chain hoist failure on mpd flow line. 2 our world is getting deeper chain hoist failure bop and...

Chain Hoist Failure on MPD Flow Line

Our World is Getting Deeper 2

Chain Hoist FailureChain Hoist Failure

• BOP and Riser running operations completed after an extensive repairs and maintenance

period while the BOP was on surface.

• Managed Pressure Drilling (MPD) choke and lines had to be rigged up: two 3rd Party

Contractor personnel & one Company personnel.

• Section of pipe (3.2mx320kg) required to be installed on the lower platform of the BOP

transporter. A 1T chain fall was added to provide additional reach

• PTW & JSA in place; however, Area Supervisor did not review the PTW and JSA correctly.

• Agreed amongst the team that the Contractor supervisor would operate the auxiliary hoist

• Hook not directly above the load; intention to man-handle the pipe clear of obstructions, no

consideration for tag lines.

• During the lift the pipe was seen to get caught under the flange. Both personnel made

attempts to stop

• Operator did not respond and continued to hoist the load, the upper chain hoist hook

stretched beyond its elastic limit, reached its yield point, and the load dropped



•The entire assembly with rigging fell to the deck, part of the rigging struck the IP’s hard hat

and knocked it off his head. The IP sustained a superficial 1.5cm laceration to his forehead as

a result. •DROPS calculator indicates Probable Fatality for the 7kg chain hoist.


Chain Hoist FailureChain Hoist FailureSummary:Critical FactorsInadequate control of lift allowed the load to be caught under the overboard valve flangeresulting in overload and failure of the chain hoistImproper positioning of people allowed IP to be in an unsafe position.

Immediate/System CausesInadequate control of 3rd Party Contractor

– Bridge crane operated by 3rd Party Contractor contrary to Company Policy– Company AD allowed this to happen

Poor leadership by Area Authority– Task not fully understood; worksite and controls not audited before

endorsing the PTW & JSAInadequate implementation of PNA safety processes by the team

– JSA completed but not appropriate for the task. The supporting T5 risk assessment process not followed and therefore appropriate controls not identified and implemented.

– No lifting plan, no tag lines, hands on load where not required, no additional supervision, positions of people, no dedicated banksman.



• Safety Stand Downs to be performed by Company Management; application of HSE policy in

relation to the incident to be a primary focus.• Post lists of trained and approved operators of mechanised handling equipment• 3rd Party Contractors to take immediate CoW refresher training & 3 monthly thereafter.• Develop specific JSA for MPD rig up and rig down• Amend Job Descriptions to include clear expectations of an Area Supervisor within the roles

and responsibilities, to be reviewed with the OIM and countersign. • Area Supervisor will cascade the HSE Policy presentation to his team including 3-5 of his

personal expectations.• Review effectiveness & implementation of the following and amend as necessary:

• 3rd Party Inductions & 3rd Party Management

• Lift Planning & Lifting Guidelines• Better planning of work • Update PTW manual to include the requirement for periodic site visits by Area Supervisors.

Record of PTW signatories will be updated to ensure the requirement is effectively

communicated.


SummaryWhilst running in the hole with 5 1/2” drill pipe, a service loop retainer bar on the vertical traverse arm of the Upper Bridge Racking Crane fell to the rig floor. The retainer bar broke free from its mounting on the upper bridge racking crane, when it contacted a stand of drill pipe that was racked back in the forward setback area.BackgroundWhilst making a connection at the rotary table an alarm tripped within the Zone Management System due to equipment proximity & collision risk.

In order to clear this the Pipe Handling Operator utilised a “Manual Mode” which allowed a greater range of operational envelope for the Vertical Pipe Handler and an increased risk of collision with the setback.

DROPS HiPo


DROPS HiPo

During the installation and commissioning of the VPH the BRC service loop was identified as a possible snagging point on the Top Drive. Concerns were raised and consideration given to a modification, possibly a drag chain.

The drag chain required engineering and support from specialist contractor thus was not an instant fix; an interim solution utilised by Company on two other similar systems in its fleet was therefore installed; this was retro fitted retention loop.


As a temporary measure a retaining bar was fitted. The material utilised was 16mm stub bar approximately 430mm in length and formed into the required shape. It was covered with heavy duty wire spiral in order to prevent chaffing of the loops on the thread.

There is/was no Management of Change (MOC), or Request for Engineering Support (RES) in place for this modification.

The positioning of the retaining bar is indicated top right, the bar following the DROPS bottom right.

DROPS HiPo


Whilst working to overcome the Zone Management System alarm the VPH was operated in manual mode and came into very close proximity to the setback, as depicted in the photograph.

The retainer bar struck against the setback and subsequently fell as a result of the contact.

The PHO was aware of the proximity and stated that he did see a slight contact with the service loop and setback.

DROPS HiPo


A person crossing the aft drillfloor from the doghouse heard the retaining bar fall and investigated.

He was approximately 3m away at the time of impact.

DROPS calculator indicates a FATAL outcome had he been struck.

DROPS HiPo

XX


Actions3 Use of protective equipment or methods3.5 Disabled guards, warning systems or safety devicesThe use of Manual whilst it is a required operating mode, effectively removes certain parameters from the system thus allowing a greater range of movement and the possibility for collision into the setback. Conditions4 Lack of focus or inattention4.6 Routine activity without thoughtManual mode is utilised frequently without any real consideration given to the hazards that are inherent in its use, particularly whilst operating in proximity to the setback. 5 Protective systems5.1 Guards or protective devices not effectiveThe design of the retaining bar was woefully inadequate as a working solution. A sturdier, better engineered, & none threaded bar should have been fitted.

Possible Immediate Causes


Personal factors13 Behaviour13.1 Antecedent not presentNo prompt present in the PHO cabin in the form of a placard/sign as a reminder that Manual mode requires extra care and attention when in use. 13.2 Antecedent not effectivePrevious training regards certain limitations of the system being removed in Manual mode, plus his seeing the VPH in close proximity to the stands were not enough to cause him to stop and rethink the operation. Job factors15 Training/Knowledge Transfer15.3 Knowledge Transfer Not EffectiveA well established OEM course was delivered, the practical aspect reiterating the requirement to pay extra care and attention in manual mode. This however was not effective in this case at driving home the importance of paying attention whilst in Manual/Direct Mode.

Possible System Causes


Conditions16 Management/supervision/employee leadership16.10 Risk analysis not effectiveA lack of understanding by senior personnel with regard the potential hazards inherent whilst operating in Manual mode.

18 Engineering/design18.1 Technical design not correctThe design of the retaining bar was woefully inadequate as a working solution. A sturdier, better engineered, & none threaded bar should have been fitted. The design should have been appropriately reviewed by several personnel and approved through the proper channels utilising management of change.

18.5 Assessment of Operational Effectiveness not EffectiveRetainer bar installation occurred after VPH commissioned with no revalidation of acceptance.

Possible System Causes (continued)


19 Control of Work (CoW)19.2 Risk assessment not effectiveA general lack of understanding with regard the potential hazards inherent whilst operating in Manual mode was apparent; no mention of hazards related were present on the JSA.22 Standards/Practices/Procedures (SPP)22.2 Development of SPP not effectiveProcedure for tripping with the VPH made no mention of Manual Mode, therefore any review and subsequent JSA would not incorporate the hazards associated as a result.23 Communication23.2 Vertical communication between Supervisor and Person not effectiveCommunication between the Driller and PHO did exist but was not effective via the talk-back system. The driller had to resort to using the telephone in order to effectively communicate.23.4 Communication between work groups not effectiveFinal installation of the retaining bar was not properly communicated between the project and operation team; the operation team had little input into the design and were not provided with any follow up information following the installation.

Possible System Causes (continued)


Operating Procedure (s) to be updatedJSA to be developed regarding VPH Operating Modes JSA to be updated to include hazards related to utilising Manual/Direct mode. Develop, install, & commission permanent retaining method for service loopImplement interim inspection plan to reduce potential damage service loopInstallation of Rig Floor Color Coding of Hazardous AreasEvaluate Enhanced Communication Capabilities between Driller & PHOComplete installation of lights/alarms on Lower Guide Arm on rig floorHazard ID training (with specific focus on VPH)Contractor Operator Training to be reviewedEvaluate/implement method to reduce use of Manual Mode Any after market/non-OEM modifications subject to rigorous MOC and testing/acceptance

Action Items

chain hoist failure on mpd flow line. 2 our world is getting deeper chain hoist failure bop and...

Documents

deeper chain hoist failure

upper chain hoist hook

auxiliary hoist hook

rd party contractor

contractor supervisor

t chain fall

area supervisor

team jsa