2008 Fatality Report - Overhead Powerline Contact

Transcription

OVERHEAD POWERLINE CONTACT
Date of Incident: February 11, 2008
Type of Incident: Fatality
File: F - 267815
TABLE OF CONTENTS
SECTION
TITLE
PAGE
1.0
DATE AND TIME OF INCIDENT
4
2.0
NAME& ADDRESS OF PRINCIPAL PARTIES
4
2.1
Prime Contractor
4
2.2
Employer(s)
4
2.3
Worker
4
3.0
DESCRIPTION OF PRINCIPAL PARTIES
3.1
Prime Contractor
4
3.2
Employers
4
3.3
Worker
4
4.0
LOCATION OF INCIDENT
5
5.0
EQUIPMENT, MATERIAL AND OBSERVATIONS
5
5.1
Equipment and Material
5
5.2
Observations
5
6.0
NARRATIVE DESCRIPTION OF INCIDENT
5
7.0
ANALYSIS
7
7.1
Direct Cause
7
7.2
Contributing Factors
7
8.0
FOLLOW-UP/ ACTION TAKEN
7
8.1
Workplace Health and Safety Compliance
7
8.2
Industry
8
8.3
Additional Measures
9
9.0
SIGNATURES
10
10.0
ATTACHMENTS
10
2
Alberta Employment and Immigration, Workplace Health and Safety & Employment Standards Compliance
File: F - 267815
SECTION 1.0
1.1
DATE AND TIME OF INCIDENT
The incident occurred on February 11, 2008, at approximately 4:30 p.m.
SECTION 2.0
NAME AND ADDRESS OF PRINCIPAL PARTIES
2.1
Prime Contractor
2.1.1
EnCana Corporation
421 – 7th Avenue SW
PO Box 2850
Calgary, Alberta
T2P 2S5
2.2
Employer
2.2.1
Swabtech, A Division of Nabors Production Services
33 Schenk Industrial Road
Sylvan Lake, Alberta
T4S 2J7
2.3
Worker
2.3.1
(Names and personal details were removed before distribution of this report)
SECTION 3.0
DESCRIPTION OF PRINCIPAL PARTIES
3.1
EnCana Corporation’s head office is based in Calgary, Alberta. The company is
engaged in exploration, development, production and marketing of natural gas and
crude oil. EnCana Corporation contracted Swabtech to perform service work on the
well.
3.2
Swabtech, A Division of Nabors Production Services (Swabtech) provides swabbing
services with site specific well swabbing tools and swabbing rigs to the oil and gas
industry. The company operates 21 swab rigs and employs approximately 50
workers.
3.3
The worker has been employed with Swabtech for approximately nine months, as a
Swamper. The worker has received training in Employee Orientation, Driver
Training, H2S and WHMIS.
SECTION 4.0
LOCATION OF INCIDENT
3
File: F - 267815
4.1
The incident occurred at an entrance to a gas well lease owned by EnCana
Corporation located approximately 15 kilometres south of New Dayton, Alberta. The
legal site description is LSD 100/16-05-05-18 W4 (Reference to Attachment A, Map
and Attachment B, Photograph 1).
SECTION 5.0
EQUIPMENT, MATERIAL AND OBSERVATIONS
5.1
Equipment and Material
5.1.1
The equipment involved in the incident was a swab rig unit 315 (swab rig) owned by
Swabtech, A Division of Nabors Production Services. The swab rig was brought to
the lease site to perform service work on the well. There was a snowdrift on the lease
road and the swab rig could not gain access to the lease site. The swab rig was
stopped directly under a three phase overhead powerline near the lease entrance
(Reference Attachment B, Photograph 2).
5.1.2
The three phase 14,400 volts overhead powerline, owned by Fortis, crossed the lease
road near the lease entrance. The westward phase of the three phase overhead
powerline was contacted by the mast of a swab rig during the incident (Reference
Attachment B, Photograph 3).
5.1.3
When the swab rig was stopped near the lease entrance, the operator made the
decision to remove the swab tools from the mast. The outriggers on the rear of the
swab rig were extended and blocked. The operator was at the control panel and
raised the mast on the swab rig. While the operator was raising the mast, the swab
tools on the mast made contact with the westward phase of the three phase overhead
powerline. The westward phase of the overhead powerline was severed and fell to
the ground (Reference Attachment B, Photographs 2, 3, 4, 5, 6 and 7).
5.2
Observations
5.2.1
The weather on the day of the incident was clear. The ground was covered with deep
drifted snow.
SECTION 6.0
NARRATIVE DESCRIPTION OF THE INCIDENT
6.1
On February 11, 2008 the rig crew consisting of the operator, the helper and the tank
truck driver, arrived at the Brooks yard at approximately 5:00 a.m. The rig crew
conducted an equipment inspection and minor maintenance before departing the
Brooks yard at approximately 6:00 a.m.
6.2
At approximately 7:15 a.m., the rig crew arrived in Taber where they met with the
customer representative for EnCana Corporation. The customer representative
provided the rig crew with a map and a list of nine wells required to be serviced on
that day.
6.3
The rig crew traveled to the first location, conducted a pre-job hazard assessment for
4
File: F - 267815
the day and commenced work. At approximately 4:00 p.m., the crew arrived at the
last well located at LSD 16-05-05-18 W4. The swab rig could not gain access to the
lease site as there was a snowdrift at the lease entrance. After two unsuccessful
attempts to gain access to the lease site, the rig crew decided to return to the yard in
Brooks.
6.4
The operator made the decision to remove the swab tools from the mast prior to
returning to the yard in Brooks. The operator then instructed the helper and the tank
truck driver to remove the swab tools from the mast to the swab rig deck floor for
transportation.
6.5
At approximately 4:29 p.m. the operator contacted the customer representative
leaving a message that they could not gain access to the last well due to the snowdrift.
The helper and the tank truck driver placed planks for the jacks at the rear of the
swab rig. The operator lowered the jacks onto the planks and leveled the swab rig.
6.6
The operator then began to raise the mast while looking to the front of the swab rig
watching for any snags in the line. The tank truck driver was standing to the left side
of the swab rig watching the front of the mast and also looking for any snags in the
line. The helper was behind the swab rig leaning against the swab rig deck floor
removing tools from the tool rack.
6.7
When the mast was raised approximately two thirds of the way, the swab tool on the
mast made contact with the live 14,400 volts overhead powerline. The tank truck
driver hit the emergency kill switch located in front of the driver door. The tank
truck driver observed flames coming from the left rear tire on the swab rig. He then
attempted to obtain a fire extinguisher mounted on the swab rig behind the cab and
received an electric shock.
6.8
The operator looked to the rear of the swab rig and saw the helper holding tools and
vibrating. The operator walked to the rear of the swab rig and reached for the helper.
At the same time, the helper fell backwards and landed on the ground. The helper
was unconscious.
6.9
The operator jumped off the swab rig to the ground and received an electric shock.
The operator saw sparking from the point where the mast contacted the overhead
powerline. The overhead powerline was severed and fell to the ground.
6.10
The operator and the tank truck driver dragged the helper away from the swab rig
towards the road and commenced CPR. Emergency Medical Services (EMS) was
contacted at 4:34 p.m. EMS arrived at the site within 20 minutes, took over CPR and
used a defibrillator on the helper. The helper was transported to the Lethbridge
Regional Hospital where he was pronounced dead.
6.11
The operator and the tank truck driver were taken to the hospital for observations and
released on the same day.
5
File: F - 267815
SECTION 7.0
7.1
ANALYSIS
Direct Cause
The worker was electrocuted when the mast of the swab rig was raised and contacted
the live 14,400 volts overhead powerline.
7.2
Contributing Factors:
The rig crew did not recognize the presence of the overhead powerline hazard.
The swab rig could not gain access to the lease due to the snowdrift at the lease
entrance and was parked directly under a live 14,400 volts overhead powerline.
The workers decided to raise the mast and remove the swab tools from the mast
before returning to the yard in Brooks.
SECTION 8.0
FOLLOW-UP/ACTION TAKEN
8.1
Employment and Immigration, Workplace Health and Safety Compliance
(WHSC)
8.1.1
WHSC received an incident notification on February 11, 2008 at 5:40 p.m.,
responded to the scene, and commenced an incident investigation.
8.1.2
WHSC issued the following orders:
8.1.3
•
EnCana Corporation:
- conduct an incident investigation and prepare a report outlining the
circumstances surrounding the incident, as well as preventative measures
•
Swabtech:
- conduct an incident investigation and prepare a report outlining the
circumstances surrounding the incident as well as preventative measures
- ensure that a hazard assessment is conducted again to identify existing or
potential hazards when the work process or conditions changed at the work
site
- ensure additional control measures are established to prevent a recurrence of a
similar incident. The control measures shall include engineering controls and
instructions to workers about the hazards
- ensure the workers are trained on safe limit of approach distances for
overhead powerlines
- Stop Use Tag was affixed on the Swabtech unit 315 until it was inspected,
repaired and recertified for service (Reference Attachment B, Photographs 8)
On April 1, 2008 WHSC met with representative from EnCana Corporation and
6
File: F - 267815
Swabtech at the Nabors Production Services office in Calgary to review their incident
investigation report.
8.2
Industry
8.2.1
After the incident, EnCana Corporation and Swabtech voluntarily stopped the work
prior to the arrival of WHSC.
8.2.2
The RCMP Raymond Detachment responded to the scene immediately and secured
the scene for WHSC.
8.2.3
On February 13, 2008, Swabtech held a Post Incident Stand Down Meeting in Brooks
and on February 14, 2008 a similar meeting was held in Sylvan Lake for crews that
work out of these areas. A number of topics were discussed; however the focus was
placed on hazard assessment when the scope of the work changed. The Job Safety
Analysis Worksheet for Rig Up was revised and workers were instructed to stand
clear of the rig when the mast is being raised.
8.2.4
On February 21, 2008, Nabors Production Services on behalf of Swabtech issued an
internal memo instructing workers when there is a change in the scope of the work,
that the hazard assessment must be revised. Each crew was instructed to hold a safety
meeting and discuss the revised hazard assessment and control measures.
8.2.5
On February 27, 2008, Swabtech held a safety meeting in Sylvan Lake and on March
3, 2008 a similar safety meeting in Brooks to re-enforce Pre-Job Hazard Assessments.
The workers were informed that computer generated Pre-Job Hazard Assessment
Forms were no longer acceptable. The workers are required to produce hand written
Pre-Job Hazard Assessment forms with more detailed instructions specific to the
work sites.
8.2.6
On March 19, 2008, Nabors Production Services provided full day training in Red
Deer for Swabtech employees. The training consisted of overhead powerline hazards
and awareness. Visual awareness warning decals regarding overhead powerlines
were created and installed on swab rigs.
8.2.7
EnCana Corporation and Swabtech investigated the incident and prepared a joint
report that was submitted to WHSC on April 1, 2008.
8.2.8 EnCana Corporation and Swabtech have complied with all the orders issued by
WHSC.
8.3
Additional Measures
8.3.1
No additional measures were taken.
SECTION 9.0
SIGNATURES
7
File: F - 267815
Original Report Signed______
Lead Investigator
_____________________
Date
Reviewer
_____________________
Date
Regional Senior Manager
_____________________
Date
Section 10.0 ATTACHMENTS:
Attachment “A” Map
Attachment “B” Photographs
8
File: F – 267815
Attachment A, Map
Location of Incident: Lease entrance LSD 16-05-05-18 W4, 8 km south of New Dayton,
Alberta
Photograph 1:
File: F- 267815
Attachment B
Photograph 1 of 8
Shows the scene of the incident located at an entrance to an EnCana
Corporation lease located at LSD 16-05-05-18 W4, approximately 8
kilometers south of New Dayton, Alberta
Photograph provided by RCMP
File: F- 267815
Attachment B
Photograph 2 of 8
4.
3.
1.
Photograph 2:
2.
Shows a closer view of the incident scene. The mast on the swab rig
unit 315 owned by Swabtech, A Division of Nabors Production
Services made contact with a three phase overhead powerline.
1. The west phase of the overhead powerline that was severed and
lying on the ground.
2. The two remaining phases of the overhead powerline.
3. Swab tools on mast.
4. Swab rig mast.
Photograph provided by RCMP
File: F- 267815
Attachment B
Photograph 3 of 8
1.
Photograph 3: Shows the three phase overhead powerline involved in the incident.
1.
The west phase of the overhead powerline that was severed by the contact and
spliced together for repair.
File: F- 267815
Attachment B
Photograph 4 of 8
1.
2.
3.
4.
5.
Photograph 4:
Shows the swab rig unit 315 parked directly under the overhead
powerline. The outriggers were extended and blocked on the rear of
the carrier. The snow drift made the lease road impassable. Swab
tools were on the mast
1. Three phase overhead powerline.
2. Swab tools.
3. Mast.
4. Snow drift
5. Outriggers.
File: F- 267815
Attachment B
Photograph 5 of 8
Photograph 5:
Shows the overhead powerline contact points on the swab tools lying
on the mast.
File: F- 267815
Attachment B
Photograph 6 of 8
Photograph 6:
Shows the operator control panel on the rear of the carrier deck.
File: F- 267815
Attachment B
Photograph 7 of 8
1.
2.
3.
4.
Photograph 7:
Shows the swab rig unit 315.
1. Three phase overhead powerline directly above.
2. Position of worker’s hard hat indicates the contact point of the
overhead powerline on the swab tools.
3. Operator control panel.
4. Snow drift.
File: F- 267815
Attachment B
Photograph 8 of 8
Photograph 8:
Shows Stop Use Tag affixed to the dash of swab rig unit 315.

2008 Fatality Report - Overhead Powerline Contact

Transcription

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