Norway's oil and gas industry safety watchdog Petroleum Safety Authority Norway (PSA) has concluded its investigation into a January 2023 incident at Equinor's onshore processing plant in Mongstad, where a worker fell from scaffolding from a height of 23.5 meters.
The investigation revealed serious breaches of safety regulations, prompting the PSA to issue an order to Equinor Mongstad.
During the installation of scaffolding at the plant, conducted by contractor Beerenberg Services AS, a Beerenberg employee of Polish origin fell a staggering 23.5 meters (77 feet) to a concrete floor, sustaining serious injuries. Had the circumstances been slightly different, the fall could have proven fatal. The incident happened on January 18, 2023.
The direct cause of the incident was that the hook on the ledger to which the worker had attached his fall-arrest safety harness to came loose from the standard at one end of the scaffolding. He lost his balance on the ledger he was standing on, causing him to fall backwards so that the hook at the other end of the ledger holding his harness bent and detached from the standard.
In addition to the direct causes, the investigation highlighted several underlying factors that contributed to the incident.
"The investigation has found that understanding by those involved of the job’s complexity and the factors which have influenced it led to inadequate planning, organization and execution of the scaffolding activity. This was a contributory cause of the incident, along with the contract format, a high workload, and stress.
Understanding the Norwegian safety regime and making provision for the necessary capacity and expertise are two important elements which are also regarded as contributory causes by this investigation," the PSA said.
The incident happened during the construction of the 30-meter tall scaffolding that was being built as a framework to protect against dropped objects during materials handling.
Shortly after the incident, on January 27, the PSA ordered Beerenberg Services AS (BBS) to cease all installation, disassembly, and alteration of scaffolding at Mongstad. BBS complied with the order and confirmed its implementation on January 30, 2023.
According to the PSA, the investigation exposed several nonconformities by Equinor, including inadequate risk assessment, follow-up of other participants, failure to ensure conformity between emergency plans, and a lack of provisions for rescue at heights in the emergency response plan.
PSA also highlighted Equinor's inadequate staffing in the health and safety service and inadequate emergency drills and training involving the ISS contractor/BBS.
The investigation likewise identified nonconformities on the part of BBS, including shortcomings in risk assessment, organization and execution of maintenance, expertise, communication of information, and preparedness for self-rescue and rescue at heights. BBS was also found to lack systematic emergency drills and training for its personnel and exhibited deficiencies in managing the psychosocial working environment.
Consequently, the PSA has ordered Equinor Mongstad to address the serious breaches of regulations it found during the investigation.
The order requires Equinor to conduct an integrated and systematic overall risk assessment of work at heights, ensuring that risk factors are adequately managed by both Equinor and contractors, "including ensuring that collective safety measures are preferred over measures directed at individuals."
Lessons learned from similar incidents must be applied to reduce risks effectively.
Furthermore, Equinor Mongstad is ordered to conduct an integrated and systematic review of management systems at contractors involved in work at heights, to ensure the necessary competence and compliance with the regulations and Equinor’s internal requirements.
The deadline for compliance with the order is set for October 1, 2023.
The Mongstad terminal receives oil crude oil vie 83-km long pipelines from the offshore installations Troll B and Troll C, and from 2019, crude oil from the Johan Sverdrup field also lands at Mongstad.