Learning from Real Incidents

This is an excellent story shared by our Head of Simulation, ​Jan Tore Knutsen, ​from a client’s recent experience, showing how training can identify (and fix) weaknesses in both procedures and ways of operating.​

Download the Case Study in PDF here.

In 2015, a client began drilling with Managed Pressure Drilling (MPD) operations on their platform. The client had only experienced one well control incident in MPD mode, which resulted in an influx that was circulated out in a controlled manner. The incident was caused by human error, and the investigation concluded that the well could have been shut in earlier than it was. This incident highlighted weaknesses in the MPD procedures and the MPD system, which needed to be addressed to prevent future incidents.

Purpose:

The purpose of this case study is to demonstrate the importance of learning from real incidents and the need for proper training to be prepared for potential accidents. The study aimed to test if the well could have been shut in earlier by programming the same sequence of events as the incident in Maersk Training’s drilling simulator. The study also aimed to determine the effectiveness of the revised MPD procedures in preventing similar incidents from occurring in the future.

Methodology:

To test the revised MPD procedures, the client programmed the same sequence of events as the incident in Maersk Training’s drilling simulator. The next MPD well on the platform was located in the same area as the well that kicked, with the potential for flow in the same formation. The drilling crews were induced with the same sequence of events as in the incident, and the MPD procedures were essentially the same as at the time of the event.

Outcomes / Results:

Running the scenario in the simulator revealed that five out of six crews acted the same way as on the live well and shut in the well too late to avoid an influx. This proved that it could happen to anyone and that the real cause of the incident was weaknesses in the MPD procedures and the MPD system. The incident underscored the importance of learning from real incidents and the need for proper training to be prepared for potential accidents.

Conclusion:

This case study demonstrates the importance of learning from real incidents and the need for proper training to be prepared for potential accidents. The use of simulators in training is one effective way to prepare crews for potential incidents and minimize the risk of future accidents. By learning from this incident and making necessary changes, the industry can continue to make progress towards a safer and more sustainable future. The MPD procedures have now been revised and will be implemented for the next MPD operation. All crews have been given good information about the well incident and are prepared for drilling the next MPD well, hopefully without well control events. The study highlights the importance of proactive measures to prevent incidents and emphasizes the need for continuous improvement in safety procedures and training.