Date of incident: June 2020
Notice of incident number: 2020170090011
Employers: Oil and gas field servicing company; oil and gas production company

Incident summary
In a laydown (storage) yard at an oil and gas site, two workers were removing a bolt from a decommissioned two-piece pumpjack component to retrieve a nut. Both pieces of the pumpjack component collapsed and one piece fell onto one of the workers while the other piece fell away from the workers. The worker who was struck sustained fatal injuries.

Investigation conclusions

Cause

• Failure to control potential energy sources. While the two workers were removing parts from the pumpjack’s horsehead, the horsehead and the walking beam it was attached to collapsed because gravitational energy sources that could affect the horsehead had not been controlled.

Contributing factors

• Failure to identify and convey hazards. The safety management system of the prime contractor (the oil and gas production company) had policies and procedures detailing requirements for identifying hazards, communicating them to workers, and eliminating or controlling them. The firm failed to ensure that requirements for the control of hazardous energy sources were enforced at the worksite. Prior to the work activity, hazardous conditions were not identified and the risks related to the partially disassembled pumpjack were not assessed. Workers were assigned job duties in close proximity to the pumpjack before effective hazard control measures had been implemented for the task.
• Lack of safe work procedures. Contrary to its safety management system, the prime contractor did not ensure that the workers of its contractor (the oil and gas field servicing company) had safe work procedures (SWPs) to mitigate the risks of removing parts from the horsehead. The contractor firm likewise did not ensure that its workers were trained on or had access to SWPs relevant to performing maintenance work on pumpjack horseheads. The firms also did not provide workers with specific lockout procedures to control hazardous energy sources, such as gravity. For instance, blocking could have been placed under the components to prevent them from collapsing.
• Inadequate facility inspections. Facility inspections at the oil battery and laydown yard were completed roughly every three years. These inspections were not done at intervals sufficient to prevent the development of unsafe conditions. The potential for the partially disassembled pumpjack to fall on a worker was not identified through this inspection process. In fact, neither of the two most recent inspections had noted any safety issues to do with equipment storage in the laydown yard.
• Ineffective supervision. The firms failed to ensure that the specific hazards of the task of removing parts from the horsehead were assessed and that control measures were implemented to address the related risks. They did not ensure that their respective SWPs for lockout were being adhered to — they did not ensure that all potential energy sources were identified and effectively controlled before the work of removing the parts from the horsehead started. They also failed to ensure that the workers wore personal protective equipment at the worksite as required.
• Inadequate oversight and coordination. As owner and prime contractor at the worksite, the oil and gas production company failed to do everything reasonably practicable to maintain a system to ensure compliance with the Workers Compensation Act and the Occupational Health and Safety Regulation. It also failed to ensure that hazards associated with contractors’ activities were assessed and communicated to all workers involved. Further, the firm did not ensure that its contractors were completing tasks according to SWPs. For example, it did not adequately analyze the risks of work activities that posed a significant risk of injury to workers and ensure that SWPs were implemented to mitigate hazards associated with the work activities that it was directing. The firm should have coordinated the work activities in a manner that reduced the risk to workers exposed to unsafe environments. For example, it could have ensured that all energy sources that could affect its equipment were effectively controlled and locked out before allowing contractors to perform work at its site.

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