The Bureau of Safety and Environmental Enforcement (BSEE) issued an investigation report on the fire onboard a Petrobras drillship during pipe handling operations in December 2017, which resulted in one fatality. The report identified poor compliance with procedures and lack of understanding for the drill floor zone areas during operations as key causes of the accident.
The incident
Petrobras Americas International (PAI) contracted Transocean Offshore Deepwater Drilling, Inc. (TODDI) to manage the drillship during the time of the incident occurring on 2 December 2017. The PBS 10k was located about 240 miles southwest of New Orleans, Louisiana, in the Walker Ridge Area, Block 469 in the Gulf of Mexico.
While the SBOP repair work was being performed, the drill crew proactively performed offline operations to prepare for future well work. This included picking up and racking back drill pipe on the auxiliary drill floor. At approximately 4:40 a.m., a floorhand sustained fatal injuries when he was pinned between the Pipe Handling Catwalk Machine’s (PHCM) skate loading platform arm and a stanchion post on the auxiliary drill floor.
The incident occurred near the end of a 12-hour shift on the first day back to the drillship after the crew had been off for 21 days. The PHCM utilized a skate (which moved along on a track) to transfer DP from the catwalk to the auxiliary well center. The skate’s design included loading platform arms that extruded from the body of the skate and were engineered to support tubulars, such as DP.
The stanchion post was located on the port side of the skate from which there was approximately a three-inch clearance between the post and the skate’s loading platform arms when aligned in the position it was in at the time of the incident. At the time of the incident, the top drive and PHCM were simultaneously being used to pick up the DP.
The victim and another floorhand were in a location away from the auxiliary well center, close to the stanchion post. The elevators were latched to the box end of the DP near the auxiliary well center and the driller had begun raising the DP with the top drive.
At this point, the victim was facing away from the equipment being used and pulling on a cable anchored to the stanchion post in the yellow zone on the port side of the skate, seemingly stretching.
While the driller lifted the DP, the skate operator used a remote control to retract the skate away from the auxiliary well center. When the loading platform arm passed by the post, it pinned the victim into the approximate three-inch clearance.
The skate operator observed the victim pinned, and reversed the skate back toward the well center, releasing the victim from between the loading platform arm and the post. The victim fell to the floor. Personnel quickly responded to the incident and contacted the onsite medic, who responded to the drill floor.
The victim was transferred to the medic’s office, where he received treatment but he was pronounced dead shortly after arrival of the SAR provider.
BSEE conducted a Panel Investigation into the victim’s death and the causal factors that led to the incident. Based on the investigation, the panel concluded that the fatal incident was the result of the victim being located in a pinch point area when the skate was moving away from well center and being pinned between the stanchion post and skate’s loading platform arm.
Probable causes
The panel identified the following causal factors:
- Victim was in a hazardous location and not facing the skate operations while the PHCM skate was being mobilized.
- Failure of crew to identify hazard and stop job when coworkers were not in safe location. Drill floor personnel failed to follow and enforce the Line of Fire and Unsafe Positioning safety rules of the rig.
- Failure to safely operate the PHCM skate.
- Lack of understanding and/or regard for the drill floor zone areas during operations.
- Failure to officially identify and mitigate the stanchion post Pinch Point hazard area.
- Failure to update and follow the Controlled Procedure.
Contributing factors
In addition, the panel identified the following contributing factors:
- Complacency and fatigue resulting from a repetitious job while over ten hours into their first shift of the hitch.
- Lack of training, familiarity, and experience with the equipment on this drillship.
- Incomplete in training requirements to perform operations.
Recommendations
To strengthen implementations of existing safety and environmental management systems, the panel makes the following recommendations:
- Ensure management effectively verifies all personnel adhere to drill floor safety rules.
- Formalize equipment operations to reemphasize the awareness of personnel before equipment is put in motion.
- Ensure employees receive effective operational equipment training.
- Ensure all Control Procedures are operationally correct.
- Ensure all personnel adhere to the Controlled Procedures. The Controlled Procedures must account for all movement of the PHCM skate.
- Ensure personnel are trained on rig access zone diagrams.
- Investigate and implement proximity technology if suitable.
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