2Q QPR – Jun 2012

Drill Pipe Elevator Failure at Rig DFXK-1000

Lesson Learned Document
Description: On 22nd December, 2016 at 1115 hours while Running in 6“ BHA with 3-1/2 drill pipes the elevator
hit the rotary table base due to failure of auxiliary brake. Driller picked up string by applying the draw works clutch.
Due to sudden hit one of the drilling lines slipped out from the crown block sheaves and stacked in between two
sheaves.
WHAT WENT WELL: LESSON LEARNED / RECOMMENDATIONS:
• No injuries to personnel • Every shift change Tool Pusher and Driller must inspect brake system.
Run a test to verify the safe working of the system
• Every shift change inspect Floor Saver and Crown Saver make sure
WHAT WENT WRONG:
equipment is working good
• Auxiliary brakes did not function • Maintenance Training must be provided to the Mechanic on the
• Maintenance of brake system not effective Electrical systems of the Draw works
• Proper procedure for maintenance of brakes not • Maintenance plan should be reviewed to ensure SCE are checked
available against checklist before each shift change
• Incident to be shared with other rigs and all concerned to learn from it
SUMMARY OF CRITICAL FACTORS: • Develop and implement an effective Computerized Maintenance
Immediate Causes Management System at rig DFXK 1000 HP for the planning and
[CF-1] Ineffective Maintenance Management system management of critical rig equipment/parts
– The auxiliary brakes did not function • Develop and implement a SPP for rig DFXK 1000 HP maintenance of
auxiliary brake
System Causes
[CF 2] Lack of Expertize to maintain a Critical
Safety component of the rig
– The Mechanic was not trained on the brake system

[CF 3] Lack of SPP (Standard Practice / Procedure)

– No procedure for maintenance of auxiliary brakes