CASE STUDY

OISD/CS/2022-23/E&P/04 Dt.: 13.01.2023

INTRODUCTION
Title: Uncontrolled flow of air from well.
Location: On-land Workover Rig Location.
Loss/ Outcome: Financial Loss.
BRIEF OF INCIDENT
After completion of pull out of hole of conical mill assembly, it was planned to run in Die
collar tool assembly with 3-1/2” LH drill pipe and accordingly BOP 2-7/8” ram was to be
changed with 3-1/2” ram. For changing of ram from 2 7/8 “to 3-1/2” size opening of
bonnet was to be carried out, while opening of bonnet bolts observed leakage of brine
followed by air from the bonnet and then rig crew tried to fix back the bonnet bolts. They
could fix bonnet bolts of one side only, meanwhile air with traces of flue gas started
gushing out from another side of bonnet door and they could not fix the bonnet door. Air
blow out was continued for approximately 8 days till it was subsided. There was no
reported incident of any injury or medical complications.
OBSERVATIONS/ SHORTCOMINGS
Following observations were made during investigation by visit at the incident site,
interaction with the related officials, their written statements, and available documents:
 In all wash over trips, wash over pipe bottom part was found broken/cracked and
severely damaged, return of metal cuttings during circulation was observed. (Suspected
Casing integrity loss) and it was followed by running impression block with 3 ½” LHDP at
966.34 m, observed mark on edge suggesting casing inner surface deformation/damage.
Formation sand influx in high quantity also indicates severe casing damage above this
depth.
 Though the casing damage was suspected with substantiated objective evidence during
fishing of GP assembly operation, the casing integrity was not checked and accordingly
the well plan was not reviewed for safe operations but continued with original plan not
considering the developed safety concerns.
 Loss of hydrostatic head in cased hole due to suspected damage of casing at the depth
of 970 meters on account of repeated milling to clear up the held up at this depth which
might have resulted in subsequent loss of brine at this depth and due to inadequate filling
of cased hole during pull out as hole filling was done manually through mud pump and
trip tank was not in operation. The mud level/brine level indicator/totalizer to monitor tank
level was not in place.

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applicable in your operations, to avoid recurrence of such incidents.
 Commonly used overbalance levels are 200 psi for oil wells and 300 psi for gas wells and
are sufficient to control the entry of formation fluid which was not maintained.
 It is evident from the work over plan of this well that severe to total mud loss had been
experienced in the section of 968 to 971 meters during drilling.

 The low pressure created due to significant loss of hydrostatic head in cased hole at
depth of 970.5 M and created a favorable low pressure area for air influx toward it. Again,
high permeability to the tune of 5-15 Darcy of the reservoir and high mobility of air under
pressure overcame the mobility of reservoir fluid (Oil and brine) and easily broke in the
well and thereby caused uncontrolled gushing due to open bonnets of pipe ram of BOP
on well head.
 It is notable that all the pay sands in this formation’s oil field had intercommunication as
all these pay-sands merge at the central–crestal part of the field.
 There were 27 active air injectors and recent open hole and cased hole logs had
established that all pay sands were saturated with flue gases. This implies that all the pay
sands were under influence of air injection.
 The integrity of casing was not tested and ensured.
 Specific safety aspects for workover services in flue gas charged EOR oil field and
management thereof had not been provided in the work over plan.
 The shift crew did not ensure subdued condition of well prior to undertaking the activity of
changing of Rams in the BOP.
 Specific SOP on ram changing operation on well head was not available at site.
 JSA for ram changing operation of BOP on well head was not carried out.
 The risk associated with RAM change operation was not discussed in Tool Box Talk.
 At Accumulator unit blind ram lever was in closed position and pipe ram lever was in
neutral position while all pressure gauges on accumulator unit were showing zero
pressure. No oil was observed in accumulator reservoir.
 The well-kept closed on blind ram prior to ram changing operation and crew did not open
the blind ram before opening of bonnet bolts for observing any activity in the well.
 Only shift mechanic and one rig man (two persons) were engaged to change the ram
without any proper supervision during such a critical operation. These two crew members
were not competent enough to carry out such critical operation as they were not trained
on well control.
 Rig crew was not equipped enough to handle well control technique/emergency.
 The contractor shift coordinator had not provided complete supervision for all activities
associated with work over operations including the activity of ram changing operation and
also, he had not undergone any well control training.
 During interaction with concerned crew members, it was informed that key persons were
not involved in key operations such as ram changing job mainly due to nighttime.
 CCTV recording of operations was not being monitored for addressing unsafe conditions
and unsafe acts.
ROOT CAUSE OF THE INCIDENT

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applicable in your operations, to avoid recurrence of such incidents.
 Lack of proper planning of work over operation.
 The integrity of well/casing.
 Work over plan was not reviewed even after observing suspected casing damage for
changing the plan to that effect but continued with initial plan.
 Lack of proper supervision during critical operations.
 Lack of competency & training.
 Failure of primary barrier (Loss of hydrostatic head).
 Lack of SOP/JSA.

RECOMMENDATIONS
 Report, discuss and deliberate all the critical observations and developments noticed
during workover operation such as suspected casing damage in this case with all
concerned teams viz. Subsurface, Surface, Well Services & Logging Teams and
accordingly make changes in the well plan with the provisions of safety aspects as per
HLC recommendations on Baghjan incident.
 Integrity of casing should be checked during work over operations specially the operation
of In- Situ Combustion areas and it should be reflected in the well plan.
 The integrity of well/casing should be tested as per clause 7.10.4 of OISD-RP-238 which
says “After stabilizing the well, observe the well for the time period equivalent to the
anticipated time required to remove X-mas tree and installation of BOP plus safety
margin. If well remains stable, one complete cycle of circulation is to be given prior to
removing X-mas tree for BOP installation. High viscous pill may also be placed to
minimize gas migration in gas wells”.
 Ensure that well servicing operation is done under the direct supervision of a competent
person authorized for the purpose specially critical jobs such as ram changing job as per
Reg 77(d) of OMR, 2017.
 Training requirement for IM, Safety officer, RIC, Shift In charge, Asst. Shift In charge and
other crew member shall be identified as per the requirement of OISD-STD-176.
 JSA should be carried out for all critical and non-routine jobs as per OISD-GDN-206 &
OISD-STD-105.
 Use of variable rams where tubular of different sizes are likely to be used to avoid
process of changing of rams of BOP on wellhead. Variable ram to close against pipe if
multiple size of string is in use as per clause 6.3 (IV)(VIII) of OISD-RP-174.
 ONGC shall review the contract requirement of drilling and workover rigs.
 Internal safety audit should be carried out by a multidisciplinary team on yearly basis as
per the requirement of OISD-STD-145 in line with the OISD checklist.
 The workover operations shall also be monitored randomly through available CCTV
system for identifying unsafe act/ unsafe condition for timely corrective actions.
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Provided for information purpose only. This information should be evaluated to determine if it is
applicable in your operations, to avoid recurrence of such incidents.
Provided for information purpose only. This information should be evaluated to determine if it is
applicable in your operations, to avoid recurrence of such incidents.