Casing Running Operations

Fatality Incident Overview

2:45 PM, 6 August 2002

Casing Operations
Fatality
6 August 2002 1
 Reporting/Investigation Process
 Immediate notifications to all Shell/Contractor management
 Sr. Contractor Management arrived onboard rig within (5) hours
 Shell D&C Ops. Manager, Superintendent, and HSE Manager
arrived early next morning to begin investigation requested by
Shell Legal
 Investigation led by Sr. Management Representative (South
Texas/Michigan Asset Manager)
 Joint investigation commenced as requested by Shell/Contractor
Attorneys: Tripod analysis performed
 Tripod report under development
 Regulatory Agency Investigations
 Sublette County Sheriff – 6 Aug
 OSHA – 7 thru 9 Aug Casing Operations
Fatality
6 August 2002 2
 Incident Summary
 Mr. Montoya was working for Central Valley Tong Services as a
stabber while running 9 5/8” casing. On the 21st joint, the
stabilizer flange on the casing fill-up tool is thought to have caught
on the adjustable stabbing board as the joint was hoisted into the
derrick.

 The stabbing board was lifted up approximately 7-8’ with Mr.

Montoya on the board. Once dislodged from the stabilizer, the
stabbing board fell down the guide tracks vertically and broke free
of its hoisting cable and manual positioning catch on the stabbing
board frame.

 Mr. Montoya fell approximately 12-14’ (6-7’ above lanyard

attachment point) and his fall was arrested by his full body harness
and lanyard. Mr. Montoya’s lanyard was attached to a fixed girt in
the derrick, between the stabbing board rails and above the
physical stabbing board.

Casing Operations
Fatality
6 August 2002 3
 Incident Summary (2)
 Mr. Montoya received chest and abdominal injuries as a result of
the lanyard becoming taught when the stabbing board was lifted,
and additional injury may have occurred as his fall was arrested by
the lanyard.
 Emergency response and first aid efforts were initiated immediately
and Mr. Montoya was lowered to the rig floor. An ambulance
arrived within 40 minutes and Mr. Montoya was transported to a
local medical clinic where he was reportedly in stable condition.
He was subsequently transferred via helicopter to a more
advanced medical center where he was pronounced dead shortly
after arrival.
 Senior contractor and Shell management commenced an
investigation on the evening of 6 Aug and further details will be
shared as they become available.

Casing Operations
Fatality
6 August 2002 4
 Key Learnings
 Contractor HSE management process is essential to assure competency and
effectiveness.
 Are your contractors/subs & third parties qualified & competent?

 Pre-job planning and focused supervisory oversight for the entire job is important.
 Who is accountable for job planning/oversight? How communicated?

 Understanding of and compliance with safety procedures and processes is essential.

 Is your fall protection equipment design and use appropriate and compliant?

 Visibility & communication between casing/drill crew is vital.

 Are communication procedures adequate between derrick and driller console?

 Hazard Identification before commencing work is crucial.

 JSA’s, work permits, MOC and/or pre-job plans well understood?
 Do you realize when operations have shifted from routine to safety critical?
 New equipment, people or procedures?
 Shutdown culture of employees strong enough?
Casing Operations
Fatality
6 August 2002 5
 Derrick View from SW Corner
Stabbing board tracks where
board was before being
dislodged from derrick.
Fixed lanyard attachment
point on derrick girt
between tracks Elevators @
approximate
pre-accident
position

Casing Operations
Fatality
6 August 2002 6
Driller’s Overhead View

Approximate position of Mr.

Montoya while stabbing

Casing Operations
Fatality
6 August 2002 7
Derrick View of Fill-up Tool & SRL
Self-retracting lanyard (SRL)
directly above stabbing board

Fill-up Tool stabilizer that

caught stabbing board

Close-up view of SRL

Casing Operations
Fatality
6 August 2002 8
Derrick View of Stabbing Board Tracks

Parted hoist cable for

stabbing board
Cable for Self-
Retracting Lifeline
(SRL)

Casing Operations
Fatality
6 August 2002 9
 Downward View of Rig Floor

East
‘V’ Door

Casing stump in rotary

Position stabbing
board landed in

Casing Tongs
Casing Operations
Fatality
6 August 2002 10
 Rig Floor View of Stabbing Board
Bottom of stabbing board
where stabilizer hung-up

Casing stump in rotary at

well center
Casing Operations
Fatality
6 August 2002 11