OCS Report

MMS 2001-010

Investigation of Crane Accident and Injury

South Timbalier Block 185

OCS-G 1569

March 21, 2000

Gulf of Mexico

Off the Louisiana Coast

U.S. Department of the Interior

Minerals Management Service

Gulf of Mexico OCS Regional Office
OCS Report

MMS 2001-010

Investigation of Crane Accident and Injury

South Timbalier Block 185

OCS-G 1569

March 21, 2000

Gulf of Mexico

Off the Louisiana Coast

Jack Leezy

Freddie Mosely

David Dykes

U.S. Department of the Interior

Minerals Management Service New Orleans

Gulf of Mexico OCS Regional Office January 2001
ii

Contents 

Investigation and Report

Authority, 1

Data Collection and Interviews, 1

Lease Information

Background, 5

Description of Platform, 5

Introduction

Brief Description of Accident, 6

Contractors, 6

Findings

Personnel, 8

Regional Drilling Engineer, 8

On-site Supervisor, 8

Day Crane Operator, 9

Night Crane Operator, 10

Relief Day Crane Operator, 11

Master of the M/V Gate Dancer, 12

Crane Maintenance, 13

Operational History of the Crane, 16

Tank Markings, 17

Safety Manuals, 18

Sequence of Events to the Accident, 18

Conclusions

Causes, 22

Recommendations

Safety Alert, 24

Annual Performance Review, 24

Regulatory Change, 24

Study, 24

Appendix

Attachment 1, Location of Lease OCS-G 1569, South Timbalier Block 185

Attachment 2, Load Chart Found in South Timbalier Crane File

Attachment 3, Photographs of the Control Handles – ST 185 Crane

Attachment 4, Photograph of the Diamond Tank Rental 25 Barrel Tote Tank

Attachment 5, Photograph of the Tote Tank Manufacturer’s Identification Plate

Attachment 6, Photograph of the Ball Ring
1

Investigation and Report

Authority An accident that resulted in one injury occurred on Louisiana Land and

Exploration Company’s (LL&E) Platform A, South Timbalier Block 185,

Lease OCS-G 1569 in the Gulf of Mexico, offshore the State of

Louisiana, on March 21, 2000, at approximately 2225 hours. Pursuant to

Section 208, Subsections 22 (d), (e), and (f), of the Outer Continental

Shelf Lands Act, as amended in 1978, and the Department of the Interior

Regulations 30 CFR Part 250, the Minerals Management Service (MMS)

is required to investigate and prepare a public report of this accident. By

memorandum dated April 13, 2000, the following MMS personnel were

named to the investigative panel (panel):

Jack Leezy, Office of Safety Management, New Orleans,

Louisiana (Chairman)

Freddie Mosely, Houma District, Houma, Louisiana

David Dykes, Office of Safety Management, New Orleans,

Louisiana

Data Collection

and Interviews

On March 22, 2000, a panel member flew to the incident location to

gather information, take pictures of the scene, and interview personnel on

location, thus initiating MMS’s investigation of the incident. Two

Incidents of Non-compliance were issued at this time.

On March 23, 2000, a panel member revisited the incident scene to

continue gathering information and interviewing personnel.
2

On March 27, 2000, MMS personnel visited the Applied Hydraulics yard

in Houma, La. and took pictures of the crane after it had been recovered

from the seafloor.

On April 04, 2000, panel members visited the Applied Hydraulics yard in

Houma to examine the crane in further detail.

On April 10, 2000, panel members revisited the Applied Hydraulics yard

to locate serial numbers on the crane for the purpose of determining

manufacturer and model. The panel members also discussed the

mechanics of the hydraulic unloading system on the crane.

On April 18, 2000, a panel member revisited the incident location to

gather copies of the annual inspection records of the crane.

On April 20, 2000, panel members revisited the Applied Hydraulics yard

to re-examine the crane and to discuss winch loads and crane design with

Applied Hydraulics personnel.

On May 10, 2000, a panel member visited the Applied Hydraulics yard to

examine and take pictures of the recovered load block.
3

On August 2, 2000, a panel member revisited the incident location to

obtain a copy of the load rating chart from the crane records.

On October 25, 2000, panel members revisited the Applied Hydraulics

yard once again in an attempt to locate serial numbers for the purpose of

determining the crane manufacturer and model.

To aid in the investigation, the panel requested and received various

documents from Burlington Resources, Crown Oilfield Services, Applied

Hydraulics, Allied Systems, Energy Operators, Tidewater Marine, and

Hydraulic Well Control.

During the course of the investigation, the following personnel were

interviewed:

Position Company

Regional Drilling Engineer Burlington Resources

Production Supervisor Burlington Resources

Onsite Supervisor Energy Operators

Operations Supervisor Applied Hydraulics

Production Foreman Baker Energy

Captain - M/V Gate Dancer Tidewater Marine

General Manager Crown Oilfield Services

Training Manager Crown Oilfield Services

Relief Crane Operator Crown Oilfield Services

Day Crane Operator Crown Oilfield Services

Night Crane Operator Crown Oilfield Services

ST 185/190 Lease Operators (6) Baker Energy

Snubbing unit personnel Hydraulic Well Control

Safety Representative OSCA Services

Fourchon Yard Manager Diamond Tank Rental

Technical Representative Allied Systems Company
4

The panel made numerous attempts to interview the riggers involved in

this incident. However, the riggers were no longer employed by Crown

Oilfield Services and the attempts to contact them were unsuccessful.

The panel’s analytical techniques involved the use of a Management

Oversight and Risk Tree, Event and Causal Factors Chart, and a Hazard

Barrier Target chart.
5

Lease Information

Background Lease OCS G-1569 covers approximately 5,000 acres and is located in

South Timbalier Block 185, Gulf of Mexico, off the Louisiana coast.

For lease location, see Attachment 1. The lease was issued effective

July 01, 1967; LL&E became the designated operator of the lease on

December 09, 1996. Burlington Resources (Burlington) has assumed

operatorship of this lease because of a merger with LL&E; however,

MMS records do not reflect Burlington as the designated operator.

Description of

Platform

Platform A was installed in January 01, 1973, in 180 feet of water. This

platform is a six-legged conventional type structure, with a complete

production process system that processes the production from the six

wells located on the platform. The wells were shut-in for the snubbing

unit work that was being performed. The platform’s deck space was

limited, as the top deck measures 120 feet by 72 feet with process

equipment and a 10-man living quarters.
6

Introduction

Brief Description of

Accident

The crane boom was lowered to a position of near 0 degrees in an

attempt to reposition a completion fluid tank located on the deck of the

motor vessel Gate Dancer, to accommodate the offloading of snubbing

pipe. As the tank was lifted off the deck approximately 6 feet, the ball

ring for the crane failed, resulting in the crane falling along with the

Crane Operator to the deck of the Gate Dancer. The Crane Operator

received injuries that required hospitalization and surgery.

Contractors There were six contractors involved in the snubbing operation. The

contractors are listed as follows:

! Crown Oilfield Services Inc. – Provided crane operators and

riggers for the snubbing operation.

! Energy Operators Inc. – Provided the onsite

supervisor/consultant to act as Burlington’s representative.

! Tidewater Inc. – Provided the vessel support services for the

snubbing operation.

! OSCA Inc. – Provided the completion fluid and necessary

personnel for the snubbing operation.

! Hydraulic Well Control Inc. (HWC) – Provided the snubbing

unit and personnel necessary to conduct the snubbing

operation.
7

! Offshore Warriors – Provided onsite dispatching services and

clerical support.

Baker Energy Inc. provided production personnel to Burlington for

production operations outside of the well workover operations. This

contractor had personnel on the platform at the time of the incident;

however, they were not involved in the operations at the time of the

incident.
8

Findings

Personnel Regional Drilling Engineer

Burlington’s Regional drilling engineer, henceforth referred to as the

Engineer, was tasked with the responsibility of designing a well

workover project for Well A6 utilizing a snubbing unit. The Engineer

also managed the coordination of all associated work with the help of

the on-site supervisor. In the development of the project, there was no

formal hazard or risk analysis performed to identify hazards/risks to

eliminate or reduce them to the lowest acceptable level. Additionally,

there were no job safety analyses (JSA) performed to ensure that all

work would be performed in a safe and workmanlike manner. The

Engineer placed the responsibility of safe operations on the On-site

Supervisor. Furthermore, this was the Engineer’s first project using a

snubbing unit on an offshore facility.

On-site Supervisor

The on-site supervisor, an employee of Energy Operators, henceforth

referred to as the Supervisor, was contracted to Burlington as one of the

Supervisors for the project. This supervisor has been on contract to

Burlington for several years; his working schedule was seven days on

followed by seven days off. His responsibilities were to oversee all onsite activities on the facility, which included the safe working of all

personnel. He has received mandatory training of API RP T-1 and T-3
9

training, in addition to first aid, CPR, and other safety training courses.

Burlington had designated the Supervisor as the onsite Incident

Commander for all emergencies on his tour. Burlington’s Employee

Environmental, Health, and Safety Handbook (safety handbook)

requires an initial training of 24 hours for incident commander training

followed by an 8-hour annual refresher. The Supervisor has not had

any of the Burlington incident commander training as required.

Additionally, the Supervisor claims to have had over 2,000 hours of

supervisory training, but cannot produce any documentation of such

training. The Supervisor stated during the interview that there was

concern by the Day Crane Operator of the Night Crane Operator’s lack

of experience (less than one year) and ability to perform his assigned

duties. The Engineer revealed during the interview that Burlington had

received complaints about the Supervisor in past years. The Supervisor

allegedly created an unsafe and stressful work environment by the

demands he imposed on the workers. Interviews with other personnel

involved in this incident revealed that the Supervisor created a stressful

work environment on this job.

Day Crane Operator

The day crane operator, an employee of Crown Oilfield Services,

henceforth referred to as the Day Crane Operator as assigned, arrived

on location after a scheduled crew change on Sunday, March 19, 2000.
10

This was his first tour on this facility, and after arriving he received a

generalized safety briefing of the facility. The Supervisor or his

designee never explained to the Day Crane Operator his role or duties

as Day Crane Operator as prescribed by Burlington’s safety handbook.

The Day Crane Operator has 33 years of experience in the operation of

cranes. He has been employed by Crown Industries for a period of one

year. The Day Crane Operator was the lead crane or senior operator for

the operation. The Day Crane Operator did not receive the Burlington

Pre-use Hydraulic Crane Preventative Maintenance Plan upon his

arrival to the facility or be made aware of any such documentation.

The Day Crane Operator stated that he conducted regulatory required

daily pre-use inspections; however, there was no formal

documentation. The Day Crane Operator stated during the interview

that he was instructed on one occasion by the Supervisor to operate the

crane during inclement weather. (Note – The crane is not equipped

with a cab to protect the operator from the elements to ensure safe

operation of the crane. Further, the Day Crane Operator wears

corrective eyewear to perform his job.)

Night Crane Operator

On March 19, 2000, an employee of Crown Oilfield Services,

henceforth referred to as the Night Crane operator as assigned, arrived

on location after a scheduled crew change. This was his first tour on

this facility, and after arriving he received a generalized safety briefing.
11

The Supervisor or his designee never explained to the Night Crane

Operator his role or duties as Night Crane Operator as prescribed by

Burlington’s safety handbook. The Night Crane Operator had less than

one year of experience as a crane operator. The Night Crane Operator

did not receive the Burlington Pre-use Hydraulic Crane Preventative

Maintenance Plan upon his arrival to the facility or be made aware of

any such documentation. The Night Crane Operator stated that he

conducted regulatory required daily pre-use inspections; however, he

did not complete any formal documentation.

Both the Day and the Night Crane Operators stated in their interviews

that they were not familiar with Burlington’s Contractor Safety &

Environmental Guidelines for Offshore Operations. This document

states, in part: “Ensure all employees, and subcontractors are familiar

with and follow not only these, but other Burlington Resources

guidelines which are applicable to the work being performed.” The

Day Crane Operator and the Night Crane Operator both advised the

Supervisor on several occasions of the poor performance of the crane.

Relief Day Crane Operator

The Relief Day Crane Operator, an employee of Crown Oilfield

Services, henceforth referred to as the Relief Crane Operator as

assigned, worked opposite of the Day Crane Operator. The Relief
12

Crane Operator was the initial crane operator at the start of this project.

He has approximately 16 years of experience operating offshore cranes.

The Relief Crane Operator stated that he conducted regulatory required

daily pre-use inspections and he did complete the forms and give them

to the On-site Supervisor.

It should be noted that the crane operators are all qualified as per

API RP 2D – Recommended Practice for Operation and Maintenance

of Offshore Cranes.

Master of M/V Gate Dancer

The Master of the M/V Gate Dancer, henceforth referred to as the

Master, is an employee of Tidewater Marine Inc. The Master has

approximately 10 years of experience on 100-ton vessels. The Master

stated during the interview that sea conditions at the time of the

incident were approximately 3- 4 feet. He arrived on location the

morning of the incident. The Master stated that in his attempts to

accommodate the movement of the tank as directed by the Night Crane

Operator, he attempted to reposition the vessel closer to the platform.

Discussions between the Master and the Night Crane Operator by radio

on the Master’s inability to reposition the vessel because of the wind

and sea conditions were interrupted by the Supervisor. The Supervisor

directed the Master to either position the vessel as directed or return to
13

shore and a master would be obtained that could perform the task. It

was at this time that the Master informed the Supervisor that he could

move back to the original position prior to the request of the Night

Crane Operator. The Night Crane Operator radioed back to the Master

after repositioning and stated that he would attempt to lift and turn the

tank 90 degrees.

Crane Maintenance The panel has been unsuccessful in making a positive identification of

the manufacturer or model of the crane involved in the incident. There

are several cranes similar to this one manufactured by various crane

manufacturers; however, the panel was unable to locate serial numbers

on the unit to make a positive identification. Burlington has made no

attempt to determine the manufacturer of the crane.

When the crane was recovered from the bottom of the Gulf, the load

chart was not attached. The load chart located in the platform crane

inspection records indicates that the load chart was generated as per

API SPECIFICATION 2C – Specifications for Offshore Cranes.

(Note – Although the manufacturing date is unknown, the crane was

installed in 1977 prior to the original development and publication of

the API 2C specifications (1983). The load chart found in the records

was generated by Diversified Oilfield Services (DOS), Inc. For a copy
14

of the load chart, see Attachment 2.

The last annual inspection, dated February 12, 2000, by Applied

Hydraulics indicated a gap of 0.014 inches between the ball ring flange

and top of the turret on the sides where there are no bolts. This

measurement is not a measurement of the ball ring deflection as

required by API RP 2D; however, it is an indication that a gap has been

noted between the turret and the ball ring. (The ball ring does not meet

the specifications of API Specification 2C [1983] edition.) The crane

mechanic noted in the inspection report that this gap should be

monitored for increase on a monthly basis.

A crane inspection on March 09, 2000, by American Aero Cranes

included a ball ring deflection over the deck with a measurement of

0.034 inches indicated. A deflection measurement of 0.044 inches was

indicated over the water. These measurements were determined to be

within tolerance according to the American Aero personnel.

The crane inspection on March 17, 2000, by Wadleigh Offshore Inc.

indicated that the main hoist cable was changed out. The crane was

load tested to 33,000 pounds. The crane mechanic noted in the report

that two of the sheaves in the boom tip were bad. The report also noted

that the crane’s dead-end connection needed to be replaced. (Note: No
15

other reports indicate that the sheaves or the dead-end connection were

repaired or replaced.)

Applied Hydraulics conducted a crane inspection on February 19, 1999.

The crane was load tested to 41,000 pounds at 25 feet radius and 75o

boom angle with a 5/8 inch 19x7 wire rope. (Note: The radius of 25

feet does not match the load chart for a 75o boom angle. According to

the load chart [generated by DOS and maintained in the crane records],

the radius should be 15 feet.

A crane inspection conducted on June 21, 1996, by Louisiana Land and

Exploration Company (LL&E) indicated that a load test to

31,000 pounds was conducted. The test indicated a 19 foot radius at a

77o

 boom angle using a 5/8 inch 19x7 wire rope in a five-part

configuration.

The load chart for the main hoist identifies static and dynamic

capacities for two-part, three-part, and four-part reeving. Capacities for

the main hoist are only identified in the four-part category. The

capacities on the upper end of the scale (high boom angle and short

radius) are incorrect. The published numbers appear to be calculated

for five-part reeving of 5/8 inch 19x7 wire rope (nominal breaking

strength of 33,600 pounds with a 5:1 safety factor). For a four-part
16

reeving of 5/8 inch 19x7 wire rope, the maximum load capacity

calculates out to 26,880 pounds.

Operational

History of the

Crane

The investigation revealed that Burlington attempted to operate the

crane outside of the designed working limits. During the month of

November 1999, personnel unsuccessfully attempted to move a

quarters building with a weight of approximately 20,000 pounds. The

hydraulic unloading system that is designed to prevent overloading of

the crane prevented the lifting of the quarters. An inspection was

requested of the crane, along with a load test. It was determined at this

time that the lift was outside the designed weight limitations of the

crane for the angle and radius for the lift. The weight limitation at this

angle and radius was 18,000 pounds.

The Relief Crane Operator stated in the interview that he made a lift of

approximately 25,000 pounds 9-10 days prior to the failure of the

crane. He stated that the lift was slightly outside the designed weight

limitations of the crane. He recommended reconfiguring the load line

to a six-part line to increase the lifting capability. He stated that he was

instructed by the supervisor in charge at that time to make the lift and

not to worry about it. The decision to continue with the lift outside of

the designed weight limitations was in violation of both Burlington and

Crown’s safety manuals and API RP 2D. The Relief Crane Operator
17

informed the panel of other operational issues regarding the crane.

Those include the following:

! The configuration of the control handles was unique to this crane

and not the typical control configuration as other cranes he had

operated. For pictures of the control handles, see Attachment 3.

! The crane would rock on the pedestal at high boom angles.

! The operation of the crane was not smooth.

Additionally, these issues were conveyed to the On-site Supervisor.

During the course of the interviews with various platform personnel, all

stated that they had experienced similar problems while operating the

crane.

Tank Markings Burlington’s safety handbook states: “All loads in excess of

5,000 pounds to be lifted by a crane offshore should, if possible, have

the weight of the load clearly marked on the load before the load leaves

the shore base as a precaution against overloading the crane.”

The tank involved in this incident was a 25-barrel tote tank owned by

Diamond Tank Rentals. For picture of the tank, see Attachment 4. The

empty weight of the tank was 4,080 pounds. This weight is marked on

the manufacturer’s plate located on the inside support leg of the tank.
18

For picture of the manufacturer’s plate, see Attachment 5. At the time

of the incident, the tank was filled with Calcium Bromide (CaBr2). The

density of the CaBr2 was 14.2 pounds per gallon. This calculates to

14,910 pounds of CaBr2 with a total weight of 18,990 pounds. The

tank involved in this incident and other numerous pieces of equipment

were not marked with the associated lift weight.

Safety Manuals Burlington does not have a fully integrated safety and environmental

management program as recommended by MMS.

Both Burlington and Crown’s safety manuals are in opposition to

API RP 2D. API RP 2D states in part, “No fewer than five (5) full

wraps of rope will remain on the drum(s) in any operating condition.”

Burlington’s safety manual states in part, “During operation, there shall

always be at least four wraps of cable on the winch drum.” Crown’s

safety manual states in part, “There should be at least two wraps of

cable on the drum at all times when operating.”

Sequence of Events

to the Accident

Night Crane Operator discusses work to be performed prior to the start

of his shift with Day Crane Operator. They discuss the necessity to

move tank to offload pipe, the tank weight, and crane boom angle.

Night Crane Operator starts offloading pipe to the Gate Dancer and
19

rearranging other cargo located on the Gate Dancer to accommodate

more pipe.

Night Crane Operator radios Master to reposition vessel in order to

relocate tank to accommodate more pipe.

The Master attempts to reposition vessel sideways to platform. Master

radios back to Night Crane Operator that he is having trouble

repositioning vessel because of current and wind conditions.

Supervisor overhears conversation on the radio between Night Crane

Operator and Master. Supervisor intervenes and tells Master to return

to base if he can’t hold position and the Supervisor will get someone

who can.

Master advises that he can reposition vessel back to its original position

and was only attempting to honor the request of the Night Crane

Operator.

Supervisor orders Night Crane Operator to quit moving cargo around

on deck of vessel and continue offloading pipe.

Master repositions vessel back to its original position and then moves
20

closer to platform.

Night Crane Operator radios to Master that vessel is too close to

platform and he cannot see tank from the crane operator’s station.

Master positions vessel farther away from platform.

Night Crane Operator radios Master of his intentions to rotate tank

90 degrees to allow the offloading of pipe and to advise riggers located

on the vessel.

Night Crane Operator lowers boom angle to near zero degrees and

lowers block in preparation to pick up tank. At boom angles less than

four degrees, the hydraulic unloading system cannot function.

Riggers attach slings to tank and signal Night Crane Operator to pick

up tank.

Night Crane Operator raises tank approximately 6 feet off deck.

Ball ring on crane snaps in four places and crane and operator fall onto

deck of vessel. For pictures of the ball ring, see Attachment 6.
21

Riggers move Night Crane Operator away from wreckage to safety.

Crane falls off the side of vessel and hangs from rigging over side of

vessel.

Personnel from platform board boat and administer first aid and move

the Night Crane Operator back to platform and prepare for medical

helicopter flight.

Night Crane Operator is flown to Terrebonne General Hospital and

undergoes surgery for his injuries.

On the following day personnel use torch to cut load line from crane

and crane sinks to Gulf floor.
22

Conclusions

Causes During the course of the investigation, the Panel detected numerous

immediate causes and underlying causes that are factors in this incident

that, by themselves, do not lead to the conditions that ultimately caused

the event; however, the factors facilitated the occurrence of the event or

increased its severity.

Immediate causes

Immediate causes are categorized as either technical failure or human

error and are listed in no particular order.

! The Night Crane Operator operated the crane outside of the

designed limitations of the crane by

1. Picking up weight outside the safe load limitations of the

crane as indicated on the load chart.

2. Not knowing that the hydraulic overloading system cannot

function at boom angles less than four degrees.

! The Night Crane Operator had minimal experience.

! The On-site Supervisor failed to recognize hazards or ignored them.

Underlying causes

The underlying causes included personnel factors, capability,

knowledge and skill, stress, improper motivation, job factors,

organizational structure, management and supervision.
23

! The On-site Supervisor created a stressful work environment in that

he placed productivity above safety.

! Burlington failed to ensure that all onsite supervisors adhere to the

guidelines set forth in Burlington’s Contractor Safety &

Environmental Guidelines for Offshore Operations.

! Burlington failed to perform a job hazards analysis of the well

workover operation during the planning stages of the job. (Note –

This should have included historical incidents that involved

snubbing operations.) Burlington experienced a similar crane

failure incident on July 19, 1996, during similar snubbing

operations with HWC on Eugene Island 196 C platform.

! Burlington failed to perform a job safety analysis.

! The crane does not meet API Specification 2C specifications, as the

crane was designed and built prior to the development of the first

edition of API Specification 2C (1983).

! Burlington failed to follow the recommendations as noted in their

safety manual on the marking of equipment with the weight.

! Burlington failed to ensure that daily crane inspections were

performed by not providing their Pre-use Hydraulic Crane

Preventive Maintenance Plan to the contract crane operators.

Recommendations
24

Safety Alert MMS should issue a Safety Alert on the referenced incident to heighten

the awareness to the current specifications of API Specification 2C.

Specifically, attention should be directed to the current recommended

ball ring design criteria and to those cranes manufactured under a

different design criterion.

Other issues that should be included in the Safety Alert are the

following:

Control handle configuration

Adherence to manufacturer’s recommended maintenance

Accuracy of the load charts

Adherence to all safety policies and recognized standards

Annual

Performance

Review

MMS should stress to each operator during the annual performance

reviews the critical role that the on-site supervisor plays in

implementing an effective safety program.

Regulatory Change MMS should incorporate by reference API Specification 2C into the

regulations.

Study MMS should audit/count/inventory the number of pre-API 2C cranes

still in use in the Gulf of Mexico. All pre-API 2C cranes that do not

meet 2C design specifications should be either upgraded or
25

decommissioned.