High Potential Incident

1. High Potential Incident Date Presented: Thursday 15th April 2010Forum : OGP/IAGC joint global forum – Rio

2. When What Where • 29th January 2010 • Offshore French Guiana • A crewmember’s left leg became entangled in a loop of rope • A Norwegian buoy was on the outboard end of the rope, which tightened around his leg and pulled him against the deck railing

3. Incidence Description • Recovering a rope from the sea manually due to a winch failure. • A wave caught the Norwegian buoy on the end, and dragged the rope out for the hands. • During the sudden drag, a loop of rope wrapped around the persons ankle pulling him against the deck railing .

4. Incidence Description

5. Immediate Actions • Another crew member was able grab the rope while a third crew member cut the rope. • Left leg treated by medic and crewmember returned to limited duties.

6. Findings • Inadequate management of change risk assessment prior to task (winch out of operation) • Change in the process of recovering the gun separation rope. • Poor situational awareness of coils of rope (never stand in a loop of rope) • Late in shift approximately 2 hours to shift change (fatigue)

7. Lessons Learnt • • Dynamic risk assessments (take 5) should be part of standard thought process in back deck operations • Management of Change risk assessment should have been completed since there was a significant change in the process of recovering the equipment. In this case, manually pulling in a rope with a Norwegian buoy on the end trailing in the sea rather than using a winch is a significant change in process brought on by equipment failure/malfunction.