IOGP fatal incident report

Incident description:

While removing polished sucker rods from the well, crews experienced difficulty in loosening one set of rods. Two different shifts of workers were unable to unscrew one set of rods. The problem was reported to management. While continuing to attempt to loosen the rods, the IP and another crew member used full-circle tongs to unscrew polished rods and used a bar as a lever. They made 3.5 rotations (counter-clockwise) of tongs with a bar. Then they turned in the opposite direction clockwise). After two turns, the workers decided to release the bar and move out of harm’s way. The senior operator released the bar and attempted to move out of the way but was struck by the bar. He was knocked down and was motionless. A medic arrived and provided medical help while the victim was brought to the nearest medical centre. The victim died before reaching the centre.

What Went Wrong:

Direct Cause: Gross carelessness of deceased. Improperly used tool (bar). System Causes: Victim did not follow manager's order; Inadequate identification of workplace hazards; Weak HSE leadership, workers did not stop unsafe work; Violation of HSE rules by workers. Crew members independently started the work without obtaining task, preparing of the work plan and without an order from the manager, receiving instructions for the safe conduct of work.

Corrective Actions:

1. Strengthen control on proper use of working tools. 2. Train workers on risk and hazard identification in the workplace.