Professional Documents
Culture Documents
CAUSES
1. Improper body position; IP was blocking view for Driller and right hand of IP
was place on handrail
2. Inadequate Knowledge and Skills; IP provided verbal signal, Green Hats not
properly supervised, inadequate Risk Assessment
3. Intervention not practiced; None involved or observers stopped the operation
when view of Driller was obstructed
LEARNINGS
• Keep your hands clear of pinch points
• Never block the view of the operator with your body
• Ensure proper supervision of Green Hats at all times
• Operation could be done “Hands Off”
CAUSES:
• The Injured Person was looking upwards to monitor the winch line while handling the slip
• Tag Line not used (hands free ) for handling the hoisted load.
• Wrong body position & incorrect hand placement of the Injured Person.
• The Farr Tong trolley was not elevated to have safe clearance and clear line of sight to
the slip being hoisted.
• The pinch point areas on the slip and Farr Tong trolley were not marked.
LEARNINGS:
• During TBT’s identify job specific Pinch Points.
• Conduct hazards hunts to ensure that all Pinch Points are identified, recorded and
marked.
• Ensure safe body position prior to handle the load / equipment
IP placed his hand wrongly close to the ACC BTM. The derrick-man felt that the
accelerator will hit the DC in rotary and removed his hand at this moment
putting all the load on the IP.
The IP couldn’t handle the accelerator himself. His right hand little finger was
crushed & Ring finger was abraded
CAUSES:
• Improper tubular handling. (no Rope used).
• Wrong hand placement of the IP
• Lack of proper supervision.
LATERAL LEARNING:
• Always use the rope to control the tubular movement.
• Avoid placing hands/finger in pinch points (between
loads).
• Never use your hand to control the tubular movement.
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Principle 1: Hands OFF Loads
Severity:
Actual =LTI(3P) ; Potential =LTI(C3P)
INCIDENT DESCRIPTION:
While offloading 3 ½” IF DP Joint, 13.3 #,9 m) from Hoist trailer, the floor
man attached 1.6 ton SWL Web Sling to the Forklift hook and tied to the
drill pipe joint on trailer pipe rack fingers. During lifting operation the pipe
joint swung to the side and suddenly the IP attempted to guide and
balance the pipe away from the Forklift to avoid hitting the Forklift
windscreen.
The Floorman got his left hand trapped between the pipe stopper and the
Drill pipe resulting in left hand middle and ring finger injuries.
CAUSES:
• Improper Lifting – Wrong use of Webbing Sling
• Improper Hand position – Use a Tag line
• Failure to use Empowerment to Stop the Work
LEARNINGS
• Always use two slings to offload tubular
• Use tag line to stabilize the load
• Do not use hands to stabilize the load
Use tag line to stabilize the load
Always use two slings to offload the tubulars
TS
OIN
H P
US
CR
FF
S O
ND
HA
Principle 2: “HANDS OFF” Crush Points
Severity:
Actual =LTI(3P) ; Potential =LTI(C3P)
INCIDENT DESCRIPTION:
• The IP, along with a Floor man and Driller were engaged in rigging down the
7” power tong from the hoist floor. Prior to rig down they were trying to retract
the lift cylinder of the power tong. In the process, instead of engaging the
lever to retract the lift cylinder, the Floor man mistakenly engaged the lever
for operating the tong. This caused the tong to rotate and inflict a crush injury
to the left middle finger of the IP who had his hands on top of the power tong.
The IP suffered compound fracture of the left middle finger.
CAUSES:
• Failure of the IP to use the proper handles provided on the tongs.
• The driller failed to warn the IP about his hands on the pinch points.
• Floor man engaged the lever for operating the tong instead of engaging the
lever to retract the piston of the lift cylinder
LEARNINGS
• Pay attention to safety messages while attending safety meetings and TBTs.
• Keep your hands and fingers away from pinch points and always use proper
handles provided on the tongs.
Principle 2: “HANDS OFF” Crush Points
PDO RIG 46
INCIDENT :
While the crew was positioning mechanical support of rig carrier ramp, the Rig Mechanic (IP) got
his left hand ring finger tip trapped and crushed in between the rig carrier ramp and the
mechanical support as he placed his left hand on top of the mechanical support
CAUSES:
• Failure to follow instruction to stay clear and not involved in the job.
• Failure to replicate use of only hands free method, best practice used on similar rigs Inadequate Design and Ladder
• Supervisor failed to identify and use the available hands free method Rungs bent
• Supervisor failed to identify and communicate the pinch point during the TBT. Left Hand Ring Finger placed in the Pinch Point Area
• Inadequate procedure
• Lack in system of sharing best practices across the fleet.
LEARNINGS:
• During TBT’s identify job specific Pinch Points.
• Conduct hazards hunts to ensure that all Pinch Points are identified, recorded and marked.
Full Body Harness
• Maximise use of hands free method to avoid manual intervention. Secured to Fall Arrestor
• Share best practices across the board. Ladder Secured
LTI C3P
CAUSES:
• Improper way of closing the door.
• Lack of attention.
LATERAL LEARNING:
• Always keep hands clear from hazard areas while opening and
closing doors
• Do not act in haste
• All incidents must be reported to PDO DSV
Potential = Partial Disability (C3P)
Boots & Coots – Hydraulic Work-over PSL-02
While breaking BOP riser spool studs with a hydraulic torque wrench during
rig down, an assistant placed his left thumb in a pinch point which resulted in
crushing the tip, requiring stitches to close the wound and time to heal.
CAUSES:
- Poor communication.
- Worker not accustomed to working with hydraulic wrenches.
- When using hydraulic torque wrenches – operate with hand off method
LEARNINGS:
- Reinforce hand tool operational awareness.
- Help crews understand that communication must be two ways, both
Communicated and Confirmed.
20
Principle 3: Hands Off...and then,Energy On!!
21
Principle 3: Hands Off...and then,Energy On!!
CAUSES
IP puts his finger between the moving piston & the sensor, as a
result of his arm slipping.
LEARNINGS
• Obtain a valid PTW, before starting the job.
• Ensure Isolating the pump ahead of fixing the sensor.
• Comply with LSR
• Third party induction to include rig rules.
Swab Cup assembly on his own accord and without supervision. In the
process of doing so the sleeve on the bottom assembly moved upwards
crushing the IP`s middle finger which was in between the bottom assembly
and the swab cup assembly. The IP was given first aid by the rig medic
then referred to the Hospital where he received further treatment.
CAUSES
1. CRTi tool was laid down with pressure in the system.
2. IP was not told of the hazards involved when working on the tool.
3. IP commenced working on the CRTi tool without being instructed to do.
LEARNINGS
• Follow operating/maintenance procedures when working on any equipment
• Do not place fingers within potential pinch points.
Always follow procedures when working on pressurized
equipment.
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Principle 3: Hands Off...and then,Energy On!!
Severity:
Actual=LTI(3P) ; Potential=LTI(C3P)
INCIDENT DESCRIPTION:
After first run up of newly installed D379 Cat camp generator the IP (Chief
Mechanic) was doing general engine inspection. While exiting the shack
past the radiator (narrow access, only 39 cm wide) inadvertently, he put
his right hand on the engine fan guard and his index and middle fingers
passed through the mesh of the fan guard. He was struck by the fan
blades resulting in amputation of the tip of his index finger.
CAUSES:
• The radiator guard was too close to the rotating fan blades.
• He did not recognise the Hazard and momentarily lacked concentration.
• Failure of Management of Change:
• Different engine being installed in shack
• Change of radiator and guard by 3rd party company
LEARNINGS
• CHECK GUARDS on rotating equipment.
• If finger can be put through the guard, then guard should be at least 150 mm
from the rotating parts.