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LEARNING FROM INCIDENTS (LFIs)

REF NO:

LFI-LL-14-001

TITLE

INCIDENT
TYPE:

Loss of
Containment

TARGET
AUDIENCE

Operations/Engineering/
Maintenance

Gas Release from 2 Globe Valve

What happened:
On Jan 7th 2014 and during the commissioning
activities of the RDS new flare, a gas leak was
reported from the gas line supplying fuel gas to
flare-fuel gas heater.
The leak was identified on a 2 globe valve in the
gas line coming from the main 8 CDS to RDS
Gas distribution header and going to the FlareFuel gas heater.
Plant emergency procedures were followed and all
personnel evacuated from the site. The
distribution header was isolated and the upstream
valve closed to stop the leak.

Why it happened:

The 2" globe valve in the gas line failed when exposed to the operating pressure.
As per the design of RDS pilot fuel gas system to flare, high pressure gas of
around 340 barg is intended for use as fuel gas after pressure reduction to 2.5
barg through a choke valve and PRVs. The system was not designed for the large
reduction in pressure at one stage and thus caused sudden spike resulting in
material failure.
The quality of the valve was suspect and it had pitting in Plug and Seat.
Sudden increase in pressure while lining up the system.

Lessons Learned:
1. HAZOP study for operational systems should cover all possible credible scenarios

of failure.
2. Stringent Quality Control and Assurance procedure during EPC Stages will

improve the Integrity of pipes and fillings in high pressure systems.

This LFI is issued by ADCO CHSE for Capturing Learning from Incidents. Its distribution shall be restricted and neither ADCO nor its
Shareholders shall accept any liability for loss or damage arising from or in connection with this content.

For more details and information contact: LFI@adco.ae

LEARNING FROM INCIDENTS (LFIs)


REF NO:

LFI-LL-14-002

INCIDENT TYPE:

Loss of
Containment

TARGET
AUDIENCE

ADCO Operations,
IPD, Integrity

Main Oil Line Leak

TITLE

What happened:
On the 20th of January 2014. Loss of
containment from cross fields Main Oil Line
was reported. The leak was arrested by
wooden peg and PLIDCO clamp. The line
was scheduled for decommissioning at the
same week of the incident. The line is buried
at the leak point and external corrosion was
identified as the cause of the leak.
Approximately 1000 barrels of free oil were
recovered. And it took two weeks to recover
the oil and remove the contaminated sand.

Why it happened:

As the line was scheduled for decommissioning, the decision was made to stop the
asset integrity program for the line. However, the line was kept operational.

Due to the aging factor of the line, this caused rapid deterioration in the condition of
the line leading to loss of containment.

Lessons Learned:
1. Asset integrity programs must not be discontinued for any asset unless it is
decommissioned and written off.
2. Recovery of free oil should be expedited to avoid further seepage of free oil in the
ground.

This LFI is issued by ADCO CHSE for Capturing Learning from Incidents. Its distribution shall be restricted and neither ADCO nor its Shareholders
shall accept any liability for loss or damage arising from or in connection with this content.

For more details and information contact: LFI@adco.ae

LEARNING FROM INCIDENTS (LFIs)


REF NO:

INCIDENT
TYPE:

LFI-LL-14-003

Road Traffic
Accident

TARGET
AUDIENCE

All ADCO Staff &


Contractors

Vehicle Roll Over

TITLE

What happened:
On 23rd Jan 2014 morning, contractor
crew was commuting in a vehicle from
town

to

field

demobilization

for

rig

from

down

location.

and
The

weather conditions were foggy. At around


0725 hrs. the driver overtook another
vehicle and then collided with a bus
coming from the opposite direction, lost
control and went sliding off road resulting
in a roll over. Four workers suffered
minor

injuries

and

the

vehicle

got

damaged.

Why it happened:

The visibility was poor due to fog and the driver could not judge the road conditions
properly.

The safe distance while driving was not maintained and hence the reaction time was
less.

Lessons Learned:
1. Keep your travel plans flexible to avoid driving in foggy conditions.
2. It is safer to provide camp facilities close to the work site to minimize travel and thereby

reduce the risk.


3. Always maintain safe distance while driving.

This LFI is issued by ADCO CHSE for Capturing Learning from Incidents. Its distribution shall be restricted and neither ADCO nor its Shareholders
shall accept any liability for loss or damage arising from or in connection with this content.

For more details and information contact: LFI@adco.ae

LEARNING FROM INCIDENTS (LFIs)


REF NO:

LFI-LL-14-004

INCIDENT
TYPE:

TITLE

Road Traffic
Accident

TARGET
AUDIENCE

All ADCO Staff &


Contractors

Vehicle Roll Over

What happened:
On Jan 28th 2014 around 1500hrs, at
sand track to RDS, a double cabin
pick up was returning to camp from
site after completion of work through
sand track. On the way, the left tire of
the
vehicle
got
punctured,
subsequently the tire slipped out of
the rim, driver lost control and the
vehicle finally rolled over.
One passenger sustained minor
injury and the driver and two other
passengers escaped unhurt. All
occupants of the vehicle were
wearing seat belts and the vehicle
was fitted with roll over bar.

Why it happened:

The driver was driving at high speed without engaging 4WD. The IVMS data shows a
maximum speed of 115 km/hr on the day.
Geo Fencing in IVMS of the vehicle was not implemented and hence no warning
given for overspeeding.
When the driver lost control of the vehicle after the tire burst, the driver tried to steer the
vehicle to the right while drifting at sand on the uphill.
The driver has less experience in driving in desert conditions.

Lessons Learned:
1. Only experienced and competent drivers are to be deployed for desert driving.
2. Always engage 4WD on sand tracks.
3. Never exceed speed limits.

This LFI is issued by ADCO CHSE for Capturing Learning from Incidents. Its distribution shall be restricted and neither ADCO nor its
Shareholders shall accept any liability for loss or damage arising from or in connection with this content.

For more details and information contact: LFI@adco.ae

LEARNING FROM INCIDENTS (LFIs)

REF NO:

LFI-LL-14-005

INCIDENT
TYPE:

Fire/Property
Damage

TARGET
AUDIENCE

ADCO Electrical
Maintenance &
Engineering Staff &
Contractors

Flash Over at Power Station

TITLE

What happened:
On 9th Feb 2014, at 1950 hrs,
several 33 KV circuit breakers
tripped at a New Power station,
resulting in a total blackout of the
neighboring facilities and smoke at
New

Power

Station

due

to

flashover and arcing fault at the


transformer

incomer

cable

termination.

Why it happened:

During the transformer incomer cable termination, the cable semi conductive layer
should have been extended above the earth connection which would have
equalized the field current around the conductor and ensured electrical contact
with the earthing system. The arcing occurred due to melting during flow of
earth/fault current because of inadequate earthing connection.
Inter-trip signal was communicated between the two sub stations (132KV & 33
KV) using auxiliary electro-mechanical relays which caused a delay in the inter
trip. Protection setting for the directional over current relay was high. This resulted
in a fault dip on the 33KV bus bar and tripped AGD 33 KV OHTL on distance
protection causing black out of the facilities.
Existing 33 KV switch gear is very old and not Arc proof, the incoming phases are
not perfectly isolated from each other which escalated the single phase fault into a
three phase fault.

Lessons Learned:
1. Good workmanship in cable terminations will reduce the chances of arcing. This

calls for checking all existing cable terminations.


2. Fiber optical communication will enhance the operation of protection relays.
This LFI is issued by ADCO CHSE for Capturing Learning from Incidents. Its distribution shall be restricted and neither ADCO nor its
Shareholders shall accept any liability for loss or damage arising from or in connection with this content.

For more details and information contact: LFI@adco.ae

LEARNING FROM INCIDENTS (LFIs)


REF NO:

LFI-LL-14-006

INCIDENT
TYPE:

Loss of
Containment

TARGET
AUDIENCE

Operations/Engineering/
Maintenance

Gas LOC from Pig Launcher

TITLE

What happened:
On Feb 11th, 2014 at around 1030
hrs, the pig launcher trap leaked
due to passing of kicker valves
and subsequent pressure build up
and failure of door safety device
sealing O-ring.
The

gas

release

resulted

in

actuation of nearby gas detectors


which prompted tripping of RMS-2
station.

Why it happened:

The barrel was pressurised due to two passing kicker valves and the sealing O-ring of
the door safety device could not hold the pressure and gas leaked outside.
Ball valves were used as kicker valves as globe valves were not available. Preventive
maiantence of the valves were inadequate.
Misalignment of door safety device due to different tap hole depths causing nonuniform compression providing ineffective sealing.
The Interlock system was partially removed and hence not in operating condition.

Lessons Learned:
1. Structured training and familiarization program is essential to upgrade the

workmanship and competency of the maintenance personnel.


2. Efficient
Preventive Maintenance program will ensure integrity of
launcher/Receiver isolation valves.
3. Revisiting all traps to verify safety devices mounting holes will prevent similar
leaks in future.
4. Regular monitoring of pigging traps will identify passing valves.
This LFI is issued by ADCO CHSE for Capturing Learning from Incidents. Its distribution shall be restricted and neither ADCO nor its
Shareholders shall accept any liability for loss or damage arising from or in connection with this content.

For more details and information contact: LFI@adco.ae

LEARNING FROM INCIDENTS (LFIs)


REF NO:

LFI-LL-14-007

INCIDENT
TYPE:

TITLE

Road Traffic
Accident

TARGET
AUDIENCE

ADCO &
Contractors

Vehicle Roll Over

What happened:
On March 4th 2014 around 1415 hrs.
a water tanker was proceeding to rig
location to deliver water. While ascending
the inclined section of the track, the driver
noticed another water tanker overtaking a
trailer and to avoid the collision, he moved
to the right side of the track and entered into
soft sand. After entering the soft sand, the
driver lost control of the tanker causing it to
rollover
The driver was wearing the seat belt and he
escaped unhurt (minor bruises & swelling).
The tanker sustained damage.

Why it happened:

The driver tried to drive close to the edge of the gatch track and vehicles wheels
entered soft sand.

Two- way track has no traffic separation and markers on the edge at an inclined
curved track.

Access road was not adequately risk assesed for haulage and heavy load and lacked
guards/warning to avoid vehicle entering soft sand at inclined curve.

Lessons Learned:
1.

Identify and communicate hazards associated with the route to drivers.

2.

Ensure functionality of IVMS in vehicles.

3.

More care should be taken while driving off road as the roads are not marked.

This LFI is issued by ADCO CHSE for Capturing Learning from Incidents. Its distribution shall be restricted and neither ADCO nor its
Shareholders shall accept any liability for loss or damage arising from or in connection with this content.

For more details and information contact: LFI@adco.ae

LEARNING FROM INCIDENTS (LFIs)


REF NO:

LFI-LL-14-010

INCIDENT
TYPE:

Property
Damage

TARGET
AUDIENCE

ADCO & Contractors

Flowline dragged by Vehicle

TITLE

What happened:
On March 7th 2014, at around 1150
hrs, while parking a Wire Line Truck
near well site, the rear outriggers
dragged a partially buried flare line
which was not live. The flare line
then hit another vehicle at the
bottom resulting in dragging of that
vehicle and hitting a third vehicle
which

was

also

parked

nearby

causing damages.

Why it happened:

The designated parking lot was in the wrong location too close to the flare line.
The burn pit flare line was not buried properly, absence of cones/warning tapes
and road signs to guide approaching work location.
The driver was not aware of the presence of the flare line in the area.
No flagman to guide the driver while accessing congested area.

Lessons Learned:
1. Specific job related Task Risk Assessment will enhance the hazard identification

and mitigation and guard against surprises.


2. For vehicular movement in congested areas, proper warning signs and guided

flagmen are a must.


3. Vehicle parking areas shall be located away from the workplace to reduce hazards
This LFI is issued by ADCO CHSE for Capturing Learning from Incidents. Its distribution shall be restricted and neither ADCO nor its
Shareholders shall accept any liability for loss or damage arising from or in connection with this content.

For more details and information contact: LFI@adco.ae

LEARNING FROM INCIDENTS (LFIs)


REF NO:

LFI-LL-14-009

INCIDENT
TYPE:

Personal Injury

TARGET
AUDIENCE

ADCO
Contractor PE

Personal Injury During BOP Testing

TITLE

What happened:
On 11th March 2014, while opening the
pipe rams after Pressure testing at well
head area, there was an uncontrolled
release of pressure from the BOP,
causing injuries to two contractors crew
members (a Coiled Tubing Operator
and a Trainee).
The Coiled Tubing Operator got injury
on both eyes and the trainees right
shoulder was dislocated.

Why it happened:

Coiled Tubing Manual/Coiled Tubing logging Procedure was not followed.

Lack of supervision during coiled tubing.

The task was not adequately risk assessed.

Incompetent contractor personnel.

Improper implementation of PTW authorization, TRA and supervision requirements.

Lessons Learned:
1. Contractors equipment must be inspected and approved before use.
2. Contractors must follow ADCO working instructions without deviation.
3. All high risk activities must be supervised as prescribed in the PTW procedure.
4. All high risk activities must be risk assessed as per ADCO PTW/TRA procedures.
5. Competency of Contractors Personnel must be assessed before deployment.
This LFI is issued by ADCO CHSE for Capturing Learning from Incidents. Its distribution shall be restricted and neither ADCO nor its Shareholders
shall accept any liability for loss or damage arising from or in connection with this content.

For more details and information contact: LFI@adco.ae

LEARNING FROM INCIDENTS (LFIs)


REF NO:

LFI-LL-14-010

INCIDENT
TYPE:

Fire
Personal Injury

TARGET
AUDIENCE

ADCO PE
PE Contractors

Burn Injuries During Green Burner Operation

TITLE

What happened:
On March 15th 2014, at around 1310
hrs, Contractor Lead Operator started a
flow to clean operation using a chock
manifold and a green burner on a gas
well. During operation, the supervisor
requested two operators to approach
the green burner to presumably ignite
the green burners pilot manually.
One operator sustained 2nd degree
burns to hand and face, 3rd degree
burns to finger and smoke inhalation.

Why it happened:

The green burner was not inspected to ensure that the pilot is working prior to
starting operation.
PE was not available at location to witness flaring.
The operators breached the Safe Zone during well flowing/flaring.
The green burner was located at a point that cant be seen from chock manifold.
The contractor was wearing cotton coverall and not Nomex.

Lessons Learned:
1.
2.
3.
4.
5.
6.

Contractors equipment must be inspected and functionally tested prior to use.


No person should cross the safe zone while the well is flowing.
ADCO minimum PPE should be used at all times, this includes Nomex coveralls.
Green burner should be located within visual range from the chock manifold.
Never attempt to manually ignite green burners/pilots.
PE should be physically present at location until flaring starts.

This LFI is issued by ADCO CHSE for Capturing Learning from Incidents. Its distribution shall be restricted and neither ADCO nor its
Shareholders shall accept any liability for loss or damage arising from or in connection with this content.

For more details and information contact: LFI@adco.ae

LEARNING FROM INCIDENTS (LFIs)


REF NO:

LFI-LL-14-010

INCIDENT
TYPE:

TITLE

Loss of
Containment

TARGET
AUDIENCE

Operations & Drilling

Oil & Gas Release from Flow Line

What happened:
On March 22nd 2014 around
1630 hrs. the rig crew as part
of the demobilization planned
to remove a water tank located
near the flow line using a chain
dozer. While excavating near
the water tank, the dozer hit
and damaged a buried flow line.
This resulted in spillage of
about 10 bbls of oil and release
of associated gas. The well was
shut down automatically.

Why it happened:

The crew was unaware of the buried flow line as the location of it was not marked in
the handover certificate.
The handover certificate was prepared without refering to the as built drawings.
There was a lack of supervision as the crew members were busy securing the mast
for the move. The job was carried out on the judgement of the Assistant Operations
Supervisor.

Lessons Learned:
1. Enhanced Management involvement for review and approval of the handover

certificate will improve quality and accuracy.


2. Planning and allocation of resources such as manpower, equipment etc. before a

Rig move will ensure efficient and error free work.


3. Permit to work (PTW) for earth moving equipment at rig site will result in better

hazard management and control.

This LFI is issued by ADCO CHSE for Capturing Learning from Incidents. Its distribution shall be restricted and neither ADCO nor its
Shareholders shall accept any liability for loss or damage arising from or in connection with this content.

For more details and information contact: LFI@adco.ae

LEARNING FROM INCIDENTS (LFIs)


REF NO:

LFI-LL-14-012

INCIDENT
TYPE:

TITLE

Property
Damage

TARGET
AUDIENCE

Maintenance/Projects and
Electrical Contractors

Flash Over of 11 KV Loop Cables

What happened:

At around 1245 hrs. on 27th


March 2014 at CDS substation,
the high pressure gas injection
compressor tripped immediately
after re-start with a loud sound
originating from Harmonic Filter
area.
On inspection it was noticed
that a flash over had occurred
in the loop cables (3 Nos.)
connecting the reactors and
resistors of the harmonic filter
elements.

Why it happened:

The cables got partially damaged during laying process due to excessive wear and
tear, resulting in weak insulation. Rain water entered the cables resulting in
insulation breakdown and flash over.

The cables used in the harmonic filter loop circuits are unarmored and without
copper braids

Lessons Learned:
1. Armored or copper braided cables for outdoor applications will minimize physical

damage during cable laying.


2. High Potential tests at 80% of factory test voltage for high voltage cables after

laying and termination will ensure healthiness of insulation.


3. Tripped equipment should not be restarted until the cause of the trip is assessed.

This LFI is issued by ADCO CHSE for Capturing Learning from Incidents. Its distribution shall be restricted and neither ADCO nor its
Shareholders shall accept any liability for loss or damage arising from or in connection with this content.

For more details and information contact: LFI@adco.ae

LEARNING FROM INCIDENTS (LFIs)


REF NO:

LFI-LL-14-007

INCIDENT
TYPE:

TITLE

Road Traffic
Accident

TARGET
AUDIENCE

ADCO &
Contractors

Vehicle Accident

What happened:
On 31st March, 2014, approximately at
0830 hrs. a rig vehicle was proceeding to
rig camp on a sand track near security
fence gate. At the same time, operations
crew vehicle was approaching an
intersection on main track. While
operations vehicle was in the middle of
the
intersection,
the
rig
vehicle
approached and collided with the
operations crew vehicle. All crew
members and drivers escaped unhurt
and vehicles sustained minor damage.

Why it happened:

The sand track was in a low lying area with dunes, blocking clear view of
approaching traffic at the intersection.
The road warning sign was disoriented, due to winds.
The rig vehicle was not fitted with desert flag. Both vehicles were driven at a speed
of approximately 60 km/hr.

Lessons Learned:
1.

Always be on guard against unexpected hazards while driving in desert terrain.

2.

Drivers shall get acquainted to the conditions before undertaking such journeys.

3.

Regular inspection of road warning signs will ensure proper guidance to drivers.

4.

Use of desert flags fitted to vehicles in sand tracks will indicate their presence from
a distance especially in low lying areas.

This LFI is issued by ADCO CHSE for Capturing Learning from Incidents. Its distribution shall be restricted and neither ADCO nor its
Shareholders shall accept any liability for loss or damage arising from or in connection with this content.

For more details and information contact: LFI@adco.ae