| Description |
My investigation into the failure of four mooring lines that occurred on 21 October 2023 whilst the Stena Spey installation was moored up at 22/14c-J, JAS Exploration & Appraisal Well, identified that you have failed to ensure that, where necessary for the health and safety of persons, comprehensible instructions on procedures to be observed on the offshore installation are put in writing in that;
a. You currently have multiple Stena Spey procedures regarding severe weather and environmental conditions (Stena Spey document ‘Severe Weather Conditions – Stena Spey’: Doc no. L4-DOC-SPY-558, chart ix within ‘Emergency Response Flowcharts Stena Spey’: Doc no. L5-DOC-SPY-6890 & ‘Environmental Effects and Operational Limits – Stena Spey’: Doc no. L4-DOC-SPY-4550). However, these documents do not include key information such as the environmental limits for the safe operation of the Stena Spey anchor winches. Furthermore, these procedures contain contradictory information regarding when to prepare to shut down operations in response to forecasted weather conditions.
b. The aforementioned procedures are written in a manner which increases the likelihood of errors being made by those following them. For example, relevant warnings (e.g. directing personnel to review location/ activity (well) specific operating limits for the installation) are not provided at the start of the procedure, multiple actions are embedded in single procedural steps and, ambiguous language is frequently used (e.g. “timely decision”, “If the situation requires”).
Therefore, you have failed to provide comprehensible instructions regarding the actions necessary to prepare the installation for the onset of weather liable to exceed operational limits. As a consequence, upon receipt of weather forecasts from 15.10.23 onwards indicating that the limits identified in both the riser (Doc no. OP234658-DR-TEN-002, Rev B) and mooring (Doc. No 27965-MA-01 Rev B1) analyses for the well location were likely be exceeded on 19.10.23 the installation did not; unlatch from the well in sufficient time to prevent the riser being exposed to a sea state out with the identified limits whilst connected or, move to survival mode in sufficient time to maintain the mooring system within the parameters of the aforementioned analysis - thus placing the safety of those on the installation at risk. |
