Author Archives: Mark Paradies

How far away is death?

Posted: August 25th, 2015 in Video

Want to see more of these? “How Far Away is Death” is a column in our weekly eNewsletter (distributed every Tuesday) that is often a startling reminder of what can happen in the blink of an eye.  If you’d like to subscribe, contact Barb at editor@taproot.com.

Monday Accident & Lessons Learned: Severe Hand Injury – What is the Root Cause?

Posted: August 24th, 2015 in Accidents, Video

This video is graphic. Don’t watch if the sight of blood makes you queasy…

Go to video …

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What does a bad day look like?

Posted: August 20th, 2015 in Accidents, Video

Just like this if you own a monster truck…

Want to see more of these? “What Does a Bad Day Look Like” is a column in our weekly eNewsletter (distributed every Tuesday) that often makes our subscribers feel they are having a pretty good day!  If you’d like to subscribe, contact Barb at editor@taproot.com.

Senior Management & Root Cause Analysis

Posted: August 19th, 2015 in Performance Improvement, Root Cause Analysis Tips

What is the easiest way to tell a good root cause analysis program from a bad one?

The involvement of senior management.

How do you know if a root cause analysis program is about to fail?

Senior management changes and the new management shows no interest in the root cause analysis program.

What level of senior management is involved in the best root cause analysis programs?

All the way to the corporate board.

MANAGEMENT INVOLVEMENT

The answers to the three questions above show that senior management involvement is extremely important to the success of any root cause analysis program. The better the root cause analysis program, the more senior management involvement counts. That’s why I thought I’d take this time to explain how senior management should be involved in a root cause analysis program.

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CORPORATE BOARD

I’ve seen a few leading companies where the Corporate Board was knowledgeable of the safety/process safety/quality improvement programs. The best had a senior manager who was responsible for reporting key reactive and proactive statistics to a special board committee with primary responsibility for safety and other improvement efforts. The committee, that included the CEO, also was provided with overviews of the most serious incident investigations and summaries of improvement efforts.

This board’s interest ensured that people paid attention to the programs and that budgets weren’t slashed for key improvement initiatives (because they were supported by the board).

VP/DIVISION MANAGER

Of course, VPs or Division Managers were interested in their division’s reactive and proactive improvement performance. What VP or Division Manager wouldn’t be if the Corporate Board was going to see their statistics. They wanted to be able to manage performance so they became involved in improvement efforts. The held divisional meetings to review progress and presentation of root cause analyses of their biggest problems. They held Plant Managers and Unit Leaders responsible for their performance making improvement programs succeed.

PLANT MANAGERS

Involved Plant Managers demand good root cause analysis and schedule reviews of detailed root cause analyses of significant problem investigations. They make sure that their key improvement programs are staffed with well trained, insightful leaders and that they have plentiful staff and budget to perform investigations, review reactive and proactive statistics, sponsor training throughout the plant, and look outside the company for improvement ideas. They are the site sponsors of the improvement programs. They are trained in the root cause analysis tools being applied at the plant. Because they are trained, they offer insightful critiques of the investigation presentations. They reward employees for their participation in root cause analyses and the improvement programs.

WHAT DOES YOUR COMPANY DO?

Is your senior management involved in performance improvement?

Do you have best practices for management involvement that I’ve missed and should be included here?

What do you need to do to improve your management involvement?

If you have support, are you ready for management turnover?

Rome wasn’t built in a day. Don’t worry if your program doesn’t have all the management support that it needs. But don’t ignore your program’s shortcomings. Work on getting more management support all the way up to the corporate board.

When safety/improvement performance is seen as equally important, you know you have achieved a level of support that most improvement managers can only dream about.

How far away is death?

Posted: August 18th, 2015 in Video

Want to see more of these? “How Far Away is Death” is a column in our weekly eNewsletter (distributed every Tuesday) that is often a startling reminder of what can happen in the blink of an eye.  If you’d like to subscribe, contact Barb at editor@taproot.com.

Monday Accident & Lessons Learned: Hand Injuries

Posted: August 17th, 2015 in Video

This is the first in a few video hand safety videos. It is from the Industrial Minerals Association of North America. The program presents the “Take Five for Finger Safety” program. Many of the lessons shared are from lessons learned from accidents.

How effective is the “pay attention” advice? How many times will we see this in future videos?

Monday Motivation: Haters

Posted: August 17th, 2015 in Video

What does a bad day look like?

Posted: August 13th, 2015 in Video

Lifting big loads is always tricky!

Want to see more of these? “What Does a Bad Day Look Like” is a column in our weekly eNewsletter (distributed every Tuesday) that often makes our subscribers feel they are having a pretty good day!  If you’d like to subscribe, contact Barb at editor@taproot.com.

How far away is death?

Posted: August 11th, 2015 in Video

Monday Accident & Lessons Learned: IOGP SAFETY ALERT- GAS BREAK-OUT FROM OIL-BASED MUD WHILE RUNNING CASING

Posted: August 10th, 2015 in Accidents, Investigations

IOGP SAFETY ALERT GAS BREAK-OUT FROM OIL-BASED MUD WHILE RUNNING CASING

What Happened?

  • The event took place on a 3000 HP Land Drilling Rig while running 9 7/8” casing in the 12 ¼” hole section of an unconventional well. Well was vertical.
  • Well architecture consists of 20” Surface Casing at 945m, 13 3/8” casing at 3348 m at 12 ¼” hole section at 4794m.
  • Run 9 7/8” casing to 4793m.
  • After landing casing, circulated 9 7/8” casing, increasing pump rates from 0.70 m3/min to 1.45 m3/min and SPP of 450 kPa.At 2000 strokes into bottoms up, returns diverted through the manifold. Maximum gas of 2500 units observed prior to going through MGS.
  • Circulate through choke at 1.0 – 1.5 m3/min. Initial casing pressure of 170 kPa and SPP of 570 kPa. Casing pressure spiking at 5800 strokes to 9500 kPa and decreasing to 2100 kPa as bottom up strokes expired.
  • Significant amount of gas observed at surface. Approximately 5 m3 of invert drilling fluid was spilled over from open bottom poor boy degasser (MGS) while circulating bottoms up.
  • Shut in well & monitored for pressure evaluation.
  • Observed increase in SIDPP & SICP.
  • Continued to monitor pressure evolution.
  • Pressure stabilized at SIDPP 300 kPa & SICP 450 kPa.
  • Performed drillers method well kill and stabilized well with mud weight of 1750 kg/m3.
  • Well was static prior to bottoms up circulation (some reports noted minor flow when landing mandrel hanger).
  • During the bottoms up, returns were diverted to MGS as a precaution for trip gas and because pump pressure was much less than expected.
  • The gain was not noticed until the well was circulated once the casing was on bottom.
  • The section was drilled with a narrow mud-weight window.

What Went Wrong?

  • Gas entered the wellbore while well was static.
  • Insufficient hydrostatic pressure to prevent influx of formation fluid.
  • Well flow checks were inconsistent prior to tripping to run casing and were not sufficient to indicate potential influx of formation fluid into the well.
  • Circulation rate was adjusted to take into account the reduced volume of the annulus associated with the casing as compared to the large annular volume associated with drill pipe to ensure that the annular velocity was the same. However, this still resulted in the gas entrained in the drilling fluids coming to surface at a rate that exceeded the capacity of the MGS.
  • Choke was in the 100% open position as it should be when gas arrived at the surface because of concerns about exceeding MAASP. This resulted in maximum flow to the MGS exceeding the off-gassing and flaring capacity of the MGS flare system.
  • Possibly drilled too far into the HPHT pressure ramp in 12 ¼” hole section.

Corrective Action & Recommendations:

A definitive HPHT well control procedure will be developed for drilling operations in noted area.

  • Review MGS Sizing calculations for maximum anticipated gas rates. Understand capacity of oil based mud to absorb gas.
  • Develop a log sheet to better monitor and finger print trip gas, bottom’s up gas, connection gas and background gas to better understand potential behaviour at surface.
  • Drilling engineering team initiate and lead researching and acquiring a better way of determining needed mud weight trip margin requirements for making trips to log or run casing, with a better understanding of the fluids system EMW and ECD’s.

safety alert number: 266
IOGP Safety Alerts http://safetyzone.iogp.org/

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.

London office: 209-215 Blackfriars Road, London SE1 8NL, United Kingdom    T. +44 (0)20 3763 9700    F. +44 (0)20 3763 9701    E. reception@iogp.org

What does a bad day look like?

Posted: August 6th, 2015 in Video

Bad enough to fall off the ladder, but with a chainsaw in your hands?

Want to see more of these? “What Does a Bad Day Look Like” is a column in our weekly eNewsletter (distributed every Tuesday) that often makes our subscribers feel they are having a pretty good day!  If you’d like to subscribe, contact Barb at editor@taproot.com.

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