Professional Documents
Culture Documents
Petrobras P36 Sinking Report
Petrobras P36 Sinking Report
Carlos HELENO Netto Barbosa Chairman - Drilling and Logistics (Sondagem e Logística) SSE
Carlos Henrique de Lima Ferreira CIPA (Internal Commission for Accident Prevention) Representati
Prof TIAGO Alberto Piedras Lopes UFRJ (Federal University of Rio de Janeiro)/ Coppe
FINAL PRODUCT:
Most probable hypothesis explaining events which
occurred
Conclusions and Recommendations
Investigation Methodology of P-36 Accident
The Accident
March 15 2001
Establishing Hypotheses
Final Report
Immediate Causes
Analysis of Formal Accident Inquiry Basic Causes
Management Recommendations
INVESTIGATION
INFORMATION COLLATING
Normal Operation
First event. Shaking (jolt). Noise reported as falling deck cargo. Probable
mechanical rupture of the starboard emergency drain storage tank.
PT-70007 pressure in fire ring fell to 7-bar set point, which automatically starts the
two seawater pumps (XA/401 A/B/C/E) as well as two fire pumps (XA/401A/B/CE)
placing the platform in a FIREFIGHTING MODE.
Jack Bates built according to the Water service pipes and ventilation
same Friede & Goldman project shafts on the 4th level
INVESTIGATION
Damaged Zones
Purpose created
diagrams
INVESTIGATION
TITLE: VENTILATION SYSTEM – FIRE ZONE 4
CAUSE AND EFFECT ANALYSIS
Purpose created
diagrams
INVESTIGAÇÃO
Audit of Management Safety System
MAIN DE
CK
SEC
OND
DEC
K
COL
UNA
FL ST
UT AB
UA ILI
DO T YB
R OX
STARBOARD AFT COLUMN
MAIN DE
CK
SEC
OND
DEC
K
COL
UMN
FA
IR L
EA
RD
BO
X
PO ST
AB
NT ILI
OO T YB
N OX
SECOND DECK
TANK TOP
SECOND LEVEL
THIRD LEVEL
FOURTH
LEVEL SEA WATER OUTLET
PIPE
QUINTO PISO
FOURTH LEVEL
SEAWATER PUMP
PONTOON
MAIN DECK
SECOND DECK
TANK TOP
VENTILATION SHAFTS
EXHAUST SHAFT
THIRD DECK
TANK TOP
EMERGENCY DRAIN
STORAGE TANK
FOURTH LEVEL
1st Event:
Rupture of the Emergency Drain Storage Tank in the starboard aft column
HEADER CAISSON
VALVE VALVE
RACQUET
PORT STARBOARD
EMERGENCY EMERGENCY
DRAIN TANK DRAIN TANK
RACQUETS
KEY:
OPEN VALVE
CLOSED VALVE
SEMI-OPEN VALVE
Events ofthe Accident on Platform P-36
2nd Event:
Explosion, damage, impact and death of the firefighting crew
Gas rises from the 4th level and reaches the upper platform levels to produce
an explosive mixture
An ignition source provokes an explosion of the gas mixture
A strong explosion occurs in the area of the starboard aft column
This explosion occurs in the area where 11 members of the Firefighting
Service are located
Shock waves and heat of the explosion severely damage the structures,
equipment and accessories on the upper levels of the starboard aft area
Attempts to rescue the wounded (1 firefighter rescued, but dies one week
later )
Difficulties in maintaining platform stability
Evacuation begins 01:45h
Platform is abandoned at 06:00h
Events ofthe Accident on Platform P-36
3rd Event:
Flooding of void spaces and loss of the platform
Flooding of the 4th level of the starboard aft column due to the rupture of the
DST, of the sea water line and the activating mechanism of the seawater
pumps
Flooding of the pumping stations, of the propellers and the the water
injection area through the ventilation shaft
Initial flooding of the 26S tank and the void space 61S through open
inspection doors
Entry of sea water occurred through the sea chest which remained open
(Fail-Set Valves)
Progressive flooding begins through the chain lockers, pontoon tanks, void
spaces of the starboard aft column and deck; greater list
Final list and loss of the platform
Results ofthe Stability Analysis
• SABOTAGE
• MISALIGNED PIPING
• MAINTENANCE SERVICES
• COLLISION
• CARGO HANDLING
As to the accident
On the basis of the available information, the commission
concluded that the most probable hypothesis for the sequence
of events was:
Excessive pressure in the Starboard Emergency Drain Tank
(EDT) due to a mixture of water, oil and gas, which caused a
mechanical rupture thus leaking the EDT fluids into the 4th level
area of the column.
As to the accident
Opening of the 26S tank and the 61S void space for inspection
without following the procedure which established contingency
measures, thereby increasing the volume subject to flooding;