DRAFT: Shell E

1
DRAFT Shell EP HSE Learning Bulletin
Location TO Expedition Date 4 June 2007
Ref. No. Fountain Actual None Potential
4C
What Happened Schlumberger cementing unit
operator had just finished pumping chemical wash
and spacer and was cleaning up prior to start
mixing and pumping cement. The operators
helper, who was assisting in the cleanup and
preparation, noticed a lump of hard cement on the
bottom of the mix tank. Without being instructed
or informing anyone, the helper climbed into the
tank to clean out the cement. At this point, the
drilling engineer who was on the cement unit
noticed the helper in the tank. He immediately
stopped the operation and ordered the helper to
exit the tank.

• Root Cause Analysis
• No Permit to Work in place
• No Mechanical or Electrical isolation in place,
  no Lock Out / Tag Out
• No communication that the helper was entering the
  tank
• Lack of awareness by the helper of the hazards
• Main Learning Points, Actions
• More and better communication with personnel on
  the hazards of activities like this dont take
  anything for granted that people understand this
  (need to show the Nigeria Socotherm incident
  video on tank entry, LOTO)
• Lock Out /Tag Out procedure needed
• Breakdown in Permit to Work process some
  routine procedures are apparently not following
  PTW
• Discuss learnings with D/S and our other cement
  contractors

• View down into the mixing tank where the
  operators helper entered

• Note A Tripod Beta is being conducted on this
  incident, so this report may be revised.