2 151130064627

RAPID-S53
Reliability and Performance Information

Database
For:
API S53 Well Control Equipment

Guidance Document
Rev 1
March 13, 2017
RELIABILITY AND PERFORMANCE INFORMATION DATABASE FOR API S53 WELL CONTROL EQUIPMENT
GUIDANCE DOCUMENT
Table of Contents
1.0 Scope and Purpose ....................................................................................................................................................4
1.1. Scope...........................................................................................................................................................................4
1.2. Purpose......................................................................................................................................................................4
2.0 Definitions and Acronyms ......................................................................................................................................4
2.1. Definitions................................................................................................................................................................4
2.2. Acronyms..................................................................................................................................................................6
3.0 Equipment Owner’s Reporter Instructions.....................................................................................................7
3.1. Downloaded Report .............................................................................................................................................8
3.2. Submit Failure Report......................................................................................................................................15
3.3. Root Cause Options, Definitions and Examples.....................................................................................16
4.0 Equipment Owner’s Super-User Instructions .............................................................................................18
5.0 Analysis .......................................................................................................................................................................21
5.1. Failure Causes......................................................................................................................................................21
5.1.1. Physical Causes...............................................................................................................................................21
5.1.2. Human Factor Causes ..................................................................................................................................21
5.1.3. Systemic Causes .............................................................................................................................................21
5.2. Analysis Overview .............................................................................................................................................21
5.3. Cause Immediately Known.............................................................................................................................22
5.3.1. Resources..........................................................................................................................................................22
5.3.2. Closure ...............................................................................................................................................................22
5.4. SME Review ..........................................................................................................................................................23
5.4.1. Resources..........................................................................................................................................................23
5.4.2. Closure ...............................................................................................................................................................23
5.5. RCFA ........................................................................................................................................................................24
5.5.1. Physical Evidence ..........................................................................................................................................24
5.5.2. Resources..........................................................................................................................................................24
5.5.3. Closure ...............................................................................................................................................................24
6.0 Capture and Share Lessons Learnt ..................................................................................................................24
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APPENDIX 1. DOWNLOAD INPUT FORM...............................................................................................................25

APPENDIX 2. REPORTING PROCESS........................................................................................................................26
APPENDIX 3. Five-Why’s Analysis Methodology................................................................................................28
APPENDIX 4. SME Review or an RCFA Report ....................................................................................................29
APPENDIX 5. MODEL TERMINOLOGY ....................................................................................................................30
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1.0 Scope and Purpose
1.1. Scope
This document applies to the owner of blowout prevention equipment for drilling wells when
reporting equipment failures.
The scope has been expanded to include all API S53 equipment components:
 Auxiliary Equipment (Drillstring valves and gas separation equipment)
 BOP Stack
 BOP Controls (Primary, Secondary and Emergency)
 Choke Manifold Equipment
 Diverter System (Although this is not included in API S53, it is too closely related to not
include it here)
 Riser System (The riser system is included because of the choke and kill lines and it does not
make sense to only include those lines and not the equipment that carries them.
1.2. Purpose
This document has been developed with the intent of providing instructions and definitions to
produce a standardized industry reliability and performance database.
2.0 Definitions and Acronyms
2.1. Definitions
Cause: Something that initiates, shapes or influences an

outcome.
Cause Immediately Known: When there is a high degree of certainty in the failure
cause, the failure report described in Section 3 is
completed describing the failure and defining the root
cause based on inspection and maintenance personnel
experience and knowledge.
Corrective Action: An action, which is taken to correct a failure and/or

the failure’s cause.
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Effect: An event or condition that is caused by another event

or condition.
Evidence: Information, data and/or items gathered which

directly relate to, or have been, affected by the
failure.
Failure: A condition that prevents the component from

operating as designed.
(A leaking O-ring is a failure even if the piston that it
should seal can fully stroke)
‘Five-Whys’ Analysis: A ‘question-answer’ process used to explore the

relationships between Cause and Effect underlying a
specific problem.
Root Cause: Is the cause (condition or action) that begins a

cause/effect chain that ends in a component defect or
failure. If corrected would prevent reoccurrence of
the event (under investigation) and similar
occurrences.
Root Cause Failure Analysis: A comprehensive systematic investigation process

undertaken to identify Physical, Human Factors and
Systemic root causes of a component failure.
Subject Matter Expert: Person or persons with an in-depth knowledge of a

subject of interest. Such knowledge will have been
gained through direct and practical dealings with
subject matter of interest.
SME Review: An internal assessment of the possible and probable

local root cause of the component failure reviewed by
an SME with the intent of recommending
intermediate actions or changes to reduce the
probability of reoccurrence.
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2.2. Acronyms
API American Petroleum Institute LMRP Lower Marine Riser Package

BOP Blowout Preventer NPT Non-Productive Time
BWM Between Wells Maintenance OEM Original Equipment Manufacturer
Bureau of Safety and Environmental Root Cause Failure Analysis
BSEE RCFA
Enforcement
BTS Bureau of Transportation Statistics RWP Rated Working Pressure
HSE Health, Safety and Environment SFI Skipsteknisk Forskningsinstitutt
International Association of Drilling
IADC SME Subject Matter Expert
Contractors
JIP Joint Industry Project QA/QC Quality Assurance/Quality Control
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3.0 Equipment Owner’s Reporter Instructions.

When is a report required?
A failure report shall be created for each failure of any component of API 53 Equipment, whether
there is NPT or not. This database was designed to trend failures to allow us to focus on problem
areas and the policy was rigid in that if we do not report all failures then we are shortchanging
ourselves.
With the benefit of hindsight, we can acknowledge that this was too rigid. In the beginning, we
reported, for example, a choke valve as a failure if it did not hold a test even if a single open/close
cycle was sufficient to correct this. While we do not condone many repeated cycles to try and achieve
a successful test, we have to accept that a foreign body could prevent the full closure of the valve and
clearing this with a single function cycle is not an equipment failure.
We should, however, continue to report failures that come to light during maintenance and testing
as well as during operation, but replacement of a ram packer, for instance, because you do not expect
it to last the next well, is not a failure; it is simply maintenance.
The report should be created, and submitted, as soon as possible after the event is discovered.
How to complete a report?
Log into the site using the credentials that have been sent to you separately.
Once in the site first time only, go to: My Profile (top right corner) Change Your Password and
Save Changes.
Select:
MANAGE WELL the Manage Well
Then check to see that the information is correct, or click on Add Well as appropriate.
The Add Well option is where the well number information is input This is also where you include
the number of riser joints run on the well. This data is used for statistical information when charting
riser failures against the quantity of riser joints in use across the database.
When this data has been confirmed to be correct, then select: Save
This default well data will be used to populate all reports until the data is changed for subsequent
wells.
FAILURE REPORTS
You then have two choices. If your company prefers you to download the
form, fill it out and then send it to town, then select
Download Failure Report
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And complete all of the required fields, as guided below, offline:
3.1. Downloaded Report
Rig Owner Information
Rig Owner / Drilling Contractor: Select your company name. If reporting online, then this
should already be prepopulated with your company
name.
Rig: Dropdown box filtered to show all of the current rigs

owned by the selected rig owner.
Operator: Dropdown box populated with a list of the current

operators in the database This includes both members
and non-members of the JIP.
Owner’s Primary Contact: Title of person who is familiar with the issue in case
further information is required. This could be the person
reporting, but that is a company decision.
Email of Owner’s Primary Contact: Email address for the Primary Contact.
Name of Person Reporting: This the name of person filling out event report. If the
report is being completed online this field should be
prepopulated based on the log-in name of the reporter.
OEM Rep. Onboard, if applicable: Name of any OEM representative on the rig that was
involved in the component analysis.
Well Identification
Lease No. : Number as provided by operator.
Well No. : Number as provided by operator.
API Well No. : Number as provided by operator.
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Not every well has all of these numbers. Provide what your well has.
If the rig is not on contract, then state “Not Applicable”.
Other Information
Owner Specific Equipment ID Number: An SFI code or similar that the equipment owner uses to
identify the specific equipment or component.
OEM Incident Reference Number: Reference number issued by the OEM if involved.
Component sent on shore: Disposal; No; OEM analysis; OEM Repair; Storage; Third
party Analysis; Third party Repair.
NO should be selected in this dropdown box if the
component was not sent ashore. If the component was
sent ashore, the appropriate reason should be selected.
Equipment
Type of WCE System: Subsea; Surface Offshore; Land.

Select SUBSEA in the dropdown box if the system utilizes
a subsea BOP designed to be operated underwater;
SURFACE OFFSHORE or LAND, as appropriate, for
others.
System Integrator: Cameron; GE; NOV.
This is not necessarily the equipment manufacturer.
Select the company who provided and or assembled the
affected system in the dropdown box.
Subunit: BOP Controls; BOP Controls Secondary – ROV, Acoustic;
BOP Controls Emergency – Automated Functions; BOP
Stack; Auxiliary Equipment; Choke Manifold System;
Diverter System; Riser System.
Select the appropriate system subunit category in this
dropdown box.
This is the first of three dropdown boxes that
predetermine the contents of each subsequent box in a
logical manner until the correct component is
identified.
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Item: The items listed in the dropdown box are contingent

upon the selected Subunit. Select the appropriate
subunit item category in this dropdown box.
Component: The components listed in the dropdown box are
contingent upon the selected item. Select the
appropriate component category in this dropdown box.
(This is the lowest maintainable item that failed. Do not
give the control pod details for a failed pressure
regulator.)
Component Manufacturer: Select the manufacturer of the component in this

dropdown box.
We have attempted to list them all. If we have missed a
particular OEM then contact the JIP Project Manager at
IADC and he can add the missing OEM to the list in a
matter of days.
Observed Failure: What alerted you to this event? This dropdown box is
focused from the component selection. Select the failure
mode for the component in this dropdown box.
Model: There are too many options to compile a dropdown box.

This is, therefore, a free text field to enter the
manufacturer’s equipment model for the defective
component.
OEM Part Number: Free text field to enter the identifying part number as
established by the OEM.
OEM Serial Number: Free text field to enter the OEM’s unique identifying
serial number.
Size: Two dropdown boxes to input the whole and fractional

size for the component.
Pressure Rating: Two dropdown boxes; the first to select in standardized

pressure ratings, and the second to select whether this
is ‘Well Bore’ or ‘Operating Circuit’ pressure.
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Component History
Date Affected Component was installed: This is a calendar field on line but only a free text field
on the downloadable form to record the date that the
component was installed into the system on the rig.
This could be the date that the equipment was delivered,

or it could be after a major inspection/maintenance
(e.g. five-yearly).
Maintenance Deferred on Component: Yes/No dropdown box to record whether planned

maintenance was overdue at the time of failure.
If YES, what maintenance was deferred: BWM/EOW; Quarterly; Annual; Five-Yearly; Other?
Dropdown box to select what category of maintenance
was deferred (BWM/EOW, Annual, 5-Year, etc.).
Date of Last Maintenance: This is a calendar field on line but only a free text field
on the downloadable form to record the date of the last
planned maintenance actually completed.
Description of Last Maintenance: Adjustment; Cleaned and Inspected; Installed seal kit;
Installed repair kit; No previous maintenance.
Dropdown box to select the maintenance that was
performed.
Amount of Usage at the Time of Failure: Number field and a dropdown box to select Hours or
Cycles (or Unknown) to associate to the whole number.
If you have automatic cycle counters, or the discipline to
actually count the cycles, then record them for valves,
cylinders and pistons. Record hours for pumps or if
‘cycles’ are not available.
Site Specific Information
IADC Code Description: 1- Rig Up and Tear Down

2- Drill Actual
3- Reaming
4- Coring
5- Condition Mud & Circulate
6- Trips
7- Lubricate Rig
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8 - Repair Rig
9 - Cut Off Drilling Line
10 - Deviation Survey
11 - Wire Line Logs
12 - Run Casing & Cement
13 - Wait On Cement
14 - Nipple Up B.O.P.
15 - Test B.O.P.
16 - Drill Stem Test
17 - Plug Back
18 - Squeeze Cement
19 - Fishing
20 - Dir. Work
21 - Running / Retrieving Riser Equipment
22 - Testing Surface Equipment
23- Other
A - Perforating
B - Tubing Trips
C - Treating
D - Swabbing
E - Testing
F - NULL
G - NULL
H – NULL
Dropdown box with a listing of IADC codes and

associated descriptions of the rig operation. Note that
these have recently been updated, by IADC, to include
specific options for Running/retrieving riser equipment
and for testing surface equipment.
Location (Region): Africa; Americas; Asia; Australia; Oceana; Europe.

Dropdown box to select appropriate continent for the
rig operation.
Location (Country): Dropdown box to select appropriate countries cascaded

by the selected region.
Water depth: Free text field to input an integer and a dropdown box
to select Feet or Meters to associate to the integer.
Drilling Fluid Type: Brine; Seawater; Synthetic Based Mud; Water Based
Mud.
Dropdown box to select from the commonly used fluids.
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GUIDANCE DOCUMENT
BOP Control Fluid: Houghton Aqualink 300-FV7; Houghton Stack Magic

ECO-F; MacDermid CLS-25; MacDermid CLS-40;
MacDermid CLS-60; MacDermid Erifon 603HP;
MacDermid Erifon HD856; MacDermid Erifon Summer
Grade; Niche Products Pelagic 50; RX Marine RXSol-16-
3764-210; Other: Free text .
Dropdown options to select the BOP control fluid in use.
Concentration: 0; 1; 2; 3; 4; 5; 6; 7; 8; 9; 10; 11; 12; 100%.

Dropdown options from which to select the actual
percentage of control fluid concentrate in the mixture.
Glycol: 0; 5; 10; 15; 20; 25; 30; 35; 40; 45; 50; 55; 60%
Number field to record the percentage of glycol in the
mixture.
Was the last laboratory sample acceptable?: Yes/No dropdown to record the answer to the question.
N.B. This specifically refers to the last laboratory sample
(as opposed to a rig test).
Date of last sample: This is a calendar field on line but only a free text field
on the downloadable form to record the date of the last
laboratory analysis.
Event Data
Event Date: This is a calendar field on line but only a free text field
on the downloadable form to record the date.
Event Date is: Date of Occurrence; Date of Detection.

This is a dropdown to select the appropriate option.
When did the event occur?: BOP #1 IN Operation, BOP #1 NOT In Operation, BOP
#2 IN Operation or BOP #2 NOT IN Operation.
If you only have one BOP then select the appropriate
version of BOP#1.
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Description of Event: Free text field where sufficient, but concise, information
should be stated so that the reader understands what
failed, what were the symptoms, what was being
functioned at the time of failure and why was it being
functioned. Include any related details that are deemed
pertinent. Do not include any unnecessary information.
Hours of NPT – Integer field to record number of hours that is inclusive

of BOP recovery and reinstallation etc., plus all time in-
between failure detection and getting back to the point
at which the failure occurred.
This is typically IADC Code 8 time. If the rig contract
includes maintenance, or similar, time allowance,
ignore that for this and record the actual NPT hours.
Hours of Repair time: Integer field that should only include the actual time to
repair and test the failed component only.
Did the event cause a BOP Stack pull?: Yes/No dropdown box to record if the failure was a
direct factor in the decision to retrieve the subsea BOP
stack for repairs.
Detection Method – Casual Observation; Continuous Condition Monitoring;

Corrective Maintenance; Functional Testing in
Operation; Inspection; On Demand; Periodic Condition
Monitoring; Periodic Maintenance; Production
Interference; Pressure Testing in Operation; Functional
Testing Surface; Pressure Testing Surface.
Dropdown box to select how the failure was discovered.
Immediate Corrective Action: Adjust; Check; Inspection; Modify; Refit; Repair;

Replace; Service; Test.
Dropdown box to select the action taken on the rig to
place the component back into an operational state.
Root Cause: Assessment Pending; Design Issue; Documentation

Error; Maintenance Error; Procedural Error; QA/QC
Manufacturing; RCFA Required; Wear and Tear.
Dropdown box to select the cause of the failure.
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The selection by the super-user of any option except

‘RCFA required’ or ‘Assessment Pending’ will close the
report.
Selection of ‘Assessment Pending’ will open a free text

box where you must justify your selection. This will
probably be something to the effect that the BOP stack
is still subsea and an MOC and risk analysis has
determined that it is safe to continue operations with
the particular failure unresolved.
Selecting ‘RCFA required’ or ‘Assessment Pending’ will

set a clock within the database to remind the
appropriate stakeholders that a root cause has not been
defined at 99 days and every 30 days thereafter.
Quantity: An integer box to allow a quantity input in case you

had multiple similar component failures at the same
time.
If the multiple items were installed at different times or
if there are any other differences then set this value at
1 and create individual reports for the other
components.
3.2. Submit Failure Report
There are two options when submitting a failure report.
The first, and preferred option, is based on submitting the data directly to the database online. To
do this select the Submit Failure Report/Fill out Report path and fill out the report using all of
the provided drop downs. This will allow you to take advantage of the fields that are pre-populated
as a result of the way the database is set up.
The second option is based on uploading the data using an incident report completed using the
offline input form. To do this select the Submit Failure Report/Upload Report path. The data will
be loaded into the database and the report will be placed in the “Draft” state.
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3.3. Root Cause Options, Definitions and Examples
Assessment Pending: This should be selected if, for instance, the BOP stack is
still subsea. The failure will be investigated when the
BOP stack becomes accessible and the root cause can be
evaluated.
Design Issue: Inadequate component design or configuration.

This can only be confidently identified after an RCFA has
been completed or if the design issue has been
previously identified by RCFA or manufacturer’s
notification.
Documentation Error: Mistake or oversight in the documentation used by

equipment operatives.
The installation, operations and maintenance
documents were followed but there were inherent
errors in the documentation supplied. The
documentation can be in the form of drawings,
manuals, procedures, work instructions and work
orders and can be supplied by the OEM, System
Integrator or the Equipment Owner.
Maintenance Error: Mistake, misuse or oversight during maintenance.

A choke line flange leaked after the maintenance had
been completed. Investigation showed that the flange
studs had been torqued to 380Nm instead of the 380ft-
lb stated in the procedure. This was a Maintenance
Error.
Procedural Error: Mistake, misuse or oversight during operation.

The BOP ram leaked because test pressure was applied
after closing pressure was vented, but without the ram
having first been mechanically locked. This was a
Procedural Error.
QA/QC Manufacturing: Failure related to manufacturing.

A new annular piston was purchased from the OEM but
we were unable to install it. Investigation showed that
it had been machined incorrectly.
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RCFA Required: Currently unknown root cause.

An RCFA is always required if there was; a loss of a well
barrier, if there was an unplanned stack/LMRP
recovery, or if there was a systemic/reoccurring event.
Either of the other investigation requirements can be
promoted to an RCFA if necessary.
Wear and Tear: An expected condition of a component that has reached

a point where it is unable to perform intended function
as the result of usage.
If wear and tear is repeatedly selected for equipment
that fails in operation then that could indicate that a
review of the maintenance procedure is required.
Pressing the ‘Submit’ button will upload it to the web and alert the appropriate super-user who will
then quality check the report, correct any errors and approve it thereby adding it to the database.
Each time a report is modified and updated, a copy will be sent to the appropriate Super-user, System
Integrator and Operator.
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4.0 Equipment Owner’s Super-User Instructions

Log in
First time only, go to: My Profile (top right corner) Change Your Password
and Save Changes
FAILURE REPORTS
Typically, reports will be submitted by the rig based Reporters.
Download Failure Report or Submit Failure Report.
It is preferable to select the second option followed by Fill out Report to fill
out the report electronically and automatically submit it to the database.
Some equipment owner’s will prefer to have the reporter download the excel
spreadsheet version and submit it internally for approval before the report is
uploaded by selecting Upload Report.
All With this tab highlighted, the list will show all of your company failure reports
(subject to the time period selected on the last tab).
In Progress This selection will show all reports that have been opened and saved, but not
yet completed and submitted (subject to the time period selected on the last
tab).
Draft This selection will show all reports that have been completed and submitted,
but are waiting on Super-User approval (subject to the time period selected
on the last tab).
Approved (Open) This selection will show all reports that have been approved with either
‘Assessment Pending’ or ‘RCFA Required’ selected as root cause (subject to
the time period selected on the last tab).
Approved (Closed) This selection will show all reports that have been approved and closed
(subject to the time period selected on the last tab).
Reject This selection will show all reports that have been rejected and archived in
the database for whatever reason (subject to the time period selected on the
last tab).
30 Days Here you can select the time period of reports you are looking for. The options
are 30days, 60 days, 90 days or ALL.
DATABASE REPORTING
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This is a simple view of all of the participating systems, similar to what we had
available on the monthly reports. You can change the views by selecting
specific filters.
ADVANCED FILTER REPORTING
This is currently a work in progress. The filters at the top will allow the
selection of any field in the database as a means of preparing a customized
data extract for export from the database in the form of an Excel file.
What is currently more useful is the ability to export the entire database to
Excel, from where you can search and filter to your hearts content. Do not
share this data in any kind of searchable format.
Your company data will be fully visible. Other company data will have all
identifying details anonymized.
RIGS
Here you can see the status of your fleet where there is the capability of
adding a rig either by clicking on Download Rig Form, filling this out and
then use the Submit Rig button to upload the information.
The right-hand column (“Actions”) has seven options that can be selected for
each rig:
Edit Rig: This allows you to edit the basic rig details for a rig already added to the
database. It also allows the selection of 1 stack or 2 stacks for that rig.
Edit Configuration: Here you can change the details of the equipment on the rig. It is not a
complete IADC equipment list as it only lists the API S53 well control
equipment that is included in the database.
Add Configuration: This will be used to add a new configuration for an existing rig and should
only be used in those cases where you are making a radical change to the
existing Well Control Equipment configuration. As an example, the type of
radical change we have in mind here is where there is an addition or reduction
in the number pipe rams in the stack.
Asset Disposal: This should only be used in the event that a rig is no longer a part of your fleet
and the asset has either been disposed of through sale or scrapping.
Show Configuration: Here you can see the complete configuration that has been submitted for this
rig. If somebody has earlier clicked on ‘Add Configuration’ then you will see
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more than one version listed. If it was an accidental addition then the new
version will be an empty form.
Manage Well: Here we should see the well data that has been applied by the Reporter. If not
then the Super-User can address it here.
Not every well will have all three numbers assigned. Every well will have at
least one number but include all that you can.
The Add Well option also asks the Reporter to include the number of riser
joints run on the well. This data is used for statistical information when
charting riser failures against the quantity of riser joints in use across the
database.
This default well data will be used to populate all reports until the data is
changed for subsequent wells.
Manage Contract: Here you will find contract information and an Add Contract button to allow
new contract details to be included.
PARTICIPANTS
Self-explanatory; this is simply a list of Equipment Owners (in the main,

Drilling Contractors), Operators and System Integrators. If you need an
Operator who is not listed then call and we can have it added at very short
notice.
USERS
A current list of your company users. The Super User can set up, or disable,
Reporters, Super Users or Executive Users. Please be careful with this
capability. Do not forget that the data collectively belongs to the members and
should not be accessible to non-members of the JIP.
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5.0 Analysis
Effective investigation is essential to identify the causes (i.e. Physical, Human, and Systemic) and root
causes of a failure to enable learning, improvement and removal of component failures. Removing
component failure causes increases inherent reliability and safety.
The initial scope of any investigation must be based on factual information (e.g. hose failure, valve
leaking in closed position) relating to failure.
5.1. Failure Causes
As part of the investigation processes, three types of causes are identified in order to understand the
root cause(s) of the failure. These are:
5.1.1. Physical Causes
These are the consequences, manifestations or outcomes, known or determinable, that initiate or
trigger component failure. Examples include corrosion, fatigue, excessive stress, erosion, rupture,
etc.
5.1.2. Human Factor Causes
These are related to human activities that contribute to component failure. Identifying and
understanding the contribution of human factors during component failure investigations will
improve corrective action identification and component performance. Examples of human factors
include; fatigue, complacency, stress, environmental conditions, etc.
5.1.3. Systemic Causes
These are related to any system or process activity that results in a reoccurring event. These include
processes used to execute the work.
NOTE: If the failure is part of a wider event then the appropriate investigative
procedure may need to be followed IN ADDITION to the creation of the report on
component failure.
5.2. Analysis Overview
This section presents the three levels of analysis to be applied with regard to events recorded in the
RAPID-S53 database:
 Cause Immediately Known.

 SME Review.
 Root Cause Failure Analysis.
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NOTE: If an investigation at one level fails to determine the root cause of the failure,
then the analysis can be promoted to the next level as appropriate.
As shown in the Failure Report Process (APPENDIX 2), in the event that the root cause is immediately
known, the relevant notifications are issued immediately a component failure report is submitted to
the database and is moved to an “Approved (Closed)” state.
If the component failure has resulted in a loss of a well barrier, if it has required the LMRP or
BOP stack to be retrieved, or if the failure has become a systemic/reoccurring event, then an
RCFA is always required.
Other events require an SME Review to be conducted by a subject matter expert, and reported.
NOTE: There will be occasions where a component failure has previously been
categorized as ‘Cause Immediately Known’ or ‘SME Review’ becomes ‘RCFA required’
because such an issue has now occurred multiple times and, as a result, becomes
classed as ‘Systemic/Reoccurring’. The previously published reports do not need to be
reclassified, but they may be referred to in the RCFA.
5.3. Cause Immediately Known
An O-ring damaged during installation can, for example, normally be categorized as ‘Cause
Immediately Known’. It is important to report such issues because if something like this were to
escalate to a systemic/reoccurring event then it may warrant a change to the design or
installation/maintenance procedure.
5.3.1. Resources
The Senior Subsea Engineer should discuss what happened with another technical member of crew
to determine:
 What happened?
 How it happened?
 Why it happened?
5.3.2. Closure
When the cause of the failure is immediately known, the investigation is considered closed when:
 A report is created in the database, with sufficient justification in the free text “Description of
Event’ to support the root-cause selected from the drop down box.
 The selection and the report are approved by the equipment owner’s super-user.
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5.4. SME Review
An SME Review is conducted when the cause of the failure is questionable and the component failure
has not triggered an RCFA (not an unplanned BOP pull, loss of well barrier, or systemic/reoccurring).
An SME Review is conducted when a failed component requires disassembly to ascertain the cause
of the failure and when the frequency (not systemic) and consequence (no loss of barrier or bop
retrieval) of the component failure are considered to be low.
If a ram failed to hold pressure during pre-deployment testing and upon opening the doors/bonnets
it was clearly seen that the packers were well worn, then an SME Review could check the records to
see if the number of functions met the expectations. Then after the rams have been successfully tested
with new packers to confirm that there was no other issue, and assuming the number of functions
met expectations, the failure can be attributed to ‘Wear and Tear’. If, however, the rams fail to test
and / or the function cycles were less than expected, the causal agent is something other than ‘Wear
and Tear’.
5.4.1. Resources
Two, or more, SMEs.
5.4.2. Closure
An SME Review Report (See APPENDIX 4), identified by the unique number used when the initial
report was submitted, must be produced. This report should arrive at a logical conclusion based on
a sound evaluation of the physical causes of what, how and why a failure occurred. The incident can
be considered closed when the Equipment Owner Super User updates the component failure report
in the database by selecting the appropriate Root Cause from the drop down box, hence closing the
initial report, and publishes the final report.
23
GUIDANCE DOCUMENT
5.5. RCFA
This investigation is more detailed and as such takes more

resources and time. There are three specific triggers, as
shown at right, for when an RCFA shall be carried out.
This analysis should output root causes that can be turned

into action items to prevent reoccurrence; for instance
OEM product bulletins, equipment owner maintenance
system changes, etc.
5.5.1. Physical Evidence
Well Control Equipment component failures are frequently

field repairable and in many cases there may not be a
replacement assembly readily available. In such an
instance, ensuring full and detailed record capture of
physical evidence is critical, even if the situation
necessitates the evidence being in the form of photographs, Figure 1 RCFA Triggers
dimensions, sketches and written reports, to allow repairs to be
effected and allow the rig to go back to work.
5.5.2. Resources
Typically, at least one SME plus the OEM or a suitably qualified third-party are utilized.
5.5.3. Closure
An RCFA report (See APPENDIX 4), identified by the unique number used when the initial report was
submitted, must be produced. This report should arrive at a logical conclusion based on a sound
evaluation of the physical and any human causes of what, how and why a failure occurred. This
document is for internal use within the affected company.
The incident is considered closed when the Equipment Owner Super User updates the component
failure report in the database by selecting the appropriate Root Cause from the drop down box, hence
closing the initial report, and publishes the final report.
6.0 Capture and Share Lessons Learnt

When these reports have been finalized and approved, it is necessary for the learnings from the
component failure to be shared internally within the equipment owner’s company and with the
appropriate stakeholders as dictated by regulations.
A lesson is only learned when the data is properly shared.
24
GUIDANCE DOCUMENT
APPENDIX 1. DOWNLOAD INPUT FORM
WELL IDENTIFICATION Form Rev: C

Lease No.: Well No.: API Well No.:
RIG OWNER INFORMATION
Rig Owner / Drilling Contractor: Pacific Rig: Operator: Pending

Owner's Primary Contact: Owner's Primary Contact's Email:
Name of Person Reporting:
Name of OEM Representative Onboard, if applicable:
Other Information
Owner's Specific Equipment ID Number:
OEM Incident Reference Number: Equipment sent on shore for: No
EQUIPMENT DATA
BOP Use: Subsea
Equipment Integrator: GE
Subunit: Choke Manifold System
Item: BOP Control Panel
Component: Auxiliary Control Panel
Component Manufacturer: Cameron OEM Part Number:
Observed Failure: Mechanical damage OEM Serial Number:
Model:
Size: 0 and 1/16" Pressure Rating: 0psi Well Bore
EQUIPMENT HISTORY
Date Affected Component was Installed: 01-Jan-15
Maintenance Deferred on Equipment: No -If YES, what maintenance was deferred: BWM/EOW
Date of Last Maintenance: 23-Oct-2016 Description of completed last maintenance ↓:
Amount of Usage at the Time of Failure: Hours Cleaned and Inspected
SITE SPECIFIC INFORMATION
IADC Code - Description: 2 - Drill Actual
Location (Region): Americas Location (Country): Gulf of Mexico - US
Water Depth: 5,250 Feet
Drilling Fluid Type: Synthetic Based Mud
BOP Control Fluid : MacDermid Erifon Summer Grade
Concentration: 3% Glycol: 0%
Was the last laboratory sample acceptable?: Yes Date of last sample: 19-Jul-2016
EVENT DATA
Event Date: 31-Oct-2016 Event Date is: Date of Detection
When did the event occur?: BOP #1 Not in Operation
Description of Event:
Hours of NPT: Hours of Repair time:

Did the event cause a BOP Stack pull? No Detection Method: On Demand
Immediate Corrective Action: Replace Root Cause: Assessment Pending
Reason :
25
GUIDANCE DOCUMENT
APPENDIX 2. REPORTING PROCESS
26
GUIDANCE DOCUMENT
27
GUIDANCE DOCUMENT
APPENDIX 3. FIVE-WHY’S ANALYSIS METHODOLOGY

Five-Whys Analysis is a simple iterative technique that can be used with either the SME Review or
with an RCFA to understand the cause-and-effect relationships underlying a particular problem. The
primary goal of the technique is to
determine the (root) cause of a defect or
problem by repeating the question "Why?"
Q1. Why did
Each question forms the basis of the next this component A1.
fail?
question. The "5" in the name derives from
an empirical observation on the number of
iterations typically required to resolve the
problem.
The method provides no fixed rules about Q2. Why did

A2.
that happen?
what lines of questions to explore, or how
long to continue the search for additional
root causes. The following outlines a
typical 5 Whys Analysis process:
Identify and define the Q3. Why did

A3.
that happen?
component/process on which the event or
failure has happened.
 Define the failure

 Brainstorm and list the possible
causes Q4. Why did
A4.
 Select the most likely cause (must that happen?
be able to explain why it was

selected)
 Apply the “5 Why” principle (on the
selected “most likely” cause)
 Repeat asking “why” until the “root Q5. Why did
A5.
that happen?
cause” is identified
 Suggest possible solution
 Implement and validate the
solution
28
GUIDANCE DOCUMENT
APPENDIX 4. SME REVIEW OR AN RCFA REPORT
While being company specific in design, the final reports must include:
The initial report unique identification number
Details of the component that failed (Part Number, Serial Number, Description,)
Date of the failure
Details of the failure
Date that the investigation commenced
Date that the investigation was completed and the report published
Investigation team member details
Failure cause(s)
Findings (including any photographs or drawings, third party reports or other supporting
information.
Recommendations
29
GUIDANCE DOCUMENT
APPENDIX 5. MODEL TERMINOLOGY
We do not (yet) have the various models linked to the equipment. To

prevent the requirement for a further clean-up when this has been
addressed, please use the exact format for each major component as
detailed below:
ANNULAR BOP
ANNULAR CAMERON GE NOV

MODEL D GL Standard (BigBoy)
MODEL DL GX SL
MODEL GX Compact NXT
MODEL MSP 7012 (Old T3)
RAM BOP
RAM BODY CAMERON GE NOV

MODEL EVO Compact 6012
MODEL T Conventional NXT
MODEL TL Quik-Lok SL
MODEL U SLX
MODEL UII
RAM Bonnet / Door
30
GUIDANCE DOCUMENT
BONNET/DOOR CAMERON GE NOV

EVO, Super Shear, 4,000psi, Compact, 14-1/4”, Low Torque, 6012, 14” x 10” Booster,
MODEL
N/A 3,000psi, MPL 3,000psi, Poslock
MODEL EVO, Tandem Booster, Compact, 14-1/4”, Pressure NXT, 14” Booster,
5,000psi, EVO Lock Differential, 3,000psi, MPL 3,000psi, Poslock
Compact 15-1/2”, Low Torque, NXT 22”, CVX, 5,000psi,
MODEL EVO, 3,000psi, EVO Lock
3,000psi, MPL Poslock
Compact, 15-1/2” Pressure NXT, 22” LFS, 5,000psi,
MODEL T, 3,000psi MOP, ST Lock
Differential, 3,000psi, MPL Poslock
Compact, 19” Low Torque, NXT, 22” x 14”, 3,000psi,
MODEL T, 3,000psi MOP, Wedgelock
3,000psi, MPL Ultralock IIB ILF
TL, Super Shear, 3,000psi, Compact, 19” Pressure
MODEL NXT, 3,000psi, Manual
N/A Differential, 3,000psi, MPL
TL, Super Shear, 4,000psi, Compact, 22” Pressure
MODEL NXT, 3,000psi, Poslock
N/A Differential, 3,000psi, MPL
TL, Super Shear, 5,000psi, Compact, 22” Pressure NXT, 3,000psi, Ultralock
MODEL
N/A Differential, 4,000psi, MPL IIB
TL, Tandem Booster, Compact, 22” Pressure NXT, 3,000psi, Ultralock
MODEL
3,000psi, ST Lock Differential, 5,000psi, MPL IIB ILF
TL, Tandem Booster, Compact, 22” Pressure NXT, Booster, 4,500psi,
MODEL
4,000psi, Ramlock Differential, 5,000psi, N/A Poslock
TL, Tandem Booster, Conventional, 14-1/4” Low
MODEL SL, 3,000psi, Poslock
4,000psi, ST Lock Torque, 3,000psi, MPL
Conventional, 15-1/2” Low
MODEL TL, 3,000psi, Ramlock SL, 3,000psi, Ultralock IIB
Torque, 3,000psi, MPL
Conventional, 15-1/2” SL, Booster, 5,000psi,
MODEL TL, 3,000psi, ST Lock Pressure Differential, 3,000psi, Poslock
MPL
Conventional, 19” Low Torque, SL, Old T3, 3,000psi,
MODEL TL, 5,000psi, Ramlock
3,000psi, MPL Manual
TL, 5,000psi, ST Lock Conventional, 19” Pressure SLX, 16” Booster,
MODEL
Differential, 3,000psi, MPL 3,000psi, Poslock
U, Large Bore with Tandem Conventional, 22” Low Torque, SLX, 18” Booster,
MODEL
Booster, 3,000psi Wedgelock 3,000psi MPL 3,000psi, Poslock
U, Large Bore, 3,000psi MOP, Conventional, 22”, Pressure
MODEL SLX, 3,000psi, Manual
Wedgelock Differential, 3,000psi, MPL
U, Tandem Booster, 3,000psi, Quik-Lok, 14-1/4” Low Torque,
MODEL SLX, 3,000psi, Poslock
Manual 3,000psi, MPL
UII, Tandem Booster, Quik-Lok, 14x14” Dual Cylinder SLX, 3,000psi, Ultralock
MODEL
3,000psi, Wedgelock Shear Boost, 3,000psi, MPL IIB
UII, without cylinder, SLX, Booster, 5,000psi,
MODEL
3,000psi, Wedgelock Poslock
MODEL UII, 3,000psi MOP,
Wedgelock
MODEL U, 3,000psi MOP, Wedgelock
MODEL U, 3,000psi, Manual
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GUIDANCE DOCUMENT
BOP Mounted Choke and Kill Valves
BOP C/K VALVES CAMERON NOV SRI WOM

Magnum – Fail
MODEL AF – Fail Open DB – Fail Open Fail Open
Open
MODEL AF – Fail Close DB – Fail Close Fail Close Magnum – Fail
Close
MODEL DF – Fail Open HB – Fail Open SL
MODEL DF – Fail Close HB – Fail Close SLX
MODEL FCS – Fail Open HPT – Fail Open
FCS – Fail Close HPT – Fail Close
MCS – Fail Open
MCS – Fail Close
Choke and Kill Stabs
CONNECTORS CAMERON GE NOV

MODEL Mini-Collet Stab 1 Ext/Ret Locking
MODEL Stab 2 Ext/Ret Non-
Locking
MODEL Stab 3 Fixed Locking
MODEL Fixed Non-Locking
MODEL
32
GUIDANCE DOCUMENT
Choke and Kill Flex Loop/Hose
CONNECTORS CONTITECH COPPERSTATE OILSTATE TECHNIP

MODEL HNBR 16C Compliant Flex Loop Rilsan
MODEL NBR Stainless Lined Coflon
MODEL NBR/CR Standard
MODEL PA
MODEL Taurocool
MODEL Tauroflon
Connectors
CONNECTORS CAMERON DRIL-QUIP GE NOV

MODEL DWHC DX-10 H4 DWHD CHX
MODEL EVOConn DX-15 H4 DxE
MODEL HC DX-DW H4 E
MODEL HCH4 DQ-DX H4 ExF
MODEL Model 70 DQ-VX H4 ExF HAR
MODEL H4 SHD
Riser Mandrel

MODEL DWHC DX H4 H4
MODEL H4 H4
MODEL HC
33
GUIDANCE DOCUMENT
Flex Joint
CONNECTORS CAMERON GE OIL STATES

MODEL Flex King 6.0 Annuflex Subsea LP
MODEL Subsea 2.0
MODEL Subsea 2.5
MODEL Subsea 3.0
MODEL Subsea 3.5
MODEL Subsea 4.0
MODEL Subsea 5.0
MODEL Subsea 6.0
Conduit Flex Loop/Hose
CONNECTORS CONTITECH COPPERSTATE OILSTATE TECHNIP

MODEL HNBR 16C Compliant Flex Loop Rilsan
MODEL NBR Stainless Lined Coflon
MODEL NBR/CR Standard
MODEL PA
MODEL Taurocool
MODEL Tauroflon
34
GUIDANCE DOCUMENT
Riser
RISER AFGLOBAL CAMERON GE MHWIRTH NOV

MODEL UDW Hybrid RCK HMF-D CLIP DT-1
MODEL RF HMF-E QTR-4000 DT-2
MODEL LoadKing 2.0 HMF-F DT-E
MODEL LoadKing 2.5 HMF-G DT-F
MODEL LoadKing 3.0 HMF-H DT-G
MODEL LoadKing 3.5 HMF-J FT-GB
LoadKing 4.0 MR-10 FT-H
LoadKing 4.5 MR-6C FT-HB-DG
MR-6E FT-I
MR-6HSE UDW
FT-DGD
Diverter Housing

MODEL 49-1/2” 49-1/2” 49-1/2” 49-1/2”
MODEL 60” 60” 60” 60”
MODEL 75” 75” 75” 75”
Diverter Assembly

MODEL CF-A CSO CSO CSO
MODEL CF-B KFDJ
MODEL KFDS
35
GUIDANCE DOCUMENT
Choke Manifold Valves
CONNECTORS CAMERON NOV QOT WOM

MODEL FC B QFC Magnum
MODEL FLS F-C
MODEL T-B
HPY
E-Mk2
Auto Chokes
AUTO CHOKE CAMERON EXPRO NOV QOT MASTERFLO SWACO

MODEL Hydraulic SCB2 MS QC P25 Super Choke
MODEL CSO (Varco)
MODEL CSO 3-15 x 3-10
MPX-40D
HxE G3
Manual Chokes
MANUAL CHOKE CAMERON EXPRO NOV QOT MASTERFLO
MODEL Manual SCB2 B-H2 QH2 P25

MODEL E-S
MODEL CSO 3-15 x 3-10
HxE G3
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GUIDANCE DOCUMENT
BOP Control Pods
PODS AXON CAMERON GE KOOMEY NOV OCEANEERING

MODEL Type 80 Hyd 48 Line Hyd-P56B Hyd 46 line Hyd 42 Line Hyd 68 Line
MODEL Hyd Modular MUX Gen 1 Hyd 60 Line MUX 98 Line
MODEL MUX Mk-I MUX Gen 2 Hyd 64 Line MUX 132 Line
MUX Mk-II MUX Gen 3 Hyd 80 Line
MUX Mk-III Sea Onyx MUX 80 Line
MUX Mk-IV MUX 90 Line

MUX 112 Line
MUX RCX
37

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RAPID-S53

Reliability and Performance Information

API S53 Well Control Equipment

APPENDIX 1. DOWNLOAD INPUT FORM...............................................................................................................25

1.0 Scope and Purpose

2.0 Definitions and Acronyms

Cause: Something that initiates, shapes or influences an

Corrective Action: An action, which is taken to correct a failure and/or

Effect: An event or condition that is caused by another event

Evidence: Information, data and/or items gathered which

Failure: A condition that prevents the component from

‘Five-Whys’ Analysis: A ‘question-answer’ process used to explore the

Root Cause: Is the cause (condition or action) that begins a

Root Cause Failure Analysis: A comprehensive systematic investigation process

Subject Matter Expert: Person or persons with an in-depth knowledge of a

SME Review: An internal assessment of the possible and probable

API American Petroleum Institute LMRP Lower Marine Riser Package

3.0 Equipment Owner’s Reporter Instructions.

How to complete a report?

Download Failure Report

And complete all of the required fields, as guided below, offline:

3.1. Downloaded Report

Rig Owner Information

Rig: Dropdown box filtered to show all of the current rigs

Operator: Dropdown box populated with a list of the current

Lease No. : Number as provided by operator.

Well No. : Number as provided by operator.

API Well No. : Number as provided by operator.

Type of WCE System: Subsea; Surface Offshore; Land.

Item: The items listed in the dropdown box are contingent

Component Manufacturer: Select the manufacturer of the component in this

Model: There are too many options to compile a dropdown box.

Size: Two dropdown boxes to input the whole and fractional

Pressure Rating: Two dropdown boxes; the first to select in standardized

This could be the date that the equipment was delivered,

Maintenance Deferred on Component: Yes/No dropdown box to record whether planned

Site Specific Information

IADC Code Description: 1- Rig Up and Tear Down

Dropdown box with a listing of IADC codes and

Location (Region): Africa; Americas; Asia; Australia; Oceana; Europe.

Location (Country): Dropdown box to select appropriate countries cascaded

BOP Control Fluid: Houghton Aqualink 300-FV7; Houghton Stack Magic

Concentration: 0; 1; 2; 3; 4; 5; 6; 7; 8; 9; 10; 11; 12; 100%.

Event Date is: Date of Occurrence; Date of Detection.

Hours of NPT – Integer field to record number of hours that is inclusive

Detection Method – Casual Observation; Continuous Condition Monitoring;

Immediate Corrective Action: Adjust; Check; Inspection; Modify; Refit; Repair;

Root Cause: Assessment Pending; Design Issue; Documentation

The selection by the super-user of any option except

Selection of ‘Assessment Pending’ will open a free text

Selecting ‘RCFA required’ or ‘Assessment Pending’ will

Quantity: An integer box to allow a quantity input in case you

3.2. Submit Failure Report

There are two options when submitting a failure report.

3.3. Root Cause Options, Definitions and Examples

Design Issue: Inadequate component design or configuration.

Documentation Error: Mistake or oversight in the documentation used by

Maintenance Error: Mistake, misuse or oversight during maintenance.

Procedural Error: Mistake, misuse or oversight during operation.

QA/QC Manufacturing: Failure related to manufacturing.

RCFA Required: Currently unknown root cause.

Wear and Tear: An expected condition of a component that has reached

4.0 Equipment Owner’s Super-User Instructions