H

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HP 206 / Bullwinkle 5/9/06 Hydrocarbon Release

• Investigation Team
• Sponsor Joe Leimkuhler
• Team Leader. Martin Baltus
• MembersMarc Gatlin Eddie Hattier

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crane
Tote initially here
ESD
Broken Nipple
Tote going here
Area of Spray
3
Sequence of Events and Casual Factors/Conditions
215 (20 spray) While lowering tote it
strikes valve on heat exchanger resulting in
broken nipple release of HCs
Rigged up and began moving tote tank using two
riggers to make room for toolbox
Lead roustabout (crane operator) assigned to move
Halliburton toolbox
Lead roustabout surveys area and prepares JSA

• Toolbox needed to prep Halliburton unit for next
  job
• Tote blocking fire extinguisher

• - Valve was not in view of crane operator and
  riggers did not see it
• Crane operator felt the load hit moved it up
  out of way
• Both taglines were not positioned diagonally on
  load possibly due to crowded conditions
• Wind conditions 15 knots w/ 22 knot gusts,
  non-issue
• - Riggers evacuated area of HC spray

• Deck crew was one person short for about a week
• Crew decided not to use DSP (reoccurring
  problem)
• Experience levels
• Crane operator 10 mos
• Riggers 3/9 mos

• Tote sitting in area where toolbox needed to be
  set
• Generic JSA did not require DSP and was not
  updated to include hazard of appendages on
  production equipment
• Lead roustabout decided on where to move tote
  after consultation with construction personnel
  but not production personnel

4
Sequence of Events and Casual Factors/Conditions,
continued
216 219 (20 spray) Shell subsea operator
responds to site and notices GIS deck foreman in
process of closing outlet valve to heater treater
thus he closes inlet
215 (20 spray) Rigger notifies construction
hand who in turn reports incident to Production
via Giatronics
219 (firewater on release) Subsea operator
calls for assistance and speaks to Process Staff
Associate, PSA
GIS employees attempt to ESD platform

• Construction were preparing hooch in area

• PSA notifies Shell Drilling Foreman by phone and
  OIM when passing in hallway

• Construction HSE Tech instructs not to ESD until
  PIC is on scene
• Construction HSE Tech did not receive typical
  contract construction HSE Tech orientation

• Subsea operator heard report of release on radio
• No gas detector at scene throughout incident
• Mechanic directs fire hose on to HC spray
• Drilling in cased hole

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Sequence of Events and Casual Factors/Conditions,
continued
247 (no flow) As flow diminishes and finally
stops a ladder is used to remove bushing
222 225(firewater on release) PSA arrives on
location and closes inlet and outlet hot water
valves
227 230 (firewater on release) PSA calls OIM
and he arrives on scene
Operator closes FWKO per instruction of PSA

• Subsea operator brakes off valve assembly
• Reliability engineer attempts to bleed oil from
  bulk tank but turned wrong valve (gas outlet)
• Flow starts again within seconds of removing
  bushing

• Reliability engineer arrives on scene
• OIM discusses ESDing and verifies that Drilling
  Foreman had been contacted
• Production personnel realized gas was breaking
  out of oil but did not manage as a gas release
  (no visible cloud present)
• OIM returned to LQ to retrieve PIds and then
  returns to area.

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Sequence of Events and Casual Factors/Conditions,
continued
255 (no flow) Stab replacement valve assembly
and shut off
247 ( 20 for lt60 sec) Second flow begins and
stops in 1 2 minutes
300 Return to normal production flow

• Reliability engineer gets sprayed with HC
• Fire hoses onto spray
• OIM discusses ESDing

• All oil was captured in skid pans below
• Washed down area

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What Should Have Happened?

• Contractors
• move out area of immediate danger
• notify Production Operations Personnel
• pull ESD
• Production Operator arrives on scene
• pull ESD and initiate ICS
• PSA/PIC arrives on scene
• pull ESD and Blowdown?
• Why ESD and Blowdown
• Uncertainty existed
• Ignition source
• Was it properly isolated
• Risk of spill identified
• Reduce the inventory

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Managing Incident Escalation ByMinimizing
Hydrocarbon Inventories
Scenario 1

• Likely Consequence Limited asset
• damage and no major injuries

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Managing Incident Escalation ByMinimizing
Hydrocarbon Inventories
Scenario 2
- Response wo/ ESD Blowdown

• Potential Consequence Severe
• asset damage and possible
• loss of life

Hydrocarbons from wells
Hydrocarbon from pipelines
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Root Causes (RC) / Conclusion (C)

• RC Elimination of EEP boat and loss of use of
  Boxer created tote tank storage problems
• RC Hazards created by the storage area were not
  identified and mitigated or were identified and
  not mitigated.
• C Some of the other appendages in this area
  would result in a larger release if damaged,
  i.e., release of the majority of the contents of
  the bulk oil tank.
• RC High demand on personnel coupled with the
  shortage on HP crane crew made it easier to run
  crane without a DSP.
• RC Construction HSE Technician prevented
  activation of ESD.
• C Although the production personnel understood
  gas vapors were present as the oil was released
  the response was not aligned with the Shells
  expectations.
• C Expectations for Responding to a Gas Release
  or Leak does not address oil releases or leaks.
• C The sequence of events do not suggest that the
  incident was managed as an ICS event.
• RC There is no established requirements for a
  structured ICS plan for non-TLP locations.

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Recommendations
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Recommendations