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Proforma Safety, LLC

Proforma PSI…when performance counts.

Control Line Protector Falls from Smart Tool, Injuring Two Workers

Two workers were injured when two segments of a control line protector (CLP), or plastic protector sleeve, fell to the rig floor. Each segment weighed 44 lbs. and fell more than 20 feet; it was fortunate that the workers were not seriously injured.

The incident resulted from a combination of factors, none out of the ordinary: due to the weather, the rig was moving, with seas 2 to 4 ft. and the heave approximately .2 ft. After stabbing the downhole flow control "smart" assembly, the bridge racker was released and backed out of the way. The connection was being made up with chain tongs, but the flex of the assembly made it difficult to turn the assembly. The threads were made up approximately 2/3 of the way and at this point there was a decision made to use the power tongs to finish tightening and tourquing the connection. It was also decided to move in the ZGA to help support the assembly. The arm was moved in, but not closed over the assembly. As the tong was rotating the assembly, the control line protector -- designed to protect connections on the tool when transporting the tool with the bridge racker and ZGA from the auxiliary to the main rotary -- came apart and the segments fell to the rig floor.The CLP came in contact with the aft finger of the ZGA gripper, and peeled it off the DHFC assembly.

Root cause analysis determined the protector sleeve was not designed for rotation, and this was the first time the protector sleeve was used. More specifically:

• The CLP was intended for picking up and moving the DHFC with the bridge racker; however it was not adequate to use to support weight of DHFC against movement during torque up.
• No training was given to crews concerning use of CLP, other than it's purpose was to protect the control lines on the DHFC.
• The CLP was built and installed because of previous problems with the DHFC assembly, however no MOC completed to address change/addition of CLP.
• The bolts used to secure the CLP to the DHFC were designed such that with any side load the bolts would slip out of their slots on the other half of the CLP and release.
• The CLP was designed and built to allow ZGA to grab and move the DHFC assembly and not damage the control lines. The CLP worked as designed for moving the DHFC assembly, however was also needed to control DHFC from whipping during torque up, but did not meet this criteria.
• No Hazard Risk Assessment or MOC completed for addition of CLP to DHFC and potential hazards recognized.
• Unevaluated changes were made to the DHFC, and an unsafe situation was introduced. The lack of documentation regarding scope, limitations, and hazards associated with change was overlooked.