Case Study – 102 – The Blowout
Welcome to Forensic Business Pathology® (FBP) with Tom Taormina. This is Case Study #102 in an ongoing series of anecdotal lessons, based on actual cases, to help litigators achieve their greatest level of success in products liability and organizational negligence tort.
Maintaining the effective extraction of crude oil from producing wells is a complex and dangerous undertaking. There is machinery with many moving parts, typically running for extended periods of time, which must operate flawlessly. Crude oil typically contains unwanted byproducts like sulfur, natural gas and paraffin that must be dealt with before refining.
The Forensic Investigation
Well production companies have a number of specialized technicians who perform periodic maintenance of the well heads. In this case study, the mission was to maintain a particular well head that was being backed up by excessive paraffin. The process involves injecting hot oil back in the well to melt the paraffin and remove it. Also in this case, the valve used to connect to the hot oil machine had recently been replaced. The “Hot Oiler” technician arrived on site and connected his equipment to the newly installed valve. He had difficulty mating the hose and the valve. The oil is heated with an open propane flame under a large storage tank. The operator started the process and within a few minutes, the well head exploded, expelling natural gas and oil that ignited from the open flame on the truck. The technician was killed.
The FBP Investigation
Our FBP investigation revealed that the new valve was actually a water valve, which did not meet the safety requirements for crude oil. A series of human errors was discovered, starting with a distributor shipping the water valve in place of the oil valve and that mistake not being discovered by a long list of individuals who caused the valve to be installed on the wellhead. The final blame was put on the technician who installed the valve, because the threads did not match and he forced it into the pipe fitting.
The FBP Expert Analysis
For any businesses, all processes must be documented, trained and the operators certified for competency. The operators must be trained in the consequences of the work they do and be accountable to themselves and everyone in the chain.
Just because a supplier, technician or other individual or process worked flawlessly for years does NOT mean it will be flawless today. They must remove liability by verifying each process step is completed to specification before moving forward. This lack of process thinking can lead to catastrophic outcomes.
Plaintiffs are able to collect large settlements in these cases. The defense is typically at a loss to find plausible excuses for such a complex and lengthy series of negligence from supply chain management to field installation and testing.
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 The case studies have been redacted and dramatized as to avoid any conflict of confidentiality. They are intended to stimulate strategic thinking, not to be used for case law references.
 Because our FBP investigations drive these cases to rapid settlement.