Category: Current Events

Corrective Action for Natural Disaster Category on the Root Cause Tree®

July 24th, 2014 by

Are you prepared for a tornado at your facility?

Watch what nuclear power plants (Watts Bar NPP – part of TVA) are doing …

Monday Accident & Lessons Learned: OPG Safety Alert – WELL CONTROL INCIDENT

July 21st, 2014 by

OGP Safety Alert

WELL CONTROL INCIDENT

While drilling 8″1/2 hole section @ 5052m with 1.51 SG MW, observe well flowing during pipe connection. Shut well in w/ 76 bbls gain. Establish 550psi SIDPP and 970psi SICP.

It took more than 7 minutes for the Driller to shut in after the well flowing situation was recognized (9 minutes 52 seconds total pumps off until well shut in) as follows: “The Mud Logger calls the dog house to inform the Driller that he has seen a gain in the trip tank; the Assistant Driller takes the call and communicates the information to the Driller. As the Driller is in the process of raising the blocks, he waits until the blocks are at 26m and calls the pit room to check that there is nothing that would affect the trip tank volume. He then waited for the return call which confirms nothing would affect the trip tank. The Driller switches over to the flow line as the trip tank is now nearly full and then lowers the TDS and screws back into the string at the rotary table. The string is then picked up and spaced out to close the annular mid joint; the Driller then unlocks the compensator. The annular is then closed by the Assistant Driller who is at the panel and the lower fail safes on the choke line are opened to monitor pressures.

Well was controlled using Drillers Method to circulate/increase MW up to 1.63 SG & decrease gas levels prior to open the well.

What Went Wrong?

Kick zone actual PP exceeds predicted PP range by ~0.07 SG EMW.

But actual PP < ECD (well not flowing while pumping).

76-bbl Kick Volume due to lengthy shut in Vs. ~30-bbl actual Kick Tolerance (KT) calculated from actual ~0.1 SG EMW Kick Intensity (design KT was 80 bbls calculated from maximum predicted PP). Note: There was gas in the influx, but no H2S. According to kick pressure & volume analysis, it is possible that part of the kick was liquid (influx density calculation). Influx density helped evacuating the kick w/out exceeding MAASP & fraccing @ shoe on exceeded KT.

Corrective Actions and Recommendations:

  1. Flow check each connection prior to starting the physical breaking of the tool joint (rather than flow check during connection).
  2. Ensure effective monitoring of the Mud Logging fingerprint screen during pumps-off real-time (connection & mid-stand “long connection test”).
  3. Correct shut-in procedure to be enforced & applied.
  4. Perform unannounced simulated kicks (kick drills).
  5. Whenever possible, implement a Well-Full-of-Gas capable casing design so that KT is not limited.

Source Contact:

safety alert number: 257 

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

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.

Blame Comes Quickly in Moscow Subway Accident – When Will the Root Causes Be Investigated?

July 16th, 2014 by

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The Cristian Science Monitor reported that the spokesperson for the Kermlin’s Investigative Committee (a police body) said:

As it is a man-caused accident, it is obvious that there are people responsible for it, so soon there will be suspects in the case.

Later the International Business Times published this headline:

Moscow Subway Accident: 2 Arrested Metro Workers Failed To Properly Supervise Track Switch Repair, Authorities Say

It seems the two arrested supervised a job where a track switch was re-wired with the wrong wire.

Twenty-one have died, over a hundred were injured, and over 1000 people had to be evacuated from the subway after the accident. 

What do you think? Will discipline solve the problem? Or does a real root cause analysis need to be done?

SmartGridNews.com reports “The U.S. grid is the worst in the industrialized world (outages are up 285%!)”

July 15th, 2014 by

The article starts with …

Power outages in the United States are up an astonishing 285% since 1984. The U.S. ranks last among the top nine Western industrialized nations in the average length of outages. That dismal performance costs American businesses as much as $150 billion every year according to the EIA.

It also has a map of power outage by state:

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CLICK HERE to see the whole article.

Monday Accident & Lessons Learned: UK RAIB Accident Report – Locomotive failure near Winchfield, 23 November 2013

July 14th, 2014 by

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The UK RAIB has issued an accident report about the failure of a locomotive near Winchfield, UK. This was a near-miss for a derailment. Here is the Summary:

At about 18:50 hrs on Saturday 23 November 2013, while a steam-hauled passenger train from London Waterloo to Weymouth was approaching Winchfield in Hampshire at about 40 mph (64 km/h), the right-hand connecting rod of the locomotive became detached at its leading end (referred to as the small end), which dropped down onto the track. The driver stopped the train immediately, about one mile (1.6 km) outside Winchfield station. There was some damage to the track, but no-one was hurt. The accident could, in slightly different circumstances, have led to derailment of the train.

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The immediate cause of the accident was that the small end assembly came apart, allowing one end of the connecting rod to drop to the ground. The reasons for this could not be established with certainty because some components could not be found after the accident. It is possible that the gudgeon pin securing nut unwound following breakage of the cotter and previous loosening of the nut. A possible factor is that the design of some components had been modified during the restoration of the locomotive some years earlier, without full consideration of the possible effect of these changes. There were deficiencies in the design and manufacture of the cotter. It is also possible, but less likely, that the securing nut split due to an inherent flaw or fatigue cracking.

RAIB has made four recommendations, directed variously to West Coast Railway Company, the Heritage Railway Association, and the Main Line Steam Locomotive Operators Association. They cover the maintenance arrangements for steam locomotives used on the national network, a review of the design of the small end assembly on the type of locomotive involved in the accident, guidance on the design and manufacture of cotters, and assessment of risk arising from changes to the details of the design of locomotives.

For the complete report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/140616_R132014_Winchfield.pdf

 

Quote from the New Your Times

July 13th, 2014 by

“These events revealed totally unacceptable behavior. They should never have happened. I’m upset, I’m angry, I’ve lost sleep over this, and I’m working on it until the issue is resolved.”

DR. THOMAS FRIEDEN, director of the Centers for Disease Control and Prevention, which halted shipments of infectious agents from the agency’s labs after accidents with anthrax and flu pathogens.

- – -

What do you think? Time for advanced root cause analysis to get beyond “bad behavior” cause?

Accident Causes Red Bull Flood on Florida Highway

July 9th, 2014 by

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Wildlife along I-95 got a caffein overdose when a truck caring Red Bull was involved in an accident. It may be days before they go to sleep and some worried that the animals may take programmers jobs once fully fueled on caffeine. 

See the real story by CLICKING HERE.

Press Release from the UK RAIB: Accident to a track worker near Redhill, 24 June 2014

July 8th, 2014 by

NewImageSite of the accident

 RAIB is investigating an accident to a track worker who was supervising a gang carrying out track maintenance work near Redhill in Surrey. The accident occurred at about 10:40 hrs on 24 June 2014. The track worker was struck by a passenger train and suffered serious injuries.

The injured person was with a gang of eleven people engaged in undertaking repairs to the Up Quarry line between Redhill Tunnel and Quarry Tunnel. The train, a passenger service from Gatwick Airport to London Victoria, was travelling at about 80 mph (129 km/h).

RAIB’s investigation will consider the sequence of events and factors that may have led to the accident, and identify any safety lessons.

RAIB’s investigation is independent of any investigations by the safety authority or the police. RAIB will publish its findings at the conclusion of the investigation. This report will be available on the RAIB website.

Monday Accident & Lessons Learned: UK Rail Accident Investigation Branch Releases Report on Accident at Balnamore Level Crossing, Ballymoney, Northern Ireland, 31 May 2013

July 7th, 2014 by

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Here’s the Summary from the report:

At approximately 03:10 hrs on Friday, 31 May 2013, a car driver was forced totake action in order to avoid colliding with an engineering train that was traversing Balnamore automatic half barrier level crossing, which is located between Coleraine and Ballymoney stations on Northern Ireland Railways’ Belfast to Londonderry/ Derry line. The car subsequently struck metal fencing forming part of the crossing, causing minor injuries to its two occupants and damage to the car. The crew of the engineering train spoke with the car driver and then continued work without reporting the accident.

At the time of the accident, the engineering train was undertaking weed-spraying operations within a possession of the line, which meant that operation of passenger trains on the line had been suspended. Because the line was under possession, Balnamore level crossing, which is normally automatically operated by approaching trains, was being operated manually via its local controls. However, as the train passed over the crossing, its half barriers had not been lowered and its road traffic signals were not operating, even though this was required by the railway rules relating to this type of level crossing. This meant that the car driver did not have enough warning to stop his car before the level crossing became occupied by the train.

The RAIB has found that the team responsible for undertaking weed-spraying was routinely not complying with the rules relating to the operation of automatic half barrier level crossings within possessions. This was probably due to a combination of factors, including the team possibly having a low perception of the risks presented by this non-compliance and a desire by them to complete the weed-spraying more quickly. In addition, the team may have been influenced by the status of rules relating to the local control of other types of crossing in possessions and the method of work adopted at level crossings during a recent project.

The RAIB has also found that this non-compliance was not detected or corrected by safety checks conducted by Northern Ireland Railways. In addition, the investigation identified that the appointment of additional competent staff to operate crossings within the possession may have prevented the accident from occurring.

The RAIB has identified three key learning points. These are: 1) that the person in charge of a possession should correctly complete the form intended to help them keep track of level crossings; 2) that boarding moving trains, where it is prohibited, should be avoided; and 3) that accidents should be reported.

The RAIB has also made three recommendations addressed to Northern Ireland Railways. These relate to: 1) ensuring that activities undertaken at level crossings within possessions are subject to effective risk controls; 2) ensuring that method statements relating to track engineering are supported by risk assessments; and 3) increasing the opportunities for non-compliances to be detected and corrected.

For the complete report, CLICK HERE.

Monday Accident & Lessons Learned: OGP Safety Alert – WELLHEAD GLAND NUT/LOCKSCREW ASSEMBLY EJECTION

June 30th, 2014 by

OGP SAFETY ALERT

A gas well installation suffered a loss of containment when a gland nut and lockscrew assembly was ejected from a wellhead while the well was under pressure, shortly before commencing tubing installation. The release of gas resulted in a fire which caused the death of a field service technician.

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Lockscrews are commonly used in surface wellhead equipment to mechanically energize or retain internal wellhead components. Lockscrews are not standardized across the industry, so manufacturers’ procedures should always be used for operations that may require manipulation of lockscrews. Work involving gland nut and lockscrew assemblies should be done under the supervision of qualified service personnel from the wellhead equipment provider who have access to the operational procedures, key dimensions, and torque ratings necessary for correct use.

Operators should consider working with their wellhead equipment and service providers to validate the integrity of gland nut and lockscrew assemblies that are exposed to wellbore pressure in the field by taking the following steps:

 

  1. Verify adequate engagement of gland nuts;
  2. Confirm lockscrew assemblies’ torque values are consistent with manufacturer’s specifications;
  3. Inspect lockscrew assemblies for any debris or damage such as scarring or bending;
  4. Follow manufacturer’s procedures if checks show any of the above are inconsistent with the manufacturer’s specifications;
  5. Conduct a pressure test to rated maximum working pressure to ensure gland nut and lockscrew assemblies have pressure integrity;
  6. Consider isolating gland nut and lockscrew assemblies from wellbore pressure by having tubing hangers and adapters installed;
  7. Reinforce with relevant personnel training and the use of procedures to address hazards associated with performing work on wellhead assemblies exposed to wellbore pressure; and
  8. Review and implement appropriate engineering and well design controls (physical design of equipment) and administrative controls (procedures) to address the hazards of work involving gland nut and lockscrew assemblies.

These same validation steps should be taken prior to commencing any well work during which gland nut and lockscrew assemblies will be exposed to wellbore pressure.

safety alert number: 256
OGP Safety Alerts http://info.ogp.org.uk/safety/

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.

 

 

Bad Day for the Blog…

June 25th, 2014 by

We had a technical malfunction this week and lost all the pictures, pdf’s, and other attachments that were uploaded to the blog. In addition, our whole web site was down for a little over 24 hours.

We will be working to recover the lost material but if you have trouble finding something … please be understanding.

Dan Verlinde is doing a TapRooT® investigation of the issue so we can prevent a recurrence.

Thanks for your understanding.

Monday Accident & Lessons Learned: Human Error Leads to Near-Miss at Railroad Crossing in UK – Can We Learn Lessons From This?

June 23rd, 2014 by

Here’s the summary from the UK RAIB report:

 

At around 05:56 hrs on Thursday 6 June 2013, train 2M43, the 04:34 hrs passenger service from Swansea to Shrewsbury, was driven over Llandovery level crossing in the town of Llandovery in Carmarthenshire, Wales, while the crossing was open to road traffic. As the train approached the level crossing, a van drove over immediately in front of it. A witness working in a garage next to the level crossing saw what had happened and reported the incident to the police.

The level crossing is operated by the train’s conductor using a control panel located on the station platform. The level crossing was still open to road traffic because the conductor of train 2M43 had not operated the level crossing controls. The conductor did not operate the level crossing because he may have had a lapse in concentration, and may have become distracted by other events at Llandovery station.

The train driver did not notice that the level crossing had not been operated because he may have been distracted by events before and during the train’s stop at Llandovery, and the positioning of equipment provided at Llandovery station relating to the operation of trains over the level crossing was sub-optimal.

The RAIB identified that an opportunity to integrate the operation of Llandovery level crossing into the signalling arrangements (which would have prevented this incident) was missed when signalling works were planned and commissioned at Llandovery between 2007 and 2010. The RAIB also identified that there was no formalised method of work for train operations at Llandovery.

The RAIB has made six recommendations. Four are to the train operator, Arriva Trains Wales, and focus on improving the position of platform equipment, identifying locations where traincrew carry out operational tasks and issuing methods of work for those locations, improvements to its operational risk management arrangements and improving the guidance given to its duty control managers on handling serious operational irregularities such as the one that occurred at Llandovery.

Two recommendations are made to Network Rail. These relate to improvements to its processes for signalling projects, to require the wider consideration of reasonable opportunities to make improvements when defining the scope of these projects, and consideration of the practicability of providing a clear indication to train crew when Llandovery level crossing, and other crossings of a similar design, are still open to road traffic.

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The full report has very interesting information about the possibility of fatigue playing a part in this near miss. See the whole report HERE.

This report is an excellent example of how much can be learned from a near-miss. People are more whilling to talk when a potential near-fatal accident happens than when a fatality happens. And all of this started because a bystander reported the near-miss (not the train crew or the driver).

How can you improve the reporting and investigation of potentially fatal near-miss accidents? Could your improvements in this area help stop fatalities?

 

 

Congressional Hearings on Whistleblowers and Delayed Investigations at the CSB

June 19th, 2014 by

I received an automated search response today that there were hearings on whistleblower reprisals, and delays in investigations at the Chemical Safety Board. Here are the links to written testimony from the committee’s web site:

http://docs.house.gov/Committee/Calendar/ByEvent.aspx?EventID=102380

Here’s a statement from the committee’s chairman and other committee members:

http://oversight.house.gov/release/hearing-today-report-leadership-failure-chemical-safety-board-jeopardizes-agency-mission-puts-safety-risk/

Here’s the written testimony of the CSB Chairman:

http://oversight.house.gov/wp-content/uploads/2014/06/Moure-Eraso-CSB.pdf

And here are two videos that I found on YouTube of part of the hearing (I wanted to see the whole hearing but this is all I could find):

 

What do you think?

 

Monday Accident & Lessons Learned: You Don’t Have to be in a High Risk Industry to be Killed on the Job

June 16th, 2014 by

 

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This fatal accident should remind all of us that you don’t have to be in a high risk occupation to be killed on the job. A forklift in the warehouse is all that is needed to provide the energy needed to start a fatal accident. See the press report here of a recent forklift fatality that is being investigated by OSHA:

http://www.pennlive.com/midstate/index.ssf/2014/06/jody_rhoads_amazon_osha.html

Proactive use of root cause analysis is needed in all sorts of industries to improve safety and prevent fatal accidents. Are you doing all you can to keep your employees safe?

Press Release from the UK RAIB: Derailment at London Paddington station 25 May 2014

June 12th, 2014 by

 

RAIB is investigating a derailment that occurred at London Paddington main line station, on Sunday 25 May 2014.

The train that derailed was an empty five car Class 360/2 passenger train (reporting number 5T08), manufactured by Siemens and operated by Heathrow Express. It was travelling from Old Oak Common to Paddington in preparation for entering passenger service.

At 05:20 hrs, both sets of wheels on the leading bogie of the third vehicle derailed to the left when the vehicle was about 150 metres from the buffer stops in platform 3 and travelling at between 12 and 14 mph (19.3 and 22.5 km/h).

The driver twice stopped the train after it derailed. On both occasions, unaware of what had happened, he restarted the train. As a consequence, the train ran nearly 100 metres in a derailed state and was finally stopped with the right side of the derailed bogie in a pit that was located between the rails, which lifted both wheels on the left side of the rear bogie off the rails. No one was injured.

Platform 3 remained closed for the remainder of the day.

NewImageImage of derailed vehicle at Paddington station

RAIB’s investigation will examine the sequence of events leading up to the derailment and will seek to identify the causes. This will include consideration of the design, maintenance and condition of both the track and the derailed vehicle.

RAIB’s investigation is independent of any investigation by the safety authority (the Office of Railway Regulation).

RAIB will publish its findings, including any recommendations to improve safety, at the conclusion of its investigation. These findings will be available on the RAIB website.

Maintenance Error Causes Fire at Power Plant in Colorado

June 10th, 2014 by

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A mechanic opened the wrong end of a filter causing oil to spray on hot piping. The immediate flash fire caused extensive damage at the Martin Drake power plant run by Colorado Springs Utilities.

See the Colorado Springs Fire Department report here:

http://www.pennenergy.com/content/dam/Pennenergy/online-articles/2014/06/CSFD%2BDuty%2BReport%2Bfor%2BDrake%2BFire%2B052314.pdf

Benna, Linda, and Michelle say: “Visit us at booth 1605 at the ASSE Conference!”

June 8th, 2014 by

Get your Spin-A-Cause™ when you stop by the booth at the ASSE Conference and talk to Linda, Benna, or Michelle at the TapRooT® Root Cause Analysis Booth.

LBM

Press Release from the US CSB: CSB Draft Report Finds Deepwater Horizon Blowout Preventer Failed Due to Unrecognized Pipe Buckling Phenomenon During Emergency Well-Control Efforts on April 20, 2010, Leading to Environmental Disaster in Gulf of Mexico

June 5th, 2014 by

 

CSB Draft Report Finds Deepwater Horizon Blowout Preventer Failed Due to Unrecognized Pipe Buckling Phenomenon During Emergency Well-Control Efforts on April 20, 2010, Leading to Environmental Disaster in Gulf of Mexico

 Report Says Similar Accident Could Still Occur, Calls for Better Management
of Safety-Critical Elements by Offshore Industry, Regulators

 Houston, Texas, June 5, 2014— The blowout preventer (BOP) that was intended to shut off the flow of high-pressure oil and gas from the Macondo well in the Gulf of Mexico during the disaster on the Deepwater Horizon drilling rig on April 20, 2010, failed to seal the well because drill pipe buckled for reasons the offshore drilling industry remains largely unaware of, according to a new two-volume draft investigation report released today by the U.S. Chemical Safety Board (CSB).

CLICK HERE to access Overview
CLICK HERE to access Volume 1
CLICK HERE to access Volume 2

The blowout caused explosions and a fire on the Deepwater Horizon rig, leading to the deaths of 11 personnel onboard and serious injuries to 17 others.  Nearly 100 others escaped from the burning rig, which sank two days later, leaving the Macondo well spewing oil and gas into Gulf waters for a total of 87 days. By that time the resulting oil spill was the largest in offshore history.  The failure of the BOP directly led to the oil spill and contributed to the severity of the incident on the rig.

The draft report will be considered for approval by the Board at a public meeting scheduled for 4 p.m. CDT at the Hilton Americas Hotel, 1600 Lamar St., Houston, TX 77010.  The meeting will include a detailed staff presentation, Board questions, and public comments, and will be webcast at:

http://www.csb.gov/investigations/webcast/.

The CSB report concluded that the pipe buckling likely occurred during the first minutes of the blowout, as crews desperately sought to regain control of oil and gas surging up from the Macondo well.  Although other investigations had previously noted that the Macondo drill pipe was found in a bent or buckled state, this was assumed to have occurred days later, after the blowout was well underway.

After testing individual components of the blowout preventer (BOP) and analyzing all the data from post-accident examinations, the CSB draft report concluded that the BOP’s blind shear ram – an emergency hydraulic device with two sharp cutting blades, intended to seal an out-of-control well – likely did activate on the night of the accident, days earlier than other investigations found.  However, the pipe buckling that likely occurred on the night of April 20 prevented the blind shear ram from functioning properly.  Instead of cleanly cutting and sealing the well’s drill pipe, the shear ram actually punctured the buckled, off-center pipe, sending huge additional volumes of oil and gas surging toward the surface and initiating the 87-day-long oil and gas release into the Gulf that defied multiple efforts to bring it under control.

The identification of the new buckling mechanism for the drill pipe ­– called “effective compression” – was a central technical finding of the draft report.  The report concludes that under certain conditions, the “effective compression” phenomenon could compromise the proper functioning of other blowout preventers still deployed around the world at offshore wells.  The complete BOP failure scenario is detailed in a new 11-minute computer video animation the CSB developed and released along with the draft report.

The CSB draft report also revealed for the first time that there were two instances of mis-wiring and two backup battery failures affecting the electronic and hydraulic controls for the BOP’s blind shear ram.  One mis-wiring, which led to a battery failure, disabled the BOP’s “blue pod” – a control system designed to activate the blind shear ram in an emergency.  The BOP’s “yellow pod” – an identical, redundant system that could also activate the blind shear ram – had a different miswiring and a different battery failure.  In the case of the yellow pod, however, the two failures fortuitously cancelled each other out, and the pod was likely able to operate the blind shear ram on the night of April 20.

“Although both regulators and the industry itself have made significant progress since the 2010 calamity, more must be done to ensure the correct functioning of blowout preventers and other safety-critical elements that protect workers and the environment from major offshore accidents,” said Dr. Rafael Moure-Eraso, the CSB chairperson. “The two-volume report we are releasing today makes clear why the current offshore safety framework needs to be further strengthened.”

“Our investigation has produced several important findings that were not identified in earlier examinations of the blowout preventer failure,” said CSB Investigator Cheryl MacKenzie, who led the investigative team.  “The CSB team performed a comprehensive examination of the full set of BOP testing data, which were not available to other investigative organizations when their various reports were completed.  From this analysis, we were able to draw new conclusions about how the drill pipe buckled and moved off-center within the BOP, preventing the well from being sealed in an emergency.”

The April 2010 blowout in the Gulf of Mexico occurred during operations to “temporarily abandon” the Macondo oil well, located in approximately 5,000-foot-deep waters some 50 miles off the coast of Louisiana.  Mineral rights to the area were leased to oil major BP, which contracted with Transocean and other companies to drill the exploratory Macondo well under BP’s oversight, using Transocean’s football-field-size Deepwater Horizon drilling rig.

The blowout followed a failure of the cementing job to temporarily seal the well, while a series of pressure tests were misinterpreted to indicate that the well was in fact properly sealed.  The final set of failures on April 20 involved the Deepwater Horizon’s blowout preventer (BOP), a large and complex device on the sea floor that was connected to the rig nearly a mile above on the sea surface.

Effective compression, as described in the draft report, occurs when there is a large pressure difference between the inside and outside of a pipe.  That condition likely occurred during emergency response actions by the Deepwater Horizon crew to the blowout occurring on the night of April 20, when operators closed BOP pipe rams at the wellhead, temporarily sealing the well.  This unfortunately established a large pressure differential that buckled the steel drill pipe inside the BOP, bending it outside the effective reach of the BOP’s last-resort safety device, the blind shear ram.

“The CSB’s model differs from other buckling theories that have been presented over the years but for which insufficient supporting evidence has been produced,” according to CSB Investigator Dr. Mary Beth Mulcahy, who oversaw the technical analysis.  “The CSB’s conclusions are based on real-time pressure data from the Deepwater Horizon and calculations about the behavior of the drill pipe under extreme conditions.  The findings reveal that pipe buckling could occur even when a well is shut-in and apparently in a safe and stable condition.  The pipe buckling – unlikely to be detected by the drilling crew – could render the BOP inoperable in an emergency.  This hazard could impact even the best offshore companies, those who are maintaining their blowout preventers and other equipment to a high standard.  However, there are straightforward methods to avoid pipe buckling if you recognize it as a hazard.”

The CSB investigation found that while Deepwater Horizon personnel performed regular tests and inspections of those BOP components that were necessary for day-to-day drilling operations, neither Transocean nor BP had performed regular inspections or testing to identify latent failures of the BOP’s emergency systems. As a result, the safety-critical BOP systems responsible for shearing drill pipe in emergency situations – and safely sealing an out-of-control well – were compromised before the BOP was even deployed to the Macondo wellhead.  The CSB report pointed to the multiple miswirings and battery failures within the BOP’s subsea control equipment as evidence of the need for more rigorous identification, testing, and management of critical safety devices.  The report also noted that the BOP lacked the capacity to reliably cut and seal the 6-5/8 inch drill pipe that was used during most of the drilling at the Macondo well prior to April 20 – even if the pipe had been properly centered in the blind shear ram’s blades.

Despite the multiple maintenance problems found in the Deepwater Horizon BOP, which could have been detected prior to the accident, CSB investigators ultimately concluded the blind shear ram likely did close on the night of April 20, and the drill pipe could have been successfully sealed but for the buckling of the pipe. 

“Although there have been regulatory improvements since the accident, the effective management of safety critical elements has yet to be established,” Investigator MacKenzie said.  “This results in potential safety gaps in U.S. offshore operations and leaves open the possibility of another similar catastrophic accident.”

The draft report, subject to Board approval, makes a number of recommendations to the U.S. Department of Interior’s Bureau of Safety and Environmental Enforcement (BSEE), the federal organization established following the Macondo accident to oversee U.S. offshore safety. These recommendations call on BSEE to require drilling operators to effectively manage technical, operational, and organizational safety-critical elements in order to reduce major accident risk to an acceptably low level, known as “as low as reasonably practicable.”

“Although blowout preventers are just one of the important barriers for avoiding a major offshore accident, the specific findings from the investigation about this BOP’s unreliability illustrate how the current system of regulations and standards can be improved to make offshore operations safer,” Investigator MacKenzie said.  “Ultimately the barriers against a blowout or other offshore disaster include not only equipment like the BOP, but also operational and organizational factors.  And all of these need to be rigorously defined, actively monitored, and verified through an effective management system if safety is to be assured.”  Companies should be required to identify these safety-critical elements in advance, define their performance requirements, and prove to the regulator and outside auditors that these elements will perform reliably when called upon, according to the draft report.

The report also proposes recommendations to the American Petroleum Institute (API), the U.S. trade association for both upstream and downstream petroleum industry. The first recommendation is to revise API Standard 53, Blowout Prevention Equipment Systems for Drilling Wells, calling for critical testing of the redundant control systems within BOP’s, and another for new guidance for the effective management of safety-critical elements in general.

CSB Chairperson Rafael Moure-Eraso said, “Drilling continues to extend to new depths, and operations in increasingly challenging environments, such as the Arctic, are being planned.  The CSB report and its key findings and recommendations are intended to put the United States in a leading role for improving well-control procedures and practices.  To maintain a leadership position, the U.S. should adopt rigorous management methods that go beyond current industry best practices.”

Two forthcoming volumes of the CSB’s Macondo investigation report are planned to address additional regulatory matters as well as organizational and human factors safety issues raised by the accident.

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Barb PhillipsBarb Phillips
Editorial Director
Chris ValleeChris Vallee
Human Factors & Six Sigma
Dan VerlindeDan Verlinde
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Dave JanneyDave Janney
Safety & Quality
Ed SkompskiEd Skompski
Medical Issues
Ken ReedKen Reed
Equifactor®
Linda UngerLinda Unger
Vice President
Mark ParadiesMark Paradies
Creator of TapRooT®
Megan CraigMegan Craig
Media Specialist
Steve RaycraftSteve Raycraft
Technical Support

Success Stories

Our challenge was to further improve the medication administration process at our facility by proactively…

Jackson County Memorial Hospital

We started using TapRooT® in the mid 1990s after one of our supervisors wanted to instill a more formal process to our investigations…

CONOCO PHILLIPS
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