The Bureau of Safety and Environmental Enforcement (BSEE) has released the panel investigation report into the November 20, 2014, explosion and fatality on a platform. The explosion occurred on West Delta Block 105 Platform E, resulting in the tragic death of Jerrel Hancock. Mr. Hancock, a Turnkey Cleaning Services supervisor, died after an explosion inside the electrostatic heater treater on the platform. At the same time, the contract cleaning crew personnel were engaged in activities related to cleaning the vessel. The five-member investigation panel identified several failures in applying basic safety management practices that may have contributed to Mr. Hancock’s death. The report concludes that there were apparent inadequacies in:
- electrical isolation and verification of that isolation,
- ineffective ventilation and air monitoring of the vessel
The report also concluded that a job safety analysis (JSA) did not align with the cleaning procedures and lacked specific assessments of the hazards associated with the job and equipment on which the work was to be done.
Based on the findings and recommendations of the panel, Director Salerno has directed BSEE staff to conduct an assessment of whether a site-specific Safety and Environmental Management System audit should be required when a safety management system gap may have contributed to an operational fatality. Director Salerno also directed several other assessments and the issuance of a safety bulletin to inform industry regarding the most significant findings of the Panel investigation and provide recommendations for preventing a similar incident.
Executive Summary
An explosion occurred offshore in the Gulf of Mexico shortly after 2:30 p.m. on November 20, 2014, while Turnkey Cleaning Services GOM (Turnkey) personnel were cleaning an electrostatic heater treater at the West Delta (WD) 105 E platform for Fieldwood Energy LLC (Fieldwood). The explosion caused fatal injuries to a Turnkey Supervisor, and injured others in the vicinity of the heater treater.
On or about November 13, 2014, the platform’s oil handling systems began to experience excess water and a ‘pad’ of thick oil and emulsifications. When Fieldwood and contract personnel were unable to resolve the issues, they contacted Turnkey on November 16, 2014, to clean the associated equipment, including the dry oil tank and heater treater on the platform’s production deck.
The platform stopped producing oil and was shut-in on or about November 17, 2014. A four-man Turnkey cleaning crew cleaned the dry oil tank on November 19, 2014. That morning, a Senior Lead Operator for Island Operating Company (Island), that was acting as the Person-in-Charge (Island Acting PIC) while the normal PICs were on vacation, took steps to isolate electrical energy from the heater treater’s transformer using energy isolation / lockout tagout (LOTO) procedures for the associated breaker located in the platform’s Motor Control Center (MCC) building. This action would have prevented electricity from reaching an electrostatic grid located inside the coalescing section of the heater treater, which used an electrical field to assist in oil and water separation.
On November 20, 2014, the Turnkey crew began draining the heater treater and pumping its fluids to containers located on the top deck. Once the fluid level was below a manway hatch on the coalescing section, the crew opened the hatch. Shortly thereafter, three Turnkey employees and a
Lead Operator with Island were standing outside the hatch while the Turnkey Supervisor was reportedly rinsing the lip of the manway hatch with water from a hose, when an explosion occurred inside the heater treater.
The initial blast forced the Turnkey Supervisor backwards, landing on the platform deck. The Island Lead Operator and two other Turnkey employees were also forced to the deck, one of which was struck on the head by the hose nozzle formerly held by the Turnkey Supervisor. Platform personnel that responded to the production deck after hearing the explosion described finding the two Turnkey crewmembers and the Island Lead Operator appearing disoriented, and the Turnkey Supervisor not breathing and without a detectable pulse.
Bureau of Safety and Environmental Enforcement (BSEE) Investigators arrived at the WD 105 E platform on November 21, 2014 to investigate the incident. They identified, among other things, that the breaker in the MCC building which controlled the electrical energy to the heater treater
transformer had been clasped with a lock and tagged for energy isolation LOTO, but was in the ‘On’ position. The BSEE Investigators took pictures, conducted interviews and gathered documents and other evidence pertaining to this incident.
The BSEE Panel found that the explosion was a result of: a partially drained vessel (the heater treater) that contained flammable vapors; an introduction of oxygen upon the opening of the manway; and an ignition source that was not sufficiently removed or mitigated during the preparation for, and activities of, internal cleaning of the WD 105 E electrostatic heater treater. The presence of these elements created a hazardous environment that was conducive to such an explosion. The BSEE Panel believes the probable cause of the ignition was the unrestricted supply of electrical energy to the electrostatic components inside the coalescing section of the heater treater. However, all other possible ignition sources could not be definitively eliminated.
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