Cause & Consequence
- Handling, lifting or carrying
Incident Location
Drilling unit
Incident Activity
Drilling, workover
Incident Info Source
International Association of Drilling Contractors
Specific Incident Equipment
4500kg floor winch
Lessons Identified
- The origina winch base did not have the same design bolt pattern as the base holding plate and required modification before use (holes were misaligned).
- Failure to recognize situation as requiring Management of Change (MOC) controls.
- Undersized bolts used to secure the winch to its base failed under load.
- There was no follow-up inspection record of the modification or load testing performed.
- Wrong team members were involved in the installation.
Incident Recommendations
- Check all lifting equipment before use for damage or potential mechanical failure.
- Follow Management of Change (MOC) process to plan the scope of work and who needs to be involved at each phase.
- Renewal and modifications to equipment are to be checked by OIM, Mantenance Supervisor and QHSET Officer at a minimum (Tourpusher to be included for drilling equipment and barge engineer for marine equipment.
- Any load bearing equpment should be load tested to SWL before use.
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