The After Action Review summary report from the DEP's Bureau of Investigations. The report faults Chevron for two things that gave rise to the fire and resulting tragic death of a contract worker: Chevron's well site managers are inexperienced and overworked, and contractors working at the site were inexperienced. This closes the DEP's investigation into the fire and resulting death. The family of the deceased worker is suing Chevron.
King Chief Darryl Jones of the Pittsburgh Fire Bureau Kingdom honors King Tee...Terrell Patillo
King Chief Darryl Jones of the Pittsburgh Fire Bureau Kingdom honors King Tee Patillo Jr. for his Leadership, Mentorship, Friendship, & being a Public Servant that that set the Highest of Standards.(*Mayor Bill Peduto*)
The document describes the key activities and organization of a typical fire prevention bureau. It discusses that fire prevention bureaus perform inspections, public education, and enforcement of fire codes. Larger bureaus may have a chief of prevention as the head, while smaller departments may have a company officer in charge. Bureaus aim to prevent fires through hazard identification, education, and ensuring fire safety systems are properly installed and maintained. Their goals are to reduce loss of life and property from fires.
This document discusses the roles of federal, state, and local governments in fire prevention. It outlines several key federal agencies and programs established over time to address fire prevention, including the U.S. Fire Administration, National Fire Academy, and National Institute of Standards and Technology. Major events like World War II, the 1947 Fire Prevention Conference, and the 1973 America Burning report increased federal involvement in fire prevention efforts beyond just protecting federal assets.
This document discusses personnel considerations for fire prevention bureaus. It notes that bureaus are often made up of a combination of uniformed firefighters and civilian specialists. Uniformed staff bring fire service experience while civilians have specific skills and education. The document emphasizes that training and certification are critical for all positions, and it outlines various national standards and certifying organizations. Retention of qualified staff is also highlighted as important for an effective fire prevention program.
This chapter discusses the importance of training for firefighters. It identifies key positions in a training bureau, including instructors, audiovisual technicians, and the training chief. Adequate training is determined by evaluating if tasks can be performed safely and efficiently. Skills are initially developed through basic training and then maintained through regular practice. Training helps firefighters perform safely and effectively at emergency incidents. It covers both technical topics and hands-on skills training. Safety is the top priority in all fire department training.
This document discusses various public and private support organizations that assist the fire service in the United States. It identifies national organizations like the American Red Cross, NFPA, and IAFC. It also discusses federal agencies including FEMA, OSHA, and NIOSH. Additionally, it covers state-level groups like state fire marshals and forestry departments, as well as local organizations that support fire departments through services, funding, and resources. The overall purpose is to outline the types of external groups that fire services can contact for information, training, standards, or assistance in their work.
Fire Prevention Program (FPP) of the Bureau of Fire Protection (BFP) in Urdan...Jo Balucanag - Bitonio
This thesis evaluates the Fire Prevention Program (FPP) of the Bureau of Fire Protection (BFP) in Urdaneta City. It examines the implementation of the FPP from 2006-2007, including the level of compliance by business/building owners to fire safety standards. It identifies problems encountered by BFP personnel and residents, and solutions adopted. The study found that while the FPP was effectively implemented, there were issues like lack of equipment and personnel for BFP. It concluded with recommendations such as providing more training for BFP personnel and addressing their problems.
King Chief Darryl Jones of the Pittsburgh Fire Bureau Kingdom honors King Tee...Terrell Patillo
King Chief Darryl Jones of the Pittsburgh Fire Bureau Kingdom honors King Tee Patillo Jr. for his Leadership, Mentorship, Friendship, & being a Public Servant that that set the Highest of Standards.(*Mayor Bill Peduto*)
The document describes the key activities and organization of a typical fire prevention bureau. It discusses that fire prevention bureaus perform inspections, public education, and enforcement of fire codes. Larger bureaus may have a chief of prevention as the head, while smaller departments may have a company officer in charge. Bureaus aim to prevent fires through hazard identification, education, and ensuring fire safety systems are properly installed and maintained. Their goals are to reduce loss of life and property from fires.
This document discusses the roles of federal, state, and local governments in fire prevention. It outlines several key federal agencies and programs established over time to address fire prevention, including the U.S. Fire Administration, National Fire Academy, and National Institute of Standards and Technology. Major events like World War II, the 1947 Fire Prevention Conference, and the 1973 America Burning report increased federal involvement in fire prevention efforts beyond just protecting federal assets.
This document discusses personnel considerations for fire prevention bureaus. It notes that bureaus are often made up of a combination of uniformed firefighters and civilian specialists. Uniformed staff bring fire service experience while civilians have specific skills and education. The document emphasizes that training and certification are critical for all positions, and it outlines various national standards and certifying organizations. Retention of qualified staff is also highlighted as important for an effective fire prevention program.
This chapter discusses the importance of training for firefighters. It identifies key positions in a training bureau, including instructors, audiovisual technicians, and the training chief. Adequate training is determined by evaluating if tasks can be performed safely and efficiently. Skills are initially developed through basic training and then maintained through regular practice. Training helps firefighters perform safely and effectively at emergency incidents. It covers both technical topics and hands-on skills training. Safety is the top priority in all fire department training.
This document discusses various public and private support organizations that assist the fire service in the United States. It identifies national organizations like the American Red Cross, NFPA, and IAFC. It also discusses federal agencies including FEMA, OSHA, and NIOSH. Additionally, it covers state-level groups like state fire marshals and forestry departments, as well as local organizations that support fire departments through services, funding, and resources. The overall purpose is to outline the types of external groups that fire services can contact for information, training, standards, or assistance in their work.
Fire Prevention Program (FPP) of the Bureau of Fire Protection (BFP) in Urdan...Jo Balucanag - Bitonio
This thesis evaluates the Fire Prevention Program (FPP) of the Bureau of Fire Protection (BFP) in Urdaneta City. It examines the implementation of the FPP from 2006-2007, including the level of compliance by business/building owners to fire safety standards. It identifies problems encountered by BFP personnel and residents, and solutions adopted. The study found that while the FPP was effectively implemented, there were issues like lack of equipment and personnel for BFP. It concluded with recommendations such as providing more training for BFP personnel and addressing their problems.
The report summarizes an investigation by BP into the causes of the Deepwater Horizon oil rig explosion and spill. The investigation found that (1) the cement barrier installed to isolate hydrocarbons in the wellbore annulus failed, allowing hydrocarbons to enter the wellbore, and (2) the barriers in the shoe track where the production casing was installed also failed, allowing hydrocarbons to enter the casing. This caused a loss of well control and allowed hydrocarbons to ignite on the rig, resulting in explosions and fire. The BOP also failed to seal the well after the explosions.
2010 1367 granskningsrapport etter hendelse på draugen og varsel om pålegg - ...Faouzi BAAZIZ
The incident occurred during a wireline operation on the Draugen facility to replace a gas lift valve. As the subsurface safety valve was being pulled out of the well, it became stuck in the Xmas tree, blocking the upper swab valve and leaving only one barrier preventing hydrocarbon outflow from the well. After re-establishing additional well barriers, the investigation found issues with risk assessment, well barrier management, and inadequate contingency planning for equipment getting stuck that contributed to the incident. Improvements were identified regarding safety, expertise, well barrier documentation, and securing toolstrings.
An isolation failure occurred at a wastewater treatment plant while clearing a blockage in a sludge line. The isolation was discussed and identified points were isolated as planned, but when the blockage was removed, sludge exited the pipe, contacting a worker. Upon inspection, two valves had not been correctly isolated and were open instead of closed as required. Key lessons included ensuring the isolation method is properly planned and confirmed by all parties, allowing adequate time and resources for complex isolations without interruptions, and stopping to reassess if there are any issues or uncertainties with the isolation.
Spring 2014 MGMT 4322 INDIVIDUAL CASE GRADING RUBRIC E.docxrafbolet0
Spring 2014 MGMT 4322
INDIVIDUAL CASE GRADING RUBRIC
Ehsan Fakharizadi
Individual Case Assignment: TBA
PART I. Summary and Issue Identification (25 pts.)
1.a. (5 pts.) Write a summary of the case (approximately 100-150 words).
1.b. (20 pts.) Identifies (lists) the ethical issues that have arisen in this case. (about 100 words)
Explain in detail each ethical issue (e.g. what’s occurred, who’s affected, etc). (about 1-2 pages)
Number Question 1: Below Expectations 2: Meets Expectations 3: Exceeds Expectations Score
1.a. Summary The answer does not
adequately summarize
the case. (0 – 3.0)
The answer adequately
summarizes the case.
(3.5 – 4.0)
The answer fully and
concisely summarizes the
case. (4.5 – 5)
1.b. Identify an ethical
issue in a given
business situation
Fails to identify the
ethical issue(s) in a
given business
situation.
(0-14.0)
Identifies the ethical
issue(s) with a few
pertinent facts. (14.5-
17.5, C+ to B+)
Accurately identifies the
ethical issue(s) with all the
pertinent details. (18-20, A to
A+)
Additional
Feedback
1.a.
1.b.
Note: 1.b. is worth 20 points because identifying ethical issues is at the heart of this case. You should identify
several issues in this case and explain why these are ethical issues with all pertinent details.
390 Chapter 11 Multinational Corporations
INVESTIGATING THE CAUSE OF
THE MIC LEAK
In the days following the gas leak, there was world-
wide interest in pinning down its precise cause. A
team of reporters from The New York Times inter-
viewed plant workers in Bhopal. Their six-week in-
vestigation concluded that a large volume of water
entered tank 610, causing the accident.f The Times re-
porters thought that water had entered when R. Khan
failed to use a slip blind as he washed out piping.
Water from his hose simply backed up and eventually
flowed about 400 feet into the tank. Their account was
widely circulated and this theory, called the "water
washing theory," gained currency. However, it was
not to be the only theory of the accident's cause.
Immediately after the disaster, Union Carbide also
rushed a team of investigators to Bhopal. But the
team got little cooperation from Indian authorities
operating in a climate of anti-Carbide popular pro-
test. It was denied access to plant records and work-
ers. Yet the investigators got to look at tank 610 and
took core samples from its bottom residue. These
samples went back to the United States, where more
than 500 experimental chemical reactions were un-
dertaken to explain their chemical composition. In
March 1985 Carbide finally released its report. It
stated that entry of water into the tank caused the gas
release, but it rejected the water washing theory.
Instead, Carbide scientists felt the only way that
an amount of water sufficient to cause the observed
reaction could have entered the tank was through ac-
cidental or deliberate connection of a water hose to
piping th.
A quality management system is only as effective as management’s ded.docxJospehStull43
A quality management system is only as effective as management’s dedication and insistence to adherence and accountability. Documentation and audit schedules aren’t enough. The system will only be as effective as the people in the organization and the investment in training, inspiring and leading employees as they take responsibility for the system’s operation and results.
The explosion of BP’s Deepwater Horizon rig on April 20th, 2010 ranks as the biggest manmade environmental disaster in US history. The explosion killed 11 on-board workers, and discharged 4 million barrels of oil into the Gulf of Mexico, before the leak was sealed on July 15th 2010. On top of widespread damage to Gulf marine wildlife and tourism industries, BP faced a slew of lawsuits, and forked out over $4.5 billion in fines and payments.
The overarching cause was a quality management failure. Contractors did not test the weak cement around the oil well, which failed to contain hydrocarbons within the reservoir and allowed flammable gas and liquids to flow up the production casing. Technicians misinterpreted fluid pressure tests, and gas passed through the ventilation system into the engine room, paving the way for ignition. After the explosion, the oil rig’s blow-out preventer located on the sea-bed failed to activate and seal the well.
Three corporations were implicated: BP for the flawed well design, Transocean as the owners of the rig, and Halliburton as the contractor who provided the bungled cements.
Question.
1. How will you ensure an efficient and effective quality management processes and procedures in you projects If you were working at BP. Relate all submissions to the case.
Please sight your sources of information. You are not to copy and paste from your sources. Provide your own thoughts based off your sources.
.
The document provides statistics on OVID inspections conducted in March and April 2014, including the number of vessels inspected and operators accredited. It also announces that the Maritime and Port Authority of Singapore has joined OVID and describes a recent accident involving pressure in a mud tank, highlighting the importance of change management and risk assessment procedures. The top 10 most frequent findings from OVID inspections over the past 12 months are also listed.
Lessons Learnt from Root Cause Analysis of Gulf.pptxq46bcx2y5j
BP oil spill
It is about the the oil spill happened in gulf of mexico.
Till date it is considered as one of the worst disaster in oil and gas industry.
What could have done to avoid this incident also is shown in the ppt.
What went wrong is also discussed.
The document summarizes the proceedings from the 5th US/German Workshop on Salt Repository Research, Design and Operation, which covered topics such as operational safety lessons from the WIPP incident, remaining geomechanics issues, the potential role of an underground research laboratory, and methods for characterizing the early evolution of salt excavations. Collaboration between US and German researchers on developing a safety case for disposing of heat-generating nuclear waste in salt formations was also discussed.
The document summarizes work done to further develop an existing remotely operated vehicle (ROV) over two academic years. In the first year, several issues prevented a full system test, including water ingress into hulls housing electronics and an incomplete control program. In the second year, the group resolved these outstanding issues by replacing cable glands, O-rings, batteries, and controllers, and rewriting the control program. They then performed a full system test in a pool to validate the ROV's waterproofing and control system functionality before beginning further modifications to achieve the project goals of sampling and sensor deployment.
Three key points from the document:
1. Two maintenance mechanics were fatally injured in a combustible dust flash fire caused by failure to follow lockout/tagout procedures when restarting a bucket elevator during maintenance. The elevator restarted, lofting iron dust into the air and igniting it.
2. Bucket elevators present risks of combustible dust fires and explosions if proper safety procedures are not followed during inspection, cleaning and maintenance when dust can be dispersed. Lockout/tagout procedures must address explosive atmosphere hazards.
3. Existing OSHA regulations do not have a specific combustible dust standard, relying instead on NFPA standards which do not provide clear guidance on identifying combustible dust fire
- On November 25, 1998, a fire at an Equilon Enterprises oil refinery delayed coking unit killed six people after a power outage caused abnormal process conditions in one of the coke drums.
- After the power was restored, operators attempted to empty the partially filled coke drum. They decided to open the vessel after injecting some steam based on the outside of the drum appearing cool to the touch. However, the core contents were still hot, causing flammable vapors to ignite upon opening and kill six people.
- The incident showed the need for management of change policies to cover abnormal situations and deviations from standard operating procedures to systematically review risks introduced by non-routine operations.
390 Chapter 11 Multinational Corporations
INVESTIGATING THE CAUSE OF
THE MIC LEAK
In the days following the gas leak, there was world-
wide interest in pinning down its precise cause. A
team of reporters from The New York Times inter-
viewed plant workers in Bhopal. Their six-week in-
vestigation concluded that a large volume of water
entered tank 610, causing the accident.f The Times re-
porters thought that water had entered when R. Khan
failed to use a slip blind as he washed out piping.
Water from his hose simply backed up and eventually
flowed about 400 feet into the tank. Their account was
widely circulated and this theory, called the "water
washing theory," gained currency. However, it was
not to be the only theory of the accident's cause.
Immediately after the disaster, Union Carbide also
rushed a team of investigators to Bhopal. But the
team got little cooperation from Indian authorities
operating in a climate of anti-Carbide popular pro-
test. It was denied access to plant records and work-
ers. Yet the investigators got to look at tank 610 and
took core samples from its bottom residue. These
samples went back to the United States, where more
than 500 experimental chemical reactions were un-
dertaken to explain their chemical composition. In
March 1985 Carbide finally released its report. It
stated that entry of water into the tank caused the gas
release, but it rejected the water washing theory.
Instead, Carbide scientists felt the only way that
an amount of water sufficient to cause the observed
reaction could have entered the tank was through ac-
cidental or deliberate connection of a water hose to
piping that led directly into the tank. This was possi-
ble because outlets for compressed air, nitrogen,
steam, and water were stationed throughout the
plant. The investigators rejected the water washing
hypothesis for several reasons. The piping system
was designed to prevent water contamination even
without a slip blind. Valves between the piping being
washed and tank 610 were found closed after the
8 The team wrote a series of articles. SeeStuart Diamond,
"The Bhopal Disaster: How It Happened," The New York
Times, January 28, 1985; Thomas J. Lueck, "Carbide Says
Inquiry Showed Errorsbut IsIncomplete," TheNew York Times,
January 28, 1985; Stuart Diamond, "The Disaster in Bhopal:
Workers Recall Horror," The New York Times,January 3D,
1985; and Robert Reinhold, "Disaster in Bhopal: Where
Does Blame Lie?" The New York Times, January 31, 1985.
accident. And the volume of water required to create
the reaction-l,OOO to 2,000 pounds-was far too
much to be explained by valve leakage.
The Carbide report gave a plausible alternative to
the water washing theory, but within months an in-
vestigation by the Indian government rejected it. This
study, made by Indian scientists and engineers, con-
firmed that the entry of water into the MlC tank
caused the reaction but concluded that the improper
washing procedure was to blame (see Exhibit 3).
Fishbone Diagram
EQUIPMENT
Responsibility
Housekeeping
Supervision
Preventative Maintenance
Age
Work Orders
Spill cleanup
Communication
Maintenance
ENVIRONMENT
PEOPLE
PROCEDURES
POLICIES
BOB FALLS AND BREAKS LEG
Running head- BARRIER ANALYSIS 1
BARRIER ANALYSIS 5
Barrier Analysis
Student’s Name
Institutional Affiliation
Type of Barrier
Function of Barrier
Performance of Barrier
FAILED
1. Existing tank’s liquid withdrawal valve
Control out flow of liquid propane gas
The valve completely failed in its function
NOT USED
1. Formal training of the technician
2. Supervision of junior technician
3. Training of emergency responders
4. placement of the 500-gallon propane tank
5. Evacuation of the area
Junior technician should have identified the fault in the liquid withdrawal valve
Guide the junior technician on procedure of transferring liquid propane gas to another tank
Handling the problem uniquely as propane gas leakage
Prevent leaking gas from entering the store through structural openings
Keep people from harm’s way
No formal training exhibited by the junior technician
Supervision provided over the phone was lacking adequate guidance
Need for evacuation was realized but not keenly implemented
The placement made it easy for propane gas to fill the store
DID NOT EXIST
1. Recognize the defect in the withdrawal valve
2. Refresher training for West Virginia fire fighters
3. Propane emergency training
4. Propane emergency guidance for 911 operators in the United States
Immediate fixing of the problem
Keep emergency responders up to date with new regulations dealing hazardous materials
Equip fire fighters with necessary skills in dealing with propane gas leakages
Give advice to the distress caller on way forward of dealing with the propane gas leakage
The defect was not recognized by the junior technician at all
the emergency responding captain had not attended training in a long time
being optional, none of the responding fire fighters had under taken this training
the 911 respondent gave no advice or guidance to the junior technician
Part 1
Part 2
The existing tank’s liquid withdrawal valve was leaking. When the junior technician pulled out the cap without checking for leaks first, the liquid propane gas was released into the atmosphere in excessive amounts. Exposed liquid propane gas is highly flammable and the tinniest hint of a flame was bound to cause an explosion.
The junior technician who was transferring the propane gas form one tank to another was reported to lack any formal training on the matter. While he should have been working under supervision, he was working on his own. Formal training in his part would have made him aware of the danger he was in once the liquid pro ...
Lee Walker is a British citizen seeking work as a rigger, slinger, banksman, or in an emergency response role. He has over 15 years of experience in offshore oil and gas and renewable energy projects. He possesses many safety and technical qualifications. His most recent roles have been as a rigger and emergency response team member on offshore wind farms. He is looking for as needed contract work and has references available.
The document summarizes five key facts about the recovery of US shale oil production:
1) Rig counts have increased by 90% since bottoming out in May 2016 and are up 30% year-over-year, signaling increased drilling and production capacity.
2) While decline rates remain steep, production profiles have increased substantially due to technological advances, meaning aggregate supply will be stronger.
3) Preliminary data shows that net new shale supply turned positive in December 2016 for the first time since March 2015, recovering just 7 months after rig counts increased.
4) Increased drilling activity is supported by a large stock of drilled but uncompleted wells, demonstrating the recovery and expansion of the shale sector.
5)
Quarterly legislative action update: Marcellus and Utica shale region (4Q16)Marcellus Drilling News
A quarterly update from the legal beagles at global law firm Norton Rose Fulbright. A quarterly legislative action update for the second quarter of 2016 looking at previously laws acted upon, and new laws introduced, affecting the oil and gas industry in Pennsylvania, Ohio and West Virginia.
An update from Spectra Energy on their proposed $3 billion project to connect four existing pipeline systems to flow more Marcellus/Utica gas to New England. In short, Spectra has put the project on pause until mid-2017 while it attempts to get new customers signed.
A letter from Rover Pipeline to the Federal Energy Regulatory Commission requesting the agency issue the final certificate that will allow Rover to begin tree-clearing and construction of the 511-mile pipeline through Pennsylvania, West Virginia, Ohio and Michigan. If the certificate is delayed beyond the end of 2016, it will delay the project an extra year due to tree-clearing restrictions (to accommodate federally-protected bats).
DOE Order Granting Elba Island LNG Right to Export to Non-FTA CountriesMarcellus Drilling News
An order issued by the U.S. Dept. of Energy that allows the Elba Island LNG export facility to export LNG to countries with no free trade agreement with the U.S. Countries like Japan and India have no FTA with our country (i.e. friendly countries)--so this is good news indeed. Although the facility would have operated by sending LNG to FTA countries, this order opens the market much wider.
A study released in December 2016 by the London School of Economics, titled "On the Comparative Advantage of U.S. Manufacturing: Evidence from the Shale Gas Revolution." While America has enough shale gas to export plenty of it, exporting it is not as economic as exporting oil due to the elaborate processes to liquefy and regassify natural gas--therefore a lot of the gas stays right here at home, making the U.S. one of (if not the) cheapest places on the planet to establish manufacturing plants, especially for manufacturers that use natural gas and NGLs (natural gas liquids). Therefore, manufacturing, especially in the petrochemical sector, is ramping back up in the U.S. For every two jobs created by fracking, another one job is created in the manufacturing sector.
Letter From 24 States Asking Trump & Congress to Withdraw the Unlawful Clean ...Marcellus Drilling News
A letter from the attorneys general from 24 of the states opposed to the Obama Clean Power Plan to President-Elect Trump, RINO Senate Majority Leader Mitch McConnel and RINO House Speaker Paul Ryan. The letter asks Trump to dump the CPP on Day One when he takes office, and asks Congress to adopt legislation to prevent the EPA from such an egregious overreach ever again.
More Related Content
Similar to PA DEP After Action Review of Chevron Lanco 7H Well Fire in Greene County, PA
The report summarizes an investigation by BP into the causes of the Deepwater Horizon oil rig explosion and spill. The investigation found that (1) the cement barrier installed to isolate hydrocarbons in the wellbore annulus failed, allowing hydrocarbons to enter the wellbore, and (2) the barriers in the shoe track where the production casing was installed also failed, allowing hydrocarbons to enter the casing. This caused a loss of well control and allowed hydrocarbons to ignite on the rig, resulting in explosions and fire. The BOP also failed to seal the well after the explosions.
2010 1367 granskningsrapport etter hendelse på draugen og varsel om pålegg - ...Faouzi BAAZIZ
The incident occurred during a wireline operation on the Draugen facility to replace a gas lift valve. As the subsurface safety valve was being pulled out of the well, it became stuck in the Xmas tree, blocking the upper swab valve and leaving only one barrier preventing hydrocarbon outflow from the well. After re-establishing additional well barriers, the investigation found issues with risk assessment, well barrier management, and inadequate contingency planning for equipment getting stuck that contributed to the incident. Improvements were identified regarding safety, expertise, well barrier documentation, and securing toolstrings.
An isolation failure occurred at a wastewater treatment plant while clearing a blockage in a sludge line. The isolation was discussed and identified points were isolated as planned, but when the blockage was removed, sludge exited the pipe, contacting a worker. Upon inspection, two valves had not been correctly isolated and were open instead of closed as required. Key lessons included ensuring the isolation method is properly planned and confirmed by all parties, allowing adequate time and resources for complex isolations without interruptions, and stopping to reassess if there are any issues or uncertainties with the isolation.
Spring 2014 MGMT 4322 INDIVIDUAL CASE GRADING RUBRIC E.docxrafbolet0
Spring 2014 MGMT 4322
INDIVIDUAL CASE GRADING RUBRIC
Ehsan Fakharizadi
Individual Case Assignment: TBA
PART I. Summary and Issue Identification (25 pts.)
1.a. (5 pts.) Write a summary of the case (approximately 100-150 words).
1.b. (20 pts.) Identifies (lists) the ethical issues that have arisen in this case. (about 100 words)
Explain in detail each ethical issue (e.g. what’s occurred, who’s affected, etc). (about 1-2 pages)
Number Question 1: Below Expectations 2: Meets Expectations 3: Exceeds Expectations Score
1.a. Summary The answer does not
adequately summarize
the case. (0 – 3.0)
The answer adequately
summarizes the case.
(3.5 – 4.0)
The answer fully and
concisely summarizes the
case. (4.5 – 5)
1.b. Identify an ethical
issue in a given
business situation
Fails to identify the
ethical issue(s) in a
given business
situation.
(0-14.0)
Identifies the ethical
issue(s) with a few
pertinent facts. (14.5-
17.5, C+ to B+)
Accurately identifies the
ethical issue(s) with all the
pertinent details. (18-20, A to
A+)
Additional
Feedback
1.a.
1.b.
Note: 1.b. is worth 20 points because identifying ethical issues is at the heart of this case. You should identify
several issues in this case and explain why these are ethical issues with all pertinent details.
390 Chapter 11 Multinational Corporations
INVESTIGATING THE CAUSE OF
THE MIC LEAK
In the days following the gas leak, there was world-
wide interest in pinning down its precise cause. A
team of reporters from The New York Times inter-
viewed plant workers in Bhopal. Their six-week in-
vestigation concluded that a large volume of water
entered tank 610, causing the accident.f The Times re-
porters thought that water had entered when R. Khan
failed to use a slip blind as he washed out piping.
Water from his hose simply backed up and eventually
flowed about 400 feet into the tank. Their account was
widely circulated and this theory, called the "water
washing theory," gained currency. However, it was
not to be the only theory of the accident's cause.
Immediately after the disaster, Union Carbide also
rushed a team of investigators to Bhopal. But the
team got little cooperation from Indian authorities
operating in a climate of anti-Carbide popular pro-
test. It was denied access to plant records and work-
ers. Yet the investigators got to look at tank 610 and
took core samples from its bottom residue. These
samples went back to the United States, where more
than 500 experimental chemical reactions were un-
dertaken to explain their chemical composition. In
March 1985 Carbide finally released its report. It
stated that entry of water into the tank caused the gas
release, but it rejected the water washing theory.
Instead, Carbide scientists felt the only way that
an amount of water sufficient to cause the observed
reaction could have entered the tank was through ac-
cidental or deliberate connection of a water hose to
piping th.
A quality management system is only as effective as management’s ded.docxJospehStull43
A quality management system is only as effective as management’s dedication and insistence to adherence and accountability. Documentation and audit schedules aren’t enough. The system will only be as effective as the people in the organization and the investment in training, inspiring and leading employees as they take responsibility for the system’s operation and results.
The explosion of BP’s Deepwater Horizon rig on April 20th, 2010 ranks as the biggest manmade environmental disaster in US history. The explosion killed 11 on-board workers, and discharged 4 million barrels of oil into the Gulf of Mexico, before the leak was sealed on July 15th 2010. On top of widespread damage to Gulf marine wildlife and tourism industries, BP faced a slew of lawsuits, and forked out over $4.5 billion in fines and payments.
The overarching cause was a quality management failure. Contractors did not test the weak cement around the oil well, which failed to contain hydrocarbons within the reservoir and allowed flammable gas and liquids to flow up the production casing. Technicians misinterpreted fluid pressure tests, and gas passed through the ventilation system into the engine room, paving the way for ignition. After the explosion, the oil rig’s blow-out preventer located on the sea-bed failed to activate and seal the well.
Three corporations were implicated: BP for the flawed well design, Transocean as the owners of the rig, and Halliburton as the contractor who provided the bungled cements.
Question.
1. How will you ensure an efficient and effective quality management processes and procedures in you projects If you were working at BP. Relate all submissions to the case.
Please sight your sources of information. You are not to copy and paste from your sources. Provide your own thoughts based off your sources.
.
The document provides statistics on OVID inspections conducted in March and April 2014, including the number of vessels inspected and operators accredited. It also announces that the Maritime and Port Authority of Singapore has joined OVID and describes a recent accident involving pressure in a mud tank, highlighting the importance of change management and risk assessment procedures. The top 10 most frequent findings from OVID inspections over the past 12 months are also listed.
Lessons Learnt from Root Cause Analysis of Gulf.pptxq46bcx2y5j
BP oil spill
It is about the the oil spill happened in gulf of mexico.
Till date it is considered as one of the worst disaster in oil and gas industry.
What could have done to avoid this incident also is shown in the ppt.
What went wrong is also discussed.
The document summarizes the proceedings from the 5th US/German Workshop on Salt Repository Research, Design and Operation, which covered topics such as operational safety lessons from the WIPP incident, remaining geomechanics issues, the potential role of an underground research laboratory, and methods for characterizing the early evolution of salt excavations. Collaboration between US and German researchers on developing a safety case for disposing of heat-generating nuclear waste in salt formations was also discussed.
The document summarizes work done to further develop an existing remotely operated vehicle (ROV) over two academic years. In the first year, several issues prevented a full system test, including water ingress into hulls housing electronics and an incomplete control program. In the second year, the group resolved these outstanding issues by replacing cable glands, O-rings, batteries, and controllers, and rewriting the control program. They then performed a full system test in a pool to validate the ROV's waterproofing and control system functionality before beginning further modifications to achieve the project goals of sampling and sensor deployment.
Three key points from the document:
1. Two maintenance mechanics were fatally injured in a combustible dust flash fire caused by failure to follow lockout/tagout procedures when restarting a bucket elevator during maintenance. The elevator restarted, lofting iron dust into the air and igniting it.
2. Bucket elevators present risks of combustible dust fires and explosions if proper safety procedures are not followed during inspection, cleaning and maintenance when dust can be dispersed. Lockout/tagout procedures must address explosive atmosphere hazards.
3. Existing OSHA regulations do not have a specific combustible dust standard, relying instead on NFPA standards which do not provide clear guidance on identifying combustible dust fire
- On November 25, 1998, a fire at an Equilon Enterprises oil refinery delayed coking unit killed six people after a power outage caused abnormal process conditions in one of the coke drums.
- After the power was restored, operators attempted to empty the partially filled coke drum. They decided to open the vessel after injecting some steam based on the outside of the drum appearing cool to the touch. However, the core contents were still hot, causing flammable vapors to ignite upon opening and kill six people.
- The incident showed the need for management of change policies to cover abnormal situations and deviations from standard operating procedures to systematically review risks introduced by non-routine operations.
390 Chapter 11 Multinational Corporations
INVESTIGATING THE CAUSE OF
THE MIC LEAK
In the days following the gas leak, there was world-
wide interest in pinning down its precise cause. A
team of reporters from The New York Times inter-
viewed plant workers in Bhopal. Their six-week in-
vestigation concluded that a large volume of water
entered tank 610, causing the accident.f The Times re-
porters thought that water had entered when R. Khan
failed to use a slip blind as he washed out piping.
Water from his hose simply backed up and eventually
flowed about 400 feet into the tank. Their account was
widely circulated and this theory, called the "water
washing theory," gained currency. However, it was
not to be the only theory of the accident's cause.
Immediately after the disaster, Union Carbide also
rushed a team of investigators to Bhopal. But the
team got little cooperation from Indian authorities
operating in a climate of anti-Carbide popular pro-
test. It was denied access to plant records and work-
ers. Yet the investigators got to look at tank 610 and
took core samples from its bottom residue. These
samples went back to the United States, where more
than 500 experimental chemical reactions were un-
dertaken to explain their chemical composition. In
March 1985 Carbide finally released its report. It
stated that entry of water into the tank caused the gas
release, but it rejected the water washing theory.
Instead, Carbide scientists felt the only way that
an amount of water sufficient to cause the observed
reaction could have entered the tank was through ac-
cidental or deliberate connection of a water hose to
piping that led directly into the tank. This was possi-
ble because outlets for compressed air, nitrogen,
steam, and water were stationed throughout the
plant. The investigators rejected the water washing
hypothesis for several reasons. The piping system
was designed to prevent water contamination even
without a slip blind. Valves between the piping being
washed and tank 610 were found closed after the
8 The team wrote a series of articles. SeeStuart Diamond,
"The Bhopal Disaster: How It Happened," The New York
Times, January 28, 1985; Thomas J. Lueck, "Carbide Says
Inquiry Showed Errorsbut IsIncomplete," TheNew York Times,
January 28, 1985; Stuart Diamond, "The Disaster in Bhopal:
Workers Recall Horror," The New York Times,January 3D,
1985; and Robert Reinhold, "Disaster in Bhopal: Where
Does Blame Lie?" The New York Times, January 31, 1985.
accident. And the volume of water required to create
the reaction-l,OOO to 2,000 pounds-was far too
much to be explained by valve leakage.
The Carbide report gave a plausible alternative to
the water washing theory, but within months an in-
vestigation by the Indian government rejected it. This
study, made by Indian scientists and engineers, con-
firmed that the entry of water into the MlC tank
caused the reaction but concluded that the improper
washing procedure was to blame (see Exhibit 3).
Fishbone Diagram
EQUIPMENT
Responsibility
Housekeeping
Supervision
Preventative Maintenance
Age
Work Orders
Spill cleanup
Communication
Maintenance
ENVIRONMENT
PEOPLE
PROCEDURES
POLICIES
BOB FALLS AND BREAKS LEG
Running head- BARRIER ANALYSIS 1
BARRIER ANALYSIS 5
Barrier Analysis
Student’s Name
Institutional Affiliation
Type of Barrier
Function of Barrier
Performance of Barrier
FAILED
1. Existing tank’s liquid withdrawal valve
Control out flow of liquid propane gas
The valve completely failed in its function
NOT USED
1. Formal training of the technician
2. Supervision of junior technician
3. Training of emergency responders
4. placement of the 500-gallon propane tank
5. Evacuation of the area
Junior technician should have identified the fault in the liquid withdrawal valve
Guide the junior technician on procedure of transferring liquid propane gas to another tank
Handling the problem uniquely as propane gas leakage
Prevent leaking gas from entering the store through structural openings
Keep people from harm’s way
No formal training exhibited by the junior technician
Supervision provided over the phone was lacking adequate guidance
Need for evacuation was realized but not keenly implemented
The placement made it easy for propane gas to fill the store
DID NOT EXIST
1. Recognize the defect in the withdrawal valve
2. Refresher training for West Virginia fire fighters
3. Propane emergency training
4. Propane emergency guidance for 911 operators in the United States
Immediate fixing of the problem
Keep emergency responders up to date with new regulations dealing hazardous materials
Equip fire fighters with necessary skills in dealing with propane gas leakages
Give advice to the distress caller on way forward of dealing with the propane gas leakage
The defect was not recognized by the junior technician at all
the emergency responding captain had not attended training in a long time
being optional, none of the responding fire fighters had under taken this training
the 911 respondent gave no advice or guidance to the junior technician
Part 1
Part 2
The existing tank’s liquid withdrawal valve was leaking. When the junior technician pulled out the cap without checking for leaks first, the liquid propane gas was released into the atmosphere in excessive amounts. Exposed liquid propane gas is highly flammable and the tinniest hint of a flame was bound to cause an explosion.
The junior technician who was transferring the propane gas form one tank to another was reported to lack any formal training on the matter. While he should have been working under supervision, he was working on his own. Formal training in his part would have made him aware of the danger he was in once the liquid pro ...
Lee Walker is a British citizen seeking work as a rigger, slinger, banksman, or in an emergency response role. He has over 15 years of experience in offshore oil and gas and renewable energy projects. He possesses many safety and technical qualifications. His most recent roles have been as a rigger and emergency response team member on offshore wind farms. He is looking for as needed contract work and has references available.
Similar to PA DEP After Action Review of Chevron Lanco 7H Well Fire in Greene County, PA (15)
The document summarizes five key facts about the recovery of US shale oil production:
1) Rig counts have increased by 90% since bottoming out in May 2016 and are up 30% year-over-year, signaling increased drilling and production capacity.
2) While decline rates remain steep, production profiles have increased substantially due to technological advances, meaning aggregate supply will be stronger.
3) Preliminary data shows that net new shale supply turned positive in December 2016 for the first time since March 2015, recovering just 7 months after rig counts increased.
4) Increased drilling activity is supported by a large stock of drilled but uncompleted wells, demonstrating the recovery and expansion of the shale sector.
5)
Quarterly legislative action update: Marcellus and Utica shale region (4Q16)Marcellus Drilling News
A quarterly update from the legal beagles at global law firm Norton Rose Fulbright. A quarterly legislative action update for the second quarter of 2016 looking at previously laws acted upon, and new laws introduced, affecting the oil and gas industry in Pennsylvania, Ohio and West Virginia.
An update from Spectra Energy on their proposed $3 billion project to connect four existing pipeline systems to flow more Marcellus/Utica gas to New England. In short, Spectra has put the project on pause until mid-2017 while it attempts to get new customers signed.
A letter from Rover Pipeline to the Federal Energy Regulatory Commission requesting the agency issue the final certificate that will allow Rover to begin tree-clearing and construction of the 511-mile pipeline through Pennsylvania, West Virginia, Ohio and Michigan. If the certificate is delayed beyond the end of 2016, it will delay the project an extra year due to tree-clearing restrictions (to accommodate federally-protected bats).
DOE Order Granting Elba Island LNG Right to Export to Non-FTA CountriesMarcellus Drilling News
An order issued by the U.S. Dept. of Energy that allows the Elba Island LNG export facility to export LNG to countries with no free trade agreement with the U.S. Countries like Japan and India have no FTA with our country (i.e. friendly countries)--so this is good news indeed. Although the facility would have operated by sending LNG to FTA countries, this order opens the market much wider.
A study released in December 2016 by the London School of Economics, titled "On the Comparative Advantage of U.S. Manufacturing: Evidence from the Shale Gas Revolution." While America has enough shale gas to export plenty of it, exporting it is not as economic as exporting oil due to the elaborate processes to liquefy and regassify natural gas--therefore a lot of the gas stays right here at home, making the U.S. one of (if not the) cheapest places on the planet to establish manufacturing plants, especially for manufacturers that use natural gas and NGLs (natural gas liquids). Therefore, manufacturing, especially in the petrochemical sector, is ramping back up in the U.S. For every two jobs created by fracking, another one job is created in the manufacturing sector.
Letter From 24 States Asking Trump & Congress to Withdraw the Unlawful Clean ...Marcellus Drilling News
A letter from the attorneys general from 24 of the states opposed to the Obama Clean Power Plan to President-Elect Trump, RINO Senate Majority Leader Mitch McConnel and RINO House Speaker Paul Ryan. The letter asks Trump to dump the CPP on Day One when he takes office, and asks Congress to adopt legislation to prevent the EPA from such an egregious overreach ever again.
Report: New U.S. Power Costs: by County, with Environmental ExternalitiesMarcellus Drilling News
Natural gas and wind are the lowest-cost technology options for new electricity generation across much of the U.S. when cost, public health impacts and environmental effects are considered. So says this new research paper released by The University of Texas at Austin. Researchers assessed multiple generation technologies including coal, natural gas, solar, wind and nuclear. Their findings are depicted in a series of maps illustrating the cost of each generation technology on a county-by-county basis throughout the U.S.
Annual report issued by the U.S. Energy Information Administration showing oil and natural gas proved reserves, in this case for 2015. These reports are issued almost a year after the period for which they report. This report shows proved reserves for natural gas dropped by 64.5 trillion cubic feet (Tcf), or 16.6%. U.S. crude oil and lease condensate proved reserves also decreased--from 39.9 billion barrels to 35.2 billion barrels (down 11.8%) in 2015. Proved reserves are calculated on a number of factors, including price.
The document is a report from the U.S. Energy Information Administration analyzing oil and gas production from seven regions in the U.S. It includes charts and tables showing historical and projected production levels of oil and gas from each region from 2008 to 2017, as well as metrics like the average production per rig. The regions - Bakken, Eagle Ford, Haynesville, Marcellus, Niobrara, Permian, and Utica - accounted for 92% of domestic oil production growth and all domestic natural gas production growth from 2011-2014.
Velocys is the manufacturer of gas-to-liquids (GTL) plants that convert natural gas (a hyrdocarbon) into other hydrocarbons, like diesel fuel, gasoline, and even waxes. This PowerPoint presentation lays out the Velocys plan to get the company growing. GTL plants have not (so far) taken off in the U.S. Velocys hopes to change that. They specialize in small GTL plants.
PA DEP Revised Permit for Natural Gas Compression Stations, Processing Plants...Marcellus Drilling News
In January 2016, Gov. Wolf announced the DEP would revise its current general permit (GP-5) to update the permitting requirements for sources at natural gas compression, processing, and transmission facilities. This is the revised GP-5.
PA DEP Permit for Unconventional NatGas Well Site Operations and Remote Piggi...Marcellus Drilling News
In January 2016, PA Gov. Wolf announced the Dept. of Environmental Protection would develop a general permit for sources at new or modified unconventional well sites and remote pigging stations (GP-5A). This is the proposed permit.
Onerous new regulations for the Pennsylvania Marcellus Shale industry proposed by the state Dept. of Environmental Protection. The new regs will, according to the DEP, help PA reduce so-called fugitive methane emissions and some types of air pollution (VOCs). This is liberal Gov. Tom Wolf's way of addressing mythical man-made global warming.
The monthly Short-Term Energy Outlook (STEO) from the U.S. Energy Information Administration for December 2016. This issue makes a couple of key points re natural gas: (1) EIA predicts that natural gas production in the U.S. for 2016 will see a healthy decline over 2015 levels--1.3 billion cubic feet per day (Bcf/d) less in 2016. That's the first annual production decline since 2005! (2) The EIA predicts the average price for natural gas at the benchmark Henry Hub will climb from $2.49/Mcf (thousand cubic feet) in 2016 to a whopping $3.27/Mcf in 2017. Why the jump? Growing domestic natural gas consumption, along with higher pipeline exports to Mexico and liquefied natural gas exports.
This document provides an overview of the natural gas market in the Northeast United States, including New England, New York, New Jersey, and Pennsylvania. It details statistics on gas customers, consumption, infrastructure like pipelines and storage, and production. A key point is that the development of the Marcellus Shale in Pennsylvania has significantly increased domestic gas production in the region and reduced its reliance on other supply basins and imports.
The Pennsylvania Public Utility Commission responded to each point raised in a draft copy of the PA Auditor General's audit of how Act 13 impact fee money, raised from Marcellus Shale drillers, gets spent by local municipalities. The PUC says it's not their job to monitor how the money gets spent, only in how much is raised and distributed.
Pennsylvania Public Utility Commission Act 13/Impact Fees Audit by PA Auditor...Marcellus Drilling News
A biased look at how 60% of impact fees raised from PA's shale drilling are spent, by the anti-drilling PA Auditor General. He chose to ignore an audit of 40% of the impact fees, which go to Harrisburg and disappear into the black hole of Harrisburg spending. The Auditor General claims, without basis in fact, that up to 24% of the funds are spent on items not allowed under the Act 13 law.
The final report from the Pennsylvania Dept. of Environmental Protection that finds, after several years of testing, no elevated levels of radiation from acid mine drainage coming from the Clyde Mine, flowing into Ten Mile Creek. Radical anti-drillers tried to smear the Marcellus industry with false claims of illegal wastewater dumping into the mine, with further claims of elevated radiation levels in the creek. After years of testing, the DEP found those allegations to be false.
FERC Order Denying Stay of Kinder Morgan's Broad Run Expansion ProjectMarcellus Drilling News
The Federal Energy Regulatory Commission denied a request to stay the authorization of Tennessee Gas Pipeline Company's Broad Run Expansion Project. The Commission found that the intervenors requesting the stay did not demonstrate they would suffer irreparable harm if the project proceeded. Specifically, the Commission determined that the environmental impacts to forest and a nearby animal rehabilitation center would be insignificant. Additionally, conditioning authorization on future permits did not improperly encroach on state authority. Therefore, justice did not require granting a stay.
13062024_First India Newspaper Jaipur.pdfFIRST INDIA
Find Latest India News and Breaking News these days from India on Politics, Business, Entertainment, Technology, Sports, Lifestyle and Coronavirus News in India and the world over that you can't miss. For real time update Visit our social media handle. Read First India NewsPaper in your morning replace. Visit First India.
CLICK:- https://firstindia.co.in/
#First_India_NewsPaper
Shark Tank Jargon | Operational ProfitabilityTheUnitedIndian
Don't let fancy business words confuse you! This blog is your cheat sheet to understanding the Shark Tank Jargon. We'll translate all the confusing terms like "valuation" (how much the company is worth) and "royalty" (a fee for using someone's idea). You'll be swimming with the Sharks like a pro in no time!
लालू यादव की जीवनी LALU PRASAD YADAV BIOGRAPHYVoterMood
Discover the life and times of Lalu Prasad Yadav with a comprehensive biography in Hindi. Learn about his early days, rise in politics, controversies, and contribution.
projet de traité négocié à Istanbul (anglais).pdfEdouardHusson
Ceci est le projet de traité qui avait été négocié entre Russes et Ukrainiens à Istanbul en mars 2022, avant que les Etats-Unis et la Grande-Bretagne ne détournent Kiev de signer.
Why We Chose ScyllaDB over DynamoDB for "User Watch Status"ScyllaDB
Yichen Wei and Adam Drennan share the architecture and technical requirements behind "user watch status" for a major global media streaming service, what that meant for their database, the pros and cons of the many options they considered for replacing DynamoDB, why they ultimately chose ScyllaDB, and their lessons learned so far.
19 जून को बॉम्बे हाई कोर्ट ने विवादित फिल्म ‘हमारे बारह’ को 21 जून को थिएटर में रिलीज करने का रास्ता साफ कर दिया, हालांकि यह सुनिश्चित करने के बाद कि फिल्म निर्माता कुछ आपत्तिजनक अंशों को हटा दें।
15062024_First India Newspaper Jaipur.pdfFIRST INDIA
Find Latest India News and Breaking News these days from India on Politics, Business, Entertainment, Technology, Sports, Lifestyle and Coronavirus News in India and the world over that you can't miss. For real time update Visit our social media handle. Read First India NewsPaper in your morning replace. Visit First India.
CLICK:- https://firstindia.co.in/
#First_India_NewsPaper
16062024_First India Newspaper Jaipur.pdfFIRST INDIA
Find Latest India News and Breaking News these days from India on Politics, Business, Entertainment, Technology, Sports, Lifestyle and Coronavirus News in India and the world over that you can't miss. For real time update Visit our social media handle. Read First India NewsPaper in your morning replace. Visit First India.
CLICK:- https://firstindia.co.in/
#First_India_NewsPaper
18062024_First India Newspaper Jaipur.pdfFIRST INDIA
Find Latest India News and Breaking News these days from India on Politics, Business, Entertainment, Technology, Sports, Lifestyle and Coronavirus News in India and the world over that you can't miss. For real time update Visit our social media handle. Read First India NewsPaper in your morning replace. Visit First India.
CLICK:- https://firstindia.co.in/
#First_India_NewsPaper
Slide deck with charts from our Digital News Report 2024, the most comprehensive exploration of news consumption habits around the world, based on survey data from more than 95,000 respondents across 47 countries.
विवादास्पद फिल्म के ट्रेलर से गाली-गलौज वाले दृश्य हटा दिए गए हैं, और जुर्माना लगाया गया है। सुप्रीम कोर्ट और बॉम्बे हाई कोर्ट दोनों ने फिल्म की रिलीज पर रोक लगा दी है और उसे निलंबित कर दिया है। पहले यह फिल्म 7 जून और फिर 14 जून को रिलीज होने वाली थी, लेकिन अब यह 21 जून को रिलीज हो रही है।
केरल उच्च न्यायालय ने 11 जून, 2024 को मंडला पूजा में भाग लेने की अनुमति मांगने वाली 10 वर्षीय लड़की की रिट याचिका को खारिज कर दिया, जिसमें सर्वोच्च न्यायालय की एक बड़ी पीठ के समक्ष इस मुद्दे की लंबित प्रकृति पर जोर दिया गया। यह आदेश न्यायमूर्ति अनिल के. नरेंद्रन और न्यायमूर्ति हरिशंकर वी. मेनन की खंडपीठ द्वारा पारित किया गया
Christian persecution in Islamic countries has intensified, with alarming incidents of violence, discrimination, and intolerance. This article highlights recent attacks in Nigeria, Pakistan, Egypt, Iran, and Iraq, exposing the multifaceted challenges faced by Christian communities. Despite the severity of these atrocities, the Western world's response remains muted due to political, economic, and social considerations. The urgent need for international intervention is underscored, emphasizing that without substantial support, the future of Christianity in these regions is at grave risk.
https://ecspe.org/the-rise-of-christian-persecution-in-islamic-countries/
The Rise of Christian Persecution In Islamic Countries
PA DEP After Action Review of Chevron Lanco 7H Well Fire in Greene County, PA
1. 1
SUMMARY OF BUREAU OF INVESTIGATIONS
INFORMATION GATHERING EFFORTS
CHEVRON LANCO PAD A GAS WELL FIRE
Introduction.
The Bureau of Investigations (BOI) was tasked with gathering information related to the
February 11, 2014 gas well fire at Chevron Appalachia, LLC’s (“Chevron”) Lanco A Pad.
Through interviews, document review, physical evidence examination and other sources BOI has
documented circumstances which may have contributed to the February 11, 2014 accident.
The BOI is an investigatory unit housed within the Department of Environmental Protection’s
(DEP’s) Office of Chief Counsel (OCC). BOI is primarily a fact finding resource. BOI
investigations, like this one, are closely coordinated with assigned counsel from OCC. BOI was
engaged to investigate the events related to this matter on or about February 14, 2014.
Background Overview.
Chevron is the owner of the Lanco A pad located in Dunkard Township, Greene County. It is
also the permittee and operator of three gas wells located on the pad, Wells 6H, 7H and 8H
(Permit Nos. 37-059-25887, 37-059-25888, 27-059-25889). Each of these wells had been
drilled, fracked and shut in. None of the wells had produced gas. In early February 2014,
Chevron commenced activities to bring the wells into production. Specifically, the company
made arrangements with various contractors to install “production tubing” in each well. The
purpose of production tubing is to remove water from the well.
The first task in this process was removing the tubing hanger. This job that was performed by
employees of Cameron International Corporation (“Cameron”). Cameron also manufactured the
well heads. After the tubing hangers were removed, workers from other contractors
(Schlumberger Oil Field Services (“Schlumberger”), Key Energy Services and Baker Hughes)
attempted to determine that the well bores were clear of obstruction so that a packer could be
installed at 5,000 feet depth. However, “hydrates,” frozen hydrocarbons, formed in the wells,
which created obstructions. In Well 7H a tool, called a guide ring, became stuck 7 feet below
ground surface. Several heating methods were used to dislodge it (heated glycol, heated brine
and blowing heated air on the well). On February 10, the guide ring was freed from Well 7H. A
gouge was observed on the ring.
On February 11, 2014, prior to the daily “safety meeting,” Well 7H began to leak gas and the gas
ignited. Several ignition sources existed on the pad, including a Rapid Hot truck, which was
heating brine, and heated air blowers. When Well 7H began to leak gas a Cameron employee
ran toward the well, and died in the fire. A Key Energy Service employee who was also on the
pad as Well 7H began to emit gas, was rescued from his vehicle and survived. Subsequently,
Well 6H also burned. The fires were extinguished by February 15, 2014. By February 23, 2014
all three wells had been capped.
2. 2
Lanco fire.
One lock pin assembly (“lock pin”) was ejected from the Tubing Spool Assembly (TSA), a part
of the well head on Well 7H, on the morning of February 11, 2014. The ejection of this lock pin
created a hole that allowed gas to escape from the well. The gas was ignited by some ignition
source. The lock pins are used to hold the tubing hanger in place. These pins were manipulated
several days earlier when tubing hangers were removed from all three wells. The lock pin has
two threaded parts, a pin, which penetrates into the well bore and holds the tubing hanger, and a
gland nut, which connects to a hole in the well head.
No mechanical cause for the lock pin ejection was identified by the investigation. The ejected
lock pin was found after the fire was extinguished. An examination of the pin by Chevron’s
consultant, Stress Engineering Services, Inc., of Houston, TX, showed that the threads on the
gland nut portion of the lock pin had not been damaged.
Cameron informed BOI that the TSA, including lock pins, was tested to 1.5 times its rated
capacity at one of its American Petroleum Institute (API) certified manufacturing facilities. The
TSA was shipped as a unit to Pennsylvania and installed as a unit on Well 7H.
BOI Investigation.
Upon being engaged to investigate events surrounding this accident, BOI personnel immediately
went to the vicinity of the Lanco well site. All told, BOI interviewed 35 persons. BOI also
obtained and reviewed documents, including photographs, logs, manuals and policies, primarily
from Chevron and Cameron. In addition, BOI personnel observed the well heads involved and
similar unaffected equipment, and performed research into entities and issues related to this
matter.
BOI was tasked with gathering facts and information related to the incident. It was not tasked
with determining the root-cause(s) of the accident or making inferences about the root cause.
The purpose of this Report is to identify circumstances that may be relevant to the accident.
Observations.
A. Chevron Well Site Managers.
Most of the workers on the Lanco A site were not Chevron employees. Rather, they were
employed by various contractors who provide specific services to Chevron. The activities of
these contractors are overseen by Chevron’s Well Site Managers (WSM). WSMs are Chevron’s
representatives on site, and are generally Chevron employees, though some are employed by
third parties, who provide these services to Chevron. The WSM is critical to the smooth
functioning of the job site and to the successful completion of tasks. Among other things, WSMs
oversee the work of contractors, conduct safety meetings, evaluate contractor employees
3. 3
(particularly, inexperienced ones), scheduling contractors’ work, communicating with upper
management about problems encountered, procuring equipment, and otherwise fostering
operations. In addition, WSM’s are required to document activities using Chevron’s database,
Wellview.
Interviews suggested that WSMs did not provide the desired oversight at Lanco A:
1. Experience. WSM’s possess a wide variation in experience and training. Some
of the WSMs had decades of experience in the oil fields. However, others had
virtually no background in the oil and gas industry. They worked, for example, in
information technology, food service, or as a construction laborer. Having limited
oil field experience reduces effectiveness of the oversight a WSM can provide.
2. Oversight. The level of contractor oversight provided by WSM’s is not
consistent. Some WSM’s regard close oversight of contractors as their duty.
Others considered occasional “checking in” with contractors to be sufficient.
Some WSMs viewed the contractors as the pros and believed that it was not their
job to tell the contractors what to do. The amount of attention to the tasks
becomes more important, when inexperienced workers are handling potentially
critical components. At least one WSM was described as spending most of his
time in a trailer while work was performed by contractors elsewhere on the well
site. Because of the limited oversight of contractors it is impossible to determine
how the lock pins on the Well 7H TSA were manipulated and if anyone other than
Cameron employees manipulated them. For example, another contractor,
Schlumberger, worked on the well using a gauge-ring, following Cameron’s work
on the tubing spool assembly. It is possible that actions taken during the course of
this work affected the condition of the Well 7H’s lock pin assembly. However,
the specific time-spent on the well-site and at the wellhead by each of the multiple
contractors through February 10, 2014, as well as the WSM’s review of each
contractor’s work, is not documented with specificity.
3. Workload. Several well site managers expressed some frustration about the
demands on their time. Several stated that documentation and paperwork took an
inordinate amount of time. Another WSM said that he was preoccupied making
calls to obtain equipment or trying to determine the whereabouts of delayed
equipment and personnel. One WSM stated that observing all of the contractors
working on site to be daunting task, though one former WSM found the challenge
manageable. Workload and distractions may explain why a contractor’s
employee with no well-site experience was allowed to work on a pressurized well
even though he was not approved for any work, as required by Chevron policy.
4. Lack of Continuity. In the time period leading up to the February 11, 2014
accident, WSMs assigned to Lanco A changed frequently. It appears that no
fewer than seven persons served as WSM during the period of interest (February
4. 4
4, 2014 - February 11, 2014). WSMs were being shuttled in an out of this Site
where three wells were being prepared for production, significant problems were
being encountered, and the weather was bitterly cold. It is unclear if “hand off”
procedures were followed or if incoming WSMs familiarized themselves
adequately with the job. Chevron only provided one set of “handover notes” in
response to BOI’s request, even though multiple “handovers” occurred. In
addition, there are not specific handover procedures with regard to
SSE/“greenhat” personnel onsite.
B. Inexperienced Worker.
Two Cameron employees reported to Lanco A to remove the tubing hangers from the TSA
portions of the wellheads. One employee was an experienced technician (3 years field work)
However, the other was an inexperienced worker or “greenhat.” The experienced worker asked
for help to pull the tubing hangers at Lanco A. Cameron’s dispatcher sent the “greenhat”
because no one else was available.
1. Short Service Employee Policy. Chevron employs a Short Service Employee
(SSE) policy. Under the policy any worker with less than 6 months experience
must be approved by the WSM (along with identified protective measures).
When the ratio of inexperienced workers to experienced workers is high Chevron
upper management must approve SSE workers. At Lanco A, the inexperienced
worker’s SSE Form was never reviewed by Chevron or approved by Chevron and
remains unsigned. Chevron’s Wellview system does not identify an
inexperienced worker for Cameron for this time-period.
2. Absence of specific limits on “greenhat” work. When the “greenhat” was
dispatched to go to Lanco, he was not advised of any limitation on his work. The
only instruction was to do what his mentor (experienced worker) told him to do.
The “greenhat” was directed by the more experienced worker to back out lock
pins from the TSAs on Wells 6H, 7H and 8H to allow the experienced worker to
remove the tubing hanger. One of the lock pins manipulated was ejected from the
7H Well several days later, allowing gas to discharge from the well and ignite. It
is unknown if anyone else subsequently manipulated any of the lock pins.
Individuals asked uniformly agreed that a worker with no field experience and
limited shop experience should not use any tools on a pressurized well. Such
employees should watch and provide support, like getting tools for an experienced
worker.
3. Inadequate supervision. The “greenhat” was not supervised closely as he
manipulated the lock pins. The “greenhat” had not been trained on this
procedure, or any other well procedure.
5. 5
The experienced worker observed the “greenhat” from a “manbasket,” a platform
attached to a hydraulic lift. He was elevated above the “greenhat” and observed
the “greenhat’s” work from this location. The experienced worker could not see
the “greenhat” at all times. He was not observing the work at the “greenhat’s”
shoulder as several persons stated is the proper procedure.
Chevron’s WSM also did not oversee the “greenhat.” The WSM “checked-in”
occasionally, but spent most of his time in the trailer attending to paperwork or
other matters.
4. Unfamiliarity with specifications. The “greenhat” had not been trained on the
techniques for manipulating the lock pins, nor was he familiar with torque specs
for the pin or gland nut parts of the lock pins. His mentor from Cameron was also
not aware of torque specifications for lock pins. A Cameron manual from the
year 2000 includes torque specs for gland nuts and lock pins. Subsequent to
February 11, 2014, Cameron provided the experienced worker with torque
specifications.
ALATex-Bossier Drilling reported that a lockdown pin was ejected from a well in
December 2008.
(http://www.4cornerssafety.com/uploads/8MZBSk6epQIV3Je0Eqw3TCO04t0aIe
XV.pdf, last visited 7/9/14) It was determined that the lock pin was fully “backed
out;” no threads on the gland nut portion of the ejected lock pin were engaged into
the well. In this incident, the workers were not aware of procedures and
specifications for manipulating the lock pins.
C. Accounting for Risk.
The tubing installation procedure chosen for the Lanco A wells required working on pressurized
wells. This work can apparently be performed on pressurized wells safely if adequate attention
and care is exercised. However, the practices noted here, such as allowing inexperienced
workers to manipulate pins and gland-nuts on the pressurized wells with limited supervision by
co-workers or WSMs increase the safety risk.
D. Completion Delay.
The completion of tubing installation on Wells 6H, 7H and 8H was delayed by several days
because of condensate (frozen hydrocarbon) obstructions in the wells. Thus, for several days the
wells were pressurized awaiting completion, after removal of the tubing hangers. The absence of
torqued-down tubing hangers increased the risk that loss of one of the eight lock pins could have
caused a release of gas and a fire.
6. 6
The wellhead manufacturer told BOI that the tubing hanger is designed to create a seal between
the outer surface of the tubing hanger and the inner surface of the wellhead. (The tubing hanger
is a tapered machined steel part). In addition, the company asserted that removal of a single lock
pin would not compromise this seal. Gas migration through the center of the hanger is prevented
by a back-pressure valve, prior to completion, and by the production tubing apparatus after
completion. Thus, it appears that if the tubing hanger were in place and held by seven properly
torqued lock pins, even if the eighth hole were open it might not have been available as a conduit
for gas to discharge to the atmosphere.
Conclusion.
This summary offers factual circumstances that may bear upon more complete evaluation of the
Lanco A Well Fire and its cause(s). BOI does not represent that any circumstances reported
above necessarily caused or contributed to the fire’s causation. Rather, these observations have
been shared because they may be germane to evaluating the cause of the fire and crafting future
preventative measures.