Reflektion – Equinor experience transfer final

We normally send out our Weekly Reflektion on Sunday morning and hopefully all our subscribers are happy with this routine. We decided to send out this extraordinary Reflektion today as it relates to one of the concerns we have on Major Accident Prevention in the Norwegian Petroleum Industry, complacency. The Reflektion is a reaction to the Safety Forum annual conference on the 8th September and we did not want to wait too long before communicating our concern.

We would rather that the industry continually believes that it is not good enough and we have no Major Accidents than we believe we are best, and a Major Accident occurs.  

We often talk about the importance of learning and experience transfer in the prevention of Major Accidents. Such opportunities arise at conferences however they are often limited by the time available for the presentation. This means the information presented needs to be correct, relevant and a good basis for interested parties to follow up the findings and learn from them.

The fire at the Melkøya LNG plant in 2020

When the opportunity arises for experience transfer and learning, do you take it?

We recently attended the Petroleum Safety Authority (PSA) Safety Forum annual conference on safety in a hotel in Stavanger. Following months of COVID-19 restrictions and meetings and seminars on Teams, it was nice to get together and meet colleagues in person. The interactions are different face to face, and we certainly have missed the ‘live’discussions. This point was emphasised by most of the presenters. One of the themes of the conference was how we should take what we have learned from the past to create a safe future. This theme is of course related to learning and experience transfer and has been an underlying focus for the PSA and for the industry for several years. 

One of the presentations was from Equinor and was related to two incidents in their onshore operation. A fire in a steam turbine at the Tjeldbergodden methanol plant and a fire in a turbine at the Melkøya LNG terminal in Hammerfest. In 20 minutes, it is not easy to communicate the incident, the context and the learnings from a single major incident let alone two. However, given the time available the information should be correct, relevant and guide the listeners to further information where the details can be found. After all, without the details how can we learn?

The Equinor presentation did not meet these requirements with regard to the Melkøya turbine fire.

In the presentation the Equinor representative summarized the important findings and learning points as:- Equipment used outside its operational limits, – Complex cause of events and several underlying (root) causes- Several initiatives underway

The learnings the audience could take away from this summary were, don’t use equipment outside its operational limits, and it’s a complex incident that has led to several actions. This approach does not help transfer learnings to other operators which should be the main goal of the presentation.

The PSA also investigated the incident, and the report is available on the PSA website.

The PSA investigation identified the direct cause of the incident as self-ignition of the pre-filter in the gas turbine air inlet system.

The PSA identified four underlying causes:- The practice of flowing hot oil manually through the filters in the air inlet of off-line turbines.- Failure to follow up previous incidents that indicated that this practice was being used.- The change out philosophy for the filters.- The manning situation at the terminal.

The PSA investigation into the incident identified five deviations from the regulations:- Follow-up and compliance with governing documentation is deficient.- There was not sufficient manning in the organisation for all phases of the operation.- Deficiencies in risk assessments related to the possibility of leaks and fires in the gas turbines.- Deficiency in the maintenance routines for the filters in the inlet filters on the gas turbines.- No description of use of external resources (vessels with firefighting capability) in the Emergency Response Plan.

The PSA also identified three improvement areas:- Improved logging and whiteboard updating during an emergency.- Inclusion of performance requirements for managing emergency situations in the emergency response plan.- Improved follow-up of leaks in the hot oil circulation system.

An obvious contrast in the information on the incident. We reviewed the PSA investigation report to get a better understanding of the incident.

The fire occurred 28th September 2020 during a start-upfollowing an unplanned shutdown. The gas turbine in question was shutdown awaiting repair to an oil filter. The gas turbine has a hot oil circulation facility in the inlet air filter to prevent icing. According to Equinor procedures, this facility should not be used when the turbine is not in operation. The operating personnel had however used circulation of hot oil through offline turbines on previous occasions to remove excess heat from the process system. On an LNG plant removing heat is the biggest challenge in the processing of the gas. There had been previous incidents where equipment had been damaged due to the hot oil circulation in offline turbines that indicated the recommended procedures were not being followeda and notifications had been established. The filter was full of dead insects that had built up since 2015. The change out of the filter was originally carried out every two years, then Equinor introduced a condition-based maintenance routine that determined the change out of the filter based on measured pressure drop and visual inspection. The operating personnel had started hot oil circulation through the turbine inlet filter 80 hours previously and at the time of the incident the control valve was at 60% open. The hot oil temperature was 260 C. The material in the inlet filter self-ignited and this started the fire. The self-ignition temperature was tested following the incident and ignited at 170 C after 160 minutes. Simulations demonstrated that the temperature in the filter mass on that day would have been between 175 C and 199 C. The hazard identification work carried out for the terminal risk analyses indicated that a fire in this area was unlikely hence no mitigation measures, such as deluge coverage, were in place for this eventuality. 

Since the inlet filter did not have any active firefighting, vessels with such facilities in the nearby harbour area were requested to assist. A firefighting vessel from the Goliath platform was by coincidence in harbour at that time and directed its fire monitors on the turbine inlet. The fire was eventually put out. This method of firefighting was not specifically covered in the Melkøya terminal emergency response plan.

The firewater from the firefighting caused significant damage to the terminal, in particular the electrical systems that will require extensive repairs. Equinor estimate that the terminal will not be in operation until 2022. This has resulted in the temporary closure of the Snøhvit, Askeladd and Albatross gas fields in the Barents Sea. This is a significant loss that was not mentioned in the Equinor presentation. The Equinor representative in fact claimed the ultimate potential had been taken out in the incident. This basis for this statement is unclear.

The PSA report noted that the manning situation at the Melkøya terminal had been highlighted on several occasions and that the organisation struggled to complete maintenance and follow up notifications. One of the notifications was related to the practice of flowing hot oil through the inlet filters of offline gas turbines.

At the PSA conference Equinor failed to communicate the seriousness of the incident, the causes of the incident and the potential learnings from the incident. The Equinor representative did not specify any actions that were relevant to other Equinor facilities and how these had been applied. Furthermore, Equinor did not give any indication on where further information on the incident could be found so that any interested party, for example every operator on the Norwegian Continental Shelf, could follow up and learn. 

A further reflection on the PSA conference itself. There were many interesting presentations and two of these we will be following up with Reflektions in the future. There were however several poor presentations including the Equinor presentation on Melkøya and Tjeldbergodden. There was also little encouragement for the participants to participate in the proceedings. We got the impression of a controlled environment that was perhaps intended to maintain a cosy atmosphere and rest on our laurels that we are so good at HSE in Norway. This is the complacency, and complacency will only lead us to disaster. It is not acceptable. There is a need for creative tension. Criticism is vital to kick ourselves out of complacency and ensure we are always looking at ways to improve. The Melkøya and Tjeldbergodden incidents, are reminders that we still have a way to go in the prevention of Major Accidents. For anyone that believes that it is only Equinor onshore operations that is not maintaining the standards of Major Accident prevention then take a look at the RNNP and then a look at yourselves and consider, how can I do better. Perhaps we will always have a way to go. One thing we know for sure is that as soon as we believe we have reached our destination we will have an incident that will remind us of our fallibilities and faults. This point was in fact noted at the PSA conference with a reminder of a Major Accident in 2016. On 28th April 2016 the RNNP (Risk level in the Norwegian Petroleum Industry) report for 2015 was presented and included the best statistics on safety in helicopter operations. On 29th April 2016 an Airbus H225 Super Puma from CHC Helicopter services crashed near the island of Turøy in the Hordaland region. All 13 people on board died.

Experience transfer and learning from serious incidents matters. The senior management in all the operator companies need to go forth as messengers and need to encourage their organisations to participate. After all, if a senior manager at Equinor is not willing to share the learning related details on a major incident, why should the rest of the organisation?

Reflekt AS