2008-IADC Alerts PDF

Safety Alert
From the International Association of Drilling Contractors

ALERT 08 01
WORKING WITH ROTATING CONTROL DEVICES

WHAT HAPPENED:
Incident #1 - The rotating control device (RCD) was leaking so the driller sent an employee to open the
clamp on it. When the driller used the drawworks to hoist the pipe and pull the rotating control device from
the bowl, the gasket was pulled out. The employee was attempting to replace the gasket when the rotating
control device slid down the pipe smashing his hand between it and the bowl severely injuring the
employees hand.
Incident #2 - The spinning chain was being used to spin up the joint of pipe that had the RCD on it. As the
pipe was turned up, the RCD slid down the pipe and smashed the employees thumb between it and the
spinning chain.
Incident #3 - The crew was installing the RCD on 4 inch casing. The RCD slid down the pipe and
smashed the employees finger between it and the casing slips.
Incident #4 - Crew was nippling up the RCD to the BOP stack. As the control device was lowered the
injured employees finger was smashed between it and one of the studs.
WHAT CAUSED IT:
Incident #1 - The driller assumed the employee was clear of the rotating control device and pulled the
control device through the floor. There was a lack of communication between the injured and the driller.
Incident #2 & #3 There was no efforts made to secure the rotating control device to prevent it from sliding
down the drill pipe as it was turned up.
Incident #4 There was a lack of communication between the men on the rig floor and the personnel
working below the rotary table.
CORRECTIVE ACTIONS: To address this incident, this company did the following:
Incident #1
Driller shall ensure all crewmembers are clear before engaging the drawworks to hoist the pipe.
Using the sling provided by the RCD rental company, rig crews are to attach the air hoist to the rotating
control device before pulling it through the floor.
Instruct employees to wait until the bushings are back in the table before working under the rotary table.
Incidents #2 & #3
The stand of pipe with the rotating control device shall be walked-in using chain tongs. Do not use the
spinning chain or pipe spinners to makeup this stand.
Keep the rotating control device as close to the lower tool joint as possible.
Secure the RCD with the air hoist prior to pulling the slips.
Incident #4
Maintain good communication between the personnel on the rig floor and personnel working below the
rotary table.
Use flagmen, spotters or other means of communication to ensure all personnel are aware of where and
when the equipment is to be moved.
Other Considerations When Working With the Rotating Control Device
Conduct a pre-job safety meeting before starting a project. Ensure all employees know what and how it
is to be done.
All rigs should write or review a JSA for this job. Ensure all employees who are not familiar with the
operation review the JSA before starting the project.
The Corrective Actions stated in this alert are one companys attempts to address the incident,
and do not necessarily reflect the position of IADC or the IADC HSE Committee.
This material is presented for information purposes only. Managers & Supervisors should
evaluate this information to determine if it can be applied to their own situations and practices
Copyright 2008 International Association of Drilling Contractors All rights reserved.
Issued January 2008
Safety Alert
Since the least experienced crew member is usually the man sent to conduct work below the rotary
table, strong consideration should be given to sending a more experienced employee. If an
inexperienced crew member must be used it is critical the employee understands exactly what is to be
done and how to do it safely. Quiz the employee to ensure ALL aspects of the task are understood.
Always wear proper fall protection while working in an elevated work site.
Ensure all employees working under the rotary table are aware of the potential for some types of fall
protection to become entangled in the rotating equipment.
Issued January 2008
Safety Alert
ALERT 08 02
STANDPIPE PRESSURE GAUGE THREAD NIPPLE

FAILURE (UNDER PRESSURE)
WHAT HAPPENED:
The rig crew was reaming back to bottom after making a connection. The hole fill was encountered before
the kelly bushings reached the table, so the driller rotated the string with the kelly spinner to clean out the fill.
While lining up the table and kelly bushings, the mud pump pressure spiked and simultaneously the mud
pump pop-off (pressure relief) valve blew. At the same instant the stand pipe pressure gauge blew out of
the standpipe. The pressure gauge glanced off the A-leg and struck a worker who was cleaning the
breakout tong dies. The worker received a laceration to the head, three broken ribs, a fractured shoulder,
and a collapsed lung.
WHAT CAUSED IT:
The investigation determined that the two inch nipple had only three threads buried (threaded) into the
standpipe receptacle.
CORRECTIVE ACTIONS: To address this incident, this company instructed rig personnel the
following:
1. Rig supervisors are to review this incident with all crewmembers.
2. Rig supervisors are to ensure crewmembers know how to properly install a high pressure nipple and / or
attachments (i.e., gauge, nipple, blow-plug, T-junctions, etc.).
3. When installing or repairing a high pressure line and /or attachments, this task must be supervised by the
Rig Manager or Driller to ensure proper nipple selection and installation.
4. Inspect all high pressure lines and fittings to ensure the correct amount of threads have been buried
(threaded) into the receiving receptacle.
5. A new standard for high pressure lines and fittings will be implemented at a later date within company.
Standpipe receptacle
Only three threads were buried into

the receptacle on the standpipe.
Issued January 2008
Safety Alert
IADC Note: Thread Engagement per Marks Standard Handbook for Mechanical Engineers
The normal amount of thread engagement necessary to make a joint for ANSI Standard Pipe
Thread joints as recommended by Crane Co. is as follows:
Size of Pipe, inch
1/8
3/8
1
1-1/4
1-1/2
2
2-1/2
3
3-1/2
4
5
6
8
10
12
Length of Thread, inch
3/8
3/8
9/16
11/16
11/16
11/16
15/16
1
1-1/16
1-1/8
1-1/4
1-5/16
1-7/16
1-5/8
1-3/4
Issued January 2008
Safety Alert
ALERT 08 03
CRANE RIG UP RESULTS IN FALL FROM HEIGHT

WHAT HAPPENED:
The rig crews were rigging up a tall pedestal crane on an offshore production
platform as the first phase of the drilling package rigup process. The heel
section of the boom was secured and pinned and the next task was to install
a hydraulic cylinder, which is used to raise and lower the boom. The Driller
and Derrickman had successfully removed the transport-securing pin and
were lowering the cylinder in place on the turntable clevis with assistance
from another crane. At this point the cylinder slipped in its rigging and fell
onto a handrail, which protected the pedestal walk around. The handrail was
broken from its base and fell 18 feet (5.4 meters) to the deck, taking with it the
Derrickman who was tied onto it by his fall protection lanyard. The injured
received skull fractures and a broken right arm.
WHAT CAUSED IT:
The rigging was not properly applied. Past work practice has dictated the procedure for rigging up
the cylinder with a second crane, and rigging that was simply slung underneath to support the
cylinder to ease the positioning of the cylinder into the turntable support clevis. As the cylinder was
lowered into position, it increased the angle exposed to the slings, causing the slings to slip upward
on the cylinder, allowing it to fall.
The Derrickman had tied off his fall protection lanyard to a handrail that was enclosing the pedestal walkaround. Handrails surrounded the platform walk-around, so there was no need for the Derrickman to tie off.
CORRECTIVE ACTIONS: To address this incident, this company instructed rig supervisors and
personnel in the following:
Just because We have always done it this way does not mean that the hazard is not present. We all need
to take a step back and review our actions and practices upon the completion of each job and ask; What
went right, what went wrong, what could we have done different?
Perform JSAs on each task in a job - not the whole job. Clearly the installation of the boom heel
section and then the cylinder are two tasks in the job of installing the crane. After the job is
complete, capture lessons learned during the review of JSA and up-date the JSA on file as needed.
Rig supervisors: Immediately audit fall protection training on your rig. Spend an equal amount of
time talking about tie-off points as you do on wear and care of the harness. Identify individual tie-off
points for your lanyards. Provide and clearly mark tie-off points around the rig. A handrail is not an
appropriate tie off point for fall protection, as it is designed to withstand only 200 pounds of side
loading, where as an appropriate fall protection tie off point is required to withstand 5000 pounds of
dynamic loading.
When rigging loads, use only API recommended hitching techniques. Improvised slinging will not be
a part of our work practice.
Issued January 2008
Safety Alert
Most importantly take the time to visualize the work to be done and identify the potential hazards,
and communicate them, so a control can be implemented. Think beyond the evident, adopt a
questioning attitude: What If? Remember:
Step 1: Identify the Hazard
Step 2: Assess the Risk
Step 3: Identify Controls
Step 4: Implement Controls
Step 5 Monitor the Process.
The above 5 steps are a simple and effective tool for all of us to use, whether crossing a busy street or
installing a crane.
Issued January 2008
Safety Alert
ALERT 08 04
FAILURE OF COUNTER BALANCED LIDS FOR

WASTE STORAGE AREAS RESULT IN INJURIES
WHAT HAPPENED:
There have been several incidents when personnel have tried to lift the counter weighted lids on these
storage areas which resulted in:
Strained backs
Hands and arms caught under the lids
Head struck by the falling lid
WHAT CAUSED IT:

This happened due to:
The weight coming off;

Not enough weight to hold the lid up;
The cable breaking due to wear or corrosion;
The wind blowing the lid down;
Someone lifting the lid without enough weight to assist in opening the lid or:
No locking devices to keep the lid open while personnel are working in the storage area.
CORRECTIVE ACTIONS: To address this incident, this company instructed rig personnel:
Eliminate these types of storage areas and replace with 100% polyethylene constructed storage
containers that meet the requirements in 40 CFR 264.175 (Containment), and Uniform Fire Code Article
80 (or equivalent local standard).
To prevent the lids from accidentally closing or falling shut while personnel are working in these storage
areas until they can be replaced rig personnel are to temporarily place safety bars or support legs on
these lids that can be pinned to hold the lids in place.
See the picture of the recommended storage areas to use.
Issued January 2008
Safety Alert
ALERT 08 05
FALL FROM SCAFFOLDING RESULTS IN EMPLOYEE INJURY

WHAT HAPPENED:
Two employees were attempting to install a mud bucket drain hose from the flow line to underneath the rig
floor. Standing on the BOP scaffolding which had been installed prior to their shift, the two men found the
hose connection to be just out of reach. Both men attached their lanyards onto scaffolding handrails. One
man was attached to the handrail on the back piece of scaffolding and the other man to the handrail on the
side piece of scaffolding. The men then climbed up onto the handrail on the side piece of scaffolding and
reached out to couple the hose. Without warning, the side piece of scaffolding flipped, and fell to the ground.
The employee whose lanyard was attached to the handrail on this piece of scaffolding was pulled
approximately 15 to the ground with the scaffolding (See pictures below). The employee suffered a severe
laceration to his head, fractured vertebrae in his back and neck as well as three broken ribs. The other man
grabbed nearby air lines to prevent himself falling. He then pulled himself back onto the remaining
scaffolding avoiding injury.
WHAT CAUSED IT:
1. The employees did not utilize any of the three safety retracting lifeline blocks mounted within arms reach
in the substructure. (See pictures below.)
2. The two men did not tie-off to a secure anchor point. The employees had a false sense of security when
they attached their lanyards to handrails.
3. Both employees climbed the handrails to access the work area.
4. The scaffolding is equipped with chain hoists at each corner to properly position the work platform. The
employees did not take the time to raise the platform which would have enabled them to perform the job
safely.
5. The scaffolding assembly was put together but not 100% assembled. The side scaffolding was not
bolted to the front and rear scaffolding to secure it as designed.
6. A pre-job meeting was not conducted prior to starting the job. As such the potential hazards were not
identified or addressed.
7. The mud bucket drain hose was not installed prior to raising the rig floor.
8. The bolt holes for securing the scaffolding are difficult to line up. Additionally, the location of the bolt
holes/bolts makes it difficult to visually observe and ensure the assembly is secure. Bolt threads are
easily damaged due to mud, dirt and corrosion.
1. These devices are installed and available to protect our employees and prevent injuries. Safety
retracting lifeline blocks are to be utilized when conducting this type of work.
2. Handrails are NOT secure anchor points.
3. Handrails are NOT ladders and should NEVER be climbed.
4. Crews must take the time needed to ensure work is completed in a safe manner.
5. When installing any equipment such as scaffolding, be sure the installation is complete before moving
onto the next job.
6. Pre-job meetings MUST be conducted prior to non-routine jobs such as this to make sure: 1) all hazards
are identified and addressed; 2) proper instruction is provided and; 3) the job is not rushed.
7. Assemble ALL possible hoses and lines prior to raising the rig floor.
8. The securing mechanism is being redesigned to simplify securing the scaffolding together to insure the
walkways are secure and provide employees a more visible means for ensuring it is secured. Pins with
keepers should be considered instead of bolts as its easier to drive a pin with a hammer.
Issued February 2008
Safety Alert
9. These incidents will continue to occur unless we STOP AND THINK.

10. ALL employees have the responsibility to observe fellow crew members and STOP UNSAFE ACTS
IMMEDIATELY and teach the correct procedure and sequence.
Safety Alert
Safety Alert
ALERT 08 05
FALL FROM SCAFFOLDING RESULTS IN EMPLOYEE INJURY

WHAT HAPPENED:
Two employees were attempting to install a mud bucket drain hose from the flow line to underneath the rig
floor. Standing on the BOP scaffolding which had been installed prior to their shift, the two men found the
hose connection to be just out of reach. Both men attached their lanyards onto scaffolding handrails. One
man was attached to the handrail on the back piece of scaffolding and the other man to the handrail on the
side piece of scaffolding. The men then climbed up onto the handrail on the side piece of scaffolding and
reached out to couple the hose. Without warning, the side piece of scaffolding flipped, and fell to the ground.
The employee whose lanyard was attached to the handrail on this piece of scaffolding was pulled
approximately 15 to the ground with the scaffolding (See pictures below). The employee suffered a severe
laceration to his head, fractured vertebrae in his back and neck as well as three broken ribs. The other man
grabbed nearby air lines to prevent himself falling. He then pulled himself back onto the remaining
scaffolding avoiding injury.
WHAT CAUSED IT:
1. The employees did not utilize any of the three safety retracting lifeline blocks mounted within arms reach
in the substructure. (See pictures below.)
2. The two men did not tie-off to a secure anchor point. The employees had a false sense of security when
they attached their lanyards to handrails.
3. Both employees climbed the handrails to access the work area.
4. The scaffolding is equipped with chain hoists at each corner to properly position the work platform. The
employees did not take the time to raise the platform which would have enabled them to perform the job
safely.
5. The scaffolding assembly was put together but not 100% assembled. The side scaffolding was not
bolted to the front and rear scaffolding to secure it as designed.
6. A pre-job meeting was not conducted prior to starting the job. As such the potential hazards were not
identified or addressed.
7. The mud bucket drain hose was not installed prior to raising the rig floor.
8. The bolt holes for securing the scaffolding are difficult to line up. Additionally, the location of the bolt
holes/bolts makes it difficult to visually observe and ensure the assembly is secure. Bolt threads are
easily damaged due to mud, dirt and corrosion.
1. These devices are installed and available to protect our employees and prevent injuries. Safety
retracting lifeline blocks are to be utilized when conducting this type of work.
2. Handrails are NOT secure anchor points.
3. Handrails are NOT ladders and should NEVER be climbed.
4. Crews must take the time needed to ensure work is completed in a safe manner.
5. When installing any equipment such as scaffolding, be sure the installation is complete before moving
onto the next job.
6. Pre-job meetings MUST be conducted prior to non-routine jobs such as this to make sure: 1) all hazards
are identified and addressed; 2) proper instruction is provided and; 3) the job is not rushed.
7. Assemble ALL possible hoses and lines prior to raising the rig floor.
8. The securing mechanism is being redesigned to simplify securing the scaffolding together to insure the
walkways are secure and provide employees a more visible means for ensuring it is secured. Pins with
keepers should be considered instead of bolts as its easier to drive a pin with a hammer.
Safety Alert

Safety Alert
Safety Alert
ALERT 08 06
FATALITY WHILE TRYING TO FILL UP CASING

WHAT HAPPENED:
The rigs crew was filling the first joint of 133/8" casing to test the shoe. To accomplish this, the crew used a
rubber hose connected to the high pressure standpipe manifold and utilized the high pressure mud pump
system to transfer fill fluid to the casing. The standpipe hose connection was located lower than the main
piping. This formed a trap for lost circulation material (LCM) to accumulate at the connection point. Three
members of the crew were holding the hose in the casing opening when the pump was activated. The crew
noticed a lack of flow from the hose nozzle. At the same time a 2,000 PSI pressure spike registered on the
standpipe gauge. This spike and lack of flow occurred just before there was a violent release of pressure.
The sudden influx of high pressure fluid into the hose caused it to kick upward and strike five workers on the
rig floor.
One worker died from a fatal head injury. Four other workers were struck by the hose or high pressure fluid
which resulted in various non-life threatening injuries to all. Forty-four operation hours of lost time occurred
while rig operations were shut down to carry out an investigation, and running a wiper trip prior to running
casing.
WHAT CAUSED IT:
Supervisors on the rig deviated from the agreed game plan to use the top drive system (TDS) to fill the
casing.
The casing was filled using the high pressure system instead of the low pressure mud tank system
(charge pump).
No Hazard Assessment (JSA) or pre-job safety meeting was conducted before this work started
CORRECTIVE ACTIONS: To address this incident, this company reminded rig and operations
personnel of the following:
Company policy requires that the TDS or service company, fills up machines that should be used to fill
casing whenever possible
Company procedures manual require that low pressure pumping equipment is to be used when filling
casing with a hose.
To prevent hose movement, when filling casing with a low pressure hose, the hose must be tied down
prior to starting the pump.
Safety Alert
ALERT 08 07
HELICOPTER LIFTS OFF WITH OUT WARNING WHILE

HLO ASSISTS PASSENGER
WHAT HAPPENED:
The crew-change helicopter was on deck with passengers preparing to disembark. The Helicopter Landing
Officer (HLO) was standing next to a seated passenger helping him adjust his 4 point safety belt.
Suddenly and without any radio notification or warning, the helicopter simply lifted off the deck. The HLO
managed to step back and slide the door closed before the chopper flew away. There was no visual or radio
contact giving the all clear to pilot before taking off. The HLO tried to contact the pilots immediately after
the incident, but there was no reply back.
WHAT CAUSED IT:
According to the helicopter company:
(1)
(2)
(3)
(4)
Pilot training was deficient;

The helicopter cabin duties were insufficiently defined allowing confusion;
The pilot did not properly assess the situation which lead to the incident;
The pilot did not observe the door open light.
Immediate Actions by Contractor Resulting in Clients Follow-up
Since personnel logistics for the operation are a Client matter, the Company Man was informed. The official
document, specific for air-related near miss / incidents was completed and immediately forwarded to the
Client. An e-mail was also sent to the Client containing a video of the incident and requesting that corrective
measures be put in place. The helicopter company was contacted by the Clients Representative. The
Clients Flight Safety Officer met with the helicopter company to show the video and discuss the causes and
preventive measures. The helicopter company asked for a copy of the video to be used in pilot training in
order to minimize chances of recurrence. The Clients Contract Manager was also notified to take the
necessary administrative measures necessary to prevent recurrence by ensuring the pilots adhere to their
checklist procedures for disembarking.
Contractor Initiatives put in place:
If HLO sees he must assist a passenger or for any need for delay he is to call the pilot on the radio or
walk to front of helicopter and signal to delay lift-off. When assistance is finished, he will radio or signal all
clear for take-off.
Pilots should be trained as per the country-of-operations laws and regulations pertaining to helicopter
operations, which include offshore pilot responsibilities. Helicopter providers pilots should be trained in the
Clients General Operations Manual that includes the safety rules related to offshore landing and take off
procedures. An annual refresher training course, that includes flight simulation and HLO ops, should be
conducted.
Further Recommended Precautions
Large crew-change operations normally have a pilot and co-pilot. It is the practice of some helicopter
companies for the co-pilot (or pilot) to walk around the helicopter (not tail rotor side) to verify:
Safety Alert
(1)
(2)
(3)
(4)
(5)
All passengers are secure.

All hatches and doors are completely closed and secured.
There is nothing on or near the helideck that can be sucked into the helicopters engine intake port.
The landing skids are not caught in the helideck net.
HLO and his crew are on standby alert prepared for take-off.
Safety Alert
ALERT 08 08
LTISTRUCK BY FLOWLINE AND FALL IN SUBSTRUCTURE

WHAT HAPPENED:
A crew was rigging down the flow-line that extended from the bell nipple to the shaker. Two pad eyes
providing for a balanced hoist of the flow-line were available to hook up to, but a chain was attached to only
one pad eye, resulting in an unbalanced load. The Dresser sleeve was knocked loose and the flow-line
pivoted from the unbalanced hookup. The unsupported end of the flow-line swung down, striking a floorman
standing on a lower beam, causing him to fall two meters (6 feet). The fall resulted in three cracked ribs.
WHAT CAUSED IT:
1. There was a lack of communication, no pre-job or JSA discussion.
2. Personnel didnt share with each other the hazards involved in the plan devised for removing the flowline. The hazard of an unbalanced crane pick-up / lift was not recognized.
3. The injured was standing below the flow-line, exposing himself to the dropped object or uncontrolled
release of the energy source (gravity), and no one recognized the hazard.
4. The 100% tie-off rule was not followed, and the injured was exposed to working above two meters
without fall protection.
1. Good communications are essential to performing the job safely.
2. The safety tools are in place, such as pre-job safety meetings, JSAs, Hazard Recognition techniques
(ABBI, STOP Observation Card, and Energy Sources).
3. Using these techniques takes time, but thats a part of making safety equal to cost, efficiency and
productivity.
4. Management must follow-up frequently with the injured to see how he is doing or if anything has
changed since the incident.
5. Instruct personnel that when injured, to relay to your supervisor (medic) any changes in how you feel.
Safety Alert
ALERT 08 09
UNSECURED LOAD RESULTS IN AN INJURED EMPLOYEE

WHAT HAPPENED:
Rig crews utilizing trucks and a crane were in the process of rigging up. The pony subs were set and the top
subs stacked. The crane set the first substructure spreader in place, however, the spreader did not set down
into the substructure pin ears all the way. At this time the crane line was unhooked from the spreader. This
action resulted in an overhead load (i.e., the spreader) not being secured. It is not clear who instructed the
crane swamper to disconnect the crane line from the spreader. A gin truck was hooked on to the drillers
side substructure at the bottom and onto one side of the load hitch. When the gin truck lifted the
substructure it spread the substructure more than expected letting the spreader fall through the substructure
to the ground. Two employees were on the ground below the spreader when it fell. They were looking up to
see what needed to be done to allow the spreader to set in place so the pins could be installed. One
employee was able to move out of harms way. The other employee was struck by the spreader and knocked
into the cellar resulting in a severe injury. A cellar cover was not in place.
WHAT CAUSED IT:

There was a failure to follow procedures detailed in the Safe Work Procedures Handbook. The companys
handbook states: All personnel to stand clear of all overhead work.
The company policy on over head loads is very clear and specific. This includes all suspended loads
and all overhead loads that are not yet secured.
1. Do not unhook from a suspended load until it is secured. Once secured approval for unhooking must be
given by the supervisor overseeing the operation.
2. Top pins should be installed first. This will secure the load before installing the bottom pins from
underneath.
3. The companys truck supervisor, rig manager or driller should be supervising rig-up of the substructure
assembly. One of these supervisors is responsible for directing ALL aspects of the job including
authorization for unhooking from the load.
4. A cellar cover is to be installed before assembling the substructure.
Issued March 2008
Safety Alert
7. Rig managers are to ensure this Safety Alert is reviewed with each crew member. A pre-tour safety
meeting is a good opportunity to conduct and document the review. The Safety Alert should be posted in
the top doghouse.
Issued March 2008
Safety Alert
ALERT 08 10
DROPPED STRING HIGH POTENTIAL INCIDENT RESULTS FROM

PULLING AGAINST CLOSED BOP PIPE RAMS
WHAT HAPPENED:
While laying down 5" drill pipe the crew proceeded until there were 3 stands in the well. The Company Man
stopped the operation and instructed the drill crew to use the cementing unit pump to conduct an integrity
test on the cement plug and casing against the BOP top pipe rams. A pre-job safety meeting was conducted
by the Senior Toolpusher (STP) for the driller and the drilling crew. After pressure testing, the cement plug /
casing showed pressure leakage. The pressure was bled off and the STP went to the Company Mans office
for further instructions. Prior to leaving the rig floor the STP informed the driller not to forget to open up the
top rams and to pull out the string. The driller decided to assist the crew in disconnecting and lying down the
cementing line, valve and circulation head prior to pulling the final three stands of drill pipe. When starting to
pull the last three stands out of the hole the driller felt an over-pull and remembered that top rams were still
closed. No remarkable change in Martin Decker reading was observed by the driller since the lower tool joint
wasnt against the top rams due to the spacing out for pressure testing. When the tool joint reached to the
top rams, the drill pipe started to stretch and unfortunately, the driller didnt have enough time to respond and
stop the operation especially, since the string had already traveled 6 ft. upwards. The drill string parted and
the rest of the string (8 joints of pipe + about 27'of the parted joint of DP) was dropped down into the well.
WHAT CAUSED IT:
Lack of supervision from STP.

Inexperienced driller as he was recently promoted and still in the probation period.
By testing against the top BOP rams, the rig crew did not follow the companys recommended
drilling practices.
Drilling instrumentation / drilling chart recorder wasnt operating thus it was not possible to verify the
maximum over-pull.
Short Term Actions:
Instructions were given to all rig crews to always perform as cement / casing integrity test against
blind rams.
Rig Superintendents are to provide coaching by at rig sites.
Long Term Actions:
Rig supervisors are to perform proper planning of work scopes and divide them up to several suboperations with each having their own pre-job meetings.
Additional supervisory resources shall be assigned to company rigs i.e. additional field
superintendent.
Issued March 2008
Safety Alert
ALERT 08 11
IMPROPER USE OF ELEVATORS WITH

TOP DRIVE ASSEMBLY
WHAT HAPPENED:
During a visit to an operating rig, the Top-drive Technician observed the elevators being used in the incorrect
position (backwards) during tripping operations. This occurred despite the fact that he had given instructions
on the proper use explained the top drive system (TDS) in detail to the rig crew the previous day.
WHAT CAUSED IT:
The Driller chose to re-install the elevators incorrectly (backwards) in order to extend the link tilts out further
for the derrick man while racking back pipe. In order for this configuration to be operated, the following steps
needed to be performed:
The elevators had to have been manually removed, turned 180 degrees and re-installed. The Driller
would then be in a position to rotate the handler 180 degrees allowing the link tilt to extend further out
(Drilling mode).
The safety system which triggers the warning alarm at 60 feet (18 meters) above the rig floor and then
triggers the braking system at 70 feet (21 meters) above the rig floor in order to prevent the TDS from
ever reaching the monkey board level when the links are in the drilling position was switched off.
In doing the above steps, the Driller knowingly violated procedures,-by-passed a safety device and put the
equipment and more importantly, the safety of the Crew at serious risk.
The job was immediately stopped by the top-drive technician. He explained again how the TDS needs to
be set up for tripping and why. He then supervised the crew to ensure that the TDS was set up properly
in the tripping mode and the safety warning device enabled.
A behavioral observation card was written and handed into the Rig Supervisor and rig Top-drive
Supervisor.
The rig Top-drive Supervisor then spoke to the Field Superintendent and explained the situation. The
Field Superintendent then immediately called the Rig Manager to ensure the proper procedures are
being maintained and enforced.
Issued March 2008
Safety Alert
Elevator
Handles
ALWAYS
to
be
positioned pointing
to the back side of
the backup tong
Back-Up tong
Elevators
Issued March 2008
Safety Alert
ALERT 08 12
FALL FROM HEIGHT RESULTS IN LTI

WHAT HAPPENED:
Two roughnecks were working in BOP area to reposition the telescopic bell nipple. After working on the bell
nipple, the Supervisor sent the winch line down through the rotary table opening. While the injured person
(IP) was standing on the rotary beams he attached himself to the winch line hook and then unhooked his
lanyard from the rotary table beams. As he disconnected his lanyard, the chest ring on his fall protection
harness slipped out of the winch line hook causing the IP to be without fall protection which resulted in him
falling 10-15 feet to the annular then another 15 feet to where he landed on his back over the BOP rams and
eventually coming to rest on the ground near BOP hoses. The Rigs Emergency Response Team stabilized
the IP and he was transported to a local hospital for evaluation and treatment then transported to a hospital
trauma facility. The medical assessment showed multiple fractures of the pelvis and back.
Place where he fell on his

feet and then on his back
on the BOP ram bonnet.
Hook that was in

unsafe condition
WHAT CAUSED IT:
The crew used a hook which was in unsafe condition.

Rig did not have in place the self retracting lifelines (SRL) for working at height in substructure/BOP
area.
The winch used was not adequate for the activity. A Man-Rider Winch should have been used as
required by standard operating procedure.
The rig had scaffolding available for working on the BOP, but it was not installed due to nature of work
being performed.
Issued March 2008
Safety Alert
The unsafe hook had been identified earlier, but had not been replaced as per established procedure.
No JSA or Permit to Work was issued to perform the activity and all potential hazards had not been
identified for this task.
Immediate action: Instructed the Rig Manager to change out the unsafe hook as soon as the mast is rigged
down.
Per the companys equipment standard, a request was made to place a dedicated man-rider winch for
the rig.
Rig personnel are to use fall protection as per company standard for personnel hoisting activities.
Rig personnel installed SRLs below rotary table that are adequate for the job.
Rig personnel were instructed that scaffolding will be erected when working in BOP area.
A third party investigation has been completed.
An inspection has been conducted of all lifting and fall protection equipment on the rig. A follow-up on its
condition has warranted several lifting equipment items to be taken out of service.
Rig supervisory personnel were instructed to reinforce company policies on following the correct safety
procedures such as, JSAs, Work Permits and use of Fall Protection Systems.
Hand-over notes and responsibilities should be identified by supervision and communicated to all
personnel.
Issued March 2008
Safety Alert
ALERT 08 13
IMPROPER ATTACHMENT OF SAFETY LINE RESULTS

IN A DROPPED OBJECT
WHAT HAPPENED:
While finishing the pressure testing of the well head valve, the rig crew members were instructed to break out
the saver sub, lower Internal Blowout Preventer (IBOP) and upper IBOP for Non-Destructive Testing (NDT)
inspection. The Top-Drive System (TDS) saver sub was broken out using the TDS Pipe Handler. While
attempting to break out the lower IBOP, it started to spin and after three attempts to break it out, the Driller
and the Night Pusher decided to use the rig tong to break out the lower IBOP. The lower IBOP was gripped
by the make-up tong and TDS applied reverse torque to the upper IBOP. The tong applied torque directly to
the TDS tracks lower attachments causing the TDS guide beam to come out from the lower tie back link
causing it to turn and twist some guide beam components. The intermediate tieback's bolts were sheared
and the intermediate tie back (Approx. 12kg) fell 10 meters to the rig floor. No one was injured.
WHAT CAUSED IT:
Night Pusher and Driller did not comply with the procedure for breaking out the IBOPs from the TopDrive System.
This was the first time to do the job with one tong which is a short cut for breaking out the lower and
upper IBOPs.
This shortcut was taken without authorization or advice from the Senior Toolpusher.
Incorrect securing for the intermediate tieback was made on the mast beam with the securing wire
wrapped around the intermediate tieback itself instead of being wrapped around the mast beam as was
required to prevent a dropped object.
Improper tieback allowed the tieback beam to fall from 10 meter
1. The pipe handler is to be used for breaking /making up the IBOP connection.
2. Make sure that the pipe handler clamp cylinder pressure is 2000 psi and the dies are in good condition.
3. In case of using rig tongs for breaking the IBOP or saver sub from the main shaft, its important to use a
pup joint in order to maintain it in the center and prevent the twisting motion.
4. Any non-routine job related to the TDS should be performed under the supervision of the Rig Senior
Mechanic and Senior Toolpusher.
Issued April 2008
Safety Alert
ALERT 08 14
MUD PUMP MAINTENANCE RESULTS IN SERIOUS INJURY

WHAT HAPPENED:
The swab in the #1 mud pump needed changing so Pump #1 was shut down and the #2 pump was placed in
service. A lock was placed on the #1 pump circuit breaker. No other Lockout/Tagout (LOTO) requirements
were performed. The crew changed the swab on the pump and the derrickman was tightening nuts on the
rod clamp and hooking up the liner washer. The motorman called the driller telling him all they had left to do
was rig up the liner washer and then went into the SCR house and removed the LOTO lock from the breaker
panel. He went back to the mud house and called the driller telling him to go ahead". The driller turned the
potentiometer on his control panel to prime the pump while the derrickman was still working on the pump. As
a result the derrickmans lower leg was caught between the rod clamp and mud pump when the pump was
powered up and his lower leg was seriously injured
WHAT CAUSED IT:
1. The crew did not follow the companys Lockout/Tagout Procedure:
a. The required Lockout/Tagout form was not completed or followed for the job.
b. All sources of energy were not locked out.
c. Work area was not inspected prior to removal of LOTO.
d. All employees were not notified prior to removal of LOTO.
e. Communications between the driller and the motorman were unspecific. The motorman
informed the driller to go ahead instead of shut down pump #2.
f. The crew working on pump #1 was not aware the driller had already shut down the #2 pump and
was preparing to start up pump #1.
g. The lock on the #1 pump circuit breaker was removed while the pump was still being worked on.
The companys Lockout/Tagout Procedure, including the LOTO Verification Form, MUST be
followed and used as a step-by-step guide for isolating equipment prior to initiating work.
2. A pre-job meeting was not held to plan the work.
3. A JSA was not written or reviewed prior to initiating the job.
4. The crew left the control switch for the blower on the pump traction motor in the Manual position. This
results in the blower continuing to run after the pump is shut down. Putting this switch in the Automatic
position will shut down the blower along with the pump. The noise created by starting the blower is a
good clue that a pump has power or is running.
1. Rig managers, drillers, superintendents, and safety managers should increase the monitoring,
supervision, and training for LOTO on a daily basis for all rigs.
2. Utilize a pre-job meeting to ensure that all personnel are aware of the hazards of the task at hand. All
communication on the rig needs to be specific for what is to be done. Examples include: shut down
pump 2; pump is unlocked and ready or dont put your fingers on top of the tong handles as opposed
to go ahead.
3. Write and utilize a JSA prior to starting the job.
4. Make certain all appropriate mud pump equipment is shut down when repairing or doing maintenance on
pumps. This includes the centrifugal pump(s), liner washer, traction motor blower. Many of these are
currently hooked up to be on when the pump is turned on and some can be overridden with a manual
control. These other pieces of equipment might also require LOTO. Install lockout devices on gate valves
and butterfly valves as a secondary lock out measure to control any unforeseen release of energized
fluid. Examples include the 4 mud line valve, tank suction valve would be locked in closed position and
the 2 bleed off valve would be locked in the open position.
IADC Note: Refer to Section 3.1 of the IADC HSE Reference Guide for additional information on
LOTO and/or IADC Safety Meeting Topic Book topic on Lockout/Tagout
Issued April 2008
Safety Alert
ALERT 08 15
MONKEY BOARD INCIDENT RESULTS IN MTO

WHAT HAPPENED:
During a rig move operation, the diving board had been secured with a tie back rope to the monkey board
which was resting in a vertical position. The derrickman had climbed up on the monkey board to align it
before raising the mast. At the same time a roustabout saw a rope that was tied on the bottom of the
monkey board hindering the operation. As the roustabout moved into position under the diving board to untie
the rope, the derrickman cut the rope holding the diving board securely in place. The derrickman did not look
down to verify if it was safe to cut that particular rope. The diving board fell approximately 1.5 meters (5 feet)
and hit the roustabout on the back of his head causing an open wound injury and rendering the IP
unconscious.
WHAT CAUSED IT:
1.
2.
3.
4.
5.
The tie back rope was cut and this allowed the diving board to free fall.
The derrickman should have been more alert to the position of the roustabout and the hazard this posed.
The roustabout should have been aware of the purpose of the secured rope.
Poor communications between both parties working.
Supervision should have provided hazard awareness and clearer work instructions.
CORRECTIVE ACTIONS: To address this incident, this company instructed rig personnel in the
following:
Follow the correct procedure in lowering the diving board and hinge up the handrail bolts back to the side
rail.
The diving board can be laid back against the back handrail and secured with a cable or safety strap.
The safety cable/safety strap keeps the board from falling when the mast is being raised or lowered.
Hold a JSA and identify hazards and job specific duties before the task is done.
Improve lines of communication from the Supervision to the employees
Issued April 2008
Safety Alert
ALERT 08 16
DROPPED OBJECT DURING TRUCK LOADING OPERATION

RESULTS IN LOST TIME INCIDENT
WHAT HAPPENED:
An incident occurred when the rig crew was in the process of loading a skid (3rd party modified shale bin) to a
truck for removal from the rig site. To give the crane operator the signal to slack off the load the injured
person (IP) positioned himself in between the rear of the load and a pipe tub (3 foot space), just as the load
was positioned onto the truck. As the crane operator slacked off the load, a 500+ pound ramp (225kg) slid
from the position it was in on the skid and fell to the ground. In the process it struck and pinned the IP under
the ramp. The IP was removed from beneath the ramp and stabilized on site and Medivaced from location
for medical treatment.
WHAT CAUSED IT:
1. The third party had no Management of Change Policy or Procedure referred to in order to ensure quality
control before the equipment was redesigned and moved to the rig site.
2. Improper risk assessment: Failure to identify hazards after the modifications had been made and no
formal JSA was completed before loading the unit onto the truck.
3. The skid being moved without all the equipment first being secured.
4. Incorrect rigging and slinging being applied to the load.
5. The IP positioning himself in between the back of the truck and the pipe tub to signal the crane operator.
6. The crane operator slacking off the load while the IP was standing between the load and pipe tub.
1. Third Party was instructed to implement Management of Change Policy and Procedures.
2. Rig supervisors were told to have better scrutiny of third party lifts and loads.
3. Operations personnel were instructed to conduct a safety audit of all cargo boxes, containers that are to
be used and loading procedures within the operations.
4. Rig personnel were instructed to ensure that proper risk analysis is completed before starting a job.
Modify and update the JSA and procedure for general lifts while using the crane.
5. Rig supervisors were instructed to reinforce the companys STOP WORK policy and get a commitment
from all the personnel on site about their responsibilities of stopping the job when unsafe acts or
conditions are noticed.
6. The company is to implement competency training program for rigging and slinging for crew members.
7. Operations personnel need to review the standard rig start up sling package for land rigs to ensure
standard equipment.
Issued May 2008
Safety Alert
ALERT 08 17
THIRD-PARTY CRANE AND CRANE OPERATOR SUPERVISION

WHAT HAPPENED:
A rig was being prepared for loading out and transporting from a third-party rig up and commissioning site.
The task at hand was to lower the main sub base section (weight 12 ton) of a 750 hp carrier-mounted rig. A
third-party crane and operator was being used to rig down the main components. The onsite Rig Manager
was directing the loading process at the time of the incident. A 25-ton crane had been engaged to lower the
main sub base and rig floor section to the ground level. The load needed to be lifted and moved to the right
for storage of the sub base. The crane operator had jibbed out all stages of the boom prior to taking control
of the load. During this operation, the crane operator was using his cell phone. One of the rig crewmen was
on the rig floor section knocking out the pins from the stabilizer beams. It would appear that there was slack
in the lifting sling and following the removal of the last pin the full weight of the sub base was suddenly taken
up by the 25-ton crane. The last section of the extended boom failed and buckled under the weight. This
caused the sub base / floor section to free-fall to the ground approximately 12-14 ft. The employee on the rig
floor section who was knocking out the pins managed to ride the load to the ground and escaped any
injury. Damage to the sub base structure consisted of bending and stress to the main six stabilizer beams.
The crane was left in position following this incident and all personnel cleared of immediate area. The area
was barricaded off while inspections and investigations into this incident took place.
WHAT CAUSED IT:
1.
2.
3.
4.
5.
6.
7.
8.
Incorrect positioning of crane by operator. The rigging crew failed to recognize potential lifting hazard.
Inadequate supervision and crane directives.
No JSA performed before the task.
Poor decision making by crane operator to use mobile phone during lifting/lowering operation. Very poor
supervision by allowing this practice to occur.
Miscalculation of load weight and incorrect methods of load bearing positions.
Failure to conduct pre-job safety meeting. Step Back 5x5 Safety Tool not utilized as recommended.
Senior Site Manager was not on location at time to offer expertise in lift.
Incorrect position of the employee who was knocking out the pins.
Personnel involved in the lift are to hold a JSA and identify the hazards before the task is done.
Lift personnel are to utilize the companys pre job 3rd party equipment check list.
Site supervisors are to check crane operator certifications for competency on the operating of hire
equipment.
Because of potential injury or equipment damage site personnel are to correctly use the Permit to Work
check off list for heavy lifts.
Improve line of communications from Senior Rig Site Personnel on their responsibilities and duties when
ever Senior Site Manager is off location.
Use of competent and ticketed Dog man / Signal man for directing all loads as required on rig
construction site.
To avoid shock load the crane operator is to be sure that the package weight is taken up by the crane
prior to the pins being moved.
Issued May 2008
Safety Alert
ALERT 08 18
FALL FROM CASING RESULTS IN LTA

WHAT HAPPENED:
The deck crew was in the process of back-loading a 30 foot mud motor to a crew boat off the port side of the
rig. The deck coordinator had slung the mud motor with a sling at each end using the double wrap method of
slinging. After attaching the tag lines to the load, the deck coordinator moved to what he perceived to be a
safe area (approximately 6 feet (2 meters) away) on the light end of the load. The deck coordinator then
signaled the crane operator to raise the load. As was discussed in the pre-job talk the crane operator raised
the load to height that the deck coordinator could determine that the load was stable (approximately 2 feet
[.6t meter]). At this time the deck coordinator approached the load on the light end and signaled the crane
operator to raise the load for back-loading. When the crane operator started his lift, the load shifted, causing
it to rise on the light end and to move towards the deck coordinator. In an effort to get away from the
unexpected movement of the load the deck coordinator put himself on the side of the load that had no room
for escape. He was then forced to sit down on the other smaller tubulars also stored on top of the casing.
The starboard aft movement of the load coupled with elevation of the light end of the mud motor caused the
entrapment of the deck coordinators left leg. Now the deck coordinator was over the edge of the racked
casing and his leg was trapped between the suspended mud motor and the two mud motors on the racked
casing. The crane operator stopped the crane, and the load then moved forward releasing the trapped deck
coordinator, who then fell approximately9 feet (2.85 meters) from the top of 10 casing stacked on the
port pipe rack to the catwalk. The injured person sustained fractures of his left leg and his right arm as a
direct result of the fall and the entrapment of his leg.
WHAT CAUSED IT:
The deck coordinators position in relation to the load when it shifted caused the entrapment and subsequent
fall. The crane block was centered prior to the lift and appropriate slinging techniques were employed for the
lift. The heavy end of the load was not free during the initial lift to see if the load was stable. The most likely
reason for the load transition is the shifting of the balanced load from the heavy end to the light end as it
came to equilibrium.
When the casing was initially loaded aboard the rig it was determined that it would be there for an extended
period. There was no mitigation of the risks associated with landing and lifting loads from that height. The
pre-job planning used a JSA that did not make mention of the height to which the deck coordinator would be
rigging the loads. The crane operator made mention of the edge and the height during the pre-job planning;
however no controls were put in place.
CORRECTIVE ACTIONS: To address this incident, this company instructed rig personnel:
The person in charge of the load is responsible to check that both ends are free.
When loading or unloading items from racked tubulars, all lifts will be checked for stability and correct
rigging.
Personnel shall move off the racked tubular prior to making the lift.
Issued May 2008
Safety Alert
ALERT 08 19
TONG CLEVIS DETACHES RESULTING IN EMPLOYEE INJURY

WHAT HAPPENED:
The crew was tripping out of the hole when the clevis attaching the back-up snub line to the tongs became
detached from the tong. The tong swung around striking an employee and he was knocked over by the
tongs and to the rig floor. The employee only suffered contusions to his legs and body. Prior to the incident
the cotter key for the bolt was lost and replaced with a larger diaper pin type safety keeper used on derrick
pins. During the TOH the keeper was dislodged from the bolt and the nut vibrated off. The bolt dropped out
of the clevis and the tongs were then free to swing around the table.
WHAT CAUSED IT:

1. The missing cotter key was replaced with an improper keeper. The replacement keeper was much more
susceptible to snagging and was apparently pulled out during the TOH.
2. The clevis connections were not thoroughly inspected prior to the trip. Had the nut been tightened the
bolt may not have come out, even if the keeper were lost.
1. Informed rig personnel that when repairing or replacing missing equipment use the proper parts, not
make-shift items.
2. Rig Personnel are to visually inspect tongs on a regular basis, especially prior to tripping pipe.
3. Rig managers are to ensure this Safety Alert is reviewed with each crew member. A pre-tour safety
meeting is a good opportunity to conduct and document the review.
4. Rig Managers are to ensure that this Safety Alert should be posted in the top doghouse with a copy filed
in the rig Safety Alert book.
Issued June 2008
Safety Alert
ALERT 08 20
IMPROPER LIFTING PRACTICE (LTI)

WHAT HAPPENED:
While rigging up the V-door during a rig move, the driller was supervising two floormen who were assigned to
install the V-door pins. The crane was holding the V-door in an inclined position and lowering it under the
drillers signals. The handrail attached to the V-door steps became stuck against the air hoist on the rig floor
(driller did not notice it). The IP was installing the middle pin and another floorman was installing another pin
beside him, the driller was helping them and giving signal to the crane operator at the same time to lower the
V-door slightly to facilitate the installation of the pin. Suddenly the handrail got free from the air hoist and
moved away fast and the V- door gate support hit the injured persons (IPs) left knee. The IP sustained a
hematoma in his left knee and put his leg in cast for 2 weeks.
WHAT CAUSED IT:
Inadequate supervision and poor communication, as the driller gave a signal to the crane operator to
lower the V-door in, was not observing the load.
At the same time the IP was still close and installing the pin.
Driller acted as banksman (signal man) and lift supervisor, thus not giving himself full view of the work
place and he failed to see the handrail hung up on the air winch.
There was a change of design when it was decided to weld the gate support of the V-door. The
Management of Change (MOC) process was not followed.
Welding the V-door gate allowed the hand rail to get tangled with the air hoist on the rig floor.
The Safe Job Assessment (SJA) did not address the potential of the load getting hung up on the air
winch.
Proper SJA to be issued and communicated with rig crews in the pre-job meeting.
Improve lifting competency of the crew and supervisors.
Issued June 2008
Safety Alert
Issued June 2008
Safety Alert
ALERT 08 21
INSTALLING ANNULAR BOP RESULTS IN RWC

WHAT HAPPENED:
The injured party (IP) was assisting in the installation of the annular preventer to the BOP stack. The annular
was being suspended by the crane at the time of the incident. The IP was attempting to get one of the nuts
started onto the BOP stud when he inadvertently placed a portion of his hand between the nut and the
bottom of the annular preventer. At the same time the annular shifted position and pinched two of the IPs
fingers.
The pinch point area between the annular body and the BOP bolt where
the IP placed his left hand fingers.
WHAT CAUSED IT:
It was determined in the accident investigation that the Annular was being suspended by slings of different
length and that the crane boom was not extended far enough to have the load properly centered over the
BOP stack. Subsequently, the Annular got caught on one side of the BOP bolts and shifted at precisely the
same time the IP had his fingers in the wrong position.
1. The job was immediately stopped and the IP treated for his injuries.
2. A safety meeting was held to communicate incident with all crew members. The JSA was revised and
reviewed to include identifiable pinch point.
3. Crew and crane operator were informed to follow safe rigging/lifting procedures.
4. A Safety Bulletin was generated for circulation to other operating rigs.
Issued June 2008
Safety Alert
ALERT 08 22
INJURY RESULTS FROM

WORKING ON PRESSURIZED EQUIPMENT
WHAT HAPPENED:
An air line from an air compressor to the air tank was leaking. The driller decided to tighten the hammer
union which was under pressure with a sledge hammer. When the 1 union was struck the air line broke
striking the employee on the leg.
WHAT CAUSED IT:
1. The employee failed to follow proper Lockout/Tagout procedures.
2. The employee failed to use the proper tool for the task.
1. Make sure all employees are aware of potential dangers when working on any pressurized equipment
and the correct way to release trapped pressure.
2. Before working on any kind of pressurized hose or line make sure the pressure is reduced to zero and
the equipment is locked and tagged out.
3. Be sure to use the proper size tool for the job. A smaller hammer would have been more appropriate for
the task.
4. Rig managers are to ensure that this Safety Alert is reviewed with each crew member. A pre-tour safety
meeting is a good opportunity to conduct and document the review. Post this Safety Alert in the top
doghouse.
IADC Note: See IADC Alert 99-13. Also, note the following from the IADC HSE Reference Guide:
Employees should not attempt to tighten or loosen unions or other connections under pressure. Never
hammer on a pipe or connection that is under pressure.
Issued July 2008
Safety Alert
ALERT 08 23
IMPROPER LIFTING PRACTICE RESULTS IN

A (RESTRICTED WORK / TRANSFER CASE)
WHAT HAPPENED:
An improper lifting practice resulted in a restricted
work/trasfter case during a rig move, and while removing the
carriers ramp off the trailer at a new location. The
workgroup consisted of a driller (supervisor), a derrick man
and a floor man (Injured Person). The forklift was positioned
to take off the ramp from the right side of the trailer and the
driller was beside it giving signals. To facilitate the lift, two
stoppers were removed from the forklift side. The forklift
operator tried to lift the load off the trailer but it couldnt lift
the load higher than the stoppers installed on the opposite
side of the trailer bed. The driller asked the forklift driver to
rest the load on the truck and asked the IP to remove the
stoppers from the other side, which were in between the
ramp and the delivery line (narrow place). The IP went to
the other side of the truck where the driller couldnt see him
and tried to remove the stoppers. Without checking on the
status of the IP, the driller asked the forklift operator to raise
the ramp again and didnt notice that the IP had not finished
removing the stopper. The IP's left index finger was crushed
in between the stopper and the ramp causing a severe cut.
Ramp to be
unloaded
Stopper
being
removed
Pinch Point
WHAT CAUSED IT:
Poor supervision and communication as the driller did not make sure that the IP had finished the job
assigned to him.
Change of procedure during task.
o Normal procedure is to lift off the ramp, from the trailer, high enough so that the trailer can pull
out from under the load. Then off load the ramp in place.
o The driller decided to have the IP remove the stoppers on the side opposite the forklift.
o The injured ended up being in a position where he was not full view of the driller.
o The driller decided to lift the load again without checking to determine if the injured person had
removed the pins and his hands were out of harms way.
Improve lifting competency of the crew and supervisors.

Failure to follow Management of Change (MOC).
Issued July 2008
Safety Alert
ALERT 08 24
DERRICK OPERATION RESULTS IN A FATAL INCIDENT

WHAT HAPPENED:
The operation was pulling out of the hole and racking back drill pipe. After the slips had been set, and before
spinning out the pipe, the iron-roughneck operator looked up at the monkey-board, and did not see either the
IP or the tugger chain attached to the stand of pipe. He commenced to break the connection and back-out
the stand. While the exact sequence of events is not clear, during this process the IPs left hand became
trapped between the pull-back chain and the pipe. The pipe rotation was stopped with the IPs left hand
facing the monkey-board, palm out.
The IP was rescued from the monkey-board and given on-board medical attention. The IP was then sent to
the hospital ashore via medivac, and subsequently passed away at the hospital.
Demonstrating placing the chain on the stand of pipe.
Demonstrating the position of the injured hand
WHAT CAUSED IT:

1. The IP had not completed the Derrickman On-The-Job Training.
2. No direct communication had taken place between the Driller and the IP immediately prior to the
incident.
3. The tugger chain used was 5.5-ft (168-cm) in length.
4. It was a common practice to place the chain on the tubular prior to it being backed out.
5. Neither the crew nor the rig had a Rescue from Heights plan as part of their Job Risk Assessment.
Instructed the Rig Manager and OIM to ensure to verify:
1. All personnel working as a Derrickman (or relieving a Derrickman), should have successfully completed
the Derrickman On-The-Job Training program.
2. All personnel manually racking tubulars (Derrickmen), have been instructed to NEVER place their pull
back ropes or air tugger chains on a tubular while it is spinning, or prior to it rotating.
Issued July 2008
Safety Alert
3. The Driller is responsible for communicating to the Derrickman (via the hands-free communication
system), that it is clear for the Derrickman to place the rope or chain on the tubular when it has been
confirmed that rotation has been stopped, the iron roughneck or spinning wrench has been removed
from the pipe, and the pin is lifted clear of the box.
4. Length of a chain used for manually racking tubulars should be formally risk assessed, to ensure that it
does not create a potential hazard (either too long or too short).
5. All Job Risk Assessments involving manually racking tubulars are reviewed to include the previous
points.
6. Ensure that the hands-free communication systems are in good working order, as per the companys
Health and Safety Manual.
7. A plan for the rescue of personnel at elevated levels is included in the relevant Job Risk Assessment and
all necessary equipment is available [References: Company Health and Safety Manual section on Fall
Protection].
Rig Specific Corrective Action Plans are to be developed, tracked, and closed in the companys
incident closure tracking system.
Regional and Rig QHSE Managers are to follow up and report to the Director of Corporate QHSE
upon completion and close out.
Issued July 2008
Safety Alert
ALERT 08 25
DROPPED OBJECT - FALLING SLEDGE HAMMER

WHAT HAPPENED:
While doing a pressure test on the stand pipe, a leak was detected at approximately 39 feet (12 meters)
from the rig floor. The Tool pusher assigned a crewman to go up and tighten the hammer union joint. The
area was cleared as per Standard Operating Procedures (SOP). Once the adjustment was finished the
worker began to come down out of the derrick. At the same time as the worker was coming down, the rest
of the crew began normal operations on the rig floor entering the cleared area. At about 23 feet (7 meters)
from the rig floor, the worker lost his grip on the 4 pounds (2kg), sledge hammer (which was covered with
mud). The hammer fell, striking a cross section brace, changing its direction and then striking a worker on
the back section of his hard hat, producing a lesion and cracking his hard hat, producing a lesion.
WHAT CAUSED IT:
Worker did not use the tool carrier bag provided.

Crew returned to the restricted area before the worker finished coming all the way down.
CORRECTIVE ACTIONS: To address this incident, this company instructed supervisors to do the
following:
Discuss with the crew, the safe handling of hand tools prior to use. Inspect before use.
Explain the importance of using the proper equipment such as tool bags and tool belts for tasks
performed in high places.
Go over with the crew, the steps in the JSA for this specific job.
Follow operational safety procedures by utilizing safety inspections.
Place Where
Hammer Fell
Hard hat Cracked by the impact of the hammer
Issued July 2008
Safety Alert
ALERT 08 26
FALL FROM HEIGHT RESULTS IN DOUBLE MTO

WHAT HAPPENED:
Two Floormen were working in the substructure approximately 4 metres (13.4 feet) above the ground and
removing the bell nipple from the top of the blowout preventer (BOP). The flow line had been disconnected
from the bell nipple but was still attached to the winch on the drill floor when it was raised unexpectedly. The
flow line flange knocked the bell nipple from the BOP seating and it fell to the ground. The Floormen had
moved from one side of the Bell Nipple (v-door side) to the other side (draw works side) where they had just
connected a soft sling to secure the Bell Nipple. One Floorman (#1 in picture below) had attached his shock
absorbing lanyard to the Bell Nipple (approx 300 kg) and he was pulled down and fell to the ground. The
other Floorman (#2 in picture below) was knocked off balance and fell backwards to the extent of his shock
absorber lanyard before coming to rest suspended upside down with the unused work platform stopping his
fall any further. His lanyard did not extend far enough to activate the shock absorber. Both workers were
standing on the BOP lifting bracket. Both workers received soft tissue injuries and returned to work the next
day.
Position of
Floorman #1
before the fall
Original position
of Bell Nipple
Position of
Floorman #2
before fall
BOP Lifting
Bracket
Position of Floorman
#2 suspended
upside down
Bell Nipple struck
work platform
Final position of
Bell Nipple and
Floorman #1
WHAT CAUSED IT:
The winch line connected to the flow line was supposed to have been disconnected.
The original plan was to use two winch lines to remove the bell nipple, one through the mouse-hole and
one through the rotary table. One line was ready and passed through the mouse hole, but not
connected. The Driller changed the plan to use only one winch.
Neither worker was connected to the Safety Retracting Life (SRL) line fall arrestors which were attached
to the underside of the rig floor on each side of the sub base.
Lanyards used were not secured above head height and in one case the lanyard was connected to an
unsecured anchor point (bell nipple).
Issued August 2008
Safety Alert
All four studs that attach the bell nipple to the BOP annular had been removed before it had been
secured with a hoist line.
No procedure was available for this job.
No JSA/JHA was used for this task.
Brief pre-job discussion was inadequate for the task being undertaken and potential risk
Lack of adequate and / or specific instructions during the task, particularly just before the incident.
Procedure to be developed with sequential steps particularly the restraining of all equipment before
unbolting or removing it.
Ensure all provided safety devices are used (in this case fall arrestors)
Processes to be put in place to ensure adequate and thorough Pre Job meetings are planned as part of
the job, including the communication of hazards and why controls are necessary to prevent an accident.
Ensure all instructions given during a job are specific, understood and recorded.
Outline Supervisor expectations to ensure that jobs are undertaken safely
Reinforce to the work force that they are empowered to STOP THE JOB when safety controls or
precautions are bypassed.
Ensure fall protection lanyard is secured to a suitable (stable) anchor point.
To reduce fall distance, lanyards are to be secured to anchor points that are above head height.
Issued August 2008
Safety Alert
ALERT 08 27
GALLEY FIRE OCCURS DURING DRILL

WHAT HAPPENED:
The rig was conducting a scheduled Well Control / H2S drill. All personnel had donned self-contained
breathing apparatus (SCBAs), had mustered and were preparing to debrief. At that time there was an
announcement over the intercom: There is a fire in the galley, this is not a drill. Fire Fighting (FF)
crews were mobilized to combat the fire. Power to the galley was shut off. Because of the amount of smoke
in the galley it was difficult to determine the source. Investigation revealed the deep fat fryer as the fires
source. CO2 and dry chemical extinguishers were used to put out the fire, and a FF crew was standing by
with fire hose. The fire in the fryer was extinguished, but fire was discovered in the vent above the stove and
fryer which was put out with a fire hose. Another crew closed off the vent which helped to extinguish the fire.
WHAT CAUSED IT:
The deep fat fryer was found in the on position, and the temperature control dial was turned to the
maximum heat setting.
Temperature dial for deep fryer.
Although the reason for the fryer left on and temperature at max
heat setting was not determined, it is believed that:
(1) In a rush to muster for the drill, personnel simply neglected to
switch off the fryer. It is common practice to set heat at max to
heat up the oil faster. When the oil gets hot, the heat is turned
down to normal frying temperature. However, when the drill alarm
sounded, the galley was abandoned quickly leaving the fryer on
max temperature; hence, the oil ignited.
(2) Another explanation is that when the alarm sounded, in a rush
to get to the muster point, the dial was erroneously turned to
maximum heat instead of the off position.
The hood and vent above caught fire due to grease buildup.
Explained to kitchen crew the following:

o It is safer and better to plan the use of the deep fryer to avoid quick overheating of the oil. Heat up
the oil at the normal frying temperature. This lowers the risk of fire (especially if kitchen work is
interrupted or galley personnel need to leave the kitchen for any reason and could forget to turn off
the fryer.)
o Heating at normal temperature prevents having to change oil frequently.
o Frying with overheated oil (or spent or old oil) can affect the taste of the fried food.
Informed the Camp Boss of the drill schedule so someone can stay in kitchen and monitor the cooking, if
that is necessary. Be sure to rotate the kitchen staff as monitors so all galley personnel participate in
drills.
Issued August 2008
Safety Alert
OIM designated a person to pass through the galley on his way to the muster point to double check that
all kitchen items (fryers, ovens, stovetops, mixers, etc) have been turned off if a kitchen monitor is not
assigned.
Installed a fire extinguishing system with a fusible link for the galley exhaust hood.
Galley crew was reminded of their duties to keep the vent hood clean and free of grease buildup.
Issued August 2008
Safety Alert
ALERT 08 28
EMPLOYEES ARM FRACTURED WHILE USING PULL BACK ROPE

WHAT HAPPENED:
The crew was tripping out of the hole. The derrick man had wrapped the pull back rope around his arm to
assist with pulling the drill collar back. The derrick man lost control of the collar and was unable to release
the rope secured around his arm. His arm was pulled around the drill collar and severely fractured in several
places.
WHAT CAUSED IT:
The board communication system was not functional at the time of the incident and there was no verbal
communication between the derrickman and the driller.
The driller and other employees on the rig floor were apparently not aware of the derrickmans activities.
The derrickman had the pull back rope wrapped around his arm and could not release it.
Instructed the Rig Managers to ensure that the communication systems should be maintained in proper
working order.
Instructed rig personnel that the pull back rope should never be secured around the hand, arm or other
part of the body.
Instructed employees working on the rig floor during trips or any time personnel are in the derrick that
they should assist the driller in monitoring the derrickmans activities.
Instructed rig personnel to never stand on or in a coil of rope or line which is moving. These hazards are
present while operating the cathead line and during rig up operations.
Instructed rig personnel that under no circumstances shall a person wrap ANY rope, wire line or cable
around their hand, arm or other body part.
Instructed derrickmen that they shall use the mule line or pull back hoist whenever practical to limit the
use of the pull back rope.
Employees were instructed of other potential activities where this type injury could occur such as holding
a tag line. Being unable to release the tag line could pull a person off a platform or into harms way.
(IADC Note: check IADC Alert 08-24)
Issued August 2008
Safety Alert
ALERT 08 29
RIG MOVE VEHICLE INCIDENT

WHAT HAPPENED:
A lowboy truck loaded with a 60 ton ( 55 Mg) crane was driven onto the new location. The driver made a
U-turn and while leaving the new location the truck came close to the edge and its left rear tires penetrated
deeply into the un-compacted edge of the recently built up access road. The lowboy started to tilt slowly
towards the road side and due to the added load of the crane tipped on its side. Both the lowboy and crane
landed on its left side. There were no injuries to personnel.
WHAT CAUSED IT:
The Rig site access road construction was not properly engineered as the road side compaction was
not adequate and has a left slight curve at the entrance.
Road survey was not properly done by the truck pushers / senior tool pusher as the roadside
uncompacted sand was not observed, highlighted or repaired, presenting a hazard for the heavy load.
Rig move trucks were not properly controlled by the truck pushers. Three trucks were parked on the
location access road as no parking area had been prepared for heavy move trucks.
Rig move preparation procedure to be followed by truck pusher(s) and rig senior toolpusher prior to
start rig move and documented by completion of the checklist.
In preparation of new location, the company Minimum Requirements for Land Rig Drilling location
procedure is to be followed by construction engineer(s).
Movement of rig move trucks is to be controlled in order to ensure proper road traffic and parking.
Issued September 2008
Safety Alert
ALERT 08 30
CASING RUNNING OPERATION RESULTS IN LTI

WHAT HAPPENED:
While running 7-5/8 casing, a Floorman working in the stabber position was attempting to hold a casing
centralizer above the casing tongs. As the tongs were brought forward the Floormens right hand was
caught and pinched when the casing tongs were actuated. The Floorman was diagnosed with a laceration
and a broken bone in his right hand.
Casing Tong and Centralizer
Casing Tong around Casing
WHAT CAUSED IT:
The injured man did not realize that he had placed his had in a pinch point.
The pre-job hazard assessment did not recognize the hazard that may result from attempting to
secure casing centralizers while making up the casing.
CORRECTIVE ACTIONS: To address this incident, this company reviewed the following lessons
learned:
Thorough pre-job hazard assessments must be held before each job. All workers involved must attend
the meetings, participate, and understand thoroughly what their roles and duties are.
During pre-job safety meetings, all pertinent guidelines, SOPs, and Hazard Recognition Worksheets
must be reviewed.
Should any scope or part of the job change, stop the job and reassess how to do the job safely
During every job it is crucial that everyone stay focused to the job at hand
Everyone must remember to stop any job that they feel is unsafe. The job must not resume until all
hazards and mitigation steps are in place, communicated, and understood by all involved.
Workers must not hold objects above the casing tong.
Safety Alert
ALERT 08 31
THUMB INJURY RESULTS IN LTI

WHAT HAPPENED:
Due to a malfunction the rig crew was instructed to lay down the Measurement While Drilling (MWD) tool.
The make-up tong was placed around the mud motor and latched. The break-out tong was placed around
the MWD tool and an attempt was made to latch the tong when the injured person (IP) placed in the thumb of
his right hand between the lever and the long jaw of the tong. His thumb was caught between the jaw and
tong body, removing the flesh from the end of his thumb. The removed flesh could not be reattached and the
bone had to be amputated and the stump of the thumb sewn closed.
WHAT CAUSED IT:

This situation was a repeat of an incident that resulted in a lesser injury three months previously.
The prior incident involved the same crew as this incident. Following the prior incident, several safety
meetings, refresher training and pre-job meetings addressed the topic of hand and finger safety. Prior to this
incident, hand safety was discussed at the pre-tour meeting, a pre-job meeting and reminders and guidance
was provided by the Rig Manager who was on the brake at the time.
Other points of note include:
The IP knew he had his hand in the wrong position.

The IP had 1.5 years of experience working on the rig floor.
The rig is fitted with an Iron Roughneck resulting in the crews being less familiar with manual tongs (only
used when running Bottom Hole Assembly)
The following learning/corrective actions have been identified and implemented:
Awareness: All personnel will attend further refresher/awareness training on hand and finger hazards.
Communication: Effective communication is essential for safe operations. If there are any doubts or
misunderstandings, ask for clarification. ASK first, ACT later.
Safety Alert
Procedure/Work Instruction: Where there is a history of deviation from work instructions or

procedures or instructions are not followed, an assessment into the persons suitability for the position
will be undertaken.
Safety Alert
ALERT 08 32
FATALITY HIGH PRESSURE AIR RELEASE

WHAT HAPPENED:
A fatality occurred when two employees working on a floating MODU, were in the process of disconnecting
the U tube of the number three tensioner from the isolation valve. This was being done in an effort to
initiate repairs to the damaged marine riser tensioner (MRT). While removing the last bolt of the isolation
valve flange, the internal parts of the valve blew out and struck the injured employee in the head and face. It
was later discovered that they were actually dismantling the valve body because they had misidentified the
flange as a separation point for the line. The employees had inadvertently released the 400 psi of air on the
3 inch line and the internal parts of the valve.
WHAT CAUSED IT:
The subsequent investigation revealed that the crew assigned with the task of preparing the tensioner for
removal did not have full knowledge of the valve assembly and the necessity for completely venting
pressure on pressurized lines.
A false sense of security was created by the lack of pressure on the downstream vent valve on the
number three tensioner.
Pressure was left on the line in the event that a quick charge was needed to put the number seven
tensioner which was paired with the number three, tensioner into service.
This job was planned to be broken down into three phases. At the completion of each phase the job was
to be stopped and the next phase was to be planned before going forward. This three phase process did
not occur.
The crews were into phase two when the incident occurred and there was no stoppage of work or phase
planning between phase one and two.
Instructed rig personnel that when they are working on pressurized lines and/or pressure vessels,
regardless of the product contained the pressure is to be vented before the work begins and isolating
valves are to be tagged-out .
Instructed supervisory personnel to discuss this alert with all employees offshore and in the various
yards.
Thee company plans to issue further recommendations in the forms of Tech Alerts, addendums to this
alert and changes to systems affected.
Safety Alert
ALERT 08 33
INADVERTENT ACTIVATION OF CONTROL LEVER RESULTS IN SERIOUS INJURY

WHAT HAPPENED:
The operation in progress was making-up 9 drill collar lifting sub in a drill collar which was setting in the
rotary table slips. A crewman was using a chain tong to tighten the lifting sub. The Rig Manager was inside
the drillers cabin lowering the elevator to latch on to the lifting sub. As he reached for the joystick on the
control panel, the back of his right hand brushed the rotary table speed knob resulting in the knob turning.
This caused the rotary table to spin in reverse with the chain tongs on the sub. The chain tong handle struck
the injured person in the left torso and threw him into the Drillers side of the drawworks, resulting in a very
serious injury.
WHAT CAUSED IT:
When the Rig Manager reached for the joystick on the control panel, the back of his right hand brushed
the rotary table speed control knob.
Due to the lack of resistance on the rotary speed control knob, the knob easily turned, causing the rotary
table to rotate in reverse.
The Stop position on the Rotary Table/Stop/Top Drive switch on the chair arm was actually a Neutral
position and does not isolate the Rotary Table throttle control.
The company requested that the manufacturer the drillers chair and control console reposition the
controls and install separation devices to prevent drillers hand from accidentally activating any controls.
This would need to be done on both the right and left sides of the chair.
Exiting chairs are to add a plexiglass / lexan cover around the rotary control knob until such time as the
control can be relocated.
Rotary table must be isolated on the touch screen when using chain tongs to manually spin-in or spin-out
tubular connections. In addition, relocate the TD lockout button to the back of the control panel to allow
room for the reconfiguration of the rotary speed control. Add a RT lockout button beside the TD lockout
button.
Change RT/Stop/TD mode selector switch to a RT/TD selector switch.
Drilling crew (including the Rig Manager, Toolpusher and Drillers) must undergo simulator training for
DDC (Digital Drilling Controller. .
Create a new JSA to include locking-out rotary table when using chain tongs for making-up or breaking
connections.
Issued October 2008
Safety Alert
ALERT 08 34
FATAL INCIDENT OCCURS DURING RIG MOVE ACTIVITY

WHAT HAPPENED:
The Barge Captain onboard a Self Erecting Tender Rig was fatally injured while assisting in the landing of
the Drillers Cantilever, a 55t section of the Drilling Equipment Set, which was being lowered to the Tender
Bow deck during Rig Down operations.
The weather at the time was favorable and radio communications was operating without fault. The lift was
going according to plan and was positioned above the raised Bow Deck. The Banksman (Signalman) (on
port side) continued to give the crane operator instructions on where and when to move, stopping regularly
for the load to settle and receive the all clear from the Barge Captain on Starboard side, before continuing
the lowering operation.
The load had a Pipe Support Post and bracket welded onto the frame, which protruded vertically downward
from the extended edge of the main load at the Starboard end. As the load was lowered to the deck, the
Barge Captain watched its progress and gave advice to the Banksman. The load had become positioned
further to the starboard than realized during this movement; placing the edge of the load and this bracket
directly above the Barge Captain.
As the load continued to be lowered on instruction by the Banksman, following the all clear advice from the
Barge Captain, this single pipe bracket impacted the Barge Captains upper left back and pushed him
downward into the stairway handrail, where he was facing (most likely leaning slightly forward over it),
crushing him in this position. This force resulted in a severe internal injury, from which he died at the scene.
WHAT CAUSED IT:
Individual positioning himself beneath load
Poor design of the starboard bow deck stairway, penetrating through mid-deck and creating a deck
obstruction for both load placement (constraint and space inefficiency) and personnel movements (crush
point).
Inadequate lighting
Lack of landing footprint or guides
Instituted design changes to stairway by removing and relocating the stairway to inboard side of deck
Conducted a lighting level survey for normal operations as well as during Rigged Down state.
Conducted a review of company policy regarding Heavy Lift operations during night-time hours
Conducted a review of procedures and documentation used to manage Heavy Lift operations
Made provisions of landing guides for all rig move loads.
Issued October 2008
Safety Alert
ALERT 08 35
CRANE FAILURE RESULTS IN DROPPED LOAD

WHAT HAPPENED:
During rig up operations a crane upper assembly failed. While lifting the draw-works platform (25-ton) by
means of 2 cranes, to install the bracket support, one of the cranes gave away and the load was dropped.
Upon investigation of the failed crane, it appeared that the bolts holding the upper structure (operators
cabin and the telescopic section) sheared which caused the boom to drop with the load hitting the
drawworks brake cover.
Upper crane structure (operator cabin, crane

boom telescopic sections) fell across the
drawworks platform and struck the drawworks
brake cover.
WHAT CAUSED IT:
Bolts holding the upper structure failed.

There had been no site supervisor at the rig up location, therefore the crane was not inspected and the
crew basically felt comfortable to operate as it had been previously assigned to another company rig.
The crane certificate was issued by an unknown office with no accreditation.
The crane operator was found not to be competent for the crane operated.
Only cranes with certificates issued by a recognized certification body are to be accepted at company
work locations.
A list of recognized certification bodies is to be communicated to contractors through the companys
Transportation Superintendent.
Adequate supervision to be performed for the jobs during the rig up operation. Each group should have
an experienced and competent supervisor, and the designated site supervisor should control all
operations.
Issued October 2008
Safety Alert
ALERT 08 36
TRAVELING BLOCK HITS CROWN

RESULTING IN A FATAL INCIDENT
WHAT HAPPENED:
The elevators were at the monkey board and the
Derrickman had just latched the stand of pipe. The relief
driller shifted into gear and picked up the stand. The
traveling block hit the crown and the drilling line parted
resulting in the traveling block with stand of pipe falling
across the monkey board. The Derrickman was struck by
the falling equipment and was killed.
WHAT CAUSED IT:
Inspection records indicated proper functioning of the

crown saver device but the safety margin for setting
the crown saver device did not allow for enough
distance to stop the blocks from striking the crown.
The drawworks was put in highest gear, not allowing
sufficient control of traveling block.
The selection of the relief driller was not done
according to company procedures.
Rig personnel are to comply with all procedures. If it is not possible to comply, stop the job, contact the
Operations Manager.
In the event procedures cannot be complied with immediately, it becomes the responsibility of the
Managers, Supervisors, and Safety Supervisors to stop the job, review and modify the standards and
procedures as needed to complete the job while ensuring safety.
To assure personnel competency, personnel qualifications for all positions both permanent and relief
should be verified with the area Human Resources department.
Supervisors are to ensure that company procedures are followed regarding relief employees.
Drillers are to ensure that the crown saver device is set in the correct place so there is sufficient stopping
distance to the crown.
Drillers are to test the crown saver device system as per company procedures.
Issued October 2008
Safety Alert
ALERT 08 37
FATAL INCIDENT WORKER CAUGHT BETWEEN

OUTRIGGER AND CHASSIS OF CRANE
WHAT HAPPENED:
Six workers were preparing a truck-mounted crane for relocation in a lay-down area on the site. During
outrigger retraction, one of the workers reached across an extended outrigger beam. It is thought that he
was attempting to retrieve a water bottle stored in a recessed area of the crane chassis. As the outrigger
was retracted into the sleeve, the worker was trapped between the chassis and the outrigger stabilizer
cylinder. The worker was severely injured and transported by the other workers to the nearby hospital.
Unfortunately on arrival the worker was pronounced dead.
Position of the operator

outrigger beam.
Position
of
Worker
reaching
across
the
WHAT CAUSED IT:

The incident investigation revealed the following key factors that contributed to the incident:
Human errors.
o The deceased placed himself between the crane chassis and the outrigger stabilizer cylinder.
o The crane operator had no visual contact with the deceased as he operated the controls for the
outrigger from the opposite side of the crane, instead of using the controls on the other side of the
crane.
o The deceased was not directly involved in the demobilization activity and the work area was not
properly barricaded off to restrict access to the crane area.
Inadequate risk awareness.
o There was no evidence that a toolbox talk was conducted and that the specific risks associated with
this activity were acknowledged and properly explained to the workers involved.
o The work group was assembled ad-hoc for this activity comprising workers from different background
and nationalities; hence language barriers may have hampered communication.
Issued November 2008
Safety Alert
Inadequate supervision.
o The supervisor left the work area before the task was completed as he considered this activity not
being part of his work scope.
Inadequate procedures and work instructions.
o There was no adequate method statement and Job Safety Analysis (JSA) for this activity available
as crane set up and breakdown activities were not properly addressed in the documentation
provided for this job (e.g. lift plan, permit to work, JSA, etc.)
Several fatalities have occurred in the Group in the past involving crane operations. In general, risk
management of those activities is focused on the actual hoisting and lifting operations at the site of work.
This incident demonstrates that crane preparation or demobilization activities involve significant safety risks
as well and hence require rigorous HSE management controls.
Supervisors and Workers are to:
Assure yourself that similar activities are adequately managed in your area of operational control and
that key controls are effectively implemented when performing these activities by asking and answering
the following questions:
o Do you use similar type of equipment in your area of operation?
o Are preparation and demobilization activities treated as being part of your lifting and hoisting plan?
o Determine if clear procedures are developed and work instructions for these activities are
communicated?
o Do you supervise these activities permanently?
o How well are your workers trained in executing the emergency response plan?
o Determine how you are going to deal with language problems?
Conduct a toolbox talk prior to commencing the work.
Ensure that the work area is barricaded off to prevent access to the crane area for those not involved in
the crane operation.
Safety Alert
ALERT 08 38
DROPPED OBJECT (CASING)

HIGH POTENTIAL NEAR MISS
WHAT HAPPENED:
The crew was picking up 13 3/8 casing with a single joint elevator and a long pick-up assembly attached to
the top drive.
The casing caught on the derrick A-frame brace / roller. Both sling links on the elevators
parted. See picture below. The joint slid down the V-door and came to rest at the end of the catwalk. No
injuriesthis time.
Impact
Point
Two slings parted. Casing falls

down V-door and slides down
catwalk.
WHAT CAUSED IT:
The JSA did not point out the risk of the casing snagging the A-frame brace, although the hazard was
verbally acknowledged at pre-tour and pre-job meetings.
The lifting speed was not adjusted to allow the casing to clear the girt.
Revise the JSA to show the danger of a joint of casing being pulled too fast up the V-door and colliding
with the top of the A-frame. Mitigate the risk by adjusting the pick-up speed.
As the joint is picked up, stop (or nearly stop) the lift before the casing enters the A-frame so there is no
chance of it colliding with the girt.
Floormen waiting on the joint--in particular the crewman with the hold-back rope--watch the joint and
signal Driller to stop if the joint gets too close to the A-frame girt or speed is not adjusted. Promote
stop-job authority to avoid release of uncontrolled killer energyfrom falling casing.
LESSONS TO LEARN for personal safety: STAY OUT OF THE DROP AND SKID ZONE UNTIL IT IS
SAFE TO ENTER. Stay alert and always be aware that lifting equipment could fail. Keep checking it.
Safety Alert
ALERT 08 39
DROPPED OBJECT: THERMAL TREE CAP (TEA COSY)

FALLS RESULTING IN FATALITY
WHAT HAPPENED:
The operation was utilizing a rig crane to move a
subsea tree from the storage bay to the transport
trolley. When the tree was approximately 20 inches
(50.8 cm) above the trolley, a crane failure resulted
in a non-powered descent of the tree to the trolley.
As a result, the unsecured thermal cap was
dislodged from its pedestal and fell, fatally striking
an employee involved in the task. The thermal cap
weighed approximately 980 pounds.
Thermal Tree Cap
WHAT CAUSED IT:

Further fact finding is currently progressing and not all the contributing factors have been identified. Further
communications may be required to highlight any additional contributing factors. The key contributing factors
in this event were:
1. The thermal cap was unsecured.
2. While suspended by the crane there was an uncontrolled descent of the subsea tree which resulted in
the unsecured thermal cap being dislodged,
3. This uncontrolled descent of the subsea tree occurred due to an over-torque of the cranes motor that
operates the main block hoist.
Instructed the Rig Manager and OIM to ensure immediate Corrective Actions to verify:
Subsea Tree Handling and Running Operation Activities:

o Review, with respective operators and their suppliers, the operators and their suppliers Dropped
Object survey accompanying subsea trees planned to be handled or run on company installations.
If a Dropped Object survey has not been conducted, it must be completed and reviewed by all parties
prior to handling or running any subsea tree.
Safety Alert
Ensure all items identified as potential dropped objects are either removed from the subsea tree
(preferred method) or secured in a manner approved by the subsea tree suppliers engineering
department to prevent and restrain any potential dropped object.
The Rig Manager is responsible to review and approve the subsea tree suppliers engineered solution
prior to implementing the securing method.
All cranes are inspected to ensure the following:
The motor fitted to the main block hoist is consistent with the part number specified by the crane
manufacturer manual.
The motor fitted to the whip line is consistent with the part number specified by the crane manufacturer
manual.
The motor fitted to the boom hoist is consistent with the part number specified by the crane manufacturer
manual.
The findings from the above checks must be communicated to the Rig Manager and recorded in the
installations planned maintenance system.
If additional assistance is needed to complete the required actions contact your respective Business Unit or
Division Field Support office.
For all lifts (including client and subcontractor equipment) aboard company installations:
Ensure all equipment is assessed for dropped object risk as part of the Job Risk Assessment plan.
Ensure all items identified as potential dropped objects are either removed or secured in a manner
approved by the Rig Manager.
Safety Alert
ALERT 08 40
FAILURE OF BACK FLOW VALVE DURING NITROGEN
FOAM FRAC RESULTS IN A FATALITY
WHAT HAPPENED:
A fatality occurred when a service company was performing a two stage nitrogen foam frac treatment. The
rig-up required four nitrogen pumps manifolded together. In the process of beginning the second stage, a
nitrogen pump failed to maintain prime on the boost pump. While attempting to regain prime, gas from the
remaining pumps back-flowed into the nitrogen pumps storage vessel. The relief system on the vessel was
not capable of venting the volume of gas entering the vessel resulting in a catastrophic failure due to overpressurization.
WHAT CAUSED IT:
A high pressure dart style check valve in the gas discharge line was modified for other than its intended
use and did not prevent the back-flow of gas from three trucks online
The pre-operation job site pressure test procedure utilized did not ensure integrity of the dart style check
valve.
CORRECTIVE ACTIONS: To address this incident, this company instructed frac personnel on the
following:
Ensure only engineered and inspected high pressure components are utilized for pressure pumping
operations.
Ensure equipment is in proper working condition prior to dispatching to job site.
Install redundant dart style check valve in gas discharge line.
Ensure pre-job pressure test procedure verifies the integrity of check valves.
Post Incident Storage Vessel Missing From Nitrogen Unit

Safety Alert
ALERT 08 41
NEAR MISS DROPPED CASING WHEN ELEVATORS NOT LATCHED

CORRECTLY
WHAT HAPPENED:
A Near Miss incident occurred when a joint of 13 3/8 inch casing fell down the V-door and continued off the
catwalk, when the single joint casing elevators (SJE) were not latched and pinned correctly. The incident
occurred on the 60th joint of casing that was run, using a casing running tool. With the winch line and sling
removed from the joint of the casing, the Driller was signaled to pick up the casing. When the weight was
taken up on the casing elevators, the elevators opened and the casing fell out and eventually came to rest
against the wire line unit off of the catwalk.
The consequence of this incident was slight damage to the wire line unit but with potential for a fatality.
WHAT CAUSED IT:
A check of the casing elevators after the incident, acknowledged that the elevators did not fail and that the
cause of the incident was human error. The investigation team established that the SJE were partially
latched. This left enough room to insert the pin behind the latching device, instead of its proper position in
front of the latching device, acting as a retaining safety pin. The safety retainer pin was still inserted after
the incident. The worker latching the elevators on the rig floor did not know the elevators were not fully
latched.
The Driller was not able to see the casing on the V-door or the elevators from the drillers console. His
vision was obstructed by four stands of 8 inch Bottom Hole Assembly (BHA) and four rows of drill pipe
which was stacked in the fingers on the drillers side derrick, because the off driller side was full of drill
pipe. The driller relied on a thumbs up signal to pick up the blocks.
It is not possible for the latch to open on the casing elevators if latched and pinned correctly. It is
possible to not fully latch the casing elevators, allowing sufficient room to insert the retainer pin behind
the latch.
There was no second person assigned to check if the casing elevators were latched and pinned
correctly.
The JSA reviewed prior to commencement of the job was a generic JSA and made no reference to the
hazard of the elevators not latching, or the requirement for a second person to check for proper
attachment.
The rig was not equipped with any form of secondary safety device i.e. stopper bar at the base of the Vdoor to prevent casing etc. from sliding down the V-door through the catwalk as it did in this case.
Drillers
Console
(Station)
Issued December 2009
Safety Alert
Casing elevators changed out for a type considered to have a better latching device. Pin inserted
through not in front of the latch.
Procedures to be reviewed and amended so that:
A second person is assigned to check that the elevator is latched correctly and the pin is inserted
correctly.
Driller must have a clear view to the V-door at all times. When the pipe of bottom hole assembly is
racked in the fingers, it will prevent this. The pipe should be racked differently to allow a clear view
or laid down when this is not achievable.
A rig-specific JSA is to be developed which outlines all the potential hazards identified in the
investigation report.
A stopper device design, to be agreed by Management, which when fabricated and fitted, will prevent
pipe or casing travelling down the catwalk uncontrollably if there is a elevator failure or human error
IADC Note: For additional information review IADC Alert 01-04.
Safety Alert
ALERT 08 42
DROPPED OBJECT: KELLY DISCONNECTS FROM HOOK

WHAT HAPPENED:
During drilling of the surface hole (12 ), the
driller made a connection and started to wash /
ream down to bottom. Due to tight hole conditions,
the drill string stopped two feet before the bushings
were able to be set into the rotary table. The driller
received direct instructions from the company
representative to operate the kelly spinner to over
come the tight hole and the drill string did move
down for foot. The driller was re-instructed by
the company representative to move the string up
and down. During the process of moving the string
down, the drill string reached a bridge, but the
driller didnt notice it. This resulted in the string
bouncing and the swivel hitting the hook, causing
the latch to open and the kelly to drop to the rig
floor resulting in damages to Kelly, rig floor
handrail, mast ladder and drillers panel.
Safety Alert
WHAT CAUSED IT:
The rig was provided with a 220 ton swivel instead of 150 ton swivel. Due to this, the bail diameter of
this swivel is bigger than the hook space could accommodate. The larger bail made it difficult to close
the hook without using force. This mismatch was not assessed by the engineering team or the rig crew.
Failure to follow Management of Change (MOC) procedures.
The air hoist was attached to a whip check that was used to close the lock of the hook latch. This
resulted in bending the locking pin, preventing the pin from fully engaging. (Deviation from standard
procedure).
The driller was not paying attention to the hook load (weight indicator), so hitting the bridge caused the
kelly to bounce.
Swivel was replaced with one that fit the hook opening. In addition the kelly was replaced.
The latch lock was repaired and the hook pin was inspected.
Rig supervisors were instructed that any change in equipment shall be accompanied with a risk
assessment in order to identify hazards and consequences. Refer to the companys. Design Control and
Development, Procedures and instructions Manual.
Safety Alert
ALERT 08 43
RIG FIRE OCCURS WHILE RIG IS IN

SHIPYARD FOR MODIFICATIONS
WHAT HAPPENED:
Rig Status: A rig was in the shipyard for upgrades, and one project involved extending a 1.5 inch diesel fuel
line to the top of the living quarters to supply fuel to the emergency generator. The new fuel line was
connected to the fuel line that supplied the crane.
Fire Event: A crewman on a nearby rig noticed a small fire start on top boards of a small scaffold erected on
the port-forward side of the living quarters. It quickly migrated outboard toward the port side and accelerated
at a high rate. The fire dropped to the deck below and immediately engulfed that area and continued to
accelerate on the walls of the living quarters. The fire spread to the shell of the emergency generator and to
the hose-storage platform. The fire went from a small size to engulfing the side of the living quarters in less
than two minutes. When it became apparent that the fire was raging on the port side, the fuel pump was
shut off. It is estimated that 50 gallons of diesel spilled. Fortunately a 15 to 20 mph wind was blowing from
starboard to port across the rig. The first attack on the fire was within four minutes but the shipyard fire main
was too small and did not have sufficient pressure. Effective fire fighting did not take place until about six
minutes after the fire began. At this time several explosions from the jack house occurred. The fire was out
in fifteen minutes. The local fire department arrived on scene after sixteen minutes.
Damage Assessment (No injuries.) Major damage to the outer shell of por-tside quartersstructure,
insulation, and wiring was destroyed. Damage to the jacking system: Cover plates warped. New bearings
and seals were required. There was damage to the emergency generator room and equipment.
WHAT CAUSED IT:
Causal Factors:
1. The welder who installed the valve to the fuel line tack, welded it in place, but did not complete the
welding of the valve to the fuel line since he intended to readjust it and weld it completely in place the next
day.
2. As it was quitting time, the welding crew picked up their tools and left the rig.
3. They did not notify anyone of the work status.
4. Their welding machine was left running with welding leads attached.
5. Following their departure, a check was made to ensure the line was installed and the valve on the end
was closed. It was not recognized that the valve fitting was only tack welded.
6. Later, the crane needed to be refueled so a call was made to have the diesel pump turned on.
7. There were no isolation valves in the fuel line, therefore all the lines were charged resulting in diesel
under pressure sprayed from the tack-welded fitting onto the top deck and down the sides of the
quarters onto the main deck.
8. Since ignition started on the scaffolding about halfway up the wall of the quarters, it is suspected that a
smoldering rod or energized welding lead triggered the fire.
Other Factors:
No JSA was written by the shipyard or the rig crew for hot work or refueling.
No lock-out or tag-out procedure applied to the fuel service line.
No verification of shipyard fire main capacity.
There was no hot work permit approved by the OIM for the job being performed by the shipyard crew.
Welding machines were left running with the live leads in the area of the fire. The welding leads were
not properly insulated with wiring exposed and were left connected to an unattended welding machine.
Safety Alert
Unsecured fittings on the fuel line were created by the shipyard workers.
Failure to communicate the status of the work at the end of the day. No formal handover procedure was
used. (same scenario as in Piper Alpha disaster)
Safety Alert
The crew involved with the task along with their supervisor is to write a JSA prior to each job.
The OIM is to ensure that all work permits are approved by prior to any work with the rig crew being
informed prior to any work on any fuel lines.
Welding machines are not to be left running while unattended and welding leads are to be in good
condition.
Work site is to be checked prior to leaving the job site to ensure housekeeping and communications of
the job status with unfinished work tagged.
When work is being done on fuel lines, the fuel pumps are to be locked and tagged out.
Company personnel are to work to improve communications between the rig personnel and shipyard
construction personnel.
As part of this effort rig management is to hold morning meetings so that both rig and shipyard personnel
know what each other will be doing.
Rig supervisors are to ensure proper controls are in use when fuel is bunkered or being transferred.
Involve RSTR to verify proper controls are in place.
Rig management is to hold fire drills even when the rig is in the shipyard.

2008-IADC Alerts PDF

Uploaded by

Copyright:

Available Formats

2008-IADC Alerts PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

2008-IADC Alerts PDF

Uploaded by

Copyright:

Available Formats

Safety Alert

From the International Association of Drilling Contractors

WORKING WITH ROTATING CONTROL DEVICES

STANDPIPE PRESSURE GAUGE THREAD NIPPLE

Only three threads were buried into

Length of Thread, inch

CRANE RIG UP RESULTS IN FALL FROM HEIGHT

FAILURE OF COUNTER BALANCED LIDS FOR

WHAT CAUSED IT:

The weight coming off;

FALL FROM SCAFFOLDING RESULTS IN EMPLOYEE INJURY

9. These incidents will continue to occur unless we STOP AND THINK.

FALL FROM SCAFFOLDING RESULTS IN EMPLOYEE INJURY

9. These incidents will continue to occur unless we STOP AND THINK.

FATALITY WHILE TRYING TO FILL UP CASING

HELICOPTER LIFTS OFF WITH OUT WARNING WHILE

Pilot training was deficient;

All passengers are secure.

LTISTRUCK BY FLOWLINE AND FALL IN SUBSTRUCTURE

UNSECURED LOAD RESULTS IN AN INJURED EMPLOYEE

WHAT CAUSED IT:

DROPPED STRING HIGH POTENTIAL INCIDENT RESULTS FROM

Lack of supervision from STP.

Long Term Actions:

IMPROPER USE OF ELEVATORS WITH

FALL FROM HEIGHT RESULTS IN LTI

Place where he fell on his

Hook that was in

WHAT CAUSED IT:

The crew used a hook which was in unsafe condition.

IMPROPER ATTACHMENT OF SAFETY LINE RESULTS

WHAT CAUSED IT:

MUD PUMP MAINTENANCE RESULTS IN SERIOUS INJURY

MONKEY BOARD INCIDENT RESULTS IN MTO

DROPPED OBJECT DURING TRUCK LOADING OPERATION

THIRD-PARTY CRANE AND CRANE OPERATOR SUPERVISION

FALL FROM CASING RESULTS IN LTA

TONG CLEVIS DETACHES RESULTING IN EMPLOYEE INJURY

WHAT CAUSED IT:

IMPROPER LIFTING PRACTICE (LTI)

INSTALLING ANNULAR BOP RESULTS IN RWC

INJURY RESULTS FROM

IMPROPER LIFTING PRACTICE RESULTS IN

WHAT CAUSED IT:

Improve lifting competency of the crew and supervisors.

DERRICK OPERATION RESULTS IN A FATAL INCIDENT

Demonstrating placing the chain on the stand of pipe.

Demonstrating the position of the injured hand

WHAT CAUSED IT:

DROPPED OBJECT - FALLING SLEDGE HAMMER

Worker did not use the tool carrier bag provided.

Hard hat Cracked by the impact of the hammer

FALL FROM HEIGHT RESULTS IN DOUBLE MTO

WHAT CAUSED IT:

GALLEY FIRE OCCURS DURING DRILL

Temperature dial for deep fryer.

Explained to kitchen crew the following:

EMPLOYEES ARM FRACTURED WHILE USING PULL BACK ROPE

(IADC Note: check IADC Alert 08-24)