ML19308B767

Sys Safety Analysis Manual for Strategic Petroleum Reserve Ofc Drilling & Completion Operations, Prepared for DOE

ML19308B767
Person / Time
Site:	Crane
Issue date:	04/30/1979
From:	Nertney R EG&G, INC.
To:
References
TASK-TF, TASK-TMR DOE-76-45-16, SSDC-16, NUDOCS 8001170265
Download: ML19308B767 (42)

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DOE 76-45/16 SSDC-16 SYSTEMS SAFETY ANALYSIS MANUAL FOR STRATEGIC PETROLEUM RESERVE OFFICE DRILLING AND COMPLETION OPERATIONS

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SYSTEM SAFETY I

DEVELOPMENT CENTER l

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DO E fy EGnG

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EG&G Idaho, Inc.

P O. Box 1625 Idaho f alls. Idaho 83401 l

M Apri! 1979 I

UNITED STATES O

DEPARTMENT OF ENERGY DIVL510N OF OPERATIONAL AND ENVIRONMENTAL SAFETY 80011702 65

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DISCLAIMER This report was prepared as an account of work sponsored by the United States Government. Neither the United States nor the United States Department of Energy nor any of their employees, nor any of their contractors, subcontractors, or their employees, makes any warranty, expressed or implied, or assumes any legal liability or responsibility for the accuracy, completeness, or

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usefulness of any infonnation, apparatus, product or process disclosed, or represents that its use would not infringe privately owned rights.

O P90R~0RGE Available from:

System Safety Development Center EG&G Idaho, Inc.

P. O. Box 1625 Idaho Falls, Idaho 83401 O

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DOE 76-45/16 i

SSDC-16 i

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SYSTEMS SAFETY ANALYSIS MANUAL i.

FOR STRATEGIC PETROLEUM RESERVE OFFICE DRILLING AND COMPLETION OPERATIONS i

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Prepared By 1

l R. J. Nertney

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j EG&G Idaho, Inc.

Idaho Falls, Idat.o r

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l H. B. Butcher i

i Williams /Fenix-Scission j

New Orleans, Louisiar,a 1

Work Performed At l

i-EG&G Idaho, Inc.

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Idaho Operations Office j

Under Contract No. DE-AM07-761D01570 i

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April 1979 6

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1 EXECUTIVE

SUMMARY

This is a guideline manual for application of the Department of Energy's Management Oversight and Risk Tree (MORT) system safety methods to SPR drilling, workover and completion operations.

Methods described are, however, universally applicable to any drilling operation.

The objectives of the MORT system are to prevent safety related oversights and to detect and refer operational risks to proper levels of management for risk acceptance decisions.

The manual includes:

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1.

A discussion indicating the desirability of applying systematic (MORT) analysis to oil operations.

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Analytical checklists applicable to SPR operations.

3.

Recommendati.ons for design of more specific "nperational readiness" checklists for SPR operations.

4.

Recommendations for the use of existing DOE training programs l

and services by SPR.

5.

Examples of application of MORT techniques to other DOE operations.

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(1)

PREFACE This document was originally prepared as a guideline document for the Department of Energy's (00E) Strategic Petroleum Reserve Operations (SPR).

It was also intended to be used by individuals trained in the Department of Energy's MORT (Management Oversight and Risk Tree) system safety program.

Reaction of reviewers outside of the DOE-SPR program has indicated that more u.iiversal use of the system would be beneficial to both the DOE and other users.

We would therefore like to indicate some of the highlights relating to use of MORT analytical methods of this type:

1.

The analytical trees and supporting texts provide a means for setting down, in a logical way, the " matters of consequence" in performing field operations.

2.

The trees are dynamic in the sense that additional factors are added as field experience exposes oversights in the trees themselves.

3.

While a fully developed tree appears complex, it is a simplifi-cation of real life.

The factors set down in the trees represent "real life" field considerations in conducting a successful operai, ion.

4.

The trees do not imply increased complexity in an operational sense.

In an operational sense, the tree indicates a consensus opinion as to what should be included to achieve complete operational control.

The risks of omitting controls or proceed-ing in ignorance of system status may be accepted by management.

5.

In the analytical sei.se the trees provide:

(a) A consensus opinion of the operational controls required (b) A checklist for system (project) evaluation (c) A training device for new personnel (d) A means for highlighting and prioritizing special controls for particular jobs (e) A standardized logical means for analyzing and cataloging things which have gone wrong in the past to provide guidance for future operations O

(ii)

l (f) A standardized means of communicating system status within organizations and between organizations (government, subcontractors, co-contractors, etc.)

The tree may be used at any of several levels by the analyst.

(a) By studying the tree once and performing future analyses i

from memory (b) By scanning the tree to determine oversights (c) By rigorous point-by point use of the tree in situations where failure consequences are more serious As we have indicated earlier, this document is a part of the entire MORT system safety program.

Information relating to other documents in the series is included on the back cover of the report.

Suggested reading for one who wishes to pursue the subject of analytical trees further includes SSDC-1, Occupancy-Use Readiness Manual, SSDC-4, MORT User's Manual and SSDC-8, Sta4dardization Guide for Construction and Use of MORT-Type Analytic Trees.

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INDEX Page i

Executive Summary........................

Preface...

ii Index.

iv V

Abstract.

Vi Acknowledgments.........

Vil Glossary...................

Introduction......

I 2

Operational Control.................

2 1.0 Wep ilirtory.....................

2.0 Operational Controls.................

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3. 0 Control of Personnel.................

6 4.0 Control of Hardware and Materials...........

7 Appendix A, Use of the Guide..................

A.1 Appendix B, Examples of Drilling Operations Readiness Trees..........

B.1 Appendix C, Similar Accidents..................

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ABSTRACT l

l This manual provides guidelines for use of the Departmen'. of Energy's i

Management Oversight and Risk Tree (MORT) system to assess Strategic l

Petroleum Reserve (SPR) drilling, completion and workover programs.

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ACKNOWLEDGMENTS The authors wish to acknowledge the assistance of the many individuals within the U. S. Department of Energy, the Norwegian Petroleum Directorate and their contractors, consultants and technical support groups who contributed from their knowledge and experience to assist us in development of this report.

We would like to specifically acknowledge the assistance of H. " Frog" Antie and John Gabriel of Louis Records in initial development of the analytical tree relating to SPR reentry operations.

Finally, a special acknowledgement is given to Mr. Lawrence G. Lee, Assistant Professor, Fire Protection and Safety Engineering Technology at the Oklahoma State University for providing important portions of the detailed analytical tree development.

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N Gl.0SSARY As-built The engineering description of hardware and equipment as actually installed in a system As-is The "here-and-now" engineering descrip-tion of installed equipment as modified by erosion, corrosion, faulty installa-tion techniques, physical damage, misuse, etc.

Bravo A drilling platform in the Norwegian sector, Ekofisk off-shore oil field where a blowout was experienced in 1977 CSR (or CS and R)

Codes, standards and regulations DHSV Downhole safety valve D00 The U. S. Department of Defense DOE The U. S. Department of Energy O

Elk Hills A Naval Petroleum Reserve oil field which experienced a blowout and fire during 1977 FEA The Federal Energy Administration (no longer exists)

Formation (In the sense used in this manual)

Geological structure as modified by previous cavern operations Hackberry (West Hackberry)

A salt dome petroleum storage operation of the Department of Energy Louis Records A subcontractor supervising drilling operations contracted to Parson-Gilbane by the Department of Energy MORT A system safety program sponsored by the U. S. Department of Energy NPD The Norwegian Petroleum Directorate NPR The Naval Petroleum Reserve O

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P-G Parsons-Gilbane, the SPR construction management contractor PB-KBB Parsons Brinkerhoff-Kavernen Bau-Betribes, a SPR architect engineering contractor REECo Reynolds Engineering and Electrical Company, a Department of Energy contractor at the DOE Nevada lest Site Re-entry (As used in this manual) Drilling into an existing oil storage cavern SPR The Strategic Petroleum Reserve Program Systems Safety The application of systems engineering and systems management methods to evaluate, establish and maintain acceptable risk levels for operational systems SSDC The System Safety Development Center, a training and services center supported by the DOE to maintain the MORT system safety program Utilities Services such as gas, electricity and water Well-formation history A description and history of a well and its geologic environment Well Program Tha written proposal to perform well work (usually as presented to management) i Workover One or more of a variety of remedial actions performed on a well l

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GUIDELINE MANUAL FOR DRILLING & COMPLETION OPERATIONS INTRODUCTION This manual has been prepared to provide basic guidelines for the use of the Department of Energy's Management Oversight and Risk Tree (MORT) system safety approach to assess SPR drilling and completion programs.

These guidelines may be used for logical and systematic:

1.

Design of well drilling and completion programs (including workovers) 2.

Evaluation and upgrading of existing programs 3.

Evaluation of work proposals (a) To identify deficiencies (b) To indicate areas for which risk evaluation studies should be performed The guidelines developed here will enable detailed readiness checklists to be prepared for specific drilling, workover and completion operations (based on logical analytical trees).

In particular, detailed checklists should be prepared for:

(a) Readiness for initial cavern fill operations (b) Readiness to conduct reentry operations (c) Readiness to perform workover operations (d) Readiness for other special and unusual operations Experience to date indicates that particular attention should be focused on workover operations.

Use of this manual in a practical way is dependent on follow-on training sessions in the methods which are used in the field to determine a state of operational readiness.

This training can be developed by adapting the programs which Reynolds Electrical and Engineering Co. (REECo) has developed for use in their drilling operations at DOE's Nevada Test Site.

While there are a number of system safety analysis methods applicable to O

the SPR oil operation, MORT has been suggested as the preferred approach for the following reasons:

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It is a DOE-wide, DOE-sponsored program with a permanently established service center for follow-on consultation and services (the System Safety Development Center in Idaho Falls, Idaho).

2.

A major DOE contractor (REECo) involved in drilling operations has completed development of MORT methods and training programs for practical field application.

3.

A number of universities including Oklahoma State University are knowledgeable of and utilize MORT methods.

4.

The Norwegian Petroleum Directorate (NPD) and their supporting research centers include MORT trained specialists and are currently utilizing MORT methods in critical North Sea oil operations.

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5.

A considerable number of private consultants are MORT trained.

6.

The MORT system has been used in investigation of accidents resulting from drilling operations including the Elk Hills blowout and subsequent recovery program.

The success of the MORT system in accident investigations associated with well drilling operations has demonstrated its value to evaluate the state-of-readiness to begin new drilling and completion programs.

OPERATIONAL CONTROL As indicated by the logic tree shown in Arpendix A, control of drilling and completion operations is based on fou elements:

1.

Maintenance and Use of Adequate Well Histories (Documentation) 2.

Providing Adequate Operational Controls 3.

Controlling Personnel Factors 4.

Controlling Hardware and Materials Factors These factors are,leveloped further in the logic tree in Appendix A.

1.0 WELL HISTORY This includes engineering and operational data and information relating to the work to be done.

As work proceeds from concept to oil production or storage, the store of information develops as follows (using SPR examples):

Information Developed by Previous Developers - Users Conceptual Design Studies (e.g., studies done by Gulf Interstate)

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Detailed Engineering Design (e.g., work done by PB-KBB)

Construction Design and Planning (e.g., design and planning done by P-G and their sub-contractors)

Detailed Well Work (e.g., engineering and work done by P-G, Louis i

Records and other contractors)

Adequate well history files must include:

1 1.1 Design Data and Specifications This includes:

(a) Specifications and descriptions inherited from previous operators.

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(b) New engineering studies, drawings, specifications created j

I since inheritance of the projects by FEA-D0E.

(c) Logs and other field data generated in the course of FEA-DOE sponsored measurement, construction and operational activities.

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1.2 Well Files 1

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As the work progresses the data developed in 1.1 must be s

collected and organized in well files.

These data must be organized and catalogued in such a way that they can be used in present and future operational planning.

1.3 Reports It is bad practice to force operational planning personnel to work from file cabinet stores of logs, general engineering i

i studies, etc.

Information must be collected in well organized reports designed for field support use.

These should typically include:

1 1.3.1 Final drilling reports 1.3.2 Testing reports

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1.3.3 Final completion reports s

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1.3.4 Workover reports (1) Formal workover (2) Other significant field changes which might not be identified as " workover" 1.4 Maintain As-Built and As-Is Drawings and Specifications "As-built" data refers to up-to-date information on catalogue hardware descriptions.

"As-is" data refers to such things as effects of corrosion, erosion, deterioration, weld quality and other considerations which might change the working capability of the hardware.

This material will include the information in reports as well as data which have not been incorporated into report form.

These "as-built" and "as-is" descriptions should include:

1.4.1 Well and Downhole Equipment (1)

Downhole casing string (2)

Cementing records (3)

Perforations (4)

Tubing Accessories (5)

Working Pressure (6)

Wellhead and Production Tree Name, Model, Nominal Size, Minimum ID's, Maximum OD's, specific length, setting depth, etc.

1.4.2 Tubing String Talley (1)

Setting Depth and Specs (2)

Manufacturer (3)

Type (4)

Dimensions l

(5)

Tubing Grade (6)

Spacing j

(7)

Etc.

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1.4.3 Well Head and Production Tree (1)

ID's (2)

Spacing (3)

Working Pressure (4)

Etc.

1.4.4 Data on stimulation treatments, conditioning treatments, completion fluids and other treat-raents or operations (use and misuse) which could affect the hardware.

2.0 PROVIDE OPERATIONAL CONTROLS l

This includes design of procedures and controls for proposed drilling, workover and completion operations.

2.1 Perform Well Problem P m nalysis This includes anticipated drilling problems as well as well problems which are being " lived-with" for existing wells.

It would include such things as anticipated " lost circulation" problems, hydraulics limitations, chronic leakage problems, troublesome hardware, depths of possible pressurized zones, etc.

Significant problems should:

(a) Be identified and analyzed (b) Have file reports for operational-engineering use.

2.2 Design Workover Jobs

2. 3 Design Reentry Operations 2.4 Design Well Maintenance Programs 2.5 Design Fill / Withdrawal-Operations 2.6 Design Ongoing Operational Supervision and Operational Control Systems i

i In all of these cases (2.2 through 2.6) the following steps l

must be performed:

2.X.1 Describe the Situation i

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Engineering planning and operations personnel must be provided with:

(a) Information on well history and geologic condition relating to the work to be done 5

(b) A description of the well status and geologic status (c) A description of well problem (s) which might affect the work, and diagnosis 2.X.2 Develop Procedures Written procedures must be developed to describe the required field operations.

The amount of detail in the procedures should be scaled to:

(a) Training and experience of the on-the-job personnel (b) Potential consequences of accidents / incidents (c) Complexity of the job itself (d) Complexity in terms of numbers and types of contractor organizations involved (e) W1 ether the job is routine or unusual (f) Availability of upper level supervision and technical sJpport personnel at the worksite on a continuous bjsis.

Procedures must include both normal procedures for job control and emergency procedures covering potential accidents and incidents.

Applicable codes, standards and regulations (CSR) must be identified and procedures must be written in accordance with these CSR.

2.X.3 Define Responsibility and Authority (a) Chains of authority and responsibility from working level to top management within the contractor, subcontractor, and DOE organizations must be defined.

(b) Authority and responsibility for changes to approved procedures must be clearly defined.

Methods for dealing with unanticipated operational conditions must be provided.

This material should be integrated and combined into a coherent well program suitable for establishment of management controls.

3.0 CONTROL PERSONNEL l

Control over all personnel involved in operations must be established I

under normal and emergency conditions.

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This includes:

3.1 Drilling Supervisors 3.2 Drilling Contractors 3.3 Consultants 3.4 Other Contractors (depending on work)

In all cases (3.1 through 3.4), workers and field supervisors must be identified by worker type.

In each case a combination of the following controls must be utilized:

(a) Training and experience (b) Written procedures (c) Work direction and support by upper level supervisors and technical support personnel.

This includes both contractor in-house technical specialist and such personnel as j

vendor-supplier representatives, well control consultants, etc.

The combination of (a), (b), (c) above must be sufficient to assure b

that field personnel are under adequate control.

In particular, V

change controls must be adequate.

This includes both response

• .o field conditions which are different than anticipated and to mc:iifica-tion of approved work programs.

4.0 CONTROL HARDWARE - MATERIALS - UTILITIES This applies to the work being performed and to such factors as:

(a) Site preparation (b) Interfaces with other operations.

4.1 Provide Hardware - Materials - Utilities List This includes both hardware, materials and utilities used for the job "as planned" and standby hardware materials and utilities for emergency response.

Special emphasis should be placed on safety equipment and materials.

This list should include:

4.1.1 Description and specifications O

4.1.2 Information on when-where needed j

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4.1.3 Quality Reliability Requirements (1)

Inspection Requirements (2) Testing Requirements (3) Work Control Requirements (4) Codes-Standards-Regulations Requirements Component and system (in place) testing for safety equipment must be spelled out in detail.

(Blowout prevention devices, down hole safety valves, etc.)

4.2 Provide Tools 4.3 Provide Equipment 4.4 Provide Materials and Utilities Tools, equipment, materials and utilities must be provided in accordance with the list (4.1).

This includes the tools, equipment, materials, utilities required to do the work and those required for emergency conditions:

(a) Fire fighting equipment (b) Booms (c) Skimmers (d) Foam (e) Fire water (f) Electical power (g) Heavy equipment I

(h) Etc.

Environmentally acceptable disposal of materials and site l

restoration must be included.

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l APPENDIX A i

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USE OF THE GUIDE I

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l APPENDIX A USE OF THE GUIDE I.

FOR WELL CONTROL PROGRAM EVALUATION 1.

Study the well control program.

2.

Use the analytical tree and guideline text Yo evaluate the program.

For example:

1.1 Does an adequate documented well-formation history exist?

1.1.1 Do we have (and use) adequate design data and specifica-tions?

1.1.2 Do adequate logs and field data exist?

1.1.3 Is well-formation information collected into readily available, properly indexed well files?

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Color code the analytical tree elements as follows:

Green - Element 0.K.

Red - System is deficient Blue - Don't know status 4.

Obtain further information to indicate the status of " blue" coded items (if possible and practical).

5.

Evaluate the risks of proceeding with " red" and " blue" coded items.

6.

Report risks associated with " red" and " blue" coded items to appropriate DOE and contractor management levels.

7.

Management accepts risks or directs change.

II.

FOR SPECIFIC WORK PROPOSALS (WORK 0VER, REENTRY, ETC.)

1.

Proceed as in I. except direct the questions to the specific proposal.

2.

Construct analytical trees tailored to the personnel, hardware, and procedures (Management controls) involved in the specific proposal.

Examples of trees of this type are included in Appendix B.

A.1

3.

Proceed as in I. using the proposal-specific trees.

This will give a more sharply focused analysis and will indicate the operational readiness to begin work.

Example:

It is very likely that reliable as-built drawings do not exist for older facilities.

Elements 1.0 and 1.4 must therefore be colored " red" (not as-built) or " blue" (don't know as-built status).

This was a factor in both the Bravo (existance of DHSV locking ring in the tubing string) and Hackberry (inability to insert a full diameter bridge plug) in:.idents.

The following must be considered in risk analysis and acceptance:

(1) Cost and feasibility of complete or partial drawing verification (2) Design of controls and counter measures to deal with " surprises" in the field (3) Potential consequences of drawing-hardware mismatches (detected or undetected)

(a) Time - Costs (b) Accidents - Incidents Based on risk analysis results:

1.

The risks of proceeding with the work may be accepted or, 2.

Drawing verification may be directed of,

3.

The work program may be modified (e.g., by depressurization) to redace the consequences of failure to acceptable level.

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A.2

I KEY TO SYMBOLS l

The "and" logic symbol.

The elements lying below the i

symbol must be combined to achieve the objective lying I

above the symbol.

i For example:

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1.0 The objective of achieving contral over drilling and completion operations is.chieved by:

1.1 Providing an adequate well history 1

i 1.2 Providing adequate optional controls l

1.3 Controlling personnel factors 1.4 Controlling hardware, materials and utilities i

factors.

1 The " transfer" or " ditto" symbol.

Continuation of the development may be found by locating an element with A

similiar letter or number code.

For example:

"Providing operational controls" on page 1, A

is continued on page 2 under I

A.3

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I Provide Well History Provide Oper%onal Contro

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I Provide Design Data &

Specs Establish Well Files Develop Reports 1.1 1.2 1.3 b

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Final Drilling Report Testing Reports Final Completion Report 1.3.1 1.3.2 1.3.3 l

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• Production Casing String

• Setting Depth & Sp

• Cementing Records

• Manufacturer

• Perforations

• Type

• Tubing & Accessories

• Dimensions

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• Wellhead & Production Tree

• Spacing etc.

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• Name, Model, Nominal Size

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• Min.10., Max. OD., Spec.

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• Length, Setting Depth etc.

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' Drilling and ipletion Operations O

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nial Oper Control Personnel Factors Co a r 1 Fac ors intenance & Changes 3.0 4.0 I

[ Performance of Field Maintain "As Built" table for Design "As-is" Drawings & Specs ations g

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Workover Report (s) 1.3.4 b

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I il Workover Other Field Changes l

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Data on Stimulation Well Head & Production Tree Treatment, Completion Fluid, and any Other 9.4.2 143 Treatment or Operation Figure A.1 ics

. ID Affecting System Establish Control Over I

• Spacing etc.

(Use Misuse) t,4,4 Drilling and Completion Operations P.1 of 4

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Control i

Field Supewisor 3.1 b

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l Training Requirement Written Frocedure Higher Supervision and Technical Support b

I Operation Supervisor O

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l Education Experience Delineation Training at Responsibility Drilling Contractor I

I State, Federal Hospital, etc.

Representatives

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armal Conddions personnel Factors

• Emergency 3.0 Conditions b

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Field Workers 3.2 b

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I Field Staff and Consultants Training Procedures I

Contractors b

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I Wire Line Contractor Well Head Contractor Mud Contractor l

l Pump Contractor Others Figure A.3 Establish Control Over Drilling and Completion Operations P.3of4(l'

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y it Kill Evaluate Effects of Contact Determine Static Bottom Between Killing Fluid &

Hole Pressure Formation Determine Killing Fluid Density & Composition d

Active Circulation Back-Pressure '

Xmas Tree Valves A

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• Scale To:

2 ell e Type of Well & Size

• Well Location I

• Geological & Reservoir Conditions O

+ Well Condition-Problem (s)

• Area ES&H Requirements Design Circulation to Remove Residual Crude-Gas and Completion Fluid Design and Utilize ntinuous Control bate Circulation Mechanical Means to Throughout Operation trential Pressures Control Pressure and Plug undancy' Tubing - Annulus (Backup on Static Head Control)*

I Residual Sealed-In Pressure l

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Downhole Plugs and Valves 80P'S Figure A.5 i

Kill Well

• Note:

.S;e also " Emergency Control Branch",

P.1 of 1 Figure A 2 N

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EXAMPLES OF DRILLING OPERATIONS READINESS j

TREES DESIGNED AND USED BY REECo AND A READINESS TREE FOR SPR REENTRY OPERATIONS I

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INDEX l

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TREES i

Strategic Petroleum Reserve Drilling j

and Completion Operations................ B1 - B2 - B3 i

MORT Positive tree for Site Preparation of Class I Drill ing Rig................ B4 - 85 i

MORT Positive Tree for Pre-Post and Post Shot Operations.................

86 - B7 - 88 1

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APPENDIX C

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SIMILAR ACCIDENTS (BRAV0-NORTH SEA, ELK HILLS) l l

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APPENDIX C SIMILAR ACCIDENTS p)

\\v The Bravo (North Sea), Elk Hills and Hackberry blowouts are similar in that they occurred in situations where government control systems were overlaid on the complex system of independent working contractors routinely used by the oil industry.

i The role of the government agency differs in that the Norwegian Petroleum Directorate (NPD) appears to act as a licensing-regulatory agency for Norwegian sector North Sea Oil operations.

At Elk Hills DOE appears to function as a member of an executive group including DOE, D0D and a private oil company.

At Hackberry the DOE appears to function as a conventional government contracting office.

The field problems encountered, however, appear to be remarkably similar.

Basic administrative problems seem to be in part due to uncertainties on the part of the contractor organizations as to what degree the government offices assume the " Oil Company" management functions.

The government agencies, on the other hand, appear to desire low risks and accident rates but are reluctant to interfere with what are described to them as

" normal oil industry practices".

Regardless of the reasons, the common problems in the three accidents include the following:

l l

S 1.

In two of the cases government' employees had limited experience in I

v}

dealing with the technical safety aspects of the extremely complex contractual work arrangement used routinely by the oil industry.

It is doubtful that the industry will (or can) change their present working arrangements.

2.

Government employees had limited recent, hands-on experience in the technical aspects of modern petroleum engineering safety and quality assurance.

3.

The operation experiencing the accident was exempted from safety rules and standards imposed elsewhere by the particular government l

agency involved.

This appeared to be attributable to three factors:

)

(a) New operations and government reorganizations.

l (b) Pressure from the oil people (government and industry) on the l

government regulatory bodies.

(c) Failure to recognize safety needs.

l i

4.

Deficiencies existed in "as-built" knowledge of the hardware systems involved.

This included both "as-built" and "as-is" knowledge of hardware in place and quality assurance relating to hardware and materials utilized in performing the work.

l V

C.1 t

7--

5.

Personnel at the job site lacked the technical skills and/or expe-rience to correctly interpret mechanical difficulties which they experienced in attempting to perform the work as programmed.

6.

Major changes in work programs were improvised by the field personnel at the worksite with limited or no technical off-site backup.

7.

Personnel at the worksite lacked the technical skills and/or experience to understand and react properly to the initial indications of impending blowout.

8.

Integrity and availability of adequate B0P devices was not assured.

9.

Deficiencies existed in emergency action plans.

This situation would indicate that priority upgrade efforts should be directed into the nine areas indicated above.

O a

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i OTHER SSDC PUBLICATICNS IN THIS SERIES l

SSDC-1 Occupancy-Use Readiness Manual SSDC-2 Human Factors in Design 3

SSDC-3 A Contractor Guide to Advance Preparation for Accident Investigation SSDC-4 MORT User's Manual SSDC-5 Reported Significant Observation (RS0) Studies SSDC-6 Training as Related to Behavioral Change SSDC-7 ERDA Guide to the Classification of Occupational Injuries and Illnesses j

SSDC-8 Standardization Guide for Construction and Use of MORT-Type Analytic Trees SSDC-9 Safety Information System Guide SSDC-10 Safety Information System Cataloging SSDC-ll Risk Management Guide SSDC-12 Safety Considerations in Evaluation of i

Maintenance Programs SSDC-13 Management Factors in Accident and Incident Prevention (Including Management l

Self-Evaluation Checksheets)

SSDC-14 Events & Causal Factors Charting l

SSDC-15 Work Process Control Guide l

-