BRAZILIAN MARITIME AUTHORITY
DIRECTORATE OF PORTS AND COASTS
INCIDENT ONBOARD PLATFORM “PETROBRAS XXXIII”
July 14th, 2010
MARINE SAFETY INVESTIGATION REPORT
Platform “Petrobras XXXIII”
Reference: IMO Casualty Investigation Code - MSC-MEPC.3/Circ.2 13 June 2008/ Resolution MSC.255(84)
Brazilian Maritime Authority - Directorate of Ports and Coasts
Surveys, Naval Inspections and Technical Expertise Management Maritime Casualty Investigation Department (CIPANAVE)
Incident onboard the Plataform “Petrobras P-XXXIII”
Marine Safety Investigation Report
2
INDEX
GLOSSARY OF ABBREVIATIONS, ACRONYMS AND TERMS ........................... 3
I - INTRODUCTION ........................................................................................................ 4
II - SINOPSYS .................................................................................................................. 4
III – GENERAL INFORMATION .................................................................................. 5
a) Characteristics of the platform “Petrobras P-XXXIII” ...................................... 5
b) Documentation (Certificates of the Platform) ...................................................... 6
IV – SEQUENCE OF THE EVENTS ............................................................................. 6
V – HUMAN FACTORS AND CREWMEMBERS........................................................9
VI – DATA OF THE PLACE OF THE ACCIDENT....................................................11
VII - POST INCIDENT PROCEDURES.......................................................................12
VIII – CONSEQUENCES OF THE INCIDENT............................................................12
IX - ANALYSIS OF THE DATA GATHERED AND CAUSAL FACTORS..............13
IX.1 - EVIDENCE /FAULTS...........................................................................................15
IX.2 – CONTRIBUTING FACTORS.............................................................................16
X - PRELIMINARY LESSONS LEARNT AND CONCLUSIONS.........................16
XI - RECOMMENDATIONS..........................................................................................17
ANNEXES..........................................................................................................................17
Brazilian Maritime Authority - Directorate of Ports and Coasts
Surveys, Naval Inspections and Technical Expertise Management Maritime Casualty Investigation Department (CIPANAVE)
Incident onboard the Plataform “Petrobras P-XXXIII”
Marine Safety Investigation Report
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GLOSSARY OF ABBREVIATIONS, ACRONYMS AND TERMS
BMA – Brazilian Maritime Authority
CPRJ - Port Captaincy of Rio de Janeiro
DelMacae – Delegacy of the Port Captaincy in Macae
DPC – Directorate of Ports and Coasts
IMO - International Maritime Organization
ISM Code - International Safety Management Code
POB – Persons on board
SMC – Safe Manning Card
WHRU - Waste Heating Recovery Unit
Brazilian Maritime Authority - Directorate of Ports and Coasts
Surveys, Naval Inspections and Technical Expertise Management Maritime Casualty Investigation Department (CIPANAVE)
Incident onboard the Plataform “Petrobras P-XXXIII”
Marine Safety Investigation Report
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I - INTRODUCTION
For the purpose of effecting the collection and analysis of evidence, the identification of the
causal factors and the elaboration of safety recommendations that should be necessary, in order to
prevent that in the future occur similar maritime accidents and/or incidents, the Delegacy of the
Port Captaincy in Macaé (DelMacae) carried out a Marine Safety Investigation, in compliance
with that laid down in the Casualty Investigation Code of the International Maritime Organization
(IMO), adopted by Resolution MSC. 255(84).
This Final Report is a technical document that reflects the result obtained by DelMacae
regarding the circumstances that contributed or may have contributed to trigger the occurrence,
and not refers to any proving procedures for determination of civil or criminal liability.
Also, one should emphasize the importance of protecting the individuals responsible for
providing information regarding the accident, and the use of information contained in this report
for purposes other than the prevention of future similar accidents could lead to erroneous
interpretations and conclusions.
II – SYNOPSIS
On 14 July of 2010, approximately at 18h00, onboard the platform PETROBRAS XXXIII, IMO
7157749, Panamanian flag, located in the Campos Basin, Campos dos Goytacazes –RJ, Marlin
Field, in the position of coordinates of latitude 22o22‟S and longitude 040
o01‟W, an incident
occurred in the Turbo compressor “B”, in which was verified damage due to the sudden increase
in the discharge pressure of the gases of the turbine, provoking the rupture of the discharge
collector along its welded connection and other damages.
The communication of the occurrence of the incident was received in the Delegacy of the Port
Captaincy in Macae (DelMacae) by telephone on June 20, 2010 and on the following day, a Naval
Inspector, acting as Accident Investigator, visited the platform to evaluate the situation and collect
evidence to conduct the present Marine Safety Investigation.
In accordance with the registries examined, the environmental conditions at the moment of the
incident were good visibility, calm sea, mild wind and clear sky, normal conditions for operation,
not being verified any contribution for the occurrence of the incident.
Brazilian Maritime Authority - Directorate of Ports and Coasts
Surveys, Naval Inspections and Technical Expertise Management Maritime Casualty Investigation Department (CIPANAVE)
Incident onboard the Plataform “Petrobras P-XXXIII”
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The accident investigation started immediately after the main interested parties had been
formally notified, in compliance with the provisions of the IMO Casualty Investigation Code.
III – GENERAL INFORMATION
On the occasion of the initial survey of Platform Petrobras PXXXIII (Photo 1), its visual aspect
was not good, with lots of corrosion in its structure.
Photo 1 – Platform P-XXXIII operating in the Campos Basin
a) Characteristics of the platform PETROBRAS XXXIII:
Vessel: PETROBRAS XXXIII Flag: PANAMA AB: 137.707
Port of Registry: PANAMA Hull: STEEL Length 337.40m
Sailing area: OPEN SEA No IMO: 7357749 Registry N
o 387-E00090-9
Call Sign: 3FKZ6 MMSI: 356790000 Gross Tonnage 135.673 tons
Displacement: 279.749 tons
Classification Society: AMERICAN BUREAU OF
SHIPPING
Year of Building: 1978
Activity: ANOTHER ACTIVITY OR SERVICE Cargo: XXX
Operator: PETROBRAS NETHERLANDS B.V. Propulsion: Without propulsion
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Incident onboard the Plataform “Petrobras P-XXXIII”
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Owner: PETROBRAS NETHERLANDS B.V. Type: PLATFORM (PPSO)
P&I: Assuranceforeningen Gard – Norway Dynamic Positioning: No.
b) Documentation (Certificates of the Platform):
Issuing Authority Title Emission Validity
ABS Class 14/05/2009 29/09/2013
ABS International Freeboard 14/05/2009 29/09/2013
ABS International of Prevention of
Pollution by Oil (IOPP)
15/07/2009 29/09/2013
ABS Safety of Mobile Drilling Unit 14/05/2009 14/09/2013
Delegacy of the Port
Captaincy in Macaé
Safe Manning Card 17/07/2010 01/12/2012
Panama International Measurement 10/06/2002 undetermined
IV – SEQUENCE OF THE EVENTS
In accordance with the information collected by the Investigators onboard the Platform, and
from the Preliminary Report of Analysis of the Incident drawn up by Petrobras, it was verified that
on July 14th
, 2010, at approximately 18h00, occurred an incident in the turbo compressor “B” due
to a failure of the functioning of the Diverter valve, which closed the outflow of gasses to the
atmosphere and affected the internal pressure in the equipment, resulting in damages in its structure.
The turbo compressor B had presented problems in its functioning moments before the
incident, when a technician of the manufacturer was called to the place. This equipment has the
function to assist in the elevation of the oil from the well and, according to testimonies, functioned
automatically from previous programming.
The Diverter valve was lining up a large flow of gas to the heat recover and disarming the
system for high temperature. The heat recover was turned off and was closed the guillotine which
gave it the passage of gases, which would have caused overheating.
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Incident onboard the Plataform “Petrobras P-XXXIII”
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The technician manufacturer of the equipment performed the procedure “force”, which means
getting the product to work alien to logic programming, overlapping thereby the protection on the
program of control of the turbine (Figure 1).
The Diverter valve operated (modulated) to fully close the outflow of gases into the
atmosphere, causing the internal pressure increase until the breaking of the exhaust manifold
(escape collector), resulting in an explosion. All procedures were carried out with the equipment in
operation.
Figure 1 – Gases lined up for the by-pass/guillotine and Diverter closed.
Source: UO-BC da PETROBRAS
The chronological sequence of the events was the following:
At 15h02 the Diverter Valve (modulator of the alignment of the exhaust gases of the turbine for
the Waste Heating Recovery Unit - WHRU, recuperative unit of the exhaust gases) opened, causing
the discharge gases were not to the atmosphere but stay stranded in the WHRU (Figure 2).
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Incident onboard the Plataform “Petrobras P-XXXIII”
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Figure 2 – Way of operation by the WHRU
This led to an increase in temperature of injection water, causing the WHRU disarm and
remain so. The water temperature rose and withdrew the line Turbo compressor “B”. At 15h32
Turbo compressor “B” was switched back on. At 15h50 the valve remained open again. The
WHRU was disabilitated. However, this Diverter valve remained open (Figures 3a, 3b and 3c) not
accepting the command given, which has led the water temperature rise once again.
Figure 3a- Way of operation modulating the diverter
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Incident onboard the Plataform “Petrobras P-XXXIII”
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From left to right: Figure 3b) Exhaustion gases blocked by the guillotine/ Figure 3c) Exhaust gases blocked by the
guillotine and by the diverter. The gases without exit provoked the breaking of the turbo.
At 16h00 the Turbo compressor “B” suffered one more stoppage, and the operator made a
new start with Turbo compressor “B” with the WHRU disabled.
At 18h01 the Diverter valve started to operate. At 18h08 Diverter valve modulated until close
to the exhaustion of the discharge gases and open to the WHRU. As the WHRU was with the
guillotine closed the gases have accumulated in the output of the turbine, activating the high
pressure alarm in the exhaust gas turbine. This caused the stoppage of Turbo compressor “B”,
causing the explosion for the accumulation of exhaust gases hurling the door of the capsule
against the bulkhead.
V – HUMAN FACTORS AND CREWMEMBERS
The Personnel embarked met the requirements stipulated in the Safe Manning Card (Annex
A) and List of Personnel onboard – Persons on Board/POB, both in the quantities and the
qualifications established. The crewmembers and the technicians (non-maritime) were competent
and were accredited for the operation of the unit. The platform possesses good accommodation for
all of the 154 persons embarked.
The key professionals involved in the incident were duly qualified. Also with regard to
personnel, there is the following:
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Platform Manager - works more than 30 years in Petrobras and is duly qualified to carry out
the tasks of the function. On the day of the incident he was carrying out the function of Sectoral
Manager of Platforms.
Technical Operations # 1 - works in Petrobras for more than 6 years and is duly qualified to
carry out the tasks of technical function of operation of the Platform PETROBRAS XXXIII. At
the time of the incident he was in the control room and learnt of the fact via VHF Radio.
Technical Operations # 2 - works in Petrobras for 8 years and carries out the function of
Production Supervisor. At the time of the incident he was in the Processing plant and has
knowledge on the functioning of the equipment, working in overseeing its operation.
The Representative of services of the company contracted to carry out the maintenance of the
equipment embarked on the platform on the day of the incident to render general technical
assistance and was requested to go to the control room of the compressor tubes to verify the bad
functioning of turbo compressor ”B”. Upon arriving there he verified that the diverter valve of
the heat exchanger was not working correctly and asked the Production Supervisor for the
equipment to stay out of operation in order to proceed with the maintenance. He was not attended
because the other compressor was out of operation. According to testimonies, representatives of
the platform decided by disabling the heat exchanger, and there was no technical impediment to
the operation of the turbine with the heat exchanger disabled.
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Incident onboard the Plataform “Petrobras P-XXXIII”
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VI – DATA OF THE PLACE OF THE ACCIDENT
The platform PETROBRAS P-XXXIII is positioned in the Campos Basin, Campos dos
Goytacazes – Rio de Janeiro, Marlim Field, in position latitude 22o22‟S and longitude 040
o01‟W, at a
distance of 180 Km east of the city of Macae (Map1).
Mapa 1 – Localization of the Platform (Google Maps)
Environmental conditions: In accordance with the information obtained and records
consulted by the investigators, on the day of the accident the weather conditions were good, with
good visibility, calm seas, light winds and clear skies.
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Surveys, Naval Inspections and Technical Expertise Management Maritime Casualty Investigation Department (CIPANAVE)
Incident onboard the Plataform “Petrobras P-XXXIII”
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VII – POST INCIDENT PROCEDURES:
After the incident were carried out the first procedures foreseen in the internal norms of the
unit and of the company, and it was verified that there had not been personal accidents. To follow
were adopted the operational procedures to disconnect the damaged equipment and the raising of
data to draw up the Statement of Occurrence of Failures, with this occurrence being communicated
to PETROBRAS and to DelMacae.
On August 11, 2010, in a new survey carried out by Investigators of the Port Captaincy of
Rio de Janeiro (CPRJ) , there were found in various different points of the platform, faults in the
air control system. This system issues commands for various systems and monitorizes many others
which could possibly cause imprecise readings and controls. Visual exams were carried out of the
parts of the turbo compressor and documental analysis.
VIII – CONSEQUENCES OF THE INCIDENT
a) Personal accidents – there were none.
b) Material damages - Damage in the turbo compressor Bravo (Photos 2 and 3).
Photo 2 – Damage on the duct of connection to the WHRU.
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Incident onboard the Plataform “Petrobras P-XXXIII”
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Photo 03 – Damage in the turbo compressor.
c) Pollution – there was no registry of pollution relating to the accident.
IX - ANALYSIS OF THE DATA GATHERED AND CAUSAL FACTORS
Given the circumstances, it was possible for researchers to note that the procedure for
maintenance of equipment should be conducted with the equipment out of operation. The closing of
the guillotine associated with the bad functioning of the Diverter valve created a situation of risk
potencialized by the execution of the procedure “force”. This was due to the fact that the closed
guillotine impeded the exhausting of the gases for the recuperater of heat whilst the Diverter valve,
defective and modulating by forced action, impeded the exit of gases to the atmosphere.
The procedure "force" means to force a direct acting of the valve, bypassing the automated
control logic.
Despite the fact that the procedure "force" has been conducted improperly, if the equipment
was not functioning the incident did not occur. It is verified a carelessness here (human error) when
performing the procedure for maintaining the equipment in operation. As we can see, there was an
unexpected sequence of events by the maintenance team during the implementation of the
corrective maintenance of equipment turbochargers A and B. It was not done an adequate planning
for the proper maintenance of the turbo-compressors, offering a great risk of accident.
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Incident onboard the Plataform “Petrobras P-XXXIII”
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In interviews with the shipboard personnel involved in the operation of the equipment the
investigators noted that all were qualified professionals and that the incident occurred on the turbo
compressor B of the plant of process. This equipment (turbo B) has the function of aiding the
elevation of oil from the well.
The investigators did not have access to the crashed turbo compressor due to Owner failure to
notify the Maritime Authority the occurrence of the incident. The incident was reported to the
Maritime Authority by a complaint, seven days after the event, when the scene of the incident had
been decharacterized.
Based on statements and the Preliminary report of Petrobras, the investigators found that there
was an improper closing of the flaps that direct the flow of exhaust gases, causing overpressure on
the collector of the exhaust gases from the turbine, resulting in the disruption of the collector, and
that equipment operated automatically by a previous schedule. It is assumed that the turbo
compressor was calibrated to controla ir at fully capacity, which was not ascertained on the
occasion of the survey of the platform for there was no access to the damaged compressor.
The undue closing of the Diverter valve that regulates the flow of exhaust gasses of the
turbine, resulted in overpressure in the interior of the discharge duct and consequently its breaking.
It was also found that the equipment presented problems in the Diverter valve, for which a
manufacturer's technical was called to the scene. In the attempt to repair the equipment the
guillotine was closed and the Diverter valve was enabled to operate with the equipment in
operation. Enabling the Diverter valve was made by the procedure denominated „force‟ that means
to force a direct acting of the valve, bypassing the automated control logic, which is not
recommended with the machine in operation, and for account of this action the valve closed totally
impeding the exit of gasses to the atmosphere. This caused an increase in duct pressure due to the
fact that the guillotine to be closed, and the explosion occurred when attempting to do maintenance
on the guillotine closed facing a defect in the Diverter Valve.
This guillotine could not be closed once that the Diverter valve was being forced, not being
this procedure recommendable with the equipment working, because could occur an undue situation
of the Diverter valve. To make it worse the fact that the turbine had not been stopped because the
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turbo compressor “A” was inoperative. Remember that the correct procedure would be to leave the
machine stopped during the maintenance.
IX.1 - EVIDENCE /FAULTS
a) Relating to personnel:
Despite the qualifications of the crewmembers and technicians involved in the operation of
the unit, by the accounts received, it was found from the testimonies given and by the documental
analysis that had occurred human error (imprudent actions) when executing maintenance of the
equipment in operation.
b) Relating to documents
There were no faults found in the documentation.
c) Relating to material
A material fault occurred in the functioning of the Diverter valve. The air control had
numerous leaks.
d) Relating to the ambient
There is no evidence that the atmospheric conditions on the day and hour of the incident
have contributed for its occurrence.
In the case under study, the faults of greater importance are referring to deficient politics and
planning of maintenance and deficient training.
In accordance with the facts described previously, it is verified that compliance had not been
given to Article 10 of the International Safety Management Code (ISM Code) that deals with the
Maintenance of Platforms and Equipment, and establishes that the company (the owner) should
ensure that inspections be made in appropriate intervals, any non-conformity be reported with its
possible cause if known, and that a appropriate corrective action be taken and register of these
activities be maintained.
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IX.2 – CONTRIBUTING FACTORS
(a) Human factor – Did not contribute, from the bio-psychological point of view.
(b) Material factor – Contributed with the failure in Diverter valve, due to the air control
system that met with numerous failures;
(c) Operational factor – Contributed, for corrective maintenance was being performed on
the turbo compressor B did not follow a minimum planning with safety, which consisted of
stopping the equipment, because of this stop interfering with the normal operation of the platform.
The causal factor of the incident was the closing of the guillotine without observation of its
monitoring, made worse by the attempt of maintenance of the temperature control system of the
heat recuperater (WHRU), through the placing of “force” on the solenoid valve of the Diverter
Valve with turbo compressor B in operation and with a guillotine closed. The investigation
concluded that these faults occurred due to the bad functioning of the Air Control system that
motivated the incident of turbo compressor B.
X - PRELIMINARY LESSONS LEARNT AND CONCLUSIONS :
Investigations into the circumstances of casualties that have occurred have shown that accidents
on board ships are in most cases caused by an insufficient knowledge of, or disregard for, the need
to take precautions. The investigation pointed out that the culture of safety and of the management
of safety on the part of those involved in the incident were not strong.
The maintenance and operational routines of a system as complex as an oil platform have a
duty to provide security, maintenance and training of personnel extremely well controlled and
effectively carried out. From the findings of this investigation it is concluded that the various
systems and in particular, that of air control that was fundamental from the operational point of
view, once that it controlled and monitored the other systems, did not act duly on the occasion of
the incident.
It stands out that equipment cannot continue to operate when faults are detected and corrections
are not made.
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XI - RECOMMENDATIONS:
First of all, safety recommendations shall in no case create a presumption of blame or liability.
The incident occurred because of a probable chain of different factors caused by the breach of the
procedures for maintenance and control of equipment and the platform as a whole.
Although the investigated incident have not caused casualties, it pointed out the necessity of
an improvement in the objectives of the Company´s Safety Management, in conformity with that
laid down in the International Safety Management Code (ISM Code), once that the incident could
have been avoided if the routines of the maintenance systems had been respected, as well if had
been given a greater attention to the air control system that met with numerous failures. This system
monitors and controls all the systems in the regions of risk of fire and explosion of the platforms.
Finally, a good Safety Management System should foresee and evaluate all the risks in the
operations carried out onboard.
The personal, technical and financial consequences of an incident or an unexpected
occurrence involving maritime operations can be devastating, and this fact emphasizes the
importance of having a verification scope of routine maintenance of equipment well defined, with
technical reference, competence and supervision, in order to be obtained service quality. Because
of the steps already taken by the owner during the investigation there is no other safety
recommendations applicable to the incident.
ANNEXES:
ANNEX A – Minimum Safe Manning Document (4 pages)
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ANNEX A
Minimum Safe Manning Document
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Surveys, Naval Inspections and Technical Expertise Management Maritime Casualty Investigation Department (CIPANAVE)
Incident onboard the Plataform “Petrobras P-XXXIII”
Marine Safety Investigation Report
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Brazilian Maritime Authority - Directorate of Ports and Coasts
Surveys, Naval Inspections and Technical Expertise Management Maritime Casualty Investigation Department (CIPANAVE)
Incident onboard the Plataform “Petrobras P-XXXIII”
Marine Safety Investigation Report
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