Oil spill to deck and sea due to lifting of production header PSV

Cause & Consequence

• Failure of vessels or pipework

Incident Location

Fixed Installation

Incident Activity

Lifting, crane, rigging, deck operations

Specific Incident Equipment

During an ESD process shutdown, the Production Header PSV 10032 lifted

Lessons Identified

• Insufficient procedures had been developed over the operating life of the installation to cover this eventuality.
• There were human factors involved as not all operations personnel were fully aware of the full procedure for alignment prior to well start-up.
• Mechanical failure of the choke valve. In conjunction with the procedural and knowledge shortfall, a coincidental failure of the mechanical choke valve exacerbated the incident

Incident Recommendations

- An improved Wellheads/manifolds procedure has been developed to cover this shortfall.

-Additional training and knowledge sharing has been introduced to ensure better understanding of the alignment issues for well start-up.

-A revision to the Wellheads/manifold procedure to identify choke valve failure will be introduced.