Transcript Lysbilde 1 - Petroleumstilsynet

Non-conformity
Normal : All training to
be done by qualified
personnel appointed by
the line management
5.2.1
October 2002:
West Epsilon
(WE) starts the
assignment on
Valhall Flank
South (VFS)
Cause and event analysis
New: All personnel
who have received
training can be used as
instructors
BP requires
Smedvig to install
so-called ”dropped
object” hatches on
the BOP deck
Design and production of
hatches and beams was
carried out by Bjørge Offshore
in Stavanger. The facility was
carried out in Rotterdam
August 2002: After start-up
on VFS, the employees
were given location and
crane specific training on
the SIMOPS crane by
personnel from Natoil
After this the
training is
communicated
from person to
person
Natoil is the supplier
of SIMOPS cranes to
Valhall Flank North
(VFN) order of 8
November 2002
Heerema (Tønsberg) was
the main contractor for
BP.
In the order it is
specified that the
SIMOPS crane must be
identical to the one on
VFS.
Barrier failure
The anti-collision
system was an option
in the order
(spec.6.5)
Instructor with inadequate competence
(inadequate training programme):
Training from person to person is inadequate.
Activities Regulations Section 19 relating to
competence. The HSE directive 26, section 6.11.4
1
Nonconformity
Normal: The FMEA should be
a documentation of the effect
of failure modes on the
operation of the crane
including safety system
New: The anti-collision
system of the crane is
not part of the analysis
5.2.2
New: FAT did
not comprise
checking of the
anti-collision
Normal : All safety
systems must be a
part of the FAT
programme
Barrier failure
Cause and event analysis
5.2.3
The anti-collision system
was back-ordered for the
SIMOPS cranes for VFN
and VFS 12 December
2002. Executed as part of
crane delivery for VFN
FMEA
completed 23
January 2003,
as built 25
April 2003
FAT (Factory
Acceptance Test)
was carried out 10
April 2003
system.
The mechanical
completion check
list made by Natoil
11 April 2003
includes check of
mechanical
completion for limit
switches ”boom up”
and ”telescope out”.
25 November 2002 the
scope was extended to
include the anti-collision
system for VFN (og VFS)
Deficiencies in FMEA (inadequate
safety analysis):
Management Regulations Section 13
regarding general requirements to
analyses, Activities Regulations
Section 43 relating to classification,
Machinery Regulations Section 7 ref.
attachment 1
Inadequate inspection under FAT
(inadequate test programme): FAT lacks a
description of the anti-collision system, lack of
testing and documentation of the system was not
discovered.
Activities Regulations Section 14 relating to facility
and commissioning, ref. Machinery Regulations
Section 7, attachment 1, subsection 4.2.4 inspection
before use.
2
Non-conformity
Normal: Certificate of
application in
accordance with AF
Section 14 og
NORSOK R003N
chapter 5.1
5.2.4
New: Maritime
(load test) certificate
New:
Commissioning
does not comprise
the anti-collision
system
Normal: All safety
systems must be a
part of the test
programme
5.2.5
Cause and event analysis
Probably 30
May 2003
The document
”Functional
Design
Specification,
Crane” dated 25
April 2003
mentions briefly
that the anticollision system
has been installed
and its mode of
operation
Allum Marine as issues
Certificate of application in May
2003.
This was done while the VFN
facility was at the building site in
Tønsberg
Commissioning for the
SIMOPS crane to be
carried out approx. 7 July
2003
Certification carried out in
accordance with the requirements of
the Maritime Directorate’s
regulations
The document describes the
crane ”as built”, and was
available on the computer
system for personnel on
VFN.
The certificate does not mention
testing of the crane’s safety
systems, and no reference has been
made to criteria for the scope of the
testing – nor acceptance criteria.
Barrier failure
The certificate does
not fulfil the
requirements of a
Certificate of
application
Inadequate certification of application and approval of the
SIMOPS crane (insufficient preparation for use): The crane
does not have a Certificate of application. Instead a load test has
been carried out with maritime certification
Activities Regulations Section 40 relating to use of work equipment,
ref. Regulation relating to use of work equipment section 14,
Inspection of work equipment
The Activities Regulation Section 44 relating to Maintenance
programme subsection f) ref. NORSOK R-003 N subsection 6.1
BP’s Guide for lifting equipment document no 1.70.010 chapter
8.5.3
BP’s HSE directive chapter 26 6.3
Inadequate inspection during
commissioning (inadequate
procedures relating to change): Missing
description of the anti-collision system
was not discovered
Activities Regulations Section14 relating
to completion
The Machinery Regulations Section 7,
Attachment 1, subsection 4.2.4
3
Inspection prior to use
Non-conformity
Normal: RFO
certification is a
confirmation that all
systems have been
checked and described in
the documentation
New: It was not recorded
that a description of the
anti-collision system was
missing from the operating
manual
5.2.6
Cause and event analysis
Consent to use
VFN was given
14 July 2003
WE arrives on
VFN approx 4 6 August 2003
Hook up starts
approx. 4 august
Take-over from
project to operation :
RFOC (ready for
operation certificate)
form was prepared 6
August 2003
RFOC shall provide an
overview of outstanding work
on the SIMOPS crane
No records concerning faults of the
anti-collision system in the RFO
Documentation of
maintenance and operation inclduing
the SIMOPS crane must be a part of the
take-over documentation
Barrier failure
The RFOC check list describes: Operational Manual
available in Dokumentum, i.e. the operations manual is
available in an electronic database
Deficiencies when taking over from project to operation,
RFOC (inadequate change procedures): Missing
documentation for the anti-collision system was not discovered
during the take-over from project to operation.
Activities Regulations Section 14 relating to installation and
commissioning
The Machinery Regulations Section 7, Attachment 1, subsection
4.2.4 Inspection prior to use
Activities Regulations Section 18 Start-up and operation of
facilities
4
Non-conformity
New: The
SIMOPS crane
is operated
while a switch
is defective
Normal: The lifting
equipment must never
be operated when
parts of the safety
system are inoperable
New:
Certificate/Certificate
of application cannot
be produced until three
weeks after the incident
Normal : The Certificate
of application must be
easily accessible on the
facility
5.2.8
5.2.7
Cause and event analysis
Natoil was out 14 August 2003. The
proximity switch (boom angle limit
switch) was damaged during work on
the window washer system on the
SIMOPS crane
Natoil replaces the
proximity switch. Closed 10
September 2003 (The report
has been erroneously dated
to 9 October.)
BP has now started using the
SIMOPS crane on VFN. No
Certificate of application exists
on the facility
BP cannot produce
Certificate of
application for the
SIMOPS crane until
21 April 2004
No documentation of
function testing after
the repair work
Barrier failure
During the period 1-10 September
2003, the crane was in daily use, ref.
form for daily check of SIMOPS
crane on VFN. This in spite of the
fact that the switch was inoperable.
The SIMOPS crane is operated while the limit switch is defective
(non-conformity with procedure):
Regulations relating to use of working equipment Section 15 subsection
c) working equipment which could involve special danger in use
Inadequate testing:
This is work on the safety system, and consequently it should be
documented
Activities Regulations Section 28 relating to Actions during conduct of
activities, ref. NORSOK R-003 N subsection 6.1
Activities Regulations Section 83 relating to lifting operations ref.
NORSOK R-003 N subsection 5.5.6
Insufficient documentation
(document missing): Certificate of
application is not available on the
facility. BP did not know if a
Certification of application existed.
Activities Regulations Section 14
relating to facility and
commissioning ref. NORSOK R-003
N subsection 5.1.1.2
BP’s Manual for lifting equipment
subsection 8.3 relating to files
offshore
5
Non-conformity
New: Documentation
from the crane supplier is
not available on the
facility
Normal: Adequate user
documentation must be
available in the crane
manual
5.2.9
Cause and event analysis
BP has now started to use the SIMOPS
crane on VFN. Documentation is missing
from the crane manual.
Documentation from the
crane supplier is not
available on the facility, or
it is inadequate:
-maintenance procedures
- description of anticollision system
- operating instructions
Basic crane operator
training. The relevant
personnel have completed
the basic requirements for
operating a 20 tonne
hydraulic crane
General crane operator
training is required to
operate a SIMOPS crane,
(Minimum G20)
Barrier failure
User manual (crane
handbook) is
insufficient
Missing /inadequate documentation for the SIMOPS crane:
Documentation for the SIMOPS crane is non-existent or not available to the user.
Activities Regulations Section18 relating to start-up and operation of facilities
Activities Regulations Section 14 relating to facility and commissioning ref. NORSOK
R-003 N subsection 5.1.2.1. (crane handbook must be available)
Activities Regulations Section 83 relating to lifting operations NORSOK R-003 N
subsection 4.1 f)
Lifting equipment manual subsection 8.3 relating to files offshore.
6
Non-conformity
New: Location-specific
training has not been
provided for the SIMOPS
crane with the equipment on
VFN
Normal: Competence
requirements include basic
training and location-specific
training for the crane to be
operated
5.2.10
New: BP has not
verified the location
and crane-specific
expertise
Normal: BP checks
and ensures that
training is in
accordance with
requirements
Cause and event analysis
5.2.11
Crane- and location-specific training. The crane training from VFS was carried on
to VFN by having a crane operator who had already been ”cleared” act as an
instructor for the new crane operator.
The training was given in
August 2002 before the
anti-collision system had
been ordered and
installed on the SIMOPS
cranes at VFS.
Barrier failure
Personnel on VFN and WE have
no knowledge of the anticollision system and its
operation
Crane- and location-specific skills were
inadequate (insufficient competence)
Crane operators do not have knowledge of the
anti-collision system.
Activities Regulations Section 19 relating to
competence, ref. NORSOK R-003 N subsection
4.5.1 relating to training of operators.
Activities Regulations Section 40 relating to use
of work equipment, ref. Regulations relating to
use of work equipment, Section 10 relating to
training, drills and instruction of employees.
Through the supervisor
the field manager is
responsible for
implementing training on
the SIMOPS crane, ref.
HSE directive 26
Demands will be made on
safeguarding competence. This
entails making demands on,
verifying and maintaining this
competence through exercise,
drills, training and education
Inadequate inspection of requirements for
crane- and location-specific training (insufficient
QA programme): BP has not verified the training.
No training has been carried out on the anticollision systems, as the training material does not
contain any description of it.
Activities Regulations Section 19 relating to
competence, ref NORSOK R-003 N subsection 4.5.1
relating to training of operators.
7
Non-conformity
New: No handling of
non-conformity
Normal:
Handling of nonconformity in BP
5.2.13
New: Planned work on
safety system defined
as ”non-critical”
Normal: Work on safety
system is evaluated
with high criticality
5.2.12
Cause and event analysis
Subsequent
facility of anticollision system
on VFS 25
October 2003
At the turn of the
year 2003/2004, a
defect in the limit
switch for
telescope out was
discovered
4 January 2004 Work
order (KAO-032703)
for wire for limit
switch on telescope is
broken ”replace wire
and limit switch if
necessary”
Barrier failure
Natoil is requisitioned
to repair the defect
19 February 2004
Natoil cannot
complete the repair of
the limit switch for
boom angle and hook
up, owing to lack of
parts
Approx. 17-19
February 2004
Natoil repairs
wire on limit
switch for
telescope out
Natoil also establishes
a defect in the limit
switch for boom angle
and hook up
19 February 2004. Natoil
reports that there is no
documentation for
electricity and hydraulics
for the SIMOPS crane
Inadequate risk assessment during the planning of
work on safety systems. (The potential risk is not
understood):
The work is defined as non-critical.
Activities Regulations Section 43 relating to
classification and 45 relating to planning and
priorities.
BP stopped operation of
the crane owing to lack
of parts
Inadequate handling of nonconformities (insufficient QA
programme)
Management Regulations Section
20 relating to handling of nonconformities
8
Non-conformities
Normal: Work on
safety equipment must
be carried out or
checked by competent
personnel
New: No inspection
by competent
personnel
(expert activity)
5.2.14
Cause and event analysis
21 February 2004. A work
order is established in Work
Mate for repair of the anticollision system
24 February 2004
Parts for the two other limit
switches arrive at VFN/BP
Work order for replacement of
boom angle limit switch XS440
(KAO-033708): ”Defective boom
angle limit switch replaced. The
function is tested after facility and
connection”
Barrier failure
Work order for replacement of
upper hook limit switch (KAO033706): ”Limit switch is
defective/broken. The function is
tested after facility and
connection.”
Inadequate planning of work on safety system (insufficient planning): Work on safety
systems is planned with personnel without the necessary expertise and without the necessary
drawings. No planned verification by expert body.
Activities Regulations Section 44 relating to maintenance programme subsection f) ref.
NORSOK R-003 N subsection. 6. Inspection, examination and testing subsection 6.1
Activities Regulations Section 43 relating to classification and 45, planning and
prioritisation, Activities Regulations Section 40 relating to work equipment, ref. regulation
relating to use of work equipment Section 14 inspection of work equipment.
9
Non-conformities
Normal:
Drawings available
for work to be
done
New: Drawings
missing
5.2.15
New: Work on
safety system
without inspection
by expert
Normal: Work on safety
system to be checked by
expert
5.2.16
Cause and event analysis
26 February 2004
Automation expert
connected to Valhall
(SWAT) replaces ”hook
up” limit switch on
SIMOPS crane VFN
The switches are replaced without
access to electric or hydraulic
drawings
According to interviews the
switches are installed in the same
way as the ones removed - the
automation expert makes a sketch
before replacing them
27 February 2004
Automation expert from
Valhall (SWAT)
replaces ”boom angle”
limit switch on SIMOPS
crane VFN
Instrument 27/02/04: ”Have
replaced 90-xs-128057 with
new limit switch. Test OK, NN”
26 February 2004: ”Have
replaced the entire limit
switch. Test OK, NN”
On request the automation expert
feels competent to replace the
switches
Barrier failure
The automation expert has no
experience with work on cranes
Work on safety systems with the necessary technical
Documentation (Documentation missing):
Activities Regulations Section 28 relating to Action
during conduct of activities.
The Machinery regulations, attachment 1 subsection
1.7.4 og subsection 4.4.2.
Activities Regulations Section 40 relating to Use of work
equipment, ref. regulation relating to use of work
equipment Section 9, Information to employees
Work on safety systems was carried out by personnel
without the necessary skills (insufficient competence):
Activities Regulations Section 19 Competence
Activities Regulations Section 40 relating to Use of work
equipment ,ref. regulation relating to use of work
equipment, Section 9 Information to employees, 10
Training, drill and instructions to employees and 14
inspection of work equipment
BP’s manual for lifting equipment Section 9.5 (i.e.
requirements related to use of competent controller)10
Non-conformities
New: The fact that
the crane’s safety
system was
inoperable was not
known
Normal: Status of the
crane’s safety system
must be known
5.1.1
Barrier failure
Cause and event analysis
After the repair the limit switch for the
”boom angle” was installed with incorrect
polarity. It is not known whether it was
installed incorrectly prior to the repair
Faulty facility means
that the limit switch is
disconnected
The SIMOPS crane
does not have a
functioning anticollision system
During the period August
2003 - 2 April 2004
several other repairs have
been carried out on the
SIMOPS crane
30 December 2003:
Loose cable tray at the top
of boom
20 February 2004: Motor
for window cleaner
inoperable
19 February 2004: Repair of
loop on hook block??.
(carried out by Natoil)
Certain parts of the crane’s safety system do not function. Status unknown
(insufficient preparation before use): Lifting appliances must never be operated if the safety systems or
parts of the safety systems are out of order.
Activities Regulations Section 24 relating to safety systems
Activities Regulations Section 83 relating to lifting operation, ref. NORSOK R-003 N subsection 5.5.6
relating to safe use of lifting equipment
11
Non-conformities
New: The crane
operator has limited
knowledge of the
crane’s condition/
status of corrective
maintenance
Normal: The crane
operator is familiar with
the crane’s condition
before use
5.2.17
Cause and event analysis
The crane operators on
VFN have no access to
the maintenance system
(Workmate )
Repairs are not recorded in
the maintenance system,
only in the daily inspection
form for the crane
There were, e.g. multiple
faults in the window shield
wipers/washers during the
period Nov/Dec 2003 og
March 2004.
1 April 2004
The whole work team
involved in the incident
came onboard the same
evening and start their
watch at 23:00.
Schlumberger is on
downtime owing to
equipment fault
Approx. 01:15 Overall
supervisor Schlumberger
has been on duty for 16
hours and cannot assist in
the work relating to
troubleshooting on this
equipment
Barrier failure
Only the flank foreman
on VFN has access to the
maintenance system
Lacking/insufficient access to the maintenance system (insufficient work preparation/basis for
work). The crane operator on the SIMOPS crane does not have access to the maintenance system.
Activities Regulations Section 23, Use of facilities (relating to status of maintenance)
Activities Regulations Section 14 , Installation and commissioning, Ref. NORSOK R-003 N
subsection 5.1.2.1 (requirements regarding available documentation)
Activities Regulations Section 83, Lifting operations, ref. NORSOK R-003 N subsection 4.5.2.1
follow-up of maintenance.
Activities Regulations Section 24, Safety systems.
BP’s HSE directive 26, chapter 6.3.
12
Non-conformities
New: Only objects
falling from the top deck
to the Xmas tree deck
were evaluated in SAS
Normal: Falling
objects from WE
should have been a
part of the risk
assessment
Cause and event analysis
5.2.18
BP Well intervention
supervisor (WIS) night shift,
decides to use Sclumberger
personnel to assist ABB in
the work on well N14.
Schlumberger personnel
usually operate the
SIMOPS crane, ref contract
with BP subsection 5.8.1
Safe work review (SAG) is
initiated by Sclumberger’s
personnel and implemented by
the involved.
Work permit
prepared and
approved
The personnel have
experience from WP and
Maersk Guardian, where
they also ”bumped into"
the hatches on the deck of
MG above
Since the crane operator is
unfamiliar with the anticollision system, he should
initiate measures to prevent
collision with WE
Barrier failure
BP has not identified risk in
the operation of the crane
when the anti-collision
system is out of order
The danger of the crane touching the hatches on the BOP deck was not assessed
in SAG (insufficient experience transfer / risk was not assessed): Despite previous
experience, collision with WE is not considered a risk. Compensatory action is not
implemented
Management Regulations Section 22, Improvement (Experience transfer)
Activities Regulations, Section 83, Lifting operations, ref. NORSOK R-003 N
subsection 4.1
Activities Regulations, Section 28, Actions during conduct of activities (planning of
13
work)
Activities Regulations, Section 40, Use of work equipment, ref. regulation relating to
use of all types of work equipment and Section 7 relating to the employer’s general
obligations and Section 43 regarding use of all types of working equipment
Non-conformities
Normal : Check list
for safety systems
New: The check list
is insufficient
5.2.19
Normal :
Operator/user of the lifting
appliance has an independent
responsibility to ensure that the
lifting appliance is in proper
condition
New:
Lifting operation carried
out without the
necessary visibility
Normal: Good
visibility to the
work area for the
crane
New:
inspection prior to use is
limited to inspection of the
oil level and visual
inspection
5.2.20
5.1.2
Cause and event analysis
There is no inspection of the
crane before use (inspection
prior to use).
Form prepared by BP for daily
checks does not describe
inspection of safety systems
The crane operator does not have access to
the maintenance system, and consequently
not status for the SIMOPS crane
No inspection of the anti-collision system. The crane
operator is unfamiliar with the operation of the system
(not referred to in the crane manual), and has not had
training in the system
Barrier failure
No check of the safety system. No
check of status for maintenance. No
function testing.
5.2.19: Inadequate procedure for daily check of the
SIMOPS crane (insufficient procedure):
Activities Regulations Section 22, Procedures.
BP’s HSE directive 26 subsection 6.1.5
Activities Regulations Section 40, Use of work equipment, ref.
regulation relating to use of work equipment, Section 14
relating to inspection of work equipment.
5.1.2: Inadequate inspection prior to use of the lifting
appliance (insufficient preparation):
Activities Regulations Section 83, Lifting operations ref.
NORSOK R-003 N subsection 5.5 .6 relating to safe use of
lifting appliances
Activities Regulations Section 19, Competence, ref. NORSOK R003 N subsection 4.5.2.1
The crane operator initiates cleaning of
window in the operator’s cab owing to poor
visibility. The skylight is not cleaned.
The window cleaning
system was out of order
The window cleaner
on the roof window is
out of order
Flagman fetches a
high-pressure washer
and washes the side
windows of the
operator’s cab.
No cleaning because this
would require work
permit for working at
heights.
Poor visibility through the roof window
(emphasis on time not safety):
Cleaning is omitted because it would require work
permit for working at heights. Therefore, a choice
was made to work with poor visibility through the
roof window.
Activities Regulations Section 31, Arrangement of
work, Section 32, Ergonomic aspects and the
Facilities Regulations Section 19 relating to
14
ergonomic design
Activities Regulations Section 28, Actions during
conduct of activities and 29, Monitoring and
control
Non-conformities
New: Flagman carries
out the work of the
crane chaser directing
the load not following
the movements of the
crane.
Normal: Flagman
directs safe movement
of crane and hook
load
5.2.21
Cause and event analysis
Operation on well
N14 starts. Well hatch
is lifted off and put on
N2
As per agreement in
SAG meeting, a crane
chaser, flagman and crane
operator are directly
involved in the lifting
operation.
Work on Xmas tree
carried out together
with ABB (pulling
of plug BPV( back
pressure valve))
Crane chaser goes down
to the Xmas tree deck and
manages the lifting of the
plug from well N14 via
radio.
On the top deck
work starts on reinstalling the
well hatch.
The roles of crane
chaser and flagman
mixed during the lift.
Flagman holds the
guide rope fixed to
the well hatch
Flagman does not
pay attention to the
boom top
Flagman and crane
chaser put on vests
Barrier failure
Flagman uses lifeline
Flagman shoves the well
hatch to position it over
the hole.
Manning level during operation is not according to procedure
(non-conformity with procedure): The jobs of the crane chaser and the
flagman are mixed
Activities Regulations Section 83, Lifting operations, NORSOK R-003 N
subsection 4.5.2.2
BP’s HSE directive no. 26 chapter 6.1.6-7 clearly states the responsibilities
and obligations of crane chaser and flagman
15
Non-conformities
Normal: The
crane must not
be driven into
obstructions
(obstacles)
New: The crane
operator has no
inspection with the
position of the boom
5.1.3
New: ”Dropped
object” hatches
were not fastened
according to
procedure
Normal: Procedure
for fastening is
followed
5.1.4
Cause and event analysis
The crane operator
extends the telescope to
reach N14 with the well
hatch. The boom is run
into the deck of WE
The crane operator
has to lean forward
during the lift to get
a better view
Could have lowered the boom (two
operations). Chose to extend the
telescope (one operation)
The boom lifts the
”dropped object” hatch
on WE from its
fastening
2 April 2004 approx. at
06:15 the ”dropped
object” hatch from
WE falls 14.9 m
straight towards VFN
Schlumberger has
received assurances
from Smedvig that the
hatches cannot fall
down
Hatches are not
fastened according to
procedures
Barrier failure
Smedvig’s procedure states
requirements for work with this
hatch. The procedure describes
how it is to be fastened with chains
and shackles to beams
Inadequate inspection of the position of the boom
(insufficient self-monitoring to avoid errors):
Compensatory actions to maintain inspection with the
boom top were not initiated
Activities Regulations Section 19, Competence, ref.
NORSOK R-003 N subsection 4.5.2.1 and 4.1.h)
BP’s HSE directive 26, subsection 6.7
Smedvig had not made sure the ”dropped
object” hatches were fastened according to
procedures (non-conformity from procedure):
Activities Regulations Section 22, Procedures
Procedure WE-02-06-05,14 incl. facility and
maintenance instruction. PBO-8250081-P-04
16
Non-conformity
New: Crane
operation leaves
the crane with
load hanging from
the hook.
Normal : Crane operator
must not leave the crane
with load hanging from
the hook.
5.2.22
Cause and event analysis
The flagman is hit
and injured in his
right foot and
face/jaw
The ”dropped object”
hatch hits both the
flagman and the well
hatch when falling
The crane operator,
work supervisor
from Schlumberger
and BP’s WIS rush
up to help the
injured flagman
The well hatch
starts to swing
approx. 1.5 m
above the deck
Notification of
SAR and
emergency
preparedness
on WE works
The crane chaser
comes running up
from the Xmas tree
deck
The well hatch is
considered a hazard, and is
set down by crane chaser
when he arrives
Nurse and OIM on
WE are notified
SAR from
Ekofisk field
centre is
requisitioned
The injured is
transported
onshore after
receiving first aid
treatment
Barrier failure
The remaining
hatches on WE
are secured
Inadequate securing of load
(non-conformity from
procedure):
Activities Regulations Section 83,
Lifting operations, ref. NORSOK
R-003 N subsection 5.5.13.
BP’s HSE directive 26 chapter
6.5.1.
17
Non-conformity
2 April
2004
The
authorities
are notified.
The PSA is
notified at
07:18
2 April 2004.
Approx. at
17:00
Investigation
group from the
PSA/Police
and BP arrive
on VFN
Natoil is requisitioned to go to
VFN to assess the SIMOPS crane,
and to find out if there is an
electronic log in the crane. Arrival
4 April 2004
There is no
electronic log in this
type of crane
In the notification
the ”dropped
object” hatch which
fell down was
reported to weigh
100 kgs, but it
turned out to be 357
kgs.
Barrier failure
Cause and event analysis
The accident
area is
secured
18
Non-conformities
Cause and event analysis
It is established that
the limit switch for
hook up is broken
off.
This could have
happened when the
hatch fell down
The PSA gives direct
order prior to departure
5 April 2004
21 April 2004 PSA’s
investigation group
receives Maritime
loading certificate
for the SIMOPS
crane on VFN from
BP
The order entails
temporary termination
of work with similar
cranes
Natoil does not have
parts to repair the two
limit switches
Barrier failure
Faults are established
in the facility of limit
switch for boom up.
Limit switch is
damaged
19