Petrobras Platform 36 
Management
Organization
People
Procedure Malfunctions
Maintenance
Management
Operating
Project design
Second Explosion
Ineffective communication system
Inefficient consultation
No coordination with emergency response team
No coordination with the platform command
After Explosion
Stability box left open
Man holes to aft star board ballast tank
No proper actions taken to stop the flooding
Continuous submersion of the platform
After Explosion
Flooding of the column and pontoon
Failure within the ventilation system
Two seawater pumps were out of operation
After Explosion
Insufficient personnel capability within emergency procedures and stability control
First Explosion
Lack of quality within the area of drained storage tanks
Designed drain tanks indoor and closed the support for sea water pipe used to help extinguish the fire created
Major reason to the disaster
Sea firefighters presented a risk of flooding
1,723 alarms were put of within 17 minutes of the incident
No system placed for alarm entry and operation
System Failures
Component Failures
Engineering Failures
Air pressure was very high within the pipe
Designed to be supported by the buoyancy of two pontoons and four support columns
Oil workers had lack of training within emergency situation
Water wasn't sealed
Lack of training to deal with emergency stability and ballast between commission of inquiry and oil workers
Door wasn't closed
An emergency drain tank located in one of the columns was shutdown due to closure of valve
One of the emergency columns shutdown and isolated due to a closure of valve
The system was in a multi-functional failure
The valve components fail while opening
Due to high pressure the water pipe was removed and the valve was partially open
Flooding distance from sea became shorter
Failure within ventilation system
Design Failures
Incident Time
First explosion took place at 12:22am March 15, due to mechanical failure
Second intense explosion took place at 12:39am due to natural gas release
Drainage operation of the drain storage tank in the aft port column on 14 March 2001
There was an evacuation of 138 people at 1:44am March 15, lasting 2hr 30min
Main cause of the incident
Killing 11 people in charge of the emergency response
No life boats were used, only cranes and personal transfer basket
At 8:15am March 15 the platform was at 20 degrees and water level reached the aft starboard chain locker entry
The platform slowly submerged and sank at 11:41am March 20
Engineer
Employees
Fire-fighting team
175 people were on board
138 were able to evacuate using cranes
Remaining were able to evacuate by helicopter
11 workers were killed
System Parts
Nature of system
Personnel
Platform
Evacuation system
Mechanical system
Headquarters
Semi-public Brazilian company
Rio de Janeiro
No sufficient backup
Lack of training and consultation
Definition
The function is performed with little work and power is provided by machine, the user controls it
System Life Cycle
Maintenance
Construction
De-commissioning
Operating
Commissioning
Valve
Drain storage tank
Seawater service pip
Adjacent stability box
Supported by buoyancy of two pontoons and four support columns
Ventilation system
aft starboard ballast tank
Was left open
Failure of watertight dampers
Partially open
Did not consulate
Failed with roles and responsibilities
Lack of training within emergency response
Cranes
Life boats
Helicopter
Were no used
Manufacturing failure
Replaced by FPSO-Brasil
The ship had sunk
Approval
Testing
Serviced up to date
Regular water check in fuel
Materials
Manufactured by component and subassemblies parts
Bunkering
Engine room
High quality check
Engineering review
Active service
Oil checks
Check for cracks
Replacement for damaged parts
Insurance
Engineer reviews
Steel
Aluminum
Fiber-reinforced plastic
Polyethylene
Engineers
Mechanical function
Quality check
Testing on docks
Equipment and machinery
Achieve efficiency
Quality output
Functions
Launching procedure
Carrying oil and gas
Communicating system
High risk
Lack of engineering review on functions
Operating system on board