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BRAZILIAN NAVY

DIRECTORATE OF PORTS AND COASTS

MARINE SAFETY SUPERINTENDENCE

DEPARTMENT OF INQUIRIES AND INVESTIGATIONS OF NAVIGATION ACCIDENTS

“FPSO CIDADE DE SAO MATEUS”

EXPLOSION WITH VICTIMS

11TH FEBRUARY 2015

MARITIME SAFETY INVESTIGATION REPORT

Platform FPSO CIDADE DE SAO MATEUS on the investigation day

Reference: Casualty Investigation Code, of the International Maritime Organization (IMO) -

MSCMEPC.3 / Circ.2 13 June 2008 / Resolution MSC.255 (84)



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Directorate of Ports and CoastsMarine Safety Superintendence

Department of Inquiries and Investigations of Navigation Accidents

Explosion with victims on “FPSO CIDADE DE SAO MATEUS”

Maritime Safety Investigation Report

2

INDEX

LIST OF ABBREVIATIONS ....................................................................................... 3

I INTRODUCTION....................................................................................................... 4

II SYNOPSIS ................................................................................................................ 4

III GENERAL INFORMATION .................................................................................. 4

IV ACCIDENT LOCAL DATA…………………........................................................ 8

V HUMAN FACTORS AND CREW........................................................................... 9

VI CHRONOLOGICAL SEQUENCE OF EVENTS ................................................. 10

VII PROCEDURES AFTER THE ACCIDENT ......................................................... 12

VIII CONSEQUENCES OF THE ACCIDENT ......................................................... 12

IX EXPERT EXAMINATIONS.................................................................................. 23

X ANALYSIS AND CAUSAL FACTORS................................................................ 23

XI LESSONS LEARNED AND PRELIMINARY CONCLUSIONS ....................... 43

XII SAFETY RECOMMENDATIONS...................................................................... 45

XIII ANNEX .............................................................................................................. 46



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LIST OF ABBREVIATIONS

ABS - Classification Society, American Bureau of Shipping

ANP - National Petroleum Agency

AJB - Brazilian Jurisdictional Waters

CCM - Engine Control Center

CPES - the Port Authority of Espirito Santo

DHN - Directorate of Hydrography and Navigation

DNV-GL - Det Norske Veritas / Germanischer Lloyd Classication Society

DPEM - Damage Compulsory Insurance of Personal Injury Caused by Ships or its load

FISPQ – Chemical Material Safety Data Sheet

FPSO - stationary production unit, Storage and Transfer Oil and Gas Export

GIO - Offshore Installation Manager

IMO - the International Maritime Organization

ISAIM – Safety Investigation of Maritime Casualties and Incidents

ISM Code - International Safety Management Code

MCA - Auxiliary Combustion Engine

NR 33 - Regulatory Standard No. 33 - Health and Safety at Work in Confined Spaces

SMQS - Health, Environment, Safety and Quality

STCW 78 - International Convention on Education Standards, Certification and Watchkeeping

for Seafarers, 1978

VHF - Very High Frequency (frequency of 30 MHz to 300 MHz)



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I – INTRODUCTION

For the purpose of accomplishing the collection and the analysis of evidences, the

identification of the causal factors and the elaboration of the recommendations of safety that are

necessary, in order to avoid that in the future occur similar maritime accidents and/or incidents,

the Directorate of Ports and Coasts (DPC) carried out the present Safety Investigation of

Maritime Accidents and Incidents (ISAIM) in compliance with that laid down in the Casualty

Investigation Code of the International Maritime Organization (IMO), adopted by Resolution

MSC.255(84).

This Final Report is a technical document that reflects the result obtained by the DPC in

relation to the circumstances that contributed or may have contributed to unleash the occurrence

and does not resort to any procedures of proof for verification of civil or criminal responsibility.

Furthermore, it should be emphasized the importance of protecting the persons responsible

for the supplying of information related to the occurrence of the accident, for the use of

information included in this report for ends other than the prevention of future similar accidents

may lead to erroneous interpretations and conclusions.

II – SYNOPSIS

On February 11, 2015 in the morning aboard the FPSO Platform CIDADE DE SAO

MATEUS, was performed the transfer of the mixture of water and condensate from the central

cargo tank 6C to port waste tank, in order to empty the cargo tank, submit it to inspection and

test the valves contained therein. This operation began at 8h53m with the use of the drain pump,

installed in the pump room. At 11h30m the images of the closed circuit television (CCTV)

showed condensate leak in a section of the pump discharge line and then a gas alarm was

activated automatically. From this occurrence, decisions were made, actions were developed and

the crisis culminated with the explosion inside the pump room, producing severe damage to the

platform, the deaths of nine crew members and injuries to others twenty six persons. The

chronology of this accident will be detailed later.

III - GENERAL INFORMATION

(A) Platform FPSO CIDADE DE SAO MATEUS

The FPSO CIDADE DE SAO MATEUS (Photo # 1) is a stationary production unit, storage,

oil and gas export and transfer, with capacity to produce 4.000m³ / day of oil and 10.000.000m³ /day of gas. Flying the Panama flag, she is registered at the Port of Panama, on the property of



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PROSAFE PRODUCTION SERVICES PTE. LTD., and held in class by the Classification

Society American Bureau of Shipping (ABS). This platform is authorized to operate in Brazilian

Jurisdictional Waters (AJB), according to Concession Agreement, issued by the National

Petroleum Agency (ANP), in favor of the PETROBRAS company. Its average production

figures for the year 2013 corresponds to 2.484.717,79m³ / day of gas, 426,66m³ / day of

condensate (coming from the gas production) and did not produce oil.

Main data and physical characteristics:

Operator: BRAZIL'S PPB, MARITIME SERVICES LTD.

Registration Number: 341E001031.

IMO number: 8706014.

International call sign: 3ENO.

Gross Tonnage: 143,323.

Hull material: steel.

Year Built: 1989

Conversion Year: 2008

Overall Length: 311,7m.

Length between perpendiculars: 310m.

Breadth: 54,50m.

Depth: 29,50m.

Design draft: 19,8m.

Propulsion: unpowered.

Accommodations: up to 85 people.



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Photo # 01 - Platform FPSO CIDADE DE SAO MATEUS, on 02/13/2015, two days after the accident.

(B) documents and deck Certificates, at the date of the accident

The statutory certificates and classification societies and the documents that the platform

should bear, are listed below:

Certificate Name : Issuing Authority: Issuer Date: Issue Validity:

Class Certificate/Certificate of Classification - ABS 8/27/2014 18/03/2019

Security Protection Certificate / International Ship Security Certificate - ISPS Code - flag

Country(Panama) 9/09/2014 09/15/2019Certificate Mobile Unit Production / Mobile Offshore Unit Safety Certificate - MODU - flag

Country (Panama) 27/08/2014, 18/03/2019

Safety Management / Safety Managment Certificate - SMC - DNV-GL

02/02/2015 15/09/2019

International Certificate of Load Line / International Load Line Certificate- LL- ABS

8/27/2014 03/18/2019



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International Oil Pollution Prevention Certificate / International Oil Pollution Prevention

Certificate IOPP - ABS 8/27/2014 03/18/2019

Security / Crew Minimum Safe Manning Certificate card - Captaincy of Rio de Janeiro

. 27/04/2010 19/02/2015

International Tonnage Certificate / International Tonnage Certificate (1969) - ABS

04/08/2008 Undetermined

Registration Certificate / Navigation Statutory Registry - Country flag (Panama)

23/09/2014 10/07/2019

International Prevention Air Pollution Certificate / Air Pollution Certificate – IAPP - ABS

8/27/2014 18/03/2019

Sewage Pollution Prevention Certificate / International Sewage Pollution Prevention Certificate -

ABS 8/27/2014 03/18/2019

Certificate of Foreign Vessel Temporary registration - AIT - Port Captaincy of Espirito Santo

20/02/2009 19/02/2015

Certificate of Foreign Vessel Temporary registration - AIT the Port Captaincy of Rio de Janeiro

14/01/2015 10/03/2018

Compliance Statement for Operation in Brazilian Jurisdictional Waters / Statement of

Compliance for Operation in Brazilian Waters - Port Captaincy of Espirito Santo

07/19/2013 04/18/2015

Insurance of Personal Injury Caused by vessels or their cargo (DPEM) Bradesco Seguros e

Previdencia 03/25/2014 25/03/2015

P & I insurance / Certificate of Entry - Mobile Offshore Unit Entry- Gard P & I

13/2/2014 13/2/2015

Continuous Synopsis Record / Continuous Synopsis Record - CSR - flag Country

(Panama) 09/17/2013 Undetermined

(C) Condition of the platform during the investigation

On February 13, 2015, day of the first visit on board, the platform had aft inclination due to

flooding of the engine room and pump room. All operations were paralyzed. On the main deck,

lay twisted cabinets, warped doors, parts of personal protective equipment, damaged

communications, and many expelled debris from internal compartments of the rooms by the blasteffect.



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The salvage material was incomplete by the absence of both lifeboats and many lifejackets

used during abandonment. There was no generation of electricity on board because of the

damage in parts of the electric cables and circuit breaker panels and, therefore, the lighting was

limited to the use of portable lamps. The stairs of access to the engine room and pump room

were unfit for use due to deformation and / or interruptions resulting from the explosion effects.

Access to the pump room and the higher levels of the engine room required the monitoring of

possible gas leaks using portable detectors. There were on board only two crew members

monitoring the platform stability and performing procedures to implement the rescue plan. The

initial actions would start by the external buffering of sea chests, to be performed by divers to cut

the communication of the engine room and pump room with the sea. Saltwater networks were

found themselves damaged by the effects of the explosion and such a situation prevented the

drain of the water in both the engine room and the pump room, necessary to ensure the safety of

the platform and to facilitate the recovery of the bodies of crew members still missing.

IV - ACCIDENT LOCAL DATA

(A) Location: geographical coordinates Lat: 19 ° 55.35'S and Long: 039 ° 38.0'W in Camarupim

field, Espirito Santo Basin, at a depth of 792 meters. It is an open sea navigation area, far about

40 km from the coast, as demonstrated by plotting the Nautical Chart DHN 22800, 2nd edition

(Photo No. 02).

22800, 2nd edition, Conceiçao da Barra - Victoria, Lat. 19 ° 55.35'S and Long. 039 ° 38.0'W

Photo # 02 - Position of the FPSO CIDADE DE SAO MATEUS in Nautical Chart DHN-



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(B) Environmental conditions at the time of the accident: wind intensity with eight knots,

direction north, calm seas, good weather and good visibility. These environmental conditions did

not contribute to the accident.

V - HUMAN FACTORS AND CREW

(A) Crew list and safety crew personnel.

On the day of the accident there was on board 74 people, including crew and crew members

not professionals. The certificates and documents of these people (specialization courses, the

enrollment and registration books extracts, occupational health certificates, statements of work

permits and social security, employment contracts extracts and plugs records of the company

BW Offshore were examined and the following non-conformities were found:

(1) - was not submitted the proficiency certificate of the Vessel Supervisor.

(2) – non- compliance of the Minimum Safe Manning certificate (CTS) - a crew member that

should occupy the Sailor Deck function provided for the certificate , held also the pumping

function. Consequently, the operating of the platform do not complied with the CTS certificate.

(B) periods of work and rest.

There was no evidence of breach of the minimum periods of rest, as established by the

STCW / 78 Convention.

(C) accommodations:

The accommodations were adequate for the crew, in accordance with the standards of

comfort, cleanliness, temperature, lighting and noise, common to the platforms of that type.

(D) alcohol, drugs and medicines.

No evidence has been obtained from the use of alcohol, drugs and or drug without medical

prescription by the crew.

(E) Safety Management:

The platform had the Safety Management Certificate issued by the classification society Det

Norske Veritas / Norway and Germanischer Lloyd / Germany (DNV-GL), under the

International Safety Management Code (ISM Code), valid until September 15, 2019. This

document attesting that the platform has been audited and that its security management system

meets the requirements of the ISM Code.



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VI - CHRONOLOGICAL SEQUENCE OF EVENTS

The chronology of the accident described below is founded on the records made in Status

Table, in the control room during the emergency on board, reported by the deck crew,

examination of documents received from PETROBRAS and BW Offshore companies, records

of the platform automation system and the observations of the investigators during the four

visits on board.

February 11, 2015:

- 8h30m - exchange of crew members, among which stand out exchanges of the Offshore

Installation Manager (GIO) and the Maintenance Supervisor. The Passage Reports of GIO and

Passage Report of the Maintenance Supervisor were checked.

- 8h53m - initiated the opening of the suction valves and discharge networks of the drain pump

(oil pump stripping) in the pump room, for transferring the condensate water from the 6C cargo

tank to the portside oily residue tank (slop tank).

- 9h - was started the drain pump.

- 9h30m – was began, in the meeting room, a videoconference between the Operations Manager

on land, the GIO, the Vessel Supervisor, Maintenance Supervisor, the Production Supervisor, the

Planner and the Safety Technician.

- 10h – the videoconference is ended ; the GIO returned to his office to complete the reading of

the Passage Reports of GIO.

- 11h30m - condensate leakage in the pump room were shown the CCTV camera 5 without being

noticed by anyone who was in the control room.

- 11h31m - The gas sensor TAG 73AB370, in the pump room, accused the presence of gas, and

automatically triggered the gas presence alarm and, as planned at the ESD, FIRE & GAS

SYSTEM CAUSE AND EFFECTS MATRIX, the exhaustion was stopped automatically. The

GIO came out of his office and went to the control room. There, upon learning of which sensor

had been activated, sent disclose in the Public Address Ads System this information; so, all the

crew drove to the meeting points. Then, when was told by the Supervisor that there was the

condensate transfer operation of the vessel using the drain pump the GIO ordered the arrest of

that operation. The personal count was started at the meeting point, coordinated by the person

designated in the control room.



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- 11h32m - The gas sensor, TAG 73AB326 also alarmed, accusing the presence of gas in the

pump room.

- 11h36m - The gas sensor, TAG 73AB327 in the pump room also alarmed accusing the

presence of gas in the compartment. The general alarm due to activation of the gas sensors was

muted to improve communication. The GIO had doubts about the gas leak source and ordered a

team made up of an Occupational Safety Technical an Instrumentation Technician and a Pump

Expert, to go to the pump room to identify the source of the gas.

- 11h40m - the emergency situation was reported to BW Offshore Company in Victoria.

- 11h44m - the technical team was in the pump room while the GIO, the Vessel Supervisor and

the Maintenance Supervisor assessed the situation in the control room.

- 11h47m - the technical team returned from the pump room and told the GIO that there was a

liquid puddle on the compartment floor, coming from the OP-068 valve, the portable gas

detectors used by his team accused high level of gas in atmosphere of the pump house and still

dripped from the vicinity of the OP-068 valve. The GIO asked if there was another source of gas

leak and was informed that there was only a pool that could be removed with water jet. The GIO

held cleaning with absorbent and determined the Maintenance Supervisor assess how the valve

could be repaired.

- 11h58m to 12h02m - another team was composed and instructed to go to the pump room and

investigate what should be done to "solve" the leak. This team was the Occupational Safety

Technician of the previous team, the Supervisor of Maintenance and the Maintenance

Technician.

- 12h09m - in the pump room, the staff asked for shovels and stairs.

- 12h10m - the staff went out of the house pumps for fresh air and to recuperate the breath.

- 12h15m - three crew members of the fire brigade, on the main deck and near the entrance to the

pump room, arranged absorbent mats to remove and clean the condensate pool. The GIO

released the staff that was in the meeting point considered not essential to toil for lunch.

- 12h20m - the GIO instructed to another team was formed to go to the pump room to clean and

contain the leak. Two Area men and three Maintenance Technicians are assigned.

- 12h22m to 12h26m - the team went to the pump room and started to contain the leak and

cleaning; first with absorbent webs, then with the use of sea water fire hose (a 1.5 inch hose and

45 meters in length was introduced at the pump room through the openings in the deck atstarboard side).



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- 12h35m to 12h37m - the explosion occurred in the pump room and its immediate effects were

seen in the control room, invaded by smoke and debris. All the platform systems were turned off

and the control room was evacuated. It was started the flooding of the pump room and engine

room, caused by disruption of fire networks, then pressurized, and salt water networks from the

sea chests. The first victims were identified and the GIO, along with the PETROBRAS`

Inspector, requested helicopters to evacuate the wounded. On deck, crew disoriented sought

refuge in the stern, under the helicopters deck, and in the bow deck, fearing further explosions

and possibly the platform to sink. The procedures for the abandonment of the unit have been

initiated; all aboard were instructed to follow for meeting points. The GIO guided 32 peoples to

board the starboard lifeboat.

- 12h47m -The GIO was ordained the platform abandonment by starboard lifeboat. They

remained on board the GIO and the nurse with other crew members to take care of removal the

victims by helicopter.

February 12, 2015:

- 2h - completely abandoned, the platform was without people on board.

VII - PROCEDURES AFTER THE ACCIDENT

After the accident took place the stoppage of the whole platform operation and started the

abandonment procedures and the rescue of the victims with ground support. After all peoples

leaving the platform, the stability and buoyancy was being monitored with the use of offshore

support vessels, while it was being prepared the rescue plan.

VIII - CONSEQUENCES OF THE ACCIDENT

(A) - Personal Injury:

This accident caused the death of nine professional and injuries to others twenty six. There

are no disappeared persons.

(B) - Environmental damage:

There was no environmental damage.

(C) - Property Damage:

The platform suffered severe structural damage to the aft section having been affected

habitable compartments, the engine room, the pump room, equipment and structural accessoriescontained in these compartments. These breakdowns were characterized by deformation, tipping



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and breaks bulkheads, stringers and caves. In addition, the effects of the flooding that followed

the engine room and pump room caused the destruction of motors, pumps, electrical panels and

equipment in general that could not have contact with seawater. The following images illustrate

the severity of damage that led to the stoppage of all operations and the platform abandonment.

There is no evidence of damage to condensate load and existing oil in cargo tanks.

(1) - Outside Deck in section and aft, corridors of accommodation and access to the elevator:

Photo # 03 Photo # 04

Cabinets twisted by the explosion and expelled from the internal compartments.

Photo # 05 - watertight door leading into the pump house, by

port, torn by the explosion.

Photo # 06 - parts of a flashlight used on board.



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Photo # 07 - access door to the elevator deformed by the explosion.

Photo # 08 - hall which gives access to the control room on the main deck level.

(2) – Engine room:

The flooding of the engine room after the explosion crippled the Auxiliary Combustion

Engines (MCA) and the electrical panel located in the compartment, including the Main Electric

Switchboard. Structural reinforcement elements and the system networks that pass through the

compartment were severely damaged by the explosion followed by flooding. The Engine Control

Center (ECC) was destroyed by the wave caused by the explosion pressure coming from the

Pump Room.

Photo # 09 - Flooding in the Engine Room( by the hatchway on the main deck aft)



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Photo # 10 - Top of the partially destroyed Engine Room

Photo #11 - Engine Room next to the starboard side with

destruction of networks and structural elements

Photo # 12 - CCM inside the Engine Room destroyed by the effects of the explosion

(3) - Pump Room:

The Pump Room is vertically divided into five levels from the main deck to the bottom of the

bay, as the following drawings:



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Photo #13 - Profile view of the stern part of the platform, highlighting the Pump Room



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Bulkhead affected by the explosion

Photo #14 - Vertical structure of the Pump Room Explosion center

Breakdowns of this compartment are partially shown in the following images:

roof of the pump room located above the main deck was moved and severely damaged by the

explosion. Just below the 1st level reinforcements of vertical uprights of the aft bulkhead, which



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separates the Pump Room and Engine Room, was founded heavily warped and no longer

fulfilled the role of increasing the rigidity of the panel formed by the bulkhead.

Photo #15 - Ceiling Pump Room on the main deck. The explosion damaged the fire network. This contributed to the flooding

of the magazine because it was kept pressurized

In the 2nd level of the Pump Room, the floor near the duct of the starboard air extraction was

found itself deformed.

Photo #16 - Floor located on the second level had severe

deformation

Photo #17 - Vertical air duct completely destroyed by the

blastwave pressure



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In the 3rd level of Pump Room, the air extraction ducts found themselves destroyed by the

pressure caused by the explosion. Access ladders found themselves also destroyed. Access to the

lower levels of the Pump Room was only possible after installation of scaffolding by the crew.

The bulkhead separating the Pump Room and Engine Room found itself deformed and tumbled

aft, opening sections that communicated the two compartments. The bulkhead was separated in

the upper welded joint with the structure of the unit due to the upward pressure caused by the

explosion in the bottom of the compartment.

Photo #18 - aft bulkhead between the Pump Room and the

Engine Room found itself overturned

Photo #19 - bulkhead between the Pump Room and the

Engine Room collapsed

In the 5th level of the Pump Room, the lower level of this compartment is divided at the time

by an intermediate floor consists of pallets that allows access to equipment such as drain tanks

pump (stripping pump). These platforms have been severely affected by the explosion. The



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stripping pump had superficial damage to the insulation housing and the drainage system

manifold.

Photo #20 - Drain pump (stripping pump) had superficial damage

On the floor of Pump Room a strong deformation was noted at the junction of the sixth beam

(longitudinal structural reinforcement of the bottom plating) told from the starboard bulkhead

with a walk-to-ram (vertical beam that supports the roof on the bottom panel).



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Photo #21 - 6th reinforcement stringer in the background

plating of the Pump Room severely damaged

Photo #22 - Detail of collapsed and deformed structure in the

vertical direction

Photo #23 - Below damaged structure; there are still remnants

of oily mixture

The shape of the strain these structural reinforcements indicates that the pressure caused bythe explosion was concentrated in the compartment floor near the condensate leak and expanded



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vertically upwards, which corroborates with the strains found in the structure and bulkhead

Pump Room levels above. The magazine also presented oily water at the bottom, between the

structural reinforcements of the compartment background plating.

IX- EXPERT EXAMINATIONS

The expert examinations started as soon as the platform security conditions showed

satisfactory levels. Four visits were made to the platform to map the network equipment and the

pump room, estimating the damage and assess the arrangements of the networks and valves

associated with the drain pump.

In addition to the onboard visits, certificates and platform plans were examined the various

documents provided by PETROBRAS and BW Offshore companies by requests from the

investigators; the data of the automation system were analyzed and were heard people who could

help to elucidate the accident in question.

X - ANALYSIS AND CAUSAL FACTORS

(A) Data from the automation system.

Data from the automation system, referred to herein, were contained in computers and data

discs removed from the platform after the accident and transported to the office of the company

BW Offshore in Vitoria, State of Espirito Santo. The importance of the information recorded

translates to allow the technical understanding of the operation and activation of the equipment

and the visualization of the condensate leak and drive a gas alarm warning light inside the Pump

Room, through the circuit images of closed circuit television (CCTV). In the case under

consideration, in addition to CCTV images, data were extracted relating to the valves, drain

pump (oil pump stripping) and gas sensors inside the Pump Room. This information in

spreadsheet format, refer to data disc.

(B) - Recovery and reading data.

The recovery and reading of data by technical company BW Offshore occurred in

PETROBRAS' installations in the city of Macae, State of Rio de Janeiro, from 24 to 28 February

2015.

(C) - criteria adopted for the selection of data for this research.

The CCTV images and data selected for examination were those contained in the HD BallastCargo N / S 9RX7JG4S (Post-EventLog.xlsx) and HD Server B - N / S 3LN2CQ1H (1E4F-



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AlarmLog-MostRecent.xlsx), with the date of February 11, 2015, related to the equipment

contained in the platform Pump Room, as it was on that date that the leak occurred of condensate

(network discharge drain pump), followed by automatic activation of the gas sensors and

explosion.

(D) - Timing Method of times of computers and CCTV.

(1)

- Computers.

When computers were linked it was found that there was no synchronization of their

clocks. In view of the need to use information to describe the chain of the explosion-related

events, the technicians made comparisons of computer clocks with the information of a cell

phone, and produced photographic records. The following images show the results of the

comparisons to the systems of interest, already mentioned.

Photograph # 24 - Position Ballast HD N / S 9RX7JG4S

Computer controlling the ballast maneuvers and platform load

Date and time of the computer: 02/26/2015, 10h07m01s

Date and time of cell phone: 02.27.2015, 09h03m

The image shows that:

a) the computer had one day delay in relation to the cell date.

b) the computer clock was early 1h4m01s.



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Synchronization - disregarding the seconds:

Given that the computer was delayed by one day and that was taken aboard in force when

daylight saving time (0h of October 19, 2014, to 0h of 22 February 2015) the synchronization is

done by:

a) add one day to the computer date.

b) reduces 1h4m of computer time.

Therefore, considering this timing criterion, the following example is presented:

Which reads the first row of data Post-EventLog.xlsx table, Appendix 2:

Time Description

10/02/2015 12:29:17 Wrote new value (1) to ICONICS.ModbusEthernetDA.2 \

Sixnet.DO.HMI_BA002_Close

Read:

Time Description

02/11/2015 11:25:17 Wrote new value (1) to ICONICS.ModbusEthernetDA.2 \

Sixnet.DO.HMI_BA002_Close

Photo #25 - HD Server B - N / S 3LN2CQ1H

Server that records the platform alarms

Date and time of the computer: 02/27/2015 12h09m

Date and time of cell phone: 02.27.2015 11h02m



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The image shows that the computer clock was early 7minutos.

Synchronization:

Reduce by 7minutos the computer time.

Therefore, considering this timing criterion, the following example is presented:

The 1E4F-AlarmLog-MostRecent.xlsx table, which reads the first line of data

ActiveTime EventTime Source

2/11/2015 13:51:31 2/11/2015 13:51:31 P_73BF319 - FAULT

Read:

ActiveTime EventTime Source

2/11/2015 13:51:31 2/11/2015 13:44:31 P_73BF319 - FAULT

(2) - CCTV.

The CCTV recording system was delayed 1h23m16s regarding the Brasilia time

(conference held on 27/02/2015 at 16h19m - Brasilia time).

(E) the transferring of the content of water and condensate from 6C cargo tank to port

waste tank (portside slop tank):

The operation consists in transferring the condensate and water from the 6C central cargo

tank to port waste tank. The arrangement of valves and networks are shown in illustration 1.

The section of interest (suction and discharge flow) is marked in red. The start of the suction

line (center suction header) until the pump, there are OP-041, OP-050, OP-047 and OP-071

valves and the pump discharge passage to the slop tank is the OP-079 and OP-084 valves. All

these valves should be opened during the transfer.

The diagram also shows another shunt in the pump discharge into the waste tank,

highlighted in yellow. This passage includes a flanged connection and OP-068 valve and is

shorter than represented in the embodied array. However, it could not be used because the OP-

068 valve was broken (was inside passage). Therefore, this valve does not retain the contentsof the tank and was the reason that the flange connection was blocked by a racket on 12

January 2014. This change will prove to be the weak point of the network system used to

maneuver that will culminate in an accident, as will be shown below.1 The flanged connections are easily detachable connections; employed mainly to 51mm tubes (2 ''), or larger, in the

following cases: to connect the pipes with valves and equipment (pumps, compressors, tanks, etc.) and also at certain points tothe along the pipe where you want ease of disassembly. Note: as a general rule it is recommended to use the smallest possiblenumber of flanged connections. A flange connection is composed of two flanges, a set of screws or bolts or case cover withnuts and a gasket. (SEA, Vocational Education Department of the Navy - Directorate of Ports and Coasts- Machines

Principles - Rio de Janeiro., 1989.).2 rackets: are used on networks when you want a strict and absolute lock. Widely used on board to insulate pipes pumps thatare used sporadically. They are usually installed between two flanges, making a tight seal. (SEA, Vocational Education Department of the Navy - Directorate of Ports and Coasts - Machines Principles- Rio de Janeiro. 1989).



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llustration 1 - network diagram

(F) Change in alignment of the suction and discharge networks during the transfer operation

and the condensate of the leak:

On February 11, 2015, after being initiated the transfer, was found that the tank level 6C

not lowered, although the drain pump was working. This fact could be originated in the

Drain

pump

6C Cargo tank

suction

Discharges into the

oily residue porttank

This network could not be used to discharge thetank because there was a

racket in this flange



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27

malfunctioning of valves in internal tanks and waste 6C, since the suction passed network used

by two tanks. In an attempt to solving the problem the Vessel Supervisor decided to change the

tank suction line 6C of the center section to the starboard (starboard suction header) through the

OP-042 valves, OP-051, OP-048 and OP-071 in order to avoid passing through the valves that

might be defective. The temporary destination of discharge in this arrangement was amended

from the slop tank to the cargo tank 2C through the OP-080 valve in the face of the starboard

suction line contain very pure condensate that should not be stored in the waste tank port, by

decision of the Vessel Supervisor. Thus OP-valve 084 should be closed. Consequently, if we

take this arrangement to practice, the discharge line should be free to 2C tank.

It was found that, in fact, the OP-084 valve was closed, but this was done while the drain

pump still running at 8% of their capacity to work without the discharge flow to the 2C tank (in

the new arrangement) was unimpeded through the OP 080 valve. Table 1 with the records of

the opening and closing of the valves, stop commands and departures of drain pump obtained

from the records of the automation system clarifies this issue.

Table 01 - Drain pump and valves - HD Cargo Ballast N / S 9RX7JG4S:

Events starting and stopping the drain pump and handling of the valves of the suction and

discharge networks.

Suction line valves OP047, OP048, OP050 and OP071

Discharge line valves: OP079 and OP084.



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28

Eve

nt

Comput

er timeLocal time

Drain

Pump

Valves of the suction network

Valves of the

discharge

network

OP04

7

OP04

8

OP05

0

OP07

1

OP07

9

OP08

4

01 08:57:09 08:53:09 open

02 08:57:14 08:53:14 open

03 08:57:20 08:53:26 open

04 08:57:26 08:53:26 open

05 08:57:34 08:53:34 open

06 08:57:55 08:53:55 open

07 09:04:31 09:00:31start

(10%)

08 11:31:35 11:27:31 start (8%)

09 11:31:48 11:27:48 shut

10 11:32:02 11:28:02 shut

11 11:33:44 11:29:44 open

12 11:34:28 11:30:28 start (7%)

13 11:34:30 11:30:30 stop(0)

14 11:34:33 11:30:33 open

15 11:42:52 11:38:52 shut

16 11:42:59 11:38:59 shut

17 11:43:02 11:39:02 shut

18 11:43:08 11:39:08 shut

19 11:43:14 11:39:14 shut

20 11:43:38 11:39:38 shut

21 11:43:52 11:39:52 shut

22 12:10:03 12:06:03 open



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29

Event 09 – the OP084 valve (pump discharge line) was closed at 11h31m48s, while the pump

was still running.

• Event 13 - the pump was stopped at 11h34m30s.

As the drain pump was of the type of positive displacement, its operations for more than

two minutes with the OP 080 and OP-084 closed valves, brought up the pressure in the discharge

network and caused the condensate leaking in the gasket flange connection upstream the OP-068

valve. This arrangement is marked in blue in the illustration 2.



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30

llustration 2 - network diagram indicating the valves closed during the operation of the drain pump

3 Positive displacement pumps have one or more cameras, within which the movement of a driving piece communicates

pressure energy to the liquid, causing it to flow. They are those in which each complete revolution deducts the same amount of

liquid and to vary the flow we have to change the speed. The resistance imposed on the flow rate does not change (is the amount

of liquid discharged in a pump unit of time and a given discharge pressure. It is expressed in m³ / h or l / min). (SEA, Maritime

Professional Education - Brazilian Navy. - Directorate of Ports and Coasts - Auxiliary Machines II - Rio de Janeiro 1989).

Drain

pump

working

leakage ofcondensate bythe flange

conection.

ValveOP080

shut

Valve

OP084

shut



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CFTV images taken from the camera's shooting 05, installed in the pump house to port,

show the condensate leaks:

Photo # 26

Camera 05 - 02/11/2015 -

10h07m01s - local time

11h30m17s leaks of evidence

of leaks.

The condensate leaked trickle

in this sector. Its origin is in a

network that, about three

meters above this point, the

following image shows.

Photograph # 27

Camera 05 - 02/11/2015 -


11h30m23s appear the first

condensate leak signals

highlighted by the red circle.

The camera lens has condensate

residue drops.

Photo # 28

Camera 05 -11/02/2015 -


11h52m11s about 22m later -

the leak traces are reduced as

well. This time the drain pump

was already off. (11h30m30s).

The black spot with

condensate remains in the pipe

is lower, but the camera lens is

dirtier with the product

splashes.

(G) The weakness of the network system used to maneuver.

Notwithstanding the operational error of closing the OP-valve 084 while the pump was

running, this action, by itself, does not cause leakage of the condensate if the integrity of the

flanged connection (obstructed by the racket) was maintained. Note that the pump worked to 8%

of their capacity, his hydrostatic test pressure was 30 kg / cm² and that had a security system that

could relieve the pressure when reached 16.5 kg / cm², beyond all network load be tested in

manufacturing and installation with 1.5 times the working pressure (item 4.6.2 - 7.3 and 4.6.2 -7.3.3 of the ABS of the ship's rules).



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Photo # 29 – Pump Room – port side

Photo # 30 Photo # 31

Details of the flange gasket wear

(images obtained after the leak - PETROBRAS source)

The company BW Offshore was consulted on the installation of the racket and reported that the

installation of this component was treated as a routine operation, with no need for approval of the

classification society. The ABS Classification Society was also consulted because the entire load

transfer system and ballast was classified, and replied that he had not received the request for

Valve OP-068 (defective) in thenetwork of discharge drain pump. This

branch of the network was not used.

Across the bulkhead is the port residue

tank (slop tank)..

Condensate leak point.

Flanged connection obstructed byracket. I was under pressure to

discharge the drain pump.

Network stretch

without pump

ressure.



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33

installation of the Owner racket and did not have sufficient information to assess whether the

material used met the technical parameters involved. The facts show that the weakness of the

flange connection and the condensate leaked into the pump room.

(H) The hydrocarbon cloud in the pump room:

The condensate leaked according to the information contained in the Material Safety Data

Sheet (MSDS) is a compound of oil that can form hydrocarbon vapors, as reported by

PETROBRAS. Effectively, this gas cloud existed and was generated from the condensate leaked

by the board, sprinkled by the effect of pressure, and the puddle is left on the floor because soon

after the gas leak sensors have been activated automatically, as well as the corresponding gas

alarm. Table 2 shows the dynamics of activations of gas sensors in the pump room according to

the records of the automation system.

Table 02 - Gas sensors - HD Server subsystem B - N / S 3LN2CQ1H:

Trigger events of gas sensors in the pump house, with the corresponding alarm level. The

gas cloud was concentrated in the lower compartment levels causing the activation of existing

sensors in the lowest compartment (main floor): 73AB326 TAG, TAG and TAG 73AB327

73AB37.

EventCompute

r time

Local time

(corrected

- 7min)

TAG

73AB326

TAG

73AB327

TAG

73AB370

TAG

73AB3

68

TAG

73AB3

69

01 11:38:04 11:31:04 HI

02 11:38:18 11:31:18 HIHI

03 11:39:16 11:32:16 HI

04 11:40:27 11:33:27 HIHI

05 11:41:59 11:34:59 FAULT

06 11:42:46 11:35:46 FAULT

07 11:43:06 11:36:06 HI

08 11:43:32 11:36:32 HIHI

09 11:44:34 11:37:34 FAULT

10 11:44:36 11:37:36 NORMALI

ZED



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11 11:45:33 11:38:33 NORMALI

ZED

12 11:45:36 11:38:36 HI - HIHI

13 11:46:33 11:39:33 HI – HIHI

14 11:47:22 11:40:22 HI - HIHI

15 11:50:26 11:43:26 INHIBIT

16 11:50:28 11:43:28 INHIBIT

17 11:50:31 11:43:31 INHIBIT

18 12:07:04 12:00:04

NORMALI

ZED

19 12:08:03 12:01:03 HI - HIHI

20 12:08:48 12:01:48INHIBI

T

21 12:08:52 12:01:52INHIBI

T

22 12:09:54 12:02:54

NORMALI

ZED

23 12:10:53 12:03:53 HI - HIHI

24 12:12:20 12:05:20 NORMALI

ZED

25 12:13:19 12:06:19 HI - HIHI

26 12:44:52 12:37:52 NORMALI

ZED

NORMALI

ZED

NORMALI

ZED

• HI - High level - indicates 20% of the explosion threshold level.

• HIHI - very high - 80% indicate the explosion threshold level. With this statement the

automation system automatically closes the dampers compartment and stops the fan.

• FAULT - failure - means that the gas level is above 100% of the explosion limit level (more

than the sensor can register).

• Normalized - normalized - the sensor returns to its normal condition of gas detection.

• HI - HIHI - high and very high - means that the high level of drive and very high level were

very close and marked at the same time.



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35

• INHIBIT - inhibited - means that the sensor continues detecting gas (if any) but does not

trigger the effects of stopping ventilation and close the dampers in the compartment.

Gas alarm signal light. Extracted images from the camera's shooting 04 positioned to starboard

in the pump house.

Photo # 32

Camera 04 - 11h31m52s local time.

The camera is in a position to view the red

signal light that is turned on when the gas alarm

occurs. The next image shows

Photo # 33

Camera 04 - local time 11h31m56s

The red signal light was turned on when the

TAG 73AB370 gas sensor was triggered with

HIHI (11h31min18s) - lag of 18s

It is noteworthy that the platform automation system off the exhaust fans of the pump room

in the gas alarm occurrence according to the Cause and Effect Matrix. Therefore, the alarms, the

properties of the atmosphere of the pump room were changed by creating an emergency situation

and turning the place in a potentially explosive area when they were activated. Thus, the pump

room began to show similar characteristics of confined space, pursuant to Regulatory Standard

No. 33 - SAFETY AND HEALTH IN THE WORK IN CONFINED SPACES (NR-33) of the

Brazilian Ministry of Labor and Employment, which defines: "33.1. 2 Confined Space is any

area or environment not designed for continuous human occupation, which has limited means of

entry and exit, whose existing ventilation is insufficient to remove contaminants or where there

may be a deficiency or oxygen enrichment”. The abovementioned standard also defines theconcept of oxygen deficiency as "atmosphere containing less than 20.9% oxygen by volume at



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36

normal atmospheric pressure, unless the reduction percentage is appropriately monitored and

controlled."

(I) the explosion:

The hydrocarbon cloud remained at the bottom of the compartment, for only the gas sensors

installed in the pump house background have been activated, so there were present the

flammable gas (fuel) and oxygen (oxidizing).

The source of ignition for the explosion occurred is uncertain and may have occurred spark in

the face of the crewmembers tools jobs in an attempt to remedy the leak; or generation of static

electricity by the use of fire hose cleaning; or use of a portable radio communication VHF; or by

action of natural heat that the magazine was submitted after the stop of exhaustion; or other

unknown causes. The following images produced by CCTV show the time of the explosion.

Photo # 34

01 camera - 12h38m01s, local

time

Photo # 35


time.

Photo # 36


time



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Photo #37 - 03 camera -

11/Feb/2015 - 11h14m42s -

local time 12h37m58s

Photo # 38 - 03 camera -

11/Feb/2015 - 11h14m45s -


Photo # 39 - 03 camera -

11/Feb/2015 - 11h14m48s -


(J) Non-compliance with current legislation (regulations, resolutions and codes):

- The Brazilian NORMAN-01 / DPC states in item 0117 that the safety of the crew of the fixed

and mobile platforms, FPSO, FSU and drillship prospecting and exploration of oil, is made up of

maritime crew and not maritime crew in accordance with the operational circumstances which

these units are involved. Part of maritime safety crew is provided in Resolution A.891 (21) of the

International Maritime Organization (IMO) and is known as Operations Section and, depending

on the type of platform, can be composed of:

- Offshore Installation Manager (GIO) - A person officially designated by the ship owner, owner

or company, as most responsible for the platform, to which all crew members are subordinate;

- Vessel Supervisor – a person to control ballast operation on mobile units (not applicable to

fixed platforms);

- Ballast Control Operator - Person responsible for the conduct of ballast operations in mobile

units (not applicable to fixed platforms); and

- Maintenance Supervisor - Person responsible for the inspection, operation, testing and

maintenance of engines and equipment essential to the safety of life on board and pollution

prevention, it can be caused by the platform or its operation. The level and the staff hierarchy the

edge of the platform, FPSO, FSU and ships probe will be according to the following flowchart:



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38

OFFSHORE INSTALLATION

MANAGER (GIO)

MAINTENANCE RESCUE GROUP

SUPERVISOR VESSEL SUPERVISOR

ENGINE SECTION CREW DECK SECTION CREW BALLAST CONTROL

OPERATOR

Therefore, according to the cited standards, it is clear that the GIO is the most responsible

for the platform, to who all crew members are subordinate.

In carrying out its responsibility and authority on board the platform, fit the GIO risk

assessment and decision on the entry of people in the pump house, as described in the Summary

Chronological accident, although there was doubt as to the existence of gas therein.

The decision taken, which subjected the crew to risk, bucked the security procedures for such

cases in various rules and instructions, as described below:

- Code for the Construction and Equipment of Mobile Offshore Drilling Units (MODU

Code1989), adopted by Resolution A.649 (16) on 19 October 1989, by which the platform was

certified. Item 14.1 of the Code, when dealing with Platform Operations Manual provides that

they should be included in this special operations procedures manual for uncontrolled leakage

events of hydrocarbon and emergency stops. Continuing in item 14.5, it is established that the

procedures for entry into confined spaces shall be those set out in IMO Resolution A.1050 (27).

- IMO Resolution A.1050 (27) brings recommendations for entry into confined spaces

aboard ships. This Resolution establishes the need for risk assessment, permission for entry,

general precautions, atmosphere test, precautions during the stay of people in confined spaces,

etc. and explains that accidents can occur, among other reasons, lack of care by the personnel

involved; and explicitly recommended the adoption of safety procedures.



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39

- The Brazilian Technical Regulations of the Operational Safety Management System of

Maritime Facilities Drilling and Production of Oil and Natural Gas (SGSO), and the National

Petroleum Agency (ANP) approved by ANP Resolution No. 3, of December 6, 2007, published

in the Official Gazette on December 7, 2007, and amended in the Official Gazette on December

10, 2007 and in the Official Gazette of 12 December 2007. This Regulation, which applies to all

platforms operating in Brazilian waters deals with, among other things, the work of running on

platforms risk areas such as the following transcript: "Work Permit 17.2 - 17.2.1 The Operator

Installation should establish a work permit system and other means of control to manage

activities in hazardous areas. In preparing this system should consider: 17.2.1.1 The Operator of

the installation shall establish the types of activity that may pose risks to operational safety and

requiring Work Permit. 17.2.1.2 That Work Permit must include additional precautionary

measures and mitigation that may be required to carry out the task safely. 17.2.1.3 The need for

prior analysis of safety conditions for the execution of tasks and hazards in the workplace. 17.2.2

The operator of the installation must ensure that the work permit system: a) Be documented and

that the instructions and forms permits are clear and concise; b) Establish that the controls and

work permits are approved at an appropriate level of management / supervision of installation.

17.3 - Monitoring - The Installation Operator will be responsible for: 17.3.1 Monitor the

performance of activities in accordance with the requirements for approved procedures, the work

permits and information and related documentation. 17.3.2 Ensure that work permits and

controls are used to completion of the work. ".

- The Contingency Plan and Emergency Response of the FPSO CIDADE DE SAO

MATEUS.

This Plan, in Section 4.1, presents the response to emergencies and organizational chart in

item 5 describes the role of GIO as the "Strategist and Incident Commander." In the control

room, he would have the functions to activate a command structure that would meet the

organizational needs to protect lives, the environment and damage to the facility; and initiate

rapid and effective action to control the incident, as well as manage response actions to ensure

that the climbing potential, the risk of injury to personnel and damage to the installation to be

minimized.

The entrance of people in the pump house without risk analysis, without the issuance of the

work permit document and no monitoring of the atmosphere compartment conditions,demonstrates a flagrant breach of regulations.



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40

(K) The failures in the ship's safety management system:

The platform provides the Safety Management Certificate issued by the classification

society Det Norske Veritas / Norway and Germanischer Lloyd / Germany (DNV-GL), under the

International Safety Management Code (ISM Code), valid until September 15, 2019. This

document certifies that the platform has been audited and that its security management system

meets the requirements of the ISM Code.

The ISM Code is expressed in broad terms and can be applied at different levels of

management, both on land and at sea, requiring varying levels of knowledge and awareness.

According to that contained in the said Code, the foundation of a good security management is

the attitudes, commitment, competence and motivation of individuals at all levels. Therefore, the

Safety Management System should be structured and documented enabling the effective

implementation of safety and environmental protection policy of the company.

The Code's objectives are to ensure safety at sea, prevention of human injury or loss of life,

and the prevention of environmental damage, in particular to the marine environment, and

property. To meet these goals the Company's security management must continually improve the

skills of the personnel security management ashore and aboard, including preparing for

emergencies related both to safety as to environmental protection by ensuring compliance with

mandatory rules and regulations; and codes, guidelines and standards, recommended by the

Organization, Administrations, classification societies and maritime industry organizations are

taken into account.

The Code classifies the noncompliance with the rules and mandatory rules for the two types

of non-compliance:

"Non-compliance” - an observed situation where the objective evidence indicates the non-

fulfillment of a specified requirement; and

“Greater non-compliance” - an identifiable deviation which poses a serious threat to the safety of

personnel or the ship or a serious risk to the environment that requires immediate corrective

action or the lack of effective and systematic implementation of a requirement of this Code. "

In this particular case, the following failures were recorded:

(1) the document submitted by BW Offshore Brazil Ltd. as the Safety Management Manual have

in your cover letter warning that the procedures contained therein should be checked before being used because it is a manual on development. This warning shows that there is no procedure



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41

for prompt adoption of onboard emergency case, going against the security management

certification issued by DNV-GL;

(2) Drain pump discharge line was altered with the installation of the racket without the

knowledge or approval of the classification society ABS;

(3) the change in alignment of the suction and discharge networks drain pump, while

maneuvering 6C cargo tank condensate transfer did not take into account the fragility of the

discharge network, in the face of the racket on the link setup flanged network;

(4) improper blocking the discharge network of the drain pump during its operation of drain of

the 6C cargo tank, by closing the valve OP-084;

(5) the failure during the passage of function between the GIO resulting from incomplete

operational information. The 6C tank condensate transfer maneuver was not in the Passage

Reports of GIO. The new GIO only became aware of the aforementioned maneuver after the gas

alarm sounded;

(6) the entries of the teams in the pump room after it was found the existence of gas, with no

identification and analysis of risks and without the issuance of the corresponding work permits;

and

(7) the absence in the board manuals of special procedures for uncontrolled leakage events of

hydrocarbon and emergency stops in the pump room.

Such failures attest to the inconsistency of the board management system, giving rise to

improvised decisions that resulted in non-compliances.

XI - LESSONS LEARNED AND PRELIMINARY CONCLUSIONS:

(A) The existence of the Safety Management Certificate issued under the ISM Code is not

enough to ensure safe operations on board the platform. There are needs to the Company's

compliance and safety principles of the platform crew to establish safe working conditions for all

operations aboard platforms.

(B) The inconsistency of the platform's operating manuals and contingency plan can be reflected

as disastrous consequences in emergency situations. It is necessary that these manuals are

correctly written, understood and which are met by the rig crew.

(C) the commitment of operators and contracting companies in maintaining the principles of

safety management of platforms is required.



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42

(D) Discard the importance of hydrocarbon leak can lead to devastating consequences for the

property and for shipboard lives.

(E) The platform management needs to be clear and properly exercised. It is necessary that the

function passages allow the transmission of all information related to ongoing operations in order

to ensure continued control of planned actions. The service passages must be made in person,

following a regularly scheduled and not only based on written reports.

(F) A classification society should always be informed of respect to change of equipment kept in

class. In this particular case, it was found that changing the network without the knowledge and

approval of the classification society proved to be disastrous for the outcome of the accident.

(G) any modification needs in selecting networks for hydrocarbon pumping implementation

should take into account the situation in which they find the equipment and should be evaluated

the risks of such changes.

(H) Ballast system operations must have a training program in order to update the operators in

the relevant technical knowledge and in order to be able to assess the consequences of failures in

the control valves and pumps.

(I) Training programs should emphasize the law requirements in force linked to the operations of

the platform highlighting the Regulatory Standards of the Brazilian Ministry of Labor and

Employment, Brazilian Maritime Authority and the Brazilian National Petroleum Agency. In

times of crisis aboard this knowledge can be applied to avoid accidents, such as improper entry

into compartment with confined space features.

(J) The atmosphere inside a confined space can be lethal.

(K) It is mandatory never to go into space containing explosive atmosphere.

(L) The Platform Operating Guide and Contingency Plan shall include all requirements of

current legislation.

(M) The crew must comply with the procedures established by the Companies with respect to

safety and, in particular, as regards the proper use of relevant safety equipment to each task.

In view of what was found, it is concluded that the accident was due to screen flammable

substance leak in the pump room, which led to the formation of gas, the resulting emergence of

explosive atmosphere, and the subsequent explosion; is not possible to determine the ignition

source of the explosion.



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43

XII - SAFETY RECOMMENDATIONS:

(A) The Company, in its Annual Training Program for the crew, must exercise on entry

procedures for confined space and indicate formally a responsible for the compliance;

(B) the Company must establish controls to ensure that the entry of people in confined spaces is

only done as there is a risk analysis and the corresponding issue of the Work Permit, and prevent

the entry into spaces containing explosive atmosphere;

(C) all of the safety management system, both the platform and the Company should be

subjected to any audits by the classification society that issued the Safety Management

Certificate and the Document of Compliance;

(D) Platform Operation Manual and the contingency plan should be reviewed and updated in

accordance with the legislation in force;

(E) Company should exercise strict supervision of the procedure to inform the classification

society on changes of equipment and systems kept in class; and

(F) Ballast System Operators should be subject to an ongoing program of training with this

system.

(G) The atmosphere inside a confined space can be lethal and all safety measures should be

taken before entry.

(H) It is mandatory never to go into space containing explosive atmosphere.

================================================== =========



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XIII - APPENDIX

Particulars of the Platform "FPSO CIDADE DE SAO MATEUS".

PARTICULARS OF THE PLATAFORM

“ FPSO CIDADE DE SÃO MATEUS”:

2.1. Unit main caracteristics:

Description

The FPSO Cidade de São Mateus is a floating production, storage and transfer

of oil and also processing and exporting gas, with the following characteristics:

2.1.1. Physical Characteristics:

a) Overall length = 322.07 m.

b) Length between perpendiculars = 310.00 m.

c) Breadth = 54.50 m.

d) Depth = 29.50 m.

e) Gross tonnage =: 143 323; net: 42 996.

f) Draft (project) = 19.8 m.

g) Accommodations = 85 people. This number may vary according to the stage of the

installation life cycle, or need to perform activities requiring labor increase, and will

be determined by the maximum permissible number of places available in salvage

equipment and conditioned the rules established by specific regulations of the

MODU Code, the Brazilian Ministry of Labor and Employment and the Brazilian

Navy.

Documents

Fpso Cidade Smateus En