Investigation Report - Petrobras 10000 Drillship fatality 2 Dec, 2017


( The Bureau of Safety and Environmental Enforcement (BSEE) issued the report of its Panel Investigation, conducted in cooperation with the US Coast Guard, into the 2 December 2017 fatality aboard the Petrobras 10000 drillship working in the Walker Ridge 469 area of the Gulf of Mexico, about 240 miles southwest of New Orleans. The purpose of this investigation was to identify the cause, or causes, of the fatality on the PBS 10k and issue recommendations to assist in preventing a similar incident from occurring. The BSEE report also includes recommendations on how to strengthen implementation of existing safety and environmental management systems and necessary reforms to existing regulations.

The panel concludes this incident occurred due to the following causal factors:

  • Victim was in a hazardous location and not facing the skate operations while the PHCM skate was being mobilized.
  • Failure of crew to identify hazard and stop job when coworkers were not in safe location. Drill floor personnel failed to follow and enforce the Line of Fire and Unsafe Positioning safety rules of the rig.
  • Failure to safely operate the PHCM skate.
  • Lack of understanding and/or regard for the drill floor zone areas during operations.
  • Failure to officially identify and mitigate the stanchion post Pinch Point hazard area.
  • Failure to update and follow the Controlled Procedure.

In addition, the panel identified the following contributing factors:

  • Complacency and fatigue resulting from a repetitious job while over ten hours into their first shift of the hitch.
  • Lack of training, familiarity, and experience with the equipment on this drillship.
  • Incomplete in training requirements to perform operations.

To strengthen implementations of existing safety and environmental management systems, the panel makes the following recommendations:

  • Ensure management effectively verifies all personnel adhere to drill floor safety rules.
  • Formalize equipment operations to reemphasize the awareness of personnel before equipment is put in motion.
  • Ensure employees receive effective operational equipment training.
  • Ensure all Control Procedures are operationally correct.
  • Ensure all personnel adhere to the Controlled Procedures. The Controlled Procedures must account for all movement of the PHCM skate.
  • Ensure personnel are trained on rig access zone diagrams.
  • Investigate and implement proximity technology if suitable.

For more details, click below to download full report:

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Source: BSEE


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