China Offshore Oil Engineering Corporation (COOEC) landed a $180 million contract to help build some key facilities for Australia's Gorgon gas field in 2010[1]. A fatality occurred at COOEC yard[2] for the Gorgon gas project[3] related work in the afternoon of November 13, 2012. An injury involving a fork lift truck had occurred on non-Gorgon related work in the yard a week earlier but had not been widely communicated. This summary reflects the essential lessons from the incident.

Incident summary

A reconstruction of the relative position of the moving vehicles at the time of incident.
Schematic layout of the COOEC fabrication yard.

In the afternoon of 13th November, 2012 a section of a Gorgon pre-assembled rack (PAR) was being moved along the main thoroughfare in the COOEC yard on a slow moving self-propelled modular transporter (SPMT), accompanied by four spotters on foot, one at each corner. Parked vehicles by the side of the road caused the transporter to move into the center of the road, temporarily restricting the width of the road to other users.

A large fork lift truck, not associated with Gorgon work, was travelling in the same direction as the transporter and was delayed for several minutes behind the load. When an opportunity to overtake the transporter appeared, the driver of the fork lift truck overtook the transporter and then cut back right in front of the load, running over the front left spotter who was severely injured and could not be revived in hospital.

Following investigation

A joint Chevron/ KJV investigation team visited the yard during the week following the fatal incident and had the opportunity to conduct interviews as part of a Privileged & Confidential investigation. The resulting incident investigation report was prepared on a Privileged and Confidential basis. Any questions should be directed to the HES Manager for Gorgon Project.

Root causes

  • No dedicated Contractor supervisor group was assigned or trained for the task of PAR transport.
  • Inadequate Contractor risk identification was completed for the PAR transport - no HAZID, no formal WMS, and an inadequate JHA and associated training were being used.
  • Contractor had an inadequate method or process in place for sharing lessons learned from significant events across the entire fabrication yard.
  • Inadequate traffic management planning was completed by Contractor for PAR transports along the multi-purpose roadway in the fabrication yard (including signage, road marking and pedestrian crossings).
  • There was a lack of verification by Contractor of credentials and practical/challenge test for forklift drivers and SPMT operators working in the fabrication yard.
  • It was recognized by Contractor’s senior leaders responsible for the fabrication yard that there was no enforcement of road rules within the yard.
  • The provision and use of management systems by Contractor for work equipment, including forklifts, in the fabrication yard was inadequate

Recommended corrective actions

  • Contractor to conduct a review to identify gaps with respect to supervisory assignments for Gorgon PAR panel transport activities accounting for multiple contractor companies and multiple craft. Develop a plan to remediate identified gaps and track planned activities to closure.
  • Contractor to develop and implement a supervisor training package for Gorgon PAR panel transport task that includes all aspects of the JHA developed for this task.
  • Contractor to conduct full Gorgon PAR panel transport HAZID, develop WMS, develop JHA and implement associated controls.
  • Include assessment of current Contractor yard systems for enforcement of road rules and address as necessary in the WMS, JHA, and associated controls.
  • After completing task risk assessment, JHA and WMS - if spotters are still required for PAR Panel transport, develop and implement a formal spotter training package for Gorgon PAR panel transport task commensurate with the risk.
  • Contractor to share serious incident and near miss learning(s) at yard-wide Contractor HSE meeting/forum. Develop a mechanism for cascading the meeting lessons learned discussion packages site-wide.
  • Assure changes in yard rules and policies are systematically and routinely communicated yard-wide (employees and subs).
  • Contractor to develop a traffic management plan for Gorgon PAR panel transport activities. Areas to be considered include route planning, signage, road barriers and people-plant interface. Audit for compliance.
  • Contractor to develop and implement a challenge test framework, including certification of driver qualifications, based on local conditions and risk profile. Apply the framework to SPMT drivers and forklift drivers.
  • Contractor to develop a minimum specification for forklift visual and audible warning devices. Install devices on equipment as per the minimum specification and conduct periodic inspections of equipment to verify ongoing compliance.
  • Develop lessons learned package and cascade to Gorgon, PRC and Chevron SBUs.
  • Verify closure of action items and validate effectiveness of action plan.