Monday, December 1, 2014

ACCIDENT INVESTIGATION REPORT – EQUIPMENT FAILURE DUE TO LACK OF MAINTENANCE/HUMAN ERROR/ELECTRICAL/FIRE DURING DEVELOPMENT PRODUCTION AT AN OFFSHORE FACILITY



ACCIDENT INVESTIGATION REPORT – EQUIPMENT FAILURE DUE TO LACK OF MAINTENANCE/HUMAN ERROR/ELECTRICAL/FIRE DURING DEVELOPMENT PRODUCTION AT AN OFFSHORE FACILITY


INVESTIGATION FINDINGS
The contract Crane Operator was preparing to do the pre-use inspection for a night operation at 10:00 PM.  According to the Crane Operator, the crane was started and then stopped so that he could go and get his glasses and a flash light to fill out the inspection form. He exited the crane and proceeded onto the standby Liftboat, A.J. Bourg to retrieve his glasses and drink a cup of coffee. As he was returning to the platform, he heard alarms going off from a second standby Liftboat, Triggerfish. The Crane Operator climbed up on the crane and quickly extinguished the fire with the use of two hand held fire extinguishers.
It was reported that the Crane Operator running the Liftboat crane at (22:15 hours) initially saw the fire inside of the cab of the WD 32 E crane. He reported that the crane was not in operation and no one was in attendance of the unit and the fire started after the Crane Operator had left the cab and away from the crane.
Preliminary results of the investigation into the crane fire at WD 32 E indicates that the causes of the fire was due to:
1.   Faulty and worn electrical wiring under the control levers floor covering which arched and created a spark which ignited a fuel source (oil) under the cab flooring.
2.   Review of documented and filed reports for Energy XXI, Seatrax and Black Elk, of the Pre-use Inspection Reports, Monthly Inspection Reports and Annual Inspection Reports indicate, there are and have been reports of crane deficiencies that have the potential to impair the safe operation of the American Aero Hydraulic Crane.
3.   The information concerning the hazards and unsafe conditions were available to all personnel involved in the maintenance, operation and supervision of the crane operation by reviewing the Energy XXI crane reports and past documents.


The investigation indicates from the reports provided to the Inspector, that:
1.   The deficiencies were not always addressed in a manner to completely eliminate the hazard. Repairs to critical components were not promptly taken care of in accordance with API RP 2D.
2.   The crane is in daily high use at WD 32 E, complying up to 18 hours run time on some days.
3.   Reports have indicated that there were reported hydraulic hose leaks, oil leaks, damaged gauges, broken windows on cab, worn sheaves, corroded/ busted grease fittings, swing brake not working properly, leaks under floor covering in cab, leaks at controls in cab on main hoist winch, high angle kick out not working, and controlling mechanisms not operating properly.
4.   Records indicate that some leaks have been repaired as late as March 21, 2014. However, on the date of the investigation on March 27, 2014, the skids were filled with oils, oily rags and absorbent pads.


LIST THE PROBABLE CAUSE(S) OF ACCIDENT:
1.   Faulty and worn electrical wiring under the control levers floor covering which arched and created a spark which ignited a fuel source (oil) under the cab flooring.
2.   Review of documented and filed reports for Energy XXI, Seatrax and Black Elk, of the Pre-use Inspection Reports, Monthly Inspection Reports and Annual Inspection Reports indicate, there are and have been reports of crane deficiencies that have the potential to impaired the safe operation of the American Aero Hydraulic Crane.
3.   The information concerning the hazards and unsafe conditions were available to all personnel involved in the maintenance, operation and supervision of the crane operation by reviewing the Energy XXI crane reports and past documents.
LIST THE CONTRIBUTING CAUSE(S) OF ACCIDENT:
The investigation indicates from the reports provided to the Inspector, that:
1.   The deficiencies were not always addressed in a manner to completely eliminate the hazard. Repairs to critical components were not promptly taken care of in accordance with API RP 2D.
2.   The crane is in daily high use at WD 32 E, complying up to 18 hours run time on some days.
3.   Reports have indicated that there were reported hydraulic hose leaks, oil leaks, damaged gauges, broken windows on cab, worn sheaves, corroded/ busted grease fittings, swing brake not working properly, leaks under floor covering in cab, leaks at controls in cab on main hoist winch, high angle kick out not working, and controlling mechanisms not operating properly.
4.   Records indicate that some leaks have been repaired as late as March 21, 2014. However, on the date of the investigation on March 27, 2014, the skids were filled with oils, oily rags and absorbent pads.




LIST THE ADDITIONAL INFORMATION:
1.   There were also electrical wiring deficiencies that the Investigator observed from the battery to the starter solenoid, and to start and horn buttons and associated wiring inside the cab.
2.   In an interview with the Crane Operator, he mentioned that he lists the deficiencies that he finds doing his pre-use inspection on the daily inspection form. However, he states that he feels his concerns go on deaf ears and not to operate the crane might affect his employment.
On April 2, 2014, a follow-up inspection was performed by the Accident Investigator to verify the repairs made to the crane.  Function test: Fast line Anti-2 Block, Load line Anti-2 Block, High Angle Boom Kick out, and test engine ESD - all tested good.  No hydraulic oil leaks.  New panel gauges. Cab is clean. Containment skid clean. Secured/ weld cab walkaround.  New exhaust blanket.  Start and wiring system replaced and good.  Boom cables replaced.  Worn gantry sheaves and pins replaced.   Installed new grease fittings.  Repainted inside cab.  Reviewed Pull Test Certificate performed on April 1, 2014.
BSEE approval was given to return crane to service.


SPECIFY VIOLATIONS DIRECTLY OR INDIRECTLY CONTRIBUTING. NARRATIVE:
I-105 (C) 205.108  CRANE DEFICIENCIES THAT IMPAIRED SAFE OPERATION.
I-153 (C) 250.108  CRITICAL REPAIRS NOT PROMPTLY TAKEN CARE OF IN ACCORDANCE WITH API RP 2D.
G-111 (C) 250.107/ 401 (e)  CRANE NOT MAINTAINED IN SAFE CONDITION.