2013 Fatality Report: Worker Fatally Injured When Thrown ... · PDF fileWorker Fatally Injured...

Worker Fatally Injured When Thrown From ATV Type of Incident: Fatality Date of Incident: June 1, 2013

File: F-OHS-042741-AD07E

TABLE OF CONTENTS

SECTION TITLE PAGE NUMBER

1.0 DATE AND TIME OF INCIDENT 3 2.0 NAME(S) & ADDRESS(ES) OF PRINCIPAL PARTIES 3 2.1 Owner 3 2.2 Employer 3 2.3 Workers 3 3.0 DESCRIPTIONS OF PRINCIPAL PARTIES 3 3.1 Owner/Employer 3 3.2 Workers 3 4.0 LOCATION OF INCIDENT 4 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 4 5.1 Equipment and Material 4 5.2 Observations 4 6.0 NARRATIVE DESCRIPTION OF INCIDENT 5 7.0 ANALYSIS 6 7.1 Direct Cause 6 8.0 FOLLOW-UP/ ACTION TAKEN 6 8.1 Industry 6 8.2 Additional Measures 6 9.0 SIGNATURES 7 10.0 ATTACHMENTS 7 Attachment A - Map Attachment B - Photographs

2 Albera Labour Occupational Health and Safety

Date: December 2016


SECTION 1.0 DATE AND TIME OF INCIDENT 1.1 The incident occurred June 1, 2013 at sometime between 9:45 a.m. and 2:00 p.m.

The worker was found deceased on June 4, 2013 at 7:30 a.m. SECTION 2.0 NAME AND ADDRESS OF PRINCIPAL PARTIES 2.1 Owner 2.1.1 Husky Oil Operations Ltd. 707 – 8th Avenue SW Calgary, Alberta T2P 3G7 2.2 Employer 2.2.1 Husky Oil Operations Ltd. 707 – 8th Avenue SW Calgary, Alberta T2P 3G7 2.3 Workers 2.3.1 The worker **** * * **** ** ****** ********** ******* *** *** 2.3.2 The production manager * ********** **** ** ***** ***** ******* *** *** SECTION 3.0 DESCRIPTION OF PRINCIPAL PARTIES 3.1 Owner/Employer

3.1.1 Husky Oil Operations Ltd. (Husky) was active in the exploration and production of

heavy oil, natural gas and natural gas liquids. 3.2 Workers 3.2.1 The worker had been working for Husky for 12 years and had been working in the oil

and gas industry for 28 years.


Date: December 2016


3.2.2 The production manager had been working with Husky since 2005 and had been

working in the oil and gas industry for over 25 years. SECTION 4.0 LOCATION OF INCIDENT 4.1 LSD 11-9-76-23W4M near Rock Island Lake (Refer to Attachment A – Map). SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 5.1 Equipment and Material 5.1.1 All-Terrain Vehicle (ATV) 5.1.2 The worker was using a red 2004 Honda ATV, serial number *****************,

with the owner being registered as Husky Oil Operations Ltd. 5.2 Observations 5.2.1 When the Occupational Health and Safety investigators arrived at the scene of the

incident, the ATV had already been removed. 5.2.2 There were two grass burn marks (Refer to Attachment C – Photographs 5, 6 and 8).

One was approximately 2.44 metres (m) across in a north/south direction and 3.81 m in an east/west direction. The second grass burn mark was approximately 61 centimetres (cm) by 46 cm. Royal Canadian Mounted Police (RCMP) photos indicate the worker’s head was on top of the burn mark; however, the back of the worker’s head was not burned.

5.2.3 A stump that was sticking out of grass by the east side of the road, 17.78 cm high by

7.62 cm across, was located 16.43 m from the centre of the larger burn mark (Refer to Attachment C – Photographs 7, 8, 9 and 10).

5.2.4 The travel marks of the ATV, after striking the stump, were washed away by the rain

that fell after the incident. 5.2.5 The remains of the ATV, transported to a local business (One Shot Hot Shot in Slave

Lake), were destroyed by the fire resulting from the incident. The ATV remains had been tagged out of service by Husky. (Refer to Attachment C – Photographs 1 and 2).


Date: December 2016


SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT 6.1 The worker was an operator at Husky’s Rock Island field, 100 kilometres (km) north

of Athabasca. Work at the Rock Island field was led by two Husky cross-shift operators with eight days on and six days off. The operators operated a small plant, a compressor station and nine gas wells. Two of the wells were accessible by truck, and the other seven wells were accessible in the summer, only by ATVs, on an old logging road. The time spent by the operators working alone varied from week to week.

6.2 As per Husky’s Working Alone Policy, on June 1, 2013, the worker telephoned the

contract answering service at 6:49 a.m. and advised the worker would be checking in again at 10:00 a.m. At 9:45 a.m., the worker called the contract answering service and stated the worker would check in again at 2:00 p.m.

6.3 At an unknown time, the worker removed the ATV from the worker’s vehicle at the

compressor station and proceeded to a well site. 6.4 At approximately 1.3 km north of the compressor station, the worker struck a stump

on the side of the road with the right front lower suspension system and lost control of the worker’s ATV (Refer to Attachment C – Photographs 3 and 4). The ATV flipped onto its left, throwing the worker approximately 3.05 m away from the ATV.

6.5 The worker was not wearing a helmet and did not have the worker’s GPS based

SPOT emergency locator device, satellite phone or cell phone booster with the worker.

6.6 At 2:00 p.m., when the worker did not check in, the contract answering service called

the worker and left a message to have the worker check in. 6.7 At 2:02 p.m., the contract answering service contacted the production manager as per

their instructions. The production manager did not do an immediate follow-up on the worker’s location.

6.8 At 7:30 a.m. on June 4, 2013, the production manager deployed a helicopter to search

for the worker, and the worker was located within an hour. The worker had succumbed to the worker’s injuries.


Date: December 2016


SECTION 7.0 ANALYSIS 7.1 Direct Cause 7.1.1 The worker had succumbed to injuries after being thrown from the worker’s ATV

after hitting a stump on the side of the road.

SECTION 8.0 FOLLOW-UP/ ACTION TAKEN 8.1 Industry 8.1.1. Husky conducted an investigation report and implemented control measures to ensure

there would be no recurrence of a similar incident.

8.1.2 Husky provided to Alberta Occupational Health and Safety the required documentation.

8.2 Additional Measures 8.2.1 Husky changed its work alone policy and now required that a worker either

personally advise they were safe or that an assigned supervisor respond that they confirmed the safety of the worker. Husky also started to use utility travel vehicles (UTVs) instead of ATVs; UTVs were more stable and safer than ATVs.

8.2.2 On May 15, 2015, Husky Oil Operations Ltd. and Husky Energy Inc. were charged

with 2 counts. The production manager was charged with 1 count. On October 20, 2016, Husky Oil Operations Ltd. (Husky) pled guilty to the second

count, failure to provide an effective communication system for an employee working alone. Husky was sentenced to a $200,000 fine (including the 15% victim fine surcharge). Charges against Husky Energy Inc. and the production manager were withdrawn.


Date: December 2016


SECTION 9.0 SIGNATURES ORIGINAL REPORT SIGNED December 4, 2016 Lead Investigator Date ORIGINAL REPORT SIGNED December 5, 2016 Investigator Date ORIGINAL REPORT SIGNED December 16, 2016 Manager Date ORIGINAL REPORT SIGNED December 16, 2016 Director Date SECTION 10.0 ATTACHMENTS: Attachment A Map Attachment C Photographs


Date: December 2016


Approximate area of incident.

Attachment A - Map


Date: December 2016


Photo 1 Shows the remainder of the ATV involved in the incident.

A - The right front end of the ATV that struck the stump.

A


Date: December 2016


Photo 2 A side view of the burned ATV.


Date: December 2016


Photo 3 Shows a closer view of the damaged mechanical linkage.

A - The damaged mechanical linkage.

A


Date: December 2016


Photo 4 Looking north where the ATV landed and burned.

A - The large burn area where the ATV landed on its side. B - The small burn area where the operator’s head was lying on.

A

B


Date: December 2016


Photo 5 Shows the two burn marks and the tree stump looking south at the site of the

incident.

A - The small burn area where the operator’s head was lying on. B - The large burn area where the ATV landed on its side. C - The tree stump that was sticking out of the ground.

A

B

C


Date: December 2016


Photo 6 Shows the old log road looking north.

A - The tree stump sticking out of the ground. B - The burn area where the ATV landing on its side.

B A


Date: December 2016


Photo 7 Shows a medium view of the tree stump sticking out of the ground and the

burn area where the ATV had landed on its side.

A - The tree stump sticking out of the ground. B - The large burn area where the ATV landed on its side.

A

B


Date: December 2016


Photo 8 Shows a close up view of the stump sticking out of the ground. The ribbon

was placed on the stump after the incident.


Date: December 2016

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