Root Cause Failure Analysis I conducted my most recent RCFA on a Colorado well completion operation From the perspective of an Oil and Gas Company that has not experienced the failure of a critical bolt. No involvement in the RCFA processes that others conducted Aware of the root causes that have been shared, but not the processes that allowed those conclusions I am however very pleased to have been a part of the information Sharing and Collaboration we experienced yesterday. In Support of Improved System Reliability April 11, 2017

The Root Cause is… Heat Treating Process Susceptibility to Embrittlement Casting Process Component Design Threading Method Forging Process Bake-Out Process Banding Installation Coatings Hardness Biological Stress Condition There was some great information sharing yesterday. I wish I could suggest the best methodology for identifying the root cause of bolting failures. I think that might be best left to a collaborative process among Subject Matter Experts and experts in RCFA. Cathodic Protection Environment Manufacturing Thread Lubricant Bad Specification Multiple Causes

Starting the Conversation RCFA is intended to identify the most basic reason(s) for the failure of a component RCFA is used in many industries and by our government The specific RCFA methodology is selected and matched to purpose For critical or complex applications, RCFA can be conducted in a sophisticated layered approach Greatest familiarity with the equipment. Collaboration with the drilling contractor and the Oil and Gas Company can further

RCFA - Highest Level Objectives Improve the Quality and Reliability of a System, especially Safety Critical Equipment Operate in a Safe and Environmentally Responsible Manner Protecting people and the environment are our top priorities

Root Cause Failure Analysis Root Cause Definition - The most basic reason for failure, which, if eliminated, changed, or controlled, would allow the system to operate in the intended way. In a simple problem, there may be a single “root cause” In more complex problems, multiple causal agents may be identified RCFA Output – The cause(s) identified should be specific and “actionable” RCFA Purpose - The output of a RCFA is information that can be used to improve performance of a component by improving its design, manufacture, installation, operation, or maintenance.

Bolting Reliability There are as many as ~844 critical bolts, studs, and nuts on a deepwater 7-ram BOP stack (Combined Upper and Lower BOPs). A flanged drilling riser deployed to 6,000 ft water depth has 450 bolts and 450 inserts (nuts). The current 39 deepwater rig count could have ~60,000 critical bolts deployed. Assuming 40 deepwater rigs/year in the GoM since 2003 => ~800,000 bolt-years (assumes 6-ram BOPs and 6,000 ft water depth). Reliability between ~10-4 to 10-5 (need actual BOP and riser utilization by rig for 2003 – 2017 to refine)* * Expected to improve with the implementation of API 20E

Improved Reliability following an Undesired Occurrence Root Cause Analysis is a tool used to reach the objective Existing Reliability Improved Reliability Undesired Occurrence Collect Evidence Identify Root Cause Implement Solution Monitor Results Capture Data & Material Utilize Root Cause Methods Develop & Implement Solution

Select RCFA Methodologies based on Problem Complexity The following are some of the methods that are being used in the deepwater Oil and Gas Industry today. 5 Whys? Fishbone Cause – Effect Event Timeline Fault Tree Apollo Shainin System Physical Testing of Components – Establishing proof of finding the Root Cause – Can the effect be duplicated in testing? Looks for missing or ineffective control Brainstorm of Possible Causes – categorized by theme

PROBLEM: The vehicle will not start. RCA Example – The 5 Why’s PROBLEM: The vehicle will not start. Why? - The battery has no charge. Why? - The alternator is not working. Why? - The alternator belt has broken. Why? - The alternator belt was well beyond its useful service life. Why? - The vehicle was not maintained according to the recommended service schedule. (The root cause)

RCA Example – Fishbone (Ishikawa) Diagram A structured approach to identify and group potential causes for an effect or problem. It can be used capture ideas from a brainstorming session. Ask “Why could it Happen?” to add branches.

RCA Example - Apollo Analysis Combining Actions and Conditions Developed following the 1979 Three Mile Island Nuclear Power Plant Incident Action Shift Change Action Condition Property Damage Why? Arc Flash Repair In Progress Caused by? Fire Condition Condition Combustible Materials Energized Circuit Condition Oxygen

API Multi-Segment Task Group IADC/IOGP BOP Reliability Industry Approach to Improved Bolting Reliability API Multi-Segment Task Group API Bolting Workgroup IADC/IOGP BOP Reliability Manufacturers

Improving Reliability following an Undesired Occurrence Design Manufacture Quality Operation Industry Standards Voluntary Response (e.g., BSEE Safety Alert 318) Undesired Occurrence Determine Cause Corrective Action Industry Practices Manufacturer Specifications Product Guidance Issue Alert to Industry Utilize Root Cause Methods Manufacturer’s Engineering Bulletins Sustainable Capture of Expectations & Requirements Audit Practices

Industry’s Multiple Paths to Improved Bolting Reliability API Standards - Multi-Segment Task Group Since 2014 API Bolting Workgroup Response to BSEE Safety Alert 318 Industry BOP Reliability Database Manufacturer’s Internal Processes for Continuous Improvement

and the API Bolting Work Group (Implementation) Bolting Timeline 2014 - 2016 Includes activities of both the API Multi-Segment Task Group (Standards) and the API Bolting Work Group (Implementation) 1220 L Street, NW • Washington, DC 20005-4070 • www.api.org

IADC/IOGP BOP Reliability Data Base Supported by Oil & Gas Companies, Drilling Contractors, and Equipment Manufacturers ~2750 Entries (as of Early April 2017) Populated with recent bolting failure information Oldest bolting entry 2013 - H4 Wellhead connector bolting Entries include H4 connector, bonnet bolts, hinge bolts, blind shear blade bolts, and others.

Using CI & Reliability Data to Increase BOP Performance

RCFA also required for inadequate component design/configuration. Root Cause Categories A RCFA is required if the failure resulted in the loss of a well barrier, an unplanned BOP/LMRP recovery, or a systemic/reoccurring event. RCFA also required for inadequate component design/configuration. Otherwise, Root Cause can be categorized in the Database under: Maintenance: Mistake, misuse or oversight during maintenance. Procedural: Mistake, misuse or oversight during operation. QA/QC Manufacturing: Failure related to manufacturing. Wear and Tear: A component that has reached a point where it cannot perform its intended function as the result of use. Human Error: Errors in judgment and behavior.

A Manufacturer’s Product Improvement Process

In Summary Documenting failures in an Industry database Oil and Gas Companies, Drilling Contractors, and Equipment Manufacturers are actively working together to improve bolting reliability. Documenting failures in an Industry database Developing the Root Cause of the reported BOP failures Developing RCFA skills Responding to the Root Cause with Corrective Actions API Multi-Segment Task Group Developing Enhanced Standards API Bolting Workgroup Drilling Contractors Executing Voluntary Industry Actions (Bolt Replacement) Tracking Actions and Bolting Performance Manufacturers Applying Updated Standards to Manufacturing Processes

Thank You