Investigation Report

Unofficial translation
Report
Report title

Activity number

Investigation of the incident "Man over board resulting in fatality on

Saipem 7000 on 12 August 2007"

12F11

Classified

; Public
Exempt publ. disc.

Restricted
Confidential

Highly confidential

Summary

A 48-year-old Philippine sailor died on Sunday, 12 August 2007 on Saipem 7000 in

connection with installation of the Tordis subsea separator. He fell into the sea from a winch
platform approximately 30 meters above sea level and drowned.
Statoil is the operator of the Tordis field, and the installation of the module constitutes part of
the expansion of the Tordis subsea facility for improved recovery of reserves. The work was
performed using the lifting vessel Saipem 7000. The work is part of a framework contract
between Statoil and Saipem UK Ltd.
The deceased was a member of a work team consisting of four people that worked together
near a winch with a hydraulic hose on its reel, on the right hand side of Crane 1 on the port
side of the vessel. The hose went from the winch via a sheave in the crane boom down to the
module itself. The sheave had become stuck, resulting in tension in the hose from the sheave
down to the module and slack from the sheave down to the winch. A loop of the hose was
laying on the winch platform next to the winch after failed attempts to free the hose. The
deceased was in all probability hit by the hydraulic hose as it suddenly was tightened. The
person in question was then either hit or pushed over the railing by the hose.
Involved
Main group

T1-StatoilHydro

Approved by / date

Kjell Arild Anfinsen

Members of the investigation team

Investigation leader

Sigurd Jacobsen
Bjrn Olsgrd

Oddvar vestad

Contents

1
2

3
4

6
7

SUMMARY...................................................................................................................... 3
INTRODUCTION ............................................................................................................ 4
2.1 PSA investigation team ........................................................................ 4
2.2 Mandate ................................................................................................ 4
2.3 PSA follow-up of the incident.............................................................. 4
2.4 Method.................................................................................................. 5
COURSE OF EVENTS .................................................................................................... 5
INCIDENT POTENTIAL................................................................................................. 9
4.1 Actual consequences ............................................................................ 9
4.2 Potential consequences......................................................................... 9
OBSERVATIONS .......................................................................................................... 10
5.1 Nonconformances............................................................................... 10
5.1.1 Nonconformance: Incorrect design of sheave arrangement. .. 10
5.1.2 Nonconformance: Deficient engineering and risk assessment10
5.1.3 Nonconformance: No evaluation of the use of technology to reduce
risk
11
5.1.4 Nonconformance: Deficient analysis of risks and understanding of
risks 11
5.1.5 Nonconformance: Deficient distribution of responsibility and
communication lines........................................................................... 12
5.1.6 Nonconformance: Deficient handover/communication ......... 12
5.1.7 Nonconformance: Deficient follow-up by operator ............... 13
DISCUSSION REGARDING UNCERTAINTY........................................................... 14
APPENDICES ................................................................................................................ 14

SUMMARY

A 48-year-old Philippine sailor died on Sunday, 12 August 2007 on Saipem 7000 in

connection with installation of the Tordis subsea separator. He fell into the sea from a winch
platform approximately 30 meters above sea level and drowned.
Statoil is the operator of the Tordis field, and the installation of the module constitutes part of
the expansion of the Tordis subsea facility for improved recovery of reserves. The work was
performed using the lifting vessel Saipem 7000. The work is part of a framework contract
between Statoil and Saipem UK.
The deceased was a member of a work team consisting of four people that worked together
near a winch with a hydraulic hose on its reel, on the right hand side of Crane 1 on the port
side of the vessel. The hose went from the winch via a sheave in the crane boom down to the
module itself. The sheave had become stuck, resulting in tension in the hose from the sheave
down to the module and slack from the sheave down to the winch. A loop of the hose was
laying on the winch platform next to the winch after failed attempts to free the hose. The
deceased was in all probability hit by the hydraulic hose as it suddenly was tightened. The
person in question was then either hit or pushed over the railing by the hose.
The Petroleum Safety Authority (PSA) appointed an investigation team on the same day,
which also assisted the police during their investigation of the accident. The mandate of the
investigation team includes mapping the course of events, identifying direct and root causes
and identifying any lack of compliance with regulations.
The investigation has identified the following nonconformances:

Incorrect design of sheave arrangement

Deficient engineering and risk assessment
No evaluation of the use of technology to reduce risk
Deficient analysis of risks and understanding of risks
Deficient distribution of responsibility and communication lines
Deficient handover/communication
Deficient follow-up of operator

Nonconformances have been identified at both Statoil and Saipem.

INTRODUCTION

A 48-year-old Philippine sailor died on Sunday, 12 August 2007 on Saipem 7000 in

connection with installation of the Tordis subsea separator. He fell into the sea from a winch
platform approximately 30 meters above sea level. The MOB (Man Over Board) boat was
launched and reached the last observed position of the deceased within three to four minutes.
In spite of the fast emergency response, it proved impossible to reach the person before he
was observed sinking in the sea. He was found drowned on the seabed at a depth of 200
meters after approximately 1.5 hours by the vessel's ROV (Remotely Operated Vehicle).
Statoil is the operator of the Tordis field, and the installation of the module is part of an
expansion of the Tordis subsea facility to improve the recovery of reserves. The work was
performed using the lifting vessel Saipem 7000. The work is part of a framework contract
between Statoil and Saipem UK.

2.1

PSA investigation team

Statoil notified the PSA of the incident on 12 August 2007 at 11:45 hours in accordance with
the requirements. The PSA established an investigation team to assist the police during their
investigation, as well as to carry out a separate investigation of the incident.
The members of the PSA investigation team were as follows:
Oddvar vestad
Sigurd Jacobsen
Bjrn Olsgrd

2.2

Investigation leader, Discipline area logistics and emergency

preparedness
Discipline area logistics and emergency preparedness
Discipline area logistics and emergency preparedness (from 15 August
2007)

Mandate

Mandate for the investigation team:

1. Assist the police
2. Map the course of events
3. Identify direct and root causes with focus on Man, Technology and Organisation (MTO)
4. Map and evaluate emergency preparedness issues, including responsibilities,
communication lines and available emergency response equipment
5. Identify lack of compliance with regulations, recommend further follow-up as well as
identify any need for policy instruments
6. Report status internally
7. Evaluate resource requirements and identify any need for assistance

2.3

PSA follow-up of the incident

There was an official inspection after the PSA and the police arrived on Saipem 7000 on
Monday, 13 August 2007. The installation of the subsea module was completed on Sunday,
12 August 2007 (after stopping for a few hours) after consultation with the police and the
PSA.
There was no reconstruction of the incident, partly because of the practical challenges
involved in carrying out a simulation, but also because the course of events and physical
causes were sufficiently clarified after the inspection at the scene and reading Saipem's
internal incident report.
Information was obtained from leading personnel on the installation, from the crew that
participated in the operation on the winch platform and from personnel that worked on the
main deck through questioning by the police with the PSA present.
In addition to questioning on board, there were also meetings with Statoil in Stavanger and
Saipem UK Ltd. in London. The purpose of these meetings was to ascertain the
responsibilities for engineering, execution of the activity and follow-up in relation to
applicable regulatory requirements.
Video recordings and still images of the activities on board Saipem 7000 before, during and
after the accident have been reviewed.
The investigation team stayed on the installation for 4 days.
An overview of documents reviewed in connection with the investigation is available in
Appendix B. A list of personnel that have participated in questioning, interviews or meetings
is available in Appendix C.
2.4

Method

A Man, Technology and Organisation (MTO) diagram describing the course of events and
direct and underlying causes as well as nonconformances is available in Appendix A.
3

COURSE OF EVENTS

The lifting operation was planned through engineering and preparation of an installation
manual and associated risk assessments (HAZID/HAZOP). This work had taken more than
one year and had been performed by Saipem UK in London. The handover and review of the
project were carried out at a separate meeting on board Saipem 7000. The Safe Job Analysis
(SJA) was performed by personnel on board Saipem 7000.
On the day before the accident took place, the module was prepared and rigged, and there
were only a few final preparations left before the module could be lifted clear of the deck and
installed on the seabed.
As the work was to continue past midnight, an ordinary shift meeting and toolbox meetings
were held for the ongoing shift between 11 and 12 August 2007 (shift plan 00 to 12).

At approximately 07:00 hours on 12 August 2007 the lifting operation itself commenced.
Lashings were removed and the module was lifted clear of the deck.
The person responsible for the lift held a meeting with relevant leading personnel, with
special focus on the high risk activity of installing lanyards between the crown blocks and
guide lines.
At approximately 08:00 hours the module was hanging in the two co-lifting cranes over the
side of Saipem 7000, and the work of connecting the lanyards between the crown blocks and
the guide lines could be performed. After the guide lines were connected, the operation
continued and the module was lowered into the sea.
The module was lowered down to a depth of approximately 190 meters, where there was a
break in the lifting operation to allow for a survey of the seabed and a final check of the
position, before the module was landed on the seabed.

The module being lowered

Winch platform

The accident took place at approximately 10:18 hours, shortly after the lowering of the
module had stopped.
"Man over board" was shouted and a life buoy thrown down on the sea. The rescue operation
was initiated immediately and the MOB (Man Over Board) boat was launched. The deceased
sank shortly thereafter. He was found on the seabed at a depth of 200 meters after
approximately 1.5 hours by the vessel's ROV.
Detailed description of the work and the incident
The deceased was a member of a work team consisting of four people that worked together
near a winch with a hydraulic hose on its reel, on the right hand side of Crane 1 on the port
side of the vessel. The crew consisted of an Italian supervisor, an Italian mechanic and two

Philippine engine men. They were responsible for operating a winch with local controls and a
hydraulic hose on the reel. The hose was routed from the winch via a sheave in the crane
boom down to the module itself.
The purpose of the hydraulic hose was to provide hydraulic power for the release mechanism
for hydraulically operated shackles that connected the slings to the subsea module. When the
module had landed on the seabed, the hydraulic shackles were actuated and the slings
disengaged and lifted back on deck.
In order to avoid tension in the hydraulic hose during the lowering of the module, the
hydraulic hose had to be reeled out. This was done by operating the winch locally using the
control lever fastened to the winch.

Winch platform
Hydraulic hose

It was observed early on during the lifting operation that the hydraulic hose was in contact
with the barrier chain on the winch platform in front of the winch. There are two chains fitted
in front of the winch to protect against falling into the sea. The hydraulic hose was initially
routed between these two chains. To prevent the hydraulic hose from being in contact with the
upper barrier chain, this chain was removed to allow the hydraulic hose to pass without any

obstacles. After a while, the upper chain was put back in place, and the hydraulic hose could
now freely pass above the upper chain.
It was observed early that there was tension on the hydraulic hose between the sheave and the
module, while it was hanging slack between the sheave and the winch. It was concluded that
the disc on the sheave was in contact with the crane boom structure, thus preventing it from
rotating freely.

Contact point between

sheave and crane boom

Hydraulic hose
sheave - winch

Hydraulic hose
sheave - module

Sheave arrangement
The work team by the winch thought they were told by the rig foreman to shake/pull the
hydraulic hose in an attempt to free it and allow it to pass over the sheave. This shaking did to
some extent make it possible for the hose to pass through the sheave, but for the work team on
the winch platform the problem appeared to increase as the module was lowered down into
the sea.
When the lifting operation was stopped at a water depth of 190 meters (10 meters above the
seabed), there were several attempts to make the hose clear the sheave by shaking the hose. In
addition, the hose was reeled out to ensure more slack so that it could be pulled sideways.
These attempts were abandoned, however, when it proved impossible to have the hose pass
through the sheave. It was hoped that the problem would resolve itself when the module was
lowered further.
As a result of having paid out slack and pulling the hose sidewise, there was now a 3-4 meter
long loop of the hydraulic hose lying on deck. Two persons moved away from the area, while
the deceased and one more person remained standing in the area where the loop in the hose
was located. It is assumed that the deceased was standing inside the loop.

Motor man

Deceased

Mechanic
Foreman

Image showing the location of the work team on the winch platform
Nothing abnormal was noticed before the deceased was observed falling down towards the
sea. It was stated that no one in the work team by the winch had seen or heard how the
deceased fell into the sea. They only observed that the hydraulic hose had been tightened.
Based on this, it is probable that the hydraulic hose, which had tension between the sheave
and the module, could pass freely over the sheave, thus tightening the slack in the hose
between the sheave and the winch. It is assumed that the deceased was hit by the hydraulic
hose as it was tightened. The person in question was then either hit or pushed over the railing
by the hose.

4
4.1

INCIDENT POTENTIAL
Actual consequences

The actual consequence of the incident was that a person fell over board and drowned.
4.2

Potential consequences

There were several persons working on the hydraulic hose earlier in the day and just before
the accident took place. Several persons could have been injured when the hose was
tightened. Several persons could also have fallen over board.

10

OBSERVATIONS

The PSA's observations are generally divided into two categories:

Nonconformances: This category is for observations that, in the opinion of the PSA,
indicate lack of compliance with regulatory requirements.
Improvement items: Used for observations of deficiencies, but where the information is
insufficient to prove a lack of compliance with regulatory requirements.
This investigation has only identified nonconformances.
5.1
5.1.1

Nonconformances
Nonconformance: Incorrect design of sheave arrangement.

Incorrect design of the sheave arrangement resulted in the sheave itself being prevented from
rotating freely and in tension in the hydraulic hose from the sheave arrangement and down to
the subsea module. When this tension was released and the hydraulic hose tightened and hit
the deceased, this most likely resulted in this person being knocked over board and drowned.
Grounds:
The rigging of the sheave arrangement did not take into consideration the steep angle of the
boom for Crane 1 on the port side of the vessel. The design of the arrangement resulted in a
collision between the sheave and steel structure of the crane boom, thus preventing the sheave
itself from rotating freely. An open sheave was used where the sheave was not protected
against contact with surrounding structures.
Verification or testing of the functionality of the sheave arrangement was not part of the
rigging operation prior to the lift.
Requirements:
Section 1 of the Management Regulations on risk reduction
Section 28 of the Activities Regulations on actions during conduct of activities
5.1.2

Nonconformance: Deficient engineering and risk assessment

The engineering and risk assessments of the sheave arrangement for supporting the hydraulic
hose in the crane boom were deficient.
Grounds:
The arrangement around the sheave for supporting the hydraulic hose in the crane boom was
not included in the detailed engineering, and the solution was improvised. The interviews
showed that the selected solution was copied from another project. It was not taken into
consideration that the angle was steeper because the crane boom was at a steeper angle, thus
making it impossible to copy the previous solution.
As the sheave arrangement was not part of the detailed engineering, it was also not included
in the risk assessments (HAZID/HAZOP) during the design and engineering phase. The
HAZID/HAZOP processes also did not identify this issue.
Requirements:

11

5.1.3

Section 27 of the Activities Regulations on planning

Nonconformance: No evaluation of the use of technology to reduce risk

An evaluation of the use of technology to reduce personnel risk could not be presented.
Grounds:
The investigation showed no evaluation of whether to install constant tension control and/or
remote operation of the hydraulic hose winch or use of other technology in order to reduce the
number of persons and thus the risk for personnel working on the winch platform.
The review of pictures and film also show that the solutions selected involve a large number
of persons working in high exposure areas, for example during rigging of anti-spin guide lines
and the work being performed on the winch platform. It was also observed that there was a
person on top of the module during the tensioning of the slings.
No documents have been presented to confirm that the use of personnel for carrying out
activities in exposed areas is optimum as regards ensuring the lowest possible risk. There is
also no documentation showing risk-reducing measures implemented out of consideration for
personnel safety.
Requirements:
Section 1 of the Management Regulations on risk reduction
Section 27 on planning and Section 31, first subsection, first sentence of the Activities
Regulations on arrangement of work (..., and so that the probability of mistakes that can
lead to situations of hazard and accident, is reduced.)

5.1.4

Nonconformance: Deficient analysis of risks and understanding of risks

The analysis of risks was inadequate for execution of the work.

Grounds:
The Safe Job Analysis (SJA) does not analyse the risks for the activities related to the
hydraulic hose.
The shift meeting and toolbox meeting did not focus on safety and risk issues related to the
activities on this day other than the use of personal protective equipment.
Personnel are located in strategic places with regard to problems that may arise during the
operation. There was no definition of which problems could appropriately be remedied
without further planning and analysis of risks.
It appears that the personnel on board were not sufficiently trained in stopping, planning and
assessing risks in the event of unforeseen changes.
The deceased was wearing a safety harness, but it was not fastened at the time of the accident.
This is not required as long as the person is located on a platform with railings. However, the
investigation showed that the personnel on the winch platform carried out work in front of the
winch with the barrier chain removed without using the safety harness. This continued until it
was pointed out by the leader.

12

Pictures reviewed in connection with the investigation also show one person supporting
himself on the tensioned hydraulic hose.
Requirements:
Section 25 of the Activities Regulations on critical activities
5.1.5

Nonconformance: Deficient distribution of responsibility and communication

lines

The investigation showed deficient allocation of responsibilities in addition to ambiguous

communication lines.
Grounds:
The SJA did not allocate responsibility for follow-up of risk factors for the work on the winch
platform with the hydraulic hose or other surrounding activities related to the lifting
operation. There was no work specification for the personnel.
Four leading personnel (operation manager, lift responsible leader, mechanical foreman, rig
foreman) discussed the problem that had occurred with the hydraulic hose via radio. The
supervisor for the winch platform was not involved in this discussion.
Someone on the deck (not formally a leader) said to shake the hose. The supervisor on the
winch platform assumed this to be an order from the deck/"leader group" to shake the hose to
allow it to pass over the sheave that was stuck.
During the further lowering of the module, the person responsible for the lift checked the
status of the hydraulic hose and sheave twice with the rig foreman without involving the
supervisor on the winch platform. There was no direct communication between the supervisor
on the winch platform and his superior in spite of the fact that both were equipped with radios
and used the same channel.
Requirements:
Section 3 of the Management Regulations on management of health, environment and
safety
5.1.6

Nonconformance: Deficient handover/communication

The handover of the project to Saipem 7000 was deficient. There was also deficient
communication regarding risk factors that had been identified and documented during the SJA
process at the shift meeting and toolbox meeting.
Grounds:
The handover and review of information from the project to the executive section on board
Saipem 7000 was handled at a meeting lasting 25 minutes. During the meeting, the project
reviewed the general activity plan step by step. There was no review of the HAZID /HAZOP
or other risk assessments at this handover.
According to the procedure, the shift meeting is intended to be a review of planned activities
and related safety issues. The minutes show that the meeting does not address issues related to

13

safety in connection with individual activities, but is a meeting for review of the work
program for the ongoing shift.
According to the minutes, the toolbox meeting does not address issues related to safety in
connection with individual activities, but is a meeting for reviewing the work program for the
ongoing shift in addition to focusing on the use of personal protective equipment, checking of
tools, isolation of equipment to be worked on and the use of chemicals.
The investigation showed that the person responsible for the lift ordered the lifting operation
stopped at a water depth of 190 meters. This order was intended to include all activities
associated with the lifting operation, but it was not perceived this way by the personnel
working on the winch platform. Thus, the work of trying to make the hydraulic hose run
freely over the sheave continued after the stop order was given.
The investigation has shown that the personnel that participated in the lifting operation spoke
different languages (Italian, English and Philippine/Indonesian). Risk assessments such as
HAZID/HAZOP and SJA are documented solely in English, and the risk factors identified
must be safeguarded by those performing the lifting operation. In addition, the personnel
participating in the lifting operation must also contribute additional details during the risk
assessments. Language barriers will prevent this flow of information. Important governing
documents, such as Lifting Operations, Work Permit System, Safe Job Analysis, are only
available in English.
Requirements:
Section 12 of the Management Regulations on information
Section 83, second subsection, second sentence of the Activities Regulations (The party
responsible shall ensure that the communication takes place in a clear and unambiguous way
and without disturbance.)

5.1.7 Nonconformance: Deficient follow-up by operator

The operator's follow-up was deficient.
Grounds:
Interviews of leading personnel on board show that Saipem 7000 complies with maritime
regulations in addition to the Installation Manual prepared for installation of the module.
There is no documentation or any other form of communication that has specified vis--vis
Saipem 7000 that the relevant requirements are those stipulated in the petroleum regulations.
The fault resulting from not reviewing the risk factors at the handover of the project/project
documentation from engineering to Saipem 7000, was not pointed out by Statoil. Statoil was
represented at this handover.
No representatives of Statoil have participated in, reviewed or provided comments regarding
the SJA.
Statoil has not made any HSE observations on board. Statoil has not reacted to the fact that
many people had to break barriers to perform their work. Statoil's representatives on board
have also not reacted to technical aids not being used to a greater extent rather than a large
number of personnel for certain sub-activities.

14

No HSE issues have been pointed out during the daily meetings between the operation
manager and the company's representative on board (SR).
Statoil has not reacted to the Italian language being used as a working language during the
lifting operation and that this reduces the opportunity for participants speaking other
languages to know what is being communicated.
Requirements:
Section 5 of the Framework Regulations on the supervision obligation

DISCUSSION REGARDING UNCERTAINTY

No one saw the deceased from the time he was observed on the winch platform until he was
falling towards the sea. The deceased was in all probability hit by the hydraulic hose as it
suddenly was tightened. The person in question was then either hit or pushed over the railing
by the hose. This is also supported by the deceased's injuries as indicated in the autopsy
report.
There are some contradictory statements regarding what was said in connection with the
problems that had occurred in connection with the hydraulic hose and the sheave. However,
there are no contradictory statements as regards the lack of communication between the
responsible supervisor on the winch platform and the person responsible for the lifting
operation.

APPENDICES

A:

MTO incident and cause analysis.

B:

The following documents have been taken into account during the investigation:
Received on board Saipem 7000:

Doc. No. S7000-HSE-033-E report no 058/2007 dated 12 August 2007 "Event Report"
Folder containing:
- Doc. No S7000-PRO-HSE-06-E Man Riding Lifting Operation Plan (Guidance)
- Man Over Board Time Report
- Master Report
- Medical Report
- Periods on Board Report (deceased)
- Doc. no. S7000-MAN-SMME-E "Ship Organization Chart"
- Doc. no. TIOR-SAI-A-RD-2021 page 12 "Project org. chart for installation"
- Crew list of 11 August 2007
- List of deck personnel 12 August 2007
- Time Sheet (deceased)
- S 7000 Tool Box Talk Report Mechanics 12-08-2007
- Doc. no. S7000 HSE-029-E 08/09/10.08.2007 Safe Job Analysis
- Doc. no. S7000-PRO-HSE-18-E "Work Permit System"

15

Doc. no. TIOR-SAI-A-RD-2019 "Emergency Preparedness Analysis"

Documentation of completed training (Four persons working on the winch
platform)
- Arrangement drawing for installation of the module
- Doc. no. S7000-HSE-036-E "Site Event Report Log" (20-29.06.2007)
- Minutes 11 August 2007 23:30 hours "Daily Work Program & Supervisors
Safety Meeting"
- TIOR-ARI-001 "Agreement to Resume Installation" dated 12 August 2007
- Documentation of winch involved in the incident
- Personnel details (deceased)
Document no. S7000-PRO-HSE-06-E "Lifting Operations" (obtained upon request)
Several drawings prepared in connection with the installation. (obtained upon request)

The following documents have been received upon request afterwards:

Hazid and risk analysis Tordis SSBI Transportation and Installation

Hazop Sea transport and installation of SSBI structure Tordis IOR project
Received at meeting on 24 August 2007 with Statoil: Contract No. SAP 4501000548
for Transportation and installation of the Tordis SSBI structure
Received at Statoil on 28 August 2007: Audit Report UPN PTT 03-03 Saipem UK
HSE Audit
Received after the meeting at Statoil on 28 August 2007:
o CD with copies of pictures from the lifting operation.
o "Notes of meeting" S7000 Daily Meeting 11 August 2007, Tordis
o Work specification for function manager for marine and heavy lifts
o Saipem Procedure Doc. No. GP-SUK-QHSE-313 "Accident Investigation"

C: List of personnel that have been questioned, interviewed or participated in meetings (not
available on the Internet)
NAME

FUNCTION

COMPANY

D: Abbreviations:
HAZID
HAZOP
HSE
MOB
MTO
PSA
ROV
SJA
SR

Hazard Identification
Hazard and Operability
Health, Safety and the Environment
Man Over Board
Man Technology Organisation
Petroleum Safety Authority
Remotely Operated Vehicle
Safe Job Analysis
Company Representative

START-UP
MEETING

INTERVIEWED
DURING
INVESTIGATIO
N

SUMMARY MEETING