A seemingly insignificant task at a fracking site proves to be a likely cause of a multimillion-dollar accident. The task involved making up the hydraulic line fittings on newly installed hydraulic pumps. The task was considered within the “skill of the trade.” Replacing existing hydraulic pumps with a new design pump was in fact a design change. An engineering specification for installing the pumps was not part of the modification work order. A maintenance-modification management failure became a fracking diesel engine fire.
As a hands-on maintenance manager and maintenance management consultant, I saw instances of management staffs assuming that simple modification work can be performed by the maintenance staff. Additionally, they thought there would be no need to get an engineering function involved. This is a misconception among managers who fail to realize that reliability of systems and equipment is directly affected by operations and maintenance activities. Since most of those activities are controlled through defined processes, alarm bells should go off when a modification (change) becomes an activity affecting systems and equipment. Having the maintenance staff handle system and equipment modifications can compromise the reliability of operating systems and equipment. When failure does occur, the cause is usually assigned as human error. But in this case, a fracking diesel engine fire cause was in fact a modification management failure.
Making up hose fittings could be executed within the “skill of the trade” if it is a simple repair/replacement task. This modification changed the hose fitting assembly for the new motors (not within the “skill of the trade”). Engineering is now needed to specify the new hose fastener parameters. To preserve design reliability, the task required review and modification of the applicable procedures and instructions. This helps avoid fracking diesel engine fires.