Case 2 - Slip and Fall Accident Study

Manual Title : Safety and Environmental System Manual MANUAL NUMBER:

Form Name : Investigation Follow-Up Report
ISSUE DATE:
Form No. :
01-Nov-04
REV. DATE:
01-March-07
SERIES No: ISSUED BY: APPROVED BY:
PAGE 1 OF 12
Level 2 QHSE CEO

SECTION A – ACCIDENT/INCIDENT OR RIG DETAILS
¨ Fatality ¨ LTA ¨ Pollution Event ¨ Recordable Injury ¨ First Aid ¨ Major Near-miss
¨ Illness ¨ RWC ¨ Incident
rd
Rig Contractor/3 Party Facility (rig, boat etc)
Rig Name: Rig Name:
rd
Location: 3 Party Co:
Facility PIC: Facility PIC Name:
rd
Operator: N/A 3 Party Co Supervisor’s
Name:
AOS Supervisor AOS Supervisor’s Name: (if
Name:(If not PIC) not PIC)
Title: Night pusher
Operators’ N/A
Supervisor’s Name:
SECTION B – DETAILS OF ACCIDENT/INCIDENT

Location on the Rig: Port side Hull- Stern to 10 Date and Time of 31 st July 11
meters from the bow Incident:
Job being Undertaken: Shipyard / SPS Program Date and Time 31 st July 11 03:00
Reported:
Activity at time of SPS Permit to Work COLD: 5174
Incident: No.
Description of Incident:
On Sunday 31-07-2011 at approx 03:00 Am IP had been tasked all through the night to keep barge clean as mud was
being removed from the mud pits via holes in the bottom of the hull (collected in1 ton big bag) then removed via
forklift.
IP had been cleaning most of the night and was due to go for his coffee break. While leaving the barge he had a
moment of lapsed concentration and slipped on the barge and put his right arm down to break his fall. He is one of
the biggest guys on the rig and that did not help his cause.

Page 1

ISSUE DATE:
Form No. :
01-Nov-04
REV. DATE:
01-March-07
PAGE 2 OF 12
Level 2 QHSE CEO

SECTION C – INJURY/ILLNESS INFORMATION
Report No. (Code/No./Year): 10-04-2011
Last Name: Badaboom First Name: Mohamed ¨ Male ¨ Female
Occupation: Roustabout
Employer:
Address: Cairo
Phone: 016-2226612482
Status of Injured/Ill Person: ¨ XXX ¨ XXX Contractor ¨ Operator ¨ Operator Subcontractor ¨ Visitor
Experience in Occupation: 08 Months Experience in Present Position: 08 Months
Time into Tour: 07 Hours : Days: 10
Nature of Illness/Injury and Treatment Given:

Small trauma at the wrist joint area with swelling and tenderness.
Small piece of plaster was done at the wrist area to maintain and protect the radius bone from any sudden movements and to
control the swelling.
Page 2

ISSUE DATE:
Form No. :
01-Nov-04
REV. DATE:
01-March-07
PAGE 3 OF 12
Level 2 QHSE CEO

SECTION D – FULL DESCRIPTION OF INCIDENT
Number (Code/No./Year): 10-04-2011
(DESCRIPTION OF FACTS KNOWN AS A RESULT OF THIS INVESTIGATION) :
- The plan was to clean out the mud below mud pit to allow the welder to replace bottom steel plate
(SPS job)
- Mud was being removed from the mud pits via holes in the bottom of the hull (collected in1 ton big
bag) then removed via forklift.
- IP was doing barge deck cleaning to prevent pollution and dry the same as much as possible.
- The IP was using squeeze and shovel to do the job.
- -The area was wet and slippery (splash from mud and water falling from mud pit room)
- -IP stops his work to take his break time. He had lack of concentration and slipped and Fell on his right
hand and fell pain in

Completed By:
Name Position Signature Date
OIM 06 - July 2011
Page 3

ISSUE DATE:
Form No. :
01-Nov-04
REV. DATE:
01-March-07
PAGE 4 OF 12
Level 2 QHSE CEO

SECTION E – SKETCH OR PICTURE OF THE INCIDENT
(Attach Actual Pictures or Draw Sketch of the Incident Scene Here. Do not Recreate the Scene

Page 4

ISSUE DATE:
Form No. :
01-Nov-04
REV. DATE:
01-March-07
PAGE 5 OF 12
Level 2 QHSE CEO

Big bag
Page 5

ISSUE DATE:
Form No. :
01-Nov-04
REV. DATE:
01-March-07
PAGE 6 OF 12
Level 2 QHSE CEO

SECTION F – SUMMARY OF WITNESS STATEMENTS
IP Statement: (summary)
Page 6

ISSUE DATE:
Form No. :
01-Nov-04
REV. DATE:
01-March-07
PAGE 7 OF 12
Level 2 QHSE CEO

IP Statement Translation: (summary)
Page 7

ISSUE DATE:
Form No. :
01-Nov-04
REV. DATE:
01-March-07
PAGE 8 OF 12
Level 2 QHSE CEO

Hospital Report
Page 8

ISSUE DATE:
Form No. :
01-Nov-04
REV. DATE:
01-March-07
PAGE 9 OF 12
Level 2 QHSE CEO

El Tur Hospital Report Translation
Completed By:
Name Position Signature Date
QHSE Officer 06 - July 2011

Page 9

ISSUE DATE:
Form No. :
01-Nov-04
REV. DATE:
01-March-07
PAGE 10 OF 12
Level 2 QHSE CEO

SECTION G – SUMMATION AND RECOMMENDATIONS
Contributing Factors
- No equipment available to remove mud from void via rig (not many equipment could even do the job)
- Access to tanks very restricted (600mm tall) via access hole and via man hole communication between
tank.
- Movement of barge (1 ft movement due to sea condition)
- Slick surface deck of barge + uneven deck
Basic Causes
- Not paying full attention to his surroundings, lack of concentration when going for the second tea break.
Actions Recommended to Prevent Recurrence
- Although it is not a normal operation we would be performing on the rig, it was relatively simple task.
- Discussed with all members of the crew to pay 100% attention to any task all the time.
Corrective Actions
What is to be Done Responsibility Time for Completion

Discussed immediately after incident.
Discussed the following day with ALL Night Toolpusher
personnel onboard after fire/Abandon Closed
drill OIM
Completed the job with two persons
QHSE Officer
Discussed at Pre-tour and weekly
Closed
safety Meeting with all crews
Supervisors
Signature/Facility PIC: Position: OIM Date: 06 - July 2011

Signature/Operations/ Position Date
Page 10

ISSUE DATE:
Form No. :
01-Nov-04
REV. DATE:
01-March-07
PAGE 11 OF 12
Level 2 QHSE CEO

SECTION H – CAUSAL ANALYSIS
Circle appropriate causal factor

A11 - Not In Conformity With Drawings/
Modified
A12 - Standard But Dangerous
A1 - Rig Equipment A13 - Insufficient
A14 - Poorly Maintained
A15 - Badly Installed

A - Equipment
A2 - Harmful Substances
A31 - Missing/Insufficient
A32 - Inappropriate
A3 - Safety Equipment
A33 - Out Of Service
A34 - Not Used
B11 - Inadequately Defined/To Be Revised

B1 - Procedures
B12 - OK But Not Applied
B21 - Safety Meeting/Prejob JSA Meeting

Not Carried Out
B2 - Information
B22 - Written Procedures/Posting Up
Insufficient
I
N B3 - Lack Of Supervision
B - Process
C
I
D B4 - Insufficient Preparation/
E Organization
N
T
B5 - Excessive Speed/
Cadence
C11 - Insufficient Theoretical Training
C1 - Training C12 - Insufficient Practical Experience
C13 - Insufficient Command Of Language

C - Personnel
C21 - Tiredness
C2 - Unfitness
C22 - Negligence
D1 - Adverse Geography/
Weather
D - Environment D2 - Insufficient Logistic

Support
E - Others D3 - Poor Communications
Page 11

ISSUE DATE:
Form No. :
01-Nov-04
REV. DATE:
01-March-07
PAGE 12 OF 12
Level 2 QHSE CEO

SECTION I – MANAGEMENT REVIEW
Yes No
Was the investigation follow-up completed fully? ¨ ¨
Is the information in the report fully detailed and accurate? ¨ ¨
Are the contributing factors of the incident correctly identified? ¨ ¨
Is further investigation necessary? ¨ ¨
Have all proposed corrective actions been considered? ¨ ¨
Corrective Action Recommendation Decision/C.A.R. Reference
Due the design of the rig, the mud falling from rig pump (when doing repair) goes in all section below rig pumps and
mud pit. There is a kind of ‘’man hole/communication hole’’ 3 inches above hull bottom.
We also suspect some leak around the mud pit. During SPS when changing bottom plate we will have better access
to check all sections.
Better cleaning under rig pump may avoid mud going everywhere. Pump man to follow.
Regular clean is required to avoid mud dry and hard to remove.
Management Incident Review
Names (Print): Rig Manager
Date: 06-July-2011

Page 12

Case 2 - Slip and Fall Accident Study

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Manual Title : Safety and Environmental System Manual MANUAL NUMBER:

SECTION B – DETAILS OF ACCIDENT/INCIDENT

Experience in Occupation: 08 Months Experience in Present Position: 08 Months

Time into Tour: 07 Hours : Days: 10

Nature of Illness/Injury and Treatment Given:

Number (Code/No./Year): 10-04-2011

(DESCRIPTION OF FACTS KNOWN AS A RESULT OF THIS INVESTIGATION) :

- The IP was using squeeze and shovel to do the job.

Name Position Signature Date

OIM 06 - July 2011

Number (Code/No./Year): 10-04-2011

Number (Code/No./Year): 10-04-2011

IP Statement Translation: (summary)

Name Position Signature Date

QHSE Officer 06 - July 2011

Number (Code/No./Year): 10-04-2011

- Movement of barge (1 ft movement due to sea condition)

- Slick surface deck of barge + uneven deck

Actions Recommended to Prevent Recurrence

What is to be Done Responsibility Time for Completion

Signature/Facility PIC: Position: OIM Date: 06 - July 2011

Number (Code/No./Year): 10-04-2011

Circle appropriate causal factor

A12 - Standard But Dangerous

A1 - Rig Equipment A13 - Insufficient

A14 - Poorly Maintained

A15 - Badly Installed

A34 - Not Used

B11 - Inadequately Defined/To Be Revised

B21 - Safety Meeting/Prejob JSA Meeting

C1 - Training C12 - Insufficient Practical Experience

C13 - Insufficient Command Of Language

D - Environment D2 - Insufficient Logistic

E - Others D3 - Poor Communications

Number (Code/No./Year): 10-04-2011

Was the investigation follow-up completed fully? ¨ ¨

Is the information in the report fully detailed and accurate? ¨ ¨

Are the contributing factors of the incident correctly identified? ¨ ¨

Is further investigation necessary? ¨ ¨

Have all proposed corrective actions been considered? ¨ ¨

Corrective Action Recommendation Decision/C.A.R. Reference

Regular clean is required to avoid mud dry and hard to remove.

Management Incident Review

Names (Print): Rig Manager

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