Level 2 – Contractor Staff Fatality Incident at Utorogu 32 Well Test

Site- 30th November 2005.

Date & time of incident 30/11/05 at 1345hrs

Region, EP Company, asset team, location EPG, SPDC, Wells, Utorogu-32 Well Test

Proposed classification at time of writing C4P.

. Lessons learned
Incident description
At about 1345 hours on 30/11/2005, a contractor staff
while operating a sand filter valve in a temporary well
test setup, sustained a severe injury caused by the
impact from a female hammer union inadvertently
dislodged from a side outlet, as well testing was in
progress. He was thrown 19 ft from the sand filter
equipment. He was immediately medevaced to Ufor
Clinic, Ughelli where he underwent emergency
surgery. He later died in the clinic.
• Banned 2” 602 unions are still around despite a
clause in the contract stipulating only 2” 1502
unions.
• Unsafe practices based on past experience should
not be accepted
• HAZOP need to clearly state the hazard and not
just recommendation
• All equipment must have proper historical
documentation before use

Provision of photograph or sketch

Outcome
1 x Fatality.

Immediate causes
• Connection that failed was a mismatch between
the male and female 2” hammer Union (602
female to 1502 male).
The potential hazard of such an easy mismatch
was already identified more than 10 years ago
and 2” 602 hammer unions had been banned
from Shell operations since. Shell procedures
and the relevant contract state that only 2” 1502
should be used.
• The victim stood directly in front of the failed
side outlet (hammer union), which was under a
pressure of approximately 3500 psi, while
operating the desander/middle valve – see
picture.
• Configuration of equipment at Utorogu-32 was
not in compliance with manufacturer’s design
layout. Manufacturer’s configuration included a
ladder/working platform for operating the middle
valves plus different orientation of the valves,
which would have positioned the victim at a
different and safe angle while working on the
valves.
Level 3 – Contractor Staff Fatality at Utorogu 32 Well Test Site-
30th November 2005.
Date & time of incident 30/11/05 at 1345hrs
Region, asset team, location EPG, SPDC, Wells, Utorogu-32 Well Test
Proposed classification at time of writing C4P.
Incident description
At about 1345 hours on 30/11/2005, a contractor staff
working for Power Well Services (PWS) while
operating a sand filter valve in a temporary well test
setup, sustained a severe injury caused by the impact
from a female hammer union inadvertently dislodged
from a side outlet, as well testing was in progress. He
was thrown 19 ft from the sand filter equipment. He
was immediately medevaced to Ufor Clinic, Ughelli
where he underwent emergency surgery. He later died
in the clinic.
Outcome
1 x Fatality.
Main findings from investigation
• Valve orientation in the as-built assembly is
different from the design layout. Change of valve
orientation aligned the discharge valves and the
side outlet with the middle valves
• Design configuration included a ladder/working
platform for operating the middle valves but
Equipment set up at Utorogu 32 and in previous
locations by PWS did not provide it.
• Failed connection was the result of a mismatch
between the male and female hammer Union ( 2“
602 female to 2” 1502 male).
• HAZOP identified absence of permanent safe
access to middle valves and a temporary ladder
was provided to close out the action item
• HAZOP did not identify the potential hazard
with valve orientation and configuration.
Main causes
• Inspection (physical check) was not done to
identify mismatch between the male and female
2” hammer Union
• Rig up configuration did not provide for
platform/permanent access to operate the middle
valves
• The victim stood directly in front of the failed
side outlet (hammer union) while operating the
desander/middle valve.
• As built Configuration (Valve orientation) is
different from the design layout.
Immediate actions
• SPDC, Halliburton and Power Well Services
stopped work on all sites, and ran a check on all
temporary piping to remove non-standard
hammer unions from site.
• Alerted SNEPCO, EA and Expro well test group
to check and remove 2” 602 unions from their
installations.
• Removed the Krebs desander from Utorogu-32
site, replaced it with a desander that have a safe
operating platform.
Underlying causes
• Insufficient dissemination of alerts on Hammer
union. Alerts on the danger of mismatch b/w
1502 & 602 were sent out but did not reach all
intended recipients.
• Manufacturer’s Assembling of Equipment Parts
not according to Design
• Inadequate handover of equipment/manual
Equipment was handed over to PWS without
necessary/relevant documentations/drawings.
• Inadequate HAZOP and HAZOP implementation
Senior management actions to address
underlying causes
• Print laminated alerts; hang on connections and
temporary piping facilities and issue to all
personnel to increase awareness
• Verify that alerts have been communicated to
relevant contractors and check that it is discussed
during regular office and site safety meetings.
• Run a check on all equipments used for high-risk
operations to confirm that they are in line with
design specifications.
• Provide HAZOP training for relevant Well
Services personnel.
• Develop a code of practice for Temporary Well
Test and other non-rig related temporary
pressure equipment set-ups.