The course of events
A scaffolding foreman and a scaffolding installer were on the skid beam, working on removing temporary equipment on Valhall IP. Both were wearing safety harnesses with a fastening line/hook because part of the work area had no grating.
First, they unscrewed the protective pipes and removed these with the aid of the crane. Witnesses confirmed that both of them were at that time secured by hook to a temporary railing. When this was completed, the two positioned themselves to unfasten the bracket for sea securing.
The scaffolding foreman probably unfastened the hook in the harness because he couldn't reach the new working position, while the scaffolding installer did not need to do this.
The scaffolding foreman had difficulty in loosening one of the nuts and asked his colleague for a wrench. He used this to hold on to the bolt while he attempted to loosen the nut.
The wrench slipped, the scaffolding foreman lost his balance, fell backwards and landed on a temporary deck about 13.5 meters below the work site.
The flagman immediately informed the nurse, who quickly proceeded to the site. The injured person was conscious and complained of pain in his stomach and hips. He was transported to the sick bay on Port Rigmar and then to Rogaland Central Hospital by means of the SAR helicopter requisitioned from Ekofisk.
The foreman was seriously injured, but his injuries were not life-threatening. The incident potential was a fatality, and only minor changes in circumstances would have led to such an outcome.
Work in an area with a fall risk without proper securing is considered to be the direct cause of the incident. Lack of skilled use of tools may have played a part in the course of events.
Planning of the work:
On 29 August 2003 a work permit was applied for by the steel foreman, which covered the removal of protective pipe. The work permit was signed in a meeting. The work permit does not describe any preventive measures or checkpoints.
At the same time a "revolving" general work permit for erecting and dismounting of scaffolding was approved. It does not specify the area for erecting scaffolding or other matters for the specific work to be carried out, but was signed off in accordance with the requirements. The steel foreman checked the area and asked the scaffolding foreman to erect scaffolding before the work was to be implemented.
The scaffolding foreman then took the initiative to do the job without scaffolding, but with a anti-fall securing equipment/safety harness. The reason for this is firstly that there was supposedly a lack of scaffolding equipment. The scaffolding foreman brought this up orally with the installation manager, who is superior to both the scaffolding foreman and the steel foreman. Reduced risk as a result of shorter fall exposure time was purportedly a factor in the reasoning. Erecting scaffolding would have led to a longer work period with a safety harness.
The change in the method for implementing the work led to a new application for a work permit or other activities such as a Safe Job Analysis (SJA) or Safe Work Review (SAG), which are covered by BP's HSE directive. The work carried out is considered by those concerned to be simple and routine without particular risk factors that require special measures.
On this basis it is clear that the work permit issued was not completely adequate for the actual work that was to be carried out. The person responsible did not ensure that the safety consequences of the change in work method were considered.
It also seems that general work permits are in use for erecting and dismounting scaffolding that revolve without a specific evaluation of risk. This impression is reinforced by the fact that the general work permit mentions the wellhead platform (WP) as the relevant area, not IP where the work actually was to be carried out.
This is a deviation from the requirements in the Regulations relating to conduct of activities in the petroleum activities, Section 27 on planning and Section 28 on actions during conduct of activities.
The incident occurred in the night towards the end of the shift, about halfway in the work period of the injured person. One cannot rule out that fatigue and lack of attention may have been a contributory cause of the incident. The work carried out is not considered to be of such a nature as to come under the criteria for night work, cf. Section 31 of the Activities Regulations on arrangement of work and the NPD's interpretation of this requirement in a letter of 10 July 2003.
The removal of the bracket for sea securing, etc. was not safety-critical and according to the work order the plan was to not carry out this job until late September or early October.
It was stated that personnel have recently been transferred from day to night to avoid shared sleeping. This is contrary to the NPD's interpretation of Section 31 of the Activities Regulations in the said letter of 10 July 2003.
The extent of overtime among the scaffolding workers was limited according to the time sheets presented. The injured person was said not to have worked overtime in the relevant work period.
There are no indications that time pressure has been a relevant issue for the job in question or for the installation work on Valhall IP in general.
Organizing the work:
The situation during hook-up of Valhall IP has been hectic and marked by the installation only having been on the field for a short while (about two weeks) before the incident took place. The project was delayed one year due to technical problems with piling of the jacket. The installation was at Stord for a period pending a solution to this problem.
Relations between BP and AkerKværner have been tense as a result of the delay. In order to improve relations between the two parties an integrated organization was formed, among other things, where the installation manager offshore is a BP employee while the project manager is from AkerKvæmer. The area authority for Valhall IP lies under BP's operating organization for Valhall.
It emerged from interviews with personnel involved that not all of them were equally familiar with roles and responsibilities in the project and the relationship with BP's operating organization.
A separate booklet was prepared on HSE matters related to the water injection project. The booklet also contains a form to be signed by the individual employee, mentor and line leader. This booklet and its use was not much known by leading personnel in Aker Kværner and has so far not been implemented. It is unclear how the booklet is intended to be used and why it has not been taken into use.
Both BP and AkerKvæmer each had a full-time HSE adviser position with the project as the area of work, and both companies had traditional HSE follow-up in the areas, including permanent inspections. In its review BP pointed out to the project matters related to temporary scaffolding and lifting gear, and the work on putting these matters straight was highly focused in the project organization.
Use of anti-fall securing equipment:
The anti-fall securing equipment used in connection with the work operation that led to the accident was certified and approved for the work to be done. It was also verified that the equipment had been subject to the necessary checks.
In BP's HSE directive on work at heights there is a requirement for "always having three-point contact when moving". According to BP this is to be understood as always having a double set of "anti-fall strap/hook" when moving at heights.
It is unclear how moving in this case actually was done. The injured person may have gone back over the scaffolding, released the hook in the safety harness, moved on the outside of the scaffolding and gone over again closer to the new work position. He believes he did this and fastened himself with the hook before he took his new position by the bracket for sea securing which was to be released.
According to Section 39 of the Activities Regulations on personal protective equipment, cf. the Directorate of Labour Inspection's Regulations relating to personal protective equipment in the workplace, Section 7 on requirements for personal protective equipment, the equipment is to be adapted to the relevant working conditions. When working at heights where moving is required, such a adaptation would be a harness with two hooks.
Temporary scaffolding / railings / lifting equipment:
In connection with the NPD's investigation of the incident on Valhall IP, we noted that there were a large number of temporary railings and scaffolding without approval on the installation.
As an example we can mention access to the offshore crane via scaffolding that was not approved. This deviates from the industry standard in the area which is the Directorate for Labour Inspection's Regulations No. 335 relating to scaffolding, ladders and work on roofs, etc, Section 14 on inspection.
We also noted extensive use and rigging of temporary lifting devices that were not approved for use offshore, such as:
extensive use of fiber slings
knotted fiber slings (to links)
the use of chain hoists for relief without extra securing
The observed matters are a deviation in relation to Section 83 of the Activities Regulations on lifting operations and Chapters 7.9, 8.1 and 8.5 of NORSOK R003N. See also BP's "golden safety rules for lifting operations" and Chapter 6.3 in BP's HSE directive no. 26 on crane and lifting operations. Considering the longer stay at Stord than expected, it should have been possible to reduce the extent of temporary scaffolding, railings and lifting equipment to a greater degree than what was the case.
Contact person in the PSA: