Gross Errors
Gross Errors
Abstract
During the last years The Norwegian Petroleum Directorate, as well as Statoil, has put
increased focus on how gross errors related to structural integrity are influencing the safety of
offshore installations. Also, the loss of the P36, a floating platform outside Brazil in 2001,
emphasised the importance to control gross errors in large projects. On this basis, a work to
assess the risk of loss of the structural integrity of the Kristin platform, during operation, due
to failure from gross errors was initiated.
The Kristin platform is a permanently moored ring-pontoon semi-submersible production
unit planned to be placed in the south-west part of Haltenbanken area in the North Sea in
2005. The water depth at the site is approximately 315 m.
The objective of this work was to quantify the risk contribution from gross errors related to
structural integrity and to pinpoint the most critical items that may govern the probability of
gross error for the Kristin platform. Some of the main findings from this work are presented in
this paper.
r 2005 Elsevier Ltd. All rights reserved.
0951-8339/$ - see front matter r 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.marstruc.2005.03.002
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1. Introduction
1.1. General
The objective of this work is to perform a risk assessment considering the potential
risk from failures of the structural integrity of the Kristin platform during operation
caused by gross errors during design, fabrication, installation and operation of the
platform. This risk assessment is performed with respect to possible loss of human
lives and loss of assets. The objective is also to pinpoint the most critical items that
may govern the probability of gross error for the Kristin platform. This information
may be used to reduce the probability of gross errors if appropriate remedial actions
are introduced at an early stage.
Gross errors are understood to be human mistakes during design, fabrication,
installation and operation of the platform.
By structural integrity is meant the main structure such as the hull and deck,
buoyancy elements and anchoring system.
supported on the west end of the deck structure. The platform draught is 21.0 m, and
the platform is planned to be operated permanently at this draught. The platform is
kept in position by 4 anchoring lines at each column. Twenty-four risers are hung at
the deck level. The risers are supported horizontally at the pontoon below as shown
in Fig. 1.
A daily production capacity of 126,000 barrels of condensate and 18 million cubic
metres of rich gas is planned. The platform is planned to operate from 2005.
The design basis for the Kristin platform is based on the regulations given by the
Norwegian Petroleum Directorate (NPD) [1] for design of offshore installations. The
structural design of the platform is based on Norsok documents N-001 [2] for
general design considerations including requirements to verification and quality
assurance, N-003 [3] for analysis of action effects and N-004 [4] for design of the hull
and deck structure. NPD refers to requirements from the Norwegian Maritime
Directorate (NMD) with respect to hydrostatic stability and floatability and for the
capacity of the anchoring system.
Risk for failure of the structure resulting from statistical variations in loads and
structural load bearing capacities.
Risk for failure due to accidents.
Risk for failure due to a gross error during design, fabrication, installation and
operation of the structure.
The first one is controlled by appropriate design standards with specified load and
resistance coefficients. A low probability of failure is aimed for when design
standards are developed. For welded offshore structures a target failure probability
less than 104–105 is aimed for when load and material coefficients are calibrated
for design codes for welded structures [5]. Thus, normally this probability of failure
becomes small compared with the other risks for structural failure.
The risk for failure due to accidents is accounted for by appropriate risk
assessment studies denoted: Quantified Risk Analysis (QRA). If the risk from an
accidental event is high (typically higher than 104 on an annual basis), the event will
be designed for.
The risk for failure due to a gross error is the most difficult to handle as this risk
cannot be removed by additional safety coefficients. Normally, a detailed plan for
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verification and quality assurance of important items in the design, fabrication and
installation process is required in order to keep the probability of gross errors in a
project at an acceptable level. However, it is difficult to assess the risk for gross error
due to its nature.
Gross errors are understood to be
Thus, gross errors are understood to be human mistakes. Different people are
involved in each project and it becomes very difficult to predict the probability of a
gross error in a project. However, from the past history, gross errors have been a
significant contributor to the failure of structures, and a focus on these issues is
considered to be important in order to ensure project success.
Matousek and Schneider [6] performed an investigation of 800 cases with damages
on onshore structures. In his work he found that the structural systems, temporary
structures, excavations and site installations cover the majority of the cases. Further,
Matousek shows that the following errors underlying the failures could have been
detected in time:
32% by a careful review of the documents by the next person in the process,
55% by additional checks, if one had adopted the right strategies.
In the first case the importance of good cooperation between all those involved in
the construction phase is recognised, and in the second the need for well-planned
quality assurance procedures. Finally, Matousek concluded that 13% of all errors
could not possibly have been detected in advance.
It should also be kept in mind that many errors are difficult to detect by self-
checks. Therefore many errors can only be discovered through independent review
by another person or through an independent analysis.
Discipline checking and verification are important for removal of human errors, but
it should be kept in mind that they reduce the risk only to a limited degree. Therefore
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possible use of other barriers should also be considered where the consequence of a
human error is significant and where such an additional barrier is feasible.
Reliability analyses are used for calibration of load and resistance factors to be
used for design codes. As pointed out by Kvitrud et al. [7], reliability analysis
underestimates the risk for accidents of offshore structures, as gross errors are not
accounted for in the analysis. The experience from four of the largest accidents in
Norway shows that human error is the main contributor to the risk.
Schneider [8] estimated based on the data from Matousek that the risk modelled in
reliability analysis contributes to 10–25% of the total risk. It is likely based on these
results to assume that a large part of the discrepancies between the experienced frequency
and the calculated risk can be explained by human errors also for offshore structures.
Most accidents may appear to have arisen from a unique set of circumstances,
which are unlikely to ever be duplicated.
Also, it is often more that one error that leads to failure. Each error may be linked
to details [9]. Example: The loss of the Sleipner A concrete platform is an example of
this, where a human error in the performance of the numerical analysis was added to
that of construction with insufficient anchoring length of reinforcement bars [10].
2.3. Requirements in design rules to minimise the risk and consequence of gross errors
There are two disasters in addition to the loss of P36 that have been important to
the industry with respect to development of appropriate rule requirements. These are
the ‘‘Alexander Kielland’’ disaster in 1980 [11] and the loss of the platform ‘‘Ocean
Ranger’’ in 1984 [12]. The ‘‘Alexander Kielland’’-disaster in 1980 was caused by a
structural rupture (initiated by fatigue crack) of one of the five main supporting
columns which consequently lead to the capsizing of the unit. Following this
disaster, NMD introduced new rules that included the requirement that a unit
should remain stable and afloat even after a loss of buoyancy volume corresponding
to one column. The consequence was that the volumes above the main deck had to
be of a certain size and be watertight, separated from the columns. Later on, in 1991,
this requirement was replaced by a requirement to a certain level of the righting arm
to be obtained from watertight volumes above the main deck [13]. This requirement
is still in excess of the international requirements in the IMO MODU Code.
After the Alexander Kielland accident in 1980, the industry made a detailed review
of their rules for mobile offshore units and stricter requirements were introduced
with respect to consequence of fatigue cracks and accidental loads.
The main event leading to the disaster with ‘‘Ocean Ranger’’ was that water
entered into the ballast control room located in one of the centre columns through a
porthole that was damaged by the waves. As a consequence, the ballast control
console was set out of function and the crew did not understand how to operate the
ballast system manually and that ballast water could be transferred from one tank to
another by gravity. The fact that the chain locker pipes were open has also been
addressed as a reason for the loss of the platform. According to the NPD a failure of
a single component should not lead to unacceptable consequences. In some way it is
realised that it is difficult to build safety into structures by verification and quality
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3.1. Approach
The risk assessment of the Kristin platform with respect to gross errors has been
performed along two different paths as indicated in Fig. 2:
(1) Statistics: Evaluate the database for relevant structural failures in relation
to the Kristin platform from the World Offshore Accidents Databank
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Statistics Scenarios
Then, at the end of the two paths a modified probability of failure for the Kristin
platform due to gross errors is made based on the statistics of MODUs that are
scaled in a relative sense to correspond with the actual design of the Kristin platform.
For assessment it has been found convenient to link the failures of structural
integrity due to human mistakes into the following groups:
From the database a probability of failure has been established for each of these
groups.
It is recognised that the derived probabilities of failure correspond to a worldwide
database. It is also recognised that the requirements to design and operation of
floating platforms are stricter in Norway than that of average worldwide requirements.
In order to assess this difference a number of RIPs have been established. These
parameters are considered to describe the risk of a gross error for the Kristin platform
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relative to the worldwide accident database for Mobile Offshore Drilling Units
(MODUs). A team of experts from the designer GVA Consultants in Gothenburg
(GVAC) and Aker Kværner Engineering (AKE), the operator (Statoil) and Det
Norske Veritas (DNV) discussed the grading of each of these parameters in a one-day
meeting. A grading system going from 1 as lowest to 5 as highest was defined as
follows. The grading was given in a relative sense in that a grade of 3 corresponds to
that of the mean of the worldwide MODUs. A grade equal to 5 is the highest grade
and corresponds to the best of fixed structures in the Norwegian part of the North Sea.
Having obtained the probability of failure from the worldwide database and assuming
that the best grade of 5 corresponds to that of fixed structures, an interpolation of
the grade was made to assess the probability of failure for the Kristin platform.
4.1. General
The World Offshore Accidents Databank (WOAD) is used as basis for the
study of historical accidents. WOAD is maintained by DNV. Events described
in public reports, papers and magazines all around the world are included
in WOAD. An agreement with NPD was made in 1990 that all accident-related
correspondence between NPD and the operators, should be sent to DNV as well,
to ensure that all relevant accidents on the Norwegian Continental Shelf are
included in WOAD. Today WOAD includes details of some 4000 offshore events
of different types. The accidents in the database are categorised and the distri-
bution on the different categories of accidents recorded from 1980 to 1997 is shown
in Fig. 3.
As the information in WOAD is found from public sources it is reasonable to
assume that the data are biased due to under reporting. This is believed to be
especially true with respect to events happening outside the North Sea region, but
also accidents in the North Sea are found to be more frequent than recorded in
WOAD when WOAD data are compared for UK waters with Health and Safety
Executive databank Orion [23]. However, it is believed that the most serious
accidents resulting in loss of structure or loss of lives are included. The sum of the
two most severe damage grades: ‘‘severe damage’’ and ‘‘total loss’’ are shown relative
to the total number of events in Fig. 4. The percentage for serious accidents to the
total are much larger for worldwide operations than for the North Sea indicating
that less serious accidents are under reported for units world wide. Hence only
serious accidents are used as basis for establishing frequencies in this study.
(Serious is defined as: severe damage+total loss). Fig. 4 also shows that the ratio of
serious damage to the total number of accidents is larger for mobile units than for
units in general.
From the WOAD database the accidents that may be related to the floatability
and stability of the structure, the load-bearing structure and the mooring system are
extracted. Other accidents in the literature that might be of relevance for this study
are also included. Totally, 831 accidents have been evaluated where the platform
stability or floatability, the load-bearing structure, or the mooring system have been
involved. The accidents are grouped according to the type of accident in order to
simplify the analysis of the statistics. The different groups of accidents are shown in
Table 1.
The distribution of the accidents on the different groups is shown in Fig. 5 for all
accidents and the distribution on the most serious accidents is shown in Fig. 6.
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900
800
700
600
500
400
300
200
100
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Fig. 3. Different types of accidents for worldwide operations for the years 1980–1997.
20.0%
Severe damage
18.0%
Total loss
16.0%
14.0%
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
All units All units North Mobile units Mobile units
worldwide 80-97 sea 80-97 worldwide 80-97 North sea 80-97
Fig. 4. Accidents classified as severe damage and total loss for units worldwide and in the North Sea for
the years 1980–1997.
The accidents that are found by the search in the database are to a large degree
related to temporary phases like fabrication, installation and transportation. These
three groups add to 42% of all accidents and 47% for the most serious accidents
(categories severe damage and total loss).
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Table 1
Group of accidents
The group denoted ‘‘Weather’’ comprises accidents where it is most likely that the
structure is loaded beyond the design values. These are cases where failure would be
expected. Typically, this yields satellite wells in the Gulf of Mexico that is damaged
during hurricanes. Older jacket-type platforms are also included as the design was
based on evacuation in case of hurricanes and it is evident that hurricanes like
Andrew in 1992 led to wind and waves that are giving forces that are much above the
capacities of these platforms. However, all cases of failure in the mooring system are
grouped under ‘‘Anchoring’’.
A large number of accidents are related to Jack-up platforms. A majority of the
accidents are related to foundation failure for these types of platforms. For this
reason, Jack-up platforms are given a separate group.
The group ‘‘accidental loads’’ covers accidents that are not related to failure in the
platform structure or its moorings, but for one or another reason has been selected in
the search in the WOAD database. Similarly, the group ‘‘non-structural elements’’
comprises failure that is selected by the search that is not related to the platforms
main structure, e.g. pipelines, antennas, burner booms, drilling rigs etc. The group
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Transportation Anchoring
11 %
26 %
Fabrication
5%
Structural
Installation
4%
11 %
Stability
2% Jack-up
14 %
Non-structural
elements
9% Miscellaneous
2%
Fig. 5. All accidents found from WOAD divided into groups based on type of accident.
Accidental loads
15 %
Weather
6%
Anchoring
1%
Transportation Fabrication
30 % 4%
Installation
13 %
Structural
2%
Stability Jack-up
4% 19 %
Miscellaneous
Non-structural 1%
elements
5%
Fig. 6. Accidents resulting in severe damage or total loss from WOAD grouped based on different types of
accidents.
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‘‘Miscellaneous’’ covers cases that are not found to fit in the other groups, e.g.
artificial island.
The accidents related to structural integrity for the operational phase are found in
the three groups: ‘‘Stability’’, ‘‘Structure’’, and ‘‘Anchoring’’. For all accidents found
in the search these groups account for 2%, 4% and 11%, respectively, giving a total
of 17% of the accidents. For the most serious accidents these groups account for 4%,
2% and 1%, respectively, with a total of 7%. It is notable that failures in the
mooring system are quite frequent, but is seldom leading to massive losses. It is
reason to believe that the accidents in the operating phase for platforms are less than
in temporary phases due to the following factors:
The structure is pre-loaded through several temporary conditions that will reveal
weakness before the structure is used for operation.
The focus on safety in temporary phases is less than for the permanent condition.
A higher risk is normally accepted for temporary phases than for the installed
structure.
4.4. Relevant accidents from the database for risk assessment of Kristin
4.4.1. General
The most serious accidents for the three groups related to structural integrity are
summarised in the following tables for each group separately.
Table 2
Relevant accidents from gross error related to floatability or loss of stability
Table 3
Relevant accidents from gross errors related to structural failure
Accidents found to be relevant for assessing failure frequency from gross error
related to anchor failure are listed in Table 4.
The number of mobile offshore platforms that are operating is given in WOAD.
From 1970 and up to 2000, about 14 500 platform years are experienced for Mobile
Offshore Platforms (MODUs). For comparison, the number of platform years for
fixed platforms are about 110 000 excluding Asia and Africa.
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Table 4
Relevant accidents from gross error related to anchor failure
In order to assess the failure frequency for MODUs in the operating phase it will
not be relevant to consider accidents in the temporary phases. Accidents that are
related to non-structural items or types of structures other than MODUs should also
be disregarded.
For this assessment it is decided to treat jack-ups differently from other types of
MODUs due to the many registered accidents related to the jack-ups foundation
which is unique to jack-ups and that is of less value when studying a semi-
submersible platform like Kristin. The group of failures related to jack-ups is
therefore also disregarded. The number of platform years for jack-ups in the actual
period is 8500 making the remaining MODUs to have experienced about 6000
platform years.
The relevant number of accidents in the period for failure group ‘‘Structural’’ was
6. But only one of these gave total loss. One is a fixed platform, which is disregarded
since we are only considering floating units. The present design requirements for
platforms like Alexander Kielland are stricter after the accident with Alexander
Kielland as explained in Section 2.3. It is therefore necessary to reduce the failure
frequency that may be calculated due to statistical numbers when we are assessing
the failure frequency due to structural failure for the MODUs of today. It is
therefore assessed that the failure frequency for the operating phase for MODUs of
today are less than 104 for world wide operation.
For accidents grouped under ‘‘Stability’’ there are 7 total losses and also one
severe damage with a large number of fatalities. The total number is 12. It is believed
that some of the older derrick barges are operated outside requirements for stability
of today. Therefore, it seems reasonable to reduce the number to 8 (7 total loss+1
severe damage) to obtain a number that is based on experienced accidents but are
representative for the practise of today. This makes the failure frequency for loss of
platform due to stability equal to 13104.
Four accidents in the database implied altogether 260 fatalities or 65 fatalities in
average. (The P36 accident is not included here as this accident is categorised under
explosion.)
The failure frequency involving loss of lives due to stability is 7104. For
accidents due to failure in the mooring system there is no total loss later than 1973
and no fatalities. Thus, the failure frequency (worldwide) for total loss of the
platform in the operating phase due to anchor failure is less than 104. There is no
loss of life reported to be associated with anchoring failure.
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The literature has been searched for a good system to evaluate the probability of
gross errors for the Kristin platform.
Bea [24,25] correlates probability of human errors to task, stress, distraction and
impairment. Detailed information about working conditions for the designer, the
fabricator and the operator of the platform would be required to follow this concept.
A required data basis for this would hardly be available before the project is finished.
Also, a number of reports presented by HSE for assessment of risks from gross
errors have been evaluated, see Refs. [26–29].
After a consideration of different alternatives it is found that an assessment of
probability of gross errors in a project may best be assessed in a relative sense. In
order to make such assessments it is necessary to establish a list of RIPs that are
considered to govern the probability of gross errors. Then each RIP is assessed
separately for the actual project relative to that of other projects.
Based on the review of accidents in the WOAD database for mobile platforms it is
found appropriate to investigate the following structural systems in detail:
RIPs are established for each of these items based on an engineering evaluation of
each parameter’s importance for the integrity of the platform.
All the listed RIPs are considered to be important for the integrity of the Kristin
platform. In general, all these parameters are given a weight equal to 1.0.
Some of the parameters are subdivided for practical reasons (such as water
tightness and control of weight and mass of gravity). These are given a weight of 0.5
in order to get a balanced contribution based on engineering judgement according to
the distribution between verification and backup systems indicated above.
5.2.1. Stability
There are three thinkable main groups of initial events that could possibly lead to
the sinking or capsizing of the unit:
(a) The event that ballast water could be distributed or entered into the unit in such
a way that the unit would capsize.
(b) The event that water would enter into the unit either from damage to a
watertight barrier or from internal leakage through pipes, etc.
(c) The event that the unit is loaded in such a way that the vertical centre of gravity
is above the allowable limit.
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The applicable rules are generally based on the approach that one single failure or
event should not lead to the loss of the unit. The above items could be regarded as
such single failures and the corresponding hazards that have been accounted for. For
each hazard that has been covered by the rules one or more pre-requisites have to be
fulfilled in order to assure that the unit will not be lost.
A scenario with water filling of compartments is considered: The unit has been
designed to stay afloat at an acceptable position when the damage involves two
compartments in collision areas (One compartment in other areas). The pre-
requisites will be factors such as:
Any corrective action such as to get the unit at even keel involves additional
hazards and the pre-requisites will be factors such as
The RIPs which could affect the above-mentioned pre-requisites can be sorted into
three main groups:
(a) Risk parameters introduced during design. The basis for the design is factors
such as the applicable rules and the designers experience and knowledge.
(b) Risk parameters introduced during construction. These are follow up and quality
control during the construction.
(c) Risk parameters introduced during operation of the unit. These are typically the
quality of the documentation onboard, the qualification of the operating
personnel and the operational routines in general.
RIPs have been established for each of these groups. It was observed from Section
2.2 that experience from a similar project, verification and quality assurance are
important parameters in design as well as construction. The watertight integrity in
way of damaged compartments is essential for the unit’s ability to stay afloat and be
stable after damage. Among the different RIPs, attention should be paid to the
arrangement of the HVAC system.
Draft reading and sounding of tanks are included as RIPs that are important
measures for the operators to get a correct picture of the flooding scenario.
Control of weights and centre of gravity is important information with respect to
stability and are included as RIPs. This also includes the ballast system and its
operation.
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It should be noted that the reference Grade 3 corresponds to the average mobile
offshore unit being built today. The standard of today’s MODUs will necessarily
reflect the upgrading of the rules that has taken place as a consequence of the
disasters that were mentioned initially and which are included in the statistics.
A high material fracture toughness is used such that a crack can grow through the
hull plate before it becomes so large that it is critical with respect to unstable
fracture.
When the crack is through the hull plating there will be some leakage that will
likely be detected provided that a proper detection system is planned.
Proper in-service inspection programme that accounts for crack growth rates.
be 1 102. By excluding systems consisting of only six-strand wire ropes and failure
in Kenter shackles and pear links the annual probability of failure was 0.7 102.
There are several reasons which should indicate that line failure in long-term
mooring systems is less frequent than for mooring systems on drilling units:
A proof loading of the lines might reveal information of possible weak links in an
anchor line. It is also considered to improve the fatigue capacity because of
introduction of residual stress in the chain links (without studs as well as with studs)
[33]. Therefore this item was included as a RIP.
5.3. Risk of the Kristin platform relative to worldwide database for mobile offshore
platform
The annual probability of an accident that leads to loss of lives due to gross errors
related to failure of stability systems and floatability is evaluated to 7104 based on
available statistics from MODUs operating worldwide.
Table 5
Risk influencing parameters for stability and floatability
General
Degree of well-known technology in design and fabrication 1 3
Are lessons learned from failures incorporated in design and fabrication? 1 5
Design
Designers experience 1 5
Quality assurance 1 4
Verification methods/ effort 1 4
Environmental conditions 1 3
Determination of environmental forces (wind) 1 4
Intact stability requirements 1 3
Weather tight integrity (deck) 0.5 4
Damage stability—watertight subdivision 1 4
Ballast system 0.5 4
Damage stability control 1.0 3
Draft reading and sounding equipment 1.0 4
Operation of watertight/weather tight closing appliances 1.0 3
Watertight integrity, bulkhead penetrations, valves, 0.5 4
Watertight doors and openings 0.5 4
Minimised vulnerability during inspections 0.5 4
Remote sounding provided in all compartments to get the correct picture in an 0.5 5
emergency situation
Construction
Quality assurance 1.0 4
External watertight and weather tight integrity, correct installation and testing 0.5 3
carried out
Internal watertight integrity. Bulkhead and bulkhead penetrations. Correct 0.5 3
installation and testing carried out
Emergency equipment. Correct installation and testing carried out 0.5 4
Operation
Ballast system 1.0 3
Ballast operation in severe storm 1.0 4
Correct action when damage has occurred, what to do, training in use of ballast 1.0 4
system. Emergency operation of ballast valves
Follow up of weights brought onboard 0.5 4
Lightweight survey every 5 years 0.5 3
Daily stability calculations 0.5 4
Periodical testing of watertight doors, hatches and valves. (All valves accessible 0.5 4
for inspections?)
Periodical inspection of weather tight closing appl. 0.5 3
Inspection and testing of bulkhead penetrations 0.5 3
Inspection of watertight compartments 0.5 3
Inlet blinding 0.5 4
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Then the annual probability of an accident that leads to loss of lives due to gross
errors related to failure of stability systems or floatability for the Kristin platform is
assessed to 1104.
The assessment is based on today’s operational practise by Statoil. It should be
pointed out that operation of the platform is a key parameter with respect to
floatability. It is therefore important to maintain the focus during project and
operation on:
It is also these items that are considered to be the most significant RIPs if a further
reduction of the risk is considered.
For the anchoring system there is no basis to distinguish between loss of lives and
loss of structure from worldwide statistics of MODUs.
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6. Conclusions
The risk for failure due to gross errors related to structural integrity of the Kristin
platform has been established.
Gross errors are understood to be human mistakes during design, fabrication,
installation and operation of the platform. By structural integrity is meant the main
structure such as the hull and deck, buoyancy elements and anchoring system. The
assessment process was made in the following steps:
First, the risk for gross errors for Mobile Offshore Drilling Units (MODUs)
operating worldwide today was derived based on available statistics from the
World Offshore Accidents Databank (WOAD).
Then, an engineering assessment of possible gross errors that might lead to loss of
the Kristin platform was performed. Risk influencing parameters (RIPs) that are
considered to be governing for these errors were established. A grading of these
RIPs for the actual design of the Kristin platform relative to those considered to
be representative for worldwide operating MODUs was performed.
Finally, the probability of failure for the Kristin platform due to gross errors was
derived by combining the results from the statistics of MODUs with the results
from grading of RIPs for the Kristin platform relative to that of MODUs.
Acknowledgements
The authors would like to tank Eldbjørg Holmås and Odd Fagerjord in DNV for
their review of the WOAD database and their contribution to the risk assessment.
The authors are also grateful to Statoil for accepting publication of this paper.
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