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BP-HZN-BLY001 07758
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= MDL2179VOL000012
: liT- Corser, KentiiiT Targeted- Corser, Kent
= BP-HZN-BLY001 07758
= BP-HZN-BLY001 07758
= BP-HZN-BLY001 07758
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: Standalone
: J D Wetherbee
= 05/09/2010
= 06/05/2010
= 11/10/2010
122880
Critical Factor 1.xls
Microsoft Excel
Corser_Kent_IIT _ TargetedLaptop_BP-013504\Thumb drive\A_Horizon Incident/Critical Factor 1.xls
\\mpdpv3store01 \c images\01914-032\2011 0203\Cont158\MDL2179VOL000012\NATIVES\0001 \BP-HZN-
BLY00107758.xls
39b0c186ebd234dea889835260b3dfce
February 7, 20111 :17 pm Page 1
-------
DRAFT
CnucaJ factor Sub-.Cnltcat Factor
AcUonSI
Actions I Factors lmmedtate Cause Comments System Cause Comments Why I Why z Why 3 Why4
Fa<IO
l . loss of lnlegrilyol9-7/8" x r 1. 1 Cement failed 10 i$01atolhe reseM>It 01 01 Did not fotlow existing procedures 0 I 3 VIOiaiiOO (by Wpel'losoi) Did not centra!ae cas.tng Of have adequate 11.71ncorreeljudgment lkcid..\:1 f10( to run C\."'tll r.11U.cn Weto (XlSS'ibk Gte1tercmph.uu ongcu mg FC3r from AtllnliS
Casing TOC as per GP lo-&0. Zonal Isolation d.vn.1gei.'l pbo: of >d<quat< ZCII.1l pope 10 bo<lomw ECD dun wnh central.tb!rs on the DD Ill
Requ rements during Dnl:ing OptratJOns and
isolation zoml uolauon. well was .1
:-:]

Wtll Abandonment and Suspension, 1,3
stn.rght bo!c
I
Zonal lsolaoondesign crn.ena for cemen6ng

of prirn.ary stnngs to meet well integnty
and future aban!Jooment requ;remeots, .sha'l

meet one of the follo'Niilg 30 mTVD (100n

1]]..., TVO) above the top of the distinct
[] J
zooe 'Where the top of cement (TOC) tS to be
by a proven cement evaluahon
:J
le<Mique (5e<ton 5.3), 300m IJD (1000 ft
[} 11
liD) abOve the d1sbnd: penneab4e zone 'Mlere
I
the hydraulic ;solation is not proven except by

= estimates of TOC (S<Ciioo 5.3). FO< each""'"
I

the aduil TOC shall be I'M.Ofded aloog with
I
= U'le method used f()( this determinaUon..
I
[t:
Where the aduaJ TOC is belo-11 the plan, the
I
,_ TOC Sha'l be reviewed wrth Slakeholders for
its 1mpauon future well integrity, operabtl1ty,
suspension and abandonment operations. In
I
the event 01e cement is not to be
'
assessed by proven cemenc evalua11on
tedlnoque pfan ror at least 30m (100ft) of

centrahsed pipe above the distinct permeable
I l oss or lnlegrity or x 7" 1. 1 Cement fai*l lo Isolate the re:servotr Of 01 O:d not existing procedures 01 3 Vlol'alion {by supervisor)
[f'
u
12.4 Cl"iellng direc!Jons/ demands R.Jg w;u: prqu.nng for nwltiplc opiiOOS. Iong Shon pl= 1118 1ime rr.,. Wanttd to k.p the rathrr Tt.am lhooght it was possible I
Casing ']
= 0:::
stnng. l.tnC'r b'3use e:tunge in e35ing dunTIA case & ment Cost of rc
;::;;, .::;;, design. 9 7/t." drilling liner dnlling w running casing 313
=a... utilized llttr dlre
I. Loss of lnlegrily or x r 1.1 lalled to lsofafolhe restl'lolt 01 0 I Did not fot:-ow existing procedures 01.3 VIOiaiiOO (by Wpel'loSO<) -
1!:
14.5 other CEMENT MODEL NOT r ULLY Jkpmdmt on sen icc Comp.lll.)' Cementing c-' pcnise is Not: a lnfrcquc:ru:

Ca'"'o
D LJ
UNDERSTOOD OR UTILIZED. Ccm:nt for cement <ksign modd iog core company discipline. oood<lmg progr.om, clw1gcs on
....} roodo:l ""' fully uuloZ<d. mood updaled ....... (Comp>ny Ius 2 Rdunt on comp311yexpc"rts &:. C<mCnl rom <OiriJ'Wil
0::.
9
arou.l cc:ntr:iliztrs but report noc: read. scr'\-itt camp;1nies. to oomp.lll) Simibr to mud
lSSU<$.
! . loss of ln!egnty ol9-7/8" x r 1.1 <:emen1 ra.HJ to isolate the resetv<Mr 01 01 O:d not foliowexisting procedures 0 f 3 VIOItion (by supoi'IISO<)

[.l
15 3 trJnsfer nol effeell'le !\lED TO IN\' ESTIGATE ruRTIIER
Caofng
SLBJEC r TO
1. l oss of fnlegrity of 9-7/8" x r 1. 1 Cemeot railed fo lsofatolhe reSOfVOi< 01 01 Did not foUowexisting procedures 01.3 VIOIIIOO (by SUP<I'Iisof) - 16. 10 Rosl< analysis or tolerance no1 effective loog stnng" lm<r ruk noo fully undcmood. Shon pUnning lime fromc Con1ingmcy pbas did noo lu'l: H3d t\\"O pmlOW C'OC1I.ingtncy
Caofng

anpa.ct o(lwe ocl on d1splat'Cr11mt cfllacnc). because lo C'<Uiog 3 r produ..--:tioo c.uing:string. Sfrings Ill the Wt-JI de$ign
I c:mtr.Wurs. design and pf.lccment (0( d<sign. 9718" drilling lm<r
""' c::
displacement tftiaeoc) utilw:d easlifr.
1. Loss of lnlegrily or 9-7/8" x r 1. 1 Cementfalfed 10 isOialolhe reseiVolt 01 01 Cf.d not fol:owe:Csting procedures o I 3 VIOiallon (by supeMSO<) 11.7 other CONTRACTOR PERr OR\IANCE Pt rfOC"'lUl)('e h3d started to H3d bn in the same position Compb.incy at BP to
Casing Hllliburtm oonentmg cn.gJDIX'r was not decline BP \ \ilS goi.ng told for 5 )-ear1 :tgrCS5i\'tly I"IUJ\l.&C nested
performing 35 t<:qUircd and BP wanted to him mo'e to n'\ l iES position. oontracton
co II rtpllcc the mgulr BP decided to \\au unhl
ri he was to a rle\\ posttJon mthin
I falhburton 10 be repbool.
! . loss of lnlegnty of 9-7/8" x 7" 1.1 Cement faUed to isolate tho reservoir 0 1 01 o:d not fol!ow eJOsting procedures 01 3 (by SUptN1S04')
t::;;,
18 1 Tedln!eal des..gn not conect Cement JOb \\'3$ dcstgn.cd around 10\\crtng Ftar or loss drrulltion wtule Shon pllnning time lo prop<rly Both C"Ontingen.:y strings tw
c as;ng
ECD and did no1 Jddn:ss adcqu te roool m<nling dro\-c e<mrnl do:sign. plan O<Jijob. bern used.
a ISOilliondue10dunnehng, Did rxx look 31all :ospcru of
pr()J)(r C"t1l'ltnl design

"'
! . l oss of x r 1.1 cement (ai!ed IOlsoCate the re-SefVOir 01 01 Did not foL!o'Nexisting procedures 01 3 VIO!at.on (by supervisor) 18.7 Technfcalanolysis fO< r1>1< noc effeelive Rul. '"""inS did no< address d15pbc<mcn1 Focu.s '''3.5 on ECD Because of c:xpc-rimcc of loss Mud "ri&ht was too tugh for
C.sfng a circub tion \\lute dnlling & I.Kk sand &.lc gradinu tathtr in
of pllnning time well.
!. lOSS Of fnlegnly ol 9-7/8" X T 1. t ceme..- rat!ed lo isolate the ruefVOCt 01 01 Did not fd.:OW existing procedures 01 3 VIOiaiiOO (by Wpel'loSO<)
Q
0:1
20.1 lncorreel ftem onlered Slip on centrahurs th.u sa'llto the ng No io\-mlory of cmtr;iliurs Not part oorigitWcootingroq' lbd "'o pre\lOUS rontin,gm...-y
Casing
"-ere D<X the l)pc that "as nc.:d to plln stringS in the ''tU design
-
ccafinn ''hat W:lS Ofdrn:d.
! . l oss of lnlegrily ol x 7" 1.1 Cernetll I ailed lo is0111elhe rese<vof< 01 01 Did not ror.owexisting procedures 01 3 VIOial;on (by SUj)OMSO<)
-.._________. 4
-
20 2 lnc:orred. item recefved Shp on cmtnh.urs t.h.J.t smt to the ng No imTntory ofT' ccntr.llltcrs Not part of original contin!J'OC)' l-bd (\\"0 prnious Coru.tngftK}'
C.sfng
o= \\U\: no( thel)pe tJut ''-;u C\:pc"Cted.DC't'd co plln strings in tho \\til deslgn
-
oonfirm "bJt was Ofdc.n:d
!.lOSS oflffiegntyof X T 1.1 Cemonlfo !ed to Isolate !he tesei'IOit 01 01 Did not for.owexisting procedures 01 3 VJOfaUOn (b'/ superv,sor) - 22 5 EnfO<etment of SPP not effea ive OP 10-&l M S ISSU<$ 2008 II No full) undtrstood No fomul uainiog oo OP 10-W
Coslng
- nunda ton hnuan. I. 2010
l . loss of lntegnly of9-7/8" x 7" t . 1 Cement co isolate lhe 01 01 O:d not fot!O'Nexisting procedures 01 3 VK)!aHon (by suprrv.sor) 23 3 communleatJoo betNten dtfrtrent H.lll1btutoo wu IX)( La.st nunutc bct"n Cmtra.ltttrs vri\ed at the rig 01t No contmgmcy for thiJ option
cas;ng oroan!z.at!OMnot errea.ve onfoml<d of dc<osion noo to run C<ll<tUiucr> b) fit ld w iV<IIJ T<>rn f..t3d<t Wt nunure
- 'L'
BP He was mfooncd ofthrs dc:UKX1 b) the
c:m'IC'Ill on the DWH
1 loss of ln:egnty of x 7" 1 1 cement to tsotato the re.sei'Voft 02 02 Use of tools. equipment or 02 5 ln<:Ofrea of tools. Centralizer Placemefll M56 centra' zed 11 7 lncO<reel judgmenl IJ<cod<d IlOilo run rrtmlizm <luc 10 ptSibk Gr\:.ltcr cmph.:uts on FL".Jr from Atbnus c:\JX"nencc
Casing vehicle equpment or materials bekm the 13 Oppg
mecluruc:al cl3rnJ&<: ' ""'" >dcqu.ue ZCII.1l pope 10 bo<oom w EC 0 dun mth centr.ti.JErs on the DO Ill
h)'drocarbon beanng sand, rt<wred to be
osobnon z:cwui iSOIJ.uon. ".:11 "as 3
lOOft above the saod per GP
strnight bole
l . loss of lnlegnty of 9- 7/8 x r 1. 1 Cement failed to Isolate the resetwir 02 02 Use of tools, plant I equipment or 02 s lnCOfre<:t placement ol tOOls Cenlra'izer Placernen1 M.S6 centra'ized. 12. 3 C>fus;ng d reellons/ demoncts Slip oo ccntrahttrs that sent tOlh ng No u1\cntory of 7 c.rntralucrs Not a contingro...") item H.ld n,o pre' ious conttngmc)'
Ct '"'o vehkte equ;pme.nt Of'mattriats eentre'tzers were below the 13.0ppg \\e-re no the type Wt was tnp:a:ed. dormon strin&S rn the ''ell dcitgn
h}'drocarbon beanng sand requll'ed to be
nude noc to run c::entn.ltzrn
l nnrt th 'r.p irv.n
1 or 3
DRAFT
Cflllcal Factor SubCullcal Factor
Achonsl
Acuons I Factors lmrntdalt Caun Comments System Caust Comments Why t Why 2 Why3 V/hy.
Factors
t. loss ortntegrily oftH/8" x 7" 1.1 cement fal:ed to boUle the. rewvolr 02 02 Use or tools, plant/ equl pment or 02-5 lncorred placement oflools, Cenltilil.er Placement. M56 centra!'ll.ed. t 3.7 Olh<r BEHAVIOR BASED ONINCORRECT Gre.trtr anplusts on f eu f'rQ'u AtUntis
C85ing vth!d e equ,pmtnt Ot mattnats c:enua!zers be!<mthe 13 Oppg IIISTORICAI. REFERENCE Bclunor p:pe to bo1torn and ECDllun '""' ""'ralt=soo lho DOIll
h)'drocalboo bearing sand, required to be
for ck."Cisioo oot: to run twcd on z.ocuJ ISOL:Iuon. "dl was a
I
100ft above the sand per GP 1()..6()
that they would <auserucdun!Cll $111.1gh! hole
r--n
probL:m< dm occurred on the DDIU
t . t.oss of lnlegri!yof 9-718" x r t . t Cement falled to isolate the ruervoir 02 02 Use of toots. plnll equ;pm.nt or 02 5 lncorred p!Omtnt of tOOlS. Ctntraraer Ptaument- M56 centralized. 16. 10 FUsJt aNIIysk or tolerance not erredive Risk orui).U bo..d on ll1<l>nical irnx:s"ilh Gre3.ttr cmpha.su on tctllDg Fe..- fian A1bnusapenence
CIISlOII vehicle equipment 01 matenats centraltlerswere bektNthe 13Oppg Clal(r.l!Jzcrs :md oot on full system ptpe co bolcom and ECDllun "lth ""''"'lu.el>on lho DO Ill
h)'Ck'oQrbon beanng sand. required to be z.oc:u l uol.mon. \\CU \\'l:S a
100ft above the sand per GP to-&0
str.ugll<holc
t . Loss of lntegrtyof &-718 x 7" 1.1 cement fatted to isolate the reservoir 02 02 Use or toots, plant / equipment Of' 02.5 II"'CCffect ptxement of tools. Centralizer Placement M56 centla!ized. 1a. t Te<hnle41 noc c:onea Centra.lim'" requitancnc: \\"U ic:kotdled m Last minute pUnning to run C1unge tn scope to run l' No invmtOI)" of 7 .. MJCnliurs Noc 3
caso.o vehk:fe equpment or mattriJts eenttatize-rs v.-ere bekrNthe t3.0ppg cement modehag. TheCIMLr.llu:ers \\tf'C nol CJ.Si.Qa casing. originaJ plJ.nwas the item
bearing sand. requred to be
run to be a.
100ft abOve the sand per GP to-60
casing
t . lon orrntegrity of &-718 x r t . t Cement raaec:t to !so!ile the reseNOfr 02 02 Use of toots, plant 1 equipment or 02 5 IOCOfrect of tools, Centralizer Placement - M56 centralzed. 18.7 Ted\nlcalanai)'Sis (Ofnsk not effective Rnk 3SS(.SSD1(nt of being Grt.ltcr C'f11ph.ls1.Son gdtlllg FelT fromAtb.nbs expenc:ace
C8sillg vehicle equ'pment or materials centraliZers Y.'efe belo"N the 13.0ppg dMuged ''u not: cfftm:: TOCll S) uem plp< to boaom :ux! ECO dun with ('(Otr3fiu.rs on the DO Ill
hydrocarbon bearing sand, requ,red to be
was oot e\.Uuatl!d m ru:k ilSSSSI11Cnt zorui iSObJM)(l. ''ell v.-u a
toon above the sand per GP 10-00
ur.ughl hole
1.Loss or lnlegrily or 9-718. x r 1.1 cement failed to isolate lhe ceservo!r 02 02 Use of tools, plant I equipment or 02 5 Incorrect placement of tools, Centralizer Pfacement M56 centtaliled, t9.5 Cllange in job S<09" Risk :sssessmcnt foc [he ronai 1SOlauon was Gt'Qfef emplw1s on gettmg FCll (rom Atla.ntlS
Casing vehicle equfpment or materials cenllaJizers \'/ere below the 13.0ppg tuscd on trui.J.'ll pcoo.:durc of 6 mime and IS prpe to bolconr >nd F.CDdun '"th CCDUahu.rs oo lb.: DO Ill
hydrocarbon bearing sand. required to be
sfip on The job chaog<d to run zorol l$obtion. \\eU \\'3$
1000 abOve the sand perGP 10-60
only 6 IJ'\Imc ccntr.llizttS and 3 nil strargbchole
..
assessment "-;.lS not conducted m ruMing, onJ)
the tnlineccnua.liz.:rs.
l . lossor lnlegrily of9-718" x r 1.1 Cement fai!ed to isolate lhe resefVOlr 02 02 Use of plant/ equipment Of 02 5 II"'CCffect placement of' Centralizer Placement M56 cenlr.J:ized, 22.4 tmp:ementation of SPP not effective Dnllmgpcoo:dun: indicated uiline >nd shp on Grt.1Ur ernph.l.stS oo gcrung Fe:u (ran Atl.lnlrs apen<nee
Casing veh1de equ;prnent or materiilS centralizers were below the 13 Oppg oentm.hzcrs ProtXdure wu OOl followed and prpo to bolcomand ECD llun "1lh on lhe DO Ill
hydrocarbon bearing sand, required to be
only the mimeO::nt ralizers wtn: run oo the, .. zorulasobuoo. Y.dl "as a
100ft above the sand pee GP lo-60
c:uing $111.1S)Itholc
1. Loss or tntegrey or &-718 x r 1.1 Cement fded co lsolotethe rese<vW 02 02 Use of t()(){s, plant I equipment or 02.5 lnc.orrecl. placement of Centralrzer Placement M56 centra'aed. 23 9 ()(ht( cmtMUiiiC.\TION WITH OTHERS - Last aunute dueon bm\"11 CC11tr.Uiu rs 31rht:d at the rig 31 No cooclng<nc) for llus option
cas;ng vthkfe eqwprnent Of maleN:S centra'izefs v.-ere bekJwthe 13Oppg Conunuru<:UJOnoo:urrcd at chc field :lnd Wells T<am i.c3d<r Llst minute
hydroc.a1bon bearing sand, requited to be
IC'atn k:xkr le\d and up\\;ud 10 the lltlf1.18CB
100ft above the sand perGP 1D-60
It \US ooc commurucatcd to Ha.lhburton
'
l
Nd coconfirmif it "as caMlWlJCOied to cbc

DP Sr DE OP SME ., .. no< full, uulued.
I] BP net informed ex
"'po<ta"""'
1. Loss orlncegrily of!l-718" x r 1. 1 Cement failed loisolatethe rservoir 03 03 Use or protective equipment or 037 Ollltr LIFT PRESSURE USED TO DETERMINE 1 t.7Cnco<re<t judgmenl of2.<lCWi.soLu100 ciTt1\a'ICSS No fully und<rscood No fomul crairung on GP 10-1
Casing me!hods TOC. GP 10-60. 53 2. Cement CO:umll \\35 bang C\ '3.1u:Ucd on column
=
baekpressure: The way of estJmating blckpr=un: The ceam drd noc rdenol) tlut
TOC is to determne 1he cement ootumn
this would not be ril'ti\( thecatK'Dt
I
[ hydrostatic by slo'Ning lhe pumps down
dcs1gn was developed to rnuunuzc: lhe cement
immediately prior to bumping the ph.JQ This
=
WJ11 only give a very coarse estimate and
rolunu1 bJdprnsure This u noc 3 (:()rMl()n
I
where cement and mud weights afe very
51(U3tion ardIS identified rn the group
similar (within 0 2 SG)ls unlikely to provide a practice
I
II
17
suffidently accurate (MW:
14.0ppg. Spacer= 14.3ppg. Foamed Cml = I
t4,SWQ)
t.Loss or Integrity of!l-718" x 7" 1.1 Cement failed to lsolate the reservoir 03 03 Use of protedive equipment Of 03 7 Ollltr LIFT PRESSURE USED TO DETERMINE 14.4 Infrequent perfOITTlance or skill The zoruJ isolouion design to mllWI'lire ECD Tram cypically docs noc run .,-pk>ration group
casing methods TOC. Used lift pressure to determine TOC. was 1'101 roullDCiy used by the production C3Sing
GP 10-60. 5,3 .2. Cement column
a
backpressure The way of estimating
I
a TOC is to determine the cement cofumn
h)-droscatic by skt.-.ing the pumps<l<fflr1
I a
r:::r immed"'Cely prio<Co bumping the p!ug Th;s
u

w;11 ooty gtve a very coarse estimate and

--.'here cement and mud weights are very
slm-'ar (Within 0 2 SG) is unf,kely to provide a
- sumcientty accurate e51imate. (MW =
a
-
Spacer= 14 Jppg. Foamed cmc =
1. Loss offntegrity or 9-718. x r 1.1 Cement fai:ed 10 i.sotile the te:Sef\tOir 03 03 lJ$8 of protedive equipment Of 03.7 LIFT PRESSURE USED TO DETERMINE 18 2 Des.gn standards, speoflcalion.s or lnfonn.:u.on used in lb.: dca.rion tn::e to r>o fully undmcood Nofomul tr.liningon GP
cas;ng melhods TOC. Usecll,ft to del ermine TOC aitefla not cocrect d...'temunc..wn.al uobbCWl. Itt\ prcssuR:'. is not
GP 10-60, 5.3 2 Cement W.umn IIJIPrllClble m tbts dc9gn

backpres.sure The v.-ay of estimal!ng
TOC lS to determ,ne the cement CO!umn
hydrosttic by s.'owing ihe pumps <I<Mn
fmmedate-ty prior to bumPtng the ptug This
will only g.ve a very coarse estimate and
where cement and mud Yt"e-ights are very
..
smi ar (w.th.n 0 2 SG) is unt \ely to provjde a
sumd tntly aecurate estmate (MW =
t
. 14 Oppg, Spacer= 14.3ppg, Foamed Cmt =

2 of 3
DRAFT
Cnlical Factor Sub-Cntcal Factor
Actions/
Fact or s
Act1ons J Factors Immediate Cause Comments System Cause Comment s Why 1 Why 2 Whyl Why 4
1. LOM orrntegrily of !l-718" x 7" 1. 1 Cement failed to lsolate the reservoir 03 03 Use of proteelive equipment or 03:7 Other LIFT PRESSURE USED TO DETERMINE 22...2 Devetopment of SPP not effed.ive Using lift (0 d.."' c-rmine zaul isob!icc1 No fully understood No fomul training on GP 10-60
Casing methods
11--
TOC. 10-60, 5.3 2. Cement column m thts ckstgn rs inaccurate.
backpfessure: The simplest way of estimaltng l his topic i.s d1SCUSS\. "'dinGP 10..00.

TOC is to determine the cement column
I hydrosta"c by slowing the pumps down
I
immediately prior to bumplng the plug. This
I
'Mil ootyg1ve a very coarse estimate and I
I
'tVhete cement and mud weights are very
similar {'Wllh'n 0 2 SG) is unfikel y to provide a
sufficiently accurate estimate. (MW =
14.0ppg. Spacer= 1<6 Jppg. Foamed Cmt =
-
1. LOM or Integrity or 1}.718" x 7" 1. t cement failed to isolate the reservoir 0 1 01 0:0 not folk>' .v existing procedures

CEMENT MODEL NOT FULLY 14.4 Infrequent pecfocmance of skill Ccm..'Tll modelling is ;a romple-.;: progrnm \\ith No fully un<krstood Not a core compc1en.... ")' Rel y oo sen ire c001pany and
Casing UNDERSTOOD. Cement modeling li mitations distinct Lintitatioos. BP subjt rnauer exp..ats C'ompanyn-perts
were not UnderstOOd by the team. It is not notd to be invoh-N \\hal wutg the program
evident that the team understood the lack of
oul5ldeof sund3nl designs The"' "'"""'
displacement efficiency at the pump rate of 4
levd ro go up as lhc degree of
bpm in the and larger hole size.
ccap.lcXft} l ncreJSGS.
!. Loss or Integrity or 9-718" x 7" 1.2 Breach of ll-718' x 1 casingJ

THIS SUB-CRITICAL FACTOR HAS BEEN
Casino [RULLED OUT.
t , Loss of l ntegnty or 9-719 x r 1,3 Seal Assembly Failure 06 06 Tools, plant I equipment & vehide.s 06.7 Other OPTIONAL HANGER LOCK RING 18. 1 Technical desi gn not eo<rect Ttam drd noc bke ll1to 3ecountlood Lood condition tud not be
Casing
]
,..
FUNCTIONALITY NOT USED The 00 seal conditions during thenegat nc rest r-ecogniud
I
assembly has an optional l OCk rlng that wi' l
lock the sea! assembly to the hjgh pre-ssure
anoer
!. loss or lnlegrity olll-718" x 7" 1.3 seal Assembly FBJl ure 06 06 Tools, peant I equi pment & vehl"des 06.7 Other
- OPTIONAL HANGER LOCK RING 18.7 Technlcal anal ysis for risk not effecttve T e.llU did not tale into a.. ""Count load Lood condit ion had not be
casing
[
FUNCTIONALITY NOT USED- The 00 seal
oonditionsduring tbeocgaril" ' "'' :>nd tbo ruk I"C'\:ogniztd
assembly has an optional lock ring that Wi l l
of lhe sea.l coming offse:Jt not Kkntified.
-
I
lock lhe seal assembly to the high pressure
-- lhanoer.
1. l oss or Integrity ol ll-718" x r 1.3 Seal Fai'!ure 06 06 Toois, plant / equi pment & vehl des 06.7 Other
... OPTIONAL HANGER LOCK RING 22. 1 Lad< or SPP for the task No standud oo "ben ro run and Jock do\\n Sbn<brd not pJSS<d on from Team is made up of Pcrf01TT131l<e b:ld beengood ""'
Casing
.
. FUNCTIONALITY NOT USED - The 00 sear theClSing tuogers usms the tungtr dev<iopmcn! group personnel did not w:mt to c-hange: the team
assembly has an optional ting thai will
lock ring or lhe lock do\m skt-\-e
l
Sock t he seal assembly to t he high pressure
Llla.o<!<L
3 01 3
Cn1 I Subc:nt
1. Loss or fnlegrity of 9--7fs x r Casing 11. 1 Cement fatled lo isolate the
reservoir
2. Unrecognized Well COnditiOns
3. BOP FaRed IO lsolale lhe SOurce
4. or Released Hydrocarbons
12 Breacll or !).718' X7" Casing)
1.3 Seal Assembly faUure
1.4 Floal Col!ar Leal<
2. 1 lnlegrily l esl Jatled 10 identify
oommunk:atfon with the reseNoff
2.2 a!!OW"ed HC fnnux to
enter and move uo the well bOre
2.3 Rig Clew response to well How
failed to the well
3.1 Action to activate lhe BOP once
weUcoodiDonwas cecognaed failed
to isolate the source
32 EDS raiJed 1o secure the weu
(v.ilen ad.ivatied from bridge aner
explosioo)
3,3 AMFIDead-man railed to sec11ce
well
3.4 Subsequent ROV fnterventions
f ailed to secure the wen
4. 1 Hydrocarbon gas <li!leded by
several gas de(ecfOJS prioor to
explosion (t.'0 'Nitnesssla!ements
'rombridoe
4 2 Several polenUal scenarios of
hydrocarbon release lo atmosphere
have been identrffed
4.3 Dynamic modeling esbmates
suggests thai nammabfe gas
mbdures could have reached non-
'edlicallv classified
Acllon I Ac-lions I Petsonal Factors Immediat e
01 101 Did not follow existing procedures 01 . r VlofatiOn (by indMduar)
lmmdt>scriptor
'OJ I v,.n: Y! (b'f.!._'"::l .. JIJ '.''(ol'.l:e: a rl_l
W'1(
- ]
Svslem
09.1 Vision defiCiency
02 02 Use of too-ls. p4ant/ equipment orvehi cte 101.2 ViolaHon (by group) 01 2 !bJ giC- Pf

or.e 1;'11 . .n lh!:

an pact..:.e --
09.2 Hearing deli<iency
03
04
OS
06
07
oa
09
10
03 Use or protective equipment or methods I 0 1..3 ViolatiOn (by supervisor)
.
09.3 Other sensory dert<iency
04 Lack of focus or inattention
Protedive systems
06 Toofs. plant/ equi pment & vehides
07 Unanticipated exposure to
08 Worl< place l ayoul
09 Ph)-sical capabilfties
10 Physical condition
OL4 Procedure not ava!Jable
01.5 Procedure was not understood
01.6 Other
02 t PlanVeqUi pment or vthicfe u.sed
In the wrong way
02 2 Tools used in the wrong way
Ql-4 ...er\ cJ t<l t:-;!
'-'IMCeolii a<";-1 ;,.: , ,; V';i'.. pl'Opo' -f'i/
'
Cl) Prc:ed-.m!'o\-'U n:'JI Cln
tJ If
ri'!"',DI!
09.4 Other permanenf physical
disabi Hies
09.5 Substance sensitivities or
aUergles
09.6 Sire or slrenqth fimitalions
i0'11 Ptan'.C.qolpiTerrf Other

a tOfid.f\ to 1,_a pe"<;t fJ)r Uie a h.ai'IO!<:t as

02 2 n ..,ae UY.dfor <Kt..-t.f':i tf.-fY'!f_erol l 10.1 Previous fnjuryor1l tness
_fon-a1'1'1p' !! 1.1"!!!-J 3V!if't'l-ctl asa or a
as a pry tir
02. 3 Use or planVequl pment or vehicle 162'3lJs.e w!h ._,;;;,....., the.: - 1102 Fatigue
with known defed tli-f\'J-.:?.-;;o-::rV8 )"lC.C>'1'![1U'M-tOIJHtl>-:H j:'il'l.;<ri. ror
rUs,!'lg <:J w:-th f .tt1i cr _a ,., lh a
Of df-"-:<U .,rM !\ Co11,:!'J'R6 - IOO's a"d

02 4 Use of tools with a k.no'.vn defett Ql 4 Of tooJs VI. t<1. a Co:'e<;t tfla pe!'W!1 U'i'C] Tf''! tOOl h!\{!Ql">'l'l"'fd t 1S
e Jd 10 liS-e th.lt 1001. fO{ t.S,i\Q'l 9f\!)dK I' a
gulrd-Of a (li'11tnortJr. <!te'
co-; uw
10 3 Di'minJ'shed pertonnance
Svsdesulol or
091 V? -or,ce..-CftKr 3'll" .. lf1ng'.'l'!.IOI'Ia .... re!'C.'/a'fo ':edt"P.Pf"f'll
Th cu 'd coio . r 8'1 l.if'OOr;-ctf .,.-,..on prol'l!t.., 51 ;,,; :4''6 ,.,..,.,;
091fi.i
ttu rr:,.. CC'-Id-rtt ..... ...
"9dt+O':f'/Ct.
ilt. 'otmtl'.l$jct
09,. 0\tler ckYb. t es Ill pt.,-_. 'tl -=<tees a
4:..- rt
10 1,, . .., f4t.'.:ure,l'!i:'.J r..shrtcru.Dt h'-0.-ted ..
5 SM$.1 r, .UOI&Jfl'g..f'S an Ct!!"''g 1!-*elft!O e ptonO.;'f.
fftdof Oil r t lll._iQL\I'J "C'I.)d'toaf.ftg-'H!ObH!!.'':\?SOf'$001oe011fd ..
n,.
096S'Z1! -w tt.e,:;t.
s:_:1 'ot eA' -p ...- coullj'\ll"'
(iO 70tl'-ft
(t lr'l/llf')'Of'&'US tO tt'aWOfltt-t.d 4(;'1'e.r0t.f!, V'Ji.I.FYOf DUI
a"'xle.J to F- of"oft'n tM:r )Ob Th s .-qucy Of
Ml "" ;_ <1fJd (It may or rn:t) n4 tlftn . .M:J ro us
HI J Fatg-A tto:e OtUOtl tr.do!d 'l tr -nctdtn: "'"" 10 llt!gh (O let' 0 c.t
uA ca,. ..-.c:uoe wo....- t f O!'t g.wen 1\fMr.'ffvus. 0\.-"ert 'TW!
c
r.or11 .;;,.,_,
1(130.n!n.\' ocJp-(f'ofl
TttS c:a., lied..-:>to
<YIS , Of ptKJ;.rP _ _. ljld ll.'dlas. Ef1C.OI.Jti'l!rt!o16t.. '"? ct;.,.-.ng
11 11 Mental capabil ity 02.5 lnoorrect placement of tools.
equi pment or materlals
02 _5 1-no:orro!'Ct eq. ro-Ys m:!:: ffi<!l c.'r _ I t 0.41mpainneot due to drug, aleof\Ot l'04 .,..,p:;;--mar-:t.. :rc.!'!hol C!f .l\ t-mecftt
eQllptiP-1\110 pt!ced 10 a pos.t<n a too's pl!-:,<!4 or mecf!Cation pe:f:VJTti!:l)(1tVoih t; atc.onol Of tr.fod.c.st OM-
t-41!rt.
12 12 Mental Stress
13 13 Behaviour
14 14 compel ency
15 15 Trai nl ng I kncrN1edge transfer
a ... ...,1s. on a ro''ed do .,n
02.6 Operation or' planVcquipment or
Vehide at irnproper speed
02 of pt'3rWi>qu 0t ... 3t oF.ce a 110.5 Other
d nQt ta\e 1[ 4 apptVfn3react
tne-s tn!oo '(tJote- ttts -:a1,ap;,ly nov pro.:e-i-'i pl:an!o;:-ffiJ'. :'19 I m
ft-{'Q!'-':-r.at'J[e r-o-... flhS'.: recl
02.7 other 111. 1
03. 1 Need f or prol ective equ
1
pment or 103 1 N--:ed f )( or J!lef.hWs nol re<-ognoze-d the "Efform!r:J 11 t.2 Poor co-ordJnation or reaction
methods not recognized tf>-! . ti'q\,llftd &\lU time
03.2 Personal prot ective equ'pment or 103 .. ptr '"nl Ofrr:<:J\od$/jol
methods nol used n lr s d?
1 L 3 Emolional status
16 116 Management I supervision I emp!oyee 103. 3 Incorrect use of personal
leadership protective equrpment or methods
;03 r me'tOds lt...:! re.1v.r_fd I' 1.4 Fears or phobias
poco<eeL oe @qJptrer-t O( \'\de u;.NJ_b,;l 001,tfa corrett 'Wlf to a'"(l..'d l'l'!
prO(E'cton ''.1.}9 an "'<Qrre<t Of -l-'l'
loc:ftlt;tgc .. l
17 117 Contractor selection & oversight 03.4 Personal protective equ'pment or 1031 P!.:$0fl!r PT-?No-rm-:.1'1->ds 1!->t .

j 11.5 l o'Nmechanical aptitude

18
19
20
21
22
18 Engi neering / design
19 Control or Worl< (CoW)
methods not e>r was feo;-og;r .::ed '1J-Pil'ei'\tv.-as /l':lt

03.5 Disabled guards, wam!ng systems -s} s' im$ or :he-eOiKt ng 111.6 Low learni ng aptitude
or safety devices s_r-!em\. er c.th<:r !l'ett:i$.!".,e: s .n p"!:c'! .. dS-lt.'.:d Cr to-a!:)\y
v.oric ro _n- s b1hss
o! tr-te;rfoclu.
03.6 Removal of guards. wamng
systems or saretv devKes
Ol 6 'Of gvlrds tlr . l 11.71ncorred. judgment
""''lL09 S):St'!ms. orotf',ff .s.a't-tt pqot. l mi' .?f'\d [Ktl
or J_Eqj J:fTIYttlh.:;twi$ V"S!J '-t-101' ..e s.
c:S: r.rld .,tO.Cmfi. s -
20 Purchas!ng, material handli ng & material 103 7 Other
control
rr 11.8 Other
21 Tools & plant I equipment 04. 1 Distracted by other concerns
22 Standards I Practices I Procedures (SPP) I04.2 InattentiOn to suNOUnd1ngs
1 C-\JoqM b.j' 'e' 11 !o'Jo!..-ted .!<'"1 rf)t 112 1 Preoccupa.Uon 'lol th pcobtems
w2rto: a":; r51
'S ... t>l
a!,urn t.ji:...:-S-.1 '\.[
til tJ:l! r_ Frustration
OC 1'2!"'1or''l'!:,.,..i''t-, 11 .. ......
10SOt:'ti" ""uU;:!d.M
11 t -..'lM<Y fa.Oe ll;t pencn s.eotl .. 'Of 1.._ .nab;;..ty to
,:-- ,.... ;I 011 to corrolo
t
r.) e'l ro!'li..:-rf'd .ctiot'--- 01 t..-: .. was "'!J
11 J Err.O(Jundl 1:\a oeosons. JOb r'-'-'1ori'T'' "...U l;.y ttter Etat,i.\.
d-.J1pos.ltr.sr. ... r .... ..s_
11 4 Of UWif*SOI\S ;ob ..... :n btn-.t:-A) Cf r!laW or
c.:ornpre
1 t ne j!'!O ,..n fhctfld Mro:.i.!.!!' .s !i r'IQ(
ba:o;JC !'.'T'e"'ts o' t\QW l"W!9S v..)' ,_
1 o:)lOINIMt:':II"Jart:.xJ.- ....
pcf"'d.d m.Jtffl2b: f'l t a.-to ..ent\'IOJ n
:orTtd f..Mg;'1'W't"Jt

t :r1.., mut.!
2 1 f- '11-(h :N' }Qtl ptJfG:matlCIIIII WK .a1fK.!4<1 Heo:..tW 1'\t'f
r- "'tdt ,...,,. r-;1 r.;!:r .a .:_:n ._..,
.tSfl.t.iOn the I*JOn'l ),;0 C*fOtmM"Ot w;u 'k(UoJ bt hi;h fniWoltien.
t .. ""
f 23
().4 31nappropnate "M>rtptace l ..;V' J?'"'C.:,f'J-.<J-!
,t_ .. t
12..3 Confus:rno dired.Jons/demands J'' 1 t"' F-f:"'-frr.;Pc.'N11
04 4 No wam.ng p<ovoded
().4 5 onnlenUOnal human error
1).4 6 Routme aellvrty wt1hout l.hooght
04 7 Other
_-y --w.r :.:
"UJ , o\_i ..s - 112.4 COnf.:"'t.Wlg ctredlonsldemands
t _e<. e;pesl!,. d ::trd
l!<]" .. a tlrnet-Jrovffj-, '); c.r
... ;;;;;;;;:..;J :::1 ::J - "!...!
...
W .m lt-fl.aj t ..... '"':'.'l .. ...s sv:.f
errok
'ff<'&.i:.,Jl".O., tt-if- Mto C<letrr._r,t"'e fire' t,r '.1' tri f'J f .,.u
. - -..... -
04 <M.1-[f\'o" .1 thd l }!H
i;<i
mu,ldec
J
II I l
'
12_5 EXfceme deo.sion detNndS
12.6 Unuwal coocenfratiOo Ol
peccepUon demands
12..7 Other emotional over1oad
05, 1 Guards or protective devices not IO..S 1 "* '1,-t!'1' f. i'C .rdl d.:t:.:H_ l'l 112.8 Other
effeaive a;,:lo"w!;:rJ .Fot.J
e. _a fJ.!-:1 Vth ot a gol!d d .j OO!
05 2 Defetltve guards Of protective
devices
OS 3 tncoooct pe..onaf protective
equ.pment
05 4 Defective personal pc-OiedJve
equpment
OS SWarning systems not elfect.iVe
OS e Otf ective wam'ng systems
OS 7 Safety devices v.-ere noc effective
05 8 Defective safety devices
-
.,.. --- t
052 guJrds ()e, .. ' g .. or to
l{!ot"Gt ....,,. ...., tt'/'W<ffe r:-ji a

05 3 Pi'Ott(;_: .a eQ .. . tfN-'t
....asJ-..tCOI"'(KI. fOftpo! tto! t tn:e ...
..., tO F(lr, '*'"' ,J' :.t" A3!> r,ral 1t<:! ,.... .,,
ap,Qt':P"' :'V,s:ovr er e'J"''"' i ,..M.t
,.....___.
.! .... .. n
currK'f;l b<. ..-t e tccf ,,n =tq,..a
r . F&Y S!-.t'l'l o' to.O.e-<j rr.l'!r il COI"!-S-("t
'iiil :.. C.::.... i:l :.t 'o.l' .!...!r=l---' -----....
13 1 Antecedenl not presen!
13.2 Antecedent not
13.3 lnOOf'Ted. be-hav;ou.r ceinfOfced
...) o\JJ. fltit-' t l. .. j 113.4111C0fTed.bthaviour not
Foe an contronled
05 a prewr-1 butl1 N at l.t"-! Proper behaviour not rewarded
f.l"tOIIrT';::''
051_, Sl' t't(Ca- .te"s "t'" e t'd t,..Kb,e u'tCf dt:tCH sUCh n t:rau,.rc .:.{ va .:sor
r-" c;.e"spH1 ir d J-nct ._1 10
' '
05 a ''X" c-t
(r,et <JpMj 1 't'd !O a<. l 't.Jlt YI"M 1!,t\ S j i;'SO lt':f-1!-i. -# S Gf
H ' =t/ n':tt d'!'\;jf'S

1:
13.6 BehaviOocalanai)'Sis proce$S
not effedive
13.7 Other
t' n.. .. .:htJ
iJ I pn;dy t,: uP.'"'* -.o ' t:o t N!n.:Ct:Ot'Q
i J. 4
=xb:IM, m!l\ltfliOM .... '" rr..a"'7l-1
ceoscn \M'NOI"II. btin9 tf"l'4-l!.'.,J trJI ""') Ngh! .,.

or
'\:' 6 L'-amal 01 berJ requ<ttod ,r.sat

1;.' 1 r 0'Mf t4 byt-.:1"11-1''"-'\""
...-:tw .J' ::.::.tJd -ltl'lr\;.. .
12 e INI'' :M; ..
1): 1 N:t.!C'f'GIH':l not PVUftl P'f'Kin bU-1.-ftl."'
""''f ......
Ar!ec:t"ddlt!l net ...w a fl :he .,."H bui4J)1 ,._t
a .. I . .,., bflwoi'IOU'. ''
t 11 ....
UH'Itt'OIO*';to. .. pe::"'W1(of
Ill .; Ot lbcOmfcr.
'114 -'
c ;od bf 01 r;oeen., a"J,j l"!tC'ft.:!'t !:.ere WBS b rhC
t...t-.J9'"''
"llX rew:a:o.J ffrl;nr .ng a btfl.f'out a.a n:.-t .4 'f
r
..,,
t 16 ''OC"'t ... a. .. ..,_,. r4 S """'o( Att-C fit'U"f
..
I) :._n-..ntdf"fi"'e
OS 9 Other OS 9 C1J:!!f .n-.nt -
::::!
14.1 Assessment of requ:red skills oci H 1 of s\ ..,or ...'.-. tl'le per$0nusJtMd M \
competency not effective tf'1 eotT"pf'tenc-t tlf'CHUfY ll <Sow. hl f;l tN;Jrtd " .,
06 1 PlanVequ pment malfunction
OG 2 Preparation of planV tQu'pment
0&.3 Too-l matfuncuon
06 4 PreparatiOn or tOOls
OG SVehrele ma!fut1(;(100
oe 6 Preparation of vehode
08 7 Other -::
07. 1 Fue. and explos.-on
.1
00 _IP:rV!:t .. .. .n1 tiot the 114 2 Practfce or s kill not effedJve
of V <Otyf'd rJ lj r.ot .. ...
a c:rnAIU'ev.ll f'l-d le
(;.) 2 on of w-t tM :m ...,-u .Mt prep: :trt-d t C.!Jt(t:y r.'!Of to 11 . 3 No coad\ing on skill
!1t'tt".-HT,p' -1\;Ut
c,rf3"''0'
003 TOOl!'!'! LI"U!Jf'l) !-tJ\IUJ 'DJU.t'<! TOS!f'
For t,.r:! .._, f"'.!f'= toOl f'l.ll et s'"W.
00 4 te.co-s r ... tl''tJ"b fct
l!.amt':! a-- .a r.,...... ..,,s-.;.! c-1- o
,f, fot\
.-HI c_ For,!ITC' u JJM f:.l! "' ,;'o;r -&.3 ('lo,vq .j.i ftct
.,eo
005 lht.''J"l-.'tt' .u ( .."'" f!J-j r:.:
t<!<M r.rr:f'1 Fe-f 'l
of ill t _ '>l\1"'-<;\j;f't
:J.,
o:: <;' -
'___l
-, .1
)="'f e a.j It' S/J-.:'1 f .r a
'l......., r
. - ..,
14... /nfrequent performance or stotl
14.5 Other
1 s. 1 No training p<ovlded
15.2 Tra:nlng effort no1 effedive
1S 3 Knov.-!edge transfer not.
errearve
15-4 Tre n;.ng materials not recae<t
Y1 ':\t1 JMIU'iC.f\.knAf'tdr..o:.n'pH'loey
14./PI -td
t ,, m., fl'ft:tbbh
14
r-1 ..ma
,,.,. "'''l.;toertortnancec.!.tou
..
14 :f tr.UU oct;.-..
1N
r-.t au.
V:o ..
....-e
trf knwf.odgt tllftl.. ... .Tot ;I) ll.ICll lf&rttlg CSft';". WQ-1 (
c..;:
lo the'rna!attl
'I ..... t .:::C:'ll'l
rr
,, ......'"""""
cwf<'tl-::-
1
.- mr.ora.-. noc te::.a!..-"'11 tn: :::1 Wn ttf'ls.' .. -t_ir._iln'i'.
1J"'"rout1tl
t " en
07.2 Nolse
07.3 Er.eryized el ectrical systems
07.4 Energized sources other Lhan
electrical
07.5 Temperature extremes
07.6 Hazardous chemicals
07. 7 hazards
07.8 Slorms or acts of nature

07.9 Other l.J""
08._1 Congestion
:=n,J
08 2 ll!um;nalion
=-=.-
-
08.3 Ventilation
08.4 Unprotected height :
-
08 5 Worl<place aosplays
]
...]
08.6 Other

of.. 1 p M
01 J i>)'sto:n-.s m ill
S(SI EiTt 'f"'.it#o"SS t ,.. IQ
1
o! 4 Fc_-er9Lc-i elt"ctrio:.l.f penen ... u_ 10 or
!.'-.ICh as ..::, &:'m.cal
6WJ!Of"r'ad.3:._, .. 'j (.;.'"'
- ,......., .- __....___, ......r------
JT s ...etrf-t'3....-a r:p-n.;dJl Y!vsn'_:, a:-t =nt
or t-1 tcu-:hn.J an o ... lrutV.n t..n:js.Ua iJ ho;t er c.of.!
:n
or t1 k.n.Yd-:.vs s ...-.s ll ti:!Urdc-us :.tn
aJM\.1- t e-.,T:t ]1"
,...u c.h3rp
..!=-
o; a S:CriT's o: acts ol nat..te E.poed to: .. of a
s.tOtrn .. -L
T - - - -
.

1 of th d'i.oot enqygl'l from_
h3lvds 3-;ce$St- :tt r? e<:;OJ frnrt or tOO!,Sv.n cb-;:rvcte-1 or og co._'d
-
03 '2 1 !'_,mMlC:.!'lv.-a;: so IO"Nor !0 t!'l;;t t a
I I I
:-e--t .a t1'\ to
or ot 01 a de:cte. ue mO()gfl'="oi!-s
15.5 Other ...
16. 1 Behavioucs not reinforced I,., I BM-t!Oif$ not ... th-e 31(11: did n-c.t F9f'OPthl'..
-vo&...t5-;.:r. rdpe<:t lo Hi- ''" btl'\i.,"OI.U'$ a"1d
to 110!..-o!tV'd t!""3' .........-
16-2 PartiCipatiOn in safety efforts nod ., 1 Par' --.r"....n kft ,;rftot( t'lt ... I' ,., lfl a1 rH a10 r.1
effective li!r-p.tr-pt..tt t-e"I.JOJY.c; wv: respect l.:l al1-d ufftt
&ctur t.'O!.IU a!..o ....-.:--V(k> "'" ....orHvrce In HfeiJ' ef'c-rr'!-
t 6 3 Cons$der.rtton of safmy in
staffing ool effective
16.4 Re.sourcing fOf safety not
erreaive
16 3C of u'dr' ';J not t" ,-n &-1 n .:lid "t7t
appt"S""'"-'1111 befU,' - 1'5 N' ' rMp4!<110 I'd" t1)!e jl"'!l
peoft:.rrn.trr.o:: wt...-, ..;r'9 !o tK'roJ '. S-!!: 'etl_ d""'"lop f'NIN'a
w"-M "'l and litJlwncfn l ..... partnfof'i
1r. 4 R' f01 .aP:t . .it :n if"'. area d.J .lppropm::.,
to ltierro'"' rt

16.5 Support of peop1e not effective l 1lJ 5 of p-op!oe t'!t--l r'rf'di'. tt>At tu1en ;n .,, 41-d r-ot
.,.1!,..re5pt W tt-.e-Jioftt ' 1"\ t-('4. '"1-9 OUi an:l ndl"'''d<J!1! v.t..o
tk."!!t ami !fl"-"alt Ot..t ttoo-...t s;etO::fll.$....ei1li"d .., b)' 8"1 ncl-dl":'l'
16.6 Monftoringtaudillng of safety
process not effective
10-Jt./Of' 1or ''"'9 proees ne1 : ... t!"f- a'\ltU OJ(I
I?PfOfol.:.l!rtrs-ot l -'!>!'I IT'J:\.tOC'"'got.-A!.ng thi:t"'..,.
offr"f> " rge'.IS prc-ti'I\Y!'f .no wnu
16 7 Lessons learned not embedded H6 7 Lts1ct H r .-. haJ ICiet'<!J Ad a ttnon 1
t:...t ....5$ no.l c... >Ai'h
16 8 l eadership Of accountabilit y
16.9 Empk)yee invotvemeot not
effective
16. tOR1sk analysis orto!erance not
effective
t& "'P 01 ..1,y- 1n lita 4Jdno: \c-t 1.1 e fqt CIJ;'IIll(; 10n or 1,.--1111 f-
ufdyCtl ,.kW.-ed a; ...
16 9 i .. <:<.tTI"' ,.., an a'H cf:t n-ot ()bot""'
n\c.an
....... ,to
1"-
of MolE Nt"M'nt Clf :J (Oiafanc:. tr.r a: or aV
08 4 WOO; .1 IOU!QI)v.toner...-offt'l ill f3 1 <lfte.!l 116. 11 Other
v. 'i''S rv poss .:,no l'lN:ar.s of 5vt.h as gu3rdra s or
11 O'fl"" m . -.1!

08 5 d.spll:r-s t.rsed !O d..::!,!IP-t
nE<::e-55?1)' on 1orm.:.l01'\ t ) o'iQ..:ctmch.J .. l"rllt
-,.,--,m-_(1 !.]hts !-,q_pment or
I I' 'IIJ"II
M600M'rrus.lder.Oe L,---]
17.t No contractor prequa1iflCaUoo
process
17.2 ContmctOf'
I orocess not effective
17,3 Use of a nonapproved
contractor
17.4 Contractor selection not
effeaive
17.5 No job ove<s;ght process
17.6 Job oversight not errecUve
17.7 Other
18.1 Technical design not correct
,, l pr..-..:eu w-as M s-t3"-j.Jitd tot'trfdor on
prOt !-!.S to ass..!Ss cy o! a to t-.r.-"'0 frm
17 2 Co1 tl?: lot .., '-et'-on e preq ... _. -.-:,,..,:.!on prooess"W3'- .npla:t>,>r>J
l.t 'ze:f boJt 1 do ::I 110t -:..,.-.tt re'eva_..-: Ce'-ere .,_ n r e COt cape!'" f.a
, 3lk of a con-:r.'OI 3 rwm 'A.f\o d.:J net m-t
'6:\- U 01 lifS f, red tn
t-r _.. Co.,"'11ra_r;.. W.-tOOo," c.l cof!_tor,.,-.\- fl'.de11o IP10t.t a-J re.'r,..c..-,c
d'J''l !t .t Qt th-s wo;)fi
1 j 5 '* ;cb FrtotM I"G lod111'1 fl'l.)i".:.y
''l..:.. n IT"etfl01s Cf
17 e Jot o-....cnig"t not J" c.L\e '! PKt"'' Mn ,,..,pix. ro or !"''.tPK! a cortret::IM hma
...."CO:: but t n ot w ' -Mat C:C'Ic.-Lfi!d

181 ...'2'St\OI
sutabfa fot taoltf'Sv.Ncl\t\Jtw't"
n'\('"3 rgy !oc tt-e ;nconf'Ct s._r-port IN

l'\... a'F.t:1 w'KH$1,,1S'\ut-sv.-.ro?NX

18 2 Design standards, specmcations, t8 2 (.'leign 1-ta:UMd.,_ sfe(tf..c.. ,ons ertffrt r.c.t OOfrKt tr ' o!mat-o., o-.. tho
orcrileria not corred .. _.ofttf'IAf .... &r.-oom

18.3 lncocrect ergonomic or human , ,s 3 g-onom--rC o: ttUft"'a"'. de"'...gl"' fatd!.n <M'-ero twOt I'W:It
ractordeslgn OO!'ted b.!frt'.!SwoliJ W'dudtwct\- too (.>'
kr,.,_. Of Ci<-t Of l".)rTf'!:tl ot 1!'-o--, o! ''"-1')(1 bttMten 8M S1'SI!1
18.4 or construction not
errecrwe
18.5 Assessment of operatlooal
readtness nol etfecttve
18.6 of fnrtial operation
not effective
..... _. 11 "-ng .' .,:cn-)tr\&"i-on ru.: ... 5-r..c.te-r.JOII"'$Mct!dlllvw. ra.-
f;.
. .t!._ __ te-t" _
tt.m.t"- lt'loirtcttorred.CtiM\ncl!ooo.wd
-'S
i'6V '-
,J td
18.7 Technlcal &nalysts f ori1Sknot 1'8 ,.,.,
effedive M l-e'SHd ..... hr.sk l vwf ThdWOI
.a r..t .t,. to Pe-iSER, L.Of'.\8n1.\'
18.8 Other I ne'
f9. t No W'Olk planning or risk
assessment performed
19 2 assessment not effective
19.3 Requked pecmit not obtained
19.4 SpeOfled oootrols not fo:Jow<d
f9.5 Change in lob scope
19.6 Worl<site not 1en safe
191 .... .......
lr.e-1 , W: PI' 01 .!o lh.1t -.\et"'
192R;" t:e -w&r< done was Lt t .. .-1 m_.--
au.enmoer:t dd MC ,,.. !YE!'Cot"t, or tMo COI'Itfds spoeo!<e<t d J I'\OC r:o'"'::t w
NCrr
t tua
_j .....

to t"'., l"-4:.trds fC'CHr.l bl.o1 ctid nQt 100 ltN'I tr4W c::c>nb

"a-s,.,.,__ ., cind t\l.:tx.r z'I)Oj I;;.Jt MworiC IQ!t no ._topld LJ 1-a HUUI1'*1 l.e

186Ao-1o-"nrl .. -rttotr\lt'fl!d_
I t9.7 Other "r"
3
..r
20. t IOOOfl'ed. rtemOfdered
202 ln<:O<Tect i'lemrecei ved
20.3 Handling or shipping not
errecuve
20.4 Storage or materials not
effective
20.5labe:ing of malelials not
effedive
20 1 !r.-c.ot"(etl 't..l'l Of\'.!1'00 1t'ot: ,-t-:>11Uir,.s ucotU"-rt>Of'lait Ofd-efed Reasor.s II'\
1.-. .d411n,;otrKl'-j:'KJ' ift4'Jf'C'--'.;!'"'

20.2 IN;:OffJ t...m re-ii+d f"'!oJ COirftCt V>'lS txA. 11\Gttfrec:t c. 'f'-""l r.;ce.'t.'M
Rt>Ut''., 'ot C'a"' lndudt bt lt\-t> cocNtt
r "CCOdu""' ... t"' Wll"t or Pfopet"
l
:-o 4 St_o'"O\g>t he w \Wf'e Of dctg.tait du.Y..J l!cr
20 S Uhe. "9 rA nlG'!ffl.llt "-!er-e .e 'o'meno1 t6for: ...cfc6nec:i /
"l t'Ct PfOVU ng re!rt-. -.t haalth ,a.-::j It 'Of"'o!i:M
20.60Cher
21.1 Wrong tools or planu equipmentl21 1 WftK'ItJtocls cw toof!o a:"'CC toiQM.
provided t.t P."Clrtd to 10015 beuu\..e t re ns\ nsoc.OI<.\'Ii'o\ '"""""''
1(\aVl'c<f'l .-ri'ie-d
2 1..2 Corred loots or pCantl
lec:tuipmeot not avaUabfe
21 3 No lnspedl<l<l
21.4 Incorrect adJu.stmenUrepair/
maintenance
2 1.5 Removal or replacement of
unsuitabte items not effe<;:tfve
21.6 No preventative ma1ntenance
l oroaram
21.7 Testing or plan1. 1oo1s or
equipment not pel'fooned
121.8 01her
22 1 Ulcl< or SPP for 1he task
22.2 DeveJopment or SPP not
effective
22 3 Communication of SPP not
efrectfve
22.-4 lmpo:ementation of SPP not
effective
22.5 Enrorcement or SPP not
effective
22.6 Other
23.1 Horizontal commuo'QIOOn
betw'een oeen; not effective
23 2 Vertical communkaUOn
bet#een .supervisor and person not

23.3 Commvnk:atJon betv.-een
d;frerent cxganizatlons not erfed.JVe
?1 "1 Corrtn I>\. Of pta.r.. tQOls elf VrUrr noc
it/&' ii JOt! S. !e e.t"fof ,.,.._,_ li.IPPbl!d. Of fi'\3CClP'st.b'o&
21 3 No ru.,:ectorr toM ana .:qiJ pmE-nt '''"e not IMpec!f'd r'lGf to ""t! ....-. Mt
u-o;:e_
21-4 l1'11:01'Jt'd e:f,U$tme"'q'rt';-a,irt rt<.: P'orerlools v..j rq-. m-:t .r.-uable-. ccA.
/"..:ldno: beef'.eort"ectlf"'-i.,_..ntldDift"Pol t ed s..-ve.N
21 rems ncr; i1l:lrM WHaf"''ong
ft"""-twd 11 USt'
.. Mlrrt!nanceptogra'n

21 i
tfJo;.,J 0( e-.-3 ua!t:>J flY fo1 TtlrS c.a1 !O pl.l/'4 tqU F'T'!Vt tot
"'--t a- 'c.1 ,., p.,-a cf 11 f\ONf'l'
22 1 Utl(ofSPP -tn\
Lrneol t.rM.' lnOdf-nt 0... tosud'l to USJgn b' lhtde'.-dopnw1of
S"P. (t(llwof, . l'l-i"'''fot s:Y,jnd
22"1 Oo-.o&or ..... SPP nJ: t ..tt ...eSPPttr.t""""
..
"''h :!M--;tl .. .. -rb_ r- ono--...,e-;g..ac!o peof!f' SPP, flOC: the- p
n st ' oc a W>t rnad,. rM SPP ., ...... liM
i22 J Of SPP n f'xh<e l,.,...f''ilffl tn SPP' ,n ti.-1 rf t.3d rd.
:b4 F:fi'<-OH.J lftCO'TI"'C-.,'ttl'r,b;,.tJon, .. l'lg'-M!l" Cf " 1o1 t _,.i
1-nCC' :l'"'!'te
224 tf'lt-re.if+"'-SPP ..tl"!
SPP not comjN-- dJt t> fitdon 3t. h:.qu11eme,-.!.s, con'v-s:nq f:wn.tts.
.. 'fOfS
?'15 of ,,.11oM ,.,. et";:;ct b.l MC
..... tu tt>e IliA IO $uth ,.,_--tort OS .nldeqtll!!t
b-- cY .. de--"
22d0f"1N' .,.,, . ,d ...
23 I HocZC ''4 CQm'1'1 - :;,;; ><1-. --1 1MS'fl.plew:-...o--....c,nt_t._. 'f. (I
f'Ota;'T'Imo
13/Vo-1 o.,., ...
J.' t
er .neo:""'(<Cif.Won
-:. J
.. ld
"oppf;ff .J;J t-ot.: a"ld tonlriKIOr "' ef19ol\Mn e":d
234CommunJc:atiOnbetweenvtOft ,tl-4 <1'\GMI::.Qislftf..OC:!le-"M\\IIIOn:FQ
rou not elfedive .,. 1
23.5 COmmun!caUoo shifts
not errective
::n s eon- ...... IOI"Jon t:t..'tt r101 f",.VW.:J from
on. dx! "t ... lt>OI.Il N':'
,-ru
23.6 Communfcatioo not received }23 s ..:a'JOn ne1 tf'"" if'IV:/,-M .n
('(ll'ftmJI"'o rtf>
lt.g.t ;M '*" 'IIU 01 pi'!O"t mto\.\.JCt rerr.lt',$J
23.7 Incorrect information In., r..-p:e...on l'!:e g:len lf".!C)Imt'Ql b-.! l!--!t
rta .:d to
23.8 fnformatlon not understood 121 8 ,for, "' <>It Nit U>'IW's.tood cJ e peop .. .n i."le lft(jr1ta: did 'N !.
tl' t."'Tidf"''ftl'ln(l
23.90ther ef"
ro
0
I-
~
::::l
ro
(.)
Q)
-m
:.0
Q)
E
E
-
0
-
c:
::::l
0
Q
I
I
I
I
I
I
I
I
I
L{)
N
I
I
I
i
I
I
I
l
I
I
I
I
I
'
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
L{)
6
0
Q)
If)
::::l
ro
(.)
E
Q)
(;)
>.
(/)
Count of Immediate Cause
System Cause Total
11.7 lncorrectjudgment 3
12.3 Confusing directions/ demands 1
12.4 Conflicting directions/ demands 1
13.70ther 1
14.4 Infrequent performance of skill 2
14.5 Other 1
15.3 Knowledge transfer not effective 1
16.10 Risk analysis or tolerance not effective 2
17.7 Other 1
18.1 Technical design not correct 3
18.2 Design standards, specifications or criteria not correct 1
18.7 Technical analysis for risk not effective 3
19.5 Change in job scope 1
20.1 Incorrect item ordered 1
20.2 Incorrect item received 1
22.1 Lack of SPP for the task 1
22.2 Development of SPP not effective 1
22.4 Implementation of SPP not effective 1
22.5 Enforcement of SPP not effective 1
23.3 Communication between different organizations not effective 1
23.9 Other 1
(blank)
Grand Total 29