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.
