INCIDENT:

1
HSE LEARNING

• INCIDENT
• Floorman was standing on the rig floor cover
  plate slipping drilling lines. The plate moved
  causing him to fall into the bottom box beam.
  He broke his jaw bone. Pics Next Page
• CAUSES
• Slip drill line procedure with old mast /sub-base
  design was used.
• Rig management did not report the inadequate /
  incorrect procedure or the lifting of the floor
  plate observed to base management.
• No MOC was raised to risk assess the change and
  put in appropriate mitigations to control and
  communicate the change.
• The JSP / TRIC and TBT failed to have a plan,
  identify the associated hazards and risks and put
  in adequate barriers to manage removal of the
  floor plate.
• The supervisor (NTP) was operating the utility
  winch, instead of supervising the job.
• LEARNINGS
• Enforce Strict compliance to Management of Change
  (MoC) process.
• Supervisor(s) are to supervise the job and stay
  away from getting manually involved.
• Immediately update procedures after a change has
  been approved for implementation.
• Refer to and Use the procedure / JSP / JHA
  during planning every job.
• Identify all associated hazards, assess their
  risks and put in effective mitigations prior to
  starting any job .

Key Learning Struggling to do a job? STOP!!!!
THINK and work a safe solution.
Broken Jaw
Use this Alert Discuss in Tool Box Talks and HSE
Meetings ? Distribute to contractors ? Post on
HSE Notice Boards ? Include in site HSE Induction
Contact MSE511 for further information or visit
the HSE Website Alert No 91
LTI 11 - 2012
July, 2012
2
HSE LEARNING
Broken Jaw
Use this Alert Discuss in Tool Box Talks and HSE
Meetings ? Distribute to contractors ? Post on
HSE Notice Boards ? Include in site HSE Induction
Contact MSE511 for further information or visit
the HSE Website Alert No 91
LTI 11 - 2012
July, 2012