brazilian navy - marinha do brasil

BRAZILIAN NAVY

Directorate of Ports and Coasts

Marine Safety Superintendence

Department of Inquiries and Investigations of Navigation Accidents

EXPLOSION WITH VICTIMS ON THE “NORBE VIII” PLATFORM

Maritime Safety Investigation Report

BRAZILIAN NAVY

DIRECTORATE OF PORTS AND COASTS

EXPLOSION WITH VICTIMS ON THE "NORBE VIII" PLATFORM

JUNE 09, 2017

MARITIME SAFETY INVESTIGATION REPORT

Photo 1- Probe platform “NORBE VIII”

Reference:

Casualty Investigation Code, of the International Maritime Organization (IMO) –

MSC-MEPC.3 / Circ.2, 13 June, 2008 / Resolution MSC.255 (84).

BRAZILIAN NAVY



Department of Inquiries and Investigations of Navigation Accidents EXPLOSION WITH VICTIMS ON THE "NORBE VIII" PLATFORM


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INDEX

I- LIST OF ABBREVIATIONS ..................................................................................................... 2

II- INTRODUCTION..................................................................................................................... 3

III- SYNOPSIS ............................................................................................................................ 3

IV- GENERAL INFORMATION .................................................................................................. 3

a) Characteristics of the vessel.............................................................................................3

b) Platform Documents and Certificates in force on the date of the accident:……...............4

V- ACCIDENT LOCAL DATA ………........................................................................................... 6

VI- HUMAN FACTORS AND CREW ........................................................................................... 7

VII- CHRONOLOGICAL SEQUENCE OF EVENTS ................................................................. ..7

VIII- PROCEDURES AFTER THE ACCIDENT ......................................................................... 10

IX- CONSEQUENCES OF THE ACCIDENT .............................................................................10

X- EXPERT EXAMINATIONS .................................................................................... .............. 12

XI- ANALYSIS AND CAUSAL FACTORS ................................. …........................................... 12

XII - PRELIMINARY LESSONS LEARNED AND CONCLUSION ........................................... 20

XIII - SAFETY RECOMMENDATIONS.......................................................................................21

XIV- ANNEX – SHIP`S PARTICULARS OF THE “NORBE VIII”"…...........................................22

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I) LIST OF ABBREVIATIONS

IOM Offshore Installation Manager CPRJ Captaincy of the Ports of Rio de Janeiro DELMACAE Delegation in Macae of the Captaincy of the Ports of Rio de Janeiro MEDVAC Medical Evacuation CTS Minimum Safe Manning (Brazil) IMO International Maritime Organization ISAIM Maritime Accident and Incident Safety Investigation MSC.255 (84) resolution dealing with maritime accident investigation IMI Industrial Metrology Institute DNV Det Norske Veritas STCW Standards of Training and Certification Watchkeeping PMTA Permissible Maximum Working Pressure PSV Pressure Safety Valve VMS Vessel Management System NR 13 Regulatory Norm 13 - BOILERS AND PRESSURE APPARATUS PH Staff Enabled

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II - INTRODUCTION

For the purpose of accomplishing the collection and the analysis of evidences, the

identification of the causal factors and the elaboration of the recommendations of safety

that are necessary, in order to avoid that in the future occur similar maritime accidents

and/or incidents, the Delegation in Macae of the Ports Captaincy of Rio de Janeiro

(DELMACAE) carried out the present Safety Investigation of Marine Accidents and

Incidents (ISAIM) 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 the

DELMACAE in relation to the circumstances that contributed or may have contributed to

unleash the occurrence and does not resort to any procedures of proof for verification of

civil or criminal responsibility.

Furthermore, it should be emphasized the importance of protecting the persons

responsible for the supplying of information related to the occurrence of the accident, for

the use of information included in this report for ends other than the prevention of future

similar accidents may lead to erroneous interpretations and conclusions.

III – SYNOPSIS

The probe platform NORBE VIII (NS-32) was located at latitude 22º20.4 'S and

longitude 040º 04.6' W, in the Marlim Field, in the Campos Basin, carrying out the annual

inspection of the boilers (certification) by the IMI company, by technicians, accompanied

by the ship's engine officer when about 07:38 hours on June 9, 2017, there was an

explosion in boiler number 01 reaching those three people who were inside the boiler

compartment (Eduardo Aragão de Lima, Jorge Luiz Damião and Ericson Nascimento de

Freitas), these three having died later, and Fernando Garcia Pinheiro, a welder, who was

in the stern, outside the compartment, which was struck by the blow (air / steam expanded

with force) from the explosion and expelled by the opening of the , watertight port door,

with wounds.

IV - GENERAL INFORMATION a) Characteristics of the vessel:

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Ship: NORBE VIII

Flag: Bahamas

Gross tonnage: 67.821

Activity: Drilling

Type: Probe Platform

Propulsion: Motor

Navigation area: Open Sea

Construction: 2010

Length: 238 meters

Soc. Classification: Det Norske Veritas

IRIN: C6YB4

Hull Material: Steel

Port of Registry: Nassau

IMO number: 9562568

Owner: ODEBRECHT Oil & Gas

Breadth: 42 meters

Draft: 13 meters

Operator: ODEBRECHT Oil & Gas

Owner: ODEBRECHT Oil & Gas

Other ship data can be found on Ship's Particulars

b) Platform Documents and Certificates in force on the date of the accident:

The statutory certificates and classification society documents that the platform should

carry out are listed below:

Nome do Certificado Português/English

Autoridade Emissora/Classifica- tion Society

Data Emissão/ Issued

Validade/ Validity

Certificado de Classe/Certificate of Classification

DNV 13-03-2016 14-03-2021

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Certificado de Unidade Móvel de Produção / Mobile Offshore Unit Safety Certificate – MODU

DNV 11-08-2016 14-03-2021

Gerenciamento de Segurança /International Safety Managment Certificate

DNV 29-02-2016 14-03-2021

Borda Livre / International Load Line Certificate- LL

Certificado Internacional de Prevenção de Poluição por Óleo / International Oil Pollution Prevention Certificate – IOPP

DNV 29-02-2016 14-03-2021

Cartão de Tripulação de Segurança-CTS / Minimum Safe Manning Certificate

CPRJ 26-05-2017 28-07-2021

Certificado Internacional de

Arqueação / International Tonnage Certificate (1969)

ABS 17-01-2011 Indeterminada

Certificado de Registro / Navigation Statutory Registry

Bahamas 07-01-2015 Indeterminada

Certificado Internacional de Prevenção a Poluição do Ar / Air Pollution Certificate - IAPP

DNV 29-02-2016 14-03-2021

Certificado de Prevenção de Poluição por Esgoto / International Sewage Pollution Prevention Certificate

DNV 29-02-2016 14-03-2021

Atestado de Inscrição Temporária de Embarcação Estrangeira / Certificate of

Temporary Registration of Foreign Vessel (AIT)

Vessel – AIT

DELMACAE 26-05-2017 28-07-2021

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Declaração de Conformidade para Operação nas Águas Jurisdicionais Brasileiras /

Statement of Compliance for Operation in Brazilian Waters

DELMACAE 11-05-2016 11-05-2018

Seguro P&I / Certificate of Entry – Mobile Offshore Unit Entry

Gard P.& I,

(Bermuda) LTD.

20-02-2017 20-02-2018

V - ACCIDENT LOCAL DATA

Photo 2- position of “NORBE VIII” at the time of the explosion

a) Location: The vessel "NORBE VIII" was in the position of latitude 22º20.4' S and

longitude 040º 04.6' W, in the field of Marlim, Campos Basin, RJ.

b) Weather conditions: At the time of the accident the weather was good, good visibility

and clear sky; two-knot current with direction 179º, wind 32 knots, medium intensity,

blowing from North. These environmental conditions did not contribute to the accident.

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VI - HUMAN FACTORS AND CREW

a) List of personnel on board and security crew. On the day of the accident, 158 people

were on board, including crew members and not crew members. The certificates and

documents of these people (specialization courses, extracts from the registration and

registration books) were examined and no nonconformities were found in this examination.

b) Periods of work and rest. No evidence of non-compliance with the minimum rest

periods was found, as established in the STCW / 78 Convention.

c) On board accommodation. The accommodations were suitable for the crew, in

accordance with the standards of comfort, hygiene, temperature, lighting and noises

common to ships of that type.

d) Alcohol, drugs and medicines. No evidence of alcohol, drug, or non-prescription

medication was available from the crew.

e) Security Management: The probe had a Security Management Certificate, issued by

Bureau Veritas (BV), under the terms of the International Security Management Code

(ISM Code) valid until August 6, 2021. This document informs that the rig was audited and

that its safety management system complies with the requirements of the ISM Code.

The chronology of the accident is described below and is based on records made in the

Passport Status Chart during the emergency situation on board, information received from

crew members of the platform, examination of documents received from ODEBRECHT,

system records automation of the vessel, the engine room and the observations of the

investigators during the on-board visit.

VII – CHRONOLOGICAL SEQUENSE OF EVENTS

On June 7, 2017, the employees (Jorge Luiz Damião and Ericson Nascimento de

Freitas) of the Instituto de Metrologia Industrial Ltda. (IMI) were taken on board the

NORBE VIII probe platform to carry out the annual inspection of the boilers.

On June 8, 2017, the IMI company team accompanied by the platform's personnel

performed tests on the boilers and verified that the boiler safety valve # 01 was opening

with the pressure of 1.9 bar and that of the boiler # 02 with pressure of 5.9 bar. After some

tests, they checked for new opening valves of the safety valves.

The boiler number 01 opened with 3.5 bar and the boiler number 02 opened with 6.8 bar.

A leak was observed in the safety valve and, as a result, the certification team decided to

cool the boiler and start maintenance on June 9.

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On June 9, 2017, at 07h39m, the high temperature alarm on the FD panel FD 931-ZF-

16-021, located on the footbridge, corresponding to the boiler room, was activated. At that

time, the annual inspection of the boilers (certification) by the company IMI (technicians

Jorge Luiz Damião and Ericson Nascimento de Freitas) was in progress, accompanied by

the ship's engine officer (Eduardo Aragão de Lima), when there was an explosion in boiler

nº 01, reaching these three people who were inside the boiler compartment and Fernando

Garcia Pinheiro, a welder, who was in the stern outside the room, was hit by the blow (air /

vapor expelled with the force of the explosion), which opening of the port side of the boiler

compartment.

Figure 3- diagram of the location of the boiler rooms

Figure 4- diagram of the location of the boiler room, in the stern marks

Boiler

compartment

Boiler

compartment

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Watertight door open

by the blast wind

Watertigt door

with marks

Figure 5 - Port door of the boiler room Figure 6 - Watertight door with marks

.

- 07:41 am - The walkway was requested by the rescue and medical team to the scene of

the accident.

- 07h48m - The General alarm sounded, real alarm. The Fire Combat team went to the

emergency stations of the vessel.

- 07h54m - It was confirmed by the Fire Combat team that there was no fire in the boiler

room and the removal of the injured began (Eduardo Aragão de Lima, Jorge Luiz Damião,

Ericson Nascimento de Freitas and Fernando Garcia Pinheiro) for infirmary on board.

Figure 7 - Location at the stern where the wounded were brought

09h52m - The first MEDVAC helicopter (medical evacuation) is placed on the ship's

helipad with a doctor on board to evaluate the wounded.

- 10h22m - second MEDVAC helicopter lands on the helipad.

- 12h01m – Take-off of the helicopter PR-OMB taking the injured Eduardo Aragão de Lima

Location to which the wounded have moved

after the explosion. From that point on, they

were removed to the infirmary.

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and Jorge Luiz Damião to Macaé.

- 12h46m – Take-off the helicopter PR-LDE taking the wounded Ericson Nascimento de

Freitas and Fernando Garcia Pinheiro to Macaé.

- 13h56m- The communication of the death of Ericson Nascimento de Freitas arrives on

board.

VIII - PROCEDURES AFTER THE ACCIDENT

The operations of the platform were immediately paralyzed and triggered the

emergency plan of the unit with isolation of the site. The four people who were at the time

of the accident were referred to the infirmary for initial care, following the medical

evacuation request (MEDVAC), by aircraft. The four injured were removed to the Public

Hospital in Macaé, RJ. Welder Fernando Garcia Pinheiro survived with injuries.

IX - CONSEQUENCES OF THE ACCIDENT

Personal Injury - This accident involved two non-maritime workers of the company IMI

and two employees of the company Odebrecht Óleo e Gás S.A., one welder and the other

seaman (2nd Machinery Officer). The four wounded were removed to the Public Hospital

of Macaé, and three died later, according to death certificates: Ericson Nascimento de

Freitas, Jorge Luiz Damião and Eduardo Aragão de Lima.

Environmental damage - there was not; and

Materials damage:

a) auxiliary boiler # 01 has been totally damaged;

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Boiler # 1

Figure 8 - Boiler # 1damage

Figure 9 Figure 11

Figure 10

Figuras 9, 10 e 11 – Boiler # 1 damage

b) Auxiliary boiler # 02 was compromised, due to the failure of its control panel,

which was hit by the accessories (burner) of boiler # 01.

Control panel 111ccontrole

controle

Boiler #1

º1rrrrrr # 101

Burner #1

###!####1r

rr 1r

Place where the

burner is fixed

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Boiler # 2

Boil Boiler Panel. # 1 Boiler panel # 02

Figure 12 – Boiler #2 Figure 13- Boiler control panels 1 and 2.

X – EXPERT EXAMINATIONS

The expert examinations began in the day after the accident (June 10). A visit was

made to the unit to map the situation of the boiler, check the damages and evaluate the

procedures of maintenance and conduction of the equipment and its accessories.

In addition to the on-board visit, the certificates and plans of the platform, the various

documents provided by ODEBRECHT, were examined, at the request of the researchers;

the data of the monitoring system were analyzed and the people who could help in the

elucidation of the accident in question were heard.

XI - ANALYSIS AND CAUSAL FACTORS

From the analysis of the data obtained and the documents examined, it is verified

that:

a) The boilers belong to the manufacturer KANGRIM HEAVY INDUSTRIES CO. LTD,

type PA 0201P32 (the combustion gases pass around the boiler feed water pipes),

working pressure of 7 bar, with steam production of 2,000 kg / hr, vapor temperature of

169 , 78 ° Celsius and gas temperature in the chimney up to 420 ° Celsius and Max.

Admissible Working Pressure (PMTA) of 9.18 bar.

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Figure 14 – Boiler # 1.

b) The boiler operating pressure data set by the manufacturer is as follows:

Pressure(Bar)

Description

9,0 Safety valve in open position

8,5 High vapor

7,5 Boiler Burner Stop

7,0 Working pressure of the boiler

6,5 Burner start

6,0 Low boiler steam pressure

Figure 15 - Boiler operating pressure data.

Furnace

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c) During the inspection carried out in the boiler room, on June 10, 2017, the

following items are verified:

- The boilers were not supplying steam for well testing. According to the boiler's

chart, these boilers were lit and erased only for maintenance.

- The boiler safety valves nº 01 were without seals and the pressure regulating

springs of the valves, also, were more compressed than those of the boiler nº 02,

thus, making adjustments, that alter the value opening and closing of the respective

valves.

Boiler # 1 Boiler # 2

Figure 16 - Springs of the PSV # 1 Figure 17 - Springs of the PSV # 2

The hand-operated knuckles of boiler safety valves # 01 were loose. If manual

actuation of these valves were necessary, it would not be possible to open the valves.

Figure 18 - loose handles of the boiler PSV nr 1.

- The safety valves PSV1 and PSV2 were fully compressed PSV springs and were

not operating under the conditions established by the project, around 9 bar. The valve

Handles of

Boiler # 1

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opening occurred at pressures above the PMTA. Thus, it is verified that the PSV valves

were fully closed blocking the steam relief.

- As a result of the explosion:

a) Boiler burner # 1 broke from the boiler and was flung to the control panels of the

boilers.

Figure 19 - Situation of boiler #1 burner

Boiler # 2 Burner Boiler # 1 Burner

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a) The floor of the furnace gave way to the floor of the compartment, which is

below the boiler, and thus opened a passage of escape of air and steam into the boiler

room.

Figure 20 - Furnace floor at bottom of boiler

b) The lower base of some tubes in the tubular bundle (the boiler feed tubes),

through which the combustion gases pass, deformed by opening a water / steam

passageway into the furnace. This liquid under pressure at a temperature above 150

degrees became saturated steam (when the water is heated to the boiling point and then

vaporized with additional heat) and expelled by the passages in the bottom floor of the

boiler and also by the opening, coming from the space of the burner, reaching the victims

that were inside the boiler compartment.

Local por onde o

vapor escapou para

o compartimento

das caldeiras.

.

Furnace Floor

Place where the steam

escaped into the

boiler compartment

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Figure 21-Bottom base of tubular bundle tubes

Tubular bundle

Lower base of

the bundle tubes

Furnace

space

Inner wall of the clean furnace, in the face

of washing carried out by the steam / water

expelled by the opening of the base of the

tubular bundle (usually soot is present).

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Figure 22 - bottom of the boiler - photo courtesy of Odebrecht Oil & Gas.

c) Regarding the management and planning for this type of activity, the following

items are observed:

- For work on the boilers, on 08 and 09 June, Work Permit (PT) were not issued,

as foreseen in procedure MB-QSHE-PR-024, item 3.4.

- For the boiler service, on 08 and 09 June, the Preliminary Risks and Impacts

Analyzes (APRI), as foreseen in procedure MB-QHSE-PR-003, were not

performed and / or presented.

- For the boiler service, on 08 and 09 June, the Task Plans (PJP) were not

carried out and / or presented, as foreseen in procedure MB-QHSE-PR-009 and

task instruction N08-ENG- TI-005, item 3.1 (boiler ignition).

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d) In relation to the provisions of Regulatory Norm NR 13 - BOILERS AND

PRESSURE VESSELS, the following items were observed:

- Item 13.3.1 - It is a serious and imminent risk condition - RGI - failure to comply with any

item provided in this NR that may cause work-related accident or illness, with serious

injury to the worker's physical integrity, especially: c) blocking of boiler safety devices,

pressure vessels and pipes, without due technical justification based on codes, standards

or formal procedures for operating the equipment.

- Item 13.3.2 - For the purpose of this NR, it is considered Qualified Professional

(PH) who has legal competence to exercise the profession of engineer in the activities

related to construction project, monitoring of operation and maintenance, inspection and

supervision of boiler inspection, pressure vessels and pipes, in accordance with the

professional regulations in force in the country. There was no PH during the inspection of

the boiler.

- Item 13.3.3 All repairs or alterations to equipment covered by this NR must

comply with the respective design and post-construction codes and the manufacturer's

instructions with regard to:

* materials;

* enforcement procedures;

* quality control procedures;

* qualification and certification of personnel.

The intervention that took place in the water / steam chamber painting was not

recorded in the boiler book.

- Item 13.3.5 Employer shall ensure that examinations and tests on boilers,

pressure vessels and pipelines are performed safely for their performers and other

workers involved. Work Permit (PT) was not opened to perform the service.

- Item 13.4.1.3 Boilers shall be fitted with the following items: safety valve, with set

pressure set to an amount equal to or lower than PMTA (Maximum Permissible Working

Pressure), considering design code requirements for stepped openings and tolerances

calibration. The safety valves were set at pressures higher than PMTA.

- Item 13.4.3.2.1 Provisional inhibition of instruments and controls is permitted

provided that operational safety is maintained and that it is provided for in the formal

operation and maintenance procedures, or with a documented justification, with prior

technical analysis and respective contingency measures for risk mitigation prepared by

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the technician responsible for the process, with the consent of the PH. Boiler control

equipment was inhibited without PH approval.

- Item 13.4.4.8 Safety valves installed in boilers shall be inspected periodically as

follows:

(a) at least 1 (one) time per month, by manually operating the lever, for category B

boilers, excluding boilers which vaporize thermal fluid and those working with treated

water as specified in item 13.4.3.3; and

e) Flanged or threaded valves shall be disassembled, inspected and bench tested

and, in the case of welded valves, shall be tested in the field at a frequency compatible

with their operating history and shall be set as maximum limits for such activities the

inspection periods established in items 13.4.4.4 and 13.4.4.5. Safety valves shall be

bench calibrated and sealed.

XII - PRELIMINARY LESSONS LEARNED AND CONCLUSIONS

From the analysis of the facts of the boiler explosion No 1 of the “ NORBE VIII” the

following preliminary lessons were extracted:

a) Adjustment of safety valves - Boiler safety valves shall be set on benches with

their relief pressures, below the Max. Admissible Working Pressure (PMTA) and sealed

prior to the tests in the boiler.

b) Safety valves installed in boilers shall be periodically inspected as follows: at

least 1 (one) time per month by manually operating the lever for Category B boilers.

c) Regarding the internal treatment of the boiler, it is due to:

- When operating - keep the feed water level in the normal position, near the

middle;

- When not in operation - keep the chamber level full with the sigh open.

d) The vapor pressure information from the pressure transmitter on the outside of

the boiler did not correctly indicate the pressure value, depending on the closed condition

of the pressure-relief valves # 6 and 7, located on the top of the boiler. They should be

checked before of boiler tests, all the control mechanisms regarding the situation of

opening and closing conditions.

e) Provisional inhibition of the instruments and controls is allowed provided that

operational safety is maintained and that it is provided for in the formal operation and

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maintenance procedures, or with a documented justification, with prior technical analysis

and respective contingency measures for risk mitigation, elaborated by the technical

responsible of the process, with the consent of the PH. Boiler control equipment was

inhibited without PH approval.

f) Failure to carry out the Task Schedules (PJP), as provided in procedure MB-

QHSE-PR-009 (ODEBRECHT) and task instruction N08-ENG-TI-005, item 3.1 (boiler - it

was possible to identify possible faults during the boiler ignition).

In light of the findings, it is concluded that the cause of the on-screen accident, with

subsequent victims, was the inadequate operation for testing the boiler # 01, where two

blocked safety valves were identified (which did not allow the relief and two closed

pressure relief valves, thus not allowing the pressure transducers to report actual vapor

pressure. Together, there was a lack of management and planning for this type of activity,

that is to say, operation and maintenance in a boiler. Thus, without actual pressure

information and without the possibility of pressure relief, the boiler continued to operate,

increasing its pressure beyond the PMTA until the internal explosion occurred at 07:25

a.m. on the day of the accident.

XIII - SAFETY RECOMMENDATIONS

a) It is necessary the commitment of the operating companies and contractors in

maintaining the principles of platform security management.

b) Platform management needs to be clearly and properly exercised. It is

necessary that the function passages allow the transmission of all the information related

to the operations in progress, in order to guarantee the continuity of the control of the

planned actions.

c) It is necessary that the task executor request the person in charge of the area to

issue the Work Permit (PT) before starting the execution of the activity.

d) It is necessary to assess the risks before starting maintenance activities.

e) Disregarding safety recommendations for boiler maintenance and operation can lead to

devastating consequences for the vessel and for board lives.

f) Boiler inspections shall be provided with a training program in order to keep their

operators up to date on the relevant technical knowledge and in a manner that is capable

of assessing the consequences of failures during boiler ignition.

g) It is essential to have the Personnel Enabled (PH) during the inspection of the

boiler.

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XIV) ANNEX

SHIP`S PARTICULARS

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SHIP`S PARTICULARS