Alert 04 – 19 Inadequate Management of Change Results in a Fatality

Alert 04 – 19 Inadequate Management of Change Results in a Fatality


An incident occurred when a 45-foot joint of 5-inch XL liner was being hoisted into the V-Door. The rig personnel were using a set of single joint elevators and the rig floor air hoist. The joint of liner came free from the latched elevators allowing it to slide down the V-Door towards the catwalk. The joint of casing then bounced and given the high center of gravity the box end “rocked” towards the rig floor where it struck the derrickman on the side of the head, resulting in a fatal blow.

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