Cause & Consequence
- Failure of PPE/RPE
Any Location Type
Lifting, crane, rigging, deck operations
WHAT CAUSED IT:
• Defective and inadequate equipment: While being operated in accordance with the 2009 manual, the center-latch elevator failed and resulted in the dropped pony collar.
• Inadequate information/data: The 2009 version of the Manufacturer’s Operator Manual was used as the reference manual. As far as the company and the drilling crew knew, the 2009 version WAS the latest version, but after the incident occurred the company found out from the Manufacturer/Equipment Provider there was a 2012 version. In the 2012 Operator Manual, which had not been sent by the Equipment Provider to the company, the use of the center-latch elevators is not allowed for this type of lift or lay down; instead, rotating elevators are required.
• Inadequate engineering/manufacturing: Design of the center-latch elevator is not compatible with laying down a pony collar.
• Inadequate maintenance of standards/procedures/work instructions: Unavailability onsite of the inserts for the rotating elevators led the crew to use the center-latch elevators as a substitute, which was noted as an acceptable substitution in the 2009 Operator Manual. It is not an acceptable substitution in the 2012 version.
• Inadequate communication: The process for communication of updated manufacturers’ technical documents and manuals was not well defined.
CORRECTIVE ACTIONS: To address this incident, this company did the following:
• The company has decided to maintain sufficient spares of inserts onboard all rigs in the fleet to allow the use of rotating elevators at both rotary centers.
• The company has decided to review and update the process, as necessary, for ensuring that current revisions of Operator/Technical Manuals are received onboard.
• The company will utilize cascade/share the learning points from this incident with other company vessels.
• The company will ensure that a clause is inserted in the Terms and Conditions of agreements with Equipment Providers that requires them to provide documentation updates, product bulletins, etc. as they are released.
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