Summary Kvaerner s Investigation Report Fatal accident at Stord, Norway 7 March 2015 1 / 5
Summary of Kvaerner s internal Investigation Report of the fatal accident at Stord 7 March 2015 Background Kvaerner at Stord is Kvaerner's assembly yard for modules and topsides for fixed and floating oil and gas production platforms and the main part of the Topsides business area within Kvaerner. Kvaerner Stord is also responsible for multi discipline and mechanical construction contracts for onshore oil and gas plants in Norway. Within decommissioning of offshore structures, Kvaerner Stord is responsible for demolition methods and onshore execution of demolition of topsides and other structures. In April 2014, Kvaerner Stord AS was awarded the contract for dismantling and recycling the Draugen FLP buoy. (FLP: Floating Loading Platform). The work comprises the engineering, deconstruction and disposal of the Draugen FLP. The topside is 285 tonnes and was lifted on to the Eldøy deconstruction site by a heavy lift vessel, and the rest of the buoy weighing 4 000 tonnes, was down ended and transported into the dry dock at Kvaerner Stord. The buoy has been cut in four sections and transported to Eldøyane deconstruction site for further demolition. The project is estimated to be completed during spring 2015. The core team at the deconstruction site consist of employees at Kvaerner Stord, supplemented by a small number of hired-in personnel, totalling 30 people. The decommissioning activities at the Eldøyane site include movement and deconstruction of large structures. Kvaerner at Stord has over time instituted numerous safety barriers beyond the requirements set out by the authorities in order to prevent work related accidents. In spite of these measures, a fatal accident occurred at the Eldøyane decommissioning site 7 March 2015. Following the accident, Kvaerner has performed an internal independent accident investigation with the objective to promote learning, improve work and safety and share knowledge internally and externally. The findings of the accident investigation are based on document reviews, inspections and interviews with involved persons related to the demolition activities at Kvaerner Stord. The labour inspection has concluded that there will be no need for additional measures. A police investigation is ongoing. The following is a summary of Kvaerner s internal independent investigation report: The accident In the morning of 7 March 2015, two operators were performing detail cutting of sections of the Draugen FLP buoy using cutting torches. During this operation, a plate fell onto one of the operators. The operator died of the injuries sustained in the accident. The operator was a hired-in, working under the supervision of Kvaerner Stord. 2 / 5
Immediate response Co-workers ran over to the scene of the accident immediately. Personnel from the emergency response team (ARL) arrived shortly after the accident and started CPR. Ambulances and a doctor arrived and the injured person was declared dead by the doctor. The company doctor and nurse arrived and contributed in the follow up work and debrief. Work at the site was stopped. In the days after the accident, management held five information meetings for all employees including hired in personnel and subcontractors. The emergency response arrangement was operational and well-functioning, and internal notifications were initiated according to established routines. Main causes The direct causes for the accident appears to be that the section standing up became unsecured from tilting over as more and more panels were cut off from the section. The cutting sequence was different to the method planned (narrow panels) as the remains of the section was cut in two larger pieces (A and B on illustration Plan view). The cut between the plate A and B (illustration Elevation view) was not fully completed when both plates fell over. When cutting, the deceased operator had placed himself on the outer side of the larger section. 3 / 5
Indirect causes leading up to the accident - No clear method defined for detailed cutting work on the section was available. -Some of the existing safety barriers were weak or imprecise. -Systematic learning from the incident history related to serious incidents at Kvaerner s operations at Stord and in the industry in general, was not fully utilized. - A separate risk assessment was not carried out for this specific work operation. Actions The internal investigation team has come up with recommendations to be implemented in the company. Some of them are related to the accident while others are related to general and continuous improvement activities. Recommendations related directly to the accident can be summarised as follows: Systematic learning More active use of experiential learning in the demolition industry when risk analyses are performed. Continuous improvement processes must ensure that recommended follow-up actions from the investigation team are developed and implemented. Review overall methods for demolition activities Minimize manual work and optimize use of machine tools. Introduce written instructions on the detailed cutting phase of operations. 4 / 5
Securing of objects Establish procedures related to securing and supporting unstable structures. Improve communication and risk awareness Establish processes to ensure that all operators with no segregation related to nationality or culture have the same risk awareness and understanding of the particular work task. The same applies to the right and responsibility to stop the work if it is unclear if the work tasks can be performed in a safe manner. Improve management process Establish routines for the presence of supervisors at the work site. Actions from management after inspections are to be completed promptly. The way forward The purpose of the investigation report is to promote learning, improvements and sharing of knowledge within Kvaerner and related parties. The recommendations from the Kvaerner Independent Investigation Team will be implemented and together with reports and recommendations from the authorities, be fundamental in Kvaerner s work to improve the HSSE culture and performance in all phases of Kvaerner s operations. 5 / 5