This web site was established to facilitate the sharing of health, safety and environmental (HSE) related lessons learnt in the energy industry. The Energy Chamber hopes that by sharing of such valuable information accidents and incidents can be reduced or totally avoided in the future.
Company Name: NGC
Location: Compressed Natural Gas (CNG) Station
Date of event: 9/28/2020
Type of Event: Loss of primary containment (LOPC)
Description of event: During a station upgrade whilst removing some piping, an odourizer pot with a residual quantity of Mercaptan spilled on the ground. The pungent Mercaptan odour caused widespread alarm.
Description of consequences: No personal injury, no environmental damage. Reputation and branding impact.
Immediate causes: Inadequate control of work
Root causes: Inadequate hazard identification and management of change preparation. Possible hazards may have been missed in the planning phase of activities. Decommissioning planning prior to execution may have had gaps.
Corrective and preventative actions: Job site immediately stood down and emergency response activated. Risk assessment for activities was reviewed, updated and staff re-oriented in control measures. Start-up safety checks conducted to verify controls in place.
Lessons learned: Be sure to plan and verify all high-risk work activities. Ensure that all personnel prior to their involvement in similar task are competent including contractors. Ensure control of work assurance is completed. Training gaps identified and addressed for the preparation of MOCs. Routinely practice and confirm emergency response communication protocol.
Company Name: NGC
Location: Tasker Road, Princess Town
Date of event: 3/31/2020
Type of Event: Vehicular Accident
Description of event: Company vehicle collided with the rear end of a truck. The driver was attention distracted by unsecured items on the front seat of the vehicle.
Description of consequences: Damage to both vehicles. There were no personal injuries in the collision.
Immediate causes: Driver appeared to have failed to secure internal items and commit to earlier training.
Root causes: Human Factors: Program for safe driving training and practice needed improvement.
Corrective and preventative actions: Defensive driving best practice was reviewed with supervisor immediately and the lessons learnt was presented to department and leadership.
Lessons learned: Regularly prepare journey management plan and ensure that all loads are secure in the vehicle. Routinely assess the health of the organizational driving safety program barrier health.
Company Name: NGC
Location: Pt. Lisas
Date of event: 1/29/2022
Type of Event: Industrial Accident
Description of event: During site construction and restoration work, a manlift operator with guidance from the banksperson proceeded to set up the manlift to paint a roof. The manlift was shut off and the operator with one of the painters went of to set up for work. The banksperson went to the welfare area. In the banksperson`s absence, the operator started the manlift to relocate it. The boom of the manlift struck the parapet of the building nearby.
Description of consequences: Three feet of the parapet was damaged. No personal injury. Site was shut down.
Immediate causes: Safety rule violation: operating the manlift without safe direction from banksperson
Root causes: Human factor- Work team hazard awareness and general competence was inadequate. Planning and sequence of rest activities with clear safety instructions may have been inadequate. Possible gaps in contractor management system.
Corrective and preventative actions: The site was stood down with a meeting held with all contractors on site. Manlift operator was immediately sent for drug testing. All contractors were instructed to stop and secure all equipment. An investigation was launched immediately. Contractor and client meeting held. Contractor performed site safety assessment and submitted for review revised control measures. Client and contractor verified controls in place before restart. Lessons learnt shared with staff. Checks for lesson implementation performed by team.
Lessons learned: Plan and risk assess all high risk work. Ensure operators and banksperson attend a recognized training course. Receive proof of competence. Always ensure site personnel are physically fit to perform high risk work. Check to make sure site equipment is functional as per standards. Supervisors should review and re-validate controls in place in daily toolbox talks with walk downs. Provide ongoing validation of Life Saving Rule compliance. Communicate routinely enforcement of Life Saving Rules. Investigate and immediately address near misses.
Company Name: NGC
Location: Pt. Lisas
Date of event: 1/17/2022
Type of Event: Near miss
Description of event: During the refurbishment of office spaces, contractor was in the process of cutting holes for vents when dust from a grinder triggered spoke alarm.
Description of consequences: A false alarm on the fire detection system caused people to evacuate as directed. A stand-down and Investigation was launched to identify threat.
Immediate causes: Dust triggered an active smoke alarm. Risk may not have been identified and controls were missing.
Root causes: The process for managing changes and threats during construction may have been inadequate. Adequate bypass/override process may not have need applied.
Corrective and preventative actions: Project leaders develop a set of actions that apply to bypass/override of detection systems where construction work has to happen. Identify the person or groups who should complete the actions. Specify whether the action is to be repeated. Specify where an action must be reviewed and the type of response that it requires. In the risk assessment create records for foreseeable hazards related to the work activities. Add and verify controls in place periodically. Return bypassed system to service and check functions.
Lessons learned: Always refer to industry safety codes with respect to bypass/override operations for fire detection. In this case the International Fire Code (IFC), the NFPA Fire Alarm Code (NFPA72). Always plan work and perm work as described in the risk assessment. Verify controls in place periodically.
Company Name: NGC
Location: Pt. Lisas
Date of event: 12/21/2021
Type of Event: Near miss
Description of event: An employee accessed a restricted area which was properly cordoned off with the appropriate signs in place. The employee had no PPE or authorization to use scaffold from the person in charge on site. Employee used restricted scaffold to access a higher floor.
Description of consequences: Job site was shut down for investigation.
Immediate causes: Scaffolding was built in an administrative area. Employee did not have suitable and sufficient awareness around scaffolding site safety rules.
Root causes: Site restrictions for a construction area built in an administrative zone needed improvement. This may have also been due to insufficient instruction and supervision for this mixed zone.
Corrective and preventative actions: Re- orientation for staff and visitors with respect to Life Saving Rules- working at heights. Strictly limit access to visitors. Inform all staff of site rules and enforcement. Test persons onsite periodically on applicable life saving rules.
Lessons learned: Ensure site access is strictly managed and controlled especially were construction meet administrative sites. Person must have routine, proven awareness with visible clear instructions around working at heights i.e. scaffolding. Strictly monitor and immediately enforce all applicable site LSRs.
Company Name: NGC
Location: Project Site- Caroni
Date of event: 1/9/2020
Type of Event: Near miss
Description of event: Contractor driver and lorry man came onto site without required PPE. Driver then used a forklift to offload material without a banksman.
Description of consequences: Breach of site rules
Immediate causes: Contractor appeared to have breached site rules. Inadequate site supervision and control by onsite authority.
Root causes: Control of Work System on site appears to have had gaps, such as poor safety culture and inadequate contractor management.
Corrective and preventative actions: Improve planning and control of site work. Site leaders are to be responsible for reviewing risk assessment and confirm site rules with contractor before job. Re-orientation of site leaders and contractors with Life Saving Rules awareness.
Lessons learned: Focus on key areas. Contractor Management Systems. Embed a continuous improvement cycle for managing contractors. Orientation, onboarding and continuous coaching. Evaluate the control of work process. Ensure all work is planned, risk assed and verified with regular checks.
Company Name: NGC
Location: Project Site- Caroni
Date of event: 9/20/2020
Type of Event: Personal accident
Description of event: Contractor was in process of sending down scaffold pipe during dismantling when pipe pinched finger against hard barrier. This caused pipe to drop out of hands to the ground approx. 8ft.
Description of consequences: Injured finger and dropped object near miss.
Immediate causes: Contractor supervision and instruction was inadequate. Non conformance with risk assessment.
Root causes: Control of Work System on site appears to have had gaps, such as poor safety culture and inadequate contractor management.
Corrective and preventative actions: Improve planning and control of site works. Immediately identify working at height risks on site and check health of barriers. Review the Job Safety Analysis with contractor
Lessons learned: Focus on key area. Contractor Management System. Embed a continuous improvement cycle for managing contractors. Orientation, onboarding and continuous assurance with coaching. Evaluate the Control of Work process. Ensure all work is planned, risk assessed and verified with regular checks.
Company Name: NGC
Location: Beachfield, Guayaguayare
Date of event: 12/25/1988
Type of Event: Industrial Accident
Description of event: Back in 1988 there was a major Loss of Primary Containment (LOPC) of condensate and an ignition source triggered a flash fire. An Operator on duty in the plant suffered injuries . A contractor who was positioned outside the plant was unhurt.
Description of consequences: *Person was seriously injured *The catastrophic fire destroyed large portions of the Abyssinia facility.
Immediate causes: Improper isolation of critical equipment, inadequate operating procedures
Root causes: Weak management of change process, inadequate process safety information and competence assurance.
Corrective and preventative actions: Immediately improved process and actions to make management system more systemic and in control. Improved process safety management in line with industry codes.
Lessons learned: * Always conduct a detailed review of the engineering design and conditions for facilities * Develop and implement comprehensive operating procedures for the facility, and ensure employees and contractors are properly trained and acquainted with all safety aspects of the facility. * Ensure modifications are made in accordance with the Management of Change method. Changes should be properly documented and communicated to all employees and contractors at the facility. * Ensure all operations at a facility follow recognized & good engineering practice.
Location: Offshore
Date of event: 2/12/2018
Type of Event: Near miss
Description of event: Immediately after helicopter operations at an offshore platform, the windscreen of the crane cabin was observed on the walkway. It was broken into two pieces, one piece being relatively smaller compared to the other.
Description of consequences: Equipment Damage - dropped crane glass
Near Miss - Potential Injury to personnel
Immediate causes:
• The cabin windscreen glass weighing 55 lbs became loose and fell approximately 20ft from the crane to the walkway below.
Root causes:
• Differential Pulsation Force caused by helicopter downdraft coupled with high seasonal winds - on the day of the incident, the significant force generated by the combination of the helicopter down draft and high seasonal winds generated differential pulsation forces within the crane cabin. This force exceeded the rubber seal capacity to hold the windscreen in place, causing it to dislodge.
• Cabin door kept open during crane operation - The crane has two sliding windows on either side of the Operator. The right side is kept closed during crane operation due to the noise and heat generated by the crane’s engine. This significantly reduces air flow in and out of the cabin and as such the cabin door is normally kept open to provide ventilation inside the cabin.
• The sliding window was not replaced in a timely manner. The left sliding window glass broke in January 2016 and was removed in December 2016, for safety reasons, by the crane operator.
Corrective and preventative actions:
1 Crane windscreen on manned platforms should be retrofitted with aluminum framing together with rubber seals.
2 The Helicopter Landing Officer (HLO) checklist should be modified to include the following steps:
• Ensure crane cabin door and windows are properly closed.
• Temporary seal(s) are in place and effective.
3. Damaged sliding door glass should be replaced and resealed
Lessons learned:
1. Ensure damaged crane components (although they appear low risk) are replaced in a timely manner.
2. Consider use of aluminum perimeter framing with rubber sealant for crane windscreen.
Location: Offshore
Date of event: 8/26/2018
Type of Event: Personal accident
Description of event: While conducting work on a condensate transfer pump the injured party (IP) suffered a laceration to the left thumb finger while removing bolts on spool between strainer and pump. A striking end spanner was in use and the maul hammer came into contact with a scaffolding pipe (Support Piping) which then ricochet onto his left thumb.
Description of consequences: First aid injury to worker
Immediate causes:
• IP's hand was positioned at base of striking end as he was holding the striking end spanner.
• Hammer used to impact striking end (to break bolts) inadvertently contacted adjacent scaffold pipe and ricocheted towards IP's hand on the striking end.
• No finger-saving device was provided by the team or contractor for this activity.
Root causes:
• Task step did not specifically identify breaking of bolts on the 10" spools and the method to be used.
• Scaffold design left accessibility issues for the rigging team due to the lack of integration among the various teams involved (Operations, Scaffolding, Rigging).
• IP was unaware of a finger saving device and was unaware of the company's procedure on the use of finger saving devices for this activity.
• Finger saving devices were not available for the activity.
Corrective and preventative actions:
1. Permits issued for bolt torqueing / de-torqueing activity to incorporate hazard of impacting fingers and include control measure of use of finger saving device.
Lessons learned:
1. Ensure activities (although considered low risk) are adequately risk assessed and the appropriate PPE used.
2. For bolt-torqueing activities, employ the use of finger saving type devices .
Location: Offshore
Date of event: 12/12/2017
Type of Event: Near miss
Description of event: While in the process of decanting / bunkering chemicals, from a portable Tote Tank to the facility’s Storage Tank, located one deck level below on an offshore platform, the tank walls (manufactured from stainless steel) collapsed. The incident was discovered when the Technician returned from his walkaround duties
Description of consequences: Damage to chemical tank - walls collapsed.
Immediate causes:
1. The vacuum breaker cap, atop the Tote tank was not removed sufficiently, to break the vacuum.
2. The task was being carried out, by one person, who was traversing between two levels.
3. There were no approved company procedures for this task. The Contractor’s procedures were being used.
Root causes:
1. There was no approved company procedure for the activity. Contractor’s procedure was used which did not provide the level of details for the activity, e.g. removal of the vacuum breaker cap.
2. The performance of this task was not adequately resourced. Two persons should have been assigned to safely perform the activity.
Corrective and preventative actions:
• Develop and implement an approved procedure for chemical bunkering.
Lessons learned:
• Ensure that approved company procedures are in place for chemical bunkering activities.
• Ensure that contactor procedures for activities are reviewed and approved for use.
• Ensure that tasks are sufficiently resourced for safe performance.
Location: Offshore
Date of event: 2/1/2018
Type of Event: Environmental accident
Description of event: During routine chemical bunkering from a portable chemical tote tank on the workover deck to the platform’s storage tank located on the production deck, the storage tank was overfilled. The chemical spilled from the storage tank via the flame arrestor. Although a toolbox conversation was held which identified the correct tank to be filled, the field team made an error by filling the wrong tank.
Description of consequences: Chemical overspill to secondary containment. No fluids entered the environment.
Immediate causes:
• Activity considered routine and did not take place under a permit.
• Verification was not confirmed between Field Technician and Control Room Operator on exact time tank was to be filled.
• The Bunkering fill lines and bunkering tanks were not properly labelled.
• There was no approved Standard Operating Procedure for the chemical bunkering activity. A generic document was being used.
• Field Technician left the site before the task was completed.
Root causes:
• Activity considered routine and did not take place under a permit or a risk assessed procedure.
• Inadequate labelling and reference to Chemical tanks in the field.
• Label on Human Machine Interaction (HMI) screen did not match field tank lables
Corrective and preventative actions:
1. Develop and implement an approved procedure for Chemical Bunkering.
2. Install field lables on tanks and piping.
3. Update HMI screen with tank field identification.
Lessons learned:
1. Ensure activities (although considered routine) are appropriately risk assessed and covered by a permit and/or standard operating procedure.
2. Ensure that piping and vessels are appropriately labelled in the field and match the control room HMI console where applicable.