Investigation report Report Report title Activity number

Report following investigation of incident on 18 December 2010 on Njord A, where a slip joint fell to the drill floor.

001107005

Classification

Public

Exempt from public disclosure

Restricted

Confidential

Strictly confidential

Summary

In connection with pulling the blowout preventer (BOP) and riser on the Njord A facility, a slip joint was to be laid down from a vertical position to a horizontal position on the catwalk. A riser running tool was connected to the drilling machine (DDM) with a 350-tonne manual elevator. When the elevator was approx. five metres above the drill floor, the bails pressed against the elevator's link blocks , causing them to break, and the bails were pushed out of the elevator's lifting lugs. The slip joint (approx. 23 tonnes) fell about four metres before it hit a support trestle, fell onto the riser spider and further down to the drill floor before it hit the driller's cabin and came to a stop. The support trestle jumped around the drill floor. There were three people inside the red zone when the incident took place. The lifting supervisor was 2-3 metres from where the slip joint fell. The support trestle, weighing approx. one tonne, was facing the lifting supervisor before it hit a tong post and changed direction. The person in question was in considerable danger of being struck by the support trestle. The incident did not result in personal injuries, but only minor material damage. Under insignificantly altered circumstances, the outcome could have been fatal and resulted in significant material damage. The direct cause of the accident was incorrect use of the elevator, so that the elevator's link blocks broke (snapped) and the bails were pushed out. The underlying causes were:

the facility was not designed and equipped for the relevant lifting operation

deficiencies in elevator construction

deficient control and management

deficient inspection of the elevator with associated documentation

deficient system for securing necessary expertise

deficient implementation of NORSOK R003N, and breach of procedures

deficient planning, risk assessments, management and execution

extensive failure in the system for follow-up and improvement

deficient safety culture

deficiencies in safeguarding responsibility, establishment of, follow-up and further development of management systems, as well as deficiencies in the follow-up of other participants

It is very serious that several of the causes are the same as in the seven lifting incidents that formed the background for the order issued to Statoil in April 2010. In several of these incidents, the outcome could have been fatal under marginally altered circumstances

Involved Main group Approved by / date

T-1 Hanne Etterlid / 4 April 2011

Participants in the investigation group Investigation leader

Sigurd Førsund and Jan Ketil Moberg Sigurd Førsund

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Table of Contents

1 Sammendrag ..................................................................................................................... 2 2 Innledning ......................................................................................................................... 4

3 Hendelsesforløp ................................................................................................................ 5 4 Hendelsens potensial ....................................................................................................... 10

4.1 Faktisk konsekvens ............................................................................. 10 4.2 Potensiell konsekvens ......................................................................... 10

5 Observasjoner ................................................................................................................. 11

5.1.1 Innretningen var ikke utformet og utstyrt for den aktuelle

øfteoperasjonen .................................................................................. 11 5.1.2 Mangler ved konstruksjon av elevator ................................... 13 5.1.3 Mangelfull styring og ledelse ................................................. 14 5.1.4 Mangelfull kontroll av elevator med tilørende dokumentasjon15

5.1.5 Mangelfullt system for sikring av kompetanse ...................... 18 5.1.6 Mangelfull implementering av styringssystem – NORSOK R003N,

og prosedyrebrudd .............................................................................. 19 5.1.7 Mangelfull planlegging, risikovurderinger, ledelse og utøring24 5.1.8 Omfattende svikt i system for informasjon, erfaringsoverøring og

forbedring ........................................................................................... 28

5.1.9 årlig sikkerhetskultur .............................................................. 31 5.1.10 Mangler ved ivaretakelse av ansvar, etablering, oppølging og

videreutvikling av styringssystem, samt mangler ved oppølging av andre

deltagere ............................................................................................. 31 5.2 Barrierer som har fungert ................................................................... 33

5.2.1 Beredskap ............................................................................... 33 6 Diskusjon omkring usikkerheter ..................................................................................... 33

6.1 Potensialet i hendelsen ....................................................................... 33 6.2 Tidligere bruk av elevator .................................................................. 33

6.3 ør jobben øte ....................................................................................... 34 6.4 Prosedyrebrudd ................................................................................... 34 6.5 ”Trygg rig” prosjektet ........................................................................ 34

7 Vedlegg ........................................................................................................................... 34

1 Summary

The incident took place on the Njord A facility on 18 December 2010 at 00:15.

In connection with pulling the blowout preventer (BOP) and riser, the slip joint was to be laid

down from a vertical to a horizontal position on the catwalk. The lift was carried out using the

drilling machine (DDM), and a deck crane was connected to the lower part of the slip joint to

reduce the load on the catwalk and later to extract the slip joint from the drill floor.

A riser running tool was connected to the drilling machine (DDM) with a 350-tonne manual

elevator. When the elevator was approx. five metres above the drill floor, the bails pushed

against the elevator's link blocks , causing them to break, and the bails were pushed out of the

elevator's lifting lugs. The slip joint (approx. 23 tonnes) fell about four metres before it hit a

support trestle, fell onto the riser spider and further down to the drill floor before it hit the

driller's cabin and came to a stop. The support trestle jumped around the drill floor.

3

There were three people inside the red zone when the incident took place. The lifting

supervisor was 2-3 metres from where the slip joint fell. The support trestle, weighing approx.

one tonne, was headed towards the lifting supervisor before it hit a tong post and changed

direction. The person in question was in considerable danger of being struck by the support

trestle.

The incident did not result in personal injuries, but only minor material damage. Under

insignificantly altered circumstances, the outcome could have been fatal and resulted in

significant material damage.

The direct cause of the accident was incorrect use of the elevator. Because the slip joint was

rotated from a vertical to a horizontal position, the elevator was rotated in the bails and the

bails were thus pushed against the elevator's link blocks so that they broke (snapped) and the

bails were pushed out of the elevator's lifting lugs.

The underlying causes were:

the facility was not designed and equipped for the relevant lifting operation

deficiencies in elevator construction

deficient control and management

deficient inspection of the elevator with associated documentation

o the elevator was not CE-labelled and did not have a declaration of conformity

o the elevator's user manual was missing

deficient system for securing necessary expertise

o no training in use of the elevator

o very deficient familiarity with NORSOK R003N

deficient implementation of NORSOK R003N, and breach of procedures

o roles and responsibilities had not been clarified

o many general breaches of procedure

o deficient facility-specific procedure for lifting operations

o the management system (APOS) is perceived as cumbersome during lifting

operations

deficient planning, risk assessments, management and execution

o deficient risk assessment in planning and execution

o deficient procedure for the lifting operation incorrect use of offshore crane

o incorrect use of elevator

extensive failure in the system for follow-up and improvement

o deficient learning from many previous incidents

o insufficient follow-up of order

deficient safety culture

deficiencies in safeguarding responsibility, establishment of, follow-up and further

development of management systems, as well as deficiencies in the follow-up of

other participants

It is very serious that several of the causes correspond to those that caused the seven lifting

incidents that formed the background for the order issued to Statoil in April 2010. In several

of these incidents, the outcome could have been fatal under marginally altered circumstances.

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2 Introduction

In connection with pulling the BOP and riser on 18 December 2010, an incident occurred on

Njord A. The slip joint that had been pulled up, fell out of the bails and down onto the drill

floor during the process of laying it down from a vertical to a horizontal position.

On 19 December 2010, the PSA decided to carry out its own investigation of the incident. The

Police also decided to carry out their own investigation with assistance from the PSA.

Composition of the investigation group: Jan Ketil Moberg and Sigurd Førsund (investigation

leader).

Procedure.

Statoil notified the PSA regarding the incident on 18 December 2010. The PSA's on-call

personnel followed up the incident during the evening, and the PSA decided the day after to

start its own investigation of the incident.

The PSA's investigation group travelled to Njord A with the Police on 19 December 2010,

and arrived at the facility around 22:00 hours.

Following the opening meeting and safety round, an inspection was carried out on the drill

floor with personnel from KCAD/Statoil. The drill floor was cordoned off and all equipment

was left as during the incident.

Afterwards, a reconstruction was done with the elevator hung from the bails. The DDM with

bails was lowered so that a reconstruction could safely be done (right above the deck). The

reconstruction clearly showed that due to the design of the elevator and bails, the bails were

pushed out of the elevator's lifting lugs when it was rotated approximately 70 to 80 degrees.

Statoil's investigation team arrived at the facility on 20 December 2010.

In cooperation with the Police, Statoil's investigation team and relevant personnel on board, a

plan was drawn up for the investigation and interviews with personnel onboard, see enclosed

list. A total of six people were questioned/interviewed on the facility.

Documents were gathered and assessed in parallel with the interviews on board Njord A. The

documents include drawings, logs, procedures, reports, safety notifications, etc. See enclosed

list of documents.

During the investigation, Statoil decided that the elevator would be sent to DNV Bergen for

further investigation.

Later, Statoil procured documentation from relevant parties, including from the elevator

manufacturer, Blohm + Voss Repair GmbH, Oil Tool Division, Hamburg,(B+V).

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A summary meeting was held on board the facility at 21:00 hours on 21 December 2010.

The participants are listed in Attachment C. The Police and PSA personnel travelled ashore on

the morning of 22 December 2010.

We want to thank Statoil and KCAD for good facilitation for carrying out the investigation.

Everyone involved has shown great candour and good cooperation in the investigation.

The investigation group received the following mandate:

Assess operational, technical and management factors related to the incident, including

triggering and underlying causes.

Assess the gathered information against other incidents – and conclude with similarities

and differences in relation to these (cf. order in case 10/443).

Prepare a report in accordance with the PSA's investigation procedure

Assess Statoil's investigation report and its action plan when these are available

This report summarises the results following the PSA's investigation and presents these with a

basis in the investigation team's mandate. The PSA's assessment of Statoil's own investigation

of the incident will be documented at another time.

3 Course of events

In connection with pulling the BOP and riser, the slip joint, with a length of approx. 22 metres

and a weight of approx. 23 tonnes, was to be laid down from a vertical position on the drill

floor to a horizontal position on the catwalk.

The lifting operation was considered to be a routine operation, and a pre-job meeting was not

held with everyone involved in the lifting operation. The lifting supervisor had a pep talk with

the driller. Later, he instructed the crane operator via radio regarding what was to happen.

The lift was carried out using the drilling machine (DDM), and an offshore crane was

connected to the lower part of the riser to reduce the load on the catwalk and later to extract

the slip joint from the drill floor. A riser running tool was connected to the DDM with a 350-

tonne manual elevator.

At the start of the operation of laying the slip joint down in a horizontal position, a

manipulator arm was used to push the lower part of the slip joint in the direction of the

catwalk, in addition to pulling with the offshore crane.

There was a chain-driven carriage (moped) on the catwalk. The moped should have been run

to the end of the catwalk to make room for the slip joint when it was to be laid down. This had

not been done, and the end of the slip joint hit the moped when the elevator was approx. 11

metres above the drill floor. The driller then had a weight of two to three tonnes on the scale.

The lifting operation was then stopped until the moped had been run to the end of the catwalk.

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When the elevator was approx. 5 metres above the drill floor, and the slip joint had an angle

of approx. 78 degrees to the vertical, the bails pushed against the elevator's link blocks ,

causing them to snap and the bails to be pushed out of the elevator's lifting lugs. The slip joint

fell about four metres before it hit a support trestle, fell onto the riser spider and further down

to the drill floor before it hit the driller's cabin and came to a stop. The support trestle jumped

around the drill floor. The support trestle would have been used to support the top of the slip

joint to prevent overloading of the catwalk.

There were three people inside the red zone when the incident took place. The lifting

supervisor was at the southern vee door frame, 2-3 metres from where the slip joint fell. The

support trestle, weighing approx. one tonne, was facing the lifting supervisor before it hit a

tong post and changed direction.

The sketch below is from Statoil's presentation of the incident, and shows the location of

those present on the drill floor during the incident.

The following people played a role in the lifting operation:

The two roughnecks on the right of the sketch. One was running the manipulator arm,

and the other was running the moped.

The driller was running the DDM.

The deckman supervisor/lifting supervisor directed the others via radio.

The crane operator ran the offshore crane. (Not shown on the sketch, but the crane was

at approx. 90 degrees on the catwalk outside the drilling module. See the pictures in

Chapter 5.1.1)

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Drill floor seen from above – sketch from Statoil.

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Picture 1.

The picture below shows the slip joint after it had fallen, seen towards the vee door and

catwalk.

The support trestle and tong post are to the left of the slip joint.

Picture 2

The picture shows the slip joint from the side towards the drilling cabin.

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Picture 3

The picture shows the elevator hanging from the bails during the reconstruction. It is evident

that the link blocks have snapped.

Picture 4

The picture shows the broken link blocks .

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Picture 5

The picture below shows that during elevator rotation towards the horizontal position, there is

pressure on the link blocks (reconstruction), and that the bails are thus pushed out of the

elevator's lifting lugs so that they fall down.

4 The incident's potential

The incident did not result in personal injury, but only minor material damage. Under

insignificantly altered circumstances, the outcome could have been fatal and resulted in

significant material damage.

There were three people inside the red zone when the incident took place. The lifting

supervisor was at the southern vee door frame, 2-3 metres from where the slip joint fell. The

support trestle, weighing approx. one tonne, was headed towards the lifting supervisor before

it hit a tong post and changed direction. The person in question was in considerable danger of

being struck by the support trestle.

4.1 Actual consequence

The incident did not result in any personal injuries, only material damage.

There was no harm to the external environmental as a result of the incident.

4.2 Potential consequences

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Under insignificantly altered circumstances, the outcome could have been fatal. The lifting

supervisor could have been struck by the support trestle.

If the fall had started at a slightly different time, the material damage could have been greater.

The PSA has no basis for evaluating whether the riser spider possibly could have been

damaged so that the riser and BOP could have fallen to the seabed, or whether the slip joint

could have fallen, resulting in greater material damage.

5 Observations

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

Nonconformities: In this category we find observations which the PSA believes are breaches

of the regulatory regulations. The nonconformities are listed chronologically and according to

severity.

Improvement items: Related to observations where we find deficiencies, but do not have

sufficient information to prove breach of the regulatory requirements.

In connection with this investigation, the PSA has used the regulations in force at the time of

the incident as a basis.

Chapter 5.1 describes ten nonconformities.

Several of the observed nonconformities have previously been reported following three other

audits of logistics and materials handling on other Statoil facilities in 2010.

5.1.1 The facility was not designed and equipped for the relevant lifting operation

Nonconformity:

The facility was not designed and equipped for lifting a slip joint from a vertical to a

horizontal position.

Description:

The catwalk and moped were not designed for the weight of the slip joint. This emerged

during the interviews. To perform the lifting operation, the offshore crane had to be used in

violation of the manufacturer's restrictions stated in the user manual (see also Chapter 5.1.7).

At the start of the lift, there was a side lead of about 6 degrees, which is approximately twice

what the manufacturer allows, i.e. 3.2 degrees at two parts steel rope hoist (which were used).

See picture below which shows the offshore crane

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The picture below shows visibility from the crane driver's cabin (blind lift)

Requirements:

Section 5 of the Facilities Regulations regarding design of facilities

Facilities must be based on robust and the simplest possible solutions and designed so that

a) they can withstand the loads as mentioned in Section 11,

………

c) failure of one component, system or a single erroneous action does not result in

unacceptable consequences,

………..

e) materials handling and transport can take place efficiently and prudently, cf. Section 13,

………………..

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g) operational assumptions and restrictions are safeguarded in a prudent manner,

Section 23 of the Activities Regulations regarding use of facilities

The use of facilities and parts of these must be in accordance with requirements laid down in

and in pursuance of the health, safety and environment legislation and any additional

restrictions that follow from fabrication, installation and commissioning. The use must at all

times be in accordance with the facility's technical condition and the preconditions for use

that have been used as a basis in the analyses, cf. Chapter V of the Management Regulations.

Section 83, first subsection, of the Activities Regulations regarding lifting operations

Lifting operations must be cleared, managed and executed in a prudent manner, e.g. by

ensuring that personnel are never under suspended loads, cf. Section 28 regarding actions

during conduct of activities. Cf. also Chapter VII regarding planning and conduct of activities

and Section 40 regarding use of work equipment.

The Guidelines to Section 83, first subsection, of the Activities Regulations relating to

lifting operations

In order to fulfil the requirement relating to lifting operations as mentioned in the first

subsection, the NORSOK R-003 standard should be used.

Cf. NORSOK R003NN, Chapter 4.1 Overall requirements

All use, maintenance, storage, checks, inspections and examinations of lifting equipment must

be in accordance with the manufacturer's user manual as well as requirements in this

NORSOK standard with annexes, see NS-EN 365. The lifting equipment must not be adapted

to purposes other than those designated without the consent of the manufacturer and

competent body.

5.1.2 Deficiencies in elevator construction

Nonconformity:

The elevator's construction does not satisfy fundamental principles for integration of safety.

Description:

The direct cause of the accident was incorrect use of the elevator. Because the slip joint was

rotated from a vertical to a horizontal position, the elevator was rotated in the bails and the

bails were thus pushed against the elevator's link blocks so that they broke (snapped) and the

bails were pushed out of the elevator's lifting lugs.

Note: The elevator was neither ordered nor delivered in accordance with the Machinery

Regulations. It was ordered and delivered in accordance with API 8C.

Requirements:

Section 82 of the Facilities Regulations regarding machinery and safety components not

comprised by the Facilities Regulations

These regulations do not apply for products covered by the Regulations of 20 May 2009 No.

544 relating to machinery (the Machinery Regulations).

The Machinery Regulations, Chapter 1.1.2 Principles for integration of safety

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a) Machinery must be constructed and designed so that it can function, be adjusted and

maintained without exposing people to risk when the operations are carried out

during conditions foreseen by the manufacturer, but also during incorrect use that can

reasonably be foreseen. The purpose of the measures must be to remove any risk of

harm to life and health that may occur over the course of the machinery's expected

lifetime, including during transport, assembly, disassembly, disconnection and when

the machinery is scrapped.

b) When choosing appropriate methods, the manufacturer or its representative must use as

a basis the following principles in the following order:

- remove or reduce the risk to the extent possible, i.e. that the machinery must

be designed and built in a manner that makes it inherently safe,

- implement necessary protective measures against risks that cannot be

removed

- inform the users regarding remaining risks that are present when potential

protective measures have been implemented, whether special training is

required, and whether it is necessary to use personal protective equipment.

c) During construction and manufacture of machinery and during preparation of user

manuals, the manufacturer or its representative must not only take into consideration

the machinery's presumed use, but also consider any reasonably predictable incorrect

use

Machinery must be designed and built so that incorrect use is prevented if such use

may result in danger. In those cases where experience shows that machinery can still

be used in an incorrect manner, the user manual must contain information to this

effect.

The Machinery Regulations were made applicable offshore on permanently placed facilities

in 1995.

5.1.3 Deficient control and management

Nonconformity:

The responsible party had not ensured that prudent and safe lifting operations could take place

in the drilling area on Njord A.

Description:

The number of nonconformities and their severity shows that there was no basis for safe and

prudent lifting operations in the drilling area on Njord A. Serious faults were identified in

management systems and in the execution of roles and responsibilities throughout the line

management on board down to and including executing personnel. (cf. all nonconformities

proven in this report).

Requirements:

Section 6 of the Management Regulations relating to management of health, safety and the

environment

The responsible party must ensure that the management of health, safety and the environment

comprises the activities, resources, processes and organisation necessary to ensure prudent

activities and continuous improvement, cf. Section 17 of the Framework

15

Regulations\\odfs01.od.local\uservolume\Regelverksorginaler_PTIL\R2010\Rammeforskrifte

n_n.htm - p17.

Responsibility and authority must be unambiguously defined and coordinated at all times.

The necessary governing documents must be prepared, and the necessary reporting lines must

be established.

5.1.4 Deficient inspection of the elevator with associated documentation

Nonconformity:

Statoil does not have a system to ensure that lifting equipment it owns meets relevant

regulatory requirements.

KCAD does not have a management system to ensure that custom-designed lifting gear in the

drilling area is checked and certified by a competent body.

Description:

Statoil owns the elevator and KCAD is, through contract with Statoil, responsible for the use

and maintenance of the elevator.

Statoil has made Norsok R003N its governing documentation by incorporating it in its

entirety in its management system, APOS. Furthermore, Statoil also has its own good

additional requirements for safe lifting operations.

However, the elevator was not CE-labelled, did not have a declaration of conformity and was

not controlled and maintained in accordance with relevant requirements. Furthermore, the

user manual was not available to the users.

During the interviews and the verification of available documentation, we learned that the

elevator had not been controlled, approved and certified by a competent body.

The user manual was not available for the users, or requested by the users, and the elevator

was not tagged with the year's color.

The involved elevator was of the type CL 350, Center Latch Elevator.

It was manufactured in 1997. Serial number: 5270 and manufacturer's part number: 613540-

Y-111. Size 5.1/2” IEU

The elevator was not ordered in accordance with the Machinery Regulations, even though this

was made applicable on permanently placed facilities in 1995, but it was ordered and

delivered in accordance with API 8C, which also requires a user manual..

A user manual dated November 2010 was later submitted.

The title of the document is:

Blohm + Voss Pipe Handling Equipment

CL 150-1000 Center Latch Elevator,

Manual Operated

Technical Documentation

Original Instructions

Page three of this user manual, under “General safety issues” includes for example:

16

”WARNING: The picking up of horizontal or tilted pipes is dangerous. This use is not

permitted.”

What the original user manual said regarding usage restrictions is unknown, it could not be

presented during the investigation.

Requirements:

Section 80 of the Facilities Regulations regarding machinery and safety components not

comprised by the Facilities Regulations

These regulations do not apply for products covered by the Regulations of 20 May 2009 No.

544 relating to machinery (the Machinery Regulations).

The Machinery Regulations were made applicable offshore on permanently placed facilities

in 1995.

Guidelines to Section 82 of the Facilities Regulations regarding machinery and safety

components not comprised by the Facilities Regulations, second and third paragraph

This means that the Machinery Regulations apply to permanently placed facilities, including

floating production facilities in permanent positions (in position for the entire life span of the

field). As regards these floating production facilities, the Machinery Regulations apply to

equipment that is necessary for carrying out drilling and production activities, and that does

not have any function in relation to normal maritime activities.

The Machinery Regulations Sections 1 and 2 stipulate the scope of the regulations and which

equipment is comprised by the Machinery Regulations. In those cases where the Machinery

Regulations do not apply, relevant parts of the Facilities Regulations will apply.

Regulations of 20 May 2009 No. 544 relating to machinery Chapter I. Introductory provisions

Section 1 Scope

1. These regulations apply during construction, manufacture and sale of the following

products:

a) machinery

b) replaceable equipment

c) safety components

d) lifting gear

e) chains, rope and sling straps

f) detachable mechanical power transmission units

g) partially commissioned machinery

Chapter 4.4 User manuals

4.1.4 Lifting gear

Each piece of lifting gear or each commercial set of indivisible stock lots of lifting gear must

be accompanied by a user manual that must, as a minimum, contain the following

information:

a) intended use,

b) restrictions for this use (in particular for the lifting gear, such as magnetic or vacuum

suction cups, that do not fully satisfy the requirements in subsection 4.1.2.6, litera e)

c) guidelines regarding assembly, use and maintenance,

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d) the employed static testing factor.

Section 44 of the Activities Regulations relating to maintenance programmes

Failure modes that constitute a health, safety or environment risk, cf. Section 43 regarding

classification, must be prevented systematically by means of a maintenance programme.

The program must include activities for monitoring performance and technical condition,

which ensure that failure modes that are under development or have occurred, are identified

and corrected.

The program must also contain activities for monitoring and control of failure mechanisms

that can lead to such failure modes”.

The guidelines to Section 44 of the Activities Regulations relating to maintenance

programmes reference NORSOK R003NN as a recommended norm for preliminary

inspection of lifting appliances and lifting gear. Annex H of this standard requires, if an

external competent body is used, that this body be certified in accordance with the

certification scheme established by DAT through requirements in the Regulations relating to

the use of work equipment.

Furthermore, this standard requires that:

”A program must be prepared that describes the expert inspection for each type of lifting

appliance and lifting gear. The periodic inspection must be in accordance with the

manufacturer's user manual and include, as a minimum,

• review of documentation, certificates, etc.,

• review of report from competent body, maintenance and equipment history from its last

inspection period,

• technical inspection (including tagging),

• function test,

• reporting and signature for completed inspection.”

NORSOK R003N, chapter 4.1 Overall requirements requires that:

”The lifting equipment must not be adapted to purposes other than those designated without

the consent of the manufacturer and competent body”.

Norsok R003N, Annex E (normative) Documentation and labelling

E.1 Requirements for user documentation - lifting equipment put to use after 8 April 1995

The requirements for labelling and documentation below will apply for lifting equipment on

permanently placed facilities that started operations after 8 April 1995.

All lifting equipment must be accompanied by a declaration of conformity and must be CE-

labelled in accordance with the Regulations relating to machinery.

All lifting equipment must be accompanied by a user manual in accordance with requirements

in the Regulations relating to machinery.

All lifting equipment must be accompanied by a certificate from a competent body.

Section 83, first subsection, of the Activities Regulations regarding lifting operations

Lifting operations shall be cleared, lead and conducted in a safe manner.”

The guidelines to Section 83 of the Activities Regulations relating to lifting operations

reference NORSOK R003N as the recommended standard for safe use of lifting equipment.

18

This standard requires the use of a user manual. This is mentioned 23 times in the standard.

For example:

”4.1 Overall requirements

All use, maintenance, storage, checks, inspections and examinations of lifting equipment must

be in accordance with the manufacturer's user manual as well as requirements in this

NORSOK standard with annexes, see NS-EN 365.”

”4.4 Planning

All lifting operations must be planned to ensure that they are carried out safely and that all

predictable risks have been accounted for. The planning must be performed by personnel with

the necessary expertise.

The planning of lifting operations must, as a minimum, ensure that

• lifting appliances and lifting gear are suitable and that the planned use is in accordance

with the manufacturer's directions”,

”7 Additional requirements for various lifting gear

Use and daily checks of lifting gear must be in accordance with the manufacturer's user

manual as well as requirements in this NORSOK standard with annexes.

Annex A – Roles and responsibilities

The party responsible for technical operations must

ensure that necessary maintenance programs are established, implemented, executed

and maintained in accordance with the manufacturer's instructions and experiences

with this type of equipment, see Annex G regarding maintenance,

ensure that necessary expert inspections are carried out and followed up in accordance

with Annex H regarding competent bodies,

ensure that required documentation for lifting equipment is available in accordance

with Annex E regarding documentation and labelling,

The operator of lifting appliances must

operate the lifting appliance and lifting gear correctly in accordance with the

manufacturer's user manual, this NORSOK standard and company-internal governing

documents,”.

The slinger must

Select and use lifting appliances and lifting gear in accordance with the manufacturer's

user manual, this NORSOK standard and company-internal governing documents,

5.1.5 Deficient system for securing expertise

Nonconformity:

It was not ensured that relevant personnel had sufficient expertise.

Description:

Statoil has made Norsok R003N its governing documentation by incorporating it in its

entirety in its management system, APOS. Furthermore, Statoil also has its own good

additional requirements for safe lifting operations. KCAD was to follow Statoil's APOS

requirements for all lifting operations.

However, through the interviews we learned that relevant personnel had not been trained in

use of this elevator in accordance with the manufacturer's user manual.

Furthermore, there was consistently poor familiarity with NORSOK R003N, and no system

had been established to secure sufficient expertise and familiarity with NORSOK R003N.

Neither had a system been established to secure maintenance of such expertise.

19

Requirements:

Section 19, first subsection of the Activities Regulations regarding expertise

It must be ensured that the personnel at all times have the expertise necessary to be able to

carry out the activities in a safe manner and in accordance with the health, safety and

environment legislation.

The guidelines to Section 19 of the Activities Regulations read:

The requirement relating to ensuring expertise implies, inter alia, that requirements are set

for the necessary expertise, that the expertise is verified, and that it is maintained through

practice, exercises, training and education.

Section 83, first subsection, of the Activities Regulations regarding lifting operations

Lifting operations shall be cleared, lead and conducted in a safe manner.”

The guidelines to Section 83 of the Activities Regulations relating to lifting operations

references NORSOK R003N as the recommended standard for safe use of lifting

equipment.

Cf. NORSOK R003NN, Chapter 4.1 Overall requirements

All use, maintenance, storage, checks, inspections and examinations of lifting equipment must

be in accordance with the manufacturer's user manual as well as requirements in this

NORSOK standard with annexes, see NS-EN 365. The lifting equipment must not be adapted

to purposes other than those designated without the consent of the manufacturer and

competent body.

Chapter 3.1 Terms and definitions reads:

3.1.3 documented training

training where it can be documented that the person that will use the lifting equipment, has

received practical and theoretical training that provides knowledge regarding construction,

operation, useful properties and area of use, as well as maintenance and inspection in

accordance with the requirements set for safe use and operation in regulations and user

manuals

The normative Annex A, roles and responsibilities, requires that

”the party responsible for operations must ensure that the lifting operations are carried out

with sufficient and qualified personnel.”

The normative Annex B, training requirements, requires that

”the OIM must ensure that all personnel involved in lifting operations, or in maintenance of

the lifting equipment, are qualified, competent and sufficiently trained to carry out the

assignments and safeguard the areas of responsibility.”

Furthermore, it is required that “personnel under training must only be assigned tasks that

correspond to their current expertise, as assessed by their mentor and the party responsible

for operations.”

5.1.6 deficient implementation of management system (NORSOK R003N), and

breach of procedures

20

Nonconformity:

The person responsible had not ensured that a management system had been established to

ensure that safe and prudent lifting operations could take place in the drilling area on Njord A.

A significant number of procedure breaches were proven.

Description:

Statoil has made Norsok R003N its governing documentation by incorporating it in its

entirety in its management system, APOS. Furthermore, Statoil also has its own good

additional requirements for safe lifting operations. KCAD was to follow Statoil's APOS

requirements for all lifting operations.

The following is an additional requirement in Statoil's paramount governing document

OMC01, Organisation, management and control, Final Ver. 3, in force from 13 January 2010:

”App C Operationally responsible lifting operations

Is responsible for ensuring that the installation has a safe work system for lifting operations

Applies for all lifting equipment (including in drilling's areas). There may therefore be a

need for several people with operational responsibility for lifts on a facility. Natural

for drilling to have a dedicated person responsible for lifting operations”

However, the investigation showed that the responsible person had not implemented a

necessary management system for ensuring prudent lifting operations in the drilling area.

Furthermore, the investigation identified a considerable number of procedure breaches.

The evidence for these was:

(Cf. roles in Norsok R003N vs. positions with relevant responsibilities)

1. Implementation of NORSOK R003N had not been ensured.

Offshore installation manager

2. Compliance with NORSOK R003NN had not been ensured.

3. Compliance with all regulatory requirements had not been ensured.

4. Establishment, implementation and maintenance of facility-specific governing

documentation had not been ensured.

5. The availability of qualified personnel to carry out safe lifting operations had not been

ensured.

6. The designation of parties responsible for technical and general operations for all lifting

appliances and lifting operations on the facility had not been ensured.

Responsible party - technical

7. The execution and follow-up of necessary expert inspections had not been ensured in

accordance with Annex H in NORSOK R003N regarding competent bodies.

8. The availability of required documentation for lifting equipment had not been ensured

in accordance with Annex E in NORSOK R003N regarding documentation and

labelling.

Responsible party - operations

9. Compliance with NORSOK R003N and facility-specific governing documentation had

not been ensured.

10. The execution of overall operational management of the lifting operation had not been

ensured.

11. Overall planning and execution of the lifting operation had not been ensured.

12. Execution of the lifting operation with qualified personnel had not been ensured.

21

Lifting appliance operator

13. Safety was not ensured for this lift.

14. Planning of this lifting operation had not been ensured in accordance with NORSOK

R003N Chapter 4.4.

Slinger:

15. Appropriate lifting gear was not selected.

16. Correct operation of the lifting gear was not ensured in accordance with the

manufacturer's user manual.

17. The participation in planning by everyone involved in this lifting operation was not

ensured.

18. The selection and use of lifting gear was not ensured in accordance with the

manufacturer's user manual

KCAD drilling superintendent:

19. It was not ensured that the performed work maintained the quality required by

governing documentation.

KCAD toolpusher

20. It was not ensured that the operation was carried out in accordance with relevant

authority and operator requirements.

21. Sufficient quality assurance of the operation procedure in ”Well Manager” was not

ensured.

KCAD in general

22. Safe operation of the equipment used was not ensured.

23. Necessary revision of the work specification in “Well Manager” was not ensured.

The evidence was gathered through interviews and review of documentation.

Comments:

To Items 4 and 6 through 12)

Local procedures pursuant to NORSOK R003NN Annex C were requested on Njord A. We

were presented with a document (copy of a powerpoint presentation titled ”Crane and lifting

on Njord A”. The following text was added by hand: ”Local addition in APOS K-21450”)

The document seemed to be a modified presentation of how roles and responsibilities in

connection with lifting operations could be distributed within Statoil's new organisational

model. For example, there were several pages with the columns “roles, role description,

example positions and expertise requirements”. The presentation was clearly modified to

show Njord A's selections. The role of “Responsible party – Technical lifting equipment” was

assigned to “Maritime logistics manager”. The same position was assigned the role of

“Responsible party – Lifting operations”. The document did not mention anything about the

existence of other positions with these roles within drilling.

In the interviews, we learned that it was very unclear who filled these roles in drilling. There

was considerable uncertainty in questions regarding who filled the role of operationally

responsible for lifting operations on the drill floor, and we received several alternate replies.

To questions regarding who filled the role of technically responsible there was similar

uncertainty among relevant personnel, with varied opinions regarding which position held this

role

22

In general, the document did not cover any of the other 18 items in Annex C in NORSOK

R003N. (see requirements below).

Regarding all items 1 – 18: These are breaches of governing

documentation/procedures, APOS/ NORSOK R003N.

Regarding item 19: This is a breach of requirements in the job descriptions for

Statoil's drilling superintendents. (see requirements below)

Regarding items 20 – 23: These are breaches of requirements in the job descriptions

for KCAD toolpusher and driller. (see requirements below)

In the interviews we learned that Statoil's management system (APOS) was perceived by

many as cumbersome and not sufficiently accessible for use during lifting operations. It was

asserted that it was difficult to find and gain an overview of all relevant requirements.

Requirements:

Section 3 of the Management Regulations relating to management of health, safety and the

environment

The responsible party must ensure that the management of health, safety and the environment

comprises the activities, resources, processes and organisation necessary to ensure prudent

activities and continuous improvement, cf. Section 13 of the Framework

Regulationshttp://www.ptil.no/rammeforskriften/rammeforskriften-n-article3855-381.html -

p13 regarding the duty to establish, follow up and further develop management systems.

Responsibility and authority shall be clearly defined at all times.

The necessary governing documents must be prepared, and the necessary reporting lines must

be established.”

Section 83, first subsection, of the Activities Regulations regarding lifting operations

Lifting operations shall be cleared, lead and conducted in a safe manner.”

The guidelines to Section 83 of the Activities Regulations relating to lifting operations

reference NORSOK R003N as the recommended standard for safe use of lifting equipment.

Cf. NORSOK R003N, Annex A (normative),

Roles and responsibility,

The company must (if it chooses to use this standard as a basis for its activities)

• implement this NORSOK standard

The OIM must

• ensure compliance with this NORSOK standard and ensure compliance with all regulatory

requirements,

• establish, implement and maintain facility-specific governing documentation,

• ensure that sufficient and qualified personnel are available to carry out safe lifting operations,

• assign technically and operationally responsible persons for all lifting appliances and lifting

operations on the facility. The responsibility must be associated with one or more positions on

board the facility,

The technically responsible party must,

23

• ensure that necessary expert inspections are carried out and followed up in accordance with

Annex H regarding competent bodies,

• ensure that required documentation for lifting equipment is available in accordance with

Annex E regarding documentation and labelling,

The operationally responsible party must,

• ensure that this NORSOK standard and facility-specific governing documentation are

complied with,

• exercise overall operational management of the lifting operations,

• ensure overall planning and execution of lifting operations in various areas and assess

safety in connection with simultaneous operations,

• ensure that the lifting operations are carried out with sufficient and qualified personnel,

The operator of lifting appliances must

• manage and ensure safety for the individual lift,

• plan the individual lifting operation, see 4.4,

• select appropriate lifting gear,

• ensure that the lifting appliance and lifting gear are in good useful condition and in accordance

with the manufacturer's user manual, specifications and instructions,

• operate the lifting appliance and lifting gear correctly in accordance with the manufacturer's

user manual, this NORSOK standard and company-internal governing documents,

The slinger must,

• participate in planning of the individual lifting operation,

• select and use lifting appliances and lifting gear in accordance with the manufacturer's

user manual, this NORSOK standard and company-internal governing documents,

Annex C (Normative) Requirements for local procedures:

Facility-specific procedures must be prepared for the individual facility, covering the

following areas:

• necessary operational restrictions for the individual lifting appliance, weather, vessel calls,

etc.;

• who holds different roles, (related to position);

• materials handling,

• prohibited areas for lifting (crane restrictions chart);

• lifting over pressurised area, hazardous loads, etc.;

• loading deck restrictions chart;

• placement and handling of various types of loads, chemicals, radioactive sources, tracers,

explosives, etc.;

• access to hazardous loads as required for moving them as a result of emergency situations,

e.g. fire;

• simultaneous operations;

• special lifting operations;

• necessary cordoning of the areas the cargo will be moved over;

• communication equipment and channel use;

• crane operations during helicopter traffic;

• maintenance, audits and inspections of lifting equipment and lifting gear;

• lifting operations related to emergency preparedness management;

24

• storage and follow-up of loose lifting equipment;

• necessary emergency procedures;

• plan for storm situation;

• pipe handling in the drilling area and lifting to and from the drill floor.

APOS Responsibilities and duties – Drilling supervisor/Drilling supervisor night, Rev. 2.5,

3 October 2010

Drilling supervisor/Drilling supervisor night must furthermore:

………..

Be responsible for ensuring that the participating personnel, the work performed as well as

delivered maintains the quality required through governing documentation, programs,

agreements and contracts

………………………….

KCAD job description – toolpusher, KCAD-06-P2-22-J21, rev 0, 5 May 2008

RESPONSIBILITIES AND DUTIES:

……………..

Be familiar with relevant authority and operator requirements, as well as be responsible for

the operation working according to these.

………………..

Quality-assure operation procedures in Well Manager.

………………

KCAD job description – driller, KCAD-06-P2-22-J24, rev 0, 5 May 2008

RESPONSIBILITIES AND DUTIES:

……………..

Ensure that equipment he/she operates is in prudent condition, and that the equipment

functions in a safe manner.

……………..

He/she must ensure that the work specifications are revised if necessary.

………………….

Section 22, second subsection, of the Activities Regulations regarding procedures

It must be ensured that procedures are designed and used such that they fulfil their intended

functions.

5.1.7 Deficient planning, risk assessments, management and execution

Nonconformity:

The planning, risk assessments, management and execution of the work of pulling the BOP,

riser and slip joint was deficient.

Description:

The risk was underestimated in the planning, both by Statoil and KCAD Drilling. The lifting

operation was considered to be a routine operation, and a standard ”Well Manager” procedure

was prepared for it, but it was particularly deficient and incorrect. Furthermore, the risk was

also underestimated by leading and executing personnel on the facility in the execution of the

operation.

25

The hazards of using a manual elevator were not identified in detail in planning the operation.

Statoil had established a ”Risk Tolerance matrix and risk register DG4 Completion” –

”Run/Pull BOP/MR”. This matrix had defined one risk in the initial ”red” (unacceptable) area.

This was the risk of ”Dropped BOP”.

The following ”Risk improvement actions” were identified: ”Follow operational procedures.

Pre-job meetings. Certified equipment. Use tounges when orienting. Halt operations during

crew changes and breaks”. Responsible for measures: KCAD.

These measures thus led to the “Remaining risk" being placed in the ”yellow” (acceptable)

risk. The investigation identified that no pre-job meeting was held with everyone involved,

that the operational procedures were particularly deficient, and that no risk analysis could be

presented for the procedure. Furthermore, the elevator was not certified in accordance with

applicable requirements.

Statoil's risk matrix was in ”Status:Draft” and with ”Expiry Date 4 September 2009”.

We requested copies of all procedures that were relevant for the operation that resulted in the

incident, as well as all documentation of associated risk assessments. We received ”Well

Manager” procedure No. KCAD-WM-NJO-8228, ”Pulling of BOP and riser”, rev. 20, dated

16 August 2010.

Under Chapter 2 HSE/hazard identification, Item 2 ”Lifting operation”, this says e.g. that

”The planning must be performed by personnel with the necessary expertise in the relevant

operation to be performed”. Under Item 4 in the same chapter ”Before the job”, it says that ”A

pre-job meeting must be held with everyone involved where the operation plan/HAZID log,

as well as necessary work specifications must be reviewed”.

However, no pre-job meeting was held with everyone involved in the lifting operation before

the job started. Through interviews, we learned that the job was considered a routine job, and

that the lift responsible and driller had a ”pep talk” in the driller cabin. Later, the lift

responsible instructed the crane operator via radio before the lifting operation started.

The following is the only reference to the use of an elevator: ”Using 5 1/2” Manual elevator”.

There is no reference to how it will be used, not used, operational restrictions or hazards in

using the elevator.

The direct cause of the accident was incorrect use of the elevator. Because the slip joint was

rotated from a vertical to a horizontal position, the elevator was rotated in the bails and the

bails were thus pushed against the elevator's link blocks so that they broke (snapped) and the

bails were pushed out of the elevator's lifting lugs. The geometric design of the elevator was

such that this would inevitably take place during this use and with these 500-tonne bails.

A manual elevator was used, even though there was a remote controlled elevator on board that

could have been used. No application for exemption was presented regarding this. The ”Pipe

handling matrix” pursuant to guideline OLF/NR – 081 was presented, and it says that ”Marine

Risers and Slip Joint > 20” can be run manually ”Horizontal to vertical”. The following is

under compensatory actions: ”Procedure No. KCAD-WM-NJO 7019”. This procedure was

not presented.

Regarding use of the offshore crane, it says that ”if weather conditions permit, the crane

should lift from the end of the slip joint and hold the weight when the slip joint is run out and

laid down on the catwalk”. Nothing is mentioned regarding usage restrictions in connection

with side lead.

26

The offshore crane was used beyond the operational limitations indicated by the

manufacturer's user manual, and beyond general standards for use of offshore cranes. During

the lifting operation, the crane was used to pull sideways almost double the allowed weight.

There was about six degrees side lead at the start of the lifting operation, while the maximum

allowed was 3.2 degrees. Furthermore, no one checked with the equipment manufacturer

whether the necessary side lead was prudent (nonconformity process).

Under the title ”Related documents”, the following document is listed: ”Document No. 8196,

Document Name Running the riser, BOP and slip joint.” This document has not been

submitted. Whether it exists, whether it says something more regarding the relevant operation

or the use of the elevator and offshore crane is unknown. In the interviews we learned that the

first mentioned “Well Manager” procedure was used in connection with the operation.

Furthermore, a KDAD Toolbox Risk Identification Card (TRIC) had been signed out on 17

December 2010. This document is part of KCAD work specification number KCAD-WM-

NJO-8228.

The back of TRIC was designed as a checklist, and is titled ”Identification of hazardous

conditions”. There were 16 checkpoints, with the following instructions: ”For all points

checked, the implemented measures must be listed.” The first four checkpoints were titled as

follows:

Risk of falling objects?

Use of lifting equipment?

Work near movable cargo?

Manual handling of equipment?

Neither these nor other points on the checklist were ticked, nor any measures described.

After reminders regarding risk assessments of the type HAZID/HAZOP, that should form the

basis for preparation of the ”Well Manager” procedure, we received a reference to the already

received document, ”Well Manager” procedure No. KCAD-WM-NJO-8228, ”Pulling of BOP

and Riser”, rev. 20, dated 16 August 2010.

27

Requirements:

Section 83, first subsection, of the Activities Regulations regarding lifting operations

Lifting operations must be cleared, managed and executed in a prudent manner, e.g. by

ensuring that personnel are never under suspended loads, cf. Section 28 regarding actions

during conduct of activities. Cf. also Chapter VII regarding planning and conduct of activities

and Section 40 regarding use of work equipment.

The Guidelines to Section 83, first subsection, of the Activities Regulations relating to

lifting operations

In order to fulfil the requirement relating to lifting operations as mentioned in the first

subsection, the NORSOK R-003 standard should be used.

Cf. NORSOK R003N, Chapter 4.4 Planning

All lifting operations must be planned to ensure that they are carried out safely and that all

predictable risks have been accounted for. The planning must be performed by personnel with

the necessary expertise.

In the event of repeated or routine operations, such planning is only necessary the first time.

This presupposes that execution of the operation is established in procedures or documented

in some other manner. Periodic audits must be performed in order to ensure that no critical

factors have changed.

The planning of lifting operations must, as a minimum, ensure that

………….

• the lifting route has been clarified and any obstacles removed before lifting,

…………

• lifting appliances and lifting gear are suitable and planned used in accordance with the

manufacturer's directions,

• the load's landing area is of sufficient size and designed for the weight of the load,

………………..

• involved personnel have sufficient expertise and familiarity with regulations and standards

that is normative for the operation to be performed,

…………….

Cf. NORSOK R003N, Chapter 6.3, Pipe handling on pipe deck and in the drilling area

The chapter deals with use of winch-hoisting or equivalent lifting equipment for lifting top

drives together with other pipe handling equipment.

Reference is made to OLF Guideline No. 081 for requirements for remote operated pipe

handling.

Cf. OLF Guideline, Chapter 6, General requirements

The following procedures must be carried out in the event of operation of pipe handling

equipment:

All pipe handling that can be remotely operated shall be handled in this manner as long as

this improves the overall safety level. IF manual handling is chosen, regardless of possible

remote handling solutions, a documented risk assessment SHALL be established. The

application for exemption shall be sent to the PSA. Remote operations shall be performed

from a safe position away from the exposed area. Each installation shall, on an individual

basis, define the safe area (Red Zone).

28

Handling procedures shall be established for all planned manual pipe handling operations

marked ”M” in the matrix. These procedures must be based on risk analysis (HAZID).

For planned manual operations, the rig specific handling procedures must be examined

before the manual operation starts.

Cf. NORSOK R003NN, Chapter 4.1 Overall requirements

All use, maintenance, storage, checks, inspections and examinations of lifting equipment must

be in accordance with the manufacturer's user manual as well as requirements in this

NORSOK standard with annexes, see NS-EN 365. The lifting equipment must not be adapted

to purposes other than those designated without the consent of the manufacturer and

competent body.

Cf. NORSOK R003N, Chapter 4.5 Limitations

The lifting appliance operator must map and consider restrictions that may affect the lifting

operation, including the lifting equipment's capacity, weather conditions, movements, landing

areas, blind spots and other restrictions resulting from the lifting route.

5.1.8 Extensive failure in the system for follow-up, transfer of experience and

improvement

Nonconformity:

Transfer of experience and learning following previous incidents were inadequately

safeguarded.

Description:

Reference is made to the incidents on West Epsilon on 14 September 2007, Deepsea Atlantic

on 10 August 2009 and Heidrun on 15 April 2010. All these incidents are recorded in Statoil's

system for information, transfer of experience and improvement, Synergy.

Those responsible have not managed to share information and experience and ensure

important improvement and learning following these important and relevant incidents.

WEST EPSILON INCIDENT 14 SEPTEMBER 2007

Available safety flashes, experience reports, investigation reports, as well as two circulars

from the PSA following the West Epsilon incident, which told of important experience gained

with the elevators, were not passed on to the users. The companies' planned measures were

not implemented.

The hazards of using a manual elevator were not identified in the well planning.

Neither were the hazards identified in the detailed planning of the operation (DOP).

The elevator had not been modified, neither according to ”safety notice” No. 1 of June

2004 nor ”production update notification” No. 16. of July 2008 from the manufacturer.

The user manual had not been made available.

The detailed procedures had not been revised.

Necessary training was not provided.

The hazards of using a manual elevator had not been passed on to the operators.

29

DEEPSEA ATLANTIC INCIDENT 10 AUGUST 2009

The direct cause of the accident was that the elevator was not properly closed and locked

when the casing was lifted.

The underlying causes included:

lack of equipment for remote pipe handling

deficient inspection and maintenance of the elevators

lacking user manual

failure in management systems

deficient initial inspection

deficiencies in the systems for information, transfer of experience and improvement

deficient expertise

deficient planning, execution and risk assessments

deficient management

deficient procedure

breach of procedure

HEIDRUN INCIDENT 15 APRIL 2010

This incident's causal relations were very similar to those of the two incidents mentioned

above. In addition to these incidents, three similar previous incidents, on Transocean Searcher

in 2007, Heidrun in 2008 and Stena Don in 2009, formed the basis for issuing Statoil the

following order:

Pursuant to the Management Regulations, Section 21 regarding follow-up and Section 22

regarding improvement, and

Section 83 of the Activities Regulations regarding lifting operations, cf. Section 58 of the

Framework Regulations regarding

administrative decisions, Statoil Petroleum AS (Statoil) is ordered to:

- identify all custom-designed lifting gear in the drilling area and ensure that these

satisfy the regulatory requirements

- verify and implement measures to ensure that NORSOK R003N is implemented and

practiced in

the drilling area. (Comment: Statoil has used NORSOK R003N as a basis for lifting

operations in

a dedicated management system, cf. Section 5 of the Management Regulations.)

- consider and decide how the company will learn from previous incidents and use

experience gained to prevent lifting incidents in the drilling area throughout the organisation

After Statoil presented plans regarding how it would implement initiatives to satisfy the

orders, the PSA elaborated on and clarified the expectations for how the measures should be

implemented through e.g. writing a reply letter to the effect that:

In our opinion, beyond mapping whether the technical equipment is of the approved design,

it would be recommended for all the relevant lifting gear to be subject to a systematic,

exhaustive and documented analysis of the risk inherent in using the equipment, and that the

equipment is

modified or renewed as needed, based on the results from these analyses. An assessment of

the need to revise the relevant user manuals would, in our opinion, be included such

work.

30

Statoil's measures for satisfying the orders were to be carried out under the auspices of

Statoil's “Safe rig” project.

Knowledge of and the results from this project were requested in the interviews. Here we

learned that a presentation of the project had been disseminated, together with a checklist. We

requested a copy of this presentation and the checklist. Following a reminder regarding the

presentation, nothing has yet been received. We have been informed that the presentation had

been disseminated to all relevant personnel on all shifts from May/June 2010 and beyond. To

questions regarding familiarity with the project, relevant personnel answered as follows:

”I'm familiar with the project. Have not seen the presentation. Have not been assigned tasks

from the project.”

”I've heard of it. Have not seen the presentation, as I was on leave of absence during the

period when the presentation was given.”

”I'm not familiar with this Statoil project.”

”I am very familiar with this. I have worked on this since early September this year.”

Upon request regarding the project's implementation on Njord A, we were presented with

several checklists and associated documentation of custom-designed lifting gear in the drilling

area. The checklist had five items:

1. Verify that maintenance programs have been established and that performed periodic

maintenance has been documented

2. Verify that the user manual (in Norwegian) is available and understood

3. Verify that product and safety bulletins have been reviewed and safeguarded

4. Verify that users of the equipment have satisfactory expertise and training

5. Perform risk assessment before use of the lifting equipment has been completed.

The checklist had three columns to be filled in:

1. Comments and any actions taken

2. Signature from executive offshore manager

3. Signature from drilling-well manager

The checklist for the relevant elevator was filled out and dated 2 December 2010.

The first column for the checkpoints was completed with OKs. The two next columns

contained the necessary signatures. As shown in Item 5.1.4, however, this was not actually the

case for this elevator.

Requirements:

Section 12, second subsection, of the Management Regulations regarding information

The responsible party must identify the information necessary to plan and carry out the

petroleum activities and improve health, safety and the environment.

Section 22 of the Management Regulations, first and third subsections relating to

improvement

The responsible party must continuously improve health, safety and the environment by

identifying the processes, activities and products in need of improvement, and implementing

31

necessary improvement measures. The measures must be followed up and the effects

evaluated.

Applying experience from own and others' activities must be facilitated in the improvement

work.”

5.1.9 Deficient safety culture

Nonconformity:

The safety culture on Njord A is deficient.

Description:

It has been demonstrated that deficient compliance with requirements was consistent from the

top line management on board down to and including the executing element. The companies'

lack of ability to implement and ensure compliance with their own and regulatory

requirements, together with the pervasive and, in part, collective breaches of these

requirements demonstrates that the safety culture on board Njord A was deficient.

Section 15 of the Framework Regulations regarding sound health, safety and environment

culture

A sound health, safety and environment culture that includes all phases and activity areas

must be encouraged through continuous work to reduce risk and improve health, safety and

the environment.

5.1.10 Deficiencies in safeguarding responsibility, establishment of, follow-up and

further development of management systems, as well as deficiencies in the

follow-up of other participants

Nonconformity:

Statoil as an operator had not sufficiently ensured that everyone performing work on its

behalf, either personally, through employees, contractors or subcontractors, complied with

requirements stipulated in the health, safety and environment legislation.

The licensees, Statoil, KCAD as a drilling contractor and employees failed in their follow-up

and further development of the management system that was to ensure compliance with

requirements stipulated in the health, safety and environment legislation.

Statoil had not sufficiently ensured that the drilling contractor KCAD was qualified to

safeguard regulatory requirements for health, safety and the environment, and had not

sufficiently followed up whether KCAD complied with the requirements during execution of

the assignment on Njord A.

Statoil had not ensured that possible deficiencies in other participants' management of health,

safety and the environment had been corrected and that necessary adaptations had been made

between its own and other participants' management systems, established pursuant to Section

13 of these regulations regarding the duty to establish, follow up and further develop

management systems, or pursuant to other Norwegian legislation, to ensure the necessary

totality.

Description:

32

Cf. paragraphs 5.1.1 - 5.1.8

Requirements:

Section 7 of the Framework Regulations regarding responsibilities according to these

regulations

The operator and other participants in the petroleum activities are responsible according to

these regulations and regulations laid down in pursuance of it. The responsible party must

ensure compliance with requirements stipulated in the health, safety and environment

legislation.

The operator must ensure that everyone who carries out work on its behalf, either personally,

through employees, contractors or subcontractors, complies with requirements stipulated in

the health, safety and environment legislation.

In addition to the duties imposed on licensees and owners of onshore facilities by individual

provisions in these regulations, the licensees are also responsible for ensuring that the

operator complies with the requirements stipulated in the health, safety and environment

legislation.

The employees have a duty to participate in accordance with Section 2-3 of the Working

Environment Act.

Section 13 of the Framework Regulations, first, second and third subsections regarding the

duty to establish, follow up and further develop management systems

The responsible party must establish, follow up and further develop a management system

designed to ensure compliance with requirements in the health, safety and environment

legislation.

The licensee must establish, follow up and further develop a management system to ensure

compliance with requirements in the health, safety and environment legislation directed

toward licensees.

The employees must contribute in the establishment, follow-up and further development of

management systems.

Section 14 of the Framework Regulations regarding qualification and follow-up of other

participants

Upon signing a contract, the responsible party must ensure that contractors and suppliers are

qualified to safeguard regulatory requirements for health, safety and the environment, as well

as follow up that the participants comply with the requirements during execution of the

assignment in the petroleum activities.

The operator must ensure that possible deficiencies in other participants' management of

health, safety and the environment are corrected and that necessary adaptations are made

between its own and other participants' management systems, established pursuant to Section

13 of these regulations regarding the duty to establish, follow up and further develop

management systems or pursuant to other Norwegian legislation, to ensure the necessary

totality.

33

5.2 Functioning barriers

5.2.1 Emergency preparedness

The emergency preparedness functioned according to plan.

6 Discussion relating to uncertainties

6.1 The incident's potential

It is uncertain how significant the material damage could have been if the slip joint had fell at

a slightly different time. The independent analyses and the assessments of the elevator, to be

carried out by DNV Bergen, could possibly answer this question.

6.2 Previous elevator use

The relevant elevator had been fully overhauled by the manufacturer in 2010, and was

returned to Njord A on 20 September 2010. Then the elevator was ”as good as new”. Through

the interviews we learned that since this time, three wells had most likely been drilled from

Njord A. It was claimed that the execution had been done in accordance with the same

procedures and with the same equipment as for the operation that led to the incident. This

means that for each of these wells, the riser joint must have been handled from a horizontal to

a vertical position and from a vertical to a horizontal position with the same elevator.

Furthermore, 22 to 23 riser joints must have been handled in the same manner. The riser joints

weigh considerably less than the slip joint.

It was claimed that the elevator had been used in this manner for all drilling activity on Njord

A since start-up in 1997. This is somewhat uncertain, however. The original drilling

contractor was Odfjell. According to the interviews, Odfjell completed its last drilling

campaign in 2002, and KCAD started its first in 2004. Furthermore, the drilling has not taken

place continuously, but rather in campaigns.

From the reconstruction with the elevator, we observed that if it had been used rotated 180

degrees, i.e. with the opening facing down and the hinge facing up, the relevant operation

would most likely have succeeded. This due to the geometric design of the elevator's lifting

lugs. These have an approx. 45-degree angle towards the diagonal on the elevator, and the

bails would therefore not have been pushed out and against the link blocks in the same

manner as they were.

It is uncertain whether the collision between the slip joint and the moped may have

contributed to a dynamic load that may have affected the failure of the link blocks . Likewise,

the non-synchronisation between the operations with the DDM and the offshore crane may

have resulted in moving the bails from the vertical position, thereby resulting in additional

horizontal forces and increased load on the link blocks .

If 350-tonne bails had been used instead of 500-tonne bails, the operation would probably

have succeeded. This because 350-tonne bails are significantly thinner than 500-tonne bails,

and these would most likely not have been pushed out of the lifting lugs in same manner.

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The independent investigation of the elevator could possibly reveal something regarding the

previous use of the elevator. Analyses of the damage and fracture surfaces could possibly

reveal whether the damage to the elevator is a result of repeated stresses or whether it is a

result of a single stress.

6.3 Pre-job meeting

We heard various opinions regarding to what extent a pre-job meeting had been carried out

with everyone involved present. During one interview, it was claimed that such a meeting had

been held. Based on other explanations and presented documentation, we consider what is

described in the report as the most probable correct description of what happened.

6.4 Breaches of procedure

Breaches of procedure may be due to deficient training, deficient use of procedures, acting

against better judgment, or a combination of these. The distribution between these underlying

causes has not been assessed.

6.5 The ”Safe rig” project

The investigation has not inquired further as regards the cause of the lack of status of the

”Safe rig” project on Njord A.

7 Attachments:

A Documents forming the basis for the investigation

B Participants