WORKER FALLS DOWN A FLIGHT OF STAIRS Date of Incident: August 17, 2007 Type of Incident: Fatality, Worker passed away September 7, 2007
TABLE OF CONTENTS SECTION TITLE PAGE NUMBER 1.0 DATE AND TIME OF INCIDENT 3 2.0 NAME& ADDRESS OF PRINCIPAL PARTIES 3 2.1 Owner 3 2.2 Employer(s) 3 2.3 Worker 3 3.0 DESCRIPTION OF PRINCIPAL PARTIES 4 3.1 Employers 4 3.2 Worker 4 4.0 LOCATION OF INCIDENT 4 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 4 5.1 Equipment and Material 4 5.2 Observations 5 6.0 NARRATIVE DESCRIPTION OF INCIDENT 5 7.0 ANALYSIS 6 8.0 FOLLOW-UP/ ACTION TAKEN 6 8.1 Workplace Health and Safety Compliance 6 8.2 Industry 6 8.3 Additional Measures 6 9.0 SIGNATURES 7 10.0 ATTACHMENTS 7 2 October 30, 2008
SECTION 1.0 DATE AND TIME OF INCIDENT 1.1 The incident occurred on August 17, 2007 at approximately 8:30 a.m. SECTION 2.0 NAME AND ADDRESS OF PRINCIPAL PARTIES 2.1 Owner(s) 2.1.1 Canadian Natural Resources Limited 2500-855-2 Street SW Calgary, AB T2P 4J8 2.2 Prime Contractor 2.2.1 Canadian Natural Resources Limited 11302 98 Avenue Grande Prairie, AB T8V 8H4 2.3 Employer(s) 2.3.1 Global Analyzer Services Limited 40, 305-4625 Varsity Dr. NW Calgary, AB T3A 0Z9 2.4 Contractor(s) 2.4.1 Global Analyzer Services Limited 40, 305-4625 Varsity Dr. NW Calgary, AB T3A 0Z9 2.5 Supplier(s) 2.5.1 N/A 2.6 Worker(s) 2.6.1 Owner 2.7 Others 2.7.1 N/A 3 October 30, 2008
SECTION 3.0 DESCRIPTIONS OF PRINCIPAL PARTIES 3.1 Canadian Natural Resources Limited (CNRL) is a senior independent oil and natural gas exploration, development and production company based in Calgary, Alberta. Their operations are focused in Western Canada, the North Sea and Offshore West Africa. 3.2 The CNRL Progress Plant located at LSD 1-1-78-10 W6 is a sour natural gas production facility. The plant produces of liquefied petroleum gas and as a result of the process is able to recover elemental sulphur. CNRL hired Global Analyzer Services Limited (GASL) to conduct servicing of continuous emissions monitoring systems (CEMS), at the work site. 3.3 Global Analyzer Services Limited (GASL) is a Calgary based organization founded in 1996 by Technician. GASL is a provider of state of the art, multi-component Continuous Emissions Monitoring Systems (CEMS), Data Acquisition Systems, Quality Assurance Plans and a wide range of regulatory compliance support and documentation. SECTION 4.0 LOCATION OF INCIDENT 4.1 The incident occurred at the CNRL Progress Plant located at LSD 1-1-78-10 W6, 25 km southwest of Gordondale, AB. SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 5.1 Stairs 5.1.1 The stairs were constructed with a rise of 3.90 m and a run of 4.03 m. The staircase had a measured length of approximately 5.18 m. The angle of the staircase was approximately 42 degrees. A hand rail that extended the full length of the staircase measured 960 mm in height with a midrail that measured approximately 450 mm in height. The treads were constructed of painted steel open grate with open risers. The individual treads measured 730 mm long and 220 mm wide. ( Photograph #5, 6). 5.2 BW Technologies Gas Alert Micro (belonging to the worker) 5.2.1 Serial # - S104 29034 Model Gamic - 34 ( Photograph #10) 5.3 Observations 5.3.1 There was no eyewitness to this incident. The general area did have electronic surveillance; however the cameras did not cover the immediate area of the incinerator stack. 4 October 30, 2008
5.3.2 The weather conditions in the area were humid with no report of rain showers that morning. It had rained later the evening of August 17, 2007; post incident. The morning of August 18, 2007 was also humid. However, it did not rain during the worksite investigation. 5.3.2 The design of the treads did not allow for water to accumulate. There was no indication to investigators that the stairs were slippery on the day of the investigation from water or any other substance. 5.3.3 On the day of the investigation the weather was overcast with a temperature of 10 0 Celsius. SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT 6.1 The Technician arrived at the gas plant on August 17, 2007, at approximately 8:00 a.m. He met with Operator #1 and Operator #2 to report on the progress of the repair work. The Technician was preparing to clean up after completing a week long repair of the incinerator stack. (, Photograph #1, 2, 4). 6.2 The Technician worked primarily from the CNRL plant control room. He would travel on foot from the plant control room to the incinerator s CEMS shack during the day a distance of approximately 115 m. This travel to and from the incinerator would occur approximately every hour for ten to twenty minute intervals; returning to the plant control room each time. (Attachment B, Diagram). 6.3 At sometime shortly after 8:00 a.m. the Technician drove his truck into the plant area, parking in the area of the incinerator to load various pieces of his monitoring equipment into the truck. He ascended the two flights of stairs leading to the CEMS shack. (, Photograph #3, 5, 6). 6.4 The Technician was traveling down the staircase when the incident occurred causing him to fall to the bottom of the staircase. 6.5 At approximately 8:30 a.m., the Technician walked back to the plant control room and was seen by Operator 2. When the Technician reached the control room he informed Operator #2 that he had fallen down the stairs. (Attachment B, Diagram). 6.6 Operator 1, the Electrician and the Service Contractor were reported as attending the scene in the control room at this time to provide first aid to the Technician. 5 October 30, 2008
6.7 Operator #1 called 911 at approximately 8:31 a.m. and stated to the 911 operator that the Technician had suffered serious lacerations to his neck and head and was bleeding profusely as a result of a fall down the stairs. An ambulance was dispatched to the worksite. 6.8 The ambulance was dispatched from Central Peace Spirit River. CNRL workers moved the Technician to the emergency conveyance vehicle available at the CNRL plant site to meet the ambulance. 6.9 The Technician was transported to Spirit River, transferred to hospital in Grande Prairie and then airlifted to an Edmonton hospital for treatment. 6.10 The Technician has succumbed to his injuries 21 days later on September 7, 2007. SECTION 7.0 ANALYSIS 7.1. Direct Cause 7.1.1 The Technician was fatally injured as a result of a fall down stairs causing blunt force trauma to the head and a laceration to the neck. 7.2 Contributing Factors 7.2.1 A review of the Progress gas plant Continuous Emissions Monitoring Systems (CEMS) report for SO 2 emissions was user disabled (UD) between the hours of 8:00 and 9:00 a.m. However, the data before 8:00 a.m. and after 9:00 a.m. appeared to be normal. There was no record of H 2 S in the work area at the time of the incident. 7.2.2 There was no indication of any slipping or tripping hazards in the Technician s work area. (Attachment A, Photograph #7, 8) 7.2.3 Photographs reviewed regarding the condition of the footwear indicated that the work boots appeared in almost new condition and free from patent defects or excessive wear and would be considered adequate for the location he was working in. (Attachment A, Photograph #9) 7.2.4 The personal gas monitor inspected at the time of the investigation was checked for downloadable information. However, there was no capability to download any readings on this particular model. (Attachment A, Photograph #10) 7.2.5 The Technician was not known to have any medical conditions that would make him prone to sudden unconsciousness. 6 October 30, 2008
SECTION 8.0 FOLLOW-UP/ ACTION TAKEN 8.1 Employment, Immigration and Industry; Workplace Health and Safety Compliance 8.1.2 Workplace Health and Safety Compliance ordered Canadian Natural Resources Limited to conduct an investigation into this incident. 8.2 Industry 8.2.1 Canadian Natural Resources Limited complied with the orders issued to them. 8.3 Additional Measures 8.3.1 Not applicable at this time. SECTION 9.0 SIGNATURES Original Report Signed Lead Investigator Original Report Signed Investigator Original Report Signed Manager Original Report Signed Regional Senior Manager, North Date Date Date SECTION 10.0 Attachment A Attachment B ATTACHMENTS: Map Diagram Photographs 7 October 30, 2008
Attachment A Map Page 8 of 2 Shearer Dale Doe River Valley View Farmington Rolla Bonanza Blueberry Mountain Groundbirch Progress Willowbrook Arras Bay Tree Briar Ridge South Dawson Pouce Coupe Gordondale Spirit River Rycroft Prestville Silverwood Fellers Heights Upper Cutbank Tomslake Tupper Woking Demmitt Valhalla Centre La Glace Webster Lymburn Hth Hythe Sexsmith 8 October 30, 2008
Attachment A Map Page 2 of 2 24 19 20 21 22 23 24 19 20 21 22 23 24 19 20 21 22 23 24 13 079-12W6 18 17 16 15 079-11W6 14 13 18 17 16 15 079-10W6 14 13 18 17 16 15 079-09W6 14 13 079-08W 12 07 08 09 10 11 12 Gordondale 07 08 09 10 11 12 07 08 09 10 11 12 01 06 05 04 03 02 01 06 05 04 03 02 01 06 05 04 03 02 01 35 36 31 32 33 34 35 36 31 32 33 34 35 36 31 32 33 34 35 36 26 25 30 29 28 27 26 25 30 29 28 27 26 25 30 29 28 27 26 25 23 24 19 20 21 22 23 24 19 20 21 22 23 24 19 20 21 22 23 24 078-12W6 078-11W6 078-10W6 078-09W6 14 13 18 17 16 15 14 13 18 17 16 15 14 13 18 17 16 15 14 13 11 12 07 08 09 10 11 12 07 08 09 10 11 12 07 08 09 10 11 12 02 01 06 05 04 03 02 01 06 05 04 03 02 01 06 05 04 03 02 01 077-12W6 077-11W6 077-10W6 077-09W6 9 October 30, 2008
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Page 1 of 10 Photograph #1 Shows the Land Survey Description (LSD) of the Canadian Natural Progress Gas Plant, approximately 55 km southwest of Gordondale, AB 11 October 30, 2008
Page 2 of 10 Welding and machine shop Incinerator Stack Office, Shop, Warehouse and control room. EAST Photograph #2 Shows the Office and Welding/Machine Shop location looking east. This is the main entrance leading into the plant. 12 October 30, 2008
Page 3 of 10 Incinerator Stack Entrance to area of the incinerator Photograph #3 Shows the approach to the incinerator stack, where the incident occurred. 13 October 30, 2008
Page 4 of 10 Photograph #4 Shows the incinerator stack looking southeast. 14 October 30, 2008
Page 5 of 10 The CEMS shack at the top of the second flight of stairs The incident occurred on the first flight of stairs. Photograph #5 Shows the lower and upper flight of stairs looking northwest. The incident occurred on the lower flight of stairs. The technician was reported as traveling down the staircase at the time of the incident (yellow arrow). A truck was parked approximately in the area along side of the stairs (orange arrow). The repair/calibration work had taken place in the incinerator s CEMS shack. To access the CEMS shack located on the incinerator stack the Technician ascended two flights of stairs (a lower and upper). Both the lower and upper flights of stairs were made of steel that was painted. 15 October 30, 2008
Page 6 of 10 Photograph #6 The yellow arrow identifies the rise of the staircase at approximately 3.9 m. The red arrow identifies the run of the staircase at approximately 4.03 m. The green arrow illustrates the length of the first flight of stairs at approximately 5.18 m. The approximate angle of the staircase was measured at 42 degrees. The orange arrow identifies the handrail height approximately 0.96 m. The blue arrow shows the mid rail height which measured approximately 0.45 m. 16 October 30, 2008
Page 7 of 10 Photograph #7 Shows the top of the first flight of stairs on the top of the intermediate platform. The platform s surface was level with no elevation changes. 17 October 30, 2008
Page 8 of 10 Photograph #8 Shows where the top step and the platform come together and meet. 18 October 30, 2008
Page 9 of 10 Photograph #9 Shows the BW Technologies Gas Alert Micro belonging to the Technician. 19 October 30, 2008
Page 10 of 10 Photograph #10 Shows the boots worn by the Technician on the day of the incident. 20 October 30, 2008