WCR_Equipment_Failure_Form

WCR Equipment Failure Report Form
OMB Control Number: 2138-0046

Burden Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply
with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current
valid OMB Control Number. The OMB Control Number for this information collection is 2138-0046 (Exp. Date 03/31/2017). Reporting of an Equipment
Failure is estimated to take approximately 30 minutes, including the time for reviewing instructions, completing and reviewing the report. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to:
SafeOCS Data Collection Office, Demetra Collia, US DOT/ BTS, 1200 New Jersey Avenue SE, Room E36-302, Washington, D.C. 20590 or e-mail:
[email protected]
Pledge of Confidentiality
The information you provide will be used for statistical purposes only. In accordance with the BTS confidentiality statute (49 U.S.C. 6307) and the
Confidential Information Protection provisions of Title V, Subtitle A, Public Law 107-347, your responses will be kept confidential and will not be
disclosed in identifiable form to anyone other than BTS employees or BTS agents such as telephone interviewers. In accordance with these
confidentiality statutes, only statistical and non-identifying data will be made publicly available through aggregate reports. By law, every BTS employee
and BTS agent has taken an oath of confidentiality and is subject to a jail term of up to 5 years, a fine of up to $250,000, or both if he or she discloses
ANY identifiable information about the respondent or reporting company or operator. BTS will not release to the Bureau of Safety and Environmental
Enforcement, Department of Interior, or any other public or private entity any information that might reveal the identity of individuals or
company/operator names mentioned in near-miss reports.
RECORD IDENTIFICATION INFORMATION
IADC Incident No:

Operator/Company Assigned Reference No:

BTS Reference No:

WELL IDENTIFICATION
Lease No:

Well No:

API Well No:

RIG OWNER INFORMATION
Rig Owner / Drilling Contractor:

Rig Name:

If "Other", specify:

If "Other", specify:

Operator:
If "Other", specify:

Owner's Primary Contact's Email:

Owner's Primary Contact:
Name of Person Reporting:
Name of OEM Representative Onboard, if applicable:
Other Information
Owner's Specific Equipment ID Number:

Equipment sent on shore for:

OEM Incident Reference Number:

EQUIPMENT DATA
BOP Use:
Equipment Integrator:

<------ If "Other", specify:

Subunit:
Item:
Component:

Component Quantity:

Component Manufacturer:

OEM Part Number:

If "Other", specify:

OEM Serial Number:

Model:
Size (in inches ):

and

Item/Component Pressure Rating:

Observed Failure:

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EQUIPMENT HISTORY
Date Affected Component Installed:
Maintenance Deferred on Equipment:

<--If Yes, what maintenance was deferred:
If "Other", specify:

Date of Last Maintenance:

Description of completed last maintenance ↓:

Amount of Usage at the Time of Failure:

SITE SPECIFIC INFORMATION
IADC Code - Description:

<------ If "Other", specify:

Location (Region):

Location (Country):

Water Depth:
Drilling Fluid Type:
BOP Control Fluid :

<------ If "Other", specify:

BOP Control Fluid Concentration:

Glycol Concentration:

Was the last laboratory sample acceptable?

Date of last sample:
EVENT DATA

Event Date:

Event Date means:

When did the event occur?
Description of Event:

Hours of NPT:

Hours of Repair time:

Did the event cause a BOP Stack pull?

Immediate Corrective Action:
If "Other", specify:

Detection Method:
Root Cause:
If "Other", specify:
RCA Status:

Reason :

SafeOCS WCR Equipment Failure Report form v.2.3

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