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High Potential Near Miss Dropped Object Dropped Wrench While Man-riding 17 th Sept 2010

High Potential Near Miss Dropped Object Dropped Wrench While Man-riding 17 th Sept 2010. Incident Investigation Findings Rowan JP Bussell. Presented by : Steve McWilliam, Shell Egypt N.V. OVERVIEW OF INCIDENT.

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High Potential Near Miss Dropped Object Dropped Wrench While Man-riding 17 th Sept 2010

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  1. High Potential Near Miss Dropped Object Dropped Wrench While Man-riding17th Sept 2010 Incident Investigation Findings Rowan JP Bussell Presented by : Steve McWilliam, Shell Egypt N.V.

  2. OVERVIEW OF INCIDENT • 17th September 2010 at 17:15 hrs. After completion of a liner cement job, a floorman was instructed to ride the man-riding winch to close the lo-torq valve and remove the cementing line. Employee ascended with hammer and TIW wrench and prior to closing the valve, the wrench weighing 1.8 kg fell 14 metres to the drill floor. No injuries occurred.

  3. POTENTIAL SEVERITY - Fatality

  4. WHAT HAPPENED • Liner was pulled back 2.5 metres after tagging bottom and cement job performed. The operation of closing valve was done after pulling back the liner running tool to the circulating position – hence working height of 14 metres. • Work Permit, Job Safety Analysis and man-riding checklist were in place for the job (more details in later section)

  5. WHY DID IT HAPPEN (Immediate Causes) • Snap hook connector not used correctly – tether should pass through the eye of the connector to prevent accidental drop-out. • Tools aloft hammer was correctly tethered but not the wrench. • Snap hook connector did not have locking device. • The above two conditions would allow the tether to drop out if the connector rotates – confirmed by reenactment. • Although disputed by floorman, the tool could have been removed from the connector to perform the task. Correct Incorrect

  6. CONTRIBUTING FACTORS (Failed / Missing Barriers) (1) • The running string was not spaced out or positioned to minimise the height at which this activity was performed. • The rig procedure for Working At Heights, identifies the risk of dropped objects and specifies the use of tool tethers and tools aloft register. • However, the requirement of only one tool per tether and the requirement to only use approved tethers through the eye of the connector is not explicitly stated in the procedure. • A pre-man-riding checklist was completed by the AD on the man-riding floorman prior to the job. However, this check was not effective in identifying the use of non-compliant tether. • The checklist was only available in English so Egyptian buddy-buddy checks not possible • The requirement to use checklist and the responsible person is not identified in the Working at Height procedure

  7. CONTRIBUTING FACTORS (Failed / Missing Barriers) (2) • Although snap hook connectors have been ordered as part of tool aloft kit from a reputable North Sea provider, the supplied connectors without locks are not aligned with the DROPS Forum handbook “Reliable Securing”. • Zip tie is not an approved tether and it’s short length (~30cm) may result in requirement to remove tool from connector to more easily perform the task. Zip tie was connected for purpose of hanging it on a hook outside the driller’s cabin. • There is no dedicated “tools aloft” tool for this job. Although the TIW (kelly cock) wrench is not the correct tool for the job, it was the best available at the time. The dedicated lo-torq wrench is a straight rod that is more difficult to use especially when working at heights.

  8. ROOT CAUSES (1) • DROPS Forum requirements for locking connectors has not fully penetrated the tool suppliers. • Examples of tool tethers from UK suppliers Non-compliant with DROPS Reliable Securing Compliant with DROPS Reliable Securing Handbook

  9. ROOT CAUSES (2) • Ergonomic “tools aloft” tool for closing lo-torq valves at height does not appear to exist. • Due to the frequency of man-riding activities on the JPB, there is a possible perception that it is routine activity, even though it is covered by PTW. • As a result, thoroughness / quality of pre-manriding checks inadequate • Insufficient challenge by the team to minimise the number and height of man-riding operations.

  10. OTHER OBSERVATIONS • All personnel involved (AD and 3 floormen) had attended the Tools at Height training and competency assessment forms completed. • “Red Zone” procedures were in place for controlled drill floor access and the area had been cordoned off for this job. • Requirement for man-riding during cementing operations : • Cementing operations requires 5 man-riding activities to connect / disconnect lines and open / close valves. • Floating drilling operations predominantly use pneumatic plug dropping heads due to the ban on man-riding activity while block is moving (drill string is compensated while cementing)

  11. ACTIONS

  12. SENV WELLS Learning From Incidents Background : This bulletin is an extension of the previous Early Learning Bulletin, subsequent to the full investigation and significant incident review. It also includes the recommendations considered most appropriate for lateral learning value. What happened: After cementing the liner, a floorman was instructed to man-ride to close the lo-torque valve and remove the cementing line from the cement head. The floorman ascended with hammer and wrench but before the valve could be closed, the wrench weighing 1.8kg fell 14 metres to the drill floor. No injuries occurred. • Investigation Findings: • Zip tie is not an approved lanyard. Its short length (~30cm) may have required the tool to be removed from the connector to perform the task. • The snap hook connectors were supplied as part of a kit from a reputable North Sea provider, but were not compliant with the Shell DROPS ABC Best Practice or the DROPS Forum Reliable Securing handbook which requires connectors to have a locking device. • Snap hook connector was not used correctly; cable tether should pass through the eye of the connector to prevent accidental opening of the gate. • There is no dedicated “tools aloft” tool for this job. • “Tools At Height” video shows use of non locking connector. • Red Zone Procedures (controlled drill floor access) as well as physical barriers for this particular job were in place and provided mitigation against serious injury. • DROPS gap analysis is only conducted against the mandatory requirements and a good level of compliance had been achieved. However, there are a lot of further best practices in the DROPs ABC that may not be captured in the gap analysis. • Lateral Learning Recommendations: • Check the type of snap hook connectors in the tools aloft kit to ensure they have a locking device • Review the tools aloft kit to ensure that it contains tools to perform all foreseeable working at heights tasks. • When rolling out the Tools At Height training, indicate the use of non-compliant connector when Peter clips the tool on the tether. • Once a good level of compliance has been achieved against the DROPS mandatory requirements based on gap analysis, it is recommended to systematically review compliance against the DROPS ABC Guide. Non-compliant (non-locking) connector and tether Compliant connector with locking

  13. Q&A

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