BP HSE COMMUNICATION – Lessons Learned Report

• Some platform crew ignored evacuation orders from

Type of Incident: Offshore Platform Fire & Spill
Business/Performance
Unit: Egypt – GUPCO Joint Venture
Country: Egypt
Location of Incident: October Complex Platform
Ras Shukheir, Egypt
Date of Incident: 6 May 2001
Brief Account of Incident: A fire occurred on the GUPCO
“October” offshore production complex in the Gulf of
Suez during a planned maintenance activity to replace a
Safety Relief Valve (SRV) on the 103 Production
Separator. There were no direct injuries from the initial
incident but a large number of staff required first aid
treatment after being involved in the emergency
response and fire fighting efforts.
The fire caused extensive damage to one area of the
production facility, including the glycol reboiler skid, an
aerial cooler for a gas lift compressor and extensive
damage to localized piping and wiring. There was an
environmental impact that came from an estimated
release of 50 barrels of oil to the Gulf of Suez during the
fire. The spill fully dissipated and is not considered to
have caused any damage to any environmentally
sensitive areas.
The platform was shut down for a total of 18 days with
lost production of over 60,000 BOPD and remained at
less than full production rates for approximately six
months after the event.
Potential Outcome: The extent of the platform damage
could have been much worse with significantly greater
loss of production capability. Workers on board the
platform during and after the incident could have
suffered more serious injury.
shore, necessitating emergency team mission
What Went Well:
• Platform ESD worked well once activated
• Platform fire deluge system worked well
• Emergency team response coordination efforts
Lessons Learned & Actions Underway:
• GUPCO’s operational HSE efforts had been focused
on developing & upgrading Safe Systems of Work
procedures and were not emphasizing assurance of use
• The existing offshore organizational structure provided
no clear line of accountability for overall platform
management – a new OIM development program
including UK training sessions has now been
implemented for all major offshore complexes
• Revised Permit to Work and Isolation Procedures
under development were implemented during
operations resumption efforts and have substantially
improved control and accountability offshore
• GUPCO’s Management Team has reviewed their
assurance process to identify an appropriate frequency
for external SMS audits for each major installation
• GUPCO has commenced providing an extensive
offshore operator competency training programme
provided by Baker International for offshore staff
• GUPCO requested assistance from BP to conduct a
Major Hazard Review Study, now under progress
Key Message: The effectiveness of any management system is
only proportional to the extent it is utilized. Having a structured,
scheduled assurance process is also vital

What Went Wrong:

• Isolation procedures were not being fully utilized to
safely isolate the vessel under maintenance
• No evidence of lockout/tagout systems in use
• Platform personnel did not feel empowered to
activate ESD system when initial leak started
• Operator error resulted in live production fluids
entering vessel being maintained with Pressure
Safety Valves removed
• MOC process not effective, P&ID’s outdated
• Personnel on Board (POB) info was inaccurate