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Investigation report Report Report title Activity number

Investigation of Big Orange XVIII's collision with

Ekofisk 2/4-W 8 June 2009

009018033

Grading

Public Exempt from public disclosure

Restricted Confidential

Strictly confidential

Summary

The vessel Big Orange XVIII collided with the water injection facility Ekofisk 2/4-W on 8

June 2009. The collision caused major material damage both to the facility and the vessel. The

collision is classified as a major accident based on the result, by endangering a facility's

integrity. There was also a major accident potential, involving several persons who could have

been seriously injured or killed.

No one was physically injured, neither on Big Orange XVIII, Ekofisk 1/4W nor other

installations on the Ekofisk field.

Big Orange XVIII was on its way to Ekofisk 2/4-X to perform well stimulation. The autopilot

had not been deactivated prior to entering the 500-metre safety zone, And because the autopilot

was active during the approach, the planned course changes were not executed the way the

duty officer on the bridge expected. Big Orange XVIII avoided the collision with Ekofisk 2/4-

X and Ekofisk 2/4-C, and passed under the bridge between these facilities. The vessel also

avoided a collision with the jackup living quarters facility COSL Rigmar.

We have based our description of the course of events on the internal investigations conducted

by the parties involved.

Involved Main group Approved by / date

T-3 O&R Hilda Kjeldstad / 2 October 2009 Participants in the investigation group Head of investigation

Sigurd Robert Jacobsen, Reidar Hamre Roger L. Leonhardsen

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Contents

1 Summary .......................................................................................................................... 3 2 Introduction ...................................................................................................................... 4

2.1 Mandate and implementation .................................................................................... 4 2.2 Ekofisk 2/4-W ........................................................................................................... 5 2.3 Big Orange XVIII ..................................................................................................... 6

2.4 Application of the petroleum regulations ................................................................. 7 2.5 Internal requirements ................................................................................................ 8

3 Course of events ............................................................................................................... 8 3.1 Similar events............................................................................................................ 9 3.2 Background ............................................................................................................... 9

3.3 Course of events on 8 June ....................................................................................... 9 4 The incident's potential .................................................................................................. 13

4.1 Actual consequence ................................................................................................ 13

4.1.1 Personal injuries ............................................................................................... 13 4.1.2 Material damage............................................................................................... 13 4.1.3 Consequence for production ............................................................................ 15

4.2 Potential consequence ............................................................................................. 15 4.2.1 Personal injuries ............................................................................................... 16

4.2.2 Material damage............................................................................................... 16 4.2.3 Discharge to the external environment ............................................................ 17

5 Observations .................................................................................................................. 17

5.1 Nonconformities ..................................................................................................... 18

5.1.1 Deficient monitoring of the vessel ................................................................... 18 5.1.2 Inadequate measures after the Ocean Carrier collision ................................... 18

5.2 Improvement items ................................................................................................. 19

5.2.1 Follow-up of management system and internal requirements ......................... 19 6 Other comments ............................................................................................................. 19

6.1 Maritime legislation and compliance with consolidated guidelines ....................... 20 6.2 Insufficient learning after similar incident .............................................................. 20

7 Barriers which have functioned ................................................................................ 20 7.1 Technical barriers.................................................................................................... 20 7.2 Organisational barriers ............................................................................................ 20

8 Discussion relating to uncertainties ............................................................................... 21 9 Appendices ..................................................................................................................... 22

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1 Summary

On 8 June 2009 the vessel Big Orange XVIII collided with the water injection facility

Ekofisk 2/4-W. The collision caused major material damage both to the facility and the

vessel. The collision is classified as a major accident1 based on the result, by endangering a

facility's integrity. There was also a major accident potential, involving several persons who

could have been seriously injured or killed.

No one was physically injured, neither on Big Orange XVIII, Ekofisk 1/4W nor other

installations on the Ekofisk field.

Big Orange XVIII was on its way to Ekofisk 2/4-X to perform well stimulation. The autopilot

had not been deactivated prior to entering the safety zone of 500 metres, And because the

autopilot was active during the approach, the planned course changes were not executed the

way the duty officer on the bridge expected. Big Orange XVIII avoided the collision with

Ekofisk 2/4-X and Ekofisk 2/4-C, and passed under the bridge between these facilities. The

vessel also avoided a collision with the jackup living quarters facility COSL Rigmar.

At 0402, the duty officer on the bridge activates the vessel’s autopilot mode and leaves his

steering position to answer a telephone call from Schlumberger's representative on Ekofisk

2/4-X. The conversation lasts for approx. 30 seconds. Upon returning to the steering position,

the autopilot is not deactivated. At 0411 the duty officer receives an approval from Ekofisk

Radar to enter the 500-metre zone to Ekofisk 2/4-X. The dynamic positioning system (DP

system) had not been tested prior to entering.

During the period from 0413 to 0417, there is no control of the vessel. An attempt is made to

steer the vessel by activating the emergency steering system. Since the autopilot is activated,

the vessel follows the preset course, and the speed increases as a result of increased gas

admission. Big Orange collides with Ekofisk 2/4-W at 0417.

Triggering cause

The duty officer on the bridge activates the vessel's autopilot mode to answer a telephone call

in an adjacent room on the bridge. The autopilot is not deactivated upon the duty officer’s

return to the steering position.

Direct cause

The duty officer tries to manoeuvre the vessel manually. Manual manoeuvering of the vessel

is not active when the autopilot is activated (cannot be oversteered).

Underlying causes

The distribution of duties and responsibility and communication between the master and

second officer was insufficient. The second officer was on board on his first trip, and had not

1 1 Major accident is defined as an accident with several serious personal injuries or deaths, or an accident endangering the integrity

of the facility, cf. guidelines to Section 6 of the Management Regulations relating to acceptance criteria for risk of major accident and

environmental risk.

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been given sufficient training and drills in tasks and routines as required by the shipping

company’s own procedure.

The culture on the bridge allowed for deviation from the established procedures prior to

entering the 500-metre safety zone. Specified checkpoint tasks were not carried out on board

even if they were checked in the checklist before entering the 500-metre zone. Testing of the

DP system should have been performed prior to entering the 500-metre zone.

Ekofisk Radar authorised entering of the 500-metre zone for Big Orange XVIII without

ensuring that the required checkpoint tasks were carried out.

Upon approaching the Ekofisk facilities, the vessel exceeded the maximum speed of 8 knots,

and the vessel's course had been set straight towards some of the facilities. Ekofisk Radar did

not respond to the speed alarm, and did not make the vessel aware of its direction.

The resting time regulations were not complied with on board the vessel.

ConocoPhillips’ measures, which were implemented after the Ocean Carrier collision on

Ekofisk in 2005, have not sufficiently improved the control of vessels on the Ekofisk field.

ConocoPhillips’ own internal requirements relating to entering of vessels have not been

sufficiently complied with by the responsible operations unit.

Wilhelmsen Ship Management has not to a sufficient degree incorporated the lessons learned

from the Far Symphony collision with West Venture in 2004 in their own routines and

management system.

In the report we point out nonconformities in relation to the regulatory requirements related

to insufficient monitoring of vessels, and insufficient measures after the Ocean Carrier

collision.

2 Introduction

2.1 Mandate and implementation

On 11 June the Petroleum Safety Authority Norway (PSA) decided to conduct a separate

investigation of the incident.

The mandate for the investigation was to clarify the course of events, direct and underlying

causes, consequences (actual and potential) and the emergency preparedness, as well as

identifying any violation of the regulations. The purpose was to contribute to the prevention

of similar events and to ensure transfer of experience.

The investigation group comprises:

Roger L. Leonhardsen (investigation leader) technical discipline - construction safety

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Sigurd Robert Jacobsen, technical discipline - logistics and emergency preparedness,

Reidar Hamre, technical discipline - HSE management and law.

The group has conducted meetings with the parties involved where the mandate for and

preliminary observations from internal investigations have been presented.

The meetings were held with

ConocoPhillips on 26 June 2009,

Wilhelmsen Ship Management and Tracer Offshore on 29 June 2009, and

Schlumberger on 2 July 2009.

On 29 2009 the group had a meeting with the police, section for North Sea/Environment. The

meeting was held at their request.

The Norwegian Maritime Directorate has contributed assistance regarding maritime

circumstances relating to the incident. Their comments are enclosed with the report, see

Appendix D.

We have based our description of the course of events on the internal investigations

conducted by the parties involved.

The mandate for this investigation does not include an analysis of people, technology and

organisation.

2.2 Ekofisk 2/4-W

Ekofisk 2/4-W is a combined bridge support and water injection facility. It has three legs

(Eng. tripod) of steel, and was installed on the field in 1972. Its original function was as a

bridge support. Water injection from the facility started in 1989. The facility is normally

unmanned, with remote control of injection from Ekofisk 2/4-K.

The flare pipe for Ekofisk 2/4-A passes over Ekofisk 2/4-W to the southern flare stack.

A 12 ¾” pipeline from Ekofisk 2/4-K conveys water for injection into the reservoir. The

pipeline is connected to a 12” riser on Ekofisk 2/4-W. The facility has a total of eight wells

for water injection. Five injection wells were in use. Work on plugging all the wells

permanently has started.

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Photo 1: Ekofisk 2/4-W (source: ConocoPhillips)

2.3 Big Orange XVIII

Big Orange XVIII is owned by the partner shipping company Tracer Offshore ANS. The

vessel contract was entered into between Tracer Offshore ANS and Schlumberger. The well

stimulation contract was entered into between ConocoPhillips and Schlumberger. Since June

2004, Wilhelmsen Ship Management has had the responsibility for the operation of the vessel

and the maritime crew.

Big Orange XVIII was built in 1984 and is especially equipped for well stimulation. The

vessel is registered (flag state) in Nassau, Bahamas. DNV has classified the vessel.

The vessel is 243 feet long and 59 feet wide. The dead weight is approx. 3700 tonnes.

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Photo 2: Big Orange XVIII (source: Schlumberger)

There were a total of 21 people on board, of which 12 were maritime crew from Wilhelmsen

and nine from Schlumberger.

2.4 Application of the petroleum regulations

Section 2 of the Framework Regulations indicates (as scope) that the Framework Regulations

and regulations laid down pursuant to this, apply to health, environment and safety in the

petroleum activities. As regards whether or not the petroleum regulations will apply, the

decisive factor is the term "petroleum activity".

As can be seen from the guidelines to Section 2 of the Framework Regulations, these

regulation and regulations pursuant to this, "... apply to all activity related to conducting

petroleum activity on the Norwegian part of the continental shelf, including if the activities

are conducted from a vessel inside the established safety zones."

Furthermore, from the guidelines it transpires that ”Pursuant to Section 1-4 of the Petroleum

Act, the Ministry of Labour and Social Inclusion can stipulate more detailed requirements

related to the safety of the petroleum activities conducted on board a vessel. This right is

limited to equipment and operations which are directly related to the implementation of the

petroleum activities, and not maritime circumstances.

The comments on Section 1-6 of the Petroleum Act specifically mention what is regarded as

vessels and facility in the legal sense. It is emphasised that activities such as simple pumping

activities without well control, installation or dismantling on secured and abandoned wells,

as well as maintenance work on subsea templates or wellheads without penetration of the

well barriers, are seen as activities performed from vessels."

The planned activity for Big Orange XVIII was to stimulate wells on Ekofisk 2/4-X, by

administering chemicals to the facility, but without taking control of the relevant wells.

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The actual well stimulation is regarded as petroleum activity, and the petroleum regulations

apply for this activity, including the requirement in Section 81 of the Activities Regulations

relating to positioning.

The activity which Big Orange XVIII was to conduct is seen as being conducted from a

vessel, cf. the above. Consequently, the petroleum regulations do not apply to Big Orange

XVIII as such, neither prior to nor during the execution of the activity.

In this case, the above-mentioned petroleum activity, the well stimulation, had not started

when the incident took place. Only the preliminary stages were implemented by Big Orange

XVIII entering the safety zone and approaching the facilities. To some degree it will be a

discretionary assessment as to when the petroleum activities are considered to have started.

However, the investigation has shown that there are distinct maritime circumstances related

to the general navigation of the vessel which is the reason for the incident, not equipment or

operations which are closely enough related the petroleum activity.

We refer to the above quote, whereby "The Ministry of Labour and Social Inclusion may

stipulate further requirements relating to the safety of the petroleum activity which takes

place on board a vessel. This right is limited to equipment and operations which are directly

related to the implementation of the petroleum activities, and not maritime circumstances."

(our underscoring)

It can be concluded that the petroleum regulations do not apply to the conditions on board

Big Orange XVII prior to the relevant incident. For conditions on board Big Orange XVII,

maritime legislation will apply.

The petroleum regulations will, however, apply to other conditions relating to the incident,

cf. the review in chapter 5 of this report.

2.5 Internal requirements

ConocoPhillips’ procedure, the Marine Operation Manual has stipulated requirements

relating to, inter alia, responsibility and organisation, monitoring of safety zones and

maritime emergency preparedness. The procedure reflects standards and norms prepared

jointly by the industry.

The operator's monitoring of and control of vessels around the Ekofisk field takes place via

Ekofisk Radar until the vessel reaches the 500-metre zone. Inside the zone, the relevant

facility, in this case Ekofisk 2/4-X, takes over the responsibility for safe approach and receipt

of the vessel. The distribution of responsibility is established in ConocoPhillips’ procedures,

the Marine Operation Manual. Ekofisk Radar is manned by two people on the night shift.

3 Course of events

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3.1 Similar events

In March 2004, the supply vessel Far Symphony collided with the drilling facility West

Venture on the Troll field. The direct cause of the incident was that Far Symphony held a

course directly towards the facility, at the same time as the autopilot was not deactivated.

With the autopilot activated, the duty officer on the bridge was prevented from performing

the planned maneuvering. Underlying causes mentioned include the fact that the duty officer

on the bridge had not followed the checklist completely when arriving at the 500-metre zone.

A full review would have revealed that the autopilot was actived. The duty officer on the

bridge was convinced that the autopilot was deactivated when entering the 500-metre zone,

and did nothing.

In June 2005, the supply vessel Ocean Carrier collided with the bridge between Ekofisk 2/4-P

and Ekofisk 2/4-T. ConocoPhillips' internal investigation recommends several measures for

better control of vessels, for example during navigation in autopilot mode and upon entering

the 500-metre zone. It is also pointed out that work routines related to vessel monitoring

should be assessed. Parts of the Marine Operation Manual, in particular chapter 5 relating to

maritime operations in the Ekofisk area, were revised after this incident.

3.2 Background

The main classification of Big Orange XVIII was renewed in May 2009. After the main

classification, the vessel went to Montrose, Scotland on 15 May, to prepare for well

stimulation of wells on Ekofisk 2/4-K and 2/4-X. During 18 - 19 May, Promarine Ltd.

conducted a technical and Common Marine Inspection Document (CMID) type inspection

on behalf of ConocoPhillips.

Well stimulation of well K29 on Ekofisk 2/4-K was carried out on 24 May, and stimulation

of wells X16 and X06 on Ekofisk 2/4-X was conducted on 26 May and 1 June respectively.

Big Orange XVIII returned to Montrose, where a crew change took place on 3 June. The

vessel was back on the Ekofisk field on 5 June, lying stand-by and awaiting orders to start

stimulation of well X16.

3.3 Course of events on 8 June

0340: Big Orange XVIII was called by Ekofisk Radar with the message to prepare for

stimulation of well X16. The second officer was on duty on the bridge. The second officer

signed on 3 June, and this was his first trip on board Big Orange XVIII. The master was

called to the bridge by the second officer.

0400: The master takes over the command and control on the bridge. Ekofisk Radar is

contacted for permission to enter the 500-metre zone. The steering mode is changed from

autopilot to manual control.

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0402: Schlumberger's representative on Ekofisk 2/4-X calls the bridge on Big Orange XVIII.

The master resets the steering mode to autopilot and leaves the steering position to answer

the call in the radio room. The radio room is a separate room adjacent to the bridge. We were

informed that the conversation lasted approx. 30 seconds. When the master returned to the

steering position, he did not deactivate the autopilot.

0406 – 0408:

The vessel's speed exceeds the permitted speed limited of 8 knots. The speed is registered at

8,4 knots in log. The speed alarm does not trigger any reaction from the personnel on duty on

Ekofisk Radar.

.0411: Ekofisk Radar gives Big Orange XVIII permission enter the 500-metre zone. The

second officer has gone through the entire the checklist for the zone.

NOTE: Before entering the 500-metre zone the Pre-entry/depature 500 m installation safety

zone checklist for offshore service vessels must be completed. Date and time for entry permit

must be entered into the bridge log, cf. chapter 20.2 of the Marine Operation Manual.

The Pre-entry checklist contains checkpoints for, inter alia, Auto Pilot Off, Manoeuvering

system tested and Emergency manoeuvering system tested. All of these were confirmed as

having been performed in the checklist for Big Orange XVIII.

Chapter 5.5.3 of the Marine Operation Manual states the requirements related to testing of

automatic positioning systems, for example Dynamic Positioning (DP), at a safe distance

from the facility. A DP test shall be carried out before entering the 500-metre zone. Big

Orange XVIII is granted permission to enter the 500-metre zone without first having

performed the DP test. The master has explained that he had intended to perform the DP test

approximately 350 metres from Ekofisk 2/4-X. This test was not performed.

Ekofisk Radar does not follow the vessel inside the 500-metre zone, since the responsibility

for activities (including vessels) inside the facility's 500-metre zone is assigned to the

Offshore Installation Manager (OIM), cf. Chapter 5.1 of the Marine Operation Manual.

0413: The master reduces the vessel's speed to turn and then go astern towards Ekofisk 2/4-

X. The master is now aware that the vessel does not respond to maneuvering attempts, but

continues forward towards the Ekofisk facilities.

0414 - 0416:

Big Orange XVIII clears the bridge between Ekofisk 2/4-X and the bridge support.

The master stated that he turned the handles for both azimuth thrusters 180 degrees, and went

into a full reverse in an attempt to stop the vessel.

NOTE: When the autopilot is activated, the azimuth thrusters are ”locked” to the vessel's set

course. Since the autopilot was enabled, the azimuth thrusters did not respond to any attempts

to change direction. This entails that instead of reversing, the vessel's speed increases

forward.

The master stated that he thought there was something technically wrong with the steering,

and therefore activated the emergency steering. The bow thrusters were used to steer clear of

the facilities.

At speeds above 5 knots, using the bow thrusters does not change the direction.

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Big Orange XVIII passes Ekofisk 2/4-FTP and COSL Rigmar and heads towards Ekofisk

2/4-W. The clearance to COSL Rigmar is estimated at between 4 to 10 metres. The master

informs Ekofisk Radar as follows via VHF: ”We have lost power”.

0417: Big Orange XVIII collides with Ekofisk 2/4-W. Speed at the point of collision is

estimated at 9.7 knots. Ekofisk Radar calls Northern Crusader to assist Big Orange XVIII.

Figure 1: The course of Big Orange XVIII based on radar plot from Ekofisk Radar and AIS (source:

Wilhelmsen Ship Management)

0417: The fire alarm is triggered on board Big Orange XVIII.

0419: Big Orange XVIII turns starboard under the bridge between Ekofisk 2/4-W and

Ekofisk 2/4-FTP. The main engines are stopped by activating the emergency stop. Ekofisk

Radar contacts the central control room (CCR) on Ekofisk 2/4-J. The CCR initiates shutdown

of Ekofisk 2/4-W. The standby vessel Esvagt Corona is ordered to go to Ekofisk 2/4-W and

launch the man-overboard-boat (the MOB boat).

0423: The MOB boat is at the location.

0424: The Coordinator Field Emergency Preparedness Centre (FEBS) is mobilised.

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0427: ConocoPhillips (the reception in Tananger) and the Main Rescue Centre (HRS) South

is informed.

0427: The Northern Crusader is in position to tow Big Orange XVIII.

0428: Ekofisk Radar informs the OIM that Big Orange XVIII has drifted in to Ekofisk 2/4-

W. The OIM requests mobilizing of the Local Emergency Preparedness Centre (LoBS).

0430: LOBS is mobilised.

0432: The main engines on board Big Orange XVIII are started again. Based on the available

information, LoBS does not consider the situation so serious as to active a general alarm.

0435: Big Orange XVIII backs off from Ekofisk 2/4-W using its own engines. A stern-to-

stern impact results in minor damage aft on both Big Orange XVII and Northern Crusader.

Ekofisk Radar gets a more detailed overview of the seriousness of the incident.

0439: A towline is fastened between the Northern Crusader and Big Orange XVIII. Big

Orange XVIII is towed to a safe location between Albuskjell 1/6-A and Albuskjell 2/4-F.

0441: CCR shuts down production on Ekofisk 2/4-A and access to 2/4-W via the gangway

connection. Equipment related to 2/4-W is also shut down.

0445: Personnel belonging to the Tananger Emergency Preparedness Centre (TABS) are

informed.

0453: ConocoPhillips' reception calls TABS personnel to inform them that the situation is

under control.

0456: HRS notifies PSA's emergency response officer of the situation on Ekofisk: “A well

simulation vessel has lost engine power and drifted under an unmanned platform and got

jammed. The vessel has broken away and has been pulled off." The PSA's emergency duty

officer decides to man the emergency preparedness centre.

0505: The PSA's emergency duty officer is in contact with COPSAS’ emergency duty

officer, who states that TABS will be manned. The boat has hit the bridge. Ekofisk 2/4-W has

been shut down, production shut down.”

0525: TABS mobilises.

0546: The PSA's emergency duty officer receives the following information from COPSAS’

emergency duty officer: “The well simulation vessel Big Orange XVII has passed under the

bridge between Ekofisk 2/4-C and X, turned and hit Ekofisk 2/4-W. The boat has been pulled

away and has anchored at Albuskjell to identify the damage. There is damage to the stern and

monkey deck. Damage to a brace was identified at Ekofisk 2/4-W. Work on getting an

overview of the damage is ongoing. All personnel has been accounted for, no personal

injuries.”

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0615: The PSA's technical department for construction safety is informed and will take part

in manning the PSA's emergency preparedness centre.

0710: New status from COPSAS to the PSA: “It has been stated that the vessel first lost

engine power, but could use the bow thurster. Gradually they also lost power on the bow

thruster, and drifted/ran into Ekofisk 2/4-W at a speed of approx. 4.5 knots. Big Orange

XVIII is being towed by Northern Crusader. Big Orange XVIII is unable to anchor due to the

damage to the bow. COPSAS' management is mobilised. COPSAS will send structure

experts to Ekofisk 2/4-W at the first opportunity."

0830: The PSA demobilises the emergency preparedness centre and follows up the operator's

normalisation work.

1345: TABS is demobilised.

4 The incident's potential

The collision caused major material damage both to the facility and the vessel. The collision

is classified as a major accident based on the result, by endangering a facility's integrity.

There was also a major accident potential, involving several persons who could have been

seriously injured or killed.

4.1 Actual consequence

4.1.1 Personal injuries

No one was physically injured, neither on Big Orange XVIII, Ekofisk 1/4W nor on other

installations on the Ekofisk field.

4.1.2 Material damage

The collision between Big Orange XVIII and Ekofisk 2/4-W caused considerable damage to

both the vessel and the facility with bridges. Equipment on the vessel, such as antennas,

masts, etc. on the roof of the bridge was torn off, rendering it inoperational. The bow was

pushed in approx. two metres by the impact. Ekofisk 2/4-W was partly pushed out of position

as several braces loosened from the main load-bearing structure, which was also pushed out

of position. In addition, the water injection riser for well W-05 was extensively bent. Several

wellheads were dislocated. The bridge connecting Ekofisk 2/4-W and the bridge support

BS01, were also pushed far out of position when the bridge abutmentat Ekofisk 2/4-W was

bent down.

Sub-sea damage to braces 2.5 metres and 15 metres under the sea surface was also identified.

14

A local deformation (buckling) was discovered on the southern leg near the cross-over to

the pile. Cracks were discovered between the legs and deck on the two northern legs

(northwest and northeast). The crack on the northwestern leg is approx. 50 per cent of the

circumference, and for the northeastern leg approx. two-thirds of the circumference.

Part of the extent of the damage to the facility and the vessel can be seen from the photos

below.

Photo 3: Damage to Ekofisk 2/4's load-bearing structure, conductor and riser (source: ConocoPhillips)

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Photo 4: Damage to Big Orange XVIII (source: ConocoPhillips)

4.1.3 Consequence for production

The immediate consequences of the material damage after the collision is, inter alia, that

production from Ekofisk 2/4-A had to be stopped due to the lack of overpressure protection.

In addition, the bridge between Ekofisk 2/4-W and bridge support BS01 had to be

temporarily secured by means of the heavy lift vessel Thialf. Due to the fact that the damage

to the fastening of the abovementioned bridge, and that both the water injection riser and

load-bearing structures on Ekofisk 2/4-W were very extensive, it was decided to remove the

bridges connecting Ekofisk 2/4 with the bridge support (BS01) to Ekofisk 2/4-FTP and to the

south flare, including its supporting frame down to 20 metres below sea surface. This was

done to ensure use of the drilling facility Mærsk Gallant for plugging of a total of six

remaining wells on Ekofisk 2/4-W. When all wells have been plugged, Ekofisk 2/4-W will be

removed. The removal activities are planned for 2010.

Production from Ekofisk 2/4-A is still shut down until new overpressure protection is

installed and ready for start-up. In addition, parts of the Ekofisk field will not have sufficient

pressure support due to lack of water injection. Future pressure support is planned by using a

subsea facility (Ekofisk 2/4-VA).

4.2 Potential consequence

The size and speed of the vessel provide a collision energy which is up to six times higher

than the energy which the exposed facilities are constructed to withstand.

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4.2.1 Personal injuries

4.2.1.1 Facilities and risers exposed to collision risk

COSL Rigmar is a jackup facility located on the south side of Ekofisk 2/4-X. COSL Rigmar

has the capacity to accommodate up to 290 people. The facility has three main load-bearing

structures placed on the seabed (spudcans) with one to three-metre penetration into the

seabed). It is uncertain whether or not the facility would have tolerated an impact with the

vessel, which at the time of passing had a speed of between 6 and 7 knots.

Ekofisk 2/4-Q has four main load-bearing structures, and would have sustained extensive

damage in a collision. The facility normally accommodates 120 people. The vessel's speed

when passing Ekofisk 2/4-Q was approx. 6 - 7 knots.

An 8” gas pipeline runs from Ekofisk 2/4-C to Ekofisk 2/4-B. In a collision the risk of

releasing substantial amounts of gas, resulting in explosion and fire, would be imminent. A

scenario like that could, under certain circumstances, result in extensive material damage

from explosion and fire, but also loss of human lives both on the facility and the vessel. The

probability of this scenario becoming a reality is medium based on the course of the

autopilot, the vessel's speed and the reduced possibility of staying clear of the bow thrusters

at speeds above 5 knots.

4.2.1.2 Big Orange XVIII

Depending on which facility the vessel could have hit, we make the following assumption

for:

a) Bridge supports (two or three main load-bearing structures) and COSL Rigmar:

Probably the same scenario as for the collision with Ekofisk 2/4-W.

b) Four or more main load-bearing structures:

A collision would have resulted in a more severe impact, depending on the speed and

facility with a potential for personal injury to the vessel's crew, particularly since the

crew had no warning that a collision was imminent.

c) In the event of a collision involving a hydrocabon-leading pipeline being torn, there

would be a danger of discharge and ignition resulting in explosion and fire. With the

cargo the vessel transported, we could not disregard cascade effects and personal

injuries.

4.2.2 Material damage

The bridge support between Ekofisk 2/4-Charlie and Ekofisk 2/4-X is not designed to tolerate

impacts at speeds of 6 - 7 knots. The probability of this scenario is high based on the vessel's

course and the fact that Big Orange XVIII passed close by.

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Ekofisk 2/4-FTP has twelve main load-bearing structures and would probably tolerate the

impact fairly well, even at a speed of 7-8 knots. Still, the material damage would be

noticeable. The probability of this scenario is high based on the vessel's course.

The bridge support BS01 consists of two main load-bearing structures, and would probably

not have tolerated an impact at a speed between 8 and 9 knots. It is also likely that bridges

could have been torn off, resulting in damage to subsea pipelines. In addition, the flare stack

of the south flare, containing hydrocarbons under low pressure, could have had ruptured. The

probability of this scenario is high based on the vessel's course.

4.2.3 Discharge to the external environment

The greatest risk of a hydrocarbon discharge would be if the bridge between Ekofisk 2/4-C

and Ekofisk 2/4 Q had been torn off, resulting in a fracture in the pipeline transporting oil and

gas from Ekofisk 2/4-A to Ekofisk 2/4-J for processing. Here large amounts of hydrocarbons

run in pipelines under medium high pressure. If the bridge between Ekofisk 2/4-Q and

Ekofisk 2/4-FTP were torn off, this could potentially have the same outcome.

Minor discharge of hydrocarbons would have been the result if the bridge south of Ekofisk

2/4-FTP had been torn off. Here smaller amounts of hydrocarbons are transported in pipes

under low pressure.

Major damage to the vessel's long sides, where products intended for well stimulation on

Ekofisk 2/4-X are kept, could have resulted in discharge.

A direct impact with Ekofisk 2/4 South Flare could have resulted in discharge of

hydrocarbons, with the probability of ignition and subsequent explosion and fire. The

probability for this scenario is high, based on the vessel's course and further increase of

speed.

5 Observations In general our observations can be divided into three categories:

Nonconformity: In this category the PSA’s observations indicate a probable violation

of the regulations.

Improvement items: Related to observations where we identify flaws, but do not have

sufficient information to prove violation of the regulatory requirements.

Conformity/barriers which have functioned: Used in the event of proven conformity

with regulatory requirements.

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5.1 Nonconformities

5.1.1 Deficient monitoring of the vessel

Description:

ConocoPhillips has not adequately complied with the requirement to monitor all activity in

the safety zone so as to avoid undesirable events.

ConocoPhillips has not made adequate provisions to ensure compliance with its own

requirements for safe entryinto the 500-metre zone.

Grounds:

Ekofisk Radar did not respond to the speed alarm for Big Orange XVII during the time 0406

- 0408, and did not make the vessel aware of its course directly towards the Ekofisk facilities.

Big Orange XVIII was given permission to enter the 500-metre zone without ensuring that

the required tests had been performed. ConocoPhillips has stated that their governing

documents do not fully describe how speed irregularities are to be handled, and that the

maritime competence of personnel at Ekofisk Radar is deficient.

Requirements:

Section 28 of the Framework Regulations relating to monitoring of the safety zones

Section 5 of the Management Regulations relating to internal requirements

Chapters 5 and 20.2 of ConocoPhillips’ Marine Operation Manual

5.1.2 Inadequate measures after the Ocean Carrier collision

Description:

The proposed measures after the Ocean Carrier collision have not been fully implemented in

ConocoPhillips’ own organisation, or followed up in relation to all vessel contractors.

Grounds:

After Ocean Carrier's collision in June 2005, ConocoPhillips’ internal investigation presented

proposals for measures to achieve better management of vessel contracts, for example

”.. ensuring that the company's expectations as regards HSE are communicated

and followed up towards shipping companies and vessels.”

“..evaluate how the requirements related to entering of safety zones, as specified

in the Marine Operations Manual and OLF's guidelines 061, shall be

implemented and be complied with in practice.”

It was also recommended that a work group be appointed to review the work routines at

Ekofisk Radar.

The recommendation in chapter 4.3.3 of the internal investigation report dated 20 August

2009, is largely the same measure as proposed following the Ocean Carrier collision.

Requirements:

Section 22, first subsection of the Management Regulations relating to improvement.

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5.2 Improvement items

5.2.1 Follow-up of management system and internal requirements

Description:

There are indications that the management system and the internal requirements relating to

entering of vessels, are not sufficiently complied with by the responsible operating unit.

Grounds:

According to Section 13, first subsection of the Framework Regulations, ConocoPhillips

shall “establish, follow up and further develop a management system which ensures

conformity in relation to the requirements of the health, safety and environment legislation.”

ConocoPhillips must ensure that the management of health, safety and the environment

comprises the activities, resources, processes and organisation necessary to ensure safe

operations and continuous improvement, cf. Section 3, first subsection of the Management

Regulations. Furthermore, there must be internal requirements specifying the requirements of

the regulations, cf. Section 5, first subsection of the Management Regulations.

Chapter 15 of the Marine Operation Manual states the requirements related to admission of

well stimulation vessels (for example by referring to chapter 3 of this procedure). Through

own requirements and reference to guidelines, the same level of requirements are stipulated

for vessels regardless of which operational unit follows up the vessel contract.

ConocoPhillips has stated that the management of stimulation operations, including vessels,

is placed under the Well Operations unit. Follow-up of vessels in general, for example supply

vessels, is placed under Logistics/Marine Group. We have been informed that Well

Operations mainly concentrate on following up the well stimulation operation. Reference is

here made to items 4.3.5 and 4.3.6 of ConocoPhillips' own investigation report.

Information from ConocoPhillips’ own investigation report may indicate that all aspects of

their management system and internal requirements have not been sufficiently followed up.

Requirements:

Section 13 of the Framework Regulations relating to the duty to establish, follow up and

further develop the management system.

Section 3 of the Management Regulations relating to management of health, safety and the

environment.

Section 5 of the Management Regulations relating to internal requirements.

Chapter 15 of ConocoPhillips' Marine Operation Manual

6 Other comments

20

6.1 Maritime legislation and compliance with consolidated guidelines

Division of responsibility, assignment of duties and communication between the bridge

personnel were insufficient prior to approaching the Ekofisk facilities.

It was not ensured that the second officer had the necessary competence. The second officer

was new in his function, and had not received the required training and drilling in accordance

with Wilhelmsen's own requirements.

The master did not comply with the resting time regulations. It was stated that the master had

an average of 8.5 hours of rest prior to the incident. The requirements stipulate a minimum of

10 hours of rest per 24 hours.

Maritime legislation and the consolidated guidelines have not been sufficiently complied

with, including the Safety at Sea Act, IMO ISM Code, the STCW Convention and guidelines

for safe management of offshore service and anchor handling operations (Northwest

European area).

Reference is here made to Appendix D 'Comments on draft investigation report: Collision

between Big Orange XVIII and Ekofisk 2/4-W 8 June 2009', with the Norwegian Maritime

Directorate's comments on resting periods, familiarising of personnel, bridge duty and

routines, and responsible shipping company.

6.2 Insufficient learning after similar incident

In connection with the Far Symphony collision, it was discovered that the duty officer had

not entirely complied with the checklist upon arrival at the 500-metre zone. The autopilot

was not deactivated before entering.

Wilhelmsen Ship Management has not to a sufficient degree incorporated lessons learned

from the Far Symphony collision into their own organisation and governing documents.

7 Barriers which have functioned

7.1 Technical barriers

Barriers which are to prevent or reduce the probability of fire and explosion (major accident):

1. Ekofisk 2/4-W was shut down on 8 June 2009 at 0419

2. Production at Ekofisk 2/4-A was shut down on 8 June 2009 at 0441

(fluid and gas in the pipeline to the south flare was still burning some hours later)

7.2 Organisational barriers

1. Ekofisk 2/4 FTP – access to Ekofisk 2/4 BS01 was closed on 8 June 2009 at 0524

21

2. Northern Crusader tows Big Orange XVIII away from the Ekofisk field to

Albuskjell to avoid damage to other facilities on 8 June 2009 at 0440

3. TaBS (emergency preparedness) established and demobilised on 8 June 2008 at

0525 / 1345

4. Normalisation team (shore) established on 8 June 2009

8 Discussion relating to uncertainties The incident has been reconstructed based on available logs, for example VISPO, radar plot,

AIS, conversation log, as well as interviews with people involved in the incident. Equipment

for logging of manoeuvring commands is not installed on Big Orange XVIII's control

console. Reconstruction of the manoeuvering is therefore based on information given by the

personnel on the bridge.

Testing of, for example, the control systems and thrusters after the incident has not identified

any defects in this equipment.

It is difficult to see how Ekofisk Radar could have done anything to prevent the actual

development of the incident during the time 0411 and 0417. After Ekofisk Radar granted

permission to enter the 500-metre zone, there was no formal communication between the

vessel and Ekofisk Radar. The vessel contacted Ekofisk Radar twice via VHF, at 0415 and

0416, without identifying itself.

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9 Appendices

A: The investigation is based on the following documents

1. The HSE regulations for the petroleum activities, in force as per 1 January 2002

2. Guidelines for safe management of offshore service and anchor handling operations

(Northwest European area), version no. 1, dated February 2006

3. ConocoPhillips Norway's Marine Operation Manual, document no. 3929, rev. 05,

dated 20 March 2006

4. Printout of VISPO 8 June 2009 for the time 0340 to 0419

5. Wilhelmsen Ship Management, Organisation chart, June 2009

6. Schlumberger - Accident Investigation Report, dated 22 July 2009

7. Wilhelmsen Ship Management – Investigation report, rev. 3, dated 17 July 2009

8. ConocoPhillips – Investigation report “Big Orange XVIII” collision with 2/4-W, rev.

2, dated 20 August 2009

9. ConocoPhillips – Investigation report Impact no. 13620 Ocean Carrier collided with

the bridge between EKOB and EKOT, dated 1 July 2005

10. Farstad Shipping ASA – Investigation summary after collision between Far

Symphony and West Venture

11. The Norwegian Maritime Directorate – Comments on draft investigation report;

Collision with Big Orange XVIII and Ekofisk 2/4-W 8 June 2009, ref. 200915551,

dated 17 September 2009

B: Overview of participants in meetings

ConocoPhillips 26 June 2009:

NAME FUNCTION

Wilhelmsen Ship Management (WSM) and Tracer Offshore 29 June 2009:

Schlumberger 2 July 2009

NAME FUNCTION

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C. Abbreviations, definitions of words and measuring units

AIS: navigation system for localisation, identification and tracking of

vessels (ships)

Azimuth-thruster: horizontally rotating propeller, used both for propulsion and

positioning

DP: Dynamic positioning

Ekofisk Radar: monitors maritime traffic, located on Ekofisk 2/4-H

FEBS: Field Emergency Preparedness Centre

HRS: Main Rescue Centre South

IMO: International Maritime Organisation

IMS: International Safety Management

LOBS: Local Emergency Preparedness Centre

MOB: Man-overboard

OIM: Offshore Installation Manager

OLF: The Norwegian Oil Industry Association

STCW: International Convention on Standards of Training, Certification

and Watchkeeping for Seafarers

TABS: Tanager Emergency Preparedness Centre

VHF: Very High Frequency

1 ft- = 0.3048 metres

1 knot = 1.852 km/h

24

D: Comments by the Norwegian Maritime Directorate regarding the draft investigation

report

Royal Arms Our date Our ref. / code

Norwegian Maritime Directorate 28 September 2009 200915551

Your ref. Our officer/

direct tel.

2009/725 RLL/BEP-

Petroleum Safety Authority Norway

P.O. Box 599

4003 Stavanger, Norway

Attn: Roger Leonhardsen

Comments regarding the draft investigation report: Collision between Big Orange

XVIII and Ekofisk 2/4-W, 8 June 2009

Background

In an email dated 10 September 2009, Roger Leonhardsen of the Petroleum Safety

Authority Norway (PSA) asked the Norwegian Maritime Directorate, Strategic Safety

Department, to comment on the PSA's draft of the above-mentioned report. The PSA has

particularly asked the Maritime Directorate (Sdir) to emphasize seamanship/maritime

aspects and the accountability of Wilhelmsen Ship Management AS as an involved player

in the incident. They also ask the Sdir to consider whether the references in the report to

regulatory requirements/guidelines should be supplemented with requirements under

maritime legislation.

Strategic Safety has therefore emphasized the following elements:

- International working hours and rest provisions

- Familiarisation of new personnel

- Watch duty on the bridge and routines

- Responsible shipowner

Comments:

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1. Rest periods

All personnel who have watch periods on ships must have sufficient rest (Section 24 of

the Ship Safety Act, which will also apply to foreign ships on the Continental Shelf).

Here both the ISM code and STCW order shipping companies and the master to follow

the norms for fitness for watch duty (STCW code A-VIII/1)

In ILO Convention 180, the international labour organsation (ILO), which is subject to

the control of the port state, stipulates a minimum rest period for sailors in all seven-day

periods of 77 hours. This standard is probably more widely enforced following the

introduction of the ILO Maritime Labour Convention in 2006.

- In practice, this means that all watchkeeping personnel shall have at least ten

hours rest during the course of any 24-hour period.

- The rest period cannot be divided into more than two parts, wherein one of the

periods must have a duration of at least six hours.

- The rest period requirements need not be observed in an emergency situation, in

connection with exercises or other 'paramount operating conditions'.

- The minimum period of ten hours can be reduced to six hours, assuming that any

such reduction does not extend over more than two days, and that the rest period

is at least 77 hours for each 7-day period.

- Watch duty lists shall be posted in an easily accessible location.

2. Familiarisation of new personnel

Pursuant to the ISM code and the STCW convention, the master and shipowner have a

duty vis-à-vis ship personnel who are new to a specific ship, to provide specific

familiarization in safety-related matters.

For watchkeeping personnel, a reasonable amount of time must be allocated for them to

get to know the equipment on board, and any associated ship procedures. The

familiarization procedure must cover written instructions that the company is obliged to

give to the master.

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One of the officers on board shall be responsible for training new personnel on the bridge

and, ideally, the training shall take place by means of the check-out method in which

checklists are used as a part of the vessel's safety management system (SMS). This

training particularly includes navigation aids that are installed and included, but is not

limited to ECDIS, ECS, ARPA, AIS, radar and echo sounders. Self-training using

handbooks, videos or computer-based training programs are examples of other training

methods that can be used on board.

3. Watchkeeping on the bridge and routines

It has been proven that, in some situations, just a single officer on watch is not sufficient;

the safety of the vessel indicates that two people shall keep watch. This can be due to

several factors:

Lack of experience: The officer on watch is inexperienced, has not been in the

waters previously, is not familiar with the vessel or has exhibited little ability to

assess situations.

Traffic conditions: Increasing traffic, fishing vessels, crossing ferries, etc. can

necessitate increasing the watch from one to two officers.

Reduced visibility: Reduced visibility conditions are among the factors that

determine manning on the bridge.

The waters: The nature of the waters is of great importance, not just whether or

not conditions are narrow, but also whether there is much/variable current,

difficult lighting in the dark, etc.

Speed: Vessels sailing at high speed may well need better staffing of the bridge

than vessels that maintain conventional speeds.

Several of these factors often occur simultaneously, for example a high-speed passenger

vessel sailing at high speed enters narrow waters with poor visibility and a new officer on

watch. The regulations do not allow for such a situation, as they require two navigators

on watch, both of whom are checked out for the relevant vessel and waters. (STCW A-

VIII/2 part 3-1).

27

However, in such a case, the regulations go on to say "guidelines regarding watchkeeping

schemes and principles to be observed". There shall be communication between the two

navigators, so that that the officer who is in control tells the other officer what he is doing

and what he intends to do; whereupon the other officer repeats this and affirms that he

agrees – i.e. that it is the best maneuver to make in the situation at hand. (STCW B-VIII/2

part 3-1).

Who these two navigators are can vary. It could be the officer on watch and the master,

the officer on watch and pilot, or two officers who are both on watch. An important point

in this context is, of course, that only one of them is in control of the vessel – gives

rudder orders and determines speed, and the other carries out the important control

function. If the master is one of them, it is recommended that he carries out the control

function, because it can be difficult for a young officer to check on the master and point

out his errors.

4. Responsible shipowner

Shipowner means the party listed as the company responsible for operation of the ship in

the safety management certificate the ship is required to have. In this case it is

Wilhelmsen Ship Management AS with address in Lysaker, Norway, who is listed as the

company responsible for the ship's operations. (SSL, Section 4 – Chap. 4, Shipowner)

The shipowner has an overarching duty to ensure that the construction and operation of

the ship take place in accordance with the rules laid down in or pursuant to this Act,

including that the master and others who work on board comply with the regulations. The

shipowner shall ensure that the requirements of the law are observed, except in those

cases where the master by law has an independent duty to ensure this. The shipowner

shall ensure that provisions are made to ensure that everyone working on board is able to

fulfill their obligations under the Act. The Ministry can issue regulations with more

detailed provisions regarding the shipowner's duties under this provision. SSL, Section 6

– Chap. 2, Shipowner's general duties)

The shipowner shall ensure that it establishes, implements and further develops a

documentable and verifiable safety management system in the shipowner's organisation

and on the individual ship, in order to map and control risk as well as to ensure

compliance with requirements stipulated in or pursuant to statutes, or in the safety

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management system itself. The content, scope and documentation of the safety

management system shall be adapted to the needs of the shipowner and the activity it

carries out. The shipowner shall ensure that the master and others who work on board

have the opportunity to participate in the establishment, implementation and further

development of the safety management system. (SSL Section 7 – Chap. 2, shipowner's

duty to establish, implement and further develop safety management system)