Fatality Report - Stop Work

18
1 MURPHY SABAH OIL COMPANY LTD. Ajang Safa Fatality

description

A report with regards to the fatality on board of offshore vessel because the stop work is not being issued.

Transcript of Fatality Report - Stop Work

  • 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

  • 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.

  • 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

  • 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.

  • 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

  • 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

  • 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

  • 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

  • 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.

  • 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.

  • 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

  • 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!

  • 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.

  • 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.

  • 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.

  • 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

  • 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

  • 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

    [email protected]

    Strictest confidence.