1 20 February 2009

Skip Garrett, SHE&S Leadfgarrett@qatargas.com.qa

Korean Shipyard (SHI/DSME/HHI) Argon/TIG Welding Inc idents* from2007, 2008, 2009

and Common Threads / Corrective Actions

*HHI reported zero Ar incidents

2 20 February 2009

Shipyard Reported Argon Incidents*1. Death due to suffocation while TIG welding

� DSME, QG Hull Jan 15, 2009

2. Medical Treatment (2 IP’s) Ar Incident� SHI non-QG, Jan 9 2009

3. Near Miss personal oxygen detector alarmed� SHI QG Hull, 6 Jan 2009

4. Death due to suffocation during grinding (air/Ar m anifold switched)� DSME QG Hull, 16 May 2007

5. Death due to suffocation during T.I.G welding� Incident report stated the IP died of Natural Causes (included here as the IP was welding prior to death

� SHI QG Hull, 31 Aug 2007

6. Death due to suffocation by argon gas remaining i n pipe� SHI non-QG, 7 Sept 2007

7. Death due to suffocation deck pipe weld� DSME non-QG, May 2002 (included even though its previous to the past 3 years)

*2007, 2008, Jan 2009 - from DSME and SHI, note: HHI reported no Ar incidents

3 20 February 2009

<the accident site condition>H.2285 NO.2 COFFERDAM AREA

N2 Pipe (SUS 150A)

OOONameOOENGCompany

NO.2 COFFERDAM AREA of H.2285Location2009.1.15(THU) 13:45DATE

� Description: IP and another worker had completed tack welding of N2 line pipe (150A, 30m) located inside cofferdam #2 from 08:00 AM to 12:00PM. From 13:00 PM to prepare N2 line pipe for welding, the pipe needed to be filled with argon. One feeder hose at base of pipe in Sump Well was not proving sufficient to fill pipe with Argon (Ar).

IP entered Cofferdam #2 to attach additional Ar feeder hose to inside pipe as more Argon was needed for the weld at higher elevation. Due to gravity and leakage from pipe through tapped connection, the sump became oxygen deficient due to Argon gas. When IP entered sump well to connect second Ar feeder hose he suffocated immediately.

Apparently there were no confined space entry controls or gas checks and he had no oxygen detector to warn him.

•There are 11 more N2 pipes similar to 150A to complete on DSME hulls.•SHI outfits the N2 pipe at block stageLesson Learned: When atmosphere is 100% Argon, death can occur in one or two breaths .

1st Death due to suffocation while TIG welding DSME 15 Jan 2009

4 20 February 2009

2nd Ar Medical Treatment Incident (2 IP’s)SHI non-QG, 9 Jan 2009

Date January 9th, 2009 10:30Location Ballast TankPersonal Damage [ Medical Treatment ]- Oxygen Deficiency due to ArgonSummary

The two injured persons went inside a tank to perform welding on 2 pipes. After finishing welding on small pipe, IP2 disconnected argon hose from nipple and then took a short break outside of the tank for 10 minutes. IPswent inside the tank and IP1 tried to remove a wooden plate stuck between floor and end of big pipe in preparation of welding works. While removing the wooden plate, IP1 lost his consciousness due to argon gas leakage. At that time, IP2 discovered IP1 and alerted situation to other workers immediately. IP2 pulled up the IP1 from the bottom area and took out IP1 to outside of tank with help of another worker. IPs were transported to Hospital immediately for further examination.

5 20 February 2009

3rd Near MissSHI QG Hull, 6 Jan 2009

Stripper Line TIG Welding Argon Gas, Cargo Tank, Le vel 1&2– Result: One personal oxygen detector alarmed (19% in one localized area but immediat

ely cleared as inspector moved from area), all work stopped and personnel evacuated the tank until source understood. This is an example of a good response to an oxygen personal detector alarm.

– Neither the welding team foreman nor the SHI Safety Supervisor checked that the dam had been positioned correctly before signing the work permit.

– Hence, the welders received a signed permit and began welding.– The stripper line had been welded in the wrong sequence meaning that a dam could not

be inserted from the liquid dome area and had to be inserted at the end of the line at the bottom of the cargo tank.

– When questioned, the new welding foreman did not know what the line they were welding was used for and was not aware that it went to the bottom of the cargo tank and was open ended. He was told to weld the joint he couldn’t insert a dam as is normal practice so he just started welding with the argon gas inserted into the line.

– Usually, the end of the stripper lines in the cargo tanks are dammed with a foam stopper and then the end of the pipe is wrapped in plastic and sealed with duct tape as a secondary defense against leaking dams at the top of the liquid dome – but this had not been done in tanks # 4 & 5 although it had been done in tanks # 1 ~ 3.

6 20 February 2009

�Description : To install insulation, IP was grindin g anchoring – bar installation. IPput Air hose connected with Air hood in line supp lying Argon.

Oxygen displacement occurred due to Argon gas and I P suffocated

- Manifold air and argon fittings were reversed .

�Line supplying AirLine supplying Argon�

Position reversed

4th Death Due to Suffocation During Grinding

DSME QG Hull, 16 May 2007

7 20 February 2009

5th Death Due to Suffocation*, SHI - QG Hull 31 Aug 2007*Incident Report Stated the IP died of Natural Caus es

8 20 February 2009

5th Argon incident showing IPNote: Incident Report Stated the IP died of Natura l Causes

9 20 February 2009

5th Argon Incident Pictures SHI QG HullIncident Report Stated the IP died of Natural Cause s

10 20 February 2009

6th Death due to suffocation during T.I.G welding, SHI non-QG Sept 2007

� Date : September, 2007

� Location : S Company

� Description : The deceased was T.I.G. welding a pip e on top of the deck of an LNGC (Refer to Picture. The worker leaned into the pipe after removing the purging sponge (seal) to check the quality of the w eld (Refer to picture. And breathed in argon gas and wa s found slumped over the open branch of the pipe The foremen had last talked to the welder at 11.40 am. The welder was found at 11.55 am (15 minutes)

11 20 February 2009

7th Death due to suffocation by argon gas remaining in pipe DSME non-QG, May 2002

Description : After welding by argon at the outside cargo suction line(700+400A), IP entered inside pipe. At that time IP was suffocated by argon remaining inside pipe.

Note: Pipe need not be in Confined Space to be 100% Argon atmosphere. After argon work deck pipes must be sufficiently ventilated BEFORE workers can enter or inspect!!!

12 20 February 2009

Common threads1. PTW, procedure or standard available and required but not followed

� Gas checks not enforced, no continuous air monitoring� Signing permit without walking the job site (observation)� Ventilation – dilution or exhaust of low areas absent (ventilation on top of tank may

not be sufficient)2. Shipyard subcontractor’s perform most TIG welding

� Difficult to determine what training is provided to subcontractor’s3. Training/Argon hazards not understood such as the following:

� One or two breaths and you are down� Heavier then air� Plan/prepare/train for inert gas leaks

4. No personal oxygen detectors in use5. Pre-job planning may lower the argon suffocation exposure

� Design, engineer, and plan to perform TIG welding in block stage or pre-fab shops� Do not place dams in lower areas where personnel have to enter� Welder’s may not understand that the pipes they are welding on may be

open at another remote location where other worker’s may be working

13 20 February 2009

Corrective Action

1. Review/comment/amend (as required) the Best Method Safe Worker procedure (first review in process)

2. Review/comment (as required) on the Root Cause Analysis received from DSME on 13 Feb 2009. Define/amend each causal factor root cause and verify controls are implemented (in process, first review 18 Feb 09)

3. Ensure Confined Space Entry (CSE) signage and JSA/Risk Assessment Pre-Work check sheet clearly state suffocation hazard (complete)

4. Continue to lead by example and promote the use of personal oxygen detectors (daily)

5. Sustained review of inert gas welding through inspections, observations and audits (daily as appropriate)

6. Continue to reinforce safe inert gas welding practices, behaviors, and strict adherence to BMSW procedure, stop work as appropriate

7. Verify welders have received appropriate training by questioning during welding operations (daily as appropriate)