MEC&F Expert Engineers : 12/01/14

Monday, December 1, 2014

BOOM HOIST WIRE ROPE FAILURE RESULTS IN FATALITY OF AN OIL WORKER




Boom Hoist Wire Rope Failure Results in Fatality of an Oil Worker



Personnel were using the platform crane to load a rental generator onto a vessel.  Positioned close to the lift were two tanks and a 14-ft high lubricator. Two riggers were using tag lines to stabilize the load.
When the load was lifted, the crane’s boom hoist wire rope parted. The boom fell, struck the generator, and broke into three sections with the nose section falling overboard. The falling nose section dragged the attached bridle behind it until its fall was arrested by the main hoist line and bridle pendant lines.
The 850-lb bridle/sheaves struck the fallen boom and ricocheted off the end coming to rest against the platform toe-board. The rigger handling the left tag line was struck by the bridle and fatally injured.

A BSEE accident investigation Panel concluded that the causes of the fatality were as follows:

1)   The Crane’s boom hoist wire rope parted due to being weakened by advanced corrosion.
2)   The vicinity of the lift was constrained by other equipment which caused the riggers to use tag lines to control the load, and to be positioned in the path of the falling boom. The positioning of riggers in the case of a boom hoist wire rope failure was not considered during the JSA.
3)   The crane’s corroded boom hoist wire rope lacked internal lubrication; probably because of improper lubrication method, frequency, and an improper lubricant type.
4)   The annual inspection of the crane conducted six months previous probably did not include a comprehensive examination of the boom hoist wire rope.
5)   The Operator had no company manual for crane operations.  It is possible that an internal company policy for crane operations may have led to actions that prevented the incident.
6)   The detachment of the main block hook from the load may have allowed the bridle to be pulled all the way to the railing, striking the rigger, rather than remaining atop the fallen boom.
7)   The crane’s operator and those supervising the lift possibly did not give “special attention” to all of the crane’s wire rope lines during the pre-use inspection per recommendations of API RP-2D.


BSEE recommends the following to Operators:

·         Operators should review their methods of inspection of crane wire ropes to insure full and comprehensive examination as per API RP-2D.
·         Third party crane inspections should be checked and verified by Operator personnel.
·         Coats of heavy grease on the crane lines should be removed during inspections so that the external and internal integrity of the lines can be examined.
·         Special attention should be given to indications of changing wire rope diameters (both increasing and decreasing).
·         Wire ropes should be regularly lubricated with the proper lubricants, using recommended methodology to ensure full penetration by the lubricant.
·         Operators should review equipment location prior to making a lift.  Removing or relocating obstructing equipment in the interest of safety should be strongly considered.
·         Operators should review the positioning of riggers using tag lines for all possible emergency contingencies.
·         Operators should consider implementing a method of recording wire rope lubrication data for cranes, including date, personnel, type and brand of lubricant, method of application, etc.


ACCIDENT INVESTIGATION REPORT – DRILLING MUD DISCHARGE TO THE GULF DURING EXPLORATION AT AN OFFSHORE FACILITY




ACCIDENT INVESTIGATION REPORT – DRILLING MUD DISCHARGE TO THE GULF DURING EXPLORATION AT AN OFFSHORE FACILITY



INVESTIGATION FINDINGS
On 12 FEB 2014 between 1630 hours and 1959 hours air pressure was lost to the primary Telescopic Joint (TJ) Packer that resulted in a 128 barrel discharge of 13.5 ppg Synthetic Base Mud (SBM) into offshore waters.  The Telescopic Joint allows the drilling riser string a location to change length as the drilling vessel moves up and down.  The rig was in the process of running 14" casing.  At 1630 hours, with 73 joints ran, the Driller noticed an 8 barrel loss of mud.  At 1700 hours with 83 joints ran an additional 23 barrels of mud was lost.  With mud losses not uncommon during casing running operations, rig personnel made the decision to slow the running of the casing.  This did slow down the mud loss rate and the crew continued to run the casing in the well.  At 1959 hours a third party employee was walking through the moon pool area and noticed mud pouring from the telescopic joint.  The employee notified the Supervisor and the secondary hydraulic packer was then manually engaged, mud losses ceased at that time.  After an inspection by the rig personnel, it was noticed that the air supply line to the TJ packer had ruptured.


The investigation revealed that:

1.   There was no automatic redundant back-up system in place. The back-up hydraulic system had to be manually engaged.

2.   The air pressure alarm for the Telescopic Joint Packer was disabled. Upon request of the Inspectors to verify the set points for the telescopic joint air pressure alarm, it was discovered that the high limit alarm was set at 0-psi and the low limit alarm was also set at 0-psi. This was confirmed at the control panel in the Central Control Unit by the two BSEE inspectors conducting the investigation.


LIST THE PROBABLE CAUSE(S) OF ACCIDENT:
1)    Pressure loss to the Telescopic Joint Packer due to a ruptured air hose.
LIST THE CONTRIBUTING CAUSE(S) OF ACCIDENT:
1)    There was no automatic redundant back-up system in place. The back-up hydraulic system had to be manually engaged.
2)    It was discovered during the course of the investigation that the air pressure alarm for the Telescopic Joint Packer was disabled.  Upon request of the Inspectors to verify the set points for the telescopic joint air pressure alarm, it was discovered that the high limit alarm was set at 0-psi and the low limit alarm was also set at 0-psi.  This was confirmed at the control panel in the Central Control Unit by the two BSEE inspectors conducting the investigation.
LIST THE ADDITIONAL INFORMATION:
1)    A back-up hydraulic packer on the telescopic joint was temporarily utilized while the damaged airline was removed and replaced.
2)    Upon arrival at the location, to conduct the investigation, inspectors were unable to see any water discoloration or sheen on the surface, possibly due to rough seas.
3)    It was noted in the Operators INC Response Letter that the alarm was unknowingly disabled in August 2013 during a software update of the system.

SPECIFY VIOLATIONS DIRECTLY OR INDIRECTLY CONTRIBUTING. NARRATIVE:
E-100 (W) -  On 2-12-2014 at approximately 1900-hrs an incident occurred that resulted in a 128-barrel discharge of 13.5 ppg synthetic based mud into offshore waters.  This incident occurred due to a loss of air pressure to the telescopic joint packer.

G-110 (W) -  At the time of the investigation the air pressure alarm for the telescopic joint packer was disabled.  Upon requests to verify the set points for the telescopic joint packer air pressure alarm it was discovered that the high limit alarm was set at 0-psi and the low limit alarm was also set at 0-psi.



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.