Maersk Ngujima-Yin Final 16112009

MARINE ACCIDENT REPORT
DIVISION FOR INVESTIGATION OF MARITIME ACCIDENTS
MAERSK NGUJIMA-YIN
Marine accident report
Fire/explosion
th
13
of April 2009
Page 1
Link to video clip on page 19
Division for Investigation of Maritime Accidents. Danish Maritime Authority,

Vermundsgade 38 C, DK 2100 Copenhagen
Phone: +45 39 17 44 00, Fax: +45 39 17 44 16 CVR-nr.: 29 83 16 10
E-Mail: oke@dma.dk - www.sofartsstyrelsen.dk
The casualty report has been issued on 16th November 2009

Case: 200905173
The casualty report is available on our homepage: www.dma.dk.
The Division for Investigation of Maritime Accidents

The Division for Investigation of Maritime Accidents is responsible for investigating accidents and serious occupational accidents on Danish merchant and fishing vessels.
The Division also investigates accidents at sea on foreign ships in Danish waters.
Purpose
The purpose of the investigation is to clarify the actual sequence of events leading to
the accident. With this information in hand, others can take measures to prevent similar
accidents in the future.
The aim of the investigations is not to establish legal or economic liability.
The Divisions work is separated from other functions and activities of the Danish Maritime Authority.
Reporting obligation
When a Danish merchant or fishing vessel has been involved in a serious accident at
sea, the Division for Investigation of Maritime Accidents must be informed immediately.
Phone: +45 39 17 44 00
Fax:
+45 39 17 44 16
E-mail: oke@dma.dk
Cell-phone: +45 2334 2301 (24 hours a day).

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Contents
1
2
3
4
5
Summary .............................................................................................................. 5
Conclusion/Findings.............................................................................................. 5
Recommendations and initiatives.......................................................................... 7
The investigation................................................................................................... 8
Factual Information ............................................................................................... 8
5.1
Accident data............................................................................................... 8
5.2
Navigation Data ........................................................................................... 8
5.3
Ship data ...................................................................................................... 8
5.4
Weather data................................................................................................ 9
5.5
The Crew ...................................................................................................... 9
5.6
VDR ............................................................................................................ 10
5.7
Narratives................................................................................................... 10
5.8
The scene of fire........................................................................................ 13
5.8.1
Compressor train A.............................................................................. 13
5.8.2
Stored oil drums................................................................................... 14
5.9
Fire fighting systems ................................................................................ 14
5.9.1
Deluge systems ................................................................................... 14
5.9.2
Foam systems ..................................................................................... 15
5.9.3
Water mist system for gas turbines...................................................... 16
5.9.4
Hydrants on the new ring fire main ...................................................... 17
5.10 Fire fighting subsystems .......................................................................... 18
5.10.1
New ring fire main/water hammer ........................................................ 18
5.10.2
Debris from aft fire water pump engine ................................................ 20
5.10.3
Glass Reinforced Epoxy piping ............................................................ 21
5.11 Investigations by other parties................................................................. 23
5.11.1
NOPSA findings................................................................................... 23
5.11.2
Maersk FPSO & Woodside findings ..................................................... 23
5.12 Project setup and organisation ................................................................ 23
5.12.1
Brief time line....................................................................................... 23
5.12.2
Project setup and Organisation............................................................ 24
5.12.3
The safety case ................................................................................... 28
5.12.4
Company policies and core values ...................................................... 29
5.13 Commissioning ......................................................................................... 29
5.14 Security systems on board....................................................................... 31
5.14.1
Maintenance systems .......................................................................... 31
5.14.2
Integrated Control and Security System (ICSS) ................................... 32
5.14.3
Closed Circuit Tele Vision (CCTV)....................................................... 33
5.14.4
SYNERGI ............................................................................................ 33
5.15 Safety climate on board ............................................................................ 34
5.15.1
Safety meetings................................................................................... 34
5.15.2
Crew concerns..................................................................................... 34
5.15.3
Working climate on board .................................................................... 35
5.15.4
Training, competency and manning ..................................................... 36
5.15.5
Post event management ...................................................................... 37
5.16 Authorities and inspection ....................................................................... 37
5.16.1
Danish Maritime Authority.................................................................... 37
5.16.2
Classification scheme .......................................................................... 38
6
Analysis .............................................................................................................. 40
6.1
The cause of the explosion and fire......................................................... 40
6.2
Course of events leading up to the explosion and fire ........................... 41
6.2.1
Safety climate prior to production start-up............................................ 41
6.2.2
Deluge system..................................................................................... 41
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6.2.3
Foam system ....................................................................................... 42
6.2.4
GRE Piping.......................................................................................... 42
6.2.5
Water mist system ............................................................................... 43
6.2.6
New ring fire main/water hammer ........................................................ 44
6.2.7
Debris from aft firewater pump engine ................................................. 45
6.2.8
Commissioning .................................................................................... 45
6.2.9
Maintenance ........................................................................................ 46
6.2.10
ICSS Integrated Control and Safety System ..................................... 46
6.2.11
Safety climate post production start-up - software................................ 47
6.2.12
Shore management ............................................................................. 48
6.3
The detection and identification of the explosion and fire ..................... 49
6.3.1
Detection of the fire scene ................................................................... 49
6.3.2
Identification of fire source ................................................................... 49
6.4
Fighting the fire ......................................................................................... 50
6.4.1
Automated systems ............................................................................. 50
6.4.2
Manual fire fighting .............................................................................. 51
6.4.3
Crew fire fighting efforts ....................................................................... 52
6.5
Post event management ........................................................................... 52
6.6
Audits and inspection ............................................................................... 53
7
Enclosures .......................................................................................................... 54
7.1
Excerpt from NOPSA improvement notice .............................................. 54
7.2
Excerpt from Woodside/Maersk report .................................................... 55
7.3
Purpose of Commissioning procedure.................................................... 58
7.4
Company policies...................................................................................... 59
7.5
ISM on board audit the 22nd 24th of October 2008................................. 61
7.6
ISM audit in Copenhagen on the 30th of January 2009............................ 62
7.7
ISM audit in Perth on the 17th of March 2009 ........................................... 64
7.8
ISM audit on board the 18th of March 2009 .............................................. 65

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1 Summary
MAERSK NGUJIMA-YIN is a FPSO (Floating Production Storage and Offloading). The
vessel is operating in the Vincent Field off the cost of North West Australia, Nigaloo
National Park.
The vessel was originally build in 2000 and served as a VLCC until September 2007.
During 2007 and 2008 the vessel was rebuild in Singapore. In June-July 2008 the vessel was commissioned and commenced oil production.
At approximately 1250 on the 13th of April 2009 an explosion and subsequent fire occurred in the vessels gas compression module M60 due to a severe breakdown of a 3rd
stage HP gas compressor. No persons were injured by the explosion and fire or subsequently during the fire fighting.
The fire was contained at approximately 1425 while boundary cooling and vigilance
was maintained until next day.
2 Conclusion/Findings
The cause of the explosion and fire
The primary reason for the HP compressor failure on April 13, 2009 has been
identified as a flow transmitter error. After the failure the explosion and fire developed through the torn seal bearing cap and through the lubricating oil system. (6.1)
Course of events leading up to the explosion and fire
It is the assessment of the Division for Investigation of Marine Accident that the
safety climate on board during the project period in Thailand and Singapore has
been poor. (6.2.1)
There have been difficulties with deluge valves on module M60 and M70 prior
to the accident. (6.2.2)
The old foam system failed to work on demand during the fire due to defective
nozzles. (6.2.3)
GRE piping in two branch lines failed during the fire. The GRE piping has been
subjected to radiant heat and flames during the fire and has repeatedly been
subjected to pressure pulsations arising from water hammer and start-up of diesel driven fire pumps. Lloyds Register gave approval for GRE piping at L3 rating
according to IMO resolution A.753(18), appendix 2. (6.2.4)
The water mist system failed to work on demand during the fire because a nitrogen regulator was either obstructed or closed. (6.2.5)
Continuous problems with the new ring fire main have been identified. The
problems have not been resolved. (6.2.6)
Debris containing carbon deposits has been excreted from the exhaust system
of the aft fire water pump. It is reasonable to believe that the carbon deposits

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originate from start-up of the engine where heavy black smoke is developed.
The issue has raised safety concerns but has not been resolved. (6.2.7)
It is the assessment of The Division for Investigation of Maritime Accident that

the commissioning has been inadequate and has not reflected the intention of
the commissioning procedure, because the crews participation has been limited. (6.2.8)
Difficulties with the planned maintenance system SAP and corrective work
originating from commissioning has compromised planned maintenance. It is
the assessment of the Division for Investigation of Marine Accidents that maintenance planning on board and maintenance support from shore management
has been inadequate. (6.2.9)
It is the assessment of the Division for Investigation of Marine Accidents that

the number of block and overrides in the ICSS has been to an extent where
credibility of the systems could be called into question. (6.2.10)
It is the assessment of the Division for Investigation of Marine Accident that the
safety climate onboard after production start-up has remained poor. (6.2.11)

the implementation of the health and safety policy on board the FPSO has been
inadequate:
o The management has not provided the means necessary to accommodate and coordinate the interests of the project team and the operations
team.
o The management has acted inadequately on the feedback from the
FPSO crew during the project and has not been able to re-establish a
healthy safety climate on board.
o The support to maintenance on board provided by management has
been inadequate. (6.2.12)
The detection and identification of the explosion and fire
The ICSS was not able to establish the location of the fire and the crew did not
have an instant overview of the facilities as the CCTV was cut off, because it
was not powered from an uninterruptible power source. The identification of the
fire source and choice of fire fighting equipment was primarily based on visual
inspection by the crew and a stand by vessel. (6.3)
From the general alarm sounded and until the fire scene and fire sources were
established 1 hour and 16 minutes passed. It is the assessment of the Division
for Investigation of Marine Accident that the on board security system did not
provide adequate barriers against loss of instant overview. (6.3)
Fighting the fire
The automatic release of the deluge on modules M30 and M60 failed. Manual
release had to be carried out and approximately one hour passed from the fire
started until water was confirmed. The functionality of the deluge systems on
M30 and M60 has been insufficient. (6.4.1)

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the old foam system could have provided effective means of extinguishing a fire
fuelled by oil from the drums. (6.4.2)

the crew handled the emergency response and fire fighting effectively and
competent with the tools and safety system available. (6.4.3)
Post event management

the post event traumatic stress management has been inadequate. (6.5)
Audits and Inspection

the class approval process has not adequately ensured that all fire fighting systems were functional. (6.6)
It is the assessment of the Division for Investigation of Maritime Accidents that

the ISM audit reports have not given Maersk management sufficient incentive to
improve the implementation of the safety management system and the intentions behind the ISM Code. (6.6)
3 Recommendations and initiatives

Maersk FPSO
The Division for Investigation of Maritime Accident recommends Maersk FPSO to analyze problems in the safety systems and the safety climate on board and in the shore
management as well in order to address how safety can be improved and how a good
safety climate can be created.
According to the FPSO crew the safety climate began to improve on board MAERSK
NGUJIMA-YIN short time before the accident, because of the efforts of the new Operations Superintendent, who was on board during the fire. The Division for Investigation
of Maritime Accident recommends that this work is continued by focusing on safety
communication in and between entities in the organisation and by focusing on safety
management.
The Division for Investigation of Maritime Accident recommends the management of
Maersk FPSO to express its commitment to the improvement of the safety climate after
the accident in order to make the FPSO more resilient to accidents.
Lloyds Register
The Division for Investigation of Maritime Accident recommends Lloyds Register to
scrutinize its approval process in order to ensure functionality of fire fighting systems.
Danish Maritime Authority
The Division for Investigation of Maritime Accident recommends the Danish Maritime
Authority to identify the need to increase focus on the assessment of the commitment
from the management to implement a safety culture at all levels in the organization.

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The Division for Investigation of Maritime Accident will emphasize the GRE piping failure when this report is forwarded to IMO.
4 The investigation
The Division for Investigation of Maritime Accidents has carried out the following activities as part of the investigation:
Meeting with Maersk FPSO, Australia on 20th of April 2009.
On board investigation on MAERSK NGUJIMA-YIN in the period from 21th to

24th of April 2009.
Meeting with the DPA and Maersk FPSO, Copenhagen on 5th of May 2009
Meeting on 4th of June 2009 with the Operational Superintendent that was on
board during the incident.
5 Factual Information
5.1 Accident data
Type of accident (the incident in details)
Time and date of the accident
Position of the accident
Area of accident
Injured persons
IMO Casualty Class
Explosion/Fire
1250 local time
21 261 S 114 040 E
North west Australia, Nigaloo National
Park
Nil
Serious
5.2 Navigation Data

Stage of navigation
Moored at STP buoy
5.3 Ship data

Name
Home port
Call sign
IMO No
Registration No
Register
Flag State
DOC holder
Construction year
Type of ship
Tonnage
Classification
Length
Engine power
Hull construction
Regulation
MAERSK NGUJIMA-YIN
Roskilde
OYTS2
9181182
8133400
DIS
Denmark
A.P. Moeller.
2000
FPSO(Floating Production Storage and
Offloading)
162154 GT
Lloyds Register of Shipping
332.95 m
27165 kW
Double hull, steel
Notice from Danish Maritime Authority B

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5.4 Weather data

Wind direction and speed
Sea
Current
Visibility
Light/dark
South 5.5 m/s

2.2 m
Southwest 1 knot
+10 nm
Light
5.5 The Crew

Number of crewmembers
Number of crewmembers certified to act as
bridge watch
Watch on the bridge
Minimum Safe Manning
41
3
N/A
13

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5.6 VDR
The vessel is equipped with Voyage Data Recorder (VDR).
The VDR is covering the bridge and the ordinary marine systems.
The cargo control room is not covered by VDR and voice recordings from the incident
have not been recorded.
5.7 Narratives
MAERSK NGUJIMA-YIN is a Floating Production Storage and Offloading (FPSO). The
vessel was originally build in 2000 and served as a VLCC until September 2007.
During 2007 and 2008 the vessel was rebuilt in Singapore. In June-July 2008 the vessel was commissioned and commenced oil production.
For more technical details please refer to:
http://www.maersk-fpsos.com/fleet/fpsos/FleetItem.aspx?fid=43&cid=6
All time indications below are local time:
At approximately 1250 on 13th of April 2009 an explosion and subsequent fire occurred
in the vessels production module M60 due to a severe breakdown of a 3rd stage HP
gas compressor. No persons were injured by the explosion/fire or subsequently during
the fire fighting.
The fire was contained at approximately 1425 while boundary cooling and vigilance
was maintained until next day.
Preparations for evacuation of the FPSO were made.
Module M60 is a gas compression module consisting of two compressor trains A and
B. The compressor trains A and B are driven by two gas turbines respectively.
The function of M60 is to return the separated gas back into the well. M60 is placed in
star board side approximately 50 metres forward of midship.
At approximately 1245 two crew members were heading towards M60 to check an
alarm on a nitrogen gas seal for the high pressure compressor A. Halfway to M85 they
heard a loud noise of a winding down turbine followed by a deep thumb and loud bang.
They looked up and saw steam above M85 and subsequently a fireball followed by
thick black smoke.
At 1250, the general alarm was sounded and the two crew members returned to their
muster station in the accommodation.
An emergency shutdown and blow down was initiated and a full muster of 41 persons
was achieved shortly after. No persons were injured.
Deluge was activated on module M10, M30 and M60 but did not release.
M10 is the high pressure oil separation module, where water and gas for re-injection is
separated from the crude oil. M10 is placed adjacent to M60 towards port side.

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M30 is the high pressure flare skid and holds a flare drum with a volume of approximately 80 m3. At the time of the accident it contained approximately 3 m3 compressed
process gas. M30 is placed in starboard side approximately 50 metres forward of M60.
M60
M30
M10
M60
Figure 1: MAERSK NGUJIMA-YIN General arrangement.
M30
Source: Maersk FPSO
Emergency response teams were engaged and the fire was assessed. It was established at 1325 that the fire was in module M60.
As the deluge did not release on module M60 and M30 a member of the fire fighting
team progressed to the deluge skids and released the deluge manually. Water from
M60 and M30 was confirmed at 1350.
Pulsing grey smoke was observed at 1359 from a standby supply vessel. At 1406, it
was confirmed that a direct current (DC) emergency lubrication oil pump for the compressors was still running. Two electricians were sent out to M85 to electrically cut of
the pump.
At 1425, the fire was contained.
A more detailed sequential overview of the events during the fire is presented below:
1250:
Indication on the Integrated Control Security System (ICSS) of fire in the compressor enclosures of module M60
Emergency shut down(ESD1) initiated
Blow down initiated
General alarm is sounded.
1251:
Switch to emergency power.
Closed Circuit Tele Vision (CCTV) is no longer available.
Deluge activated automatically from the ICSS on module M60.
Deluge activated manually from cargo control room on module M30.
1305
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The production system is depressurized by way of the HP separator according

to ICSS log.
1316:
Attempt to visually confirm water on deluge from Monkey Island. No confirmation possible.
1320
According to white board in the cargo control room the flare is off indicating that
the production system is depressurized. Emergency response teams can be
engaged.
1324:
Public announcement of no blowing in facility, i.e. the production system is depressurized.
1325:
Positive visual confirmation of fire in M60 by emergency response team.
Identification of oil drums between compressor trains.
1327:
Emergency response team establishes that deluge is not active on M60.
1328:
Standby vessel visually confirms fire aft of forward crane.
1330:
Cargo fire pumps started in attempt to activate the old foam system.
1334:
Deluge manually released on M60 by an emergency team member and water is
confirmed visually.
1340:
Emergency response team is preparing attack with fire hoses.
1343:
1346:
confirmed visually.
13:50:
Emergency response team attacked M60 with fire hoses from M20 blast wall
1359:
Pulsing smoke identified by a standby vessel.
1406:
It is identified that a DC lubrication oil pump is running on compressor A.
Flames are still observed on compressor A
1420:
Manual isolation of DC lubrication oil pumps accomplished.
1425:
The fire is reported to be contained and boundary cooling is maintained.

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5.8 The scene of fire

5.8.1 Compressor train A
The nitrogen gas seal bearing cap of the 3rd stage HP compressor was found torn open
and a jet fire had occurred, which was indicated by the fire damages to the adjacent
compressor train B.
The fire had spread to the enclosure, housing the gas turbine driving the compressor.
There were signs of an explosion in the enclosure
The compressors, the enclosures and their surroundings sustained severe damage
from the fire. See pictures 1-4
Picture 1: Damaged gas seal bearing cap
Picture 2: Damages to adjacent compressor
Picture 3: Gas turbine enclosure
Picture 4: Inside gas turbine enclosure
According to the compressor makers representative, who was on board during the
investigation, there has been a general record of leaks in nitrogen gas seals in the industry, but no record of explosion fires.
According to the FPSO crew there have been issues with compressor bearings and
alignments during the project before commissioning.

Page 13
5.8.2 Stored oil drums

Five 200 litres drums, containing lubrication oil, were stored between HP Compressor
trains A & B. The drums were exposed to heat or flames during fire. See picture 5
and 6.
Picture 5: Exposed oil drums
Picture 6: Foot prints of oil drums
5.9 Fire fighting systems

5.9.1 Deluge systems
The deluge system covers all production modules on the deck.
The system is designed to offer boundary protection by way of sea water cooling
through a number of drenching nozzles. Deluge on all modules can be activated independently.
The deluge is controlled by an automatic detection system that responds on signals
from local fire detectors. When any fire detector is activated the deluge system is to fire
automatically.
Deluge on all modules can be activated manually from the Cargo Control Room.
On all modules there is a deluge valve that can be activated locally.
The deluge system is supplied by the new ring fire main.
The deluge was activated automatically on module M60 when the fire was detected
which was confirmed on the Integrated Control and Safety System (ICSS).
The deluge was activated manually from the cargo control room on module M30 when
the fire was detected which was confirmed on the Integrated Control and Safety System (ICSS).
The emergency response team reported back that no water was coming from M60 and
M30.
A member of the Emergency response Team manually released the deluge manually
by way of deluge valves on both modules M60 and M30. Release of water was confirmed.

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The deluge valves are placed in close vicinity of the modules.

M60 was commissioned on 27th of June 2008.
During the investigation on board the deluge system for module M11 was tested. The
test showed that the deluge valve worked and could be activated remotely. It was
found that several nozzles were blocked and did not provide water.
After the test, more than 20 minutes endured before the M11 deluge valve was manually and locally reset. Large quantities of water were lead into a common oil drain tank
which subsequently overflowed resulting in a minor oil spill to sea.
According to the FPSO crew the M70 deluge system was tested in August 2008 by the
crew. During this test the deluge valve failed to open on demand.
In a list of completed work orders, provided by Maersk FPSO, Australia, a job completed on 3rd of September 2008 has stated in the description field: Investigate/Repair
Deluge Valve M-60
It has not been clarified what the above mentioned investigation/repair consisted of.
According to Maersk FPSO, Copenhagen, all systems were tested according to maintenance procedure.
It has not been clarified to what extent the systems have been tested before the accident.
According to the FPSO crew:
Testing after the accident found a huge number of blocked nozzles.
The deluge pipe work on the topsides is unlined bare steel internally, meaning
the nozzles will always be liable to block.
There is no provision to fresh water flush the system despite this was being requested by Operations team during the project phase.
According to an as built system drawing, dated 8th October 2007 the deluge system is
provided with an air flushing option.
According to the FPSO crew not all scheduled maintenance jobs for the deluge systems have been carried out.
5.9.2
Foam systems
There are two foam systems onboard.

1. The vessels original system that covers the entire deck.
2. A new system installed during the rebuilding. The system covers the new production plant modules except M60 and M20.
The foam systems require sea water combined with foam liquid. Sea water is supplied
by two engine room general service pumps or the diesel driven fire pumps. Foam liquid
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is supplied by dedicated foam pumps and a predefined mixture of sea water and foam
liquid is conveyed to the foam monitors/hydrants via the fire mains on upper deck.
Old system
During the accident the old foam system failed to work on demand.
According to the Operations Superintendent who was on board during the accident, the
foam system activated but the nozzles on the foam monitors were incorrectly set and
thus not usable.
In Lloyds Register Validation Activity Report 3 of 15th June 2009 it is stated that:
Deck Deluge Foam Monitors were witnessed to be operational on the 10/06/2009 following
progressive identification and rectification of significant defects
According to the FPSO crew the old foam system was inspected after the accident.
The inspection found that the system would never have worked properly, as the in line
proportioner was fitted back to front, and 2 pneumatically operated valves supplying
foam to the system were fitted back to front, meaning when the valves were commanded to open to supply foam concentrate to the pumps, they were in fact shut.
According to the FPSO crew the system had been signed off as fully tested and commissioned.
It has not been clarified when the old foam system was last tested before the accident.
New foam system
Foam should be instantly available from the foam hydrants on those modules where
foam hydrants are installed as the new ring fire main is constantly pressurized.
The system was commissioned from 13th of May to 7th of June 2008. Foam was not
released on any module during this period.
According to the FPSO crew the system was tested shortly after being commissioned.
During the test it showed several leaks in welds in several areas of the ship. A work
order was made in order to get it fixed, i.e. Maersk FPSO was informed.
In a list of completed work orders, provided by Maersk FPSO, Australia, a job completed on 27th of August 2008 has stated in the description field: EXT: Temp repair
topsides foam leaks. A job completed on 30th of August 2008 has stated in the description field: Pump does not pump to capacity pressure
On an internal Defects list from February 2009 it was noted: Topside foam pump A.
No discharge pressure
5.9.3 Water mist system for gas turbines

The HP compressors are driven by gas turbines which are installed in separate enclosures.
The water mist system is designed to offer local protection within the gas turbine enclosures.

Page 16
The water mist is controlled by an automatic detection system that responds on signals
from local fire detecting sensors. When any fire detector is activated the water mist
system is to release automatically.
The water mist system did activate automatically when the fire was detected, but water
and nitrogen was not released. Nitrogen is the driving media for the system.
According to Maersk FPSO, Copenhagen the water mist system did not release because a nitrogen regulator was obstructed.
According to Maersk/Woodside report of 12th of May 2009 a nitrogen regulator was
incorrectly set. See enclosure 7.2
According to the FPSO crew the above mentioned regulator was fully wound down and
closed. I.e. it did not operate at all.
According to the FPSO crew all water mist systems protecting on board gas turbines, in
total 5 (Three driving power generators and two driving the HP compressors), were
inspected after the accident. It was found on all 5 systems that none of the regulators
would have operated.
The mentioned regulator is set manually.
When The Division for Investigation of Maritime Accident came on board the regulators
had been operated due to testing.
On a general safety meeting on 25th of May 2008 it was raised that Water mist system
for turbines had not been signed off. The water mist system was commissioned on 26th
of May 2008.
According to the FPSO crew the water mist system has not been tested since it was
commissioned.
In the commissioning documents it was noted that none of the nitrogen bottles, containing the driving media, had been released during the commissioning tests.
In order to test the systems with out releasing the nitrogen bottles it is necessary to
close the regulator.
According to the FPSO crew not all scheduled maintenance jobs for the water mist
systems have been carried out.
5.9.4 Hydrants on the new ring fire main

According to the FPSO crew there has been difficulties with hydrants on the new ring
fire main because the hydrants are installed with the spindle facing down and with no
draining options. This has caused the hydrants to clog with scale and rust.
According to the Maersk/Woodside investigation report:
ERT witness statements describe that one of the fire hydrants on the main deck
immediately forward of the HP gas compression process modules failed to deliver water, the next monitor forward off the same ring main delivered at good pressure. Dis-

Page 17
cussions with personnel onboard indicate a previous problem with this design of hydrant, which is the subject of a technical query..1
5.10 Fire fighting subsystems

5.10.1 New ring fire main/water hammer
The vessel has two fire main pipe lines.
1. The vessels original system. Deliverers fire water to deck hydrants, foam monitors and hawse pipes. The system is supplied from the engine room general
service pumps. Working pressure 9 bar. Maximum permissible working pressure is 10 bar.
2. A new system, the new ring fire main, installed during the rebuild comprising of
a ring fire main situated on deck. Delivers fire water to process plant hydrants,
foam monitors and deluge. The system is supplied from two diesel driven
pumps situated on deck. Working pressure 16-17 bar. Maximum permissible
working pressure is 18 bar.
The new system is a part of the topside production system and is not covered by the
regulations of the Danish Maritime Authority.
However, the two systems are interconnected in a way that enables the original system
to act as emergency supply for the new ring fire main and vice versa.
The new ring fire main is to be constantly pressurized. In the system design this pressure is maintained by two jockey pumps. When this pressure drops, the diesel driven
pumps start automatically. Each of the diesel driven fire pump supply sea water at a
rate of 2460 m3/h at 13.5 bar.
In order to protect the old fire main system from the pressure of the new ring fire main
system a one way pressure reduction valve was installed in the interconnection line
between the two systems. This followed by the old systems pressure relief valve.
During the incident the jockey pumps were not in place, they were removed from the
system because of break down. The pressure in the new ring fire main was maintained
provisionally, in order to avoid running the diesel driven fire pumps 24/7, by the general
service pumps from the engine room. To facilitate this, the internals from the one way
pressure reduction valve were removed.
The old fire main system was at the time of the accident protected by the pressure relief valve only.
As a consequence of the above mentioned modification a strong water hammer has
occurred every time the diesel driven fire pumps have been in use due to the pressure
relief valve opening and closing to protect the old fire system from over pressure.
During the investigation on board the water hammer occurred several times. See video
1 below.
Source: Major Investigation Report: Fire in gas compression module Asset/site: Maersk Ngujima-Yin,
Australia Date: 12.5.2009

Page 18
Click here to watch video
Video 1: Water hammer
The Division for Investigation of Maritime Accident observed that at least one DN 200
gate valve had to be manually closed in order to isolate the old fire system and thus
stopping the water hammer. See video 1.
The Division for Investigation of Maritime Accident observed several leaks in the safety
valve overflow system and on a safety valve.
The water hammer has occurred whenever the new ring fire main has been utilized for
any purpose.
When the new ring fire main has been used for deck wash or similar purposes a remotely controlled over board discharge valve on the forward part of the vessel has to
be opened manually in order to ensure a sufficient flow through the diesel driven
pumps to avoid damage. The mentioned discharge line has the dimension DN400 and
is supposed to be used in connection with tests of the diesel driven fire pumps.
In the cargo control room an arrangement drawing of the new fire ring main was posted
with a yellow post it on it saying:
Any extended period of time that the FWP is online, the dump valve is required to be
open to stop dead heading of the pump. There is a mark indicating the position. You
can also confirm the flow rate of 1600 m3/h at the FWPs
The jockey pumps have been out of service several times since they were installed.
Since May 2008 they have been in service for approximately 3 months.
According to the FPSO crew it has been verbally raised to Maersk FPSO that the water
hammer could compromise the safety of the fire mains.
According to the Operations Superintendent who was on board during the accident,
Maersk FPSO, Australia was approached by him regarding the water hammer. From
their side he was informed that a solution was in progress.
According to the Operations Superintendent the water hammer issue has descended
from the project phase. He does not know the exact details but has noted that the new
ring fire main system is very confusing.
Maersk FPSO, Copenhagen, has informed that they have been aware of the water
hammer issue since the vessel came on site and does not regard the water hammer as
a serious problem.

Page 19
Maersk FPSO, Copenhagen, has informed that the issue has been handled locally by
the engineering manager in Perth.
Maersk FPSO, Copenhagen, has informed that the provisional technical solution has
been tested to the satisfaction of Maersk FPSO, Copenhagen.
In Lloyds Register Validation Activity Report 3 of 15th June 2009, it is stated that:
An anomaly was previously noted and remains on the on the fire main due to water hammer
when the deluge pumps start and was also observed when they stop during deluge system testing
in June 09. The water hammer is noted to be sufficient magnitude to require deck isolation
valves to be manually closed.
WEL/Maersk to take the necessary steps to minimise the potential for water hammer in the fire
main during operations including hydraulic analysis and adjustments to ring main fire system
including new settings for jockey pump operations.
During the investigation on board there was no evidence of an operating procedure to
secure safe operation of the amended new ring fire main system.
According to Maersk FPSO, Copenhagen a temporary operating procedure was instated the first time the jockey pumps failed. However, by later failures the procedure
has not been reinstated.
5.10.2 Debris from aft fire water pump engine

During running of the aft fire pump debris with carbon deposits is excreted from the
diesel engine exhaust system. See picture 5
According to the Operations Superintendent heavy black smoke is developed during
start up.
The Division for Investigation of Maritime Accident observed notable carbon residues
on structures in the area around the exhaust outlet. See picture 6.
Picture 5: Debris with carbon deposits
Picture 6: Carbon residues

Page 20
The exhaust system is placed a few meters outside the dangerous zone as defined in
the class rules.
According to the Operations Superintendent the debris issue has been discussed with
the class and has been raised in SYNERGI (a corporate near miss and safety breach
reporting system, see 5.14.4). He has informed that he is not confident that it is safe.
The issue has not been rectified.
It was noted that solid material was exhausted from the Aft Firewater Pump from time
to time. This material appears to be a salt accumulation possibly from crystallisation
from an internal spray cooler.
WEL/Maersk should determine where the material dropping from the Aft Firewater
Pump is coming from and assess potential impacts to the pump and surroundings.
According to Maersk FPSO, Copenhagen the internal spray cooler cools the exhaust
pipe and also prevents carbon deposits to come alive.
5.10.3 Glass Reinforced Epoxy piping

Glass reinforced Epoxy (GRE) piping is used in the new ring fire main and in major
branch pipes for hydrants and deluge lines.
During the fire two branch lines of the new ring fire main burst. The branch line supplied ordinary hydrants on top of module M60.
The burst GRE piping was observed during the fire fighting by one of the emergency
response team members.
Both lines have been subject to radiant heat and flame exposure from the fire. See
picture 7 and 8.
Picture 7: GRE pipe star board side of module M60
Picture 8: GRE pipe port side of module M60
According to the FPSO crew the pressure in the new ring fire main rises from 8 bar to
16-17 bar upon start-up of the diesel driven fire pumps.
A strong water hammer has occurred every time the diesel driven fire pumps have
been in use.
Page 21
According to the FPSO crew the operations team raised concerns, during the project
stage in Singapore 2007 - 2008, about the integrity and safety of GRE. They were informed by Maersk FPSO that the GRE piping was accepted by class and had the same
heat resistance properties as steel.
Maersk FPSO, Australia has informed that:
The GRE piping might have been damaged by the initial explosion and
GRE has a very poor resistance to explosion/chock.
The GRE piping might have failed due to radiant heat from the fire after an unknown time.
A material failure analysis is ongoing.
Lloyds Register gave approval for GRE piping at L3 rating according to IMO
resolution A.753(18), appendix 2.
According to IMO resolution A.753(18), appendix 2, a water filed pipe is to be fire endurance tested for 30 minutes. The internal pressure during the test is to be maintained
at 3 0.5 bar. The resolution was adopted on 4th of November 1993.
Maersk FPSO, Copenhagen has informed that MAERSK NGUJIMA-YIN may be the
first Maersk project where GRE is used in fire systems.
Lloyds Register Technical Association has issued An interpretation of the IMO guidelines on the application of plastic pipes on ships, Paper No. 7. Session 1993-94
According to Lloyds Register rules approval of GRE piping will in general be accepted
in Class III piping systems (I.e. working pressure 16 bars and working temperature
200C.)

Page 22
5.11 Investigations by other parties

5.11.1 NOPSA findings
The National Offshore Petroleum Safety Authority (NOPSA) conducted an investigation
on board in the period from the MAERSK NGUJIMA-YIN in the period from 14th to the
17th of April.
NOPSA is the Australian equivalent to the Danish Energy Agency. The role of NOPSA
is to administer Australian offshore petroleum safety legislation.
The NOPSA investigation findings resulted in 5 improvement notices. See enclosure
7.1.
5.11.2 Maersk FPSO & Woodside findings

Maersk FPSO and Woodside have issued a preliminary report on 12th of May 2009.
According to The investigation terms of reference the areas to be addressed and reported were:
Investigation to be carried out in accordance with Tap Root Methodologies.

Highlight where warning signs prior to the incident have either been missed or
inappropriately addressed, including relevant previous failures/incidents involving the HP compression system.
Comment specifically on the following:
o Status of the process plant prior to the incident.
o Functioning of the fire protection systems during the incident.
o Functioning of the Emergency command and Response team during the
incident.
o WEL and Maersk communication during the incident.
Finalise incident category
Provide a summery report, including a Snap Chart, for publication and recommendations in line with the root causes identified.2
The findings of the report are presented in enclosure 7.2.
5.12 Project setup and organisation

5.12.1 Brief time line
2005:
The project setup initiated. Production of topside modules commenced in Thailand.
2006:
ELLEN MAERSK was purchased. Rebuilding commenced at Keppel FELS shipyard in
Singapore.
2007: Rebuilding at Keppel shipyard in Singapore.
2

Page 23
2008: Rebuilding finalized. MAERSK NGUJIMA-YIN arrived on-site in August. Oil production commenced. Commissioning in progress.
2009: Remaining commissioning. Projects team handed over punch lists of the systems to operations team in March 2009. Unfinished items still remained under the responsibility of projects team until March 2009.
5.12.2 Project setup and Organisation

The MAERSK NGUJIMA-YIN project was launched under the responsibility of Maersk
Contractors, Copenhagen and involved Maersk Contractors Australia Pty Ltd.
The design of the new production modules was subcontracted to VETCO AIBEL, Norway.
Maersk Contractors Copenhagen was divided into Maersk Drilling, Copenhagen and
Maersk FPSO, Copenhagen in the last quarter of 2008.
Maersk FPSO, Copenhagen was from thereon responsible for the project.
Maersk Contractors Australia, located in Perth, Western Australia changed name in last
quarter of 2008 to Maersk FPSO Australia. The organisation in Australia did not
change.
Maersk FPSO Copenhagen
Maersk FPSO, Copenhagen has been responsible for recruitment of top-officers during
the entire project period and still is.
Maersk FPSO, Copenhagen settled a projects team at the beginning of the project. The
projects team responsibility has been to carry through the project according to the client contracts and the project specifications.
The projects team has as well been responsible for the entire commissioning process
and has had several persons stationed in Thailand, Singapore and onsite during the
project for commissioning purposes.
Maersk FPSO, Copenhagen is responsible for the vessels ISM and makes the general
procedure. Yearly internal audits are also coordinated from Copenhagen.
Until March 2009 Maersk FPSO, Copenhagen has been responsible for all outstanding
items in connection with the MAERSK NGUJIMA-YIN project.
Maersk FPSO Australia
Maersk FPSO Australia has been involved in the project on the operational aspects of
the project since assembly of production modules began in Thailand.
Throughout the project Maersk FPSO Australia has had an operations team occasionally inspecting in Thailand and subsequently stationed in Singapore.
In the beginning the operations team consisted of four employees recruited by Maersk
FPSO, Copenhagen. From thereon the operations team was expanded by employees
recruited by Maersk FPSO Australia.

Page 24
The responsibility of the operations team has been to ensure that the vessel and all
equipments are suitable and provide safe operability.
Since March 2009 Maersk FPSO, Australia has been responsible for all outstanding
items in connection with the MAERSK NGUJIMA-YIN project.
According to the Operations Superintendent who was on board during the accident the
vessel has very little contact to Maersk FPSO, Copenhagen in daily life. It is Maersk
FPSO, Australia that handles all inquiries from the vessel.
Woodside
Woodside is the operator of the Vincent field and owner of the safety case. See below.
Woodside is a customer of Maersk FPSO.
The Vincent Facility includes the wells, subsea manifolds, multiphase pumps, flowlines,
umbilicals, risers, the mooring anchors, chains, STP buoy and the MAERSK NGUJIMA-YIN.
Woodside manages the overall day to day operation of the Vincent Facility via the Vincent Field Manager, who is on board the FPSO and is accountable for ensuring that
conduct of all activities are in accordance with the Safety Case and approved Operating Procedures when the FPSO is connected to the STP Buoy, i.e. connected to the
continental shelf.
Woodside is accountable to The National Offshore Petroleum Safety Authority
(NOPSA) and other relevant Australian authorities with respect to safety and environmental protection when the vessel is connected to the continental shelf.
The Operations Superintendent who was on board during the fire
The Operations Superintendent who was on board during the fire was employed on
MAERSK NGUJIMA-YIN in January 2009.
He has 32 years of experience at sea and has worked on several off-shore installations
in the North Sea. Most lately he has been supervisor on 3 off-shore new building projects.
During his first rosters he was on board with another Operations Superintendent familiarizing with the vessel.
The roster during which the explosion and fire occurred was his first roster in charge of
MAERSK NGUJIMA YIN.

Page 25
Organisation on board the FPSO

Organisational chart for Navigation mode3:
Master/Operations Superintendent.The Maersk Ngujima-Yin FPSO Operations Superintendent supervises, and is responsible for the safe conduct of all activities and personnel on the Maersk NgujimaYin FPSO and reports to the Woodside Vincent Field
Manager when the FPSO is connected to the STP Buoy.
The Operations Superintendent will take on the role of Master when the FPSO is disconnected from the STP Buoy.
Chief engineer/Maintenance Supervisor
The person who is responsible for the maintenance of the FPSOs equipment.
Deck officers/POT Operations
The Production Operations Technician Operations are not deck officers in the normal
sense and will normally carry out process and utility operations, offtake and maintenance tasks.
Engine room officers/POT Mechanical
The Production Operations Technician Mechanicals are not marine engineers in the
normal sense and will normally carry out process and utility operations, offtake and
maintenance tasks.
3
Source: Maersk Contractors: General Management System Date: May 2007

Page 26
All positions in Marine Mode require qualifications as per STCW.

Organisational chart Offshore4:
Production Supervisor
Responsible for the supervision, planning and implementation of all production activities incorporating: Production, Utilities, to maximise optimum oil/gas production and
water injection rates within safety, legislative, environmental and company requirements.
Medic/safety officer
4
Source: Maersk Contractors: General Management System Date: May 2007

Page 27
Responsibility: To provide medical treatment and support, both operationally and in an

emergency and to assist the Operations Superintendent. Manage safety performance
and compliance with the safety management system on the installation
Materials & Tech. Clerk
Responsibility: To ensure all maintenance and classification records, certification,
documentation and associated paperwork and administration is maintained and controlled and responsible for the management and control of all materials stocks, issued,
and handled offshore.
5.12.3 The safety case

The safety case is owned by Woodside
The Safety Case applies to all activities associated with the operation of the Vincent
Facilities, including the MAERSK NGUJIMA-YIN FPSO whilst connected to the STP
mooring system. The Safety Case comes into force upon the initial connection of the
FPSO to the STP mooting system and risers, including the subsequent commissioning
and hook up activities.
.
The objectives of the Safety Case are to:
Provide a resource for staff to use as a reference which:
Identifies all hazards that could cause a Major Accident Event (MAE) anti with
the Vincent Facility.
Identifies the controls in place to prevent and mitigate these hazards.
Describe the likelihood and consequences of any identified MAEs associated with the
Vincent Facility.
Demonstrate that there is a management system that is in place to continuality and
systematically manage hazards (all health and safety hazards) in the Operations Phase
in the life of the facility.
Demonstrate that the risks to personnel associated with the facility are eliminated or
reduced to As Low As Reasonably Practicable (ALARP) and that the control measures
are adequate; and
Comply with applicable regulations in relation to Safety Cases.
. 5
The Maersk FPSO Safety Management System (SMS) is a part of the safety case
Woodside normally has 2-3 representatives on board.
According to the Operations Superintendent, who was on board during the event, it is
an unusual setup that Woodside owns the safety case. With this setup it is not clear
who is actually in charge.
According to Maersk FPSO, Copenhagen it is common in Australia that the operator of
the field owns the safety case.
5
Source: Vincent Production Facility Safety Case Operations Phase Revision 1. Date: April 2008

Page 28
According to the Operations Superintendent Woodside claims the right to control certain work systems, which in his opinion can confuse the crew. For instance, by leak
tests there are discrepancies between Maersk and Woodside procedures.
According to the Operations Superintendent Woodside has sometimes wanted to take
direct command over Maersk crew, which has resulted in friction between the two parties.
According to the Operations Superintendent he ought to be fully in charge since he has
the command in emergency situations and is responsible for the overall safety onboard. He does not want to accept that daily work is to be carried out as per other systems than Maersk management systems.
According to the Operations Superintendent this has been an ongoing discussion between him and Woodside on several occasions.
5.12.4 Company policies and core values

There were four company policies included in the general management system on
board:
Health and Safety Policy.

Environmental Policy.
Security Policy.
Quality Policy.
Health and Safety Policy and Quality Policy is presented in enclosure 7.4.
On more safety meetings during 1st quarter of 2009 the Operations Superintendents
gave presentations on management commitment and company core values
AP Moeller Maersk Group Core Values were presented in the booklet Defining Our
Core Values
The core values are:
Constant Care: Take care of today, actively prepare for tomorrow.

Humbleness: Listen, learn, share, give space to others.
Uprightness: Our word is our bond.
Our Employees: The right environment for the right people.
Our Name: The sum of our values, passionately striving higher.
5.13 Commissioning
According to Maersk FPSO, Copenhagen commissioning has been carried out by the
projects team, lead by Maersk FPSO, Copenhagen.
The commissioning process is described in company commissioning procedures, also
containing the commissioning documents.
The purpose of the commissioning procedure for Firewater, Foam, Deluge and Sprinkler system is presented in enclosure 7.3.

Page 29
The commissioning process commenced in Thailand and Singapore and was finalized
on-site.
According to Maersk FPSO, Copenhagen the FPSO crew and Maersk projects team
held meetings every time a part was to be handed over and mechanical completion
punch lists containing items to be corrected were being made out.
According to Maersk FPSO, Copenhagen the Maersk projects team has been responsible for clearing out the items on the punch lists and testing the systems according to
procedure before final signing off.
It is stated in the commissioning procedure that:
System performance shall be executed, according to separate procedures, by Operations as part of the "daily operation" of system with assistance from Project Commissioning as required.
.6
According to the FPSO crew they identified more safety and operability issues which
were brought up to Maersk Projects. Some of these issues have not yet been addressed.
According to the FPSO crew, they were told during job interviews that they were to
assist the commissioning process.
According to the FPSO crew they meet resistance form Maersk Projects in more aspects:
FPSO crew was not granted access to full technical documentation of the plant.
FPSO crew was not allowed to participate in performance tests.
According to the FPSO crew many systems were commissioned and signed off without
being fully tested.
According to Maersk FPSO, Copenhagen, all systems were tested according to maintenance procedure and there exist handover documents on all systems.
The Division for Investigation of Maritime Accidents has received information on the
following defective systems:
Deluge systems (see 5.9.1)
Foam systems (see 5.9.2 )
Water mist systems (see 5.9.3)
Glycol contactor:
o
According to the FPSO crew the glycol contactor was commissioned. In

spite of this the internal mesh was missing. The crew operated the device for 4-5 month before it was discovered.
According to the FPSO crew the glycol contactor consumed 0.75m3 of

glycol pr. day and was supposed to consume 0.1 US gallon pr million
Source: Commissioning Procedure: Firewater, Foam, Deluge & Sprinkler System Date: 21.01.2008

Page 30
scuffs of gas. The excessive glycol was carried over to the 3rd stage HP
compression suction scrubbers.
The Operations Superintendent who was on board during the accident has informed
that he has been taking part in start-up of rigs since 1992.
The Operations Superintendent has learnt from his previous projects that the crew
should be a part of commissioning and class testing because:
The crew gains confidentiality and training with the systems.

The crew can make certain that systems are actually working.
The above creates confidentiality and safety
It is the opinion of The Operations Superintendent that the crew should always make
certain that all systems are working.
According to the Operations Superintendent many of the tests in connection with commissioning and class approval has not been verified by the MAERSK NGUJIMA-YIN
crew nor been carried out to their satisfaction. The crew more or less has been excluded from the commissioning process hence it has not been possible to establish
certainty about the systems.
The Operations Superintendent believes that the current problems on board MAERSK
NGUJIMA-YIN originate from the commissioning period and that the crew from the operations team has been excluded during the project phase.
5.14 Security systems on board

5.14.1 Maintenance systems
SAP is a corporate online maintenance system provided on board MAERSK NGUJIMA-YIN.
A separate change management system handles the technical requests (TQs) from
the vessel.
Maersk FPSO, Copenhagen has informed that SAP is an open system that can be accessed online from Copenhagen.
Maersk FPSOs Copenhagen has informed that it has looked into the SAP system and
is of the opinion that the tasks are divided too much into minor issues and that the descriptions are too detailed.
Maersk FPSO, Australia has direct access to SAP and the change Management system.
Maersk FPSO, Copenhagen has informed that the job descriptions in SAP are mainly
made by Maersk Contractors, Esbjerg, but with regard to the production modules
VETCO AIBEL has contributed with input also.
SAP contains the TECO work orders list which contains work orders on all specified
systems.
According to the FPSO crew SAP contains many insufficient job descriptions, i.e. many
job descriptions are not complete but are external references such as as per manufacMarine accident report
Page 31
turers manual. SAP equipment number design is reported as bad, un-logical and nonuser friendly.
NOPSA found that maintenance work orders did not provide appropriate descriptions
and task actions.
NOPSA found a maintenance backlog of over 2000 overdue safety critical items.
The Division for Investigation of Marine Accidents has requested NOPSA to confirm the
number mentioned above. NOPSA has not been able to confirm or reject this due to
confidentiality reasons imposed by Australian legislation.
According to Maersk FPSO, Copenhagen the maintenance backlog of SAP contained
pr. 24th April 2009:
497 outstanding items on planned safety critical maintenance.
55 outstanding items on corrective work orders on safety critical equipment.
According to the FPSO crew, 270 technical requests (TQs) have been submitted since
the vessel left Singapore. Approximately 70 technical requests have been concluded.
process through the change management system takes too long time.
The Operations Superintendent informs that he has never before experienced so much
outstanding maintenance on other projects this late in a project.
According to the Operations Superintendent maintenance on overdue safety critical
items has a certain time limit. In his opinion the handling of these due items has failed
onboard.
5.14.2 Integrated Control and Security System (ICSS)

According to NOPSA7:
The ABB Central Control Room (CCR) Alarms Management System record of initiated
alarms during the period 1st March 2009 to 16th April 2009 details daily alarm counts
from 192 up to 3605 per day with the majority in excess of 300 per day. The Control
Room display screen available to the Operator only provides three lines of alarm detail.
The control room operators console is exposed to constant distraction with other activities ongoing at other work stations.
According to the Woodside/Maersk report8:
Witness statement from control panel operator indicated that he must go through a
number of steps in order to view the Emergency Control Panel. This delays the initiating of the emergency systems. The current DCS emergency panel design should be
reviewed; consider the implementation of a separate and designated screen for fire
system operations.
Source: NOPSA: Prohibition Notice, Notice Number 0197 Date: 20.4.2009


Page 32
Control system logs indicate a large volume of alarms prior to and during the incident..
According to the FPSO crew the number of blocks and overrides in the ICSS and deficiencies within the procedures has been of great concern.
According to the FPSO crew 4-6 blocks would normally cause concern on other facilities.
5.14.3 Closed Circuit Tele Vision (CCTV)

CCTV surveillance monitors are located in the cargo control room and provide live information from cameras on selected spots around the vessel
CCTV surveillance monitors were not available during the fire.
CCTV surveillance monitors were not powered from the emergency switch board or
another uninterruptible power sources (UPS).
5.14.4 SYNERGI
SYNERGI is a corporate near miss and safety breach reporting system.
According to Maersk FPSO, Copenhagen SYNERGI contains 1505 records from May
2008 till 5th May 2009 reported by MAERSK NGUJIMA-YIN.
According to Maersk FPSO, Copenhagen SYNERGI has been available during the
entire project, since the vessel arrived in Singapore in 2007. The system is being accessed from Copenhagen on a daily basis and Copenhagen has received an average
of 116 reports per month from MAERSK NGUJIMA-YIN since May 2008.
Maersk FPSO, Australia has direct access to SYNERGI.
According to the FPSO crew, the online reporting systems such as SYNERGI were not
operable upon start of production in June-July 2008. In lieu of an online reporting system a provisional hazard card system was adopted.
According to the FPSO crew SYNERGI cannot be edited by crew members and all
safety cards have to be typed in by the Operations Superintendent which, by crewmembers, has been regarded as a management barrier in order to avoid sensitive information to Maersk FPSO, Copenhagen.
The Operations Superintendent who was on board during the event has informed that
the Operations Superintendent normally types in the safety cards to the system in order
to maintain a uniform quality of the reports so that these can be used in daily safety
work.
According to the Operations Superintendent it is normal practice on other installations
that the safety cards are handed out to and typed in by duty specific groups having
expert knowledge on a certain areas.
According to the Operations Superintendent the person who types in the safety card,
does not have the duty specific competencies, which can result in reports of variable
quality.

Page 33
According to the Operations Superintendent more issues have had to be raised in

SYNERGI several times before they were resolved. He has informed that there are
about 100 outstanding items in SYNERGI
5.15 Safety climate on board

5.15.1 Safety meetings
The first official general safety meeting was held in May 2008.
According to the FPSO crew management was approached by the crew and notified
about their obligation in holding safety meetings.
Safety meetings have since been held regularly every two weeks.
Minutes of meeting have been issued after each meeting.
5.15.2 Crew concerns

Following concerns have been expressed independently by the FPSO crew during the
investigation on board:
The vessel came to Singapore in a poor mechanical state and left in the same
state if not worse due to the equipment installed.
The shear volume of corrective and break-down maintenance is a major safety
concern.
Due to the shear volume of corrective and break-down maintenance there is no
or very little time for planned maintenance.
The plant is suffering from poor commissioning causing a lot of work.
Maersk only does the bare requirement to meet the standard in order to get
things running.
The work force has lost confidence that MAERSK NGUJIMA-YIN is a safe
place to work.
Lots of operators have left because they dont have confidence in Maersk
management
Maintenance comes second and production first
Behavioural based safety is missing in Maersk
I am very disappointed about how Maersk handles safety
I am a little concerned about future safety in connection with the loss of experience on board
Maersk has failed to meet their duty of care
During the construction in Singapore Maersk Projects made the crew feel like
2nd class citizen
Management in Perth is not supporting management on board
There has been a Systemic failure in the conception of this project from design/commissioning/operations, that is ongoing today and, if anything, getting
worse because of the increased workload being placed on workers
The big problem I see is that this model is still being used and the next project
will have the same problems
During the project phase in Singapore the crew raised concerns in letters to management several times.

Page 34
On a human resource general meeting on board in October 2008 crew concerns and
opinions were being presented to the management of Maersk FPSO, Australia by the
crew.
A memorandum of this meeting has been recorded in the vessel Safety Management
System.
A list of issues, made out by the crew and presented on the meeting, was published on
a white board in the mess.
The headlines were
Crew expectations and statements.

Conditions onboard.
Onboard issues (not including technical/workscope issues)
Shore based issues.
Training issues.
Manning.
HR processes.
Benefits.
Fatigue.
The statements in the list expressed concerns regarding:
Commissioning and Involvement of crew

Project concepts
Respect/Appreciation
Confidence in management
Communication with management
Turnover in manning
Blocks and overrides in ICSS system
Level of manning
Confidence in commissioned systems
Loss of experience due to turnover in manning
Permit to work system
Block and overrides required in the ICSS system
Procedures.
Levels of training.
The above mentioned issues were to a large extent reflected in the memorandum of
meeting of the HR meeting.
During the project phase in Singapore the crew raised concerns in letters to management several times.
According to Maersk FPSO, Copenhagen a climate survey with anonymous participation on board MAERSK NGUJIMA-YIN from October 2008 did not show significant deviations from climate surveys on board other entities.
5.15.3 Working climate on board

Before the accident
According to the Operations Superintendent, who was on board during the fire, the
crew has been complaining a lot and has generally seemed dissatisfied. He informs
Page 35
that there has been a huge turnover in manning during the project. He believes that the
turnover in manning has decreased during the first quarter of 2009.
According to the Operations Superintendent the drainage of experience due to turnover
in manning has influenced negatively on his work onboard since the crew has been
concerned about this.
The Operations Superintendent informs that before the accident the crew did not feel
ownership towards the project.
According to the FPSO crew the Operational Superintendent has an approach to safety
that is a radical change in a positive direction and is very much appreciated among the
crew.
After the accident
The FPSO crew has expressed their contentment with the approach to leadership and
safety work of the Operations Superintendent, who was on board during the fire.
The Operations Superintendent has informed that after the accident, it has been the
crew that has the good arguments when it comes to normalizing the conditions on
board.
It is the opinion of the Operations Superintendent that the crew should be appreciated
and encouraged in their commitment towards safety and encouraged to take ownership
of the project.
The Operations Superintendent has informed that he and one of his colleagues has
been trying to create a working climate where ownership is the central element. Both
have good experience with this approach from previous projects.
The Operations Superintendent has observed that the working climate on board has
been improving compared to when he came onboard first time, which he believes is
caused by an increased feeling of ownership among the crew.
5.15.4 Training, competency and manning

NOPSA found no evidence of a system in place to provide training and competency for
cargo control room related safety critical activities and found that some control room
operators had not received facility specific training.
According to the FPSO crew not all crewmembers have received the training they were
supposed to and have been assigned tasks outside their areas of competency, i.e.
panel surveillance.
According to the Operations Superintendent there has been a huge turnover in crew
during the project. He believes that the turnover in manning decreased during the first
quarter of 2009.
According to the FPSO crew there has been a huge turnover in manning during the
project. It is estimated by FPSO crew that approximately 40% of the initial core crew is
still on board.
According to the FPSO crew the Human Resource department from Maersk FPSO,
Perth announced that a high turnover in manning was expected within the first 12
months.
Page 36
According to the FPSO crew Woodside requested an internal investigation in 3rd quarter of 2008 due to the high turnover in manning.
On a Human resource general meeting on board in October 2008 turnover in manning
was discussed between crew and management.
5.15.5 Post event management

According to the FPSO crew Maersk FPSO, Australia had instructed, with regard to
handling of post event traumatic stress management, that any need for counselling
after the fire should be directed to Maersk FPSO, Australia through the on board HSE
advisor/medic.
In the Greenfields Agreement 2007, made between Maersk Contractors and several
unions on 4th of January 2008, it is stated in clause 23:
23 Counselling
The company shall provide to all employees an independent confidential counselling
service to be the first resource in relation to any stress/addiction/problem including in
home or workplace relationships that may, if untreated, affect performance in the workplace.
The Operations Superintendent has informed that he was disappointed with Maersk
FPSO, Australia, for not having anonymous counselling in place at the time when he
signed off the vessel 15th April 2009.
Management from Maersk FPSO, Australia came on board on 22nd of April.
On a morning meeting on 23rd of April management from Maersk FPSO, Australia
made their first public appearance since the accident occurred.
5.16 Authorities and inspection

5.16.1 Danish Maritime Authority
The Danish Maritime Authority is the flag administration.
The Danish Maritime Authority is not involved in the specific regulation and validation of
the production systems on board, which is subject to approval by Lloyds Register and
NOPSA.
However over all safety is covered by the scope of the Danish Maritime Authority.
The Danish Maritime Authority issued the first Interim Safety Management Certificate
for the vessel on 29th of April 2008. Place of issue was Singapore.
An initial ISM audit was conducted onboard from 22nd to 24th of October 2008. No non
conformities were notes but 10 recommendations were given.
Audit summery and recommendations are presented in enclosure 7.5.
The Interim Safety Management Certificate was extraordinary extended after the above
mentioned audit and would expire on 29th of April 2009.
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On 30th of January 2009 an ISM audit was conducted in the Maersk FPSO, Copenhagen office. 2 non conformities were noted and 7 recommendations were given.
Non conformities, Recommendations and conclusion from the audit report are presented in enclosure 7.6.
On 17th of March 2009 an ISM audit was conducted in the Maersk FPSO, Perth office.
3 non conformities were noted and 3 recommendations were given.
Non conformities, Recommendations and conclusion from the audit report are presented in enclosure 7.7.
On 18th of March a second ISM audit was conducted onboard. 5 non conformities were
noted and 3 recommendations were given.
Non conformities, recommendations and conclusion from the audit report are presented in enclosure 7.8.
5.16.2 Classification scheme

The vessel is classed by Lloyds Register and the classification covers both old marine
systems and the new production facilities.
Lloyds Register has informed on 4th of June:
After completion of offshore commissioning activities LR Asia, on behalf of LR Europe
Middle East & Africa, issued a Validation Statement for the start up of hydrocarbon
process operations, which contained a list of items which had to be completed. The
Validation Statement was accepted by NOPSA and production operations began immediately.
Simultaneously, LR Asia, on behalf of LR Europe Middle East & Africa, issued an Interim Class Certificate for the vessel together with interim editions of the International
Regulatory Certificates issued on behalf of DMA.
Since that time further Interim certificates have been issued pending the completion of
outstanding items. The current Interim Class Certificate expires on 29th. July 2009
The main outstanding items were:
The maximum environmental conditions at which the vessel has to disconnect

from the offshore mooring and seek shelter were reduced from the 100 year
equivalent storm to a 10 year equivalent storm. This restriction was pending further analysis of the mooring system. This restriction was removed on 14th. May
2009.
The final approval of the Trim and Stability information, intact & damaged, and
the associated Longitudinal Strength calculations.
The final approval and testing of the on board computer for the calculation of
stability and longitudinal strength.
The approval of the Operations Manual for the vessel.

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The final approval of the Trim and Stability information is currently nearing completion
and it is hoped that the approval process will be completed by 20th. June 2009. When
that approval is made LR will issue all the full status International Regulatory certificates on behalf of DMA.
The other 2 outstanding items, i.e. the approval of the on board computer and the approval of the Operations Manual are Class requirements and may possibly not be completed in time for the issue of a full term class certificate at the time of the expiry of the
current interim certificate.
However, when the approval of the Trim and Stability information is complete I shall
request the Lloyds Register Class Committee to consider granting a full term Class
Certificate with conditions specifying the dates for the completion of the outstanding
activities. If that request is successful I hope to be able to issue a full term Class Certificate before the expiry of the current interim certificate.
Another of the outstanding items to be closed out comprised of a list, "Anomaly Register-DRIMS-Doc No-4340896-v3_Safety_Critical_Equipment_Impairment_Listing" which
was not attached to the validation statement.
On 4th November 2009 The Division for Investigation of Maritime Accident has received
DRIMS-#Doc No-4340896-v3_Safety_Critical_Equipment_Impairment_Listing from
Lloyds Register.

Page 39
6 Analysis
6.1 The cause of the explosion and fire
Maersk/Woodside has conducted a preliminary Root Cause Analysis:9
.
The primary reason for the HP compressor failure on April 13, 2009 has been identified
as a flow transmitter error.
The flow transmitter error consisted in an offset that was interpreted as a flow rate. As
a consequence the anti-surge system was led to believe that the compressor operated
at flow rates above the surge protection line, and the anti-surge valve was therefore
kept close. In reality, the HP compressor was operating with insufficient discharge
pressure to inject and a closed anti-surge valve (i.e., no flow through the discharge
nozzle) causing significant internal heat generation. This off-design operating condition
was maintained for about an hour without the protection system or operators realising
the problem. Eventually, the internal temperature rise of the compressor led to a full
catastrophic failure. The exact sequence of events in the last phase up to the gas release is not yet fully understood, but inspection suggests that gas release was possible
due to the simultaneous failure of all gas barriers (primary and secondary dry gas seal
stages as well as tertiary seals). This simultaneous failure was a consequence of the
DE bearing cap bolts being torn out of the bearing housing, allowing the shaft motion to
exceed all internal sealing clearances.
..
According to the Root Cause Analysis a review has confirmed that the compressor
control system is fully in line with the industry standard.
According to the Root Cause Analysis it is unknown how the above described failure
sequence could generate enough power to tear the seal bearing cap open.
Propagation fire:
The increased pressure in the nitrogen gas seal allowed the leaking process gas to
propagate back through the bearing lubricating oil system and further through a common lubrication oil drain tank and into the gas turbine enclosure. The leaking process
gas exploded within the lubrication oil tank and the enclosure which, among other
things, was indicated by the enclosure doors being forced open. Buckling of the plate
fields forming the enclosure was also observed.
The supply of process gas process was interrupted shortly after the emergency shut
down.
Lubrication oil from the drain tank was still available and thus fuelling the fire.
According to the FPSO crew there have been issues with compressor bearings and
alignments during the project before commissioning.
It can be established that there has been issues raised concerning bearings and alignments and loose bolts on the compressors. However, it is not known if these issues
have had any influence on the sequence of events.
9
Source: Root Cause Analysis Conclusion

th
Date: Received by mail on the 29 September from the FPSO management.

Page 40
The primary reason for the HP compressor failure on April 13, 2009 has been identified
as a flow transmitter error. After the failure the explosion and fire developed through
the torn seal bearing cap and through the lubricating oil system.
6.2 Course of events leading up to the explosion and fire

6.2.1 Safety climate prior to production start-up
During the investigation on board the FPSO crew expressed discontent related to the
project management in Thailand and Singapore.
The vessel came to Singapore in a poor mechanical state and left in the same
state if not worse due to the equipment installed.
During the construction in Singapore Maersk Projects made the crew feel like
2nd class citizen
There has been a Systemic failure in the conception of this project from design/commissioning/operations, that is ongoing today and, if anything, getting
worse because of the increased workload being placed on workers
The big problem I see is that this model is still being used and the next project
will have the same problems
According to the FPSO crew, management was approached continuously during the
project.
On a Human resource general meeting on board in October 2008 crew concerns and
opinions related to project management in Thailand and Singapore were being presented to the Management of Maersk FPSO, Australia by the crew.
The FPSO crew has felt kept out of commissioning and has felt disrespected. Crew has
felt that they were not listened to be management and that their involvement was not
appreciated.
It is the assessment of the Division for Investigation of Marine Accident that the safety
climate on board during the project period in Thailand and Singapore has been poor.
6.2.2 Deluge system

In a list of completed work orders, provided by Maersk FPSO, Australia, a job completed on 3rd of September 2008 has stated in the description field: Investigate/Repair
Deluge Valve M-60
According to the FPSO crew the M70 deluge system was tested in August 2008. During this test the deluge valve failed to open on demand.
After the test, more than 20 minutes endured before the M11 deluge valve was manually and locally reset.

Page 41
During the investigation on board the deluge system for module M11 was tested. The
test showed that the deluge valve worked and could be remotely released, but it was
later found that several nozzles were blocked.
There have been difficulties with deluge valves on module M60 and M70 prior to the
accident.
6.2.3 Foam system

Old system
During the accident the old foam system failed to work on demand.
According to the Operations Superintendent who was on board during the accident, the
foam system started but the nozzles on the foam monitors were incorrectly set and
thus not usable.
It has not been clarified when the old foam system was last tested.
Deck Deluge Foam Monitors were witnessed to be operational on the 10/06/2009 following
progressive identification and rectification of significant defects
According to the FPSO crew the old foam system was inspected after the accident.
The inspection found that the system would never have worked properly, as the in line
proportioner was fitted back to front, and 2 pneumatically operated valves supplying
foam to the system were fitted back to front, meaning when the valves were commanded to open to supply foam concentrate to the pumps, they were in fact shut.
The old foam system failed to work on demand during the fire due to defective nozzles.
6.2.4 GRE Piping

GRE (Glass reinforced Epoxy) piping is used in the new ring fire main and in major
branch pipes for hydrants and deluge lines.
During the fire two branch lines of the new ring fire main bursted. The branch line supplied ordinary hydrants on top of module M60. Both lines have been subject to radiant
heat and flame exposure from the fire. See picture 5 and 6.
According to the FPSO crew the pressure in the new ring fire main rises from 8 bar
gauge to 16-17 bar gauge upon start-up of a the diesel driven fire pumps. And a strong
water hammer has occurred every time the diesel driven fire pumps have been in use.
According to the FPSO crew the operations team raised concerns about the integrity
and safety of GRE during the project stage in Singapore. They were informed by
Maersk FPSO that the GRE piping was accepted by class and had the same heat resistance properties as steel.
Maersk FPSO, Australia has informed that:
The GRE piping might have been damaged by the initial explosion and
GRE has a very poor resistance to explosion/chock.
The GRE piping might have failed due to radiant heat from the fire after an unknown time.
Page 42
A material failure analysis is ongoing.

Lloyds register gave approval for GRE piping at L3 rating according to IMO
According to IMO resolution A.753(18), appendix 2, a water filed pipe is to be fire endurance tested for 30 minutes. The internal pressure during the test is to be maintained
at 3 0.5 bar gauge.The resolution was adopted on the 4th of November 1993.The
testing scheme does not take pressure pulsations into account.
According to Lloyds register rules approval of GRE piping will in general be accepted in
Class III piping systems (I.e. working pressure 16 bars and working temperature
200C.)
Under was has been regarded a normal working condition the GRE piping in the new
ring fire main has been subjected to pressure pulses from start-up of diesel driven fire
pumps and from water hammer.
It is the assessment of the Division for Investigation of Marine Accidents that the IMO
resolution A.753(18), appendix 2 testing scheme does not correspond to or reflects the
actual working conditions of the GRE piping used on board in the new ring fire main
system.
GRE piping in two branch lines failed during the fire. The GRE piping has been subjected to radiant heat and flames during the fire and has repeatedly been subjected to
pressure pulsations arising from water hammer and start-up of diesel driven fire
pumps. Lloyds Register gave approval for GRE piping at L3 rating according to IMO
6.2.5 Water mist system

The water mist system did release automatically when the fire was detected, but water
and nitrogen was not released.
According to Maersk FPSO, Copenhagen the water mist system did not engage because a nitrogen regulator was obstructed.
According to Maersk/Woodside report of 12th of May 2009 a nitrogen regulator was
incorrectly set.
According to the FPSO crew the above mentioned regulator was fully wound down and
closed. I.e. it did not operate at all.
According to the FPSO crew all water mist systems protecting on board gas turbines, in
total 5 (Three driving power generators and two driving the HP compressors), were
inspected after the accident. It was found on all 5 systems that none of the regulators
would have operated.
The mentioned regulator valve is set manually. The system was commissioned on 26th
of May 2008.
In the commissioning documents it was noted that none of the N2bottles, containing the
driving media, had been released. In order to test the water mist system without releasing the N2 the N2 bottles have to be isolated from the remaining parts of the system.
Isolation of the N2 bottles could be achieved by manually closing the nitrogen regulator.

Page 43
The Division for Investigation of Maritime Accident cannot establish weather the regulator has been left closed after the testing or it has been closed later or has been obstructed for other reasons.
The water mist system failed to work on demand during the fire because a nitrogen
regulator was either obstructed or closed.
6.2.6 New ring fire main/water hammer

The jockey pumps have been out of service several times since they were installed in
Singapore. Since May 2008 they have been in service for approximately 3 months.
When the pumps were out of service diesel driven fire pumps were used. These pumps
deliver a much higher pressure and much more water than the jockey pumps. As a
consequence a strong water hammer has occurred every time the diesel driven fire
pumps have been in use.
According to the FPSO crew it has been verbally raised to Maersk FPSO that the water
hammer could compromise the safety of the fire mains.
According to the Operations Superintendent who was on board during the accident,
Maersk FPSO, Australia was been approached by him regarding the water hammer.
From their side he was informed that a solution was in progress.
Maersk FPSO, Copenhagen, has informed that they have been aware of the water
hammer issue since the vessel came on site and does not regard it as a serious problem and that the issue has been handled locally by the engineering manager in Perth.
Maersk FPSO, Copenhagen, has informed that the provisional technical solution has
been tested to the satisfaction of Maersk FPSO, Copenhagen.
An anomaly was previously noted and remains on the on the fire main due to water hammer
when the deluge pumps start and was also observed when they stop during deluge system testing
in June 09. The water hammer is noted to be sufficient magnitude to require deck isolation
valves to be manually closed.
The Division for Investigation of Maritime Accident observed several leaks in pressure
relief valve overflow system and on the actual pressure relief valve causing the water
hammer.
It is the assessment of the Division for Investigation of Marine Accidents that the water
hammer has been imposing unnecessary strain on the new ring fire main and its connected subsystems.
When the new ring fire main has been used for deck wash or similar purposes a remotely controlled over board discharge valve on the forward part of the vessel has to
be opened manually in order to ensure a sufficient flow through the diesel driven
pumps to avoid damage. The mentioned discharge line has the dimension DN400 and
is supposed to be used in connection with tests of the diesel driven fire pumps.
In the cargo control room an arrangement of the new fire ring main was posted with a
yellow post it on it saying:

Page 44
Any extended period of time that the FWP is online, the dump valve is required to be
open to stop dead heading of the pump. There is a mark indicating the position. You
can also confirm the flow rate of 1600 m3/h at the FWPs
In the case where the DN 400 over board dump valve is open, the back pressure in the
new ring fire main will be substantially reduced and with any other system on line the
pressure would drop further.
If the over board dump valve for some reason would be left open it could compromise
or delay the functionality of the new ring fire main. With a DN400 line open it is likely
that sufficient pressure in the new ring fire main for deluge and foam operation could
not be maintained.
Continuous problems with the new ring fire main have been identified. The problems
have not been resolved.
6.2.7 Debris from aft firewater pump engine

During running of the aft fire pump debris with carbon deposits is excreted from the
diesel engine exhaust system. Heavy black smoke is developed during start up.
The exhaust system is placed a few meters outside the dangerous zone as defined in
the class rules.
According to the Operations Superintendent the debris issue has been discussed with
the class and has been raised in SYNERGI. He has informed that he is not confident
that it is safe. The issue has not been rectified.
It was noted that solid material was exhausted from the Aft Firewater Pump from time
to time. This material appears to be a salt accumulation possibly from crystallisation
from an internal spray cooler.
WEL/Maersk should determine where the material dropping from the Aft Firewater
Pump is coming from and assess potential impacts to the pump and surroundings.
According to Maersk FPSO, Copenhagen the internal spray cooler cools the exhaust
pipe and also prevents carbon deposits to come alive.
Debris containing carbon deposits has been excreted from the exhaust system of the
aft fire water pump. It is reasonable to believe that the carbon deposits originate from
start-up of the engine where heavy black smoke is developed. The issue has raised
safety concerns but has not been resolved.
6.2.8 Commissioning
According to the FPSO crew, they were not allowed to participate in performance tests
and were not granted access to full technical documentation of the plant.
According to Maersk FPSO, Copenhagen commissioning has been carried out by the
projects team, lead by Maersk FPSO, Copenhagen.
It is stated in the commissioning procedure that:

Page 45

.
Several systems deluge, water mist, the new foam system and the glycol contactor have been defective after commissioning.
It is the assessment of The Division for Investigation of Maritime Accident that the
commissioning has been inadequate and has not reflected the intention of the commissioning procedure, because the crews participation has been limited.
6.2.9 Maintenance
NOPSA found a maintenance backlog of over 2000 overdue safety critical items during
their investigation.
NOPSA found that maintenance work orders did not provide appropriate descriptions
and task actions.
According to Maersk FPSO, Copenhagen the maintenance backlog of SAP contained
pr. 24th April 2009:
497 outstanding items on planned safety critical maintenance.
55 outstanding items on corrective work orders on safety critical equipment.
According to the FPSO crew SAP contains many insufficient job descriptions, i.e. many
job descriptions are not complete but are external references such as as per manufacturers manual. SAP equipment number design is reported as bad, un-logical and nonuser friendly.
Maersk FPSOs Copenhagen has informed that it has looked into the SAP system and
is of the opinion that the tasks are divided too much into minor issues and that the descriptions are too detailed.
According to the FPSO crew, 270 technical requests (TQs) have been submitted since
the vessel left Singapore. Approximately 70 technical requests have been concluded.
The corrective work after commissioning has caused so much work that planned maintenance has been postponed or sparsely done.
process through the change management system takes too long time.
Difficulties with the planned maintenance system SAP and corrective work originating
from commissioning has compromised planned maintenance. It is the assessment of
the Division for Investigation of Marine Accidents that maintenance planning on board
and maintenance support from shore management has been inadequate.
6.2.10 ICSS Integrated Control and Safety System

According to NOPSA:
Page 46
According to the Woodside/Maersk report:
system operations.
Control system logs indicate a large volume of alarms prior to and during the incident..
According to the FPSO crew the number of blocks and overrides in the ICSS and deficiencies within the procedures has been of great concern.
According to the FPSO crew 4-6 blocks would normally give rise to concern on other
facilities.
It is the assessment of the Division for Investigation of Marine Accidents that the number of block and overrides in the ICSS has been to an extent where credibility of the
systems could be called into question.
6.2.11 Safety climate post production start-up - software

During the investigation on board the FPSO crew expressed discontent related to
Maersk management and the conditions on board:
The shear volume of corrective and break-down maintenance is a major safety

concern.
The plant is suffering from poor commissioning causing a lot of work
The work force has lost confidence that MAERSK NGUJIMA-YIN is a safe
place to work.
Maintenance comes second and production first
I am a little concerned about future safety in connection with the loss of experience on board
Management in Perth is not supporting management on board
Maersk only does the bare requirement to meet the standard in order to get
things running.
Behavioural based safety is missing in Maersk
I am very disappointed about how Maersk handles safety
According to the FPSO crew, management has been approached continuously.

The first official general safety meeting was held in May 2008. According to the FPSO
crew the management on board was approached by the crew and notified about their
obligation in holding safety meetings.
According to Maersk FPSO, Copenhagen SYNERGI has been available during the
entire project, since the vessel arrived in Singapore in 2007. The system is being accessed from Copenhagen on a daily basis and Copenhagen has received an average
of 116 reports per month from MAERSK NGUJIMA-YIN since May 2008.
Page 47
According to the FPSO crew, the online reporting systems such as SYNERGI were not
operable upon start of production in June-July 2008. In lieu of an online reporting system a provisional hazard card system was adopted.
On a Human resource general meeting on board in October 2008 crew concerns and
opinions were being presented to the Management of Maersk FPSO, Australia by the
crew.
Several concerns were related to the conditions on board regarding.
Commissioning and Involvement of crew

Project concepts
Respect/Appreciation
Confidence in management
Communication with management
Turnover in manning
Blocks and overrides in ICSS system
Level of manning
Confidence in commissioned systems
Loss of experience due to turnover in manning
Permit to work system
Block and overrides required in the ICSS system
Procedures.
Levels of training.
The FPSO crew has been disillusioned with Maersk FPSO due to lack of managerial
commitment and support with respect to safety, maintenance, manning and confidentiality.
It is the assessment of the Division for Investigation of Marine Accident that the safety
climate onboard after production start-up has remained poor.
6.2.12 Shore management

Several systems have been defective after commissioning. The actual commissioning
has not reflected the intention of the commissioning procedure.
Difficulties with the planned maintenance system SAP and corrective work originating
from commissioning has compromised planed maintenance.
The FPSO crew has felt kept out of commissioning and has felt disrespected. Crew has
felt that they were not listened to be management and that their involvement was not
appreciated.
The FPSO crew has felt disillusioned with Maersk FPSO due to lack of managerial
commitment and support with respect to safety, maintenance, manning and confidentiality.
It is the assessment of the Division for Investigation of Marine Accidents that the implementation of the health and safety policy on board the FPSO has been inadequate:
The management has not provided the means necessary to accommodate and
coordinate the interests of the project team and the operations team.

Page 48
The management has acted inadequately on the feedback from the FPSO crew
during the project and has not been able to re-establish a healthy safety climate
on board.
The support to maintenance on board provided by management has been inadequate.
6.3 The detection and identification of the explosion and fire

6.3.1 Detection of the fire scene
1250:
Emergency shut down(ESD1) initiated
1251:
Switch to emergency power.
Closed Circuit Tele Vision (CCTV) is no longer available.
1325:
1328:
A standby vessel visually confirms fire aft of forward crane.
The location of the fire was immediately identified by the ICSS to be in M60. The CCTV
was not accessible and could not provide confirmative information on the location of
the fire. The emergency response team and a standby vessel visually confirmed the
location of the fire. From the general alarm was raised and to the location of fire was
visually confirmed 35 minutes passed.
The ICSS was able to establish the location of the fire. However the crew did not have
an instant overview of the facilities as the CCTV was cut off, because it was not powered from an uninterruptible power source.
6.3.2 Identification of fire source

1250:
1325:
1359:
Pulsing smoke identified by a standby vessel.
1406:
It is identified that a DC lubrication oil pump is running on compressor A.
Flames are still observed on compressor A
1420:
Manual isolation of DC lubrication oil pumps accomplished.
1425:
The fire is reported to be contained and boundary cooling is maintained.
Radio communication in CCR was only available with handheld radio in simplex mode,
which hampered communication.
Page 49
The emergency response team identified 5 oil drums between the two compressor
modules and the stand by vessel identified pulsing smoke which originates from a running DC lubrication oil pumps.
From the location of fire was visually confirmed until the sources of the fire were identified 41 minutes passed.
The identification of the fire source and choice of fire fighting equipment was primarily
based on visual inspection by the crew and the stand by vessel.
From the general alarm sounded and until fire sources were identified 1 hour and 16
minutes passed. It is the assessment of the Division for Investigation of Marine Accident that the on board security system did not provide adequate barriers against loss of
instant overview.
6.4 Fighting the fire

6.4.1 Automated systems
Blow down (MBD):
12:50:
Blow Down initiated
1305
The production system is depressurized by way of the HP separator according
to ICSS log.
1320
According to white board in the cargo control room the flare is off indicating that
the production system is depressurized. Emergency response teams can be
engaged. Emergency response teams can be engaged.
1324:
Public announcement of no blowing in facility, i.e. the production system is depressurized.
From blow down was initiated approximately 30 minutes passed until it was certain to
the crew that the system was depressurized.
Deluge:
1251:
Deluge activated automatically from the ICSS on M60.
Deluge activated manually from cargo control room on module M30
To protect the adjacent module M30, which holds a flare drum with a volume of approximately 80 m3, that at the time of the accident it contained approximately 3 m3
compressed process gas, deluge on this module was released from the Cargo Control
Room (CCR)
The Integrated Control and Safety System (ICSS) indicated that deluge had been activated on module M30 and M60. But flow of water could not be positively confirmed on
the ICSS.
1316:
Page 50
Attempt to visually confirm water on deluge from Monkey Island. No confirmation possible.
1327:
1334:
confirmed visually.
1343:
1346:
confirmed visually.
Deluge on modules M30 and M60 was released manually by way of the local deluge
skids by a member of the emergency response team.
From deluge was activated on M60 until it is established that it is not active 36 minutes
passed
From deluge was activated on M30 until it is established that it is not active 52 minutes
passed
From it is established that deluge is not active on M60 until water is confirmed 7 minutes passed
From it is established that deluge is not active on M30 until water is confirmed 3 minutes passed
The automatic release of the deluge on modules M30 and M60 failed. Manual release
had to be carried out and approximately one hour passed from the fire started until water was confirmed. It is the assessment of the Division for Investigation of Marine Accident that the functionality of the deluge systems on M30 and M60 has been insufficient.
6.4.2 Manual fire fighting

Foam:
1325:
Foam extinguishing was requested by the Emergency Response Team because the
fire was fuelled by lubricating oil and because of the drums stored between HP Compressor train A & B contained oil and could have leaked or exploded.
1330:
Cargo fire pumps started in attempt to activate the old foam system.
The old foam system failed to work on demand due to incorrect settings of the nozzles.
It is the assessment of the Division for Investigation of Marine Accidents that the old
foam system could have provided effective means of extinguishing a fire fuelled by oil
from the drums.

Page 51
Hydrants and fire hoses

1325:
1340:
Emergency response team prepared attack with fire hoses.
1350:
Emergency response team attacked M60 with fire hoses from M20 blast wall
The bursted GRE piping was observed during the fire fighting by one of the emergency
response team members.
It was observed during the fire fighting that one hydrant failed to deliver water while the
adjacent monitor delivered good pressure.
6.4.3 Crew fire fighting efforts

CCTV surveillance monitors were not available during the fire and an overview could
not easily be established.
The FPSO crew engaged emergency response teams to appraise the fire.
Radio communication in CCR was only available with handheld radio in simplex mode,
which hampered communication.
The FPSO crew managed to get an overview of the fire and to coordinate evacuation
plans with nearby vessels and installations.
The crew quickly managed to manually release deluge on module M60 and M30 when
it was established that there was no water.
Foam was not available.
The FPSO crew managed to extinguish the fire within 1.5 hours by means of fire hoses
and eventually deluge.
It is the assessment of The Division for Investigation of Maritime Accident that the
FPSO crew handled the emergency response and fire fighting effectively and competent with the tools and safety system available.
6.5 Post event management

The FPSO crew was under considerable pressure during the fire. An explosion had
occurred in the production area and subsequently a fire developed. The emergency
response teams attacked the fire without knowing the cause, the source, the location or
the extent of the fire. They had reasons to be very uncertain about the development of
the fire until it was extinguished. Preparations for evacuation of the FPSO were made.
According to the FPSO crew Maersk FPSO, Australia had instructed, with regard to
handling of post event traumatic stress management, that any need for counselling
after the fire should be directed to Maersk FPSO, Australia through the on board HSE
advisor/medic.
Page 52
In the Greenfields Agreement 2007 of 4th of January 2008 clause 23 it is stated:

23 Counselling
The company shall provide to all employees an independent confidential counselling
service to be the first resource in relation to any stress/addiction/problem including in
home or workplace relationships that may, if untreated, affect performance in the workplace.
Management from Maersk FPSO, Australia made their first appearance on board 10
days after the accident occurred.
It is the assessment of The Division for Investigation of Maritime Accident that the post
event traumatic stress management has been inadequate.
6.6 Audits and inspection

It is mentioned above that commissioning during the project has been inadequate. After
the accident it has been established that several systems deluge, water mist, old
foam system, glycol contactor, new ring fire main water hammer, GRE piping - have
been defective.
It is the assessment of The Division for Investigation of Maritime Accident that the mentioned defects cannot exclusively be assigned to the time period after system approval.
It is the assessment of The Division for Investigation of Maritime Accident that the class
approval process has not adequately ensured that all fire fighting systems were functional.
The Danish Maritime Authority has conducted four ISM audits on board and in the offices of Perth and Copenhagen.
The ISM audit reports have disclosed operational non-conformities in the documentation of the safety system regarding procedures, survey items not closed out, records
not correctly filled, expired certificates etc.
The ISM audits reports also contained recommendations indicating that the safety
management system and the intentions behind the ISM Code were not adequately implemented.
However, it is the assessment of the Division for Investigation of Maritime Accidents
that the ISM audit reports have not given the management sufficient incentive to improve the implementation of the safety management system and the intentions behind
the ISM Code.

Page 53
7 Enclosures
7.1 Excerpt from NOPSA improvement notice
Source: NOPSA: Prohibition Notice, Notice Number 0197
Date: 20.4.2009
Improvement Notice 1
During a fire emergency response situation on the 13th April 2009, the deluge system
did not function on demand.
During the course of an investigation on board the facility from the 14th - 17th April
2009, I observed, based on the SAP maintenance backlog report on 17th April, that
there was a maintenance backlog of over 2000 safety critical items. It was also observed that maintenance work orders in SAP do not provide appropriate descriptions
and task actions.
During the course of an investigation on board the facility from the 14th -17th April 2009,
I observed, that there was no evidence of a system in place to provide training and
competency for control room related safety critical activities. For example, a Control
Room Operator (CRO) has only received basic (generic system) training on the ABB
control system with no facility specific training. There is no evidence of a competency
based assessment system in place, which coupled with recent turnover of CROs has
resulted in the potential for knowledge gaps regarding the facility process control system
During the course of an investigation on board the facility from the 14th 17th April
2009, I observed the firewater GRP (glass-reinforced plastic) pipework failed in 2 locations on the HP gas compression module.

Page 54
7.2 Excerpt from Woodside/Maersk report

Source: Major Investigation Report: Fire in gas compression module Asset/site:
Maersk Ngujima-Yin, Australia
Date: 12.5.2009
.
3.1.7 Technical Conclusion
At this stage the root cause of the event has not been identified. Further investigation
comprising of a detailed strip down of the compressor is required to identify failure
modes and root causes. As a minimum this should include seal gas filter element removal for analysis and 3rd stage compressor casing drain liquid collection and analysis. This is to rule out the possibility that liquid contaminants have been carried over
into the 3rd stage HP compressor. Additionally the gas turbine driver should be boroscoped to identify internal condition, specifically if there has been a fire inside the turbine.
Analysis of the process parameters associated with the dry gas seals has failed to
identify an external failure mode of these seals. The only indication of impending problem was through the DE seal cavity temperature transmitter 36-TT-4251A recording a
rise in temperature up to the maximum scale of 206C for the device. There was no
other indication of high heat, or excess vibration, prior to the failure.
3.2 Emergency Systems, Preparedness and Response:
Evidence from witnesses suggests that the on-board Emergency Command Group and
Emergency Response Team did an exceptional job in the management and coordination of the incident. Further to note, is that a few days prior to the incident, the Production Supervisor had reviewed the control centre and recognised that improvements
should be made through the adoption of command centre boards as used by ERGT
(training facility) and redesign of tables and layout. The new layout was put in place two
days prior to the incident. An emergency exercise was carried out to familiarise the
emergency team members with the new layout the day prior to the incident.
During the incident the facility went to emergency shutdown status ESD-1, all main
power generation tripped. The CCTV system is not powered from the emergency
switch board or UPS and was not able to be utilised to view, record and assess the fire.
The only visual feedback available on the incident location was via attending support
vessels, until such time as the process was blown down and the fire teams were deployed. Consideration should be given to powering CCTV systems from emergency
board or UPS.
Witness statements from the CCR and ERT report poor radio coverage in some areas.
The radio base stations are not supplied from the emergency switchboard or UPS. As a
result, control room operators were required to use hand held radios in simplex mode
only, and had to move around both the CCR and in the field to receive reception. There
is an open technical query on this issue which should be given priority.
During the investigation, it was ascertained that there had been a confirmed fire signal
within the A turbine enclosure via activation of two heat detectors. The cause and effects for this were reviewed and it was confirmed that the ICSS system processed
these signals correctly. From investigation on site, it was noted that the nitrogen cylinders providing drive to the system had fired, confirming that solenoid 84-XY-4022 had
received the signal from the ICSS. However, the nitrogen cylinders still retained their
full charge and the water tank was full. Following further testing of the water mist system to A gas compression package turbine enclosure, it has been confirmed that the
Page 55
regulator 84-PCV-4071 was incorrectly set and that no nitrogen could pass this point.
To confirm the integrity of the rest of the system, the regulator was properly set and a
controlled manual discharge of the water mist was carried out. Correct operation of the
system, including nozzle discharge within the A enclosure, was confirmed.
M60 deluge: At the time of the incident, fire within module M60 was confirmed via activation of two flame detectors. The ICSS system functioned as per the cause and effects, and a signal was sent to the ICSS system to activate deluge in M60. A pressure
response was noted within the deluge pipe work a short time later. However, a member
of the fire team confirms that he manually activated the deluge system some time later.
Initial investigation of the associated cabling indicates that it has not been compromised by the fire. Further investigation is required to understand what occurred.
GRE (Glass Reinforced Epoxy) fire system piping which ran adjacent to the compressor packages, failed at the joint, dropping water over the enclosure (This proved to be
positive in the mitigation of this particular fire). This is thought to be due to radiant heat
exposure (testing will confirm) resulting in the loss of water to 2 hydrants which were
positioned above the fire floor (this was not detrimental to the mitigation of this fire). It is
recommended that a review be conducted to ensure that the GRE piping installed is in
accordance with the appropriate standard for use in fire fighting systems.
ERT witness statements describe that one of the fire hydrants on the main deck immediately forward of the HP gas compression process modules failed to deliver water, the
next monitor forward off the same ring main delivered at good pressure. Discussions
with personnel onboard indicate a previous problem with this design of hydrant, which
is the subject of a technical query.
ERT witness statements mention that the fire hoses that were laid out, were stored 3
ways;
Standard Roll As used by FESA/ERGT
Dutch Roll Universal Roll
Out of Service Roll Rolled from the male coupling, this is to show that there is a fault
with the hose.
All fire hose should be made up in the FESA/ERGT Standard Roll unless it is damaged, then it is to be rolled from the male coupling and an Out of Service tag placed
on the female BIC.
4. OBSERVATIONS AND ADDITIONAL ACTIONS
The ERT witness statements have suggested that the fire safety plans available in the
fire locker should be reviewed, and if required made available in a larger format. It is
recommended ERT members use this plan in conjunction with regular emergency drills
throughout the facility to ensure they become and remain familiar with fire equipment,
its location and operation.
There were 5 x 200 litre oil drums stored between the two compression trains. Without
portable foam extinguishing equipment it may have been difficult to extinguish an oil
fire. Ensure all flammable liquids are stored and segregated as per the Australian Dangerous Goods Code of Practice or the relevant NORSOK standard and the Off-Shore
Petroleum and Greenhouse Gas Storage Act 2006.
The Emergency Response Team members do not have Nomex flash hoods. These are
now considered basic fire-fighting PPE within industry and consideration should be
given to issuing these to each member.

Page 56
The 2nd ERT were 1 member down due to the final member being required in the
ECR. Review current ERT manning levels to ensure that adequate ERT members are
trained and available in-line with the station bill.
ERT witness statements request that the current steel breathing apparatus cylinders be
replaced with the Aluminium/fibre wrap cylinders. Conducting this change would reduce
the weight of a breathing apparatus from 16Kg down to 11Kg. Consideration could be
given that any cylinders that are due for hydrostatic test could be removed from service
and replaced with Aluminium/Fibre wrapped cylinders on an on-going basis.
system operations.
The control room operator on shift at the time of the incident had been on the facility for
seven months. He was employed as a production operator. He had recently transferred
to the panel and was half way through his third three week swing as a control room
operator.
At the time of the incident the control room operator who had just come off shift was
redeployed to the control room operator to manage the fire and gas panel whilst the
onshift operator focused on the process panel. The operator on shift at the time of the
incident described having the second more experienced panel operator available as a
god send. A review of the manning levels in the control room should be undertaken.
Control system logs indicate a large volume of alarms prior to and during the incident.
An alarm rationalisation program should be conducted to reduce the number of standing alarms and the frequency of alarms. First out alarming should be considered to
enable clarity to the panel operators during process upsets.
There is no Master Clock for the numerous instrument and control systems. This has
made it impossible to accurately create a true sequence of events when accessing
information from the various systems. A Master Clock system should be incorporated
to ensure all instrument and control system data is time stamped in true chronological
order.
.

Page 57
7.3 Purpose of Commissioning procedure

Source: Commissioning Procedure: Firewater, Foam, Deluge & Sprinkler System
Date: 21.01.2008
1 PURPOSE
The purpose of this procedure is to define and describe all activities required to safely
perform commissioning activities for the system.
This includes:
Define all information and requirements necessary to prepare, plan and execute
Commissioning in a safe way.
Describe MC punch out and handover from construction to commissioning.
Define preparation for commissioning required for package(s)
Define functional testing of equipment and preparation before start up.
Detailed procedures for dynamic testing
Handover from commissioning to Company
It shall also be used as a pre-check list prior to handover of the systems to the Operation Group.
It is important to note that the following procedure only covers equipment installed during the conversion of the vessel. Existing equipment should be brought back into operation using existing vendor manuals and vessel operating manual.

Page 58
7.4 Company policies

Source: Maersk Contractors: General Management System
Date: May 2007

Page 59

Page 60
7.5 ISM on board audit the 22nd 24th of October 2008

Source: DMA: ISM-/SECURITY DIVISION
Date: 22nd 24th October 2008
2 Summary
[..
The general impression is that knowledge about Danish law and regulations do nearly
not exist. The familiarity to the GMS management system is very poor. The chain of
responsibility on board are very open, it was not observed that there were no clear
channels of command who is responsible for what?
The document control and the way documents are treated on board are not at all in
accordance to the objectives which are formulated in the ISM Code, no library was established. It was hardly possible to find copies of relevant reports from DMA and PSC
The Company uses many resources for implementing and improving safety culture on
board, however, the auditor did not observe that this initiative was reflected on board. It
was observed that some part of the crew on safety boards in the mess room used posters which if notice were taken of them tried to inform about general safety behaviour on board. It should also be mentioned that LTA on board was app. 147 days, and
that is good on board this FPSO where there are many difficult and dangerous work to
be done.
A positive observation was the system called working permits no work outside on open
deck were started before an effective working permit was worked out and approved by
the ship management.
..]
7 Recommendations
Recommendation Description
No.
1
All recognition certificates should ASAP be in place
2
Mandatory certificates were found outdated: Cargo Ship Safety
Equipment Certificate; Cargo Ship Safety Construction Certificate; Cargo Ship Safety Radio Certificate; International Air
Pollution Prevention Certificate and International Sewage
Pollution Prevention Certificate are the certificates which were
found out dated during this audit. This is a major NC, if it was an
ordinary ship; all activities would be stopped imidiately. Who is
responsible for these severe mistakes? According to Danish laws
the Company is responsible for this. The auditor talked to the
Class representative in Fremantle, but he washed his hands.
This items will be brought up, when DMA audit the Company in
Denmark in the nearest future.
It should be clearly written in the GMS who are responsible
for what.
3
The new Company address should ASAP be written on all relevant certificates ex. The register certificates
4
ISM Code chapter 1.2.3 should be fulfilled by establishing a library
The library should be organized in such a way so all the content
are described and all relevant Danish publications should be included. The SOLAS Convention are translated into Danish and
published under the title Meddelelser fra Sfartsstyrelsen B. A
translation into English is also available.
5
Garbage log and Marpol log Annex VI should be available
Page 61
A Dangerous Cargo Certificate should ASAP be issued by the

Class.
A procedure should be written and it should be controlled that this
procedure regarding how to organize historic documents are followed. It should be stated who are responsible for this procedure
It is needed to refresh the Company course safety culture and
maybe designate this course to the operational conditions on
board a FPSO
The FPSO management should be given more education on Danish laws and regulations. It was objective observed that this a
weak link
It should be considered how to organize the operative safe operation on board. There are objective evidences indicating that there
are confusion among senior officers on board who is in charge for
duties and whom to report to. It is recommended to work out a
sort of diagram where the FPSO is divided into divisions. What is
the general responsibility for the master, what is the responsibility
for woodside and is there any responsibility for NOPSA?
10
7.6 ISM audit in Copenhagen on the 30th of January 2009

Source: DMA: Audit report
Date: 4th February 2009
5. NON-CONFORMATIES
The following deviations were found during the audit:
NC no. Description
Ref. to the ISM Code Time-limit
01
STCW/ILO requirements not fulfilled 1,6
30-04-2009
03
Standards and regulations outdated
1, 11
30-04-2009
The shipping company must submit proposals for corrective actions to the Lead
Auditor no later than on 30-04-2009
6. RECOMMENDATIONS
A key role, as identified by the ISM Code, in the effective implementation of a safety management system is that of the Designated Person. This is the person based ashore whose influence
and responsibilities should significantly affect the development and implementation of a safety
culture within the Company.
The designated person should verify and monitor all safety and pollution prevention activities in
the operation of each ship. This monitoring should include, at least, the following internal processes:
communication and implementation of the safety and environmental protection policy;

evaluation and review of the effectiveness of the safety management system;
reporting and analysis of non-conformities, accidents and hazardous occurrences;
organizing and monitoring of internal audits;
appropriate revisions to the SMS; and
ensuring that adequate resources and shore-based support are provided.

Page 62
The DP was not present at this audit, due to other activities, but was substituted by one of two
sub- DP. Furthermore the job description and role as described in the Code and MO Circulars
are not fully implemented in the SMS. It is strongly recommended that the function and the
qualification requirements of the DP mirror the intention of the Code.
The auditors were presented to the Company's Participants Committee, minutes of meeting during the audit, and had hence no possibility to review the document in advance. The company
should, when needed, review and evaluate the effectiveness of the SMS in accordance with procedures established by the company.
Management reviews support companies efforts in achieving the general safety management
objectives as defined in section 1.2.2 of the ISM Code. Based upon the results of such reviews,
the company should implement measures to improve further the effectiveness of the system. The
review should be performed on a periodical basis or when needed, e.g., in case of serious system failures. Any deficiencies found during the management review should be provided with
appropriate corrective action taking into account the Company's objectives. The results of such
reviews should be brought to the attention of all personnel involved in a formal way.
From the minutes of meetings, the auditor can not conclude how effective the company believes
the SMS is. The management review should at least take into account the results of the internal
audits, any non-conformities reported by the personnel, the master's reviews, analysis of nonconformities, accidents and hazardous occurrences and any other evidence of possible failure of
the SMS, like non-conformities by external parties, PSC inspection reports, and other key performance indicators.
The Company has recently changed the brand name, and a bulk part of the documents still
carry the old name. However, the company are in the process of downsizing the documentation
and will within the next half year, have changed a larger portion of the SMS so meanwhile they
will keep the old name on the SMS. This decision has not reached the units/ships.
During the audit, it was expressed by one of the audited a "blind faith in the documentation. The
audit showed that two standards and one regulation were obsolete. The company has established procedures to control all documents and data, which are relevant to the SMS, but there
room for improvements. The company should ensure that valid documents are available at all
relevant locations, changes to documents are reviewed and approved by authorised personnel
and that obsolete documents are promptly removed.
The company should re-emphasise the master's responsibility and authority. The company
should ensure that the SMS operating on board the ship contains a clear statement emphasising
the master's authority. The company should establish in the SMS that the master has the overriding authority and the responsibility to make decisions with respect to safety and pollution
prevention and to request the company's assistance as may be necessary.
7. CONCLUSION
The entity that is responsible for the operation of the ship is other than the owner, the owner
must report the full name and details of such entity to the auditor.
To comply with the requirements of the ISM Code, the Company should develop, implement and
maintain a safety management system to ensure that the safety and environmental protection
policy of the Company is implemented. The Company policy should include the objectives defined by the ISM Code.
The ISM Code identifies general safety management objectives. These objectives are:
to provide for safe practices in ship operation and a safe working environment;
to establish safeguards against all identified risks; and
Page 63
to continuously improve the safety-management skills of personnel ashore and aboard,

including preparing for emergencies related both to safety and to environmental protection.
The audit showed that the company has developed high safety and environmental standards,
and that the company is more than capable of conducting their business in accordance with the
intent of the Code.
The company has more than one shore side premises, which was not visited at the initial
assessment, but these will be audited in conjunction with the assessment of the ships/units initial
audits, during the period of validity of the Document of Compliance.
A Document of Compliance was issued to the company, copies of which should be forwarded to
each shore side premises and each ship in the company's fleet.
7.7 ISM audit in Perth on the 17th of March 2009

Date: 17th March 2009
5. NON-CONFORMATIES
NC
Ref. to the ISM
Description
Time-limit
no.
Code
04
Interim Statutory Certificates
1, 11
30/04/2009
05
Manning not in accordance with SMD
1, 6
17/06/2009
Work/rest hours not filled in concerning
06
1,6
17/04/2009
office
Auditor no later than on 30-04-2009
6. RECOMMENDATIONS
It is the opinion of the auditor;
That the company should formalize its procedures when it comes to quality control of statutory
and class
certificates, take ownership of those and not rely on the Recognised Organisation. DMA would
like to draw attention to the responsibilities given in the Lov om Sikkerhed til Ss (The law of
safety at Sea) Section 411 which clearly states the companys responsibilities regarding survey
and certification.
That the management of Crew Certificates and Certificates of Competency should include instructions and-or procedures that includes requirement of original CoC to be carried out on
board. And that the terminologyshould be harmonised with the Safe Manning Document. Whatever the contractual relation is between the two companies, the requirements of the law are not
negotiable.
That the whole ISM system should be questioned, when it comes to ownership of procedures and
their accountability. This matter was particularly obvious when it came to procedures for loading and discharging.
7. CONCLUSION
Page 64
The general theme of the audit was the companys knowledge of and the responsibility toward
the flag State,and knowledge of statutory requirements. The DMA conclude that the staff was
familiar with the companys SMS and that the system overall was understood and used effectively by them. However, due to the nature of the business, i.e. offshore oil exploration, the focus
on maritime activities has room for improvements, as concluded in the interim audit of the
Maersk Ngujima-Yin. During the interviews, a lot of questions were answered truthfully and
comprehensively to my satisfaction and showed good understanding of the SMS and the underlying regulations and requirements.
However, the whole set-up between the operator and the company is complex and somewhat
blurred, probably due to the situation where the involved parties have to take into account both
maritime laws and continental shelf laws. Here among, the ownership of safety cases, when a
strong client makes the whole situation even more complicated and confusing. The auditor believes that the responsibility of the operator and of the company can remain divided and shared
at the same time, if improved with more transparency and accountability. If the operator takes
care of procedures involving continental shelf law in the interface with tankers, and the exploitation of the oil, and allow the company to take responsibility of the procedures which involves
the ship itself, things should be much clearer. This is not new to the shipping business, it is actually quite common that charterers of a ship do direct the shipmasters regarding its commercial activities, but remains uninvolved regarding safety of the crew, ship, cargo and environment, and I believe it can be done in this situation too. Those particular requirements, that the
operator might have and the company not, can be regulated in the contract.
7.8 ISM audit on board the 18th of March 2009

Date: 18th March 2009
5. NON-CONFORMATIES
NC
Ref. to the ISM
Time-limit
Description
no.
Code
Statutory Certificates not correct or on
01
1.1.2.3.1
18/04/2009
board
02
Records not correctly filled
1.1.2.3.1, 7
18/04/2009
03
Survey items not closed out
1.1.2.3.1, 7
18/04/2009
04
Critical items not closed
10.1, 10.3
18/06/2009
05
Two discharge procedures not controlled 7
18/06/2009
Auditor no later than on 18/06/2009
6. RECOMMENDATIONS
It is the opinion of the auditor;
That the ship should formalise its procedures when it comes to quality control of statutory and
class certificates, and take ownership of them and not rely on the Recognised Organisation.
That the management of crew certificates and Certificates of Competency should include instructions and or procedures that includes requirement of original CoC to be carried on board
That the whole system should be questioned when it comes to ownership of the procedures and
accountability. This was particular obvious when it came to procedures for loading and discharging.
7. CONCLUSION
Page 65
The general theme of the audit was the knowledge of the ships responsibility toward the flag
State, and
knowledge of statutory requirements. The DMA conclude that the officers was familiar with the
companys SMS and that the system overall was understood and used effectively by them. However, due to the nature of the business, i.e. offshore oil exploration, the focus on maritime
activities has room for improvements, which was also concluded in the interim audit of the
Maersk Ngujima-Yin. During the interviews, a lot of questions was answered truthfully and
comprehensively to my satisfaction and showed good understanding of the SMS and the underlying regulations and requirements.
Among other things, the following topics was covered
Last audit, DMA survey and PSC report

Knowledge of DMA regulations
Knowledge of DP
On board library
Company policies
Crew certificates, endorsements, Blue

Book and rest hours
Logs and records
Register of lifting appliances
SAP
The standard and knowledge of the SMS on board is high. However, the auditor believes there
is room for improvements. Some of the findings, both NC and Observations, are somewhat beyond the responsibility of the company, but should be included the SMS.
During the audit one of the things that stroke me most was the procedure for discharging. The
last discharge was scrutinised and there where two versions of checklists in use, both of which
belongs to the operator.
None of the checklists had a revision number. The officer in charge could not answer to the
question why or what had been changed or when. Nothing in his hand over note revealed anything of the reason. When I asked him how he should find out what version was correct or the
reason for change, he was uncertain of whom to ask, the operator or the company. Furthermore, the officer had no discharge plan, no ship/shore safety checklist (ISGOTT) or had no
reference to the OCIMF Ship to Ship Transfer Guidelines. All of this due to the fact that the
operator has taken charge of this procedure and dont involve the ships officers in the procedures. It is my opinion, that international recognised standard and industry practises should be
utilised as much as possible, i.e., ISGOTT, and STS Transfer Guidelines and the ownership of
these ship procedures should belong to the company.

Page 66

Maersk Ngujima-Yin Final 16112009

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MARINE ACCIDENT REPORT

DIVISION FOR INVESTIGATION OF MARITIME ACCIDENTS

Division for Investigation of Maritime Accidents. Danish Maritime Authority,

The casualty report has been issued on 16th November 2009

The casualty report is available on our homepage: www.dma.dk.

The Division for Investigation of Maritime Accidents

Marine accident report

Marine accident report

Course of events leading up to the explosion and fire

Marine accident report

It is the assessment of The Division for Investigation of Maritime Accident that

It is the assessment of the Division for Investigation of Marine Accidents that

It is the assessment of the Division for Investigation of Marine Accidents that

The detection and identification of the explosion and fire

Fighting the fire

Marine accident report

It is the assessment of the Division for Investigation of Marine Accidents that

It is the assessment of The Division for Investigation of Maritime Accident that

Post event management

It is the assessment of The Division for Investigation of Maritime Accident that

Audits and Inspection

It is the assessment of the Division for Investigation of Marine Accidents that

It is the assessment of the Division for Investigation of Maritime Accidents that

3 Recommendations and initiatives

Marine accident report

Meeting with Maersk FPSO, Australia on 20th of April 2009.

On board investigation on MAERSK NGUJIMA-YIN in the period from 21th to

5.2 Navigation Data

Moored at STP buoy

5.3 Ship data

Marine accident report

5.4 Weather data

South 5.5 m/s

5.5 The Crew

Marine accident report

Marine accident report

The production system is depressurized by way of the HP separator according

Marine accident report

5.8 The scene of fire

Picture 1: Damaged gas seal bearing cap

Picture 2: Damages to adjacent compressor

Picture 3: Gas turbine enclosure

Picture 4: Inside gas turbine enclosure

Marine accident report

5.8.2 Stored oil drums

Picture 5: Exposed oil drums

Picture 6: Foot prints of oil drums

5.9 Fire fighting systems

Marine accident report

The deluge valves are placed in close vicinity of the modules.

There are two foam systems onboard.

5.9.3 Water mist system for gas turbines

Marine accident report

5.9.4 Hydrants on the new ring fire main

Marine accident report

5.10 Fire fighting subsystems

Marine accident report

Click here to watch video

Video 1: Water hammer

Marine accident report

5.10.2 Debris from aft fire water pump engine

Picture 5: Debris with carbon deposits

Picture 6: Carbon residues