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What happened?
A worker was fatally injured when they were entangled in the drill line and draw works.
The worker was assisting a downhole pump removal operation. This procedure required the crown saver to be adjusted to assist with the extra-long pump layout.
After the pump was laid out, the operator raised the blocks and discovered the worker.
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Why did it happen?
- Hazards were not recognized as the operator made a quick crown saver adjustment and did not communicate to workers or worksite management as the adjustment was made.
- Lock Out Tag Out (LOTO) procedures were not followed.
- The worker was positioned in the line of fire when blocks were set in motion.
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What did they learn?
- Review lock out tag out (LOTO) procedures and competencies.
- Communicate position responsibilities and authority.
- Implement three-way notification before a safety device can bypassed or adjusted.
- Review of tasks, procedures and competencies of all workers.
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Ask yourself or your crew
- How can something like this happen here (e.g. on our site)?
- What safety measures (i.e. procedures, controls/barriers) do we have in place to mitigate the risk?
- How do we know the risk controls/barriers are working?
- What improvements or changes should we make to the procedures, controls/barriers or the way we work?
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Published on 06/06/23
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A worker was assisting a downhole pump removal operation. This procedure required the crown saver to be adjusted to assist with the extra-long pump layout. After the pump was laid out, the operator raised the blocks and discovered the worker. The worker was fatally injured having been entangled in the drill line and draw works.
Original material courtesy of Energy Safety Canada
Other resources:
Watch the Line of Fire microlearning video.
Watch the Bypassing Safety Controls microlearning video.
