• Published: 20 Jun 2011
  • Incident ID: 3271

NEAR MISS – Spool Valve Ejected from Manifold of Iron Roughneck

Cause & Consequence

  • Handling, lifting or carrying
Incident Consequence

Incident Location

Drilling unit

Incident Activity

Drilling, workover

Incident Info Source

Fiona Gibson, Chevron Upstream Europe,

Specific Incident Equipment

Iron Roughneck

Lessons Identified

  1. The Iron Roughneck had been serviced during the summer and the circlip had not been correctly re-fitted by the service company (not the manufacturer).
  2. There was inadequate planning of maintenance activies once a hydraulic oil leak (as a consequence of the ill-fitting circlip) was reported. Drilling leadership were not consulted to determine whether there would be a suitable opportunity to undertake maintenance work on Iron Roughneck while it was not required operationally and, as a consequence, the Iron Roughneck was not taken out of service prior to commencement of maintenance work.
  3. The work party did not recognise the hazards associated with deviating from normal operations and operating practices, meaning that the Iron Rouchneck was used operationally while known to be malfunctioning. The consequences of the malfunction were not understood and Stop Work Authority was not used.

Incident Recommendations

  1. Drilling supervision must be involved in decisions relating to drilling equipment maintenance planning/scheduling.
  2. Personnel must improve their hazard recognition and willingness to use Stop Work Authority where operations start to deviate from normal operating practices.
  3. Maintenance personnel must ensure that they always leave the worksite in a safe condition.

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