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P36

Facility: P36 Platform, Brazil
Date: Mar 2001
Consequences: 11 fatalities
Fatalities: 11 fatalities
Description
of Accident:

Drainage operations caused two explosions in the starboard aft column of the P36 platform. The first explosion was caused by the rupture, due to excessive pressure, of the emergency drain storage tank in the column. The explosion resulted in damage to equipment, pipes and electrical/electronic installations. Emergency firefighting crew attended the affected area.

 

A second explosion occurred in the column approximately 17 minutes later from the ignition of an explosive gas mixture. The explosion resulted in 11 fatalities among the firefighting crew. The damage from the explosion also caused flooding in the column. Subsequent flooding of interconnected compartments resulted in the sinking of the platform.
Key Lessons
Learnt:

·         Clear and well-defined supervisor’s functions

Responsibilities must be clearly defined in relation to the operation, maintenance and supervision of areas of production, platform infrastructure and control of stability. In addition, the supervisor’s bureaucratic activities should be reduced so that they can concentrate their focus on operating activities.

 

·         Size and skills of crew

The number and skills of platform crew should be aligned with the complexity of the installation, the operations involved and the strategic importance of the platform.

 

·         Maintenance

Maintenance activities should be prioritised to ensure compliance with scheduled maintenance programs and elimination of preventive maintenance routines.

 

·         Management of change

Project changes should only be carried out after completion of risk analysis, updating of documentation, approval from relevant authorities and training of operating and maintenance team.

 

·         Training

Personnel need to have technical training in control of stability and ballast and in emergency control. Retraining should be promoted.

 

·         Recovery of Information

Implement system for recovery of key information before final evacuation similar to black box in the aeronautical industry so that operating information can be recovered in the event of an emergency.

 

Report: P36.pdf
Links: Final report from inquiry commission P-36 accident
Thursday, May 31, 2007