2011 q4 learning from incidents

المستفادة منها عبرالدروس وال منع وقوع الحوادث من خالل

Incident Prevention Through

Learning from Incidents

October- December, 2011

قسم الصحة والسالمة والبيئة

Health, Safety & Environment Division

1

For further information, comments and suggestions please contact:

Dr. Muhammad. R. Tayab ([email protected])

Health, Safety & Environment Division

Tel: 02-6042979; Mobile – 00971 (0) 50 324-3996

معلومات وإبداء المالحظات واالقتراحات يرجى االتصال بـ:للمزيد من ال

[email protected]على البريد االلكتروني التالي : محمد ريحان طيب الدكتور قسم الصحة والسالمة والبيئة

72 9792606رقم الهاتف :

This Booklet is circulated within ADCO organization within the framework of HSEMS. It should only serve as guidance and ADCO shall in no event

accept any liability for either the fact described, nor for any reliance on the contents by any third party.

mailto:[email protected]

mailto:[email protected]

2

During the 4th Quarter of 2011 we have had 47 injuries ranging from lost

time injury to first aid cases; 4 spills including a major spill and 17 vehicle

accidents. Incident investigations highlighted deficiencies in work planning,

supervision; and inadequate behaviour. These cause categories are similar

to findings of earlier quarters of 2011.

I request all ADCO including leadership team members to take diligently

review of work planning at grass root levels and effectively address

these deficiencies. You can be the catalyst to create a positive change

and improve safety culture at work.

Brad Kerr Senior Vice President (Technical Services)

3

Table of Contents

Damage to Over Head Line (OHL) 4

Improper Lifting Causing Damage to Forklift 5

Loss of Containment During Sand Clearance 6

Al Gaith Vehicle Rollover 7

Hand Injury During Unloading of Gas Cylinder 8

Water Tanker Rollover 9

Fall from Elevation 10

Finger Injuries from Broken Laboratory Glassware 11

Quiz 12

HSE Performance 13

Incident Sub Types 2011 14

Distribution of Incident Sub Types 2011 15

Incident Immediate & Root Cause Categories 16

Incident Immediate Cause Analysis 2011 17

Incident Root Cause Analysis 2011 18

Asset Based Causes 2011 20

Causes of Top Two Incident Sub Types, 2011 24

4

Damage to Over Head Line (OHL)

Area Incident Description Causes

BUH

08-12-

11

A crew was engaged in preparing gatch road

along BUH fence. Task risk assessment (TRA) was

prepared and Permit to Work (PTW) and

excavation certificates were obtained. While

unloading Gatch approximately 20 meters away

from 33KV Over Head Line (OHL) the tipper truck

driver moved the vehicles towards OHL while

extending tipper bucket, to ensure complete

unloading of gatch material. There was no

banksman/flagman to guide the driver. During the

process, the vehicle crossed underneath the OHL

and the extended bucket made contact and

damaged OHL conductors.

Outcome: Damage to OLH resulting in power

supply disconnection to 10 water clusters.

Inadequate Leadership (TRA was not

adequate and was not chaired by ADCO; IA

issued the PTW without ensuring presence

of banksman; availability of adequate

resources (i.e. transportation &

communication with staff))

Inadequate Identification of

Worksite/Job Hazards (Risk of damage

to OHL by tipper truck was not adequately

identified; access and agrees for unloading

not marked/ identified)

Inadequate Work Planning (New Job

Pperformer (JP) was not aware of work

site hazards; No vehicle or telephone was

provided to safety officer hindering him

from site visits)

Lesson Learned

1. Do not drive tipper truck while bucket is

raised

2. Identify access and egress point for heavy

vehicles.

3. Check for operational readiness and do not

issue PTW in haste

http://adcoedss2/essential-ehs/ADCO-E6EventManagerUI/Events.aspx?id=12420&modid=26

5

Improper Lifting Causing Damage to Forklift


DD

04.11.11

During routine operations, the driller requested

a Roustabout to arrange to transfer a landing

joint pipe from tool box basket. The roustabout

noted that rig crane operator was busy assigned

on another task and he requested forklift

operator to remove/lift the joint. A sling was

used to tie the joint end and started to pull

backward and lifting it. The joint swung and

broke through the front screen of the forklift.

Outcome: It resulted in broken cabin glass

protector screen and the operator escaped

unhurt.

Inadequate Leadership (Assistant Rig

Manager (ARM) assigned a task of transferring

drill joint to an inexperienced roustabout

without ensuring availability of resources;

Forklift operator agreed to use the equipment

improperly (i.e. lifting long joint from tool box

basket)

Inadequate Work Planning (Task involving

lifting was assigned to inexperience worker;

crane’s availability was not checked properly)

Lessons Learned

1. Use right lifting equipment for the task and do

not take short cuts.

2. Ensure availability of resources (equipment

and skilled staff) when assigning tasks.

3. Effectively empower staff to STOP unsafe

actions.


6

Loss of Containment During Sand Clearance


TPO

08.11.11

Mile Point 21 is an off site valve station where

BUH crude oil joins NEB/SE/Bab Main Oil Line

(MOL) network point on route to JDA terminal.

This station has manifolds and valves for isolating

or connecting individual pipelines to the MOL

network. Due to sand storms, sand had

accumulated inside the station. The sand

clearance was planned and the work started under

Hot Work Permit using Mechanical Shovel.

The job performer and his supervisor who was

acting as Permit Issuing Authority (IA) and Area

Authority (AA) were relatively new staff and were

not fully familiar with all location’s utilities. While

the mechanical shovel was used to shift sand a

stub pipe extending from MOL1, was struck by the

shovel. Due to dislocation of the stub pipe, oil

under pressure gushed out and released and

continued to drain toward low lying catchment

areas.

Outcome: Approximately 25,000 Bbl were

released before the MOL was completely isolated.

Inadequate Work Planning (Work was

planned using a mechanical shovel in

hazardous area, sand clearance was not

carried at the site since the last two years)

Inadequate Assessment of Work/Job

Hazards (The task was not risk assessed;

assigned staff lacked knowledge of PTW

requirements)

Inadequate Management of Change (A

stub pipe was installed on MOL without

Management of Change (MOC)

documentation)

Lesson Learned

1. Obtain excavation certificate for sand

clearance activities in restricted areas as

per ADCO PTW requirements (Sec 3.4

Grading and leveling is considered as

excavation and Excavation Certificate must

be issued for any excavation activity)


7

Al Gaith Vehicle Rollover


TPO

21.11.11

Following an oil spill at MP 21 on 08-11-2011, a

contractor crew was assigned on oil recovery

job. On 21st Nov, 2011, after finishing daily

activities, the driver was using a gatch road

from MP 21 toward Abu Dhabi – Sila Highway,

driving back to Abu Dhabi with two crew

members. The vehicle was not engaged in 4x4

gears and driven at high speed (107 km/Hr).

The vehicle drifted from the gatch road and the

driver tried to steer it back and applied harsh

brakes. He lost control of the vehicle resulting

in vehicle to roll over.

Outcome: Driver and two passengers

sustained injuries and taken to Mirfa Hospital.

After treatment they were discharged from the

Hospital on the same day. The vehicle was

damaged.

Inadequate Identification of Worksite or

Job Hazards (Risks of driving off road by new

driver were not adequately assessed).

Inadequate practice of skill (The driver was

not familiar to drive automatic transmission

vehicle resulting in many harsh brake events).

Per RS RAG report the driver was repeatedly

applying harsh brakes and sharp steering to the

control vehicle when drifted from the gatch road)

Lesson Learned

1. Always adjust vehicle speed according to road

condition and engage vehicle in 4x4 mode when

driving off roads

2. Do not apply harsh brakes & sharp steering to

control the vehicle when driving off roads

3. Plan your journeys and do not rush to reach your

destination


8

Hand Injury During Unloading of Gas Cylinder Area Root Causes

E & P

Asab

12-11-11

A pipe fitter and one helper were trying to

manually unload a propane gas cylinder

(weighting approximately 70 kg) from a crane

mounted truck (Hiab/boom truck). Cylinders

were secured with a guard rail in a modified

basket on the back of the truck. This

modification was done based on earlier incident

where a loaded compressor caught fire and it

was decided to keep cylinders away from the

main carriage in a separated basked/partition.

While the crew unbolted the guard rail and

started offloading the first cylinder the second

cylinder fell down from the basket onto the

ground trapping pipe fitter’s left hand between

cylinders.

Outcome: Pipe Fitter sustained crush wound

injuries on his two left hand fingers and he was

assigned on light duties for 5 days.

Inadequate Management of Change

(Design and location of new cylinder

basket was not risk assessed and not

tested/ inspected for fitness as lifting

boom could not access cylinders due to

design limitations)

Inadequate Identification of

Worksite/ Job Hazards (Untrained staff

were assigned to handle gas cylinders)

Inadequate Procedure (There was no

working procedure in place for lifting and

handling of gas cylinders)

Inadequate Communication (Earlier

incident lessons learned involving gas

cylinders were not effectively

communicated to contractor staff)

Lesson Learned

1. Assign trained staff to handle gas cylinders

2. Develop a working procedure/ instructions

on handling gas cylinders

3. Assess fitness/suitability of equipment

design modifications prior to their use.


9

Water Tanker Rollover


E & P

Sahil

07-10-11

During construction activities, a 20 wheeler

water tanker (7000 Gallon capacity) approached

the site. The crew was waiting for permit

Issuing Authority (AI) and the tanker driver

intending to enter the site and park the vehicle

pending offloading the consignment. The there

was an excavated area which was not

barricaded and there was no banksman to guide

the tanker operator. During the maneuvering of

the tanker, the vehicle came close to the

excavation and the ground collapsed resulting

in tanker to loose balance and falling into the

ditch/excavation.

Outcome: The driver/operator escaped unhurt

and the tanker sustained damage.

Inadequate Leadership (Job Performer did

not stop the tanker operator from

maneuvering the vehicle in hazardous

conditions)

Inadequate Audit/Inspection/ Monitoring

(Missing barriers around excavated area were

not identified; site supervisors and job

performer did not control access to the site)

Lessons Learned

1. Mark and barricade areas around excavations

2. Do not move vehicles without banksman in

construction/congested areas

3. Do not allow drivers/operators in work sites

without site familiarization


10

Fall from Elevation

Area Incident Description Root Causes

E & P

Bab

27-10-2011

Blasting and painting work was ongoing at a

water storage tank. There were 11 Scaffolders

and they were tasked with the erection of the

scaffold inside the tank. They had reached the

first level, which was at a height of 2.5 Meters

and they had decked out the platform with a

series of scaffold planks to facilitate the

erection of the second level.

There were some damaged scaffold boards

which were used in the construction of the

working platforms and there was no prior check

or inspection done to assess fitness of

scaffolds. The scaffolder was not using body

harness. While he was transversing across the

unsupported platform, the scaffold plank

snapped at the midpoint and he fell to the

floor. Outcome: He sustained facial injuries

(fractured tooth and wound on upper lip).

Inadequate Leadership (Issuing Authority

issued the permit without checking

scaffolds; Safety professional lacked

knowledge of inspecting scaffold; All three

project management (ADCO, PMC and

SKEC) levels failed to ensure on site

supervision & monitoring)

Inadequate Audit/ Inspection/

Monitoring (There was no mechanism in

place for inspection of scaffold materials;

there was no effective supervision on site)

Lesson Learned

1. Inspect scaffold material prior to erection

2. Do not use scaffold platform without

inspection by a competent inspector

3. Use body harness when working at heights

Assign trained safety professional/s to

inspect scaffolds

11

Finger Injuries from Broken Laboratory Glassware

Area Incident Description Root Causes

SE

Sahil

28-06-

2011

During normal operation at Asab Laboratory,

crude oil samples were tested and after

completing the test, a new helper/labourer was

assigned to drain the sample and wash the

glassware. The sample had volatile hydrocarbons

and the worker tried to insert a cork in the

sample bottle before taking it to washing area.

The labourer was newly assigned to assist staff in

the laboratory and he not aware of hazards of

working with laboratory glassware. When he tried

to insert the cork forcefully, the bottle broke into

pieces in his hands.

Outcome: Worker received cut wound on his

three fingers.

Inadequate Identification of Worksite/Job

Hazards (Risks of using untrained labourer in

laboratory environment were not mitigated;

bottles with glass stopper were not used; Sample

was not stabilized prior to handing over to

labourer for draining and cleaning; right PPE was

not selected)

No Training Provided (Labourer was assigned

to work in laboratory without any job specific

training)

Lesson Learned

1. Prior to assigning any task, ensure

helpers/labourers are trained to perform the task

2. Use Cut-resistant safety gloves when handling

glassware

3. Use sampling bottles with glass conical stoppers

to avoid pushing or struggling with corks

12

Quiz Event True False

1. Damage to Over Head Line (OHL) It is safe to move the topper truck with raised bucket (F)

There were two banksman/flagman to guide the driver (F)

2. Improper Lifting Causing Damage to Forklift A sling was used to tie the joint end (T)

Task involving lifting was assigned to an experienced worker (F)

3. Loss of Containment During Sand Clearance

Work was planned using a mechanical shovel in hazardous area (T)

Assigned staff were not familiar with location of utilities (T)

4. Al Gaith Vehicle Rollover The driver was not familiar to drive automatic transmission vehicle resulting in many harsh brake events (T)

The vehicle was not engaged in 4x4 gears and driven at high speed (107 km/Hr) (T)

5. Hand Injury During Unloading of Gas Cylinder

Untrained staff were assigned to handle gas cylinders (T)

There was a working procedure in place for lifting and handling of gas cylinders) (F)

6. Water Tanker Rollover Site supervisors and job performer did not control access to the site (T)

Banksmaen were guiding the tanker driver during maneuvering (F)

7. Fall from Elevation

Checks were done to assess fitness of scaffold boards (F)

Worker was using body harness when working at heights (F)

8. Finger Injuries from Broken Laboratory Glassware Worker was trained for the job (F)

The bottle broke in his hands when he tried to insert the cork forcefully (T)

(F)

13

HSE Performance

Historical Vs Q1 2011 HSE Performance

ADCO & Contractors LTIF & TRIR (YTD) vs Manhours worked

56

55

57

.36

11

7

32

.3

32

.5

2729

44

.434 4

7

0.28

0.16

0.29

0.70

0.80

0.550.51

0.26 0.090.34

0.63

0.12

0.55

0.36

0.16

0.34

0.78

1.29

0.93

0.810.66 0.68

0

0.2

0.4

0.6

0.8

1

1.2

1.4

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Year

Lo

st

Tim

e In

jury

Fre

qu

en

cy R

ate

/

To

tal R

eco

rdab

le In

jury

Rate

0

20

40

60

80

100

120

140

Millio

n M

an

ho

urs

Wo

rked

Manhours Actual LTIF TRIR

14

Incident Sub Types 2011 (Work & Non-Work Related -265 Events )

BAB

Injury/Illness

63%

Onshore Spill

5%Gas Release

5%

Fire

11%

Property

Damage

16%

ADCO

Gas Release

2%

Fire

6%Onshore Spill

10%

Property

Damage

15%

Transportation

22%

Injury/Illness

45%

BUH

Injury/ Illness

37%

Onshore Spill

21%

Transport at ion

18%

Propert y Damage

12%

Gas Release

6%Fire

6%

DD

Property Damage

40%

Injury/Illness

35%

Transportation

17%

Onshore Spill

4%

Fire

4%

E & P

Fire

6%Property

Damage

17%

Transportation

31%

Injury/Illness

46%

TPO

Injury/Illness

46%

Onshore Spill

27%

Transportat ion

20%

Fire

7%

NEB

Injury/Illness

56%Transportation

19%

Fire

10%

Property Damage

10%

Gas Release

5%

SE

Transportation

29%

Onshore Spill

29%

Injury/Illness

24%

Fire

2%Gas Release

4%

Property Damage

12%

15

Distribution of Incident Sub Types 2011

Fire

E & P

28%

AUH

18%BAB

12%

BUH

12%

NEB

12%

DD

6%

TPO

6%

SE

6%

Gas Release

SE

33%

NEB

17%

BUH

33%

BAB

17%

Injury

E & P

34%

AUH

12%BUH

11%

BAB

10%

NEB

10%

SE

10%

DD

7%

TPO

6%

Property Damage

E & P

34%

DD

23%

SE

15%

BUH

10%

BAB

8%

AUH

5%

NEB

5%

Transportation

E & P

44%

SE

24%

BUH

10%

DD

7%

NEB

7%

TPO

5%

AUH

3%

Onshore Spills

SE

51%BUH

26%

TPO

15%

BAB

4%

DD

4%

16

Incident Immediate & Root Cause Categories

Immediate Causes

Innattention / Lack of

Awareness

25%

Following Procedures

24%Use of Protective

Methods

16%

Work Exposures To

10%

Work Place

Environment / Layout

8%

Protective Systems

7%

Tools, Equipment &

Vehicles

6%

Use of Tools or

Equipment

4%

Root Causes

Work Planning

23%

Management /

Supervision /

Employee Leadership

22%Behavior

14%Tools & Equipment

9%

Work Rules / Policies

/ Standards /

Procedures

8%

Engineering / Design

5%

Skill Level

7%

Communication

5%

Repetitive Immediate Causes

Inattention to footing and surroundings

Improper decision making or lack of judgments

Routine activity without though

Violation by individual

Repetitive Root Causes

Inadequate work planning

Inadequate identification of worksite/job hazards

Inadequate adjustment/repair/maintenance

Inadequate audit/inspection/monitoring

17

Incident Immediate Cause Analysis 2011


Violation by supervisor

18%


26%

Work or motion at

improper speed

14%

Improper position or

posture for the task

13%

Violation by group

5%

Improper loading

5%

Improper lifting

8%

Violation by individual One individual intentionally chose to violate an established

safety practice.

Violation (by supervisor):

A supervisor or other management person either personally violated an established safety practice or directed people under their supervision to do so.

Work or motion at improper speed

The person involved was not working at the proper speed, not taking time to do things safely, e.g., driving too fast, running or adding chemicals too fast or too slow, etc.

EMPD, 21

DD, 13 SAS, 13

BU, 8

BAB, 5

JD, 2 NEB, 2

0

5

10

15

20

25

E P

33%

DD

20%

SE

20%

BUH

13%

BAB

8%

TPO

3%

NEB

3%

Inattention

Failure to warn

4%

Distracted by

other concerns

5%Routine

activity without

though

16%

Inattention to

footing and

surroundings

18%

Improper

decision

making or lack

of judgement

53%

Improper decision making or lack of judgment

This cause is the opposite of violations, which are intentional acts. Unintended human error can consist of perception errors, memory errors, decision errors or action errors. A person’s job performance was affected by their inability to make an appropriate judgment when confronted by an ambiguous situation.

Inattention to surroundings:

The person was not alert to their surroundings and just tripped or ran into something that was clearly visible and obvious.

Routine activity without thought:

The person involved was performing a routine activity, such as walking, sitting down, stepping, etc., without conscious thought, and was exposed to a hazard as a result.

SE, 24

E P, 20

BUH, 7 DD, 7

BAB, 4TPO, 2

NEB, 1

0

5

10

15

20

25

30

SE

36%

E P

31%

BUH

11%

DD

11%

BAB

6%

TPO

3%

NEB

2%

18

Incident Root Cause Analysis 2011

Work Planning

Inadequate audit/

inspection/

monitoring

46%

Inadequate work

planning

39%

Inadequate

preventive

maintenance

9%

Inadequate job

placement

6%

Inadequate Work Planning

The work being done was not planned or was not risk assessed prior to starting that work.

Inadequate audit /inspection/ monitoring

Supervisors did not monitor, inspected or audited the work as planned.

Inadequate preventative maintenance program

The tools or equipment involved in the incident were not covered by a preventative maintenance program, and became unserviceable.

E & P, 19

SE, 12DD, 10

BUH, 4 NEB, 4BAB, 3

TPO, 2

0

5

10

15

20

E & P

35%

SE

22%

DD

19%

BUH

7%

NEB

7%

BAB

6%

TPO

4%

Management Supervision & Employee Leadership

Inadequate

identification of

worksite/job

hazards

73%

Inadequate

management of

change system

4%

Inadequate

correction of prior

hazard/incident

2%

Inadequate

leadership

17%

Inadequate

identification of

worksite/job hazards

The incident was caused by the failure to perform or properly

respond to a loss exposure study, such as Job Safety

Analysis.

Inadequate Leadership The leaders in an area did not set the right direction or tone for

safety or allowed roles and responsibilities for safety activities

to be unclear or undefined.

E & P, 16

SE, 10

BAB, 6 DD, 6 TPO, 6BUH, 5

NEB, 3

0

5

10

15

20

E & P

30%

SE

18%BAB

12%

DD

12%

TPO

12%

BUH

10%

NEB

6%

19

Tools & Equipment

Inadequate

assessment of

needs and risks

37%

Inadequate

adjustment/repair/

maintenance

23%

Inadequate

availability

10%

Inadequate human

factors/

ergonomics

considerations

10%

Inadequate

removal/

replacement of

unsuitable items

10%

SE, 7

BUH, 5

BAB, 4

E & P, 3

TPO, 1 NEB, 1

0

2

4

6

8

SE

33%

BUH

24%

BAB

19%

E & P

14%

TPO

5%

NEB

5%

Inadequate assessment of

needs and risks

The tools and equipment provided were thought to be right,

but proved to be the wrong tools or equipment, because the

risk associated with their use was incorrectly assessed.

Inadequate adjustment

/repair/maintenance

Proper tools and equipment were available, but had not been

correctly maintained or repaired

Behaviour

Improper

supervisory

example

23%

Employee

perceived haste

26%

Inadequate

identification or

critical safe

behaviors

19%

Inadequate

Behavior

16%Improper

performance is

rewarded

16%

Employee perceived haste

The incident was caused by the employee’s perception that

speed in completing the work was required causing laps in

safety considerations.

Improper supervisory

example

Supervisors not giving the proper example to the people working in their organizations.

Inadequate reinforcement of

critical behaviors

A supervisor seeing someone not following the safety

procedures and guidelines and not correcting immediately

is an example of inadequate reinforcement of proper

behavior.

SE, 10

E & P, 7BUH, 6

BAB, 5

DD, 2JD, 1

0

2

4

6

8

10

12

SE

33%

E & P

23%

BUH

19%

BAB

16%

DD

6%

JD

3%

20

Asset Based Causes 2011

Asset Immediate Causes

Root Causes

SE


Awareness

34%


19%

Use of Protective

Methods

13%

Tools, Equipment &

Vehicles

9%

Work Place


9%

Work Exposures To

7%

Protective Systems

6%

Use of Tools or

Equipment

3%

SE

Behavior

16%

Work Planning

20%

Management /

Supervision / Employee

Leadership

16%

Tools & Equipment

11%

Mental State

11%


5%

Work Rules / Policies /

Standards / Procedures

5%

NEB


20%

Protective Systems

20%

Use of Protective

Methods

20%

Work Exposures To

20%


Awareness

10%

Tools, Equipment &

Vehicles

10%

NEB

Management /

Supervision /

Employee

Leadership

33%

Skill Level

11% Tools & Equipment

11%

Work Planning

45%

21


Root Causes

E & P


25%


Awareness

24%

Work Place


15%

Use of Protective

Methods

12%

Work Exposures To

10%

Protective Systems

5%

Use of Tools or

Equipment

5%

Tools, Equipment &

Vehicles

4%

E & P

Work Planning

27%Communication

9%

Management /

Supervision /

Employee

Leadership

23%

Behavior

10%

Work Rules /

Policies /

Standards /

Procedures

9%

Skill Level

10%

Tools & Equipment

4%

BAB


20%

Use of Protective

Methods

20%Innattention / Lack of

Awareness

16%

Use of Tools or

Equipment

16%

Protective Systems

8%

Work Exposures To

8%

Work Place


8%

Tools, Equipment &

Vehicles

4%

BAB

Skill Level

4%Engineering / Design

11%



11%

Work Planning

11%

Tools & Equipment

15%

Behavior

19%

Management /


Leadership

21%

22


Root Causes

BUH


27%


Awareness

23%

Protective Systems

13%

Use of Protective

Methods

13%

Use of Tools or

Equipment

7%

Work Exposures To

7%

Work Place


7%

Tools, Equipment &

Vehicles

3%

BUH

Behavior

18%

Skill Level

16%



3%Communication

3%


9%

Work Planning

13%

Tools & Equipment

16%

Management /


Leadership

16%

DD Following Procedures

34%

Use of Protective

Methods

24%


Awareness

18%

Work Exposures To

16%

Protective Systems

5%

Tools, Equipment &

Vehicles

3%

DD

Work Planning

33%



20%

Management /


Leadership

19%

Mental State

3%

Communication

13%

Training / Knowledge

Transfer

3%


3%

Behavior

6%

23

TPO

Use of Protective

Methods

24%


16%


Awareness

15%

Protective Systems

15%

Tools, Equipment &

Vehicles

15%

Work Exposures To

15%

TPO

Management /

Supervision /

Employee

Leadership

50%Work Planning

17%

Skill Level

17%

Tools & Equipment

8%Behavior

8%

24

Causes of Top Two Incident Sub Types, 2011

Immediate Causes

Root Causes

Injuries

Violation by

supervisor

6%

Routine activity

without though

6% Mechanical Hazards

6%

Inadequate guards or

protective devices

6%

Congestion or

restricted motion

6%

Improper position or

posture for the task

9%

Improper decision

making or lack of

judgement

12%

Lack of knowledge of

hazards present

18%

Work Planning

32%

M anagement /


Leadership

30%



7%

Training / Knowledge

Transfer

7%


4%

Communicat ion

4%Behavior

4%

Transpor

tation

Improper decision

making or lack of

judgement

21%

Inadequate tools

5%

Violation by supervisor

6%

Work or motion at

improper speed

6%


6%

Slippery floors or

walkways

6%

Routine activity

without though

6% Inattention to footing

and surroundings

6%

Inadequate workplace

layout

6%

Lack of knowledge of

hazards present

10%

Inadequate guards or

protective devices

5%

Improper use of

equipment

5%

Behavior

23%

Management /


Leadership

22%

Work Planning

22%

Mental Stress

11%

Physical Condition

11%



11%

25

Keep him safe

ABU DHABI COMPANY FOR ONSHORE OIL OPERATIONS

(ADCO)

2011 q4 learning from incidents

Documents