For: API S53 Well Control Equipment - SafeOCS Reporting … · 3 reliability and performance information database for api s53 well control equipment guidance document appendix 1

Rev 1March 13, 2017

RAPID-S53Reliability and Performance Information

DatabaseFor:

API S53 Well Control Equipment

Guidance Document

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RELIABILITY AND PERFORMANCE INFORMATION DATABASE FOR API S53 WELL CONTROL EQUIPMENTGUIDANCE DOCUMENT

Table of Contents1.0 Scope and Purpose ....................................................................................................................................................41.1. Scope...........................................................................................................................................................................41.2. Purpose......................................................................................................................................................................42.0 Definitions and Acronyms ......................................................................................................................................42.1. Definitions................................................................................................................................................................42.2. Acronyms..................................................................................................................................................................63.0 Equipment Owner’s Reporter Instructions.....................................................................................................73.1. Downloaded Report .............................................................................................................................................83.2. Submit Failure Report ......................................................................................................................................153.3. Root Cause Options, Definitions and Examples.....................................................................................164.0 Equipment Owner’s Super-User Instructions .............................................................................................185.0 Analysis .......................................................................................................................................................................215.1. Failure Causes......................................................................................................................................................215.1.1. Physical Causes...............................................................................................................................................215.1.2. Human Factor Causes ..................................................................................................................................215.1.3. Systemic Causes .............................................................................................................................................215.2. Analysis Overview .............................................................................................................................................215.3. Cause Immediately Known.............................................................................................................................225.3.1. Resources..........................................................................................................................................................225.3.2. Closure ...............................................................................................................................................................225.4. SME Review ..........................................................................................................................................................235.4.1. Resources..........................................................................................................................................................235.4.2. Closure ...............................................................................................................................................................235.5. RCFA ........................................................................................................................................................................245.5.1. Physical Evidence..........................................................................................................................................245.5.2. Resources..........................................................................................................................................................245.5.3. Closure ...............................................................................................................................................................246.0 Capture and Share Lessons Learnt ..................................................................................................................24

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APPENDIX 1. DOWNLOAD INPUT FORM...............................................................................................................25APPENDIX 2. REPORTING PROCESS........................................................................................................................26APPENDIX 3. Five-Why’s Analysis Methodology................................................................................................28APPENDIX 4. SME Review or an RCFA Report ....................................................................................................29APPENDIX 5. MODEL TERMINOLOGY ....................................................................................................................30

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RELIABILITY AND PERFORMANCE INFORMATION DATABASE FOR API S53 WELL CONTROL EQUIPMENTGUIDANCE DOCUMENT1.0 Scope and Purpose

1.1. ScopeThis document applies to the owner of blowout prevention equipment for drilling wells whenreporting equipment failures.The scope has been expanded to include all API S53 equipment components: Auxiliary Equipment (Drillstring valves and gas separation equipment) BOP Stack BOP Controls (Primary, Secondary and Emergency) Choke Manifold Equipment Diverter System (Although this is not included in API S53, it is too closely related to notinclude it here) Riser System (The riser system is included because of the choke and kill lines and it does notmake sense to only include those lines and not the equipment that carries them.

1.2. PurposeThis document has been developed with the intent of providing instructions and definitions toproduce a standardized industry reliability and performance database.2.0 Definitions and Acronyms2.1. DefinitionsCause: Something that initiates, shapes or influences anoutcome.Cause Immediately Known: When there is a high degree of certainty in the failurecause, the failure report described in Section 3 iscompleted describing the failure and defining the rootcause based on inspection and maintenance personnelexperience and knowledge.Corrective Action: An action, which is taken to correct a failure and/orthe failure’s cause.

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Effect: An event or condition that is caused by another eventor condition.Evidence: Information, data and/or items gathered whichdirectly relate to, or have been, affected by thefailure.Failure: A condition that prevents the component fromoperating as designed.(A leaking O-ring is a failure even if the piston that itshould seal can fully stroke)‘Five-Whys’ Analysis: A ‘question-answer’ process used to explore therelationships between Cause and Effect underlying aspecific problem.Root Cause: Is the cause (condition or action) that begins acause/effect chain that ends in a component defect orfailure. If corrected would prevent reoccurrence ofthe event (under investigation) and similaroccurrences.Root Cause Failure Analysis: A comprehensive systematic investigation processundertaken to identify Physical, Human Factors andSystemic root causes of a component failure.Subject Matter Expert: Person or persons with an in-depth knowledge of asubject of interest. Such knowledge will have beengained through direct and practical dealings withsubject matter of interest.SME Review: An internal assessment of the possible and probablelocal root cause of the component failure reviewed byan SME with the intent of recommendingintermediate actions or changes to reduce theprobability of reoccurrence.

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2.2. AcronymsAPI American Petroleum Institute LMRP Lower Marine Riser PackageBOP Blowout Preventer NPT Non-Productive TimeBWM Between Wells Maintenance OEM Original Equipment ManufacturerBSEE Bureau of Safety and EnvironmentalEnforcement RCFA Root Cause Failure AnalysisBTS Bureau of Transportation Statistics RWP Rated Working PressureHSE Health, Safety and Environment SFI Skipsteknisk ForskningsinstituttIADC International Association of DrillingContractors SME Subject Matter ExpertJIP Joint Industry Project QA/QC Quality Assurance/Quality Control

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RELIABILITY AND PERFORMANCE INFORMATION DATABASE FOR API S53 WELL CONTROL EQUIPMENTGUIDANCE DOCUMENT3.0 Equipment Owner’s Reporter Instructions.When is a report required?A failure report shall be created for each failure of any component of API 53 Equipment, whetherthere is NPT or not. This database was designed to trend failures to allow us to focus on problemareas and the policy was rigid in that if we do not report all failures then we are shortchangingourselves.With the benefit of hindsight, we can acknowledge that this was too rigid. In the beginning, wereported, for example, a choke valve as a failure if it did not hold a test even if a single open/closecycle was sufficient to correct this. While we do not condone many repeated cycles to try and achievea successful test, we have to accept that a foreign body could prevent the full closure of the valve andclearing this with a single function cycle is not an equipment failure.We should, however, continue to report failures that come to light during maintenance and testingas well as during operation, but replacement of a ram packer, for instance, because you do not expectit to last the next well, is not a failure; it is simply maintenance.The report should be created, and submitted, as soon as possible after the event is discovered.How to complete a report?Log into the site using the credentials that have been sent to you separately.Once in the site first time only, go to: My Profile (top right corner) Change Your Password and

Save Changes.Select:MANAGE WELL the Manage WellThen check to see that the information is correct, or click on Add Well as appropriate.The Add Well option is where the well number information is input This is also where you includethe number of riser joints run on the well. This data is used for statistical information when chartingriser failures against the quantity of riser joints in use across the database.When this data has been confirmed to be correct, then select: SaveThis default well data will be used to populate all reports until the data is changed for subsequentwells.FAILURE REPORTS You then have two choices. If your company prefers you to download theform, fill it out and then send it to town, then select

Download Failure Report

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And complete all of the required fields, as guided below, offline:3.1. Downloaded Report

Rig Owner InformationRig Owner / Drilling Contractor: Select your company name. If reporting online, then thisshould already be prepopulated with your companyname.

Rig: Dropdown box filtered to show all of the current rigsowned by the selected rig owner.

Operator: Dropdown box populated with a list of the currentoperators in the database This includes both membersand non-members of the JIP.

Owner’s Primary Contact: Title of person who is familiar with the issue in casefurther information is required. This could be the personreporting, but that is a company decision.

Email of Owner’s Primary Contact: Email address for the Primary Contact.

Name of Person Reporting: This the name of person filling out event report. If thereport is being completed online this field should beprepopulated based on the log-in name of the reporter.

OEM Rep. Onboard, if applicable: Name of any OEM representative on the rig that wasinvolved in the component analysis.

Well IdentificationLease No. : Number as provided by operator.

Well No. : Number as provided by operator.

API Well No. : Number as provided by operator.

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Not every well has all of these numbers. Provide what your well has.If the rig is not on contract, then state “Not Applicable”.Other InformationOwner Specific Equipment ID Number: An SFI code or similar that the equipment owner uses to

identify the specific equipment or component.

OEM Incident Reference Number: Reference number issued by the OEM if involved.

Component sent on shore: Disposal; No; OEM analysis; OEM Repair; Storage; Thirdparty Analysis; Third party Repair.

NO should be selected in this dropdown box if thecomponent was not sent ashore. If the component wassent ashore, the appropriate reason should be selected.

EquipmentType of WCE System: Subsea; Surface Offshore; Land.

Select SUBSEA in the dropdown box if the system utilizesa subsea BOP designed to be operated underwater;SURFACE OFFSHORE or LAND, as appropriate, forothers.System Integrator: Cameron; GE; NOV.

This is not necessarily the equipment manufacturer.Select the company who provided and or assembled theaffected system in the dropdown box.Subunit: BOP Controls; BOP Controls Secondary – ROV, Acoustic;BOP Controls Emergency – Automated Functions; BOPStack; Auxiliary Equipment; Choke Manifold System;Diverter System; Riser System.

Select the appropriate system subunit category in thisdropdown box.

This is the first of three dropdown boxes thatpredetermine the contents of each subsequent box in alogical manner until the correct component isidentified.

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Item: The items listed in the dropdown box are contingentupon the selected Subunit. Select the appropriatesubunit item category in this dropdown box.Component: The components listed in the dropdown box arecontingent upon the selected item. Select theappropriate component category in this dropdown box.

(This is the lowest maintainable item that failed. Do notgive the control pod details for a failed pressureregulator.)

Component Manufacturer: Select the manufacturer of the component in thisdropdown box.

We have attempted to list them all. If we have missed aparticular OEM then contact the JIP Project Manager atIADC and he can add the missing OEM to the list in amatter of days.

Observed Failure: What alerted you to this event? This dropdown box isfocused from the component selection. Select the failuremode for the component in this dropdown box.

Model: There are too many options to compile a dropdown box.This is, therefore, a free text field to enter themanufacturer’s equipment model for the defectivecomponent.

OEM Part Number: Free text field to enter the identifying part number asestablished by the OEM.

OEM Serial Number: Free text field to enter the OEM’s unique identifyingserial number.

Size: Two dropdown boxes to input the whole and fractionalsize for the component.

Pressure Rating: Two dropdown boxes; the first to select in standardizedpressure ratings, and the second to select whether thisis ‘Well Bore’ or ‘Operating Circuit’ pressure.

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Component HistoryDate Affected Component was installed: This is a calendar field on line but only a free text fieldon the downloadable form to record the date that thecomponent was installed into the system on the rig.

This could be the date that the equipment was delivered,or it could be after a major inspection/maintenance(e.g. five-yearly).

Maintenance Deferred on Component: Yes/No dropdown box to record whether plannedmaintenance was overdue at the time of failure.

If YES, what maintenance was deferred: BWM/EOW; Quarterly; Annual; Five-Yearly; Other?

Dropdown box to select what category of maintenancewas deferred (BWM/EOW, Annual, 5-Year, etc.).

Date of Last Maintenance: This is a calendar field on line but only a free text fieldon the downloadable form to record the date of the lastplanned maintenance actually completed.

Description of Last Maintenance: Adjustment; Cleaned and Inspected; Installed seal kit;Installed repair kit; No previous maintenance.

Dropdown box to select the maintenance that wasperformed.

Amount of Usage at the Time of Failure: Number field and a dropdown box to select Hours orCycles (or Unknown) to associate to the whole number.If you have automatic cycle counters, or the discipline toactually count the cycles, then record them for valves,cylinders and pistons. Record hours for pumps or if‘cycles’ are not available.

Site Specific InformationIADC Code Description: 1 - Rig Up and Tear Down2 - Drill Actual3 - Reaming4 - Coring5 - Condition Mud & Circulate6 - Trips7 - Lubricate Rig

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8 - Repair Rig9 - Cut Off Drilling Line10 - Deviation Survey11 - Wire Line Logs12 - Run Casing & Cement13 - Wait On Cement14 - Nipple Up B.O.P.15 - Test B.O.P.16 - Drill Stem Test17 - Plug Back18 - Squeeze Cement19 - Fishing20 - Dir. Work21 - Running / Retrieving Riser Equipment22 - Testing Surface Equipment23- OtherA - PerforatingB - Tubing TripsC - TreatingD - SwabbingE - TestingF - NULLG - NULLH – NULL

Dropdown box with a listing of IADC codes andassociated descriptions of the rig operation. Note thatthese have recently been updated, by IADC, to includespecific options for Running/retrieving riser equipmentand for testing surface equipment.

Location (Region): Africa; Americas; Asia; Australia; Oceana; Europe.

Dropdown box to select appropriate continent for therig operation.

Location (Country): Dropdown box to select appropriate countries cascadedby the selected region.

Water depth: Free text field to input an integer and a dropdown boxto select Feet or Meters to associate to the integer.

Drilling Fluid Type: Brine; Seawater; Synthetic Based Mud; Water BasedMud.

Dropdown box to select from the commonly used fluids.

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BOP Control Fluid: Houghton Aqualink 300-FV7; Houghton Stack MagicECO-F; MacDermid CLS-25; MacDermid CLS-40;MacDermid CLS-60; MacDermid Erifon 603HP;MacDermid Erifon HD856; MacDermid Erifon SummerGrade; Niche Products Pelagic 50; RX Marine RXSol-16-3764-210; Other: Free text .

Dropdown options to select the BOP control fluid in use.

Concentration: 0; 1; 2; 3; 4; 5; 6; 7; 8; 9; 10; 11; 12; 100%.

Dropdown options from which to select the actualpercentage of control fluid concentrate in the mixture.

Glycol: 0; 5; 10; 15; 20; 25; 30; 35; 40; 45; 50; 55; 60%

Number field to record the percentage of glycol in themixture.

Was the last laboratory sample acceptable?: Yes/No dropdown to record the answer to the question.

N.B. This specifically refers to the last laboratory sample(as opposed to a rig test).

Date of last sample: This is a calendar field on line but only a free text fieldon the downloadable form to record the date of the lastlaboratory analysis.

Event DataEvent Date: This is a calendar field on line but only a free text fieldon the downloadable form to record the date.

Event Date is: Date of Occurrence; Date of Detection.

This is a dropdown to select the appropriate option.

When did the event occur?: BOP #1 IN Operation, BOP #1 NOT In Operation, BOP#2 IN Operation or BOP #2 NOT IN Operation.

If you only have one BOP then select the appropriateversion of BOP#1.

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Description of Event: Free text field where sufficient, but concise, informationshould be stated so that the reader understands whatfailed, what were the symptoms, what was beingfunctioned at the time of failure and why was it beingfunctioned. Include any related details that are deemedpertinent. Do not include any unnecessary information.

Hours of NPT – Integer field to record number of hours that is inclusiveof BOP recovery and reinstallation etc., plus all time in-between failure detection and getting back to the pointat which the failure occurred.

This is typically IADC Code 8 time. If the rig contractincludes maintenance, or similar, time allowance,ignore that for this and record the actual NPT hours.

Hours of Repair time: Integer field that should only include the actual time torepair and test the failed component only.

Did the event cause a BOP Stack pull?: Yes/No dropdown box to record if the failure was adirect factor in the decision to retrieve the subsea BOPstack for repairs.

Detection Method – Casual Observation; Continuous Condition Monitoring;Corrective Maintenance; Functional Testing inOperation; Inspection; On Demand; Periodic ConditionMonitoring; Periodic Maintenance; ProductionInterference; Pressure Testing in Operation; FunctionalTesting Surface; Pressure Testing Surface.

Dropdown box to select how the failure was discovered.

Immediate Corrective Action: Adjust; Check; Inspection; Modify; Refit; Repair;Replace; Service; Test.

Dropdown box to select the action taken on the rig toplace the component back into an operational state.

Root Cause: Assessment Pending; Design Issue; DocumentationError; Maintenance Error; Procedural Error; QA/QCManufacturing; RCFA Required; Wear and Tear.

Dropdown box to select the cause of the failure.

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The selection by the super-user of any option except‘RCFA required’ or ‘Assessment Pending’ will close thereport.

Selection of ‘Assessment Pending’ will open a free textbox where you must justify your selection. This willprobably be something to the effect that the BOP stackis still subsea and an MOC and risk analysis hasdetermined that it is safe to continue operations withthe particular failure unresolved.

Selecting ‘RCFA required’ or ‘Assessment Pending’ willset a clock within the database to remind theappropriate stakeholders that a root cause has not beendefined at 99 days and every 30 days thereafter.Quantity: An integer box to allow a quantity input in case youhad multiple similar component failures at the sametime.

If the multiple items were installed at different times orif there are any other differences then set this value at1 and create individual reports for the othercomponents.

3.2. Submit Failure ReportThere are two options when submitting a failure report.The first, and preferred option, is based on submitting the data directly to the database online. Todo this select the Submit Failure Report/Fill out Report path and fill out the report using all ofthe provided drop downs. This will allow you to take advantage of the fields that are pre-populatedas a result of the way the database is set up.The second option is based on uploading the data using an incident report completed using theoffline input form. To do this select the Submit Failure Report/Upload Report path. The data willbe loaded into the database and the report will be placed in the “Draft” state.

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3.3. Root Cause Options, Definitions and ExamplesAssessment Pending: This should be selected if, for instance, the BOP stack isstill subsea. The failure will be investigated when theBOP stack becomes accessible and the root cause can beevaluated.

Design Issue: Inadequate component design or configuration.

This can only be confidently identified after an RCFA hasbeen completed or if the design issue has beenpreviously identified by RCFA or manufacturer’snotification.

Documentation Error: Mistake or oversight in the documentation used byequipment operatives.

The installation, operations and maintenancedocuments were followed but there were inherenterrors in the documentation supplied. Thedocumentation can be in the form of drawings,manuals, procedures, work instructions and workorders and can be supplied by the OEM, SystemIntegrator or the Equipment Owner.

Maintenance Error: Mistake, misuse or oversight during maintenance.

A choke line flange leaked after the maintenance hadbeen completed. Investigation showed that the flangestuds had been torqued to 380Nm instead of the 380ft-lb stated in the procedure. This was a MaintenanceError.

Procedural Error: Mistake, misuse or oversight during operation.

The BOP ram leaked because test pressure was appliedafter closing pressure was vented, but without the ramhaving first been mechanically locked. This was aProcedural Error.

QA/QC Manufacturing: Failure related to manufacturing.

A new annular piston was purchased from the OEM butwe were unable to install it. Investigation showed thatit had been machined incorrectly.

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RCFA Required: Currently unknown root cause.

An RCFA is always required if there was; a loss of a wellbarrier, if there was an unplanned stack/LMRPrecovery, or if there was a systemic/reoccurring event.Either of the other investigation requirements can bepromoted to an RCFA if necessary.

Wear and Tear: An expected condition of a component that has reacheda point where it is unable to perform intended functionas the result of usage.

If wear and tear is repeatedly selected for equipmentthat fails in operation then that could indicate that areview of the maintenance procedure is required.

Pressing the ‘Submit’ button will upload it to the web and alert the appropriate super-user who willthen quality check the report, correct any errors and approve it thereby adding it to the database.Each time a report is modified and updated, a copy will be sent to the appropriate Super-user, SystemIntegrator and Operator.

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RELIABILITY AND PERFORMANCE INFORMATION DATABASE FOR API S53 WELL CONTROL EQUIPMENTGUIDANCE DOCUMENT4.0 Equipment Owner’s Super-User InstructionsLog in First time only, go to: My Profile (top right corner) Change Your Password

and Save Changes

FAILURE REPORTS Typically, reports will be submitted by the rig based Reporters.Download Failure Report or Submit Failure Report.It is preferable to select the second option followed by Fill out Report to fillout the report electronically and automatically submit it to the database.Some equipment owner’s will prefer to have the reporter download the excelspreadsheet version and submit it internally for approval before the report isuploaded by selecting Upload Report.All With this tab highlighted, the list will show all of your company failure reports(subject to the time period selected on the last tab).In Progress This selection will show all reports that have been opened and saved, but notyet completed and submitted (subject to the time period selected on the lasttab).Draft This selection will show all reports that have been completed and submitted,but are waiting on Super-User approval (subject to the time period selectedon the last tab).Approved (Open) This selection will show all reports that have been approved with either‘Assessment Pending’ or ‘RCFA Required’ selected as root cause (subject tothe time period selected on the last tab).Approved (Closed) This selection will show all reports that have been approved and closed(subject to the time period selected on the last tab).Reject This selection will show all reports that have been rejected and archived inthe database for whatever reason (subject to the time period selected on thelast tab).30 Days Here you can select the time period of reports you are looking for. The optionsare 30days, 60 days, 90 days or ALL.

DATABASE REPORTING

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This is a simple view of all of the participating systems, similar to what we hadavailable on the monthly reports. You can change the views by selectingspecific filters.ADVANCED FILTER REPORTINGThis is currently a work in progress. The filters at the top will allow theselection of any field in the database as a means of preparing a customizeddata extract for export from the database in the form of an Excel file.What is currently more useful is the ability to export the entire database toExcel, from where you can search and filter to your hearts content. Do notshare this data in any kind of searchable format.Your company data will be fully visible. Other company data will have allidentifying details anonymized.RIGS Here you can see the status of your fleet where there is the capability ofadding a rig either by clicking on Download Rig Form, filling this out andthen use the Submit Rig button to upload the information.The right-hand column (“Actions”) has seven options that can be selected foreach rig:Edit Rig: This allows you to edit the basic rig details for a rig already added to thedatabase. It also allows the selection of 1 stack or 2 stacks for that rig.Edit Configuration: Here you can change the details of the equipment on the rig. It is not acomplete IADC equipment list as it only lists the API S53 well controlequipment that is included in the database.Add Configuration: This will be used to add a new configuration for an existing rig and shouldonly be used in those cases where you are making a radical change to theexisting Well Control Equipment configuration. As an example, the type ofradical change we have in mind here is where there is an addition or reductionin the number pipe rams in the stack.Asset Disposal: This should only be used in the event that a rig is no longer a part of your fleetand the asset has either been disposed of through sale or scrapping.Show Configuration: Here you can see the complete configuration that has been submitted for thisrig. If somebody has earlier clicked on ‘Add Configuration’ then you will see

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more than one version listed. If it was an accidental addition then the newversion will be an empty form.Manage Well: Here we should see the well data that has been applied by the Reporter. If notthen the Super-User can address it here.Not every well will have all three numbers assigned. Every well will have atleast one number but include all that you can.The Add Well option also asks the Reporter to include the number of riserjoints run on the well. This data is used for statistical information whencharting riser failures against the quantity of riser joints in use across thedatabase.This default well data will be used to populate all reports until the data ischanged for subsequent wells.Manage Contract: Here you will find contract information and an Add Contract button to allownew contract details to be included.PARTICIPANTS Self-explanatory; this is simply a list of Equipment Owners (in the main,Drilling Contractors), Operators and System Integrators. If you need anOperator who is not listed then call and we can have it added at very shortnotice.USERS A current list of your company users. The Super User can set up, or disable,Reporters, Super Users or Executive Users. Please be careful with thiscapability. Do not forget that the data collectively belongs to the members andshould not be accessible to non-members of the JIP.

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RELIABILITY AND PERFORMANCE INFORMATION DATABASE FOR API S53 WELL CONTROL EQUIPMENTGUIDANCE DOCUMENT5.0 AnalysisEffective investigation is essential to identify the causes (i.e. Physical, Human, and Systemic) and rootcauses of a failure to enable learning, improvement and removal of component failures. Removingcomponent failure causes increases inherent reliability and safety.The initial scope of any investigation must be based on factual information (e.g. hose failure, valveleaking in closed position) relating to failure.

5.1. Failure CausesAs part of the investigation processes, three types of causes are identified in order to understand theroot cause(s) of the failure. These are:5.1.1. Physical CausesThese are the consequences, manifestations or outcomes, known or determinable, that initiate ortrigger component failure. Examples include corrosion, fatigue, excessive stress, erosion, rupture,etc.5.1.2. Human Factor CausesThese are related to human activities that contribute to component failure. Identifying andunderstanding the contribution of human factors during component failure investigations willimprove corrective action identification and component performance. Examples of human factorsinclude; fatigue, complacency, stress, environmental conditions, etc.5.1.3. Systemic CausesThese are related to any system or process activity that results in a reoccurring event. These includeprocesses used to execute the work.NOTE: If the failure is part of a wider event then the appropriate investigativeprocedure may need to be followed IN ADDITION to the creation of the report oncomponent failure.

5.2. Analysis OverviewThis section presents the three levels of analysis to be applied with regard to events recorded in theRAPID-S53 database: Cause Immediately Known. SME Review. Root Cause Failure Analysis.

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NOTE: If an investigation at one level fails to determine the root cause of the failure,then the analysis can be promoted to the next level as appropriate.As shown in the Failure Report Process (APPENDIX 2), in the event that the root cause is immediatelyknown, the relevant notifications are issued immediately a component failure report is submitted tothe database and is moved to an “Approved (Closed)” state.If the component failure has resulted in a loss of a well barrier, if it has required the LMRP orBOP stack to be retrieved, or if the failure has become a systemic/reoccurring event, then anRCFA is always required.Other events require an SME Review to be conducted by a subject matter expert, and reported.NOTE: There will be occasions where a component failure has previously beencategorized as ‘Cause Immediately Known’ or ‘SME Review’ becomes ‘RCFA required’because such an issue has now occurred multiple times and, as a result, becomesclassed as ‘Systemic/Reoccurring’. The previously published reports do not need to bereclassified, but they may be referred to in the RCFA.5.3. Cause Immediately KnownAn O-ring damaged during installation can, for example, normally be categorized as ‘CauseImmediately Known’. It is important to report such issues because if something like this were toescalate to a systemic/reoccurring event then it may warrant a change to the design orinstallation/maintenance procedure.

5.3.1. ResourcesThe Senior Subsea Engineer should discuss what happened with another technical member of crewto determine: What happened? How it happened? Why it happened?

5.3.2. ClosureWhen the cause of the failure is immediately known, the investigation is considered closed when: A report is created in the database, with sufficient justification in the free text “Description ofEvent’ to support the root-cause selected from the drop down box. The selection and the report are approved by the equipment owner’s super-user.

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5.4. SME ReviewAn SME Review is conducted when the cause of the failure is questionable and the component failurehas not triggered an RCFA (not an unplanned BOP pull, loss of well barrier, or systemic/reoccurring).An SME Review is conducted when a failed component requires disassembly to ascertain the causeof the failure and when the frequency (not systemic) and consequence (no loss of barrier or bopretrieval) of the component failure are considered to be low.If a ram failed to hold pressure during pre-deployment testing and upon opening the doors/bonnetsit was clearly seen that the packers were well worn, then an SME Review could check the records tosee if the number of functions met the expectations. Then after the rams have been successfully testedwith new packers to confirm that there was no other issue, and assuming the number of functionsmet expectations, the failure can be attributed to ‘Wear and Tear’. If, however, the rams fail to testand / or the function cycles were less than expected, the causal agent is something other than ‘Wearand Tear’.5.4.1. ResourcesTwo, or more, SMEs.5.4.2. ClosureAn SME Review Report (See APPENDIX 4), identified by the unique number used when the initialreport was submitted, must be produced. This report should arrive at a logical conclusion based ona sound evaluation of the physical causes of what, how and why a failure occurred. The incident canbe considered closed when the Equipment Owner Super User updates the component failure reportin the database by selecting the appropriate Root Cause from the drop down box, hence closing theinitial report, and publishes the final report.

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5.5. RCFAThis investigation is more detailed and as such takes moreresources and time. There are three specific triggers, asshown at right, for when an RCFA shall be carried out.This analysis should output root causes that can be turnedinto action items to prevent reoccurrence; for instanceOEM product bulletins, equipment owner maintenancesystem changes, etc.5.5.1. Physical EvidenceWell Control Equipment component failures are frequentlyfield repairable and in many cases there may not be areplacement assembly readily available. In such aninstance, ensuring full and detailed record capture ofphysical evidence is critical, even if the situationnecessitates the evidence being in the form of photographs,dimensions, sketches and written reports, to allow repairs to beeffected and allow the rig to go back to work.5.5.2. ResourcesTypically, at least one SME plus the OEM or a suitably qualified third-party are utilized.5.5.3. ClosureAn RCFA report (See APPENDIX 4), identified by the unique number used when the initial report wassubmitted, must be produced. This report should arrive at a logical conclusion based on a soundevaluation of the physical and any human causes of what, how and why a failure occurred. Thisdocument is for internal use within the affected company.The incident is considered closed when the Equipment Owner Super User updates the componentfailure report in the database by selecting the appropriate Root Cause from the drop down box, henceclosing the initial report, and publishes the final report.

6.0 Capture and Share Lessons LearntWhen these reports have been finalized and approved, it is necessary for the learnings from thecomponent failure to be shared internally within the equipment owner’s company and with theappropriate stakeholders as dictated by regulations.A lesson is only learned when the data is properly shared.

Figure 1 RCFA Triggers

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APPENDIX 1. DOWNLOAD INPUT FORM

Form Rev: CLease No.: Well No.:

Rig Owner / Drilling Contractor: Rig:

Owner's Primary Contact:

Name of Person Reporting:

Name of OEM Representative Onboard, if applicable:

BOP Use:

Equipment Integrator:

Subunit:

Item:

Component:

Component Manufacturer: OEM Part Number:

Observed Failure: OEM Serial Number:

Model:

Size: 0 and 1/16" Pressure Rating: 0psi

BWM/EOW

Hours

IADC Code - Description:

Location (Region): Location (Country):

Water Depth:

Drilling Fluid Type:

BOP Control Fluid :

Concentration: Glycol: 0%

Yes Date of last sample:

Event Date:

When did the event occur?:

Reason :

EVENT DATA

Cleaned and Inspected

Description of completed last maintenance ↓:

Hours of NPT:

Detection Method:

Description of Event:

On Demand

3%

31-Oct-2016

Hours of Repair time:

01-Jan-15

Auxiliary Control Panel

Date of DetectionEvent Date is:

19-Jul-2016

BOP #1 Not in Operation

Was the last laboratory sample acceptable?:

Assessment PendingRoot Cause:

Did the event cause a BOP Stack pull?

Replace

No

Immediate Corrective Action:

Gulf of Mexico - US

No

WELL IDENTIFICATION

Cameron

Mechanical damage

RIG OWNER INFORMATIONAPI Well No.:

Date Affected Component was Installed:

Owner's Specific Equipment ID Number:

OEM Incident Reference Number:

Choke Manifold System

GE

Operator: Pending

Other Information

Owner's Primary Contact's Email:

Pacific

EQUIPMENT HISTORY

Equipment sent on shore for:EQUIPMENT DATA

Subsea

BOP Control Panel

MacDermid Erifon Summer Grade

Feet

Well Bore

2 - Drill Actual

Americas

Synthetic Based Mud

Maintenance Deferred on Equipment:

SITE SPECIFIC INFORMATION

-If YES, what maintenance was deferred:

Amount of Usage at the Time of Failure:

No

23-Oct-2016Date of Last Maintenance:

5,250

26


APPENDIX 2. REPORTING PROCESS

27


28


APPENDIX 3. FIVE-WHY’S ANALYSIS METHODOLOGYFive-Whys Analysis is a simple iterative technique that can be used with either the SME Review orwith an RCFA to understand the cause-and-effect relationships underlying a particular problem. Theprimary goal of the technique is todetermine the (root) cause of a defect orproblem by repeating the question "Why?"Each question forms the basis of the nextquestion. The "5" in the name derives froman empirical observation on the number ofiterations typically required to resolve theproblem.The method provides no fixed rules aboutwhat lines of questions to explore, or howlong to continue the search for additionalroot causes. The following outlines atypical 5 Whys Analysis process:Identify and define thecomponent/process on which the event orfailure has happened. Define the failure Brainstorm and list the possiblecauses Select the most likely cause (mustbe able to explain why it wasselected) Apply the “5 Why” principle (on theselected “most likely” cause) Repeat asking “why” until the “rootcause” is identified Suggest possible solution Implement and validate thesolution

Q1. Why didthis component

fail?

Q2. Why didthat happen?




A1.

A2.

A3.

A4.

A5.

29


APPENDIX 4. SME REVIEW OR AN RCFA REPORT

While being company specific in design, the final reports must include:The initial report unique identification numberDetails of the component that failed (Part Number, Serial Number, Description,)Date of the failureDetails of the failureDate that the investigation commencedDate that the investigation was completed and the report publishedInvestigation team member detailsFailure cause(s)Findings (including any photographs or drawings, third party reports or other supportinginformation.Recommendations

30


APPENDIX 5. MODEL TERMINOLOGY

We do not (yet) have the various models linked to the equipment. Toprevent the requirement for a further clean-up when this has beenaddressed, please use the exact format for each major component asdetailed below:ANNULAR BOP

ANNULAR CAMERON GE NOV

MODEL D GL Standard (BigBoy)MODEL DL GX SLMODEL GX Compact NXTMODEL MSP 7012 (Old T3)

RAM BOPRAM BODY CAMERON GE NOV

MODEL EVO Compact 6012MODEL T Conventional NXTMODEL TL Quik-Lok SLMODEL U SLXMODEL UII

RAM Bonnet / Door

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BONNET/DOOR CAMERON GE NOV

MODEL EVO, Super Shear, 4,000psi,N/A Compact, 14-1/4”, Low Torque,3,000psi, MPL 6012, 14” x 10” Booster,3,000psi, PoslockMODEL EVO, Tandem Booster,5,000psi, EVO Lock Compact, 14-1/4”, PressureDifferential, 3,000psi, MPL NXT, 14” Booster,3,000psi, PoslockMODEL EVO, 3,000psi, EVO Lock Compact 15-1/2”, Low Torque,3,000psi, MPL NXT 22”, CVX, 5,000psi,PoslockMODEL T, 3,000psi MOP, ST Lock Compact, 15-1/2” PressureDifferential, 3,000psi, MPL NXT, 22” LFS, 5,000psi,PoslockMODEL T, 3,000psi MOP, Wedgelock Compact, 19” Low Torque,3,000psi, MPL NXT, 22” x 14”, 3,000psi,Ultralock IIB ILFMODEL TL, Super Shear, 3,000psi,N/A Compact, 19” PressureDifferential, 3,000psi, MPL NXT, 3,000psi, ManualMODEL TL, Super Shear, 4,000psi,N/A Compact, 22” PressureDifferential, 3,000psi, MPL NXT, 3,000psi, PoslockMODEL TL, Super Shear, 5,000psi,N/A Compact, 22” PressureDifferential, 4,000psi, MPL NXT, 3,000psi, UltralockIIBMODEL TL, Tandem Booster,3,000psi, ST Lock Compact, 22” PressureDifferential, 5,000psi, MPL NXT, 3,000psi, UltralockIIB ILFMODEL TL, Tandem Booster,4,000psi, Ramlock Compact, 22” PressureDifferential, 5,000psi, N/A NXT, Booster, 4,500psi,PoslockMODEL TL, Tandem Booster,4,000psi, ST Lock Conventional, 14-1/4” LowTorque, 3,000psi, MPL SL, 3,000psi, PoslockMODEL TL, 3,000psi, Ramlock Conventional, 15-1/2” LowTorque, 3,000psi, MPL SL, 3,000psi, Ultralock IIBMODEL TL, 3,000psi, ST Lock Conventional, 15-1/2”Pressure Differential, 3,000psi,MPL SL, Booster, 5,000psi,PoslockMODEL TL, 5,000psi, Ramlock Conventional, 19” Low Torque,3,000psi, MPL SL, Old T3, 3,000psi,ManualMODEL TL, 5,000psi, ST Lock Conventional, 19” PressureDifferential, 3,000psi, MPL SLX, 16” Booster,3,000psi, PoslockMODEL U, Large Bore with TandemBooster, 3,000psi Wedgelock Conventional, 22” Low Torque,3,000psi MPL SLX, 18” Booster,3,000psi, PoslockMODEL U, Large Bore, 3,000psi MOP,Wedgelock Conventional, 22”, PressureDifferential, 3,000psi, MPL SLX, 3,000psi, ManualMODEL U, Tandem Booster, 3,000psi,Manual Quik-Lok, 14-1/4” Low Torque,3,000psi, MPL SLX, 3,000psi, PoslockMODEL UII, Tandem Booster,3,000psi, Wedgelock Quik-Lok, 14x14” Dual CylinderShear Boost, 3,000psi, MPL SLX, 3,000psi, UltralockIIBMODEL UII, without cylinder,3,000psi, Wedgelock SLX, Booster, 5,000psi,PoslockMODEL UII, 3,000psi MOP,WedgelockMODEL U, 3,000psi MOP, WedgelockMODEL U, 3,000psi, Manual

32

RELIABILITY AND PERFORMANCE INFORMATION DATABASE FOR API S53 WELL CONTROL EQUIPMENTGUIDANCE DOCUMENTBOP Mounted Choke and Kill Valves

BOP C/K VALVES CAMERON NOV SRI WOM

MODEL AF – Fail Open DB – Fail Open Fail Open Magnum – FailOpenMODEL AF – Fail Close DB – Fail Close Fail Close Magnum – FailCloseMODEL DF – Fail Open HB – Fail Open SLMODEL DF – Fail Close HB – Fail Close SLXMODEL FCS – Fail Open HPT – Fail OpenFCS – Fail Close HPT – Fail CloseMCS – Fail OpenMCS – Fail Close

Choke and Kill StabsCONNECTORS CAMERON GE NOV

MODEL Mini-Collet Stab 1 Ext/Ret LockingMODEL Stab 2 Ext/Ret Non-LockingMODEL Stab 3 Fixed LockingMODEL Fixed Non-LockingMODEL

33

RELIABILITY AND PERFORMANCE INFORMATION DATABASE FOR API S53 WELL CONTROL EQUIPMENTGUIDANCE DOCUMENTChoke and Kill Flex Loop/Hose

CONNECTORS CONTITECH COPPERSTATE OILSTATE TECHNIP

MODEL HNBR 16C Compliant Flex Loop RilsanMODEL NBR Stainless Lined CoflonMODEL NBR/CR StandardMODEL PAMODEL TaurocoolMODEL Tauroflon

ConnectorsCONNECTORS CAMERON DRIL-QUIP GE NOV

MODEL DWHC DX-10 H4 DWHD CHXMODEL EVOConn DX-15 H4 DxEMODEL HC DX-DW H4 EMODEL HCH4 DQ-DX H4 ExFMODEL Model 70 DQ-VX H4 ExF HARMODEL H4 SHD

Riser MandrelCONNECTORS CAMERON DRIL-QUIP GE NOV

MODEL DWHC DX H4 H4MODEL H4 H4MODEL HC

34

RELIABILITY AND PERFORMANCE INFORMATION DATABASE FOR API S53 WELL CONTROL EQUIPMENTGUIDANCE DOCUMENTFlex Joint

CONNECTORS CAMERON GE OIL STATES

MODEL Flex King 6.0 Annuflex Subsea LPMODEL Subsea 2.0MODEL Subsea 2.5MODEL Subsea 3.0MODEL Subsea 3.5MODEL Subsea 4.0MODEL Subsea 5.0MODEL Subsea 6.0

Conduit Flex Loop/HoseCONNECTORS CONTITECH COPPERSTATE OILSTATE TECHNIP

MODEL HNBR 16C Compliant Flex Loop RilsanMODEL NBR Stainless Lined CoflonMODEL NBR/CR StandardMODEL PAMODEL TaurocoolMODEL Tauroflon

35

RELIABILITY AND PERFORMANCE INFORMATION DATABASE FOR API S53 WELL CONTROL EQUIPMENTGUIDANCE DOCUMENTRiser

RISER AFGLOBAL CAMERON GE MHWIRTH NOV

MODEL UDW Hybrid RCK HMF-D CLIP DT-1MODEL RF HMF-E QTR-4000 DT-2MODEL LoadKing 2.0 HMF-F DT-EMODEL LoadKing 2.5 HMF-G DT-FMODEL LoadKing 3.0 HMF-H DT-GMODEL LoadKing 3.5 HMF-J FT-GBLoadKing 4.0 MR-10 FT-HLoadKing 4.5 MR-6C FT-HB-DGMR-6E FT-IMR-6HSE UDWFT-DGD

Diverter HousingCONNECTORS CAMERON DRIL-QUIP GE NOV

MODEL 49-1/2” 49-1/2” 49-1/2” 49-1/2”MODEL 60” 60” 60” 60”MODEL 75” 75” 75” 75”

Diverter AssemblyCONNECTORS CAMERON DRIL-QUIP GE NOV

MODEL CF-A CSO CSO CSOMODEL CF-B KFDJMODEL KFDS

36

RELIABILITY AND PERFORMANCE INFORMATION DATABASE FOR API S53 WELL CONTROL EQUIPMENTGUIDANCE DOCUMENTChoke Manifold Valves

CONNECTORS CAMERON NOV QOT WOM

MODEL FC B QFC MagnumMODEL FLS F-CMODEL T-BHPYE-Mk2

Auto ChokesAUTO CHOKE CAMERON EXPRO NOV QOT MASTERFLO SWACO

MODEL Hydraulic SCB2 MS QC P25 Super ChokeMODEL CSO (Varco)MODEL CSO 3-15 x 3-10MPX-40DHxE G3

Manual ChokesMANUAL CHOKE CAMERON EXPRO NOV QOT MASTERFLO

MODEL Manual SCB2 B-H2 QH2 P25MODEL E-SMODEL CSO 3-15 x 3-10HxE G3

37

RELIABILITY AND PERFORMANCE INFORMATION DATABASE FOR API S53 WELL CONTROL EQUIPMENTGUIDANCE DOCUMENTBOP Control Pods

PODS AXON CAMERON GE KOOMEY NOV OCEANEERING

MODEL Type 80 Hyd 48 Line Hyd-P56B Hyd 46 line Hyd 42 Line Hyd 68 LineMODEL Hyd Modular MUX Gen 1 Hyd 60 Line MUX 98 LineMODEL MUX Mk-I MUX Gen 2 Hyd 64 Line MUX 132 LineMUX Mk-II MUX Gen 3 Hyd 80 LineMUX Mk-III Sea Onyx MUX 80 LineMUX Mk-IV MUX 90 LineMUX 112 LineMUX RCX

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