Category: Accidents

Keeping TapRooT® Investigations Out of Court

December 18th, 2014 by

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We would all agree that performing accident investigations and investigations of quality issues to prevent repeat accidents is a good idea. But some may be reluctant to perform investigations because of the legal liability they think the investigation report may represent.

Of course, they are at least partially right. Frequently, significant accidents result in lawsuits. And if your investigators aren’t careful, they may put poorly chosen words or even un-true statements in their investigation report. Thus, company counsel or outside counsel may prefer that the actual accident investigation reports be excluded from evidence in a court proceeding to reduce the liability that an accident investigation report may represent.

Excluding a report performed after an accident to look for ways to prevent future accidents is a protected activity under federal law. FRE Rule 407. Subsequent Remedial Measures, states:

When measures are taken that would have made an earlier injury or harm less likely to occur, evidence of the subsequent measures is not admissible to prove:

  • negligence;
  • culpable conduct;
  • a defect in a product or its design; or
  • a need for a warning or instruction.

But the court may admit this evidence for another purpose, such as impeachment or — if disputed — proving ownership, control, or the feasibility of precautionary measures.

How can you help preserve your right to exclude your report from discovery and use at trial? Outside counsel for one of our clients has suggested that all TapRooT® users add one of the following preambles or appendices to every TapRooT® Investigation. We thought this sounded like a good idea and so we are passing along the following preambles or appendices for you to consider when writing your investigations….

For safety investigations at a company, the preamble suggested by the attorneys was as follows:

– – –

Note:

1. Substitute/insert the correct company name for “COMPANY” throughout, and

2. Add this preamble to every TapRooT® investigative report.

COMPANY TapRooT® Investigation Preamble

In order improve COMPANY’s overall safety performance and to prevent or significantly reduce the likelihood of the same or a similar work-related incident/injury/illness (“incident”) from reoccurring, COMPANY conducts a TapRooT® systematic investigative approach to incident investigation and analysis to solve significant performance problems and/or equipment failures that may arise from time to time during its operations. TapRooT® is an efficient and effective method that helps to identify best practices and/or missing knowledge related to an incident, which will allow COMPANY to execute/institute lasting fixes faster, thereby increasing reliability thru identification of remedial measures.  TapRooT® reveals root causes, causal factors, events, and/or conditions within COMPANY’s management control so that corrective action can be taken. Said more succinctly, root causes in TapRooT® are causes COMPANY management has control over.  The information generated during a TapRooT® investigation is essential to implementing an effective prevention program under the control of COMPANY’s management by using hindsight analysis of the incident to perform remedial measures.

TapRooT® is a system used to determine subsequent remedial measures COMPANY may take to improve future performance.  This investigation therefore is excluded from evidence under Federal Rule of Evidence 407 based on the policy of encouraging COMPANY to remedy hazardous conditions without fear that their actions will be used as evidence against them, that is, to encourage COMPANY to take, or at least not discourage them from taking steps in furtherance of added safety.

Incidents, injuries and illness may occur as a result of third parties’ conduct.  TapRooT® may not focus on the acts and/or omissions of third parties, contractors, subcontractors and/or vendors. Errors made by third-parties in design, repair, assembly, installation, construction, etc. are not the focus of TapRooT® inasmuch as COMPANY management has no control over errors made by these vendors except expected conformance with their duties owed to COMPANY.

Even though COMPANY makes every effort to determine what happened during an incident and to minimize future incidents through the COMPANY investigative team, TapRooT® is generated in hindsight and does not determine legal cause(s), “but for” causation, or proximate cause(s) of an incident. To infer this from a TapRooT® investigation would be a misuse of the TapRooT® analysis. Instead, TapRooT® determines events, conditions and causal factors in the root cause analysis. Each causal factor may have one or more root causes.  Any causal factors and/or recommendations which may be generated in a TapRooT® investigation are based on the investigator/ investigation team’s own views, observation, educated opinions, experience, and qualifications. TapRooT® identifies remedial measures to reduce the probability of events such as the one being investigated from happening in the future.  This information is not intended to replace the advice or opinion of outside COMPANY retained experts who may have more specialized knowledge in an area made the basis of this investigation. Equally important, while information gathered during a TapRooT® investigation is obtained from sources deemed reliable, the accuracy, completeness, reliability, or timeliness of the information is preliminary in nature until the final report is issued. Thus, the findings and/or conclusions of a TapRooT® investigation are subject to change based on information and data gathered during subsequent investigations by experts who may be more focused on legal causation, which is outside the scope of TapRooT®.

(1) FRE Rule 407. Subsequent Remedial Measures

When measures are taken that would have made an earlier injury or harm less likely to occur, evidence of the subsequent measures is not admissible to prove:

  • negligence;
  • culpable conduct;
  • a defect in a product or its design; or
  • a need for a warning or instruction.

But the court may admit this evidence for another purpose, such as impeachment or — if disputed — proving ownership, control, or the feasibility of precautionary measures.

– – –

For quality investigations subsequent to an issue with a product, the following preamble/appendix is suggested:

– – –

Note:

1. Substitute/insert the correct company name for “COMPANY” throughout, and

2. Add this preamble to every TapRooT® investigative report.

VENDOR TapRooT® Investigation Preamble

In order improve VENDOR’s overall quality performance and to prevent or significantly reduce the likelihood of the same or a similar quality issues from reoccurring which may lead to work-related incident/injury/illness or client related issues (“incident”), VENDOR conducts a TapRooT® systematic investigative approach to incident investigation and analysis to solve significant quality and/or performance problems and/or equipment failures that may arise from time to time during the use or manufacture of its products. TapRooT® is an efficient and effective method that helps to identify best practices and/or missing knowledge related to an incident, which will allow VENDOR to execute/institute lasting fixes faster, thereby increasing reliability thru identification of remedial measures.  TapRooT® reveals root causes, causal factors, events, and/or conditions within VENDOR’s management control so that corrective action can be taken. Said more succinctly, root causes in TapRooT® are causes VENDOR management has control over.  The information generated during a TapRooT® investigation is essential to implementing an effective prevention program under the control of VENDOR’s management by using hindsight analysis of the incident to perform remedial measures.

TapRooT® is a system used to determine subsequent remedial measures VENDOR may take to improve future performance.  This investigation therefore is excluded from evidence under Federal Rule of Evidence 407 based on the policy of encouraging VENDOR to remedy hazardous conditions without fear that their actions will be used as evidence against them, that is, to encourage VENDOR to take, or at least not discourage them from taking steps in furtherance of added safety and quality.

Incidents, injuries, illness, and quality issues may occur as a result of third parties’ conduct.  TapRooT® may not focus on the acts and/or omissions of third parties, contractors, subcontractors, vendors, and/or clients. Errors made by third-parties in design, repair, assembly, installation, construction, etc. are not the focus of TapRooT inasmuch as VENDOR management has no control over errors made by these third parties except expected conformance with their duties owed to VENDOR.

Even though VENDOR makes every effort to determine what happened during an incident and to minimize future incidents through the VENDOR investigative team, TapRooT® is generated in hindsight and does not determine legal cause(s), “but for” causation, or proximate cause(s) of an incident. To infer this from a TapRooT® investigation would be a misuse of the TapRooT® analysis. Instead, TapRooT determines events, conditions and causal factors in the root cause analysis. Each causal factor may have one or more root causes.  Any causal factors and/or recommendations which may be generated in a TapRooT® investigation are based on the investigator/ investigation team’s own views, observation, educated opinions, experience, and qualifications. TapRooT® identifies remedial measures to reduce the probability of events such as the one being investigated from happening in the future.  This information is not intended to replace the advice or opinion of outside VENDOR retained experts who may have more specialized knowledge in an area made the basis of this investigation. Equally important, while information gathered during a TapRooT® investigation is obtained from sources deemed reliable, the accuracy, completeness, reliability, or timeliness of the information is preliminary in nature until the final report is issued. Thus, the findings and/or conclusions of a TapRooT® investigation are subject to change based on information and data gathered during subsequent investigations by experts who may be more focused on legal causation, which is outside the scope of TapRooT®.

(1) FRE Rule 407. Subsequent Remedial Measures

When measures are taken that would have made an earlier injury or harm less likely to occur, evidence of the subsequent measures is not admissible to prove:

  • negligence;
  • culpable conduct;
  • a defect in a product or its design; or
  • a need for a warning or instruction.

But the court may admit this evidence for another purpose, such as impeachment or — if disputed — proving ownership, control, or the feasibility of precautionary measures.

– – –

Of course, before adopting any advice to reduce potential liabilities in future courtroom actions, you should consult your own in-house or outside counsel. They may modify the forms provided above or have other wording that they prefer.

So consider the advice provided above and get your own protective wording added to all your standard reports. We are looking at ways to add this to the TapRooT® Software and we’ll let you know when we’ve figured out a way to do it. Until then, we suggest manually adding the wording to your official final reports.

Monday Accident & Lessons Learned: OPG Safety Alert 262 – Shallow Gas Leads to Well Control Incident

December 15th, 2014 by

SHALLOW GAS LEADS TO WELL CONTROL INCIDENT

  • The well is located in a well-known, shallow gas prone area.
  • Deep gas wells with high pressurized layers.
  • Crowded platforms with wells anti-collision complex management.
  • SIMOPS including construction and well intervention
  • After each incident, procedures for shallow section drilling were enhanced.

The sequence of events were:

  • 0:00 – Skid rig on well. Batch drilled 12 ¼’’ hole section + 9 5/8’’ intermediate casing
  • 08:30 – Cleaned out CP 24’’ with 17 ½’’ BHA to 131m
  • 16:30 – Drilled 12 ¼’’ hole to 286m with 1.15+ SG mud. Heavy losses (67 m3/h)
  • 20:20 – Homogenize mud to 1.12 SG
  • 20:33 – Resume drilling to 296m. Heavy losses (70 m3/h)21:10 – Spot 10m3 LCM pill. POOH wet.
  • 22:20 – Well swabbing and started to flow. Closed diverter. Started pumping 1.12 SG mud at high flow rate.
  • 23:04 – Pumped kill mud 1.50 SG, followed by sea water at high rate.
  • 00:30 – Flow outside CP. Well out of control. Full rig evacuation.

What Went Wrong?

The cause of the incident could be listed as follows:

1. Supervision on rig

  • POOH wet (no pump out)
  • Continue with pulling operations, despite swabbing, until well kicked in. Shallow gas procedure not followed

2. Mud weight

  • Inconsistency in MW control and reporting
  • Pack off at 291m interpreted as a (new) loss zone

3. Documentation

  • No comprehensive instructions concerning total loss situation

Corrective Actions and Recommendations

  • Maintain a continuous awareness on shallow gas hazard, even when the shallow gas section has already been penetrated in other wells. This aims at avoiding routine approach hence complacency.
  • The standard drilling Instructions should be enriched and reinforced with lessons learnt e.g. Management of Change, the required concentration of KCl for the top hole section, the threshold of heavy losses, hole cleaning procedure for the top hole, responsibility assignment for key personnel, ‘Ready to drill’ checklist.

Disclaimer

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.

Safety Alert Number: 262
OGP Safety Alerts http://info.ogp.org.uk/safety/

Monday Accident & Lessons Learned: Fatal Auto Accidents

December 8th, 2014 by

REDWRECK

If a fatality happens at a business, OSHA descends to investigate. The company must come up with corrective actions that will make sure the accident never happens again.

When a traffic accident happens, police investigate. A ticket is given to the party at fault. And a lawsuit is probably filed. But nobody ever talks about making sure the accident never happens again. Root causes aren’t mentioned unless it is excessive speed, drunk driving, or distracted driving … and are those really root causes?

What is the difference?

Why are fatal traffic accidents seemingly acceptable?

Could we learn from fatal car accidents and make sure they never happen again?

What would have to change to make this learning possible?

Could we save 10,000, 20,000, or 30,000 lives per year here in the US?

Remembering An Accident: The Halifax Explosion

December 6th, 2014 by

On December 6, 1917, a ship traveling to France that carried approximately 9,000 tons of wartime explosives caught fire after a collision in the Halifax Harbour. The fire quickly ignited the explosives. Approximately 1,800 were killed and 9,000 were injured by the fire, debris and collapsed buildings.

Here is an article on History.com: http://www.history.com/this-day-in-history/the-great-halifax-explosion

And following is a video of the footage after the explosion, showing devastation and relief effort. 

We’ve all read the headlines about catastrophic events. Don’t let an accident of this magnitude devastate your city.  Learn root cause analysis techniques to investigate near-misses, and take proactive steps to avoid a major disaster. (Click here to find out more about TapRooT® Root Cause Analysis Training.)

Monday Accident & Lessons Learned: Don’t Wear a Scarf!

December 1st, 2014 by

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A woman, trying to board a London Underground train, stopped when the doors of the train shut. But her scarf swung forward and was trapped in the doors.

As the train pulled forward, she was dragged along the platform. A member of the staff tried to catch hold of her and help, but this caused her to fall to the platform.

The scarf was eventually pulled from around her neck and into the tunnel, still trapped in the train door.

The woman suffered injuries to her neck and back but was lucky that she wasn’t dragged into the tunnel and onto the tracks.

What are the lessons learned? See the UK RAIB report.

Or just stop wearing scarfs!

Monday Accident & Lessons Learned: Fatality Near-Miss Because of Corrective Actions NI or Corrective Action NYI

November 24th, 2014 by

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A recent rail accident report by the UK Rail Accident Investigation Branch described a facility maintenance failure that could have caused a fatality. Here’s a brief excerpt from the report:

 “At about 16:00 hours on Thursday 1 August 2013, concrete cladding fell from the bridge spanning Denmark Hill station, London, and most of the debris landed on platform 1. … The concrete cladding had been added to the bridge structure in about 1910 and fell because of gradual deterioration of the fixing arrangements. Deterioration of the cladding fixing arrangements had been reported to Network Rail over a period of at least four years but the resulting actions taken by Network Rail and its works contractor were inadequate.”

Under the Management System portion of the TapRooT® Root Cause Tree® you will find Corrective Actions Need Improvement and Corrective Actions Not Yet Implemented root causes under the under the Corrective Action near root cause. We used to abbreviate these CANYI and CALTA in the old days (Corrective Action Not Yet Implemented and Corrective Actions Less Than Adequate).

The TapRooT® theory of management requires that management implements effective corrective action once they are aware of a problem. The corrective action must not only be effective, but also it must be implemented in a timely manner (commensurate with the risk the problem presents). 

In this case, I would probably lean toward the Corrective Action Not Yet Implemented root cause, although, the Corrective Action Needs Improvement root cause might apply to the previous inadequate temporary fixes. 

What can you learn from this?

Does your management support effective timely corrective actions? Or do you have a large backlog of ineffective fixes? Maybe you need corrective action improvements!

Remembering An Accident: San Juanico Disaster

November 19th, 2014 by

On November 19, 1984, a series of explosions caused one of the deadliest industrial accidents in the history of the world.  The explosions occurred at a storage and distribution facility for liquified petroleum gas belonging to Petroleos Mexicanos. It is believed that the explosion started with a gas leak which caused a plume that grew large enough to be transported by the wind and reach a flare pit where it ignited.

The explosions and fires demolished most of the town of San Juan Ixhuatepec, and it is estimated that up to 600 people died and 5,000 – 7,000 people suffered severe injuries. The fire created such an inferno that most corpses were reduced to ashes, making it hard to determine who perished.

SanJuanico20

Learn more about the disaster.

When something catastrophic happens, companies often discover a series of errors and process flaws that were present all along. Advanced root cause analysis skills can help you uncover these error and flaws.  Visit our training page to find a course near you:

http://www.taproot.com/courses

 

 

Monday Accident & Lessons Learned: UK RAIB Report – Freight train derailment near Gloucester

November 10th, 2014 by

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Here’s the summary of the report:

At about 20:15 hrs on 15 October 2013, a freight train operated by Direct Rail Services, which was carrying containers, derailed about 4 miles (6.4 km) south west of Gloucester station on the railway line from Newport via Lydney. It was travelling at 69 mph (111 km/h) when the rear wheelset of the last wagon in the train derailed on track with regularly spaced dips in both rails, a phenomenon known as cyclic top. The train continued to Gloucester station where it was stopped by the signaller, who had become aware of a possible problem with the train through damage to the signalling system. By the time the train stopped, the rear wagon was severely damaged, the empty container it was carrying had fallen off, and there was damage to four miles of track, signalling cables, four level crossings and two bridges.

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The immediate cause of the accident was a cyclic top track defect which caused a wagon that was susceptible to this type of track defect to derail. The dips in the track had formed due to water flowing underneath the track and although the local Network Rail track maintenance team had identified the cyclic top track defect, the repairs it carried out were ineffective. The severity of the dips required immediate action by Network Rail, including the imposition of a speed restriction for the trains passing over it, but no such restriction had been put in place. Speed restrictions had repeatedly been imposed since December 2011 but were removed each time repair work was completed; on each occasion, such work subsequently proved to be ineffective.

The type of wagon that derailed was found to be susceptible to wheel unloading when responding to these dips in the track, especially when loaded with the type of empty container it was carrying. This susceptibility was not identified when the wagon was tested or approved for use on Network Rail’s infrastructure.

The RAIB also observes: the local Network Rail track maintenance team had a shortfall in its manpower resources; and design guidance for the distance between the wheelsets on two-axle wagons could also be applied to the distance between the centres of the bogies on bogie wagons.

The RAIB has made seven recommendations. Four are directed to Network Rail and cover reviewing the drainage in the area where the train derailed, revising processes for managing emergency speed restrictions for cyclic top track defects, providing track maintenance staff with a way of measuring cyclic top after completing repairs, and investigating how cyclic top on steel sleeper track can be effectively repaired. Two are directed to RSSB and cover reviewing how a vehicle’s response to cyclic top is assessed and amending guidance on the design of freight wagons. One is directed to Direct Rail Services and covers mitigating the susceptibility of this type of wagon to cyclic top.

For the complete report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/141009_R202014_Gloucester.pdf

Tulsa Public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

November 4th, 2014 by

Final case studies being presented in our Tulsa, Oklahoma course.

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For more information on our public courses click here or to book your own onsite course click here.

San Antonio 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

November 4th, 2014 by

Students presenting their final case studies on day 5 of the course. Students always learn something new in the case that they brought to be reviewed.

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For more information on our public courses click here or to book your own onsite course click here.

New York Post reports: “Huge drill almost skewers packed subway car”

November 4th, 2014 by

Once again, human error in the news …

A tragedy nearly occurred when a giant drill bit almost penetrated a subway full of people in New York.

See:

http://nypost.com/2014/10/30/massive-drill-bit-nearly-skewers-packed-subway-car/

Airplane Crashes: Pilot and People in a Simulator Die

November 4th, 2014 by

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Airplane loses power during take off at a Kansas Airport and plane strikes building. Pilot of the King Air Aircraft that crashed and 3 people working in a flight simulator inside that building are dead. Read more here at KAKE News in Wichita, KS.

I post this because of the debates and blame that are going to ensue. Was it just one thing, the plane crashing, that caused this issue to occur? Was it the location of all the flight buildings in the vicinity of an airport. Was this just a “freak accident”. So much more to learn… I hope they get it right so it does not happen again.

Washington Post reports: “Commercial spaceship suffers catastrophic failure, at least 1 dead”

October 31st, 2014 by

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The suborbital commercial flights give passengers a small taste of space travel by piloting international flights 62 miles above the Earth’s atmosphere for about $250,000 per seat.

So far, more than 700 prospective passengers have paid for tickets.

See:

http://www.washingtontimes.com/news/2014/oct/31/commercial-spaceship-suffers-catastrophic-failure-/

Did Retiring Warthogs to “Save Money” Lead to The Recent Friendly Fire Accident In Afganistan?

October 30th, 2014 by

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And interesting article in the Washing Post suggests that using a B-1B for night time close air support and insufficient training led to the death of 7 Americans and 3 allies in a friendly fire accident.

See the story at THIS LINK and see what you think.

How Do We Stop the Ebola Blame Game?

October 27th, 2014 by

The media debate about Ebola is subtly shifting from how to stop the spread of this horrific disease to finger pointing. How do we stop the blame game?

A recent analysis & opinion column (Reuters.com), “Why Finger Pointing about Ebola Makes Americans Less Safe,” suggests:

With Ebola, root cause analysis is going to be key to avoid mistakes in the future, but this will require a culture where it is safe to admit to errors.

Read the opinion here:

http://blogs.reuters.com/great-debate/2014/10/27/why-finger-pointing-about-ebola-makes-americans-less-safe/

And let us know what you think by commenting below. How can the healthcare community create a culture where workers are not afraid to self-report mistakes? Do you think root cause analysis is key to stopping Ebola?

Monday Accident & Lessons Learned: UK RAIB Accident Report on a Passenger Becoming Trapped in a Train Door and Dragged a Short Distance at Newcastle Central Station

October 27th, 2014 by

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Here is a summary of the report:

At 17:02 hrs on Wednesday 5 June 2013, a passenger was dragged by a train departing from platform 10 at Newcastle Central station. Her wrist was trapped by an external door of the train and she was forced to move beside it to avoid being pulled off her feet. The train reached a maximum speed of around 5 mph (8 km/h) and travelled around 20 metres before coming to a stop. The train’s brakes were applied either by automatic application following a passenger operating the emergency door release handle, or by the driver responding to an emergency signal from the conductor. The conductor, who was in the rear cab, reported that he responded to someone on the platform shouting at him to stop the train. The passenger suffered severe bruising to her wrist.

This accident occurred because the conductor did not carry out a safety check before signalling to the driver that the train could depart. Platform 10 at Newcastle Central is a curved platform and safe dispatch is particularly reliant upon following the correct dispatch procedure including undertaking the pre-dispatch safety checks.

The investigation found that although the doors complied with the applicable train door standard, they were, in certain circumstances, able to trap a wrist and lock without the door obstruction sensing system detecting it. Once the doors were detected as locked, the train was able to move.

In 2004, although the parties involved in the train’s design and its approval for service were aware of this hazard, the risk associated with it was not formally documented or assessed. The train operator undertook a risk assessment in 2010 following reports of passengers becoming trapped. Although they rated the risk as tolerable, the hazard was not recorded in such a way that it could be monitored and reassessed, either on their own fleet or by operators of similar trains.

As a consequence of this incident, RAIB has made six recommendations. One of these is for operators of trains with this door design to assess the risk of injuries and fatalities due to trapping and dragging incidents and take the appropriate action to mitigate the risk.

Two recommendations have been made to the train’s manufacturer. One of these is to reduce the risk of trapping on future door designs, and the other to review its design processes with respect to hazard identification and recording.
One recommendation has been made to the operator of the train involved in this particular accident. This is related to the management of hazards associated with the design of its trains and assessment of the risks of its train dispatch operations.

Two recommendations have been made to RSSB. One is to add guidance to the standard on passenger train doors to raise awareness that it may be possible to overcome door obstruction detection even though doors satisfy the tests specified within the standard. The other recommendation is the consideration of additional data which should be recorded within its national safety management information system to provide more complete data relating to the risk of trapping and dragging incidents.

See the complete report here:

http://www.raib.gov.uk/cms_resources.cfm?file=/140918_R192014_Newcastle.pdf

Monday Accident & Lessons Learned: Remove the Hazard – Snow & Ice Removal

October 13th, 2014 by

What do you have planned to keep walkways clear this winter?

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Here are some tips for snow and ice removal from WeatherChannel.com: (Read tips.)

Monday Accident & Lessons Learned: OPG Safety Alert #260 – Planning & Preparation … Key Elements for Prevention of MPD Well Control Accidents

October 6th, 2014 by

OPG Safety Alert #260

PLANNING AND PREPARATION – KEY ELEMENTS FOR PREVENTION OF MPD WELL CONTROL INCIDENTS

Summary

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?

  1. 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.
  2. 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.
  3. It was incorrectly assumed that monitored volume gains were due only to mud transfer.
  4. 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.
  5. Operational focus was on choke manifold flushing whereas supervision should have maintained oversight of the broader situation including well monitoring.

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Corrective Actions and Recommendations

  1. 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).
  2. 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).
  3. Install a landing nipple above the down hole circulation sub-assembly to allow a sealing drop dart to be run if required.
  4. Always close-in, or line-up, in such a way that allows for monitoring of all the closed-in pressures at all times.
  5. “Walk the lines” prior to commencing (concurrent) operations involving pressure and flow.
  6. Develop procedures in advance for flushing of the Well Control system, especially for recognisable potential cases of concurrent operations.
  7. Develop clear procedures covering all aspects of unconventional operations, including reasonably expected scenarios, and ensure effective communication of these to all relevant staff.

Disclaimer

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.

Remembering an Accident: Ajka Alumina Sludge Spill

October 4th, 2014 by

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.)

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