DEP cites human error in fatal gas well fire

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Investigators from the state Department of Environmental Protection concluded in a report released Wednesday that human error by a contract worker with no oilfield experience may have led to the explosion and fatal fire Feb. 11 at Chevron Appalachia’s Lanco well pad in Dunkard Township.


The DEP report also faulted Chevron site managers for not always providing enough oversight to contractors at the site where 27-year-old Ian McKee, a field service technician for Houston-based Cameron International, was killed.


A lock pin improperly secured on a well head assembly by an inexperienced worker may have allowed gas from the pressurized well to escape and ignite, the report said.


The report criticizes Chevron for allowing an inexperienced “greenhat” employee of Cameron to do work for which he was neither trained nor properly supervised.


In a separate “after action review” of the response to the fire, DEP also cited as a problem a lack of communication between it and Chevron. The company failed to provide DEP with “meaningful” updates during regularly scheduled briefings and excluded DEP from discussions between Chevron and Wild Well Control, the company brought in by Chevron to control the fire, the report said.


“We had to pull teeth to get information,” DEP spokesman John Poister said. “There was no reason to be secretive. It was a tragic accident, and in an emergency, everybody has to work together. Eventually, they opened up the flow of information, but it took a couple days, which was unacceptable.”


Chevron spokeswoman Lee Ann Wainwright, in an email response, said the company received the reports.


“We are reviewing the DEP reports, and we look forward to the opportunity to discuss them with the DEP in the near future,” she said. “Chevron is committed to safe operations. We look forward to continuing to work with the Pennsylvania DEP and (the federal Occupational Safety and Health Administration) in order to fully understand what happened with this incident, and we are determined to prevent it from happening again.”


The fire ignited about 6:45 a.m., while employees for Cameron were preparing for a safety briefing and two of the employees walked toward the 7H well head, which was covered by a tarp, to investigate a hissing sound. When the well ignited, one of the workers was injured but escaped and survived. McKee was listed as unaccounted for until Feb. 27, when his remains were located on the well pad site.


The cause of the ignition is not known though several ignition sources were on the well pad, including a truck that was heating brine and heated air blowers, the report said.


Prepared through interviews with employees, including those at the site at the time of the fire, and a review of documents, the summary details work conducted on the well prior to the fire and notes work on the lock pin assembly had been completed several days before the fire by an unnamed inexperienced employee.


The wells had been drilled and fracked and Cameron was removing tubing hangers from the wells to prepare the wells for production. The greenhat, working with a more experienced employee, was asked to “back out” the lock pins while the experienced worker removed the tubing.


The greenhat had not been trained in the procedure and his work could not always be observed by the more experienced worker who was on a platform on a hydraulic lift. In addition to his work not being closely supervised, the greenhat had not been identified by Chevron as an inexperienced employee, with less than six month on the job, as required by its Short Service Employee policy, the report said.


It is not known whether others who worked on the well prior to the fire might have affected the condition of the lock pin assembly, the report said.


However, on the morning of the Feb. 11, one lock pin was ejected from the well head assembly, creating a hole allowing gas to escape. The pin was found about a week later 73 feet from the well. Threads on the gland nut portion of the pin had not been damaged, indicating no mechanical cause for its ejection, it said.


The report also cites the lack of oversight at the well pad by Chevron’s well site managers, some of whom lacked experience in the gas industry and provided only limited oversight of contractors working at the pad.


Some of the managers had “virtually no background” in the industry and had worked in jobs such as information technology, food service or construction. They reported little time to supervise contractors because of other duties. Between Feb. 7 and Feb. 11, the site had seven site managers, the report said. It was unclear if any “hand off” procedures were followed to familiarize new well site managers with the job.


Because of the limited oversight of contractors, the bureau could not determine what the greenhat had done in regard to the lock pin assembly or whether other contractors who worked on the site afterward but before the fire might have affected the condition of the lock pin assembly, the report said.


In its “after action review,” DEP cites problems encountered during the response because of a lack of communication by Chevron. While Chevron’s emergency response was sufficient, its communication with DEP “was too guarded,” the report said.


DEP had cited the company in April for initially barring DEP personnel from accessing the site. Poister said the agency intends to meet with the company to discuss the violation but was waiting for the reports to be completed.


DEP access to the site should not even have been a question, Poister said. “In an emergency like this, our emergency response people should have access; they are as well-trained and knowledgeable as anybody,” he said. Chevron controlled site access based on what it believed were state police directives, the report said.


The report recommended DEP assert its oversight authority immediately with operators on any emergency response. The agency also must have appropriate staff present in command centers to participate in discussions regarding well control, options and time frames, it said.


In addition, the report recommended DEP develop a response protocol for these types of events to coordinate emergency management and to assure that staff has proper equipment, training and adequate staffing to perform its duties.


The report further notes Wild Well Control’s response was adequate as the company had a team on site with 12 hours; that local first responders and emergency personnel performed their roles well; and that in such events a joint information center be established for media that includes personnel authorized to speak on behalf of the company.


Poister said DEP hopes others in the industry learn from the reports. “We hope this document, outlining the lessons we learned, serves as a framework for the entire industry should anything like this happen again,” he said.



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