·Decision to deviate from procedure – Group proceeded with a task for which there was no approved procedure.
·Insufficient controls recorded on work permit – inadequate assessment of risk, no work site visit.
·Proceed with a task with insufficient resources – Initial planning resourced for three personnel. One of theoriginal team was replaced by a specialist vendor for one task. On completion, the specialist vendor demobbed and the the third original team member was not replaced.
·No protection to prevent reverse flow between A annulus and Active Mud pit when valve was opened – Failed to identify the annulus pressure was greater than the hydrostatic head imposed by the seawater in the active mud pit and the relative elevation of the tank to the casing head.
·Tasks to have specific procedures/programs to include hazard identification and control measures.
·Adherence to risk assessment procedures to be reinforced.
·Review Control of Work procedure and permit meetings.
·Review effectiveness of permit auditing system.
·Review Well Maintenance and Pumping Operation resources and competences.
·Amend annulus top up procedure.
·Learning from this incident to be shared with Onshore and Offshore Teams.
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