container resulted in left leg becoming entangled incident, learnings (Completed 20th and 21st May 2020)
    in tool stand
    Why? – Tool stand was not cleared after use - poor housekeeping  Reinforce 5S and Housekeeping culture – weekly Supervisor
    Why? – Behavior - individual 5S walkthroughs to be reinforced (Ongoing). Accountability
    Why? – Supervision and enforcement needs improvement Measures to be applied where individual deficiencies are
    identified
    Root Cause: Management Systems > SPAC Not Used > Enforcement NI  Safety Behavioral School (BBS) to be conducted in all
    locations.
    Primary Causal Factor: Struck by falling object after tripping and falling

    Why? – IP moving in backwards motion from container resulted and left leg
    becoming entangled in tool stand
    Why? – IP not fully aware of surrounds - did not recognize risk / identify clear route  Global Corrective Action: Not Applicable
    to be taken (ensuring travel path clear of obstacles prior to carry)
    Why? – Risk Normalization – IP level of risk tolerance needed improvement
    Why? – IP Personal perception of hazard situation (area) ineffective
    Why? – Behavioral Based Safety training needs improvement

    Root Cause: Training > Understanding Needs Improvement > Continuing Training
    NI

    FOR INTERNAL USE ONLY 2


    RWC – Reenactment sequence

    PCE Skid from where IP was IP removes CCL and places on IP backs away from container and
    removing CCL shoulder leg entangles in tool stand –
    resulting in trip and fall

    IP falls to ground, arms CCL lands on IP right hand striking IP sustains laceration to index
    outstretched and hands down index and ring fingers finger requiring 5 stitches

    FOR INTERNAL USE ONLY 3

    You might also like