Pearl GTL Project CEO Summit HSSE

Andy Brown EVP Qatar & Managing Director Pearl GTL Project

June 2010

HSSE Achievements Pearl GTL Project

Currently > 60 Million man hours worked LTI free on the onshore project
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Shell Group record

6 years worked LTI free on the offshore drilling campaign until May 2010 >212 Million Kilometers driven without a serious incident or injury Delivered >318,000 safety related training courses to individuals Winner of Shell Chief Executive HSSE & SP Award 2009
Awarded

to Pearl GTL Workers Welfare Team for improving performance in global HSSE risk areas

Successful Safety Day 2010 with engagement, motivation and focus within all ICs
Month 2010 2

Pearl GTL Project CEO Summit HSSE: 2) A Fatality in Ras Laffan

Ken Marnoch COO QG4/Deputy COO QG3&4

June 2010

Fatal Incident Leadership Learning

Situation The Work Activity

External Dry Out of Refractory - internal heating of vessel to dry/cure refractory cement on inner wall

Horizontal vessel that will contain catalyst No burner fitted in vessel as standard

Refractory dry-out sub-contracted to HTPL

Active >10 years (working mainly inside India)

On QG3&4 since 20 Jan 10 one different activity for QG2 in 09

Completed 31 (of 36) similar dry-outs

Temporary burners fitted into two side-nozzles on vessel

Fueled by vaporised LPG provided remotely from tanker

Hot gases from vessel vented through top nozzles Set-up work performed under Cold Work Permit; Dry-out work performed under Hot Work Permit

Additional supervision of HTPL by

CTJV supervisor; QG Operations; Refractory vendor rep

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Situation Systems and Culture

Recordable Incident Frequency reduction to world class project levels. High risk activities subject to Risk Assessment, Job Safety Analysis and

additional Task Instruction sign off.

Pre Mechanical Completion (PMC) activities controlled using Operational PTW Paperwork permit initiated by contractor and final site verification step by Company Operations and Supervisor of work activity. Supervisor Ratios monitored by area and by discipline strong focus on having supervision on site with their work crews. Clear accountabilities for PMC and PMC areas strictly controlled.

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Work place overview

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Work place overview

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Work place overview

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Explosion

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Explosion

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Explosion

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Explosion

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Explosion

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Explosion

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Explosion

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Explosion

Rajesh Rohit
Indian, unmarried, age 24 operator, 3.5 yrs with HTPL welder by training

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Investigation Findings
Equipment supplied was different to that in Method Statement

absence of pilot burner (as MS) forced ignition with full gas flow

HTPL unaware of the risks of burner ignition

no control on air purge prior to ignition pressure reducing valve used as on-off valve (gas pressure too high) burner valve suspected to be passing (based on testing) delay (due to data logger) between air purge and ignition gas gave opportunity for accumulation of explosive gas mixture in vessel

flame eye disconnected for ignition forced SOV override open

open SOV left only single valve isolation between gas supply and vessel

Position of operator

manual gas valve and air damper operation required operator to work close to temporary burner at ignition
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Investigation Findings
Neither Risk Assessment (RA) or Job Safety Assessment (JSA) recognized the risk of internal explosion in vessel

No discipline engineering review of a vessel converted into a fired furnace, using substandard temporary burner assembly and minimal instrument safeguarding No site check of contractors equipment to see if it matched that described in the Method

Statement supplied for contractor Qualification

Supervisors aware of contractors deviation from agreed work method but did not intervene (deference to specialist contractor) Work method eliminated instrumented safeguards SOV in bypass and flame eye disconnected Cold Work Permit included extensive documentation that could not realistically be reviewed or understood by those doing the work
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Leadership Questions (1)

How do you select contractors/subcontractors and how well do you understand their capabilities? Where do you have specialists that are not

experts?

How well does every individual in your organisation understand their accountabilities?

What assumptions are being made today with respect to the management
of risks on your project? How often are working practices different from the procedure? What percentage of the time do people intervene when they become aware of an issue?

How do you know the answers to the questions above are valid?
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Leadership Questions (2)

What are you promoting and encouraging that makes a

positive difference?

What are you accepting and allowing that has a negative effect? What are you endorsing and driving that does not cause the impact you intend or that has unintended consequences?

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Back Up

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Work place top view

Closed Manholes Upper Manholes Burner # 2 and Temporary platform
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Process inlets used as chimney vents

Victim Burner # 1 and Temporary platform

53-V0942
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1. 2. 3. 4. 5. HTPL Control Panel Operator CTJV Supervisor HTPL Supervisor ESU Operations Supervisor Refractory Supplier Specialist

1 3 5 4

Laptop temporary Shelter Working Crew

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Temporary burner arrangement

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Reports of the technical specialists

Burner design

burner design is unusual but considered fit for purpose

total absence of instrumentation forced operator to control flame manually based only
on what could be seen through the peephole burner safeguarding is inadequate for safe operation and not fit for purpose

Explosion characteristics

explosion initiated near burner 1

flame propagation was sub-sonic deflagration, not detonation

flammable gas just sufficient for internal pressure rise (not external combustion) and estimated as 3 ~ 7 barg (vessel design 4 barg)

flammable gas estimate 10 ~ 20 kg (5 ~10 Nm3) in bottom 2/3 of vessel

burner ejected from manhole towards victim at 220 km/hr (lethal force)
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victim thrown at 50 km/hr

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Pearl GTL Project CEO Summit HSSE: 3) The Reality on PEARL GTL - CSU

Steve Johnson Commissioning and Start Up Manager

June 2010

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HSSE: Incident data

Unauthorised removal of red spades Valve removed from completed Instrument Air line 3 air hose connection snapped off Bolt missing from live line Bolts missing from live RV flange End blind missing from live header Red spade isolation disturbed Waste chemicals drained to AOC Quench water hose sheered off Improper system line up prior to commissioning Knife edge connections opened in live cabinet Loose flange discovered during final pressure test Vessel overflowed when operational valves closed
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HSSE: contributing causes

Poor discipline, compliance or understanding Different attitude Inadequate supervision and surveillance Inadequate planning and preparation Bad communication Unclear responsibility Incompatible goals volume of work and time pressure; tiredness

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HSSE: Help needed

Write to me: what actions have you agreed with your site teams to:

Strengthen their understanding of the HSE Standards and procedures Ensure PD, SM, Com M and Supervisors know which hazardous activities they must personally Supervise Establish routine and risk based Surveillance of commissioning activities Verify that good short term planning and preparation is done to ensure incompatible activities are Segregated and resource requirements Synchronised

How will you know your expectations have been met?

People do what you inspect, not what you expect

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