Incident Summary: An injury recently occurred on an oil and gas site undergoing production workover activities. A worker had the first three fingers of his right hand pinched and severely injured in the winch line of a cat (bulldozer unit). The oil and gas company, well servicing contractor and cat contractor have examined the circumstances of the incident to determine basic causes. Incident Description: The well servicing crew was en-route to a well site (specifically on the entry road that accesses the lease). The tractortrailer (coil tubing unit) assembly had previously chained up and the well servicing company supervisor had completed a Site Assessment. The coil tubing unit had spun out, and the cat, which was on standby was summoned to tow the coil tubing unit to location. The cat operator positioned his machine on the lease road approximately four meters in front of the coil tubing unit. The passenger in the coil tubing unit then proceeded to the rear of the cat and examined the winch line, with the intention of extending the line so it could be hooked to the front of the tractor unit. The worker then crouched down and brushed snow from the cable/tail chain, which was bolted to the cat hitch. He then, with his right hand, grasped the cable with the intention to disconnect the tail-chain. At that point the cat operator retracted the cable pinching/crushing the fingers of the coil tubing unit worker s hand. What Went Wrong: The following immediate causes were identified: Both the cat operator and injured worker failed to effectively communicate their intentions to the other. The cat operator retracted (tightened) the cable unexpectedly. The injured worker placed his hand in a high-risk pinch point area. The basic causes of this incident have been determined to be, lack of communication on site. All site supervisors failed to fully communicate the hazards and hazard control measures. Cat operator actuated the controls when not safe to do so. Cat was not ready to perform the intended service. This incident highlights the importance of completing On-the-Job Hazard Assessments and Pre-task Safety Meetings. Workers must establish a common means of communication (verbal, hand signals, other) prior to the commencement of work. Pre-task safety meetings must include all personnel who are involved or participating in the task.
On the Job Hazard Assessment JOB / LOCATION: Towing Equipment Example DATE: Dec 19 2002/Jan 10 2003 JOB STEP HAZARDS RISK CONTROL RISK 1 Determine need for towing Lack of traction on road surface 6 H Back down hill if manoeuvre can be completed in safety 3 M Unit spun out Planning ahead (eg prior to climbing the hill, customer request, dispatch instructions etc.) Vehicle in unsafe precarious position Other users of the road Stop secure unit wait for instructions Do not back down hill unless can be completed in safety Dig hole to prevent from sliding backwards Apply all parking brakes (do not use trailer hand valve for parking ) Set out warning devices All personnel involved to wear reflective clothing (striped coveralls or traffic vests) Weather conditions/light conditions, Grade of hill, Ground conditions 6 M Units chained up in advance Request hill be sanded or graded prior to mobilization 3 rd party or customer does not allow the use of wheel chains (to help maintain ice roads) 4 M Assess situation and consider control measures Call office for instructions 2 Assess situation In adequate cat capacity 6 H Pre job planning where possible ensures adequate towing is available. Determine requirements & available at dispatch stage of job if possible Acquire adequate Discuss options with customer. Call management. Refuse tow if necessary. Unit location & stability 6 H If unit is in trouble Supervisor must be present Conduct informal hazard assessment 3M
In experienced operator (driver & operator) Operator not fit for work Substandard condition of towing (condition of cable on cat/winch truck, method of tail chain connection) 6 H Driver-replace with more experienced driver Have towing operator replaced (not by employee) Review towing procedure/requirements - discuss towing process, signals, slow down Ensure experienced driver in unit Utilizes GODI training for all employees (course has winching & towing information) Warn all involved personnel, Minimize number of people in area Refuse tow if situation deems necessary (call management) 6 H Use tow sling (cable or nylon) Visual inspection of (include cable, all attachments, winch if applicable) Ensure cable is sufficient 3 4 Hold meeting Lack of or poor communication 6 H Establish towing plan -discuss signals to be used, horn on unit, towing speed, PPE, Unit gear selection -if towing on surface with good traction the unit is to be out of gear (includes ice) if in muddy conditions the unit may be in gear Supervision (Supervisor may not be at tow site due to other activities involved in the operation ie. On site spotting & rig up) Assign one designated signal person Use radio communication (headsets) if available 4 H Supervisor to designate person in control (lead hand senior personnel at tow site, this could be a supervisor from another service). Supervisor needs to ensure task can be completed safely Supervisor to hold meeting & assign roles for towing & provide unit order Position towing Pinch point area for workers 6H Pre towing communication & plan Worker visibility clothing (striped coveralls or reflective vest Ensure signal person is not positioned between 1L
5 Connect unit & towing unit Pinch points 6 H Ensure winch cable is slacked off before starting Method of connecting (cable, sling, hooked back to cable, shackle) Unplanned activation of Visibility of between operators & person making connections Never grab a winch line unless it is unhooked, do not grab inside hook or chain, do not hold on to cable when winch is activated, wear leather gloves, Ensure cat is properly parked with brakes applied If tail chain is hooked up to or pinned in to something (ie hitch) have cat operator prepare their own for towing 4 M Use tow sling, ensure attachments are of adequate capacity 3 M Communicate expectations Have cat operator place hands in air to prevent unplanned activation 3 M Designated signal person must ensure all involved personnel are aware of worker inbetween 6 Tow unit Improper/inadequate communication Jerky/uneven towing Unit being towed running in to back of tow unit, causing damage Operator distractions Emergency stop 4 M Radio communication (headsets for cat operator) if available, designated signal person must be in safe area 4 M Select speed & stay with it Determine in advance if unit to be in gear or out of gear Unit gear selection -if towing on surface with good traction the unit is to be out of gear (includes ice) if in muddy conditions the unit may be in gear Driver and operator must pay attention to tow sling tension to ensure slack cable does not occur during towing 4 M Turn off/dim headlights Have cat operator turn off back up lights Establish in pre tow meeting Other road users 3 M Stop oncoming traffic/ close road if necessary/warn other road users, Follow cat directions
7 Disconnect from unit Pinch points 6 H Ensure winch cable is slacked off before starting Method of disconnecting (cable, sling, hooked back to cable, shackle) Unplanned activation of Never grab a winch line unless it is unhooked, do not grab inside hook or chain, do not hold on to cable when winch is activated, wear leather gloves, Ensure cat is properly parked with brakes applied 4 M Complete visual inspection of tow sling and attachments to ensure they are ready to disconnect 3 M Communicate expectations Have cat operator place hands in air to prevent unplanned activation