PROCESSSAFETYSERIES6 MAERSKGRYPHON

Sharingtheexperience
MAERSKGRYPHONFPSO IncidentSummary
TheGryphonAFPSO,islocated175miles(281km)offthecoastofAberdeen,andhasa
productionrateofaround20,000barrelsofoilequivalentaday.
Waterdepthis112mandtheFPSOhasaturretjustforwardofmidships
Anincidentoccurredat07:05hoursonFridaythe4ofFebruary2011whilstthe
GryphonAlphaFPSOwasengagedinproductionoperations.
Thevessellostheading&positionduringstormyconditions(about60knotsmaximum
windspeedwithsignificantwaveheightofbetween10mto15m).
Theinitiatingeventwasthelowtensionfailureofwindwardmooringline7.
ThePMthendrovetheFPSOintotheprevailingweather
Gasrisersbrokefreeandgascloudformedbutdispersed
Noonewasinjured.
Afternearly20yearsofuninterruptedservice,
theFPSOhadtoleavetheGryphonfieldforthefirst
timeforrepairsandupgrade

2
 IncidentTimeline
Turretmaintainedinafixedorientationequippedwitha10pointmooringsystem
Tomaintainpositionandminimiseenvironmentalfactorsthevesselusesfivethrusters,
controlledbyaSimradDynamic PositioningandPositionMooringsystem(SDPM)
Headingofthevesselischangedtoalignthebowintotheprevailingseas
TheGryphonwasinautomodewithasetheadingof250intotheprevailingweather
Badweatherleadingto21degreerollsandsnappedfouranchorchains.
Drifted180metresoffstationandrippedalloftheGasLiftRiserscleanoutofthebottom
oftheship,mangledpipeworkintheturret.
Gas clouddetectedbutquicklycleared,probablybecausethe11gasliftriserswere
disappearingdowntheItubetotheseabed
Authoritiescontactedanddownmanningfrom70personnelleaving40behind. (RAF
SeaKing,theCoastguardhelicopterandtwoScotiaemergencyhelicoptersliftedallsafely
totheBerylplatforms. )
AWACoverheadcheckingforoilspillsetc.
Deployedfourtugstoholdusstable,initiallybypushingusround
TwotugsatFWDandAftforemergencyheadingcontrol.
ROV'sinthewaterhavefedbackthatsubseaclusterwrecked.Chainswrappedaround
risers,riserbasesrippedcleanofftheseabed,someturnedupsidedownmangling some
of theflowlines,oneoftheriserbases moved70metres
Twoofthechains haveactuallycrossedover!, oneiswrappedaroundtheriserarch
Slide3
Mainlessonsfromincident
ThePMsystemdrovethevesselbeamontotheprevailingweatherduetoachainofcoincident
eventsproducinginaccurateinputstothePMsystemmodels.Thiscausederroneouscalculationof
theforcesandmomentsactingonthevessel.
Manufacturingdefectonachainlinkinanchorchain7
Mooringsystemworkingoutwithdesignparameters
Insufficientredundancyinpositionreferencesystems
FailureoflinebreakdetectionsystemtoinitiatetransfertofullDPmode
Ineffectivemethodoftransferfromautoheadingcontroltomanuallevercontrol
Basisofdesignandfailuremodeanalysis(FMEA)didnotincludelossofheading
PersonnelusingtheSDPMsystemhadnotrefreshedorrevalidatedtheirinitialtraining.
Emergencydrillsdidnotroutinelyinclude SDPMsystemmalfunctions
PerformanceStandardforthemooring systemwastooreliantontheanchorchainsabilityto
maintainposition
Lackofproceduremechanismto;refreshtheSDPMsystemmodel,carryoutregularcheckson
accuracyofbaseinputs orformalisetheactionsnecessaryonspecificcriticalalarms
Initiatingeventwasfailureofmooringline7.Thislinefailedasaresultofa failureoftheflashbutt
weldofachainlinkatatensionsignificantlybelowitsdesignload.
Failureofmooringlines6,5and4asthevesselheadingturnedbeamontotheenvironment.

4
 SwissCheeseFailures

Effective
Relief and Blowdown Operations Supervision / Audit & Self Active & Passive Fire Rescue & Investigation &
System Learning from the Procedures Leadership Regulation Communication Protection Recovery Lessons Learned
Past

Work Control Training & Management of Escape / Support to Next of Kin

Inherent Design Control, Alarm & Maintenance & Competency Access & Injured
Change
Plant Layout Shutdown system Inspection
HAZARD
REALIZATION
HAZARD
Extreme
weather
Loss of
Mooring

Loss of position

Loss of
containment

No fatalities
No plant and injuries
layout issues Training and
however some No issues emergency drill
No work control did not include No issues, 70 non
design issues No issues issues No issues
the scenario of No essential guys evacuated
with the
the SDPM failing communication
SDPM
issues
Blow down
worked,
No issues
inventory
decreased Access & escape route Investigation
No issues diversity carried out
Access to scene
No issues
No issues Lack of
procedures to
refresh SDPM,
PS also heavily
relied on
anchor chain to
maintain
position

Slide5
 EXAMPLEOFPSEXPECTATIONS FROMALL
Operator Level
Participate in Risk Analysis
(HAZOP, What if, HAZID,
constructability review.);
Check on a regular basis that
Safety Critical Measures are in
place in the process unit (valves
/ locked open or close, Restricted
Orifices);
Check on a regular basis that
equipments for fire protection
are operational;
Check the date of validity of PPE
(included specific PPE like
Breathing Apparatus);
Check the date of validity of
different equipments like hoses;
Check the cleanliness of bunds
(absence of water, );
Participate in test of critical
instruments;
Participate in test of gas
detectors;
Check that the list of
(instrumented) Safety Critical
Equipment bypassed is in
agreement with the reality;
Report possible process safety
improvements to management.
Engineer / Supervisor
Participate in Risk Analysis
(HAZOP, What if, HAZID,
constructability review.);
Collect / organize lessons
learned and explain to
operators;
Elaborate lists of items that
must checked by operators
(valves, blinds, RO, safety
valves, rupture disc,);
Review emergency
procedures;
Participate in Risk
Assessments for
Modifications;
Test / Check all
communications equipment
used for emergency plan;
Check that all document /
relevant information is up to
date in the emergency crisis
room;
Implement best practices on
process safety developed on
corporate level;
Management Level
Participate in a HAZOP study (e.g. 1/2
day participation) and discuss with the
team about your findings (e.g. quality
of the team);
Present Safety Case finding to the
team offshore;
Elaborate / Approve a five year plan of
Process Safety Studies;
Understand status of all recs from
process safety studies
Analyse lesson learned to prevent re-
occurrence of accident;
Ensure that all modifications are
properly analysed in term of risks;
Elaborate action plan after audits, risk
analysis,
Elaborate Process Training Session for
Intermediate Management;
Ensure that all people who have PS
Expectations are trained for this
specific job;
Organize and participate in
Emergency Management Exercise drill;
Enforce best practices on process
safety developed on corporate level;
Ensure that the Process safety
systems in place meet the
expectations of new regulatory/legal
requirements
Slide6
PROCESSSAFEYCULTURE whereareYOU!!!!!!!
isacontinuumofbehaviorswithincreasinglevelsofsafetyawarenessandactivity

- Chronicunease(Mindfulness)
Generative
Safetyishowwedobusiness Safetyisseenasgoodbusiness
aroundhere Newideasarewelcomed

- Resourcesareavailabletofixthingsbeforeanaccident
Proactive
Weworkonproblemsthat Managementisopenbutstillobsessedwithstatistics
westillfind Proceduresareownedbytheworkforce

Calculative WehaveourHSEMSnailed!
Wehavesystemsinplaceto Lotsandlotsofaudits
manageallhazards Wecollectlotsofstatistics

Reactive Weareserious,butwhydontpeopledoastheyaretold?
Safetyisimportant wedoalotof Lotsofdiscussionstoreclassifyaccidents
iteverytimewehaveanaccident! Youhavetoconsidertheconditionsunderwhichweareworking.

Thelawyerssaiditwasokay.
Pathological IvedonemypartforHSSEthisyear.
whocaressolongaswere Ofcoursewehaveaccidents;itsadangerousbusiness
notcaught! Firethepersonwhohadtheaccident! 7