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SafeOCSWell Control Equipment

Failure Reporting

Guidance Document Rev. 11 19-Dec-2016

SafeOCS Well Control Failure Reporting Guidance Document. Rev. 11

Table of Contents

1.0 Scope and Purpose........................................................................................................................................4

1.1 Background.............................................................................................................................................4

1.2 Scope4

1.3 Purpose...................................................................................................................................................4

2.0 Definitions and Acronyms..............................................................................................................................5

2.1 Definitions...............................................................................................................................................5

2.2 Acronyms................................................................................................................................................5

3.0 Equipment Failure Notification......................................................................................................................5

3.1 Well Identification and Rig Owner Information.......................................................................................6

3.2 Equipment Data......................................................................................................................................7

3.3 Equipment History..................................................................................................................................8

3.4 Site Specific Information.........................................................................................................................8

3.5 Event Data...............................................................................................................................................9

3.6 Notification Root Cause Options, Definitions and Examples.................................................................10

3.7 Compliance............................................................................................................................................12

4.0 Investigation and Failure Analysis................................................................................................................12

4.1 Failure Causes.......................................................................................................................................12

4.1.1 Physical Causes...........................................................................................................................13

4.1.2 Human Factor Causes................................................................................................................13

4.1.3 Systemic Causes.........................................................................................................................13

4.2 Analysis Overview................................................................................................................................13

4.3 Level One: Cause Immediately Known..................................................................................................14

4.3.1 Example of Cause Immediately Known........................................................................................14

4.3.2 Resources....................................................................................................................................14

4.3.3 Closure.........................................................................................................................................14

4.4 Level Two: SME Review........................................................................................................................15

4.4.1 Example of an SME Review..........................................................................................................15

4.4.2 Resources....................................................................................................................................15

4.4.3 Closure.........................................................................................................................................16

4.5 Level Three: RCFA Required..................................................................................................................16

4.5.1 Physical Evidence.........................................................................................................................16

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4.5.2 Resources....................................................................................................................................16

4.5.3 Closure.........................................................................................................................................17

4.6 Compliance............................................................................................................................................17

5.0 Communication of Failure Information and Lessons Learned......................................................................18

6.0 Reporting Design and Procedural Changes..................................................................................................18

APPENDIX 1. Definitions.......................................................................................................................................19

APPENDIX 2. Failure Notification Form................................................................................................................22

APPENDIX 3. Failure Reporting Process...............................................................................................................23

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1.0 Scope and Purpose

1.1 Background

BSEE works with the industry to ensure that the terminology, data, and content for failure reporting information

is consistent and up to date with the existing data reporting systems that are currently being used within a large

part of the industry. Specifically, BSEE has worked with the IOGP/IADC BOP Reliability JIP to ensure that the failure

reporting guidance for the BOP Reliability JIP Database and the SafeOCS Failure Database are consistent to the

extent practicable. Consistent reporting processes and formats will facilitate sharing of data across the industry.

BSEE encourages you to report information required under 30 CFR 250.730(c) directly to the SafeOCS reporting

system operated and maintained by the Bureau of Transportation Statistics (BTS) at www.safeocs.gov. BTS will

protect confidential and proprietary information in these submissions in accordance with the Confidential

Information Protection and Statistical Efficiency Act (CIPSEA). While section 250.730(c) requires that the

information be submitted directly to the Chief of BSEE’s Office of Offshore Regulatory Programs, BSEE has entered

into an agreement with BTS with the approval of OMB that allows you to submit the required reports directly to

BTS and gain the CIPSEA protections.

1.2 Scope

This document applies to submissions of well control equipment failures to SafeOCS in accordance with 30 CFR

250.730(c).

1.3 Purpose

This document has been developed with the intent of providing guidance, instructions, and definitions to aid you

in meeting the failure reporting (to BSEE/BTS) requirements of 30 CFR 250.730(c).

The regulation establishes a continuum of required failure reporting from initial notification; investigation and

failure analysis; communication of failure information and lessons learned; and design or procedural changes.

This document will establish the minimum criteria and provide guidance:

On component failure reporting (Section 3)

o When it is required

o How to complete report

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On component investigation and failure analysis and documentation (Section 4)

o What is needed to ensure thoroughness

o What is expected to ensure high quality and investigation objectivity

o What are the levels of analysis

o What is expected for investigation and failure analysis reporting

o How to incorporate corrective actions

On communication of component failure information to support learning (Section 5)

o How to communicate information about component failures to appropriate stakeholders to

- support elimination of failures

- prevent reoccurrence

On reporting design and procedural changes (Section 6)

o How to report design changes

o How to report changes in operating and repair procedures

2.0 Definitions and Acronyms

2.1 Definitions

A list of definitions is provided in Appendix 1.

2.2 Acronyms

API American Petroleum Institute LMRP Lower Marine Riser Package

BOP Blowout Preventer NPT Non-Productive Time

BSEEBureau of Safety and Environmental

EnforcementOEM Original Equipment Manufacturer

BTS Bureau of Transportation Statistics QA/QC Quality Assurance/Quality Control

BWM Between Wells Maintenance RCFA Root Cause Failure Analysis

HSE Health, Safety and Environment RWP Rated Working Pressure

IADC International Association of Drilling Contractors SFI Skipsteknisk Forskningsinstitutt

JIP Joint Industry Project SME Subject Matter Expert

3.0 Equipment Failure Notification

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A written failure notice should be submitted, using the Failure Notification Form, for each failure of any

component of well control equipment, whether there is NPT or not.

The complete Failure Notification Form is illustrated in Appendix 2.

Appendix 3 outlines the notification and reporting process and the stakeholders involved.

You are responsible for ensuring that each failure notice is submitted, preferably online, in a timely manner.

NOTE: Care should be taken that no owner-identifying data is input into any free text field of

this form.

Instructions for completing the Failure Notice Form are included below.

Mandatory fields are marked with an asterisk *, but all relevant fields should be completed wherever possible.

The Failure Notification Form may be modified or updated at any time using the unique reference number

assigned by the SafeOCS system or an equivalent unique identifier that was established when the written failure

notice was originally submitted.

3.1 Well Identification and Rig Owner Information

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The system will assign each failure notice a SafeOCS unique identifier. The system will also provide an option for utilizing a company-assigned identifying number as provided by the submitter, as well as an optional data field for providing the IOGP/IADC JIP report number, if applicable.

Lease No. – Number as provided by operator.

Well No. – Number as provided by operator.

API Well No. – Number as provided by operator.

Rig Owner / Drilling Contractor – Dropdown box populated with the rig owner.

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Operator – Dropdown box populated with the operator.

Rig Name – Dropdown box filtered to show all of the current rigs owned by the selected rig owner.

Primary Contact – Name of person who is familiar with the issue in case further information is required.

Contact Email – Email address for the Primary Contact.

Name of Person Reporting – Name of person who submitted the report.

Name of OEM Representative Onboard, if applicable – Name of any OEM representative on the rig that was involved in the component analysis.

Owner Specific Equipment ID Number – An anonymous SFI code or similar that the equipment owner uses to identify the specific equipment or component.

OEM Incident Reference Number – Reference number issued by the OEM if involved.

Equipment sent on shore – NO should be selected in this dropdown box if the equipment was not sent ashore. If the equipment was sent ashore, the appropriate reason should be selected.

3.2 Equipment Data

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Subsea / Surface – Select SUBSEA in the dropdown box if the system utilizes a subsea BOP designed to be operated underwater; BOPs that are designed to be operated underwater, but are located at the surface (e.g. on the deck of a drill ship) during the failure should still be reported as a SUBSEA BOP. A BOP that is designed to be operated on the facility (e.g. installed on a surface wellhead system) should be reported as a SURFACE BOP.

System Integrator – Select the OEM who assembled the BOP stack and/or the BOP control system in this dropdown box.

Subunit – Select the system subunit category in this dropdown box. This is the first of three dropdown boxes that cascade update each subsequent box until the component is identified.

Item – Select the subunit item category in this dropdown box.

Component – Select the component in this dropdown box. (This is the lowest maintainable item that failed. Do not give the control pod details for a failed pressure regulator.)

Component Manufacturer – Select the manufacturer of the component in this dropdown box.

Observed Failure – Select the failure mode for the component in this dropdown box. This dropdown box is cascade updated from the component selection.

Model – A free text field to enter the manufacturer’s equipment model for the defective component.

Size – Two dropdown boxes to input the whole and fractional size for the component.

Pressure Rating – Dropdown box to select the rating in standardized pressure ratings.

OEM Part Number – Free text field to enter the identifying part number as established by the OEM.

OEM Serial Number – Free text field to enter the OEM’s unique identifying serial number.

3.3 Equipment History

Date Affected Component was installed – Calendar field to record the date that the component was installed into the system on the rig.

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Maintenance Deferred on Equipment – Yes/No dropdown box to record whether planned maintenance was overdue at the time of failure.

If YES, what maintenance was deferred – Free text field to describe the planned maintenance that was deferred (BWM, Annual, 5-Year, etc.).

Date of Last Maintenance – Calendar field to record the date of the last planned maintenance actually completed.

Description of Last Maintenance – Free text field to describe the maintenance that was performed. (i.e. Corrective, BWM- visual and lubrication), Annual – Somewhat invasive for measurements and or operator tests or 5-year – Total disassembly) and any comments that may link the failure with the last maintenance carried out.

Amount of Usage at the Time of Failure – Number field and a dropdown box to select Hours or Cycles rounded to the nearest whole number. If you have automatic cycle counters, or the discipline to actually count the cycles, then record them for valves, cylinders and pistons. Record usage hours for pumps.

3.4 Site Specific Information

IADC Code Description – Dropdown box with a listing of IADC codes and associated descriptions of rig operations.

Location (Region) – Dropdown box to select appropriate continent for the rig operation.

Location (Country) – Dropdown box to select appropriate countries cascaded by the selected region.

Water depth – Free text field to input an integer and a dropdown box to select Feet or Meters to associate to the integer.

Wellbore Fluid Type – Dropdown box to select from the commonly used fluids.

Control Fluid (Manufacturer/Model) – Free text fields to record the details for the control fluid OEM.

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Concentration – Number field to record the percentage of control fluid concentrate in the mixture.

Glycol – Number field to record the percentage of glycol in the mixture.

Was the last sample acceptable? – Yes/No dropdown to record the results of the last laboratory sample (as opposed to a rig test).

Date of last sample – Free text field to record the date of the last laboratory analysis.

3.5 Event Data

Incident Date – Date that the failure was discovered.

When did the failure occur? – Dropdown box to select when the failure occurred: ‘BOP #1 In Operation’, ‘BOP #1 Not in Operation’, ‘ BOP #2 In Operation’, ‘BOP#2 Not in Operation’.

Description of Event – Free text field where sufficient, but concise, information should be stated so that the reader understands what failed, what were the symptoms, what was being functioned at the time of failure and why was it being functioned. Include any related details deemed pertinent.

Hours of NPT – Field to record number of hours that is inclusive of BOP recovery and reinstallation etc., plus all time in-between failure detection and getting back to the point at which the failure occurred. This is typically IADC Code 8 time.

Hours of Repair time – Number field that includes only the time to repair and test the failed component.

Did the event cause a BOP Stack pull? – Yes/No dropdown box to record if a subsea BOP stack retrieval was required.

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Detection Method – Dropdown box to select how the failure was noticed.

Immediate Corrective Action – Dropdown box to select the action taken on the rig to place the component back into an operational state.

Root Cause – Dropdown box to select the cause of the failure. See section 3.6 for additional guidance on the dropdown options.

3.6 Notification Root Cause Options, Definitions and Examples

The following are options for selection from the Root Cause dropdown box.

Design Issue: Inadequate equipment design or configuration.

This is typically identified after an RCFA has been completed, or if the design issue

has been previously identified by an RCFA or manufacturer’s notification.

Documentation Error: Failure related to procedures, specifications, drawings, reporting, etc.

A control valve was delivered with documentation stating that the RWP was 5,000

psig. The valve leaked and the subsequent investigation showed that the valve

was really only rated for 3,000 psig. This was a documentation error because of

the stated RWP.

Maintenance Error: Mistake, misuse or oversight during maintenance.

A choke line flange leaked after the maintenance had been completed.

Investigation showed that the flange studs had been torqued to 380 Nm instead

of the 380 ft-lb stated in the procedure. This was a Maintenance Error.

Operational Error: Mistake, misuse or oversight during operation.

The BOP ram leaked because test pressure was applied after closing pressure was

vented, but without the ram having first been mechanically locked. This was an

Operational Error.

QA/QC Manufacturing: Failure related to manufacturing.

A new annular piston was purchased from the OEM but we were unable to install

it. Investigation showed that it had been machined incorrectly.

Wear and Tear: An expected condition of a component that has reached a point where it is

unable to perform intended function as the result of usage.

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RCFA Required: Currently unknown root cause.

The root-cause cannot be confidently applied before the subsea BOP stack is

recovered to surface. In such a case, ‘RCFA required’ should be selected but this

requirement could be changed when the equipment is accessible on surface.

Other / Comment: The root cause is known, but is none of the above. Selection of ‘Other’ will open

a free text comment box.

Pressing the ‘Submit’ button will upload the form to SafeOCS. Other options may be made available.

Each time a report is submitted, modified, or updated, an acknowledgment will be sent to the appropriate point

of contact.

3.7 Compliance

Completion and submission of the Failure Notification Form according to the guidance in Section 3 will ensure

compliance with the written failure notice requirements of 30 CFR 250.730(c).

NOTE: Submission of the Failure Notification Form to SafeOCS does not fulfill the requirement of 30 CFR

250.730(c) to report failures to the OEM.

4.0 Investigation and Failure Analysis

SafeOCS will allow the submitter to modify or update the Failure Notification Form as needed using the unique

reference number assigned by the SafeOCS system or an equivalent unique identifier. All reports, modifications

and updates should be submitted using the reference number that was established when the Failure Notification

Form was originally submitted.

Effective investigation and failure analysis is essential to identify the causes (i.e., physical, human, and systemic)

and root cause(s) of a failure to enable learning, improvement and prevention of component failures to the

extent practicable thereby increasing inherent reliability and safety.

Several major approaches to investigation and failure analysis are used within the industry, e.g., events and causal

factor analysis, change analysis, barrier analysis, and management oversight and risk tree analysis, etc. The

approach selected should be sufficient to identify the causes and verify the root cause(s).

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The initial scope of any investigation and analysis must be based on factual information (e.g. hose failure, valve

leaking in closed position) relating to the failure.

4.1 Failure Causes

As part of the investigation and failure analysis process, three types of causes are identified in order to

understand the root cause(s) of the failure. These are:

4.1.1 Physical Causes

These are the consequences, manifestation or results determined through evidence that have influenced or

triggered the component to fail. Examples include corrosion, fatigue, excessive stress, erosion, rupture, etc.

4.1.2 Human Factor Causes

These are related to human activities that contributed to the component failure. Identifying and understanding

the contribution of human factors or human error during equipment failure investigations will improve corrective

actions and performance improvement. Examples include maintenance error, failure to follow procedures, etc.

4.1.3 Systemic Causes

These are related to any system or process activity. These include failures in the processes used to execute the

work. Examples include change management, control of work, procedures, quality control, resource

management, competence management, etc.

4.2 Analysis Overview

This section presents the three levels of investigation and failure analysis, as indicated in the flow chart

(APPENDIX 3):

Root Cause Immediately Known

SME Review

Root Cause Failure Analysis

NOTE: If an investigation at one level fails to sufficiently determine the root cause(s) of the

failure, then the analysis can be promoted to the next level as appropriate.

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As shown in the Failure Reporting Process (APPENDIX 3), if the root cause is immediately known, this information

is submitted to SafeOCS.

If the equipment failure 1) resulted in a loss of a well barrier, 2) required the LMRP or BOP stack to be retrieved,

or 3) has become a systemic/recurring event, then an RCFA should be conducted and the RCFA documentation

submitted to SafeOCS.

If the equipment failure does not involve one of these events, an SME Review should be conducted and the SME

Review documentation submitted to SafeOCS.

NOTE: There will be occasions where a component failure previously categorized as ‘Cause

Immediately Known’ or ‘SME Review’ is reclassified as ‘RCFA required’ because such an

issue has occurred multiple times and has been classed as ‘Systemic/Reoccurring’. The

previously submitted reports do not need to be re-classified, but they may be referred to

(and modified if necessary) in the SME Review or RCFA.

The Failure Notification Form can be updated as needed during the investigation and analysis process and

uploaded along with the appropriate documentation using the unique reference number assigned by the SafeOCS

system or an equivalent unique identifier that was established when the Failure Notification Form was originally

submitted.

4.3 Level One: Cause Immediately Known

4.3.1 Example of Cause Immediately Known

An O-ring damaged during installation, for example, normally can be easily categorized as Cause Immediately

Known. It is important to report such issues because if this were to escalate to a systemic/reoccurring event then

it may warrant a change to the design or installation/maintenance or other operating procedures.

4.3.2 Resources

An SME (such as the Senior Subsea Engineer) should discuss what happened with another technical member of

crew to determine:

What happened?

How it happened?

Why it happened?

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A free text description of the event and other appropriate information should be provided on or with the Failure

Notification Form.

4.3.3 Closure

If the Failure Notification Form has previously been submitted as “final”, it may be modified or updated as

appropriate and, if needed, supporting documentation attached using the unique reference number assigned by

the SafeOCS system or an equivalent unique identifier that was established when the Failure Notification Form

was originally submitted. When the cause is immediately known and the information under 4.3.1 and 4.3.2 above

is provided then the system views your submittal as fulfilling the regulatory requirement for an investigation and

analysis report. Other cases that do not show a cause immediately known are discussed next under Level Two,

4.4 and Level Three, 4.5.

4.4 Level Two: SME Review

An SME Review should be conducted when the cause of the failure is questionable and the component failure has

not triggered an RCFA (did not involve an unplanned BOP pull, loss of well barrier, or a systemic/reoccurring

event).

An SME Review is conducted when:

a failed component requires disassembly to ascertain the cause of the failure,

the event frequency is not systemic – see definition of systemic event in Appendix 1 or

the consequence (no loss of barrier or BOP retrieval) of the component failure are considered low.

However, one result of a SME review could be the finding that an RCFA is required.

4.4.1 Example of an SME Review

If a ram failed to hold pressure during pre-deployment testing and upon opening the doors/bonnets the packers

were observed to be well worn, an SME Review could check the records to see if the number of functions met

expectations. After the rams have been successfully tested with new packers to confirm that there is no other

issue, and assuming the number of functions met expectations, the failure can be attributed to ‘Wear and Tear’.

If, however, the rams fail to test and / or the function cycles are less than expected, the causal agent is something

other than ‘Wear and Tear’ and a RCFA may be required.

4.4.2 Resources

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Typically, two or more SMEs are utilized.

The SME Review should show a logical conclusion of the causes of what, how and why a failure occurred.

While acknowledging that every company has a specific approach for failure investigation and analysis, the SME

Review documentation should typically include the following information either as an integral part of the SME

Review documentation or by cross-referencing the Failure Notification Form using one of the unique reference

numbers established when the Failure Notification Form was originally submitted:

Details of the component that failed (Part Number, Serial Number, Description)

Date of the failure

Details of the failure

Date that the SME Review commenced and was completed

Investigation team member description

Failure cause(s)

Findings

Corrective Actions taken

Recommendations

4.4.3 Closure

If needed, the Failure Notification Form should be modified or updated and the necessary documentation

supporting the identified cause(s) should be attached using the unique reference number assigned by the

SafeOCS system or an equivalent unique identifier that was established when the Failure Notification Form was

originally submitted to be considered in compliance

with the regulatory requirement for the investigation

and analysis report.

4.5 Level Three: RCFA Required

The RCFA is more detailed and requires more

resources and time. There are three specific triggers,

as shown on right in Figure 1, for when an RCFA

should be carried out.

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Was there loss of a well barrier?

Was there an unplanned stack/LMRP

recovery?

Is it a systemic/recurring event?

The Operator ensures that a RCFA is arranged.

NO

NO

YES

YES

YES


This analysis should output root causes that can be turned into action items to prevent reoccurrence; for

instance, OEM product bulletins, equipment owner maintenance system changes, etc.

4.5.1 Physical Evidence

Well Control component failures are frequently field repairable and in many cases there may not be a

replacement assembly readily available. In such an instance, ensuring full and detailed documentation of physical

evidence is critical even if the situation necessitates the evidence being in the form of photographs, dimensions,

sketches and written reports to allow repairs to be effected and allow the rig to go back to work. This information

can be submitted to SafeOCS, as appropriate, with the final RCFA report.

4.5.2 Resources

Typically, at least one SME plus the OEM or a suitably qualified third party are utilized.

The RCFA report should show a logical conclusion of the physical, human, and systemic causes of what, how and

why a failure occurred.

The RCFA documentation should typically include but is not limited to the following and must refer to one of the

unique reference numbers established when the Failure Notification Form was originally submitted to be

considered in compliance with the regulatory requirement for the investigation and analysis report:

A copy of the initial report

An accurate description of the failure

As much information as possible on the operating conditions that existed at the time of the

malfunction or failure and any applicable operating conditions that existed prior to or immediately

after the failure

Description of the immediate corrective actions that were taken as identified in the failure

notification

Any relevant operating history of the equipment leading up to the failure (e.g. field repair,

modifications made, etc.)

Description of any inspection, testing, laboratory analysis, or other activities conducted to determine

the root cause and causal factors

Description of the causal factors determined to be associated with the failure

Additional equipment problems beyond the initial failure notification identified during the failure

analysis

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Figure 1. RCFA Triggers


Other conclusions or findings resulting from the investigation and failure analysis

Corrective actions recommended and taken in addition to the immediate corrective actions noted in

the initial report, if known at the time of the investigation and analysis report

Photographs, pressure tests, inspection records, laboratory analyses results, verification documents,

etc. to support the investigation and failure analysis conducted.

4.5.3 Closure

If needed, the Failure Notification Form should be modified or updated and the necessary documentation

supporting the identified cause(s) should be attached using the unique reference number assigned by the

SafeOCS system or an equivalent unique identifier that was established when the Failure Notification Form was

originally submitted.

4.6 Compliance

Completion and submission of information according to the guidance in this section will ensure compliance with

the investigation and failure analysis requirements of 30 CFR 250.730(c).

5.0 Communication of Failure Information and Lessons Learned

Communicating information about component failures and their causes among appropriate stakeholders supports

learning, improvement and prevention of component failures to the extent practicable, thereby increasing

inherent reliability and safety.

You must ensure that component failures and the associated lessons learned are shared with the appropriate

stakeholders as required by the regulations and cited industry standards at 30 CFR 250.730(c).

6.0 Reporting Design and Procedural Changes

Changes in design and operating procedures, resulting from a failure, that are not submitted as part of the Failure

Notification or Investigation and Failure Analysis reporting process should be submitted to SafeOCS within 30 days

of the changes, as required in 30 CFR 250.730(c). This information should be submitted using the unique

reference number assigned by the SafeOCS system or an equivalent unique identifier that was established when

the Failure Notification Form was originally submitted.

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For questions contact SafeOCSwww.safeocs.gov

1-844-OCS-FRST (1-844-627-3778)

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http://www.safeocs.gov/


APPENDIX 1. DEFINITIONS

GENERAL DEFINITIONS

Preventative Maintenance Maintenance on Well Control equipment conducted when it is out of

service.

Cause Something that initiates, shapes or influences an outcome.

Cause Immediately Known When there is a high degree of certainty in the failure cause, the failure

information described in Section 3 is completed describing the failure and

defining the root cause based on inspection and maintenance personnel

experience and knowledge.

Corrective Action An action, which is taken to correct a failure and/or the failure’s cause.

Effect An event or condition that is caused by another event or condition.

Evidence Information, data and/or items gathered which directly relate to, or have

been, affected by the failure.

Failure A condition that prevents the component from operating as designed,

e.g. A leaking O-ring is a failure even if the piston that it should seal can

fully stroke.

Non-productive time (NPT) The number of hours that is inclusive of BOP recovery and reinstallation

etc., plus all time in-between failure detection and getting back to the

point (in the well operation) at which the failure occurred. This is typically

IADC Code 8 time.

Rated Working Pressure (RWP) The maximum internal pressure that equipment is designed to contain or

control in the form of standardized pressure ratings.

Reoccurring/Systemic Event A failure that occurs periodically or repeatedly. A reoccurring event, also

known as a systemic event, may be identified at:

an individual component or equipment system level,

a company’s level, or

an industry-wide level.

Root Cause The cause (condition or action) that begins a cause/effect chain that ends

in equipment component failure and, if eliminated, would prevent the

reoccurrence of the event (under investigation) and similar occurrences.

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Root Cause Failure Analysis (RCFA) A comprehensive systematic investigation process undertaken to identify

Physical, Human Factors and Systemic root causes of a component

failure.

SafeOCS Subject Matter Expert A person or persons with an in-depth knowledge of a subject of interest,

hired or appointed by the Government to evaluate failure submissions in

accordance with 30 CFR 250.730(c).

SafeOCS SME Review An evaluation of failure submissions by a SafeOCS SME to determine the

gravity of a failure event’s potential consequence with respect to

equipment context, causal factors, and other considerations.

Skipsteknisk Forskningsinstitutt (SFI) Ship Research Institute of Norway

Subject Matter Expert Your designated person or persons with an in-depth knowledge of a

subject of interest. Such knowledge will have been gained through

direct and practical dealings with subject matter of interest.

SME Review An internal assessment of the possible and probable local root cause of

the component failure reviewed by an operator-designated SME with the

intent of recommending intermediate actions or changes to reduce the

probability of reoccurrence.

ROOT CAUSE DEFINITIONS (as used in the failure notification Input Form (Appendix 2) and Section 1 of the

Investigation and Failure Analysis Summary Form (Appendix 5)

Design Issue: Inadequate equipment design or configuration.

This is typically identified after an RCFA has been completed or if the design issue

has been previously identified by RCFA or manufacturer’s notification.

Documentation Error: Failure related to procedures, specifications, drawings, reporting, etc.

A control valve was delivered with documentation stating that the RWP was 5,000

psig. The valve leaked and the subsequent investigation showed that the valve

was really only rated for 3,000 psig. This was a documentation error because of

the stated RWP.

Maintenance Error: Mistake, misuse or oversight during maintenance.

A choke line flange leaked after the maintenance had been completed.

Investigation showed that the flange studs had been torqued to 380 Nm instead

of the 380 ft-lb stated in the procedure. This was a Maintenance Error.

Operational Error: Mistake, misuse or oversight during operation.

22


The BOP ram leaked because test pressure was applied after closing pressure was

vented, but without the ram having first been mechanically locked. This was an

Operational Error.

QA/QC Manufacturing: Failure related to manufacturing.

A new annular piston was purchased from the OEM but we were unable to install

it. Investigation showed that it had been machined incorrectly.

Wear and Tear: An expected condition of a component that has reached a point where it is

unable to perform intended function as the result of usage.

RCFA Required: Currently unknown root cause.

The root-cause cannot be confidently applied before the subsea BOP stack is

recovered to surface. In such a case, ‘RCFA required’ should be selected but this

requirement could be changed when the equipment is accessible on surface.

Other / Comment: The root cause is known, but is none of the above. Selection of ‘Other’ will open

a free text comment box.

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APPENDIX 2. FAILURE NOTIFICATION FORM

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APPENDIX 3. FAILURE REPORTING PROCESS

(Note: Clarifying information discussed on the right hand blue portion of this diagram is generally viewed as verbal information during a telephone call. Such a request for clarifying information does not affect the status of the equipment being placed back into service.)

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