Pinch Bar Incident at Loading Arm - Tool Control Failure

1. DROPS Forum12th April 2011Ron MartinCorporate HSE Advisor 1 1

2. What Happened? At approximately 0045 on the morning of 28th September 2010, a vessel was being prepared for loading at the plant jetty. As the operations team were in the process of extending out loading arm 2 a 12” pinch bar fell and landed on the deck of the vessel causing no injury or damage. The most likely point of origin was assessed as being from the area of the Apex joint approximately 10m above the deck. No personnel were in the immediate vicinity at the time that the object fell but were present on the deck area and they had been within 3ft of the drop prior to the incident. The pinch bar is approximately 12” in length and weighs 750g. In the days prior to the incident, maintenance work had been carried out on the Apex joint of the arm to replace a faulty seal.

3. What Happened? Apex joint on loading arm 2 Arm shown in raised position

4. Background Info: • In the days prior to the incident, maintenance work had been carried out on the Apex joint of the arm to replace a faulty seal. • To enable access, scaffolding had been erected by a sub-contractor to the level of the joint. The scaffold construction and dismantling was carried out without incident as was the maintenance task and all tools were accounted for by visual sweep at the end of the work. • None of the scaffold team or maintenance crew was able to recall either using or leaving the pinch bar on the loading arm. • At the end of the task accounting for the tools and equipment relied on a sweep of the area rather than a positive tool check • The colour of the pinch bar would have meant that it would not have been easily visible against the colour of the loading arm.

5. Investigation Findings: • The investigation team were not able to positively determine the source of the tool. None of the personnel involved could remember using the tool, nor had cause to use it in the course of this task although the scaffold team said that it would be something they would use on a job with longer plywood runs. However, all of their crowbars and pinch bars were accounted for. • The maintenance crew tools were pre-positioned at the top lift by others as the maintenance crew were not trained in use of the gin wheel hoist. • In order to cater for any unforeseen tooling requirements a large variety of tools were placed in a large crane bag and taken to the worksite, although only a few tools were actually required to carry out the seal change. • The current method for tool accountability is carried out by carrying out a visual sweep of the work area to ensure that nothing is left behind rather than a positive check to ensure that all tools that went up to the work face have been accounted for.

6. Investigation Findings: • The tools in use are of a colour that does not make them easily visible and so makes it easy for them to blend into the background of the work area. This makes detection difficult and diminishes the effectiveness of a visual sweep. • The lack of tool identification prevented identification of the source and opens the possibility that the tool may have been left from previous maintenance although the lack of corrosion on the pinch bar could exclude this as a source but does not rule it out as a credible scenario. • Neither the permit issued for the scaffold work nor that issued for the maintenance work provided clear detail for tool control and accountability (counted out and in) nor reference to relevant procedures. • There is no identification on tooling (colour coding or etching) to aid traceability and tool kits are generally uncontrolled and available for anyone to access.

7. Why Did it Happen? Latent Failure Active Failure Pinch bar not Accounted For at cease work Incident Pinch bar was left on the loading arm Pinch bar was not visible Pinch bar fell from loading arm Positive Tool control not active Pinch bar was taken to the worksite but was not required For the job Pinch bar was not required

8. Corrective Actions

9. Reflections • DROPS is regarded by supervision and managers on site as an offshore “Drillers” initiative • DROPS posters have reference to “Drillers” and are not generic • Human factors and Human Reliability assessments need to feature in site risk assessments