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Hole Plugger Fatality - USA Summary of Incident

Hole Plugger Fatality - USA Summary of Incident. IAGC Forum Rio – 2010 Apr 15. Hole Plugger Fatality - USA. Hole Plugger (Victim, “HP”) was struck on top of his head when the Fast Plug released prematurely drill stem. - Single fatality 5 March 2010 – 13:19 Drilling Subcontractor

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Hole Plugger Fatality - USA Summary of Incident

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  1. Hole Plugger Fatality - USASummary of Incident IAGC Forum Rio – 2010 Apr 15 W LTI 1202 208 - Final report

  2. Hole Plugger Fatality - USA Hole Plugger (Victim, “HP”) was struck on top of his head when the Fast Plug released prematurely drill stem. - Single fatality • 5 March 2010 – 13:19 • Drilling Subcontractor • Hole Plugger • Rain/Wet, Snow/Ice • Barren Plain, Snow/ice • Truck Mount Conventional Drill LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  3. Site Photo 1 LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  4. StoryBoard • Drill completing hole • HP pulls up to site & approaches rig from behind driller • Driller retrieving last stem • HP places tools (poles, etc) under rig, between the drilled hole and R. Rear tire • HP stands beside pipe rack while last stem being lowered into rack • Fast plug fails and pipe falls, striking HP LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  5. Tech Details • Standard truck-Mount Conventional Drill • 20 ft (6m) stems, 3 1/2 in (9cm) diameter • Est. weight 150 lbs (68kg) per stem • Pipe dropped an est. 10-15 ft (3-5m) • Murphy “Fast Plug” attached to rig’s sand line LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  6. Danger Zone Diagram LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  7. Photo 2 – Murphy Fast Plug LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  8. Site Photo 3 LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  9. Site Photo 4 LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  10. Analysis • What Changed? • Boggy Conditions • Decision to stop work early • Urgency to complete hole • Triggers • T-Fast Plug malfunction • P-HP decision to stand in danger zone LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  11. Analysis • Organization Factors • Training – Lack of hazard understanding • Lifting, Hoisting and Rigging, suspended equipment • Crew general hazard orientations & HSE meetings were confirmed, including to the HP • Unclear communication of rules • Maintenance Procedures • Culture– Failure to promote positive culture, mixed signals • People • Driller did not control worksite • Helper without hardhat (Escalation Factor) • Rules violations LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  12. Analysis • Similar Events • Fast plugs fail from time to time • Manufacturer recognizes & warns of this • HP had the habit of placing tools under rig prior to completion • Environment • Atmosphere of urgency to complete hole • Shallow holes, big rig – Cultureof SC Mgt staff to get work done - shortcuts LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  13. Analysis • Technology Factors • Maintenance of Murphy Fast Plug • Equipment Selection • Conventional drill rig for shallow holes? • Selection of the fast plug for retrieving pipe • A note about supervision • 2 dedicated HSE present, and in field • SC drilling supervisor in field during day • Numerous rigs on project with several SC’s • Competence of HSE & Supervisors with regards to trade skills such as drilling? LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  14. General Findings • Cultureof Urgency & Mixed signals by SC Leadership • Lack of hazard awareness • Habit of cutting corners for efficiency • Maintenance & Inspection could not be shown • Lack of control by driller, despite written rule to do so. • Get ‘er done mentality • Failure of Care • Fundamentally enabled the chain of events to occur LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  15. General Findings • Field supervision occurring, but the guys couldn’t be everywhere • Other reported instances of cutting corners for efficiency were not strongly dealt with • Training, Maintenance could not be proven • Crew project hazard orientations did occur • Daily HSE meetings were occurring LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  16. General Recommendations • Pease make a commitment to improve Culture, particularly with the Sub Contractors. It takes time & dedication • Of course strengthen of SC qualification, and be clear and agreed as to what the expectations are in advance of operations • Eliminate use of the Fast Plug • Better consideration of equipment selection LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  17. General Recommendations • Truly monitor performance on equipment inspections and maintenance, particular special hazard areas • Insist that work sites HSE are fully controlled by person in charge – and responsible • Green Hands monitoring, Including visitors • Better temporary hazard barriers (such as cones, flagging, placards) for hazard areas LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  18. General Recommendations • HSE Personnel supervision with knowledge and training about drilling operations – ie competency to supervise • Stronger verification & Less leniency toward Subcontractor training • Sit down and STRESS with SC management the expectations regarding their leadership role – and make it clear that lack of Positive culture leadership will not be tolerated. Make them sign off on it. LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

  19. A Plea • We’re taking all the recommendations to heart too. • IN HSE, our success with our programs is solely determined by what DOES NOT happen. • This means Lives Preserved • We talk (and go to conventions) all the time. • Truly create (and maintain) a culture of incident prevention. It will serve us well. LTI = Lost Time Injury (unfit for work case); MTC = Medical Treatment Case; FAC = First Aid Case W LTI 1202 208 - Final report

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