GUPCO Kamose Fatality Incident

Toolbox Talk Lessons pack

Presenter’s NameTitle Department

Prepared By Dave Goodwill for Dave Blevins

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.

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 ?

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

Your PlanYour 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

What else do you need to do ?

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.

Would You be happy with this ?

The Incident

He died in hospital of these injuries several weeks later

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

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 ?

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

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 ?

If you answer “no” to any of these it could happen to you