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Pryor Trust Final Investigation Report Gas Well Blowout and Fire at U.S. Chemical Safety and Pryor Trust Well 1H-9 Hazard Investigation Board Pittsburg County, Oklahoma | Incident Date: January 22, 2018 | No. 2018-01-I-OK Investigation Report Published: June 12, 2019 KEY ISSUES: • Poor Barrier Management • Underbalanced Operations Performed Without Proper Planning, Procedures, or Needed Equipment • Signs of Influx Either Not Identified or Inadequately Responded To • Alarm System Off • Flow Checks Not Conducted • Gaps in Safety Management System • Driller’s Cabin Design • BOP Could Not Close Due to Burned Hydraulic Hoses • Lack of Safety Requirements by Regulation Page 1 Gas Well Blowout and Fire at U.S. Chemical Safety and Pryor Trust Well 1H-9 Hazard Investigation Board Pittsburg County, Oklahoma | Incident Date: January 22, 2018 | No. 2018-01-I-OK The U.S. Chemical Safety and Hazard Investigation Board (CSB) is an independent Federal agency whose mission is to drive chemical safety change through independent investigations to protect people and the environment. The CSB is a scientific investigative organization, not an enforcement or regulatory body. Established by the Clean Air Act Amendments of 1990, the CSB is responsible for determining accident causes, issuing safety recommendations, studying chemical safety issues, and evaluating the effectiveness of other government agencies involved in chemical safety. More information about the CSB is available at www.csb.gov. The CSB makes public its actions and decisions through investigative publications, all of which may include safety recommendations when appropriate. Types of publications include: Investigation Reports: formal, detailed reports on significant chemical incidents that include key findings, root causes, and safety recommendations. Investigation Digests: plain-language summaries of Investigation Reports. Case Studies: reports that examine fewer issues than Investigation Reports. Safety Bulletins: short publications typically focused on a single safety topic. Hazard Investigations: broader studies of significant chemical hazards. Safety Videos: videos that animate aspects of an incident or amplify CSB safety messages. CSB products can be freely accessed at www.csb.gov or obtained by contacting: U.S. Chemical Safety and Hazard Investigation Board Office of Congressional, Public, and Board Affairs 1750 Pennsylvania Ave NW, Suite 910 Washington, DC 20006 (202) 261-7600 No part of the conclusions, findings, or recommendations of the Board relating to any accidental release or the investigation thereof shall be admitted as evidence or used in any action or suit for damages arising out of any matter mentioned in such report. 42 U.S.C. § 7412(r)(6)(G). Page 2 Gas Well Blowout and Fire at U.S. Chemical Safety and Pryor Trust Well 1H-9 Hazard Investigation Board Pittsburg County, Oklahoma | Incident Date: January 22, 2018 | No. 2018-01-I-OK Table of Contents GLOSSARY ............................................................................................................................................................ 8 1 EXECUTIVE SUMMARY ............................................................................................................................... 13 2 BACKGROUND ............................................................................................................................................ 14 2.1 Red Mountain Energy and Red Mountain Operating ............................................................................ 14 2.2 Patterson-UTI ........................................................................................................................................... 14 2.3 Business Relationship Between Red Mountain Operating and Patterson-UTI ..................................... 15 3 INTRODUCTION TO DRILLING, PERSONNEL, AND TERMINOLOGY .............................................................. 15 3.1 Drilling Rig ................................................................................................................................................ 15 3.2 Drilling Personnel ..................................................................................................................................... 15 3.3 Well Control ............................................................................................................................................. 17 3.4 Equivalent Circulating Density (ECD) and Annular Pressure Loss (APL) ................................................ 19 3.5 Other Drilling Techniques ........................................................................................................................ 21 4 WELL BACKGROUND .................................................................................................................................. 22 5 INCIDENT DESCRIPTION ............................................................................................................................. 24 5.1 Tripping Out of the Well from the Lateral Section to the Top of the Curve ......................................... 25 5.1.1 Determination of Tripping Procedure .............................................................................................. 25 5.1.2 Analysis of Trip Out to The Top of The Curve .................................................................................. 27 5.2 Well Circulation at Top of Curve ............................................................................................................. 35 5.3 Spotting Weighted Pill Above Top of Curve: Introduction of Lost Circulation Material ...................... 39 5.4 Tripping Out of Vertical Section of Well ................................................................................................. 40 5.4.1 Driller and Company Man Had Difficulties Interpreting Data Due to Mud Bucket Alignment ..... 41 5.5 Attempt to Unplug Drill Pipe Before Shift Change ................................................................................. 43 5.6 Activities During Day Tour: Monday, January 22, 2018 ......................................................................... 45 5.7 Blowout and Fire ...................................................................................................................................... 48 5.8 Emergency Response ............................................................................................................................... 50 5.9 Incident Consequences ........................................................................................................................... 51 6 INCIDENT ANALYSIS .................................................................................................................................... 52 6.1 Failure of Barriers .................................................................................................................................... 53 Page 3 Gas Well Blowout and Fire at U.S. Chemical Safety and Pryor Trust Well 1H-9 Hazard Investigation Board Pittsburg County, Oklahoma | Incident Date: January 22, 2018 | No. 2018-01-I-OK 6.1.1 Well Control Barrier Philosophy ....................................................................................................... 53 6.1.2 Primary, Prevention Barrier: Hydrostatic Pressure Produced by Mud, Adjusted by Rig Workers at Direction of Operator ...................................................................................................................................... 56 6.1.3 Secondary, Mitigation Barrier: Human Detection of Gas Influx and Closure of Blowout Preventer ………………………………………………………………………………………………………………………………………………..57 6.1.4 Need for Safety Instrumented Systems in Drilling Industry ............................................................ 58 6.2 Underbalanced Operations Proceeded Without Needed Planning, Equipment, Skills, or Procedure 58 6.2.1 Drilling Operations Planned for Near-Balance Conditions ............................................................. 58 6.2.2 Mud Program Selection.................................................................................................................... 59 6.2.3 Unexpected Flaring / Decision to Continue ..................................................................................... 60 6.2.4 RMO and Patterson Attempted an Unplanned Underbalanced Operation ................................... 61 6.2.5 Need for Industry Tripping Guidance .............................................................................................. 62 6.3 Driller Had Difficulties with Electronic Trip Sheet .................................................................................. 62 6.4 Incorrect Determination That There Was No Surface Pressure Before Opening BOP ........................ 64 6.5 Weighted Pill Did Not Overbalance the Well ......................................................................................... 64 6.6 Lack of Detail in Procedures .................................................................................................................... 65 6.6.1 Tripping Procedure for Trip Out of Lateral Section ......................................................................... 65 6.6.2 Tripping Procedure Did Not Specify Equipment Alignment ............................................................ 65 6.6.3 Procedures and Management of Change are Safety-Critical Components of a Company’s Safety Management System .....................................................................................................................................
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