Learning From Incidents

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

[email protected]
HSE & Risk Management
Tel: 02-60412017
1
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 7

Loss of Well Containment During Coil Tubing Activities 8
Well Control Incident 9
Spill from a Flow Line 11
Loss of Containment - Oil Spill 12
Gas Release while Depressurizing Gas Injection Trunk Line 13
Gas Release from Closed Drain System during Calibration of Multiphase Flow Meter 14
Oil Spill from a Flow Line 16
Leak from Flow Suction Tank 17
Buried Gas Line Struck by an Excavator (Near Miss) 18
Oil & Gas Release from a Flow Line 19
Gas Release from Choke Valve 20
Oil Carry Over to Flare Stack 21
H2S/ Hydrocarbon Gas Release from Water Separation Tank 22
Oil Spill from Flow Line 23
Oil Carry Over to Flare Stack 24
Oil Spill from Redundant Flow Line 25
Loss of Containment- Oil Spill 26
Release of Oil from Metering Prover 27
Gas Release from Compressor 28
Oil Spill from Redundant Main Oil Line (MOL) 29
Fall of Derrickman on Monkey Board 32
Fall of Lubricator & BOP Assembly on Christmas Tree During Lifting 33
Fire during Hot Cut of a Water Injection Flow Line 34
Fall of a Driver from Kenworth Trailer 35
Dropped Tubing Joint from Elevator 36
Damage to Over Head Lines – OHL 37
Hand Injury from Front End Loader’s Bucket 38
3
Burn Injuries during Well Testing Activities 39
Fall of Travel Block on Rig Floor (Rig Move) 40
Fatal Fall of Driller from Height (Rig Move) 41
Damage to Over Head Lines –OHL 42
Drop of Drill Pipe Stand from Derrick 43
Fall of Banksman from a Sand Dune 44
Finger Entrapment between Sliding Door of a Crane and its Frame 45
Disengagement & Fall of Upper Link Guide Support Clamp on Rig Floor 46
Finger Trapped between Scaffold Pipes 47
Finger Trapped Between Falling Load and Vehicle 48
Buried Electrical Cable Cut during Site Preparation 49
Fall of Operator from Batch Mixing Platform 50
Finger Injury during Dismantling of Wire line Tool 51
Drop of Drill Pipe Stand from Derrick 52
Finger Caught Between Spinners of Hawk Jaw 53
Finger Trap between “V” Door on Rig Floor 54
Damage to Well ESD Panel during Sand Clearance 55
Arm Injury Due to fall of Jumbo Bag 56
UV/IR Fire Detectors Pole Damage 57
Fire at Asab Accommodation 58
Road Safety 59
Kenworth Rollover 60
Man Lost in Desert 61
Vehicle Collision 62
Fatal Road Traffic Accident 63
Fatal Road Traffic Accident 64
Vehicle Rollover 65
Water Tanker Rollover 66
Vehicle Rollover 68
Vehicle Collision & Rollover 69
Vehicle Rollover 70
Vehicle Rollover 71
Vehicle Rollover 72
4
Fatal Vehicle Collision 77
Fatal Vehicle Rollover 78
Fatal Vehicle Rollover 79
Diesel Tanker Rollover 80
HSE Performance, 2013 81
Vehicle Accident Frequency, Vehicle Crashes vs KMs Driven 82
Incident Sub Types 2013 82
Incident Immediate Causes 2013 84
Incident Root Causes - 2013 86
Asset Wide Incident Root Causes- 2013 87
5
Process Safety
6
Closed Drain Header Gas Leak
Area Incident Description Causes
Since 2006, due to corrosion, the closed drain  Inadequate Leadership (Deviation
network had leaked 12 times. The drain header is from SOP was known but no effective
isolated from drain network by closing two corrective action was taken; Instead
manual isolation valves and accordingly the of replacing/fixing passing valves,
purging fuel gas isolated. Due to passing these were kept in closed position; No
problems in the Train instruments and process effective )
drain valves, these main two manual isolation
 Inadequate Preventive
valves were kept in closed position and these
Maintenance Programme
were opened if there was demand to drain.
(Programme (The passing valves was
1st stage level transmitter of train 2 was flushed not reported to maintenance; Closed
and transmitter chamber was drained to process drain system had leaked 12 times
drain without lining it up to underground drain since 2006. PMRF raised to replace
header. The process drain line, already subjected the closed drain header)
BAB & Gas to corrosion, was exposed to 18 bar pressure and
a leak developed causing activation of H2S Lessons Learned
alarm. Outcome: The train production was
shifted to other trains and started depressurizing
the train to flare. 1. Line up individual train isolation
30-01-13 Valves to main underground header
2. Identify and rectify/replace the
Immediate Causes
passing or defective valve of the
 Violation by Group (Closed drain outlet individual Train‟s drain valves.
valves were kept in closed position without 3. Maintain continuous fuel gas purging
management of change) through the drain lines.
 Defective Equipment (individual drains 4. Follow Standard Operating Procedures
valves were passing) at all times and subject any change to
 Lack of Knowledge of Hazards Management of Change (MOC)
Presents (Due to corrosion issues, the process.
closed drain network had leaked 12 times
since 2006 and there was lower level of
risk perception)
7
Loss of Well Containment During Coil Tubing Activities
Area Incident Description Root Causes
 Inadequate Audit/ Inspection

Bb-731 was drilled and completed with 3 ½” /Monitoring (Inadequate Supervisory
completions in Habshan 2 reservoir. (H2S content Verification of Task Execution)
22% & well shut in pressure 2500 psi). Production
Logging operation was planned to define fluid inflow  Inadequate Identification of Work
using Coiled Tubing (CT) logging package. The Site/Job Hazards (A generic Task Risk
deployment of the PLT dummy tool string on the CT Assessment (TRA) template was used
BOP had been completed. While conducting pressure without taking work sequence and well
equalization across CT Blowout Preventer ( BOP), an characteristics into consideration)
uncontrolled hydrocarbon release occurred this  Inadequate Work Planning (There was
resulted in a fire on the CT injector head. The CT inadequate availability of supervisory staff)
operator activated the shear seal ram and
subsequently closed the Christmas Tree valves
(Swab & Upper Master) to control the situation Lessons Learned
BAB & Gas 1. Do not use generic Task Risk
Immediate Causes Assessment (TRA). Update existing
14-03-2013 TRAs according to work sequence and
work location.
2. Do not perform high risk activities
 Violation by Group (Coiled Tubing
without effective ADCO supervision.
Manual/Coiled Tubing logging Procedure was
not followed ; Improper operation of Pressure 3. Ensure integrity of Pressure Control
Control Equipment(PCE); Incomplete surface Equipment (PCE) via pressure testing
pressure test of PCE) prior to exposure to well head
pressure.
 Improper Decision Making (Improper
4. Ensure double sealing barriers are in
engagement of mechanical lock of Pipe/Slip
place during pressure deployment of
rams (Closure position not verified) and
logging tools.
premature activation of Pipe/Slip ram release
5. Pressure Control Equipment (PCE)
mechanism)
configuration and pressure test
 Lack of Knowledge of Hazards Present certificate should be countersigned by
(The task was not adequately risk assessed) both Job Performer and ADCO Engineer
In charge
8
Well Control Incident
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  Inadequate Practice of Skill (Drilling
taking the proper amount of mud & flowing at a Supervisor (DS) reduced the mud weight
rate of 30bbls/hour. The Rig Crew & Drilling for the 6” section)
supervisor decided to Run In Hole (RIH) back,
circulated hole & flow was checked, found the  Inadequate Communication (DS did
well flowing. After that informed Office without not consult drilling team members prior
securing the well. Office informed the DS to to reducing mud weight
SIDPP 250 PSI
shut the well immediately. Well was killed

using driller method with 88 pcf mud weight. SICP 280 PSI
Modular Dynamic Tester (MDT) in the 8 1/2”

pilot hole confirmed that formation pressure is Lessons Learned
4950 psi instead of 5100psi.Therefore, the
Drilling decision was made to lower the mud weight in
6” hole compared with the well program due to
ND 01 SA-106 water injector was near to SA-170
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)
9
 Inadequate Work Planning or Risk

Assessment Performed (Drilling plan was
based on predicted reservoir pressure and did
In Thamama zone B single oil producer, 8 not require to update reservoir pressure based
½” deviated pilot hole was drilled. The on MDT)
Modular Dynamic Tester (MDT) recorded
 Inadequate Correction of Worksite/Job
4875 psi pressure Vs 4100 psi predicted
Hazards (Nearby injection wells were not shut
reservoir pressure. The 6”horizontal hole
down as requested creating reservoir pressure
was planned but did not cater for updating
uncertainties)
the pressure and mud weight after recording
MDT. While drilling 6 “ Horizontal hole  In adequate communication (There was no
across the formation with 71 pcf mud effective communication between Drilling
considering the predicted pressure of 4100 Engineer, Reservoir Engineer and Petroleum
psi Vs 4875 psi recorded (775 psi Engineer to discuss reservoir pressures and
underbalanced), the well started to flow, results of MDT pressure; The driller and crew
alarm was activated and 5 bbls gain in the were not aware of another well control incident
Drilling
mud tanks was observed. Outcome: The of ND-1 ( Sa-170) occurred on 12th January,
well was shut & secured and crew was 2013)
ND 09
evacuated.
28-01-2013 Lesson Learned
Immediate Causes 1. The reservoir pressure should be continuously

 Lack of Knowledge of Hazards monitored and updated considering injection and
faults affect in the area and the mud weight
Present (Crew were not aware that
should adjusted accordingly.
there was 775 psi pressure difference
between MDT and e-prognosis pressure) 2. Identify and shut down nearby injection wells
 Inadequate Guard or Protective two weeks before penetrating the reservoir.
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 adjusted- mud weight to be adjusted accordingly
the well was drilled underbalanced)
10
Spill from a Flow Line
A 1.9 km. long flow line from well Sb-195 to
RDS-4 was subjected to internal/external
corrosion pitting at the 6 o‟clock position in
the main body of the pipe line. The type of
randomly occurring isolated pitting, in flow  Inadequate Engineering / Design
lines with relatively high water-cut, and low (Selected material for flow lines was non-
flow-rates is a common occurrence. It relates Protected Carbon Steel pipe material exposed
with reservoirs age and fluid chemistry on to isolated internal / external corrosion
unprotected carbon-steel piping. An oil leak concentrated at 6 O‟clock position of flow
was reported from the flow line and the well line).
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
Lessons Learned
sent to treatment facility.
03-02-2013
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
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
 Inadequate Assessment of Potential
of the 16” transfer line has cathodic protection
Failure (Acceleration of internal
and it is separated electrically from the above
corrosion due to change in fluid
ground piping at RDS-4 with isolation joint
characteristics and stray current flow
(MONOBLOC). There was shift (-1.4 V) between
across MONOBLOC was not anticipated
protected and unprotected sides with a
during design stage)
conductive electrolyte (water with high chloride),
accelerating internal corrosion close to the
isolation joint. A pin-hole leak developed at 7
o‟clock position. The line was isolated and
production flow from RDS-4 was diverted to new Lessons Learned
South East CDS through a new transfer line. Effected pipe
line was depressurized for inspection and repairs.
Shah Outcome: It resulted in spillage of approximately
60 bbls of oil. 30 bbls of free oil was recovered
the contaminated sand (38 m3) was transferred
to BeeAt Treatment Facility.
1. Connect both ends of MONOBLOC
01-04-13
with conductor to pass the current
and avoid the flow of stray current
Immediate Causes
2. Monitor Cathodic Protection (CP)
voltage across the MONOBLOC of
 Equipment/Material Not Secured (The transfer lines as a part of preventive
above ground part of the transfer line was not maintenance plan
subjected to cathodic protection)
 Improperly Prepared Equipment (Both
ends of MONOBLOC were not connected
through conductor to avoid flow of stray
current)
12
Gas Release while Depressurizing Gas Injection Trunk Line
 Lack of Procedure (There was no formal

or standard operating procedure for
depressurizing trunk line)
Due to a leak from a gasket at a well site (Bb-645),it
 Inadequate Preventive Maintenance
was planned to depressurize the associated Trunk Line
(There was no specific preventive
(TL). An Operations Foreman tried to open 6” isolation
maintenance schedule for gaskets &
valves, upstream, the choke valve (for depressurizing
valves; maintenance work orders are not
the trunk line) but the first main isolation valve got
specific to individual valves but it cover the
stuck and did not open. The Foreman called the Control
entire area)
Room Foreman and after discussing the issue, the
Operations Foreman opened 2” vent valve located  Inadequate Training Efforts (There is
between Main Shut Down Valve (SDV) and Main trunk no structured training/familiarization
line manual isolation valve. It resulted in 2” vent line, program to assure the competency of the
between the double block valves, to shear from the new staff with respect to the operation of
BAB & Gas
flare header and resulted in gas release and activation gas gathering & injection facilities)
of Hydrocarbon Alarm in the Control Room. ADCO
ASR  Inadequate Technical Design (The
personnel approached the location and closed the
selected valve had no provision for
depressurization valve to bring the situation under
18-04-13 greasing, lack of maintenance philosophy
control. Outcome: It resulted in release of
and no interlock system was considered to
approximately 3.2 MMSCF of gas to atmosphere.
prevent using 2” vent valve for
depressurization)
Lessons Learned
1. Ensure availability of Standard Operating

Immediate Causes Procedure (SOP) prior to depressurize
trunk lines.
 Improper Use of Equipment (A vent line was 2. Familiarize new staff with site specific
used to depressurize a high pressure gas operating procedures prior to their
injection trunk line) assignment.
 Improper Decision Making/Lack of 3. Review & update schedule & scope of

Judgment (Operators decided to use a vent preventive maintenance to ensure all
line for depressurization when the main isolation critical equipment are effectively
valve got stuck and did not open) maintained
13
Gas Release from Closed Drain System during Calibration of Multiphase Flow Meter
The calibration of Multiphase Flow Meters  Inadequate Work Planning or Risk

(MPFM) was planned and it included injecting Assessment Performed (Oil sample
crude oil samples in MPFM and passing samples was provided to vendor for calibration
through Gamma Sensors; and then the sample without ensuring crew is aware of PTW
is discharged into a closed drain system. A requirements and risks associated with
joint meeting was conducted between the task).
commissioning team & a third party vendor to
plan and execute the task.  Inadequate Supervision (Job
Originator did not ensure effective
An Operations representative was assigned supervision and control of work)
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 Lessons Learned
MPFM and opened the blind & globe valve to
drain the sample into the closed drain system.
South East During the process bubbles were noted at the
sample injection point and H2S was detected.
Shah
21-05-13 Immediate Causes
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
the crew started the work without the whilst working in ADCO Areas especially
permit) in restricted areas.
 Lack of Knowledge of Hazards Present

(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
 Inadequate Work Planning or Risk

Well -Sy22 is (Simsima) single Oil producer Assessment Performed (Job order was issued
with Electrical Submersible Pump (ESP) without assessing operational risks; Pre spud
string. While pulling submersible pump meeting was not conducted; Job order was not
completion out of the hole (POH) and filling endorsed by Drilling Supervisor (DS))
the annulus with 200 bbls of location water
(65 PCF), it created “U tubing” from tubing  Inadequate Leadership (DS started the job
string and flow through tubing was without endorsing job order, discussing risks and
observed. Outcome: The crew attempted What If scenarios)
to install low torque valves but failed. Then
the crew closed the shear ram across tubing
Drilling and dropped in hole to secure the well.
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
volume) 2. Always Conduct Pre spud meeting before the
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
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  Inadequate Technical Design (There was
subjected to high water cut from Sy-63 no corrosion inhibitor injection on well
(28% to 43%) for 9 months prior to the heads)
closure of Sy-63. There was no corrosion  Inadequate Assessment of Needs &
inhibitor injection on well heads and de- Risks (Weak flow line (Sch 40) was
emulsifiers were injected to enhance connected to high water cut well Sy-63
separation. The flow line operating pressure (28% to 43%) was introduced to this flow
was increased from 130 psi to 320 psi. Due line for a period of nine months before this
to internal corrosion, a pinhole (~ 3mm) well was closed)
South East leak developed at 6 O‟clock position.
Outcome: It resulted in spillage of 81 bbls
Shah of oil. The flow line was isolated &
depressurized and the HAZMAT team
28-05-13 recovered 76 bbls. The contaminated sand Lessons Learned
was removed and transferred to BeAAT
treatment facility.
Immediate Causes 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
A Flow Suction Tank was in service since 2005 with weir
 Inadequate Technical Design (The
height of 1.75 meters. The internal GRE lining was
internal lining of the tank was one meter
provided up to a height of 1 meter from the tank floor.
and its adequacy was not reviewed)
The settled water level within the oil compartment
accumulated to levels higher than 1 meter (over GRE-  Inadequate Implementation of
internal lining level), and created corrosive conditions for Procedure (Tank operating & draining
deterioration of steel. During routine patrolling, a jet of oil procedure was not implemented to
from tank shell, near oil outlet nozzle of the tank about monitor water level in the tank and
1.5m high from the bottom plate, forming a pool of oil periodic water drainage either upstream
was observed by an Operations Foreman and the leak was or downstream the weir)
reported to control room. Outcome: The leaked oil
 Inadequate Assessment of Required
(approximately 130 bbls.) was contained within the
Skill or competency (New Operations
secondary containment (bund area). Input to the tank
staff were not adequately familiarized
was isolated and its inventory was pumped out through
with operating procedures and hazards)
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. Lessons Learned
Immediate Causes 1. Implement draining procedures to ensure

that water level is monitored and water is
 Inadequate Guards or Protective Devices (The drained periodically.
internal part of tank had GRE lining up to 1 meter
whilst the oil and accumulated water level in the oil 2. Review & Update Tank design
compartment was higher than 1 meter) specifications to ensure adequacy of
internal GRE lining.
 Improperly Prepared Equipment (Due to non-
availability of operation drain in the oil compartment, 3. Develop a mechanism to ensure skills &
the accumulated water was not drained and the competency of new staff with respect to
presence of Sulfide Reducing Bacteria (SRB) in the site specific procedures & facilities prior
tank and its effects on steel structures were not known to assignment.
operations teams; water level was not monitored and
drained in the downstream of the weir)
17
Buried Gas Line Struck by an Excavator (Near Miss)
A crew was involved in well head tie-ins and flow
line installation works. After the completion of  Inadequate Supervisory Example (JP
route & topography (to identify the geographical did not use metal detector to identify
profile along the route and the existing facilities buried lines prior to
crossing that route) excavation work started. As commencing mechanical excavation)
a part of Excavation Certificate requirement, the
use of cable/metal detector was required prior to  Inadequate Standards or
commencing mechanical excavation. Job Specification of Equipment (The
Performer (JP) started mechanical excavation equipment used for topographic survey
without using the metal detector. The JP was had limitation to locate buried pipes
using a topographic Survey (Up to 2 meter during humidity)
depth) report as a guide to identify buried lines.
While excavating, under a gatch road, the
bucket of the excavator struck against a hard Lessons Learned
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 1. Clearly identify underground facilities

prior to commence site work.
 Violation by Individual (Job Performer did
not utilize cable / metal detector prior starting 2. Beware of limitation of topographic
mechanical excavation of the trench) survey equipment
 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)
18
Oil & Gas Release from a Flow Line
Bu-632 flow line was commissioned in late 2003 and

the flow line was not subjected to Cathodic Protection  Inadequate implementation of
(CP). Flow lines‟ crossing through gatch bund create Standards and Procedures (ADCO
Oxygen Gradient Corrosion phenomenon resulting in standards and procedures (for flow
external metal loss. Due to lack of CP protection and line crossing were not implemented)
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
Buhasa
recovered 23 bbls of free oil.
(BUH) Lessons Learned
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
During 2005 most Chock valves of Gas
Producer wells were subjected to repairs/
refurbishment/ design modifications due to
experienced repeated seizing. After  Inadequate Assessment of Potential
modifications stem packing started to fail. Failure (Failure of stem packing material due
On July, 14th, a gas release occurred from to high reservoir temperature was not
the stem packing of modified choke valve of anticipated/assessed)
a gas producer well. The gas was detected by  Inadequate Evaluation of Change (Original
H2S alarm in well head area. Outcome: The Equipment Manufacturer (OEM) stem packing
well was shut down and the flow line was material was replaced without considering
depressurized through flare. The damaged impact of operating conditions)
choke valve was replaced with a refurbished
one and the well was restarted.
South East
Asab Lessons Learned
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 1. Consider using stem packing material which
Extreme (High reservoir temperatures can stand higher reservoir temperatures.
(in excess of 110oC))
20
Oil Carry Over to Flare Stack
 Inadequate Assessment of Needs &

Risks (Instrument Air Compressor‟s oil
cooler was not adequately prepared
resulting in high lube oil temperature
Due to hot weather conditions, Instrument Air
causing compressor to trip)
Compressors (IAC) tripped, causing plant
emergency shutdown (ESD). Due to the
shutdown, shutdown valve, (SDV) at the inlet
 Inadequate monitoring of initial
of Test Separator, closed and the Knock out
operation (ESD alarm was not detected
Drum (KOD) blow down valve (BDV) opened.
on timely basis due to large number of
At the time a 2” bypass valve to the Test
both critical and non-critical alarm
Separator inlet SDV was passing, the oil from
display on the control panel)
inlet line passed into the test Separator,
South East overflowing to Flare Knock out Drum (KOD)
and subsequently to the flare stack. It resulted Lessons Learned
Asab in spillage of approximately 4 bbls of oil.
20-07-13
Immediate Causes
1. Enhance maintenance of oil cooler of
 Defective Equipment (The Ball Valve (2”)
Air Compressor especially during
on the bypass line of inlet SDV of test
summer months.
separator was passing; Air Compressor‟s oil
cooler was not effective in maintaining lube
oil temperature)
 Temperature Extreme (Two Instrument

Air Compressors (IAC) tripped due to hot
summer spell)
21
H2S/ Hydrocarbon Gas Release from Water Separation Tank
 Inadequate Training Efforts
Due to malfunctioning of cooling system at suction
(Operators were not trained on
knock out drum (KOD) for vapors recovery had
instrumentation and operations of newly
resulted in frequent choking of VRC (Vapor Recovery
commissioned Effluent Produced Water
Compressor) Strainer. A crew was involved in
Treatment System)
cleaning of suction strainer and old VRC was shut
down. Newly installed VRC suction isolation sharing
 Inadequate Assessment of Potential
the Water separation tank relief and flare header
Failure (Frequent chocking of VRC
was closed, instead of isolating the immediate
compressor suction strainer was not
double block at old VRC compressor suction. This
adequately evaluated to identify the
had resulted in pressure build up in the water
cause and effectiveness of remedial
separation tank. Upon actuation of tank high
action)
pressure alarm, the control room operator tried to
control the pressure. He reduced the controller
 Inadequate Reference Materials
output but resulted in opening of tank blanket gas
(There was no P& IDs for the isolation of
inlet Valve due to reverse acting, compounded the
VRC compressor available)
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 Lesson Learned
closed and shared flare header/VRC suction isolation
was opened to bring the situation under control.
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
VRC compressor suction) 2. Ensure facilities P&IDs are readily
available to operations staff.
 Improper Decision Making or Lack of
Judgment (The operator reduced the controller 3. Review effectiveness of repairs&
output resulting in more opening of tank blanket preventive maintenance to ensure all
gas inlet valve) critical equipment are effectively
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
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.  Inadequate Engineering / Design
This flow line has failed (leaked) on three occasions in the (Carbon Steel flow line did not have any
past. internal and external protection against
corrosion).
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
Asab spillage of approximately 1300 bbls and HAZMAT team
was mobilized to recover free oil. Lessons Learned
19-08-13
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,
except at areas of intended burial i.e. road/track 2. Consider chemical inject at well head to
crossings) protect against internal corrosion
 Work place Layout (Layout of pipeline in desert

terrain caused burial of unprotected flow line by dune
action)
23
Oil Carry Over to Flare Stack
Inadequate Preventative Maintenance

(The isolation valve was passing and that
allowed oil/gas to flow and fill the closed
A test separator‟s 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
commissioning activities, electrical pump‟s isolated for testing and not restored)
contactor was isolated and after commissioning it
was not put back. Therefore, the pump did not Inadequate Adjustment / Repair /
function at high fluid level in closed drain vessel Maintenance (DCS configuration cannot
causing fluid carryover to flare stack. Upon accurately detect if the motor in on manual
activation of alarm in control room, Operations setting)
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
1. Do not isolate process equipment

Immediate Causes without obtaining isolation certificate
 Defective Equipment (Test separator outlet 2. Assess readiness of equipment and
isolation valve was passing and second valve set up (line-up) prior to operations.
was in open position)
3. Set closed drain motor on auto mode
 Inadequate Isolation of Process or be default.
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)
24
Oil Spill from Redundant Flow Line
 Inadequate Planning or Risk

Assessment Performed (During
construction activities, test flow line was
As a part of Full Field Development (FFD) cut without ensuring the isolation)
activities, a test flow line was cut from RDS-2 end  Inadequate Supervision (Audit/
and blind flange was installed while the upper end Inspection/Monitoring) (During line up
(at the remote manifold) it was isolated by a ball of test separator, effectiveness/integrity
valve (without blind). During preparation of of interconnecting isolation valve was not
access road, the test flow line was cut. checked)
While lining up test separator at RDS-2 (Sy-69)
the oil pressure in the production remote manifold  Inadequate Implementation of
transferred to the test manifold through the ball Procedure (PTW) (PTW & Task Risk
valve (which was not fully closed and oil started Assessment implementation was not
to flow from the opened end of the test flow. adequate for control of work)
South East Outcome: It resulted in spillage of approximately Lessons Learned
30 bbls. The isolation valve was closed and
Shah approximately 24 bbls of free oil were recovered
12-09-13
Immediate Causes
1. Positively isolate flow lines prior to
 Inadequate Isolation of Process or abandonment/making it redundant.
Equipment (The test flow line was not 2. Subject all isolations of process and
positively isolated and ball valve was not fully equipment to isolation certificate.
closed)
(The test flow line was considered redundant
although it was not isolated with blind flange
from both sides)
25
Loss of Containment- Oil Spill
A new oil producer (Bb-923) was completed and  Inadequate Leadership (Supervisor
flow lines were installed. After flow line issued the handover certificate without
hydrotesting, spades were installed at both ends. ensuring removal of spade)
Later, Nitrogen (N2) kick off operations were
 Lack of Procedure/Standard/Policy
planned using a coil tubing unit. Prior to handing
(There was no Pre-Start-up Safety Review
over the well and flow line, the spade at RDS end
checklist for rig less operations to support
was not de-spaded (removed).
issuance of handover certificate)
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 Lessons Learned
meantime, flange gasket failed. Outcome: It
BAB & Gas resulted in release of approximately 40 bbls of
well fluid.
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
 Lack of Procedures (There was no

procedure/checklist for Removal of Sphere
and Removal of Stuck Sphere)
ADCO Mechanical Team and FMC crew  Inadequate Communication (There was
(vendor) were involved in MOT Metering ineffective communication between FMC
Prover Skid U-1601 sphere inspection. The Engineer & ADCO Crew)
work includes draining under nitrogen
purging. After draining, the sphere was found  Inadequate Management of Change (The
stuck in the prover loop. The crew pressurized work was planned as draining under
the system (8psi) to dislodge the sphere. The atmospheric pressure and later it was
sphere was dislodged and oil under pressure changed to draining under nitrogen purging
splashed/released though the cover of the without assessing risks and without
home Position Chamber which was not fully procedure/checklist)
secured
Terminal &
Pipeline Lessons Learned
Outcome: It resulted in release of
Operations
approximately 40 liters of oil.
Fujairah
31-10-13
Immediate Causes 1. Always perform task risk assessment before
executing a task, especially for new tasks as
 Equipment or Material Not Secured (the per TRA Procedure.
cover of the ”Home Position Chamber” was
closed but not effectively sealed) 2. Provide clear work instructions/ procedure to
crew prior to assigning tasks.
(Crew did not anticipate sudden release of 3. When face with any unforeseen/ unexpected
stuck sphere and subsequent release of oil situation, stop, reassess and ask for advice.
from Home Position Chamber)
 Violation by Group (PTW) (Hot Work Permit
(PTW) was issued without Method
Statement/Task Risk Assessment/Procedure)
27
Gas Release from Compressor
During commissioning of the high pressure (HP)

compressor, a technician made several
 Inadequate Audit/ Inspection/
connections but did not check if ferrule punching
Monitoring (There was no mechanism in
for each joint was adequately done. After
place to check adequacy of connections made
commissioning and during normal operations, the
by the technician during commissioning)
compressor tripped due to High-High pressure
level (at discharge knock out drum –KOD). The  Inadequate Practice of Skills (The
compressor was reset, restarted and pressurized technician did not check the adequacy of
to 300 bars. The compressor again tripped due to joints after making connections)
Low-Low pressure at the 2nd stage discharge.
Later, the compressor was restarted and tubing of
seal gas Differential Pressure Indicator
SE
Transmitter (DPIT) disengaged and gas leaked. Lessons Learned
Sahil
The leak was detected by the three surrounding
detectors.
19-11-13
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)
Incident Description Root Causes
Shah Main Oil Line (MOL) was in use since

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

plug from an oil producer prior to coil tubing  Inadequate development of
logging operation. Policies/Standards/Procedures: There
were no procedures/policies in place to
After gas test, the crew started to rig up and
inspect the O-Ring between the 1st and any
pressure test the lubricator and BOP
subsequent jarring attempts. Further to
assembly. The crew run in hole with pulling
this, the procedure does not clearly define
tools to retrieve the phoenix plug, tried
the intervals to conduct O-ring inspection
many times after latching to pull the plug by
hard jarring up and observed an oil leak
below the BOP (Between BOP and
crossover). Lessons Learned
Outcome: The incident resulted in 2 bbls of
SE oil and water mixture spilled.
SQM
 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
 Improper use of equipment (Due to the O-ring during multiple jarring
hard jarring and lubricator movement attempts.
during operation, the new O-Ring seals
between BOP and crossover was damaged)
30
Occupational Safety
31
Fall of Derrickman on Monkey Board
During pulling out of 6” horizontal hole, a

Derrick man was working at monkey board,
racking stands. After unlatching the elevator,  Technical Analysis for Risk not Effective
the Driller started running the top drive (Fall protection Anchor point was 35 feet
service downwards to pick the next stand. On from the latching point of Derrick man safety
its way, downward, the Top Drive Blower harness, prone to shift during windy
Assembly (slightly protruded) entangled with conditions)
the extended fall arrestor cable, which was  Inadequate Identification of Worksite/
inclined due to heavy wind. Job Hazards (Job Safety Analysis (JSA) was
Derrick man experienced a strong downwards too generic and did not address hazards of
pull where he lost his balance & fell on lowering TDS and the required level of
monkey board. The fall arrestor cable broke communication between Derrick man &
Drilling off from the side of the safety harness due to Driller)
extreme tension. Outcome: The fall arrestor
ND 54 cable broke off from the side of the safety
harness due to extreme tension. Lesson Learned
23-02-2013
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
A wire line crew was mobilized to retrieve valves. The

wire line unit crane was inspected and certified and
Monitoring (The wire line unit including
the last load test for wire rope was conducted 3 years
lifting equipment were certified without
ago. The wire rope was subjected to wear & tear and
adequate due diligence as wire rope was
corrosion.
not subjected to load test and absence of
The crew started to rig up lubricator and BOP
Automated Safe Load Indicator (ASLI))
assembly (weighing approximately 1.4 tons) by
using wire line unit crane with safe working load of  Inadequate Identification of Work
approx. 3 tons. While the load was positioned over site or Job Hazards (Ensuring adequate
the Christmas Tree (X-mas), the wire rope failed certification/testing of lifting devices to
near the wedge socket of the whip line block and eliminate use of uncertified wire rope
parted causing the load to fall down on the Xmas was not part of Task Risk Assessment
South East tree. Outcome: X mass tree valves handles, (TRA).
hydraulic actuator and a spectacle spade were
Asab damaged Lessons Learned
1. Ensure all lifting devices are duly tested

 Violation by Supervisor (Wire rope was not and certified prior to initiating permit to
subjected to annual load test) work (PTW).
 Use of Defective Equipment (The used wire 2.

rope was deteriorated due to wear & tear and 3. Conduct ad hock quality audit of Lifting
corrosion) Equipment Inspection & Certification
Companies (LEICC) and wire line crew‟s
 Improper Use of Equipment (Wire rope was competency
not adequately lubricated resulting in accelerated
inner and outer surface od wire rope)
33
Fire during Hot Cut of a Water Injection Flow Line
Dismantling of old Flow line was ongoing and  Inadequate Identification of

water injection flow line was isolated and handed Worksite/Job Hazards (The Task Risk
over to a crew. The line was not cleaned prior to Assessment (TRA) did not cover the full
handing over as it was assumed free from sequence of the activities i.e. cutting and
hydrocarbons. The Task Risk Assessment (TRA) removal of the flow line; and hazards of
did not consider presence of pyrophoric scale scaling was not considered)
and a work permit (PTW) was issued to
 Inadequate Work Planning (The
commence the work (Hot & Cold cutting). The
method statement was prepared for tie in
crew performed a cold cut followed by hot
and complete sequence of work was
cutting. During hot cutting, fire started.
included in the statement
Outcome: The fire was extinguished by the job
 Inadequate Communication Between Work
performer using a fire extinguisher.
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

 Lack of Knowledge of Hazards Present to handing over for cutting/repair tasks
(The presence of pyrophoric scale was not
anticipated in water injection well flow line 2. Do not use generic task risk assessment.
therefore the flow lines were not cleaned as Revalidate all TRAs for works on water injection
per Manual 10, Part 12 section no 12.3 prior flow lines.
to handing over to the crew) 3. Familiarize all new Area Authorities (AA) and
 Work Exposure to Fire (Pyrophoric scale Issuing Authorities with prior incidents.
caught fire during cutting)
34
Fall of a Driver from Kenworth Trailer
A crew was working on hydrotesting of flow lines
and after the completion of the task, hydrotesting
equipment were being transferred to another well  Inadequate Audit/ Inspection/ Monitoring
site using a Kenworth trailer. Once the trailer was (Kenworth trailer with deteriorated floor was not
loaded with equipment, the driver went on the inspected before commencing the work)
back of the trailer to check the stability of the
load. The trailer bed had a section of deteriorated  Inadequate Identification of Work Site/Job
wooden floor. While the driver was maneuvering Hazards ( During Task Risk Assessment, fall of
around holes he tripped and lost balance, driver from the trailer was not adequately
resulting him to fall down from the trailer identified/controlled)
(approx. 2 m high) on the ground.
Outcome: He sustained shoulder fracture.
Lessons Learned
Terminal &
Pipeline
Operations Immediate Causes
 Inattention to Footing & Surroundings

(The driver was inspecting the load and
14-01-2013
walking around hole and deteriorated wooden
floor of the trailer)
 Defective vehicle (The trailer floor was
1. Inspect fitness of trailers prior to their use.
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)
35
Dropped Tubing Joint from Elevator
Running Completion Tubing using pick up & lay

down (PC machine) machine, was in progress.
 Excessive Wear & Tear ( Due to wear & tear
After running the 34th joint, after receiving the
latch spring became weak and jaws were worn
signal from floor man, the Driller picked up the
out)
35th joint from the PC machine to start lifting
and he started elevating the joint to stab &  Inadequate Audit/Inspection or
make it up to the string in hole. monitoring (Integrity of the jaws & latch
spring was not assessed prior to start of the
While the joint was about 15 ft. high (from
job)
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
Drilling door opened, which resulted in joint falling Lessons Learned
down though the catwalk on the pipe rack area.
ND 01 Outcome No Injury or property damage had
occurred.
(Mender)

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
Damage to Over Head Lines – OHL
 Distracted by other concerns (The operator

was emotionally stressed and not focused due
to personnel issues)
As a part of the Habshan- Ruwais- Shuweihat Gas

Pipeline Project, GASCO contractor crew was moving  Inadequate identification of worksite/
job hazards (Task Risk Assessment (TRA)
Pipe Laying Vehicle with attached side boom, from
did not adequately identify the hazards &
one location to another location. There were no goal controls for the movement of the equipment)
postings/height level markers installed at the
overhead line crossing and the operator was moving  Inadequate supervision (There was no
the vehicle with side boom in elevated (raised) supervisor on site and task was assigned to
an operator who was unfamiliar with site
BAB & Gas position. While crossing 33kV overhead power line,
the side boom hit overhead lines and damaged three conditions; No Tool box Talk was conducted
for the operator)
14-04-13 poles causing loss of power to 5 water injection
clusters and Remote Degassing Station (RDS) 7.
Lessons Learned
Immediate Causes
 Unintentional Human Error (Pipe layer operator 1. Assess suitability of route prior to moving
moved the vehicle, under overhead lines, with its heavy load/equipment.
side boom in elevated position)
2. Always use approved route and crossing
 Inadequate guards or protective devices
(There were no goal posts/height level markers
installed at the overhead line crossing)
37
Hand Injury from Front End Loader’s Bucket
A crew was involved in manual excavation for  Improper Supervisory Example (The
ground leveling and grading. The crew had Job Performer did not move the loader and
accumulated the excavated sand and was asked the labourer to work in front of the
planning to transfer it into bucket of a loader, loader with energized engine)
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 laboure‟s hand between the wooden
piece and the edge of the bucket. Outcome: Lesson Learned
South East
The labourer sustained multiples fracture on his
hand and after the treatment he was assigned
Shah
on light duties.
07-05-13
Immediate Causes
1. Do not work in front of machinery/
equipment while its engine is running.
 Improper Position or Posture for the
2. Always apply brakes and keep equipment
Task (Worker was attempting to pull out the
in neutral gear when in stationary position.
wooden Piece from the ground close to the
bucket of the loader, with its engine 3. Position Banksmen at a location where
running) they can fully observe the situation in front
& around the equipment.
 Improper Decision Making/ Lack of
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)
38
Burn Injuries during Well Testing Activities
Well testing activities were in progress and a night  Inadequate Development of Procedure
shift crew member (an operator) was involved in (Standard Operating Procedure (SOP) for
collecting oil samples and manual filling of diesel fuel igniting green burner did not identify the
to generator which resulted in oil & diesel splashes on situation on what to do when green burner
his coverall. There was a change in wind direction pilot fail to ignite)
and the operator decided to switch the gas flow to
 Inadequate Technical Design (Green
another green burner. He energized the electrical
burners pilot could not be ignited due to
ignition and started propane flow to and then
lack of wind barrier near spark & propane
attempted to ignite pilot of the green burner
interface or due to carbon deposit on the
remotely. The pilot did not ignite due to lack of wind
tip of the pilot)
barrier near spark & propane interface & carbon
deposit on the tip of the pilot. He then decided to use  Inadequate Enforcement of
a fire stick (long metal rod with diesel soaked rag on Procedures/ Standards/Policies
one end) and went near the burner. When he lighted (Contract requirements concerning PPE,
South East
the Fire Stick near the burner, the accumulated emergency response and HSE inspections
propane gas ignited. It caused his cotton coverall to were not adequately enforced.)
catch fire. Outcome: He sustained 2nd & 3rd degree Lesson Learned
Qusahwira
burn injuries on his arm, face, back and leg
18-04-13
Immediate Causes
 Inadequate Equipment (Green burner failed to 1. Remove all Fire Sticks and other
ignite) homemade type (banned) tools/
 Violation by Group (The use of Fire Stick to equipment from the site
ignite green burner pilot was common and done 2. Provide & Use Fire Retardant Coveralls
with knowledge of supervisors- Not in line with when working in hazardous
SOP) areas/conditions
 Improper Decision Making/Lack of Judgment 3. Test site specific emergency plan for each
(Operator let the propane flow for extended work location prior to commence
period of time and did not anticipate accumulation operations
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)
39
Fall of Travel Block on Rig Floor (Rig Move)
The rig was subjected to major maintenance program and
 Inadequate Audit / Inspection /
moved to Qusahwira field where rig up operations started until
Monitoring (Rig audit and
the mast rose to vertical position and conventional Rig up
inspections were inadequate to
operations commenced. There was no actual calculation done
identify that checklists were not
for the required length of drilling line for the hoisting system.
used and procedures were not
The length of slacked wire prior to raising mast was assumed to
followed; Older version of procedure
be adequate. Assistant Rig Manager (ARM) started to lower the
was found at the rig location )
Travelling Block to rig floor from Yoke position (at
approximately 130 from rig floor) in order to complete the rig  Inadequate Supervisory
up operation. According the basic calculations there was a Example (Mast raising checklist,
shortage of drilling line on the Draw Work Drum to bring the rig move procedures were not
blocks to rig floor position. The block was lowered to 40 ft, reviewed, and basic calculations
prior to the draw work drum become out of drilling line. The were not done due to
fast line anchor on the Draw Work Drum got exposed to sudden overconfidence)
/ excessive tension (+/-2500 lbs) and the drill line slipped off
Drilling  Inadequate assessment for
and travelling block and started to fall from 40 ft height. Once
work site / Job Hazard (There
the rig floor crew heard friction sound from the drilling line,
ND 21 was no task specific Job Safety
they moved away to safer place. Outcome: ARM & crew
Analysis (JSA) and a generic JSA
escaped and proceeded to dog house until the block fell &
was used)
rested on rig floor.
26-04-13 Lessons Learned
Immediate Causes
 Routine activity without thought (The crew was working 1. Conduct Rig Move Audits to
on this rig had performed similar operation on many check, review and strength the
occasions and ARM has conducted 5 similar moves) move procedures
 Improperly prepared equipment (The crew used shorter 2. Calculate & state exact length of
length of drill line for the execution of hoisting system) drill line on the spool on the
drum prior raising the mast in
 Improper decision making and lack of judgment (The the JSA
crew did not calculate the required length of the drilling line
for normal hoisting operations and relied on visual
observations).
40
Fatal Fall of Driller from Height (Rig Move)
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  Inadequate Work Planning or Risk
task included to lift the travel block carriage frame. Assessment Performed (There was no
He was working alone and moving from one end to Derrikman assigned to assist the Assistant
another end to maneuver slings. Each time, while Driller)
moving from one end of belly board he had to  Inadequate Leadership (ARM did not follow
unhook his safety lanyard. The activity was the work procedure; work was not subjected to
supervised by Assistant Rig Manager (ARM). During
job safety analysis; work was not stopped by
the work ARM requested A/D to assist in freeing wire the Driller )
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 Lessons Learned
Drilling of 11 feet on travel block base plate. He sustained
head injuries. Outcome: He was attended by rig
ND 50 medic and then transferred to RAMS Clinic in Shah.
Later he was pronounced dead.
(Shah)
Immediate Causes
1. Subject all changes in job procedure/practice
28-05-13 and task risk assessment.
 Violation by Supervisor (ARM did not stop the
activity where AD had to unhook his safety 2. Enforce STOP THE JOB program, when safety
lanyard and move to other side of the board ) controls or precautions are bypassed
 Improper Decision Making/ Lack of
3. Drop object checklist should be completed
Judgment (The task required two workers but
one worker was assigned to complete the task). before lowering/raising the mast.
 Lack of Knowledge of Hazards Present (Job

Safety Analysis (JSA) was not prepared for the
task)
41
Damage to Over Head Lines –OHL
A crew was working on gas pipe line installation  Inadequate Leadership (Site Engineer used
project and after completion of the task the crew was an alternative route without ensuring
returning back. A pipe laying machine, with raised suitability of the route; Raised boom of pipe
boom, was loaded on a low bed trailer. The laying machine was not noticed; Learning
identified/approved access track was blocked due to from similar incident (14-04-2013) was not
sand accumulation and the supervisor decided to use captured in work planning or in Tool Box Talk
an alternative route. The route had 33Kv overhead (TBT))
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
Lessons Learned
Immediate Causes

(Supervisor decided to take a route which is not
approved for equipment transportation and had
1. Assess suitability of route prior to moving
OHL)
heavy load/equipment.
 Improper Decision Making/Lack of Judgment
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
Drop of Drill Pipe Stand from Derrick
During Run in Hole (RIH) activities, Derrick man  Inadequate Identification of Worksite/
missed latching Drill Pipe (DP) stand and it dropped Job Hazards (The task of pulling the missed
to the opposite side of the derrick DP rack. The DP stand back towards derrick was not risk
crew started to return the stand back to Derrick assessed and no crew safety meeting was
Rack, using both rig floor winches. Winch cables conducted)
were wrapped around the stand, anchoring it, with
make-up chain, to the rotary table stand and began  Inadequate Implementation of Procedure
pulling it back. While pulling, the makeup chain (Procedure for the recovery of missing stand
slacked causing the stand to slide/slip and go out was not implemented; Rig Manager was not
through the gap between rig floor post and V-door notified prior to attempting the recovery of
handrail. Outcome: Drill pipe stand slipped through missing stand)
DD the gap between rig floor post and V-door handrail

and fell on the ground below in Vertical Position
Lessons Learned
ND 1
(Mender) Immediate Causes
1. Secure/Tie off the bottom of stand with other

25-06-13  Violation by Group (The crew did not follow the stands in derrick to prevent it from slipping.
procedure to pull back missing stand)
2. Consider pulling the missing stand as a critical
 Improperly Prepared Equipment (Makeup operation and conduct Job Safety Analysis
chain was not properly tied to prevent stand before pulling it back.
movement)
3. Install handrail with toes board to prevent
 Equipment or Materials not Secured (Bottom dropping stand from rig floor.
of the stand with other stands in derrick was not
tied to prevent slippage of stand; Handrail with
toe board was not installed)
43
Fall of Banksman from a Sand Dune
A crew was engaged in excavation,

backfilling and grading activities and a  Inadequate Assessment of Required Skill
newly assigned Banksman was monitoring or Competency (The Banksman was
activities of an excavator, from an working at camp location and assigned on
elevated area (sand dune). The site location without adequate assessment of
Banksman decided to get closer and training/ skills required for the job and job
started to descend down from the steep site)
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 Lessons Learned
24-06-13
Immediate Causes
 Inattention to Footing & 1. Always use dedicated walkway/passage and

Surroundings (The Banksman did not do not take short cuts.
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
 Lack of Knowledge of Hazards 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

Monitoring (There was no effective
inspection programme in place to assess
During Laydown Completion Tubing Operations, a
fitness of crane onsite)
crane was on stand-by, near Pipe Rack. The crane
cabin sliding door handle was missing and there was  Inadequate Training Efforts (A newly
no rubber beading on the sharp edge of the door. A assigned crane operator was not subjected
new & crane operator positioned himself in the crane to training on Safety Rules and no daily
and while closing the sliding door, his two fingers effective Tool Box Talk conducted)
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.
Lesson Learned
Drilling
Immediate Causes
ND- 25
21-07-13  Defective Equipment (The handle of the sliding 1. Subject all equipment & vehicles to daily
door was broken; and there was no rubber checklist to assess fitness.
beading on the sharp edge of the sliding door)
2. Report all defects immediately to
 Lack of Knowledge of Hazards Present (The supervisors and do not operate defective
operator continued operating the crane with equipment.
defective cabin door and he was not aware of
3. Conduct daily Tool Box Talks for operators
hazards associated with pinch-point)
and drivers specific to their tasks.
45
Disengagement & Fall of Upper Link Guide Support Clamp on Rig Floor
A new rig was recently commissioned and it was
drilling a 17 ½‟‟ hole. The Driller along with drilling
crew made the connection and he was relieved for
Morning Meal (Sahoor) by Assistant Rig Manager  Inadequate Technical Design
(ARM). The guide clamp of the upper link of the (Clearance between upper link and the
Integrated Drilling system (IDS), which protects guide clamp was not adequate)
upper link from hitting the electrical junction box,
dropped from 90 feet height on the rig floor near
Assessment (The most of rig crew
Driller‟s Cabin. Outcome: IDS Hydraulic hose was
were transferred from different rigs and
ripped off by guide clamp before dropping on the
they were not adequately familiarized
rig floor resulting in spillage of approximately 100
with new rig design limitation)
Liters of oil on the rig floor.
Drilling
ND -60 Lessons Learned
(NEB)
Immediate Causes
04-08-13  Inadequate Guards or Protective Devices 1. Ensure all similar design rigs (IDS 4 A
(There was no Secondary retention on Guide model) have secondary retention on upper
Clamp) link guide clamp.
 Improper Decision Making or Lack of 2. Include IDS upper link guide clamp in
Judgment (Unintentional Human Error) (Staff “Drop Object Items” checklist.
from other rigs were not fully accustomed to
new rig design and Driller over slacked the 3. Arrange extensive training for key rig crew
travelling block) members on new rig design and its
limitation.
46
Finger Trapped between Scaffold Pipes
During commissioning activities, crew members  Improper Supervisory Example (Job

were working on main motor shaft with crankshaft to Performer did not provide adequate tools to his
align and install flywheel to complete the assembly. crew)
While rotating the main motor shaft using a
 Inadequate Assessment of Needs & Risks
scaffolding tube, one worker‟s finger was trapped
(Availability of right tools was not ensured and
between two scaffold tubes/pipes. Outcome:
workers were using homemade type tools)
Worker sustained crush injury of left finger injury
and he went through surgical procedure.
South East
Qusahwira Lessons Learned
13-08-13
Immediate Causes
1. Always use right tools for the task and do not
take short cuts
 Violation by Group (Proper tools for the task 2. During task/work planning, identify
were not available and the crew members were requirements and availability of right tools
using scaffold tubes for alignment) 3. Provide hand tool safety awareness to all
 Inadequate Tools (Two scaffold pipes were Forman, helpers/labourers
used for the alignment instead of wrench
spanner)
47
Finger Trapped Between Falling Load and Vehicle
Modification of high mast flood light was  Inadequate Leadership (Electrical Engineer
ongoing and an electrical winch trolley was assigned untrained staff (the Storekeeper) to
required to assist in lowering the high mast. transfer the equipment to the site without
A storekeeper was assigned the task of ensuring availability of necessary
delivery of winch trolley at the location and tools/equipment for the task; Site Civil
he arranged the transfer to RDS location. Engineer authorized the use of JCB to unload
the equipment from a trailer)
Site Electrical Engineer was not available at
the location and there was no arrangement to  Inadequate Planning or Risk Assessment
unload the equipment at the location. The Performed (The transfer of equipment
storekeeper decided to use a JCB to unload during mid-day break and availability of
the trolley from trailer. While offloading the lifting equipment at the site was not ensured)
trolley in JCB‟s bucket, the trolley became
unbalanced and a crew member tried to
South East support it with his hand. During the process
his fingers were trapped between the trolley Lesson Learned
and trailer bed. Outcome: The worker
Qusahwira sustained finger crush injury.
15-08-13
Immediate Causes
1. Use proper lifting equipment and do not take
 Violation by Supervisor (Site Civil short cuts.
Engineer authorized the use of JCB for 2. Do not assign untrained workers to perform
unloading of trolley from trailer) risky tasks.
 Improper Lifting (The crew was using
JCB to unload unsecured winch trolley
from a trailer)
 Improper Decision Making/Lack of
Judgment (Worker tried to stabilize lifted
load with his hand)
SE-2013-13526
48
Buried Electrical Cable Cut during Site Preparation
Rig Move road preparations were planned and site

 Inadequate Identification of
handover certificate was issued to Drilling Team. The
Worksite/ Job Hazards (Location of
certificate did not identify any buried cable.
buried cable was not identified in
Although, there was a 33Kv cable which was buried
handover certificate and no surface
(without protection) approximately 20 cm below the
markers exited; cable was not
surface. While the wheel dozer operator was
subjected to physical protection)
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
Drilling
clusters. Later, the cable was repaired and power
restored.
BUH
Immediate Causes
 Lack of Knowledge of Hazards Present (The

operator was not aware of the presence of buried
cable) 1. Identify and mark location of buried cables and
utilities in hand over certificate.
 Inadequate Guards or Protective Devices
(The cable was not buried at required depth and 2. Physically mark location of buried utilities on
had no protection against physical dame) site especially during site works.
 No Warning Provided (There were no sign

boards or makers to indicate presence of the
cable)
49
Fall of Operator from Batch Mixing Platform
Rig was preparing for cement job and two  Inadequate Identification of Worksite/ Job
helpers were assigned mixing chemicals Hazards (Hazards associated with removal of
(Lead & Tail slurry) on top of the batch handrails were not assessed; Entanglement with
mixer. A forklift was used to place chemical loose strap was not considered & risk assessed)
pallet on top of the batch mixer. In order to
 Inadequate Development of Operating
place the pallet, platform‟s guard rails were
Procedure (Procedure did not include use of fall
removed. After completing the job, a helper
protection devices, barricading unprotected
was cleaning the site and throwing down
height, removal of binding straps and chemical
empty bags and wooden pallet. While he was
loading mechanism (e.g. Forklift Vs. lifting
throwing down the empty wooden pallet,
Crane))
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 Lesson Learned
Drilling
ankle injuries.
Immediate Causes
ND-55
20-08-13  Disabled Guards or Safety Devices 1. Remove binding straps from the work area
(Handrails were removed from the after opening the pallet.
platform to enable loading)
2. Do Not Remove hand rails while working on
 Lack of Knowledge of Hazards batch mixer platform.
Present (Entanglement with loose
binding strap on the pallet was not 3. Use fall protection devices such as full body
harness with appropriate lanyard or Self
anticipated whilst throwing down the
pallet from the platform) Retract Line while working on batch mixer
platform.
 Unprotected Height (Work was
performed at height with disabled guard
without any body harness)
50
Finger Injury during Dismantling of Wire line Tool
 Inadequate Human Factors/ Ergonomics

A wire line crew was assigned to carry out Bottom Consideration (Vice was installed/fabricated
Hole Closed in Pressure (BHCIP) survey and after on the side of the truck not allowing 360o
the completion of the work, during rig down, the movement)
crew was dissembling/opening pulling tool, held on a
vise using pipe wrench. The vise was located close to  Inadequate Management of Change (Other
truck‟s body and did not allow 360o movement. wire line trucks have the vise installed at the
While an operator was applying the pressure, the rear end providing free movement while one
wrench slipped, trapping his right hand between the truck had vice installed on the side. The change
wrench and edge of the truck body. Outcome: He was not adequately risk assessed).
sustained crush injuries on his three fingers.
BAB & Gas 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
movement) HAZOP
 Improper Placement of Tool (The wrench was 2. Conduct specific hand tool safety sessions for
not adequately secured/latched resulting in operators
downward movement)
 Routine Activity without Thought (Operators
perform the task on daily basis and have low risk
perception)
51
Drop of Drill Pipe Stand from Derrick
During Run in Hole (RIH) activities, Derrick man  Inadequate Identification of Worksite/
missed latching Drill Pipe (DP) stand and it dropped Job Hazards (The task of pulling the missed
to the opposite side of the derrick DP rack. The DP stand back towards derrick was not risk
crew started to return the stand back to Derrick assessed and no crew safety meeting was
Rack, using both rig floor winches. Winch cables conducted)
were wrapped around the stand, anchoring it, with
make-up chain, to the rotary table stand and began  Inadequate Implementation of Procedure
pulling it back. While pulling the makeup chain (Procedure for the recovery of missing stand
slacked causing the stand to slide/slip and go out was not implemented; Rig Manager was not
through the gap between rig floor post and V-door notified prior to attempting the recovery of
handrail. Outcome: Drill pipe stand slipped through missing stand)
Drilling the gap between rig floor post and V-door handrail
and fell on the ground below in Vertical Position
ND-1 Lessons Learned
(Mender)
Immediate Causes
25-06-13 1. Secure/Tie off the bottom of stand with other

 Violation by Group (The crew did not follow the stands in derrick to prevent it from slipping.
procedure to pull back missing stand)
2. Consider pulling the missing stand as a critical
 Improperly Prepared Equipment (Makeup operation and conduct Job Safety Analysis
chain was not properly tied to prevent stand before pulling it back.
movement)
3. Install handrail with toes board to prevent
 Equipment or Materials not Secured (Bottom dropping stand from rig floor.
of the stand with other stands in derrick was not
tied to prevent slippage of stand; Handrail with
toe board was not installed)
52
Finger Caught Between Spinners of Hawk Jaw
During routine drilling operations, crew was making

drill pipe stand connection, through mouse hole. A
floor man was operating Hawk Jaw and while making  Inadequate Training Efforts (All crew
connections, he was observing the joint and placed members were not trained on the operations of
his hand near spinner of Hawk Jaw and his finger Hawk Jaw)
was finger inside the spinning circle. During the  Inadequate Management of Change
course, he operated the push button with the right System (Hawk Jaw was introduce to replace
hand, to start the spinning motion. It resulted in his rotary table with rig tongs and the change was
left hand small finger getting trapped between the not supported by training of crew members)
spinners and he sustained finger crush injury.
Outcome: The Floor man underwent surgical
procedure and part of a finger was amputated.
Lessons Learned
Drilling
ND-60 Immediate Causes
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) 1. Ensure all crew members are adequately to
 Lack of Knowledge of Hazards Present (Pre operate power tools & equipment.
Job Safety meeting did not cover pinch point 2. Discuss Job Safety Analysis (JSA) with crew
hazards; All crew members were not trained on members prior to start of job.
the operation of Hawk Jaw)
53
Finger Trap between “V” Door on Rig Floor
During Run in Hole (RIH) operations, a newly

promoted Floor man (on his fist shift) was closing a  Inadequate Technical Design (“V” door
sliding “V” door. There were no handles on the was not fitted with handles for sliding;
sliding door and the Floor man was pushing the door Pinch point was not colour coded))
with his foot and right hand. During the process, tip  Inadequate Supervisory Example (A
of his middle finger was trapped between “V” door new Floor man was not adequately
stabilizer bar and rig floor hand rails. Outcome: He supervised and coached on required skills)
sustained fingertip crush injury resulting in loss of
nail.
Lessons Learned
Drilling
ND-55 Immediate Causes
08-09-13
 Improper Position or Posture for the Task
(Floor man placed his hand on the edge of sliding
1. Closely supervise newly hired workers
“V” door (pinch point))
(Green Hat) especially when assigned on rig
 Inadequate Equipment (“V” door did not have floor.
handles to support movement)
2. Provide handles on “V” doors and/or colour
 Lack of Knowledge of Hazards Present all pinch points on rig floor
(Newly appointed Floor man was not aware of
the hazard)
54
Damage to Well ESD Panel during Sand Clearance
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  Inadequate Identification of Worksite/
1.5 m high) outside the fence. Due to sand Job Hazards (Excavation Certificate was
storms/sand movement ESD panel was buried under issued without referring to P&IDs)
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
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
 Inadequate Material Packing (The

straps/handle of Jumbo bags were not
A crew was mixing cement spacer for cement plug
adequate to sustain the load of contents)
and a jumbo bag (1.5 Tons) was suspended over
batch mixer with a crane. A crew member positioned  Inadequate Audit/Inspection/ Monitoring
himself to open/cut the bag and extended his body (There was no effective quality control in place
under the suspended load. Suddenly bag‟s to ensure bags handles are robust enough to
handle/strap broke/parted causing the bag to tilt sustain it contents)
and fall over his hand.
 Lessons Learned on Embedded (Similar
incident had occurred on 29-10-2012 and the
lessons learned were not communicated to new
Outcome: The worker sustained bruises and muscle
crew members)
sprain.
Drilling
ND-8 Lessons Learned
18-09-13
Immediate Causes
1. Always assess compliance of received
materials with contractual requirements for
 Improper Position or Posture for the Task packaging.
(The worker went under a suspended load)
2. Whenever emptying jumbo bags at mud
 Lack of Knowledge of Hazards Present (The hopper, use Jumbo Bag Stand
worker was not aware of hazards of suspended
3. Communicate prior incident Lessons learned
jumbo bag or risk of fall load)
to new crew members.
 Inadequate Equipment (There was no stand to
place the bag on the hopper)
56
UV/IR Fire Detectors Pole Damage
 Inadequate Product Acceptance

Requirements: The quality of fillet weld on
During the monthly preventive maintenance of
the pole which was subcontracted by the
the UV/IR fire detectors that are mounted on a
vendor was not assured.
9 meters pole, the pole sheared off the hinge
and fell down on the floor.  Inadequate mechanical design and
integrity: 9 meters height poles should not be
The investigation revealed that the pole was
lowered manually.
held by one hinge only as the other hinge fillet
weld had already failed  Inadequate preventive Maintenance
Program: Standard maintenance Procedure
did not mention lowering and raising of XFD
Outcome: Property damage sustained to the mount pole.
pole assembly, cables and accessories.
Lessons Learned
SE
Immediate Causes
Asab
20-10-13 1. Initiate visual inspection and NDT on

hinges of all similar poles to quantify
potential hazard.
2. Hinges of such mounted poles should be
regularly greased and visually inspected
for any defects.
 Use of Defective Equipment: the fillet weld on 3. Preventive maintenance procedures
the hinges was sheared off and only hinge was should mention the sequence of works
holding the upper section during lowering. 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
A smoke detector activated at Asab  Inadequate identification of

accommodation camp at night and all worksite/job hazards: The lamp was
personnel evacuated to designated assembly placed new the curtain without identifying
points. The Fire & Rescue team mobilized to hot surface hazards and assessing the fire
the fire scene and managed to distinguish the risk.
fire, preventing it from spreading to other
 Inadequate assessment of potential
rooms.
failure: The type of dimmer switch used for
Investigation team identified the bedside stand the bed lamp is prone to fail causing the
lamb as the cause of fire when it came in lamp to stay switched on.
contact with the curtains due to possible failure
in the light dimmer.
SE Lessons Learned
Asab 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.
Immediate Causes
2. Keep the socket switch off when the room
is unoccupied.
3. Replacing the dimmer switch that is prone
 Exposure to thermal Radiation (The curtain to failure with a normal on/off switch.
was in direct contact/in close proximity to the 4. Remove flammable curtains from rooms.
lamp hot surface)
58
Road Safety
59
Kenworth Rollover
 Inadequate Work Planning or Risk Assessment

Performed (The journey was not effectively planned
e.g. driver was not accompanied on this long journey
A logistic contractor vehicle (Kenworth
and no communication means were provided)
Trailer), carrying casing tubing, was on
its way, from BAB-13 stores to a rig  Inadequate Audit/ Inspection/ Monitoring (The
location in Mandar Field (approximately vehicle was not fitted with IVMS and drivers driving
300 km away). The journey was not behavior (RAG Reports) was not monitored; drivers
subjected to effective journey were working all calendar days for the last three
management (no book in/book out, no months without off days and unknown working hours)
means of communication and the driver
 Inadequate Implementation of
had worked for months without rest
Policy/Standards/Procedure (ADCO Safety
days). After four and half hour of driving,
Requirements (i.e. IVMS and Journey Management);
Corporate the driver lost control of the vehicle on a HSE Management of Contractors( i.e working hours
Support sand track and the vehicle started to
and rest – contributing to fatigue & inattention) were
drift until it entered low lying areas, next
not effectively implemented)
to the sand track and finally rolled over.
04-02-2012 Outcome: The driver sustained minor  Inadequate or Lack of Safety Meetings (Drivers
injuries and the vehicle was badly were not subjected to daily tool box talks)
damaged.

Lessons Learned
Immediate Causes 1. Implement journey management plan to consider

route hazards, fatigue and means of communication.
 Inattention to Footing &
Surrounding (The vehicle started to 2. Minimum two persons per vehicle shall conduct the
drift and ran off the track into low journey (to remote locations)
lying area)
3. Conduct daily Tool Box Talk (TBT) for logistic drivers
 Over excretion of Physical before start of journeys.
Capabilities (Fatigue factor,
solitary driving)
60
Man Lost in Desert
A service company engineer arrived to the rig  Inadequate Audit/ Inspection/

site in the morning and after completing the Monitoring (Compliance with ADCO Night
task, he booked out from rig site and proceeded Driving Guidelines was not monitored
to the rig camp, situated approximately 7 km between Rig Site & Camp; Effectiveness of
from the rig site. Later in the evening, he was sign boards/marking between Rig Site and
called in to perform a job at the rig site and he Camps were not monitored)
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 Lesson Learned
button to initiate the emergency but it
Drilling
malfunctioned.
After waiting for about an hour, two search
ND 52
vehicles were dispatched on Search & Recovery
mission. In the meantime the engineer used
1. Check and monitor effectiveness of
flare gun to attract attention and search &
31-01-2013 signage/makings between Rig site and rig
recovery team located him and evacuated him
camp.
to the rig site.
Immediate Causes 2. Visitors should be escorted while travelling
between Rig site and rig camp at night and
follow ADCO Night Driving guidelines
 Improper Decision Making/Lack of
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)
61
Vehicle Collision
A tubular handling crew booked in at a rig location Worksite/Job Hazards (Night Time
(ND 24) and then booked out to proceed to NDC driving hazards between the rig location
Central Camp) to book rooms and to take dinner. and central camp were not identified and
Then the crew left the camp and they were on the journey was not subjected to ADCO
their way to the rig location (approximately 45 km Night Driving Guidelines)
away from the camp). Due to earlier sand storm
there was sand accumulation on the road. The
Assessment Performed (In Vehicle
driver was surprised by the sand on the road and
Monitoring System (IVMS) is not geo
tried to change lane to avoid sand. At the same
referenced with posted speed limits)
time another 3rd Party vehicle was approaching
from opposite site and both vehicles collided.
Outcome: Four crew members sustained serious
injuries. Lesson Learned
Drilling
Immediate Causes
ND 24
 Violation by Individual (Driver was over 1. Do not drive at night or during low
14-03-13 speeding (105 km/Hr Vs 80 km/Hr posted visibility unless it cannot be avoided.
speed limit)
2. Subject night time driving to risk
 Inattention to Footing & Surrounding assessment /Journey Management
(Upon noticing sand accumulation, the driver System
suddenly changed the lane in front of
oncoming vehicle ) 3. Always adjust/reduce vehicle speed
according to visibility and road
 Work Exposure to Storm or Act of Nature conditions
(Sand accumulation after sand storm)
62
Fatal Road Traffic Accident
 Inadequate Leadership (Night time

driving during foggy conditions was not
stopped)
While a project vehicle (pick-up) was on its way to
Dubai from Al Habtoor Camp (Qusahwira), it  Inadequate Audit/ Inspection/
collided with a water tanker (supplying water to Monitoring (Compliance with road
another project) in Al Qua‟a (approximately 122 km safety requirements (book in/out, fog
away from Qusahwaira contractor camp). There markers and night driving was not
was dense fog with reduced visibility and both adequately monitored)
vehicles collided head on. Outcome: It resulted in
the death of the pick-up driver and the passenger
Assessment Performed (Early water
sustained serious injuries.
delivery timing encouraged water
supplier to undertake night time driving)
South East
Qusahwira
Immediate Causes
 Violation by Group (Nigh time driving during

foggy conditions was undertaken by project 1. Do not undertake driving assignment during
staff and the water tanker operator) low visibility.
 Inattention to footing & Surroundings 2. Implement book in/out at site
(Vehicles speed was not adjusted to weather accommodation camps.
and road conditions)
3. Plan journeys to avoid driving at night
63
Fatal Road Traffic Accident
A crew was driving from Asab to Shah Central  Inadequate Assessment of Needs &
Degassing Station (CDS) for installing marker Risks (In Vehicle Monitoring System
posts along MOL (Main Oil Line). The crew (IVMS) is not geo-fenced with posted
was travelling on Hameem Road. speed limit and driver was driving at
Approximately 12 km before Shah Junction, speed of less than 121 km/hr. to avoid
over a blind crest hill climb is a roundabout IVMS violation regardless of the posted
where the posted speed limit is 60 km/Hr. A speed on Hameem Road )
private vehicle was parked on the hard
 Inadequate Recall of Training
shoulder and one person came out from
Materials (Driver did not anticipate
behind the parked vehicle and started to
hazards ahead and continued driving at
cross the road. The project vehicle (driven at
high speed towards a blind spot)
South East a speed of 120 km/Hr.) hit the pedestrian.
Outcome: The pedestrian sustained head
Shah injuries and he was taken to hospital in an
ambulance. He later died in the hospital
Lesson Learned
07-05-13
Immediate Causes 1. Always follow the posted speed limits and
reduce speed according to road and driving
 Violation by Individual (The driver was conditions (e.g. blind spots, low visibility &
driving at speed of 120 km/hr. in 60 build up areas)
km/hr. section of the road) 2. Watch out for pedestrians especially near
 Inattention to Footing & Surrounding crossings and parked vehicles along road
(The vehicle was parked approximately 80 side.
meters after the blind spot and the driver 3. Subject drives to daily Tool Box Talks (TBT)
was not able to react in time (high speed discussing hazards specific to the assigned
and shorter distance) route.
64
Vehicle Rollover
A driver was assigned to collect and deliver medical

reports from Madinat Zayed Hospital to NDC Base
Camp. After delivering documents, the driver was
Monitoring (Drivers driving behavior
returning back to rig location. While driving on the
reports (RAG Reports) were not
black top road, his vehicle drifted towards hard
effectively reviewed to provide
shoulder and he attempted to return back on the
counseling/coaching on his driving
road but he steered into opposite (wrong) lane and
skills)
then again he attempted to steer it back and applied
harsh brakes to reduce the speed of the vehicle. It  Inadequate Assessment of Needs
resulted in vehicle to rollover. Outcome: The driver & Risks (In Vehicle Monitoring
Drilling escaped unhurt as he was wearing seat belt and the System (IVMS) is not geo fenced with
vehicle windscreen and windows glass was damaged. posted speed limits)
ND 24
(BUH) Lessons Learned
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 lost2. Review drivers‟ driving behavior reports
concentration and the vehicle drifted from the (RAG Reports) to identify risky drivers
road) and provide counseling/ coaching on
 Improper Decision Making/Lack of Judgment driving skills.
(Driver applied harsh brakes and sharp steer
maneuvering to control the vehicle)
65
Water Tanker Rollover
Shah Gatch track widening project was on-  Inadequate Monitoring of Construction
going and crash barriers were installed on the (Access to under construction track were not
track to separate the old (existing) and new blocked and no warning signs were provided
Gatch track. In some areas, the distance to deter road users entering the under
between barriers was large enough for construction track)
vehicles to enter.
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 Lesson Learned
South East 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
Shah right side. Outcome: The driver escaped
unhurt and the tanker sustained minor
07-06-13 damage 1. Do not use under construction roads/ access
Immediate Causes tracks
2. Barricade access to under construction
 Improper Decision Making/Lack of road/access tracks
Judgment (Driver decided to use under
construction track which was not yet
opened for use).
 Inadequate Guards or Protective
Devices (There were large gaps between
barriers allowing access to under
construction part of the track)
 Lack of Knowledge of Hazards
Present ( Driver did not anticipate soft
sand at the edge of the track)
66
A water tanker was assigned to earthwork  Inadequate Performance of Skills (Driver

activities and used for water spraying & gatch parked the water tanker on an inclined slope)
stabilization. The tanker operator collected
 Employee Perceived Haste (Tanker
water from a well (Well No. 5) and sprayed
Operator was in hurry to catch staff bus to go
water on side slope of accommodation camp
to the camp for mid-day brake and parked
site. At mid-day break time, he parked his
the taker near the location where he was
vehicle at the work location (inclined slope)
working)
and went to the camp for lunch. The tanker‟s
hand break (Air Brake) became released and
partially filled water tanker started to roll
backward for about 100 meters and then
Monitoring – (Inadequate Supervision) (Site
rolled over. Outcome: No personnel injury
In charge did not ensure if the site and
had occurred and tanker sustained broken
equipment are left in safe condition/position
wind screen.
South East prior to the break time)
Lesson Learned
Qusahwira
18-06-13
Immediate Causes
 Equipment or Materials Not Secured 1. Always park vehicles in dedicated parking

(Water tanker was parked on a sloped areas.
area without inserting wheel chokes to
immobilize wheels) 2. Do not park vehicles, especially heavy
vehicles, on a slope.
 Lack of Knowledge of Hazards
Present (There was no dedicated parking
area for tanker at the location and the
driver did not anticipate risk of tanker
rolling)
67
Vehicle Rollover
A project driver and a passenger were travelling

from Asab to Qusahwira to collect materials. There  Inadequate Identification of Worksite or
was accumulation of sand on the track and the Job Hazards (Journey was planned without
driver tried to avoid a sand bar and while returning identifying hazards associated with the route)
back to his lane, the front right tire punctured and  Inadequate Preventive Maintenance (The
the driver lost control of the vehicle. It resulted in track was not adequately maintained especially
vehicle to rollover. Outcome: Both driver and after sand storm/ windy conditions)
passengers were wearing seat belts and escaped
unhurt; and the vehicle sustained damage.
South East
Lessons Learned
Qusahwira

1. Always adjust/reduce vehicle speed according
to road conditions.
 Inattention to Footing & Surroundings 2. Do not apply harsh brakes and sharp
(Driver did not adjust/lower his speed when maneuvering of steering, simultaneously, to
encountered sand accumulation and tried to control vehicle at high speed.
drive around sand bars)
3. Subject drivers to daily tool box talks to
 Improper Decision Making or Lack of discuss route hazards and to reinforce safe
Judgment (Driver applied harsh break to control driving behavior.
the vehicle on Gatch Road, while maneuvering
around sand accumulation)
68
Vehicle Collision & Rollover
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.  Inadequate Identification of Worksite/Job
Hazards (Risks associated with the journey
Each vehicle selected a different route and
were not adequately identified; lack of road
proceeded to Jebel Dhanna. At an intersection, one
traffic warning signs was not notices/rectified;
vehicle approached the main track from a blind spot,
crew did not travel in a convoy)
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.
Terminal & Lessons Learned
Pipeline
Operations
Immediate Causes
23-06-13  Improper Decision Making/Lack of

Judgment (Vehicle, approaching from blind
spot, did not stop at the intersection to ensure 1. Slow down when approaching an intersection
clearance). from a blind spot.
 No Warning Provided (There were no road 2. When travelling in multiple vehicles, travel in
warning signs before the intersection). 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
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  Physical Conditions- Fatigue (The driver
refresh and after taking his lunch he started his had completed his daily tasks and then he
journey. Approximately 5 kilometers after the was sent on another long trip)
Security Check Point, the driver lost concentration
and the vehicle started to drift. The drive attempted  Diminished Performance (Driver felt
to adjust the direction to the right and applied harsh sleepy/drowsy after lunch break resulting in
brakes causing vehicle to come off the road and rolled loss of concentration while driving)
over. Outcome: The driver escaped unhurt and the
North East vehicle sustained major damage.
Bab (NEB)
Al Dabbiya
09-07-13
Lessons Learned
1. Do not apply harsh brakes and sharp

Immediate Causes
maneuvering of steering simultaneously to
 Inattention to Footing & Surroundings (Driver control vehicle‟s course.
lost concentration and the vehicle went off 2. Prior to assigning trip, review drivers fitness
course) and rest to avoid fatigue during the journey.
 Improper Decision Making/Lack of 3. Conduct tool box talks (TBT)/briefing for
Judgment/Unintentional Human Error (Driver drivers, highlighting hazards associated with
attempted to apply harsh brakes while route and physical condition of drivers.
maneuvering steering to control the vehicle
direction)
70
Vehicle Rollover
 Inadequate Practice of Skill (Driver

A crew was proceeding for site inspection, driving on a acted on impulse and did not follow safe
sand track. There was a hump/small dune on the track desert driving techniques)
followed by a bend. The driver did not adjust his speed  Inadequate Reinforcement of Safe
and drove over the hump and then he was surprised by Critical Behaviour (Prior incident lessons
the bend. The driver applied harsh brakes and sharp learned involving inadequate practice of
maneuvering of steering to control the vehicle direction, skill while driving off road were not
resulting in vehicle to rollover to its side. Outcome: All effectively communicated to drivers)
crew members escaped unhurt and the vehicle sustained
damage.
BAB & Gas
13-07-13
Lessons Learned
Immediate Causes
1. Do not apply harsh brakes and sharp
 Work or Motion at Improper Speed (The driver maneuvering of steering simultaneously
did not adjust his speed according to road conditions to control vehicle‟s course.
and he was driving at a speed of 90 km/Hr. against
2. Adjust (reduce) vehicle speed according
maximum speed of 80 Km/Hr.)
to road conditions especially when not
 Lack of Knowledge of Hazards Present (The familiar with the route.
driver was not familiar with track conditions
3. Conduct coaching sessions on how to
especially the bend after the dune)
respond in case of any emergency (tire
 Improper Decision Making/Lack of burst) while driving on sand track.
Judgment/Unintentional Human Error (Driver
attempted to apply harsh brakes while maneuvering
steering to control the vehicle direction)
71
Vehicle Rollover

Monitoring (Drivers‟ RAG reports were
not adequately reviewed; Use of former
drivers‟ blue keys was not
While a crew was driving on blacktop, the front
detected/monitored)
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
Immediate Causes
15-07-13
 Improper Decision Making/Lack of 1. Do not apply harsh brakes and sharp
Judgment/Unintentional Human Error maneuvering of steering simultaneously to
(Driver attempted to apply harsh brakes control vehicle‟s course.
while maneuvering steering to control the
vehicle direction) 2. Periodically review drivers‟ driving
behavior (RAG) Reports and provide
counseling as necessary.
72
Vehicle Collision
A vehicle carrying crew was proceeding to a well worksite/job hazards (Hazards of sand
site (Sb-35). The sand track had a curved slope accumulation on the track were not
and due to earlier stand storms, the track had considered and crew was not aware of track
sand accumulated, narrowing the track. conditions)
Another, vehicle was approaching from opposite
 Inadequate Preventive Maintenance
direction and due to sand accumulation; the
(Sand track clearance was not performed
vehicle was driven in the wrong lane. Both
after the sand storm)
vehicles emerged from opposite directions and
collided head on. Outcome: Minor injuries to
Drilling drivers and damage to vehicles had occurred.
Shail
Lesson Learned
21-07-13
Immediate Causes 1. Always follow the posted speed limits
and reduce speed according to road and
driving conditions (e.g. blind spots, low
 Violation by Individual (One vehicle was visibility & build up areas)
driven in wrong lane of the sand track) 2. Watch out for pedestrians especially
 Congestion or Restricted Motion (Due to near crossings and parked vehicles
sand accumulation the width of the track along road side.
was reduced and only a narrow section was 3. Subject drives to daily Tool Box Talks
clear) (TBT) discussing hazards specific to the
assigned route.
73
Vehicle Collision
After completing the job at a well site, an  Inadequate Preventive Maintenance

Operations Crew was returning back to Asab. The (Sand track was not maintained to clear
driver was using the security fence patrolling track accumulated sand)
leading to black top road. An Engineering crew  Inadequate Work Planning or Risk
was heading to well site (Sa-213) using the same Assessment Performed (Both vehicles were
track. Due to sand accumulation, engineering using security patrolling fence road/track
crew vehicle was driving in opposite lane. Both instead of using approved routes)
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.
10-08-13
Lessons Learned
Immediate Causes 1. Do not use Fence Security Patrolling Track.

 Violation by Individual (Project driver was 2. Maintain sand tracks to remove accumulated
driving the vehicle in wrong lane). sand, especially after sand storms.
 Congestion or Restricted Motion (One lane 3. Identify access routes and associated hazards
of the track had sand accumulation) before embarking on journeys especially when
driving off road.
 Inattention to Surroundings (Both Drivers
approached the blind spot without due care
and attention)
74
 Inadequate Practice of Skill (The

After making a water delivery to Shah Camp, driver did not apply safe driving
a water tanker was returning back, on main techniques)
Gatch Road. A part of the road had inclined
slope and the surface was wet. The driver  Inadequate Audit/ Inspection/
was applied harsh brakes to avoid entering Monitoring (Driver‟s safe driving
wet areas, resulting in vehicle to veer off and document (ADSD) had expired in 2010
roll over to its side. Outcome: The driver and there was no effective monitoring in
escaped unhurt and the vehicle sustained place to ensure refresher training)
Drilling
minor damage.
Shah
23-08-13
Lessons Learned
Immediate Causes
 Lack of Knowledge of Hazard Present 1. Do not apply harsh brakes on slopes and
(The driver was not aware of wet surface gatch road to control vehicle.
ahead).
2. Subject driver to refresher safe driving
 Improper Decision Making/Lack of techniques every three years.
Judgment (The driver applied harsh
brakes at an inclined section of Gatch
Road)
75
Vehicle Collision
An Operations crew vehicle with four (4) passengers

was proceeding to well locations (Bb955) and due to  Inadequate Implementation of Procedure
traffic congestion, the driver decided to drive (Journey Management) (Selection of route and
through a gatch road. A Project crew vehicle with associated hazards were not identified and
three (3) passengers was on its way to another well Operations crew driver selected an alternative
location (Bb348) using the same gatch road. Project route during the journey; Operations crew
crew vehicle was driven in the wrong lane (more vehicle was not fitted with desert flag)
towards right side). Both vehicles approached a blind  Inadequate Practice of Skill (Operations
spot (uphill) from opposite directions and collided crew driver did not adjust/reduce speed while
head on. Outcome: All passengers and drivers approaching the blind spot)
escaped unhurt and vehicles sustained minor
damage
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.
 Improper Decision Making or Lack of
Judgment (Operations crew vehicle did not
adjust/reduce speed while approaching the blind
spot (uphill))
76
Fatal Vehicle Collision
 Inadequate Identification of Worksite/Job

While a Kenworth truck was returning from a well Hazards (Hazards of Ghazal on road were not
site (Sb-545) in Asab, after delivering chemicals adequately identified (awareness, road signs
(Calcium chloride), a private car (KIA saloon), hit and barriers to prevent access to road)
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.
Lessons Learned
Corporate
Support
Immediate Causes
11-09-13 presence of free roaming Ghazal was not known
to road users)
 Inadequate Guards /Protective Devices
(There was no barrier (fence) to avoid Ghazal 1. Create awareness about presence of Ghazal
entering the road) and wildlife in BAB and other ADCO areas
 Inattention to Footing & Surrounding 2. Install road wildlife warning signs on BAB-
(During low visibility conditions (night time) Madinat Zayed Road
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
Kenworth‟s trip to rig location)
77
Fatal Vehicle Rollover
An oil based mud (OBM) haulage tanker was  Inadequate Audit/Inspection/

travelling from Mud Plant towards Rig location in Monitoring
Asab Field. The haulage tanker had defective valve
1. OBM Haulage tankers were not
resulting in leakage of OBM on the road.
subjected to effective inspections and
A project vehicle with tow passenger was travelling vehicle fitness was not adequately
to Buhasa Field for inspection and testing of welding monitored
job. The driver was noticed spillage on the road but
2. Project vehicle was not fitted with online
perceived it to be water and he continued driving at
In Vehicle Monitoring System (IVMS)
high speed (120 Km/Hr. on the road with 80 Km/Hr.
and therefore the system did not warn
speed limit). After driver through the spill, he lost
when driver over speeded
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 Lessons Learned
Buhasa
resulted in fatal injuries to back seat passenger and
the driver and another passenger escaped with
minor injuries.
10-09-13
Immediate Causes
1. Driver should ensure all passengers wear seat
belts before moving the vehicle.
 Defective Vehicle (OBM Haulage tanker had
2. Always follow posted speed limits and reduce
defective valve resulting in spillage of OBM on
vehicle speed according to road conditions.
the road)
3. Inspect haulage vehicles fitness prior to their
 Work or Motion at Improper Speed (Project
use
vehicle was driven at high speed and the driver
did not reduce speed after noticing the spill on
the road)
78
Fatal Vehicle Rollover
A crew vehicle was commuting to work from

Contractor Accommodation in Al Ain (Al-Quaa) to
Qusahwira Field (approximately 130 km long trip).
 Inadequate leadership (ADCO road safety
The driver was over speeding and at the same time
requirements were not adequately enforced on
he felt sleepy, resulting in vehicle to drift from the
subcontractor).
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. Lessons Learned
South East Outcome: Vehicle roof collapsed resulting in fatal
injuries to one crew member.
Qusahwira
07-10-13 1. All passengers (rear occupants) must fasten

Immediate Causes
their seatbelt (seat belt save lives)
2. Conduct Awareness sessions for contractors
 Violation by Supervisor and sub-contractors explaining the benefit of
1. An untrained and inexperienced driver using ROB.
was assigned to drive crew vehicle 3. Ensure that all contractors & Sub-contractors
2. Unapproved vehicle (without IVMS and residing nearby working site (avoid long
Rollover Bars) was used for crew transfer journeys while commuting between worksite
and camp).
3. Crew was transferred from Site Camp and
accommodated in Al-Quaa without
authorization and Journey Management
Plan
79
Diesel Tanker Rollover
 Inadequate Training Efforts (The newly

assigned driver and other contractor staff were
A Diesel Tanker Driver filled the tanker from the
not familiarized with ADCO night time driving
camp location and proceeded to Gatch Stockpile
guidelines)
location, in Asab. While approaching Asab T Junction,
the rear left tire punctured and the tanker started to  Inadequate Implementation of Procedure
drift. The driver tried to steer it and applied harsh (ADCO requirements for Journey Management
brakes resulting in driver to lose control, causing were not effectively implemented)
tanker to rollover.
 Inadequate Audit/ Inspection/ Monitoring
Outcome: The driver escaped unhurt and the vehicle (Effectiveness of book in/out from Camp were
sustained major damage. Approximately 2000 gallons not monitored)
of diesel were spilled.
Lessons Learned
South East
Asab Immediate Causes
 Improper Decision Making/Lack of Judgment

(The driver decided to transfer the tanker at night
10-11-13
to save time and to attend to his personal tasks in
the morning) 1. Do not apply harsh brakes and sharp
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
disconnected; No book in/out checks at the filling staff on Night Time Driving Guidelines
site and in the camp) 3. Establish/Maintain effective Journey
 Violation by Group (Driver undertook night time Authorization & book in/out at Camp Gates.
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)
80
HSE Performance, 2013
ADCO & Contractors LTIF & TRIR (YTD) vs

Manhours worked
1.4 1.29 180
Lost Time Injury Frequency Rate / Total
160
1.2
160.49
0.93 140
Recordable Injury Rate
Million Manhours Worked

120
0.80
118.92
0.8 0.70 0.68 0.81 100
0.66 0.78 0.47
0.6 0.55
0.51 80
0.63 0.46
0.34 60
86.29
0.55 0.36 0.34
0.4 0.28 0.29
56
55
0.26 40
0.16 0.16 0.12
0.2
34
47
44.4
57.36
32.5
0.09 0.08 0.07 20
29
27
32.3
0 Historical HSE Performance
0
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
0.45
0.45
0.40 200
Vehicle Accident Frequency Rate
Million Kilometer Driven / No. Of Vehicle Accidents

198.6
0.35
0.30 0.29
0.30 150
0.27
136.9
0.25
0.22 0.20
0.18 0.19 0.18
0.20 100
0.17
122.1
0.15
0.12
80.4
78.0
76.9
0.11 0.12
70.0
64.0
0.10 50
61.0
57.5
26 24
44.0
21 14 22
40.0
0.05
36.0
18 11 13 14 14 10 7 10
0.00 0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year
KM Driven Vehicle Crashes VAF
82
Incident Sub Types 2013
(Work & Non-Work Related-316)
200
150
100
50
0
2009 2010 2011 2012 2013
Fire Gas Release Injury/Illness Transportation Onshore Spill
83
Incident Immediate Causes -2013
84
Inattention
No Warning
Distracted by other Provided
concerns 8%
8%
Routine activity
without though Improper decision
12% 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
‫منعوقوعالحوادث من الل الدروس‬
‫لمستفادة منها‬
‫والعبر ا‬
INCIDENT PREVENTION
THROUGH LEARNING FROM
INCIDENTS
July-Sept (Q3) 2014
HSE & RISK MANAGEMENT

FUNCTION
We are glad to share the Learning from Incidents (LFIs) for 2014, Q3incidents.
Every LFI includes three sections:
 What happened: This section covers the incident description.

 Why it happened: This section covers what went wrong leading to the incident.
 Lessons learned: This section covers the main learning’s from the incident.
We have identified target audience for every LFI which should make it easier for Line
HSE to communicate. However, Line HSE can communicate it to any other stakeholder
within their organization at their discretion. As usual, Line HSE will maintain relevant
records to document such communication.
During the 3rd quarter of 2014, we had 19 Injuries ranging from Restricted Work Cases
to First Aid Cases (FAC), 1 Major Oil Spill and 2 recordable Road Safety Accidents.
Incident Investigations highlighted deficiencies in Supervision and Work Planning, all
requiring immediate attention.
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 liability for either the fact described or for any reliance of the contents by any third party.
For further information, comments and suggestions, please contact [email protected]
OCCUPATIONAL SAFETY
Supply Chain
Management
REF INCIDENT OCCUPATIONAL TARGET
LFI-LL-14-036 Department
NO: TYPE: SAFETY AUDIENCE
Employees and
Contractors
TITLE Slip & Fall of a Contract worker
What happened:
On 2nd July 2014 at around 0900 Hrs. a
contractor employee working at Bab-13
Chemical Warehouse, slipped from the top of a
jumbo bag containing calcium chloride and fell
to the ground, resulting in hand injury. He was
immediately taken to RAMS Clinic and later to
hospital for treatment.
The jumbo bags were stacked outside the

warehouse in the open yard and the injured
person prior to the incident was working along
with two others to cover the jumbo bags with
tarpaulin sheets.
Why it happened:
 Improper stacking arrangement.
 The injured person was walking at the edge of the stacked jumbo bag.
 After covering the bags with tarpaulin sheet the gaps/holes between jumbo bags were not
visible.
 No specific task plan for the subject work existed at site.
 The workers were not guided properly about the job.
 Hazard/ Risk Assessment were not adequate for this non-routine job.
Lessons Learned:
 Non-routine jobs require careful risk assessment to analyze new hazards.
 Non-routine jobs also demands close supervision.
 Proper job planning is a requirement even for minor jobs.
This LFI is issued by ADCO CHSE for ‘Capturing Learning from Incidents’. Its distribution shall be restricted and neither ADCO nor its
Shareholders shall accept any liability for loss or damage arising from or in connection with this content.
For more details and information contact: [email protected]

All Drilling &
REF INCIDENT OCCUPATIONAL TARGET Operations
LFI-LL-14-037
NO: TYPE: SAFETY AUDIENCE Employees and
Contractors
TITLE Scorpion Bite

What happened:
On 17th Aug-2014 at 10:30AM, during
housekeeping job at the outside fence area
south side of Jabal Dana-MPS; a contract
worker was bitten by a scorpion in his left
foot just above the ankle. The scorpion was
found inside his shoes. The injured was
taken to RAMS clinic in Habshan and after
clinical examination and first aid was
released. The worker resumed duty
afterwards.
Why it happened:
 Though it was not clear from where the scorpion entered the long safety boot, it
might have entered while the worker was performing his duty in the desert or even
before he worn it.
 The workers were not aware about the scorpion hazard.
 Inattention to surroundings by the personnel.
Lessons Learned:
 Awareness about animals, insects and reptiles in deserts will be enhanced if the
same is covered in Permit to Work & Tool Box talks.
 All personnel working in desert areas shall be very conscious about the presence of
the dangerous animals, insects and reptiles.
 Before wearing shoes and coverall, make sure that these are free of insects and
reptiles.

REF INCIDENT Occupational TARGET All Drilling staff and related
LFI-LL-14-038
NO: TYPE: Safety AUDIENCE Contractor’s Personnel
TITLE Fall of Operator from Catwalk
What happened:
 On 22nd Aug 2014 Tubular Tong Services were required
for 13 3/8 casing job. During rig down PC (pickup)
machine the crew tried to manually lift a stand. While an
operator was pulling the arm out of the stand standing
close to the edge of catwalk the arm suddenly came out
and he lost balance and fell down on the ground with the
arm falling on his foot. The operator sustained foot
fracture.
Why it happened:
 The operator attempted to pull out the arm of the stand
while standing on the edge of the catwalk which was not
a proper position for the task.
 The crew arrived at rig location but was put on standby
for 5 hours. Later the crew was issued permit to work and
the started the job which continued for about 10 hours.
The crew was tired and exhausted and did not wait for the
crane and started to manually lift the parts.
 The crew was probably not aware of the hazards present.
Since the rigging down of the PC machine was not
addressed in Job Safety Analysis, the Tool Box Talks
were not effective.
Lessons Learned:
 Regular updating of the Job safety analysis/ task risk assessment will enhance awareness of
the hazards and safe working.
 Job planning meetings between the contractor and rig teams upon arrival to the site would
result in better coordination of the job.
 Maintaining the employee shift pattern without exceeding the normal working hours would
reduce fatigue and result in proper decision making and judgment for the task.

LFI-LL-14-039
TITLE Fall of Floorman on Rig Floor

What happened:
On 21st Sept 2014 at ND-62 in Bab field, Slip & Cut Operation
was ongoing and the drill line cover plate was raised. A
Floorman who was passing through the area tripped over the
cover plate’s lifting eye pad and fell down on the floor. He
sustained closed fracture of the rib.
Why it happened:
 Due to the movement of the drill line the cover plate
was lifted. The eye pad of the lifter plate was not fully
pushed inside, due to accumulation of sand/mud,
creating a tripping hazard.
 The newly hired Floorman was rushing to complete
the assigned tasks and was not skilled enough to
identify hazards on the rig floor. The Floorman did not
anticipate/focus on the tripping hazard as the area
was not barricaded.
 The rig floor was not adequately inspected by the Rig
management to identify and correct the tripping
hazards from the extended eye pad of the lifter plate.
Lessons Learned:
 Inspect /clean eye pads of lifter plates after each rig
move.
 Painting the eye pads of lifter plate with pinch point
color will aid in easy identification of the hazard.
 Initiate “Knowledge Transfer Session” for the crew on
a weekly basis where new and inexperienced crew
member can discuss operational issues & hazards
with other experienced crew members.

LFI-LL-14-040
TITLE Dropped Object From Rig Floor
What happened:
On 26th Sept 2014 at ND-56 in Bab field as part of
preparation for the BOP test, the crew was tightening a test
joint using a pipe spinner. In the process the test joint broke
out from the testing assembly and fell freely to the ground
through the V-door causing damage to the test joint.
Why it happened:
 The crew used a chain tong and pipe spinner instead
of a rig tong to connect the testing joint (30 ft long) at
the top and BOP test plug at the bottom. Full torque
was not applied and hence the joint got unscrewed.
 The crew was not aware of the inherent risks in using
the chain tong and pipe spinner. The Job Safety
Analysis (JSA) did not specifically cover the required
use of rig tong.
 There was lack of supervision as no one prevented
the crew from taking short cuts.
Lessons Learned:
 Use correct and specified tool for the job. When
tightening connections, ensure recommended torque
to obtain fool proof joints.
 The JSA and instructions to workers shall provide
clear guidance on control measures.

LFI-LL-14-041
TITLE Finger Injury
What happened:
On 20th Sept 2014 at ND-38 in Bab field the rig
crew was unscrewing the bumper sub while
laying down the Fishing Bottom hole assembly
by using a chain tong. The crew lowered it into
the mouse hole, while being suspended from
pipe elevator attached with slings to the
traveling block. An air winch line was used to
suspend the mouse-hole rest (spacer) and
placed the connection between jar and bumper
sub above the rig floor. When connection was
fully broken out, bumper sub dropped half foot
and pushed down the mouse hole to rest, which
caused the air winch line to jerk. The Fishing
Supervisor who was standing next to the air
winch line observing the operation got his
fingers trapped between air winch line and the
pulley. He sustained finger fracture.
Why it happened:
 Fishing supervisor was standing at a wrong location with his left hand rested on the air
winch wire close to the pulley.
 The Rig Leadership team did not stop the Fishing Supervisor from standing at the wrong
location.
 Driller and other crew members were focusing on the task at hand and did not notice
improper position of Fishing Engineer.
Lessons Learned:
 Always maintain safe position & posture at rig floor
 Maintain visual contact with service company crew on rig floor
 Always STOP unsafe action

LFI-LL-14-042
TITLE Fall from Mud Tank
What happened:
On 27th July 2014 at ND-51 in Asab a Roustabout was
cleaning Shale Shaker Ditch and while he was moving
around, a mud tank grating dislodged, resulting in Roustabout
to fall through the gap on motor housing (about 2 meter
below). He sustained knee sprain.
Why it happened:
 Grating was not secured with grating stoppers–grating
stopper/stud were missing
 Grating stoppers/studs were not adequately welded &
painted causing it to deteriorate
 Roustabout was performing routine activity and was
not aware of defective/missing grating stopper
 Earlier audit findings were not effectively implemented
Lessons Learned:
 Inspecting integrity of gratings and grating
studs/stoppers after each rig move will enable the
crew to identify and rectify hidden hazards.

All Drilling and Operations
REF INCIDENT Occupational TARGET
LFI-LL-14-043 staff and related
NO: TYPE: Safety AUDIENCE
Contractor’s Personnel
TITLE Fall from Rig Pump Module
What happened:
On 8th Aug 2014 at ND-57 in Bab field as part of
installing a pop off valve (safety valve) of a mud
pump a Floorman was tightening the hammer
union connection (at a height of 2 m) by
standing on the rig pump module with a hammer
and in the process he missed the strike and fell
down to the ground hitting his head against a
tool box. He sustained open cut wound was
treated at the hospital.
Why it happened:
 The Floorman was standing on an elevated mud pump module instead of a
scaffold/platform.
 Proper hazard analysis was not conducted for the operation.
 Lack of supervision as no one prevented him from carrying out the unsafe act.
Lessons Learned:
 Use a firm platform/scaffold while doing work at height.
 Identifying hazards at work and its close monitoring will enhance safety at work place.

LFI-LL-14-044
TITLE Fall from Mast Beam
What happened:
On 11th Sep 2014 at ND-51 in Asab field during rig
move, the mast was lowered and a Floorman was
sent on top of mast moving dolly beam to check the
center of mast beam against dollies. The Floorman
informed driller to adjust the alignment and removed
his lanyard to come down. During this time, the
Driller instructed the forklift operator to lift the push
bar. The lifting of push bar caused the upper mast
seating section to flip, hitting the Floorman by push
bar. The Floorman fell down on substructure and
sustained rib fracture.
Why it happened:
 The crew was not aware of dolly push bar
swinging hazard as there was no Job Safety
Analysis (JSA) for this task and hence no
instructions.
 Driller assigned forklift operator to lift the
push bar while the Floorman was still on the
mast.
 Steering tow bar was not connected to
balance mast dollies and avoid flip over.
 There was no working procedure for
installing mast dollies.
Lessons Learned:
 Use man lift for inspecting the mast moving dolly beam.
 Connect steering tow bar to balance dollies and avoid flip over.
 Conduct JSA specific to the job and accordingly inform/instruct the crew.

REF INCIDENT Occupational TARGET
LFI-LL-14-045 staff and related
NO: TYPE: Safety AUDIENCE
TITLE Shoulder Injury from fall of Drill Line
What happened:
On 28th Sep 2014 at ND-62 in Bab field a crew (Forklift
operator & Roustabout) was engaged to transfer 50 feet
long (spooled) used drill line (1 3/8”) from storage area to
welding area, for cutting it into pieces. The spooled drill
line was tied, across, using manila rope. Drill line was
picked up by fork lift and the Roustabout was guiding the
forklift operator. Once forklift operator started to lower
forks to offload drill line, one end of drill line slipped from
its place, fell down from 15 feet height on to the shoulder
of the Roustabout. He sustained minor injury on his
shoulder.
Why it happened:
 Dead end of the spooled drill line was not
adequately secured and it was not placed closer
to the ground.
 Inexperienced Roustabout did not maintain safe
distance.
 The crew did not anticipate release of drill line end
from the spool.
 Foreman assigned inexperienced crew to transfer
the drill line and the crew was not supervised
 Crew was not adequately coached to identify drop
hazards and placement of dead end of the drill
line closer to the ground.
Lessons Learned:
 Maintain safe distance during transfer of load (stay away from “Line of Fire”)
 Ensure that load is properly secured while transferring using heavy equipment.
 Conduct task specific tool box talk (TBT) prior to executing the task.
 Always supervise activities of newly hired/inexperienced crew members.

LFI-LL-14-049
TITLE Operator Leg Injury on entanglement with counter weight
What happened:
On 5th Sep 2014 at ND-88 in Asab field during rig move
preparation, an inexperienced Assistant Driller (A/D) was
sent to monkey board to check/rectify stuck counter
weight. He started climbing monkey board ladder and
when he reached to the monkey board, he hooked FBH
with handrail of the monkey board.
He noted counter weight line coiled on the board and he
kicked the line to release it. Suddenly counter weight got
released and started to fall freely. The counter-weight
line got entangled around his leg and after hitting his leg,
the line slipped and the counter weight dropped on the rig
floor. Assistant Driller sustained fracture on his leg and he
was brought down by rig crew and transferred him to
hospital.
Why it happened:
 The task was not planned and there was no Job
Safety Analysis performed, Work permit was not
issued
 Inexperienced crew member was assigned to
execute a risky job
Lessons Learned:
 Assign experience crew member to execute high risk tasks.
 Include counter weight in drop checklist
 Conduct task specific pre-job safety meeting with crew members

ROAD SAFETY
All Operations and
REF INCIDENT TARGET Drilling staff and
LFI-LL-14-035 Road Traffic
NO: TYPE: AUDIENCE related Contractor’s
Personnel
TITLE Vehicle Roll over
What happened:
On 19th July 2014 along the access road close to QW 69, a
water tanker transporting fresh water for flushing well testing
equipment at ND-21 rolled over when the driver lost control of
the vehicle as the sand close to a desert ditch collapsed. The
driver who had supplied twice in the day to the site was on his
way to make the third supply when the accident occurred.
The driver escaped with minor injury and the tanker sustained
damages.
Why it happened:
 Poor access road because of no road markings and bad
weather conditions.
 The access road was not adequately surveyed by the end
user to find out the hazards prevailing.
 No briefing to the driver before the commencement of the
work.
 Inattention from the driver due to poor job planning,
supervision and awareness.
 No assistant in the vehicle to help the driver.
 No monitoring of the vehicle as the IVMS was not working
for many months together.
Lessons Learned:
 Identify hazards associated with the route prior to commencing a journey in desert conditions.
Monitoring of road conditions will reveal hidden hazards.
 Tool Box talks or briefing to the drivers will equip them to manage the hazards effectively.
 Empowering workers to stop the work and report the hazard will improve productivity and better
safety culture.

REF INCIDENT TARGET
LFI-LL-14-047 Road Traffic staff and related
NO: TYPE: AUDIENCE
TITLE Truck roll over
What happened:
On 22nd July 2014 in Dabiyya Jetty in NEB a truck was
involved in transferring tents to Rig ND-34. The truck
arrived to the Jetty and the driver was maneuvering the
vehicle to enter a barge in reverse position. During the
process, right side wheel went on higher ground (out of
the ramp) resulting in truck to rollover to its left side, on
the jetty slope. It resulted in minor injuries to driver and
his assistant and vehicle sustained minor damage.
Why it happened:
 An inexperienced and un-untrained driver with
non-approved vehicle was deployed to transfer
materials. ADCO Road Safety Requirements were
not adequately enforced on sub-contractor.
 Contractor’s compliance with drivers’ training,
vehicle fitness and journey management was not
tracked.
 Risks associated with transfer of vehicle onto a
barge were not assessed.
Lessons Learned:
 Assess competency of drivers prior to their assignment.
 Assess hazards associated with offshore/inshore movement as a part of journey
management plan.

REF INCIDENT TARGET
LFI-LL-14-048 Road Traffic staff and related
NO: TYPE: AUDIENCE
TITLE Vehicles Collision
What happened:
On 30th Aug 2014 a contractor driver was driving between
Buhasa Central Camp and Gayathi Roundabout. The
driver was over speeding @120 km/Hr on a road with
posted speed limit of 80 km/Hr. The driver did not have
ADSD (ADCO Safe Driving Document) and therefore, he
was using another person’s credential to drive company
vehicle.
At a curved section of the road, the vehicle drifted into
opposite lane, where a private vehicle was approaching.
To avoid collision both the vehicles entered into opposite
lanes and then tried to return back to their lanes. During
the process both vehicles collided sideways.
No injury was reported but both the vehicles sustained
damage.
Why it happened:
 The Driver was exceeding the posted speed limit
(120 km/Hr. Vs. 80 km/Hr
 The driver did not reduce vehicle speed before
approaching the curved section of the road
 The over speed warning did not work as the
Vehicle IVMS not geo-fenced
Lessons Learned:
 Always drive within the posted speed limit.
 Obtain ADSD if you intend to drive company vehicle and do not use other driver’s
credentials to drive company vehicle.
 Geo-fence IVMS to warn the driver if he exceeds posted speed limit.

ANALYSIS
INCIDENT INVESTIGATION ANALYSIS
Workplace Protective systems

Environment/Layo 13%
ut
2%
Tools, Eqpt & Following
Vehicles procedure
5% 25%
Inattention/Lack of Use of Protective

Awareness Methods
35% 20%
IMMEDIATE CAUSES- 2014 Q3
Skill Level Behaviour

Communication Tools & Eqpt 4%
4%
7% 7%
Work
Rules/Policies/Stds
/Procedures
4%
Work Planning,
Control of work Management
18% Supervision
56%
ROOT CAUSES- 2014 Q3

ROOT CAUSES- Major
Inadequate
Inadequate
Leadership
identification of
47%
worksite/job
hazards
53%
ROOT CAUSES-
Supervision
Inadequate
planning or risk
assesment
performed
20%
Inadequate
work planning
40%
Inadequate
audit/inspectio
n/monitoring
40%
ROOT CAUSES-
Work Planning
LEARNING FROM INCIDENTS (LFIs)
INCIDENT Loss of TARGET Operations/Engineering/

REF NO: LFI-LL-14-001
TYPE: Containment AUDIENCE Maintenance
TITLE Gas Release from 2” Globe Valve
What happened:
On Jan 7th 2014 and during the commissioning
activities of the RDS new flare, a gas leak was
reported from the gas line supplying fuel gas to
flare-fuel gas heater.
The leak was identified on a 2” globe valve in the
gas line coming from the main 8” CDS to RDS
Gas distribution header and going to the Flare-
Fuel gas heater.
Plant emergency procedures were followed and all
personnel evacuated from the site. The
distribution header was isolated and the upstream
valve closed to stop the leak.
Why it happened:
 The 2" globe valve in the gas line failed when exposed to the operating pressure.
 As per the design of RDS pilot fuel gas system to flare, high pressure gas of
around 340 barg is intended for use as fuel gas after pressure reduction to 2.5
barg through a choke valve and PRV’s. The system was not designed for the large
reduction in pressure at one stage and thus caused sudden spike resulting in
material failure.
 The quality of the valve was suspect and it had pitting in Plug and Seat.
 Sudden increase in pressure while lining up the system.
Lessons Learned:
1. HAZOP study for operational systems should cover all possible credible scenarios
of failure.
2. Stringent Quality Control and Assurance procedure during EPC Stages will
improve the Integrity of pipes and fillings in high pressure systems.

Loss of TARGET ADCO Operations,

REF NO: LFI-LL-14-002 INCIDENT TYPE:
Containment AUDIENCE IPD, Integrity
TITLE Main Oil Line Leak
What happened:
On the 20th of January 2014. Loss of
containment from cross fields Main Oil Line
was reported. The leak was arrested by
wooden peg and PLIDCO clamp. The line
was scheduled for decommissioning at the
same week of the incident. The line is buried
at the leak point and external corrosion was
identified as the cause of the leak.
Approximately 1000 barrels of free oil were
recovered. And it took two weeks to recover
the oil and remove the contaminated sand.
Why it happened:
 As the line was scheduled for decommissioning, the decision was made to stop the
asset integrity program for the line. However, the line was kept operational.
 Due to the aging factor of the line, this caused rapid deterioration in the condition of
the line leading to loss of containment.
Lessons Learned:
1. Asset integrity programs must not be discontinued for any asset unless it is
decommissioned and written off.
2. Recovery of free oil should be expedited to avoid further seepage of free oil in the
ground.
This LFI is issued by ADCO CHSE for ‘Capturing Learning from Incidents’. Its distribution shall be restricted and neither ADCO nor its Shareholders
shall accept any liability for loss or damage arising from or in connection with this content.

INCIDENT Road Traffic TARGET All ADCO Staff &

TYPE: Accident AUDIENCE Contractors
TITLE Vehicle Roll Over
What happened:
On 23rd Jan 2014 morning, contractor
crew was commuting in a vehicle from
town to field for rig down and
demobilization from location. The
weather conditions were foggy. At around
0725 hrs. the driver overtook another
vehicle and then collided with a bus
coming from the opposite direction, lost
control and went sliding off road resulting
in a roll over. Four workers suffered
minor injuries and the vehicle got
damaged.
Why it happened:
 The visibility was poor due to fog and the driver could not judge the road conditions
properly.
 The safe distance while driving was not maintained and hence the reaction time was
less.
Lessons Learned:
1. Keep your travel plans flexible to avoid driving in foggy conditions.
2. It is safer to provide camp facilities close to the work site to minimize travel and thereby
reduce the risk.
3. Always maintain safe distance while driving.

INCIDENT Road Traffic TARGET All ADCO Staff &


What happened:
On Jan 28th 2014 around 1500hrs, at
sand track to RDS, a double cabin
pick up was returning to camp from
site after completion of work through
sand track. On the way, the left tire of
the vehicle got punctured,
subsequently the tire slipped out of
the rim, driver lost control and the
vehicle finally rolled over.
One passenger sustained minor
injury and the driver and two other
passengers escaped unhurt. All
occupants of the vehicle were
wearing seat belts and the vehicle
was fitted with roll over bar.
Why it happened:
 The driver was driving at high speed without engaging 4WD. The IVMS data shows a
maximum speed of 115 km/hr on the day.
 Geo Fencing in IVMS of the vehicle was not implemented and hence no warning
given for overspeeding.
 When the driver lost control of the vehicle after the tire burst, the driver tried to steer the
vehicle to the right while drifting at sand on the uphill.
 The driver has less experience in driving in desert conditions.
Lessons Learned:
1. Only experienced and competent drivers are to be deployed for desert driving.
2. Always engage 4WD on sand tracks.
3. Never exceed speed limits.

ADCO Electrical
INCIDENT Fire/Property TARGET Maintenance &
TYPE: Damage AUDIENCE Engineering Staff &
Contractors
TITLE Flash Over at Power Station
What happened:
On 9th Feb 2014, at 1950 hrs,
several 33 KV circuit breakers
tripped at a New Power station,
resulting in a total blackout of the
neighboring facilities and smoke at
New Power Station due to
flashover and arcing fault at the
transformer incomer cable
termination.
Why it happened:
 During the transformer incomer cable termination, the cable semi conductive layer
should have been extended above the earth connection which would have
equalized the field current around the conductor and ensured electrical contact
with the earthing system. The arcing occurred due to melting during flow of
earth/fault current because of inadequate earthing connection.
 Inter-trip signal was communicated between the two sub stations (132KV & 33
KV) using auxiliary electro-mechanical relays which caused a delay in the inter
trip. Protection setting for the directional over current relay was high. This resulted
in a fault dip on the 33KV bus bar and tripped AGD 33 KV OHTL on distance
protection causing black out of the facilities.
 Existing 33 KV switch gear is very old and not Arc proof, the incoming phases are
not perfectly isolated from each other which escalated the single phase fault into a
three phase fault.
Lessons Learned:
1. Good workmanship in cable terminations will reduce the chances of arcing. This
calls for checking all existing cable terminations.
2. Fiber optical communication will enhance the operation of protection relays.

INCIDENT Loss of TARGET Operations/Engineering/

TYPE: Containment AUDIENCE Maintenance
TITLE Gas LOC from Pig Launcher
What happened:
On Feb 11th, 2014 at around 1030
hrs, the pig launcher trap leaked
due to passing of kicker valves
and subsequent pressure build up
and failure of door safety device
sealing O-ring.
The gas release resulted in
actuation of nearby gas detectors
which prompted tripping of RMS-2
station.
Why it happened:
 The barrel was pressurised due to two passing kicker valves and the sealing O-ring of
the door safety device could not hold the pressure and gas leaked outside.
 Ball valves were used as kicker valves as globe valves were not available. Preventive
maiantence of the valves were inadequate.
 Misalignment of door safety device due to different tap hole depths causing non-
uniform compression providing ineffective sealing.
 The Interlock system was partially removed and hence not in operating condition.
Lessons Learned:
1. Structured training and familiarization program is essential to upgrade the
workmanship and competency of the maintenance personnel.
2. Efficient Preventive Maintenance program will ensure integrity of
launcher/Receiver isolation valves.
3. Revisiting all traps to verify safety devices mounting holes will prevent similar
leaks in future.
4. Regular monitoring of pigging traps will identify passing valves.

INCIDENT Road Traffic TARGET ADCO &

What happened:
On March 4th 2014 around 1415 hrs.
a water tanker was proceeding to rig
location to deliver water. While ascending
the inclined section of the track, the driver
noticed another water tanker overtaking a
trailer and to avoid the collision, he moved
to the right side of the track and entered into
soft sand. After entering the soft sand, the
driver lost control of the tanker causing it to
rollover
The driver was wearing the seat belt and he
escaped unhurt (minor bruises & swelling).
The tanker sustained damage.
Why it happened:
 The driver tried to drive close to the edge of the gatch track and vehicles’ wheels
entered soft sand.
 Two- way track has no traffic separation and markers on the edge at an inclined
curved track.
 Access road was not adequately risk assesed for haulage and heavy load and lacked
guards/warning to avoid vehicle entering soft sand at inclined curve.
Lessons Learned:
1. Identify and communicate hazards associated with the route to drivers.
2. Ensure functionality of IVMS in vehicles.
3. More care should be taken while driving off road as the roads are not marked.

INCIDENT Property TARGET

REF NO: LFI-LL-14-010 ADCO & Contractors
TYPE: Damage AUDIENCE
TITLE Flowline dragged by Vehicle
What happened:
On March 7th 2014, at around 1150
hrs, while parking a Wire Line Truck
near well site, the rear outriggers
dragged a partially buried flare line
which was not live. The flare line
then hit another vehicle at the
bottom resulting in dragging of that
vehicle and hitting a third vehicle
which was also parked nearby
causing damages.
Why it happened:
 The designated parking lot was in the wrong location too close to the flare line.
 The burn pit flare line was not buried properly, absence of cones/warning tapes
and road signs to guide approaching work location.
 The driver was not aware of the presence of the flare line in the area.
 No flagman to guide the driver while accessing congested area.
Lessons Learned:
1. Specific job related Task Risk Assessment will enhance the hazard identification
and mitigation and guard against surprises.
2. For vehicular movement in congested areas, proper warning signs and guided
flagmen are a must.
3. Vehicle parking areas shall be located away from the workplace to reduce hazards

INCIDENT TARGET ADCO

REF NO: LFI-LL-14-009 Personal Injury
TYPE: AUDIENCE Contractor PE
TITLE Personal Injury During BOP Testing
What happened:
On 11th March 2014, while opening the
pipe rams after Pressure testing at well
head area, there was an uncontrolled
release of pressure from the BOP,
causing injuries to two contractor’s crew
members (a Coiled Tubing Operator
and a Trainee).
The Coiled Tubing Operator got injury

on both eyes and the trainee’s right
shoulder was dislocated.
Why it happened:
 Coiled Tubing Manual/Coiled Tubing logging Procedure was not followed.
 Lack of supervision during coiled tubing.
 The task was not adequately risk assessed.
 Incompetent contractor personnel.
 Improper implementation of PTW authorization, TRA and supervision requirements.
Lessons Learned:
1. Contractors’ equipment must be inspected and approved before use.
2. Contractors must follow ADCO working instructions without deviation.
3. All high risk activities must be supervised as prescribed in the PTW procedure.
4. All high risk activities must be risk assessed as per ADCO PTW/TRA procedures.
5. Competency of Contractors Personnel must be assessed before deployment.

INCIDENT Fire TARGET ADCO PE

TYPE: Personal Injury AUDIENCE PE Contractors
TITLE Burn Injuries During Green Burner Operation
What happened:
On March 15th 2014, at around 1310
hrs, Contractor Lead Operator started a
flow to clean operation using a chock
manifold and a green burner on a gas
well. During operation, the supervisor
requested two operators to approach
the green burner to presumably ignite
the green burner’s pilot manually.
One operator sustained 2nd degree

burns to hand and face, 3rd degree
burns to finger and smoke inhalation.
Why it happened:
 The green burner was not inspected to ensure that the pilot is working prior to
starting operation.
 PE was not available at location to witness flaring.
 The operators breached the “Safe Zone” during well flowing/flaring.
 The green burner was located at a point that can’t be seen from chock manifold.
 The contractor was wearing cotton coverall and not Nomex.
Lessons Learned:
1. Contractors’ equipment must be inspected and functionally tested prior to use.
2. No person should cross the safe zone while the well is flowing.
3. ADCO minimum PPE should be used at all times, this includes Nomex coveralls.
4. Green burner should be located within visual range from the chock manifold.
5. Never attempt to manually ignite green burners/pilots.
6. PE should be physically present at location until flaring starts.

INCIDENT Loss of TARGET

REF NO: LFI-LL-14-010 Operations & Drilling
TYPE: Containment AUDIENCE
TITLE Oil & Gas Release from Flow Line
What happened:
On March 22nd 2014 around
1630 hrs. the rig crew “as part
of the demobilization” planned
to remove a water tank located
near the flow line using a chain
dozer. While excavating near
the water tank, the dozer hit
and damaged a buried flow line.
This resulted in spillage of
about 10 bbls of oil and release
of associated gas. The well was
shut down automatically.
Why it happened:
 The crew was unaware of the buried flow line as the location of it was not marked in
the handover certificate.
 The handover certificate was prepared without refering to the as built drawings.
 There was a lack of supervision as the crew members were busy securing the mast
for the move. The job was carried out on the judgement of the Assistant Operations
Supervisor.
Lessons Learned:
1. Enhanced Management involvement for review and approval of the handover
certificate will improve quality and accuracy.
2. Planning and allocation of resources such as manpower, equipment etc. before a
Rig move will ensure efficient and error free work.
3. Permit to work (PTW) for earth moving equipment at rig site will result in better
hazard management and control.

INCIDENT Property TARGET Maintenance/Projects and

TYPE: Damage AUDIENCE Electrical Contractors
TITLE Flash Over of 11 KV Loop Cables
What happened:
At around 1245 hrs. on 27th
March 2014 at CDS substation,
the high pressure gas injection
compressor tripped immediately
after re-start with a loud sound
originating from Harmonic Filter
area.
On inspection it was noticed
that a flash over had occurred
in the loop cables (3 Nos.)
connecting the reactors and
resistors of the harmonic filter
elements.
Why it happened:
 The cables got partially damaged during laying process due to excessive wear and
tear, resulting in weak insulation. Rain water entered the cables resulting in
insulation breakdown and flash over.
 The cables used in the harmonic filter loop circuits are unarmored and without
copper braids
Lessons Learned:
1. Armored or copper braided cables for outdoor applications will minimize physical
damage during cable laying.
2. High Potential tests at 80% of factory test voltage for high voltage cables after
laying and termination will ensure healthiness of insulation.
3. Tripped equipment should not be restarted until the cause of the trip is assessed.

INCIDENT Road Traffic TARGET ADCO &

TITLE Vehicle Accident
What happened:
On 31st March, 2014, approximately at
0830 hrs. a rig vehicle was proceeding to
rig camp on a sand track near security
fence gate. At the same time, operations
crew vehicle was approaching an
intersection on main track. While
operations vehicle was in the middle of
the intersection, the rig vehicle
approached and collided with the
operations crew vehicle. All crew
members and drivers escaped unhurt
and vehicles sustained minor damage.
Why it happened:
 The sand track was in a low lying area with dunes, blocking clear view of
approaching traffic at the intersection.
 The road warning sign was disoriented, due to winds.
 The rig vehicle was not fitted with desert flag. Both vehicles were driven at a speed
of approximately 60 km/hr.
Lessons Learned:
1. Always be on guard against unexpected hazards while driving in desert terrain.
2. Drivers shall get acquainted to the conditions before undertaking such journeys.
3. Regular inspection of road warning signs will ensure proper guidance to drivers.
4. Use of desert flags fitted to vehicles in sand tracks will indicate their presence from
a distance especially in low lying areas.

Learning From Incidents

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Learning From Incidents

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Incident Prevention Through

Learning from Incidents

January - December, 2013

HSE & Risk Management

Husam Eddin Al Khaldi, MSc, PE, CSP, CRSP

Abdulla Hussain Mohammad Al Marzooqi

Closed Drain Header Gas Leak 7

 Inadequate Audit/ Inspection

During the operation of pulling out of hole

shut the well immediately. Well was killed

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

 Violation by Individual (The first 5 stands

 Inadequate Work Planning or Risk

Immediate Causes 1. The reservoir pressure should be continuously

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

 Lack of Procedure (There was no formal

1. Ensure availability of Standard Operating

 Improper Decision Making/Lack of 3. Review & update schedule & scope of

The calibration of Multiphase Flow Meters  Inadequate Work Planning or Risk

21-05-13 Immediate Causes

1. Ensure all vendors are aware of ADCO

 Lack of Knowledge of Hazards Present

 Inadequate Work Planning or Risk

(Shah) Immediate Causes

The flow line (6” carbon steel Sch 40) was

Immediate Causes 1. Inject corrosion inhibitor from well heads

Immediate Causes 1. Implement draining procedures to ensure

08-06-13 Immediate Causes 1. Clearly identify underground facilities

Bu-632 flow line was commissioned in late 2003 and

1. Provide Coating upto 25 m each side

Asab Lessons Learned

 Defective Equipment (Choke valve had

 Inadequate Assessment of Needs &

 Temperature Extreme (Two Instrument

Immediate Causes 1. Develop a mechanism to ensure skills &

A 3.3 km long flow line from well no Sb-392 was

 Work place Layout (Layout of pipeline in desert

Inadequate Preventative Maintenance

1. Do not isolate process equipment

 Inadequate Planning or Risk

 Lack of Procedures (There was no

During commissioning of the high pressure (HP)

 Improperly Prepared Equipment (Ferrule

Shah Main Oil Line (MOL) was in use since

Area Incident Description Root Causes

The Wireline crew was retrieving a phoenix

22-12-13 Immediate Causes

 A procedure clearly defining the process to

During pulling out of 6” horizontal hole, a

 Routine Activity Without Thought

A wire line crew was mobilized to retrieve valves. The

07-01-2013 Immediate Causes

1. Ensure all lifting devices are duly tested

 Use of Defective Equipment (The used wire 2.

Dismantling of old Flow line was ongoing and  Inadequate Identification of

1. Water injection flow lines must be cleaned prior

 Inattention to Footing & Surroundings

Running Completion Tubing using pick up & lay

06-04-13 Immediate Causes