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Faculty of Engineering and IT Risk Management in Engineering (49006) Assignment 1 – Topic and Case Study Analysis Table of Contents Introduction. 3 Case study I 3 1.1 Case Description. 3 1.2 Setting boundaries. 3 1.3 Stakeholders Analysis. 4 1.4 Inherent Risk Determination. 5 1.5 Causal Chain Analysis. 5 Case study II 6 2.1 Case Description. 6 2.2 Setting boundaries. 6 2.3 Stakeholders Analysis. 6 2.4 Inherent Risk Determination. 7 2.5 Causal Chain Analysis. 8 Summary. 9 References. 10 Introduction This report consists of two different case studies of accidents that have occurred in the past. An in-depth research of the uncertainties, stakeholders and the boundaries for these types of systems and engineering projects has been carried out.  The first case focuses on the blast that had occurred at the blast furnace 5 of the Corus UK Ltd at Port Talbot. The second case is on the fire blowout that had occurred at the Pryor Trust of the IH-9 gas well’s rig at Pittsburg, Oklahoma. Case study I 1.1 Case Description The explosion had occurred on November 8th 2001 at 17:13 hours at Port Talbot, UK. Corus UK Ltd is an iron and steel making company which is a part of Tata Steel Europe. The issue occurred in the 5th number blast furnace that is used for the production of iron. The issue occurred due to the interaction of water with a mixture of molten materials. Due to this extreme pressure that had got generated inside the furnace, the part that is above the lap joint of the furnace got lifted up by 0.75 m. This created an opening of 400 to 600 mm around the circumference[1]. This allowed a total of about 200 tonnes of materials that includes semi-solid, liquid and solid which released on the caste house floor. A lot of mixture of materials that was in gaseous form passed through various openings of the building and was released in the atmosphere which got ignited[2]. This resulted into the formation of cloud of all of these mixture of gaseous materials in the air above the furnace at the height of several hundred feet. The bleeder valves that were at the top of the furnace also started discharging due to opening up also realising gases that got ignited from the valves. 1.2 Setting boundaries The reason behind the high amount of water entering the furnace is because of the delay by the waterman in identifying how the water was entering due to which the sealing and locating of the source of leakage duration allowed a huge 50 to 80 tonnes of water to enter the furnace. The operation of the furnace was also running at a 55% of its total needs of water cooling for about 10 to 12 minutes due to which a few coolers of the blast furnace got overheated. The efforts that were made towards recovering the furnace, this approach led towards the large quantity of water reacted and came in direct contact with the molten and semi-solid materials due to which a lot of energy was released and, inside the blast furnace over pressure was created[3]. There were bolts that connected furnace to its supporting columns which had also got severely damaged before the explosion occurred due to which it did not help in a positive way by holding the furnace in its position when the explosion occurred. 1.3 Stakeholders Analysis Following are the stakeholders that were connected to this blast. They have been divided into 2 parts which are internal and external. Category Stakeholder RoleImpactInternalCorus WorkersDaily task around the production units3 lost lives and many were severely injured along with many having minor injuries and shock.InternalCorus ManagerMonitoring and managing the whole process of production on daily basisWeren’t around and available due to which they were unaware of the events occurring and take actions on it accordinglyInternalQuality Assurance TestersRandom checks of the condition of the machineryDid not identify the possible risk and take required actions resulting in the blastExternalSafety Policy MakersMaking the safety rules to be followed by the company at the time of its establishmentDid not cover related rules which would avoid any such issue to occur resulting in the blastExternalTown / Provence GovernmentPort Talbot’s government examining all the projects/ business properly before allowing them to start functioningDid check for all the related possible risks and take required steps resulting in the blastExternalNational GovernmentChecking and verifying all the manufacturing companies that the Town government has approvedDid not identify the mistake made by the Town government in identifying all the related risk of the company resulting in the blast The manufacturing manager and Area technologist are the people there are in direct contact with the site and the specific manufacturing plant. Their primary role is to monitor and manage the staff as well as the manufacturing plants which should be functioning smoothly. However, they did not pay enough attention to the process resulting in the blast. The workers that also took various decisions before the blast occurred under pressure are also responsible for the blast which resulted in a few of them loosing their lives. The senior blast furnace manager who was the one most responsible for furnace 5 did not seek any type of involvement of risk managing experts for the various meetings that they conducted by the extension committee that were working towards the life of the furnace. 1.4 Inherent Risk Determination A number of inherent risks were associated to this explosion. Starting from the functions and the role of Safety Department needing more integration with the engineering and operational management. IN case if the blast furnace is under the COMAH ( Control of Major Accident Hazards Regulations ), identifying and evaluating all the major hazards is legally required. Another issue is that predictive tools are limitedly used in the metal (steel) industry. Predictive tools for assessment must be implemented more commonly in the steel industry. Performing blast furnace recoveries post the operations is a specific process that rises additional risks that are much more dangerous compared to the general operational risks. It is important to educate all the involved personnel about these risks and their control measures along with the arrangements required to communicate effectively to maintain proper risk control. Carrying out best engineering practices, to ensure that there is no impact on the risk profiles while modifying a plant’s physical characteristics, is also very necessary. From this incident we also learn that keeping sufficient amount of cooling water for blast furnaces can become really helpful during such accidents. The companies need to clearly define a line of responsibility for the members on site, as it plays a very important role in the decision making in emergency situations. All changes including the changes made in the operating parameters should be implemented by formal system that manages the risk assessments. These changes are made considering the safety reviews received post modifications in order to safeguard the functioning of the equipment and plant. Raising awareness among all the staff members including the workers who are going to be on the site is mandatory. They need to know about dangers of explosion that can occur because of the water and slag or the water and metal interactions. This will make them aware of the intensity of risk that may occur if a molten material comes in contact with water. Finally many rigorous processes should have been designed to understand and assess the risk associated to safety-critical plant and especially those plants that are ageing, and these processes must be subjected to regular reviewing. 1.5 Causal Chain Analysis The actual cause of this explosion was the mixing of the hot molten and the water in the furnace vessel’s lower part. The cooling system allowed the water to enter into the furnace after which many different linked events took place starting from the safety critical cooling system failure. While the explosion was taking place, the staff made multiple attempts to solve the issues that were taking place because of the abnormal operations created by the system failure in order to recover furnace. The events that influenced the explosion were a group of many significant failures that had taken place in the health and safety department over the years[4]. By events here it means, not just the maintenance of the blast furnace but many other issues within the company and more particularly the department of energy. The energy department is responsible for supplying the cooling water which is essential for furnace.  The company failed to perform sufficient and suitable risk assessments of the operations taking place in the blast furnace and this resulted in a failure to implement the robust procedural and technical controls. Both insufficient reliability of the cooling system and insufficient security and redundancy of the cooling water supply had showed deteriorating and downward trend for manty months. Case study II 2.1 Case Description In 2018 a blowout fire happened at 0718 Pryor Trust in a rig IH-9 the number of gas well at Pittsburg, Oklahoma. Five employees of the company were in the cabin of driller at rig floor died[5]. The reason for death was inhalation of carbon, injuries of thermal-burn and smoke. The blowout happened after three and a half hours of drill pipe removal which is used for swinging out from gas well. During drilling the clay is dispatched down through drill pipe and sent up via well annulus. This soil might be based on oil or water. When this accident happened the soil was based on oil.  Other parameter which requires considerations in the maintenance wellbore pressure by hydrostatics application[6]. This pressure relies on the height and density of the column of the mud. The pressure of hydrostatic is proportional directly to density.  Large variations in pressure might result into influx. On regular intervals the crew of drilling is expected to administer the volume of clay by stopping all operations. Additionally, secondary barriers application in the terms of detection of flux and BOP activation may prevent blowout. 2.2 Setting boundaries In this case the cause after the blowout was submerging of primary and secondary barriers. The pressure of hydrostatic developed, detection of influx as well as BOP activation by a member. There are other factors that involves many aspects. Tripping and drilling were not executed in a symmetrical manner. The training of the drillers inefficiently done. Equipment alignment was unusual and this was not taken into consideration. Supervising the pressure of the surface was not regularly done. Both drillers Shut down the alarm system did not allow them to identify the issue till 14 hours.  Partial or fractional checks of main flow. All such aspects involving the stakeholders did not consider before executing the tripping. 2.3 Stakeholders Analysis Category Stakeholder Role/ DutiesImpactInternalPryor drillersPerform duties as per needLost their lives because they were not trained properlyInternalPryor managersControl and Organize the entire drilling procedureCarry out more sessions of training and can also go through the training sessions.InternalRed Mountain Energy, LLCOperatorAppear with innovative policy of CID as per the APIInternalPatterson-UTI Company of DrillingThe Company of DrillingDevelop alarm system as well as tripping procedureExternalInstitute of American Petroleum (API)Association of US tradeDevelop and update new recommendationsExternalOccupational Health and Safety Administration (OSHA) United States Labour Department AgencyApply and develop the new procedure of managing safety.ExternalInternational Association of Contractors of DrillingA Association of tradeParticipate in development according to recommendationsExternalPason Systems Inc.Supplier of systems of Data managementDesign the data-system of electric drilling and UIExternalNational Oilwell Varco (NOV)Supplier of equipment and componentsDesign the data-system of electric drilling and UIExternalState of OklahomaLocalityExecute and develop safety regulations. The company named red mountain energy which invests in upstream oil and gas projects. 2H-16 was first well of Pryor trust that was managed by RMO and the second well was 1H-9 (disaster well) Pryor Trust[7]. A drilling company, Patterson-UTI. Here, the company determines the mud weights, preparing well design, preparing well plan, analyzing casing depth, taking routine drilling and operational decisions all were executed by RMO however Patterson provides crew members and equipment for drilling. 2.4 Inherent Risk Determination The monthly program of audit of Patterson is a program which verifies the designs and defect a RWP for better performance and avoiding risk. Patterson didn’t carry out any such performance assurance of tripping sheet of practical situations. This program was a failure in various categories, the decision of RMO to go on with drilling also after mud return and flaring was a main inherent cause of accident, so these were 2 causes that resulted unbalanced drilling as well as the primary barriers were nullified. The procedure also was not able to qualify the standards of API for unbalanced drilling. Control specifications were not designed by RMO nor by Rig 219 possess the equipment required, neither the workers were trained as per the IADC-UBO Rig-Pass who worked at rig.  If the risks mentioned above were discovered at the time of audit then the accident might be avoided. No evidence was found that RMO has done any planning for venturing an operation like this. Addition to this both the firms included in the venture did not plan a system to identify and prevent any conditions which is unexpected like barriers loss. If the worker was provided with proper guidance as per industry standard they might have utilize another method for tripping. 2.5 Causal Chain Analysis Analysis of Causal Chain or analysis of root cause is closely associated to systems thinking and approach of DPSIR.  Causal chain is particularly arranged events list that connect the cause of an incident to the effect it may have. Many investigations were carried out on the data of procedure like the wellbore, trip sheet, every other equipment from the time prior to the accident happened. The standards of the industry for the cabin of driller and the location were not considered. This resulted the escape routes blockage from the cabin of driller. Further the cabin of driller was situated at rig floor and the five employees who were there at the time of incident were killed in blowout.    The regulations that are necessary were not complied, No interface document for well construction for operations of drilling were files and no hazard analysis or MOC were executed while the well was unbalanced. RMO was inadequately considered the lost barrier. RMO did not follow the API RP 92U and have not done enough planning and training nor have enough equipments. This resulted to continue the drilling without rising the weight of mud. The weight of mud was quite low to avoid the influx and the pressure of hydrostatic was low than the pressure of formation. This resulted into unbalanced well. As per the API, best practices for safe tripping of drill pipe while under balanced functions did not imply. Neither RMO nor Patterson had any kind of policy to overbalance well prior to tripping. Thus, tripping was executed on a well that is unbalanced might lead to influx of gas during tripping via lateral section.   The management of alarm for the industry of drilling was not as the standards. Patterson had not planned any alarm philosophy or rationalization. This confused the drillers for a unpleasant alarm system. Thus, the driller shut down the alarm system. The impact was that the alarms were not activated to notice 14 barrel increase in the pits of mud. Also the drillers did missed the signs of influx at the peak of curve.  For the procedures of wet tripping no terms were provided for the required alignment of the equipment. The company face alignment issues at rig. Due to which the bucket of mud drained to trip tank during executing the operations of tripping. This resulted into multiple fluctuations of the volume in trip tank. The members were having problems in supervising the correct fill of well. Signals of influx were missed during tripping via vertical section. The attention of drillers was on floor activities of the rig when the crew pull the plug of the drill pipe. No employee watched the volume of trip tank actively. The worker did not notice the gain of thirty-one barrel in trip tank. This resulted into missing the signals of influx even during the operations of surface. The industry of drilling as of now did not utilize the automatic controls of BOP. The BOP was not closed as the controls were not available. The fire and blowout were rapid that any kind of effective reactions. No actions were taken during the sings of influx were studied. Summary The incident that took place on 8th November 2001 killed 3 employees. The explosion also seriously injured around 12 of the contractors and employees. Investigation for this incident was carried out by HSE and South Wales police resulting in prosecution of “Corus UK Ltd in December 2006 under sections 2(1) and 3(1) of the HSWA 1974.” Furthermore the company had to pay a fine of £ 1.33 millions as well as a cost of £ 1.74 millions. It was clear that water entering the furnace was the main cause of the explosion followed by failure of the safety critical water cooling system. The explosion resulted in upliftment of a furnace that weighed 5000 tonnes about 0.75 metres from the supporting structure resulting in release of hot gases and material into cast house. The incident that took place on 22nd January 2018 killed five employees. The blowout also had major impacts on the surrounding area and hence on the local community. Investigation for this incident was carried out by U.S. Chemical Safety and Hazard Investigation Board (CSB). A number of issues together contribute to the underlying cause of this blowout starting from poor management of barriers, performing underbalanced operations, turning off the alarms, location and design of driller’s cabin, no safety regulations, not conducting flow checks on regular intervals et cetera. Inaccurately performed drilling operations resulted in the blowout. This report discusses two case studies of accidents occurred in the past. Their scenario is described, the stakeholders of both the cases are discussed, inherent risks are determined and finally a causal chain for each case has been analyzed individually. References [1]          J. Hodges and S. Curry, “Blast furnace no. 5 incident, Corus, Port Talbot, 08 November 2001,” Loss Prevention Bulletin, no. 219, 2011. [2]          M. V. was formerly Senior, “Corus restructures UK arm,” Steel Times International, 2003. [3]          S. d. Barros, R. Barbastefano, C. d. Souza, and L. d. Silva, “Journal of Materials–Design and Applications: Twenty years of contributions to the materials technology,” ed: SAGE Publications Sage UK: London, England, 2019. [4]          J. C. Belausteguigoitia, “Causal chain analysis and root causes: the GIWA approach,” AMBIO: A Journal of the Human Environment, vol. 33, no. 1, pp. 7-12, 2004. [5]          S. Rassenfoss, “Report Recounts the Missed Signals Leading to a Blowout That Killed Five,” Journal of Petroleum Technology, vol. 71, no. 08, pp. 40-42, 2019. [6]          K. Kulinowski, “SAFETY MATTERS.” [7]          M. Nazaruk and J. Thorogood, “Closing the Gap in Human Factors Everybody Has a Role To Play,” Journal of Petroleum Technology, vol. 72, no. 11, pp. 35-38, 2021.


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