LESSON LEARNED

Major Serious Project – Unsafe Condition by Spent Bullet Casing

Contributory - Qurainat DS
Factors:
Type of Incident:
Medium Minor Poor supervision.
Business Activity: Excavation
Country: Southern Iraq, Basra
Incident Location: DS 05

Brief account of the incident:

On 26th June, during a site visit, it was observed that excavation work was being
conducted without the necessary Permit to Work (PTW). The site supervisor
arrived early at 5:30 AM and sent the PA to obtain the PTW. In an attempt to
avoid working in extreme hot weather later in the day, he ordered the workers to
start the excavation without waiting for the PTW. Unaware of the underground
fiber optic cable, a mechanical excavator was used instead of the permitted
hydro-vac and manual excavation, leading to the accidental striking of the fiber
optic cable. This incident highlights a significant deviation from the approved
procedures due to the site supervisor's negligence in following HSE rules. The
root cause was identified as the site supervisor's failure to adhere to safety
protocols. As a corrective measure, the site supervisor has been sent for re-
qualification and re-training on the golden rules of safety.

Outcome: Key lessons for other facilities/contracts to consider:

• Always obtain the necessary PTW and conduct line detection before
Actual: Unsafe Act •
excavation work.
Enforce strict adherence to safety protocols and immediate work stoppage for
non-compliance.
• Conduct ongoing re-qualification and re-training on safety protocols and ROO
golden rules. Always follow COW procedure ROO-ALL-HS-PRO-001 141 | P a
ge
Potential: May cause of serious accident

Golden Rules of Safety breached: (Please tick the appropriate box) Picture

Control Of Work

What human factors were involved?

What did people do intentionally? Not followed ROO HSE rules

What did people do unintentionally? N/A

What barriers would help prevent this incident?

• Establish and enforce protocols for clear communication between supervisors, workers, and
management to ensure everyone is informed of safety procedures.
• Provide comprehensive TBT for all personnel, including supervisors, on safety protocols, hazard
recognition, and adherence to procedures.
• Must follow ROO HSE procedures like COW procedure ROO-ALL-HS-PRO-001.alag
• Strengthen the Permit to Work system to include specific requirements for identifying and
protecting underground utilities, ensuring all safety measures are in place before work begins.