WARNING!!! Some images may be upsetting.
Accident Description
On Saturday, 9 April 2011, at approximately 09:30 am, a Coil Tubing Unit (CTU) operator entered a water tank that contained water mixed with nitrogen from the displacement of coil tubing before unloading Mutiara – 135 well.
In an attempt to rescue the operator, his co-worker entered the same tank and, for the same reason, was followed by two other co-workers. Realizing that four (4) workers were inside the tank, the on-site supervisor ordered to drain the tank and then asked two (2) personnel to enter the tank to rescue the four personnel by using a rope (safety line).
Three (3) of the rescued personnel were found unconscious, and one (1) was semi-conscious. All four (4) personnel immediately evacuated to an on-site clinic. After first aid treatment, the semi-unconscious personnel was evacuated to a nearby hospital for further treatment.
The three (3) unconscious personnel were declared passed away by local medical doctor.
Preliminary Accident Analysis
What went wrong:
- Did not follow procedures:
- Did not conduct multi-gas test (LEL, O2, CO2 & H2S) before entering Confined Space.
- Did not wear proper PPE for the task. (Appropriate Masks for acceptable range limits and Breathing Apparatus for over range limits).
- Poor and unthoughtful rescue attempts.
What went well:
- Immediate contact to report the incident.
- Immediate handling of IPs
- The incident site was properly secured with a police line for further police investigation.
- All Rigless Coil Tubing activities shut down for further assessment regarding confined space activities.
- All Rig activities involving confined space were postponed for further review.
IMMEDIATE ATTENTION
- Always follow procedures before conducting your tasks:
- Ensure the Confined Space Work Permit is conducted before entering.
- Conduct a multi-gas test before entering a Confined Space.
- Always wear proper PPE, and other Mitigations such as Purging or Ventilation is conducted where required.
- Always implement 3 Safety Golden Rules:
- Think first
- Stop immediately
- Report immediately
