LS/OHI

Incident
Inspection Yard
Injury
With Preventative Actions

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Incident Description

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Re-Enactment

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Re-Enactment

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Re-Enactment

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Findings
1. IP relocated the rod safety fork & then untie the tie wire(Failure to follow the
correct task procedure).
2. IP was Short Service Employee(SSE).
3. Failure to recognize the potential hazards.
4. The task was performed by one crew member, IP proceeded with the task by
his own. The task required minimum 2-3 crew members.
5. Failure to utilize the stop work authority.
6. There was insufficient length of rod protruding from the reel to feed it into the
inspection pipeline. Once the rod is safely in the pipeline the tie wire can be
removed. The rod can then be advanced through the pipeline and the safety
forks be progressively removed.
7. Used tie wire should not be reused to tie rod into the reel. Tie wire that is
repeatedly used will fatigue and become brittle.
8. Transport Reel involved in incident is designed as a breakdown reel and absent
of standard support guides creating longer span for stored energy to escape if
rod end pushes on safety fork slowing it to move further to next guide support,
therefore creating potential for higher stored energy force on the rod end
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Other Future Proposed Improvement
Actions
1. Develop incident management process flow chart to ensure all required
steps are taken, in order on time and the right people are
communicated to as part of incident management plan
2. Evaluate option to hire English teacher for field team to develop higher
English language comprehension.
3. Review all critical JSAs and procedures and develop plan for document
translation to occur.
4. Translate LS Behavior Safety Program "Home Safe" cards to improve
engagement and participation from more team members
5. Develop fit for purpose Spot Check Program and set minimum
requirement to be performed by management, trend results and take
appropriate actions to correct
6. Perform controlled stored rod release simulation at safety meeting to
demonstrate to team the significant risk of working with stored energy

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Appendix – Supplemental

• Pin end anchor device

• Crosby Clip For Rod

Securement

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Preventative Action Log
Action # Preventative Action Description Target Completion Date Responsible Person

1 20-Nov-22 Shane Fleck

Review and revise task JSA to ensure it clearly describes multi person requirement to perform this task
2 Create Hazard Alert describing incident, hazards and preventative actions 20-Nov-22 Shane Fleck

3 Perform count and visual assessment on Oxy owned reels to identify how many reels are breakdown 20-Nov-22 Shane Fleck
type and determine general condition

4 Have Safety Standdown on LS/OHI yard to review Hazard Alert and ensure acknowledgment and sign off 30-Nov-22 Shane Fleck
by all LS/OHI field employees and yard contractors

5 30-Nov-22 Shane Fleck

Create fit for purpose critical task list describing all tasks that SSE must only perform under supervision
6 Rollout and signoff acknowledgment of SSE critical takes list to all employees 30-Nov-22 Shane Fleck
7 Re-introduce Oxy Stop Work Authority Program 30-Nov-22 Shane Fleck
8 Re-introduce LS/OHI Stop Work Authority Program 30-Nov-22 Shane Fleck

9 Create Technical Bulletin to describe rod tailing protrusion length requirement for internal and external 30-Nov-22 Shane Fleck
distribution

10 Develop incident management process flow chart will accurate communication process, contact numbers 30-Nov-22 Shane Fleck
and each persons responsibilities

11 Update training and competency package to ensure clear description of 2 or more people requirement to 10-Dec-22 Shane Fleck
perform this task and reassess all.

12 Create Technical bulletin for interval and external distribution introducing procedural change to use pin 15-Dec-22 Shane Fleck
end anchor t secure pin end in reel

13 15-Dec-22 Shane Fleck

Evaluate option to transition to Crosby clip tie in method and if agreed development rollout plan

14 Develop plan to either modify existing breakdown reels to standardized design with support guides 15-Dec-22 Shane Fleck
and/or replace reels with new.

15 31-Dec-22 Shane Fleck

Have revised JSA and new Hazard Alert translated to Arabic and Hindu and redistribute once translated.
16 Translate LS/OHI Stop Work Authority "Home Safe" cards 31-Dec-22 Shane Fleck

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