Incident Investigation
Getting to the root cause
minutes reading time
Rod Gibbons
It has been a fact that incidents occur in the oil and gas industry, and while no-one wants an incident to happen, it does provide a unique learning opportunity. If facilitated properly, an investigation into an incident can bring resolution to the people involved.
It is important to have a neutral third party review the facts, interview witnesses, and follow-up on technical issues. Engaging with those involved in an incident in an empathatic manner benfits everyone in the short and long term and provides a baseline level of respect required if a company is to truly have a "no-blame" culture.
Other projects: Flowline Modelling
Hurricanes and blowouts
We have been involved in a number of large incident investigations and countless smaller near-miss or minor incidents. One of the interesting things about root cause analysis is the level of technical expertise required to execute an action is much higher than the level required to understand why an action was taken. Using this approach has allowed Ballycatter Engineering personnel to be involved in the investigations in a variety of incidents
In the early 2000's an offshore platform in the Gulf of Mexico caught fire following a hurricane evacuation. The investigation was made more difficult by the arrival of another hurricane before the investigation could begin which wiped what was remaining of the topsides overboard. Using remote telemetry data and staff interviews it was determined the fire had started in the accomodation module and spread to the process module, rather than the other way around. Water ingress from a door with faulty weather sealant one level above a main circuit breaker was suspected to have triggered the fire.
Sometimes and interested party will initiate an incident investigation. In the early 2010's a major well blowout and platform fire occured during drilling activities with a rig, crew, and supervisorsory team used by an oil company that asked Ballycatter Engineering staff to determine the reasons how this could of happened and why it didn't occur when this team was performing their drilling activities.
Everyone wants to understand
We believe it always pays to treat people with respect, and this is no truer than when investigating an incident. During the investigation of an explosion of glycol reboiler on start-up following major plant turnaround, one of the investigators had the feeling that a production operator wanted to tell him something but couldn't.
So he asked to interview him again, and at this point the operator admitted to turning the position of the fuel supply valve stems during the turnaround. He was just placing them in the position indicated by the original P&ID's, which had been updated but not communicated to that person. It can be a difficult thing to wrestle with the feelings of guilt around an event, but a successful investigation should explain the root cause to everyone.
"it always pays to treat people with respect"
We manage projects and operations in the ioil and gas industry so we understand the demands and decisions people face everyday. We bring neutrality and professionalism to every investigation we perform. Our goal is to meet the expectations of our client, and not provide a self-righteous speech on how things "should be done".
An investigation has to be 1 - thorough, and 2 - respectful, and if we can't do those two things, we don't consider it a successful investigation.
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