External Safety Alert circulated by Saudi Aramco Drilling Operational Excellence and Compliance Division for Sharing purposes

Only

Pipe fall from skids resulting in

2 fatalities of Contractor
employees. Two employees
received fatal injuries when a
section of 36 inch gas export
line they were working under
or near fell off the
approximately 2 ft high
temporary wooden supports
(skid stacks) and crushed them.
The two employees, a grinder
and a welder, were completing
a construction weld repair at
the north-eastern-most weld
joint of a c.120 meter curved
section of the export pipeline.

What Went Wrong?

The work permit system in place was rigorously applied to the known risks,
but there was a lack of awareness of:

 The hazard presented by temporarily suspended pipes, which constituted

a dynamic load / dropped object hazard.
 The hazard of thermal expansion, differential heating, and residual pre-
stress forces contributing to the lateral movement of curved pipe
segments.
Corrective Actions and Recommendations:

CAUSAL ANALYSIS
 The curved pipeline section elongated and deflected due to thermal
expansion, which in combination with other forces, such as pre-stress,
resulted in the incident end of the pipe moving inwards relative to the
radius of curvature of the pipe, by a distance exceeding the width of the
northeast end skid stack, and falling to the ground.
  The lateral movement of the curved pipeline section was initially
restrained by friction between the pipe and the skid stacks and potentially
by wedging of the installed chocks. As stored energy continued to
accumulate in the curved pipeline section, the restraining capability of the
support skids / chocks was exceeded, and the stored energy was released
in a rapid movement of the incident end of the pipeline towards the truck
(pictured). Prior to that release, the pipeline appeared to be in the normal
position on the skids.
 The hazards revealed by this investigation (thermal expansion, differential
heating and pre-stress, resulting in elongation and deflection of long
curved pipe section, as well as the broader hazard of pipelines dropping
from temporary support skids) were not appropriately recognized.

SUMMARY OF LOCAL ACTIONS

1. Develop design and monitoring methods and procedures to reduce the
probability of unplanned fall of temporarily elevated pipeline sections caused
by movement. Ensure supports are large enough to accommodate the worst
possible movement and do not use chocks to constrain / restrain the lateral
movement of curved pipe, but rather predict and accommodate for such
movement.
2. Identify those tasks that place individuals at risk of injury caused by
movement / falling of the pipeline and ensure that a secondary barrier is in
place.
3. To review all current temporary pipeline supports across the project (e.g.
wooden, skidding and sand berm supports) to assess suitability, stability and
margin against axial and lateral pipe loading.

KEY LEARNINGS TO SHARE

1. Recognize that suspended pipelines represent dropped object (working
underneath) and stored energy (working alongside) risks, and fully consider
these risks in associated job hazard analyses and risk mitigations.
2. While conducting risk assessments, in addition to focusing on obvious
hazards of main work activities, ensure rigor in identifying less obvious and
latent risks that could materialize under certain conditions.
3. If activities are to be undertaken in accordance with industry custom and
practice, make sure these requirements are clearly communicated to those
undertaking the task, fully understood by all stakeholders (including
permitting authorities) and clearly documented.