Sangachal Terminal Area

Lessons Learned Communication

ST HS&ER Team
 Incidents Summary
Overall 7 Lessons Learned:
• 2HiPo:
- Mechanical technician head injury during MOL Pump foam line test – TR (BIL), PT1 on 3rd
October
- Electrocution Near Miss (HiPo) - TR (BIL), PT 3 on 17th October
• 1 Process Safety Incident
- PSV passing - AGT Midstream, Sangachal Terminal – 12th October
• 1 Restricted Work Case
- Employee Shoulder Injury - AGT Midstream, Sangachal Terminal - 15th October
• 2 Vehicle Incidents:
- Vehicle-to-vehicle collision - AGT Midstream, Sangachal Terminal – 8th November
- Vehicle struck against the goal post - AGT Midstream, Sangachal Terminal - 6th November
• Winter Safe Driving Reminder
 ACCIDENT WITH INJURY
HIPO 02 October 2011
Incident Summary
During the test of the MOL pumps MOL 3 foam line was connected to a fire hose for testing and in addition to that 3” test line was tied to the
forklift forks and test water pool by using slings to keep the pipe fixed. Under these conditions, MOL 3 foam line test was carried out
successfully. Later, the crew started MOL 5 foam line test. But, this time they did not fixed the 3” test line end to the pool. When the fire
pump was run, which pressurizes water, loose test line end moved up suddenly and hit the head of the personnel.

Causes Summary
• The Forklift is not designed for that kind of activity.

• Not fixing the end of foam line (shortcutting)

• The personnel was standing in the line of fire

• Inadequate RA and PTW meeting, and not determining the risks of work with the
crew and not sharing the risks with them.

• No site controls and inspections were done in scope of PTW

• The changes of test process procedure and personnel changes were not controlled as
in Management of Change System (MoC).

Lessons Learned
 Use equipment only for purposes it was designed.
 Be aware of the risks inside of the barricaded areas and stay away from the line of fire.
 Follow the procedures. If any change is required, consider the criteria of MoC. Determine the risks of new situtation and additional
control measures with the attendance of the crew. Therefore, PTW, RA and toolbox meetings should be comprehensive and participatory.
 Site managements should limit the number of permits at a time for efficient control.
 The roles for operating PTW system should always be complete and competent.
IR-3961193.mht
 ELECTROCUTION ACCIDENT - PT3
HIPO 17 October 2011
Incident Summary
The pig cleaning machine was going to be used for cleaning oily
equipment. When the operator tried to open the valve his other hand
contacted the machine body and he suddenly received an electric shock.
During the initial investigation, it is understood that the related electrical
socket guide set screw was dismantled by itself that leading wrong
connection of electrical plug (ground line connected to phase line)
Causes Summary
Although manufactured with a safety pin to protect inaccurate plugging
the pin was not in the place.
Although there was an earthing cable in place, the person did not use it.
The system designed without RCD.
Hand over of the system was not completed. BIL did not take over the
system.
The plug was not checked prior to use.
No work planning or risk assessment performed.
IR-3973929.mht

Lessons Learnt
 The work being done was not taken seriously and this caused lack of attention and the incident as result.
 Personnel should not use any equipment unless he/she is trained for it.
 Personnel should not use any equipment that is not comissioned and handed over to operations.
 Prior to start, energized systems should always be inspected visually, even if they are maintained and inspected
periodically.
 New systems/equipments should be inspected and approved by the relevant disciplines. Permit should not be
issued if such approval is not in place.
 Employee Shoulder Injury at ST on 15th October

Incident Summary
• While person was descending by the platform ladder to the lower platform, he couldn't keep the
balance and skip last 2 steps and landed his left feet on grating. When his feet touch the platform
grating, due to body disbalance it moved the body towards ladder and hit his left shoulder to the ladder
end edge. Person was sent to ST doctor for examination and has got first aid with following dispatch to
the X-ray.
Causes of Summary
• Inattention to surroundings - Last 2 steps of the ladder were skipped and person immediately lost the
balance and hit his shoulder to the ladder edge.
• The person was thinking that he has reach the end of the ladder and immediately stepped of onto a
grating.

IR-3970880.mht

Lessons Learned
 Proper vertical ladder climbing techniques (3-point contact at all times, using stiles as a handhold) to be
exercised at all times.
 Regardless of how routine an activity may seem the working environment and equipment has to be
watched for potential risks.
 Process Safety related Near Miss at ST on 12 October
Incident Summary
• While operator was on site at H2S scavenger he noted noise in close vicinity. He realized that such kind of noise is not acceptable for normal operations. Then he went towards noise direction and reached PSV on H2S Scavenger Injection Filter. The
discharge of the PSV routed to the atmospheric vent of the level pot which is normally designed for H2S chemical. He suspected that PSV is passing and to confirmed it by squeezing discharge valve of the PSV.

Causes of Summary
• Damage believed to occur due to PSV chatting, which was happening as a result of unclear procedural requirement and operating control of required chemical flow rate
• Subject PSV was not included into PM
• Relevant OPS Procedure does not address the steps to follow control of chemical flow rate.
• Estimated passing rate of the check-valve HV-421323 exceeded acceptable passing rate / operational envelope based on BP ETP-43-35
• As per Safety Related Devise requirements mentioned check valves are not subject to inspections and were failed to identify passing rate

IR-3969922.mht

Lessons Learned
 All Operating Procedures for chemical injection should address valve positions while injection pumps are offline.
 All PSVs MUST be included into the PM list (recertification/inspection) Ensure that Gas Detection system is suitable for
gas detection on vent points.
 Frequent communication on Lessons Learned in reminding to operators always conduct thorough inspections on site, as in
some cases they may become only one and last layer in barrier model to prevent an incident.
 NRV backflow always must be considered during HAZOPS and plant operation parameters/conditions changing.
Swiss Cheese Model
 Vehicle struck against the goal post at ST
06 November 2011
Incident Summary
• During turning on the left the driver hit the left side of vehicle on the post of Height Restriction Barrier.
As result both left doors of vehicle were damaged.
Causes of Summary
• Inattention to surroundings.
• Driver did not chose appropriate speed and driving pattern for rainy and poor visibility driving
conditions.
• Driver did not apply skills gained during training .

Lessons Learned
 During rainy and poor visibility driving conditions, the driving must be conducted only in the event
absolute necessity, and appropriate speed and driving pattern shall be followed.
 At no time driver shall take risk to drive with misting windows. IR-3985149.mht
 Two vehicles collision at ST
08 November 2011

Incident Summary
• During reversing maneuver vehicle struck with another pick-up truck stopped behind. As result rear
bumper and left back wing of reversing vehicle as well as left fog light and front bumper of second
vehicle were slightly damaged.
Causes of Summary
• Inattention to surroundings. Before reversing driver did not notice vehicle behind
• Driver did not implement knowledge gained during training/assessment

Lessons Learned
 Unexpected condition change shall always be considered while driving, especially during reversing
maneuver.
 At no time driver shall take risk to drive with misting windows. IR-3987158.mht
 Winter Safe Driving Reminder

Lessons Learned
 Eliminate driving on icy road.
 Prepare your car for driving in adverse weather (Clear windows, warm up vehicle etc.)
 Pay attention to vehicles and objects around you.
 Do not press on brake sharply.
 Keep the distance at all time.
ST Lessons Learned