Fatal Fall from Offshore Platform – Investigation Report

On the morning of May 19, 2000, a contract employee was using a portable of Accident winch (come-along) to remove a section of removable guardrail for the purpose of accommodating the installation of the mounting beams of a temporary crane. One end of the come-along was attached to the section of guardrail to be removed, while the other end was attached to a section of fixed guardrail located approximately 5 feet above the guardrail to be removed. As tension was applied to the come-along, the upper guardrail failed at its base welds and detached from the deck. As a result of the detachment, the employee fell approximately 60 feet to the Plus 10 deck and sustained fatal injuries.

Coiled tubing operations were to be conducted on Well A-15 sidetrack. The close proximity of the well to the platform crane precluded safe usage of the crane during the coiled tubing operations. It was therefore decided that a temporary crane would be installed in order to conduct the operation safely.

On the morning of May 18, 2000, the Contractor’s employees began arriving on Platform B to begin the crane installation operation. At 1300 hours, prior to beginning of the offloading of the crane components, a Safety/Job Safety Analysis (JSA) meeting was held. The Contractor’s on site supervisor (M-1) and the Operator’s contracted representative (B-1) led the meeting. Attending the meeting also were four other Contractor’s employees (M-2 through M-5). Two other Contractor employees attended the meeting. After the meeting, crane components were offloaded onto the platform. Work was suspended at 1700 hours because of inclement weather.

On May 19, 2000, prior to the accident a Job Safety Analysis (JSA) meeting was held. The meeting, as did the previous day’s meeting, centered on the activities of unloading the crane components and erecting the crane. Discussed also was the need to remove the guardrail as previously mentioned. Cold-cutting was the decided method of removal. Fall protection was referred to only in the context of crane erection and seemingly not with reference to the removal of the guardrail. The meeting documentation was not detailed.

After the safety meetings and after surveying the platform with Contractor’s employees, B-1 left the deck to do office work. M-2 suggested to M-1 that, instead of removing the guardrail by cutting and then latter welding it back into place, the guardrail could be lifted out of the sockets into which its vertical posts were inserted. M-1 accepted the suggestion and ordered the crew to use a come-along to lift the guardrail. One end of the 1½ -ton come-along was attached by a chain to the top portion of the guardrail to be removed on the main deck and the other end by a strap to the top portion of the guardrail on the platform’s crane access deck. The crane’s access deck is approximately five feet above the main deck.

While M-1 and M-2 were hammering on one end of the guardrail to be removed and another employee, M-3, was attempting to loosen the other end by using a pry bar, a fourth employee, M-4, was tensioning the come-along. After experiencing difficulty in loosening the guardrail, M-1 instructed M-4 to put further tension on the come-along. At that point, approximately 0815 hours, various employees heard a sound from the access deck and saw that the guardrail on that deck had fallen from the deck. M-4 was then witnessed to have fallen from the access deck. After having rushed to the edge of the platform, crewmembers saw that M-4 had fallen to the Plus 10 deck, approximately 60 feet below the main deck. They also saw M-4 roll off the deck into the water. B-1 stated after the accident that, had he been present during the attempt to remove the guardrail, he would not have allowed the come-along to be tiedoff to the upper guardrail.

M-1 jumped into the water and placed M-4, who had been floating face down, into a life ring. M-1 attempted to assist M-4 by applying CPR. The M/V Ensco Master arrived on site approximately 10 minutes later and pulled the men aboard where CPR attempts continued. Both men were then transferred to the platform. A defibrillator was used unsuccessfully in an attempt to revive M-4 who was then medivaced to West Jefferson Hospital in New Orleans. A preliminary medical evaluation revealed that the cause of death was a broken neck.

A visual examination by a metallurgist of the base posts of the guardrail that failed revealed that the failure was the result of:

• Both incomplete and poor welding of the posts to the platform’s crane access deck.
• Paint and corrosion on the post surfaces indicated that portions of the posts were not welded, while flat weld metal surfaces indicated that some welded portions did not thoroughly fuse with the deck.
• Where fusion did occur, the weld was very thin.

The investigation report concluded to the following root causes regarding the accident:

1. The Operator did not ensure at the time of the guardrail placements on the access deck, that the guardrail posts were properly welded to the access deck in accordance with the Operator’s existing standards.
2. The Operator did not have a policy detailing the prohibitions against certain uses of guardrails.
3. The failure of the JSA meeting attendees (especially B-1 and M-1) to address fully the hazards associated with the removal of the guardrails.
4. The failure of the Contractor, once the method of guardrail removal had changed, to formally address the hazards associated with the new method.
5. The failure of the Operator’s onsite representative to observe the activities of the Mar-Con employees.

Finally the incident investigation made the following recommendations regarding the accident:

1. A recommendation that designated operators and their contractors perform a second JSA for any activity for which an initial JSA was performed and whose steps have been changed since the initial JSA was performed.
2. A recommendation that operators instruct both their representatives and contractors to communicate regarding any change in the steps of an activity that is to be performed, especially when a JSA has been performed prior to the change.

Source: BSEE