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Topic 43: Unsafe acts/conditions during routine tasks in platforms/offshore and how to avoid them.

Rovshan's picture

Dear all. Most of us are working already or planning join to oil and gas industry as an engineer,so you will do routine jobs frequently. I would like to share incidents/accidents and near misses those happened in the rig where I work and explain reasons ,how to avoid them. I hope you will benefit from this information in you future career. 


release of energy in the top drive

Target audience for this alert

 Drilling Supervisors

What happened

 Whilst running in hole with the 13
3/8” seal assembly, as the driller picked up the string to remove the slips,
there was an unplanned rotation of the pipehandler. This caused the elevators
to make contact with the dolly tracks and subsequently open, dropping the
string downhole.

 Well barrier was compromised with
8” DC lying across the BOP. Ability to close in using the Annular, but couldn’t
use the pipe rams or shear rams.

Why it happened

 String picked up whilst top drive
was still running.

 No visual checks were made on the
top drive or RPM gauge, decision based on torque gauge alone.

 Dual activities being performed in
the dog house with insufficient communications between the two parties (driller
and Toolpusher). At the time the Toolpusher was mentoring the driller, who was

new to the rig.

Lessons learned

 Though it was unknown at the time,
the internal plug in the PORRT Tool would have enabled an internal seal.

 As both Annular preventers are part
of the LMRP and not the BOP, it resulted in a compromised ability to disconnect
the BOP and further escalation risk to subsea assets.


 Well Control considerations for
every tubular and BHA need to be assessed prior to running.

 Specific risk assessments should be
performed for any fullbore tool or unshearable BHA.

 Reinforce the Red Zone policy. 


I would like to thank you for your very interesting blob, which is basically focusing on procedures taking place on drilling rigs. This blog is very beneficial for those planning to work in this sector of oil and gas industries. Safety issues are very important when performing operations related to the wells, having people exposed to the highest risks in comparison with the rest oil and gas operations' chain.

During my undergraduate studies our lecturer of Well Drilling was mentioning all the time that it is extremely bad practice, unless using tongs or roughnecks to screw or unscrew pipes, applying rotation of the rotary table to perform the job to some extent. I have seen many videos so far where it is obvious that people are applying these unsafe practices.

I will disagree with you at the point where you consider these jobs as routine jobs. In my opinion while working over rig every trip no matter if RIH (running into hole) or ROOH (running out of hole) is different experience. Almost every time something new happens. For instance, damages of the equipment due to human factor, drilling fluid circulation problems or even different approaches of the personnel having duty. Also, many times wells can have some unexpected surprises. For example, when I was in terms of my internship offshore and being part of work over rig crew we encountered with unexplained presence of gravel into the well. After some considerations and pressure measurements of the annular space there was a conclusion that the liner was damages and the cement was inadequate to stand the formation pressure. Thus the rocks from the formation were entering the well through damaged liner. The core of problem was the damaged pipe during one of the trips performed in the past.

mohamed.elkiki's picture

i also agree with Sergios about the word routine. drilling job can sometime be routine but most of the time its challenging job. Each area has difficulties and you may drill in same reservoir with different wells and each well face different problems. Drilling is not an easy task and need fast and experience engineer to tackle the problem and solve it before it reach the surface different jobs is done regarding testing and as mentioned in my colleges comments the RIH and ROOH. and the most difficult part in my opinion is cementing and running casing because most of the problems rise from this point. Drilling now became more challenging due to the deep water conditions. Safety procedure now are very important. At past oil or gas was found in shallow distance but now with the new technology and ways to extend the well to reach the deep water oil or gas, safety became more important because any mistake can lead to death of many life and also damage to environment like what happened in Macondo.

faizakhatri's picture

Unsafe act and unsafe condition both are related with each other unsafe condition create hazard which results in an accident and number of persons would may be injured in a working place But unsafe acts are more dangerous as it has direct link to human behaviour  and how we act in unsafe condition or convert safety practise to unsafe condition  which result  in incident/accident may happen or how we behave accordingly to make it more worth able with safety and I believe Every accident/incident occurs in working place in part or in full due to "an unsafe act” of employee and it is also possible that because of individual or groups of individual may not doing their job to ensure safety and generate unsafe conditions but For ensuring safety it is necessary to perform safe acts on jobsite and especially when unsafe conditions occur  Faiza khatri  M.Sc oil and gas engineering 


c.ejimuda's picture

I just want to add to what I have been posted on this blog. I have discovered that some of the problems encountered when carrying out routine operations is as a result of human error or equipment failure. Sometimes routine task becomes boring, personnel get used to the task and fails to carry out a proper assessment of the job, equipment and the environment that the job is carried out. This can eventually lead to an accident.

Some of the ways to avoid unsafe acts during routine operations are as follows:

  • Taking breaks when carrying out serious task can help in increasing your awareness and concentration on carrying out the task effectively.

  • Depending on the nature of the job carried out periodic review to make sure the task is done the right way.

  • Carrying out periodic visual checks/inspections of the work equipment can reduce unsafe act.

  • Carrying out a risk assessment on each task or related task can help.

  • Ensuring there is regular relief and rotational work within shift.

I believe with some of these points highlighted above, unsafe acts will be reduced to As Low As Reasonably Practicable (ALARP). 


Chukwumaijem M Ejimuda

MSC Safety and Reliability Engineering.

Ike Precious C.'s picture

I would like to add that there is nothing more dangerous than Routine activities, especially in the Oil and Gas industry. When one tends to do a particular task over and over again that he/she can tell a scenario without being there is really dangerous.
But I think its high time that activities should be carefully analyzed to see the element/factor of routine tasks attached to it. The more rouitne the tasks are, the easier it is to break the safety rules surrounding that task/acitivity.
On the other hand, I think Management should really be firm and conduct regular workshops/training for their staff regarding the dangers that surround Activities that contain Routine acitivity-elements,  and how they (the staff) can overcome such feeling/urge to break safety standards just because you've been doing it.

Thank you

Bassey Kufre Peter's picture

I agree with you Ike, that most accidents in the industry are function of routine activities.As the saying goes:familiarity brings contempt,operators often times overlook the safety requirements and guidelines of carrying out most routine jobs.They often times believe that they did the first activities like this and that the second should be done in same way, they may not consider they may be different safety requirements at each stage,so they jump into the activities in the same way they did the first. The aftermath effect is serious fatalities.For examples, during drilling operations subsea or onshore, casing the well is a monotonous activities and often times operator cut corners while carrying out this operation and may not necessary adhere to the HSE requirements at each stage of the casing. This will lead to improper casing and the aftermath effect is leakages. I will say that safety personnel during always identify and pay critical attention to routine activities to ensure that HSE requirements are strictly adhere to. 
Bassey, Kufre Peter
M.Sc-Subsea Engineering-2012/2013
University of Aberdeen.

Dike Nwabueze Chinedu.'s picture

If equipment/machines work continuously without maintenance and repair, they are bound to break down. This is analogous to humans-beings as well. Although it is true that if an individual does same task over and over, He is likely to be parfect in the task, but it is even proven that the individual gets bored and tired of repeating same task everyday and fatigue may set-in. Routine tasks brings about laxity, lack of proper job assessment, misconduct, negligence and sometimes carelessnes and the offspring of all of these is conspicious unsafe practices in an offshore platform. I will categorize unsafe acts/conditions as either man-made or equipment made. The man-made are those caused by humans (such as improper handling or lubrication oil on the platform which could spill and become a potential hazard etc), the equipment made results from equipment failure.

The following steps can be taken to tackle the safety issues associated with routine tasks offshore: Avoid multi-tasking always; carry-out a job safety assessment check no matter how little the task seems; take breaks at sufficient times; workers should be rotated as often as possible; carry out close supervision when a job is being carried out; competency check is always required for each task.

For the technician in a workshop, there is nothing more aggrevating than working in a wobbling bench. Applying this maxim offshore means that routine, preventive and corrective maintenance of all stationary and rotating equipment on the platform is required at all times.

Foivos Theofilopoulos's picture

If I can divert your attention for a moment, I think the point I want to make is
relevant to your discussion. At least from personal experience, I think that routine
tasks are the ones where you have the most chances of something devastating
going unnoticed. When we have done something for time and time again, it
changes the way our brain handles the decision-making processes. The quickest
and better, in terms of time consumption and precision, decision making process
is termed “recognition-primed decision making”. This mode of decision making “…relies
on remembering responses to previous situations of the same type.
choosing a course of action is likely to be experienced almost as an automatic
process, with little conscious deliberation…”. (continued)

References:  Klein, G., 1998, Sources of Power: How People Make Decisions, MIT Press, Cambridge, Mass

Foivos Theofilopoulos's picture

my point is that when routine takes over any kind of activity,
recognition-primed decision making kicks in and we work mechanically without
losing time to gather information and think of the particular task at hand.
This process is beneficial most of the time. However, the problem lies within
relating the task at hand to previous conditions.

our relation is incorrect, or we do not spend enough time to gather clues that
might elude us, we are at risk of many…unpleasant incidents. It is very
difficult though to force people to deliberately take a routine task slowly and
painstakingly look through every detail. So, at least for the human part of the
problem Rovshan describes, the answer lies with proper training and good safety
culture in a company, explain to employees why they must always be on their
toes for slight changes even in everyday tasks.

Emmanuel Mbata's picture

This topic is very important....

There has been so many regulations in place to ensure work place safety, But accidents can not be prevented soley by regulatory requirements, Understanding the fundamental root causes and widely sharing the lessons learnt and intergrating this lessons into safe operations are also required.

Accidents are nearly always caused by unsafe acts/connditions, i.e someone doing something that is unsafe. this unsafe act comes in many form, failing to follow procedure, failing to wear the proper PPE, failing to lockout equipments etc.

Making individuals aware of these acts and taking steps to ensure they not occur, will reduce the amounts of accidents drastically.

Azeezat's picture

Serious and
dangerous accidents happen on offshore installations during routine operation
and this might be as a result of not following procedure or lack of situation

As my colleague have
mentioned ways to avoid unsafe act during routine activities offshore. I would
like to add that a good Safety Intervention could also help reduce unsafe act
during routine operations. A good intervention approach stops the unsafe act,
identifies the critical factors that allowed that behaviour or condition to stop
to occur, and then some sort of personal, group, or organizational fix to be
made to avoid further unsafe act could then be agreed upon. 

Derek Porter.'s picture

The following is a procedure from the northwest european guidelines and adopted by many companies operating in the north sea. Several safety stages are implemented:

  • Pre tower safety meeting (everyone on that specific shift). This is a briefing on the 12 hourly shift i.e. all jobs in process.
  • A risk assessment of the job involved, required permits are signed off by OIM and returned to control room every 12 hours
  • Working area is set up with appropriate barriers, highlight hazards such as openings and full radio control is maintained if needed
  • STOP or START cards are required to record unsafe or even safe actions (2 or 3 a day)
  • Time out for safety is often required once per shift to refresh employees of the dangers involved (eg Transocean)

One issue in my opinion occurs with the STOP cards. The requirement to fill in 2/3 a day often puts pressure on employees to fill them out. From witness sources these workers have the added pressure as they feel someone is always 'looking over their shoulder'. This may cause the encouragement to unknowingly causes a higher risk. Can anyone support this view?????

Ref : Patrick Folan, Marine superintendent, Intermoor marine services.

Agba A. Imbuo's picture

In doing a routine job, we tend to overlook very critical and minor deflections from the everyday procedures. These deflections tend to be the root causes of major accident and as such, make most of the act unsafe. The aftermath effect could be a very disastrous occurrence leading to serious fatalities. Looking at the oil and gas industry, drilling operation are required to conform with the occupational health and safety code, but most employees overlook this making them very unsafe acts. Operations like cementing or casing tend to be monotonous hence those who do this job easily get bored as a result of repetition of task. This repetition result to stress and eventually fatigue. Hence  to avoid unsafe acts, periodic risk assessment and reviews of existing procedures, regular supervision, rotation and on the job assessment should be carried out regularly to ensure that safety is not undermined and if identified are made safe.


Catriona Ogg's picture

I fully agree the previous comments regarding how conducting routine tasks can lead to improper practices or 'bad habits' in working practices.  We can all relate to a time when we've had to carry out a repetitive or familiar action and how it can soon become monotonous and we hence look for ways to cut corners.  It is easy to soon become distracted and attention can divert away from the task at hand.  

While I feel my classmates have successfully found solutions to help reduce this happening such as breaks and rotations, I personally feel that another way to remedy the problem would be to place more emphasis on accountability of the individual worker who carries out the malpractice. The supervisor will most likely hold ultimate responsibility for ensuring that tasks are carried out by the book, and this could mean that individuals are more willing to take chances on safety because they don't consider the full gravity of the possible repercussions of their actions. If the employer were to ensure awareness of the possible effects of their negligence, employees would hopefully be less likely to adopt bad practices.

Kyle McFarlane's picture

I agree with Foivos that If a task becomes "routine" it can be carried out without much thought, and although perfectly natural this aspect of human nature needs to be regulated as it can lead and has led to a variety of accidents and incidents throughout history.
The less care and attention taken by an individual the more likelihood there is of an incident. Admittedly for the most part this is balanced by the individuals required experience in order to have the level of competency with their job that they can do it without much thought, however in a high risk industry such as offshore drilling we cannot allow risks to increase needlessly.
I wonder if anyone has any potential solutions to ensure that every task is given the level of focus and commitment necessary to ensure the safety of the individual and others? It is no easy task to change the way we as a people think and act.

 I have seen from the above comments that the suggestion of job rotation and increased supervision has been suggested and I feel these would work very well to limit this affect but do any of you think there is a possible soloution to the way we think?

amir masoud bayat's picture


An accident is an inevitable event which is never planned or
scheduled. It is my belief that several factors such as bodily injuries and
losses contribute to occurrence of accidents. All accidents are resulted and
all of them are the consequences of human or equipment error. Also, all of
accidents involve an unsafe condition or behavior or a combination of both. Unfortunately
the inherent characteristic of the behavior or environment which causes the
accidents is rarely tackled in its entirety. Therefore, the safety managers
wait for the next hazard in order to recognize the next required appropriate
actions. What I mean is that they are still unknown unknowns before an accident
happens and makes them knowns.

To sum up, as my friends wrote above, we can reduce the
human error and unsafe behavior to the level As Low As Reasonably Practicable (ALARP).


Manuel Maldonado's picture

I agree with the participants in this forum that operations routines can lead to use of bad practices believed to be the best ways. This can be seen in old installations where oil workers have been there for years (20 or more). Activities which at some point had proper procedures now are being carried out without even looking at them. Experienced operators teach new operators on the job and tell them how they think is the best way for doing those routines. Bad habits are then learned along with lack care of critical aspects of that activity.

Sometimes there is an excuse for workers doing routines in the way they have been told to do them. It happens particularly in brownfield installations where procedures have not been updating reflecting process modifications or new equipment in used. This things cause a misleading learning and also potential causes for accidents.

It is recognised that workers gain confidence by doing the same activities regularly and during that process they develop easier ways to complete their tasks. Those easier ways are not always the safer ways and could sometimes be the worst ways which create sources of risks. It creates deviation from existing operating procedures which can lead to equipment damage and accidents in the worksite. Lack of due care an attention is also another cause developed from doing routines when confidence is gained. Routines also become high potential risk activities because in some installations risky activities fall within that operations envelop, which allow them to be completed or executed without any work permits or risk assessments.

In order to prevent these bad habits and ensure routines do not become causes of accidents, it is necessary to ensure procedures are followed and adequate and formal training is provided for workers. It is also required to create safety awareness and consciousness of the risks associated to each activity. Regular audits of processes would be an option and a kind of last resource to ensure the formal processes are followed and those activities which can be routines are carried out with due care and attention, recognising the risks associated to them.

Carry out a risk
assessment: this should include identifying the risks, analysing them
thoroughly and devising measure to mitigate them. No work should be carried out
without a well documented risk register sheet. Everyone working on the job
activity must participate and have a full understanding of each risk before the
job can proceed.

Also intermittent
review of the process should be carried out at regular intervals to review the
risks and identify those that are imminent.

It is also important
to review the risk register if an unexpected event occurs during the cause to
the job activity and update registered risk that such event might affect.

Also if a job
activity runs into an unexpected schedule, the risk register should be reviewed
to capture such changes as effect of other plant activities that could have

also regular breaks are important to revive concentration

Mohamed H. Metwally's picture


day when I was offshore, an accident happened because of over-confidence during
routine work.

When one rigger was rigging up the basket, instead of hooking the
steel ring (at the end of the basket sling) to the crane block, he hooked the
whole string formed as a result of attaching an emergency sling (which is too
weak); and as a result of that the weak sling carried as much load as the wire sling
and the 4 people riding the basket fell after parting of the weak sling in few

Luckily there were no fatalities
in that accident. 



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