April 18, 2011 | Mark Paradies

Monday Accident & Lessons Learned: Fatal Lifting Accident

OGP Safety Alert


Country: VIETNAM – Asia/Australasia

Location: OFFSHORE : Mobile Drilling Unit

Incident Date: 3 November 2010

Type of Activity: Lifting, Crane, Rigging, Deck operations

Type of Injury: Struck by

Function: Drilling

A Service Company Supervisor was fatally injured when a lifting operation on an offshore drilling rig snagged and then lost control. Originally intended to be present as an observer, the Injured Person (IP) entered the hazard zone when a roustabout handling a tag line queried the rigging arrangement with him. During this brief distraction, the roustabout released tension on the tag line, and one leg of the sling caught on an overhead obstruction (a stairwell platform). When the sling became free, the load swung towards the IP, and his head was caught between the load and a container.

What Went Wrong?:

Human Factors:

– The roustabout did not address the lift supervisor first and the lift was not stopped properly

– The IP entered the hazard zone without permission from the lift supervisor

Inadequate planning and organization of the work:

– An adequate and effective Job Safety Analysis (JSA), either written or verbal, was not conducted beforehand; the risks, precautions, lift plan, rigging arrangements, roles and responsibilities, and communication were not discussed, consequently:

  • The rigging arrangements were not discussed leading to confusion over how the load was rigged and the roustabout’s distraction from the job
  • There was a lack of awareness of the dangers of the lifting environment
  • People did not know the arrangements to stop the job. The IP got drawn into the lift, although his role was to observe from a safe place

Failure to follow known procedures:

– There was casual compliance with the rig’s processes for the control of work which, if followed more robustly, would have led to better planning and control over the operation.

Corrective Actions and Recommendations:

Plan and Organise Work:

  • Only competent and authorized personnel should be directly involved in any work
  • Rigging and lifting arrangements should be discussed and agreed prior to commencing a lift
  • All parties shall participate in the JSA/JRA process, including those with a ‘passive’ role
  • Prompt cards should be used to help personnel conduct high-quality JSA conversations
  • Roles and responsibilities for any work shall be clearly defined and agreed upon, including a clear definition of how communication will be conducted (e.g., directly to the lift supervisor)
  • Clear and unambiguous “stop the job” signals or commands will be agreed
  • No activity should start until all involved confirm they believe it is safe to do so
  • Hazard zones around worksites should be clearly identified, and no unauthorized people should be able to enter during activities
  • Plan workload and resources – being undermanned or in a rush encourages shortcuts

Plan well for new contracts:

  • Ensure that minimum competence criteria are clearly defined in the contract and are met before acceptance
  • Ensure that the minimum crew/manning and supervision requirements are considered and met before the contract commences
  • Evaluate key risk areas by assessing the quality and effectiveness of standards, procedures, and practices for:

– Safe Control of Work (permit to work, work instructions, JSA/JRA/Risk assessment, etc.)

– Lifting and rigging

– Competence Assurance

– Observational safety programmes

– and any other safety-critical activities and risks as defined by your own risk assessment of the activities to be performed

  • In circumstances where it has not been practicable to see these areas in action before acceptance, audit them as soon as the activities start during the contract.
  • Engage subcontractors and third parties early in the planning and risk assessment process to understand their needs, standards, and best practices and to confirm roles and responsibilities
  • Plan and resource an audit, assurance, and supervision programme, and prioritize on the biggest risks
  • Thoroughly check the effectiveness of controls and practices on site and compliance with procedures. Tell management how it really is.

Safety alert number: 230

OGP Safety Alerts http://info.ogp.org.uk/safety/


Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP nor any of its members, past, present, or future, warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.

This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.

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