INVESTIGATION FINDINGS
On November 24, 2014 at approximately 0830, an injury
occurred at Fieldwood Energy's Matagorda Island (MI) 622 'C' platform, Lease
G-05000.
At approximately 0800, Operators were not receiving a flow
rate indication on the Programmable Logic Controller (PLC) from the gas outlet
meter on the #4 Production Separator, MBD-2000.
The MI 622 'C' facility consists of four (4) connected structures: Quarters, Wells, Production, and Compressor.
The #4 Production Separator is located on the 'C' Production
structure. The Contract 'A' Operator /
Injured Party (IP) proceeded to the #4 Production Separator to determine why
the PLC was not receiving a signal or flow rate indication. The IP decided to verify that an Orifice
Plate (OP) was properly installed in the Daniels Senior Orifice Fitting.
The IP manipulated the OP carrier shaft in the body (lower
chamber) of the Senior Orifice Fitting (SOF) and it turned freely indicating
the OP carrier was located in the top (upper chamber) of the SOF. The IP verified the OP and carrier location
by turning the OP carrier shaft in the upper chamber of the SOF, and it did not
turn.
This also indicated the slide gate was closed. The IP opened the blow down valve on the
upper chamber of the SOF to remove line pressure. The blow down valve on the upper chamber of
the SOF relieved briefly and the IP assumed there was no pressure
remaining. The IP started by loosening
the first clamp bar bolt on the top of the SOF closest to his body.
When the IP began to loosen the second clamp bar bolt, there
was a pressure release of approximately 915 pounds per square inch gauge
(PSIG). Natural gas and debris blew
upward striking the IP on the left side of his face and left eye. The IP immediately went to the eye wash
station and began to irrigate his face and left eye.
The Person in Charge (PIC) heard the gas release and
immediately reported to the scene. The
PIC activated the Emergency Shut Down (ESD) and observed the IP at the eye wash
station. The PIC assisted the IP to the
Medic.
The Medic continued face and eye washing procedures for
approximately 40 minutes until the Field Helicopter arrived. The Field Helicopter arrived at MI622'C' at
approximately 0920 and transported the IP to Christus Spohn Memorial Hospital
in Corpus Christi, TX.
LIST THE PROBABLE CAUSE(S) OF ACCIDENT:
The IP failed to close the equalizer valve between the upper
(top) and lower (bottom) chamber on the SOF prior to loosening the clamp bar
bolts on the upper chamber (this was confirmed by PIC after the incident).
LIST THE CONTRIBUTING CAUSE(S) OF ACCIDENT:
The blow down valve on the upper chamber of the SOF plugged
with debris and/or frozen hydrates when it was opened to atmosphere. This resulted in the false impression that
the upper chamber of the SOF had bled to zero pressure.
The IP failed to loosen the clamp bar bolts on the top of
the SOF away from his body.
When the IP found the SOF in an abnormal condition, all
steps in OP removal procedure have been reevaluated.
LIST THE ADDITIONAL INFORMATION:
Line pressure of approximately 915 PSIG was released into
the IP's left eye when he loosened the top two clamp bar bolts on the upper
chamber of the SOF. The IP was wearing safety glasses at the time of the
incident.
The incident resulted in injury to the IP's left eye.
A Corneal Surgeon removed debris from the IP's left eye on
25-Nov-2014.
A second surgery was performed on 26-Nov-2014 to remove
additional debris.
The IP is expected to recover fully.
The IP returned to work on 24-Dec-2014.
PROPERTY DAMAGED:
None.
NATURE OF DAMAGE:
RECOMMENDATIONS TO PREVENT RECURRENCE NARRATIVE:
POSSIBLE OCS VIOLATIONS RELATED TO ACCIDENT:
Yes.
SPECIFY VIOLATIONS DIRECTLY OR INDIRECTLY CONTRIBUTING.
NARRATIVE:
G 110 'C'. 30CFR250.107(a)
The Lessee failed to perform all operations in a safe and
workmanlike manner. The IP failed to
close the equalizer valve on the Daniel Senior Orifice Fitting prior to
removing the Clamp Bar Bolts which resulted in an uncontrolled gas release and injury
to the IP's left eye.
Daniel Dual-Chamber
Orifice Fitting - Senior
This fitting reigns as the most widely used means of
measurement for natural gas. It saves users time and money by providing a fast
and simple method of changing orifice plates under pressure without flow
interruption, preventing unscheduled shutdowns. In addition, the dual-chamber design
eliminates the burden of bypass piping, valves and other fittings required with
conventional orifice flange installations.
