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Case Study: Lessons Learned from Explosive Decompression at Byford Dolphin

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Case Study: Lessons Learned from Explosive Decompression at Byford Dolphin Case Study: Lessons Learned from Explosive Decompression at Byford Dolphin Denis Su-Feher PhD Student, Chemical Engineering Mary Kay O’Connor Process Safety Center Outline • Byford Dolphin Overview • Decompression • Sequence of Events • Investigation Findings • Analysis • Lessons Learned Byford Dolphin Drilling Rig1 2 Byford Dolphin Overview2,3 • Date: November 5, 1983 • Time: 04:00 AM • Location: Frigg Gas Field • Semi-submersible Closed Diving Bell2 offshore drilling rig • Operated by Dolphin Drilling Comex Decompression Chamber4 3 Decompression Sickness5,6,7 • Formation of gas bubbles in the body • Results in pain, fatigue, and loss of consciousness; possibly lethal 4 Explosive Decompression5 • Occurs at a rate swifter than that at which air can escape from the lungs • Less than 0.1 to 0.5 seconds • High risk of lung trauma • Danger of unsecured objects becoming projectiles • Likened to a bomb Explosive Decompression of detonation Boeing 7478 5 Explosive Decompression 6 Explosive Decompression 7 Explosive Decompression 8 History of Explosive Decompression Incidents • May, 1973 - Turkish Airlines Flight 9819 – TC-JAV – Cargo door failure • April,1975 - Tan Son Nhut10 – C-5 – Improper maintenance • August, 1981 - Far Eastern Air Transport Flight 10311 – Boeing 737 – Corrosion • August, 1985 - Japan Airlines Flight 12312 – Boeing 747 – Structural failure of rear pressure bulkhead 9 Gradual Decompression Procedure2,14 Byford Dolphin Diving Bell and Decompression Chamber 10 Gradual Decompression Procedure2,14 Byford Dolphin Diving Bell and Decompression Chamber 11 Gradual Decompression Procedure2,14 Byford Dolphin Diving Bell and Decompression Chamber 12 Gradual Decompression Procedure2,14 Byford Dolphin Diving Bell and Decompression Chamber 13 Gradual Decompression Procedure2,14 Byford Dolphin Diving Bell and Decompression Chamber 14 Gradual Decompression Procedure2,14 Byford Dolphin Diving Bell and Decompression Chamber 15 Gradual Decompression Procedure2,14 Byford Dolphin Diving Bell and Decompression Chamber 16 Incident Chronology2,14 Byford Dolphin Diving Bell and Decompression Chamber 17 Incident Chronology2,14 Byford Dolphin Diving Bell and Decompression Chamber 18 Incident Chronology2,14 Byford Dolphin Diving Bell and Decompression Chamber 19 Incident Chronology2,14 Byford Dolphin Diving Bell and Decompression Chamber 20 Incident Chronology2,14 Byford Dolphin Diving Bell and Decompression Chamber 21 Investigation Findings2,13,14 • Direct Cause: Human Error • Contributing Factors: – Clamp had not been designed to stay locked on – Hinge mechanism had not been designed to close the door – Multiple decompression control panels – Bullhorn attached to the wall surface was the only communication the tenders had 22 Investigation Findings2,13,14 • Other Findings: – It is unclear whether the tender had released the clamp on orders or on his own – Divers worked 16 hour shifts – Two of the divers had no basic safety training 23 Forensics Report14 • Divers 1, 2, and 3 – Blood boiled • Diver 4 – violently exploded 24 Analysis • Regulations/Safety Culture • Inherent Safety • Damage from Pressure 25 Regulations/Safety Culture2 • Norwegian Maritime Directorate – Shift Plan • Norwegian Petroleum Directorate15 – Safety Training – Clock Run Time Exceeded • DNV GL - Oil & Gas – Safety Interlock • Comex Manual – Control Panels 26 Inherent Safety2 • Inherently safer clamp15 • Door hinge fail safe13,14 • Multiple control panels • Complexity of communication 27 Pressure • Brode’s Equation16 푃 − 푃 푉 퐸 = 2 1 훾 − 1 • Baker’s Model16 1 푃 3 푅′ = 푟 1 퐸 E = Energy (J) 푃 = Atm. Pressure (Pa) 1 Pressure vs Scaled Radius16 푃2 = Chamber Pressure (Pa) V = Volume r = Radius 훾 = Heat Capacity Ratio R’ = Scaled Radius 28 Pressure16,17 95% Probability of No Distance (m) Serious Damage (Safe 63.9 Distance) Glass Breakage 42.6 Structural Damage 9.9 Heavy Equipment Damage 9.2 Eardrum Rupture 8.5 Death from lung hemorrhage 3.6 29 Lessons Learned • Pay attention to your safety management system • Failure to pay attention to regulations may be a sign of an unhealthy safety culture • Update systems to standards, even if they are not required 30 Lessons Learned • Inherently safer systems can prevent incidents • Always fail to a safer state • Complexity causes confusion 31 Lessons Learned • Even though it has never happened before in your industry, it doesn’t mean it won’t happen to you • Account for the worst case scenario 32 References 1. H. Patil, "Alchetron," 27 February 2008. [Online]. Available: https://alchetron.com/Byford- Dolphin-1958484-W. [Accessed 22 May 2017]. 2. R. Godo, "Dykkerulykken på Byford Dolphin 5 november 1983 : rapport fra ekspertkommisjonen," Norges Offentlige Utredninger, Oslo, 1984. 3. Rigzone, "Byford Dolphin Rig Data," [Online]. Available: http://www.rigzone.com/oil/data/offshore-rig-search/rig-profile/102. [Accessed 22 May 2017]. 4. "Orkney Hyperbaric Chamber," Scottish Diving Medicine, 4 February 2011. [Online]. Available: http://www.sdm.scot.nhs.uk/scottish_chambers/orkney/. [Accessed 29 May 2017]. 5. S. D. Fell, "The Bends (Decompression Syndromes)," EMedicineHealth, 2017. [Online]. Available: http://www.emedicinehealth.com/decompression_syndromes_the_bends/article_em.htm. [Accessed 29 May 2017]. 6. J. B. Smith, "Boeing 747 : the shorted wiring/unlatch motor on/ruptured open forward cargo door/explosive decompression/inflight breakup explanation for the Boeing 747 events of TWA Flight 800, UAL Flight 811, Pan Am Flight 103, and Air India Flight 182," 22 February 2010. [Online]. Available: http://www.planetofearth.com/. [Accessed 29 May 2017]. 7. C. Parrott-Sheffer, "Decompression sickness," Encyclopaedia Britannica, 1998. 8. R. L. DeHart and J. R. Davis, Fundamentals of Aerospace Medicine: Translating Research into Clinical Applications, Philadelphia: Lippincott Williams & Wilkins, 2002. 33 References 9. T. F. S. o. S. f. T. "Turkish Airlines DC-10 TC-JAV Report on the Accident in the Ermenonville Forest, France on 3 March 1974," French State Secretariat for Transport, London, 1974. 10. "Accident description," Aviation Safety Network, 1991. 11. "Accident Description," Aviation Safety Network, 1981. 12. "Aircraft Accident Investigation Report," Aircraft Accident Investigation Commission, Ministry of Transport, 1985. 13. J. Limbrick, North Sea Divers: A Requiem, Hertford: New Generation Publishing, 2002. 14. J. Giertsen, E. Sandstad, I. Morild, G. Bang, A. Bjersand and E. S., "An Explosive Decompression Accident," American Journal of Forensic Medicine and Pathology, vol. 9, no. 2, pp. 94-101, 1988. 15. "Rules for Certification of Diving Systems," Det Norske Veritas, Norway, 1988. 16. M. Pasha, D. Zaini and A. M. Shariff, "Physical explosion analysis in heat exchanger network design," in International Conference on Chemical Engineering and Bioprocess Engineering, Paris, 2016. 17. D. A. Crowl and J. F. Louvar, Chemical Process Safety, Upper Saddle River: Prentice Hall, Pearson, 2014. 18. T. Nowakowski, Safety and Reliability: Methodology and Applications, Wroclaw: CCPS, 2000. 19. "Regulation," Petroleum Safety Authority Norway, 22 May 2015. [Online]. Available: http://www.ptil.no/regulations/category216.html. [Accessed 22 May 2015]. 34 Questions? Comments? [email protected] 35 Backup Slides 36 Acknowledgements • Dr. Mannan • Dr. Koirala • Ms. Valerie Green • Alanna Scheinerman • Steering Committee • All members of the MKOPSC 37 Explosive Decompression • Mythbusters 38 Pressure17,18 • Brode’s Equation works well for close distances • Prugh’s Model is based on isothermal expansion • Isentropic works well for far distances 39.
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