OCS Report 

 MMS 2007-037

Investigation of Fatality and Loss of Well Control 

High Island Block A466, Well No. B-11 

OCS G-03242 

20 February 2006 

Gulf of Mexico 

Off the Texas Coast 

U.S. Department of the Interior 

Minerals Management Service New Orleans 

Gulf of Mexico OCS Regional Office June 2007
 OCS Report 

 MMS 2007-037

Investigation of Fatality and Loss of Well Control 

High Island Block A466, Well No. B-11 

OCS G-03242 

20 February 2006 

Gulf of Mexico 

Off the Texas Coast 

J. David Dykes – Chair 

Richard Clingan 

Jim Hail 

Frank Patton 

U.S. Department of the Interior 

Minerals Management Service New Orleans 

Gulf of Mexico OCS Regional Office June 2007
Contents 

Executive Summary 1 

Introduction 2 

Authority 2 

Background 2 

Findings 3 

Physical Living Conditions Onsite 3 

Preliminary Activities – Plug and Abandonment Procedures 3 

Activity Subsequent to the Incident 5 

Incidents of Noncompliance Issued 6 

Blowout Prevention Equipment Information 7 

Tubing Specifications 8 

Job Safety Analyses 11 

Observed and Documented Unsafe Acts 13 

Project Management 15 

Forest Oil Corporation Management Responsibilities 15 

Twachtman, Snyder & Byrd, Inc., Management Responsibilities 20 

Conclusions 27 

Causes 27 

Contributing Causes 27 

Possible Contributing Causes 28 

Offsite Management Failures 28 

Onsite Management Failures 31 

Recommendations 34 

Appendix 

Attachment 1 – Location of Lease OCS-G 03242, High Island Block A466, Platform B 

Attachment 2 – Photograph of High Island Block A466 Platform “B” 

Attachment 3 – Diagram of Approved BOP Configuration 

Attachment 4 – Photograph of BOP Stack on Location 

Attachment 5 – Photograph of TSB Crewmember Working Without Fall Protection 

Attachment 6 – Photograph of Bleeding Gas at BOP Stack 

Attachment 7 – Photograph of Pollution 

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Attachment 8 – Forest Oil Company Chain of Command (At Time of Incident) 

Attachment 9 – Twachtman, Snyder & Byrd, Inc., Chain of Command (Normal P&A 

Operations) 

Attachment 10 - Twachtman, Snyder & Byrd, Inc., Chain of Command (HI A466 P&A 

Operations) 

ii
Executive Summary 

An accident that resulted in one fatality and a brief loss of well control occurred on Forest Oil 

Corporation’s (FOC) Platform B, High Island Block A-466, Well B-11, Lease OCS-G 03242 in the Gulf 

of Mexico, offshore the State of Texas, on February 20, 2006, at approximately 0820 hours. Forest Oil 

Corporation had hired the contractor, Twachtman, Snyder & Byrd, Incorporated (TSB), to conduct plug 

and abandonment operations on Well B-11. 

From February 14, 2006, to February 19, 2006, plug and abandonment operations were being conducted 

on the subject well. The tubing was being stripped out of the hole by using a hydraulic rig (casing jacks) 

when the tubing became stuck on February 19, 2006. On the morning of February 20, 2006, an attempt 

was made by FOC’s “company man” to pull the tubing, when the tubing parted. The parted tubing was 

forced upward, causing the top slips to be ejected from the top bowl of the casing jacks. The ejected slips 

fatally struck FOC’s “company man” as he attempted to evacuate the immediate area. 

This investigative panel has concluded, based on information in the report findings, that the deceased 

exceeded the yield strength of the tubing when he pulled approximately 135,000 pounds on the tubing, 

causing it to part. This resulted in the tubing and slips being ejected from the wellbore, the slips fatally 

striking the deceased as he attempted to evacuate the area, and a brief loss of well control. It is also the 

conclusion of this panel that the deceased did not calculate enough of a safety factor when he determined 

maximum amount pull for the grade of pipe. Furthermore, this panel concludes that the lack of 

appropriate equipment (snubbing unit) and appropriately trained personnel are contributing causes to this 

incident. Additionally, poor judgment and decisionmaking by the deceased and TSB’s field supervisors 

on the platform are also considered contributing causes to this incident. This investigative panel has also 

concluded that ineffective management and supervision of the operation by both FOC and TSB (at all 

levels) is a possible contributing cause of this incident. Upper management at FOC and TSB were 

detached from the field operation and failed to provide direct oversight and control. At TSB, no effective 

chain of command structure was in place and no one in the office was overseeing the operation. FOC 

relied entirely on consultants to supervise the operation onsite and offsite. The deceased exceeded his 

authority and made operational decisions on behalf of FOC and TSB without input from management. 

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Introduction 

Authority 

An accident that resulted in one fatality and a brief loss of well control occurred on Forest Oil 

Corporation’s (FOC) Platform B, High Island Block A-466, Lease OCS-G 03242 in the Gulf of Mexico, 

offshore the State of Texas, on February 20, 2006, at approximately 0820 hours. Pursuant to 43 U.S.C. 

1348(d)(1) and (2) and (f) [Outer Continental Shelf (OCS) Lands Act, as amended] and Department of the 

Interior regulations 30 CFR 250, the Minerals Management Service (MMS) is required to investigate and 

prepare a public report of this accident. By memorandum dated February 23, 2006, the following 

personnel were named to the investigative panel: 

J. David Dykes, Chairman – Office of Safety Management, GOM OCS Region; 

James Hail – Lake Jackson District, Field Operations, GOM OCS Region; 

Frank Patton – New Orleans District, Field Operations, GOM OCS Region; 

Richard Clingan – Accident Investigation Board, Office of Offshore Regulatory Programs, 

Offshore Minerals Management 

The panel members met numerous times throughout the investigation to conduct interviews, review the 

facts of the incident, draw necessary conclusions, and prepare this report. 

Background 

Lease OCS-G 03242 covers approximately 5,760 acres and is located in High Island Block A-466, Gulf 

of Mexico, off the Texas Coast. (For lease location, see Attachment 1.) The lease was issued to Atlantic 

Richfield Company, effective September 1, 1975. Forest Oil Corporation became owner and designated 

operator of the lease on December 7, 2000, and was the operator of record at the time of the incident. 

Mariner Energy, through a merger/acquisition, has become the designated operator of the lease. 

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Findings 

Physical Living Conditions Onsite 

This job was taking place on platform “B” in High Island Block A466. “B” platform is an eight-pile 

structure with a top deck and a cellar deck. The top and cellar decks have an approximate dimension of 

130 ft by 60 ft. (See Attachment 2 for Photograph of Platform.) 

This is an unmanned facility that has been targeted to be plugged and abandoned. The platform is 

equipped with a 10-feet by 20-feet emergency quarters/office building designed only to provide shelter in 

inclement weather. According to the TSB personnel interviewed, the TSB crew would use a portable 

6-man sleeper/office and the quarters available on the field boat (M/V Lytal Queen). The only bathroom 

facilities were the use of a port-o-let (porta-potty) on the platform and the bathroom facilities on the boat. 

Meals were prepared on the boat by the crew of the M/V Lytal Queen. Lifesaving equipment consisted 

of two life-floats and eight life ring buoys. There is an escape capsule on the platform; however, it out of 

service. 

Preliminary Activities - Plug and Abandonment Procedures 

The regulations at 30 CFR 250.613(b) require in part that the following information be submitted with 

MMS Form 124: 

• A brief description of the well workover procedures to be followed, a statement of the expected 

surface pressure, and type and weight of workover fluids; 

• When changes in existing subsurface equipment are proposed, a schematic drawing of the well 

showing the zone proposed for workover and the workover equipment to be used; 

On May 5, 2005, Forest Oil contracted Tetra Technologies to conduct a turnkey abandonment of 11 wells 

on HI A466 Platform B. The original procedure to abandon this well was submitted to MMS Lake 

Jackson District Office on July 11 and approved July 12, 2005. This procedure was a standard procedure, 

but did not indicate the type of equipment that would be used to accomplish the abandonment. The 

procedure only mentioned pumps and wireline operations. On October 10, 2005, verbal approval was 

granted to Forest Oil allowing a coil tubing unit to remove obstructions on wells B-8, B-10, and B-11. 

Tetra began work on B-11 on October 19, 2005, using coil tubing equipment, but shut down the 

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operation on October 21, 2005, after several unsuccessful attempts at retrieving the subsurface safety 

valve (storm choke). Tetra rigged down their equipment and secured the well with approximately 1,000 

psi on the casing and the storm choke stuck in the landing nipple at 629 feet measured depth. 

A revised procedure was submitted and approved on December 8, 2005, for the use of a snubbing unit 

with additional pumping equipment. The procedure did not indicate that there would be a pressure 

problem. It stated they would fill the casing and tubing with fluid. Just prior to the beginning of 

operations, another revised permit was submitted on February 9 and approved on February 14, 2006, to 

use casing jacks. The revised procedure submitted to MMS was the same procedure previously submitted 

and approved by MMS, with casing jacks substituted for snubbing equipment. FOC contracted TSB to 

complete the plug and abandonment of the B11 well. 

When operations began on February 14, 2006, the shut-in tubing pressure was 1,900 psi, which was bled 

to zero. The shut-in casing pressure was 700 psi, which could not be bled to zero. A plug was set in the 

tubing with a slickline unit at 300 feet wireline measurements, and the blowout preventers (BOP) were set 

up. The installation of the BOP’s and testing continued on the 15th and 16th, and the operations began on 

the 16th, when TSB released the packer on the tubing string. Four barrels of weighted fluid were pumped 

down the casing to fill the hole prior to releasing the packer. 

In an e-mail dated February 14, 2006, from the deceased to the president of TSB, the deceased discussed 

killing the subject well with seawater. The e-mail reads as follows: 

The tubing had a SITP of 1900 psi. The tubing will bleed to 0 psi within 20 seconds of opening 

the choke. The production casing had a shut-in pressure of 700 psi. We are presently testing the 

intermediate casing. We will N/U BOPs afterwards. I will contact you and D.J. when we have a 

better idea of the timing for pulling the packer free. We intend to use the production casing as a 

means to pump into the well or to keep the hole full while pulling tubing. A column of seawater 

from the surface to the packer has a hydrostatic equivalent of 4242 psi the tubing builds up to 

1900 psi with 0 fluids when bleeding down. The column of fluid in the casing will have a greater 

hydrostatic pressure than the well. This will allow you to have sufficient fluid to kill/control the 

well once the packer is released and the fluid can reach the perforations. 

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Operations began on the 17th to start pulling tubing from the well by using the casing jacks. The 

operation involved stripping the tubing through the annular preventer. Stripping pipe through the annular 

preventer is a critical operation because this task can damage the annular element. Eight joints of tubing 

were removed. The well began flowing 1⁄4 barrel per minute of 8.6-ppg fluid and the crew initiated “lube 

and bleed” operations to try to control the flow. TSB crewmembers stated during the interviews that they 

would just fill the hole and bleed it off. The crew continued having trouble controlling the pressure on the 

well and only one additional joint of tubing was removed prior to the accident. 

According to the TSB crewmembers, the lubrication and bleed procedures consisted of the following: 

• Pump seawater into the casing. 

• Wait anywhere from 5 to 60 minutes for fluid to fall. 

• Bleed off gas pressure either through the gas buster or directly at the choke/kill spool at tree. 

According to the TSB daily report dated February 18, 2006, the crew pumped 42 bbls of seawater into the 

casing from 0001 hours to 0200 hours. Pressure rose to 3,000. They monitored for 15 minutes, then bled 

off the pressure and got back 39 bbls of fluid. From 0200 hours to 0400 hours, they pumped 40 bbls of 

seawater and monitored for 15 minutes. From 0400 hours to 0600 hours, the pumped an additional 30 

bbls of seawater and monitored for 15 minutes. At 1300 hours, they pumped 100 bbls for three hours. 

From 1600 to 1800 hours, they attempted to bleed pressure off the casing and got back 75 bbls of fluid. 

The industry-accepted practice of lubricating and bleeding operations includes the following key points: 

• Determine pressure on casing, including hydrostatic pressure of the formation. 

• Determine hydrostatic equivalent for volume of fluid to be pumped. 

• Pump fluid into the wellbore or annulus and allow it to fall. 

• Allow sufficient time (at least a half hour) for the well to stabilize. 

• Bleed off pressure of gas equivalent to the hydrostatic pressure of the volume of fluid pumped. 

Activity Subsequent to the Incident 

After the accident, a procedure for using a snubbing unit was submitted, and the operation was 

successfully completed. This operation included removing the equipment stuck in the hole, circulating a 

proper density kill fluid, setting cement plugs, and removing the tubing from the wellbore. The initial 

5
procedure to use a snubbing unit, approved in December, did not address the storm choke stuck in the 

tubing, but could have effectively handled this problem. Using the casing jacks, TSB was trying to get 

the tubing out of the hole to the obstruction; hot tap the tubing below the obstruction, equalizing the 

pressure and fluid level in the tubing and casing annulus; and then proceeding with the plugging 

operations. The use of casing jacks presupposes that the well is dead. 

Incidents of Noncompliance Issued 

On March 2, 2006, the MMS Lake Jackson District Manager requested a meeting with Forest Oil 

Company to discuss the fatality at HI A466 ‘B’ and the safety and planning for the latest proposed plug 

and abandonment (P&A) procedures, schedules, service companies and the equipment to be used. 

Representing Forest Oil were the Gulf Coast Region Manager; the Project Manager for HI A466 B-11 

P&A; the Assistant General Counsel; the Vice-President of Shelf and Offshore; and the Environmental, 

Health, and Safety Manager. 

 

During the meeting on March 2, 2006, MMS issued four Incidents of Noncompliance (INC) to Forest Oil 

and they are listed below: 

• G-112 C Lessee does not provide for the safety of all personnel and take necessary precautions 

to correct and remove any Hazardous Oil and Gas accumulation or other health, safety, or fire 

hazards (RE: Grating missing from casing jack at the well slot B-11, bolts missing from casing 

jack riser joints). 

• Z-135 C At the BOP’s and well tree, the deck does not have suitable guards or handrails. 

• W-122 C No remote control station in a readily accessible location. 

• W-120 C No automatic backup accumulator charging system with a power source independent 

from the power source of the primary accumulator charging system. 

MMS issued four additional INC’s to the operator on March 3, 2006, and forwarded those to the operator 

by mail. Those INC’s were as follows: 

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• W-162 W All records, including pressure charts, operations logs, and reference documents of 

BOP tests, actuations, and inspections, were removed from the facility. 

• G-116 C Operations were not conducted in accordance with approved plans (RE: rigging down 

and removal of casing jack). 

• W-115 C MMS’s approval of 2 pipe rams, 1 blind ram, 1 annular; (Lessee only installed 1 pipe 

ram, 1 blind ram, and 1 annular) 

• W-153 C The Well #B-11 was not equipped with a pump-through type tubing plug and a backpressure valve prior to removal of the tree. 

Blowout Prevention Equipment Information 

The approved permit displayed a drawing of the blowout preventer (BOP) stack to be used. The diagram 

shows a 7 1/16 inch, 5000-pound BOP with 1 annular, 2 pipe rams, 1 blind ram, and a spool with a proper 

choke kill valve configuration. (See Attachment 3 for diagram of approved BOP configuration.) 

Observations made following the incident indicate that the BOP stack was not configured as approved. 

The configuration of the BOP stack consisted of 1 annular, 1 pipe ram, 1 blind ram, and a choke/kill 

Spool. The choke/kill spool consisted of 1 manual valve for the choke line and 1 manual valve for the kill 

line. (See Attachment 4 of picture of BOP stack on location.)

According to the approved procedures dated February 14, 2006, the BOP’s were to be tested by using sea 

water to 250 pounds for the low and 5,000 pounds for the high. The TSB morning report of 

February 16, 2006, states that the BOP’s were tested from 11:30 to 12:30 with 250 pounds for the low and 

3,000 pounds for the high. Each was tested for 15 minutes apiece. The total test time was one hour. 

According to the TSB day-crew supervisor’s tally book, on the fifth page it was recorded, “nipple up 

BOPs from 11:30 – 12:30 and test from 12:30 – 15:30.” This indicates a total test time of three hours. 

The regulations at 30 CFR 250.615(c) state in part that the BOP systems for well workover operations 

with the tree removed shall be equipped with......a choke line and a kill line each equipped with two full 

opening valves and a choke manifold. At least one of the valves on the choke-line shall be remotely 

7
controlled. At least one of the valves on the kill line shall be remotely controlled, except that a check 

valve on the kill line in lieu of the remotely controlled valve may be installed, provided two readily 

accessible manual valves are in place and the check valve is placed between the manual valves and the 

pump. (See Attachment 4 of picture of BOP stack on location.) 

The regulations at 30 CFR 250.616(a), “Blowout preventer systems testing, records, and drills,” state that 

prior to the conducting of high-pressure tests, all BOP system components shall be successfully tested to a 

low pressure of 200 to 300 psi. Ram-type BOP’s, related control equipment, including the choke and kill 

manifolds, and safety valves shall be successfully tested to the rated working pressure of the BOP 

equipment or as otherwise approved by the District Manager. 

The regulations at 30 CFR 250.616(d) state that the lessee shall record pressure conditions during BOP 

tests on pressure charts, unless otherwise approved by the District Manager. The test interval for each 

BOP component tested shall be sufficient to demonstrate that the component is effectively holding 

pressure. The charts shall be certified as correct by the operator’s representative at the facility. 

The regulations at 30 CFR 250.616(e) state that the time, date, and results of all pressure tests, actuations, 

inspections.....shall be recorded in the operations log. The BOP tests shall be documented in accordance 

with the following: (1) The documentation shall indicate the sequential order of BOP and auxiliary 

equipment testing and the pressure and duration of each test. 

Neither Forest Oil nor TSB have provided a BOP test chart as proof of the BOP having been tested. In all 

of the records supplied to the investigation, there is no record of other BOP components and/or valves 

being listed as tested. 

Tubing Specifications 

The High Island Block A-466 Well B11 was originally drilled and completed in 1989. There have been 

no sidetracks, bypasses, or re-completions on this well; therefore, the tubing in the well is approximately 

17 years old. It is not known whether or not this tubing had been used in an earlier well completion. The 

tubing string identified in the plug and abandonment procedures, submitted to MMS on 

December 8, 2005, had the following specifications: 

8
O.D 

(inch) 

Weight 

(lb/ft) Grade Connection Set Depth 

2 7/8” 6.5 L80 EUE 9590’ 

According to the Halliburton Cementing Tables Handbook, the Western Engineers Handbook, and the 

Association of Energy Service Companies Basic Data Manual, this tubing has a joint yield strength of 

145,000 pounds. 

During the interviews, the TSB day-crew supervisor stated that he recalled that the TSB job supervisor 

(the deceased) informed him that the breaking strength of the tubing was approximately 140,000 pounds 

and that the maximum pull should not exceed 120-130,000 pounds (approximately 80-90% of the actual 

joint yield strength of 145,000 pounds). 

The daily morning reports do not disclose the maximum allowable pull weight for the tubing string; 

however, it is noted on the report dated February 16, 2006, that the tubing was worked from 68,000 to 

98,000 pounds until the packer released. It is also noted on the daily report dated, February 19, 2006, that 

130,000 pounds were pulled on the tubing in attempting to free the stuck tubing. Furthermore, the TSB 

night-crew wireline operator stated during the interview that he was operating the casing jacks when the 

130,000 pounds were pulled. He indicated that he left the pipe in tension with 113,000 pounds on the 

tubing. He further stated that he showed the TSB job supervisor (the deceased) where the pipe had 

stretched. 

Post-incident evaluation/analysis of the hydraulic power pump was conducted by FOC and Deepwell 

Rentals at the Deepwell Rentals Houma facility. Upon receiving the pump at Deepwell, the relief valve 

for the hydraulic power pump was tested and the set point was found to be 1,200 psi. This set point 

indicates a pulling capacity of 135,720 pounds. 

FOC obtained the services of Exponent Failure Analysis Associates (EFAA) to conduct an examination 

of the parted tubing sections to determine if any deficiency in the tubing caused or contributed to the 

parting of the tubing joint. FOC advised EFAA that destructive testing of the parted tubing sections 

9
should not be undertaken; however, FOC did provide EFAA with an additional joint of identical tubing 

from the same tubing string from the subject well. The following is taken in part from EFAA’s analysis 

summary report: 

“......The tubing of both the accident and exemplar was measured to be 2.91 inches diameter, with 

a wall thickness of 0.25 inches. The intact exemplar section of tubing was 32 feet 9 inches long. 

The accident tubing was in two sections, and had been stretched as a result of the applied forces, 

so its original length could only be estimated to be approximately the same as the exemplar 

tubing section. Based on the results of the testing described below, I determined that the tubing 

was produced to API Specification 5A, Grade N-80. 

The exemplar section of tubing was destructively tested to the requirements of API Specification 

5A, Grade N-80 (March 1982) by machining the specified tensile samples and pulling them to 

failure. The exemplar tubing was found to meet all of the tensile requirements (yield strength, 

tensile strength, and elongation) of the 5A, Grade N-80 specification. Hardness testing was also 

performed on five sections of the exemplar tubing for comparison to hardness testing that was 

performed on the accident section of pipe. Within the experimental error inherent in hardness 

testing of intact tubing with a portable hardness tester, the accident tubing was found to meet the 

tensile requirements of API Specification 5A with an estimated tensile yield stress of 

approximately 85,000 psi (pounds per square inch). 

Further, the fracture region of the subject pipe was examined optically and by measurements. 

Significant ductile elongation and reduction of area was observed at the fracture site, confirming 

that the tubing was sufficiently ductile and free of metallurgical or geometric stress risers. The 

absence of anomalies on the fracture surface is further evidence that the accident tubing was free 

of defects. 

To compare the strength of this tubing to the specifications published in the Halliburton 

Cementing Tables Handbook ........it is necessary to convert the intrinsic yield stress of the tubing, 

in pounds per square inch, into the strength of the tubing, expressed in pounds. The area of the 

tubing, in square inches, can be computed from the formula for the area of a hollow circle 

10
Area = π/4(D2

-d2) 

where D is the outer diameter of the tubing and d is the inner diameter of the tubing. 

For 2.875 inch tubing with a 2.441 inch inner diameter, the area of the tubing is 1.812 square 

inches. Multiplying this area by the minimum yield stress of the tubing, 80,000 pounds per 

square inch, yields an overall strength of 144,960 pounds, which is exactly the value found in the 

Halliburton Cementing Tables Handbook for 2.875 inch tubing joint yield strength for an upset 

threaded and coupled joint of N-80 tubing. 

Following this analytical technique, the panel applied the same formula, and using the actual tensile yield 

of 85,000 pounds per square inch (determined from the destructive testing by EFAA), calculated that the 

yield on the subject pipe was approximately 154,020 pounds. EFAA described the destructive test 

method during a follow-up interview and indicated that the environmental conditions (age, corrosion, 

internal/external pressure, etc.,) of the subject pipe could have reduced the actual yield of the subject pipe 

by approximately 15-20 percent. This reduction indicates a calculated potential yield range of 123,216 

pounds to 130,917 pounds. 

Job Safety Analyses 

Numerous job safety analyses (JSA) were created during this plug and abandonment job. The panel 

reviewed approximately 32 JSA’s that were used over the course of seven days. These JSA’s covered the 

following eleven topics: 

Rig Up and Pull Tubing with Casing Jacks Bullhead Down Tubing Crane Operations 

Rig Up Plug & Abandonment Equipment Boat Work Police Deck 

Nipple Up Blowout Prevention Stack Mixing Cement Cutting With Torch 

Break Out Tubing Pumping Operations 

A review of the JSA’s by panel members revealed the following: 

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• The JSA’s are generated on the computer by the TSB crew supervisors. Areas covered in the 

JSA’s include Protective Equipment Required or Recommended, Safety Measures Required or 

Recommended, Required Appropriate Work Permits, Personnel Required to Perform This Job, 

List Specialized Equipment Required by Job Scope, and List Basic Steps Required for Safe 

Completion of Job. There is no reference in the JSA’s to specific pieces of equipment for which 

the hazards need to be avoided. 

• Most of the JSA’s are generic in content. Very few are specific with respect to what equipment is 

to be used and/or specific steps for setting up the equipment. Most of the hazards that are 

identified are the generic slip, trip, and falls; pinch points; hearing hazards; etc. No hazards were 

identified for the specific operation. 

• All of the JSA’s identify the number of personnel required for the job tasks; however, according 

to a tally of the signatures of the participants, most of the JSA’s did not have enough participants 

to conduct the jobs. 

• Hot work was conducted on February 14, 2006. According to the hot work permit, the flowline 

flange was cut away. Hot work was again conducted on February 16, 2006. According to this 

hot work permit, the grating around the well-head was removed. Neither of these specific jobs 

included a JSA for the work to be conducted. 

• During the interviews, some of the TSB crewmembers stated that JSA’s were discussed and 

reviewed during every pre-job safety meeting prior to starting their tour, while other TSB 

crewmembers indicated that the JSA’s were not discussed or reviewed and safety meetings were 

not conducted. These crewmembers indicated that they were instructed to sign the JSA’s prior to 

beginning work. 

• There was no JSA created for the “lubrication and bleeding” of fluid into the production annulus 

of the well to kill the well. 

• There was no JSA created for taking returns to the gas buster following the “lubrication and 

bleeding” process. 

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• TSB had a JSA for Rigging Up & Pulling Pipe with Casing Jacks. This JSA did not specifically 

address stripping pipe under pressure with the casing jacks. 

Observed and Documented Unsafe Acts 

During the interviews, several TSB crewmembers expressed their concern about the use of casing jacks. 

The day-crew electric line operator stated that casing jacks are not considered normal for this type of job. 

The day-crew wireline operator also stated “nothing about this job was normal.” He further stated that he 

voiced his concern to the deceased and that he [the deceased] appeared to be in another world. The nightcrew senior pump operator stated that he questioned the deceased at the dock about not using a snubbing 

unit. He stated that the deceased told him that the decision was his [the deceased]. 

TSB crewmembers stated that the annular control lines were reversed. Further, several crewmembers 

stated that the remote BOP control station was either not hooked up or did not function, while other 

crewmembers stated that the remote station was hooked up and did function. Further testimony indicated 

that the remote station shared the same air supply line as the crane. According to the TSB crewmembers 

onsite at the time of the incident, they shut in the BOP from the accumulator unit located on the 

well/production deck and not from the remote BOP station (located on the main/top deck). 

During a review of pictures taken by a TSB crewmember, another TSB crewmember was observed 

operating the choke on the gas buster. The choke is located on top of the trip tank at an elevation greater 

than six feet off the deck and near the outside edge of the platform (See Attachment 5 of photograph of 

TSB crewmember working without fall protection). TSB’s Supervisor’s Health/Safety/Environmental 

Manual and Training Guide (Safety Manual) states in the section titled “Personal Protective Equipment 

Programs,” subsection “Fall Protection,” the following: 

Safety harnesses.....are mandatory when working above the ground. This equipment must be 

worn and tied off to independent life lines, overhead pipe or structures when working from 

elevated areas under the following conditions: 

• Working six feet above ground elevation or platform 

• Two-point suspension scaffolds or stages are in use 

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• Working off scaffolds 

• Ladders are placed near the edge of a roof or floor opening 

• Elevated work where no protection is available to prevent the worker from falling 

requires 100 percent tie-off at all times. 

TSB’s safety manual further states that the personal protective equipment training will be documented by 

identifying the employees trained, date of training, and instructor. The training documentation is kept on 

file for each employee. A review of the TSB crewmembers’ training records provided to this 

investigative panel indicates that none had received any personal protective equipment training. 

During the interviews, several TSB crewmembers stated that they had observed unsafe acts by the 

supervisory personnel. One crewmember stated that he observed the deceased in the work area without 

safety toe shoes and hard hat. 

Another crewmember stated that he observed the TSB day crew supervisor bleeding the gas off the casing 

at the wellhead instead of bleeding it off through the gas buster (see Attachment 6 for photograph of 

bleeding gas at BOP stack). The result of the action led to pollution of the Gulf waters (see Attachment 7 

for photograph of pollution). 

When the TSB day crew supervisor was shown photographs of the lube and bleed procedure (blowing 

down the well overboard through the choke and kill lines) during the interview, he conceded that it must 

have made a sheen and “[he] shouldn’t have done it.” 

The regulations at 30 CFR 250.300 state that during the exploration, development, production, and 

transportation of oil and gas or sulphur, the lessee shall take measures to prevent unauthorized discharge 

of pollutants into the offshore waters. The lessee shall not create conditions that will pose unreasonable 

risk to public health, life, property, aquatic life, wildlife, recreation, navigation, commercial fishing, or 

other uses of the ocean. 

 

According to the TSB crewmembers, on Sunday, February 19, 2006, the M/V Lytal Queen was being sent 

in to the dock to take the senior pump operator in for a back injury that he had experienced earlier in the 

week. The deceased informed the night crew staying on the boat that they would have to stay/sleep “hot 

14
sheet” on the platform while the boat went to the dock. Several crewmembers expressed their concern to 

the deceased about “hot sheeting” and overall safety on the facility and refused to stay on the facility. 

According to their statements, the deceased informed them that if they went in to the dock, they would be 

fired. 

Project Management 

Forest Oil Company (FOC) operated HIA-466 Platform B at the time of the incident. FOC’s linear 

reporting structure for Gulf Coast Region operations is illustrated in Attachment 8. The principal 

individuals managing the B-11 well abandonment on February 20, 2006, for FOC were the 

• Vice President of Operations, Gulf Coast Region (Operations VP); 

• Operations Manager, Gulf Coast Region; 

• Private consultant in charge of managing the day-to-day operation in the office (offsite) (FOC 

office consultant); and the 

• TSB consultant/FOC “company man” on the platform (the deceased). 

Twachtman, Snyder, & Byrd, Inc. (TSB) was the primary contractor conducting the B-11 well 

abandonment for FOC. TSB’s reporting structure for “normal” plug and abandonment (P&A) operations, 

and for the subject operation, is indicated in Attachments 9 & 10, respectively. The individuals involved 

in the operation were 

• TSB President in charge of decommissioning and P&A operations 

• TSB Downhole Division Operations Manager 

• Sales representative with the sales group 

• TSB consultant/FOC “company man” on the platform (the deceased) 

• Field supervisors with the Downhole Division. 

Forest Oil Corporation Management Responsibilities 

The responsibilities and actions of FOC’s project management team prior to and immediately following 

the incident are detailed below. In conjunction with this investigation, we interviewed the Operations 

Manager for the Gulf Coast Region and FOC’s office consultant. We declined to interview the VicePresident of Operations for the Gulf Coast Region. During the interviews, the FOC Operations Manager 

15
stated that he reported to the Vice-President of Operations and spoke daily with FOC’s Vice-President of 

Operations for the Gulf Coast Region; however, those conversations did not routinely include specifics of 

the subject operation. 

Operations Manager 

During the interview, the Operations Manager stated that on May 5, 2005, he contracted Tetra 

Technologies to plug and abandon the B-11 well by using coil tubing, as previously discussed. Tetra was 

unsuccessful in completing the operation and the Operations Manager subsequently assigned FOC’s 

office consultant to complete the abandonment. He also stated that during the planning phase that he 

• drafted the initial snubbing procedure and approved the final snubbing procedure prior to 

submittal to MMS; 

• approved the revised procedure and equipment change from a snubbing unit to casing jacks 

prior to submittal to MMS because it would save time and money and because he assumed 

the well could be easily killed; 

• tasked FOC’s office consultant with locating an additional consultant to oversee the onsite 

operation; and 

• requested a copy of the deceased’s lubricate and bleed procedure, which he never received. 

When shown the photographs of the lube and bleed process (blowing down gas through the choke and kill 

lines and causing pollution), the Operations Manager stated that he was unaware that TSB had been 

blowing down gas through the choke and kill lines. He stated that he would have shut down the operation 

if he had known about the lube and bleed procedure and resulting pollution. 

During the conduct of the operation, the FOC Operations Manager briefed the FOC Operations VP on the 

progress of the operation, based on information submitted by the deceased in the morning reports and 

passed on to him by the FOC office consultant. The FOC Operations Manager was on personal time from 

February 17-20, 2006. He told the panel members that he was concerned about the length of time it was 

16
taking to kill the well and complete the job. He further indicated that he intended to address those 

concerns when he returned to work on Tuesday, February 21, if the situation remained unchanged. 

The morning reports revealed that TSB was having problems killing the well, but did not indicate the 

occurrence of unsafe work practices or pollution on the platform, or that several crew members had left 

the platform because they felt the job was unsafe. 

FOC Office Consultant 

The FOC Office Consultant is a petroleum engineer and private consultant specializing in drilling, 

workover, and abandonment operations. He was hired by FOC (Denver) to supervise several drilling 

projects in the Gulf Coast Region and was assigned the task of abandoning the subject well on 

December 5, 2005, by the FOC Operations Manager. 

The FOC Office Consultant stated in the interviews that during the planning phase, he did the following: 

• Reviewed Tetra’s previous coil tubing work on B-11 and was aware of the pressure 

consideration, but felt the pressure would be dealt with in time and that the well would be 

killed. He would have preferred conducting another coil tubing operation; however, the FOC 

Operations Manager rejected the idea, as it had been tried before and had failed. 

• Hired the deceased to manage the project onsite with the expressed understanding that the 

deceased would maintain a “wall” between himself and the TSB crews conducting the 

operation (which would have precluded him from operating the equipment) and “take no 

chances.” 

• Revised the original snubbing procedure to substitute casing jacks for the snubbing 

equipment (as previously discussed). 

• Submitted the revised procedure to MMS for approval. 

• Contracted TSB to plug and abandon the well. 

17
• Reviewed the original snubbing procedure with the deceased and the TSB day-crew 

supervisor) prior to mobilizing the operation. 

FOC initially selected a snubbing company as the primary contractor for the snubbing work, with TSB 

providing supporting e-line, wireline, pumping, and consulting services. Following several site visits to 

the facility, the deceased recommended the equipment substitution referenced in the revised procedure for 

the reasons cited below. At the invitation of the TSB sales group, the FOC office consultant met with the 

deceased and the TSB sales representative and discussed the B-11 well abandonment. 

The FOC Office Consultant approved the deceased’s recommendation to substitute casing jacks for 

snubbing equipment because of the following considerations: 

• He considered the use of casing jacks to be normal for this type of operation (a consideration 

based on his previous experience). 

• He had used casing jacks once before on a “live well.” 

• He assumed the well could be killed with seawater once the packer was unseated (an 

assumption based on his previous experience). 

• He assumed the tubing string would remain “pipe heavy” throughout the operation (an 

assumption based on his previous experience). 

• Industry-wide Post-Katrina deficiencies in experienced personnel and equipment limited his 

options in selecting contractors and vessels. 

• He was unable to locate suitable portable housing or a vessel to accommodate all personnel 

needed for both snubbing and wire line operations and, therefore, he needed to reduce the 

number of contract personnel by half in order to house everyone on the platform and vessel. 

18
• The deceased (and possibly the TSB sales representative) indicated that TSB had experienced 

personnel available to do the job with casing jacks and that he (the deceased) didn’t need a 

second crew (snubbing crew) to P&A the well. 

• He could reduce project costs by reducing the number of contract personnel and equipment 

on the job. 

The FOC Office Consultant made the decision to contract the abandonment work to TSB for the reasons 

cited above. In addition, FOC had an existing Master Service Agreement (MSA) for time and materials 

with TSB, which simplified the process. 

The FOC Office Consultant stated that, during the conduct of the operation, he reviewed the morning 

reports submitted by the deceased each day and discussed the progress with the FOC Operations 

Manager. The FOC Office Consultant typically had telephone conversations in the morning with the 

deceased and at other times as needed; the conversations were mainly goal oriented and not detailed. The 

deceased never revealed either in conversation or in the morning reports that any improper or unsafe work 

practices or pollution had occurred during the operation, only that TSB was having difficulty killing the 

well. The FOC Office Consultant was not concerned by this situation and believed that the well would be 

killed in time, based on his experience. 

On the two days prior to the day of the accident (February 18 and 19), the FOC Office Consultant spoke 

with the deceased on three separate occasions. During those conversations, the deceased never provided 

the FOC Office Consultant with a complete and accurate picture of the conduct and progress of the 

operation, the difficulties encountered, or any indication that the job wasn’t headed in the right direction. 

The FOC Office Consultant didn’t learn that TSB had been pulling forcefully on the pipe until he read 

about it in the morning report on February 20 (for activities conducted on February 19), which the 

deceased transmitted approximately 45 minutes before the incident. 

The FOC Office Consultant visited the platform in December 2005 and never revisited the platform (or 

witnessed the operation) until February 21, 2006, following the accident. At that time, he accompanied 

the United States Coast Guard (USCG) to the platform, where the USCG conducted a site investigation 

19
and interviewed several contract personnel. According to the FOC Office Consultant, prior to 

February 21, 2006, he was unaware of 

• equipment malfunctions (BOP) other than a minor problem with the crane; 

• the deceased’s practice of operating the casing jacks; 

• unsafe work practices and safety concerns of the crew; 

• the deceased’s lubricate and bleed procedure and the resulting pollution; 

• the crew working through the night despite being shorthanded after six crew members left the 

job; 

• the deceased’s gag order preventing the crew from communicating with managers offsite and 

with the TSB Downhole Division Manager in particular; 

• the deceased’s lack of communication or coordination with anyone onshore at TSB; 

• TSB’s poor housekeeping practices; and 

• the force applied to the pipe in attempting to free the tubing. 

Twachtman, Snyder & Byrd, Inc. Management Responsibilities 

The responsibilities and actions of TSB’s managers and field supervisors prior to and immediately 

following the incident are detailed below. In conjunction with this investigation, we interviewed the TSB 

President in charge of decommissioning and P&A operations and the TSB Downhole Division Manager. 

We also interviewed the TSB day and night crew supervisors on the platform. We declined to interview 

the TSB sales representative as his involvement in this incident appears to have been limited to the 

acquisition of the contract rather than the onsite or offsite management of the operation. 

20
The TSB President 

The TSB President is a professional engineer and partner in charge of decommissioning and P&A 

operations. He was also the supervisor of the deceased. The TSB President stated that he considered the 

subject operation to be “unusual” for TSB, but he never perceived the job to be unsafe or one the 

company was ill-equipped to handle. 

The TSB President was not in favor of the deceased working in the field and would have preferred 

keeping him in the office where he could work on multiple projects. He felt that FOC needed the 

deceased’s expertise onsite and reluctantly agreed to the arrangement. 

Beyond approving the deceased’s consulting assignment with FOC, the TSB president did not manage or 

oversee any of the work. The TSB president left the coordination and consultation up to the deceased and 

the TSB Downhole Division Manager. He expected that 

• the TSB Downhole Division Manager would initially coordinate crews and equipment 

mobilized for the job, obtain daily reports from the platform, consult with the deceased as 

needed, and generally stay abreast of progress and problems with the operation day-to-day, 

and 

 

• the deceased would be working for FOC as a consultant on the platform and function as 

TSB’s primary contact with FOC on the job. 

During the interview, the TSB President stated that he understood that the decision to substitute casing 

jacks for the snubbing equipment was FOC’s decision. He was surprised to learn that the deceased had 

not consulted with the TSB Downhole Division Manager during the operation and that there was discord 

and disagreement between the two men from the beginning, regarding the conduct and oversight of the 

operation. According to the TSB President, the TSB Downhole Division Manager called him daily but did 

not mention these kinds of problems in any of their conversations. The TSB President apparently never 

had a clear understanding of FOC’s intention to use the deceased as their “company man” on the platform 

nor envisioned this assignment as a conflict of interest when TSB was awarded the contract to abandon 

the well. It is not clear to this panel who he thought was making the decisions on the platform. The TSB 

21
President did not coordinate the efforts of the various groups and personnel engaged in the project or see 

to it that his managers were effectively coordinating and consulting with one another. 

TSB’s Safety Manual’s “Administrative Procedures” state in part “... that the President is invested with 

the ultimate responsibility for the safety and health protection of all Twachtman, Snyder & Byrd, Inc., 

employees and for the loss prevention of facilities and operations under his supervision.” 

The TSB Downhole Division Manager manages TSB’s Downhole Division operations in Houma, 

Louisiana and reports to the TSB President. The TSB Downhole Division Manager is normally in charge 

of P&A wireline and e-line crews on the platform (Attachment 9) but was left out of the operations loop 

on this job (Attachment 10). Although he did not understand the deceased’s function on this job, he felt 

that the deceased had the authority to fire his crew, which is contrary to the testimony provided by the 

TSB President. 

The TSB Downhole Division Manager further testified that there was nothing about this job that he 

considered “normal” as 

 

• TSB does not do snubbing work, but he stated that TSB does not pull tubing on live wells 

during P&A operations; 

• his crews are only experienced using casing jacks to pull casing on “dead wells” (wells not 

under pressure). 

He initially selected personnel for this job to assist in e-line and wire line operations in support of a 

snubbing procedure that was to be conducted by another contractor (snubbing contractor). He did not 

know why the procedure changed from snubbing to casing jacks. 

During the interviews, the TSB Downhole Division Manager stated that he would not have used the 

procedure that was proposed. He further stated that he would have incorporated the use of a snubbing 

unit for the job. Then, using a 11⁄4” work string, he would have tried either to pull the fish out of the well 

or push the fish out the bottom of the tubing. Only after exhausting this procedure would he have tried to 

lube and bleed in on the back side and strip out of the hole to a point below the fish for a hot tap. 

22
The TSB Downhole Division Manager stated that he learned about the safety concerns of his crew when 

they returned early from the job and showed up at the office at 8 a.m. on Monday, February 20. He 

indicated that he probably would have shut down the job had he known about the unsafe working 

conditions on the platform. He subsequently rehired all but two crew members who left the job and were 

fired by the deceased. 

The Day-crew and the Night-crew Supervisors 

The day-crew and the night-crew supervisors supervised the crews on the platform and consulted with the 

deceased regarding the daily tasks. In addition to supervising the crews, they were responsible for 

• writing the JSA’s; 

• holding a safety meeting at the beginning of each shift to review the JSA’s for each task to be 

performed; 

• maintaining a safe working environment by advising, monitoring, and enforcing the company 

safety rules and procedures in accordance with TSB’s safety manual; and 

• operating equipment as needed. 

TSB’s Safety Manual’s “Statement of Management Safety and Environmental Policy” states in part: 

Safety is line management responsibility. Supervisory staff at all levels are charged with the 

responsibility of ensuring that employees under their control, perform each job within the 

guidelines of all federal and state regulations as well as TSB and Client policy. Furthermore, 

strict compliance by all personnel to all federal and state regulations, as well as TSB and Client 

policy in the performance of their duties while on any TSB or Client work site is mandatory. Any 

employee not respecting these safety rules and government regulations will be subject to 

disciplinary action. Any unsafe acts or conditions must be reported to the supervisor, project 

manager, offshore manager and/or TSB management immediately. Ultimately, each employee is 

responsible for his own safety as well as the safety of those around him. 

23
The supervisors normally reported to the TSB Downhole Division Manager, but on this job they were 

prohibited from doing so and only reported to the deceased. In general, the day crew conducted the lube 

and bleed operations (attempting to kill the well) while the night crew worked the casing jacks 

(attempting to free the stuck tubing). The day-crew supervisor testified that his crew also tested the BOP 

and that the deceased kept the test charts in his possession. 

Neither supervisor had prior experience using casing jacks to P&A “live wells.” The day-crew supervisor 

felt the use of casing jacks was “safe” but knew others disagreed and considered the procedure to be 

inappropriate and unsafe, given there was pressure on the well and that they were unable to kill the well 

successfully. The day-crew supervisor also felt he understood the pipe stripping procedure although he 

had never conducted an operation like this before. Others were critical of the procedure and feared that 

they could lose control of the well if the pipe rams failed. 

The night-crew supervisor openly disagreed with both the deceased and the day-crew supervisor 

regarding job safety and felt the job was unsafe from the beginning. On his last shift prior to the accident, 

he was instructed by the deceased to pull and turn the pipe, which he refused to do. He felt that given the 

pressure on the annulus, they could not control the well if the pipe parted. He did not discuss his 

concerns with the TSB Downhole Division Manager or shut the job down. He wanted to get off the 

platform and indicated that he would have boarded the boat, along with the other men who left on 

December 19, if he had been awake at the time. 

The TSB Consultant/FOC “Company Man” on the Platform (“The Deceased”) 

The deceased wore two hats on this job and had conflicting responsibilities as the onsite project manager 

for the primary contractor (TSB) and as FOC’s “company man” on the platform (see Attachments 8 & 

10). He was employed with TSB’s consulting group in Houston, Texas, as a P&A specialist/project 

manager and reported to the TSB President in charge of decommissioning and P&A operations. He was 

originally hired by the TSB Downhole Division Manager as a field supervisor for the downhole division 

before being transferred to the sales group (Houston) during or about May 2005. His assignments with 

the sales group included the preparation of estimates, proposals, and procedures for downhole operations. 

He was hired by FOC’s Office Consultant in December 2005 as TSB's P&A consultant and FOC’s 

“company man” on the platform for the B-11 well abandonment. According to the TSB President, the 

deceased was being paid by TSB and, to the TSB President’s knowledge, was not being paid by FOC. 

24
According to FOC personnel interviewed, FOC was not paying the deceased directly but were paying 

TSB. 

According to interview statements, the FOC Operations Manager did not know of the deceased’s 

affiliation with TSB prior to the accident and would have been uncomfortable with that arrangement 

(because of the conflicting roles and divided loyalties) if he had known. The TSB President did not 

consider the deceased to be FOC’s “company man” on the platform, although he did consider him to be 

working for FOC and to be TSB’s primary contact with FOC and conversely. In his opinion, the 

deceased was on the platform to coordinate the crews and to consult with the TSB Downhole Division 

Manager on operational matters. According to the TSB president, the deceased was responsible (on this 

project) for the 

• coordination and continuity of two downhole division crews (TSB’s field supervisors 

reported to the deceased instead of the TSB Downhole Division Manager throughout the 

operation (see Attachment 10); 

• coordination of equipment and materials; and 

• transfer of information, including daily reports, between FOC and TSB. 

According to the TSB President, the deceased did not have the authority to fire downhole division 

personnel; however, this viewpoint is not shared by the TSB Downhole Division Manager. 

During the preparation phase, the deceased conducted several site visits to the platform to assess 

conditions and subsequently recommended substituting casing jacks for snubbing equipment. After TSB 

was awarded the contract to P&A the well, the deceased told the TSB Downhole Division Manager that 

“me and FOC are running this job; it’s not your concern.” The TSB Downhole Division Manager 

provided the equipment and personnel. After the job was mobilized and the vessel left the dock for the 

job site (on or about February 13, 2006), the deceased had no further verbal communications with either 

the TSB President or the TSB Downhole Division Manager. 

Between February 13 and 20, 2006, according to TSB crewmembers interviewed, the deceased 

25
• Fired personnel for refusing to stay on the facility while the boat left the field; 

• Made operational decisions without consulting with anyone offsite; 

• Acted “differently” on this job (“taking risks”) according to some observers, while others 

considered his behavior to be “normal” for him (“safe”); 

• Disregarded comments and complaints from various personnel regarding long hours, inadequate 

housing, cold food, unsafe working conditions/work practices, poor housekeeping practices, and 

equipment problems; 

• Communicated daily with FOC and TSB managers via email (morning reports) and with FOC’s 

office consultant via telephone/cell phone in the morning and as needed during the day; 

• Criticized the crew for making telephones calls to the office and prohibited further telephone 

communication between platform personnel and management, particularly with the TSB 

Downhole Division Manager; 

• Worked the casing jacks without FOC’s knowledge or consent; 

• Operated the annular preventer (Hydril) in reverse (“open” was closed and “closed” was open) to 

save time in lieu of correcting the problem; 

• By-passed safety systems and created pollution (opened the Hydril and conducted the lube and 

bleed procedure through the choke and kill lines instead of through the gas buster; vented well 

fluids and gases into the atmosphere/water, causing pollution), and 

• Pulled the pipe on the morning of February 20, causing the pipe to part. 

 

26
Conclusions 

Causes 

It is the conclusion of this panel that, on the morning of February 20, 2006, the deceased attempted to free 

the stuck tubing string on the B-11 well. In doing so, he exceeded the yield strength of the tubing when 

he pulled approximately 135,000 pounds on the tubing, causing it to part. This action resulted in the 

tubing and slips being ejected from the wellbore, the slips fatally striking the deceased as he attempted to 

evacuate the area, and a brief loss of well control. It is also the conclusion of this panel that the deceased 

did not calculate enough of a safety factor when he determined maximum amount pull for the grade of 

pipe. 

Contributing Causes 

Prudent operations plans would have been to shut this operation down on the 17th, when TSB could not 

contain wellbore pressure, and use more appropriate equipment such as a snubbing unit. A snubbing unit 

is designed to perform downhole operations and can remove tubing while keeping the wellbore pressure 

under control. The fish in the tubing magnified their problem, and they were using basically seawater to 

control the flow when a higher density fluid was needed. The method they were using to plug and 

abandon the well – using casing jacks – should only be used if a well is dead and there is virtually no 

chance of any pressure being on the wellbore. 

The operation should have been shut down. The procedure should then have been revised to use 

appropriate equipment for the circumstances and submitted to MMS for approval before continuing 

further. This decisionmaking process was complicated, since the person in charge represented both FOC 

and TSB. 

The deceased made operational decisions on the platform without consulting either FOC’s or TSB’s 

offsite managers. His decisions and actions placed the platform, personnel, and environment in constant 

threat from a potential loss of well control, and resulted in a brief loss of well control, pollution, and a 

fatal accident. The two TSB field supervisors had differing opinions about the conduct and safety of the 

operation. Neither supervisor shut down the job in spite of the safety violations, unsafe work practices, 

27
and attendant pollution. Further, neither man attempted to report what was happening on the platform to 

the TSB Downhole Division Manager.

Therefore, this panel concludes that the lack of appropriate equipment (snubbing unit) and appropriately 

trained personnel are contributing causes to this incident. Additionally, poor judgment and 

decisionmaking by the deceased and TSB’s field supervisors on the platform are also considered 

contributing causes to this incident

Possible Contributing Causes 

Offsite Management Failures 

 FOC’s Operations Manager 

FOC’s Operations Manager for the Gulf Coast Region approved the equipment substitution but didn’t 

revise the actual procedures or require that they be revised. He felt the operation was safe given certain 

assumptions that he didn’t attempt to verify. He was kept informed of the progress by the FOC office 

consultant, but was generally disengaged from the day-to-day operation and on personal time during the 

long holiday weekend when the accident occurred. He left the day-to-day conduct and oversight of the 

operation to offsite and onsite consultants, but didn’t inquire about the deceased’s background and 

affiliations. Although he indicated that he would have shut down the operation had he known the details 

about the deceased’s lube and bleed procedure and the resulting pollution, he failed to follow up after he 

requested a copy of the procedure and didn’t receive one. 

As FOC’s Operations Manager for the platform, he was detached from the day-to-day operations and did 

not 

• Effectively manage the project, 

• Ensure that the operation was conducted in a safe and workmanlike manner, 

• Ensure that personnel and the environment were protected, and 

• Ensure that pollution would be prevented. 

28
FOC’s Office Consultant 

FOC’s Office Consultant in charge of the operation was uninformed about the serious equipment 

problems, poor housekeeping conditions, unsafe work practices, and pollution resulting from operations 

on the platform. After a site visit in December 2005, he never visited the platform again until after the 

accident. Although he was misinformed about the day-to-day progress and conduct of the operation by 

the deceased, he never personally inspected the operation despite the recurring difficulties encountered 

killing the well, as verified in the morning reports. He specifically failed to 

• Recognize the potential conflict of interest created by allowing the deceased to represent 

simultaneously both FOC’s interests and TSB’s interests on the job; 

 

• Effectively oversee the conduct of the operation; 

• Ensure that the operation was conducted in a safe and workmanlike manner; 

• Ensure the protection of personnel and the environment; 

• Ensure the prevention of pollution; and 

• Ensure and verify that all required tests of the blow out prevention equipment were conducted 

and documented. 

 

TSB’s President 

TSB’s President considered this to be an unusual job for TSB; however, he was completely disengaged 

from the day-to-day management and oversight of the operation and did not communicate directly with 

the deceased after approving his assignment. He was unaware of the internal and external 

communications problems within the organization, the lack of a clear chain of command structure for this 

project, the operational problems and safety issues on the platform, and the generic (“canned”) JSA’s. He 

assumed his personnel were coordinating and communicating effectively with one another. 

TSB’s president apparently never had a clear understanding of FOC’s intention to use the deceased as 

their “company man” on the platform or envisioned this assignment as a conflict of interest when TSB 

29
was awarded the contract to abandon the well. It is not clear to the panel members who he thought was 

making the decisions on the platform. TSB’s President did not coordinate the efforts of the various 

groups and personnel engaged in the project or see to it that his managers were effectively coordinating 

and consulting with one another. 

Considering the new and unusual roles, responsibilities, and tasks assigned to the separate groups and 

personnel assigned to the project, TSB’s President failed to 

• Manage, coordinate, and integrate the tasks of project personnel; 

• Recognize the potential conflict of interest created by allowing the deceased to represent 

simultaneously both FOC’s interests and TSB’s interests on the job; 

• Establish clear lines of authority, responsibility, and communication between key personnel on 

the project; and 

• Ensure that everyone connected with the project understood their jobs and were effectively 

coordinating and communicating with one another. 

TSB’s Downhole Division Manager 

TSB’s Downhole Division Manager was intentionally left out of the operations and communications 

structure throughout much of the operation by the deceased. He became concerned when he learned that 

some of his crew had been fired for leaving the job early and had indicated they left for a variety of 

safety-related and other reasons. He attempted unsuccessfully to reach the platform by telephone but did 

not attempt to visit the platform. He disagreed with the revised equipment and procedural changes and 

did not understand why the deceased was managing the project, but apparently did not communicate his 

concerns to TSB’s President. His view of his role and responsibilities on this project was significantly 

different from the TSB President’s views. TSB’s Downhole Division Manager was not personally 

responsible for writing the JSA’s for tasks performed by his crews. That task apparently fell to the 

supervisors in the field. However, all the JSA’s we reviewed for a given task looked generic (“canned”), 

30
regardless of the date or time the task was performed, and didn’t appear to have been reviewed or revised 

by anyone associated with this project to reflect the unique tasks and safety considerations of the job. 

As the individual normally in charge of field personnel conducting P&A operations, TSB’s Downhole 

Division Manager was not consulted with or kept abreast of the conduct and progress of the operation, 

except through e-mail transmissions of the morning reports from the platform. We do not know if he 

questioned or attempted to remedy the situation. Beyond the communications problems on the 

platform, which were out of his control, he failed to 

• Clarify his role and responsibilities on the project with upper management, 

• Coordinate effectively with the other key personnel involved in the project, 

• Communicate with downhole division personnel (field supervisors and crews) on the platform, 

and 

• Review and recommend revisions to JSA’s to reflect the unique tasks and safety considerations 

on the job. 

Onsite Management Failures 

 FOC’s “Company Man” on the Platform (The Deceased) 

The deceased generally kept his own counsel and made operational decisions on his own or in 

consultation with the TSB day-crew supervisor. The panel members received contradictory and 

perplexing testimony of the deceased’s demeanor and attitude on this job. According to some, he acted 

“normally,” while others viewed his demeanor as “different” on this job. Many crewmembers and one 

supervisor were concerned about safety and felt the job was unsafe and should be shut down. Prior to the 

accident, one injured crew member and five others left the job early for various reasons, leaving the tower 

crews on the platform shorthanded. Daytime and nighttime operations continued in spite of the manpower 

shortages and in opposition to the manpower requirements as described in the JSA’s. The deceased’s 

decisions and actions engendered that opinion and fostered an atmosphere of tension and fear among the 

31
crewmembers who left the job on February 19, as well as many of those who remained on the platform. 

The panel members have been unable to identify a motive for the deceased’s apparent “different” 

behavior on this job. The panel members can only conclude that many of the unsafe and unworkmanlike 

practices, equipment failures, safety violations, and incidents on the platform are directly and indirectly 

related to decisions made and actions taken by the deceased. 

In the panel members’ opinion, the deceased made a number of inappropriate decisions and actions that 

negatively affected the operation. As FOC’s representative (and TSB’s project coordinator) on the 

platform, the deceased exceeded his authorities and failed to 

• Communicate verbally with anyone offsite at TSB and was openly critical of communication 

between the crew and TSB’s offsite management and prohibited further communications, 

particularly with the TSB Downhole Division Manager; 

 

• Provide FOC’s managers with complete and accurate information regarding the conduct, 

problems, and progress of the operation (i.e., safety-related issues, unsafe work practices, poor 

housekeeping, equipment problems, pollution, etc.); 

• Conduct the operation in a safe, workmanlike, and environmentally sound manner (i.e., exposed 

the facility, personnel, and environment to unsafe conditions, loss of well control, pollution, and 

serious injury); 

• Consult with TSB’s Downhole Division Manager and TSB crew supervisors to review and 

revise the JSA’s to address the unique procedures and safety considerations on the job (e.g., use 

of casing jacks to pull pipe and P&A a well under pressure); 

• Test and operate the blowout prevention equipment as required and intended; 

• Prevent pollution; 

• Maintain a “wall” between himself and the TSB crew, and “take no chances” per FOC’s 

instruction; 

32
• Shut down 24-hour operations because of manpower shortages; and 

• Address safety concerns raised by personnel (i.e., job safety, the use of casing jacks, pulling 

pipe under excessive tension, lube and bleed procedures, shut down job, etc.). 

TSB’s Day-Crew and Night-Crew Supervisors 

The TSB day and night crew supervisors on the platform were specifically responsible for writing JSA’s 

on the job to reflect every aspect of the job. Although they disagreed about the safety of the operation, 

both supervisors failed to 

 

• Inform the TSB Downhole Division Manager of the unsafe and unworkmanlike procedures 

and conditions or the safety concerns of the crew; 

• Shut down the job because of unsafe work practices, lack of personnel, or to prevent pollution; 

• Require workers to wear proper safety equipment, as indicated in TSB’s safety manual (fall 

protection gear); 

• Revise the JSA’s to reflect changes in the tasks performed or the equipment used on the job, 

or to reflect safety concerns related to plugging and abandoning a “live well” by using casing 

jacks; and 

• Conduct effective safety meetings with the crews. 

On the basis of this information, it is concluded by the panel members that ineffective management and 

supervision of the operation by both FOC and TSB (at all levels) is a possible contributing cause of this 

incident. Upper management at FOC and TSB were detached from the field operation and failed to 

provide direct oversight and control. At TSB, no effective chain of command structure was in place and 

no one in the office was overseeing the operation. FOC relied entirely on consultants to supervise the 

operation onsite and offsite. 

33
Recommendations 

Safety Alert 

This investigative panel recommends that the MMS should issue a Safety Alert to industry regarding this 

incident. The Safety Alert should briefly describe the accident and identify all the causes. The following 

recommendations should be made to industry: 

• When conducting this type of operation, operators should maintain adequate oversight of the 

contractors by whatever means to ensure that the contractor is not taking any unnecessary 

shortcuts and that the contractor is following industry-accepted practices. 

• Operators should conduct a pre-job meeting with all involved parties. The purpose of the 

meeting should be to outline the scope of work to be conducted and the manpower requirements, 

identify lines of authority and responsibility, outline the process for managing changes in the job, 

and stress the importance of “Stop Work” authority and reporting unsafe acts and conditions. 

• When using consultants as the operator representative, operators should require a site inspection 

by an operator representative employed by the operator prior to the commencement of work to 

verify that the equipment is rigged up according to approved plans and methods. 

• Operators should require the contractors to provide detailed activity logs of the work being 

performed. 

34
Attachment 1

Western Central

Eastern

LAKE CHARLES

GALVESTON

HOUSTON

CORPUS CHRISTI

BILOXI

MOBILE

PENSACOLA

PANAMA CITY

TAMPA

MIAMI

KEY WEST

LAFAYETTE

BATON ROUGE

NEW ORLEANS

HOUMA

GRAND ISLE

TEXAS

LOUISIANA

MISSISSIPPI

ALABAMA

FLORIDA

SOUTH

PADRE IS.

NORTH

PADRE IS.

MUSTANG

IS.

PORT

ISABEL

EAST BREAKS GARDEN BANKS

KEATHLEY CANYON

NG 15-8 NG 15-9

ALAMINOS CANYON

MAT.

CORPUS

CHRISTI

IS.

BRAZOS

GALVESTON

HIGH ISLAND

WEST CAMERON

EAST CAMERON

VERMILION

GREEN CANYON ATWATER

MISSISSIPPI CANYON

LUND WALKER RIDGE

SOUTH MARSH IS.

EUGENE IS.

SHIP SHOAL

SO. TIMBALIER

G.I.

W.D. S.P.

KNOLL

MAIN

PASS B.S.

SO.

PASS

VIOSCA

PENSACOLA MOBILE

DESTIN DOME

APALACHICOLA

GAINESVILLE

FLORIDA

MIDDLE GROUND

TARPON

SPRINGS

THE ELBOW ST. PETERSBURG

VERNON CHARLOTTE HARBOR

HOWELL HOOK

RANKIN

PULLEY RIDGE

MIAMI

DRY

TORTUGAS

DESOTO CANYON

LLOYD

HENDERSON

NG 16-8

NG 16-7

MM U.S. Department of the Interior Minerals Management Service Gulf of Mexico OCS Region

STATUTE MILES

KILOMETERS

0

0

50 100

100 200

GEORGIA

High Island

Block A466

Platform B

OCS-G 03242

Location of Lease OCS-G 03242, High Island Block A466, Platform B.
Photograph of High Island Block A466 Platform “B” 

Attachment 2 
Diagram of Approved BOP Configuration 

Attachment 3 
Attachment 4 

Photograph of BOP Stack on Location 
Photograph of TSB Crewmember Working Without Fall Protection 

Attachment 5 
Attachment 6 

Photograph of Bleeding Gas at BOP Stack 
Attachment 7 

Photograph of Pollution 
?

VP of Operations 

Gulf Coast Region

Operations Manager 

Gulf Coast Region 

Private Consultant/Offsite Project Manager 

HIA-466 B-11 P&A Operation 

TSB Consultant/Onsite “Company Man” 

HIA-466 B-11 P&A Operation 

Forest Oil Company Chain of Command (At time of Incident) 

Attachment 8 
President/Professional Engineer 

Decommissioning / P&A 

Operations 

Houston, TX 

Division Manager 

Downhole Division 

Houma, LA 

 (Deceased) 

P&A Consultant/Project 

Manager 

Consulting Group 

Houston, TX 

Sales Representative 

Sales Group 

Houston, TX 

P&A Day-Crew Supervisor P&A Night-Crew Supervisor 

Twachtman, Snyder & Byrd Inc., Chain of Command (Normal P&A Operation) 

Attachment 9 
President/Professional Engineer 

Decommissioning / P&A Operations 

Houston, TX 

Division Manager 

Downhole Division 

Houma, LA 

 (Deceased) 

P&A Consultant/Project Manager 

Consulting Group 

Sales Representative 

Sales Group 

Houston, TX 

P&A Field Supervisor 

Day Crew 

P&A Field Supervisor 

Night Crew 

Attachment 10 

Twachtman, Snyder & Byrd Inc., Chain of Command (HI A466 P&A Operations)