Dec 122010

Transocean Leader, key personnel did not understand the risk management system used onboard.

Deepwater Horizon owner Transocean has come under pressure from Norway’s Petroleum Safety Authority following an audit covering the company’s management of major accident risk and handling of barriers. In addition to some 14 non-conformities ranging from inappropriate headoffice directives to firefighting and lifesaving equipment the PSA found that manager were not familiar with the risk management methodology it recently introduced.

The four-day audit of the Transocean Leader facility, preceded by a one-day management meeting onshore

Transocean is  implementing a Bow-tie methodology which illustrate hazardous situations and probability-reducing barriers on one side, and consequence-reducing barriers following incidents on the other side of a diagram that resembles a bow-tie.

On the Transocean Leader facility, the PSA verified Transocean’s management and knowledge of major accident risk by reviewing two major accident scenarios in the form of ”table-top” exercises related to the facility’s defined hazard and accident situations.

Says PSA: “The audit activity was well-organised by Transocean”

Transocean’s main management defined which defined situations of hazards and accidents, DFUs, can primarily trigger major accidents. Currently there is not a complete overview of the operational and organisational barrier systems, and the company lacks a systematic approach in the area..

The implementation of the ”bow-tie” methodology is intended to maintain and visualise the connection between hazardous situations and barriers. PSA “views the methodology as a useful tool that has a good potential for practical application through further development in the company. The methodology has recently been introduced, and has not yet been prepared for all major accident scenarios.

“The PSA found little familiarity with the bow-tie methodology and little knowledge of how this methodology was supposed to be used among the personnel on board Transocean Leader. The PSA found varying degrees of knowledge and understanding of which DFUs have major accident potential. It was not clear to the audit team that training and exercises focused on major accident risk were awarded special attention”.

Six nonconformities and eight improvement items were identified during the audit.


Example bow-tie diagram

Management of major accident risk

  • Nonconformity: Major accidents – follow-up of barriers and performance requirements
    Comprehensive strategies and principles were not established for the design, use and maintenance of barriers.
  • Nonconformity: Maintenance management and barrier follow-up
    The RMS maintenance system was the planned tool for testing and verification of the quality of technical barriers designed to prevent major accidents. The system was, however, lacking and not updated to handle this function.
  • Improvement item: Emergency preparedness plan – Defined hazard and accident situations (DFU)
    The DFUs were inadequate, and did not describe all relevant hazardous situations.
  • Improvement item: Upgrading the drill floor area
    The equipment and design of the drill floor and in the derrick was not optimal.
  • Improvement item: Fire fighting fire using fixed CO2 extinguishing systems. CO2 fire extinguishing systems were installed in many rooms to fight larger fires in the room. Such a system is not considered a fast and effective fire extinguishing system.
  • Improvement item: The company’s master management system and local adjustments
    Some directives from the company’s main office are not well-adapted to local conditions.

Other factors

  • Nonconformity: Fire hoses
    Some fire hoses were not in accordance with the requirements.
  • Nonconformity: Battery emergency lighting
    Inadequate battery emergency lighting in rooms for Co2 bottles
  • Nonconformity: Training and exercises
    Inadequate training plan and logging of fire team training.
  • Nonconformity: Storage and access to rescue equipment
    Unsuitable design of changing area and storage of fire-fighter and MOB boat crew equipment.
  • Improvement item: Deploying anchor lines after highest ESD level
    It was unclear which measures were implemented to avoid a risk of ignition in connection with deployment of anchor lines in an emergency situation.
  • Improvement item: Communication equipment for smoke divers
    Unsuitable communication equipment.
  • Improvement item: Escape routes
    Inadequate marking of escape routes.
  • Improvement item: Information flow in the safety delegate service
    Inadequate information flow between management and the safety delegate service offshore and between the safety delegate service offshore and on land.

PSA Audit

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