Cause & Consequence
Incident Info Source
Specific Incident Equipment
Rigless snubbing units and associated equipment
The immediate cause of the incident was the failure of the operating yoke on the QRC BOP.
The original purchaser of the rams had requested the manufacturer to modify the original equipment
design to improve overall ease of handling, as well as, rigging in and rigging out of the BOP.
The underlying causes of the failure included a faulty design that did not account for the conditions
the QRC BOP was being used.
A full management of change review was not conducted prior to the changes made to the
Prior to commencing operations a safety meeting was held and a review of the company’s ram to ram
staging Job Safety Analysis (JSA) was completed. These actions were documented with all personnel
The company has 6 sets of the faulty QRC BOPs and all were upgraded with new, heavier yokes. The
yokes that were removed from service were sent for Non-Destructive Testing (NDT) and it was
discovered that they were ALL cracked in the same spot.
Recommended that snubbing operators add a visual inspection of BOP components to the supervisor’s
Recommended that snubbing operators utilize original equipment manufacturer (OEM) or an OEM
approved vendor for BOP service and recertification.
All companies that purchase remanufactured equipment must not take for granted that all designs are