Incident Sharing: Release line detached during Bleed off

Date: 16 sept 2015 PSL: CMT Location: Bedidi 1X- Papua

RHS no: 665998 Case Classification: MTC

Description: 16th Sep 2015 early morning at 02.15 AM Papua Times, whilst conducting pressure
testing on DST #7 with operation pumping pressure up to 7000 psi. The incident occurred when
Halliburton Service Operator release the pressure thru 1” Lo-Torc valve on release manifold at
Cementing pump truck then suddenly the release line connection detached at Victaulic clamp
connection that make the release line swung and hit the IP on his back, which resulted bruised on
IP’ back, hand and foot fore head..

Consequence: The IP was immediate taken to rig clinic and doctor performed visual screening on
whole body of the IP. The doctor also checked IP respond to make sure there is no fracture. Then
the doctor gave infusion and pain killer to reducing IP’s pain. IP was in conscious and able to
interact all the time.

.
Causes:
▌ Causal Factor 1: It was found that 2ea of the U-bolts that hold down the release line were
missing causing none of the line was properly held and retained to the pumping unit. Then
when fluid flow back thru the release line aggressively, the line accidentally dismantled at the
weakest point (Victaulic clamp) and make the line swung then hit the IP back side and pushed
the IP up front hitting the control panel before fell down to the floor.
▌ Causal Factor 2: Lo-Torc valve was not properly maintained after several pressure testing job
that causing restriction and hard to be operated.

Preventive actions:
Immediate actions:
▌ Properly check thoroughly equipment prior to job include for missing nuts and bolts.
▌ Ensure all valves easy to operate for easier to control fluid flow ▌ Replace missing Nuts/Bolts to hold the flow line
▌ Ensure lines are free from any restriction to avoid pressure build up ▌ Conducted safety stand down on locations
▌ Re-fresh all personnel for bleeding-off pressure procedure.
▌ Utilize Halliburton Standard Lo-Torc Open/close Bar
.