Inspector fatally pinned by falling steel plates aboard drillship West Neptune

Probable / root cause

Allrig personnel failed to recognize a pinch point and securely block / stabilize the weight of the plates prior to releasing the tie down, as recommended by the ratchet strap manufacturer; the Allrig assistant was not authorized to work without a mentor; and personnel went outside the intended job scope (BSEE probable causes).

Contributing factors

• Seadrill personnel failed to orientate the plates so the cable slings could be removed after placement against the stanchion.
• Seadrill stored the plates in a position that reduced their stability when the ratchet strap was removed.
• Seadrill directives do not clearly address storage of heavy materials.
• The service provider competency checklist was not completed.
• The loose lifting gear inspection was considered low risk by many personnel.

Recommendations

• Operators should ensure all hazards are identified and communicated to personnel in a timely and meaningful way.
• Operators and contractors should abide by their respective SEMS bridging documents.
• Supervisory personnel should take an active role in supervision, task planning, hazard analysis, and ensuring the job scope is followed, especially for short-term contractors.
• Supervisory roles over contract personnel should be clearly defined, with enforced policies for reassigning them.