Lysbilde 1

1
Normal All training to be done by qualified
personnel appointed by the line management
New All personnel who have received training can
be used as instructors
Non-conformity
5.2.1
October 2002 West Epsilon (WE) starts the
assignment on Valhall Flank South (VFS)
Natoil is the supplier of SIMOPS cranes to
Valhall Flank North (VFN) order of 8 November
2002
August 2002 After start-up on VFS, the employees
were given location and crane specific training
on the SIMOPS crane by personnel from Natoil
Cause and event analysis
BP requires Smedvig to install so-called dropped
object hatches on the BOP deck

After this the training is communicated from
person to person
Heerema (Tønsberg) was the main contractor for
BP.
Design and production of hatches and beams was
carried out by Bjørge Offshore in Stavanger. The
facility was carried out in Rotterdam
In the order it is specified that the SIMOPS
crane must be identical to the one on VFS.

The anti-collision system was an option in the
order (spec.6.5)


Barrier failure
Instructor with inadequate competence (inadequate
training programme) Training from person to
person is inadequate. Activities Regulations
Section 19 relating to competence. The HSE
directive 26, section 6.11.4
2
Normal The FMEA should be a documentation of the
effect of failure modes on the operation of the
crane including safety system
New The anti-collision system of the crane is
not part of the analysis
Non-conformity
New FAT didnot comprise checking of the
anti-collision system.
5.2.2
Normal All safety systems must be a part of the
FAT programme
5.2.3
The mechanical completion check list made by
Natoil 11 April 2003 includes check of
mechanical completion for limit switches boom
up and telescope out.
The anti-collision system was back-ordered for
the SIMOPS cranes for VFN and VFS 12 December
2002. Executed as part of crane delivery for VFN
FAT (Factory Acceptance Test) was carried out 10
April 2003
FMEA completed 23 January 2003, as built 25 April
2003
Cause and event analysis


Barrier failure
Inadequate inspection under FAT (inadequate test
programme) FAT lacks a description of the
anti-collision system, lack of testing and
documentation of the system was not
discovered. Activities Regulations Section 14
relating to facility and commissioning, ref.
Machinery Regulations Section 7, attachment 1,
subsection 4.2.4 inspection before use.
Deficiencies in FMEA (inadequate safety
analysis) Management Regulations Section 13
regarding general requirements to analyses,
Activities Regulations Section 43 relating to
classification, Machinery Regulations Section 7
ref. attachment 1
3
Normal Certificate of application in
accordance with AF Section 14 og NORSOK R003N
chapter 5.1
New Maritime (load test) certificate
Non-conformity
5.2.4
New Commissioning does not comprise the
anti-collision system
Normal All safety systems must be a part of the
test programme
5.2.5
Probably 30 May 2003
The documentFunctional Design Specification,
Crane dated 25 April 2003 mentions briefly that
the anti-collision system has been installed and
its mode of operation
Allum Marine as issues Certificate of application
in May 2003. This was done while the VFN
facility was at the building site in Tønsberg
Commissioning for the SIMOPS crane to be carried
out approx. 7 July 2003
Cause and event analysis

Certification carried out in accordance with the
requirements of the Maritime Directorates
regulations
The document describes the crane as built, and
was available on the computer system for
personnel on VFN.
The certificate does not mention testing of the
cranes safety systems, and no reference has been
made to criteria for the scope of the testing
nor acceptance criteria.

The certificate does not fulfil the requirements
of a Certificate of application


Barrier failure
Inadequate certification of application and
approval of the SIMOPS crane (insufficient
preparation for use) The crane does not have a
Certificate of application. Instead a load test
has been carried out with maritime
certification Activities Regulations Section 40
relating to use of work equipment, ref.
Regulation relating to use of work equipment
section 14, Inspection of work equipment The
Activities Regulation Section 44 relating to
Maintenance programme subsection f) ref. NORSOK
R-003 N subsection 6.1 BPs Guide for lifting
equipment document no 1.70.010 chapter 8.5.3
BPs HSE directive chapter 26 6.3
Inadequate inspection during commissioning
(inadequate procedures relating to change)
Missing description of the anti-collision system
was not discovered Activities Regulations
Section14 relating to completion The Machinery
Regulations Section 7, Attachment 1, subsection
4.2.4 Inspection prior to use
4
Normal RFO certification is a confirmation that
all systems have been checked and described in
the documentation
New It was not recorded that a description of
the anti-collision system was missing from the
operating manual
Non-conformity
5.2.6
WE arrives on VFN approx 4 - 6 August 2003
Take-over from project to operation RFOC (ready
for operation certificate) form was prepared 6
August 2003
Consent to use VFN was given 14 July 2003
Hook up starts approx. 4 august

RFOC shall provide an overview of outstanding
work on the SIMOPS crane
Cause and event analysis

No records concerning faults of the
anti-collision system in the RFO
Documentation of maintenance and operation
inclduing the SIMOPS crane must be a part of the
take-over documentation

The RFOC check list describes Operational Manual
available in Dokumentum, i.e. the operations
manual is available in an electronic database


Barrier failure
Deficiencies when taking over from project to
operation, RFOC (inadequate change procedures)
Missing documentation for the anti-collision
system was not discovered during the take-over
from project to operation. Activities Regulations
Section 14 relating to installation and
commissioning The Machinery Regulations Section
7, Attachment 1, subsection 4.2.4 Inspection
prior to use Activities Regulations Section 18
Start-up and operation of facilities
5
New The SIMOPS crane is operated while a switch
is defective
New Certificate/Certificate of application
cannot be produced until three weeks after the
incident
Normal The lifting equipment must never be
operated when parts of the safety system are
inoperable
Normal The Certificate of application must be
easily accessible on the facility
Non-conformity
5.2.8
5.2.7
Natoil was out 14 August 2003. The proximity
switch (boom angle limit switch) was damaged
during work on the window washer system on the
SIMOPS crane
BP has now started using the SIMOPS crane on
VFN. No Certificate of application exists on the
facility
BP cannot produce Certificate of application for
the SIMOPS crane until 21 April 2004
Cause and event analysis
Natoil replaces the proximity switch. Closed 10
September 2003 (The report has been erroneously
dated to 9 October.)
No documentation of function testing after the
repair work
During the period 1-10 September 2003, the crane
was in daily use, ref. form for daily check of
SIMOPS crane on VFN. This in spite of the fact
that the switch was inoperable.

Barrier failure
Insufficient documentation (document missing)
Certificate of application is not available on
the facility. BP did not know if a Certification
of application existed. Activities Regulations
Section 14 relating to facility and
commissioning ref. NORSOK R-003 N subsection
5.1.1.2 BPs Manual for lifting equipment
subsection 8.3 relating to files offshore
The SIMOPS crane is operated while the limit
switch is defective (non-conformity with
procedure) Regulations relating to use of
working equipment Section 15 subsection c)
working equipment which could involve special
danger in use Inadequate testing This is work on
the safety system, and consequently it should be
documented Activities Regulations Section 28
relating to Actions during conduct of activities,
ref. NORSOK R-003 N subsection 6.1 Activities
Regulations Section 83 relating to lifting
operations ref. NORSOK R-003 N subsection 5.5.6
6
New Documentation from the crane supplier is not
available on the facility
Normal Adequate user documentation must be
available in the crane manual
Non-conformity
5.2.9
Basic crane operator training. The relevant
personnel have completed the basic requirements
for operating a 20 tonne hydraulic crane
BP has now started to use the SIMOPS crane on
VFN. Documentation is missing from the crane
manual.
Cause and event analysis

• Documentation from the crane supplier is not
  available on the facility, or it is inadequate
• maintenance procedures- description of
  anti-collision system- operating instructions

General crane operator training is required to
operate a SIMOPS crane, (Minimum G20)
User manual (crane handbook) is insufficient


Barrier failure
Missing /inadequate documentation for the SIMOPS
crane Documentation for the SIMOPS crane is
non-existent or not available to the user.
Activities Regulations Section18 relating to
start-up and operation of facilities Activities
Regulations Section 14 relating to facility and
commissioning ref. NORSOK R-003 N subsection
5.1.2.1. (crane handbook must be
available) Activities Regulations Section 83
relating to lifting operations NORSOK R-003 N
subsection 4.1 f) Lifting equipment manual
subsection 8.3 relating to files offshore.
7
New Location-specific training has not been
provided for the SIMOPS crane with the equipment
on VFN
Normal Competence requirements include basic
training and location-specific training for the
crane to be operated
Non-conformity
New BP has not verified the location and
crane-specific expertise
Normal BP checks and ensures that training is in
accordance with requirements
5.2.10
5.2.11
Crane- and location-specific training. The crane
training from VFS was carried on to VFN by
having a crane operator who had already been
cleared act as an instructor for the new crane
operator.
Cause and event analysis

Through the supervisor the field manager is
responsible for implementing training on the
SIMOPS crane, ref. HSE directive 26
Demands will be made on safeguarding competence.
This entails making demands on, verifying and
maintaining this competence through exercise,
drills, training and education
Personnel on VFN and WE have no knowledge of the
anti-collision system and its operation

Barrier failure
Inadequate inspection of requirements for crane-
and location-specific training (insufficient QA
programme) BP has not verified the training. No
training has been carried out on the
anti-collision systems, as the training material
does not contain any description of
it. Activities Regulations Section 19 relating to
competence, ref NORSOK R-003 N subsection 4.5.1
relating to training of operators.
Crane- and location-specific skills were
inadequate (insufficient competence) Crane
operators do not have knowledge of the
anti-collision system. Activities Regulations
Section 19 relating to competence, ref. NORSOK
R-003 N subsection 4.5.1 relating to training of
operators. Activities Regulations Section 40
relating to use of work equipment, ref.
Regulations relating to use of work equipment,
Section 10 relating to training, drills and
instruction of employees.
8
New No handling of non-conformity
Normal Handling of non-conformity in BP
Non-conformity
5.2.13
New Planned work on safety system defined as
non-critical
Normal Work on safety system is evaluated with
high criticality
5.2.12
Approx. 17-19 February 2004 Natoil repairs wire
on limit switch for telescope out
At the turn of the year 2003/2004, a defect in
the limit switch for telescope out was discovered
Subsequent facility of anti-collision system on
VFS 25 October 2003
Cause and event analysis
Natoil also establishes a defect in the limit
switch for boom angle and hook up

4 January 2004 Work order (KAO-032703) for wire
for limit switch on telescope is broken replace
wire and limit switch if necessary
BP stopped operation of the crane owing to lack
of parts
19 February 2004. Natoil reports that there is no
documentation for electricity and hydraulics for
the SIMOPS crane

Natoil is requisitioned to repair the defect


Barrier failure
Inadequate handling of non-conformities
(insufficient QA programme) Management
Regulations Section 20 relating to handling of
non-conformities
Inadequate risk assessment during the planning of
work on safety systems. (The potential risk is
not understood)The work is defined as
non-critical. Activities Regulations Section 43
relating to classification and 45 relating to
planning and priorities.
9
Normal Work on safety equipment must be carried
out or checked by competent personnel
New No inspection by competent personnel (expert
activity)
Non-conformities
5.2.14
21 February 2004. A work order is established in
Work Mate for repair of the anti-collision system
24 February 2004 Parts for the two other limit
switches arrive at VFN/BP
Cause and event analysis

Work order for replacement of boom angle limit
switch XS440 (KAO-033708) Defective boom angle
limit switch replaced. The function is tested
after facility and connection

Work order for replacement of upper hook limit
switch (KAO-033706) Limit switch is
defective/broken. The function is tested after
facility and connection.

Barrier failure
Inadequate planning of work on safety system
(insufficient planning) Work on safety systems
is planned with personnel without the necessary
expertise and without the necessary drawings. No
planned verification by expert body. Activities
Regulations Section 44 relating to maintenance
programme subsection f) ref. NORSOK R-003 N
subsection. 6. Inspection, examination and
testing subsection 6.1 Activities Regulations
Section 43 relating to classification and 45,
planning and prioritisation, Activities
Regulations Section 40 relating to work
equipment, ref. regulation relating to use of
work equipment Section 14 inspection of work
equipment.
10
Normal Drawings available for work to be done
New Drawings missing
New Work on safety system without inspection by
expert
Non-conformities
Normal Work on safety system to be checked by
expert
5.2.15
5.2.16
27 February 2004 Automation expert from Valhall
(SWAT) replaces boom angle limit switch on
SIMOPS crane VFN
26 February 2004 Automation expert connected to
Valhall (SWAT) replaces hook up limit switch
on SIMOPS crane VFN
Cause and event analysis
According to interviews the switches are
installed in the same way as the ones removed -
the automation expert makes a sketch before
replacing them
On request the automation expert feels competent
to replace the switches
The automation expert has no experience with work
on cranes

Work on safety systems was carried out by
personnel without the necessary skills
(insufficient competence) Activities Regulations
Section 19 Competence Activities Regulations
Section 40 relating to Use of work equipment
,ref. regulation relating to use of work
equipment, Section 9 Information to employees,
10 Training, drill and instructions to employees
and 14 inspection of work equipment BPs manual
for lifting equipment Section 9.5 (i.e.
requirements related to use of competent
controller)
Barrier failure
Work on safety systems with the necessary
technical Documentation (Documentation
missing) Activities Regulations Section 28
relating to Action during conduct of activities.
The Machinery regulations, attachment 1
subsection 1.7.4 og subsection 4.4.2. Activities
Regulations Section 40 relating to Use of work
equipment, ref. regulation relating to use of
work equipment Section 9, Information to employees
11
New The fact that the cranes safety system was
inoperable was not known
Normal Status of the cranes safety system must
be known
Non-conformities
5.1.1
After the repair the limit switch for the boom
angle was installed with incorrect polarity. It
is not known whether it was installed incorrectly
prior to the repair
Cause and event analysis
30 December 2003 Loose cable tray at the top of
boom
Faulty facility means that the limit switch is
disconnected
20 February 2004 Motor for window cleaner
inoperable
The SIMOPS crane does not have a functioning
anti-collision system
19 February 2004 Repair of loop on hook
block??. (carried out by Natoil)

Barrier failure
Certain parts of the cranes safety system do not
function. Status unknown (insufficient
preparation before use) Lifting appliances must
never be operated if the safety systems or parts
of the safety systems are out of
order. Activities Regulations Section 24 relating
to safety systems Activities Regulations Section
83 relating to lifting operation, ref. NORSOK
R-003 N subsection 5.5.6 relating to safe use of
lifting equipment
12
New The crane operator has limited knowledge of
the cranes condition/ status of corrective
maintenance
Non-conformities
Normal The crane operator is familiar with the
cranes condition before use
5.2.17
Schlumberger is on downtime owing to equipment
fault
Cause and event analysis

Approx. 0115 Overall supervisor Schlumberger has
been on duty for 16 hours and cannot assist in
the work relating to troubleshooting on this
equipment
Repairs are not recorded in the maintenance
system, only in the daily inspection form for
the crane There were, e.g. multiple faults in the
window shield wipers/washers during the period
Nov/Dec 2003 og March 2004.


Barrier failure
Lacking/insufficient access to the maintenance
system (insufficient work preparation/basis for
work). The crane operator on the SIMOPS crane
does not have access to the maintenance system.
Activities Regulations Section 23, Use of
facilities (relating to status of
maintenance) Activities Regulations Section 14 ,
Installation and commissioning, Ref. NORSOK
R-003 N subsection 5.1.2.1 (requirements
regarding available documentation) Activities
Regulations Section 83, Lifting operations, ref.
NORSOK R-003 N subsection 4.5.2.1 follow-up of
maintenance. Activities Regulations Section 24,
Safety systems. BPs HSE directive 26, chapter
6.3.
13
Non-conformities
New Only objects falling from the top deck to
the Xmas tree deck were evaluated in SAS
Normal Falling objects from WE should have been
a part of the risk assessment
5.2.18
BP Well intervention supervisor (WIS) night
shift, decides to use Sclumberger personnel to
assist ABB in the work on well N14.
Safe work review (SAG) is initiated by
Sclumbergers personnel and implemented by the
involved.
Work permit prepared and approved
Cause and event analysis

The personnel have experience from WP and Maersk
Guardian, where they also bumped into" the
hatches on the deck of MG above
Schlumberger personnel usually operate the
SIMOPS crane, ref contract with BP subsection
5.8.1
Since the crane operator is unfamiliar with the
anti-collision system, he should initiate
measures to prevent collision with WE
BP has not identified risk in the operation of
the crane when the anti-collision system is out
of order


Barrier failure
The danger of the crane touching the hatches on
the BOP deck was not assessed in SAG
(insufficient experience transfer / risk was not
assessed) Despite previous experience, collision
with WE is not considered a risk. Compensatory
action is not implemented Management Regulations
Section 22, Improvement (Experience
transfer) Activities Regulations, Section 83,
Lifting operations, ref. NORSOK R-003 N
subsection 4.1Activities Regulations, Section
28, Actions during conduct of activities
(planning of work) Activities Regulations,
Section 40, Use of work equipment, ref.
regulation relating to use of all types of work
equipment and Section 7 relating to the
employers general obligations and Section 43
regarding use of all types of working equipment
14
Normal Check list for safety systems
New The check list is insufficient
New Lifting operation carried out without the
necessary visibility
Normal Good visibility to the work area for the
crane
5.2.19
Non-conformities
Normal Operator/user of the lifting appliance
has an independent responsibility to ensure that
the lifting appliance is in proper condition
New inspection prior to use is limited to
inspection of the oil level and visual inspection
5.2.20
5.1.2
There is no inspection of the crane before use
(inspection prior to use).
The crane operator initiates cleaning of window
in the operators cab owing to poor visibility.
The skylight is not cleaned.
Form prepared by BP for daily checks does not
describe inspection of safety systems
Cause and event analysis
The crane operator does not have access to the
maintenance system, and consequently not status
for the SIMOPS crane

Flagman fetches a high-pressure washer and washes
the side windows of the operators cab.
No inspection of the anti-collision system. The
crane operator is unfamiliar with the operation
of the system (not referred to in the crane
manual), and has not had training in the system

No cleaning because this would require work
permit for working at heights.
No check of the safety system. No check of status
for maintenance. No function testing.

5.2.19 Inadequate procedure for daily check of
the SIMOPS crane (insufficient procedure)
Activities Regulations Section 22, Procedures.
BPs HSE directive 26 subsection
6.1.5 Activities Regulations Section 40, Use of
work equipment, ref. regulation relating to use
of work equipment, Section 14 relating to
inspection of work equipment. 5.1.2 Inadequate
inspection prior to use of the lifting appliance
(insufficient preparation) Activities
Regulations Section 83, Lifting operations ref.
NORSOK R-003 N subsection 5.5 .6 relating to safe
use of lifting appliances Activities Regulations
Section 19, Competence, ref. NORSOK R-003 N
subsection 4.5.2.1
Barrier failure
Poor visibility through the roof window (emphasis
on time not safety)Cleaning is omitted because
it would require work permit for working at
heights. Therefore, a choice was made to work
with poor visibility through the roof
window. Activities Regulations Section 31,
Arrangement of work, Section 32, Ergonomic
aspects and the Facilities Regulations Section
19 relating to ergonomic design Activities
Regulations Section 28, Actions during conduct of
activities and 29, Monitoring and control
15
New Flagman carries out the work of the crane
chaser directing the load not following the
movements of the crane.
Normal Flagman directs safe movement of crane
and hook load
Non-conformities
5.2.21
On the top deck work starts on re-installing the
well hatch.
Operation on well N14 starts. Well hatch is
lifted off and put on N2
The roles of crane chaser and flagman mixed
during the lift.

Cause and event analysis

Flagman holds the guide rope fixed to the well
hatch
As per agreement in SAG meeting, a crane
chaser, flagman and crane operator are directly
involved in the lifting operation.
Flagman does not pay attention to the boom top
Flagman and crane chaser put on vests
Flagman shoves the well hatch to position it over
the hole.
Flagman uses lifeline


Barrier failure
Manning level during operation is not according
to procedure (non-conformity with procedure) The
jobs of the crane chaser and the flagman are
mixed Activities Regulations Section 83, Lifting
operations, NORSOK R-003 N subsection
4.5.2.2 BPs HSE directive no. 26 chapter 6.1.6-7
clearly states the responsibilities and
obligations of crane chaser and flagman
16
Normal The crane must not be driven into
obstructions (obstacles)
New The crane operator has no inspection with
the position of the boom
Non-conformities
New Dropped object hatches were not fastened
according to procedure
Normal Procedure for fastening is followed
5.1.4
The crane operator extends the telescope to reach
N14 with the well hatch. The boom is run into the
deck of WE
The boom lifts the dropped object hatch on WE
from its fastening
2 April 2004 approx. at 0615 the dropped
object hatch from WE falls 14.9 m straight
towards VFN
Cause and event analysis
The crane operator has to lean forward during the
lift to get a better view
Hatches are not fastened according to procedures
Could have lowered the boom (two operations).
Chose to extend the telescope (one operation)
Smedvigs procedure states requirements for work
with this hatch. The procedure describes how it
is to be fastened with chains and shackles to
beams


Barrier failure
Smedvig had not made sure the dropped object
hatches were fastened according to procedures
(non-conformity from procedure) Activities
Regulations Section 22, Procedures Procedure
WE-02-06-05,14 incl. facility and maintenance
instruction. PBO-8250081-P-04
Inadequate inspection of the position of the boom
(insufficient self-monitoring to avoid
errors) Compensatory actions to maintain
inspection with the boom top were not
initiated Activities Regulations Section 19,
Competence, ref. NORSOK R-003 N subsection
4.5.2.1 and 4.1.h) BPs HSE directive 26,
subsection 6.7
17
New Crane operation leaves the crane with load
hanging from the hook.
Non-conformity
Normal Crane operator must not leave the crane
with load hanging from the hook.
5.2.22
The flagman is hit and injured in his right foot
and face/jaw
The crane operator, work supervisor from
Schlumberger and BPs WIS rush up to help the
injured flagman
Notification of SAR and emergency preparedness
on WE works
The well hatch starts to swing approx. 1.5 m
above the deck

Cause and event analysis
Nurse and OIM on WE are notified

The dropped object hatch hits both the flagman
and the well hatch when falling

The crane chaser comes running up from the Xmas
tree deck

SAR from Ekofisk field centre is requisitioned
The well hatch is considered a hazard, and is set
down by crane chaser when he arrives
The injured is transported onshore after
receiving first aid treatment
The remaining hatches on WE are secured


Barrier failure
Inadequate securing of load (non-conformity from
procedure) Activities Regulations Section 83,
Lifting operations, ref. NORSOK R-003 N
subsection 5.5.13. BPs HSE directive 26 chapter
6.5.1.
18
Non-conformity
2 April 2004. Approx. at 1700 Investigation
group from the PSA/Police and BP arrive on VFN
Natoil is requisitioned to go to VFN to assess
the SIMOPS crane, and to find out if there is an
electronic log in the crane. Arrival 4 April 2004
2 April 2004 The authorities are notified. The
PSA is notified at 0718
The accident area is secured
Cause and event analysis
There is no electronic log in this type of crane
In the notification the dropped object hatch
which fell down was reported to weigh 100 kgs,
but it turned out to be 357 kgs.


Barrier failure
19
Non-conformities
Faults are established in the facility of limit
switch for boom up. Limit switch is damaged
It is established that the limit switch for hook
up is broken off.
21 April 2004 PSAs investigation group receives
Maritime loading certificate for the SIMOPS
crane on VFN from BP
The PSA gives direct order prior to departure 5
April 2004
Cause and event analysis

This could have happened when the hatch fell down
The order entails temporary termination of work
with similar cranes
Natoil does not have parts to repair the two
limit switches


Barrier failure