Through its management efforts in the Gulf of Mexico (GOM), Minerals Management Service (MMS), an agency of the US Department of the Interior, has identified accident investigations as a critical element of its safety strategy.
These investigative efforts culminate in reports that contain information on the circumstances surrounding the accidents, the root cause or causes of the accidents, and recommendations to prevent recurrences of such incidents.
MMS uses these findings to perform accident trend analyses, which allow MMS and industry to identify possible trends within a company or within the industry at large. Additionally, these analyses provide possible predictive indicators that allow necessary pre-emptive actions to be taken.
Common causes
The GOM's Outer Continental Shelf (OCS) currently has more than 7,000 active leases covering more than 39 million acres with about 35,000 personnel working offshore on more than 3,850 platforms and 200 drilling rigs.
MMS' recent investigations of fatal accidents in the OCS have revealed that the fatalities occurred during the performance of day-to-day tasks.
The tasks ranged from common production activities such as blowing down a pipeline and bringing a well back on production to equally common construction activities such as the removal of a section of platform piping and the rigging up of a platform drilling rig.
The investigations further revealed that common causes contributing to each of these accidents were procedural and communicative in nature. In each of the accidents, a lack of written, procedural guidelines for the performance of these routine tasks was identified as a cause of the accidents. Additionally, a majority of the accidents showed a lack of very basic and necessary communications before and during each task.
Recent accidents
Brief descriptions of some of the above-referenced accidents are as follows:
- During removal of a platform's drain-line system, condensate flowed from a cut being made in a section of piping with an electric band saw. A fire resulted, claiming the life of one employee and injuring another.
The fuel source of the fire was concluded to have been a process vessel that had not been isolated from the section of pipe being removed.
The MMS investigation (OCS Report MMS 2000-029) revealed, in part, the following:
- There were no written procedures for the construction work to be performed.
- Certain important communications between the designated operator and the construction contractor bypassed the platform's operating contractor.
- Planned work on the process vessel, which ultimately led to the discharge of the fire's fuel source, was not discussed in the pre-job safety meeting.
- Communications of the hot work to be performed and the understanding of the hot-work permitting process by some were critically lacking.
- While a gas well was being brought back on production, the well's manual wing valve was opened against a closed boarding shutdown valve on another platform that had inadvertently not been opened by the employees performing the task.
As a result, a section of piping was over-pressured and subsequently ruptured, allowing gas to escape and ignite.
The ensuing fire resulted in one fatality and two injuries. MMS' investigation revealed in part that a serious lack of communication existed between the two employees involved with respect to the exact steps to be taken in performing the task.
The investigation also revealed that no written procedures existed for the process of bringing a shut-in well back on production (OCS Report MMS 99-0067).
- During the final rigging-up stages of a platform drilling rig, the upper substructure was being skidded to accommodate the placement of the derrick when the supporting structure tilted, causing a partial collapse of the rig. The accident resulted in three fatalities and 12 injuries.
The potential for many more fatalities and injuries for this accident was very high. MMS' investigation revealed in part that a lack of various written procedural guidelines on the part of the drilling contractor resulted in a lack of critical yet simple calculations.
The investigation also revealed a critical inconsistency between engineering analysis assumptions and field conditions at the time of the accident and communication problems among all parties involved (OCS Report MMS 99-0027).
- During an attempt to blow down a well's casing pressure, an employee attached a bent piece of tubing to a blow-down valve assembly. When a valve on the assembly was opened to release the casing pressure, the bent tubing rotated rapidly, fatally striking the employee.
The MMS investigation revealed in part that the designated operator had no written procedures for blowing down casing pressure (OCS Report MMS 99-0009).
- While attempting to blow down a pipeline through a pig launcher, two employees were fatally injured when the launcher exploded as the closure lid of the launcher was being opened under pressure by one of the employees. MMS' investigation revealed in part that there were no written procedures for blowing down a pipeline.
It was also revealed that the operations supervisor at the time of the accident considered the use of the launcher to be an unacceptable method for blowing down a pipeline. A previous supervisor, however, officially commended one of the employees for doing so in a previous pipeline blow-down operation.
Other communication problems were also revealed (OCS Report MMS 96-0069).
Addressing the issues
Analyses of these events make clear that all tasks pose certain hazards, which if not identified and addressed, can contribute to an accident. The best way to identify and address hazards associated with a task is to analyze each step involved in the task systematically, identify the hazards in each step, and formulate a strategy for either eliminating or controlling as much as possible every identified hazard.
Job hazards analysis (JHA) and the job safety analysis (JSA) provide two industry-recognized, systematic techniques for hazard analyses.
JHAs are used to review the scope of work to be performed on a broad scale and can uncover hazards overlooked in the original design, mock-up, or setup of a particular process, operation, or task.
JHAs can also locate hazards that developed after a particular process, operation, or task was implemented, as well as indicate the need for modifying processes, practices, operations, and tasks.
A JSA, on the other hand, is a process used to review site-specific detailed job steps and uncover hazards that may have:
- Been overlooked in the layout of the facility or building and in design of the machinery, equipment, tools, workstations, and processes.
- Developed after the process started.
- Resulted from changes in work procedures or personnel.
Used together, JHAs and JSAs provide a very effective method of identifying hazards.
When the hazards have been identified and their severity evaluated, a strategy must then be developed to eliminate or reduce these hazards. This strategy includes developing operating procedures. These procedures should incorporate safe work practices and involve multiple JSAs to ensure that the hazards have been addressed.
These procedures must then be made available to the employees performing the tasks. To do so, JHAs and JSAs must be provided in a written format, and updated as needed, for all pertinent operations. This process of mitigating hazards and developing operating procedures is commonly used in industry for situations in which the inherent risks are recognizably high.
Unfortunately, this process is not used as frequently in the more day-to-day tasks. Thus, the aforementioned accidents highlight the need to use hazards identification and the development of written, detailed operating procedures for all tasks, including those that may be considered routine and are commonly performed on a daily basis.
Communications
Further analysis of these accidents reveals that a lack of communication within and among the various parties involved. In these events and in other investigations conducted by MMS, the need for effective communication is identified and highlighted as a critical element in the process of successfully and safely accomplishing a task.
It is also observed that the need for effective communication increases proportionately as the number of participating personnel and contracting companies increases and as the number of tasks simultaneously conducted increases. Effective communications allow all involved parties to become aware of the operations to be conducted and identify the roles and responsibilities of each party in safely accomplishing that task.
Responsibility
When it is discovered during an accident investigation that an employee did something that contributed to the accident (i.e., not observing a pressure gauge, opening the wrong valve, or failing to communicate with a fellow employee), there is an initial tendency to view the accident as primarily one of human error.
Upon further analysis, however, such errors, including those listed in the above examples, often occur as a result of a management-system failure.
Identifying and addressing those aspects of a task that are potentially hazardous is an organizational responsibility. Providing written operating procedures that, if followed, would have eliminated or lessened the severity and likelihood of identified hazards is part of that organizational responsibility.
Ensuring effective communication within a company is also another organizational responsibility. Failure to ensure that these elements are present within an organization is a management-system breakdown. These elements represent only part of a lessee's management responsibility in ensuring clean and safe operations.
Failure or breakdowns in other management responsibility areas include, but are not limited to, training, quality assurance, managing changing conditions and operations, and verifying adherence to internal policies.
Standards
The need for a system that encompasses all phases of management responsibility in conducting safe and clean oil and gas operations on the OCS has been recognized by both industry and MMS. This need prompted the collaborative effort between industry and MMS that resulted in the establishment of an industry standard-API Recommended Practice 75.1
This document was later revised as a Second Edition in July 1998 in an attempt to bridge the management systems between the lessee and its contractors. RP 75 provides a framework for establishing a management program and a method for verifying the program's effectiveness.
A large number of lessees have incorporated the elements of RP 75 into their management scheme and made the principles of the elements part of their operating philosophy. In fact, many lessees have expanded upon the elements of RP 75 to take into account the management systems they may have already had in place.
MMS continues to support this document and encourages all lessees operating on the OCS to adopt similar programs. Although these types of management systems will not prevent all accidents from occurring, they do provide a very reliable system of trying to minimize and prevent the recurrence of undesirable events. F
Reference
- API Recommended Practice 75, Recommended Practice for Development of a Safety and Environmental Management Program for Outer Continental Shelf (OCS) Operations and Facilities, First Edition 1993.
The authors
Joe Gordon graduated from the University of Missouri-Rolla with a BS in petroleum engineering. Upon graduation, he worked in production operations for Murphy USA in the East Texas area. Gordon then joined MMS as a staff engineer in the technical assessment group in the Gulf of Mexico region. Currently, Gordon is chief of the Office of Safety Management, an office responsible for coordinating the Gulf of Mexico's OCS safety program.
David Dykes joined the MMS in August 1999 and is the safety and environmental management specialist for the Gulf of Mexico region Office of Safety Management. He holds a BS in petroleum services technology from Nicholls State University. Dykes has 15 years' experience in oil and gas production operations and has worked for Maxus Energy, Burlington Resources, and Taylor Energy Co. His responsibilities in the Office of Safety Management include prioritizing and coordinating the operator annual performance review meetings, conducting accident investigations, and auditing operators' safety and environmental management programs.
Frank Pausina is currently senior accident investigator for MMS' Gulf of Mexico region. He has been with the MMS for 26 years, during which time he also served as a civil penalty reviewing officer and supervisor of the measurement and exploration-development plans units. Previously, he was a contract claims analyst with the US Navy. Pausina holds a BS in mathematics from the University of New Orleans and an ME in engineering from Tulane University.
