2011 Fatality Report: Worker Struck with Pipe Cap€¦ · located inside the zoom boom parked...

Worker Struck with Pipe Cap Type of Incident: Fatality Date of Incident: July 31, 2011

File: F-564834

2 Human Services, Occupational Health and Safety July 2, 2013

TABLE OF CONTENTS

SECTION TITLE PAGE NUMBER

1.0 DATE AND TIME OF INCIDENT 4 2.0 NAME & ADDRESS OF PRINCIPAL PARTIES 4 2.1 Owner/Prime Contractor 4 2.2 Employer 4 2.3 Workers 4 3.0 DESCRIPTION OF PRINCIPAL PARTIES 5 3.1 Owner/ Prime Contractor 5 3.2 Employer 5 3.3 Workers 5 4.0 LOCATION OF INCIDENT 5 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 6 5.1 Equipment and Material 6 5.2 Observations 6 6.0 NARRATIVE DESCRIPTION OF INCIDENT 7 7.0 ANALYSIS 8 7.1 Direct Cause 8 7.2 Contributing Factors 8 8.0 FOLLOW-UP/ ACTION TAKEN 9 8.1 Occupational Health and Safety 9 8.2 Industry 9 8.3 Additional Measures 9 9.0 SIGNATURES 10 10.0 ATTACHMENTS 10 Attachment A Map Attachment B Diagram Attachment C Photographs

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SECTION 1.0 DATE AND TIME OF INCIDENT 1.1 The incident occurred on July 31, 2011 at approximately 5:00 p.m. SECTION 2.0 NAME AND ADDRESS OF PRINCIPAL PARTIES 2.1 Owner and Prime Contractor 2.1.1 Suncor Energy Inc.

P.O. Box 2844, 150-6th Avenue S.W. Calgary, Alberta TP2 3E3

2.2 Employers 2.2.1 Transfield Asset Management Services Integrated Ltd. Suite 3000

715 5th Avenue S.W. Calgary, Alberta T2P 2x6

2.2.2 HSE Integrated 1000, 630-6th avenue S.W. Calgary, Alberta T2P 0S8

2.3 Workers 2.3.1 Pipefitter 1 (

2.3.2 Pipefitter 2 (

2.3.3. Pad Operator (

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2.3.4 Zoom Boom Operator ( 2.3.5 Welder ( 2.3.6 HSE Integrated Operator 1 (

2.3.7 HSE Integrated Operator 2 ( SECTION 3.0 DESCRIPTION OF PRINCIPAL PARTIES 3.1 Owner/Prime Contractor 3.1.1 Suncor Energy Inc. recovers bitumen from oil sands through its mining and in-situ

operations. The bitumen from both operations is then upgraded to refinery-ready feedstock and diesel fuel. The incident occurred at the Suncor Firebag site which is their in-situ operation. Suncor Energy Inc. contracted Transfield Asset Management Services Integrated Ltd (TAMSIL) to provide maintenance services at the Firebag site.

3.2 Employer 3.2.1 TAMSIL provides asset management; turnaround and shutdown management and

execution; site wide maintenance support; and sustaining capital construction services within the mining and oil and gas industries. TAMSIL is the Building Trades Union affiliated operating arm of FT Services; a joint venture between Transfield Services Ltd. - Australia and Flint Energy Services Ltd. – Canada. TAMSIL was a maintenance contractor to Suncor Energy Inc. at the time of the incident. The maintenance workers are required to get work permits from Suncor Energy Inc. operations prior to working on any equipment.

http://www.suncor.com/en/about/257.aspx



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3.3 Workers 3.3.1 Pipefitter 1 ( was employed with TAMSIL, he was a journeyman

pipefitter. At the time of the incident he was in the process of replacing the pipe crossover spool.

3.3.2 Pipefitter 2 ( was employed with TAMSIL, he was a journeyman

pipefitter, at the time of the incident Pipefitter 2 ( was working directly with Pipefitter 1 (

3.3.3 The Pad Operator ( was employed by Suncor Energy Inc. All work to

occur on the Well Pad during the shift went through the Pad Operator ( The Pad Operator ( was responsible to issue any work permits. Work Permits are issued based upon equipment isolation packages and work requests. It is the responsibility of the Pad Operator ( to ensure the equipment is isolated and the gas monitoring is completed prior to the issuance of work permits.

3.3.3 The Zoom Boom Operator ( was employed by TAMSIL at the time of

the incident. The Zoom Boom Operator ( was responsible to lift the new pipe spool into position for the pipefitters. At the time of the incident he was located inside the zoom boom parked approximately 15 metres away from the pipe rack. Only the pipefitters were permitted to be in close proximity to the pipe rack during the initial breaking of the flange (opening the pipe) as this task was completed under supplied air.

3.3.4 The Welder ( ) was employed by TAMSIL at the time of the incident. At

the time of the incident the Welder ( ) was also located away from the pipe rack observing the work.

3.3.5 HSE Integrated Operators ( and HSE provided

the Supplied Air Breathing Apparatus (SABA) to Pipefitter 1 ( and Pipefitter 2 ( for the work that was occurring at the time of the incident. The HSE air trailer was parked approximately 4 m from the pipe rack at the time of the incident.

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SECTION 4.0 LOCATION OF INCIDENT 4.1.1 The incident occurred at the Suncor Energy Inc. Firebag site located

approximately 60 km northeast of Fort McMurray (Refer to Attachment A – Map).

4.1.2 At the Firebag site the incident occurred on Well Pad 103 at well pair 3WP11. SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 5.1 Equipment and Materials 5.1.1 Well Pair

The well on pad 103 the well pair 3WP11 consisted of 3S11- the steam injector and 3P11 the producer. The well pair 3WP11 was configured for a steam circulation phase. This was the initial commissioning stage which utilizes the steam to warm up the reservoir prior to production. To configure the well for this phase the steam lines were reversed to allow the steam to return to the surface. This phase was to last approximately 90 days.

5.1.2 Piping Configuration The piping configuration on the system in which the incident occurred included the Wellhead Wing Valve, then a vent valve and a drain valve, followed by a check valve positioned to prevent flow back towards the Wellhead Wing Valve. There was then a series of pipe spools and then the pipe crossover spool. (Attachment B- Sketch)

5.1.3 Wellhead Wing Valve

The flanged gate valve is the main valve from the wellhead, this valve was used for the isolation of the piping system on which the incident occurred. The isolation included locking the Wellhead Wing Valve in the closed position. This valve is located upstream of the pipe crossover spool. (Attachment C – Photograph # 6)

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5.1.4 Pipe Crossover Spool The pipe crossover spool was installed as part of the reconfiguration for the steam circulation phase of the well. The original pipe crossover spool eroded after 3 days of operation. The system was subsequently isolated to allow for replacement of the spool.

5.1.5 Pipe End Cap

The pipe end cap was placed at the end of the pipe to cover the opening once the crossover spool was removed. The pipe end cap weighed approximately 16 kg and it remained in place for 22 days while the new crossover spool was being fabricated. The pipe end cap was equipped with a nipple that was capped. The pipe end cap was attached to the pipe with a clamp connector. The pipe end cap was a piece of equipment that was brought onto the Suncor Energy Inc. site and owned by TAMSIL. (Attachment C- Photograph # 4).

5.1.6 Clamp Connector

The pipe end cap was attached to the pipe with a clamp connector. The clamp connector consisted of two clamps (each weighed 12 kg), a seal ring and four bolts. (Attachment B - Diagram). Each clamp covered 180 degrees of the pipe and they are held into place by the four bolts.(Attachment C- Photograph # 4)

5.2 Observations 5.2.1 Occupational Health and Safety arrived on site at 9:00 a.m. on August 01, 2011. 5.2.2 The well pad was shut down and the entire well pad was cordoned off with security

posted at the entrance. The incident scene was flagged off. The pipe end cap was positioned on the ground next to the two sections of the clamp connector. (Attachment C- Photograph # 4) The bolts from the clamp connector were on the pipe rack beside the pipe that was involved in the incident.

5.2.3 The HSE Integrated supplied air trailer was located adjacent to the incident scene,

with air hoses positioned on the ground to the incident location. (Attachment C- Photograph # 1)

5.2.4 The wellhead wing valve was locked in the closed position. The drain and vent valves

immediately downstream were both closed and capped. The newly fabricated crossover spool was located next to the pipe rack upstream of the incident location. (Attachment B –Sketch) (Attachment C- Photograph # 5)

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5.2.5 The location where the incident occurred was very congested with piping with limited

space to move around.

5.2.6 The end of the pipe spool was open and the pipe end cap was located on the ground below. The clamp connectors were located on the ground next to the pipe end cap. The bolts from the clamp connectors were on the pipe rack next to the open ended pipe. (Attachment C- Photograph # 3)

SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT 6.1 A hole eroded through the pipe crossover spool, releasing steam and some product.

The line was subsequently isolated to stop the leak and allow for replacement of the spool. The isolation involved closing and locking the wellhead wing valve. The line was depressurized as it was open to atmosphere via the hole.

6.2 On July 9, 2011 a work order was issued to TAMSIL to remove the failed spool.

Pipefitter 1 ( and Pipefitter 3 ( removed the failed spool and installed a pipe end cap with a clamp connector onto the open pipe. The installation of the pipe end cap created a closed system.

6.3 The well remained isolated until July 31, 2011 when the new crossover spool was

ready for installation. 6.4 On the morning of July 31, 2011 the TAMSIL work crew was completing another

task, which involved the installation of pressure safety valves in the manifold building. This task was completed with the Pad Operator’s ( support. The permit for this work was issued based upon the same isolation (lockout/tag out) as the installation of the new pipe crossover spool.

6.5 At 1:00 p.m. the work crew went for lunch. After lunch the work crew completed the

final steps for the installation of the pressure safety valves. 6.6 Pipefitter 1 ( contacted the Pad Operator ( to add a

Zoom Boom (variable reach forklift) to the permit as it would be required to lift the new pipe crossover spool in place.

6.7 Pipefitter 1( and the Pad Operator ( met at the job

location to add the Zoom Boom to the permit. Pipefitter 1 ( confirmed with the Pad Operator ( that the new pipe crossover spool installation was to be completed on the same isolation (lock out/tag out) as the task

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completed earlier that day involving the pressure safety valves in the manifold building.

6.8 At approximately 4:30 p.m. Pipefitter 1 ( and Pipefitter 2 (

donned their Supplied Air Breathing Apparatus (SABA) in preparation for the removal of the pipe end cap. SABA is required for initial opening of a piping system as a mitigating control for potential exposure to gas.

6.10 HSE Integrated Operators ( and and the Zoom

Boom Operator ( positioned themselves accordingly and waited for Pipefitter 1 ( and Pipefitter 2 ( to remove the pipe end cap and check for gas levels. (Attachment “B” Sketch).

6.11 Pipefitter 1 ( removed the bolts from the clamp connector and

placed them on the pipe rack. Pipefitter 2 ( struck the clamp connector with his pipe wrench to remove it from the pipe.

6.12 As the clamp connector came off, the pipe end cap projected from the pipe striking

Pipefitter 1 ( in the abdomen. Pipefitter 1 ( fell to the ground and started to crawl out of the pipe rack area.

6.13 The Welder ( ) who was positioned west of the area watching the removal

of the pipe end cap ran over to assist Pipefitter 1 ( 6.14 At 4:50 p.m. “man down” was called on the Suncor radio. 6.15 Suncor Energy Inc Emergency Response was dispatched and arrived on scene at 4:58

p.m. 6.16 Pipefitter 1 ( was transported to the hospital in Fort McMurray

via helicopter. 6.17 Pipefitter 1 ( passed away in the Fort McMurray Hospital on

August 01, 2011. SECTION 7.0 ANALYSIS 7.1 Direct Cause 7.1.1 Pipefitter 1 ( received fatal injuries when the stored energy

(pressure build up) within the piping system was released. When the clamp connector was removed, the energy released and caused the pipe end cap to be projected, hitting Pipefitter 1 (

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7.2 Contributing Factors 7.2.1 The work on the piping system was completed under a single isolation. Approval by a

professional engineer was not obtained. This may have contributed to the pressure build up within the piping system.

7.2.2 The piping system configuration in conjunction with the addition of the pipe end cap

closed the system without an adequate means to relieve any pressure build up within the piping system.

7.2.3 The installation of the pipe end cap did not follow Suncor Energy Inc.’s blinding

procedure. This was not recognized by the pipefitters installing the pipe end cap or by the Pad Operators.

7.2.3. The potential hazard of pressure build up in the system was not recognized by the Pad

Operator ( or by Pipefitter 1 ( and Pipefitter 2 ( prior to the removal of the pipe end cap.

7.2.4. Pad Operator ( did not confirm the status of the pipe system prior to

issuing the work permit to the pipefitters to install the new crossover spool. 7.2.5. Pipefitter 1 ( and Pipefitter 2 ( did not follow the

manufacturer’s specifications for removal of the clamp connectors.

SECTION 8.0 FOLLOW-UP/ ACTION TAKEN 8.1 Human Services; Occupational Health and Safety 8.1.1 Occupational Health and Safety Investigators placed a stop use order on Well Pair

3S11. 8.1.2 Occupational Health and Safety Investigators requested documentation from Suncor

Energy Inc. 8.1.3 Occupational Health and Safety Investigators requested documentation from TAMSIL. 8.2 Industry 8.2.1 Suncor Energy Inc. complied with all orders.

8.2.2 Suncor Energy Inc. provided all requested documentation. 8.2.3 Suncor Energy Inc. conducted an investigation into the incident and implemented

corrective actions to prevent recurrence.

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8.2.4 Suncor Energy Inc. implemented an amendment to the Safe Permit Process for

verification of zero energy. Both the permit issuer and receiver must now sign that they have witnessed a state of zero energy and the method by which it was verified.

8.2.5 Field tours must be conducted by both the permit issuer and receiver to verify lock-

outs and zero energy as part of the safe work system. 8.2.6 In all cases of single isolation, where positive isolation cannot be achieved a risk

review must be conducted and signed off and approved by a professional engineer, before proceeding.

8.2.7 All maintenance crews were retrained on isolation procedures and standards. 8.2.8 TAMSIL provided all requested documentation. 8.3 Additional Measures 8.3.1 There were no additional measures taken. SECTION 9.0 SIGNATURES ____________________________ _____________________ Original Signed, Lead Investigator Date ____________________________ _____________________ Original Signed, Investigator Date ____________________________ _____________________ Original Signed, Manager Date ____________________________ _____________________ Original Signed, Director, Central Date SECTION 10.0 ATTACHMENTS: Attachment A Map Attachment B Diagrams and Sketch Attachment C Photographs

File: F-564834 Attachment “A” Map

Showing Incident Location

Human Services, Occupational Health and Safety

Showing incident location: Suncor Firebag site located 65 km northeast of Fort Mcmurray

HSE Air Trailer Incident Location

Zoom Boom

Steam

Injector

Well

Producer Well

Manifold Building

Pipe rack

Pressurized section of line

Human Services, Occupational Health and Safety July 02, 2011

Simplified Plot Plan Overview

Attachment B

Sketch 1

File F:564834

Pipe end cap

Vent Closed

Pressurized section of line

Steam Injector Well

Drain Closed

Check Valve

Pipe End Cap

WellHead Wing Valve

Locked Closed


Attachment B

Sketch 2

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Valve Configuration on Piping system involved in the incident

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Attachment “C”

Page 1 of 6


Photograph #1

Shows the incident location at the Firebag site Well Pad 103 Well 3WP11 pipe rack and the

HSE Integrated supplied air trailer to the east of the pipe rack.

File: F-564834 Attachment “C”

Page 2 of 6


B

C

A

Photograph #2 Close up of the incident scene

A- Shows the location of the incident B- Shows the pipe spool that was going to be installed C- Shows the wellhead upstream of the piping involved in the incident


Page 3 of 6


A

B

Photograph #3 A- The open end of the pipe that the pipe end cap was attached to at the time of the incident. B- Similar clamp connectors installed on adjacent piping.


Page 4 of 6


Photograph #4

A- The pipe end cap that struck Pipefitter 1 B- The clamp connectors that held the pipe end cap onto the pipe.

A B


Page 5 of 6


Photograph # 5 The new spool that was going to be installed onto the pipe.


Page 6 of 6


Photograph #6 The wellhead upstream of the piping involved in the incident.

2011 Fatality Report: Worker Struck with Pipe Cap€¦ · located inside the zoom boom parked...

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