The NPD's investigation shows that the most important causes of the accident are many and collective violations of the applicable procedures. The accident would not have happened if the relevant procedural requirements had been observed, according to the report.
The underlying causes of the accident are multiple and complex. The NPD has uncovered serious defects in BP's management system. The company itself had identified the danger associated with relevant personnel not having sufficient knowledge of the lifting procedures, and it was aware that breach of procedures was a problem. However, sufficient measures were not implemented to follow up this problem.
In late April/early May, the NPD conducted an audit aimed at lifting and crane operations on the Gyda platform. In the audit report, the NPD pointed out several flaws that can be directly related to the accident. The NPD's investigation of the accident shows that these flaws had not been rectified.
The scope and gravity of observations made in connection with the investigation indicate a poor HES culture in BP's land organization and in BP's and Smedvig's offshore organization.
The NPD has issued letters to the operating company, BP, and to the drilling contractor, Smedvig, notifying both companies of orders.
BP is ordered to review its management system. The investigation has revealed deficient follow-up of identified risks, and also that the company has neglected to implement corrective actions. BP is also ordered to review its systems for ensuring contractors' compliance with procedures.
Both BP and Smedvig are ordered to identify the causes of the violations of procedures, and to implement measures to prevent such breaches of procedures. The companies must verify that such measures function as intended. This process must be quality-assured by a third party. The order is primarily aimed at the companies' activities related to lifting operations on all installations where BP/Smedvig have such operations. The companies must also evaluate whether this work should address other activities on the installations they operate.
The Norwegian Petroleum Directorate asks both companies to submit a binding schedule and plan for implementation of the orders. The plan must contain information concerning which resources will be used in this work, and it must be presented to the NPD within one month after the order is issued. The companies have been given the deadline of January 15th to comment on the NPD's investigation report and notification of order.
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