GUPCO Kamose Fatality Incident

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GUPCO Kamose Fatality Incident

• Toolbox Talk Lessons pack

Prepared By Dave Goodwill for Dave Blevins
Presenters Name Title Department
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Background

• Mohi Mohammed Gouda was a Barge Engineer on the
  EDC rig Kamose working for BPs GUPCO joint
  venture operation offshore Egypt.
• On 18th June 2001 he was involved in an incident
  during a lifting operation he was supervising.
• He fell 4m and sustained serious head injuries.
• Several weeks later he died of these injuries
  having never recovered.

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Learn from a fatal error

• This accident would not have happened if existing
  procedures and good practice had been used
• What will You Learn from Mohis death ?
• Could you and your workmates be at risk of a
  similar incident ?

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The Job

• Your Task
• Replace the crane engine
• Your Procedure
• The job has been done before using the spare
  crane and another available rig crane
• Youve identified a better way
• But youve never done it this way before

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Your Plan

• Your Equipment
• The other crane
• Rigging equipment
• An air winch from another location on the rig
  welded to the generator room roof
• Your Team
• You (supervisor)
• Crane driver
• Asst crane driver
• 2 x Roustabouts

What else do you need to do ?
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How it was done

• A permit is not being used
• A JSA has not been carried out
• The welds fixing the winch to the deck have not
  been tested
• The old engine has been successfully removed
  using the method.

Would You be happy with this ?
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The Incident

• What happened
• The weld between the winch and the roof failed
• The winch was dragged over the handrail
• Mohi (the supervisor) was first trapped between
  the air line and the handrail
• He was then forced over the handrail and fell 4m
  to the deck below sustaining serious head
  injuries

He died in hospital of these injuries several
weeks later
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The Key CausesWhat Do You Think ?

• Now that you know what happened
• What do you think were the key causes ?
• What should have been done here ?

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The Key CausesThe Investigation Findings

• Three Critical factors identified
• The weld was inadequate. It was neither designed
  for the job, carried out by a certified welder or
  properly tested.
• No permit to work , risk assessment or Safe Job
  Analysis (JSA) was completed.
• The previous procedure, known to be sound, was
  not followed

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Could something like this happen on your rig ?

• Think about it. Do you always
• Use established and proven procedures ?
• Carry out a thorough risk assessment before using
  a new procedure ?
• Carry our work like this under the control of a
  Permit To Work System ?
• Conduct JSAs and pre job safety meetings ?
• Ensure that load bearing welds are properly
  designed, inspected and tested ?

If you answer no to any of these it could
happen to you