BOI Multiple Fatality

Halliburton M-135
9 April, 2011
Accident Description
• On Saturday, 9 April 2011 at approximately 09:30 WITA
am Operator Halliburton Coil Tubing Unit (CTU) operator
entered a water tank that contained water mixed with
nitrogen from displacement of coil tubing before unloading
Mutiara – 135 well.

• His co-worker in attempt to rescue the operator entered

the same tank and for the same reason follow by two
other co-workers. Realizing that four (4) workers were
inside the tank, on site Rigless supervisor ordered to drain
the tank and then asked two (2) personnel to enter the
tank to rescue the 4 personnel by using rope (safety line).
• Three (3) of the rescued personnel found unconscious
and one (1) semi-conscious. All four (4) personnel
immediately evacuated to VICO Mutiara clinic. After first
aid treatment the semi-unconscious personnel was
evacuated to nearby Handil hospital for further treatment.
The three (3) unconscious personnel declared passed
away by local medical doctor.
VICO Indonesia
Preliminary Accident Analysis
• What went wrong:
– Did not follow procedures:
• Did not conduct multi-gas test (LEL, O2, CO2 & H2S) before entering
Confined Space.
• Did not wear proper PPE for task. (Appropriate Masks for acceptable
range limits, and Breathing Apparatus for over range limits).
• Poor and unthoughtful rescue attempts.
• What went well:
– Immediate handling of IPs
– Incident site was properly secured with police line for further police
investigation.
– All Rigless Coil Tubing activities shut down for further assessment
regarding confined space activities.
– All Rig activities involving confined space were postponed for further
review.

VICO Indonesia
IMMEDIATE ATTENTION

• Identify Confined Space and their Risks in your working

area.
• Follow Safety Guideline No.3 – Confined Space Entry.
• Always follow procedures before performing your tasks.
Ensure Confined Space Work Permit has been
prepared, and the requirements have been fulfilled
(Gas Test, Ventilation, Buddy System, Equipment &
PPE, etc).
• Always implement 3 Safety Golden Rules:
– Think first.
– Stop immediately
– Report immediately

VICO Indonesia
VICO Indonesia