ACG Pipelay Barge “Israfil Guseynov” Fatal Accident Summary 24 th April 2005

1. ACG Pipelay Barge “Israfil Guseynov”Fatal Accident Summary24thApril 2005

2. Key Messages • Nature of the incident • Ugurlu Gasanov (40 yrs old, Azeri, married with 2 children) fell through grating that he was working on and into the sea at 01:30hrs. Despite good weather at the time, rescue attempts were unsuccessful and he has not been found. • Work being undertaken: • Safety improvement work to remove grating, install a beam to improve mechanical support, and reinstall the grating on the bow deck extension of the MCCI (McDermott) Pipelay Barge (PLB). • What went wrong: • Inadequate work control processes (job planning, permits, task risk assessments, toolbox talks) by the barge management, supervision and the work crew allowed the job to be undertaken, without a full understanding of the hazards and without proper safety precautions. • Key forward actions: • Improve the work control processes and accountabilities, and implement an audit process to ensure that work is controlled as planned. Area where Ugurlu Gasanov was working Starboard Existing support in place New support to be placed here Tack welds being cut out Port

3. What Happened? • What was the job: • Safety improvement work to remove grating, install a beam to improve mechanical support, and reinstall the grating. • Pre Incident: • The pipelay barge had just laid down pipe in advance of a storm, and workers were reallocated onto storm fastening of deck equipment and maintenance jobs. • The grating safety improvement job was not included on any planned activity list and was not part of the planned activity for that night and was not discussed at the start of shift toolbox talk. Two remaining tack welds in green STARBOARD Grating to be removed Uprights 900mm Welder Leaderman Walkway grating Welding Foreman Air Tugger Ugurlu Welder Hydraulic rollers Location of support to be inserted Pipework PORT • Events: • The barge foreman and welding foreman discussed the workscope and this resulted in the welding foreman assembling a work team. No permit was issued, and no task risk assessment or job specific toolbox talk undertaken. • Welder leaderman cut around the grating and together with the welder were to use hooks to pick up the grating from each side and remove. Near the end of the job, the welder was reassigned to a different job and was replaced by Ugurlu, an assistant welder; by this time the welder leaderman had already cut most of the welds around the grating. • Within moments of arriving in position, Ugurlu stepped fully onto the grating with only two welds remaining. The grating gave way, and Ugurlu with the grating fell into the sea. • Despite a fast ‘man overboard’ response and subsequent search activity Ugurlu was not recovered

4. What Went Wrong? • Work Planning & Control Processes: • Work planning processes were inadequate: • Jobs to be completed were not identified within a central list, collectively reviewed by the barge management and supervision regarding the requirement for a permit or a task risk assessment, or communicated as a whole to the crew. • Work control processes were inadequate: • Although four other jobs were satisfactorily permitted that night, the grating removal job did not have a permit, task risk assessment or toolbox talk • When the welder was replaced by Ugurlu there should have been an effective handover but there was not • Barge leadership were unaware of the totality of jobs that were being performed at any time • Leadership & Supervision: • Barge management and supervision did not enforce the work control processes • The site ‘BP Rep’ was unclear of his safety responsibilities and did not enforce the work control processes

5. What Actions Are Needed? AzBU • Work Planning & Control: • Improve work planning & control on the barge: • Implement a revised job planning process that includes: compilation of a job list, a daily planning meeting to review jobs to be performed that day and an active discussion of each job regarding the requirement of a permit or task risk assessment • Develop and implement an audit process to ensure that jobs are executed with the appropriate permit or task risk assessment and a toolbox talk • Establish a requirement for the toolbox talk to be repeated if there is a change in personnel performing the task • Across the BU: • Undertake the required verification to ensure that all locations in the BU have adequate work planning and control processes being practised • Roll out the updated version of the ‘Supervisor Safety Leadership’ programme • Leadership & Supervision: • Establish clear accountabilities for barge leadership, supervision and work crews with regard to work planning and work control • Re-enforce the safety expectations and accountabilities of the ‘BP Rep’ • Enhance the focus of management visits, particularly at remote locations across the BU, and strive to include all aspects of the operation

6. Messages for Other E&P BUs • Although your site may have a good Permit-to-Work system, are you confident that all jobs undertaken are permitted, if appropriate, or have a task risk assessment? In particular, does the Permit-to-Work system cover non routine tasks as well as routine tasks? • Are your supervisors clear on their roles and responsibilities regarding Permit-to-Work, task risk assessments and toolbox talks? Are they fulfilling their roles and responsibilities? • Is the BP Rep on your contractor managed work site fully aware of his safety roles and responsibilities and competent to fulfill them? • Do BP management get out to all of your remote worksites to conduct ASAs at sufficient frequency and with sufficient focus upon non core activities? Is the interaction on site broader than ASAs alone – e.g. does it include engagement of staff in work meetings and townhalls?

7. Backup: Further Pictures of the PLB