As a result of an extended analysis of a double fatal incident, several deep underlying causes and deficiencies were found in various parts of the HSE-Management System of the Nederlandse Aardolie Maatschappij (NAM). The main deficiencies found were about organizational, communication aspects and lack of balance between operational and process safety. A remarkable observation was that approximately 80% of the potential interventions were missed in the office e.g. on work preparation, planning of the work and management of change (MoC). On site there is often adequate attention for e.g. good housekeeping and PPE however a clear lack of attention for process related safety issues was observed e.g. risks of working in a plant with hydrocarbons and lack of competence about process risks of especially (sub)contractor staff.

This paper describes the summary of the incident, the findings and the change which was established after the incident on three levels of the organization:

  1. organizational aspects,

  2. supervision on site and

  3. provision of fit for purpose information to contractor staff.

Additional experience and practical results will be shared around:

  • The clarification of HSE accountabilities of asset leaders and supervisors on site.

  • The connection between office and field staff on HSE issues.

  • A communication program named "HSE, a way of living" where basic HSE information is provided to contractors in an easy language and attractive format.

The incident (Shell, 2005)

On 31st May 2005 at 09:00 a.m. an explosion occurred, followed by a fire, on water / condensate (WaCo) tank T3 at NAM's Warffum location in the North of The Netherlands. Since February 2005, maintenance and project activities had been carried out on the location for which parts of the plant were made safe. The incident took place during pipe work installation of a vapour recovery system on the tank roof.

The tank explosion and subsequent fire caused fatal injuries to a welder and a fitter who were working on the roof and injured one other fitter. A fire fighter received first aid for minor burns sustained during the subsequent rescue operation.

The main findings

The following main conclusions were drawn regarding the underlying causes for the incident:

Roles and responsibilities

  • Roles and Responsibilities as defined under Dutch Law for NAM as site owner, the Integrated Service Contractor (ISC) as Employer, and individual staff of both NAM and the ISC were not effectively discharged and were not fully understood.

  • Within the operational organization structure for the execution and delivery of activities, connections and hence communications across disciplines were not always functioning properly. As a consequence, there was a lack of communication at lower (local) levels in the organization.

  • Alignment of HSE efforts in the organization was not completely effective and did not support site operations effectively enough.

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