Category: Accidents

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

August 22nd, 2016 by

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

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

August 15th, 2016 by

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

August 8th, 2016 by

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.

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

August 1st, 2016 by

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

Tappan Zee Crane Collapse: What We Know

July 25th, 2016 by

Crane boom collapse

Last week’s collapse of the 235 foot boom on a crane building the new Tappan Zee bridge is still under investigation. There are apparently 3 separate investigations in progress, and as expected, not much information has been released.

The boom came down across all lanes of traffic on the old (still active) portion of the bridge. Amazingly enough, there were only 4 minor injuries, and it cause direct damage to a single vehicle. If you’ve ever driven across that bridge (I was on it just 30 days before the incident), you understand how lucky we were not to have any fatalities.

What we know so far:

– There was almost no wind, and this has been eliminated as a cause.
– The crane was being used to drive piles into the river bottom using a 60 ton vibratory hammer.
– There is a “black box” on the crane which will supply data on the boom angle, weight, etc.
– The operator says he knows what caused it (it wasn’t him).
– This is a new model crane with several safety features designed to eliminate human error.
– This is the only crane of this model being used on the project.
– The crane operator is licensed, with over 30 years of experience.

Tappan Zee Before

This seems to be a good start to an investigation. And as expected, there are a lot of questions (and “expert” opinions) about what happened.  Some of the questions that might be asked:

  • Was the crane properly inspected and certified?
  • What was the condition of the vibratory hammer?
  • Was there any sense of urgency that may have caused someone to make a mistake?  The contract specified $120,000 per day fine of the project finished late.
  • Was there an adequate review and approval of the safe zone around the crane operation?

It’s important not to just ask the hard questions, but also to give the hard answers.  For example, one option that could have been in place (20/20 hindsight) would be to close the operating section of the bridge during construction.  While this would definitely have been 100% safer, does it actually make sense to do this?  Were there adequate safeguards in place to allow continued use of the old span?  The answers here might be yes, and it was perfectly appropriate to operate the old bridge during contruction.  I’ve seen hundreds of construction projects that have cranes in near proximity to the public.  In fact, almost every downtown construction project has the potential to cause injury to the public if a crane collapses.  Some of the criticism I’ve seen written about this accident (“Why wasn’t the old span closed during this constructiuon project?”) is too simplistic for the real world.  The real question should be, “Were there adequate safeguards put in place for the level of risk imposed by this projct?”  We don’t know the answers yet, but just asking these questions in an unbiased investigation can provide useful information.

Crane Collapse

It appears that there is plenty of information available to the investigators. I’m very interested to see the results after the investigations are complete.

Monday Accident & Lessons Learned: Human Error That Should Not Occur

July 25th, 2016 by

This Accident shares a “Call Back” Report from the Aviation Safety Reporting System that is applicable far beyond aviation.

In this case, the pilot was fatigued and just wanted to “get home.” He had a “finish the mission” focus that could have cost him his life. Here’s an excerpt:

I saw nothing of the runway environment…. I had made no mental accommodation to do a missed approach as I just knew that my skills would allow me to land as they had so many times in past years. The only conscious control input that I can recall is leveling at the MDA [Rather than continuing to the DA? –Ed.] while continuing to focus outside the cockpit for the runway environment. It just had to be there! I do not consciously remember looking at the flight instruments as I began…an uncontrolled, unconscious 90-degree turn to the left, still looking for the runway environment.

To read about this near-miss and the lessons learned, see:

http://asrs.arc.nasa.gov/docs/cb/cb_436.pdf

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Monday Accident & Lessons Learned: Freight Train Derailment in the UK – Three New Recommendations

July 18th, 2016 by

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Derailment of freight train near Angerstein Junction, south east London, 3 June 2015

At about 12:10 hrs on 3 June 2015, one wagon of an empty freight train derailed on the approach to Angerstein Junction, near Charlton in south east London. The train continued over the junction, derailing two further wagons, before it stopped on the Blackheath to Charlton line. The three derailed wagons were partly obstructing the line used by trains travelling in the opposite direction. No other trains were involved in the accident and no-one was injured, but there was significant damage to the railway infrastructure.

The wagons derailed because the leading right-hand wheel on one of them was carrying insufficient load to prevent the wheel climbing up the outer rail on a curved section of track. The insufficient load was due to a combination of the suspension on that wheel being locked in one position, a twisted bogie frame and an intended twist in the track.

As a consequence of this investigation, RAIB has made three recommendations.

The first, addressed to VTG (the wagon owner), seeks improvements to its wagon maintenance processes.

The second, also addressed to VTG, seeks liaison with industry to improve understanding of how wagon suspension wear characteristics relate to maintenance processes.

The third, addressed to Network Rail, seeks a review of infrastructure arrangements at the accident location.

The report also includes a learning point reinforcing a previous recommendation intended to encourage use of currently available wheel load data to enable identification of wagons with defects or uneven loads that are running on Network Rail’s infrastructure.

To see the complete report, go to:

https://assets.digital.cabinet-office.gov.uk/media/5748532b40f0b60366000016/R102016_160601_Angerstein_Junction.pdf

The above information and report are from the UK Rail Accident Investigation Branck. See their web site at:

https://www.gov.uk/government/organisations/rail-accident-investigation-branch

Monday Accident & Lessons Learned: What Next?

July 11th, 2016 by

Contact a power line and no one is hurt. What do you do next?

Is Discipline All That Is Needed?

July 6th, 2016 by

You’ve seen it hundreds of times. Something goes wrong and management starts the witch hunt. WHO is to BLAME?

Is this the best approach to preventing future problems? NO! Not by a long shot. 

We’ve written about the knee-jerk reaction to discipline someone after an accident many times. Here are a few links to some of the better articles:

Let me sum up what we know …

Always do a complete root cause analysis BEFORE you discipline someone for an incident. You will find that most accidents are NOT a result of bad people who lack discipline. Thus, disciplining innocent victims of the systems just leads to uncooperative employees and moral issues.

In the very few cases where discipline is called for after a root cause analysis, you will have the facts to justify the discipline.

For those who need to learn about effective advanced root cause analysis techniques that help you find the real causes of problems, attend out 5-Day TapRooT® Root Cause Analysis Training. See: http://www.taproot.com/courses

 

You are just one Causal Factor from your next major Incident. Can you prevent it?

July 5th, 2016 by

comic

Words that I hate to hear when asked to help with an investigation: “I am surprised this incident did not happen earlier!” Rarely have I seen an incident where there is not a history of the same problems occurring.  Think of it like a math equation:

X + Y (A) = The Incident

A company’s issues are just waiting for the right math equation to occur at the right time. What are some of the common factors that populate the equation above?

  • Audit Findings (risk or compliance)
  • Near Misses (or some cases, Near Hits)
  • OSHA Non-Recordable(s)
  • Defects (caught before the defect reached the customer)
  • Project Delays
  • Procurement Issues
  • Behavior Based Safety Entries

This list of variables is infinite and dependent on the industry and service or product that your company provides. Should you be required to perform a full root cause analysis on each and every write-up or issue listed above to prevent an Incident? Not, necessarily.

Instead, I recommend that you start looking at what would be a risk to employees, customers, environment, product/service or future company success if you combined any of your issues in the same timeline or process of transactions (in TapRooT® our timeline is called a SnapCharT®). For example, take the 3 issues listed below that have a higher potential of incident occurrence when combined in the right equation.

Issue 1: Audit finding for outdated procedures found in a laboratory for testing blood samples.

Issue 2: Behavior Based Safety Write-up entered for cracked and faded face shields

Issue 3: Older Blood Analyzer has open equipment work orders for service issues.

Combining the 3 items above could cause a contaminated blood sample, exposure of contaminated blood to the lab worker or a failed test sample to the patient.

If the cautions about your future combination of known issues are not heeded then please do not acted surprised after the future Incident occurs.

Want to learn about causal factors? It’s not too late to sign up for our Advanced Causal Factor Development Course, August 1-2, 2016, San Antonio, Texas.

Monday Accident & Lessons Learned: WELL CONTROL EVENT WHEN USING AN MPD SYSTEM

July 4th, 2016 by

IOGP SAFETY ALERT

WELL CONTROL EVENT WHEN USING AN MPD SYSTEM

A High Pressure exploration gas-condensate bearing reservoir section was being drilled using automated Managed Pressure Drilling (MPD) and Rig Pump Divertor (RPD) equipment. Total gas and Connection Gas (TG/CG) peaks were noted the day before during drilling so the degasser was run. The drilled stand was backreamed at normal drilling flow rate prior to taking a MWD survey, making a connection and then taking Slow Circulating Rates (SCRs) on all 3 mud pumps. During taking SCRs an initial pit gain of 16bbl was noticed and reported.

It was suspected that pit gain was continuing, so a dynamic flow check was carried out in which it was confirmed that the well was flowing. Subsequently the well was shut in on the BOP (SICP=5,800psi, SIDPP=0psi). Dual float valves behind the bit were holding; total pit gain was estimated at 306bbls. Due to high casing pressure/MAASP concerns, an attempt was made to lower the annulus casing pressure by bleeding off gas through the choke and ‘poor boy’ mud-gas separator (MGS). This attempt was quickly aborted due to inadequate choke control leading to loss of the MGS liquid seal (SICP=7,470psi, SIDPP=0psi (floats holding).

After mobilization of high pressure bleed down facilities, the casing pressure was successfully reduced to zero psi through the “Lubricate and Bleed” well control method.

What Went Wrong?

During “pump off” events the Bottom Hole Pressure (BHP) dropped below Pore Pressure (Po) which resulted in initial small influxes into the wellbore. These were not recognized and therefore not reported as and when they occurred.

In MPD-RPD mode, fluid density dropped below the setpoint of 16.6 ppg (0.86 psi/ft) during pump off events (first and second survey and connections) due to a ‘sluggish’ RPD auto-choke. The RPD system had not been properly calibrated and the choke not run in the optimum position for effective control.

The formation pressure gradient of the gas-condensate bearing reservoir was evaluated to be 0.84psi/ft (Po~13,950psi).

NewImage

Corrective Actions and Recommendations:

  • Comprehensive and clear communication and action protocols (eg. close-in) should be tested, and verified as effective, across all Crews and Shifts.
  • Drillers must be clear that immediately on detecting an influx, they need to shut-in the well (applies for both MPD and non-MPD operations). The deployment of MPD does not change this basic principle.
  • Choke drills (A/B Crews and Day/Night shifts), including operation of remote choke(s) through a remote choke control panel, are critical to verifying that the total system (equipment, procedures, people including actions and communication protocols) are effective to operate the chokes against the maximum anticipated casing pressure.

Safety Alert Number: 272 

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.

 

 

 

 

 

 

Is “Ordering” Improvements Enough?

June 27th, 2016 by

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Can command and control improve safety?

According to this ABC article,  Chinese government has “ordered” improvements in safety. Yet 11 people died in an accident at an Aluminum Corp. of China aluminum plant when equipment they were dismantling fell on them. The article also mentions the chemical explosion that killed 173 people in the port city of Tianjin last year.

What are you doing to improve safety?

Can you or your management “order” improvements?

Perhaps you need to learn root cause analysis and best practices and skills to make your safety program world class?

If you want next year to be better than this year, sign up for the 2016 Global TapRooT® Summit in San Antonio, Texas, on August 1-5.

Pick the advanced course that will help you learn the skills you need to to improve your company’s performance.

Then pick the best practice sharing sessions at the Summit that will help you meet the biggest challenges that face your company.

Learn from your peers from around the world (see the LIST here).

Learn from people in your industry and other industries (see the LIST here).

And don’t forget our Summit GUARANTEE:

Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire Summit fee.

With a guarantee like this one, you have nothing to lose and everything to gain!

Monday Accident & Lessons Learned: Derailment at Godmersham, Kent, UK

June 27th, 2016 by

 

 

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Here’s a summary of the report from the UK Rail Accident Investigation Branch about a derailment at Godmersham, UK:

 

“At around 21:40 hrs on 26 July 2015, a passenger train derailed after striking eight cows that had gained access to the railway at Godmersham in Kent, between Wye and Chilham stations. There had been a report of a cow on the railway an hour earlier, but a subsequent examination by the driver of the next passing train did not find anything. There were no further reports from other trains that passed before the accident occurred.

 

The train involved in the accident was travelling at 69 mph (111 km/h) at the point of impact. There were 67 passengers on board plus three members of staff; no injuries were reported at the time of the accident. Because the train’s radio had ceased to work during the accident, the driver ran for about three-quarters of a mile towards an oncoming train, which had already been stopped by the signaller, and used its radio to report the accident.

 

The accident occurred because the fence had not been maintained so as to restrain cows from breaching it, and because the railway’s response to the earlier report of a cow on the railway side of the fence was insufficient to prevent the accident. In addition, the absence of an obstacle deflector on the leading unit of the train made the derailment more likely.

 

As a result of this accident, RAIB has made five recommendations addressing the fence inspection process, clarification of railway rules in response to reports of large animals within the boundary fence, the fitting of obstacle deflectors to rolling stock (two recommendations), and the reliability of the train radio equipment.

 

RAIB has also identified two learning points for the railway industry, relating to the railway’s response to emergency situations, including the response to reports of large animals within the boundary fence and the actions to take following an accident.

Here is a link to read the report…

R052016_160406_Godmersham

How Far Away is Death?

June 22nd, 2016 by

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Special thanks to TapRooT® Instructor, Jim Whiting for sending in the video.

Monday Accident & Lessons Learned: Collision between a tram and a pedestrian, Manchester

June 20th, 2016 by

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The UK Rail Accident Investigation Branch published a report about a tram hitting a pedestrian in Manchester, UK.

A summary of the report says:

At about 11:13 hrs on Tuesday 12 May 2015, a tram collided with and seriously injured a pedestrian, shortly after leaving Market Street tram stop in central Manchester. The pedestrian had just alighted from the tram and was walking along the track towards Piccadilly.

The accident occurred because the pedestrian did not move out of the path of the tram and because the driver did not apply the tram’s brakes in time to avoid striking the pedestrian.

As a result of this accident, RAIB has made three recommendations. One is made to Metrolink RATP Dev Ltd in conjunction with Transport for Greater Manchester, to review the assessment of risk from tram operations throughout the pedestrianised area in the vicinity of Piccadilly Gardens.

A second is made to UK Tram, to make explicit provision for the assessment of risk, in areas where trams and pedestrians/cyclists share the same space, in its guidance for the design and operation of urban tramways.

A further recommendation is made to Metrolink RATP Dev Ltd, to improve its care of staff involved in an accident.

For the complete report, see:

https://assets.digital.cabinet-office.gov.uk/media/5705107640f0b6038500004d/R062016_160412_Market_Street.pdf

 

Preparedness: Responding To An Accident

June 15th, 2016 by

Part One

 

Part Two

In these videos (Part One and Part Two above), Alan Smith introduces fascinating case studies of serious incidents he has been involved in and lessons learned. He is the former Head of Major Crime Operations – Grampian Police, Scotland. As a career detective, he was the lead investigator in numerous homicide investigations. He is a Certified TapRooT® Instructor/Facilitator and has in-depth experience in numerous offshore tragedies including Piper Alpha and the MV Bourbon Dolphin. He is an Accredited Senior Investigator in Counter Terrorism and Kidnap and Ransom. Alan is the former Chair of the Scottish Senior Investigating Officer’s Conference.

Alan will be co-teaching Interviewing & Evidence Collection Techniques at the 2016 Global TapRooT® Summit, August 1 & 2, San Antonio. He will also be leading a special session you don’t want to miss: Risk Assessing the Perfect Murder.

It’s not too late to register for the 2016 Global TapRooT® Summit!

How Far Away is Death?

June 15th, 2016 by

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Special thanks to TapRooT® instructor, Jim Whiting, for sending in the video.

Monday Accident & Lessons Learned: Can Tesla’s Autopilot Cut Accidents by 50% ?

June 13th, 2016 by

Automation versus manual human control … the result? Tesa predicts a 50% reduction in crashes even with their first version (and more with later revisions).

Here is the story …

http://www.techinsider.io/teslas-autopilot-reduces-accidents-2016-4

 Here’s the video – go to the 22 minute point to watch the comments about autonomous driving cars.

What do you think? Will automation drastically cut the accident rate?

Monday Accident & Lessons Learned: Why Arc Flash is Important

June 6th, 2016 by

Electrical energy helps us in many ways, but when it is misused and an arc flash occurs … perhaps this video will help people get the message that arc flash precautions are important!

WARNING – GRAPHIC CONTENT AT VARIOUS POINTS – DON’T WATCH IF YOU WILL BE UPSET

Want to learn more about arc flash safety? We have a session about it at the 2016 Global TapRooT® Summit. The session titled “Arc Flash Prevention” is from 1:40-2:50 on Thursday in the Safety Best Practices Track. 

Scott King and Terry Butler will present Employee and contractor protection utilizing general electrical principles as referenced by OSHA and NFPA 70E 2015 guidelines and qualified low voltage safety training.

Learning Objectives for this session include:

  • Provide an overview of the importance of Arc Flash Safety
  • Understanding Electrical Hazards
  • Safe Work Practices
  • Incident Energy Exposure Levels
  • Risk Assessment Analysis
  • Personal Protective Equipment (PPE)
  • Safety Training

See the complete 2106 Global TapRooT® Summit schedule at:

http://www.taproot.com/taproot-summit/summit-schedule

And register for the Summit at:

http://www.taproot.com/taproot-summit/register-for-summit 

 

 

 

 

What does a bad day look like?

May 31st, 2016 by

Since 2011 more than 2,000 accidents involving horses and riders have occurred on Britain’s roads.

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