All,
As we are discussing process safety, I recommend for anyone who is interested in furthering their knowledge to read: 

• Disastrous Decisions by Andrew Hopkins,
• Against the Gods - The remarkable story of risk by Peter Bernstein
• The Logic of Failure by Dietrich Dorner

For many, HSE consists of personal safety only. This is a complete misunderstanding as HSE consists of two parts (personal safety and process safety) that have to work in cohesion. The sad part is that many safety initiatives or systems such as the old Dupont 'STOP' system is misused by mainly or even solely focussing on personal safety which is exacerbated by the requirement to submit x number of safety observation cards per day.
As mentioned in previous posts, for a well control event to escalate into a blow-out many indicators have been ignored, not identified and surely not investigated.This requires a change in mind set. It is OK to stop, think and consult ... revise the plan using the Management of Change procedure.

It would be very interesting to review the root cause analysis report on this blow-out and I would caution everyone not to speculate on the how's, the when's and the why's until a report is made public.

Best regards,
Harald Benning.

In follow up on Anoop’s very valid comments, indeed, most stakeholders [operator and contractor alike] do not invest enough in training efforts that would benefit staff engaged in workover operations. During some of my workover classroom training sessions I find delegates’ perception of what ‘process safety’ really entails relatively low. They do not engage in discussion, neither do they challenge what is being said. They do not necessarily get to know and understand the risks they are being exposed to. They follow the program as given to them but are not skilled enough in performing their own mini risk assessment [with regards to process safety] to the level that is required, hence no timely intervention or objection to an unchallenged program step may take place.

 

As we all know, the difference between an incident like this, and a ‘just in time’ action to prevent it altogether, is immense. The former gets attention as it affects the lives of thousands of people living in the area [like in Assam], whereas the latter may be laughed off, yes possibly recorded, but not in true detail, not with the aim to rectify the root cause [which is almost always an organizational and human factor related one], and often not disseminated to a wider audience either [why would you want to expose your dirty linen].

 

Although it may seem like shooting from the hip, when visiting the website of the workover contractor that was given the work to do on the Baghjan-5 well I came up empty-handed when looking for the word ‘process safety’, although there was plenty to find on personal safety. This may be indicative for the way attention is paid by planners and executioners alike to this most critical aspect of their daily job.

 

But again, repeating Anoop’s response, let us wait what the full report has to say and hopefully it will give us an unbiased account.

Fully agreed with Miaody's observation that  "most workover team don't have enough well kill skills, even don't know how to shut in the well or how to kill a well".

Here is the gray area which has to be looked after by the industry. The rigorous well control training are given to drilling people are not always gone by the workover people. Therefore the workover operation plannings at the base office should be more comprehensive factorising all possible human error.
Regarding Baghjan, we can not comment on how and why it happened,  until we get a detail investigation report 

173days is a long time for a wellcontrol incident. mostly, well control incident  easy happen in during workover operations. Workover strings have more different size (diameter), it is difficult to shut the well use normal method. gas well, wire line, injection pipe,eg, all these small parts are challenges. Another thing is the team, most workover team don't have enough well kill skills, even don't know how to shut in the well or how to kill a well.So we should do more trainning before workover operations.

An independent investigation with Root Cause Analysis is required - in fairness as Jan says the cement plug failure and not WOC a significant factor; But everyone involved needs to sit down and ask Why? Why/ Why....to find the underlying factors/reasons and address them. 

Anoop, 

Steve has presented some of the recent evident facts, however.

I believe one has to go further back and  strip back the several more layers of
- Physcial (parts)
- People
- Paperwork 
Evidence and trails of failures that exists to these events.

Because we know one has to work extremely hard to have a blow out. 

Where facts are that  a multiplicity of evident things have had to have failed. With several active and latent reasons to be discovered.  Note: There is never one root cause or one person to blame in such events.

Best advice, I can offer from a career of not having too many secondary well control events, because we were adamant and compliant with primary well control principles and practices in the first place. and W-CAP trained. 

However having experienced a career hundreds of evident well operational failures that we never truly investigated that well, that is systemic in a majority of oil and gas well's organizations (not all)

Is to find a good course or method to address this gap. i.e. train one self to be able to truly gather and investigate all the 3P's of evidence of all things that fail with your current well projects. Conclude both 'active and latent (human factoring) failings that result and try to act (who when how**) to address these. 

**So that not only learning results, but more importantly that these are translated and sustained into future projects. 

Then try an develop a far more proactive approach in your projects to prevent vs the more common 'status quo' of: respond react and cure where bigger and more consequential problems are at risk to result.

Finally, 'Failing to plan is planning to fail'.

     

Is there any more information of this well? what was the reason of this well blow out?

The baghjan well-5 blowout incident occurred on 27th May'20 and caught fire on 9th Jun'20. The well is brought fully under control on 15th Nov'20 (Attached is the press note)


Anoop Hansda