BSEE issues investigative report on fatal gulf accident
A series of failures to apply basic safety management practices may have contributed to an assistant driller’s death in a Mar. 16, 2016, accident on Gulf of Mexico Green Canyon Block 18, the US Bureau of Safety and Environmental Enforcement said as it released a report of its investigation.
A series of failures to apply basic safety management practices may have contributed to an assistant driller’s death in a Mar. 16, 2016, accident on Gulf of Mexico Green Canyon Block 18, the US Bureau of Safety and Environmental Enforcement said as it released a report of its investigation. The injured worker had to wait 3 hr before emergency services personnel arrived because of adverse weather conditions, the report added.
“In particular, the panel found documentation of nonconformances related to task-level hazardous analysis,” BSEE Acting Director Margaret N. Schneider said in a Mar. 8 memorandum.
“In particular, [it] found that after a third-party Safety and Environmental Management Systems audit in August of 2015, the operator, Whistler Energy II LLC, self-verified that corrective actions have been taken in December of 2015. However, the panel found numerous inconsistencies after the correction action completion date,” she said.
The injury occurred on the Whistler production platform after the Nabors Offshore Corp. worker placed his head and an arm inside the platform’s vertical mud-gas separator (MGS) through its inspection hatch while performing an assigned, but non-routine task of removing built-up and hardened material from the interior.
“The contaminating material, believed to be cement, had already begun to cure and harden inside the MGS when it was discovered. The decision was made to attempt to remove the material, and supervisors authorized the task without understanding of the extent of the buildup,” BSEE said in a Mar. 8 safety bulletin.
The tools and work environment changed as work progressed, but the Job Safety Analysis (JSA) was not revised or updated to reflect the associated impacts and potential hazards from the changes, it continued. On the second day of the task, during the morning safety meeting, multiple supervisors advised personnel not to place any parts of their bodies into the MGS because the cement could fall.
The tools provided to the work crew were not suitable for completion of the task without placing parts of their bodies into the MGS, the bulletin said. “The supervisors and their work crew deviated from the verbal work instructions by placing their head and/or arm(s) into the MGS throughout the morning and into the afternoon,” it noted.
It said that as work progressed, some crew members assumed that the amount of material built up inside the MGS was enough to reach the height of its internal baffles. This led to the belief that the baffles would support and prevent the overhead material from falling. “Despite some of the workers having expressed individual concerns about the task conditions, stop work authority was not invoked.
Personnel were not provided a stopping point short of total task completion,” the bulletin said.
The assistant driller sustained traumatic injuries when material fell and trapped his head and right arm at the inspection hatch access, the investigation report said. He was extricated and first response medical care efforts were initiated. Bad weather delayed the arrival of a helicopter to transport him to shore, and his vital signs diminished en route. He was pronounced dead after he arrived at the onshore medical center.
In its safety bulletin, BSEE recommended that companies operating on the US Outer Continental Shelf:
• Ensure that authorizing personnel take an active role in task planning and verify that all required task authorization documents are complete, accurate, and meaningful.
• Ensure that hazard analyses are updated or revised to reflect all impactful changes in task conditions, and the working environment.
• Ensure that equipment approved and made available for each assigned task is adequate to perform the task-work safely and in accordance with safe work practices and work instructions.
• Clarify through initial and recurrent training how “confined space” and “entry” are defined.
• Evaluate emergency response plans and supporting response organization agreements to ensure everything is adequately in place to support emergency response plans and strategies.
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