Cause & Consequence
- Moving, flying or falling object
Incident Info Source
IADC Alert 08-41&amp;
Specific Incident Equipment
The equipemt being used was 13 3/8 Single Joint Elevators, a check of the elevators during the investigation identified that the elevators did not fail and that the occurence was primarily down to human factors. Because the safety pin was inserted behind the latch on the elevators it was prevented from acting as a retaining safety pin.
The driller was unable to see the joint of casing within the V door or the elevators from the drillers console.It was not possible for the elevators to inadvertantly open if the safety pin is correctly located.There was no second person assigned to check if the elevators were latched correctly.The available Job Safety Analysis (JSA) was generic and did not consider the elevators not opening.The rig was not fitted with a secondary means of retaining tubulars at the bottom of the V door nor catwalk.
Change out the elevators for a type with a better latching deviceReview and amend procedures as and where necesarryDevelop a site specific JSA in lines with the findings of the investigation findings.Devise a stop system, have it agreed by management prior to installation.