ウェルインジェクション（well injection）の現場でジェット火災が起き、一人が死亡し、大きな物損が生じた

何が起こったのですか？

A coil tubing operation was being conducted at an injection well.
The gas injection manifold was left under pressure and isolated via manual wing valves.
An instrument plug was ejected unexpectedly from the manual wing valve flange, causing a gas leak and subsequent fire.
The jet fire destroyed the coil tubing equipment and spread to nearby vehicles.
A worker received 3^rd degree burns from the fire and later died.
なぜ、そのようなことが起きたのでしょうか？

Energy isolation procedure was not followed correctly - the isolation valve at the inlet to the well pad was left open.
The plug damage was caused by an external shock. It is possible that the coil tubing unit (CTU) mast moved due to weather conditions (incoming sandstorm).
彼らは何を学びましたか？

Verify that the energy isolation procedure is strictly followed during coil tubing operations - apply the lock-out, tag-out (LOTO) procedure.
Ensure that workers are aware of the risks associated with their tasks, and of the safety measures and procedures in place.
Ensure that personnel are trained for emergency situations
自問自答するか、クルーに質問してください
Have you ever experienced a fire due to a gas leak?
- What happened?
- How could it have been prevented?
What do you verify energy isolation?
Are there any risks associated with the geographical area in which we conduct our operations (i.e. weather events/extreme temperatures)? What measures do we have in place to minimise risk?
What is our inspection regime for critical equipment? What more can we do?
What is our emergency procedure in case of fire?