BSEE Releases Investigation Into Fatal Offshore Incident
The Bureau of Safety and Environmental Enforcement (BSEE) released the report of the panel investigation into the October 27, 2013 incident on the Talos Energy, LLC owned "A" Platform of Vermillion Block 200, that resulted in the tragic death of Peter Jorge Voces.
On October 27, 2013, a fatal incident occurred on the “A” Platform, of Vermilion Block 200, Lease number OCS-G 9500. This location is approximately 53 miles south of Lake Charles, Louisiana in the Gulf of Mexico.
At approximately 7:05 p.m., a 130 ton dry oil storage tank skid assembly, consisting of one (1) 16 feet diameter x 85 feet long horizontal cylindrical tank and two (2) 83 feet long flare booms mounted to and extending away from the skid at a 17-degree angle, toppled over and fell 115 feet into the Gulf of Mexico from the Vermilion Block 200 Platform “A”. A welder, working for Offshore Specialty Fabricators, LLC (OSF) and performing preliminary welding cuts, was standing on the walkway attached to the top of the cylindrical tank when the skid assembly toppled overboard. The dry oil storage tank skid assembly, along with the welder, sank within minutes. Despite man overboard procedures and a concerted search effort, the welder was not rescued. After 2 days of surface and undersea searching, divers located and recovered the body of the welder.
Vermilion Block 200 Platform “A” is owned by Talos Energy, LLC (formerly Energy Resources Technology or ERT). Talos/ERT had contracted with OSF to decommission and remove the platform. Following a bid process, OSF was awarded the work as a ”lump sum” contract, based on their previous work history with Talos/ERT, the availability of a large derrick barge (DB) William Kallop which provided the desired operating flexibility, and price. The contract specified that OSF was to be responsible for managing and carrying out all tasks associated with this job including the planning, preparation and ultimate dismantling of Vermilion Block 200 Platform “A”. A SEMS Bridging Agreement between Talos/ERT and OSF outlined the respective expectations and responsibilities for safety policies and procedures, work practices and ultimate safety performance for this job.
The OSF Barge Superintendent was in charge of all platform removal activities, including the sequencing of activities and any decisions related to the weather. Talos/ERT had one Onsite Representative on board, whose primary role was to monitor the work for compliance to the contract. The decommissioning crew of the DB William Kallop included personnel with various skill sets, one of which was welding. A primary work activity for a welder during the decommissioning/removal of a platform is to cut infrastructure components of the platform such as the piping, production skid supports, catwalks, and other structures into smaller “packages” prior to the lifts or removal by crane to the material barge. The sequence of the lifts is a critical component in the planning of the job and is largely determined by engineering assessments of the size, weight, and configuration of the “packages”, the DB crane capacity, and material barge size.
The lift sequence for removal of Vermilion Block 200 Platform “A” was identified in the Work Plan developed by the OSF Project Manager and reviewed by the Talos/ERT Platform Removal Engineer.
Upon the arrival of the DB William Kallop to the Vermilion Block 200 Platform “A” location on October 26, 2013, the OSF Barge Superintendent, with the support of the Talos/ERT Onsite Representative, delayed the planned heavy lifts using the DB William Kallop’s large crane due to weather and sea conditions. Until such time as the weather conditions improved, the work crews were assigned to preparation work, also known as “prep” work. This “prep” work consisted of the cutting away of the welded mount plates to equipment skid assemblies, under the standing instruction that the cutting each of the welds was not to exceed “50%”. The DB William Kallop and its crew had been moored adjacent to the Vermilion Block 200 Platform “A” and had been carrying out their fell into the water.
The Bureau of Safety and Environmental Enforcement (BSEE) conducted a panel investigation into the death of the OSF welder and the causal factors that led to the incident. The panel consisted of professionals from both BSEE and the United States Coast Guard (USCG). The panel identified key failures that led to the death of the OSF welder. These included:
The lack of recognition that “prep” work should have been integrated directly with the planned steps for the removal of the platform.
Lack of consistent communication to and understanding by workers of what “cutting 50%” meant.
Inadequate recognition and implementation of the Safety and Environmental Management System (SEMS) elements outlined in the SEMS Bridging Agreement between Talos/ERT and OSF:
o Weak management oversight, tracking, and documentation of “prep” work (Management Oversight)
o No recognition that the decisions that resulted due to the weather should have triggered application of the company’s change management procedures. (Management of Change (MOC))
o Failure to stop work and assess the situation after an unexpected “pop” was heard and movement of the skid assembly occurred. (Stop Work Authority, Hazard Recognition/Risk Assessment)
o Failure to stop work, communicate and assess the situation when work practices began to deviate from work instructions (MOC, Hazard Recognition, Management Oversight)
o No recognition of the potential risks posed by the smaller package lifts or that the platform history and change in configuration from “as designed” required some level of review by a qualified engineer. The engineering/planning focus was only on the lifts associated with the platform’s superstructure and jacket. (Risk Assessment and Hazard Identification)
o Failure to follow OSF’s SEMS policies and procedures as written (Safe Work Practices)
The Talos/ERT Onsite Representative was focused on OSF’s compliance to the contract. Compliance to the SEMS Bridging Agreement was not considered.
Based on the Panel’s interviews with Talos/ERT and OSF personnel and contractors and on the document review, the Panel investigation yielded a number of recommendations aimed at improving the safety of offshore platform decommissioning and removal. In addition, the Panel recognized three recurring themes throughout this investigation which can broadly apply to all OCS oil and gas safety programs and practices. The Panel recommends that all OCS lease holders and their contractors:
incorporate seemingly routine activities including the preparation work into the overall project planning, implementation and oversight.
confirm a common understanding of the expectations, hazards, and safety procedures when communicating job assignments.
enable and enforce a safety culture where work practices reflect the written policies, procedures, and SEMS elements; and, where written policies and procedures reflect realistic work scenarios and mitigation steps.
The Panel has also identified several recommendations for the Bureau of Safety and Enforcement to consider:
The Bureau should consider allocating additional resources to perform inspections of platform during abandonment, and/or decommissioning operations.
SEMS audits should include verifying the expectations included in a SEMS bridging document or agreements per 30 CFR 250.1914 are actually being followed and enforced by both the operator and contractor.
The full report, complete with recommendations and memo from BSEE Director Brian Salerno, is available here.