Fatal head injury during blow out preventer pressure testing

What happened?

During this operation, the chiksan line suddenly rotated and hit the floorman, causing a severe head injury.

The injured person was evacuated to the clinic by ambulance, where he was pronounced dead.

Why did it happen?

The floorman was standing in the proximity of the chiksan reach during rotation.

There was no detailed procedure to cover the process of assembling and aligning the cement line components for BOP equipment pressure testing.

Hazards were not properly recognised.

Process of connecting the cement line to the string for BOP pressure testing is considered a basic routine activity without procedure.

The crew did not spend enough time connecting the cement line.

Assistant rig manager (ARM) did not exercise his leadership skills to do the job safely without shortcuts. He rotated full turn at a high speed (44 rpm) without informing the crew or ensuring that the area was clear.

What did they learn?

Develop a detailed procedure to cover the process of preparation for BOP equipment pressure testing and other activities with similar rig up (i.e. casing, liner cement jobs, test completion etc.) in accordance with industry’s best practices where applicable.

Ban the use of rotary tables for any alignment/adjustment of string and identify alternative methods.

Review the job safety analysis (JSA) and reinforce effective communication prior to conducting the activities with focus on the change in the activity(ies) like rotating operations.

Reinforce the rig leadership team role(s) in health, safety and environment (HSE), supervision, effective work planning, leadership skills etc.

Ask yourself or your crew

How can something like this happen here?

How can we ensure all hazards have been identified?

How can we enhance communication during critical activities?

What can we do differently to prevent something like this happening here?

What happened?

While preparing for blow out preventer (BOP) pressure testing, the team first installed the circulating head (T-sub) with chiksan lines and then tried to connect the top drive to the circulating head.
During this operation, the chiksan line suddenly rotated and hit the floorman, causing a severe head injury.
The injured person was evacuated to the clinic by ambulance, where he was pronounced dead.
Why did it happen?

The floorman was standing in the proximity of the chiksan reach during rotation.
There was no detailed procedure to cover the process of assembling and aligning the cement line components for BOP equipment pressure testing.
Hazards were not properly recognised.
Process of connecting the cement line to the string for BOP pressure testing is considered a basic routine activity without procedure.
The crew did not spend enough time connecting the cement line.
Assistant rig manager (ARM) did not exercise his leadership skills to do the job safely without shortcuts. He rotated full turn at a high speed (44 rpm) without informing the crew or ensuring that the area was clear.
What did they learn?

Develop a detailed procedure to cover the process of preparation for BOP equipment pressure testing and other activities with similar rig up (i.e. casing, liner cement jobs, test completion etc.) in accordance with industry’s best practices where applicable.
Ban the use of rotary tables for any alignment/adjustment of string and identify alternative methods.
Review the job safety analysis (JSA) and reinforce effective communication prior to conducting the activities with focus on the change in the activity(ies) like rotating operations.
Reinforce the rig leadership team role(s) in health, safety and environment (HSE), supervision, effective work planning, leadership skills etc.
Ask yourself or your crew

How can something like this happen here?
How can we ensure all hazards have been identified?
How can we enhance communication during critical activities?
What can we do differently to prevent something like this happening here?

Published on 06/09/24 671 Views

While preparing for blow out preventer (BOP) pressure testing, the team first installed the circulating head (T-sub) with chiksan lines and then tried to connect the top drive to the circulating head. During this operation, the chiksan line suddenly rotated and hit the floorman, causing a severe and fatal head injury.

Original material courtesy of IOGP