Petrobras Platform 36 images

Management main-1398

Organization

People

Procedure Malfunctions

Maintenance

Management

Operating

Project design Capture

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 valve

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 design

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