koc wsg accident review forum mar 2017 updated

Accident Review Forum

WELL SURVEILLANCE GROUP

Form 1st April 2016 – To 30th March 2017

H S E M a j o r I n d i c a t o r s

Acc idents

1st Apr.2016 : 28st Mar 2017

+2

1st Apr.2016 : 28st Mar 2017

+2

WSG QHSSE Review

1st April 2014 : 31st March 2015


Acc idents

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Motor Vehicle Accident (MVA)Well Services Technical (NK)

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Description Of Incident

incident occurred around 10:30 but the driver and passengers are fine alhamdullellah and no injuries. While driving in north Kuwait high way at KM 43 already exited the abdally road took right side road The road is just 2 lanes one for each direction.and In the middle of the road the driver decided to take left to go off road.While turning left on the opposite direction lane a 3rd party big trailer truck hit the car from the back. The truck was driving trying to overtake our WSG engineer vehicle and most probably he was in the blind spot.WSG Engineer was driving a contractor vehicle and having 2 other WSG passengers and thanks god no injuries happened as all were fasten their set belt,

112 & 160 was informed and all 3 employees are fine. No one got hurt but the driver felt some dizziness and went to the hospital for check up by ambulance helicopter which reached the location within 5 minutes from reporting the driver dizziness

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Moderate Motor Vehicle Accident (MVA)Well Services Technical (NK)

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review

1st April 2014 : 31st March 20151st Apr.2016 : 28st Mar 2017

Incident Photos

WSG QHSSE Review


Minor Motor Vehicle Accident (MVA)Well Services Technical (S&EK/WK)/ WSG

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Description of Incident

The accident took place in Ahmadi. WSG Engineer was on the left side on the road. WSG Engineer Driving with around 80 – 90 KM/hr speed and suddenly the road got closed because of a problem in the road which make the two ways to one way only, he tried to catch the break but it was failed, then he tried to slow down his speed as much as he can but unfortunately he hit a bus on the back right side. Minimal damage happened to his car on the left front side.

Immediate Action Taken

Stop KOC employee from driving KOC vehicle until he attend the defensive driving course again as refreshment

AC20160630121002

1st Apr.2016 : 28st Mar 2017

http://mcsadd1:8082/MyHSSE/Accident.aspx?modId=AC20160630121002&SearchMode=1&ModeType=edit&modType=3&Search=1

WSG QHSSE Review


Minor Motor Vehicle Accident (MVA)Well Services Technical (S&EK/WK)

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Description of Incident

While driving in Gaber Al-Ali area and in the main road the Taxi stopped suddenly in a traffic light and unfortunately, the WSG driver failed to control the company vehicle and smash the Taxi from the back with light damages of both vehicles.


Stop KOC employee from driving KOC vehicle until he attend the defensive driving course again as refreshment

AC20160630121002

1st Apr.2016 : 28st Mar 2017


WSG QHSSE Review


Minor Motor Vehicle Accident (MVA)

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Incident Description

1st Apr.2016 : 28st Mar 2017

The accident took place in Burgan area at the wraha roundabout toward ahamadi . WSG employee was on the left side on the road. behind a bus which did a hard breaking before the speed pumped which forced the driver to do a hard break, and while holding the breaks my right front tire exploded which forced the car to slip toward the right while breaking and by that I hit the edge of the car in front which pushed his car toward the car on the right side of the road

WSG QHSSE Review


Incident Photos

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Rout Causes

1) High temperature could cause damage to the tires. 2) Not following rules / procedures (Speeding)

3) Lack of Training (Short following distances and wrong reaction for punctured tire)

Immediate Cause

right front tire exploded

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Action taken to prevent the recurrence

1) Car providers should check on tires also not just oil filter every car service and change the tire after 50000 Km of driving.

2) KOC employee to join a defensive driving course A.S.A.P before driving any related KOC vehicles.

3) To issue HSE Alert about the incident which emphasize about the importance of following the speed limits and importance of following distance.

AC20160620131002

1st Apr.2016 : 28st Mar 2017


WSG QHSSE Review



Acc idents

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Vehicle Accident (MVA)Rig Road Opposite to GC 24 North Kuwait

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Incident Photos

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Immediate Causes Root

1st Apr.2016 : 28st Mar 2017

• Lack of attention/forgetfulness, • Not following rules/Procedures/Permit • Inadequate warning system/signs • Lack of training

WSG QHSSE Review



AC20170327211004

1st Apr.2016 : 28st Mar 2017

• Reported to 160, Alkhorayef Management & WS HSE Specialist• Investigation committee formed and TOR issued

http://mcsadd1:8082/MyHSSE/View.aspx?modId=AC20170327211004&modType=3

WSG QHSSE Review


LTDMotor Vehicle Accident (MVA)

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Incident Photos

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Immediate causes of incident

1st Apr.2016 : 28st Mar 2017

Unsafe Practices (Acts & Behavior leading to the incident):• Not following rules / procedures / permits: Driver was driving before getting defensive driving training.

• Operating or working at unsafe speed/short cutting: He was over speeding (58 Km/Hr while speed limit 40-45 Km/Hr).

Unsafe Conditions (Conditions leading to the incident): • Slippery or uneven surface: It was on a Rig Road/ sandy road.

WSG QHSSE Review


Root Causes / Contributing factors

1st Apr.2016 : 28st Mar 2017

Personal Factors (Weaknesses associated with people)• Inattention• Lack of training• Lack of knowledge/skill experience

WSG QHSSE Review


Action Taken

AC20170305061001

1st Apr.2016 : 28st Mar 2017


WSG QHSSE Review


Motor Vehicle Accident (MVA)

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Incident Photos

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review



1st Apr.2016 : 28st Mar 2017

2. Lack of respect for procedures Failed to adopt SAFE DRIVE – Defensive driving techniques

1. Inattention Distraction during driving would have caused for a delayed response by driver.

WSG QHSSE Review


Action Taken

AC20161127161003

1st Apr.2016 : 28st Mar 2017

• Refrain the concerned employee from driving until further notice.• Re-attend Defensive driving training.• Warning letter to the concerned employee for “ non HSE compliance” • Stand down meeting arranged on the 3rd December 16 to highlight the incident finding and

precautionary measures. • Safety talk with all employees on “ Driving Safety”• Prepare incident alert and cascade among all other SGS locations.


WSG QHSSE Review


Severe Motor Vehicle Accident (MVA)

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Photos of Incident 1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Immediate causes of incident

• Informed 160 and KOC HSE advisor.

• Making sure the involved person had no injuries.

• Taking some phots from the incident scene.

• Started the police reporting process.

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review



• Excessive physical / mental stress

• Lack of knowledge / skill experience

• Lack of training

• Inadequate maintenance / inspection

• Wear & Tear

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Action Taken

• Involved driver to be send for refreshment Defensive Driving training and practical driving test.

• All four Tires to be changed together every 50000 to 60000 km. working distance with rotation of the tire every 20000 KM.

• All Tires to be filled with Nitrogen gas which having better working quality and less puncture incident probability.

• Review the quality of the IVMS report and the scoring process.

• To issue HSE Alert to be shared as lesson learned with all employees and KOC

AC20160709221001

1st Apr.2016 : 28st Mar 2017


WSG QHSSE Review


FatalityMVA

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Incident Photos

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


WSG QHSSE Review


Minor Motor Vehicle Accident (MVA)

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Incident Photos

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Roots cusecs

Fatigued due to lack of sleep.Failure to adopt defensive driving techniques.Lack of manpower for the area with lack of days off and long working hours.

Immediate Causes

The vehicle user fell asleep behind the wheels while drivingFailure to maintain adequate distance from the vehicle in front.Routine activity like long/continuous driving & long shifts during fasting periods.

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review



• Refresher training on Defensive Driving to the vehicle user who met with accident.• Hiring of Third party drivers to work for the field staffs in different areas.• Awareness session on Fatigue Management During Driving to all Field Staffs.• An internal memo released on non usage of company vehicles by field staffs after work

shift. • Review manpower working in the area and hiring enough people to do all the required

operational actions.• An HSE Alert distributed company wide.

AC20160623161004

1st Apr.2016 : 28st Mar 2017


WSG QHSSE Review


Vehicle Accident (MVA)

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Incident Photos

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Immediate Causes Root

Failure to brake early/Lack of attention

Failure to comply with defensive driving procedures

Root Causes:

Driver had an eye medical condition that should not permit him to drive

on duty

Periodical Eye check up was not implemented on annual basis to ensure

getting an update on eye fitness to drive on duty.

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


ACTIONS TAKEN

The employee’s driving activities were suspended until eye condition improvement is realized

Stand Down for all employees explaining the accident and how it could have been avoided

Refreshing defensive driving assessment by 3rd party for all drivers

Review and amendment of Strengths of Defences Matrix for Motor Vehicle Operations, by adding eye vision check up on annual basis instead of biannual

Sharing lessons learned thru WSG incident review meeting & KOC exclusive workshop for incident review

Send out Alert covering accident direct, root cause and communications with all employees

AC20160509151003

1st Apr.2016 : 28st Mar 2017


WSG QHSSE Review


Lesson Learned From All MVA

The Main General Root Causes:

Lack of Training and Awareness.

Lack of PMC.

Lack of supervision and follow up.

Inattention and Distraction.

Fatigue .

1st Apr.2016 : 28st Mar 2017

Accident Review From 1st April 2016 - 31st March 2017


Form 1st April 2016 – To 31st March 2017

Lost Time Injury

WSG QHSSE Review


WSG QHSSE Review


Lost Time Injury InvolvingPersonnel

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


WSG QHSSE Review


ROOT CAUSESThere was Poor communication between the two parties on where todrop and rest and how to drop the item

Immediate Action

1. The two parties where already fatigued after carrying out a nitrogen activation operation2. The half loop has a swivel area which makes it awkward and difficult to maintain a centreof gravity while lifting3. The Half loop is heavy and can only be carried by minimum of two personnel

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Action item taken • Toolbox talk should be done at the end of every job, before rigging down and this should be documented.• Refresher course should be done for IP and the entire crew members • The crane should be used to pick up heavy items above 40kg, Above 20kg two persons

must lift it. • Put weight signs on irons. This should be included in the company procedure• Impact hand glove must be used when rigging up and down. This is added to the procedure.• Implementation of hands free lifting procedure. Use of hands free tools• Activate 160 in any incident

AC20161020151005

1st Apr.2016 : 28st Mar 2017


Accident Review From 1st April 2016 – 28st March 2017



Environmental Incidents

WSG QHSSE Review


Total 6

WSG QHSSE Review


WSG QHSSE Review


Spill Incident ReviewCrude Oil Spill/Release at SEK BG 809

Environmental Incidents

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Incident Photos

WSG QHSSE Review


Immediate Causes

1st Apr.2016 : 28st Mar 2017

Polished rod was broken 1 inch below stuffing box flange.Flow line was not equipped with Check valve to avoid return from flow lineto the wellbore

WSG QHSSE Review


Rout Causes

1st Apr.2016 : 28st Mar 2017

Well head and production tubing not concentric, generating deviation and keepingpolished rod bended• There was no Check valve installed on the flow line to prevent back flow.

WSG QHSSE Review



AC20170121121001

1st Apr.2016 : 28st Mar 2017

• Well program must ensure proper alignment of wellhead and tubing string beforeperform the RIH.• Check valve must be installed in the flow line to avoid back flow.• WFT must verify the availability of Check valve at each installation, and to be added asa part of the well Commissioning Report.• WFT to verify the installation of check valve on all existing dual completions well.• Install ejection clamp on drive head (as an Engineering control) on all dual completionwells


WSG QHSSE Review


Diesel Leakage Environmental Incidents

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review

1st April 2014 : 31st March 2015Photo of Incident 1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Immediate Action

• Closed the valve and clogged the diesel leakage.

• Retrieved the spilled oil

• Plans to remove the contaminated sand from the location and to be replaced with normal sand.

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Rout Causes

As Job Factors,

Unclear or inadequate work procedures / instructions Inappropriate design

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review



1) to remove the contaminated sand from the location and to be replaced with normal sand.

2) Fully disable the changeover option between internal and external fuel tank usage after discussing the issue with KOC WSG staff and agreed about the suitable option.

3) Update the generator use procedure to have a clear fully disabling option for the changeover option between internal and external fuel tank usage.

4) Organize an awareness session for all Al- Khorayef manpower explaining the procedure and make sur the message is clear for all.

AC20161106101001

1st Apr.2016 : 28st Mar 2017


WSG QHSSE Review


Diesel Leakage Environmental Incidents

BG-0913

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


WSG QHSSE Review


Immediate Causes

Unsafe Practices (Acts & Behavior leading to the incident) Improper positioning

Fuel filter return hose damaged due to improper positioning the hose which affected by vibration of the generator Unsafe Conditions (Conditions leading to the incident)Erosion and Excessive vibration

As explained above the hose martial erosion due to the wrong position of the hose and generator vibration

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Rout Causes

Personal Factors (Weaknesses associated with people) Lack of knowledge / skill experience

Which lead to the wrong positioning of the hose

Job Factors (Insufficiently organized work procedures or weaknesses associated with the workplace

Inadequate maintenance / inspection

There is no rules to change the hose after a certain working hours and the manufacture recommendation was unknown

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review



1) Make sure all the installation crew members will be aware about the Generator Vibration hazards and trained about the right hose position to prevent the tear because of the generator vibration.

2) Use Sleeves or wear pads to secure Hose to avoid rubbings on surfaces.

3) Communicate with the hose manufacture to have the documented recommended replacing manufacture recommendation after a certain working hours.

4) Add the recommendation to all maintenance protocol and communicate it with KOC WSG contract controller to communicate with other business partners

5) Add inspection of all hoses in the inspection maintenance check list.

6) Issue a HSE alert about the incident and share with KOC WSG contract controller to communicate with KOC employees and other business partners .

AC20161107131001

1st Apr.2016 : 28st Mar 2017


WSG QHSSE Review


Diesel LeakageEnvironmental Incidents

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Incident Photos

WSG QHSSE Review


Immediate Causes

Diesel primary filter crack at bottom.

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Rout Causes

Diesel primary filter crack at bottom.

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review



Close mentoring to be exercised to check adequate maintenance , safety and security of generator working in the field.

AC20161107151004

1st Apr.2016 : 28st Mar 2017


WSG QHSSE Review


Asset Damage with Environmental Spill SEK

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Incident Photo

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Immediate Causes • The tank incorrectly placed on trailer and supported by two belts.• One of two belts not tighten properly.• When trailer on roundabout one belt released.• The tank move and the other belt cut by the sharp edge of tank basement.• The tank fall on the left side of trailer.

Rout Causes

• Falling / incorrectly placed objects• Inadequate tools and equipment• Lack of attention / forgetfulness• Lack of knowledge / skill experience

1st Apr.2016 : 27st Mar 2017

WSG QHSSE Review


Action Item taken

• Give awareness to all employees regarding tie down equipment's on trucks and inspection of supporting belts.

• Administration actions taken against involved employees.• Review the DDC (Defensive Driving Course) for all drivers.• Review the required WSG minimum HSE training for all new employees including

backing & lifting courses.• Implement and using a vehicle inspection before start moving the vehicles via a

checklist form.• Apply the Road risk assessments for all trips.• Apply the PMP (Preventive maintenance program) for all vehicles.• Apply the Stop Work Authority by all employees.• Encourage all Employees to report any HSE Concern.• Inspect all chains & belts used in the company.• Issue HSE Alert & distribute for all employees.

AC20160710151001

1st Apr.2016 : 28st Mar 2017


WSG QHSSE Review


KOC Weatherford 46982

Crude Oil Spill/Release at SEK - AH-183Environmental Incidents

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Incident Photos

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Root Causes

Lack of procedures (Standard Operating Procedure (SOP)), as flex-insert running procedures are not covering securing the well in case of job did not complete (polished rod/ stuffing box installation).Lack of second barrier, as only one barrier was in place to control in case of well kick as required by well control procedures.Lack of supervision, as No monitoring exist on well after securementLack of certification evidence recording BOP testLack of Training, as well control training was not conductedRecommendations are suggested below to improve systems Lack of Planning.Lack of maintenance. Lack of Risk Assessment.

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


• provide specification of the rubber element for the BOP (elastomer seal) • provide suitable Tank Capacity for the brine (150 bbl) to be used for well killing• equip the unit with suitable lightning to ensure its capable to work during night time• Procure a Safety Valve to be used in case of emergency and uncontrolled leak.• Have a continues monitoring on well in case of well secured without job completion• Implement a Pre-Job Check list and witnessed functional BOP tests to be part of this PJC, and procure

devices to record pressure test • All supervisors will attend Well control training• procure devices to record pressure test in addition to procuring data acquisition system to FBU• All employees who will supervise the flush by unit to attend Well Control course • Issue HSE alert as lesson learn from the incident


AC20160525091002

1st Apr.2016 : 28st Mar 2017


WSG QHSSE Review


Actions TO prevent the recurrence

AC20160525091002

1st Apr.2016 : 28st Mar 2017


WSG QHSSE Review


Lesson Learned From All Spill Incidnets


Lack of Maintenance

Lack Procedure / Procedure not followed

Lack of supervision

1st Apr.2016 : 28st Mar 2017

Accident Review From 1st April 2016 – 28st March 2017



Fire/Explosion Incidents

WSG QHSSE Review


Total 2

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


WSG QHSSE Review


Generator Fire

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Incident Photo

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Roots Causes

• Personal Factors (Weaknesses associated with people) • Misperception of risk

• Standby Generator spare cable kept inside generator aggravated fire• Job Factors (Insufficiently organized work procedures or weaknesses associated with

the workplace

• Poor Housekeeping standard• Materials should not be kept inside generator• Lack of maintenance

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Immediate Causes

• Unsafe Practices (Acts & Behavior leading to the incident)• Improper loading, positioning, or storing of materials• Standby Generator cable was stored inside near filter aggravated fire• Unsafe Conditions (Conditions leading to the incident)• Fire & Explosion Hazard• Failure of cooling fan in Generator or Bursting of battery which resulted in ignition

(Vendor to investigate and confirm).

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


Action Item Taken

AC20160814141004

• 1.Communicate with the vendor to confirm the root cause so that recommendation can be finalised.

• 2.To inspect and remove immediately unwanted materials stored in generators

• 3. Add materials shall not to be stored inside Generator in the inspection maintenance checklist.

• 4.Review Generator Maintenance checklist is in line with vendor manual

• 5.Awareness Training on Housekeeping to be provided to all employees in Operation

• 6. Issue a HSE alert about the incident and share with Alkhorayef/ KOC WSG contract controller to communicate with KOC employees and other business partners

1st Apr.2016 : 28st Mar 2017


WSG QHSSE Review


Generator Circuit Breaker Burnt

1st Apr.2016 : 27st Mar 2017

WSG QHSSE Review


Incident Photo

Circuit Breaker(Sample) Generator

(Sample)

Burned Circuit Breaker

1st Apr.2016 : 27st Mar 2017

WSG QHSSE Review


Roots Causes

Internal failure of the circuit breaker whereas the contactor was partially latched due to defected “Solenoid” (Internal component) that prevented the electrical busbar to be fully engaged.This leaded the circuit breaker to generate heat, sparks then fire on the system.

1st Apr.2016 : 28st Mar 2017

WSG QHSSE Review


• Report the incident to KOC and SLB HSE.• Removed and replaced the generator with another one and restarted HPS the next day.• Initiate investigation with Fawars to identify the root cause and prevention plan.

Action Item Taken

AC20160814141004

1st Apr.2016 : 28st Mar 2017


WSG QHSSE Review


Lesson Learned From All Genertor Fire Incidents


Lack of Maintenance

Lack Procedure / Procedure not followed

Lack of supervision

1st Apr.2016 : 28st Mar 2017

koc wsg accident review forum mar 2017 updated

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