1. BOI Multiple Fatality Halliburton M-135
9 April, 2011

2. Accident Description
On Saturday, 9 April 2011 at approximately 09:30 WITA am Operator Halliburton Coil Tubing Unit (CTU) operator entered a water tank that contained water mixed with nitrogen from displacement of coil tubing before unloading Mutiara – 135 well.
His co-worker in attempt to rescue the operator entered the same tank and for the same reason follow by two other co-workers. Realizing that four (4) workers were inside the tank, on site Rigless supervisor ordered to drain the tank and then asked two (2) personnel to enter the tank to rescue the 4 personnel by using rope (safety line).
Three (3) of the rescued personnel found unconscious and one (1) semi-conscious. All four (4) personnel immediately evacuated to VICO Mutiara clinic. After first aid treatment the semi-unconscious personnel was evacuated to nearby Handil hospital for further treatment. The three (3) unconscious personnel declared passed away by local medical doctor.

3. 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 task. (Appropriate Masks for acceptable range limits, and Breathing Apparatus for over range limits).
Poor and unthoughtful rescue attempts.
What went well:
Immediate handling of IPs
Incident site was properly secured with 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.

4. IMMEDIATE ATTENTION
Identify Confined Space and their Risks in your working area.
Follow Safety Guideline No.3 – Confined Space Entry.
Always follow procedures before performing your tasks. Ensure Confined Space Work Permit has been prepared, and the requirements have been fulfilled (Gas Test, Ventilation, Buddy System, Equipment & PPE, etc).
Always implement 3 Safety Golden Rules:
Think first.
Stop immediately
Report immediately

5. Words cannot even begin to express
our sorrow.
together let's silence