Fatality Report - Stop Work
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Transcript of Fatality Report - Stop Work
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1M U R P H Y S A B A H O I L C O M P A N Y L T D .
Ajang Safa Fatality
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2M U R P H Y S A B A H O I L C O M P A N Y L T D .
Ajang Safa Fatality
Yusri bin Baha
36 years old
Lawas, Sarawak.
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3M U R P H Y S A B A H O I L C O M P A N Y L T D .
Ajang Safa Fatality
Cargo had been secured collectively
Cargo lashing was removed - unloading by crane on
starboard side of FPSO.
Weather and seas were considered marginal but still
safe for offloading - Wind was 10 knots - Swell was 1.5
2 meters. Waves 1.8 2.5 meters
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4M U R P H Y S A B A H O I L C O M P A N Y L T D .
Ajang Safa Fatality
Captain positioned boat to deal with the strong current
which was affecting their holding position.
Wind and swell were now on port bow
She was rolling as much as 80 by the Captains estimate.
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5M U R P H Y S A B A H O I L C O M P A N Y L T D .
Ajang Safa Fatality
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6M U R P H Y S A B A H O I L C O M P A N Y L T D .
Ajang Safa Fatality
There were four personnel on the deck. Captain saw a
larger than normal swell approaching from the port
side
VHF to Banksman for crew to clear the deck
Banksman heard the order and called out to the crew
to clear the deck
All the crew moved to a safe position but Yusri did not
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7M U R P H Y S A B A H O I L C O M P A N Y L T D .
Ajang Safa Fatality
AB Silas was close to Yusri at the stern Silas had clearly heard the order and repeated it to Yusri. Yusri
made eye contact with Silas but did not escape to
safety.
Ajang Safa rolled heavily - A tote container slid from
starboard to port side crushing Yusri between them
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8M U R P H Y S A B A H O I L C O M P A N Y L T D .
Ajang Safa Fatality
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9M U R P H Y S A B A H O I L C O M P A N Y L T D .
Ajang Safa Fatality
Underlying Causes
1. There was inadequate assessment of risk
2. Deceased positioned in the line of fire between the two tote tanks
3. Cargo was not lashed at time of incident.
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10M U R P H Y S A B A H O I L C O M P A N Y L T D .
Ajang Safa Fatality
Underlying Causes
4. Deteriorating sea conditions during offloading
operation.
5. A Clear the Deck instruction was not followed by the deceased. The reason why the deceased did not
respond is unknown.
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11M U R P H Y S A B A H O I L C O M P A N Y L T D .
Ajang Safa Fatality
Root Causes
1. Inadequate procedures and work instructions
in relation to cargo handling operations and
lashing of cargo.
2. Stop Work Policy was not applied on the
morning of the incident in a timely manner by
the Master
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12M U R P H Y S A B A H O I L C O M P A N Y L T D .
Ajang Safa Fatality
3. Stop Work Policy was not imposed in the
months preceding the incident.
The Captain was concerned about cargo operations
on Ajang Safa during Monsoon season.
Other professional marine personnel within Murphy
also held the same concern.
Although the topic was discussed, it was never
documented or investigated. The job was never
stopped!
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13M U R P H Y S A B A H O I L C O M P A N Y L T D .
Ajang Safa Fatality
Recommendations
1. Ajang Safa to be restricted to line / hose handling
and certain specific cargo. Cargo handling to be
specifically risk assessed.
2. Review and update the relevant JHA (Ref. No.
JHA002) to include hazards of cargo shifting and
weather conditions.
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14M U R P H Y S A B A H O I L C O M P A N Y L T D .
Ajang Safa Fatality
3. Murphy to commission an independent audit of its
marine operations - suitability of individual vessels to
operate offshore particularly during monsoon season,
cargo handling operations and securing of cargo.
4. Conduct refresher training for Ajang Shipping crews
on hazard identification, risk assessment and control
as well as Stop Work Authority.
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15M U R P H Y S A B A H O I L C O M P A N Y L T D .
Ajang Safa Fatality
5. Communicate the Stop Work Authority
requirements and lessons learned from this
incident to all Murphy facilities and contractors.
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16M U R P H Y S A B A H O I L C O M P A N Y L T D .
Dale Bradford Murphy General Manager
Personal pride in the accomplishments of the
Murphy Malaysian Operations Team.
Extremely valuable members of the Murphy
Family.
1st fatality
Not acceptable
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17M U R P H Y S A B A H O I L C O M P A N Y L T D .
Dale Bradford Murphy General Manager
The authority, the right and the obligation
Unsafe act or condition
Unsure of the plan or you see someone else who isn't sure
If conditions change
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18M U R P H Y S A B A H O I L C O M P A N Y L T D .
Dale Bradford Murphy General Manager
Ever reprimanded or punished for stopping a
unsafe act or operation I would ask you to contact
me directly
+603-7490-7446
Strictest confidence.