Fatality during cementing operations

Cause & Consequence

• Trapped or crushed

Incident Location

Drilling unit

Incident Activity

Drilling, workover

Incident Info Source

Step change in safety

Specific Incident Equipment

Cement Head assembly including all valves and associated pipework.

Lessons Identified

The Job Safety Analysis eas NOT conducted with all participants in the task.The valve was not opened to ensure there was no pressure in the cementing head.Pressure build up was not checked prior to removing the bolts.The Well Head Engineer began the task after being told to WAIT until the cementing supervisor was on site.

Incident Recommendations

No work to start before all involved personnel being present and a prejob meeting being conducted.Complex tasks that involve multi disciplines need to be properly and systematically undertaken through the use of detailed work procedures.No critical task process to be modified without the management of change process being followed.Assume that equipment with a capacity to be under pressure is in that state until it can be proved otherwise.Compliance with and the effective use of pre job meetings, making it a condition of employment.JSA's are not substitute for detailed instruction guides, and should be seen as a supplement to the guides.Every critical task requires detailed instruction procedures.