COVERAGE Carlson Well Service (CWS) is a small oil service company that provides well servicing rigs to land owners or for land leases. The company is located in Powers Lake, ND. The company has 14 employees and was running three well servicing rigs prior to the accident None of the three well servicing rigs were located in the same area The company orders equipment and materials that support interstate commerce. NATURE AND SCOPE: cause to inspect this site was based on a reported fatality. The fatality was reported 9?14-11. The fatality occurred in the late evening at an existing oil well site that was being prepared for the installation of a new horse head (Pumpjack). The Pumpj ack was being installed because the well hole, which had been previously drilled, had stopped ?owing due to natural overnpresnne. The site was identi?ed as the Kline 5300?1 outside of AleXander, North Dakota This fatality was reported to OSHA by both CWS and the McKenzie County Sheri??s Department. ACCIDENT SYNOPSIS: This inspection was initiated as a result of a double fatality and amputation after an explosion at an existing oil well site. The oil well began over?owing and the blowout preventh (BOP) was not able to be activated. The oil over?ow reached a height of over 50 feet and several minutes later the well exploded. One employee on the well mast was engulfed in ?ames and died. Another employee at ground level died the following day due to severe burn injuries. Two other ?oor hand employees were blown backward from the blast and ?ames; one had both legs amputated due to severe burns. The youngest victim, Brenden Wegner, was in the process of climbing down from the well mast, of the ?monkey boar when the well exploded and engulfed him in ?ames. The operator and his two other floor bands were on the ground to the east of the driller ?oor by the controls of the BOP. The operator, (bits). (tattle. (bimd, who was reported to have been behind a BOP control panel, su?'ered burns to his upper torso. The two ?oor hands were blown backwards by the blast. One ?oor hand, Raymond Hardy, died of his burns the following day. The second ?oor hand, (axe). su??ered critical burns resulted in both legs being amputated. The service rig was completely destroyed. Statements taken ?om an adjacent drilling rig, located a mile away, indicated that the concussion ?om the blast shook their trailers, despite their trailers positioned behind an earthen berm. The service rig?s drilling pipes were heated to a where they buckled and bent. All plastic and organic parts were melted. The rig mast Was fully extended at the time of the ?re and the heat of the ?re caused it to bend. The ?re was still smoldering at the time arrived the afternoon after the explosion. NOTE: During the inspection process (bil?ii?ias accompanied by another Compliance Safety and Health out Of the BiSIIlanCk Area Of?ce, (bus). OPENING CONFERENCE: Opening conference was conducted with Scott and Rick Carlson (Owners of CWS). Credentials were presented and accepted. Nature and scope of the inspection was explained. Trade secrets, and employee intendewing were discussed. Video camera usage was also discussed. Four employees were involved in the ?re and explosion. Two employees died and one employee is still in the burn unit after having both legs amputated. The (bus). mm mm had been released from the hospital bum unit, but has refused to answer phone calls from CSHO. PROCESS OVERVIEW: Listed below is a diagram of a anpjack (horse head well). At the time of the accident a new Pumpjack was emplaced on a. concrete stand. CWS was responsible for ?nal installation of the in?hole pump mechanisms up through the Polished Rod/Bridle and ?nale hook up to the Pumpj ack itself. It was during this installation process that the well exploded, fatally injuring and burning two employees, and seriously bunting two others. Pumpj ack From Wildpedia, the free MW WM as A diagram of a pumpj ask. A pumpjack (nodding donkey, pumping unit, horsehead pump, beam pump, sucker rod pump (SRP), grasshopper pump, thirsty bird, jack pump) is the over ground drive for a reciprocating piston pump in an oil well. It is used to mechanically lift liquid out of the well if there is not enough bottom hole pressure for the liquid to ?ow all the way to the surface. The arrangement is commonly used for onshore wells producing little oil. Pumpjacks are common in oil-rich areas. Depending on the size of the pump, it generally produces 5 to 40 liters of liquid at each stroke. Often this is an emulsion of crude oil and water. Pump size is also determined by the depth and weight of the oil to remove, with deeper extraction requiring more power to move the heavier of sucker rods. - Modern pumpjacks are powered a prime mover. This is commonly an electric motor, but combustion are used in isolated locations without economic access to electricity. Common off-grid pumpjack engines run on casing gas produced from the well, but pumpjacks have been run on many types of fuel, such as propane and diesel. In harsh climates such motors and engines may he housed inside a 1.91133}; to protect them from the elements. ACCIDENT RECREATION: The accident re-creation below is based on limited interviews and a time- line analysis: (Note: The Company Man for Oasis Drilling was not on site to witness the hooking up of the BOP.) At approximately 5:38 PM on 9! 14/2011, W?liston 911 received a phone call about an oil well explosion Just prior to this time CWS, as part of a Pumpj ack installation, had removed the well pipe and was in the process of re?inserting it into the well hole, when the well started to over?ow. The over?ow of the well was initially only several inches high, but rapidly grew to a height of more than 50 feet. At the beginning of the well over?ow CWS employees attempted to put a ?swedge? in place, in order to close ed the well by reducing the oil over?ow. While conducting this process, the well over?ow gained internal pressure and rapidly shot up to a height of 50 feet or more. At this point the ?Operator? (person in charge of the well servicing rig) executed hitting the controls of the BOP (blow out preventer) in an effort to stop/reduce the well head ?ow. According to the witness account, the Operator threw the lever to shut the BOP three different times. None of these three efforts successfully initiated the BOP. The Operator then recharged the BOP system, as it had lost pressure. After recharging the system, the Operator attempted to initiate the shut off levers an additional three times, again without success. At approximately the third initiation of the BOP shut off, cf the second charging, the well over service rig engines started racing and the operator ran over to the engine to turn it off. Immediately thereafter, the well exploded. Victim location coupled with limited wimess remembrances placed the victim locations, at the time of the explosion, as follows: The youngest victim (Brenden Wegner) was in the process of climbing down from the well mast, off of the ?monkey board,? when the well exploded and engulfed him. The Operator and his two other ?oor hands were on the ground to the east of the driller ?oor by the controls of the BOP. The Operator was behaved to have been behind a BOP control panel. "The two ?oor hands were blown backwards by the blast. One ?oor hand (Raymond Hardy) died of his burns the following day. The second ?oor hand (13st (same was burned so bad that both legs had to be amputated. The Oasis representative, Loren Baltrusch who was in charge of the land lease on which the rig was operating, had left the service rig right after the rig engine had started revving up. Accordingly, he was a quarter mile away item the rig by the time it exploded and was therefore not injured by the explosion. The service rig was completely destroyed. Statements taken from an adjacent drilling rig, located a mile away, indicated that the concussion from the blast shook their trailers, deSpite the fact that the trailers were positioned behind an earthen berm. The service rig?s drilling pipes were heated to a point they buckled and bent. All plastic and organic parts were melted. The rig mast was extended at the time of the ?re and the heat of the ?re caused it to bend. The ?re was still smoldering at the time arrived the afternoon after the explosion. FACTS BEARING ON THE ACCIDENT: OVERVIEW (Facts) 1. The service rig had been purchased May 16, 2011 from Falcon Rigs. 2. The service rig was completely destroyed, leaving little forensic evidence of other potential safety 7. 3. 9. 10. ll. 12. 13. issues. The company man had closed off the well the day prior with approximately 230 barrels of salt water (42 gallons a barrel) or 9,660 gallons. The water used was salt water which has a greater speci?c gravity than regular water. However, for simple calculations standard water speci?c gravity of 8.3 per gallon gives a cumulative weight of 80,178 pounds. The service rig had driven out to the site the morning of the accident and started to set up and perform operations. Witnesses in the adjacent drilling rig stated the impact of the explosion shook their job trailers. This drilling rig was approximately 34 of a mile from this site. The service rig engine started naming at a higher rate of speed before it exploded. FIRE RETARDENT CLOTHING (Facts) The victim that was binned while climbing down the drilling mast was 21 years old and had been with the company for only two days. None of the employees were wearing ?re retardant clothing at the time of the accident. None of the employees were provide FR clothing by the company ownership. The company ownership had stated to both at the scene of the accident that their crews had previously worn FR clothing where required at other job sites. It had been almost eighteen months since OSHA had issued its ?Enforcement Policy for Flame- Resistant Clothing in Oil and Gas Drilling, Well Servicing, and Production Operations?. Memo dated March 19, 2010). The company stated they do not remember receiving the memo. The well had been free ?owing oil for approximately 60 days prior to CW3 attaching the horsehead. The well depth was well below the hydrocarbon zone for both oil and for gas. When the company removed the pipe from the hole, they opened the well directly to the hydrocarbon zone. FACTS 14. The servicing rig did not have a ?safety slide? (Geronimo Line) attached which would allow an employee working on the ?monkey boar (derrick hands working platform) an emergency esca - route should the mast toyer become com a romised another hazard. 15. In addition to the API recommendations a ?safety slide? or its equivalent is recommended as a safety practice by the International Association of Drilling Contractors (IADC) as far back as their 1979 edition. 16. Both the IADC and the API are considered the leads in creating industry practice within the oil and gas well industry. 17. The companv ownership stated to the compliance of?cers at the accident site that theyr chose not to install a ?safety slide? on their new service rig because they did not believe there was enough evidence in the oil ?eld to iustifv the exuense. According to API Recommended Practice 54, Third Edition (Recommended Practice for Occupational Safety for Oil and Gas Well Drilling and Servicing Operations) section 6.10 AUXEIARY ESCAPE 6.10.1 On all land rigs, the derrick or mast shall have an auxiliary means of escape installed prior to personnel working in the derrick. The auxiliary escape route should use a specially rigged and securely anchored escape line attached to the derrick or mast so as to provide a ready and convenient means of escape from the derrick? man?s working platform. The escape line route should be kept clear of obstructions. a. ~The escape line on masts or derricks should be a 7/16?in. (11.5?mm) minimum diameter wire rope in good condition. A safety buggy equipped with an adequate braking or controlled descent device should be installed on the wire rope, kept at the derrick-man?s working platform, and secured in a manner that will release when weight is applied. Tension on the escape line should be periodically checked and adjusted to enhance safe landing of the user. Tension should be set with six to twelve feet of sag in the middle, depending upon the length of cable run. It is recommended that the ground anchor point of the escape line should be located a minimum lateral distance ?om the derrick or mast equal to two times the height of the work platfonn. The ground anchor point should be able to withstand a pull of at least 3,000 lb. lfthe rig con?guration or location con?guration will not permit use of the escape system, an alternate means of fast emergency exit from the derrick-man?s working platform to a safe place should be provided. 18. The company did not install another emergency means of fast exit from the working platform. The only means of egress from the derrick was a ladder that would take an employee through any gas or oil blowout ?om directly above the well head. 19. Falcon Rigs will install a ?safety slide? at the request of the purchaser; however, during a phone interview their Company Comptroller (Jay Steuart) he stated that most companies have a preference for a speci?c ?safety slide? manufacturer. He said most companies will install their own or provide the type that want installed to Falcon Rigs for installation. Mr. Steuart compared the installation of a ?safety slide? to the installation of a car stereo where the employer has any number of personnel choices available based on their own personal preference. BLOWOUT PREVENTER (Facts) 20. From Wikipedia, the free A blowout preventer is a large, specialized ng? used to seal, control and monitor oil and gas wells. Blowout preventers were developed to cope with extreme erratic pressures and uncontrolled ?ow (formation kick) emanating from a meg reservoir during drilling. Kicks can lead to a potentially catastrophic event known as a blowout. In addition to controlling the down hole (occurring in the drilled hole) pressure and the ?ow of oil and gas, blowout preventers are intended to prevent tubing g. drill pipe and well casing), tools and drilling ?uid from being blown out of the wellbore (also known as bore hole, the hole leading to the reservoir) when a blowout threatens. Blowout preventers are critical to the safety of crew, r_i_g (the equipment system used to drill a wellbore) and environment, and to the monitoring and maintenance of well integn'ty; thus blowout preventers are intended to be fail; safe devices. The term BOP (an initialism rather than a spoken acronm, pronounced B-O- P, not "bop") is used in oil?eld vernacular to refer to blowout preventers. The abbreviated term preventer, usually prefaced by a type g. ram preventer), is used to refer to a single blowout preventer unit. A blowout preventer may also simply be referred to by its type g. ram). Two categories of blowout preventer are most prevalent: m_m and annular. BOP stacks ?equently utilize both types, typically with at least one annular BOP stacked above several ram BOPs. 21. The BOP was rated for 3000 pounds. The BOP was manufactured by VISTA Inc and was produced in 2001. 22. The BOP had been purchased from Yankee Fishing and Rentals, Inc on 1/24/11 for a price of $39,900. 23. The BOP was pressurized on at least two occasions. 24. The BOP closing mechanism was tried at least six times without success. 25. The Oasis Company Man left the job site to get a part that was needed for the operation. The company man returned just prior to the accident and was not there to witness the full set up or any BOP drills. 26. The work crew tried to manually close the well stern pipe at least once and were not success?il either before, during or after the initiation of the BOP. 27. The BOP at the time of the inspection (post accident) did not have both rains closed. One of the rams was not properly hooked up preventing it from closing. - - I Lower RAM not hooked up. ACCIDENT BOP 28. There was no well validation in accordance with API 53 Recommended Practices for Blowout Prevention Equipment Systems for Drilling Wells that the BOP used for the well hole (Vista 3000 lb) would equal the maximum anticipated surface pressure to be encountered. 29. The company did not maintain documentation of this BOP equipment and function tests in accordance with API 53 Section 17.3.7 Test Docmnentation: The results of all BOP equipment pressure and function tests shall be documented and inhiude, as a minimum, the testing sequence, the low and high test pressures, the duration of each test, and the results of the respective component tests. Pressure tests shall be performed with a pressure chart recorder or equivalent data acquisition system and signed by pinup operator, contractor?s tool pusher, and operating company representative. 30. The BOP was a Vista 3000 lb unit. It was purchased in Odessa Texas from Vista Inc. The President of Vista Inc (Dan Walter) stated to CSHO that he designed the BOP to have both rams hooked up at all times for the BOP to be considered fully functional. 31. As identi?ed in the picture above only the top ram is hooked up. 32. Under the API RP it speci?cally addresses the BOP requirements for servicing rigs under API RP 54, 6.4.1. ?When drilling or well servicing operations are in progress on a well where there is any indication that the well will ?ow, either through prior records, present well conditions, or the planned well work, blowout prevention equipment shall be installed and tested?. 33. RP 54, 6.4.3 states ?Blowout prevention equipment, when required, should be installed, operated, and maintained in accordance with API RP 5 3 (Recommended Practices for Blowout Prevention Equipment Systems for Drilling Wells). 34. RP 54, 6.4.7 While in service, blowout prevention equipment should be inspected daily and a preventer actuation test should be performed on each round trip, but not more than once per 24~ hour period. Notation of actuation tests performed should be made on the daily report. Annular blowout preventers should be tested in accordance with the manufacture?s recommendations. OTHER (Facts). 34. The company man on site was an independent contractor who had been hired by Mitchell?s Oil Field Service which was a subcontractor of Oasis Oil and Gas. . 35. The company man had authority to direct servicing activities related to the well hole, but did not have supervisory authority over the operator of the servicing rig or its crew. 36. The company man did not have authority to ?re employees, but really did not know what his authority was since it had never been explained to him. His job as he understood it was to be consulted on the engineering aspect of the well itself. 37. Carlson Well Service did not have any written safety procedures. it did conduct job site safety meetinos. 38. (bits). (blmv. (hll7ld ANALYSIS: 1. According to API 53 Section 12.3.3? Accumulator Response Time. Response time between activation and complete operation of a function is based on BOP or valve closure and seal off. For surface installations, the BOP control system should be capable of closing each ram BOP within 30 seconds. Closing time should not exceed 30 seconds for annular BOPS smaller than 18V4 inches (47.63 cm) nominal bore and 45 seconds for annular preventers of 183% inches (47.63 cm) nominal bore and larger. Response time for choke and kill valves (either open or close) should not exceed the minimum observed ram close response time. Measurement of closing response time begins at pushing the button or uniting the control valve handle to operate the function and ends when the BOP or valve is closed a?ectipg a seal. NOTE: Based on this recommendation and witness statements that the BOP shut was initiated six times at two di?erent charging intervals we have a max cumulative time period of (6 30 180 seconds divided by 60 seconds or three minutes). Additionally, from witness statements the BOP system had to be recharged and that took 2-3 minutes. This gives a maximum exposure window of 5-6 minutes for total reaction time. The BOP shut off was not initiated until after the employees could not manually crimp down the pipe with a swedge and cap it while the oil rig was over?owing out of the pipe. This indicates that the employees knew that hazard existed in excess of 5 minutes. The actions of the employees after initiating the BOP indicated a lack of training and not having a policy on how to handle uncontrolled oil and gas over?ows. Typical oil ?eld practice after initiating the BOP emergency shut o??s is to ma upwind and away ?orn. the well over?ow. A ?ve minute walk at four miles an hour would have allowed an employee to have been 1/3 of a mile away at the time of the explosion. This would have prevented three of the employees from being burned. Prima Facie Case Elements: 95-" Cited Standard: Sal. (Serious) Failure to Comply Proof: The Companies Vista BOP was not properly installed, tested, or maintained to provide emergency protection in case of an unexpected well over?ow. One of the rams on the Vista BOP was not hooked up thus neutralizing the redundancy of protection for the employees at the well site. . Access to Violative Condition: Two employees died from burns and two other employees were injured when a well over?owed to heights of ?fty feet, and then exploded, partly due to the improper ?mctioning of the BOP. The BOP did not function because both rams were not properly hooked up and CWS did not ensure that the BOP could withstand the pressure of the well. Additionally, when the BOP was initiated, the CWS employees did not respond appropriately. Rather than watching the continued attempts to get the BOP working, the employees should have immediately ?ed the scene, thereby protecting themselves item the explosion. Employer Knowledge: The employer?s had purchased two other for its other servicing rigs and had been using them since the company had started. The owners had used when the servicing rigs were run by themselves. The owners had completed BOP training with other companies in the past. The owners were exposed to common industry practice which included the of both the IADC and the API and they chose to follow neither. Cited Standard: (Serious) Failure to Comply Proof: None of the employees who were working on the rig were wearing ?re retardant clothing while installing a new pumpjack on an open well site that was open into the hydro carbon zone. Access to Violative Condition: Two employees died ?'om burns and two other employees were injlned when a well exploded ?om over?owing to heights of ?fty feet. All four employees su??ered third degree burns over various portions of their bodies. None of the employees were wearing ?re retardant clothing as a means of PPE. The depth of the well place the well clearly into the hydrocarbon zone of both oil and gas. When CWS removed the pipe from the well they exposed this zone to their employees. Employer Knowledge: The employer stated they Were aware of companies wearing ?re retardant clothing in the oil ?elds. The employers stated they did not see a need for FR clothing prior to this accident occurring. The employer stated to both at the accident scene that they had been required to wear FR clothing in support of other companies. It had been almost a full eighteen months since OSHA had issued its ?Enforcement Policy for Flame-Resistant Clothing in Oil and Gas Drilling,- Well Servicing, and Production Operations?. (Memo dated March 19, 2010). The company stated they do not remember receiving the memo, but knew there was discussion throughout the oil ?elds inND and MT about FR Clothing. 9. Cited Standard: Sal. (Willful) 10. Failure to Comply Proof: The company ownership chose not to install a ?safety slide? on there knew service rig because they did not believe there was enough evidence in the oil ?eld to justify the expense. At the time of the accident there was not a ?safety slide? on the service rig. According to API Recommended Practice 54, Third Edition (Recommended Practice for Occupational Safety for Oil and Gas Well Drilling and Servicing Operations) section 6.10 AUXILIARY ESCAPE 6.10.1 On all land rigs, the derrick or mast shall have an auxiliary means of escape installed prior to personnel working in the derrick. If the rig con?guration or location con?guration will not permit use of the escape system, an alternate means of fast emergency exit from the deniekman?s working platform to a safe place should be provided. 11. Access to Violative Condition: One employee died while climbing down a drilling mast using a ladder while a ?fty plus foot column of oil ignited creating an explosion. The employee that died did not have access to a safety line to slide away from the servicing rig when an uncontrolled release of oil was to occur. The only means of egress afforded this employee was a ladder that would take him directly through any gas or oil blowout ?ora directly above the well head. 12. Employer Knowledge: The employer?s knew that auxiliary escape lines coming of the ?monkey beards? were standard industry practice. The owners stated to both at the accident site that they chose not to install these ?safety lines? The owners had been trained using ?safety lines? in other companies prior to starting their own company. The owners new that both API and are considered the lead in creating industry practice in the oil and gas industry and that both have recommended the use of ?safety slides? with the International Association of Drilling Contractors (IADC) recommending it as far back as their 1979. CLOSING CONFERENCE: A fennel closing conference has not been conducted yet for this case. Check Applicable Boxes and Explain Findings: [Complaint Items 1 I lReferral Items I lAccident Investigation Summary Findings ILEP ix lPlanned Inspection I NATURE AND SCOPE -- UNUSUAL CIRCUMSTANCES (Mark and explain all that apply:) lx [None I IDenial of entry (see denial memo) I I IDelays in conducting the inspection I I IStrikes I I IJurisdictional Issues I I Trade Secrets I I IOther I Comments: Severe language barrier. RECORDKEEPING PROGRAMS (Other than 29 CFR 1904 requirements) Does the employer have a recordkeeping program relating to any occupational health issues (monitoring, medical, training, resPirator ?t tests, ventilation measurements, etc.)? I Are any programs required by OSHA health standards? I COMPLIANCE PROGRAMS (engineering controls, PPE, regulated areas, emergency procedures, compliance plans, etc.) Address any relevant compliance e??orts regarding potential health hazards covered by the scope of the inspection. PERSONAL HYGIENE FACILITIES AND PRACTICES (showers, lockers, change rooms, etc.) Are any required by OSHA health standards? I What Standards: HAZARD COMMUNICATION PROGRAM Written Program (complete) I if I (all) I Labeling (adequate) I Training (complete) Yes Copy MSDS's/Program attac I I Comments: ACCESS TO EXPOSURE MEDICAL RECORDS FIRE PROTECTION AND EVACUATION PROCEDURES SYSTEMS SAFETYAND EMERGENCY RESPONSE RESPIRATOR PROGRAM LOCKOUT SAFE WORKPRACTICES FIRST AID: First aid kits on site. ELECTRICAL SAFE WORKPRACTICES EXPOSURE CONTROL PLAN LABORATORY STANDARD ERGONOMTC PROBLEMS If yes, complete the items 1 and 2 below. 1. Lifting (10% or more similarly exposed employees injured) a. Total of employees exposed to job: b. Total of cases for job: 2. (10% or more similarly exposed employees have 5% or more CTS cases) a. Total of employees exposed to job: 13. Total of cases for job: Other signi?cant injury/illness trends .- If yes, explain. EVALUATION OF OVERALL SAFETYAND HEALTH PROGRAM General Indus Yes No Employer has a Safety Health Program I lYes [No Written I Yes No Copy Attached Construction Industry: I Yes lx lNo Accident Prevention Program lYes Ix [No Written Yes it No Copy Attached Evaluation of Safety and Health Program (O=Nonexistent 1=Inadequate 2=Average 3=Above average) 1 Written Program Communication to Employees I Enforcement 1 Safety Training Program 1 Health Training Program 1 Accident Investigation Performed 1 Preventive Action Taken Comments: CLOSING CONFERENCE NOTES: Were any unusual encountered such as, but not limited to, abatement problems, expected contest and/or negative employer attitude? Ifyes, explain below. I [Yes No 19.Closing Conference Checklist as appropriate) I [No Violations Observed 3; Gave Copy Employer Rights Ix [Reviewed Hazards Standards Discuss Employer Rights/Obligations [x lEncouraged Informal Conference Offered Abatement Assistance Discussed Consultation Programs I [Employer/Employee Questionnaires Closing Conference Held with Employee Representative