What do you have planned to keep walkways clear this winter?
Monday Accident & Lessons Learned: OPG Safety Alert #260 – Planning & Preparation … Key Elements for Prevention of MPD Well Control AccidentsOctober 6th, 2014 by Mark Paradies
OPG Safety Alert #260
PLANNING AND PREPARATION – KEY ELEMENTS FOR PREVENTION OF MPD WELL CONTROL INCIDENTS
During drilling the 6″ reservoir section in an unconventional well, a kick-loss situation occurred. After opening the circulation port in a drillstring sub-assembly, LCM was pumped to combat losses. When LCM subsequently returned to surface it plugged the choke. Circulation was stopped, the upper auto-Internal BOP (IBOP) was activated, and the choke manifold was lined up for flushing using a mud pump. During the course of this operation mud backflow was observed at the Shaker Box. The Stand Pipe Manifold and mud pumps were isolated to investigate. After a period of monitoring the stand pipe pressure, the upper IBOP, located at the top of the drillpipe, was opened to attempt to bullhead mud into the drillstring. Upon opening, a pressure, above 6500psi and exceeding the surface system safe working pressure, was observed. The upper IBOP was closed immediately and the surface system bled down. An attempt to close the lower manual IBOP as a second barrier was not successful. Due to the presence of high pressure, the Stand Pipe Manifold could not be used as the second barrier, nor could it be used for circulation. Well control experts were mobilised to perform hot tapping and freeze operations which were successfully executed and allowed a high-pressure drillpipe tree to be installed in order to re-instate 2 barriers on the drillpipe.
What Went Wrong?
- With the down-hole circulation sub-assembly open in the drillstring, the upper IBOP was either leaking or remained open due to activation malfunction (this could not be substantiated), and a flow path developed up the drill pipe.
- The line up for flushing the Choke Manifold with the mud pumps did not allow for adequate well monitoring. The set up as used resulted in unexpected flow up the drillstring to go undetected.
- It was incorrectly assumed that monitored volume gains were due only to mud transfer.
- Assessment of flow, volume and pressure risks did not consider in sufficient detail the concurrent operations involving pumping mud off line and a pressurized drill string.
- Operational focus was on choke manifold flushing whereas supervision should have maintained oversight of the broader situation including well monitoring.
Corrective Actions and Recommendations
- Develop a barrier plan for all operational steps; always update the plan as a result of operational changes prior to continuing (ie. ensure a robust Management of Change process).
- Take the time required to verify that intended barriers are in place as per the Barrier Plan and, when activated, have operated properly (eg. IBOP’s).
- Install a landing nipple above the down hole circulation sub-assembly to allow a sealing drop dart to be run if required.
- Always close-in, or line-up, in such a way that allows for monitoring of all the closed-in pressures at all times.
- “Walk the lines” prior to commencing (concurrent) operations involving pressure and flow.
- Develop procedures in advance for flushing of the Well Control system, especially for recognisable potential cases of concurrent operations.
- Develop clear procedures covering all aspects of unconventional operations, including reasonably expected scenarios, and ensure effective communication of these to all relevant staff.
Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP 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.
On October 4, 2010, toxic sludge leaked from a metal refinery in Hungary. Over 100 people were injured, many suffering burns, and at least ten deaths were attributed to the disaster. The company was fined $647 million for environmental damage (Read article and view dramatic photos on The Guardian).
Learn how TapRooT® Root Cause Analysis can help you avoid injuries, deaths and costly fines. (Click here to learn more.)
This week accident information is from the US Chemical Safety Board …
CSB Chairperson Moure-Eraso Warns About Danger of Hot Work
on Tanks Containing Biological or Organic Material
Earlier this month a team of CSB investigators deployed to the Omega Protein facility in Moss Point, Mississippi, where a tank explosion on July 28, 2014, killed a contract worker and severely injured another. Our team, working alongside federal OSHA inspectors, found that the incident occurred during hot work on or near a tank containing eight inches of a slurry of water and fish matter known as “stickwater.”
The explosion blew the lid off the 30-foot-high tank, fatally injuring a contract worker who was on top of the tank. A second contract worker on the tank was severely injured. CSB investigators commissioned laboratory testing of the stickwater and found telltale signs of microbial activity in the samples, such as the presence of volatile fatty acids in the liquid samples and offgassing of flammable methane and hydrogen sulfide.
The stickwater inside of the storage tank had been thought to be nonhazardous. No combustible gas testing was done on the contents of the tank before the hot work commenced.
This tragedy underscores the extreme importance of careful hot work planning, hazard evaluation, and procedures for all storage tanks, whether or not flammable material is expected to be present. Hot work dangers are not limited to the oil, gas, and chemical sectors where flammability hazards are commonplace.
The CSB has now examined three serious hot work incidents—all with fatalities—involving hot work on tanks of biological or organic matter. At the Packaging Corporation of America (PCA), three workers were killed on July 29, 2008, as they were performing hot work on a catwalk above an 80-foot-tall tank of “white water,” a slurry of pulp fiber waste and water. CSB laboratory testing identified anaerobic, hydrogen-producing bacteria in the tank. The hydrogen gas ignited, ripping open the tank lid and sending workers tumbling to their deaths.
On February 16, 2009, a welding contractor was killed while repairing a water clarifier tank at the ConAgra Foods facility in Boardman, Oregon. The tank held water and waste from potato washing; the CSB investigation found that water and organic material had built up beneath the base of the tank and decayed through microbial action, producing flammable gas that exploded.
Mixtures of water with fish, potatoes, or cardboard waste could understandably be assumed to be benign and pose little safety risk to workers. It is vital that companies, contract firms, and maintenance personnel recognize that in the confines of a storage tank, seemingly non-hazardous organic substances can release flammable gases at levels that cause the vapor space to exceed the lower flammability limit. Under those conditions, a simple spark or even conducted heat from hot work can prove disastrous.
I urge all companies to follow the positive example set by the DuPont Corporation, after a fatal hot work tragedy occurred at a DuPont chemical site near Buffalo, New York. Following CSB recommendations from 2012, DuPont instituted a series of reforms to hot work safety practices on a global basis, including requirements for combustible gas monitoring when planning for welding or other hot work on or near storage tanks or adjacent spaces.
Combustible gas testing is simple, safe, and affordable. It is a recommended practice of the National Fire Protection Association, The American Petroleum Institute, FM Global, and other safety organizations that produce hot work guidance. Combustible gas testing is important on tanks that hold or have held flammables, but it is equally important—if not more so—for tanks where flammables are not understood to be present. It will save lives.
Why is the CSB Investigation of the Deepwater Horizon Accident Taking So Long? A 2010 Subpoena Ruled Valid By Federal Appeals Court…September 25th, 2014 by Mark Paradies
The Louisiana Record published the following article: “Fifth Circuit allows federal safety board review of Deepwater Horizon incident”.
Perhaps they can complete their investigation now…
Monday Accident & Lesson Learned: Fatal accident at Barratt’s Lane No.2 footpath crossing, Attenborough, Nottingham, 26 October 2013September 22nd, 2014 by Mark Paradies
The UK Rail Accident Investigation Branch issued a report about the fatal accident of a train striking a pedestrian at a footpath crossing near Nottingham, UK. See the entire report and the one lesson learned at:
Note: We have decided to republish articles from the Root Cause Network™ Newsletter that we find particularly interesting and still applicable today. These are used with the permission of the original publisher. In some cases, we have updated some parts of the text to keep them “current” but we have tried to present them in their original form as much as possible. If you enjoy these reprints, let us know. You should expect about two per month.
BEAT ‘EM OR LEAD ‘EM
A TALE OF TWO PLANTS
You’re the VP of a 1000 MW nuclear power plant. A senior reactor operator in the control room actuates the wrong valve.
The turbine trips.
The plant trips.
If the plant had just 30 more days of uninterrupted operation, your utility would have been eligible for a better rate structure based on the Public Service Commission’s (PUC) policy that rewards availability. Now you can kiss that hefty bonus check (that is tied to plant performance goals) good-bye.
To make matters worse, during the recovery, a technician takes a “shortcut” while performing a procedure and disables several redundant safety circuits. An inspector catches the mistake and now the Nuclear Regulatory Commission (the plant’s nuclear safety regulator – the NRC) is sending a special inspection team to look at the plant’s culture. That could mean days, weeks or even months of down time due to regulatory startup delays.
What do you do???
PLANT 1 – RAPID ACTION
He who hesitates is lost!
Corporate expects heads to roll!
You don’t want to be the first, so you:
- Give the operator a couple of days off without pay. Tell him to think about his mistake. He should have used STAR! If he isn’t more careful next time, he had better start looking for another job.
- Fire the technician. Make him an example. There is NO excuse for taking a shortcut and not following procedures. Put out another memo telling everyone that following procedure is a “condition of employment.”
- Expedite the root cause analysis. Get it done BEFORE the NRC shows up. There is no time for detailed analysis. Besides, everyone knows what’s wrong – the operator and technician just goofed up! (Human error is the cause.) Get the witch-hunt over fast to help morale.
- Write a quick report. Rapid action will look good to the regulator. We have a culture that does not accept deviation from strict rules and firing the technician proves that. Tell them that we are emphasizing the human performance technology of STAR. Maybe they won’t bother us any more.
- Get the startup preparation done. We want to be ready to go back on-line as soon as we can to get the NRC off our backs and a quick start-up will keep the PUC happy.
PLANT 2 – ALTERNATIVE ACTION
No one likes these types of situations, but you are prepared, so you:
- Start a detailed root cause analysis. You have highly trained operations and maintenance personnel, system and safety engineers, and human factors professionals to find correctable root causes. And your folks don’t just fly by the seat of their pants. They are trained in a formal investigation process that has been proven to work throughout a variety of industries – TapRooT®! It helps them be efficient in their root cause analysis efforts. And they have experts to help them if they have problems getting to the root causes of any causal factors they identify.
- Keep the NRC Regional Office updated on what your team is finding. You have nothing to hide. Your past efforts sharing your root cause analyses means that they have confidence that you will do a thorough investigation.
- “Keep the hounds at bay.” Finding the real root causes of problems takes time to perform a trough investigation. Resist the urge (based on real or perceived pressure) to give in to knee-jerk reactions. You don’t automatically punish those involved. Yoiu believe your people consistently try to do their best. You have avoided the negative progression that starts with a senseless witch-hunt, progresses to fault finding, and results in future lies and cover-ups.
- Check to see that the pre-staged corrective maintenance has started. Plant down time – even unscheduled forced outages – is too valuable to waste. You use every chance to fix small problems to avoid the big ones.
- Keep up to date on the root cause analysis team’s progress. Make sure you do everything in your power to remove any roadblocks that they face.
- Get ready to reward those involved in the investigation and in developing and implementing effective corrective actions. This is a rare opportunity to show off your team’s capabilities while in the heat of battle. Reward them while the sweat is still on their brow.
- Be critical of the investigation that is presented to you. Check that all possible root causes were looked into. Publicly ask: “What could I have done to prevent this incident?” Because of your past efforts, the team will be ready for good questions and will have answers.
Which culture is more common in your industry?
Which plant would you rather manage?
Where would you rather work?
What makes Plant 1 and Plant 2 so different? It is really quite simple…
- Management Attitude: A belief in your people means that you know they are trying to do their best. There is no higher management purpose that to help then succeed by giving them the tools they need to get the job done right.
- Trust: Everyone trusts everyone on this team. This starts with good face to face communications. It includes a fair application of praise and punishment after a thorough root cause analysis.
- Systematic Approach and Preparation: Preparation is the key to success and the cause of serendipity. Preparation requires planning and training. A systematic approach allows outstanding performance to be taught and repeated. That’s why a prepared plant uses TapRooT®.
Which plant exhibited these characteristics?
HOW TO CHANGE
Can you change from Plant 1 to Plant 2? YES! But how???
The first step has to be made by senior managers. The right attitude must be adopted before trust can be developed and a systematic approach can succeed.
Part of exhibiting the belief in your people is making sure that they have the tools they need. This includes:
- Choosing an advanced, systematic root cause analysis tool (TapRooT®).
- Adopting a written accident/incident investigation policy that shows managements commitment to thorough investigations and detailed root cause analysis.
- Creating a database to trend incident causes and track corrective actions to completion.
- Training people to use the root cause analysis tool and the databases that go with them.
- Making sure that people have time to do proper root cause analysis, help if things get difficult, and the budget to implement effective corrective actions.
- Providing a staff to assist with and review important incidents, to trend investigation results, and to track the implementation of corrective actions and report back to management on how the performance improvement system is performing.
Once the proper root cause analysis methods (that look for correctable root causes rather than placing blame) are implement and experienced by folks in the field, trust in management will become a forgone conclusion.
YOU CAN CHANGE
Have faith that your plant can change. If you are senior management, take the first step: Trust your people.
Next, implement TapRooT® to get to the real, fixable causes of accidents, incidents, and near-misses. See Chapter 6 of the © 2008 TapRooT® Book to get great ideas that will make your TapRooT® implementation world class.
_ _ _
Copyright 2014 by System Improvements, Inc. Adapted from an article in the March 1992 Root Cause Network™ Newsletter (© 1992 by System Improvements – used by permission) that was based on a talk given by Mark Paradies at the 1990 Winter American Nuclear Society Meeting.
The UK Rail Accident Investigation Branch has published a report about two accidents where things (a wheelchair and a baby stroller) rolled onto the tracks.
To see the report and the one lesson learned, CLICK HERE.
Monday Accident & Lessons Learned: NTSB Investigation – Grounding and Sinking of Towing Vessel Stephen L. Colby”September 8th, 2014 by Mark Paradies
Below is the NTSB investigation PDF. Read it and see what you think of the “probable cause” of the accident … “The National Transportation Safety Board determines that the probable cause of the grounding and sinking of the Stephen L. Colby was the failure of the master and mate to ensure sufficient underkeel clearance for the intended transit through the accident area.“
See the whole report here:
This is big news in that the fines for the spill are multiplied and could reach $18 billion dollars. See the whole story at:
On September 3, 1991, a fire broke out at Imperial Foods Processing Plant in Hamlet, North Carolina after a repaired hydraulic line burst.
Heating gas plumes from a cooking vat ignited hydraulic fluid spreading heavy black smoke throughout the plant within a couple of minutes. Twenty-five workers lost their lives including a route salesman who had been filling food machines in the break room. Fifty-four people were injured.
It was determined that the deaths were caused by smoke inhalation when the workers could not exit the building due to blocked or locked exits. According to the Fire & Rescue Journal, “Hydrocarbon-charged smoke, particularly as heavy as this, is extremely debilitating to the human body and can disable a person with one or two breaths.”
Imperial Food’s owner pleaded guilty to involuntary manslaughter and was sentenced to 19 years 11 months in prison. The victims received a $16.1 settlement. (New York Times.)
In the following video, a visitor films the memorial for all the workers whose lives were lost.
It’s devastating when a workplace becomes a memorial to workers who perished there. Learn best practices to find and fix root causes so this never happens at your facility:
Halliburton’s agreement caps the amount of money it will pay and significantly cuts into the legal liabilities it faces. See the story at:
Monday Accident & Lessons Learned: RAIB Investigation Report – Road Rail Vehicle Runs Away, Strikes ScaffoldSeptember 1st, 2014 by Mark Paradies
Here is the summary of the report from the UK Rail Accident Investigation Branch:
At about 03:00 hrs on Sunday 21 April 2013, a road rail vehicle (RRV) ran away as it was being on-tracked north of Glasgow Queen Street High Level Tunnel on a section of railway sloping towards the tunnel. The RRV ran through the tunnel and struck two scaffolds that were being used for maintenance work on the tunnel walls. A person working on one of the scaffolds was thrown to the ground and suffered severe injuries to his shoulder. The track levelled out as the RRV ran into Glasgow Queen Street station and, after travelling a total distance of about 1.1 miles (1.8 kilometres), it stopped in platform 5, about 20 metres short of the buffer stop.
The RRV was a mobile elevating work platform that was manufactured for use on road wheels and then converted by Rexquote Ltd to permit use on the railway. The RRV’s road wheels were intended to provide braking in both road and rail modes. This was achieved in rail mode by holding the road wheels against a hub extending from the rail wheels. The design of the RRV meant that during a transition phase in the on-tracking procedure, the road wheel brakes were ineffective because the RRV was supported on the rail wheels but the road wheels were not yet touching the hubs. Although instructed to follow a procedure which prevented this occurring simultaneously at both ends of the RRV, the machine operator unintentionally put the RRV into this condition. He was (correctly) standing beside the RRV when it started to move, and the control equipment was pulled from his hand before he could stop the vehicle.
The RRV was fitted with holding brakes acting directly on both rail wheels at one end of the vehicle. These were intended to prevent a runaway if non-compliance with the operating instructions meant that all road wheel brakes were ineffective. The holding brake was insufficient to prevent the runaway due to shortcomings in Rexquote’s design, factory testing and specification of maintenance activities. The lack of an effective quality assurance system at Rexquote was an underlying factor. The design of the holding brake was not reviewed when the RRV was subject to the rail industry vehicle approval process because provision of such a brake was not required by Railway Industry Standards.
The RAIB has identified one learning point which reminds the rail industry that the rail vehicle approval process does not cover all aspects of rail vehicle performance. The RAIB has made four recommendations. One requires Rexquote to implement an effective quality assurance system and another, supporting an activity already proposed by Network Rail, seeks to widen the scope of safety-related audits applied by Network Rail to organisations supplying rail plant for use on its infrastructure. A third recommendation seeks improvements to the testing process for parking brakes provided on RRVs. The final recommendation, based on an observation, relates to the provision of lighting on RRVs.
To read the whole report, see:
UK Rail Accident Investigation Branch investigates electrical arcing and fire on a Metro train and parting of the overhead line at Walkergate station, Newcastle upon Tyne, on 11 August 2014August 29th, 2014 by Mark Paradies
Here’s the press release …
Electrical arcing and fire on a Metro train and parting of the overhead line
at Walkergate station, Newcastle upon Tyne, on 11 August 2014
RAIB is investigating an accident which occurred on the Tyne and Wear Metro system at Walkergate station on Monday 11 August 2014.
At 18:56 hrs a two-car Metro train, travelling from South Shields to St James, arrived at Walkergate station. While standing in the station an electrical fault occurred to a line breaker mounted on the underside of the train, which produced some smoke. It also caused the circuit breakers at the sub-stations supplying the train with electricity, via the overhead line, to trip (open). About one minute later power was restored to the train. There followed a brief fire in the area of the initial electrical fault and further smoke. Shortly afterwards, the overhead line above the train parted and the flailing ends of the wire fell on the train roof and one then fell on to the platform, producing significant arcing and sparks for around 14 seconds. Fortunately, there was no-one on the platform at the time. However, there were at least 30 passengers on the train who self-evacuated on to the platform using the train doors’ emergency release handles. The fire service attended but the fire was no longer burning. No-one was reported to be injured in the accident and there was no significant damage to the interior of the train.
Image courtesy of Tyne and Wear Metro
RAIB’s investigation will consider the sequence of events and factors that led to the accident, and identify any safety lessons. In particular, it will examine:
- the reasons for the electrical fault;
- the response of the staff involved, including the driver and controllers;
- the adequacy of the electrical protection arrangements; and
- actions taken since a previous accident of a similar type that occurred at South Gosforth in January 2013 (RAIB report 18/2013).
RAIB’s investigation is independent of any investigations by the safety authority. RAIB will publish its findings at the conclusion of the investigation. The report will be available on the RAIB’s website.
You can subscribe to automated emails notifying you when the RAIB publishes its report and bulletins.
RAIB would like to hear from any passengers who were on the train. Any information provided to assist our safety investigation will be treated in strict confidence. If you are able to help the RAIB please contact us by email on firstname.lastname@example.org or by telephoning 01332 253300
Compilation of aviation crashes … some fatal, some not.
FATALITY DURING CONFINED SPACE ENTRY
- Two cylindrical foam sponge pads had been inserted in a riser guide tube to form a plug. Argon gas had been pumped into the 60 cm space between the two sponges as shielding gas for welding on the exterior of the riser guide tube.
- After completion of the welding, a worker descended into the riser guide tube by rope access to remove the upper sponge. While inside, communication with the worker ceased.
- A confined space attendant entered the riser guide tube to investigate. Finding his colleague unconscious, he called for rescue and then he too lost consciousness.
- On being brought to the surface, the first worker received CPR; was taken to hospital; but died of suspected cardio-respiratory failure after 2 hours of descent into the space. The co-worker recovered.
What Went Wrong?
- Exposure to an oxygen-deficient atmosphere: The rope access team members (victim and co-worker) were unaware of the asphyxiation risk from the argon gas shielding.
- Gas test: There was no gas test done immediately prior to the confined space entry. The act of removing the upper foam sponge itself could have released (additional) argon, so any prior test would not be meaningful.
- Gas detectors: Portable gas detectors were carried, but inside a canvas bag. The co-worker did not hear any audible alarm from the gas detector when he descended into the space.
- Evacuation time: It took 20 minutes to bring the victim to the deck after communication failed.
Corrective Actions and Recommendations
- As a first step: assess whether the nature of the work absolutely justifies personnel entering the confined space.
- Before confined space entry:
- identify and communicate the risks to personnel carrying out the work
- define requirements, roles and responsibilities to control, monitor and supervise the work
- check gas presence; understand how the work itself may change the atmospheric conditions
- ensure adequate ventilation, lighting, means of communication and escape
- Ensure step by step work permits are issued and displayed for each work phase, together with specific job safety analyses
- During confined space entry:
- station a trained confined space attendant at the entrance to the space at all times
- ensure that communication and rescue equipment and resources are readily available
- carry and use portable/personal gas detectors throughout the activity
Review your yard confined space entry practice, keeping in mind the lessons learned from this incident.
safety alert number: 259
OGP Safety Alerts http://info.ogp.org.uk/safety/
A deadly pipeline gas explosion in San Bruno, California has the state government of California involved to investigate what the root cause was. It has been reported that the alleged local gas company, Pacific Gas and Electric Co., has been working with the California Public Utilities Commission in a corrupted relationship resulting in unfair and dishonest regulations. It was also reported that after pleading guilty, the grand jury accused them of 28 counts of safety violations. Mayor Jim Ruane has recognized this and ensured that there will be an independent monitor to investigate the company to restore the public’s confidence.
Additionally, more reports have indicated that PG&E was at fault for a similar incident in 2010 including a gas explosion and failure to comply with regulations. It is suspected that they also obstructed the National Transportation Safety Board by falsely denying that they ignore federal pipeline inspection requirements. Now current investigations are showing that PG&E played a large role in organizing an upcoming gas safety conference causing many to question the quality of the conference. Once revealed, protests caused cancellation of the conference and less confidence in the company.
PG&E describes this as a “tragic accident” and it is suspected that they are in denial in order to keep up the integrity of the business. They claim to be unsure if their employees are making bad judgments as opposed to blatant violations. Officials will continue to investigate as the trials also continue in hopes of an answer and compromise.
Monday Accident & Lessons Learned: OPG Safety Alert – Well Control Incident – Managing Gas Breakout in SOBMAugust 18th, 2014 by Mark Paradies
Safety Alert Number: 258
OGP Safety Alerts http://info.ogp.org.uk/safety
While drilling at a depth of 4747m, the well was shut-in due to an increase in returns with a total gain of 17bbls recorded. The well kill needed an increase in density from 1.40sg to 1.61sg to achieve a stable situation. With the well open the BHA was pumped out to the shoe and tripped 400m to pick up a BOP test tool to perform the post-kill BOP test.
The BOP and choke manifold test were performed as well as some rig maintenance. The BHA was then tripped into the hole and the last 2 stands were washed to bottom. Total pumps-off time without circulation was 44 hours.
Gas levels during the bottoms-up initially peaked at around 14% and then dropped steadily to around 5%. HPHT procedures were being followed and this operation required circulation through the choke for the last 1/3 of the bottoms up. This corresponds to taking returns through the choke after 162m3 is circulated.
After 124 cubic metres of the bottoms-up had been pumped the gas detector at the bell nipple was triggered. Simultaneously, mud started to be pushed up out of the hole, reaching a height of around 1 joint above the drill floor. The flow continued for around 30 seconds corresponding to a bubble of gas exiting the riser. The pumps and rotation were shut down, followed by closure of the diverter, annular and upper pipe rams. Approximately 2bbls of SBM were lost over-board through the diverter line. The flow stopped by itself after just a few seconds and casing pressure was recorded as zero. No-one was on the drill floor at the time and no movement, damage or displacement of equipment occurred.
After verifying that there was no flow (monitored on the stripping tank) the diverter was opened and 10 cubic metres of mud used to refill the riser, equal to a drop in height of 56m.
The riser was circulated to fresh mud with maximum gas levels recorded at 54%. This was followed by a full bottoms up through the choke.
A full muster of POB was conducted due to the gas alarms being triggered.
What Went Wrong?
Conclusion – An undetected influx was swabbed into the well during the BOP test which was then circulated up inadvertently though a non-closed system breaking out in the riser.
- Stroke counter was reset to zero after washing 3 stands to bottom (this resulted in 136 cubic metres of circulation not being accounted for in the bottoms up monitoring).
- Review of Monitoring While Drilling Annular Pressure memory logs identified several swabbing events identified – main event was when the BOP test tool was POOH from the wellhead – ESD as measured by APWD dropped to 1.59sg on 10 or 11 occasions.
- Swabbing was exacerbated by Kill Weight Mud not having sufficient margin above PP.
Corrective Actions and Recommendations:
- Take into account all washing to bottom for any circulation where bottoms up is to be via choke.
- Tool Pushers shall cross check the bottoms up calculation and joint agreement on reset of the stroke counter.
- All BHA tripping speeds to be modeled so that potential swabbing operations are identified and so that tripping speed limits can be specified.
- Verify, when possible, actual swabbing magnitude using PWD memory logs (ie after a trip out of the hole).
- Pumping out (even inside liner/casing) shall be considered in tight tolerance liner/drilling BHA. Modeling shall be used to underpin the decision.
Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP 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.
OSHA General Duty Clause Citations: 2009-2012: Food Industry Related Activities
Doing a quick search of the OSHA Database for Food Industry related citations, it appears that Dust & Fumes along with Burns are the top driving hazard potentials.
Each citation fell under OSH Act of 1970 Section 5(a)(1): The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed……
Each company had to correct the potential hazard and respond using an Abatement Letter that includes words such as:
The hazard referenced in Inspection Number [insert 9-digit #]
for violation identified as:
Citation [insert #] and item [insert #] was corrected on [insert
Okay so you have a regulatory finding and listed above is one of the OSHA processes to correct it, sounds easy right? Not so fast…..
….are the findings correct?
….if a correct finding, are you correcting the finding or fixing the problems that allowed the issue?
….is the finding a generic/systemic issue?
As many of our TapRooT® Client’s have learned, if you want a finding to go away, you must perform a proper root cause analysis first. They use tools such as:
o SnapCharT®: a simple, visual technique for collecting and organizing information quickly and efficiently.
o Root Cause Tree®: an easy-to-use resource to determine root causes of problems.
o Corrective Action Helper®: helps people develop corrective actions by seeing outside the box.
First you must define the Incident or Scope of the analysis. Critical in analysis of a finding is that the scope of your investigation is not that you received a finding. The scope of the investigation should be that you have a potential uncontrolled hazard or access to a potential hazard.
In thinking this way, this should also trigger the need to perform a Safeguard Analysis during the evidence collection and during the corrective action development. Here are a few blog articles that discuss this tool we teach in our TapRooT® Courses.
Monday Accident & Lesson NOT Learned: Why Do We Use the Weakest Corrective Actions From the Hierarchy of Safeguards?http://www.taproot.com/archives/28919#comments
Root Cause Analysis Tip: Analyze Things That Go Right … The After-Action Review
If you have not been taking OSHA Finding to the right level of action, you may want to benchmark your current action plan and root cause analysis process, see below:
BENCHMARKING ROOT CAUSE ANALYSIS
Hydrocarbon Process Reports: “Pemex Blast at Ciudad Madero Refinery Kills Four Workers, Injures More”August 12th, 2014 by Mark Paradies
An oil refinery in Ciudad Madero burst into flames earlier this week killing four workers. After evaluating the situation, officials determined that the refinery was under maintenance and not operating at the time of the fire. What caught fire? How did this happen? Reports indicated that this particular refinery, being the smallest of six in the company, may not have been producing it’s quota for daily production due to refining inefficiencies and infrastructure that went ignored for too long.
Fortunately, this accident forced the government to pass a law for private investments for the National Energy Industry. Consequently, they waited too long to invest in this maintenance and inefficiencies which lead to destruction.
Here’s the Executive Summary from the CDC Report:
The Centers for Disease Control and Prevention (CDC) conducted an internal review of an incident that involved an unintentional release of potentially viable anthrax within its Roybal Campus, in Atlanta, Georgia. On June 5, 2014, a laboratory scientist in the Bioterrorism Rapid Response and Advanced Technology (BRRAT) laboratory prepared extracts from a panel of eight bacterial select agents, including Bacillus anthracis (B. anthracis), under biosafety level (BSL) 3 containment conditions. These samples were being prepared for analysis using matrix-assisted laser desorption/ionization time-of-flight (MALDI- TOF) mass spectrometry, a technology that can be used for rapid bacterial species identification.
This protein extraction procedure was being evaluated as part of a preliminary assessment of whether MALDI-TOF mass spectrometry could provide a faster way to detect anthrax compared to conventional methods and could be utilized by emergency response laboratories. After chemical treatment for 10 minutes and extraction, the samples were checked for sterility by plating portions of them on bacterial growth media. When no growth was observed on sterility plates after 24 hours, the remaining samples, which had been held in the chemical solution for 24 hours, were moved to CDC BSL-2 laboratories. On June 13, 2014, a laboratory scientist in the BRRAT laboratory BSL-3 lab observed unexpected growth on the anthrax sterility plate. While the specimens plated on this plate had only been treated for 10 minutes as opposed to the 24 hours of treatment of specimens sent outside of the BSL-3 lab, this nonetheless indicated that the B. anthracis sample extract may not have been sterile when transferred to BSL-2 laboratories.
Why the Incident Happened
The overriding factor contributing to this incident was the lack of an approved, written study plan reviewed by senior staff or scientific leadership to ensure that the research design was appropriate and met all laboratory safety requirements. Several additional factors contributed to the incident:
Use of unapproved sterilization techniques
Transfer of material not confirmed to be inactive
Use of pathogenic B. anthracis when non-pathogenic strains would have been appropriate for
Inadequate knowledge of the peer-reviewed literature
Lack of a standard operating procedure or process on inactivation and transfer to cover all procedures done with select agents in the BRRAT laboratory. What Has CDC Done Since the Incident Occurred CDC’s initial response to the incident focused on ensuring that any potentially exposed staff were assessed and, if appropriate, provided preventive treatment to reduce the risk of illness if exposure had occurred. CDC also ceased operations of the BRRAT laboratory pending investigation, decontaminated potentially affected laboratory spaces, undertook research to refine understanding of potential exposures and optimize preventive treatment, and conducted a review of the event to identify key recommendations.
To evaluate potential risk, research studies were conducted at a CDC laboratory and at an external laboratory to evaluate the extent to which the chemical treatment used by the BRRAT laboratory inactivated B. anthracis. Two preparations were evaluated: vegetative cells and a high concentration of B. anthracis spores. Results indicated that this treatment was effective at inactivating vegetative cells of B. anthracis under the conditions tested. The treatment was also effective at inactivating a high percentage of, but not all B. anthracis spores from the concentrated spore preparation.
A moratorium is being put into effect on July 11, 2014, on any biological material leaving any CDC BSL-3 or BSL-4 laboratory in order to allow sufficient time to put adequate improvement measures in place.
Since the incident, CDC has put in place multiple steps to reduce the risk of a similar event happening in the future. Key recommendations will address the root causes of this incident and provide redundant safeguards across the agency, these include:
The BRRAT laboratory has been closed since June 16, 2014, and will remain closed as it relates to work with any select agent until certain specific actions are taken
Appropriate personnel action will be taken with respect to individuals who contributed to or were in a position to prevent this incident
Protocols for inactivation and transfer of virulent pathogens throughout CDC laboratories will be reviewed
CDC will establish a CDC-wide single point of accountability for laboratory safety
CDC will establish an external advisory committee to provide ongoing advice and direction for laboratory safety
CDC response to future internal incidents will be improved by rapid establishment of an incident command structure
Broader implications for the use of select agents, across the United States will be examined.
This was a serious event that should not have happened. Though it now appears that the risk to any individual was either non-existent or very small, the issues raised by this event are important. CDC has concrete actions underway now to change processes that allowed this to happen, and we will do everything possible to prevent a future occurrence such as this in any CDC laboratory, and to apply the lessons learned to other laboratories across the United States.
On August 9, 1965, 53 contract workers were killed during a fire at a Titan missile silo at Little Rock AFB in Searcy, Arkansas. The investigation indicated that the fire was caused by a ruptured hydraulic line spraying diesel fluid on a wire, igniting it.
One of the two workers who survived told his story after keeping it to himself and his close circle for 33 years. He was only 17 and had only been working in the silo for two days when the accident happened. He recalled seeing a sign at the site, “206 days without an accident.”
Click the link below to read his account:
Are you relying too much on your good record? Learn best practices in analyzing accidents, incidents, near-misses, equipment failures, operating issues or quality problems: