DROPS Incident Review: Control Line Sheave Fell 4 Meters to Rig Floor (Pot 4B)

Location: Noble Roger Lewis - QSGTL Date: March 3, 2010 Incident: 485866
What Happened:
At 16:30 while RIH with the 7” completion, the Halliburton TRSSSV control line sheave fell onto the rig floor. This was
due to the sheaves eyebolt-retaining nut backing off, allowing the sheave that weighed 48Lbs (22kg) to drop to the
floor. The sheave was suspended from the rig floor hydraulic hoist at a height of 12’ (4M) above the rig floor. The
sheave was certified (14/01/2010) and had passed the onshore QA/ QC inspection on the 31/01/2010 (potential for
dropped object was not identified)

Initial Observations
 No securing/ retaining or locking devices to prevent the nut from backing off.
 Grease nipple painted over preventing proper maintenance of the pin

Initial Recommendations:
1) Non compliance to DROPS standards
2) Ensure QA/QC inspection standards comply with DROPS prior to mobilizing to
rig site
3) Review maintenance (PMS) of contractor equipment used at height

Piston Down-Stop

Allen Screw
EPT-Wells Incident Review: Tree Actuator Uncontrolled Spring Tension Release

Location: Qatar Shell Pearl-1 Platform Date: March 28, 2009 Incident: 346439
What Happened:
During a tree actuator strip down (as part of the well suspension programme), the outer can of the actuator was removed,
exposing the actuator springs. These springs are removed by slowly backing out the spring retainer plate, until all spring
tension is released (46 turns). A further 8 turns will unscrew the retainer plate completely and the springs can then be
removed without tension. However, while backing out the spring retainer plate, the piston down-stop also backed off. By
design this down-stop should stay in place, secured with 2 Allen screws. After the initial 7 turns the down-stop was fully
unscrewed and as a result the spring and retainer plate was ejected under tension, landing ~8 meters away from the tree
(striking a scaffold platform on its path). Nobody was injured as the risk of an uncontrolled spring tension release was
identified and no personnel was positioned in front of the actuator.

Initial Root Causes

 Piston down-stop Allen screws not engaged properly (confirmed tight before
spring removal but not all the way in)
 Difficult to notice piston down-stop movement while backing out spring
retainer plate, especially with springs installed
Actuator Position
Main learning points/ Actions:
1. Physically verify piston down-stop Allen screws are fully screwed in, prior
to spring retainer plate removal (perform dimensional check)
2. Continuously monitor for piston down-stop movement by installing a ‘flag’
in an Allen screw hole. This ‘Flag’ protrudes to above the springs and
unintentional rotation of the down-stop should be noted immediately

Spring
Piston Down-Stop
Spring Retainer
Plate

Allen Screw