BSEE Panel Investigation Cites Misunderstood Verbal Instructions And Failure To Account For Seemingly Routine Tasks

The Bureau of Safety and Environmental Enforcement (BSEE) issued its results of a panel investigation into an October 2013 fatality off the Louisiana coast last week.  The incident involved the death of a welder who fell into the Gulf when a 130-ton dry oil storage tank skid assembly became detached from a platform unexpectedly.  The worker was employed by an oilfield services contractor who had been commissioned by the platform’s owner/operator to decommission and remove the platform, which had ceased production in 2012.

When the contractor’s employees arrived via barge the day before the incident, bad weather delayed the start of the planned heavy lifts to remove the platform, and the contractor’s employees instead starting “prep work” to prepare for the heavy lifts once the weather improved.  During this time, the verbal instruction to “cut 50%” of the existing welds on the platform was given to the welders, but the BSEE panel investigation concluded that this instruction was misinterpreted across the team, with some removing 50% of all welds and some removing half of the welds in full.  This was one of several “key failures” in the operation that the panel investigation cited as support for its recommendation that both the operator and the contractor receive Incidents of Noncompliance.

The panel investigation also cited a lack of recognition that the “prep work” should be fully implemented and accounted for in the full work hazard analysis and inadequate recognition and implementation of the SEMS elements outlined in the companies’ SEMS Bridging Agreement.  Specifically, the panel cited weak management oversight and documentation of the prep work, no recognition that the weather delay should have triggered application management of change procedures, and the failure to stop work and address hazards when an unexpected “pop” was heard earlier in the day that allegedly caused the skid assembly to move.  The panel criticized the operator’s on-site representative for not knowing the details of the companies’ SEMS Bridging Agreement and knowing only that such an agreement existed.

The panel made the following recommendations/reminders to all operators and their contractors:

-Incorporate seemingly routine activities including the preparation work into the overall project planning, implementation, and oversight.

-Confirm a common understanding of the expectations, hazards, and safety procedures when communicating job assignments.

-Enable and enforce a safety culture where work practices reflect the written policies, procedures, and SEMS elements; and, where written policies and procedures reflect realistic work scenarios and mitigation steps.