Author Archives: Mark Paradies

Rickover Quote…

Posted: August 24th, 2016 in Performance Improvement, Pictures

When you waste your time remember …
Even God cannot undo the past.

Admiral Hyman Rickover 

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What does abad day look like?

Posted: August 24th, 2016 in Pictures

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Bet you will be watching trees for porcupines for a while …

Monday Accident & Lessons Learned: CORROSION COUPON PLUG EJECTED FROM PRESSURIZED PIPELINE

Posted: August 22nd, 2016 in Accidents, Current Events, Investigations, Performance Improvement

The following is a IOPG Safety Alert from the International Association of Oil & Gas Producers…

IOGP SAFETY ALERT

CORROSION COUPON PLUG EJECTED FROM PRESSURISED PIPELINE

Target audience:

Personnel accountable or responsible for pipelines and piping fitted with corrosion coupons.

What happened:

A routine corrosion coupon retrieval operation was being conducted on a 28” crude oil pipeline. Two retrieval technicians were located in a below ground access pit, to perform the operation. The operation involved removal of the corrosion coupon carrier ‘plug’ from its threaded 2” access fitting on the pipeline. The plug was ejected at high velocity from the access fitting (pipeline pressure 103 bar), during the operation to ease the plug using a ring spanner to a maximum of ¼ turn (as per procedure) and before the service valve and retrieval tool were installed. A high volume of crude oil spilled from the pipeline via the access fitting. Fortunately, the two technicians escaped the access pit without injury from the plug projectile or crude oil release.

What Went Wrong?

The Venture is still in the process of conducting the incident investigation. Based on their findings to date, the most probable cause is that the threads of the access fitting were worn down to such an extent, that they were unable to restrain the plug upon minor disturbance (the ¼ turn of the plug).

  • The access fitting was installed during pipeline construction in 1987. It is estimated to have been subject to over 140 coupon retrieval and installation cycles.
  • Bottom-of-pipeline debris can cause galling of threads on stainless steel plugs, which in turn can damage the threads of carbon steel access fittings.
  • The repair (chasing) of worn threads on access fittings is performed using an original equipment manufacturer supplied thread tap assembly service tool.
  • In the presence of bottom-of-pipeline debris and thread damage, the repetitive removal of internal thread material, can lead to ever smaller contact surfaces, increasing contact stress, increasing wear rates and/or galling.
  • Smaller thread contact surfaces reduce the ability of the access fittings to restrain plugs.
  • In this incident, the original equipment manufacturer supplied thread tap assembly service tool had been used routinely for every plug coupon retrieval and installation cycle without the use of flushing oil to remove debris from the threads.

Corrective Actions and Recommendations:

Lessons Learned –

  • As yet, there is no standard method to determine internal thread condition of on-line corrosion probe/coupon original equipment manufacturer access fittings. Thread condition is not easily inspected.
  • The risk posed by long term use of thread tap assembly service tools on access fittings, has not been previously identified.

Action taken in originating company –

Temporarily suspend all corrosion coupon retrieval operations on pressurised lines furnished with threaded access fittings in the 6 o’clock position (bottom of pipeline). This provides time to complete the investigation and complete work with the original equipment manufacturer to develop clear guidance on the maximum number of retrieval cycles.

  • A subsequent notification will be issued based on the completed investigation and original equipment manufacturer tests*. In this alert any changes to guidance or maintenance routines (i.e. how and when these type operations can be recommenced) will be advised.
  • The temporary suspension does not cover retrieval operations on lines which are depressurised.

* the use of ‘no go’ gauges for checking access fittings after every use of a thread tap assembly service tool or access fitting body seat reamer, is being explored.

Disclaimer

Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the IOGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.

Safety Alert Number: 273 

IOGP Safety Alerts http://safetyzone.iogp.org

Rickover Quote…

Posted: August 18th, 2016 in Performance Improvement, Pictures

At this school, the smartest work as hard
as those who must struggle to pass.

Admiral Hyman Rickover 

RickoverTraining

Monday Accident & Lessons Learned: Five Items To Remember When Using a Checklist

Posted: August 15th, 2016 in Accidents, Current Events, Documents, Investigations

Another great article from NASA’s Aviation Safety Reporting System that applies to a much broader audience than just aviation folks. If you use checklists, there something to be learned from this article. Click on the picture of the article below to read more…

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Will Rogers Dies in a Plane Crash – August 15, 1935

Posted: August 15th, 2016 in Accidents, Pictures

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Click image to read more…

Rickover Quote…

Posted: August 11th, 2016 in Performance Improvement, Pictures

The secret of success:

late to bed,

early to rise,

work like hell and you’ll be wise.

Admiral Hyman Rickover

 

RickoverMeeting

Monday Accident & Lessons Learned: Simple Human Error – Safeguards – Weight and Balance Issues

Posted: August 8th, 2016 in Accidents, Current Events, Documents, Investigations

The errors reported in this Aviation Safety Reporting System “Call Back” article are simple but serious. If you load a plane wrong, it could crash on takeoff. Click on the picture of the article below to read the whole report.

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These simple errors seem like they are just an aviation problem. But are there simple errors that your people could make that could cause serious safety, quality, or production issues? maybe a Safeguard Analysis is in order to see if the only Safeguard you are relying on could fail due to a simple human error.

Start of Day 2 at the TapRooT® Summit

Posted: August 4th, 2016 in Pictures, Summit

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Wow! Just attended a great talk by Kurt Mix about the Justice Departments out-of-control prosecution after the Deepwater Horizon accident. You would be outraged if you had been here. 

Rickover Quote…

Posted: August 3rd, 2016 in Performance Improvement, Pictures

Heaven is blessed with perfect rest.

The blessing of earth is toil.

Admiral Hyman Rickover

Rickover sub0001

Pictures from the Summit – The Courses #taprootsummit

Posted: August 1st, 2016 in Courses, Pictures, Summit, TapRooT

Here are pictures from the 11 pre-Summit Courses ….

TapRooT® Incident Investigation & Root Cause Analysis Course

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Equifactor® Equipment Troubleshooting and Root Cause Analysis

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Advanced Causal Factor Development Course

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Advanced Trending Techniques

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TapRooT® Analyzing and Fixing Safety Culture Issues

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Risk Assessment and Management Best Practices

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TapRooT® Quality Process Improvement Facilitator Course

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Getting the Most from Your TapRooT® VI Software

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TapRooT® for Audits

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Effective Interviewing & Evidence Collection Techniques

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Understanding and Stopping Human Error

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Monday Accident & Lessons Learned: Is the Information Collected as Part of an Accident Investigation “Privileged” – Canadian Court Rules

Posted: August 1st, 2016 in Accidents, Current Events, Documents, Investigations

The Occupational Health and Safety Act (“OHS Act”) in Canada requires an employer to conduct and investigation and prepare a report following an accident in the workplace. But an Aberta Queens Bench ruled that the obligation does not “foreclose or preclude” the employer’s ability to claim privilege over information collected during an internal investigation into the incident.

Want to learn more? See the article about the Alberta v Suncor Energy case at:

http://www.mondaq.com/canada/x/495040/Health+Safety/Court+Of+Queens+Bench+Confirms+That+Privilege+May+Apply+To+Workplace+Accident+Investigation

Spreadsheet for Grade Your Investigation Session

Posted: July 28th, 2016 in Documents, Performance Improvement, Summit

Download this Excel® Spreadsheet to your laptop or other device to participate in the exercise in the “Grade Your Investigation” Best Practice Session at the 2016 Global TapRooT® Summit:

RateRootCauseAnalysisSummit2016.xlsx

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