BRAZILIAN MARITIME AUTHORITY DIRECTORATE OF PORTS … · pressure alarm in the exhaust gas turbine. This caused the stoppage of Turbo compressor “B”, causing the explosion for

BRAZILIAN MARITIME AUTHORITY

DIRECTORATE OF PORTS AND COASTS

INCIDENT ONBOARD PLATFORM “PETROBRAS XXXIII”

July 14th, 2010

MARINE SAFETY INVESTIGATION REPORT

Platform “Petrobras XXXIII”

Reference: IMO Casualty Investigation Code - MSC-MEPC.3/Circ.2 13 June 2008/ Resolution MSC.255(84)

Brazilian Maritime Authority - Directorate of Ports and Coasts

Surveys, Naval Inspections and Technical Expertise Management Maritime Casualty Investigation Department (CIPANAVE)

Incident onboard the Plataform “Petrobras P-XXXIII”

Marine Safety Investigation Report

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INDEX

GLOSSARY OF ABBREVIATIONS, ACRONYMS AND TERMS ........................... 3

I - INTRODUCTION ........................................................................................................ 4

II - SINOPSYS .................................................................................................................. 4

III – GENERAL INFORMATION .................................................................................. 5

a) Characteristics of the platform “Petrobras P-XXXIII” ...................................... 5

b) Documentation (Certificates of the Platform) ...................................................... 6

IV – SEQUENCE OF THE EVENTS ............................................................................. 6

V – HUMAN FACTORS AND CREWMEMBERS........................................................9

VI – DATA OF THE PLACE OF THE ACCIDENT....................................................11

VII - POST INCIDENT PROCEDURES.......................................................................12

VIII – CONSEQUENCES OF THE INCIDENT............................................................12

IX - ANALYSIS OF THE DATA GATHERED AND CAUSAL FACTORS..............13

IX.1 - EVIDENCE /FAULTS...........................................................................................15

IX.2 – CONTRIBUTING FACTORS.............................................................................16

X - PRELIMINARY LESSONS LEARNT AND CONCLUSIONS.........................16

XI - RECOMMENDATIONS..........................................................................................17

ANNEXES..........................................................................................................................17





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GLOSSARY OF ABBREVIATIONS, ACRONYMS AND TERMS

BMA – Brazilian Maritime Authority

CPRJ - Port Captaincy of Rio de Janeiro

DelMacae – Delegacy of the Port Captaincy in Macae

DPC – Directorate of Ports and Coasts

IMO - International Maritime Organization

ISM Code - International Safety Management Code

POB – Persons on board

SMC – Safe Manning Card

WHRU - Waste Heating Recovery Unit





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I - INTRODUCTION

For the purpose of effecting the collection and analysis of evidence, the identification of the

causal factors and the elaboration of safety recommendations that should be necessary, in order to

prevent that in the future occur similar maritime accidents and/or incidents, the Delegacy of the

Port Captaincy in Macaé (DelMacae) carried out a Marine Safety Investigation, in compliance

with that laid down in the Casualty Investigation Code of the International Maritime Organization

(IMO), adopted by Resolution MSC. 255(84).

This Final Report is a technical document that reflects the result obtained by DelMacae

regarding the circumstances that contributed or may have contributed to trigger the occurrence,

and not refers to any proving procedures for determination of civil or criminal liability.

Also, one should emphasize the importance of protecting the individuals responsible for

providing information regarding the accident, and the use of information contained in this report

for purposes other than the prevention of future similar accidents could lead to erroneous

interpretations and conclusions.

II – SYNOPSIS

On 14 July of 2010, approximately at 18h00, onboard the platform PETROBRAS XXXIII, IMO

7157749, Panamanian flag, located in the Campos Basin, Campos dos Goytacazes –RJ, Marlin

Field, in the position of coordinates of latitude 22o22‟S and longitude 040

o01‟W, an incident

occurred in the Turbo compressor “B”, in which was verified damage due to the sudden increase

in the discharge pressure of the gases of the turbine, provoking the rupture of the discharge

collector along its welded connection and other damages.

The communication of the occurrence of the incident was received in the Delegacy of the Port

Captaincy in Macae (DelMacae) by telephone on June 20, 2010 and on the following day, a Naval

Inspector, acting as Accident Investigator, visited the platform to evaluate the situation and collect

evidence to conduct the present Marine Safety Investigation.

In accordance with the registries examined, the environmental conditions at the moment of the

incident were good visibility, calm sea, mild wind and clear sky, normal conditions for operation,

not being verified any contribution for the occurrence of the incident.





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The accident investigation started immediately after the main interested parties had been

formally notified, in compliance with the provisions of the IMO Casualty Investigation Code.

III – GENERAL INFORMATION

On the occasion of the initial survey of Platform Petrobras PXXXIII (Photo 1), its visual aspect

was not good, with lots of corrosion in its structure.

Photo 1 – Platform P-XXXIII operating in the Campos Basin

a) Characteristics of the platform PETROBRAS XXXIII:

Vessel: PETROBRAS XXXIII Flag: PANAMA AB: 137.707

Port of Registry: PANAMA Hull: STEEL Length 337.40m

Sailing area: OPEN SEA No IMO: 7357749 Registry N

o 387-E00090-9

Call Sign: 3FKZ6 MMSI: 356790000 Gross Tonnage 135.673 tons

Displacement: 279.749 tons

Classification Society: AMERICAN BUREAU OF

SHIPPING

Year of Building: 1978

Activity: ANOTHER ACTIVITY OR SERVICE Cargo: XXX

Operator: PETROBRAS NETHERLANDS B.V. Propulsion: Without propulsion





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Owner: PETROBRAS NETHERLANDS B.V. Type: PLATFORM (PPSO)

P&I: Assuranceforeningen Gard – Norway Dynamic Positioning: No.

b) Documentation (Certificates of the Platform):

Issuing Authority Title Emission Validity

ABS Class 14/05/2009 29/09/2013

ABS International Freeboard 14/05/2009 29/09/2013

ABS International of Prevention of

Pollution by Oil (IOPP)

15/07/2009 29/09/2013

ABS Safety of Mobile Drilling Unit 14/05/2009 14/09/2013

Delegacy of the Port

Captaincy in Macaé

Safe Manning Card 17/07/2010 01/12/2012

Panama International Measurement 10/06/2002 undetermined

IV – SEQUENCE OF THE EVENTS

In accordance with the information collected by the Investigators onboard the Platform, and

from the Preliminary Report of Analysis of the Incident drawn up by Petrobras, it was verified that

on July 14th

, 2010, at approximately 18h00, occurred an incident in the turbo compressor “B” due

to a failure of the functioning of the Diverter valve, which closed the outflow of gasses to the

atmosphere and affected the internal pressure in the equipment, resulting in damages in its structure.

The turbo compressor B had presented problems in its functioning moments before the

incident, when a technician of the manufacturer was called to the place. This equipment has the

function to assist in the elevation of the oil from the well and, according to testimonies, functioned

automatically from previous programming.

The Diverter valve was lining up a large flow of gas to the heat recover and disarming the

system for high temperature. The heat recover was turned off and was closed the guillotine which

gave it the passage of gases, which would have caused overheating.





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The technician manufacturer of the equipment performed the procedure “force”, which means

getting the product to work alien to logic programming, overlapping thereby the protection on the

program of control of the turbine (Figure 1).

The Diverter valve operated (modulated) to fully close the outflow of gases into the

atmosphere, causing the internal pressure increase until the breaking of the exhaust manifold

(escape collector), resulting in an explosion. All procedures were carried out with the equipment in

operation.

Figure 1 – Gases lined up for the by-pass/guillotine and Diverter closed.

Source: UO-BC da PETROBRAS

The chronological sequence of the events was the following:

At 15h02 the Diverter Valve (modulator of the alignment of the exhaust gases of the turbine for

the Waste Heating Recovery Unit - WHRU, recuperative unit of the exhaust gases) opened, causing

the discharge gases were not to the atmosphere but stay stranded in the WHRU (Figure 2).





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Figure 2 – Way of operation by the WHRU

This led to an increase in temperature of injection water, causing the WHRU disarm and

remain so. The water temperature rose and withdrew the line Turbo compressor “B”. At 15h32

Turbo compressor “B” was switched back on. At 15h50 the valve remained open again. The

WHRU was disabilitated. However, this Diverter valve remained open (Figures 3a, 3b and 3c) not

accepting the command given, which has led the water temperature rise once again.

Figure 3a- Way of operation modulating the diverter





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From left to right: Figure 3b) Exhaustion gases blocked by the guillotine/ Figure 3c) Exhaust gases blocked by the

guillotine and by the diverter. The gases without exit provoked the breaking of the turbo.

At 16h00 the Turbo compressor “B” suffered one more stoppage, and the operator made a

new start with Turbo compressor “B” with the WHRU disabled.

At 18h01 the Diverter valve started to operate. At 18h08 Diverter valve modulated until close

to the exhaustion of the discharge gases and open to the WHRU. As the WHRU was with the

guillotine closed the gases have accumulated in the output of the turbine, activating the high

pressure alarm in the exhaust gas turbine. This caused the stoppage of Turbo compressor “B”,

causing the explosion for the accumulation of exhaust gases hurling the door of the capsule

against the bulkhead.

V – HUMAN FACTORS AND CREWMEMBERS

The Personnel embarked met the requirements stipulated in the Safe Manning Card (Annex

A) and List of Personnel onboard – Persons on Board/POB, both in the quantities and the

qualifications established. The crewmembers and the technicians (non-maritime) were competent

and were accredited for the operation of the unit. The platform possesses good accommodation for

all of the 154 persons embarked.

The key professionals involved in the incident were duly qualified. Also with regard to

personnel, there is the following:





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Platform Manager - works more than 30 years in Petrobras and is duly qualified to carry out

the tasks of the function. On the day of the incident he was carrying out the function of Sectoral

Manager of Platforms.

Technical Operations # 1 - works in Petrobras for more than 6 years and is duly qualified to

carry out the tasks of technical function of operation of the Platform PETROBRAS XXXIII. At

the time of the incident he was in the control room and learnt of the fact via VHF Radio.

Technical Operations # 2 - works in Petrobras for 8 years and carries out the function of

Production Supervisor. At the time of the incident he was in the Processing plant and has

knowledge on the functioning of the equipment, working in overseeing its operation.

The Representative of services of the company contracted to carry out the maintenance of the

equipment embarked on the platform on the day of the incident to render general technical

assistance and was requested to go to the control room of the compressor tubes to verify the bad

functioning of turbo compressor ”B”. Upon arriving there he verified that the diverter valve of

the heat exchanger was not working correctly and asked the Production Supervisor for the

equipment to stay out of operation in order to proceed with the maintenance. He was not attended

because the other compressor was out of operation. According to testimonies, representatives of

the platform decided by disabling the heat exchanger, and there was no technical impediment to

the operation of the turbine with the heat exchanger disabled.





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VI – DATA OF THE PLACE OF THE ACCIDENT

The platform PETROBRAS P-XXXIII is positioned in the Campos Basin, Campos dos

Goytacazes – Rio de Janeiro, Marlim Field, in position latitude 22o22‟S and longitude 040

o01‟W, at a

distance of 180 Km east of the city of Macae (Map1).

Mapa 1 – Localization of the Platform (Google Maps)

Environmental conditions: In accordance with the information obtained and records

consulted by the investigators, on the day of the accident the weather conditions were good, with

good visibility, calm seas, light winds and clear skies.





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VII – POST INCIDENT PROCEDURES:

After the incident were carried out the first procedures foreseen in the internal norms of the

unit and of the company, and it was verified that there had not been personal accidents. To follow

were adopted the operational procedures to disconnect the damaged equipment and the raising of

data to draw up the Statement of Occurrence of Failures, with this occurrence being communicated

to PETROBRAS and to DelMacae.

On August 11, 2010, in a new survey carried out by Investigators of the Port Captaincy of

Rio de Janeiro (CPRJ) , there were found in various different points of the platform, faults in the

air control system. This system issues commands for various systems and monitorizes many others

which could possibly cause imprecise readings and controls. Visual exams were carried out of the

parts of the turbo compressor and documental analysis.

VIII – CONSEQUENCES OF THE INCIDENT

a) Personal accidents – there were none.

b) Material damages - Damage in the turbo compressor Bravo (Photos 2 and 3).

Photo 2 – Damage on the duct of connection to the WHRU.





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Photo 03 – Damage in the turbo compressor.

c) Pollution – there was no registry of pollution relating to the accident.

IX - ANALYSIS OF THE DATA GATHERED AND CAUSAL FACTORS

Given the circumstances, it was possible for researchers to note that the procedure for

maintenance of equipment should be conducted with the equipment out of operation. The closing of

the guillotine associated with the bad functioning of the Diverter valve created a situation of risk

potencialized by the execution of the procedure “force”. This was due to the fact that the closed

guillotine impeded the exhausting of the gases for the recuperater of heat whilst the Diverter valve,

defective and modulating by forced action, impeded the exit of gases to the atmosphere.

The procedure "force" means to force a direct acting of the valve, bypassing the automated

control logic.

Despite the fact that the procedure "force" has been conducted improperly, if the equipment

was not functioning the incident did not occur. It is verified a carelessness here (human error) when

performing the procedure for maintaining the equipment in operation. As we can see, there was an

unexpected sequence of events by the maintenance team during the implementation of the

corrective maintenance of equipment turbochargers A and B. It was not done an adequate planning

for the proper maintenance of the turbo-compressors, offering a great risk of accident.





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In interviews with the shipboard personnel involved in the operation of the equipment the

investigators noted that all were qualified professionals and that the incident occurred on the turbo

compressor B of the plant of process. This equipment (turbo B) has the function of aiding the

elevation of oil from the well.

The investigators did not have access to the crashed turbo compressor due to Owner failure to

notify the Maritime Authority the occurrence of the incident. The incident was reported to the

Maritime Authority by a complaint, seven days after the event, when the scene of the incident had

been decharacterized.

Based on statements and the Preliminary report of Petrobras, the investigators found that there

was an improper closing of the flaps that direct the flow of exhaust gases, causing overpressure on

the collector of the exhaust gases from the turbine, resulting in the disruption of the collector, and

that equipment operated automatically by a previous schedule. It is assumed that the turbo

compressor was calibrated to controla ir at fully capacity, which was not ascertained on the

occasion of the survey of the platform for there was no access to the damaged compressor.

The undue closing of the Diverter valve that regulates the flow of exhaust gasses of the

turbine, resulted in overpressure in the interior of the discharge duct and consequently its breaking.

It was also found that the equipment presented problems in the Diverter valve, for which a

manufacturer's technical was called to the scene. In the attempt to repair the equipment the

guillotine was closed and the Diverter valve was enabled to operate with the equipment in

operation. Enabling the Diverter valve was made by the procedure denominated „force‟ that means

to force a direct acting of the valve, bypassing the automated control logic, which is not

recommended with the machine in operation, and for account of this action the valve closed totally

impeding the exit of gasses to the atmosphere. This caused an increase in duct pressure due to the

fact that the guillotine to be closed, and the explosion occurred when attempting to do maintenance

on the guillotine closed facing a defect in the Diverter Valve.

This guillotine could not be closed once that the Diverter valve was being forced, not being

this procedure recommendable with the equipment working, because could occur an undue situation

of the Diverter valve. To make it worse the fact that the turbine had not been stopped because the





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turbo compressor “A” was inoperative. Remember that the correct procedure would be to leave the

machine stopped during the maintenance.

IX.1 - EVIDENCE /FAULTS

a) Relating to personnel:

Despite the qualifications of the crewmembers and technicians involved in the operation of

the unit, by the accounts received, it was found from the testimonies given and by the documental

analysis that had occurred human error (imprudent actions) when executing maintenance of the

equipment in operation.

b) Relating to documents

There were no faults found in the documentation.

c) Relating to material

A material fault occurred in the functioning of the Diverter valve. The air control had

numerous leaks.

d) Relating to the ambient

There is no evidence that the atmospheric conditions on the day and hour of the incident

have contributed for its occurrence.

In the case under study, the faults of greater importance are referring to deficient politics and

planning of maintenance and deficient training.

In accordance with the facts described previously, it is verified that compliance had not been

given to Article 10 of the International Safety Management Code (ISM Code) that deals with the

Maintenance of Platforms and Equipment, and establishes that the company (the owner) should

ensure that inspections be made in appropriate intervals, any non-conformity be reported with its

possible cause if known, and that a appropriate corrective action be taken and register of these

activities be maintained.





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IX.2 – CONTRIBUTING FACTORS

(a) Human factor – Did not contribute, from the bio-psychological point of view.

(b) Material factor – Contributed with the failure in Diverter valve, due to the air control

system that met with numerous failures;

(c) Operational factor – Contributed, for corrective maintenance was being performed on

the turbo compressor B did not follow a minimum planning with safety, which consisted of

stopping the equipment, because of this stop interfering with the normal operation of the platform.

The causal factor of the incident was the closing of the guillotine without observation of its

monitoring, made worse by the attempt of maintenance of the temperature control system of the

heat recuperater (WHRU), through the placing of “force” on the solenoid valve of the Diverter

Valve with turbo compressor B in operation and with a guillotine closed. The investigation

concluded that these faults occurred due to the bad functioning of the Air Control system that

motivated the incident of turbo compressor B.

X - PRELIMINARY LESSONS LEARNT AND CONCLUSIONS :

Investigations into the circumstances of casualties that have occurred have shown that accidents

on board ships are in most cases caused by an insufficient knowledge of, or disregard for, the need

to take precautions. The investigation pointed out that the culture of safety and of the management

of safety on the part of those involved in the incident were not strong.

The maintenance and operational routines of a system as complex as an oil platform have a

duty to provide security, maintenance and training of personnel extremely well controlled and

effectively carried out. From the findings of this investigation it is concluded that the various

systems and in particular, that of air control that was fundamental from the operational point of

view, once that it controlled and monitored the other systems, did not act duly on the occasion of

the incident.

It stands out that equipment cannot continue to operate when faults are detected and corrections

are not made.





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XI - RECOMMENDATIONS:

First of all, safety recommendations shall in no case create a presumption of blame or liability.

The incident occurred because of a probable chain of different factors caused by the breach of the

procedures for maintenance and control of equipment and the platform as a whole.

Although the investigated incident have not caused casualties, it pointed out the necessity of

an improvement in the objectives of the Company´s Safety Management, in conformity with that

laid down in the International Safety Management Code (ISM Code), once that the incident could

have been avoided if the routines of the maintenance systems had been respected, as well if had

been given a greater attention to the air control system that met with numerous failures. This system

monitors and controls all the systems in the regions of risk of fire and explosion of the platforms.

Finally, a good Safety Management System should foresee and evaluate all the risks in the

operations carried out onboard.

The personal, technical and financial consequences of an incident or an unexpected

occurrence involving maritime operations can be devastating, and this fact emphasizes the

importance of having a verification scope of routine maintenance of equipment well defined, with

technical reference, competence and supervision, in order to be obtained service quality. Because

of the steps already taken by the owner during the investigation there is no other safety

recommendations applicable to the incident.

ANNEXES:

ANNEX A – Minimum Safe Manning Document (4 pages)





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ANNEX A

Minimum Safe Manning Document





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Documents

BRAZILIAN MARITIME AUTHORITY DIRECTORATE OF PORTS … · pressure alarm in the exhaust gas turbine. This caused the stoppage of Turbo compressor “B”, causing the explosion for