Cause & Consequence
Incident Info Source
Step change in safety
Specific Incident Equipment
Lockout procedures were overlooked.There was a 'percieved' pressure of the operator rep to perform the task.No TBT took place prior to commencement.The act should have been halted in accordance with the company job observation programme.No 'Simops' coordination, ie drilling and maintenance.Communications within the drill crew to inform the driller of maintenance activities were lacking.Lack of proper training to most personnel.
Division management emphasised the following:
- To take time to correctly comply with company procedures.
- Compliance and understanding of the STOP processes.
TBT or similar to be held prior to commencement of tasks.Better planning to be implemented.SIMOPS needs to be better planned Training in lockout procedures for all rig personnel.