WORKER CRUSHED BY OILWELL PUMPJACK’S ROTATING COUNTERWEIGHT Type of Incident: Fatality Date of Incident: May 14, 2009

File: F-493566

2 November 16, 2009

Alberta Employment and Immigration, Occupational Health and Safety

TABLE OF CONTENTS

SECTION TITLE PAGE NUMBER

1.0 DATE AND TIME OF INCIDENT 3 2.0 NAMES & ADDRESSES OF PRINCIPAL PARTIES 3 2.1 Owner 3 2.2 Prime Contractor 3 2.3 Contractor 2.4 Employer 3 2.5 Worker 3 3.0 DESCRIPTIONS OF PRINCIPAL PARTIES 4 3.1 Employer 4 3.2 Prime Contractor 4 3.3 Contractors 4 3.4 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 6 7.0 ANALYSIS 7 7.1 Direct Cause 7 7.2 Contributing Factors 7 8.0 FOLLOW-UP/ ACTION TAKEN 8 8.1 Occupational Health and Safety 8 8.2 Industry 19 8.3 Additional Measures 10 9.0 SIGNATURES 11 10.0 ATTACHMENTS 11

File: F-493566

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Alberta Employment and Immigration, Occupational Health and Safety

5.1.1 Oilwell Pumpjack 5.1.1.1 Manufacturer (Texas, USA) Lufkin Foundry and Machine Co. Structure Size T5A Safe Load Capacity 10,000 lbs. Maximum Polish Rod Stroke 42 inches Maximum Counterbalance at Maximum Stroke 4930 lbs. Lufkin Designation No. T5A 8DA Serial No. 348 Lufkin Weights, Made in Canada 5C, B5116

(Attachment C, Photograph 2). 5.2 Observations 5.2.1 The weather was partly cloudy on the day of the incident with approximately a 4 kph

breeze from the north. The temperature was 2 degrees C at the nearest weather station (Edson) to the site of the incident. The lack of wind would have had an effect on the dispersal of methane gas being vented at the oilwell during the time of the incident.

5.2.2 Pumpjacks are the above-ground drives for a reciprocating piston pump installed in

an oilwell. Pumpjacks are used to lift liquid out of the well if there is not enough bottom-hole pressure for liquid to flow all the way to the surface. The arrangement is commonly used for land-based oilwells producing relatively little oil. The pumpjack at the site of the incident was driven by an electric motor. (Attachment B, Pumpjack Diagram)

5.2.3 Methane is a highly flammable gas that is an asphyxiant and may also have a mild

narcotic effect according to a Material Safety Data Sheet from a prominent energy company. Methane gas from underground reservoirs also contains small amounts of ethane, propane and hydrogen sulphide along with numerous other hydrocarbon derivatives. When raw methane is handled, inhalation is the primary route of exposure. When raw methane is handled all ignition sources should be eliminated, and transfer containers should be bonded and grounded to avoid static accumulation.

5.2.4` Prior to the incident supplementary information was discussed and left at the worksite by an Occupational Health and Safety Officer after a number of inspections. Specific reference was made to the Occupational Health and Safety Code Definition Part 1 Safeguard, and the Explanation Guide, Part 22, Safeguards, Wire Mesh.

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Alberta Employment and Immigration, Occupational Health and Safety

SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT 6.1 On May 13, 2009 it was noted by the Bonterra Energy Corp’s operator for the site of

the incident, that the oilwell had ceased flowing oil, even though the pumpjack was operating. A decision was made by the Field Superintendent to have the casing and the tubing in the oilwell, pressure tested to ensure there was no corrosion leakage. The oilwell casing and the tubing carrying the oil was pressure tested by Pressure Truck Operator and the oilwell casing and tubing were found to be in satisfactory condition. The Pressure Truck Operator

vented methane gas pressure from the oilwell tubing. The pumpjack was activated and the oil started to flow again.

6.2 On May 14, 2009 it was noted by the Bonterra Energy Corp’s operator for the site of

the incident, that the oilwell had again ceased flowing oil even though the pumpjack was operating. A decision was made by the Field Superintendent to have two maintenance technicians attend to the site with him to troubleshoot the problem and re-establish the flow of oil from the well.

6.3 On May 14, 2009 during the mid-morning the Field Superintendent ,

Maintenance Technician 1 , and Maintenance Technician 2, met at the site to try to solve the problem and re-establish the flow

of oil from the oilwell. The Field Superintendent and the Maintenance Technician 1 proceeded to relieve methane gas pressure from the tubing in the oilwell. Methane gas pressure had built up overnight to 60 psi as noted by the Maintenance Technician 2 . They directed the flow of methane gas into a plastic pail that had been used for collecting debris around the site. (Attachment C, Photograph 3) The unexpected high rate of methane gas flow scattered the debris in the pail around the well site. The methane gas was released until liquid started to come out, and then the flow valve was closed off.

6.4 During this time the Pressure Truck Operator arrived and was standing

at the entrance to the enclosure. He had returned to the site to retrieve a pipe wrench that he had left the previous day.

6.5 On May 14, 2009 at approximately 11:15 a.m. Maintenance Technician 1

proceeded to the east side of the pumpjack to pick up pieces of debris that had been spread around the site by the process of relieving methane gas pressure from the oilwell. The Maintenance Technician 2 heard a yelp from Maintenance Technician 1 when he was hit by the point of the rotating

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Alberta Employment and Immigration, Occupational Health and Safety

7.2.4 Bonterra Energy Corp. had received orders from an Occupational Health and Safety Inspection Officer on 13 similar worksites where hazard assessment, fire and explosion considerations, and safeguarding were all required. These orders were made to the Operations Manager and two Field Superintendents

, and in the month of August 2007. Safeguarding of moving equipment at other pumpjack sites was progressing. (Attachment C, Photographs 6, 7) The site of this incident had not received guarding for moving equipment.

7.2.5 At the time of the incident investigation, Bonterra Energy Corp. did not have a formal

system or process in place to ensure the health and safety of the workers and contractors at the worksites of this field operation.

7.2.6 Bonterra Energy Corp. did not have contractual agreements with supervisory

personnel nor with contractors outlining the company’s expectations pertaining to management’s and contractor’s responsibilities for ensuring worker and contractor safety.

SECTION 8.0 FOLLOW-UP/ ACTION TAKEN 8.1 Employment and Immigration; Occupational Health and Safety (OHS) 8.1.2 Occupational Health and Safety Investigators attended the Bonterra Energy Corp.

Field Office in Drayton Valley and also traveled to the site of the incident on May 14, 2009 to investigate the incident.

8.1.3 Other Bonterra Energy Corp. sites were visited to determine how guarding of the

pumpjack rotating equipment was accomplished. (Attachment C, Photographs 6, 7) Six additional pumpjack sites belonging to other oil and gas companies in the general area of the incident were visited to determine if and how guarding of the pumpjack rotational equipment was being implemented. The majority visited were found to have guarding of the pumpjack rotational counterweights.

8.1.4 The following orders were written to the management of Bonterra Energy Corp.:

- Stop Use Order and tag were affixed on the pumpjack involved in the incident until moving equipment was guarded and until procedures were developed that would prevent a fire or explosion with the handling of methane gas. (Attachment C, Photograph 8)

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Alberta Employment and Immigration, Occupational Health and Safety

- Requirement to supply written confirmation of how the company will ensure hazard assessments are conducted at their worksites.

- Requirement to develop a safe method of performing maintenance on moving machinery in compliance with the Occupational Health and Safety Code (OHS) under ‘managing the control of hazardous energy’.

- Requirement to ensure that work practices at similar worksites were established to include protective procedures and precautions against fire and explosion hazards.

- Requirement to ensure that worker exposure to a harmful substance listed in the Chemical Hazards section of the OHS Code (methane) was established and maintained.

- Requirement to assess the overhead danger hazards at an operating pumpjack location and determine if head protection should be mandatory for workers performing tasks around moving equipment.

- Bonterra Energy Corp., as an employer and contractor managing employees, employers, and other contractors, was required to ensure as far as reasonably practicable, that the Occupational Health and Safety Act, Regulation and Code were complied with on their worksites.

- Bonterra Energy Corp. was required to investigate the circumstances of the incident and produce a report outlining the corrective measures that would be implemented to prevent a similar incident from occurring again.

- Bonterra Energy Corp. was required to ensure that all their employees and contractors were aware of the hazards and corrective measures associated with this incident. Bonterra Energy Corp. was encouraged to share this information through an industry alert with their respective industry association for similar incident prevention among their peer group.

8.1.5 The following orders were written to the owner of Horseshoe Creek Contracting Ltd.

:

- To reply in writing as to how this company, acting as an employer with Bonterra Energy Corp. will ensure the health and safety of their workers and those other workers present at the worksite.

- To reply in writing as to how this company, acting in an operations management

capacity for Bonterra Energy Corp., and as a contractor directing the activities of other contractors, will ensure that all employers/contractors under the management of the business comply with the Occupational Health and Safety Act, Regulations, and Code.

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8.2 Industry 8.2.1 Bonterra Energy Corp. staff secured the scene of the incident, and reported the

incident to the Occupational Health and Safety Call Center in a timely manner. 8.2.2 Bonterra Energy Corp. staff cooperated fully with the Occupational Health and Safety

Investigators and complied with all the orders that were given. The pumpjack where the incident occurred had guarding added to protect workers from the rotational counterweight. (Attachment C, Photograph 8)

8.2.3 Bonterra Energy Corp. prepared an internal safety alert bulletin relating to the

incident and the corrective measures. The company indicated that this bulletin was shared with all staff and contractors on June 12, 2009.

8.3 Additional Measures 8.3.1 An Industry Alert Bulletin relating to the findings of this incident has been prepared

by the Occupational Health and Safety Investigator and added to the catalogue of bulletins in the Occupational Health and Safety Website. The Industry Alert Bulletin has been shared with ENFORM (the oil and gas industry training organization) and the Canadian Association of Petroleum Producers and the Small Explorers and Producers Association of Canada.

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SECTION 9.0 SIGNATURES ____________________________ _____________________ Lead Investigator Date ____________________________ _____________________ Investigator Date ____________________________ _____________________ Manager Date ____________________________ _____________________ Regional Director Date SECTION 10.0 ATTACHMENTS: Attachment A Map Attachment B Diagram Attachment C Photographs

File: F-493566 Attachment “C”

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Alberta Employment and Immigration, Occupational Health and Safety

Photograph #1 Shows the lease road leading into the site of the incident looking south. The pumpjack where the incident occurred is at the end of the road.

File: F-493566 Attachment “C”

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Alberta Employment and Immigration, Occupational Health and Safety

Photograph #2 Shows the side view of the pumpjack looking east. The pumpjack had been stopped at the time of the incident. The rotating counterweights are in the ‘up’ position. (See Attachment B, ‘Pumpjack Diagram’, for an explanation of all the components of a pumpjack)

File: F-493566 Attachment “C”

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Alberta Employment and Immigration, Occupational Health and Safety

Photograph #3 Shows a re-enactment of how the field supervisor and the Maintenance Technician 1 (who became fatally injured) were using a plastic pail to relieve the methane pressure from the oil well and catch any fluids that might drain out. This is the actual bucket that was used and the debris in the bucket was scattered around the pumpjack enclosure due to the unexpected high rate of flow of the methane.

Plastic pail with debris inside The vent line from the

wellhead that was blowing methane into the plastic pail

File: F-493566 Attachment “C”

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Alberta Employment and Immigration, Occupational Health and Safety

Photograph #4 Shows how the Maintenance Technician 1 was hit by the rotating counterweight and came to rest in this location.

Pumpjack counterweight rotating downward in a clockwise direction

File: F-493566 Attachment “C”

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Alberta Employment and Immigration, Occupational Health and Safety

Photograph #5 Shows the pumpjack counterweight in the ‘down’ position with a depiction of how the Maintenance Technician 1 was caught underneath.

Pumpjack Counterweight

File: F-493566 Attachment “C”

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Alberta Employment and Immigration, Occupational Health and Safety

Photograph #6 Shows how another Bonterra Energy Corp. owned pumpjack, in the area of the incident, had guarding built around the rotating counterweights.

File: F-493566 Attachment “C”

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Photograph # 7 Shows how another Bonterra Energy Corp. owned pumpjack, in the area of the incident, had guarding build around the rotating counterweights.

This is an additional guard around the rotating counterweights inside the fenced enclosure to protect workers having to enter the enclosure.

File: F-493566 Attachment “C”

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Alberta Employment and Immigration, Occupational Health and Safety

Photograph #8 Shows how new guarding around the rotating counterweights has been installed around the pumpjack at the site of the incident.

This is the counterweight that struck the Maintenance Technician 1. It is now protected by a new fence guard.