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A learning from incident slide for a fatality incident during a project at Teddington (2011)
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S7000 Fatality 15 April 11 Presentation
Presentation of the S7000 Incident duringThe Pemex Power Generation Platform
Project
Lensbury Club, Teddington - 11th May 2011
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
2
Sequence for Further Information / Actions
• Completion and Issue of Final Report - 15th June 2011
• Completion of Follow-up Plan - 21st June 2011
• Closure of Follow-up Plan - 1st April 2012
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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AGENDA
- Coffee and Welcome
- Safety and Housekeeping
- Introduction of Attendees
- Moment of Silence
- Description of the Event - Factual Statement
- Timeline Description of the Event
- Remedial Actions relevant for 2011 North Sea Season
BREAK
- Close
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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Description of the Event
FACTUAL STATEMENT
The morning of the 15th of April 2011 the S7000 was preparing for the installation of the PEMEX power generation module on the ZAAP C Jacket, located offshore Gulf of Mexico. The S7000 work programme included mooring of Cargo Barge Crowley 455/6 at mooring points CB1 and CB2 weather permitting. Based on weather information and information from a wave buoy located in the field the decision was taken to go ahead with the connection of the second tug.
Permits specific to workboat activities were prepared, Job Safety analysis were performed as well as a toolbox talk where safety mitigation measures where discussed. It can be confirmed that all workboat personnel were wearing type approved life jackets and high power strobe locator lights. The starboard side workboat was prepared for launching and finally launched at approximately 01.25hrs.
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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Description of the Event (Cont)
FACTUAL STATEMENT (Cont)
The workboat contained a team of 8 personnel listed below.Endit Ak Gatal Boatswain Johnny Anak Jarop RiggerJesus A. Escandón Tow MasterJuan Jose Godon Muniz Rigger ForemanGlowacki Wojciech MotormanHoline Kilat Rigger and CoxswainChristopher Ely T. Suarez Deck ElectricianHenry Anthony Morgan Safety Officer
Weather conditions at that time were Wind E – 16-18 kts, Sea state:Significant Wave 0.7m / Period 3.8sec. Max. Sea – 1.3m .The work boat was launched from the starboard side of the S7000, all the crew confirmed that it was very rough when in the water and whilst the boat was still within the launch cradle, however once out of the cradle it seemed to improve. The workboat then proceeded towards the tug Sea Venture which was towing the Crowley 455/6 positioned approximately 1100 mts from S7000.
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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Description of the Event (Cont)
FACTUAL STATEMENT (Cont)
The plan was to drop off the Tow Master who would discuss the operation with the tug Captain who had recently been changed out and Saipem in the field had only just been informed of this rotational change. The work boat approached the Sea Venture from the stern port side in an attempt to discharge the Tow Master, two attempts were made, on the first attempt the boat took on water approximately 20 cm deep so the coxswain increased speed, completed a circuit route to clear the water and had a second attempt to discharge the Tow Master however the swell and wave was too much for the disembarkation so the team headed for the cargo barge 455/6 .
The workboat approached the cargo barge 455/6 from port side and positioned itself at approximately 45 degrees to the barge steps and the Safety Officer disembarked the workboat and climbed on board the cargo barge. As he was climbing up the barge ladder the workboat was backing away from the barge approximately 1 or 2 metres (confirmed by the remaining workboat crew) as the Safety Officer turned around to face the workboat he saw the boat lift up and flip upside down, this was approximately at 01:45hrs.
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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Description of the Event (Cont)
FACTUAL STATEMENT (Cont)
On this second approach the working boat was hit by at least one wave, which listed the boat 45 º to port then was hit again and the work boat capsized.( 01:45hrs ) All remaining 7 crew members went overboard. Immediately the Safety Office raised the alarm “Men in the water, boat capsized” over the radio picked up by the S7000 Bridge.
When the workboat capsized, 5 crewmembers were thrown clear into the water and Johnny Anak Jarop and Holine Kilat were trapped under the boat with inflated life jackets. Holine Kilat managed to get out, Johnny Anak Jarop had to remove his life jacket to do so. Holine Kilat and Glowacki Wojciech climbed onto the capsized workboat.
Endit Ak Gatal, Johnny Anak Jarop, Jesus A. Escandón, Juan Jose Godon Muniz and Christopher Ely T. Suarez all made there way to the polyprop rope attached to the emergency tow wire located on the stern port side of the barge 455/6. First and nearest the barge was Johnny Anak Jarop followed by Jesus A. Escandón then Juan Jose Godon Muniz then Endit Ak Gatal and finally Christopher Ely T. Suarez.
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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Description of the Event (Cont)
FACTUAL STATEMENT (Cont)
Endit Ak Gatal made his way past Juan Jose Godon Muniz, and Jesus A. Escandón and put his arms round Johnny Anak Jarop as he had removed his life jacket in order to exit the capsized workboat, Johnny Anak Jarop stated that Endit Ak Gatal was tired and let go but held on to Johnny Anak Jarop by wrapping his legs wrapped around him. Endit Ak Gatal at some point let go and floated away with the sea motion. Juan Jose Godon Muniz and Christopher Ely T. Suarez had also let go because of the wash and waves in the vicinity of the barge.
At 01:50hrs tug Floriana was requested to search for and recover personnel. At 02:00hrs the Port side S7000 workboat was deployed with 3 crew members to assist with the rescue. They found the sea conditions rough and whilst they did locate the upturned workboat they did not locate any of the missing personnel and returned to S7000 at 02:55hrs.
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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Description of the Event (Cont)
FACTUAL STATEMENT (Cont)
At 02:15 Holine Kilat, Glowacki Wojciech and Christopher Ely T. Suarez where confirmed recovered to the Floriana. Henry Anthony Morgan the Safety Officer had recovered Johnny Anak Jarop to the barge, then aided by Johnny Anak Jarop they recovered Jesus A. Escandón the Tow Master, this was approximately 02:35 hrs, at 02:49 recovers Juan Jose Godon Muniz.
At 03:06 Floriana sights Endit Ak Gatal and attempts to recover, however the attempt failed and they reported that the person is unconscious or in shock.
At 03:13 S/V IRIS along with Tug Miss Dee requested to assist, IRIS recovers body at 03:38hrs.
Saipem head office were inform of the incident the 15th of April AM and immediately mobilised an investigation team which consisted of E Baldoni Vessel Operations Manager, F Rizzo HSE Manager and G S Ruffino QHSE Manager. The Investigation team have collected statements, photographs and associated data the investigation is ongoing.
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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Timeline Description of the Event
Continued…
LEGEND
Events
Incident
Conditions
Causal Factors CF
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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Permits issued, JSA Performed and Toolbox Talk held
23:00 Night shift work programme meeting held
01:25 Stbd Workboat launched into water
Workboat proceeded towards the tug Sea Venture, tug towing CB 455/6
Workboat approaches Sea Venture from stern on the port side
CF Other than lifejackets and strobe lights no additional precautions taken
Sea conditions rough
Safety Officer calls bridge for update on weather conditions. Weather conditions were Wind ESE 16-18kts. Sea state Significant wave 0.7 to 1.2 -3.8 secs. Max Sea 1.3 m. The CB was 1200 to 1400 metres away. The Safety Officer onboard was concerned
Approaches tug in order to discharge tow master to discuss operations with recently changed out Tug Master
Workboat takes on water approximately 20cm Coxswain increases speed completes circuit route to clear water
Continued…
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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01:45 workboat capsized 7 men in the water
workboat approaches tug Sea Venture a second time
Workboat approaches CB 455/6 at 45° angle and discharges Safety Officer
Swell and wave too heavy for disembarkation 1.5 to 1.7m decision taken to head for the barge
CF Big wave hits workboat on port side filling it with water and making it heel to starboard. Another bigger wave hits the port side
CF Wind and sea state increased , sea approx 1.8 to 2 m wind 25kts. Coxswain places boat at 90º to barge increases power
CF Holine and Wojciech climb on capsized boat and attempt to activate righting system on workboat and this fails
Conversation took place between Safety on the Workboat and Safety on the S7000 about the weather conditions. Safety Onboard S7000 contacted the bridge to confirm conditions
Tow Master informs tug Master and requests a change of heading 20°to port which was acknowledged
Assistant Superintendent calls Rigger Foreman Godon requesting update on weather conditions and can the barge be boarded. Godon stated there was no problem
Alarm raised by Safety Officer men in water boat capsized. However he was using channel 2 which communicates with Safety
Johnny and Holine surface under the boat. Holine manages to get out. Johnny removes his life jacket in order to get out
Endit, Johnny, Jesus, Godon and Cristopher all made their way to the barge and hang on to polyprop rope. Johnny does not have a life jacket.
Continued…
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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01:46 Captain and Superintendent informed
01:50 tug Floriana informed to proceed and recover personnel from water
02:00 S7000 port workboat launched to assist in recovery proceeds to CB 455/6
Captain and Superintendent on the bridge. Captain requesting second boat to be launched and contacting the 2 tugs in the field Sea Venture and Floriana. Superintendent in contact with Safety Officer on the Barge who confirmed that the boat had capsized and crew was in water
Not sure of timing . Hanging on to emergency tow line are Johnny , Jesus, Godon, Endit and Christoper in that order on line
Not sure of timing Johnny tells Safety Officer on CB 455/6 that he does not have a life jacket having removed it to escape the boat Safety Officer searches for life ring cant find one. Endit makes his way up the line in order to hold on to Johnny. Safety Officer gives Johnney his own life jacket
Continued…
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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02:05 PEMEX onboard informed
02:15 tug Floriana has recovered 3 persons from water
02:25 Johnny recovered to CB 455/6
Not sure of timing Endit and Johnny face to face joking and chatting. Endit gets tired lets go of Johnny wraps his legs round Johnny and is behind him. Finally lets go and drifts off, Godon and Christopher also let go of line
Holine, Wojciech and Christopher recovered
After several attempts by the Safety Officer Johnny recovered to the CB 455/6
Continued…
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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02:35 Jesus recovered to CB 455/6
02:49 tug Floriana recovers one more person from water. Total now 4 on Floriana
02:50 Marine Controller informed
Safety Officer assisted by Jonney recover Jesus the Tow Master to CB 455/6
Godon located and recovered
Continued…
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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03:06 Floriana attempts to recover person from the water
03:08 workboat number 2 back onboard S7000
Floriana unable to recover due to seas boat not really suitable for emergency recovery does not have a safe zone
Continued…
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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03:10 Floriana calls Marine Control informing them that there is still one person remaining to be recovered
03:13 Supply Vessel Iris and tug Miss Dee requested to proceed to Floariana and assist
03:23 Iris approaches the Floriana
Continued…
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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03:38 Iris recovers Endit
03:39 Iris calls Marine Control PEMEX representative confirms that Iris has unconscious person onboard
03:59 Iris transfers Endit to S7000
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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REMEDIAL ACTIONS RELEVANT FOR 2011 NORTH SEA SEASON
Transfer of Personnel Offshore by Use of S7000 Workboat – Avoidance if Possible
Consider Potential Alternative Personnel Transfer Methods
Review of Personnel Transfer Procedure
Review of JSA & TBT Relative to Personnel Transfer
Review of Emergency Response Procedures and Drills
Familiarisation of S7000 Crew, Safety/Standby Vessel and Towing/Assisting tug onboard Management
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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1. Assessment to Avoid Transfer of Personnel Offshore by Use of S7000 Workboat.
Questions:
a) Is it possible for every eventuality?
b) Are we reducing risk or transferring the risk?
c) Are we unnecessarily pre-empting the outcome of full accident investigation?
d) Is there enough time to implement fully alternative methods and measures including communication to relevant crew members?
Answers:
a) Yes it is.
b) Risk is being reduced to an ALARP situation using the proposed method.
c) In the circumstances and until completion of the investigation, it is not unreasonable to avoid at least temporarily the use of S7000 workboat transfer.
d) Yes there is adequate time – provided a transfer method using existing known technology is utilised.
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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2. Consider Potential Alternative Personnel Transfer Methods
a) Can transfer of personnel be fully avoided?
- No, as release of seafastenings and attachment of lift rigging to S7000 is always required
- For unmanned cargo barges it is not possible to place personnel onboard inshore and leave on the cargo barge is not practicable and may increase risk to personnel
b) Use of “Ampelmann System” ?
- Vessel to vessel transfer system has not been fully developed by Ampelmann and necessary testing to satisfy Saipem and our Clients
- Needs to have a significant training plan to be arranged involving:
Ampelmann – S7000 Personnel – Tug Crew
- In conclusion Saipem believe this system has merit but requires to be developed in conjunction with Ampelmann over a period of some 6-9 months
c) Use of other “walk to work” systems?
- All other “walk-to-work” systems do not have the capability to deal with two differentially moving bodies and as such have been excluded at this stage.
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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2. Consider Potential Alternative Personnel Transfer Methods (Cont.)
d) Use of an Alternative Transfer Craft
- Availability and suitability of such a craft requires investigation over a period of 3 months
- Deployment and recovery using existing system from S7000 requires potential modification should craft be of different dimensions, weight etc.
- Egress from craft onto boarding ladder of cargo barge including ladder systems mounted on cargo barges
- Use of a safety/standby vessel in-field to ensure personnel can be recovered quickly
- In conclusion, this method requires detailed investigation and a period of 6-9 months is necessary
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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2. Consider Potential Alternative Personnel Transfer Methods (Cont.)
e) Use of Personnel (ESVAGT) Basket Transfer with Contingency Safety/Standby Vessel Transfer
- Procedures are in place and methodology is well known
- Each transfer allows only 4 persons per trip
- Onboard spreadsheet available and used to enable assessment of motions to be made
- Contingency plan for recovery of personnel from cargo barge in the event of shift working time being exceeded
- Make connection of stern towing tug via streaming line and buoy to enable the tug/barge/tug configuration to be held in position for personnel transfer
- In conclusion, this method offers the most time effective and robust solution
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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3. Review of Personnel Transfer Procedure
- The Personnel Transfer Procedure – S7000-PRO-HSE-37-REV-02 has been reviewed and as such it is deemed suitable for the transfer method under item d).
The use of the motions spreadsheet for transfer will also be fully implemented as part of the Go/No-go decision process.
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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4. Review of JSA & TBT relative to Personnel Transfer
- In this instance a review has shown the Job Safe Analysis (JSA) and Toolbox Talk (TBT) could be improved in terms of implementation of further barriers once an error or failure has occurred. As such the use of a Safety / Standby Vessel to ensure personnel recovery will be implemented.
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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5. Review of Emergency Response Procedures & Drills
- For the avoidance of doubt and whilst Saipem considers the Man Overboard Procedure S7000-PRO-EMG-05-E to be fully sufficient, a Safety / Standby Vessel will be used in-field to enhance the recovery of personnel in an emergency. In addition a ‘Drill’ will be conducted in-field prior to ensure the Emergency Recovery System is fully operational.
Saipem BU OffshoreS7000 Fatality 15 April 11 Presentation
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PRESENTATION OF S7000 FATALITY – 15TH APRIL 2011
CURRENT STATUS OF INVESTIGATION – MAY 2011
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6. Familiarisation of S7000 Crew, Safety/Standby Vessel and Towing/Assisting tug onboard Management
- Upon the S7000 arrival in Stavanger a full briefing of the Vessel Management and the relevant crew involved will take place. This will also be recorded.