Cause & Consequence
- Moving, flying or falling object
Well services / intervention
Incident Info Source
Step change in safety
Specific Incident Equipment
Hydraulic Workover Snubbing Unit
The HWO controls were NOT fail safe. Equipment design did not preventthe operator having both sets of slips partially open when the pipe weight is <4500lbsThe investigation identified system failures in the management of the HWO unit, specifically with regard maintenance, operating procedures, competence and supervision.Defined competency for safety critical positions were not adhered to in the selection of personnel, the client failed to verify competence of these individuals.
Design of snubbing unit controls to incorporate fail safe interlock system.
Competency verification of contractor staff
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