This incident occurred while lifting part of a gangway during the removal of a chemical tote tank storage frame from the weather deck on Johan Sverdrup’s riser platform.
Part of Equinor’s logistics department on the North Sea field, the work team involved comprised two slingers, a signaller and a crane operator.
The team had attached the lifting chains to the gangway structure and was detaching the latter from the frame by releasing the first of two ratchet straps. This meant the structure was then supported by the crane hook which the chains were hung from as well as the second strap.
When the first strap was released, the structure began to shift. At the same time, one of the slingers moved into the lift zone and was crushed in the stomach area between the structure and the frame.
The person hurt suffered internal injuries in the stomach area. They were flown by search and rescue helicopter to Haukeland University Hospital in Bergen for medical treatment.
The PSA’s assessment is that, under slightly different circumstances, the incident could have resulted in a fatality.
Direct and underlying causes
The direct causes of the incident were that the structure moved out of control at the same time as the injured person found themselves in the exposed area when the structure was released from the first ratchet strap. This lead to them being crushed between the structure and the tote tank frame.
Underlying causes identified by the investigation are as follows.
- Responsibility for releasing the ratchet strap had not been agreed in advance
- No message was given over the communication network that the ratchet strap was to be released before the signaller released it.
- Signaller took the role of slinger.
- The team executing the lifting operation made no use of aids to identify risks, (SJA, checklists, Equinor A standard, etc). See nonconformity 8.1.2 for details concerning risk.
- Equinor’s management system was not followed during the lift operation.
- Nobody in the land organisation, on board, or in Johan Sverdrup’s logistics department appreciated that deficiencies existed in the early planning of the lifting operation.
- No role was identified for verification of compliance.
- The structure’s centre of gravity was unknown.
- Attachment points on the structure were not identified.
- The hooks used for attachment to the structure (chokes) were not suited for the purpose.
The following nonconformities related to the incident have been identified.
- Inadequate clearance for, management of and execution of the lifting operation.
- Inadequate planning.
- Inadequate barriers.
The PSA investigation has identified serious breaches of the regulations and has therefore given the following order to Equinor.
Pursuant to section 69 of the framework regulations on administrative decisions, see sections 30 and 92 of the activities regulations on safety clearance of activities and on lifting operations respectively, and section 6 of the management regulations on management of health, safety and the environment, Equinor is ordered to do the following:
- identify and implement measures which ensure that lifting operations on Johan Sverdrup receive safety clearance before being executed
- ensure that the responsibility and authority of those planning and executing lifting operations on Johan Sverdrup are unambiguously defined and coordinated at all times.
The deadline for compliance with the order is 10 January 2022. We must be notified when the order has been complied with.
The PSA has requested that a scheduled plan for complying with the order is submitted by Equinor no later than 13 October 2021.