learning the lessons
DESCRIPTION
Communication Pack. Learning the lessons ELNG Construction Site Train 2, Idku Egypt - Fatal Incident on 21st March 2005. Contents. Incident description Findings Improvement actions Way forward. ELNG Fatal Incident – 21 March 2005. - PowerPoint PPT PresentationTRANSCRIPT
BG Group
Communication Pack
Learning the lessons
ELNG Construction Site Train 2, Idku Egypt - Fatal Incident on 21st March 2005
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Contents
• Incident description
• Findings
• Improvement actions
• Way forward
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• Incident on Train Two 54” stainless steel Ethylene Line from Cold Box involving Aresco subcontractor workers
• Leading activity was welding ethylene line to Cold Box
• Grinder asphyxiated by Argon gas inside pipe during seal weld preparation activities
• Scaffolding supervisor, pipe fitter and 2nd grinder asphyxiated by Argon gas inside pipe during failed rescue operation
ELNG Fatal Incident – 21 March 2005
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ELNG Idku - Location of Incident
Compressor DeckColdBox
ArgonSupply
Scaffolding
35m
FoamSeal
Location Of Weld
4”line
• Argon purge and shield gas being controlled from roof
• Welders complete first two welds on 54” incident pipe
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ELNG Idku Fatalities – 21 March
• Deceased #1 and Welder enter 54” incident pipe at compressor deck with tools and equipment to perform seal weld
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ELNG Idku Fatalities – 21 March
• Deceased #1 dies and Welder exits and raises alarm
• Deceased #2 and #3 enter pipe in rescue attempt
• Deceased #4 enters later
• 4” pipe cut at Cold Box end to allow air into 54” pipe
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Surface Causes
• Asphyxiation assumed to have been caused by Argon gas that accumulated in low point at end of line
• Worker entered confined space with argon gas present
• No permit for confined space entry or work
• Personnel not trained in confined space entry and hazards
• Gaps in supervision, coordination and communication during work
• Delayed notification and uncoordinated emergency response
• Gaps in compliance to project permitting procedure
• Gaps in Supervision of Project HSE Plan
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Contributory Causes
• Inadequate allocation of safety responsibility (in practice, Bechtel’s safety dept is in charge of safety)
• Insufficient supervision level of sub contractors by Bechtel. Minimum control of method statements
• inadequate site-wide hazard identification
• Poor design constructability for 54” line
• Lack of coordination and communication at various levels e.g. Bechtel/sub contractors
• Inappropriate incentives scheme
• Lack of competency assessment in training process (risk specific)
• Limited scope of contractual HSSE obligations to cover full scope of work and limited contractual recourse
• Insufficient resources for effective supervision
• Recognised cultural issues not sufficiently addressed
• Auditing at all levels not sufficient to verify compliance with Project procedures
• Inadequate emergency response planning system
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Main Improvement Actions
• Management & Leadership– Increase the quantity and quality of supervision levels at the work-face– Conduct hazard identification studies of all activities– Review coordination and communication activities– Perform an independent safety management evaluation
• Policies, Standards & Procedures– EPC contractor and ELNG to review Method Statements for all high
risk activities.
• Behaviours / People– Behaviour-Based Safety initiative will be reinforced – BG Egypt and ELNG to review training programme and ensure
competency based testing is implemented
• Work planning– BG Egypt to monitor implementation of audit plan at formal project
review meetings
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Next Steps
• HSSE Away day for GEC on 27th May to review high level implications for BG Group and agree performance step change
• Regional workshops, led by respective EVP & MD’s, discuss implications and way forward for own Region with support from Group HSSE.
• Cascade by AGM’s to own Assets during Town Hall meetings
• Time out for safety and/or stand downs at all BG sites led by line management to review incident findings and discuss implications for own site and/or activities
• Project and Operations managers will formally present, to their Asset Management Teams, arrangements in place to prevent similar disasters
• AGM’s to provide assurance that actions have been taken to assess risks and mitigating measures implemented
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Way Forward
• Consolidation of feedback from:– Safety Meetings led by AGMs– Time Outs For Safety and/or Stand Downs in the Assets– Regional Workshops– GEC Safety Away Day
• Development of an improvement framework and action plan for the next performance step change
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Implications for BG X [Asset name]
• This is an Asset-specific slide where the AGM needs to:
–Flag own risks (e.g. unskilled contracted workforce, land transport, new projects, …)
–Compare with causal factors from fatal incident–Review existing controls–Trigger a debate on the adequacy of controls and
tease out ideas
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Incident Investigation Process
• First BG management visit was on 22nd March. Jorn Berget, Stuart Fysh, Malcolm Brown, Ray Betros visited ELNG site, held discussions with local staff and agreed to a joint stakeholders investigation team (led by Bechtel)
• Frank Chapman appointed Jorn Berget to lead an independent BG team to review findings of the Bechtel-led investigation and to identify high level lessons for the BG Group
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Independent Investigation Team
• Review team (Jorn Berget, Ray Betros, Nebil Younes, Ross Michie, Peter Joyce) visited Egypt from 30th March to 1st April.
• Findings of the Bechtel investigation reviewed and fully supported
• Other causes identified:– Group implication
• Several “Immediate Actions” were discussed and agreed with Bechtel
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Immediate follow up
• Improve physical barriers including Train 1 segregation and security inspectors
• Review of all site permits and procedures and communicate to workforce
• Tighten Safe Work Permit systems (CSE, Hot Work, Live Electricity etc)
• Review the Emergency Response System
• Zero tolerance of major Safety rules violations
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Completed actions
• Stand down (x 2) of ELNG site and presentations of incident facts to ELNG Staff and Board
• Presentation of findings to Frank Chapman, GEC, Board and at senior managers workshop by AGM, Jorn Berget and Head of HSSE
• Guidance on inert gas and confined space entry precautions including best practice and case studies issued by Group HSSE to all BG group Assets
• Letters from Frank Chapman to all staff and to AGMs on progress and requirements
• Communication Pack produced by Group HSSE