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8/2/2019 SPM-34 Hose Failure Investigation Report2
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Terminal Operation Department
Investigation Report
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TERMINAL OPERATION DEPARTMENT
Terminal Engineering DivisionJuaymah Terminal Engineering Unit
Investigation Report of SPM-34 Hose Failure
August 23, 2011
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EXECUTIVE SUMMARY
On Tuesday August 9th
, 2011 at approximately 21:00 hours, informed by port control center senior
pilot reported the SPM 34 hoses observed bending and need to be check. At 2130 hours BERRI # 5with RIMTHAN II coordinator inspected SPM 34 and observed two of the port surface hoses P-28
and P-27 before breakaway coupling squeezed and bending. The hose P-28 was observed squeezed
about more than one meter and the hose P-27 was observed bending more than 45degrees.
Two surface full float hoses at SPM-34 were observed collapsed completely while in service. Next
day, third hose was discovered suffering from the same collapse effect. An investigation committee
was formed to determine the root cause of such premature failure and to prevent reoccurrence infuture. The failed hoses are located near the breakaway coupling in a sequence ( #26, 27 and
#28).The failed hoses are manufactured by Parker ITR (formerly known as Treg Pirelli) and had
failed while in service for only 383 days. This type of hose is supposed to stay in service for around
2190 days (i.e. 17% only of the required service life). It is worth mentioning that this type of failurehas happened before two times already in May 2010 and April 2011. An on-going investigation and
analysis is being conducted right now by the vendor and a third party office to determine the causeof this type of failure. Several tests have been conducted on the failed hoses and other analysis and
recommendation will be issued in this investigation report. Fortunately, there was no product leak
or spill associated with this failure.
Moreover, this report represents the analysis leading to the hose failure, defines the causes and
suggests recommendations to prevent similar failures. In addition, the report addresses thefollowing important points:
The root causes of the failure and the action plan to avoid reoccurrence of such incident.
The adequacy and quality of the hose manufacturer providing this type of hoses.
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TABLE OF CONTENTS
1. INTRODUCTION
2. DESCRIPTION OF THE FAILURE
3. FINDINGS & ANALYSIS
4. DETAILED DISCUSSION
5. RECOMMENDATIONS
6. ATTACHMENTS
7. INVESTIGATION TEAM MEMBERS
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1.0 INTRODUCTION:
This report presents the analysis leading to the hose failure, identifies root causes and suggests
recommendations to prevent reoccurrences. The investigation was based on the following standards,
manuals and publications:
o Saudi Aramco Material Specifications; 22-SAMSS-004 Oil Hose for Offshore TankerLoading
o General Instruction manual; GI 86.001 Handling, Storage, Inspection and Testing of SPMHoses
o Terminal Instruction Manual; TIM 934601 Hose Evacuation and Backfill Systemo Terminal Instruction Manual; TIM 934201 Loading Hoses Inspection and Testingo Oil Companies International Marine Forum OCIMF; Single Point Mooring Maintenance and
Operations Guide, 2nd
Edition 1995
o OCIMF; Guidelines for the Handling, Storage, Inspection and Testing of Hoses in the Field,
2
nd
Edition 1995o OCIMF; Guide to Manufacturing and Purchasing Hoses for Offshore Moorings (GMPHOM
2009), 5th
Edition 2009
2.0 DESCRIPTION OF THE FAILURE:
On Tuesday August 9th
, 2011 at approximately 21:00 hours, informed by port control center
senior pilot reported the SPM 34 hoses observed bending and need to be check. At 2130 hoursBERRI # 5 with RIMTHAN II coordinator inspected SPM 34 and observed two of the port
surface hoses P-28 and P-27 (before breakaway coupling) squeezed about more than one meter
and the other hose was observed bending more than 45degrees. Third hose P-26 was discovered
one day later suffering from the same problem. Fortunately, there was no product leak or spill
associated with this failure.
2.1Sequence of Events:
Following is the timed events, which indicate the actions thatwere taken before and after thefailure of the hoses as logged by operations.
DATE TIME EVENTS
August 7th 19:31 Started Loading operation via SPM-34
August 8th
18:30 Completed Loading operation via SPM-34
19:00 Started Evacuation Operation down to -18.50 inch of Hg
August 9th
21:00 Full Float Port Surface Hoses#27 and 28 were reported with
severe squashing and bending.
August 10th
18:00 Another (3rd
) full float hose#26 was reported suffering the same
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collapse effect.
August 11th
12:00 Crew replaced defective hoses and SPM-34 back in service.
August 12th
06:30 Started new loading operation via SPM-34
2.2Effect on Operations:
There was no effect on Crude Offshore operations as a result of this Failure:
1. Hoses were replaced directly during the free window of SPM-34 as can be seen from theabove sequence of events.
2. There was no leak associated with the failure of these hoses.
3.0 FINDINGS & ANALYSIS:
3.1 Single Point Mooring (SPM) Normal Operation
During the normal operation of the SPMs, the offshore platform operator, in preparation for
the coming tanker, gradually evacuate the intended SPM Hose to reduce the weight of the
hose for tanker handling and to prevent product spillage. Once vacuum pressure of between
10 Hg 20 Hg (inch of Mercury) is maintained in the hose, hose connection is made tothe tanker and loading commence. Upon completion of the loading, once again, hose is
subjected to vacuum pressure to disconnect the hoses from ships manifold. After that and
according to TIM#934601, Hose must be backfilled with product to protect floating hosesfrom collapsing when not in use. The required pressure inside the hoses shall be 35 psig.
3.2 What Happened?
After Ship completed loading at SPM-34, Evacuation process was started on SPM-34 hoses
down to -18 inch/Hg.
3.3Why it Happened (Immediate Causes)?
The investigation that was carried out by the team members revealed that the immediate
cause of the incident was the poor design of Parker ITR Full Floating Hoses to sustainvacuum pressure above the designed setting of -25inch\Hg. These hoses are designed towithstand vacuum down to -25inch/Hg yet failed at values within the design tolerances.
Associated with the vacuum deficiency, vacuum pressure of -18inch/Hg was maintained in
the SPM-34 Hose for excessive duration of time violating the requirement to backfill thehose after each evacuation process.
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3.4 Causal Factors:
The below chart indicates several causal factors associated with two immediate causes
related to the incident events.
Causal Factor Chart
Consequently, the contributed immediate causes of this failure are attributed to the
followings:
3.4.1 The bolts that secure the outboard cylinder maneuvering axis to the sheave sleeve
bearing flange were loosen and not well tighten in place as a result of frequent use ofthe loading arm. Consequently, these bolts could not carry the load of the 8 tonscounterweight causing them to shear off during the movement of the outboard arm.
3.4.2 As a result of lack of lubricant, some of the sheared bolts were found corroded anderoded which did not help in carrying the shearing force on the axis.
Failure ofthe FullFloatingHoses
Poor InternalDesign of ParkerITR Full Floating
Hoses
Pre-arrivalPreparation and
Evacuation/BackfillingOperation
IMMEDIATE CAUSES
Causal Factors
START END
So far, Seven (7)Parker ITR hosesreported with failureagainst vacuum.
1. No inspection.2. No PM on joints.3. Seizing of swivel
screwed pin andbushings.
4. No clearance betweenpins and bushings.
1. All failed hosesmanufacturedbetween March-May2009
2. Inadequate adhesionbetween the Liner andmain bodycomponents of thehose.
3. Not withstand vacuumunder designtolerances.
5. No greasingnipples installed byFMC.6. Not included inthe pre-arrival checklist.
Excessive VacuumDuration imposed on
Hoses
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3.5 Root Causes:
The root causes of this incident were attributed to the followings:
3.5.1. Hose Design was less than adequate
o Parker ITR Full Floating Hoses shows clear indication of design deficiency whensubjected to vacuum pressure even within the design tolerances included in the hosecertificate.
o Parker ITR Hoses tends to fail under vacuum especially if they were installed incritical areas in the SPM string. This includes first-off buoy and hoses near the
breakaway coupling for CALM SPMs and the subsea/surface transition area in theSALM SPMs.
3.5.2. SPM Hose Backfilling and Evacuation Operation is not Clear
o Not including the FMC manufacturers maintenance instructions in neither theannual external Inspection Work (IW) for the loading arm components nor the PM
program tasks. The greasing application task is not part of the PM procedure as it isnot indicated in the attached PM sheet for the loading arm.
o
3.5.3. Equipment design was less than adequate
o The use of normal washers by the FMC loading arm manufacturer. Instead, springtype of washers should be installed with the bolts to keep them well secured in place
and accordingly avoid looseness.
o Missing of greasing nipples on the screwed swivel pins. Grease should beperiodically injected between the cylinder securing bracket bushings and the pins to
allow free 90 degrees movement of the cylinder during the outboard arm extension.
o There was no clearance between the moving swivel screwed pins and the outboardcylinder securing bracket bushings which resulted from frequent use of the loadingarm and could be FMC fault during the installation of the arm. This clearance is
required for free movement of the cylinder and to avoid seizing mechanism.
3.5.4. Problem detection was less than adequate
o Other cause of the failure was aging of the securing bolts for the outboard cylindermaneuvering assembly where two bolts were found broken before the incidentoccurred as it is clear from their corroded surfaces compared to the shiny surfaces of
the newly sheared bolts.
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o Abnormal noise from the adjacent loading arm (L/A-5C) outboard cylinder securingbracket during simulation was an indication of possible mechanical failure that might
occurred to loading arm (L/A-4C) before the incident occurred.
4.0 DETAILED DISCUSSION:
An investigation team was formed by Juaymah Terminal Operations Superintendent to
investigate SPM-34 Full Float Hoses Failure on August 10, 2011. The kick-off meeting was
held on Saturday August 13. The team has subsequently collected the related data and
documentations to investigate this failure and has conducted a vacuum test on the failed hosesand also on a new hose as well. The followings are the aspects of the discussion.
4.1 SPM Evacuation and Backfill Operation
The team has reviewed the operation procedure of the evacuation and backfilling following
each ship loading. It is noted that disconnection of SPM hoses to ship manifold takes usuallyfrom 2 to 3 hours. So, it is normal to have vacuum for this duration on SPM hoses without
affecting the integrity of the hoses. Sometimes, this duration increases when changing hoses
for planned or emergency situations by Rimthan Vessel crew. The team observed a realoperation at SPM-33 where pressure inside the hoses was reduced from 28 psig to -18
inch/Hg in about 10 minutes. The visual alarm of the hose pressure reduction was started
when pressure in the hoses dropped to 10 psig.
In the nearest SPM-34 Hose Failure, the vacuum remained in the hose for almost 23 hours
until discovered. It remains for an additional 40 Hours until replacing the defective hoses.
Similar hose failures had happened in the past as follows:
o Two Full Floating Hoses in SPM-34 (March 2011), the team found for this case thatvacuum was kept inside the hoses for more than 23 hours.
o Two Full Float Hoses in SPM-35 (April 2010), the vacuum was kept inside thehoses for more than 26 hours.
In addition, the investigation team found that in a random selection of SPM-31, 32, 33, 34
and 35 during the last year, long duration of vacuum has been maintained in the hoses for
more than one day as can be seen from the Historical Trend Data in Attachment# X.
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4.2 Parker ITR Marine Hoses Performance
The investigation team found from the documents that there is no dedicated task as a
Preventive Maintenance measure for the securing parts of the moving components including
the maneuvering assembly of the outboard cylinder neither in the PM program nor theFMC manufacturer maintenance manual. However, FMC is insisting in his maintenance
manual on the application of periodic lubrication merely for the swivel joints such as
outboard cylinder joint at a frequency of 500 hours of operation or obligatory every sixmonths. It was found by the team that FMC did not provide greasing nipples on the swivel
joint screwed pins of the outboard cylinder securing bracket to comply with his PM
recommendation.
Hose Brand Total In
Service
Total in
Warehouse
Total
BS- Bridgestone 33 6.4% 39 7.6% 72 7%
DU- Dunlop 76 14.8% 343 67% 419 41%
KL- Kleber(Trelleborg) 32 6.3% 30 5.9% 62 6%
TP- Parker ITR (Treg Pirelli) 260 51% 77 15% 337 33%YK- Yokohama 112 21.8% 22 4.3% 134 13%
Total 513
511
1024
Table1:HoseBrandDistributionforJuaymahSPMs
SPM# Total In Service
SPM#31 14
SPM#32 73
SPM#33 60
SPM#34 67SPM#35 47
Total 260
Table2:InServiceTPHosesDistributionsamongfiveSPMs
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The CSD Structural Engineer evaluated the incident and indicated that there could be three
reasons for the failure. The friction between the cylinder (where the bolts are fastened to)
and the housing is very high notice the grease nipples and grease lines may not be doing
their job in getting enough grease to lubricate the cylinder. If the cylinder is frozen (ornearly frozen), then the torque exerted will be resisted by the frozen cylinder and bolts will
shear off. The loading arm is forced to turn while it is in the locked position (with a lockingmechanism). The bolts will resist the arm movement and the applied torque eventually
overcame the strength of the bolts and sheared them off.
Some bolts are shown in the pictures are loose. If this was the case, then the load sharing
between bolts would have been different, putting more load on some bolts that are tight,shearing them off, transferring the load to the remaining bolts that could not handle it and
also sheared off. Loose bolts also weakens the connection making the cross-sectional area
of the bolts as the only resisting mechanism, while if they are torqued correctly, additionalcontact area (metal on metal) will be resisting the applied forces.
Furthermore, FMC highlighted by e-mail that the screwed bolts for the manoeuvringassembly should be periodically checked for tightness, as they can become loose due tovibrations after some time of frequent loading arm operations. Also when one or two screws
got loose, the probability of all screws getting loose and shearing is very high.
On the other hand, Ras Tannura Terminal reviewed Berth 64 L/A-4C incident and they
suspected possible multiple problems if the following assumptions derived from the pictures
of the incident are correct. First, the bolts in the outboard drive assembly broke due to them
being loose. Judging from the pictures of the bolts being bent and broken at differentlengths and the smearing of the bolt-hole metal, other arms bolts should be checked for
looseness at the bracket in question. Second, if the other outboard cylinder brackets are
being deformed/bent as it appears to be in the pictures, something else much more seriouscould be happening and the arm where hydraulic systems and operating envelopes should be
checked very closely. This could be an indicator of very excessive overloading or
misalignments.
In addition, Ras Tanura Terminal indicated that they have typical type of FMC loading arms
at their loading jetties but fortunately they did not encounter similar incident since they
increased the PM program on the securing parts by modifying the outboard cylindermanoeuvring axis assembly and installing grease nipples on the screwed pins.
The investigation team members discussed the requirements of conducting PM on the
critical moving components and the securing parts of the loading arm such as themaneuvering axis assembly, hydraulic cylinders and counterweights securing mechanisms.
The PM should consist of cleaning, greasing, and checking the looseness of the securingparts.
Sent: Sunday, March 13, 2011 10:55 AM
Thank you for your follow up and please be noted that the ITR-Parker proposal is not
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acceptable as submitted due to the following reasons:
Based on the information we have, the failure mode of ITR-Parker hoses cannot be
associated with positions or operational conditions as failures had occurred in different
location of the same string. Additionally, failure type has been only occurring on ITR-Parker
hoses and not to any of the other marine hose brands which are installed in the same stringand position and have been exposed to similar condition.
The root cause of the collapsed hose failure has not been identified yet.
Saudi Aramco still have large number from the marine hoses Inferior Roma Design
which are either installed or in the warehouse. Until a genuine evaluation of the actual causeof failure is concluded, it would be risky to use these hose design without close monitoring
and evaluation as a mass failure may occur in the future similar to what had happened to
those two hoses.
It should also be highlighted that Saudi Aramco still have an outstanding failure issuewith ITR-Parker hoses that have failed in Jazan in 1994 and so far had not been resolved asITR-Parker were reluctant to pursue this issue or even admit it. For this reason, we would
like to ensure that this will not happen again and therefore this failure issue will be tackled at
the beginning rather than waiting until it gets bigger to a point that ITR-Parker unable toresolve.
To avoid any unexpected mass failure of the remaining hoses and to ensure full
responsibility of ITR-Parker to the performances of their marine hoses at Saudi Aramcofacilities, the hose strings with suspected inferior design will all be removed from service
next year and then subjected to rigorous testing and inspection. Based on the result, a
decision can then be made and ITR-Parker will be notified accordingly.
4.3 Marine Hose Management
Moreover, FMC emphasized on the periodic inspection for the loading arms components.
The team found that there was no inspection performed on the securing mechanism parts for
all critical moving components since the commissioning of BI-8339 YCOT ExpansionProject in 1993. In spite of, the FMC maintenance manual indicates that there should be a
periodic inspection on monthly basis on the moving components of the loading arms fortheir general operating condition and security, for example all swivel joints lubrication and
leakage, an untightening of screws on the flanges, foundation anchor bolts and nuts andcounterweights and security rods.
In addition, the loading arms inspection should be performed every six months for damages,cracks, bent parts and looseness of securing nuts and bolts.
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5.0 RECOMMENDATIONS:
The investigation team derived the following recommendations for immediate action plan andavoidance of future reoccurrence of such incident.
Item
#
Description Recommended
ByAction by
1Determine the maximum duration of vacuum that the hoses
should be applied to without subjected to failureTeam Members JTEU
2 Ensure that Team Members RU
3
Perform immediate Inspection for all TP Full Floating
Hoses to ensure their integrity and to establish the baselinefor future inspection.
Team Members COS
Maint.
4
The berth operator who usually operates the loading armsshould be more attention for any abnormal noise that
indicates possible failure of the moving component and he
should report it for immediate action for maintenance.
Team MembersCOS
Operation
5
Include the PM requirements for the loading arm critical
components in the Instruction Manual (including the rules
and responsibilities of all parties).
Team Members COSOME
6
Test the pressure relieve valve in the hydraulic circuit to
check if excessive force was exerted on the cylinder bracketand caused the bolts to shear off.
RT Terminal
(e-mail)COS
OME
7 Check other arms bolts for looseness at the bracket.RT Terminal
(e-mail)COS
OME
8
Hydraulic systems and operating envelopes should be
checked very closely. This could be an indicator of veryexcessive overloading or misalignments.
RT Terminal
(e-mail) COS
OME
9Provide greasing nipples on the swivel joint screwed pins forthe outboard cylinder securing bracket.
COS Maint.(Innovation
Idea)
COSOME
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10
The set of screws for the manoeuvring assembly axis should be periodically checked for tightness, as they can become
loose due to vibrations after some time of loading arms
operation. And when one or two screws loose, the probabilityof all screws getting loose and shearing is very high.
FMC(e-mail) COS
OME
12
On monthly basis, inspect the condition of all movingcomponents for general operating condition and security.
Area OME will provide scaffoldings for inaccessible
locations. Replace or repair parts that indicate possiblemalfunction.
FMC(maintenance
manual)COSOME
13On six months basis, inspect all components for damage or
safety, fix all loose nuts and bolts, cracks, bent parts, etc.
FMC(maintenance
manual)RU
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6.0 ATTACHMENTS
1. Investigation Team Members Sign Sheet
2. SPM-34 Loading Historical Trend
3. Other SPMs Loading Trends
4. SPM Hose Change Out Schedule
5. Failed Hoses Data Sheet
5. Inspection Failure Hose Report 2010
6. Inspection Failure Hose Report 2011
7. Manufacturer Hose Inspection and Test Certificate of the
Failed Hoses
9. Parker ITR e-mail response
10. FMC Maintenance Manual and Loading Arm Drawing
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7.0 INVESTIGATION TEAM MEMBERS
___________________________
Abdullah S. Al-ZahraniMech. Engineer & Chairman
____________________________ _________________
Ali H. Al-Noor Abdulrehman I. AnsariForeman, Juaymah Pier Maint. Unit Foreman, Juaymah Offshore Unit
________________________ _____________
Amin A. Bushnag Noori M. HashimMechanical Engineer, Juaymah Pier Maint. Unit Inspector, Terminal Inspection Unit
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ATTACHMENT#1
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ATTACHMENT#2
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ATTACHMENT#3
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ATTACHMENT#4
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ATTACHMENT#5
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ATTACHMENT#6
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ATTACHMENT#7
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ATTACHMENT#8