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  • Investigation Report Unofficial translation Report Report title Activity number Investigation of the incident "Man over board resulting in fatality on Saipem 7000 on 12 August 2007"

    12F11

    Classified

    Public Exempt publ. disc.

    Restricted Confidential

    Highly confidential

    Summary A 48-year-old Philippine sailor died on Sunday, 12 August 2007 on Saipem 7000 in connection with installation of the Tordis subsea separator. He fell into the sea from a winch platform approximately 30 meters above sea level and drowned. Statoil is the operator of the Tordis field, and the installation of the module constitutes part of the expansion of the Tordis subsea facility for improved recovery of reserves. The work was performed using the lifting vessel Saipem 7000. The work is part of a framework contract between Statoil and Saipem UK Ltd. The deceased was a member of a work team consisting of four people that worked together near a winch with a hydraulic hose on its reel, on the right hand side of Crane 1 on the port side of the vessel. The hose went from the winch via a sheave in the crane boom down to the module itself. The sheave had become stuck, resulting in tension in the hose from the sheave down to the module and slack from the sheave down to the winch. A loop of the hose was laying on the winch platform next to the winch after failed attempts to free the hose. The deceased was in all probability hit by the hydraulic hose as it suddenly was tightened. The person in question was then either hit or pushed over the railing by the hose.

    Involved Main group Approved by / date T1-StatoilHydro Kjell Arild Anfinsen

    Members of the investigation team Investigation leader Sigurd Jacobsen Bjrn Olsgrd

    Oddvar vestad

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    Contents 1 SUMMARY...................................................................................................................... 3 2 INTRODUCTION ............................................................................................................ 4

    2.1 PSA investigation team ........................................................................ 4 2.2 Mandate ................................................................................................ 4 2.3 PSA follow-up of the incident.............................................................. 4 2.4 Method.................................................................................................. 5

    3 COURSE OF EVENTS .................................................................................................... 5 4 INCIDENT POTENTIAL................................................................................................. 9

    4.1 Actual consequences ............................................................................ 9 4.2 Potential consequences......................................................................... 9

    5 OBSERVATIONS.......................................................................................................... 10 5.1 Nonconformances............................................................................... 10

    5.1.1 Nonconformance: Incorrect design of sheave arrangement. .. 10 5.1.2 Nonconformance: Deficient engineering and risk assessment10 5.1.3 Nonconformance: No evaluation of the use of technology to reduce risk 11 5.1.4 Nonconformance: Deficient analysis of risks and understanding of risks 11 5.1.5 Nonconformance: Deficient distribution of responsibility and communication lines........................................................................... 12 5.1.6 Nonconformance: Deficient handover/communication ......... 12 5.1.7 Nonconformance: Deficient follow-up by operator ............... 13

    6 DISCUSSION REGARDING UNCERTAINTY........................................................... 14 7 APPENDICES ................................................................................................................ 14

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    1 SUMMARY A 48-year-old Philippine sailor died on Sunday, 12 August 2007 on Saipem 7000 in connection with installation of the Tordis subsea separator. He fell into the sea from a winch platform approximately 30 meters above sea level and drowned. Statoil is the operator of the Tordis field, and the installation of the module constitutes part of the expansion of the Tordis subsea facility for improved recovery of reserves. The work was performed using the lifting vessel Saipem 7000. The work is part of a framework contract between Statoil and Saipem UK. The deceased was a member of a work team consisting of four people that worked together near a winch with a hydraulic hose on its reel, on the right hand side of Crane 1 on the port side of the vessel. The hose went from the winch via a sheave in the crane boom down to the module itself. The sheave had become stuck, resulting in tension in the hose from the sheave down to the module and slack from the sheave down to the winch. A loop of the hose was laying on the winch platform next to the winch after failed attempts to free the hose. The deceased was in all probability hit by the hydraulic hose as it suddenly was tightened. The person in question was then either hit or pushed over the railing by the hose. The Petroleum Safety Authority (PSA) appointed an investigation team on the same day, which also assisted the police during their investigation of the accident. The mandate of the investigation team includes mapping the course of events, identifying direct and root causes and identifying any lack of compliance with regulations. The investigation has identified the following nonconformances:

    Incorrect design of sheave arrangement Deficient engineering and risk assessment No evaluation of the use of technology to reduce risk Deficient analysis of risks and understanding of risks Deficient distribution of responsibility and communication lines Deficient handover/communication Deficient follow-up of operator

    Nonconformances have been identified at both Statoil and Saipem.

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    2 INTRODUCTION A 48-year-old Philippine sailor died on Sunday, 12 August 2007 on Saipem 7000 in connection with installation of the Tordis subsea separator. He fell into the sea from a winch platform approximately 30 meters above sea level. The MOB (Man Over Board) boat was launched and reached the last observed position of the deceased within three to four minutes. In spite of the fast emergency response, it proved impossible to reach the person before he was observed sinking in the sea. He was found drowned on the seabed at a depth of 200 meters after approximately 1.5 hours by the vessel's ROV (Remotely Operated Vehicle). Statoil is the operator of the Tordis field, and the installation of the module is part of an expansion of the Tordis subsea facility to improve the recovery of reserves. The work was performed using the lifting vessel Saipem 7000. The work is part of a framework contract between Statoil and Saipem UK.

    2.1 PSA investigation team Statoil notified the PSA of the incident on 12 August 2007 at 11:45 hours in accordance with the requirements. The PSA established an investigation team to assist the police during their investigation, as well as to carry out a separate investigation of the incident. The members of the PSA investigation team were as follows: Oddvar vestad Investigation leader, Discipline area logistics and emergency

    preparedness Sigurd Jacobsen Discipline area logistics and emergency preparedness Bjrn Olsgrd Discipline area logistics and emergency preparedness (from 15 August

    2007)

    2.2 Mandate Mandate for the investigation team: 1. Assist the police 2. Map the course of events 3. Identify direct and root causes with focus on Man, Technology and Organisation (MTO) 4. Map and evaluate emergency preparedness issues, including responsibilities,

    communication lines and available emergency response equipment 5. Identify lack of compliance with regulations, recommend further follow-up as well as

    identify any need for policy instruments 6. Report status internally 7. Evaluate resource requirements and identify any need for assistance

    2.3 PSA follow-up of the incident

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    There was an official inspection after the PSA and the police arrived on Saipem 7000 on Monday, 13 August 2007. The installation of the subsea module was completed on Sunday, 12 August 2007 (after stopping for a few hours) after consultation with the police and the PSA. There was no reconstruction of the incident, partly because of the practical challenges involved in carrying out a simulation, but also because the course of events and physical causes were sufficiently clarified after the inspection at the scene and reading Saipem's internal incident report. Information was obtained from leading personnel on the installation, from the crew that participated in the operation on the winch platform and from personnel that worked on the main deck through questioning by the police with the PSA present. In addition to questioning on board, there were also meetings with Statoil in Stavanger and Saipem UK Ltd. in London. The purpose of these meetings was to ascertain the responsibilities for engineering, execution of the activity and follow-up in relation to applicable regulatory requirements. Video recordings and still images of the activities on board Saipem 7000 before, during and after the accident have been reviewed. The investigation team stayed on the installation for 4 days. An overview of documents reviewed in connection with the investigation is available in Appendix B. A list of personnel that have participated in questioning, interviews or meetings is available in Appendix C.

    2.4 Method A Man, Technology and Organisation (MTO) diagram