Fire with Fatality and Injuries

Effective Date: 11/19/1999

U.S. Department of the Interior
Minerals Management Service
Gulf of Mexico OCS Region

Safety Alert No. 184
November 19, 1999

Contact: Frank Pausina

Fire with Fatality and Injuries

An operator, in attempting to return to production a well that had been automatically shut in by an upset on another platform, opened the well’s manual wing valve. The operator was unaware that the valve was opened against a closed boarding shutdown valve on another platform. This caused the pressure in a flowline segment on the platform to increase to a value that exceeded the segment’s working pressure. As a result, a flow safety valve and a pig launcher located in the flowline segment failed, allowing gas, which was later ignited by an unknown source, to escape. In attempting to escape the resultant fire, one operator jumped from a height of 52 feet and a pilot and another operator jumped from a height of 72 feet into the Gulf. One operator and the pilot received various injuries, while the other operator was unable to be resuscitated after his retrieval from the Gulf.

Although written procedures existed for other types of operations for which unchanging specific steps were required, there existed no written procedures for those operations, such as returning a well to production, for which the steps to be followed could and/or must vary with location.

Therefore, from this information and information contained in the MMS report on the subject accident, the following are recommended for operators:

1. Analyze all potentially dangerous operations for which specific procedural guidelines have not been included in a safety/procedural document.
2. Formulate a set of required procedures for those operations and include such in a safety/procedural document.
3. For an operation, such as bringing a well back on production, for which the procedural steps do vary by well or location,

a. Formulate a set of procedures that address basic safety concerns that are independent of well characteristics and/or location, such as observing pressure gauges and being aware of flowline working pressures and valve status, and include such in a safety/procedural document, and/or
b. Formulate a complete set of procedures for each well and/or location and include such in a safety/procedural document.

4. Refer to API Recommended Practice 75, Second Edition, July 1998, in the implementation of the above recommendations.

For details of the accident, see OCS Report MMS 99-0067. Copies of the report may be obtained from the MMS Public Information Office, located at 1201 Elmwood Park Boulevard, New Orleans, Louisiana 70123 (1-800-200-GULF or local 504-736-2519).



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