Serious Incidents in EPCJuly-August 2008

Drowning – SEIC LNG, 25 August RTI – SEIC LNG, 7 AugustRTI – SEIC LNG, 26 July

Excavation collapse – AKCO, 23 and 31 July

Drowning Incident, 25 August, LNG Jetty

Date and location: 25 August 08 at 12h15 hrs , Prigorodnoye LNG Jetty

Employee: 48 years old, Filipino National, 30 years with Shell. Married, 5 children.

Position: SEIC-ALEM Mechanical supervisor (and acting Area Engineer, Utilities)

Timeline:• The victim went to check for the warranty insulation work in the area.• On CCTV records he is seen 5 times moving on the west side of the lower

jetty, the last sighting at approximately 12:45.• Apparently he climbed over or through a barrier, slipped and fell into the

sea, where he drowned.• No witnesses, no-one else on jetty at the time.• Absence noted at 13h30, search started.• Body found 300 m ashore, 2 km downstream from jetty, at 18h30.

Outcome: Drowning is confirmed as cause. No injuries.

Overview of site with incident location

Current

Wind and Swell

250 m

300 m

Fishing Net

Jetty

2 Km

Coastline

Coastal road

Body Found

Sketch of Jetty and Coastline

• Jetty area has barriers all along length, it is impossible to slip or fall through the barrier accidentally.

• The victim could not swim, but had HUET (cold water) training.• There were no jobs planned at Jetty on day, but as supervisor the victim

may have been scoping future jobs (he mentioned a warranty insulation job in the morning) in preparation for the afternoon PTW planning meeting.

• The work pressure was not abnormally high, but the victim was deputising for his Area Engineer on leave.

• The warranty insulation job did have a deadline and was gaining in urgency.

• The victim’s movements and attitude were ‘normal’.• Drowning and behaviour do not suggest suicide.• Interviews with close colleagues indicate that the rule breaking

suspected in this case is plausible (individuals in this community follow their own risk perception and are willing to violate the rules).

Early Findings

Vehicle in the washout

Vehicle in the washout

Preliminary explanations:• The victim went to check for the insulation warranty job.• He climbed over or went through the barrier.• He slipped and fell into the sea, where he drowned.

Initial recommendations and next steps:1. Make working on the lower deck of the jetty “accompanied”

only to reduce the opportunity for unobserved violations.2. Investigate what motivated apparent violation.3. Check arrangements for jetty’s that are standard for LNG

plants elsewhere.

Explanations and Recommendations

Vehicle in the washout

Vehicle in the washout

• Use of lifejackets [currently mandatory outside barriers, not within barriers]

• Lone work [currently ok in main transept, but not outside or on the dolphin berth]

• Water survivability training [currently not mandatory in main transept, but mandatory outside the barriers on on the dolphin berth]

• First Aider availability, CCTV usage

• Use of double decks – are all jetties with 'hidden' lower areas ?

• Working on lower decks – same rules as on top deck ?

• Access rules & training for being allowed on jetty – permits, general passes etc.

Jetty’s Arrangements under Investigation

Generic Learnings

1. Further strengthen compliance with rules at all levels, starting with management and supervisors.

2. Strengthen supervisors “HSE leadership skills”. Supervisors must lead by example.

3. Review and reinforce jetty access procedure with focus on limiting access and monitoring / controlling presence.

Serious Incidents in EPCJuly-August 2008

RTI – SEIC LNG, 7 August

RTI, 7 Aug 08, Water Tanker, SEIC LNG/OET

Date and location: 7 August 2008, 11:16 am, LNG/OET Gate 4Employing company: CTSD, LNG/OET Contractor

Timeline: A water tanker driver was turning to enter the construction site Gate

4. A 3rd party car (Toyota, right hand drive) was approaching from the

opposite direction at 100km/hr. Another articulated truck, leaving the site, blocked the water tanker

driver’s sight. He started his turn when he estimated the view was clear and stopped as soon as he saw the Toyota.

Toyota driver braked hard, locked his wheels, could not avoid collision.

In the collision the passenger side A-pillar was bent downwards and the roof was deformed backwards by 27 cm.

Outcome: 3rd party passenger died after 8 days in coma. 3rd party driver had minor injuries. Project driver no injury.

3rd party driver

Overview of site with incident location

RTI, 7 Aug 08, Water Tanker, SEIC LNG/OET

Accident scene, provisions and gasoline drum

transported in the car.

Immediate causes: The CTSD water tanker driver turned in too early before his field of vision

was good enough to complete the manoeuvre. The 3rd party car was travelling at 100 km/h.

Tentative underlying causes: The entry gate 4 is located in the vicinity of a bend. Warning/traffic lights or flagmen were not in place at vehicle exits. The graded bypass road was not equipped with any traffic calming

measures. Due to legacy contract, a Front Underrun Protection was not installed on

the water tanker that contributed to the passenger’s severe injuries.

Lessons learnt Journey management did not cover risks associated with Gate 4 location

and with Heavy Goods Vehicles turning on/off the road. Entrances across are dangerous due to speeding third party vehicles and

need to be controlled by flagmen or traffic lights. Further work with the authorities required to add traffic lights at the

main site entrance and additional traffic calming measures. Risks at other entrances across the assets need to be assessed.

Causes and Lessons Learnt

Generic Learnings

1. DDT for truck drivers to address turning at junctions and entering through gates.

2. Junction design issues increase probability of incidents (bends, limited visibility).

3. Traffic calming measures (road bumps) must be used to reduce risk of incidents with 3rd party speeding vehicles.

4. Vehicles with missing safety equipment must be identified and other control measures in place to reduce the risks.

Serious Incidents in EPCJuly-August 2008

RTI – SEIC LNG, 26 July

RTI, 26 July 08, Sewage Truck, LNG/OET Camp

Date & location: 26th July 08, 0:55h, driving from LNG/OET camp

Employing company: Ritter, Subcontractor of CTSD, LNG/OET Contractor

Timeline:

A subcontractor driver of a sewage truck saw a 3rd party light vehicle approaching him in the wrong lane at very high speed

The truck driver slowed down and pulled onto the road shoulder

The light vehicle lost control and collided head on with the truck

Outcome: Double fatalities of 3rd party driver and passenger. Project truck driver had slight injuries. Truck damage.

Sketch of the Incident

Immediate causes:A driver of 3rd party was driving at a very high speed in a residential area lost control and collided with the sewage truck.

Underlying causes:No management failures identified by SEIC.

Causes

Generic Learnings

1. Night driving must be minimized and controlled.

2. DDT to include specific night driving techniques.

Serious Incidents in EPCJuly-August 2008

Excavation collapse – AKCO, 23 and 31 July

Excavation Collapse Incidents, Agip KCO

Date and location: 23 July and 31 July, Bolashak Construction

Outcome: Fatality in each incident

Underlying causes: (similar trends for both incidents)

• Inadequate contractor supervision during work • Toolbox Talk only once in the morning or afternoon break dealing

with general topics, not the task at hand • Ineffective communication of hazards to workforce: language,

documentation, markings/signage, confirmation of understanding• No documented specific risk assessment discussed with work force• Casualties did not realize the hazardous situation in either incident• Non-compliance with contractual requirements for risk assessment• Non-compliance by contractor with excavation procedures and HSE

requirements

d

a

b

c

PouredConcrete Wall

Shuttering

Acro Bracing

<= +/- 2.4 Meters =>

Soil

<=

4.0

7 M

ete

rs =

>

Each concrete block is 2.4x0.6x0.6 meters.Weight is 2.0 tons

(per notation on blocks)

Background to Incident 1Rich Amine Pump Sump Pit on the

Bolashak plant Gas area for train 1

d

a

b

c PouredConcrete Wall

+/- 1.5 Mtr

< ==== >

Soil

<=

4.0

7 M

ete

rs =

>

Background to Incident 1

Xd

a

b

c

Location of IP

Rich Amine Pump Sump Pit on the Bolashak plant

Gas area for train 1

Overall view of soil and blocks after incident. 3 blocks on right have been removed by crane.

Incident 2 – Collapse of Side Wall inside Trench

The area for the trench was congested and limited any possibility for a reasonable slope into the trench.

The methodology employed was “benching”, a perfectly acceptable practice.

However, the angle of the slope and size of the “bench” was too small for the depth of the trench and soil type.

Features of Activity at Incident Sites1st incident• First time procedure used by contractor, but no evaluation of safety

impact• Procedure for removal of braces not made clear to workers • No contractor supervisor present at the time of incident• Soil backfill unstable due to high water table and recent heavy rain• No barrier or signage to indicate hazardous area• One party who escaped from the collapsed area states that he did not

attend the morning Toolbox Talk, yet he signed off as being present

2nd incident• Contractor supervisor did not follow the existing procedures for

excavation layout• Contractor supervisor did not comply with method statements • Contractor Execution Authority, approving specific PTW, was not the

actual Contractor Supervisor executing the work

Recommendations• Improve pre entry excavation inspection with color coded entry tags• Effective pre-job and task safety information to be delivered at work

site• Review of competency requirements for all contractor supervision• PTW implementation and coordination to be reviewed and improved• Improve effectiveness of work risk assessment process & toolbox risk

identification card implementation• Further development of appropriate risk assessments and method

statements for revised or amended practices• Ensure contractors implement requirements for barrier and signage as

mitigation measures• Improve on site monitoring of standards by HSE and Management• Further develop appropriate mix of supervisor and HSE personnel

dependent on work team numbers• Disseminate findings to other sites• Instill culture of strict compliance with procedures and/or implement

formal authorization process to deviate• Specific recommendations on the bracing of shuttering for concrete

pours and on excavation design and implementation

Management Actions• MD, Project and District Division Directors visited site and met involved

Contractors’ leaders immediately after the incidents.• Company Directors held incident review panels with investigation Teams.• Eni Senior VP and AKCO senior management met all main Contractors’

CEOs at site. Co-ordinated Action plan with Contractors has been agreed.• Changes of selected personnel have been effected.

• Agip KCO planned specific actions to ensure step change in HSE performance:

– Establishment of a Senior Leadership HSE Integrated team. Kicked off earlier this year for EP Offshore, will be extended to EP Onshore.

– Instigate Agip KCO “safety watcher” teams, with control, advice and coaching role.

– Extend assessment of competency and skills to key (sub) contractors’ resources.

– Regular checks of compliance with policies and procedures.– Sample checks on back-to-back HSE conditions to subcontracts.– Increase number and reach of safety awareness initiatives.

AgipKCO Actions • Steps taken to immediately improve safety at site :

– Site Talks and Management re-enforcement of HSE with all contractors

– Inspections of similar conditions– Review of PTW compliance– Increased site HSE monitoring

• Instituted pre-entry excavation inspections with colour coded entry tags

• Review of applicable operating procedures to ensure lessons learned are considered

• Review of contractor Method Statements and improved coordination of daily activities

• Dissemination of lessons learned from these incidents across the company

Generic Learnings

1. Risk assessment must be specific, not generic, and discussed with work force during tool box talks to communicate hazards for planned work.

2. On-site supervision of contractors and subcontractors must be increased.

3. Continue to implement culture of strict compliance with procedures and formal authorization process to deviate if required.