1. 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

2. 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

3. 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

4. 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

5. 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.

6. 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

7. 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

8. 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

9. 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)

10. 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.

11. 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

12. 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

13. 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

14. 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

15. and the API Bolting Work Group (Implementation)
Bolting Timeline
Includes activities of both the API Multi-Segment Task Group (Standards)
and the API Bolting Work Group (Implementation)
1220 L Street, NW • Washington, DC •

16. 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 H4 Wellhead connector bolting
Entries include H4 connector, bonnet bolts, hinge bolts, blind shear blade bolts, and others.

17. Using CI & Reliability Data to Increase BOP Performance

18. 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.

19. A Manufacturer’s Product Improvement Process

20. 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

21. Thank You