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PDO FATAL INCIDENT REVIEW 13th NOVEMBER 2000 AGENDA

PDO FATAL INCIDENT REVIEW 13th NOVEMBER 2000 AGENDA. Introduction Fatality Review Road Traffic Incident 3rd August, resulting in double fatality Road Traffic Incident 23rd August, resulting in single fatality Progress against previous FAR 4th September HSE-MS audit October

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PDO FATAL INCIDENT REVIEW 13th NOVEMBER 2000 AGENDA

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  1. PDO FATAL INCIDENT REVIEW 13th NOVEMBER 2000AGENDA • Introduction • Fatality Review • Road Traffic Incident 3rd August, resulting in double fatality • Road Traffic Incident 23rd August, resulting in single fatality • Progress against previous FAR 4th September • HSE-MS audit October • Focus of Corporate 2001/2 HSE Plan

  2. PDO FATALITIES IN 2000 Date Fatalities Inc. PDO Department Contractor Type 23- Aug 1 Road Marmul Asset Marmul Contracting 03-Aug 2 Road Gas Al-Kharousy Est. (Dodsal) 22-Jul 1 Road Well EngineeringDamac (Sea&Land) 21-Jun 1 Indus. Electrical Infrastructure Al Hassan (BHEL) 10-Jun 1 Road Exploration Veritas Geophysical 08-Jun 1 Indus. Bahja/Rima Asset Al Hassan 05-Jun 1 Road Well Services PDO 27-May 1 Road Tech. Services Tuboscope Vetco

  3. 1 YR LTIF/TRCF ROLLING AVERAGE, 1993-2000

  4. PDO & Contractors LTI Free Milestones, 2000

  5. Target Zero in PDO LTIF versus Fatality frequency over the years 92 93 94 Oct-00 98 LTI frequency (LTI/million hrs) 97 95 96 00-Target 99 Zero Fatality frequency (Fatalities per million hrs)

  6. Double Fatality Road Traffic Accident Collision with a Third Party Vehicle Incident Details • Date : Thursday, 03rd August, 2000 • Time : Approximately 08.00 hrs • Location : 18 km South of Adam, on Muscat - Salalah Highway • Incident Type : Road Transport • Severity : 5P multiple fatality • Potential : D5(P) multiple fatality • Contractor : Dodsal & Company C580046 (sub-contracted to Ahmed Al-Kharousi Enterprises) • Deceased : Hafedh Mohammed Adam Al-Baluchi. (Omani driver, 26 years old, Ahmed Al-Kharousi Ent) Ahmed Khalfan Ahmed Al-Shueiby, (third party) (Omani, Royal Guard)

  7. Double Fatality Road Traffic Accident - 3 Aug. 2000 Collision with a Third Party Vehicle 4 Ton Mitsubishi Truck

  8. Double Fatality Road Traffic Accident - 3 Aug. 2000Collision with a Third Party Vehicle third party Toyota Land Cruiser

  9. Double Fatality Road Traffic Accident - 3 Aug. 2000Collision with a Third Party Vehicle Findings • Primary cause: lack of due care and attention by the third party driver • Third party driver failed to judge the close proximity of the approaching Mitsubishi truck • High speed and fatigue of third party driver are possible contributory causes • Mitsubishi driver was in good physical and mental condition before commencing the journey • Journey Management Plan was in place, minor deficiencies were identified • PDO site management during leave coverage needs enhancement • Failure to use the emergency telephone number by site team

  10. Double Fatality Road Traffic Accident - 3 Aug. 2000Collision with a Third Party Vehicle Corrective Actions • Review the communication efficiency in case of accidents see later discussion • Carry out an RTA Emergency Exercise assuring proper use of Emergency Alarm number (38)5555 and mobilisation of LEBC completed • Discuss the incident with all relevant subcontractors and suppliers completed • Audit all relevant subcontractors and suppliers on road transport safety management completed • Update Journey Management procedures to ensure that subcontractor Journey Managers are contactable completed • Sign off and file all completed Journey Management Plans completed • Transport gas cylinders in purpose-built cages and separate from other loads completed • Align PDO driving permit classification with that of ROP being implemented

  11. Road Traffic Fatality 23rd August 2000 Roll-over Incident Details • Date : Wednesday, 23rd August, 2000 • Time : Approximately 08.00 hrs • Location : 40km East of Shelim, on government graded road • Incident Type : Road Transport • Severity : 4P single fatality • Potential : D5(P) multiple fatality • Contractor : Marmul Contracting and Trading Co. C2K-5019 • Deceased : Malik Mohammed Suleiman (Omani civil supervisor, 50 years old)

  12. Road Traffic Fatality 23rd August 2000 Roll-over 3 Ton Toyota Canter Truck

  13. Road Traffic Fatality 23rd August 2000 Roll-over Findings • Primary cause: Lack of vehicle control by driver • Driver had a heart condition and was medically unfit • Lack of HSE commitment by Local Community Contractor management • None wearing seat belts • No Journey Management applied • Roadworthiness of vehicle not assured • Vehicle load not properly secured • Lack of PDO contract management • Absence of detailed guidelines on how to deal with unqualified Local Community Contractors, combined with pressure to award them work • No detailed risk assessment conducted • Less than adequate resources to supervise and coach LCC staff • No communication possibilities at work and incident locations

  14. Road Traffic Fatality 23rd August 2000 Roll-over Corrective Actions 1. Contract specific • Immediately suspend work of MCTC contractor until minimum HSE requirements are met completed • Apply significantly more PDO supervision to MCTC work, commensurate with risk when work recommences 2. Generic Local Community Contractors (LCC’s) • Confirm minimum HSE compliance with all LCC’s Initial sample assessment done, rest target end 2000 • Coach all Contract Holders, CSR’s and LCC’s to understand and apply HSE HEMP March 2001 • Implement authority system for contract management, similar to engineering technical authority system August 2001

  15. LCC’s Initial sample risk assessment

  16. NON-ACCIDENTAL DEATH CASESINVESTIGATIONS COMPLETE SINCE 4th SEPT 2000 • 05 22.05.00 58 years old AL HASSAN Employee (driver) developed cardiological complications. He died after admission due to myocardial infarction. Investigation and reporting completed. Not work related. • 06 08.08.00 52 years old DODSAL Employee collapsed in his room while preparing for his breakfast and later died at Qarn Alam Clinic due to cardio-vascular arrest. Investigation and reporting completed. Not work related. • 07 30.08.00 35 years old PDO Employee (IT specialist) admitted at the Khoula Hospital with a prolapsed disc died due to cardiological complications. Medical case, history known with PDO doctors. Natural death. Not work related. • 08 18.09.00 43 years old PDO Employee (mechanical technical assistant), with known ischaemic heart disease admitted at the ICU of Royal Hospital, died due to cardiological complications. Medical case, history known with PDO doctors. Natural death. Not work related.

  17. Road Traffic Fatality Pedestrian hit by vehicle Incident Details Date : Saturday 27 May, 2000 Time : Approximately 15.15hrs Location : 106km north of Bahja (midway between Bahja and Qarn Alam) Incident Type : Road transport Severity : Third party fatality (C4P) Contractor : Tuboscope Vetco (Deutschland) GmbH (TVD) Contract : C682038 - MFL Inspection of Flowlines Deceased : Tariq Mahmoud Mohammed Saddiq, 39 years old (Pakistani) • Findings • Primary cause of the incident was the pedestrian’s apparent lack of attention to traffic on the road • Deceased arrived in Oman from Pakistan 3 weeks before the incident and was probably disoriented with the direction of traffic flow in Oman • Deceased and companion appear to have been solely focussed on hitching a ride back to Haima • Driver was in good physical and mental condition before commencing the journey • Some flaws revealed in the administration of contractor Journey Management Plan but these had no direct influence on the incident

  18. Road Traffic Fatality 27th May Pedestrian hit by vehicle Corrective Actions • Speed limiter option(on/off) removed from all contractor vehicles • Contractor to tighten up on Journey Management procedures • Compulsory toolbox briefings by Journey Manager for all drivers prior to commencement of any journey • Warning letter issued to driver and Journey Manager all actions completed

  19. Road Traffic Fatality Collision pick-up & trailer-truck Incident Details Date : Monday 5 June, 2000 Time : Approximately 15.45 hrs Location : Between Qarn Alam and Saih Rawl (About 26 km from Qarn Alam Camp) Incident Type : Road traffic accident Severity : 4P Single Fatality Potential : C5P Multiple Fatality Dept involved : Well Services Contractor : Offsat - Contract No. C688007 (Al Mutahidha Transport subcontractor to Offsat) Deceased : Khalfan Mubarak Al Omairy (46 years, PDO Omani staff) • Findings • Pick-up driver and passenger were listening to a radio phone-in debate. Their vehicle wandered into oncoming traffic lane • Progress of the journey indicates pick-up average speed 80km/hour • All three occupants in pick-up were wearing seat belts • Passengers failed to alert driver (“buddy” system). One asleep the other distracted driver with discussion on the radio debate • Trailer-truck driver had Journey Management plan. Well Services crew called Fahud on leaving Barik-6 well site • Truck driver used flashing headlights to alert pick-up, not effective in broad daylight. Horn would have been more appropriate.

  20. Road Traffic Fatality 5th June Collision pick-up & trailer-truck • Corrective Actions • Introduce competency assessment tests where date of birth is amended • completed • Emphasize effectiveness of using vehicle’s horn • completed • Increase efforts to reduce kilometres driven • 21% achieved overall since 1998 • 12% on Journey Management rate (km/manhrs) • Follow Journey Management procedure in Well Services • completed • Improve toolbox communication methods to combat language differences • ongoing, see Corporate HSE plan 2001/2

  21. Road Traffic Fatality 10th June Roll-over Fuel Tanker of Seismic Contractor Incident Details Date : Saturday 10 June, 2000 Time : 13:37 hrs. (from In-Vehicle Monitoring System) Location : Blacktop road between Salalah and Thumrait, 15km N of Salalah Severity : 4P Single Fatality Potential : D4P Single Fatality Contractor : Veritas Geophysical (Contract Number C889004) Deceased : Kasab Amur Sulaiyam Al Junaibi, Omani Driver (39 years old) Findings • Driving too fast for the road conditions • Attitude: failure to follow rules and procedures • Insufficient hazard identification • Heavy Good Vehicle (HGV) course lacks practical assessment • Low gear road sign missing • Safety belt mounting design fault • Performance of in-vehicle monitoring system erroneous

  22. Road Traffic Fatality 10th June Roll-over Fuel Tanker of Seismic Contractor Corrective Actions • Include risk assessment of supply routes in scouting trips • Completed. In addition Veritas developed Hazardous Route Matrix spreadsheet to quantify risk levels, used for most recent seismic survey • Define standards for In Vehicle Monitoring Systems (IVMS) • Completed for Seismic Operations. Pilot ongoing corporately. • Revise HGV course • In progress as part of Defensive Driving training modifications • Introduce driving disciplinary standards within PDO operations • Completed through MD note on Road Safety Behaviour • Recommend placement “engage low gear” sign to ROP • ROP asked to install. No action yet. Being pursued. • Review seat belt mounting and HGV rollbars with manufacturer Hino • In progress, no satisfactory answer from Hino yet. • Agree consistent standards for tankers across Shell group (centre of gravity) • Discussions ongoing with Shell Marketing ME

  23. Fatal Incident Grader operator killed by his grader driving over him Incident Details Date : 21st June, 2000 Time : 18:00 hrs Location : Outside perimeter fence of Hubara Power Station (under construction) Severity : 4P Single Fatality Pot. Severity : 4P(C) & 4A(C) Contractor : Al Hassan (subcontractor to BHEL) Deceased Name : Mohammed Saleem (40 years old, Pakistani grader operator) Operation : Grading • Findings • Position of body indicated deliberate fall, suggesting suicide. Supported by letter and other evidence • Operator is able to exit the grader whilst the vehicle is in motion. (No ‘dead man’s handle’) • Point of entry/exit from grader is very exposed. • Long time in desert camp with long working hours and limited rest periods • Evidence of family problems and disturbed mind

  24. Fatal Incident 21st June 2000 Grader operator killed by his grader driving over him Corrective Actions • Revise Company specification for earth moving and construction equipment completed consequences for existing contracts being assessed • Review requirement for contractor staff to have a counsellor available informal counselling available in contractor communities no dedicated counselling wanted

  25. Road Traffic Fatality 22nd July 2000 Roll-over Incident Details Date : 22st July, 2000 Time : 17:00 hrs Location : 57 km South of Adam on the Muscat - Salalah Highway Severity : 4P Single Fatality Potential : D5P Multiple Fatality Contractor : Sea and Land (Draieh Catering Services (DAMAC)) Deceased Name : Aslam Darvi (age 39, Indian) Operation : Rig Boy • Findings • Recruitment of an inexperienced driver • Inadequate Journey Management • Complacency with regard to managing road safety • Inadequate Safety Management Systems (DAMAC) • Inadequate sub-contractor management (S&LDC) • Inadequate PDO monitoring of sub-contractor

  26. Subcontractor compliance with PDO road safety specifications Working group of key DOIRC members established A mentor Lead Contractor assigned for each Subcontractor in Well Engineering Flash compliance audits, particularly on Journey Management, start Q1 2001 Five year experience requirement for all drivers Being implemented, target end 2000 Additional driver assessments for those below the age of 25 Being implemented, target Q1 2001 Improved information cascade to subcontractors via the PDO external web site Being implemented, target Nov. 2000 Road Traffic Fatality 22nd July 2000 Roll-over Corrective Actions

  27. Fatal Industrial Incident 8th June Vacuum truck Incident Details Date : 8 June, 2000 Time : Approximately 09.30 hrs Location : Rima Environmental Complex Incident Type : Industrial Severity : 4P Single Fatality Potential : C5P Multiple Fatality Dept involved : Bahja/Rima Asset OBM Contractor : Al Hassan Deceased : Leth Bahadur (age 36,Nepali) Operation : Vacuum truck operator • Findings • Design of door retaining assembly of ELCO vacuum tanker substandard • Poor functioning of safety relieve valves • No indications of explosion • Inexperience of driver and helper

  28. Fatal Industrial Incident 8th June Vacuum truck • Progress on Corrective Actions (1) • ELCO tankers taken out of service • completed • technical audit on ELCO carried out • ELCO suspended • Inspection of all inventorised tankers • completed • Non-approved tankers are no longer allowed in PDO operations CH’s and CSR’s informed several times • Government informed of risks • Inspect routinely suction tanker door bolts/housing • completed initial inspections • process for continued assurance being developed

  29. Fatal Industrial Incident 8th June Vacuum truck • Progress on Corrective Actions (2) • Implement detailed safety valve testing procedure • completed, annual inspection now part of certification process • List of further equipment requiring certification being prepared • Inspect suction tankers for potential blockages • revision of transport manual ongoing to cover need for routine de-sludging of tankers • Revise procedures for use of vacuum tankers • revision of transport manual ongoing • - Specification being written by Technical Specialists • - Implementation initially by Corporate HSE • the wider issue of managing equipment on trucks to be addressed • inventory of Equipment and Process Owners being made by Corporate HSE

  30. Vehicle Mounted Work Equipment

  31. Fatal Accident Review, 4th Sept 2000Progress on Action Points (1) • Fatal Accident Investigation to be led by Asset Manager at least • Tripod B: train 3-4 personnel to facilitate; train Asset Managers to use • Develop plan to ensure full compliance with Oman Labour Law • Road safety • Model analysis to identify common root causes of traffic incidents • Develop roadmap for In Vehicle Monitoring System (IVMS) • Expedite development of defensive driving training • Review effectiveness of Journey Management • SIEP HSE-MS audit to focus on Integrity-MS, ref. Vacuum trucks • STOP info to MGDPW

  32. Fatal Accident Review, 4th Sept 2000Progress on Action Points (2) • Tripod B: train 3-4 personnel to facilitate; train Asset Managers to use • Tripod was used in latest fatal incident review • Tested, but no quality in-country support available • Additional Corporate HSE position established, also to facilitate High Potential incident reviews, sourcing candidate • Candidate and training planned to be in place by end 2000 • Develop plan to ensure full compliance with Oman Labour Law • All contractors and CH’s received letter pointing out adherence to OLL with particular reference to minimum pay. Given the confusion on this topic companies are given a 1.1.2001 deadline to ensure compliance • PDO will audit and will take necessary steps up to contract termination to ensure compliance • Leave conditions are now set contractually by PDO • Living conditions compliance is now 89% (excl. PAC’s)

  33. Permanent Accommodation for ContractorsRenaissance Hospitality Services Co at Fahud

  34. Road Safety (1) • Model analysis to identify common root causes of traffic incidents (Review/Redefine overall PDO-Road Safety Programme) • AFPC Bow-Tie model followed as best practice • Expert review to assure soundness being conducted • (Transport Research Lab/National Safety Council/ Stichting Wetenschappelijk Onderzoek Verkeersveiligheid) • Target completion January 2001 • In Vehicle Monitoring/Driver Merit System (IVMS/DMS) Pilot • Pilot started with 25 Vehicles/75 drivers. Baseline taken • Initial results positive, drivers start changing behaviour (First week data only) • Long term strategy/options in development, total implementation costs some $5 million • Note: AFPC sees reduction in effectiveness in its pilot

  35. Example IVMS graph (speeding)

  36. Road Safety (2) • Expedite development of defensive driving course • New structure based on Omanised National Safety Council model (USA) • Introduce a new DDC for blacktop followed by DDC for graded/off-road • Introduce a medical check prior to training (vision, reaction) • Yearly Supervisor Driver Assessment for all drivers • Role out new training program in March 2001 • Improve effectiveness of Journey Management • Basic procedures are OK • Implementation often not in line with spirit • Road Safety Monitoring Team will audit compliance at contractors’ sites (in new contract to start 1st December 2000) • PDO will take contractual steps to ensure compliance

  37. Road Safety (3) • Low Centre of Gravity vehicles to become the norm • 2WD for graded roads authorised October 2000 • Implementation included in new PDO North Oman lease contract • Saloon cars allowed on all interior blacktop roads • justification required for 4WD • Disciplinary actions for road safety violations • Implemented in August • Number of people dismissed for drink/driving • Acceptance of staff varied (seen as negative by many) • Road Safety Monitoring Teams • Coaching role to drivers emphasised • Feedback/correcting loop for to contractors being improved • New contract will include quarterly feed-back/awareness presentation to drivers

  38. Road Safety Monitoring TeamCoaching the drivers

  39. Road Safety Monitoring TeamClass ‘A’ Defects - Shaming Graph

  40. Road Safety (4) • Roadworthiness Assurance Scheme (RAS) • Audit of the system confirmed numerous deficiencies • 30% of RAS inspection sites closed (failed audit) • Reduce number of inspection sites from 45 to 15 by mid 2001 • Vehicle ER Communication • 800 out of 6000 vehicles have radio (radio coverage 85% of concession) • others often have GSM (10-15% coverage in concession) • 100% coverage for full concession: GSM/Radio will cost $20-30 million • Lack of communications did not contribute to fatal incidents last 10 years • Satellite asset tracking being piloted for security reasons, if implemented total costs estimated to be $6 million

  41. October HSE-MS auditPrincipal positive findings • PDO and contractor staff have documented and agreed job mandates / descriptions with HSE task and targets • The PDO contracting process is sound (not always fully complied with) • Well-structured HSE meetings throughout PDO and contractor organisations • PDO possess a well-structured system to define their standards (but seen as complex and cumbersome by many) • Considerable reduction in flaring and leaks and good HSE performance in Lekhwair • STOP programme implemented in PDO and some contractors

  42. October HSE-MS auditConclusion is POOR Findings primarily relate to: • More focus required to close competency gaps in HSE critical roles • Lack of accountability for non-compliance with HSE requirements • Insufficient emphasis on integrity of assets, e.g. intolerable gaps related to safeguarding systems • also: • Contract management • NORM management • Vehicle emergency communications • Documentation control • Audit lateral learning and close-out

  43. October HSE-MS auditConclusion is POOR

  44. October HSE-MS auditClassified Findings

  45. Corporate HSE plan 2000/1 • Unable to sustain the best ever safety performance of 1999: • One year without a fatality • One year without a permanent disability • 49 -> 70 days without an LTI • 11 million+ manhours without LTI • LTIF best-ever at 0.37

  46. Corporate HSE plan 2001/2 (1) Further shift to implementation support • Accelerate competence assurance of HSE professionals in the field • use implementation example of SSB (ref. EP-HSE skills workshop) • Make the specific responsibilities for HSE critical jobs more visible • implement ISO14001-type awareness training • Assist the operations line in understanding and applying mandatory HSE systems (e.g. PtW, Workplace Hazard Information and Management System) • Further improve communication of on-site hazards to the workplace: • Haz-ID, Videos, packaged to facilitate Tool Box Talk • STOP (prime audit finding 1)

  47. Corporate HSE plan 2001/2 (2) Further shift to implementation support • Structure and enforce HSE compliance monitoring and review in the line (prime audit finding 2) • Apply the Marmul and Nimr ‘Holding the Gains’ approach across the Product Flow Asset Teams (Integrity Management initiative) (prime audit finding 3) • Implement simple lateral learning tool (prime audit finding 4) • Coach contract management (incl. LCC’s) in applying defined HSE-MS (as per Contractor Coaching Follow-up, prime audit finding 4) • Contractor/contract holder HSE plan to be signed off by ‘coach’ • Coach PDO contract management in HSE-MS req’s (especially HEMP) • Start competence training/assurance of contract management • Continue focus on Road Safety

  48. Corporate HSE plan 2001/2 (3) Further shift to implementation support • Maintain Management Commitment • Interior visits programme, facility inspection programme • Presentations and attendance at forthcoming interior Safety Conferences • Continue to use STOP • Continue weekly LTI/High Potential incident reviews • Continue Safety Champions approach with contractor managers • Continue individual contractor safety dialogue through Coaching Visits follow-up • Continue focus on Road Safety

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