worker struck by pipe elevator type of incident: fatality ... · able to take one step before being...

WORKER STRUCK BY PIPE ELEVATOR

Type of Incident: Fatality

Date of Incident: October 18, 2012

File: F-OHS -032171-3D88C

2

Labour, Occupational Health and Safety Date: May 18, 2016

TABLE OF CONTENTS

SECTION TITLE PAGE NUMBER

1.0 DATE AND TIME OF INCIDENT 3

2.0 NAME & ADDRESS OF PRINCIPAL PARTIES 3

2.1 Owner / Prime Contractor 3

2.2 Employer 3

2.3 Contractors 3

2.4 Workers 3

3.0 DESCRIPTION OF PRINCIPAL PARTIES 4

3.1 Owner/ Prime Contractor 4

3.2 Employer 4

3.3 Workers 4

4.0 LOCATION OF INCIDENT 5

5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 5

5.1 Equipment and Material 5

5.2 Observations 5

6.0 NARRATIVE DESCRIPTION OF INCIDENT 6

7.0 ANALYSIS 7

7.1 Direct Cause 7

7.2 Contributing Factors 7

8.0 FOLLOW-UP/ ACTION TAKEN 7

8.1 Occupational Health and Safety 7

8.2 Industry 8

8.3 Additional Measures 8

9.0 SIGNATURES 9

10.0 ATTACHMENTS 10

Attachment A Map

Attachment B Photographs


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SECTION 1.0 DATE AND TIME OF INCIDENT

1.1 The incident occurred on October 18, 2012 at approximately 1:30 p.m.

SECTION 2.0 NAME AND ADDRESS OF PRINCIPAL PARTIES

2.1 Owner and Prime Contractor

2.1.1 Harvest Operations Corporation

2100-330 5 Ave SW

Calgary, Alberta

T2P 0L4

2.2 Employer

2.2.1 Nabors Canada

2800-500 4 Ave SW

Calgary, Alberta

T2P 2V6

2.3 Contractors

2.3.1 Trol Consulting

107 Coulee Creek Lane

Lethbridge, Alberta

T1K 8B9

2.3.2 Kingdom Cats Ltd.

P.O. Box 68

Conklin, Alberta

T0P 1H0

2.4 Workers

2.4.1 Floor Hand

** ********** ***

******* ****** ****** ******

*** ***

2.4.2 Rig Manager

***

********* *******

*** ***


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2.4.3 Motor Man

**** **** ****** ****

****** ****** ******

*** ***

2.4.4 Labourer

****** ****** **** *****

**** ********* *******

*** ***

2.4.5 Loader Operator

********* ******

***** ****** ****

*** ***

SECTION 3.0 DESCRIPTION OF PRINCIPAL PARTIES

3.1 Owner and Prime Contractor

Harvest Operations Corporation was originally formed in July 2002 as an energy

royalty trust. Currently Harvest Operations Corporation is a Canadian based

subsidiary of Korea National Oil Company (KNOC) since it was acquired in 2009. In

2010 Harvest Operations Corporation transitioned from an energy royalty trust to a

corporation and acquired BlackGold oil sands project (SAGD in-situ plant).

3.2 Employer

Nabors Industries Ltd. is a large company of which Nabors Canada is a division of.

Nabors Canada has three business units: Nabors Drilling, Nabors Productions

Services, and Academy Services. Nabors Drilling operates 86 drilling rigs and works

primarily in Western Canada. Nabors Drilling has been in the contract drilling

business in Canada since 1952. At the time of the incident Nabors Drilling was

contracted by Harvest Operations Corporation to conduct drilling operations at Pad

#101.

3.3 Workers

3.3.1 The Floor Hand started working for Nabors Drilling on October 7, 2011. The Floor

Hand was working in a labourer capacity on drilling rig #103 for the two days prior to

the incident.


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3.3.2 The Rig Manager was employed by Nabors Drilling for the past 16 years and was in

charge of operations on the drilling rig.

3.3.3 The Motor Man was employed by Nabors Drilling for 1 year.

3.3.4 The Labourer was employed by Kingdom Cats Ltd.

3.3.5 The Loader Operator was employed by Nabors Drilling for the past 8 years.

SECTION 4.0 LOCATION OF INCIDENT

4.1 The incident occurred approximately 10km south of Conklin, Alberta at Harvest

Operations Corporation well pad #101. Legal location LSD 12 – Section12 –

Township 76 – Range 7 West 4 Meridian (Refer to Attachment A – Map).

SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS

5.1 Equipment and Material

5.1.1 The Pipe-Matic 3000XT is a powered catwalk that is used to move tubulars (i.e.

drilling pipe) between the pipe rack area and the drilling floor. The equipment

consists of a catwalk on a sub-frame with two pipe elevators (approximately 4500 lbs.

each), one on either side of the catwalk, on four sets of wheels. The Pipe-Matic

3000XT is manufactured by Canrig Drilling Technology Limited.

5.2 Observations

5.2.1 Officers arrived on site at approximately 5:40 p.m. and a brief meeting was held with

the company representatives to discuss the events of the incident. The incident scene

on drilling pad #101 was secured by the RCMP and was still under the RCMP’s

jurisdiction. A discussion was held with the RCMP officers on site and at 6:20 p.m.

the incident scene was turned over to Occupational Health and Safety.

5.2.2 The scene contained the catwalk with the two pipe elevators removed and laying on

the ground. The North side elevator was on the ground with no equipment attached to

it. The South elevator was attached to a loader with chain; the arms of the loader

were in the down position.

5.2.3 At 6:30 p.m. the site was ribboned off by Occupational Health and Safety.


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SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT

6.1 On the morning of October 18, 2012 Nabors Drilling was in the process of rigging

down (dismantling) drilling rig #103. At approximately 9:30 a.m. the Pipe-Matic

3000 XT was removed from the drilling rig and moved to the location where the

incident occurred.

6.2 After lunch the Floor Hand and the Motor Man were assigned the work of rigging

down the Pipe-Matic 3000XT by the Rig Manager. The Motor Man was driving a

loader, with a grappling fork attached, completing other jobs while the Floor Hand

was removing the four bolts from each of the two pipe elevators

6.3 At approximately 1:30 p.m. the Motor Man drove his loader to the pipe elevator on

the North side of the Pipe-Matic 3000 XT and placed the forks at the top of the pipe

elevator to support it for removal.

6.4 The Motor Man noticed that the hydraulic lines were still connected to both pipe

elevators and instructed the Floor Hand to disconnect the hydraulic line on the South

side and that he would disconnect the line on the North side.

6.5 The Motor Man climbed on the inside of the pipe elevator to disconnect the hydraulic

line on the North elevator. The Labourer witnessed the Floor Hand working under the

Pipe-Matic 3000XT. When the Floor Hand came out from under the Pipe-Matic

3000XT, to the East, he hit or struck the pipe elevator with either his gloved hand or

with gloves in his hand and proceeded to walk in front of the pipe elevator in a South

West direction.

6.6 While the Motor Man was getting back into the loader, he heard a loud bang when the

South elevator fell.

6.7 The Labourer yelled at the Floor Hand to get out of there but the Floor Hand was only

able to take one step before being struck by the pipe elevator causing fatal injuries.

6.8 The Motor Man ran around the Pipe-Matic 3000 XT where he saw the Floor Hand

pinned under the South pipe elevator and went to get the Rig Manager

6.9 The pipe elevator was lifted off of the Floor Hand by the Loader Operator with the

use of another loader and chain.

6.10 The Floor Hand was pulled from underneath the pipe elevator and medical assistance

was initiated by the medic and workers on site. The Floor Hand was pronounced

dead on the way to a hospital.


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SECTION 7.0 ANALYSIS

7.1 Direct Cause

7.1.1 The cause of the incident is the pipe elevator falling and striking the Floor Hand

causing fatal injuries.

7.2 Contributing Factors

7.2.1 Through the investigation there was no evidence that the Floor Hand had completed

the task of rigging down (dismantling) the Pipe-Matic 3000XT before. As well there

is no evidence that the Floor Hand had received proper training for the task and was

not under the direct supervision of a competent worker.

7.2.2 Most training that is completed by employees is done mostly by job shadowing other

individuals. Once an individual has been deemed competent by an individual it is

reported to the Rig Manager. There is no process in place that the Rig Manager uses

to confirm the competency of individuals. At the time of the incident there were no

documents available to determine when a worker was deemed competent.

7.2.3 The pipe elevators were no longer secured to the catwalk once the eight bolts (four

per side) were removed, leaving the pipe elevators balancing on a ledge on the side of

the catwalk.

SECTION 8.0 FOLLOW-UP/ ACTION TAKEN

8.1 Labour; Occupational Health and Safety

8.1.1 On October 18, 2012 a Stop Work Order was issued to Harvest Operations

Corporation for Occupational Health and Safety to complete the initial investigation.

8.1.2 On October 20, 2012 the Stop Work Order was lifted on Harvest Operations

Corporation.

8.1.3 On October 20, 2012 a Stop Work Order was issued to Nabors Drilling for the rigging

up and rigging down process for Nabors Drilling Rig #103 (Pipe-Matic 3000XT).

8.1.4 On October 24, 2012 permission was granted to Nabors Drilling to conduct a single

lift of a pipe elevator to determine weight.

8.1.5 On October 25, 2012 Nabors Drilling was requested to supply information pursuant

to Section 19 of the Occupational Health and Safety Act.


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8.2 Industry

8.2.1 On October 24, 2012 Nabors Drilling requested permission to lift a pipe elevator to

determine weight.

8.2.2 On October 25, 2012 both Harvest Operations Corporation and Nabors Drilling were

requested to supply information pursuant to Section 19 of the Occupational Health

and Safety Act.

8.2.3 During the investigation both Harvest Operations Corporation and Nabors Drilling

supplied all requested information.

8.3 Additional Measures

8.3.1 October 24, 2012 permission was given to Nabors Drilling to conduct a single lift of a

pipe elevator to determine the weight of the pipe elevator for the purpose of

engineering new mounting assembly and lifting points.


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SECTION 9.0 SIGNATURES

ORIGINAL REPORT SIGNED May 18, 2016

Lead Investigator Date


Manager, Investigations Date


Director, Investigations Date


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SECTION 10.0 ATTACHMENTS:

Attachment A Map

Attachment B Photographs


Attachment “A” Map

Incident Location

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Map A – Incident Location

1 – Conklin, Alberta

2 – Incident Location

1 2


Attachment “B” Photographs

Page 1 of 2

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Photograph #1 - Pipe-Matic 3000XT

1 - Catwalk

2 – South Pipe Elevator

1 2


Attachment “B” Photographs

Page 2 of 2

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Photograph #2 - South Pipe Elevator

1 – Hydraulic Line

2 – Bolt

3 – Bolt Hole

4 – Bolt Hole

1 2 3 4

worker struck by pipe elevator type of incident: fatality ... · able to take one step before being...

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