Attachment 3-PCSB Baronia Fire

BNP-B FIRE ACCIDENT
INVESTIGATION REPORT
JULY 29th, 2004
BNP-B
PRESENTATION OUTLINE
1. SUMMARY
2. BACKGROUND
3. THE FIRE ACCIDENT
4. INVESTIGATION TEAM
5. FINDINGS
6. TRIPOD BETA ANALYSIS
7. CONCLUSION
8. RECOMMENDATIONS
2.0 SUMMARY
Baronia B Complex under simultaneous production, construction

and maintenance operations from 16th July 2004 to 20th August
2004.
Baronia B Complex shutdown for five day from 28th July 2004 for
shutdown related activities.
On 29th July 2004 at about 17.50 hr fire broke out at Baronia
Production Platform (BNP-B).
Five contractor's personnel injured, suffered first and second degree
burns on different parts of their bodies.Two given outpatient
treatment, three warded for treatment.
Fire damaged instrument control panel, separators, process piping,
electrical cables and platform steel structures at the main and cellar
decks.
Reinstatement cost estimated RM 7.6 millions, crude production loss
of 7500 bbls/day and gas of 40 mmscf/day.
The accident was designated as Category 1 with a Risk Assessment
Code of RAC3 (Rare, Catastrophic).
Caused of fire was due to spilled hydrocarbon ignited by hot spots
left by hot work activities.
Tripod Beta V3 Analysis identified three active failures and 11 latent
failures.
3.0 BACKGROUND
Baronia-B Complex topside major maintenance commenced on

17th July 2004 on arrival of the workboat Ajang Hira for
non-shutdown works.
On 28th July 2004 at 09.00 hr the 4B (Betty, Bokor, Bakau and
Baronia fields) platforms were shutdown for five days to carryout
integrated maintenance and engineering activities.
BNP-B was shutdown and depressurized with following activities
carried out:
Draining of liquid from the separators and process piping.
Spading / positive isolation of piping and process vessels for
hot-work.
Removal of relief valves for re-certification.
W ash down and soaking of vessels (V100/200/300) with
degreaser in preparation for inspection.
Hotwork activities at BNP-B started on 29th July 2004.
4.0 THE FIRE ACCIDENT
On 29th July 2004 at 17.40 hr three DESB riggers unbolted a

flange connection on a 3" line to de-oil and gas free a test separator
3" liquid line and test header return line to V-300 in preparation for
hot works.
The 3 " flange connection was pried open and large amount of
hydrocarbon discharged onto drip pan.
AGT advised the riggers to control discharge flow rate while tried
to trace the pipeline configuration for other isolation valve to
close.
At about 17.50 hr fire broke out around the area.
6.0 INVESTIGATION TEAM FINDING
Accident's impact to PCSB SKO

The accident was classified as Category 1 with a Risk Assessment
Code of RAC3 (Rare, High).
Resulting in personnel injury with three (warded case) lost time injuries
(LTI) and two first aid cases (FAC).
Lost of oil production amounting to 7500 bbls/day and gas of 40
mmscf/day.
Estimated RM 7.6 millions to reinstate the platform .
6.1 HYPOTHESIS ON CAUSE OF FIRE
Overflow of drip pan content as a result of blockage in the drip pan

drainage system and huge inventory of hydrocarbon drained.
The overflow hydrocarbon ignited by a heat source from hot work
activity at the cellar deck (directly underneath the drip pan).
This hypothesis was tested by a simulation test.
V300
Production
Manifold
V200
V400
Main Deck Break 3" 8" 8" V100 V500

Flange
4" Test Header
3" 4" Pump Recycle

BNDP-B
Oil 8" Inlet to V300 2" Sump Pump

Drip Pan 15" 6"
8"
Hotwork Area
Cellar Deck Drip pan sleeve
hole
BNP-B PROCESS LINES TO V-300 INLET LINE
V-200
V-400
L.P Sep @ BNP-B
LP Sep
8" 4"
V-300
2 " Fuel Gas Scrubber Surge Vessel
Liq.Outlet HOTWORK
TEST 4"
PUMPS
HDR
4"
4X COTPs
3"Flange
cracked
opened.
TEST HDR
3" RELIEF HP HDR

LINE
LP HDR
8"
2"
2"
BNDP-B BNDP-J
SUMP PUMP SUMP PUMP
7.0 TRIPOD BETA V3 ANALYSIS
Active failures:
Safety precautions were not adequately identified in the work
permits.
Drip pan drain system was not checked for blockage.
Insufficient time lapse between hot work completion and
hydrocarbon draining.
7.1 TRIPOD BETA V3 ANALYSIS
Latent Failures:
The draining rate was not properly controlled to prevent excessive
accumulation of hydrocarbon in the drip pan.
Hazards associated with the hydrocarbon draining not adequately
addressed.
Inadequate risk assessment. Procedure to identify the hazards of
hydrocarbon draining to the drip pan was not adequately
addressed.
Failure to check all the process line connections to the header
before draining.
Drive to reduce shutdown durations.
Improper housekeeping of drip pan and drainage system
Change in implementation plan.
Insufficient time allocated to complete hot work activities in the
shutdown period.
Heat residue from the last oxy-acetylene cutting of the 8" line was
not eliminated.
Insufficient fire fighting equipment specified in the SISO.
Escape route for working in drip pan below grating not identified
(confine space).
8.0 CONCLUSION
The fire accident was caused by an overflowed drip pan due to

blockages in its drain system and uncontrolled draining of huge
amount of hydrocarbon inventory (In excess of 20 bbls).
The overflow hydrocarbon spilled through a 15" pipe sleeve onto
the 8" HHP gas line underneath the drip pan at the cellar deck.
Remnant heat from an oxy-cut 8" pipe ignited the spill
hydrocarbon thus resulting in fire accident.
Tripod Beta V3 Analysis identified three active failures and 11
latent failures.
The basic risk failures (BRF) were due to incompatible goals in the
optimization of shutdown activities, lack of procedures with respect
to open draining of hydrocarbon, error enforcing conditions due to
change in work schedule, improper housekeeping of drainage
system, inadequate communication of hydrocarbon hazards to all
parties and design of fire suppression system.
9.0 RECOMMENDATIONS
Prepare Hazard and Effect Register for Baronia and ensure that
hazards associated with hydrocarbon draining be thoroughly
addressed.
Action party: BON by Q1 2005
Include schematic drawing of system to be de-oil, gas free and
isolation system required in PTW. Inventory of hydrocarbon drained
and released must be known.
Action party: Assets/BTS immediate
Implement project on paper (IPOP) for systematic challenging and
optimization of shutdown activities.
Action party: Assets/BTS immediate
Enforce management of change procedure for a change of work
schedule. Highlight requirement in SISO.
Action party: Asset immediate
9.0 RECOMMENDATIONS
Review JHA for hot work activities; highlight danger of heat residue
as source of ignition.
Action party: BTS immediate
Review requirement of fire fighting requirements and escape routes
as specified in the SISO.
Action party: Assets by Q4 2004
Prepare procedure for working inside drip pan.
Action party: Assets by Q4 2004
Prepare drip pan and sump management procedure during
engineering activities
Action party: Assets immediate
END

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BNP-B FIRE ACCIDENT

Baronia B Complex under simultaneous production, construction

Baronia-B Complex topside major maintenance commenced on

On 29th July 2004 at 17.40 hr three DESB riggers unbolted a

Accident's impact to PCSB SKO

Overflow of drip pan content as a result of blockage in the drip pan

Main Deck Break 3" 8" 8" V100 V500

3" 4" Pump Recycle

Oil 8" Inlet to V300 2" Sump Pump

3" RELIEF HP HDR

The fire accident was caused by an overflowed drip pan due to

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