System Causes:19.2 Risk assessment not effectiveWorking around open cellar or tank not identified as a hazard on

JSEA

Critical Factor:Hazards were not recognized

Brief Account of Incident: On the Uptegroove GC 1A well site a 21 bbl tank was being prepared to be cleaned. The tank had a two piece expanded metal top. A roustabout crew had just finished removing the bolts holding the expanded metal top on to give access to a vacuum truck to clean out 3" of mud in the bottom. A laborer on the roustabout crew placed his left foot on the expanded metal and his right foot on the cellar board. It was at this time the expanded metal top folded into the tank under his weight. The laborer rode the expanded metal to the bottom and ended up in a standing position on the expanded metal and mud laying in the bottom of the tank. He received a small scratch on the tip of his nose with no other injury reported or noticed. The laborer quickly climbed out of the tank and the job was stopped.

Safety Learning: Could This Happen in Your OC?San Juan South May 20th, 09

Immediate Causes: 3.2 Personal protective equipment or methods

not used (i.e. fall arrest or guardrails)3.6 Removal of guards, warning systems or

safety devices (i.e. protective fencing)

Key Learnings:• Expanded metal tank

tops are not intended as a working or walking surface

• Job steps and associated hazards related to tank cleaning were not identified and reviewed on JSEA