investigation report fatality worker struck by piping ......purchased by secure in the fall of 2014...

F-OHS-111897-EAFEA

February 2020

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Classification: Public

Investigation Report

Fatality – Worker Struck By Piping Components

October 23, 2016

F-OHS-111897-EAFEA Alberta

Final Report

Labour and Immigration

Occupational Health and Safety

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The contents of this report This report documents the Occupational Health and Safety (OHS) investigation of a reportable

incident involving a worker who sustained a fatal injury in October 2016. It begins with a short

summary of what happened. The remainder of the report reviews this same information in

greater detail.

Incident summary A worker sustained a fatal injury after being struck by piping components that detached under

pressure from a trailer-mounted water transfer pump. The employer of the worker had been

retained to conduct water transfer operations to support fracing activity on the premises of the

owner/prime contractor.

Background information Owner/prime contractor Shell Canada Energy (Shell) conducts oil and gas extraction operations to recover

unconventional hydrocarbon resources in northwestern Alberta. In the Fox Creek area, Shell

operates approximately 107 horizontal wells from which oil and gas are extracted using the

process of hydraulic fracturing (fracing).

The pipeline involved in the incident was owned and operated by Shell. The Riser D site was the

aboveground terminus portion of the pipeline used to feed the fracing operation approximately

14 kilometres (km) from the Riser D terminal.

Fracing involves injecting large volumes of water under high pressure into the fissures of the

underlying geological formation. This process stimulates the well (forces open the fissures), and

releases the oil and gas. The fracing process is reliant on large volumes of water which is

introduced to the wells from a water source using permanent and temporary piping.

Employer Secure Energy (Onsite Services) Inc. (Secure) has multiple offices throughout North America

with the corporate head office in Calgary, Alberta. They provide integrated support services to

clientele in the energy, resource, pipeline, and civil construction industries. These support

services include provision of fluid transfer equipment. Typically, as in this event, the fluid

being transferred was water.

The equipment provided to support the fracing operation included pumps, hoses, piping,

connections, and metering instrumentation. Personnel to operate and maintain the equipment

were also provided by Secure.


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Worker 1 was employed as a Field Labourer Level II Equipment Operator. Worker 1 had over 20

years of oilfield experience and had been involved in oil and gas drilling operations since the mid

1990’s. Worker 1 had completed a technical certificate (drilling rigs) from SAIT in 1995.

Worker 1 had been employed at Secure since October of 2015. Previously, worker 1 was

employed from 2010-2015 by Infinity Oilfield Services Inc. In June 2014, Infinity Oilfield

Services was acquired by Secure Energy.

The main responsibilities of worker 1 included set up, operation, maintenance, and monitoring of

pump equipment. On the day of incident, October 23, 2016, worker 1 was completing a

scheduled day shift.

Worker 2 had been employed as an on-site representative for Shell since September 2015.

Worker 2 was assigned to the wells and completions division. The general responsibilities of

worker 2 included coordination of long-term planning of water transfer projects to support the

fracing operations of the wells and completions division.

Specific responsibilities of worker 2 included coordinating with companies providing fluid

transfer services and determining how projects would be completed. Worker 2 oversaw and

supervised rigging in and out of water transfer crews and their equipment and the operations of

pumping water. Worker 2 also liaised with the prime operations group who operated the fixed

pipeline.


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Equipment and materials Permanent piping infrastructure

The pipeline involved in this incident was owned and operated by Shell. It was a 10 inch

(25 centimetre (cm)) and 12 inch (30 cm) steel pipeline that had several aboveground risers from

Riser D to the terminus end. A riser is a segment of curved pipeline that protrudes aboveground.

The pipeline was approximately 18 km in total length with a majority of it buried under

approximately 1.5 metres (m) of earth (Figure 1).

Figure 1. Perspective of the incident location on suction side of Pump 4.

A. Inlet connection to the Riser D trunkline. This was where the discharge hose from Pump

4 was connected.

B. The 10 inch (25 cm) diameter layflat hose connected to the suction inlet.

C. Position of high-pressure limit gauge (Figure 6).

D. Suction inlet of the trailer mounted water transfer pump.

A

B

C

D


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Diesel pump The Cornell diesel pump was used to transfer water in support of fracing operations. It was

purchased by Secure in the fall of 2014 (Figure 2).

Figure 2. Perspective of the incident location looking east.

A. Pump 4 mounted on trailer at Riser D location.

A


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Pump discharge outlet Worker 1 was standing on the south side of Pump 4 beside the pump discharge. As a result of

overpressure in the system, the clamp (Figure 3B) failed propelling the 90 degree fabricated

elbow into contact with worker 1 who sustained fatal injuries (Figure 3).

Figure 3. Close up of Pump 4 discharge outlet with the clamp in place post incident.

A. Suction inlet from Pump 3.

B. Clamp used to attach the 90 degree elbow to the discharge flange.

C. The 8 inch (20 cm) diameter discharge outlet.

A

B

C


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Hose clamp US Couplings & Accessories 8 inch (20 cm) HF clamp and steel bolt with locking nut. This

clamp failed to restrain the pressurized hose at Pump 4 discharge outlet (Figure 4).

Figure 4. Close up of the clamp post incident.


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Discharge hose

The layflat discharge hose was constructed of thermoplastic polyurethane (TPU). The segments

connected to Pump 4 were 10 inches (25 cm) in diameter. Rated burst pressure was indicated as

4137 kilopascals (kPa) (600 pounds per square inch (psi)) (Figure 5).

Figure 5. Post incident photograph of the hose on the east side of Pump 4. Worker 1 was struck

by the 90 degree formed elbow (B) after it detached from the Pump 4 discharge.

A. The hose segment connecting Pump 4 discharge to Riser D inlet. The length was 10 m.

The total weight of the hose assembly and elbows was 150 kilograms (kg).

B. The 90 degree formed elbow connected to Pump 4 discharge. The weight of the formed

elbow and adaptor connections was 57 kg.

A

B


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Pressure gauge This pressure gauge was located at the inlet to Pump 4. Its purpose was to measure the internal

pressure of the pipeline segment at the pump inlet.

Post incident functionality testing of Pump 4 identified a high pressure limit gauge was not

functioning. At the time of the incident, Pump 2 pressure was calculated to have had to have

been greater than 200 psi, and Pump 3 pressure had to have been greater than 300 psi. If the high

pressure limit switches were functioning and were set at a pressure below 200 psi, one of the

pumps would have shut down (Figure 6).

Figure 6. Post incident photograph of the high limit gauge (Murphy Swichgage) removed from

Pump 4.


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Sequence of events On November 1, 2015, Secure entered into a contract with Shell to provide fluid transfer

services in support of Shell fracing operations in the Fox Creek area. The effective date of the

contract was from Nov 1, 2015 to October 31, 2018.

On October 21, 2016, Secure mobilized to begin the water transfer project. This project was

intended to introduce fracing water to the Shell water trunkline from the Fox Creek municipal

lagoon to the Shell Riser D location.

The plan was to move water from a lagoon through approximately 8.5 km of layflat hose and

buried pipeline that had a number of risers, which were access points to the pipeline. A series

of 8 inch (20 cm) and 10 inch (25 cm) diameter layflat hoses was to be temporarily connected

and linked to a series of four high-volume centrifugal pumps between the municipal lagoon

water source and the Riser D location.

Secure began connecting hoses and completed this activity at approximately 10:00 a.m. on

October 23, 2016. The hose from Pump 3 was connected to the suction inlet side of Pump 4.

The hose from the discharge side of Pump 4 was connected to the inlet connection at Riser D

(Figure 1).

Filling the layflat hose commenced at 1:30 p.m. on October 23, 2016. At 2:30 p.m., a line dis-

connection was identified and was reconnected by approximately 2:45 p.m. The pump log

indicated start up occurred at 5:00 p.m. and was shut down at 5:50 p.m.

At 5:41 p.m. on October 23, 2016, worker 2 arrived at the Riser D location where worker 1 was

already operating Pump 4 (Figure 2). Worker 2 stated that Pump 4 discharge bleeder valve was

open because air was releasing and whistling loudly.

Worker 1 was manipulating valves and throttling the diesel engine of Pump 4 in an attempt to

improve the performance of the pump. Worker 2 stated that worker 1, in response to water

releasing from the 2 inch (5 cm) bleeder valve, closed the bleeder valve on the discharge side of

Pump 4.

Worker 2 observed worker 1 return to the suction side of Pump 4 and increase the revolutions

per minute (RPM). Worker 2 also observed worker 1 touch the 10 inch (25 cm) diameter hose on

the suction side of Pump 4. The hose was hard, indicating it was pressurized with water.

Worker 1 returned to the discharge side of Pump 4, cracked the 2 inch (5 cm) bleeder valve, and

then closed it. Increased RPM on the pump engine was audible to worker 2; however, worker 1

was not visible to worker 2 due to the height of Pump 4.

Worker 2 heard a ‘pop’ at 5:46 p.m. as the clamp on Pump 4 discharge hose failed (Figure 3 and

4). Worker 1 was struck by piping components at Pump 4 discharge (Figure 5). Worker 2


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observed worker 1 being propelled approximately 1.5 m off the ground. Worker 1 was found 8 m

away from the Pump 4, face down, but conscious and talking.

At approximately 5:47 p.m., worker 2 declared an emergency on the radio and fluid transfer

operations were shut down at 5:50 p.m.

At approximately 5:58 p.m., a paramedic arrived at Riser D and initiated first aid on worker 1.

At 6:07 p.m., emergency medical services (EMS) arrived at Riser D and conveyed worker 1 to

Fox Creek Hospital. Arrival at Fox Creek Hospital was 6:17 p.m.

At 8:00 p.m. on October 23, 2016, the physician at Fox Creek Hospital prounced worker 1

deceased.

Completion A review for enforcement action was completed on April 25, 2018, and it was determined that

the file would be referred to Alberta Justice for review. The entire file was sent to Alberta Justice

on June 25, 2018. Alberta Justice conducted a comprehensive review of the case. It was

determined the evidence in the case did not meet the reasonable likelihood of conviction

standard. On July 13, 2018, Alberta Justice advised OHS that charges were not recommended.

This investigation was closed on December 3, 2019.


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Signatures

ORIGINAL REPORT SIGNED March 9, 2020

Lead Investigator Date


Manager Date


Director Date

investigation report fatality worker struck by piping ......purchased by secure in the fall of 2014...

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