2013 Learning From Incidents PDF

Incident Prevention Through
Learning from Incidents
January - December, 2013
HSE & Risk Management
This booklet is circulated within ADCO organization within the framework of HSEMS. It should only serve as guidance and ADCO shall in no event accept
any liability for either the fact described, nor for any reliance on the contents by any third party
.For further information, comments and suggestions please contact:
Husam Eddin Al Khaldi, MSc, PE, CSP, CRSP
halkhaldi@adco.ae
HSE & Risk Management
Tel: 02-60412017
During 2013, we have had 40 injuries of varying nature, 23 fire incidents, 31 cases of property damage, 25 transportation and
29 spills related incidents. Sadly, we also had 6 non accidental deaths and 10 non work related fatalities. During this period, we
have worked over 84 Million Man-hours and driven over 150 Million kilometers.
Incident investigations have revealed deficiencies in effective supervisory management and leadership, work planning and
fitness of equipment & tools. We all must discuss these incidents and root causes within our teams and work groups. We can
effectively address these gaps by ensuring:
Tasks are properly risk assessed, ensure effective barriers are in place to control the identified hazards and avoid
making any unverified assumptions
Leadership should check & ensure the competency of the assigned staff members (ADCO /Contractors) to execute
critical activities are meeting the preset competency profile requirements for those activities .
Supervisors and job performer must stop works whenever an unsafe actions or conditions are observed. Never turn a
blind eye for the sake of gaining time or production incentives.
I would like you to review and learn from this collection of incident lessons learned. Once these lessons learned are embedded
into your work plans we can avoid recurrence of such incidents in future and also avoid injuries to ourselves and our colleagues.
Let us make ADCO as a safe place to work in.
Abdulla Hussain Mohammad Al Marzooqi

SVP (HSE&RM)
2
Table of Contents
Closed Drain Header Gas Leak

Loss of Well Containment During Coil Tubing Activities
Well Control Incident
Spill from a Flow Line
Loss of Containment - Oil Spill
Gas Release while Depressurizing Gas Injection Trunk Line
Gas Release from Closed Drain System during Calibration of Multiphase Flow Meter
Oil Spill from a Flow Line
Leak from Flow Suction Tank
Buried Gas Line Struck by an Excavator (Near Miss)
Oil & Gas Release from a Flow Line
Gas Release from Choke Valve
Oil Carry Over to Flare Stack
H2S/ Hydrocarbon Gas Release from Water Separation Tank
Oil Spill from Flow Line
Oil Spill from Redundant Flow Line
Loss of Containment- Oil Spill
Release of Oil from Metering Prover
Gas Release from Compressor
Oil Spill from Redundant Main Oil Line (MOL)
Fall of Derrickman on Monkey Board
Fall of Lubricator & BOP Assembly on Christmas Tree During Lifting
Fire during Hot Cut of a Water Injection Flow Line
Fall of a Driver from Kenworth Trailer
Dropped Tubing Joint from Elevator
Damage to Over Head Lines OHL
Hand Injury from Front End Loaders Bucket
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
32
33
34
35
36
37
38
3
Burn Injuries during Well Testing Activities

Fall of Travel Block on Rig Floor (Rig Move)
Fatal Fall of Driller from Height (Rig Move)
Drop of Drill Pipe Stand from Derrick
Fall of Banksman from a Sand Dune
Finger Entrapment between Sliding Door of a Crane and its Frame
Disengagement & Fall of Upper Link Guide Support Clamp on Rig Floor
Finger Trapped between Scaffold Pipes
Finger Trapped Between Falling Load and Vehicle
Buried Electrical Cable Cut during Site Preparation
Fall of Operator from Batch Mixing Platform
Finger Injury during Dismantling of Wire line Tool
Finger Caught Between Spinners of Hawk Jaw
Finger Trap between V Door on Rig Floor
Damage to Well ESD Panel during Sand Clearance
Arm Injury Due to fall of Jumbo Bag
UV/IR Fire Detectors Pole Damage
Fire at Asab Accommodation
Road Safety
Kenworth Rollover
Man Lost in Desert
Vehicle Collision
Fatal Road Traffic Accident
Vehicle Rollover
Water Tanker Rollover
Vehicle Rollover
Vehicle Collision & Rollover
Vehicle Rollover
Vehicle Rollover
Vehicle Rollover
Vehicle Collision
Vehicle Collision
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
4
Vehicle Collision
Fatal Vehicle Collision
Fatal Vehicle Rollover
Diesel Tanker Rollover
HSE Performance, 2013
Vehicle Accident Frequency, Vehicle Crashes vs KMs Driven
Incident Sub Types 2013
Incident Immediate Causes 2013
Incident Root Causes - 2013
Asset Wide Incident Root Causes- 2013
76
77
78
79
80
81
82
82
84
86
87
Process Safety
Closed Drain Header Gas Leak

Area
Incident Description
Since 2006, due to corrosion, the closed drain
network had leaked 12 times. The drain header is
isolated from drain network by closing two
manual isolation valves and accordingly the
purging fuel gas isolated. Due to passing
problems in the Train instruments and process
drain valves, these main two manual isolation
valves were kept in closed position and these
were opened if there was demand to drain.
1st stage level transmitter of train 2 was flushed

and transmitter chamber was drained to process
drain without lining it up to underground drain
header. The process drain line, already subjected
BAB & Gas to corrosion, was exposed to 18 bar pressure and
a leak developed causing activation of H2S
alarm. Outcome: The train production was
shifted to other trains and started depressurizing
the train to flare.
30-01-13
Immediate Causes
Violation by Group (Closed drain outlet

valves were kept in closed position without
management of change)
Defective Equipment (individual drains

valves were passing)
Lack of Knowledge of Hazards

Presents (Due to corrosion issues, the
closed drain network had leaked 12 times
since 2006 and there was lower level of
risk perception)
Causes
Inadequate Leadership (Deviation

from SOP was known but no effective
corrective action was taken; Instead
of replacing/fixing passing valves,
these were kept in closed position; No
effective )
Inadequate Preventive
Maintenance Programme
(Programme (The passing valves was
not reported to maintenance; Closed
drain system had leaked 12 times
since 2006. PMRF raised to replace
the closed drain header)
Lessons Learned
1. Line up individual train isolation

Valves to main underground header
2. Identify and rectify/replace the
passing or defective valve of the
individual Trains drain valves.
3. Maintain continuous fuel gas purging
through the drain lines.
4. Follow Standard Operating Procedures
at all times and subject any change to
Management of Change (MOC)
process.
Loss of Well Containment During Coil Tubing Activities

Area
Bb-731 was drilled and completed with 3

completions in Habshan 2 reservoir. (H2S content
22% & well shut in pressure 2500 psi). Production
Logging operation was planned to define fluid inflow
using Coiled Tubing (CT) logging package. The
deployment of the PLT dummy tool string on the CT
BOP had been completed. While conducting pressure
equalization across CT Blowout Preventer ( BOP), an
uncontrolled hydrocarbon release occurred this
resulted in a fire on the CT injector head. The CT

operator activated the shear seal ram and
subsequently closed the Christmas Tree valves
(Swab & Upper Master) to control the situation
BAB & Gas

Immediate Causes
14-03-2013
Violation by Group (Coiled Tubing

Manual/Coiled Tubing logging Procedure was
not followed ; Improper operation of Pressure
Control Equipment(PCE); Incomplete surface
pressure test of PCE)
Improper Decision Making (Improper

engagement of mechanical lock of Pipe/Slip
rams (Closure position not verified) and
premature activation of Pipe/Slip ram release
mechanism)
Lack of Knowledge of Hazards Present

(The task was not adequately risk assessed)
Root Causes
Inadequate Audit/ Inspection
/Monitoring (Inadequate Supervisory
Verification of Task Execution)
Inadequate Identification of Work
Site/Job Hazards (A generic Task Risk
Assessment (TRA) template was used
without taking work sequence and well
characteristics into consideration)
Inadequate Work Planning (There was
inadequate availability of supervisory staff)
Lessons Learned
1. Do not use generic Task Risk
Assessment (TRA). Update existing
TRAs according to work sequence and
work location.
2. Do not perform high risk activities
without effective ADCO supervision.
3. Ensure integrity of Pressure Control
Equipment (PCE) via pressure testing
prior to exposure to well head
pressure.
4. Ensure double sealing barriers are in
place during pressure deployment of
logging tools.
5. Pressure Control Equipment (PCE)
configuration and pressure test
certificate should be countersigned by
both Job Performer and ADCO Engineer
In charge

Area
During the operation of pulling out of hole
(POH) at a speed of 500ft/hr. After POH / wipe
log 5 stands, it was noticed that well was not
taking the proper amount of mud & flowing at a

rate of 30bbls/hour. The Rig Crew & Drilling
supervisor decided to Run In Hole (RIH) back,
circulated hole & flow was checked, found the
well flowing. After that informed Office without
securing the well. Office informed the DS to
shut the well immediately. Well was killed
using driller method with 88 pcf mud weight.
Causes
Inadequate Practice of Skill (Drilling

Supervisor (DS) reduced the mud weight
for the 6 section)
Inadequate Communication (DS did
not consult drilling team members prior
to reducing mud weight
SIDPP 250 PSI
SICP 280 PSI
Modular Dynamic Tester (MDT) in the 8 1/2

Lessons Learned
pilot hole confirmed that formation pressure is
4950 psi instead of 5100psi.Therefore, the
decision was made to lower the mud weight in
Drilling
6 hole compared with the well program due to
SA-106 water injector was near to SA-170
ND 01
which was closed only 2 weeks before the
12-01-2013 incident. Therefore, the decision was made to
lower the mud weight compared with the well
1. Continuously monitor reservoir pressure
program. This resulted in an under balance
update based on injection and faults
between mud weight and formation pressure,
affect in the area.
resulting the well to flow. Outcome: The well
2. Discuss MDT pressures with team
was shut & secured and crew evacuated.
members involved in developing the
drilling program
Immediate Causes
Violation by Individual (The first 5 stands

were pulled without using trip sheet)
Improper decision making / lack of

judgment (inadequate mud weight was
being used)

Area
Root Causes
Drilling
ND 09
In Thamama zone B single oil producer, 8

deviated pilot hole was drilled. The
Modular Dynamic Tester (MDT) recorded
4875 psi pressure Vs 4100 psi predicted

reservoir pressure. The 6horizontal hole
was planned but did not cater for updating
the pressure and mud weight after recording
MDT. While drilling 6 Horizontal hole

across the formation with 71 pcf mud
considering the predicted pressure of 4100
psi Vs 4875 psi recorded (775 psi
underbalanced), the well started to flow,
alarm was activated and 5 bbls gain in the
mud tanks was observed. Outcome: The
well was shut & secured and crew was
evacuated.
28-01-2013
Inadequate Work Planning or Risk

Assessment Performed (Drilling plan was
based on predicted reservoir pressure and did
not require to update reservoir pressure based
on MDT)
Inadequate Correction of Worksite/Job
Hazards (Nearby injection wells were not shut
down as requested creating reservoir pressure
uncertainties)
In adequate communication (There was no
effective communication between Drilling
Engineer, Reservoir Engineer and Petroleum
Engineer to discuss reservoir pressures and
results of MDT pressure; The driller and crew
were not aware of another well control incident
of ND-1 ( Sa-170) occurred on 12th January,
2013)
Lesson Learned
Immediate Causes
1. The reservoir pressure should be continuously

monitored and updated considering injection and
faults affect in the area and the mud weight
should adjusted accordingly.

Present (Crew were not aware that
there was 775 psi pressure difference
between MDT and e-prognosis pressure) 2. Identify and shut down nearby injection wells
two weeks before penetrating the reservoir.
Inadequate Guard or Protective
Devices (The well was drilled with

3. The new MDT pressure should be reported and
higher than predicted reservoir pressure
communicated directly between all teams and
and the mud weight was not adjustedmud weight to be adjusted accordingly
the well was drilled underbalanced)
10
Spill from a Flow Line

Area
A 1.9 km. long flow line from well Sb-195 to

RDS-4 was subjected to internal/external
corrosion pitting at the 6 oclock position in
the main body of the pipe line. The type of
randomly occurring isolated pitting, in flow
lines with relatively high water-cut, and low

flow-rates is a common occurrence. It relates
with reservoirs age and fluid chemistry on
unprotected carbon-steel piping. An oil leak
was reported from the flow line and the well
was isolated and flow line was depressurized
for oil spill assessment, inspection and
repairs. Outcome: It had resulted in release
South East of well fluid approximately 1500 bbls and
gases. 1490 bbls of free oil were recovered.
Asab
Contaminated soil/sand was removed and
sent to treatment facility.
03-02-2013
Root Causes
Inadequate Engineering / Design

(Selected material for flow lines was nonProtected Carbon Steel pipe material exposed
to isolated internal / external corrosion
concentrated at 6 Oclock position of flow
line).
Lessons Learned
Immediate Causes
Inadequate Guards/Protective
Devices (Isolated internal/ external
1. Enhance inspection of internal / external
pitting & corrosion due to absence of
corrosion of flow lines
internal protective coating or chemical
2. Conduct small-bore intelligent pigging
treatment at well head. No protective
survey ( SBIPS) at-risk flow lines
system provided for external corrosion
protection to pipeline i.e. wrapping or
paint coating, except at areas of intended
burial i.e road/track crossings)
11
Loss of Containment - Oil Spill

Area
RDS-4 transfer line is Carbon Steel (CS), 4.3 km

long & of 16 diameter and it connects to RDS -6.
It was commissioned in 1975. The buried section
of the 16 transfer line has cathodic protection

and it is separated electrically from the above
ground piping at RDS-4 with isolation joint
(MONOBLOC). There was shift (-1.4 V) between
protected and unprotected sides with a
conductive electrolyte (water with high chloride),
accelerating internal corrosion close to the
isolation joint. A pin-hole leak developed at 7
oclock position. The line was isolated and
production flow from RDS-4 was diverted to new
South East CDS through a new transfer line. Effected pipe
line was depressurized for inspection and repairs.
Outcome: It resulted in spillage of approximately
Shah
60 bbls of oil. 30 bbls of free oil was recovered
the contaminated sand (38 m3) was transferred
to BeeAt Treatment Facility.
01-04-13
Immediate Causes
Equipment/Material Not Secured (The

above ground part of the transfer line was not
subjected to cathodic protection)
Improperly Prepared Equipment (Both

ends of MONOBLOC were not connected
through conductor to avoid flow of stray
current)
Causes
Inadequate Assessment of Potential

Failure (Acceleration of internal
corrosion due to change in fluid
characteristics and stray current flow
across MONOBLOC was not anticipated
during design stage)
Lessons Learned
1. Connect both ends of MONOBLOC

with conductor to pass the current
and avoid the flow of stray current
2. Monitor Cathodic Protection (CP)
voltage across the MONOBLOC of
transfer lines as a part of preventive
maintenance plan
12
Gas Release while Depressurizing Gas Injection Trunk Line

Area
Root Causes
Due to a leak from a gasket at a well site (Bb-645),it
was planned to depressurize the associated Trunk Line

(TL). An Operations Foreman tried to open 6 isolation
valves, upstream, the choke valve (for depressurizing
the trunk line) but the first main isolation valve got
stuck and did not open. The Foreman called the Control
Room Foreman and after discussing the issue, the
Operations Foreman opened 2 vent valve located

between Main Shut Down Valve (SDV) and Main trunk
line manual isolation valve. It resulted in 2 vent line,
between the double block valves, to shear from the
BAB & Gas
flare header and resulted in gas release and activation
of Hydrocarbon Alarm in the Control Room. ADCO
ASR
personnel approached the location and closed the
depressurization valve to bring the situation under
18-04-13
control. Outcome: It resulted in release of
approximately 3.2 MMSCF of gas to atmosphere.
Lack of Procedure (There was no formal

or standard operating procedure for
depressurizing trunk line)
Inadequate Preventive Maintenance
(There was no specific preventive
maintenance schedule for gaskets &
valves; maintenance work orders are not
specific to individual valves but it cover the
entire area)
Inadequate Training Efforts (There is
no structured training/familiarization
program to assure the competency of the
new staff with respect to the operation of
gas gathering & injection facilities)
Inadequate Technical Design (The
selected valve had no provision for
greasing, lack of maintenance philosophy
and no interlock system was considered to
prevent using 2 vent valve for
depressurization)
Lessons Learned
Immediate Causes
1. Ensure availability of Standard Operating

Procedure (SOP) prior to depressurize
trunk lines.
Improper Use of Equipment (A vent line was 2. Familiarize new staff with site specific
operating procedures prior to their
used to depressurize a high pressure gas
assignment.
injection trunk line)
3. Review & update schedule & scope of
Improper Decision Making/Lack of
preventive maintenance to ensure all
Judgment (Operators decided to use a vent
critical equipment are effectively
line for depressurization when the main isolation
maintained
valve got stuck and did not open)
13
Gas Release from Closed Drain System during Calibration of Multiphase Flow Meter
Area
Causes
The calibration of Multiphase Flow Meters
(MPFM) was planned and it included injecting

crude oil samples in MPFM and passing samples
through Gamma Sensors; and then the sample
is discharged into a closed drain system. A
joint meeting was conducted between
commissioning team & a third party vendor to
plan and execute the task.
South East
Shah
An Operations representative was assigned

with the team and oil sample was provided to
the vendor to perform the calibration. The
vender started the job and injected crude oil in
MPFM and opened the blind & globe valve to
drain the sample into the closed drain system.
During the process bubbles were noted at the
sample injection point and H2S was detected.

Assessment Performed (Oil sample
was provided to vendor for calibration
without ensuring crew is aware of PTW
requirements and risks associated with
the task).
Inadequate Supervision (Job
Originator did not ensure effective
supervision and control of work)
Lessons Learned
Immediate Causes
21-05-13
1. Ensure all vendors are aware of ADCO

requirements for Permit to Work
Violation by Group (Job Originator did not

apply or facilitate permit to work (PTW) and 2. Accompany & Supervise vendor crew
whilst working in ADCO Areas especially
the crew started the work without the
in restricted areas.
permit)

(The activity was not risk assessed and
workers were not aware of risk of H2S in
closed drain system and any associated
back pressure)
14

Area
Drilling
Well -Sy22 is (Simsima) single Oil producer

with Electrical Submersible Pump (ESP)
string. While pulling submersible pump
completion out of the hole (POH) and filling
the annulus with 200 bbls of location water
(65 PCF), it created U tubing from tubing
string and flow through tubing was
observed. Outcome: The crew attempted
to install low torque valves but failed. Then
the crew closed the shear ram across tubing
and dropped in hole to secure the well.
Root Causes

Assessment Performed (Job order was issued
without assessing operational risks; Pre spud
meeting was not conducted; Job order was not
endorsed by Drilling Supervisor (DS))
Inadequate Leadership (DS started the job
without endorsing job order, discussing risks and
What If scenarios)
Lesson Learned
ND 50
(Shah)
Immediate Causes
22-05-13
Violation by Group (The well was killed 1. Issue clear & detailed job order and risk
three times (once rig less & twice with
assessment for all critical operations
rig) without pumping the required
2. Always Conduct Pre spud meeting before the
volume)
spud and discuss risks associated with the
Improper Decision Making/ Lack of
program
Judgment (Location water was pumped
in the annulus while POH which lead to U
tube from tubing string).
15
Oil Spill from a Flow Line

Area
Root Causes
The flow line (6 carbon steel Sch 40) was

placed in 2008. It was connected with three
wells (Sy-51, Sy-54 & Sy-63) and it was

subjected to high water cut from Sy-63
(28% to 43%) for 9 months prior to the
closure of Sy-63. There was no corrosion
inhibitor injection on well heads and deemulsifiers were injected to enhance

separation. The flow line operating pressure
was increased from 130 psi to 320 psi. Due
to internal corrosion, a pinhole (~ 3mm)
South East leak developed at 6 Oclock position.
Outcome: It resulted in spillage of 81 bbls
of oil. The flow line was isolated &
Shah
depressurized and the HAZMAT team
28-05-13 recovered 76 bbls. The contaminated sand
was removed and transferred to BeAAT
treatment facility.
Immediate Causes
Inadequate Technical Design (There was

no corrosion inhibitor injection on well
heads)
Inadequate Assessment of Needs &
Risks (Weak flow line (Sch 40) was
connected to high water cut well Sy-63
(28% to 43%) was introduced to this flow
line for a period of nine months before this
well was closed)
Lessons Learned
1. Inject corrosion inhibitor from well heads
Improperly Prepared Equipment

2. Do not expose week (Sch 40) flow line to
(Flow lines were not subjected to
high operating pressures.
corrosion inhibitor for extended period of
time and operated at higher operating
pressures)
16
Leak from Flow Suction Tank

Area
Root Causes
A Flow Suction Tank was in service since 2005 with weir
height of 1.75 meters. The internal GRE lining was

provided up to a height of 1 meter from the tank floor.
The settled water level within the oil compartment
accumulated to levels higher than 1 meter (over GREinternal lining level), and created corrosive conditions for
deterioration of steel. During routine patrolling, a jet of oil
from tank shell, near oil outlet nozzle of the tank about
1.5m high from the bottom plate, forming a pool of oil
was observed by an Operations Foreman and the leak was
reported to control room. Outcome: The leaked oil
(approximately 130 bbls.) was contained within the

secondary containment (bund area). Input to the tank
was isolated and its inventory was pumped out through
BAB & Gas Main Oil Line (MOL) system. The hole was plugged and
HAZMAT Team was mobilized to recover oil from the
12-06-13 secondary containment.
Immediate Causes
Inadequate Guards or Protective Devices (The

internal part of tank had GRE lining up to 1 meter
whilst the oil and accumulated water level in the oil
compartment was higher than 1 meter)
Inadequate Technical Design (The

internal lining of the tank was one meter
and its adequacy was not reviewed)
Inadequate Implementation of
Procedure (Tank operating & draining
procedure was not implemented to
monitor water level in the tank and
periodic water drainage either upstream
or downstream the weir)
Inadequate Assessment of Required
Skill or competency (New Operations
staff were not adequately familiarized
with operating procedures and hazards)
Lessons Learned
1. Implement draining procedures to ensure

that water level is monitored and water is
drained periodically.
2. Review & Update Tank design
specifications to ensure adequacy of
internal GRE lining.
Improperly Prepared Equipment (Due to nonavailability of operation drain in the oil compartment, 3.
the accumulated water was not drained and the
presence of Sulfide Reducing Bacteria (SRB) in the
tank and its effects on steel structures were not known
operations teams; water level was not monitored and
drained in the downstream of the weir)
Develop a mechanism to ensure skills &

competency of new staff with respect to
site specific procedures & facilities prior
to assignment.
17
Buried Gas Line Struck by an Excavator (Near Miss)

Area
A crew was involved in well head tie-ins and flow

line installation works. After the completion of
route & topography (to identify the geographical

profile along the route and the existing facilities
crossing that route) excavation work started. As
a part of Excavation Certificate requirement, the
use of cable/metal detector was required prior to
commencing mechanical excavation. Job
Performer (JP) started mechanical excavation
without using the metal detector. The JP was
using a topographic Survey (Up to 2 meter
depth) report as a guide to identify buried lines.
While excavating, under a gatch road, the
bucket of the excavator struck against a hard
BAB & Gas object. The operator stopped the work and
informed JP. The JP started the manual
excavation to expose the buried line. After
exposing the line, damage on the coating and
base metal was noticed.
08-06-13
Immediate Causes
Violation by Individual (Job Performer did

not utilize cable / metal detector prior starting
mechanical excavation of the trench)
Improper Decision Making / Lack of

judgment (Job Performer relied on imprecise
alignment sheet and Topographic survey
report as a single source of information)
No warning provided (No visible

identification / markings of underground
pipeline)
Causes
Inadequate Supervisory Example (JP
did not use metal detector to identify
buried lines prior to
commencing mechanical excavation)
Inadequate Standards or
Specification of Equipment (The
equipment used for topographic survey
had limitation to locate buried pipes
during humidity)
Lessons Learned
1. Clearly identify underground facilities

prior to commence site work.
2. Beware of limitation of topographic
survey equipment
18
Oil & Gas Release from a Flow Line

Area
Buhasa
Bu-632 flow line was commissioned in late 2003 and

the flow line was not subjected to Cathodic Protection
(CP). Flow lines crossing through gatch bund create
Oxygen Gradient Corrosion phenomenon resulting in
external metal loss. Due to lack of CP protection and
coating a pinhole developed, resulting in spillage of oil
and release of gas. Outcome: It resulted in release of
approximately 20,000 SCF of gas and 25 bbls of oil.
The HAZMAT team was mobilized and the team
recovered 23 bbls of free oil.
Root Causes
Inadequate implementation of
Standards and Procedures (ADCO
standards and procedures (for flow
line crossing were not implemented)
Lessons Learned
(BUH)
Immediate Cause
16-07-13
1. Provide Coating upto 25 m each side

of the crossing and install CP for flow
Inadequate Guards/Protective Devices (No
lines.
protective system provided for external
corrosion protection i.e. wrapping or paint
coating)
19
Gas Release from Choke Valve

Area
Root Causes
During 2005 most Chock valves of Gas

Producer wells were subjected to repairs/
refurbishment/ design modifications due to
experienced repeated seizing. After

modifications stem packing started to fail.
On July, 14th, a gas release occurred from
the stem packing of modified choke valve of
a gas producer well. The gas was detected by
H2S alarm in well head area. Outcome: The
well was shut down and the flow line was
depressurized through flare. The damaged
choke valve was replaced with a refurbished
one and the well was restarted.

Failure (Failure of stem packing material due
to high reservoir temperature was not
anticipated/assessed)
Inadequate Evaluation of Change (Original
Equipment Manufacturer (OEM) stem packing
material was replaced without considering
impact of operating conditions)
South East
Lessons Learned
Asab
14-07-13
Immediate Causes
Defective Equipment (Choke valve had

damaged (brittle & cracked) stem packing
and worn out lower guide ring)
Work exposure to Temperature

Extreme (High reservoir temperatures
(in excess of 110oC))
1. Consider using stem packing material which

can stand higher reservoir temperatures.
20

Area
Root Causes
South East
Asab
Due to hot weather conditions, Instrument Air

Compressors (IAC) tripped, causing plant
emergency shutdown (ESD). Due to the
shutdown, shutdown valve, (SDV) at the inlet
of Test Separator, closed and the Knock out

Drum (KOD) blow down valve (BDV) opened.
At the time a 2 bypass valve to the Test
Separator inlet SDV was passing, the oil from
inlet line passed into the test Separator,
overflowing to Flare Knock out Drum (KOD)
and subsequently to the flare stack. It resulted
in spillage of approximately 4 bbls of oil.

Risks (Instrument Air Compressors oil
cooler was not adequately prepared
resulting in high lube oil temperature
causing compressor to trip)
Inadequate monitoring of initial
operation (ESD alarm was not detected
on timely basis due to large number of
both critical and non-critical alarm
display on the control panel)
Lessons Learned
20-07-13
Immediate Causes
Defective Equipment (The Ball Valve (2)

on the bypass line of inlet SDV of test
separator was passing; Air Compressors oil
cooler was not effective in maintaining lube
oil temperature)
Temperature Extreme (Two Instrument

Air Compressors (IAC) tripped due to hot
summer spell)
1. Enhance maintenance of oil cooler of

Air Compressor especially during
summer months.
21
H2S/ Hydrocarbon Gas Release from Water Separation Tank

Area
Due to malfunctioning of cooling system at suction

knock out drum (KOD) for vapors recovery had
resulted in frequent choking of VRC (Vapor Recovery
Compressor) Strainer. A crew was involved in
cleaning of suction strainer and old VRC was shut
down. Newly installed VRC suction isolation sharing
the Water separation tank relief and flare header

was closed, instead of isolating the immediate
double block at old VRC compressor suction. This
had resulted in pressure build up in the water
separation tank. Upon actuation of tank high
pressure alarm, the control room operator tried to
control the pressure. He reduced the controller
output but resulted in opening of tank blanket gas

inlet Valve due to reverse acting, compounded the
BAB & Gas over pressurization of the tank and consequently
lifting of Pressure Vacuum Release Valve (PVRV) and
18-08-13 hatch. Outcome: Tank blanketing gas isolation was
closed and shared flare header/VRC suction isolation
was opened to bring the situation under control.
Root Causes
Inadequate Training Efforts
(Operators were not trained on
instrumentation and operations of newly
commissioned Effluent Produced Water
Treatment System)
Failure (Frequent chocking of VRC
compressor suction strainer was not
adequately evaluated to identify the
cause and effectiveness of remedial
action)
Inadequate Reference Materials
(There was no P& IDs for the isolation of
VRC compressor available)
Lesson Learned
Immediate Causes
1. Develop a mechanism to ensure skills &

competency of staff with respect to
Inadequate Isolation of Process or
specific facilities prior to their
Equipment (The flare header isolation valve was
assignment.
closed instead of isolating the double block at old
2. Ensure facilities P&IDs are readily
VRC compressor suction)
available to operations staff.
Improper Decision Making or Lack of
Judgment (The operator reduced the controller 3. Review effectiveness of repairs&
preventive maintenance to ensure all
output resulting in more opening of tank blanket
critical equipment are effectively
gas inlet valve)
maintained
Inadequate Warning System (High pressure
alarm was over looked due to the high flux of the
alarms in Distributed Control System (DCS)
22
Oil Spill from Flow Line

Area
A 3.3 km long flow line from well no Sb-392 was
commissioned in 2004. The flow line is connected to dual
string well with water cut range between 21 to 24%.
There is no chemical injection at well head to protect the
pipe line from internal corrosion. The flow line is laid in
desert terrain and part of the line is buried under sand.

This flow line has failed (leaked) on three occasions in the
past.
Due to recent GASCO plant shut down, Asab field was also
partially shut down and after the shutdown, startup of
facility started and RDS-3 wells were opened. Operations
staff noticed low flow line pressure and upon inspection it
South East two leaks were noticed. The well was closed and the flow
line was depressurized. Outcome: It resulted in in
spillage of approximately 1300 bbls and HAZMAT team
Asab
was mobilized to recover free oil.
19-08-13
Root Causes
Inadequate Engineering / Design

(Carbon Steel flow line did not have any
internal and external protection against
corrosion).
Lessons Learned
Immediate Causes
Protective Systems (Isolated internal/ external

pitting & corrosion due to absence of internal
protective coating or chemical treatment at well head. 1. After leak (failure) Hydrotest flow lines
No protective system provided for external corrosion
before putting lines back in service.
protection to pipeline i.e. wrapping or paint coating,
2. Consider chemical inject at well head to
except at areas of intended burial i.e. road/track
protect against internal corrosion
crossings)
Work place Layout (Layout of pipeline in desert

terrain caused burial of unprotected flow line by dune
action)
23

Area
Root Causes
Inadequate Preventative Maintenance

(The isolation valve was passing and that
allowed oil/gas to flow and fill the closed
A test separators drain valve was in open position drain vessel)
and another valve was passing leading to fluid
carry over to closed drain vessel. It resulted in an Inadequate Assessment of Operational
increase of fluid level in the vessel. Due to earlier Readiness (Motor power connector was
isolated for testing and not restored)
commissioning activities, electrical pumps
contactor was isolated and after commissioning it
Inadequate Adjustment / Repair /
was not put back. Therefore, the pump did not
function at high fluid level in closed drain vessel Maintenance (DCS configuration cannot
accurately detect if the motor in on manual
causing fluid carryover to flare stack. Upon
setting)
activation of alarm in control room, Operations
crew responded and restored the circuit and
South East started the pump to control the situation.
Lessons Learned
Outcome: Approximately 1 bbl. of oil carried over
Sahil
to flare stack and spilled on the ground
07-09-13
Immediate Causes
Defective Equipment (Test separator outlet

isolation valve was passing and second valve
was in open position)

Equipment (Drain pump motor contactor was
taken without isolation
certificate/authorization)
Improper Decision Making (Alarm system
was kept in silence mode due to ongoing
commissioning activities)
1. Do not isolate process equipment

without obtaining isolation certificate
2. Assess readiness of equipment and
set up (line-up) prior to operations.
3. Set closed drain motor on auto mode
be default.
24
Oil Spill from Redundant Flow Line

Area
As a part of Full Field Development (FFD)

activities, a test flow line was cut from RDS-2 end
and blind flange was installed while the upper end
(at the remote manifold) it was isolated by a ball
valve (without blind). During preparation of
access road, the test flow line was cut.
While lining up test separator at RDS-2 (Sy-69)
the oil pressure in the production remote manifold
transferred to the test manifold through the ball
valve (which was not fully closed and oil started
to flow from the opened end of the test flow.
South East Outcome: It resulted in spillage of approximately
30 bbls. The isolation valve was closed and
Shah
approximately 24 bbls of free oil were recovered
Root Causes
Inadequate Planning or Risk

Assessment Performed (During
construction activities, test flow line was
cut without ensuring the isolation)
Inadequate Supervision (Audit/

Inspection/Monitoring) (During line up
of test separator, effectiveness/integrity
of interconnecting isolation valve was not
checked)
Procedure (PTW) (PTW & Task Risk
Assessment implementation was not
adequate for control of work)
Lessons Learned
12-09-13
Immediate Causes

Equipment (The test flow line was not
positively isolated and ball valve was not fully
closed)
1. Positively isolate flow lines prior to

abandonment/making it redundant.
2. Subject all isolations of process and
equipment to isolation certificate.

(The test flow line was considered redundant
although it was not isolated with blind flange
from both sides)
25
Loss of Containment- Oil Spill

Area
A new oil producer (Bb-923) was completed and

flow lines were installed. After flow line
hydrotesting, spades were installed at both ends.
Later, Nitrogen (N2) kick off operations were
planned using a coil tubing unit. Prior to handing
over the well and flow line, the spade at RDS end
was not de-spaded (removed).
After completing N2 kick off operations, well flow
was diverted to the flow line. After noticing
pressure build up (950 psi) in the line, the crew
stopped the flow by closing the wing valve. In the
meantime, flange gasket failed. Outcome: It
BAB & Gas resulted in release of approximately 40 bbls of
well fluid.
Root Causes
Inadequate Leadership (Supervisor

issued the handover certificate without
ensuring removal of spade)
Lack of Procedure/Standard/Policy
(There was no Pre-Start-up Safety Review
checklist for rig less operations to support
issuance of handover certificate)
Lessons Learned
25-09-13
Immediate Causes
Improperly Prepared Equipment (Flow line 1. Always assess/verify de-spading of flow line
was handed over for production without being
prior to operations
de-spaded)
Violation by Group (Handover Certificate

was issued without physical checks on site)
Work Exposure to Energized System

(Spaded flow line was exposed to well
pressure)
26
Release of Oil from Metering Prover

Area
Root Causes
ADCO Mechanical Team and FMC crew

(vendor) were involved in MOT Metering
Prover Skid U-1601 sphere inspection. The
work includes draining under nitrogen
purging. After draining, the sphere was found
stuck in the prover loop. The crew pressurized
the system (8psi) to dislodge the sphere. The
sphere was dislodged and oil under pressure
splashed/released though the cover of the
home Position Chamber which was not fully
secured
Terminal &
Pipeline
Outcome:
It
resulted
in
Operations
approximately 40 liters of oil.
release
of
Lack of Procedures (There was no

procedure/checklist for Removal of Sphere
and Removal of Stuck Sphere)
Inadequate Communication (There was

ineffective communication between FMC
Engineer & ADCO Crew)
Inadequate Management of Change (The

work was planned as draining under
atmospheric pressure and later it was
changed to draining under nitrogen purging
without assessing risks and without
procedure/checklist)
Lessons Learned
Fujairah
31-10-13
Immediate Causes
Equipment or Material Not Secured (the

cover of the Home Position Chamber was
closed but not effectively sealed)

(Crew did not anticipate sudden release of
stuck sphere and subsequent release of oil
from Home Position Chamber)
Violation by Group (PTW) (Hot Work Permit

(PTW) was issued without Method
Statement/Task Risk Assessment/Procedure)
1. Always perform task risk assessment before

executing a task, especially for new tasks as
per TRA Procedure.
2. Provide clear work instructions/ procedure to
crew prior to assigning tasks.
3. When face with any unforeseen/ unexpected
situation, stop, reassess and ask for advice.
27
Gas Release from Compressor

Area
SE
Sahil
19-11-13
During commissioning of the high pressure (HP)
compressor, a technician made several
connections but did not check if ferrule punching

for each joint was adequately done. After
commissioning and during normal operations, the
compressor tripped due to High-High pressure
level (at discharge knock out drum KOD). The

compressor was reset, restarted and pressurized
to 300 bars. The compressor again tripped due to
Low-Low pressure at the 2nd stage discharge.
Later, the compressor was restarted and tubing of
seal gas Differential Pressure Indicator
Transmitter (DPIT) disengaged and gas leaked.
The leak was detected by the three surrounding
detectors.
Root Causes
Inadequate Audit/ Inspection/

Monitoring (There was no mechanism in
place to check adequacy of connections made
by the technician during commissioning)
Inadequate Practice of Skills (The
technician did not check the adequacy of
joints after making connections)
Lessons Learned
Outcome: Plant emergency procedure was

activated and all personnel were evacuated.
Depressurisation of compressor was carried out to
bring the situation under control.
1. Always check adequacy of ferrule punching
after making connections.
Immediate Causes
Improperly Prepared Equipment (Ferrule

punching for joints was not adequately done
and at high pressure tubing for DPIT
disengaged)
28
Oil Spill from Redundant Main Oil Line (MOL)

Root Causes
Shah Main Oil Line (MOL) was in use since

1983 and as part of Full Field Development
(FFD) project, a new MOL was installed and
commissioned in June, 2013. The old MOL
had oil inventory and it was planned to drain
the inventory and work was planned but not
yet executed.
Due to deterioration of old MOL, the
inventory released, at a buried area. It was
detected by a crew who noticed hydrocarbon
odour and informed the control room. The
site was excavated and a clamp was
installed on the old MOL and the leak was
stopped.
SE
Shah
Outcome: It resulted in
approximately 9 bbls of oil.
12-11-13
spillage
Inadequate
Assessment
of
Potential Failure (Old MOL was
depressurized since June 2013 but was
not drained in due time accelerating
the corrosion & resulting in leakage)
Inadequate
Work
Planning
(Draining of old MOL was delayed after
commissioning of new MOL)
Lessons Learned
of
Immediate Causes
1. Drain & secure inventory from line and
vessels prior to their disuse/ abandonment.
Inadequate Protective System (Corroded

line failed resulting in release of oil)
Improper Decision Making (Old MOL was

not in use for five months and it was not
drained)
29
Loss of Containment during Coil Tubing

Area
The Wireline crew was retrieving a phoenix

plug from an oil producer prior to coil tubing
logging operation.
Root Causes
After gas test, the crew started to rig up and

pressure test the lubricator and BOP
assembly. The crew run in hole with pulling
tools to retrieve the phoenix plug, tried
many times after latching to pull the plug by
hard jarring up and observed an oil leak
below the BOP (Between BOP and
crossover).
Inadequate
development
of
Policies/Standards/Procedures: There
were no procedures/policies in place to
inspect the O-Ring between the 1st and any
subsequent jarring attempts. Further to
this, the procedure does not clearly define
the intervals to conduct O-ring inspection
Lessons Learned
Outcome: The incident resulted in 2 bbls of

oil and water mixture spilled.
SE
SQM
Immediate Causes
22-12-13
Improper use of equipment (Due to

hard jarring and lubricator movement
during operation, the new O-Ring seals
between BOP and crossover was damaged)
A procedure clearly defining the process to

be followed for inspection / change of the
O-ring must be developed. This procedure
must reflect the need to inspect / change
the O-ring during multiple jarring
attempts.
30
Occupational Safety
31
Fall of Derrickman on Monkey Board

Area
During pulling out of 6 horizontal hole, a
Derrick man was working at monkey board,
racking stands. After unlatching the elevator,
the Driller started running the top drive
service downwards to pick the next stand. On
its way, downward, the Top Drive Blower
Assembly (slightly protruded) entangled with
the extended fall arrestor cable, which was
inclined due to heavy wind.
Drilling
ND 54
Derrick man experienced a strong downwards

pull where he lost his balance & fell on
monkey board. The fall arrestor cable broke
off from the side of the safety harness due to
extreme tension. Outcome: The fall arrestor
cable broke off from the side of the safety
harness due to extreme tension.
23-02-2013
Causes
Technical Analysis for Risk not Effective

(Fall protection Anchor point was 35 feet
from the latching point of Derrick man safety
harness, prone to shift during windy
conditions)
Inadequate Identification of Worksite/

Job Hazards (Job Safety Analysis (JSA) was
too generic and did not address hazards of
lowering TDS and the required level of
communication between Derrick man &
Driller)
Lesson Learned
Immediate Causes
Routine Activity Without Thought

1. Driller should not start lowering the TDS Block
(Driller started lowering the Top Drive
unless derrick man gives OK signal.
System (TDS) Block without confirmation
from Derrick man)
2. Modify/ redesign secondary Self Retracting Line
(SRL) anchor point in such a way that the SRL
Equipment/Material Not Secured (Self
cable does not entangle or come in contact with
Retracting Line (SRL) anchor point was
TDS at any circumstances
not far enough from moving TDS to avoid
entanglement between TDS and SRL
cable)
32
Fall of Lubricator & BOP Assembly on Christmas Tree During Lifting

Area
Root Causes
A wire line crew was mobilized to retrieve valves. The
wire line unit crane was inspected and certified and

the last load test for wire rope was conducted 3 years
ago. The wire rope was subjected to wear & tear and
corrosion.
The crew started to rig up lubricator and BOP
assembly (weighing approximately 1.4 tons) by
using wire line unit crane with safe working load of

approx. 3 tons. While the load was positioned over
the Christmas Tree (X-mas), the wire rope failed
near the wedge socket of the whip line block and
parted causing the load to fall down on the Xmas
South East tree. Outcome: X mass tree valves handles,
hydraulic actuator and a spectacle spade were
Asab
damaged

Monitoring (The wire line unit including
lifting equipment were certified without
adequate due diligence as wire rope was
not subjected to load test and absence of
Automated Safe Load Indicator (ASLI))
Inadequate Identification of Work
site or Job Hazards (Ensuring adequate
certification/testing of lifting devices to
eliminate use of uncertified wire rope
was not part of Task Risk Assessment
(TRA).
Lessons Learned
Immediate Causes
07-01-2013
Violation by Supervisor (Wire rope was not

subjected to annual load test)
Use of Defective Equipment (The used wire

rope was deteriorated due to wear & tear and
corrosion)
Improper Use of Equipment (Wire rope was

not adequately lubricated resulting in accelerated
inner and outer surface od wire rope)
1. Ensure all lifting devices are duly tested

and certified prior to initiating permit to
work (PTW).
2.
3. Conduct ad hock quality audit of Lifting
Equipment Inspection & Certification
Companies (LEICC) and wire line crews
competency
33
Fire during Hot Cut of a Water Injection Flow Line

Area
Root Causes
Dismantling of old Flow line was ongoing and
water injection flow line was isolated and handed

over to a crew. The line was not cleaned prior to
handing over as it was assumed free from
hydrocarbons. The Task Risk Assessment (TRA)
did not consider presence of pyrophoric scale
and a work permit (PTW) was issued to
commence the work (Hot & Cold cutting). The

crew performed a cold cut followed by hot
cutting. During hot cutting, fire started.
Outcome: The fire was extinguished by the job
performer using a fire extinguisher.
Inadequate Identification of
Worksite/Job Hazards (The Task Risk
Assessment (TRA) did not cover the full
sequence of the activities i.e. cutting and
removal of the flow line; and hazards of
scaling was not considered)
Inadequate Work Planning (The
method statement was prepared for tie in
and complete sequence of work was
included in the statement
Inadequate Communication Between Work
Groups (Requirements for safe handing over of
facilities was not properly communicated)
South East
Lessons Learned
Asab
14-01-2013
Immediate Causes
1. Water injection flow lines must be cleaned prior

to handing over for cutting/repair tasks
(The presence of pyrophoric scale was not
2. Do not use generic task risk assessment.
anticipated in water injection well flow line
Revalidate all TRAs for works on water injection
therefore the flow lines were not cleaned as
flow lines.
per Manual 10, Part 12 section no 12.3 prior
to handing over to the crew)
3. Familiarize all new Area Authorities (AA) and
Issuing Authorities with prior incidents.
Work Exposure to Fire (Pyrophoric scale
caught fire during cutting)
34
Fall of a Driver from Kenworth Trailer

Area
Root Causes
A crew was working on hydrotesting of flow lines

and after the completion of the task, hydrotesting
equipment were being transferred to another well
site using a Kenworth trailer. Once the trailer was
loaded with equipment, the driver went on the
back of the trailer to check the stability of the
load. The trailer bed had a section of deteriorated
wooden floor. While the driver was maneuvering
around holes he tripped and lost balance,
resulting him to fall down from the trailer
(approx. 2 m high) on the ground.
Outcome: He sustained shoulder fracture.
Inadequate Audit/ Inspection/ Monitoring

(Kenworth trailer with deteriorated floor was not
inspected before commencing the work)
Inadequate Identification of Work Site/Job
Hazards ( During Task Risk Assessment, fall of
driver from the trailer was not adequately
identified/controlled)
Lessons Learned
Terminal &
Pipeline
Operations
Immediate Causes
Inattention to Footing & Surroundings

(The driver was inspecting the load and
walking around hole and deteriorated wooden
floor of the trailer)
Defective vehicle (The trailer floor was

deteriorated and had broken wooden planks
on the floor)
Congestion or Restricted Movement (An

over-sized tank was loaded on the trailer and
there were slings/wire ropes to secure the
load restricted movement of the driver)
14-01-2013
1. Inspect fitness of trailers prior to their use.
35
Dropped Tubing Joint from Elevator

Area
Running Completion Tubing using pick up & lay
down (PC machine) machine, was in progress.
After running the 34th joint, after receiving the
signal from floor man, the Driller picked up the
35th joint from the PC machine to start lifting
and he started elevating the joint to stab &
make it up to the string in hole.
Drilling
ND 01
(Mender)
While the joint was about 15 ft. high (from

total 35 ft.), the stabber noted that missing
safety pin and alerted the driller. Driller applied
brake to stop the traveling block and due to
momentum of the traveling block, elevator
door opened, which resulted in joint falling
down though the catwalk on the pipe rack area.
Outcome No Injury or property damage had
occurred.
Root Causes
Excessive Wear & Tear ( Due to wear & tear

latch spring became weak and jaws were worn
out)
Inadequate Audit/Inspection or
monitoring (Integrity of the jaws & latch
spring was not assessed prior to start of the
job)
Lessons Learned
Immediate Causes
06-04-13
1. Confirm mechanical integrity of all tubular

handling equipment before sending to the
Job.
Equipment not secured (Elevator Door was 2. The pre-job safety meeting with drilling crew
not secured with safety pin)
to be repeated if situation demand.
Defective Equipment (Latch Spring was
weak and the jaws were worn out resulting in

elevator jaws to disengage)
36

Area
Root Causes
As a part of the Habshan- Ruwais- Shuweihat Gas

Pipeline Project, GASCO contractor crew was moving
Pipe Laying Vehicle with attached side boom, from
one location to another location. There were no goal
postings/height level markers installed at the
overhead line crossing and the operator was moving
the vehicle with side boom in elevated (raised)
BAB & Gas position. While crossing 33kV overhead power line,
the side boom hit overhead lines and damaged three
14-04-13 poles causing loss of power to 5 water injection
clusters and Remote Degassing Station (RDS) 7.
Distracted by other concerns (The operator

was emotionally stressed and not focused due
to personnel issues)
Inadequate identification of worksite/
job hazards (Task Risk Assessment (TRA)
did not adequately identify the hazards &
controls for the movement of the equipment)
Inadequate supervision (There was no
supervisor on site and task was assigned to
an operator who was unfamiliar with site
conditions; No Tool box Talk was conducted
for the operator)
Lessons Learned
Immediate Causes
Unintentional Human Error (Pipe layer operator

moved the vehicle, under overhead lines, with its
side boom in elevated position)
Inadequate guards or protective devices
(There were no goal posts/height level markers
installed at the overhead line crossing)
1. Assess suitability of route prior to moving

heavy load/equipment.
2. Always use approved route and crossing
37
Hand Injury from Front End Loaders Bucket

Area
South East
Shah
A crew was involved in manual excavation for
ground leveling and grading. The crew had
accumulated the excavated sand and was
planning to transfer it into bucket of a loader,
for removal. A Banksman was positioned on the
back of the loader and he was signaling the
operator. The excavated sand was transferred
into the bucket and at that moment one wooden
piece was spotted (partially buried) near the
bucket. The Job Performer (JP) asked a labourer
to pull out the wooden piece and while pulling
out the piece the loaded moved forward,
trapping laboures hand between the wooden
piece and the edge of the bucket. Outcome:
The labourer sustained multiples fracture on his
hand and after the treatment he was assigned
on light duties.
07-05-13
Immediate Causes
Improper Position or Posture for the

Task (Worker was attempting to pull out the
wooden Piece from the ground close to the
bucket of the loader, with its engine
running)
Judgment (The Job Performer did not
arrange to move the loader away and
requested the labourer to work in front of
the bucket of the loader)
Root Causes
Improper Supervisory Example (The

Job Performer did not move the loader and
asked the labourer to work in front of the
loader with energized engine)
Lesson Learned
1. Do not work in front of machinery/

equipment while its engine is running.
2. Always apply brakes and keep equipment
in neutral gear when in stationary position.
3. Position Banksmen at a location where
they can fully observe the situation in front
& around the equipment.
38
Burn Injuries during Well Testing Activities

Area
South East
Qusahwira
Well testing activities were in progress and a night
shift crew member (an operator) was involved in
collecting oil samples and manual filling of diesel fuel
to generator which resulted in oil & diesel splashes on
his coverall. There was a change in wind direction
and the operator decided to switch the gas flow to
another green burner. He energized the electrical
ignition and started propane flow to and then
attempted to ignite pilot of the green burner
remotely. The pilot did not ignite due to lack of wind
barrier near spark & propane interface & carbon
deposit on the tip of the pilot. He then decided to use
a fire stick (long metal rod with diesel soaked rag on
one end) and went near the burner. When he lighted
the Fire Stick near the burner, the accumulated
propane gas ignited. It caused his cotton coverall to
catch fire. Outcome: He sustained 2nd & 3rd degree
burn injuries on his arm, face, back and leg
18-04-13
Root Causes
Inadequate Development of Procedure

(Standard Operating Procedure (SOP) for
igniting green burner did not identify the
situation on what to do when green burner
pilot fail to ignite)
Inadequate Technical Design (Green

burners pilot could not be ignited due to
lack of wind barrier near spark & propane
interface or due to carbon deposit on the
tip of the pilot)
Inadequate Enforcement of
Procedures/ Standards/Policies
(Contract requirements concerning PPE,
emergency response and HSE inspections
were not adequately enforced.)
Lesson Learned
Immediate Causes
Inadequate Equipment (Green burner failed to

ignite)
Violation by Group (The use of Fire Stick to

ignite green burner pilot was common and done
with knowledge of supervisors- Not in line with
SOP)
Improper Decision Making/Lack of Judgment

(Operator let the propane flow for extended
period of time and did not anticipate accumulation
of propane near the burner where he attempted
to light the Fire Stick; Worker had oil & diesel
splashes on his cotton coverall when he
attempted to light the fire stick)
1. Remove all Fire Sticks and other

homemade type (banned) tools/
equipment from the site
2. Provide & Use Fire Retardant Coveralls
when working in hazardous
areas/conditions
3. Test site specific emergency plan for each
work location prior to commence
operations
39
Fall of Travel Block on Rig Floor (Rig Move)

Area
Drilling
ND 21
26-04-13
The rig was subjected to major maintenance program and
moved to Qusahwira field where rig up operations started until

the mast rose to vertical position and conventional Rig up
operations commenced. There was no actual calculation done
for the required length of drilling line for the hoisting system.
The length of slacked wire prior to raising mast was assumed to
be adequate. Assistant Rig Manager (ARM) started to lower the
Travelling Block to rig floor from Yoke position (at
approximately 130 from rig floor) in order to complete the rig

up operation. According the basic calculations there was a
shortage of drilling line on the Draw Work Drum to bring the
blocks to rig floor position. The block was lowered to 40 ft,
prior to the draw work drum become out of drilling line. The
fast line anchor on the Draw Work Drum got exposed to sudden
/ excessive tension (+/-2500 lbs) and the drill line slipped off
and travelling block and started to fall from 40 ft height. Once

the rig floor crew heard friction sound from the drilling line,
they moved away to safer place. Outcome: ARM & crew
escaped and proceeded to dog house until the block fell &
rested on rig floor.
Root Causes
Inadequate Audit / Inspection /
Monitoring (Rig audit and
inspections were inadequate to
identify that checklists were not
used and procedures were not
followed; Older version of procedure
was found at the rig location )
Inadequate Supervisory
Example (Mast raising checklist,
rig move procedures were not
reviewed, and basic calculations
were not done due to
overconfidence)
Inadequate assessment for
work site / Job Hazard (There
was no task specific Job Safety
Analysis (JSA) and a generic JSA
was used)
Lessons Learned
Immediate Causes
Routine activity without thought (The crew was working

on this rig had performed similar operation on many
occasions and ARM has conducted 5 similar moves)
1. Conduct Rig Move Audits to

check, review and strength the
move procedures
Improperly prepared equipment (The crew used shorter

length of drill line for the execution of hoisting system)
Improper decision making and lack of judgment (The

crew did not calculate the required length of the drilling line
for normal hoisting operations and relied on visual
observations).
2. Calculate & state exact length of

drill line on the spool on the
drum prior raising the mast in
the JSA
40
Fatal Fall of Driller from Height (Rig Move)

Area
Drilling
ND 50
Rig move activities were in progress and the mast
was lowered on the stand. An Assistant Driller (A/D)
was assigned to fold & secure the belly board. The

task included to lift the travel block carriage frame.
He was working alone and moving from one end to
another end to maneuver slings. Each time, while
moving from one end of belly board he had to
unhook his safety lanyard. The activity was

supervised by Assistant Rig Manager (ARM). During
the work ARM requested A/D to assist in freeing wire
sling which was trapped between the Belly Board
Pad Eyes. Whilst he was moving, travel block
hanging off wire got released and hit him resulting
him to loose balance and he fell down from a height
of 11 feet on travel block base plate. He sustained
head injuries. Outcome: He was attended by rig
medic and then transferred to RAMS Clinic in Shah.
Later he was pronounced dead.
(Shah)
28-05-13
Root Causes

Assessment Performed (There was no
Derrikman assigned to assist the Assistant
Driller)
Inadequate Leadership (ARM did not follow
the work procedure; work was not subjected to
job safety analysis; work was not stopped by
the Driller )
Lessons Learned
Immediate Causes
1. Subject all changes in job procedure/practice
and task risk assessment.
Violation by Supervisor (ARM did not stop the

2. Enforce STOP THE JOB program, when safety
activity where AD had to unhook his safety
controls or precautions are bypassed
lanyard and move to other side of the board )

3. Drop object checklist should be completed
Judgment (The task required two workers but
before lowering/raising the mast.
one worker was assigned to complete the task).
Lack of Knowledge of Hazards Present (Job

Safety Analysis (JSA) was not prepared for the
task)
41

Area
Root Causes
A crew was working on gas pipe line installation

project and after completion of the task the crew was
returning back. A pipe laying machine, with raised
boom, was loaded on a low bed trailer. The
identified/approved access track was blocked due to
sand accumulation and the supervisor decided to use
an alternative route. The route had 33Kv overhead
lines (with no goal posts) and while crossing the
raised boom hit and damaged overhead lines.

Outcome: It resulted in power loss to water injection
facilities and damage to several overhead poles and
BAB & Gas conductors.
10-06-13
Inadequate Leadership (Site Engineer used

an alternative route without ensuring
suitability of the route; Raised boom of pipe
laying machine was not noticed; Learning
from similar incident (14-04-2013) was not
captured in work planning or in Tool Box Talk
(TBT))
Lessons Learned
Immediate Causes

(Supervisor decided to take a route which is not
approved for equipment transportation and had
OHL)
1. Assess suitability of route prior to moving

heavy load/equipment.

2. Always use approved route and crossing
(Crew did not lower the boom of pipe laying
machine before moving the trailer)
Inadequate Guards or Protective Devices

(There no goal post markers were installed at the
overhead line crossing points)
42

Area
DD
Root Causes
During Run in Hole (RIH) activities, Derrick man
missed latching Drill Pipe (DP) stand and it dropped

to the opposite side of the derrick DP rack. The
crew started to return the stand back to Derrick
Rack, using both rig floor winches. Winch cables
were wrapped around the stand, anchoring it, with
make-up chain, to the rotary table stand and began
pulling it back. While pulling, the makeup chain
slacked causing the stand to slide/slip and go out
through the gap between rig floor post and V-door
handrail. Outcome: Drill pipe stand slipped through
the gap between rig floor post and V-door handrail
and fell on the ground below in Vertical Position
ND 1
(Mender)

Job Hazards (The task of pulling the missed
DP stand back towards derrick was not risk
assessed and no crew safety meeting was
conducted)
Inadequate Implementation of Procedure
(Procedure for the recovery of missing stand
was not implemented; Rig Manager was not
notified prior to attempting the recovery of
missing stand)
Lessons Learned
Immediate Causes
25-06-13
Violation by Group (The crew did not follow the

procedure to pull back missing stand)
Improperly Prepared Equipment (Makeup

chain was not properly tied to prevent stand
movement)
Equipment or Materials not Secured (Bottom

of the stand with other stands in derrick was not
tied to prevent slippage of stand; Handrail with
toe board was not installed)
1. Secure/Tie off the bottom of stand with other

stands in derrick to prevent it from slipping.
2. Consider pulling the missing stand as a critical
operation and conduct Job Safety Analysis
before pulling it back.
3. Install handrail with toes board to prevent
dropping stand from rig floor.
43
Fall of Banksman from a Sand Dune

Area
A crew was engaged in excavation,
backfilling and grading activities and a

newly assigned Banksman was monitoring
activities of an excavator, from an
elevated area (sand dune). The
Banksman decided to get closer and
started to descend down from the steep
slope and he tripped and fell down.
Outcome: He sustained knee (medial
South East tibial plateau) fracture and he was
assigned on light duties.
Asab
24-06-13
Root Causes
Inadequate Assessment of Required Skill

or Competency (The Banksman was
working at camp location and assigned on
site location without adequate assessment of
training/ skills required for the job and job
site)
Lessons Learned
Immediate Causes
1. Always use dedicated walkway/passage and

Inattention to Footing &
do not take short cuts.
Surroundings (The Banksman did not
pay attention to steep slope of the
2. Assess competency of new staff/workers and
dune and started to descend down)
ensure they are made aware of worksite/job
hazards.
Presents (The newly assigned
Banksman was not aware of hazards at
the site)
44
Finger Entrapment between Sliding Door of a Crane and its Frame

Area
During Laydown Completion Tubing Operations, a

crane was on stand-by, near Pipe Rack. The crane
cabin sliding door handle was missing and there was
no rubber beading on the sharp edge of the door. A
new & crane operator positioned himself in the crane
and while closing the sliding door, his two fingers
were caught between the edge of the door and the
frame of the cabin. Outcome: He sustained blunt
trauma on finger tips and his nail was surgically
removed.

Monitoring (There was no effective
inspection programme in place to assess
fitness of crane onsite)
Inadequate Training Efforts (A newly

assigned crane operator was not subjected
to training on Safety Rules and no daily
effective Tool Box Talk conducted)
Lesson Learned
Drilling
Immediate Causes
ND- 25
21-07-13
Root Causes
Defective Equipment (The handle of the sliding

door was broken; and there was no rubber
beading on the sharp edge of the sliding door)
Lack of Knowledge of Hazards Present (The

operator continued operating the crane with
defective cabin door and he was not aware of
hazards associated with pinch-point)
1. Subject all equipment & vehicles to daily

checklist to assess fitness.
2. Report all defects immediately to
supervisors and do not operate defective
equipment.
3. Conduct daily Tool Box Talks for operators
and drivers specific to their tasks.
45
Disengagement & Fall of Upper Link Guide Support Clamp on Rig Floor
Area
A new rig was recently commissioned and it was
drilling a 17 hole. The Driller along with drilling
crew made the connection and he was relieved for
Morning Meal (Sahoor) by Assistant Rig Manager
(ARM). The guide clamp of the upper link of the
Integrated Drilling system (IDS), which protects
upper link from hitting the electrical junction box,
dropped from 90 feet height on the rig floor near
Drillers Cabin. Outcome: IDS Hydraulic hose was
ripped off by guide clamp before dropping on the
rig floor resulting in spillage of approximately 100
Liters of oil on the rig floor.
Root Causes
Inadequate Technical Design

(Clearance between upper link and the
guide clamp was not adequate)

Assessment (The most of rig crew
were transferred from different rigs and
they were not adequately familiarized
with new rig design limitation)
Drilling
ND -60
Lessons Learned
(NEB)
Immediate Causes
04-08-13

(There was no Secondary retention on Guide
Clamp)
1. Ensure all similar design rigs (IDS 4 A

model) have secondary retention on upper
link guide clamp.

Judgment (Unintentional Human Error) (Staff
from other rigs were not fully accustomed to
new rig design and Driller over slacked the
travelling block)
2. Include IDS upper link guide clamp in

Drop Object Items checklist.
3. Arrange extensive training for key rig crew
members on new rig design and its
limitation.
46
Finger Trapped between Scaffold Pipes

Area
South East
Root Causes
During commissioning activities, crew members

were working on main motor shaft with crankshaft to
align and install flywheel to complete the assembly.
While rotating the main motor shaft using a
scaffolding tube, one workers finger was trapped

between two scaffold tubes/pipes. Outcome:
Worker sustained crush injury of left finger injury
and he went through surgical procedure.
Qusahwira
Improper Supervisory Example (Job

Performer did not provide adequate tools to his
crew)
Inadequate Assessment of Needs & Risks
(Availability of right tools was not ensured and
workers were using homemade type tools)
Lessons Learned
13-08-13
Immediate Causes
Violation by Group (Proper tools for the task

were not available and the crew members were
using scaffold tubes for alignment)
Inadequate Tools (Two scaffold pipes were

used for the alignment instead of wrench
spanner)
1. Always use right tools for the task and do not

take short cuts
2. During task/work planning, identify
requirements and availability of right tools
3. Provide hand tool safety awareness to all
Forman, helpers/labourers
47
Finger Trapped Between Falling Load and Vehicle

Area
Modification of high mast flood light was
ongoing and an electrical winch trolley was
required to assist in lowering the high mast.
A storekeeper was assigned the task of
delivery of winch trolley at the location and
he arranged the transfer to RDS location.
South East
Qusahwira
Site Electrical Engineer was not available at

the location and there was no arrangement to
unload the equipment at the location. The
storekeeper decided to use a JCB to unload
the trolley from trailer. While offloading the
trolley in JCBs bucket, the trolley became
unbalanced and a crew member tried to
support it with his hand. During the process
his fingers were trapped between the trolley
and trailer bed. Outcome: The worker
sustained finger crush injury.
15-08-13
Root Causes
Inadequate Leadership (Electrical Engineer

assigned untrained staff (the Storekeeper) to
transfer the equipment to the site without
ensuring availability of necessary
tools/equipment for the task; Site Civil
Engineer authorized the use of JCB to unload
the equipment from a trailer)
Inadequate Planning or Risk Assessment

Performed (The transfer of equipment
during mid-day break and availability of
lifting equipment at the site was not ensured)
Lesson Learned
Immediate Causes
Violation by Supervisor (Site Civil

Engineer authorized the use of JCB for
unloading of trolley from trailer)
Improper Lifting (The crew was using

JCB to unload unsecured winch trolley
from a trailer)

Judgment (Worker tried to stabilize lifted
load with his hand)
1. Use proper lifting equipment and do not take

short cuts.
2. Do not assign untrained workers to perform
risky tasks.
SE-2013-13526
48
Buried Electrical Cable Cut during Site Preparation

Area
Drilling
BUH
Rig Move road preparations were planned and site

handover certificate was issued to Drilling Team. The
certificate did not identify any buried cable.
Although, there was a 33Kv cable which was buried
(without protection) approximately 20 cm below the
surface. While the wheel dozer operator was
leveling the site, bucket of the wheel dozer hit and
damaged the cable. Later sparks and smoke was
observed at the location due to short circuit.
Outcome: It resulted in power interruption to 5
clusters. Later, the cable was repaired and power
restored.
Root Causes
Worksite/ Job Hazards (Location of
buried cable was not identified in
handover certificate and no surface
markers exited; cable was not
subjected to physical protection)
Lessons Learned
07-08-13
Immediate Causes

operator was not aware of the presence of buried
1. Identify and mark location of buried cables and
cable)
utilities in hand over certificate.
(The cable was not buried at required depth and 2. Physically mark location of buried utilities on
site especially during site works.
had no protection against physical dame)
No Warning Provided (There were no sign
boards or makers to indicate presence of the
cable)
49
Fall of Operator from Batch Mixing Platform

Area
Drilling
Rig was preparing for cement job and two
helpers were assigned mixing chemicals
(Lead & Tail slurry) on top of the batch
mixer. A forklift was used to place chemical
pallet on top of the batch mixer. In order to
place the pallet, platforms guard rails were
removed. After completing the job, a helper
was cleaning the site and throwing down
empty bags and wooden pallet. While he was
throwing down the empty wooden pallet,
loose binding strap on the pallet, entangled in
his feet & dragged him and he fell down from
11 feet height on the ground (sand).
Outcome: The worker sustained knee and
ankle injuries.
Inadequate Identification of Worksite/ Job

Hazards (Hazards associated with removal of
handrails were not assessed; Entanglement with
loose strap was not considered & risk assessed)
Inadequate Development of Operating

Procedure (Procedure did not include use of fall
protection devices, barricading unprotected
height, removal of binding straps and chemical
loading mechanism (e.g. Forklift Vs. lifting
Crane))
Lesson Learned
Immediate Causes
ND-55
20-08-13
Root Causes
Disabled Guards or Safety Devices

(Handrails were removed from the
platform to enable loading)

Present (Entanglement with loose
binding strap on the pallet was not
anticipated whilst throwing down the
pallet from the platform)
Unprotected Height (Work was

performed at height with disabled guard
without any body harness)
1. Remove binding straps from the work area

after opening the pallet.
2. Do Not Remove hand rails while working on
batch mixer platform.
3. Use fall protection devices such as full body
harness with appropriate lanyard or Self
Retract Line while working on batch mixer
platform.
50
Finger Injury during Dismantling of Wire line Tool

Area
A wire line crew was assigned to carry out Bottom

Hole Closed in Pressure (BHCIP) survey and after
the completion of the work, during rig down, the
crew was dissembling/opening pulling tool, held on a
vise using pipe wrench. The vise was located close to
trucks body and did not allow 360o movement.
While an operator was applying the pressure, the
wrench slipped, trapping his right hand between the
wrench and edge of the truck body. Outcome: He
sustained crush injuries on his three fingers.
BAB & Gas
Root Causes
Inadequate Human Factors/ Ergonomics
Consideration (Vice was installed/fabricated
on the side of the truck not allowing 360o
movement)
Inadequate Management of Change (Other
wire line trucks have the vise installed at the
rear end providing free movement while one
truck had vice installed on the side. The change
was not adequately risk assessed).
Lessons Learned
Immediate Causes
30-08-13
Inadequate Equipment (The vice was located

close to the edge of the vehicle, not allowing free 1. Subject all equipment design changes to
HAZOP
movement)
Improper Placement of Tool (The wrench was 2. Conduct specific hand tool safety sessions for
operators
not adequately secured/latched resulting in
downward movement)
Routine Activity without Thought (Operators

perform the task on daily basis and have low risk
perception)
51

Area
Drilling
ND-1
During Run in Hole (RIH) activities, Derrick man
missed latching Drill Pipe (DP) stand and it dropped

to the opposite side of the derrick DP rack. The
crew started to return the stand back to Derrick
Rack, using both rig floor winches. Winch cables
were wrapped around the stand, anchoring it, with
make-up chain, to the rotary table stand and began
pulling it back. While pulling the makeup chain
slacked causing the stand to slide/slip and go out
through the gap between rig floor post and V-door
handrail. Outcome: Drill pipe stand slipped through
the gap between rig floor post and V-door handrail
and fell on the ground below in Vertical Position
(Mender)
25-06-13
Root Causes
Job Hazards (The task of pulling the missed
DP stand back towards derrick was not risk
assessed and no crew safety meeting was
conducted)
(Procedure for the recovery of missing stand
was not implemented; Rig Manager was not
notified prior to attempting the recovery of
missing stand)
Lessons Learned
Immediate Causes
Violation by Group (The crew did not follow the

procedure to pull back missing stand)
Improperly Prepared Equipment (Makeup

chain was not properly tied to prevent stand
movement)
Equipment or Materials not Secured (Bottom

of the stand with other stands in derrick was not
tied to prevent slippage of stand; Handrail with
toe board was not installed)
1. Secure/Tie off the bottom of stand with other

stands in derrick to prevent it from slipping.
2. Consider pulling the missing stand as a critical
operation and conduct Job Safety Analysis
before pulling it back.
3. Install handrail with toes board to prevent
dropping stand from rig floor.
52
Finger Caught Between Spinners of Hawk Jaw

Area
Root Causes
During routine drilling operations, crew was making

drill pipe stand connection, through mouse hole. A
floor man was operating Hawk Jaw and while making
connections, he was observing the joint and placed
his hand near spinner of Hawk Jaw and his finger
was finger inside the spinning circle. During the
course, he operated the push button with the right

hand, to start the spinning motion. It resulted in his
left hand small finger getting trapped between the
spinners and he sustained finger crush injury.
Outcome: The Floor man underwent surgical
procedure and part of a finger was amputated.
Inadequate Training Efforts (All crew

members were not trained on the operations of
Hawk Jaw)
Inadequate Management of Change
System (Hawk Jaw was introduce to replace
rotary table with rig tongs and the change was
not supported by training of crew members)
Lessons Learned
Drilling
Immediate Causes
ND-60
28-08-13
Improper Position or Posture for the Task

(The floor man placed his hand near spinners of
Hawk Jaw instead of hand rest)
Lack of Knowledge of Hazards Present (Pre
Job Safety meeting did not cover pinch point
hazards; All crew members were not trained on
the operation of Hawk Jaw)
1. Ensure all crew members are adequately to

operate power tools & equipment.
2. Discuss Job Safety Analysis (JSA) with crew
members prior to start of job.
53
Finger Trap between V Door on Rig Floor

Area
During Run in Hole (RIH) operations, a newly

promoted Floor man (on his fist shift) was closing a
sliding V door. There were no handles on the
sliding door and the Floor man was pushing the door
with his foot and right hand. During the process, tip
of his middle finger was trapped between V door
stabilizer bar and rig floor hand rails. Outcome: He
sustained fingertip crush injury resulting in loss of
nail.
Root Causes
Inadequate Technical Design (V door

was not fitted with handles for sliding;
Pinch point was not colour coded))
Inadequate Supervisory Example (A

new Floor man was not adequately
supervised and coached on required skills)
Lessons Learned
Drilling
ND-55
Immediate Causes
08-09-13

(Floor man placed his hand on the edge of sliding
V door (pinch point))
Inadequate Equipment (V door did not have

handles to support movement)

(Newly appointed Floor man was not aware of
the hazard)
1. Closely supervise newly hired workers

(Green Hat) especially when assigned on rig
floor.
2. Provide handles on V doors and/or colour
all pinch points on rig floor
54
Damage to Well ESD Panel during Sand Clearance

Area
Sb-107 is a Zone-B Gas lift oil producer well and it

was converted to Gas Lift Well. It has a manual
Emergency Shut Down (ESD) panel (approximately
1.5 m high) outside the fence. Due to sand
storms/sand movement ESD panel was buried under
the sand. As a part of pre-commissioning activities
sand clearance was required. While clearing sand,
using a wheel dozer, the wheel dozer hit and
damaged the buried ESD panel. Outcome: The
South East panel was damaged
Root Causes

Job Hazards (Excavation Certificate was
issued without referring to P&IDs)
Asab
07-09-13
Lessons Learned
Immediate Causes

crew was not aware of the presence of the buried
ESD panel and the cable detector did not detect 1. Refer to P&ID prior to issuance of excavation
the buried panel)
certificate.
Storm or Act of Nature (Due to sand
storms/sand movement the ESD Panel was
completely buried)
55
Arm Injury Due to fall of Jumbo Bag

Area
Root Causes
A crew was mixing cement spacer for cement plug

and a jumbo bag (1.5 Tons) was suspended over
batch mixer with a crane. A crew member positioned
himself to open/cut the bag and extended his body
under the suspended load. Suddenly bags
handle/strap broke/parted causing the bag to tilt
and fall over his hand.
Drilling
Outcome: The worker sustained bruises and muscle

sprain.
Inadequate Material Packing (The

straps/handle of Jumbo bags were not
adequate to sustain the load of contents)
Inadequate Audit/Inspection/ Monitoring
(There was no effective quality control in place
to ensure bags handles are robust enough to
sustain it contents)
Lessons Learned on Embedded (Similar
incident had occurred on 29-10-2012 and the
lessons learned were not communicated to new
crew members)
Lessons Learned
ND-8
18-09-13
Immediate Causes

(The worker went under a suspended load)

worker was not aware of hazards of suspended
jumbo bag or risk of fall load)
Inadequate Equipment (There was no stand to

place the bag on the hopper)
1. Always assess compliance of received

materials with contractual requirements for
packaging.
2. Whenever emptying jumbo bags at mud
hopper, use Jumbo Bag Stand
3. Communicate prior incident Lessons learned
to new crew members.
56
UV/IR Fire Detectors Pole Damage

Area
Root Causes
During the monthly preventive maintenance of

the UV/IR fire detectors that are mounted on a
9 meters pole, the pole sheared off the hinge
and fell down on the floor.
Inadequate Product Acceptance

Requirements: The quality of fillet weld on
the pole which was subcontracted by the
vendor was not assured.
The investigation revealed that the pole was

held by one hinge only as the other hinge fillet
weld had already failed
Inadequate mechanical design and

integrity: 9 meters height poles should not be
lowered manually.
Inadequate preventive Maintenance

Program: Standard maintenance Procedure
did not mention lowering and raising of XFD
mount pole.
Outcome: Property damage sustained to the

pole assembly, cables and accessories.
Lessons Learned
SE
Immediate Causes
Asab
1. Initiate visual inspection and NDT on

hinges of all similar poles to quantify
potential hazard.
20-10-13
2. Hinges of such mounted poles should be

regularly greased and visually inspected
for any defects.
Use of Defective Equipment: the fillet weld on

the hinges was sheared off and only hinge was
holding the upper section during lowering.
3. Preventive
maintenance
procedures
should mention the sequence of works
including the method of lowering the pole.
4. Review the existing design of mounting
poles in relation to the approved
maintenance procedure.
57
Fire at Asab Accommodation

Area
A
smoke
detector
activated
at
Asab
accommodation camp at night and all
personnel evacuated to designated assembly
points. The Fire & Rescue team mobilized to
the fire scene and managed to distinguish the
fire, preventing it from spreading to other
rooms.
Root Causes
Inadequate
identification
of
worksite/job hazards: The lamp was
placed new the curtain without identifying
hot surface hazards and assessing the fire
risk.
Inadequate assessment of potential

failure: The type of dimmer switch used for
the bed lamp is prone to fail causing the
lamp to stay switched on.
Investigation team identified the bedside stand

lamb as the cause of fire when it came in
contact with the curtains due to possible failure
in the light dimmer.
SE
Asab
Lessons Learned
Outcome: Room property damage of around

$16000.
24-11-13
1.
Ensure that side table lamps and stand

lamps are positioned away from curtains or
any other flammable/combustible material.
2.
Keep the socket switch off when the room

is unoccupied.
3.
Replacing the dimmer switch that is prone

to failure with a normal on/off switch.
4.
Remove flammable curtains from rooms.
Immediate Causes
Exposure to thermal Radiation (The curtain

was in direct contact/in close proximity to the
lamp hot surface)
58
Road Safety
59
Kenworth Rollover
Area
Root Causes
A logistic contractor vehicle (Kenworth

Trailer), carrying casing tubing, was on
its way, from BAB-13 stores to a rig

location in Mandar Field (approximately
300 km away). The journey was not
subjected to effective journey
management (no book in/book out, no
means of communication and the driver
had worked for months without rest

days). After four and half hour of driving,
Corporate the driver lost control of the vehicle on a
sand track and the vehicle started to
Support
drift until it entered low lying areas, next
to the sand track and finally rolled over.
04-02-2012 Outcome: The driver sustained minor

injuries and the vehicle was badly
damaged.
Inadequate Work Planning or Risk Assessment

Performed (The journey was not effectively planned
e.g. driver was not accompanied on this long journey
and no communication means were provided)
Inadequate Audit/ Inspection/ Monitoring (The
vehicle was not fitted with IVMS and drivers driving
behavior (RAG Reports) was not monitored; drivers
were working all calendar days for the last three
months without off days and unknown working hours)
Policy/Standards/Procedure (ADCO Safety
Requirements (i.e. IVMS and Journey Management);
HSE Management of Contractors( i.e working hours
and rest contributing to fatigue & inattention) were
not effectively implemented)
Inadequate or Lack of Safety Meetings (Drivers
were not subjected to daily tool box talks)
Lessons Learned
Immediate Causes
Inattention to Footing &

Surrounding (The vehicle started to
drift and ran off the track into low
lying area)
Over excretion of Physical
Capabilities (Fatigue factor,
solitary driving)
1. Implement journey management plan to consider

route hazards, fatigue and means of communication.
2. Minimum two persons per vehicle shall conduct the
journey (to remote locations)
3. Conduct daily Tool Box Talk (TBT) for logistic drivers
before start of journeys.
60
Man Lost in Desert

Area
Drilling
ND 52
31-01-2013
A service company engineer arrived to the rig
site in the morning and after completing the
task, he booked out from rig site and proceeded
to the rig camp, situated approximately 7 km
from the rig site. Later in the evening, he was
called in to perform a job at the rig site and he
left the camp and proceeded to the rig location.
The rig access route makings/sign were not
visible at night and he took a wrong turn and
continued driving. Upon realizing the situation
he tried to return back but his vehicle got stuck
in loose sand. He did not have any means of
communications. The vehicle IVMS (In vehicle
Monitoring system) was equipped with a panic
button to initiate the emergency but it
malfunctioned.
After waiting for about an hour, two search
vehicles were dispatched on Search & Recovery
mission. In the meantime the engineer used
flare gun to attract attention and search &
recovery team located him and evacuated him
to the rig site.
Immediate Causes

Judgment (Before leaving the camp, the
engineer did not ensure he had means of
communication)
Inadequate Warning System (Rig access

track was not adequately signed/marked and
at an intersection, the engineer took a
wrong turn)
Root Causes

Monitoring (Compliance with ADCO Night
Driving Guidelines was not monitored
between Rig Site & Camp; Effectiveness of
sign boards/marking between Rig Site and
Camps were not monitored)
Lesson Learned
1. Check and monitor effectiveness of

signage/makings between Rig site and rig
camp.
2. Visitors should be escorted while travelling
between Rig site and rig camp at night and
follow ADCO Night Driving guidelines
61
Vehicle Collision
Area
A tubular handling crew booked in at a rig location

(ND 24) and then booked out to proceed to NDC
Central Camp) to book rooms and to take dinner.
Then the crew left the camp and they were on
their way to the rig location (approximately 45 km
away from the camp). Due to earlier sand storm
there was sand accumulation on the road. The
driver was surprised by the sand on the road and
tried to change lane to avoid sand. At the same
time another 3rd Party vehicle was approaching
from opposite site and both vehicles collided.
Outcome: Four crew members sustained serious
injuries.
Root Causes
Worksite/Job Hazards (Night Time
driving hazards between the rig location
and central camp were not identified and
the journey was not subjected to ADCO
Night Driving Guidelines)

Assessment Performed (In Vehicle
Monitoring System (IVMS) is not geo
referenced with posted speed limits)
Lesson Learned
Drilling
Immediate Causes
ND 24
Violation by Individual (Driver was over

speeding (105 km/Hr Vs 80 km/Hr posted
speed limit)
Inattention to Footing & Surrounding

(Upon noticing sand accumulation, the driver
suddenly changed the lane in front of
oncoming vehicle )
14-03-13
Work Exposure to Storm or Act of Nature

(Sand accumulation after sand storm)
1. Do not drive at night or during low

visibility unless it cannot be avoided.
2. Subject night time driving to risk
assessment /Journey Management
System
3. Always adjust/reduce vehicle speed
according to visibility and road
conditions
62

Area
While a project vehicle (pick-up) was on its way to

Dubai from Al Habtoor Camp (Qusahwira), it
collided with a water tanker (supplying water to
another project) in Al Quaa (approximately 122 km
away from Qusahwaira contractor camp). There
was dense fog with reduced visibility and both
vehicles collided head on. Outcome: It resulted in
the death of the pick-up driver and the passenger
sustained serious injuries.
South East
Root Causes
Inadequate Leadership (Night time

driving during foggy conditions was not
stopped)

Monitoring (Compliance with road
safety requirements (book in/out, fog
markers and night driving was not
adequately monitored)

Assessment Performed (Early water
delivery timing encouraged water
supplier to undertake night time driving)
Qusahwira
Lessons Learned
14-03-13
Immediate Causes
Violation by Group (Nigh time driving during

foggy conditions was undertaken by project
staff and the water tanker operator)
Inattention to footing & Surroundings
(Vehicles speed was not adjusted to weather
and road conditions)
1. Do not undertake driving assignment during

low visibility.
2. Implement book in/out at site
accommodation camps.
3. Plan journeys to avoid driving at night
63

Area
South East
Shah
A crew was driving from Asab to Shah Central
Degassing Station (CDS) for installing marker
posts along MOL (Main Oil Line). The crew
was travelling on Hameem Road.
Approximately 12 km before Shah Junction,
over a blind crest hill climb is a roundabout
where the posted speed limit is 60 km/Hr. A
private vehicle was parked on the hard
shoulder and one person came out from
behind the parked vehicle and started to
cross the road. The project vehicle (driven at
a speed of 120 km/Hr.) hit the pedestrian.
Outcome: The pedestrian sustained head
injuries and he was taken to hospital in an
ambulance. He later died in the hospital
07-05-13
Causes

Risks (In Vehicle Monitoring System
(IVMS) is not geo-fenced with posted
speed limit and driver was driving at
speed of less than 121 km/hr. to avoid
IVMS violation regardless of the posted
speed on Hameem Road )
Inadequate Recall of Training

Materials (Driver did not anticipate
hazards ahead and continued driving at
high speed towards a blind spot)
Lesson Learned
Immediate Causes
1. Always follow the posted speed limits and

reduce speed according to road and driving
conditions (e.g. blind spots, low visibility &
Violation by Individual (The driver was
build up areas)
driving at speed of 120 km/hr. in 60
km/hr. section of the road)
2. Watch out for pedestrians especially near
(The vehicle was parked approximately 80
meters after the blind spot and the driver 3.
was not able to react in time (high speed
and shorter distance)
crossings and parked vehicles along road

side.
Subject drives to daily Tool Box Talks (TBT)
discussing hazards specific to the assigned
route.
64
Vehicle Rollover
Area
Drilling
A driver was assigned to collect and deliver medical
reports from Madinat Zayed Hospital to NDC Base
Camp. After delivering documents, the driver was
returning back to rig location. While driving on the
black top road, his vehicle drifted towards hard
shoulder and he attempted to return back on the
road but he steered into opposite (wrong) lane and
then again he attempted to steer it back and applied
harsh brakes to reduce the speed of the vehicle. It
resulted in vehicle to rollover. Outcome: The driver
escaped unhurt as he was wearing seat belt and the
vehicle windscreen and windows glass was damaged.
Root Causes

Monitoring (Drivers driving behavior
reports (RAG Reports) were not
effectively reviewed to provide
counseling/coaching on his driving
skills)
Inadequate Assessment of Needs

& Risks (In Vehicle Monitoring
System (IVMS) is not geo fenced with
posted speed limits)
ND 24
Lessons Learned
(BUH)
Immediate Causes
24-04-13
Violation by Individual (The driver was driving 1. Do not apply harsh brakes and sharp
at speed of 105 km/Hr. on against 80 km/Hr.
maneuvering of steering, simultaneously,
posted speed limit)
to control vehicle at high speed.
Distracted by other Concerns (The driver lost

concentration and the vehicle drifted from the
road)
2. Review drivers driving behavior reports

(RAG Reports) to identify risky drivers
and provide counseling/ coaching on
driving skills.
(Driver applied harsh brakes and sharp steer
maneuvering to control the vehicle)
65

Area
Shah Gatch track widening project was ongoing and crash barriers were installed on the
track to separate the old (existing) and new
Gatch track. In some areas, the distance
between barriers was large enough for
vehicles to enter.
South East
Shah
07-06-13
Root Causes
Inadequate Monitoring of Construction

(Access to under construction track were not
blocked and no warning signs were provided
to deter road users entering the under
construction track)
A water tanker was on its way from Tarif

Water Filling Station to Shah and the driver
decided to use the under construction part of
the Gatch track. Upon reaching km 22 point,
a barrier, perpendicular to the track, was
observed and the driver veered to the
extreme right side to avoid the barrier. As a
result, the right side wheels of the tanker
entered the soft sand at the edge of the
track. It resulted in tanker to roll over to its
right side. Outcome: The driver escaped
unhurt and the tanker sustained minor
damage
Immediate Causes
1. Do not use under construction roads/ access

tracks

Judgment (Driver decided to use under
construction track which was not yet
opened for use).
2. Barricade access to under construction

road/access tracks
Inadequate Guards or Protective

Devices (There were large gaps between
barriers allowing access to under
construction part of the track)

Present ( Driver did not anticipate soft
sand at the edge of the track)
Lesson Learned
66

Area
South East
A water tanker was assigned to earthwork
activities and used for water spraying & gatch
stabilization. The tanker operator collected
water from a well (Well No. 5) and sprayed
water on side slope of accommodation camp
site. At mid-day break time, he parked his
vehicle at the work location (inclined slope)
and went to the camp for lunch. The tankers
hand break (Air Brake) became released and
partially filled water tanker started to roll
backward for about 100 meters and then
rolled over. Outcome: No personnel injury
had occurred and tanker sustained broken
wind screen.
Root Causes
Inadequate Performance of Skills (Driver

parked the water tanker on an inclined slope)
Employee Perceived Haste (Tanker

Operator was in hurry to catch staff bus to go
to the camp for mid-day brake and parked
the taker near the location where he was
working)

Monitoring (Inadequate Supervision) (Site
In charge did not ensure if the site and
equipment are left in safe condition/position
prior to the break time)
Lesson Learned
Qusahwira
18-06-13
Immediate Causes
Equipment or Materials Not Secured

(Water tanker was parked on a sloped
area without inserting wheel chokes to
immobilize wheels)
Present (There was no dedicated parking
area for tanker at the location and the
driver did not anticipate risk of tanker
rolling)
1. Always park vehicles in dedicated parking

areas.
2. Do not park vehicles, especially heavy
vehicles, on a slope.
67
Vehicle Rollover
Area
A project driver and a passenger were travelling

from Asab to Qusahwira to collect materials. There
was accumulation of sand on the track and the
driver tried to avoid a sand bar and while returning
back to his lane, the front right tire punctured and
the driver lost control of the vehicle. It resulted in
vehicle to rollover. Outcome: Both driver and
passengers were wearing seat belts and escaped
unhurt; and the vehicle sustained damage.
Root Causes
Inadequate Identification of Worksite or

Job Hazards (Journey was planned without
identifying hazards associated with the route)
Inadequate Preventive Maintenance (The

track was not adequately maintained especially
after sand storm/ windy conditions)
South East
Lessons Learned
Qusahwira
20-06-13
Immediate Causes
1. Always adjust/reduce vehicle speed according
to road conditions.
Inattention to Footing & Surroundings

(Driver did not adjust/lower his speed when
encountered sand accumulation and tried to
drive around sand bars)

Judgment (Driver applied harsh break to control
the vehicle on Gatch Road, while maneuvering
around sand accumulation)
2. Do not apply harsh brakes and sharp

maneuvering of steering, simultaneously, to
control vehicle at high speed.
3. Subject drivers to daily tool box talks to
discuss route hazards and to reinforce safe
driving behavior.
68
Vehicle Collision & Rollover

Area
A crew was working a Main Oil Line (MOL-1) and
after completion of their activities, crew was
returning back to Jebel Dhanna Accommodation
camp, in two vehicles.
Terminal &
Pipeline
Operations
Each vehicle selected a different route and

proceeded to Jebel Dhanna. At an intersection, one
vehicle approached the main track from a blind spot,
while the other vehicle was crossing through. It
resulted in vehicle collision causing one vehicle to
rollover. Outcome: No personnel injury to any of 9
crew members and damage to both vehicle
occurred.
Root Causes
Inadequate Identification of Worksite/Job

Hazards (Risks associated with the journey
were not adequately identified; lack of road
traffic warning signs was not notices/rectified;
crew did not travel in a convoy)
Lessons Learned
Immediate Causes
23-06-13

Judgment (Vehicle, approaching from blind
spot, did not stop at the intersection to ensure
clearance).
1. Slow down when approaching an intersection

from a blind spot.
No Warning Provided (There were no road

warning signs before the intersection).
2. When travelling in multiple vehicles, travel in

convoy.

journey was not adequate planned and crew
vehicle did not proceed in convoy; risks
associated with the journey were not adequate
identified).
69
Vehicle Rollover
Area
After finishing his daily tasks, a project driver was

assigned to take a vehicle to Abu Dhabi workshop for
routine maintenance. The driver went to his camp to
refresh and after taking his lunch he started his
journey. Approximately 5 kilometers after the
Security Check Point, the driver lost concentration
and the vehicle started to drift. The drive attempted
to adjust the direction to the right and applied harsh
brakes causing vehicle to come off the road and rolled
over. Outcome: The driver escaped unhurt and the
North East vehicle sustained major damage.
Bab (NEB)
Root Causes
Physical Conditions- Fatigue (The driver

had completed his daily tasks and then he
was sent on another long trip)
Diminished Performance (Driver felt
sleepy/drowsy after lunch break resulting in
loss of concentration while driving)
Al Dabbiya
09-07-13
Lessons Learned
Immediate Causes
Inattention to Footing & Surroundings (Driver

lost concentration and the vehicle went off
course)
Judgment/Unintentional Human Error (Driver
attempted to apply harsh brakes while
maneuvering steering to control the vehicle
direction)

maneuvering of steering simultaneously to
control vehicles course.
2. Prior to assigning trip, review drivers fitness
and rest to avoid fatigue during the journey.
3. Conduct tool box talks (TBT)/briefing for
drivers, highlighting hazards associated with
route and physical condition of drivers.
70
Vehicle Rollover
Area
A crew was proceeding for site inspection, driving on a

sand track. There was a hump/small dune on the track
followed by a bend. The driver did not adjust his speed
and drove over the hump and then he was surprised by
the bend. The driver applied harsh brakes and sharp
maneuvering of steering to control the vehicle direction,
resulting in vehicle to rollover to its side. Outcome: All
crew members escaped unhurt and the vehicle sustained
damage.
Root Causes
Inadequate Practice of Skill (Driver

acted on impulse and did not follow safe
desert driving techniques)
Inadequate Reinforcement of Safe
Critical Behaviour (Prior incident lessons
learned involving inadequate practice of
skill while driving off road were not
effectively communicated to drivers)
BAB & Gas

13-07-13
Lessons Learned
Immediate Causes
Work or Motion at Improper Speed (The driver

did not adjust his speed according to road conditions
and he was driving at a speed of 90 km/Hr. against
maximum speed of 80 Km/Hr.)
driver was not familiar with track conditions
especially the bend after the dune)
Judgment/Unintentional Human Error (Driver
attempted to apply harsh brakes while maneuvering
steering to control the vehicle direction)

maneuvering of steering simultaneously
to control vehicles course.
2. Adjust (reduce) vehicle speed according
to road conditions especially when not
familiar with the route.
3. Conduct coaching sessions on how to
respond in case of any emergency (tire
burst) while driving on sand track.
71
Vehicle Rollover
Area
Root Causes
While a crew was driving on blacktop, the front

tire of the vehicle got punctured and the vehicle
became unsteady and started to drift to the left
side. The driver maneuvered the vehicle to the
right side and applied harsh brakes. It caused
the vehicle to rollover. Outcome: The driver
and passengers escaped unhurt and the vehicle
sustained damaged.
Lesson Learned
BAB & Gas

BAB
15-07-13

Monitoring (Drivers RAG reports were
not adequately reviewed; Use of former
drivers blue keys was not
detected/monitored)
Immediate Causes

Judgment/Unintentional Human Error
(Driver attempted to apply harsh brakes
while maneuvering steering to control the
vehicle direction)

maneuvering of steering simultaneously to
control vehicles course.
2. Periodically review drivers driving
behavior (RAG) Reports and provide
counseling as necessary.
72
Vehicle Collision
Area
Drilling
A vehicle carrying crew was proceeding to a well

site (Sb-35). The sand track had a curved slope
and due to earlier stand storms, the track had
sand accumulated, narrowing the track.
Another, vehicle was approaching from opposite
direction and due to sand accumulation; the

vehicle was driven in the wrong lane. Both
vehicles emerged from opposite directions and
collided head on. Outcome: Minor injuries to
drivers and damage to vehicles had occurred.
Causes
worksite/job hazards (Hazards of sand
accumulation on the track were not
considered and crew was not aware of track
conditions)
(Sand track clearance was not performed
after the sand storm)
Shail
Lesson Learned
21-07-13
Immediate Causes
Violation by Individual (One vehicle was

driven in wrong lane of the sand track)
Congestion or Restricted Motion (Due to

sand accumulation the width of the track
was reduced and only a narrow section was
clear)
1. Always follow the posted speed limits

and reduce speed according to road and
driving conditions (e.g. blind spots, low
visibility & build up areas)
2. Watch out for pedestrians especially
near crossings and parked vehicles
along road side.
3. Subject drives to daily Tool Box Talks
(TBT) discussing hazards specific to the
assigned route.
73
Vehicle Collision
Area
After completing the job at a well site, an

Operations Crew was returning back to Asab. The
driver was using the security fence patrolling track
leading to black top road. An Engineering crew
was heading to well site (Sa-213) using the same
track. Due to sand accumulation, engineering
crew vehicle was driving in opposite lane. Both
South East vehicle emerged from a blind spot and collided
head on. Outcome: No personnel injuries and
Sahil
minor damage to both vehicles was reported.
Root Causes

(Sand track was not maintained to clear
accumulated sand)

Assessment Performed (Both vehicles were
using security patrolling fence road/track
instead of using approved routes)
10-08-13
Lessons Learned
Immediate Causes
1. Do not use Fence Security Patrolling Track.
Violation by Individual (Project driver was

driving the vehicle in wrong lane).
2. Maintain sand tracks to remove accumulated

sand, especially after sand storms.
Congestion or Restricted Motion (One lane

of the track had sand accumulation)
Inattention to Surroundings (Both Drivers

approached the blind spot without due care
and attention)
3. Identify access routes and associated hazards

before embarking on journeys especially when
driving off road.
74

Area
Drilling
After making a water delivery to Shah Camp,

a water tanker was returning back, on main
Gatch Road. A part of the road had inclined
slope and the surface was wet. The driver
was applied harsh brakes to avoid entering
wet areas, resulting in vehicle to veer off and
roll over to its side. Outcome: The driver
escaped unhurt and the vehicle sustained
minor damage.
Root Causes
Inadequate Practice of Skill (The

driver did not apply safe driving
techniques)

Monitoring (Drivers safe driving
document (ADSD) had expired in 2010
and there was no effective monitoring in
place to ensure refresher training)
Shah
23-08-13
Lessons Learned
Immediate Causes
Lack of Knowledge of Hazard Present

(The driver was not aware of wet surface
ahead).

Judgment (The driver applied harsh
brakes at an inclined section of Gatch
Road)
1. Do not apply harsh brakes on slopes and

gatch road to control vehicle.
2. Subject driver to refresher safe driving
techniques every three years.
75
Vehicle Collision
Area
An Operations crew vehicle with four (4) passengers
was proceeding to well locations (Bb955) and due to
traffic congestion, the driver decided to drive
through a gatch road. A Project crew vehicle with
three (3) passengers was on its way to another well
location (Bb348) using the same gatch road. Project
crew vehicle was driven in the wrong lane (more
towards right side). Both vehicles approached a blind
spot (uphill) from opposite directions and collided
head on. Outcome: All passengers and drivers
escaped unhurt and vehicles sustained minor
damage
Root Causes
(Journey Management) (Selection of route and
associated hazards were not identified and
Operations crew driver selected an alternative
route during the journey; Operations crew
vehicle was not fitted with desert flag)
Inadequate Practice of Skill (Operations
crew driver did not adjust/reduce speed while
approaching the blind spot)
Lessons Learned
BAB & Gas

Immediate Causes
01-09-13
Violation by Individual (Project crew driver

was driving the vehicle in wrong lane)
1. Always reduce speed when approaching a blind
No Warning Provided (Operations crew vehicle
spot.
was not fitted with desert flag; there were no
warning road signs when approaching the blind 2. Check/fix desert flag on vehicle before
spot)
proceeding on off road driving.
Judgment (Operations crew vehicle did not
adjust/reduce speed while approaching the blind
spot (uphill))
76
Fatal Vehicle Collision

Area
Root Causes
While a Kenworth truck was returning from a well

site (Sb-545) in Asab, after delivering chemicals
(Calcium chloride), a private car (KIA saloon), hit
two deer on the road and lost control of the vehicle
resulting in vehicle to rollover and land in font of
oncoming Kenworth truck. It resulted in fatal injuries
to private car driver.
Inadequate Identification of Worksite/Job

Hazards (Hazards of Ghazal on road were not
adequately identified (awareness, road signs
and barriers to prevent access to road)
Lessons Learned
Corporate
Support
11-09-13
Immediate Causes
presence of free roaming Ghazal was not known
to road users)
Inadequate Guards /Protective Devices
1.
(There was no barrier (fence) to avoid Ghazal
entering the road)
2.
(During low visibility conditions (night time)
private car driver was surprised by the presence
of Ghazal on the road)
Inadequate Warning System (There were no
road warning signs to indicate presence of
Ghazal)
Violation by Group (Effective journey
management planning was not implemented for
Kenworths trip to rig location)
Create awareness about presence of Ghazal

and wildlife in BAB and other ADCO areas
Install road wildlife warning signs on BABMadinat Zayed Road
77

Area
An oil based mud (OBM) haulage tanker was
travelling from Mud Plant towards Rig location in
Asab Field. The haulage tanker had defective valve
resulting in leakage of OBM on the road.
Buhasa
10-09-13
A project vehicle with tow passenger was travelling

to Buhasa Field for inspection and testing of welding
job. The driver was noticed spillage on the road but
perceived it to be water and he continued driving at
high speed (120 Km/Hr. on the road with 80 Km/Hr.
speed limit). After driver through the spill, he lost
control of the vehicle resulting in vehicle to rollover.
The back seat passenger was no wearing seat belt
and he was ejected from the vehicle. Outcome: It
resulted in fatal injuries to back seat passenger and
the driver and another passenger escaped with
minor injuries.
Root Causes
Inadequate Audit/Inspection/
Monitoring
1. OBM Haulage tankers were not
subjected to effective inspections and
vehicle fitness was not adequately
monitored
2. Project vehicle was not fitted with online
In Vehicle Monitoring System (IVMS)
and therefore the system did not warn
when driver over speeded
Lessons Learned
Immediate Causes
Defective Vehicle (OBM Haulage tanker had

defective valve resulting in spillage of OBM on
the road)
Work or Motion at Improper Speed (Project

vehicle was driven at high speed and the driver
did not reduce speed after noticing the spill on
the road)
1. Driver should ensure all passengers wear seat

belts before moving the vehicle.
2. Always follow posted speed limits and reduce
vehicle speed according to road conditions.
3. Inspect haulage vehicles fitness prior to their
use
78

Area
A crew vehicle was commuting to work from

Contractor Accommodation in Al Ain (Al-Quaa) to
Qusahwira Field (approximately 130 km long trip).
The driver was over speeding and at the same time
he felt sleepy, resulting in vehicle to drift from the
road and causing vehicle to rollover.
The vehicle was not fitted with in vehicle monitoring
system (IVMS), rollover protection bars (RPB) and
the driver was not subjected to ADCO Safe Driving
Document (ADSD) training. The driver and the front
seat passengers had fastened their seat belts whilst
rear seat passengers were not wearing seat belts.
South East Outcome: Vehicle roof collapsed resulting in fatal
injuries to one crew member.
Qusahwira
07-10-13
Immediate Causes
Violation by Supervisor
1. An untrained and inexperienced driver
was assigned to drive crew vehicle
Root Causes
Inadequate leadership (ADCO road safety

requirements were not adequately enforced on
subcontractor).
Lessons Learned
1. All passengers (rear occupants) must fasten

their seatbelt (seat belt save lives)
2. Conduct Awareness sessions for contractors
and sub-contractors explaining the benefit of
using ROB.
3. Ensure that all contractors & Sub-contractors

residing nearby working site (avoid long
2. Unapproved vehicle (without IVMS and
journeys while commuting between worksite
Rollover Bars) was used for crew transfer
and camp).
3. Crew was transferred from Site Camp and
accommodated in Al-Quaa without
authorization and Journey Management
Plan
79
Diesel Tanker Rollover

Area
Root Causes
A Diesel Tanker Driver filled the tanker from the

camp location and proceeded to Gatch Stockpile
location, in Asab. While approaching Asab T Junction,
the rear left tire punctured and the tanker started to
drift. The driver tried to steer it and applied harsh
brakes resulting in driver to lose control, causing
tanker to rollover.
Outcome: The driver escaped unhurt and the vehicle

sustained major damage. Approximately 2000 gallons
of diesel were spilled.
Inadequate Training Efforts (The newly

assigned driver and other contractor staff were
not familiarized with ADCO night time driving
guidelines)
(ADCO requirements for Journey Management
were not effectively implemented)
Inadequate Audit/ Inspection/ Monitoring
(Effectiveness of book in/out from Camp were
not monitored)
Lessons Learned
South East
Immediate Causes
Asab
10-11-13

(The driver decided to transfer the tanker at night
to save time and to attend to his personal tasks in
the morning)
maneuvering of steering to control vehicle.
Inadequate Guards/protective Devices (In
Vehicle Monitoring System (IVMS) malfunctioned/ 2. Avoid night time driving and training all new
staff on Night Time Driving Guidelines
disconnected; No book in/out checks at the filling
site and in the camp)
3. Establish/Maintain effective Journey
Violation by Group (Driver undertook night time

driving and the filling station attended & Camp
Gate Security did not stop the driver)
Operation of Equipment without Authority

(Tank filling attendant allowed the driver to fill the
tanker)
Authorization & book in/out at Camp Gates.
80
HSE Performance, 2013
ADCO & Contractors LTIF & TRIR (YTD) vs

180
1.29
0.8
0.70
0.68
0.66
0.81
0.55
0.6
0.78
0.12
57.36
0.26
32.5
55
0.29
44.4
47
34
0.16 0.16
0.34
32.3
0.36
0.28
27
0.2
0.34
56
0.55
0.4
100
0.47
0.51
0.63
120
80
0.46
86.29
0.80
140
118.92
0.93
160
160.49
1.2
60
40
0.09 0.08 0.07
20
0
Historical HSE Performance
Million Manhours Worked
1.4
29
Lost Time Injury Frequency Rate / Total

Recordable Injury Rate
Manhours worked
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Manhours
Actual LTIF
TRIR
81
Vehicle Accident Frequency, Vehicle Crashes vs KMs Driven

0.50
250
198.6
200
0.35
0.30 0.29
150
0.27
0.25
0.22 0.20
0.18
0.20
0.18
0.19
13
57.5
0.11
14
21
14
14
10
0.12
26
24
100
122.1
76.9
0.12
61.0
80.4
70.0
64.0
11
44.0
18
36.0
0.10
78.0
0.17
0.15
0.05
136.9
0.30
40.0
Vehicle Accident Frequency Rate
0.40
50
22
10
0.00
0
2001
2002
2003
2004
2005
2006
KM Driven
2007
Year
2008
Vehicle Crashes
2009
2010
2011
2012
2013
Million Kilometer Driven / No. Of Vehicle Accidents
0.45
0.45
VAF
82
Incident Sub Types 2013

(Work & Non-Work Related-316)
200
150
100
50
0
2009
Fire
2010
Gas Release
2011
Injury/Illness
2012
2013
Transportation
Onshore Spill
83
Incident Immediate Causes -2013
84
Inattention
Distracted by other
concerns
8%
No Warning
Provided
8%
Routine activity
without though
12%
Improper decision
making or lack of
judgement
47%
Inattention to
footing and
surroundings
25%
85
Incident Root Causes - 2013
86
Asset Wide Incident Root Causes- 2013
87
Do Not Compromise on the Safety of Staff & Workers, Protection of the Environment and Integrity of Assets
ABU DHABI COMPANY FOR ONSHORE OIL OPERATIONS

(ADCO)
88

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2013 Learning From Incidents PDF

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Incident Prevention Through

Learning from Incidents

January - December, 2013

HSE & Risk Management

Abdulla Hussain Mohammad Al Marzooqi

Closed Drain Header Gas Leak

Burn Injuries during Well Testing Activities

Closed Drain Header Gas Leak

1st stage level transmitter of train 2 was flushed

Violation by Group (Closed drain outlet

Defective Equipment (individual drains

Lack of Knowledge of Hazards

Inadequate Leadership (Deviation

1. Line up individual train isolation

Loss of Well Containment During Coil Tubing Activities

Bb-731 was drilled and completed with 3

resulted in a fire on the CT injector head. The CT

BAB & Gas

Violation by Group (Coiled Tubing

Improper Decision Making (Improper

Lack of Knowledge of Hazards Present

Well Control Incident

taking the proper amount of mud & flowing at a

Inadequate Practice of Skill (Drilling

SICP 280 PSI

Modular Dynamic Tester (MDT) in the 8 1/2

Violation by Individual (The first 5 stands

Improper decision making / lack of

Well Control Incident

In Thamama zone B single oil producer, 8

4875 psi pressure Vs 4100 psi predicted

MDT. While drilling 6 Horizontal hole

Inadequate Work Planning or Risk

1. The reservoir pressure should be continuously

Lack of Knowledge of Hazards

Devices (The well was drilled with

Spill from a Flow Line

A 1.9 km. long flow line from well Sb-195 to

lines with relatively high water-cut, and low

Inadequate Engineering / Design

Loss of Containment - Oil Spill

RDS-4 transfer line is Carbon Steel (CS), 4.3 km

of the 16 transfer line has cathodic protection

Equipment/Material Not Secured (The

Improperly Prepared Equipment (Both

Inadequate Assessment of Potential

1. Connect both ends of MONOBLOC

Gas Release while Depressurizing Gas Injection Trunk Line

Due to a leak from a gasket at a well site (Bb-645),it

was planned to depressurize the associated Trunk Line

Operations Foreman opened 2 vent valve located

Lack of Procedure (There was no formal

1. Ensure availability of Standard Operating

The calibration of Multiphase Flow Meters

(MPFM) was planned and it included injecting

plan and execute the task.

An Operations representative was assigned

Inadequate Work Planning or Risk

1. Ensure all vendors are aware of ADCO

Violation by Group (Job Originator did not

Lack of Knowledge of Hazards Present

Well Control Incident

Well -Sy22 is (Simsima) single Oil producer