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| Record Number: |
2125 |
| CIS Descriptors: |
PETROLEUM AND NATURAL GAS
INDUSTRY
HYDROGEN SULFIDE
ACUTE POISONING
MANAGEMENT
FAILURE
FAULTY
SUPERVISION
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REPORT
CHARACTERISTICS:
DONOR: Office of the Chief
Coroner
JURISDICTION: British Columbia
REPORT TITLE:
Judgement of Inquiry
INDIVIDUAL PRESIDING: Dr. Albert D. Bibby,
Coroner
PLACE OF INQUIRY: Dawson Creek
DATE OF INQUIRY :
1988-11-21
INFORMATION ABOUT DECEASED:
NAME:
Confidential
OCCUPATION: Oil Well Servicing
INDUSTRIAL
SECTOR: Oil and Gas
ACCIDENT INFORMATION:
DATE OF
ACCIDENT : 1988-08-22
PLACE OF ACCIDENT: Land Location:
14-22-78-13-W6, near Bay Tree,
Alberta. Gas well site.
BRIEF
CAUSE OF DEATH: Hydrogen sulphide poisoning.
BRIEF MANNER OF
DEATH: Accidental hydrogen sulphide poisoning.
ACCIDENT
DESCRIPTION:
The deceased was an employee of an oil well
servicing company of Red
Deer, Alberta.
At the time of
his death, the deceased and his partner were involved
in
obtaining flow pressure rates on a new oil well located
at
14-22-78-13-W6th, which is about 1/2 km east of the
B.C./Alta. border
and due east of Dawson Creek, B.C.
The
deceased was last seen alive by his supervisor, an
oilfield
consultant, at approximately 0045 hours on 22 August
1988. At this
time, his supervisor left the well site to return
to Dawson Creek. A
tank truck was also on the site removing
fluid from the holding tank
and left the site around 0100
hours.
The deceased and the partner were to obtain readings
on the well flow
every 1/2 hour. Charts located at the scene
indicate the last entry
was made at 0200 hours.
At 0725
hours on 22 August 1988, the Tool Push, along with the
Driller
and Floorhand arrived at the site and found the
deceased and the
partner lying on the ground approximately 8
meters south of the rig
tank. The Tool Push send the Floorhand
in to shut the well and ordered
the Driller to get the
resuscitator. The Tool Push called Dawson Creek
Ambulance via
radio/telephone and then checked both bodies for vital
signs.
The Tool Push could not detect a pulse on the deceased
and
presumed him dead, but did find a pulse on the partner who
was loaded
into the back of a 1/2 ton pick-up truck. The
Driller and the
Floorhand manned the resuscitator while The
Tool Push proceeded towards
Dawson Creek to meet the ambulance.
2.7 km from the well site, The
Tool Push intercepted the
Supervisor who was returning to the well site
and told him one
man appeared dead back at the well and they were
transporting
one to meet the ambulance. The Supervisor was warned
about
possible sour gas at the well.
The Tool Push proceeded on
and met the ambulance approximately 10 km
from the well
location, where the transfer was made. The Tool Push
then
returned to the site to retrieve the deceased. Upon arrival,
the
odour of H2S gas was very strong and Scott air packs were
used to
approach the deceased, who was placed in the back of
the pick-up truck
and removed to a safe distance from the site.
At this time, the second
ambulance arrived and transported the
deceased to Dawson Creek
Hospital. C.P.R. was administered
enroute, but the deceased was
pronounced dead on arrival by the
doctor at 0756 hours, 22 August,
1988.
The deceased was
transferred to Vancouver, B.C., where an autopsy was
conducted
by the pathologist. He concluded that death was the result
of
hydrogen sulphide poisoning.
Information received from
Occupational Health and Safety, Grande
Prairie, Alberta, 6
February 1989, offers the following Prosecution
Recommendations
and Summary:
A prosecution recommendation will be commenced
against the responsible
company for failing to comply with
Section 2(5) of the Occupational
Health and Safety Act and
Alberta Regulation 448/83 Section 15.
The reason for the
prosecution recommendation against the company under
Section
2(5) of the Act, is that first they made no attempt
to
determine what any of the companies were doing on site
regarding
compliance of the regulations addressing work in
potentially toxic
atmospheres, even though they knew through
reports from the drilling
consultant that the well was
sour.
The responsible company was in contravention of
448/83 Section 15 in
that they were aware that the well was
sour, yet made no attempt to
bring this fact to the attention
of anyone, including their
consultant.
A prosecution
recommendation will be commenced against the
resource
consultants for failing to comply with Alberta
Regulation 448/83
Section 15. The reason for the prosecution is
that the consultants
knew the well had the potential of being
sour from past experience and
a review of the drilling program.
They were also aware of the drill
stem test results which
showed low levels of H2S in the well.
A prosecution
recommendation will be commenced against the
supervision
company for failing to comply with Alberta
Regulation 448/83 Section
15. The reason for the prosecution is
that the supervision company was
in charge of the site at the
time of the accident and was told by an
oil company, that there
was H2S in the well, yet did nothing to test
the location or
notify workers on site.
Summary
A service rig
company had been hired by an oil company to "complete" a
well.
The service company believed the well to be "sweet". Prior
to
the accident, the producing formation had been acidized and
two members
of the crew had been requested to stay overnight
and flow the well.
At approximately 01:00 after all the
acid flush water had been returned
to surface, oil began to
flow. At 02:30, after gauging the rig tank,
one worker was
overcome with H2S. The second worker who was sleeping
at the
time of the first knockdown, awoke at 03:30 and found the
first
worker down. While attempting to rescue the first worker,
the second
worker was knocked down. Both workers were found on
the ground the
next morning, one had expired, the other was
unconscious, but alive and
has since recovered.
The
investigation was conducted by Occupational Health and
Safety
Officers from Grande Prairie, E.R.C.B. Inspectors from
Grande Prairie
and a member of the Spirit River R.C.M.P.
Detachment. A site visit was
made for photographs, measurements
and the taking of statements. Tests
were conducted on site by
Occupational Health and Safety, E.R.C.B. and
a private lab to
determine the H2 content of the well.
The conclusion
reached by the Occupational Health and Safety
Investigator was
that because this well was a "tight hole" and because
the
amounts of H2S anticipated were minimal (less the 1%) according
to
industry standards, the service rig crew was not told the
well was
sour. Since the crew was unaware the well was sour,
they took no
precaution to protect themselves during the well
gauging operation.
All companies directly involved with
this accident, have reviewed and
revised their procedures to
address the problems associated with
information dissemination
and work on wells with low concentration of
H2S.
The
deceased came into contact with poisonous gas from an oil
well
which he was flow testing. Death was the result of
hydrogen sulphide
poisoning.
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Health & Safety 