  HSE LEARNINGS INCIDENT: Root Causes: LEARNINGS:

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  HSE LEARNINGS INCIDENT: Root Causes: LEARNINGS: During the operation of changing out the 1” drilling line from the spare spool to the draw-works, the spare drum was jamming and it was decided to lay it on it’s side on the ground. During securing it on to the dead line anchor, the line twisted due to release of tension and stored energy and trapped and broke the IP’s right thumb. Root Causes: The TP and Driller are involved in the task instead of supervising The TP and the driller failed to stop the job after repeated unsafe situation of twisted rope under tension due to unreeling in the vertical position. The hazards due to change of conditions introduced by the damage on the wooden reel were not assessed LEARNINGS: Supervisors should supervise the job instead of directly doing the job. Do not unreel in the vertical position Supervisors should stop the job and rethink when there is a change in the job conditions. Wooden spooling to be eliminated The wrong method of unspooling with the wooden reel on the vertical position.  Key Learning: Assess the risks and acquire manager approval before deviating from standard procedure. Lack of Supervision. Failure to stop unsafe conditions and acts–> Broken Thumb Use this Alert: Discuss in Tool Box Talks and HSE Meetings  Distribute to contractors  Post on HSE Notice Boards  Include in site HSE Induction Contact: MSE511 for further information or visit the HSE Website Alert No 59 LTI #3 2011 May, 2011