The U.S. Department of the Interior Bureau of Safety and Environmental Enforcement (BSEE) Gulf of Mexico OCS Region recently issued a Safety Alert regarding a fatality that occurred during platform well plug and abandonment activities. The findings indicated supervision, operational, equipment and organization errors. While the work team had conducted a pre-shift JSA meeting, the meeting did not address all potential hazards (including the fatal hole into which the worker fell), was not attended by all involved parties (including the worker who was later fatally injured) and did not included a unique, signed JSA document.
A work team was conducting well plug and abandonment activities to decommission a production platform this past April. The activities took place at night, and equipment included a power swivel skid, casing jack and crane. The roustabout worker was acting as a rigger to help control the load of the power swivel as it was being moved from atop the well. When the power swivel was lifted above the well access opening in the deck on the platform, the roustabout either stepped or was dragged by the load into the opening. Night medevac callout was delayed due to confusion in emergency planning, and the worker’s fall into the opening resulted in his death.
A BSEE investigation team indicated several factors contributed to the accident, a few of which are highlighted below:
• The pre-lift meeting did not discuss the existence of the hole beneath the power swivel, which would be exposed once the swivel was lifted off of it. Therefore, no fall protection was provided as required by company policies, BSEE, and USGC.
• The pre-shift JSA meeting also did not address the hole in the main deck beneath the power swivel, and was not attended by all involved parties (including the roustabout).
• No signed, unique JSA document was created.
• The lighting may have been inadequate for a night operation.
• Equipment on the platform was positioned poorly and interfered with the crane operation:
o The power swivel skid was equipped with two “tag lines” that were only three-feet long, requiring riggers to be in close proximity to the load.
o The tag lines were attached to the power swivel in such a way that they would drag across the open hole as the skid was moved.
o A rudimentary, inherently dangerous, “pipe rack area” allowed the box ends of 15 joints to protrude over the skid, requiring riggers to manually maneuver the load to keep from hitting the pipe.
o The temporarily stored casing jack interfered in the crane operator’s vision of the lift.
• There was no clearly designated, direct supervision of the lift because of multiple responsibilities assigned to the only supervisor on duty.
• The supervisor and company man on site did not have an emergency plan with medevac procedure and contact information readily available.
In developing a JSA, it is important to meticulously and thoroughly evaluate each aspect of the job ahead of time. Including input from workers who have performed the task in the past may be of particular value, as they can identify hazards, control measures and job steps a supervisor might not be aware of. The JSA can also be used to designate specific tasks for each person, and enable the supervisor to discern if additional workers or supervisory staff will be necessary, before beginning the job.
It may also be necessary to designate a pre-task JSA to include worksite preparation activities, such as adequate lighting and visibility, clear walkways and lines of travel, moving and stowing of unnecessary equipment, and designated “safe” areas for spotters and supervisors.
In addition to clearly designated supervision, a comprehensive lift plan and fall protection, easily retrievable emergency and medevac plans, standard operating procedures and a work-site risk assessment, a thorough and well prepared JSA covering all risks and hazards associated with the task can aid in safe performance of jobs similar to this. By utilizing a worker sign-in sheet (now available in the JSABuilder individual JSA dashboard), supervisors and health and safety officers can ensure all workers have been briefed on the risks and controls, and are fit to perform their assigned tasks.