Important learning from the FPSO Cidade de São Mateus gas explosion

The gas explosion on the FPSO Cidade de São Mateus 11th February 2015 in Brazilian offshore sector has some important lessons, also for Norwegian offshore operations, in addition to design issues discussed separately. A condensate leak occurred from a flange in the pump room due to overpressure, and was ignited probably by the activities of one of the response teams. Nine fatalities occurred in the pump room, engine room, on deck and in the quarters.

When we compare the organizational faults that lead to the condensate leak in the first place, we find that the majority of root causes in this accident are parallel with the main root causes of the gas leaks on offshore installations in the Norwegian sector as well as the Macondo accident.

More than 50% of the hydrocarbon leaks (>0.1 kg/s initial leak rate) are due to work on normally pressurized equipment. The root causes that are common for the majority of these cases include inadequate procedures and other documentation, inadequate risk assessment, failure to learn from previous events, lack of communication and awareness as well as prioritizing production over safety. This is one of the reasons why it is so crucially important to investigate incidents and try to learn the lessons in order to prevent the most serious occurrences, the ignited hydrocarbon leaks.

It may be claimed that eliminating all leaks with operational root causes, should be ‘low-hanging fruits’, if compliance with procedures and instructions were achieved. Lack of compliance and leadership are two of the most critical root causes in accident investigations of oil and gas leaks in the Norwegian sector (Vinnem & Røed, 2015).

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