GUPCO Kamose Fatality Incident

1. GUPCO Kamose Fatality Incident Toolbox Talk Lessons pack

2. Background Mohi Mohammed Gouda was a Barge Engineer on the EDC rig �Kamose� working for BP�s GUPCO joint venture operation offshore Egypt. On 18th June 2001 he was involved in an incident during a lifting operation he was supervising. He fell 4m and sustained serious head injuries. Several weeks later he died of these injuries having never recovered.

3. Learn from a fatal error This accident would not have happened if existing procedures and good practice had been used What will You Learn from Mohi�s death ? Could you and your workmates be at risk of a similar incident ? Highlight the fact that this incident need never have happened. Point out that it is vital that we learn the lessons from this incident and ensure that we don�t allow its causes to be replicated at this (our) site. Highlight the fact that this incident need never have happened. Point out that it is vital that we learn the lessons from this incident and ensure that we don�t allow its causes to be replicated at this (our) site.

4. The Job Your Task Replace the crane engine Your Procedure The job has been done before using the spare crane and another available rig crane You�ve identified a better way But you�ve never done it this way before Background information The crane engine had been identified as needing changed 6 weeks before the incident, Changeout of the engine had been successfully (and safely) completed previously. On these occasions two cranes had been used together to carry out the lift Originally this had been the plan and time had been made available to do this. The team who were going to conduct the task had identified an alternative method. Although this had never been tried, they believed it would be more efficient.Background information The crane engine had been identified as needing changed 6 weeks before the incident, Changeout of the engine had been successfully (and safely) completed previously. On these occasions two cranes had been used together to carry out the lift Originally this had been the plan and time had been made available to do this. The team who were going to conduct the task had identified an alternative method. Although this had never been tried, they believed it would be more efficient.

5. Your Plan Your Equipment The other crane Rigging equipment An air winch from another location on the rig welded to the generator room roof Your Team You (supervisor) Crane driver Asst crane driver 2 x Roustabouts Background information The proposed method used an air hoist to perform the main lift with the second crane �tailing� the load to control lateral movement. The air hoist was moved to this location from another position on the rig. It had previously been bolted in position. It was welded using 4 welds to beams in the emergency generator house roof. An air supply was rigged up from the generator house below Key Points for the question �What else do you need to do� Risk assessment is the key. This is an untried method Fixing of the winch is critical. Try to get the group to identify this and say what they would do about this Work control measures are critical. Review with the group what controls they would employ. Look for : Permits JSA or TRA Competency of personnel Design/Execution/Inspection of fixing welds Pre job talkBackground information The proposed method used an air hoist to perform the main lift with the second crane �tailing� the load to control lateral movement. The air hoist was moved to this location from another position on the rig. It had previously been bolted in position. It was welded using 4 welds to beams in the emergency generator house roof. An air supply was rigged up from the generator house below Key Points for the question �What else do you need to do� Risk assessment is the key. This is an untried method Fixing of the winch is critical. Try to get the group to identify this and say what they would do about this Work control measures are critical. Review with the group what controls they would employ. Look for : Permits JSA or TRA Competency of personnel Design/Execution/Inspection of fixing welds Pre job talk

6. How it was done A permit is not being used A JSA has not been carried out The welds fixing the winch to the deck have not been tested The old engine has been successfully removed using the method. Point out that the removal of the old engine was completed successfully using the method. Ask the group if they are comfortable with the way the job is being conducted. Ask them if they would consider this to be a �routine� task which doesn�t need permits JSA�s etc. Ask the group if there is anything they would change before proceeding with the next stage (I.e. lifting the new engine into place) Point out that the removal of the old engine was completed successfully using the method. Ask the group if they are comfortable with the way the job is being conducted. Ask them if they would consider this to be a �routine� task which doesn�t need permits JSA�s etc. Ask the group if there is anything they would change before proceeding with the next stage (I.e. lifting the new engine into place)

7. The Incident What happened The weld between the winch and the roof failed The winch was dragged over the handrail Mohi (the supervisor) was first trapped between the air line and the handrail He was then forced over the handrail and fell 4m to the deck below sustaining serious head injuries Background information The weld proved to be completely inadequate. It hadn�t been designed for the load. Hadn�t been carried out by a certified welded and hadn�t been tested before use. If it had been properly designed and installed the method would have been safe and a successBackground information The weld proved to be completely inadequate. It hadn�t been designed for the load. Hadn�t been carried out by a certified welded and hadn�t been tested before use. If it had been properly designed and installed the method would have been safe and a success

8. The Key CausesWhat Do You Think ? Now that you know what happened: What do you think were the key causes ? What should have been done here ? Key discussion points around causes Try to steer the discussion towards The management of change. A different method was being used but no consideration had been given to the potential risks Why normal (established) work controls were not being used The method of attachment of the winch. This had not been engineered to handle the loads or tested. Key discussion points around what should have been done Try to guide group discussion towards: Work control processes (permits/JSA�s etc) Control/design/testing of load bearing welds. Change control: What do we need to do if we are changing a procedure Key discussion points around causes Try to steer the discussion towards The management of change. A different method was being used but no consideration had been given to the potential risks Why normal (established) work controls were not being used The method of attachment of the winch. This had not been engineered to handle the loads or tested. Key discussion points around what should have been done Try to guide group discussion towards: Work control processes (permits/JSA�s etc) Control/design/testing of load bearing welds. Change control: What do we need to do if we are changing a procedure

9. The Key CausesThe Investigation Findings Three Critical factors identified: The weld was inadequate. It was neither designed for the job, carried out by a certified welder or properly tested. No permit to work , risk assessment or Safe Job Analysis (JSA) was completed. The previous procedure, known to be sound, was not followed Self explanatory. Group discussion over the last slide should have identified all these points. Use this slide to re affirm these key points or identify them to the group if the discussion session failed to identify them.Self explanatory. Group discussion over the last slide should have identified all these points. Use this slide to re affirm these key points or identify them to the group if the discussion session failed to identify them.

10. Could something like this happen on your rig ? Think about it. Do you always: Use established and proven procedures ? Carry out a thorough risk assessment before using a new procedure ? Carry our work like this under the control of a Permit To Work System ? Conduct JSA�s and pre job safety meetings ? Ensure that load bearing welds are properly designed, inspected and tested ? Get the group to consider and discuss activities on your site. In particular pose the questions: Have we recently changed any procedures without going back to basics and considering the risks ? Have we installed any load bearing welds without giving full consideration to their engineering and testing for the load they will carry ? If so where are they and do we need to take corrective action ? How well do we use the permit to work system/JSA/pre job meeting tools. What could we do to improve the way we use them and improve safety ? Get the group to consider and discuss activities on your site. In particular pose the questions: Have we recently changed any procedures without going back to basics and considering the risks ? Have we installed any load bearing welds without giving full consideration to their engineering and testing for the load they will carry ? If so where are they and do we need to take corrective action ? How well do we use the permit to work system/JSA/pre job meeting tools. What could we do to improve the way we use them and improve safety ?