Dropped Object Incident Investigation

SIRS Incident # 1169

Job: Pulling 13.3/8” Casing

Winston Longue, Far East QHSE Manager

This document contains confidential and proprietary information which is the property of Frank ’s International. None of the information contained herein may be disclosed, reproduced, distributed or used without prior wr itten

consent from Frank’s International. © 2013 Frank’s International. All rights reserved.

Incident Summary

Job - Laying Out Casing with Varco 200T SSD Elevator

• 13 3/8” casing cut completed

Casing speared at the Platform Wellhead location at 25 m and pulled to the rig floor.

• Casing speared and first casing pup joint laid down.

Six (6) joints of 13 3/8” casing were laid out

• Elevator door down

• No issues.

The seventh (7) joint was raised in the Elevators and broken out

• Elevator door down

• No issues

7th joint tailed out towards V-door with elevator

• Elevator door down

Joint of casing drops

• During the descent, 13 3/8” casing joint released from the Side Door Elevator and fell to the Rig Floor (approx 36 ft)

• The joint came to rest between

the rotary stump and the Draw-

works.

• Rig operation stopped

• No injuries to personnel

This document contains confidential and proprietary information which is the property of Frank ’s International. None of the information contained herein may be disclosed, reproduced, distributed or used without prior wr itten

consent from Frank’s International. © 2013 Frank’s International. All rights reserved.

Rig Floor Layout

Frank’s Crew 1

Frank’s Crew 2

Crew chief - Frank’s

Frank’s Crew 3

Driller 1

Driller 2

Floorman 1

Floorman 3

Floorman 4 Roustabout 1

Roustabout 2 Dogman Floorman 2

This document contains confidential and proprietary information which is the property of Frank ’s International. None of the information contained herein may be disclosed, reproduced, distributed or used without prior wr itten

consent from Frank’s International. © 2013 Frank’s International. All rights reserved.

Critical Contributing Factors

Procedures not followed

• JSA 145 was not used/referenced prior to the job.

Failure to secure

• The Side Door Elevator not securely latched

• The safety latch lock pin was installed incorrectly. Pin was found

inserted behind the latch handle.

Lack of clear responsibility

• No specific actions assigned to a responsible person.

• Multiple/different rig crews were responsible for latching elevator.

• Practice of only drilling contractor to operate around rotary table

This document contains confidential and proprietary information which is the property of Frank ’s International. None of the information contained herein may be disclosed, reproduced, distributed or used without prior wr itten

consent from Frank’s International. © 2013 Frank’s International. All rights reserved.

Critical Contributing Factors

Breakdown in communication between work teams

• Rig crews changed tasks throughout the job. This occurred during

the 6 joints that were laid down, not standard rig floor practice

• Change of duties on the rig floor should be managed

Insufficient training

• Lack of training and underpinning knowledge of rig crew to check

safety pin is properly installed and elevator latch is completely

closed.

Equipment deficiency

• Frank’s had carried out retrofit per Varco Service Bulletin 17 but

not Service Bulletin 47

• Frank’s service bulletin 23 and subsequent retrofit 38 did not

address Varco SSD series

This document contains confidential and proprietary information which is the property of Frank ’s International. None of the information contained herein may be disclosed, reproduced, distributed or used without prior wr itten

consent from Frank’s International. © 2013 Frank’s International. All rights reserved.

Elevator

Elevator Safety Pin Located BEHIND The Elevator Latch (As Found Position immediately after the event)

This document contains confidential and proprietary information which is the property of Frank ’s International. None of the information contained herein may be disclosed, reproduced, distributed or used without prior wr itten

consent from Frank’s International. © 2013 Frank’s International. All rights reserved.

Investigation findings:

Relevant Frank’s

JSA was not

referenced

during job.

Drilling

contractor had a

drill ops work

instruction which

did not highlight

using elevators

with doors down

This document contains confidential and proprietary information which is the property of Frank ’s International. None of the information contained herein may be disclosed, reproduced, distributed or used without prior wr itten

consent from Frank’s International. © 2013 Frank’s International. All rights reserved.

Investigation findings:

Elevator latched by drilling

contractor

It was a practice that only

drilling contractor crew

could operate on rig floor

(this was communicated

but never confirmed)

This document contains confidential and proprietary information which is the property of Frank ’s International. None of the information contained herein may be disclosed, reproduced, distributed or used without prior wr itten

consent from Frank’s International. © 2013 Frank’s International. All rights reserved.

Investigation findings:

Required retrofit not

applied to elevator.

Frank’s previous service

bulletins and retrofit

instructions did not

address the Varco SSD

elevators

This document contains confidential and proprietary information which is the property of Frank ’s International. None of the information contained herein may be disclosed, reproduced, distributed or used without prior wr itten

consent from Frank’s International. © 2013 Frank’s International. All rights reserved.

Investigation findings:

Side Door Elevator not latched

properly. Pin inserted behind

latch. Operator did not carry

out checks as required by

Varco Service Bulletin 45

INCIDENT!

Joint of 13.3/8”

csg drops to rig

floor

This document contains confidential and proprietary information which is the property of Frank ’s International. None of the information contained herein may be disclosed, reproduced, distributed or used without prior wr itten

consent from Frank’s International. © 2013 Frank’s International. All rights reserved.

Conclusions

The root causes of this incident;

• Incorrect latching and installation of safety pin by

floorman.

• Failure to carry out a required retrofit update to the

elevator. This would have avoided the incorrect

installation of the safety pin, which was a

contributing factor leading to the incident.

• Communication of responsibilities (casing crew to

operate own equipment)

This document contains confidential and proprietary information which is the property of Frank ’s International. None of the information contained herein may be disclosed, reproduced, distributed or used without prior wr itten

consent from Frank’s International. © 2013 Frank’s International. All rights reserved.

Varco User Manual – Manual Elevators

Extracted from operation procedure

• “….Ensure the latch lock safety pin (cotter pin) is in place ensuring the

latch lock can not open and the latch is actually locked”

• “…Check the latch and latch lock for full engagement when closed around

the pipe”

• “…Ensure the “latched-and-locked verification pin” (cotter pin) is

engaged.”

This document contains confidential and proprietary information which is the property of Frank ’s International. None of the information contained herein may be disclosed, reproduced, distributed or used without prior wr itten

consent from Frank’s International. © 2013 Frank’s International. All rights reserved.

Mitigation

• The subject SSD elevator was immediately pulled from service

• Frank’s identified that there are five Varco Model SSD Side Door Elevators in inventory. All are taken out of service.

• March 2013, Frank’s issues Retrofit Notice RF – 229 – Following incident, detailed instructions required to install Latch

Lock Safety Pins sent to the three Frank’s locations where Varco Model SSD Side Door Elevators are located.

• All other side door elevators models worldwide have been subjected to checks – Ensure fit for purpose per Frank’s Service Bulletin 177

This document contains confidential and proprietary information which is the property of Frank ’s International. None of the information contained herein may be disclosed, reproduced, distributed or used without prior wr itten

consent from Frank’s International. © 2013 Frank’s International. All rights reserved.

Other mitigation methods: Hands Free Systems.

• Use of automated systems including ;

- remote tong technology

- Hands free technology (elevators) used in conjunction with remote tongs.

- CRT systems

• All of which take away the manual handling and need for people on the rig floor

This document contains confidential and proprietary information which is the property of Frank ’s International. None of the information contained herein may be disclosed, reproduced, distributed or used without prior wr itten

consent from Frank’s International. © 2013 Frank’s International. All rights reserved.

Questions?

Thank You