Manual Title: Safety and Environmental System Manual

Form Name: Investigation Follow-Up Report

Form No.: PRIDE-02-01-109-F002

Issue Date Revision No. Revision Date Prepared By Approved By Level No.
01-Apr-02 1 14-Aug-02 QA/HSE CD/JA 2

SECTION A – ACCIDENT/INCIDENT OR RIG DETAILS PCB-2010-001

Fatality LTA Pollution Event Recordable Injury First Aid Major Near-miss Illness
rd
Rig Contractor/3 Party Facility (rig, boat etc)
Rig Name: Rig Name:
rd
Well Location: Towing 3 Party Co:
Facility PIC: Facility PIC Name:
rd
Operator: 3 Party Co Supervisor’s Name:

Pride Supervisor Name: (If not PIC) Pride Supervisor’s Name: (if not PIC)
Title: Ch. Electricien
Operators’ Supervisor’s Name:

SECTION B – DETAILS OF ACCIDENT/INCIDENT

Location on the Rig: Emergency Generator Date and Time of Incident: 14-Feb-2010 at 17.40
Job being Undertaken: Visual check of Emergency Generator room Date and Time Reported: 14-Feb-2010 at 17.40
during Tow

Activity at time of Incident: Tow from Location to Pointe Noire for Permit to Work No.
Technical STOP
Description of Incident: The IP was going into the Emergency Generator room to check
that everything was ok since there was occasional water on the
deck. When he opened the door the rig pitched approx 3.5 deg
causing the water tight door to close on his right ring finger right
behind the finger nail.

SECTION C – INJURY/ILLNESS INFORMATION

Report No. (Code/No./Year): PCB-2010-001
Last Name- First Name: Male Female
Occupation: Rig Electrican
Employer: Pride

Address:
Phone:
Status of Injured/Ill Person: Pride Pride Contractor Operator Operator Subcontractor Visitor
Experience in Occupation: 10 years Experience in Present Position:
Time into Tour: Hour: 11.30 Days: 11

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 Manual Title: Safety and Environmental System Manual

Form Name: Investigation Follow-Up Report

Form No.: PRIDE-02-01-109-F002

Issue Date Revision No. Revision Date Prepared By Approved By Level No.
01-Apr-02 1 14-Aug-02 QA/HSE CD/JA 2

Nature of Illness/Injury and Treatment Given:

Visual check by the doctor diagnostic was
Right 4th finger after the distal phalange with deep cut around and with possibility of fracture? (X ray will confirm).
Disinfected and clean the wound with betadine and dressing.
Immobilization of the finger was done for transportation.
Given Medication:
-Tramadol 100mg (1 Tab).
-Ibuprofen 400mg (1 Tab).
Cefriaxone 500mg (1Tab)

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 Manual Title: Safety and Environmental System Manual

Form Name: Investigation Follow-Up Report

Form No.: PRIDE-02-01-109-F002

Issue Date Revision No. Revision Date Prepared By Approved By Level No.
01-Apr-02 1 14-Aug-02 QA/HSE CD/JA 2

SECTION D – FULL DESCRIPTION OF INCIDENT

Number (Code/No./Year): PCB-2010-001

 

(Description of Facts Known as a Result of This Investigation :)

The rig was under Tow and weather conditions as follow: - Pitch and Roll 3.5 degrees.
Swell 3 to 3.5 meters period 12 second. Towing speed 1.2 knots under Leg repair. (Leg
#3).
Around 17.30 the electrician went to check inside the Emergency Generator Room for
any water entry. He opened the door to enter and due to the pitch and roll motion,
(Approx 3.5 degrees), he lost his balance, and in order to recover it,
grabbed the door frame. Due to the motion of the rig, the door closed
suddenly by itself, crushing the right 4th finger after the distal phalange of
the IP. At the time of the accident the IP was wearing all PPE 's.

Completed By:

Name Position Signature Date

Gonzalez Jose HSE Coordinator 19-02-2010

 

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 Manual Title: Safety and Environmental System Manual

Form Name: Investigation Follow-Up Report

Form No.: PRIDE-02-01-109-F002

Issue Date Revision No. Revision Date Prepared By Approved By Level No.
01-Apr-02 1 14-Aug-02 QA/HSE CD/JA 2

SECTION E – SKETCH OR PICTURE OF THE INCIDENT

Number (Code/No./Year): PCB-2010-001

 

(Attach Actual Pictures or Draw Sketch of the Incident Scene Here. Do not Recreate the Scene for Photo Purposes)

Emergency Generator located in the starboard FWD of main deck

IP  open  the  door  of  the  Emergency  Generator  and  

went  inside.    
Due to pitch and roll motion, (Approx 3.5 degrees), he
lost his balance, and in order to recover it, grab the
door frame  

When IP saw the door closing by itself he tried to

remove his hand but not fast enough. His right finger
became stuck in between the little gap in between
Door and Door Frame.  

Completed By:

Name Position Signature Date

HSE Coordinator 15-02-2010

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 Manual Title: Safety and Environmental System Manual

Form Name: Investigation Follow-Up Report

Form No.: PRIDE-02-01-109-F002

Issue Date Revision No. Revision Date Prepared By Approved By Level No.
01-Apr-02 1 14-Aug-02 QA/HSE CD/JA 2

 
 

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 Manual Title: Safety and Environmental System Manual

Form Name: Investigation Follow-Up Report

Form No.: PRIDE-02-01-109-F002

Issue Date Revision No. Revision Date Prepared By Approved By Level No.
01-Apr-02 1 14-Aug-02 QA/HSE CD/JA 2

SECTION G – SUMMATION AND RECOMMENDATIONS  

Number (Code/No./Year): PCB-2010-001

 
Contributing Factors

- Failure to recognize the danger while opening watertight door during Tow.
- Did not recognize the danger on leaving water tight door open without closing it
behind him.
- Improper Hand Placement
- Failure to follow Procedure.
 
Basic Causes

- Inadequate evaluation of changes.

- Down-graded situation not properly assessed.

- Procedure not followed. (Never go out alone on deck during Tow) .

- Inadequate assessment of needs and changes.
- Welding repairs not done before the Tow.
 
Actions Recommended to Prevent Recurrence

- Working in pairs is compulsory while under Tow. .

- JSA to be updated accordingly.
- Step back 5X5 to be applied and reminded during safety meetings.
- Bottom part of the Emergency generator to be welded properly to avoid water ingress.
- All Watertight doors locks must be repaired.

 
Corrective Actions
SAIL No What is to be Done Responsibility Time for Completion

Complete check of all watertight

PCB_-
doors has to be done to check that
2010- Technical Coordinator 28/02/2010
00019 latches for keeping doors open are
working.
PCB_-
2010- JSA must be updated RSTA / Barge Master Immediate- Done
00026

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 Manual Title: Safety and Environmental System Manual

Form Name: Investigation Follow-Up Report

Form No.: PRIDE-02-01-109-F002

Issue Date Revision No. Revision Date Prepared By Approved By Level No.
01-Apr-02 1 14-Aug-02 QA/HSE CD/JA 2

 
OIM 20/02/2010
Signature/Facility PIC Position Date
Rig Manager 21-2-10
Signature/Operations/Rig Manager Position Date

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 Manual Title: Safety and Environmental System Manual

Form Name: Investigation Follow-Up Report

Form No.: PRIDE-02-01-109-F002

Issue Date Revision No. Revision Date Prepared By Approved By Level No.
01-Apr-02 1 14-Aug-02 QA/HSE CD/JA 2

SECTION H – CAUSAL ANALYSIS  

Number (Code/No./Year): PCB-2010-001

Indicate appropriate causal factor A14-A33-B12-C22  

A11 - Not In Conformity With Drawings/
Modified

A12 - Standard But Dangerous

A1 - Rig Equipment A13 - Insufficient

A14 - Poorly Maintained

A15 - Badly Installed

A - Equipment
A2 - Harmful Substances

A31 - Missing/Insufficient

A32 - Inappropriate
A3 - Safety Equipment
A33 - Out Of Service

A34 - Not Used

B11 - Inadequately Defined/To Be Revised

B1 - Procedures
B12 - OK But Not Applied

B21 - Safety Meeting/Prejob JSA Meeting

Not Carried Out
B2 - Information
B22 - Written Procedures/Posting Up
Insufficient
I
N B3 - Lack Of Supervision
B - Process
C
I
D B4 - Insufficient Preparation/
E Organization
N
T
B5 - Excessive Speed/
Cadence
C11 - Insufficient Theoretical Training

C1 - Training C12 - Insufficient Practical Experience

C13 - Insufficient Command Of Language

C - Personnel

C21 - Tiredness
C2 - Unfitness
C22 - Negligence

D1 - Adverse Geography/
Weather

D - Environment D2 - Insufficient Logistic

Support

E - Others D3 - Poor Communications

 

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 Manual Title: Safety and Environmental System Manual

Form Name: Investigation Follow-Up Report

Form No.: PRIDE-02-01-109-F002

Issue Date Revision No. Revision Date Prepared By Approved By Level No.
01-Apr-02 1 14-Aug-02 QA/HSE CD/JA 2

SECTION I – MANAGEMENT REVIEW  

Number (Code/No./Year): xxx-2010-001

 

Yes No

Was the investigation follow-up completed fully?

Is the information in the report fully detailed and accurate?

Are the contributing factors of the incident correctly identified?

Is further investigation necessary?

Have all proposed corrective actions been considered?

Corrective Action Recommendation Decision/C.A.R. Reference

Injured Person has covered the points required to prevent this type of incident from
happening again. Now it is up to the HOD’S to make sure the message is
presented to their people and followed through to ensure that all points
are followed.

Management Incident Review

Names (Print):

Date: 21-2-10

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