WELDER DIED AFTER CONDUCTING WELDING ACTIVITIES INSIDE A 30” PIPELINE
Country: AZERBAIJAN - FSU
Location: ONSHORE : Terminal
Incident Date: 17 March 2006 Time: ---
Type of Activity: Construction, Commissioning, Decommissioning
Type of Injury: Confined Space
Function: ---
Applicabale Filter Categories: Explosion/burn
The task was to install a 30 inch gate valve into the gas export line. This work was not on the critical path or under time pressure.
The pipeline, buried nine months earlier, was excavated and cut and the plan was to weld the gate valve in place. Subsequent Radiography inspections detected weld defects and specialist welders attempted to repair the weld but concluded that it was not possible and left the site. The deceased attempted to complete the weld repairs from outside the pipe. But as was unsuccessful he, support by the crew, decided to attempt to repair the weld from inside the pipeline.
The crew cut a slot in the pipe near the weld and used an air hose to provide ventilation. The deceased then entered the 30” pipe feet first with a rope and welding cable tied to his body and a small pen light. He completed about 20cm of the weld and was heard shouting “I am burning”. The crew attempted to pull him out but the rope and welding cable were not connected to him.
No further sounds were heard from inside the pipe and it was later confirmed that he had died.
Note this task was conducted out of normal working hours by this crew, there was no authorisation from site management, no permit to work, no formal risk assessment and no emergency stand by for this activity.
What Went Wrong?:
There were 3 Critical Factors
- The welders attempted to complete a joint which was outside the stated tolerance in the welding procedure.
- The deceased entered the 30” pipe to run a root pass repair.
- The deceased remained in the pipe under extreme conditions to repair the root pass.
SUMMARY OF IMMEDIATE CAUSES:
CRITICAL FACTOR 1
- Violation by group: -Job started even though the job was out of spec due to excessive misalignment
- Improper decision making or lack of judgement - Repairs made the gap larger than allowed by procedure and welders continued to attempt a repair
- Inadequate tools - Hi-Lo gauge not used to measure misalignment
CRITICAL FACTOR 2
- Violation by individual - Violation of CSE procedure
- Violation by group - DP was assisted in action of preparing for entry, entry into pipe and then whilst DP was in the pipe
- Violation by supervisor - The job was not stopped
- Improper decision making or lack of judgement - High temperatures, fumes, unknown atmosphere, awkward position all existed within the pipe near the valve.
CRITICAL FACTOR 3
- Improper decision making or lack of judgement - DP did not abandon the job despite the intense heat generated by welding.
SUMMARY OF SYSTEM CAUSES:
CRITICAL FACTOR 1
- Behaviour (other) - Deceased party had a low weld failure rate. Welders failure rates are well known across site (causing possible competition between welders).
- Inadequate leadership - Reliance on guidance from the welding crew rather than a specialist.
- Inadequate technical design - Misalignment of the pipe and valve was not considered in Engineering MOC, risk assessment or method statement.
- Inadequate monitoring of construction – Inadequate QA/QC standards for misalignment
- Inadequate availability (equipment) - Hi Lo gauge was not available for this job
CRITICAL FACTOR 2
- Poor judgement - DP enter the pipe.
- Employee implied haste Root pass repair from inside the pipe would result in a successful weld that would pass radiography that night.
- Behaviour (other) - DP’s entry into the pipe and the work inside the pipe was supported by team. No action taken to stop the job despite earlier discussions with DP where he was discouraged from entering the pipe.
- Inadequate leadership - Leadership standards i.e. not stopping the job.
- Inadequate enforcement of PSP – COW PSP were available, but in this situation the team went outside of the PSP.
CRIITCAL FACTOR 3
- Extreme Motivation - DP remained in pipe despite extremes in temperature, discomfort and confinement.
Excavation of Area of Valve | Entrance to pipeline |
Corrective actions and Recommendations:
SUMMARY OF LOCAL ACTIONS:
- Welding Inside the Pipe - Mandate that welding inside a pipe is unacceptable without Project Director approval.
- Stop the Job - Site leadership must personally reinforce the obligation to all to stop the job.
- Construction Manager must enforce awareness of the limitations of the permit before starting and the consequences for deviation.
- Conduct a review of all team leaders to determine whether team leaders have the leadership skills to lead a work team.
- Welder Failure Rate - Remove the focus on a welders defect performance by keeping the records confidential.
- Team Culture - Consider issues and propose actions where crews have been together for a long period and could develop traits of over confidence.
- Hold Point After First Repair - Create requirement for NDT manager to inform Quality Manager and Job Engineer when a weld goes beyond first repair.
- Stop when set up is out of spec. after installing the valve (3 days)
- Stop after weld 5 had failed twice and weld 4 once (2 & 1 day)
- Stop after the first argon welders said it was not possible (4 hours)
- Stop the job when the second argon welder said it was not possible after using both argon and stick and left job uncompleted (45 mins).
- Stop once DP had completed weld from outside (15mins)
- Stop when DP says he is planning to enter the pipe (10mins).
- Stop when DP is in pipe by switching off the welding power.
KEY REMINDERS:
There were at least 7 opportunities where the job could have been stopped (time prior to fatality):
Source Contact:
Jacobus Nieuwenhuijze
Project /Program Director
STEP Sangachal Office
+994 12 4448020/1