BSP-AA-201609 Brunei Shell Petroleum - TWD April 2016

WPSI: Well Control equipment failures

Target audience for this alert

 Well Operation Team Leads, Drilling Supervisor
 Drilling Contractors. OIM, Toolpusher, driller, assistant driller, maintenance supervisors.

What happened?
In the period between October 25th and December 28th multiple leakages were experienced of the BOP hydraulic
control system. Leaks were found on the upper pipe ram piston seals, the blind shear ram piston seals, lower pipe
ram piston seals, the 4-way valve of the Lower Kill HCR, the 4-way valve of the upper pipe ram and the manifold
pressure regular. If left undetected these failures had the potential to reduce functionality of the BOP.
The immediate consequences of these incidents was a total 12 days of operation lost due to carrying out repairs.

The immediate cause for the leakages on the HCR and UPR 4-W valves
were found to be light scratches on the sealing surfaces. The overhaul
history on the 4W valves was not available. The specifications of the
hydraulic control fluid in use were found to be in compliance with OEM
requirements and the fluid was renewned 8 months prior to the
incidents occurred. The rig has a small offline filter unit for purification
and a specific CJC filter to remove water. However, a fluid sample
taken after the incidents showed the hydraulic fluid cleanliness
specification to be out of OEM requirement. OEM recommends
cleanliness of <NAS-10. Results showed cleanliness to be only >NAS-
12. Study of historic fluid samples showed previous samples also to be
out of OEM requirements. The investigation concluded that the current
setup of the filtration system is insufficient. Fluid samples were measured according to ISO Code 4406. OEM
recommends fluid cleanliness according to NAS 1638. The ISO Code 4406 specifies particle count per 1ml. NAS
1638 measure particle count per 100ml.

The failure of the piston seals was investigated by doing a full root
cause analysis. This was conducted jointly by the drilling contractor
and the OEM, consisting of disassembly and inspection, verification of
machined component tolerances and pressure testing after reassembly
with new seals. As part of the investigation, the history nd tracebility
of the upper bonnets could not be established. The certificates that
were available in the Shell eWCAT system for these bonnets were
found to be incorrect.

This document is made available for information only and on the condition that (i) it may not be relied upon by anyone, in the conduct of their own operations or otherwise; (ii) neither Brunei Shell
Petroleum Company Sendirian Berhad (BSP) nor any other person or company concerned with furnishing information or data used herein (A) is liable for its accuracy or completeness, or for any
recommendations or advice given in or any omission from this document, or for any consequences whatsoever resulting directly or indirectly from any use made of this document by any person, even if
there was a failure to exercise reasonable care on the part of BSP or any other person or company as aforesaid; or (B) makes any claim, representation or warranty, express or implied, that acting in
accordance with this document will produce any particular results with regard to the subject matter contained herein, or to satisfy the requirements of any applicable federal, state or local laws and
regulations and (iii) nothing in this document constitutes technical advice. If such advice is required it should be sought from a qualified professional advisor. The content of this document may (i) be
based on, but not identical to facts relating to a third party incident about which BSP has become aware; (ii) contain recommendations that are one, but not necessarily the only way, of addressing
incident learnings.
The key findings from this RCA and full disassembly of the piston seal failure
were:
 There was significant contamination of the hydraulic fluid.
 Piston seals were found to be visibly worn, likely due to the
contaminated hydraulic fluid
 Machined component tolerances were measured and found within
OEM standards

Investigation of the recent history of the function tests revealed that the leak
on the BSR piston seals was apparent 2 weeks earlier prior to being visually
confirmed.

Why it happened

 Immediate causes:
o Excessive contamination in BOP hydraulic operating fluid resulting in degradation in sealing
components. The contamination created excessive wear in both the elastomer and metal-to-metal
sealing surfaces of multiple components of the BOP control system, resulting in leak-by and
pressure loss.
o Insufficient capability to purify the BOP hydraulic operating fluid control fluid on-site.
o Lack of trend analysis and subsequent inability to recognize and react appropriately to detrimental
trends in fluid sample results.

 Underlying causes of the incident:

o Insufficient understanding of fluid sampling testing results and criteria.
o Failure to recognize trends in operating volumes from weekly function tests.

Actions
 Verify COC’s for all BOP related components in eWCAT are correct, valid and maintained within 5 year
window.
 Establish that the maintenance program for all components in the BOP control system fully captures the
OEM requirements, including 4W-valves and ram piston seals.
 Review fluid analsyis requirements as requested from third party labs for the regular analysis of hydraulic
fluid cleanliness and confirm they match with the OEM requirements.
 Verify the filration system for the BOP hydraulic control system is adequate and is capable of removing
contamination.
 Verfiy calibration of the hydraulic fluid flow meter on the BOP control unit.

Further information
Rob Grauwmans , TWD/32 : rob.grauwmans@shell.com

This document is made available for information only and on the condition that (i) it may not be relied upon by anyone, in the conduct of their own operations or otherwise; (ii) neither Brunei Shell
Petroleum Company Sendirian Berhad (BSP) nor any other person or company concerned with furnishing information or data used herein (A) is liable for its accuracy or completeness, or for any
recommendations or advice given in or any omission from this document, or for any consequences whatsoever resulting directly or indirectly from any use made of this document by any person, even if
there was a failure to exercise reasonable care on the part of BSP or any other person or company as aforesaid; or (B) makes any claim, representation or warranty, express or implied, that acting in
accordance with this document will produce any particular results with regard to the subject matter contained herein, or to satisfy the requirements of any applicable federal, state or local laws and
regulations and (iii) nothing in this document constitutes technical advice. If such advice is required it should be sought from a qualified professional advisor. The content of this document may (i) be
based on, but not identical to facts relating to a third party incident about which BSP has become aware; (ii) contain recommendations that are one, but not necessarily the only way, of addressing
incident learnings