CASE STUDY

OISD/CS/2022-23/E&P/06 Dt.: 06.02.2023

INTRODUCTION
Title : Fall of Travelling Block
Location : On-land Workover Location
Loss/ Outcome: Major Loss of Asset

BRIEF OF INCIDENT
During pulling out operation of tubings, the travelling block hit the crown block resulting in
snapping of casing rope and fall of travelling block at workover rig hitting first to the monkey
board and to the derrick floor. In this incidence, the top man who was working at the monkey
board got injured, rescued safely, and sent to the hospital for further treatment. In this incident
travelling block, casing line, monkey board and derrick floor got damaged.

OBSERVATIONS/ SHORTCOMINGS
Following observations were found during investigative inquiry carried out by visit of the
incident site, interaction with the related officials, their written statements thereof and
available documents:
 The rig had two types of twin stop safety device, electronic PLC based and other was
mechanical based which is a Safety Critical Equipment (SCE) for controlling the
movement of travelling block to prevent hitting the crown block (upper side) and derrick
floor of the rig (lower side).
 The chain of mechanically operated twin stop device was coming out frequently from its
sprocket and this issue was not communicated to Maintenance group thereby integrity
of mechanical SCE was not ensured.
 As per standard operating procedure (SOP), the twin stop device must be available in
functional condition at all the time, but the same was not maintained.
 After every slip & cut of the casing rope, subsequent testing of twin stop device was not
carried out.
 The Rig In-Charge (RIC) was entrusted additionally to look after the duties of safety
supervisor who was neither having adequate qualification and experience nor
performing his duties as safety supervisor.

Provided for information purpose only. This information should be evaluated to determine if it is applicable in
your operations, to avoid recurrence of such incidents.
 The bridging document was full of anomalies and without any correction, both the
parties signed the document. Hence, due importance of bridging document was grossly
ignored.
 Rig performance is being evaluated monthly on the basis of certain parameters, but
neither the backup observation sheet for shortcomings was available nor any official
advisory was issued to the contractor for violations.
 Time norms was given for each activity under the workover operations which might
have created the unsafe condition by speeding up the job to complete within the
timeline.
 Installation Manager was given additional responsibility for another rig.
 From CCTV footage, it was observed that none of the crewmember was monitoring the
movement of travelling block.

ROOT CAUSE OF THE INCIDENT

 Non-maintenance of Safety Critical Equipment as per requirement,
 Lack of alertness of person on brake and other crewmember working on derrick floor &
 Lack of competency.

RECOMMENDATIONS
 A competent person shall examine brakes, functioning of twin stop device and linkage
of draw works at least in every shift. If any defect is noticed during such examination,
the draw works shall not be used until such defect is rectified as per clause 5.4 (a) of
OISD-STD-190. Also, the crown-o-matic device/floor-o-matic should be tested before
each trip and after each casing line slip/cutting operation and shall be recorded in the
IADC report as per clause 5.4 (f) of OISD-STD-190.
 Considering the importance of SCE, second twin stop device preferably, PLC based
shall be made mandatory for all drilling and workover rigs.
 Functionality of twin stop devices shall be ensured at all the time. They should be
checked, tested, and recorded in the daily progress report.
 The entire crewmember working at the derrick floor shall remain alert all the time.
 Organisation shall review the contract requirement of drilling and workover rigs w.r.t the
following:
 Competency of crewmember, in terms of experience, should be in line with that of
the departmental rig.
 Dedicated safety officer, having requisite qualification, experience, training shall be
included in the contract.
 Training requirement for IM, Safety officer, RIC, Shift In charge, Asst Shift In charge
and other crew member shall be identified as per the requirement of OISD-STD-
176 apart from MVT, Well control, Firefighting and First-Aid.

Provided for information purpose only. This information should be evaluated to determine if it is applicable in
your operations, to avoid recurrence of such incidents.
  The current practice of giving timeframe for different operations needs review, as it
may result in unsafe act/ unsafe condition to meet the target.
 Introduction of penalty clauses for safety violations.
 The bridging document shall be reviewed and should be consistent with the
contract. Key personnel shall be identified and responsibility & accountability to be
fixed accordingly. The RACI (Responsible, Accountable, Consulted & Informed)
Chart shall be included in the bridging document.
 Internal safety audit should be carried out by a multidisciplinary team on yearly basis as
per the requirement of OISD-STD-145 in line with the OISD checklist. The audit team
shall also check and verify the functioning of SCE during the audit and carry out drills.
 The detailed guidelines for performance evaluation required as per contract shall be
established. The result of performance evaluation should be shared with the contractor
along with details of non-compliances for taking corrective action.
 The organisation should evaluate effectiveness of QHSE audit being carried out in
virtual mode.
 IM shall be given the charge of only one rig as per the HLC recommendation.
 IM shall visit and examine the installation or part thereof under his charge on every
working day to see that safety in every respect is ensured and maintain a detailed
record of the results of each of his inspection and also of the action taken by him to
rectify the defects noticed, if any as per regulation 29 of OMR 2017.
 Safety meeting shall be conducted on weekly basis as per the HLC recommendation
and safety violations, pending audit observations emerged during the meetings shall be
complied on priority.
 Monitoring of actionable point in Management Review Meeting should be monitored on
regular basis for its compliance and special emphasis shall be given for SCE.
 Bypass register shall be put into place as per the bypass policy of organisation for
recording and approval from higher authorities.
 As per the regulation 27 & 28 of OMR 2017, the Manager and Deputy Manager shall
frequently inspect the mine and maintain a record therein the findings of each of the
inspection and the action taken by them to rectify the defects mentioned, if any.
 Crewmembers shall be encouraged/ suitably rewarded to report near misses, unsafe
acts, and unsafe conditions.
 The workover operations shall also be monitored randomly through available CCTV for
unsafe act/ unsafe condition.
 As recommended by Baghjan HLC, organizations should develop a zero-tolerance
policy for operational lapses and fix responsibility on all persons responsible for the
lapses and initiate departmental action against them. Similarly, responsibility should be
fixed on the contractor’s company for its functional lapses and action taken against it for
the acts of omission and commission contributing to the incident.

Provided for information purpose only. This information should be evaluated to determine if it is applicable in
your operations, to avoid recurrence of such incidents.
 ********************

Some of photographs of the incidents are provided below.

Travelling
Block

Monkey
Board

Rotary
Table

Provided for information purpose only. This information should be evaluated to determine if it is applicable in
your operations, to avoid recurrence of such incidents.
Provided for information purpose only. This information should be evaluated to determine if it is applicable in
your operations, to avoid recurrence of such incidents.