SHERIFFDOM OF GRAMPIAN,
DETERMINATION
by
SHERIFF COLIN JOHN HARRIS, Esquire, Queen's
Counsel
in
FATAL ACCIDENT INQUIRY
into the deaths of
SEAN SCOTT McCUE
and
KEITH SCOT MONCRIEFF
SHERIFF CLERK
AB10 1AP
INDEX
PAGE
1. Introduction................................................................................................... 1
2. Witnesses:-
(a) who gave oral evidence........................................................................... 3
(b) who provided affidavits.......................................................................... 11
3. The Brent Bravo Offshore Platform:-
(a) General Description............................................................................... 12
(b) The Power Sources............................................................................... 13
(c) The Utility Shaft:-
(i) Pipework......................................................................................... 14
(ii) Gas & Fire Alarm Systems........................................................ 15
(iii) C.C.T.V................................................................................... 17
(iv) Communications........................................................................ 17
(v) Emergency Lighting................................................................... 17
(vi) Procedure in 2003 for entry to the Shaft..................................... 18
(d) Operation of the Platform:-
(i) Produced Vapour & liquid separation & gas compression.......... 22
(ii) Product Storage........................................................................ 23
(iii) Utility Shaft Seawater Level Control.......................................... 25
(iv) Open Drains & Process Drains.................................................. 25
(v) High Pressure & Low Pressure Flare Systems............................ 26
4. The Temporary Repair on Line D-115-A1105............................................. 27
5. Non-return Valve 9 P 097........................................................................... 31
6. Level Control Valve 6600............................................................................ 32
7. Emergency Shutdown Valve EZV 44715..................................................... 33
8. AUER Chemical Oxygen Self-rescuers........................................................ 35
9. Crowcon triple Plus Gas Meters.................................................................. 36
10. Control of Work Activities:-
(a) Permit to Work System......................................................................... 38
(b) Work Orders........................................................................................ 39
(c) Routine Tasks....................................................................................... 40
(d) Operations Umbrella............................................................................. 40
11. Start-up August 2003.................................................................................. 42
12.
Events of
13. Narcotic Effects of Hydrocarbons................................................................ 54
14.
Changes since
15. Determination.............................................................................................. 57
SHERIFFDOM OF GRAMPIAN,
FATAL ACCIDENTS AND SUDDEN
DEATHS INQUIRY (
INQUIRY INTO THE DEATHS OF
SEAN SCOTT McCUE and KEITH SCOT MONCRIEFF
DETERMINATION BY THE SHERIFF
This
is an inquiry under the Fatal Accidents and Sudden Deaths Inquiry (
On
The scope of a fatal accident inquiry is limited by the terms of section 6 of the 1976 Act, which requires the Sheriff to:-
"make a determination setting out the following circumstances of the death so far as they have been established to his satisfaction:-
(a) where and when the death and any accident resulting in the death took place;
(b) the cause or causes of such death and any accident resulting in the death;
(c) the reasonable precautions, if any, whereby the death and any accident resulting in the death might have been avoided;
(d) the defects, if any, in a system of working which contributed to the death or any accident resulting in the death; and
(e) any other facts which are relevant to the circumstances of the death."
At the inquiry the Procurator Fiscal who appeared and adduced evidence regarding the circumstances of the deaths was Ernest Barbour, Esq. Also appearing were Stuart Gale, Esq, Queen's Counsel, who represented Shell U.K. Limited and adduced evidence on their behalf; Peter Gray, Esq, Queen's Counsel, who represented the Wood Group; Christine McCrossan, Solicitor, representing the interests of Jackie Ogilvy, the partner of the late Keith Moncrieff; Gary McAteer, Esq, Solicitor, who acted on behalf of two Offshore Installation Managers, namely Terry Stout and John McEwan, and who led evidence on their behalf; and David Sheldon, Esq, Advocate, who represented the Health and Safety Executive.
The
inquiry sat on 38 days during which the evidence of 61 witnesses was taken,
either orally or by way of affidavit and, following submissions on behalf of
each of the parties represented at the inquiry, concluded on
During the course of the inquiry it became apparent that evidence relating to the condition of certain valves on the platform might be relevant to the cause of the deaths of the two men, or have contributed to the incident which resulted in their deaths. However certain evidence, such as the possible consequences to the structure of the platform, and its crew, of the ignition of the vapour within the utility shaft, while of concern to some of the parties and no doubt of importance to the offshore oil industry and those who work in it, was, in my opinion, beyond the scope of the 1976 Act and more appropriate for consideration at an inquiry of a more general nature.
1. KENNETH THOMSON (41) - a photographer employed by Grampian Police who, on 13 September, 2003, took a series of photographs, and a video, at the 81 metre level within the utility shaft of the Brent Bravo platform.
2. THOMAS WOTHERSPOON (47) - a maintenance scheduler employed by the Wood Group on the Brent Bravo platform who, on or about 17 November, 2002 in his capacity as mechanical lead technician, placed patch No. 86 on the closed drain degasser rundown line located within the utility shaft of the Brent Bravo platform.
3. IAN ALEXANDER SILK (41) - a logistics manager employed by Shell U.K. Limited who presented, by text and graphics, a general description of the Brent Bravo platform, the utility shaft, the relevant work area and its location, a brief introduction to the function of the main equipment and pipework systems within the utility shaft.
4.
PAUL WILLIAM
ADIE (35) - an operations technician employed by Shell U.K. Limited, who,
on
5.
SYDNEY CECIL
THOMSON (38) - a systems supervisor, process (S.S.P.) employed by Shell
U.K. Limited on the Brent Bravo platform, who, on
6.
PETER LAYCOCK
(45) - an electrical technician employed by the Wood Group on the Brent Bravo
platform who, on
7. STEPHEN ALAN DEETH (26) - an operations technician employed by Shell U.K. Limited on the Brent Bravo platform and who, on 11 September, 2003 was a trainee involved in preparations for a pig launch.
8. ALISTAIR STUART HARCOMBE (38) - an operations technician employed by Shell U.K. Limited on the Brent Bravo platform who, during the annual shutdown in August, 2003 investigated with Scott Fraser a single gas head low level alarm at the 81 metre level in the utility shaft.
9. CLARK ANDERSON (27) - a productions operator who was employed by Shell U.K. Limited on the Brent Bravo platform and had during the shutdown in August, 2003 investigated with Paul Buchan a gas alarm at the 81 metre level in the utility shaft and had on or about 9 September, 2003 together with Alistair Harcombe checked Patch No. 86.
10.
PAUL ARTHUR
BUCHAN (28) - an operations technician employed by Shell U.K. Limited on
the Brent Bravo platform who, a few months prior to the annual shutdown in
August, 2003, looked at, and assessed the condition of Patch No. 86. On
11. JOHN DELANEY CAIRNEY (43) - an installation inspection engineer presently employed by the Salamis Group who was employed by Motherwell Bridge Inspection and has worked, from about 1997 on the Brent Bravo platform. He kept the patch register and monitored all temporary repairs during his monthly inspection.
12. TREVOR CHRISTOPHER ANCELL (51) - a chartered mechanical engineer who, in September, 2003 was employed by Shell U.K. Limited on shore as the principal technical authority (piping and static equipment), for all the Shell Expro installations including the Brent Bravo platform.
13. TERRY WILLIAM ANDERSON STOUT (38) - an offshore installation manager employed by Shell U.K. Limited who, on 11 September, 2003 was an operations supervisor but was acting as installation manager on the Brent Bravo platform.
14. MARK GALLAGHER (45) - a mechanical technician employed on the Brent Bravo platform by the Wood Group who, on 11 September, 2003 was asked by Keith Moncrieff if he would go down the utility shaft and replace a patch on a pipe.
15. DR ROBERT STRACHAN STEPHEN (56) - a doctor employed by Shell U.K. Limited who, in 2003 was based on the North Cormorant installation and attended the Brent Bravo platform on 11 September, 2003 and at about 19:55 pronounced Sean McCue and Keith Moncrieff dead.
16. DAVID ANTHONY CHAPMAN (51) - an operations technician employed by Shell U.K. Limited who on 11 September, 2003 was the responsible person electrical on the Brent Bravo platform and who, during the general platform alarm and emergency shutdown was dispatched to check, and manually start, the emergency generator, which had not started automatically, in order to restore lighting.
17. THOMAS MURPHY STELMACH (48) - an offshore medic employed by Universal Sodexho on behalf of Shell U.K. Limited and based on the Brent Bravo platform who on 11 September, 2003 at about 7.00 pm descended the utility shaft together with Iain Ayers and Billy Boyse and found Sean McCue and Keith Moncrieff lying at the 81 metre level.
18. GEOFFREY TALBOT (52) - an inspection team leader employed by Shell U.K. Limited for the central asset unit and who is based onshore.
19. FRANK MILLAR (56) - a shutdown co-ordinator employed by Wood Group Engineering (North Sea) Limited who was the integrated services contract team leader on 11 September, 2003 on the Brent Bravo platform and who, on 9 September, 2003 instructed Keith Moncrieff to contact the area technician and together they should look at Patch No. 86, which reportedly was leaking, and assess its condition and report back to him.
20. ANNE WILSON HART (41) - employed by Shell U.K. Limited onshore as the engineering and maintenance leader for the central asset and who as maintenance team leader was responsible in September, 2003 for the Brent Bravo platform. One of her teams was responsible for arranging the design and fabrication of replacement pipe spools.
21. CHRISTOPHER JAMES GRANT (31) - a campaign maintenance co-ordinator employed by Shell U.K. Limited at their Tullos office in Aberdeen who was, on 11 September, 2003 acting systems supervisor, process (S.S.P.) on the Brent Bravo platform.
22. JAMES ALEXANDER SMITH (37) - a pipeline engineer employed by Shell U.K. Limited who during the general platform alarm and emergency shutdown assisted Paul Buchan to attach a hose to the closed drain system in order to put water down the line and thereafter assisted Dave Chapman to start the emergency generator.
23.
STEPHEN JOHN
CLAYTON (54) - a senior control and automation engineer employed by Shell
U.K. Limited at their Tullos office in
24. WILLIAM JOHN BOYSE (39) - who in September, 2003 was employed by the Wood Group on the Brent Bravo platform as an instrument technician. On 11 September, 2003 was told by Keith Moncrieff that he was going down the utility shaft that day to change a bit of rubber and a couple of jubilee clips.
25. JOHN JAMES MACASKILL (26) - an electrical technician employed by the Wood Group on the Brent Bravo platform and who, on 11 September, 2003 was an apprentice and heard Keith Moncrieff, at the 3.00 pm tea break, ask Peter Laycock if he had any rubber.
26.
IAIN AYERS
(43) - an instrument technician employed by the Wood Group who, on
27. SCOTT FRASER (37) - an operations technician employed by Shell U.K. Limited on the Brent Bravo platform who, on 17 August, 2003 together with Alistair Harcombe investigated a single gas head low level alarm at the 81 metre level in the utility shaft and whose role on 11 September, 2003 was technical custodian instruments.
28. JONATHAN ROBERT STATHAM (40) - a senior scientist employed by the Health and Safety Executive at their laboratory in Buxton, Derbyshire, who together with Christopher Parker and Dr Roy Parrott carried out tests on a number of items and prepared a report thereon.
29. CHRISTOPHER JOHN PARKER (31) - a scientific officer employed by the Health and Safety Executive at their laboratory in Buxton.
30. DR ROY PETER PARROTT (56) - a senior materials scientist employed by the Health and Safety Executive at their laboratory in Buxton.
31. RAVINDER KUMAR SHARMA (54) - a chartered mechanical engineer employed by the Health and Safety Executive as a specialist inspector who carried out an investigation into, and prepared a technical report on, the fitness for purpose of Patch No. 86, the condition of the non-return valve 9P097, the emergency shut-off valve EZV 44715 (including the actuator) and the level control valve 6600.
32. DR BERNARD EMERY (61) - an operations inspector employed by the Health and Safety Executive who specialises in control instrumentation and electrical engineering and investigated the gas detection systems used on board the Brent Bravo platform and who prepared a report thereon.
33. DAVID MICHAEL HARRIS (48) - an operations supervisor employed by Shell U.K. Limited on the Brent Bravo platform who in July, 2003 assisted Norman Lloyd to review outstanding work orders including 10449718.
34.
JOHN ROBERT McEWAN
(57) - an offshore installation manager employed by Shell U.K. Limited on board
the Brent Bravo platform who was the O.I.M. on board when the platform started
up on
35. MARTIN ALAN BREARLEY (57) - an inspector employed by the Health and Safety Executive specialising in fire and explosions who, together with Dr Venessa Forbes and V Karthigeyan, prepared a report on the potential consequences of ignition of the gas release in the utility shaft of the Brent Bravo platform.
36. PROF. GEOFFREY ALAN CHAMBERLAIN (57) - the manager of the major hazards management team within the health, safety and environment department of Shell Global Solutions who prepared the report "Brent Bravo Incident: Summary of the Dispersion and Explosion Analyses Performed by Shell Global Solutions".
37. V. KARTHIGEYAN (57) - an inspector with the Health and Safety Executive specialising in structural integrity of concrete, structural dynamics, earthquake engineering and vessel impact who co-authored the technical report on the potential consequences of ignition of the gas release in the Brent Bravo utility shaft.
38. DR. VENESSA JANE FORBES (35) - an inspector with the Health and Safety Executive specialising in structural integrity who was the report co-ordinator for the technical report on the potential consequences of ignition of the gas release in the Brent Bravo utility shaft.
39. ROBERT JOHN WHITE (46) - a principal inspector employed by the Health and Safety Executive specialising in structural integrity who prepared an addendum and update to the technical report on the potential consequences of ignition of the gas release in the Brent Bravo utility shaft.
40. TREVOR HODGSON (50) - a chartered engineering who acts as a chief consultant for Galbraith Consulting Limited and who prepared a report entitled "Explosion Loading in Utility Shaft".
41.
ROBERT ERNEST
GOWERS (52) - a specialist inspector employed by the Health and Safety
Executive in their offshore safety division who, between
42. DR JAMES HENDERSON KERR GREIVE (52) - a fellow of the Royal College of Pathologists employed in the Forensic Medicine Unit of the Department of Pathology at the University of Aberdeen who on 15 September, 2003 together with Dr Sameena Rashid carried out, and thereafter prepared a report on, the post-mortem examinations of Sean McCue and Keith Moncrieff.
43.
DR VALERIE FLOOK
(65) - a chartered physicist who is the principal of a company Unimed
Scientific Limited and prepared a report dated
44. ANILKUMAR CHOHAN (52) - a relief operations supervisor employed by Shell U.K. Limited and who was on board the Brent Bravo platform from 20 August, 2003 and was on board when the platform started up following the annual shutdown.
45. NORMAN LLOYD (56) - an electrical engineer employed by the Wood Group who, as integrated services team leader (I.S.C. team leader) in the Brent Field carried out with David Harris a review of outstanding work orders and cancelled work order 10449718 relating to the emergency shut-off valve EZV 44715.
46. DAVID RICHARD BEAN (59) - a mechanical technician employed by the Wood Group on board the Brent Bravo platform who worked on the emergency shut-off valve EZV 44715 during the annual shut down in 2002 and reported to his mechanical supervisor Peter O'Brien.
47. GEORGE ALEXANDER LANG (55) - employed by Shell U.K. Limited as the engineering and maintenance team leader for their cross border asset who in September, 2003 was based onshore as the asset leader for the four platforms in the Brent field.
48. RAYMOND WILLIAM PATERSON (59) - an inspector employed by the Health and Safety Executive who was a member of the team that went on board the Brent Bravo platform to investigate the incident which occurred on 11 September, 2003 and took a number of photographs with Phil Mullery and was party to the issuing of prohibition notices.
49. MARJORIE CHAMBERLAIN (33) - employed by Shell U.K. Limited as head of design for the Brent project group who in 2003 provided onshore mechanical maintenance support for the Brent asset and in August, 2003 considered the patch register and on 4 September, 2003 requested a new spool for 2"D-115-A1105 from the maintenance delivery team.
50. ROBERT MILLER NICOLL (53) - a senior control and automation engineer employed by Shell U.K. Limited who is the technical authority for their mature assets group.
51. JOHN CARDWELL (49) - an off-shore installation manager employed by Shell U.K. Limited who took timings, or caused timings to be taken relating to the time taken to descend from the DICS to the 81 metre level in the utility shaft.
52.
JENNIFER TALBOT (28)
- employed by Shell U.K. Limited as a styles and procedures co-ordinator at
their Tullos office in
53. JOHN HOLROYD (56) - an inspection team leader employed by Shell U.K. Limited who is in charge of the inspection and corrosion engineers within the Brent asset.
54. COLIN DAVID LEIGHTON (44) - a chartered mechanical engineer employed by Shell U.K. Limited at their Tullos office in Aberdeen and who is involved in the performance standards assurance programme.
55. BRIAN ROBERT TWADDLE (42) - an employee of Shell U.K. Limited and the project manager of MACH (minicell and column hydrocarbon project).
56. JOSEPH PRIEST (52) - a non-destructive tester on the Brent Bravo platform who was employed, in September 2003 by Motherwell Bridge Inspection.
57.
JANICE FLINT - a personnel manager employed by Wood Group
Engineering (
58.
JOHN ARMSTRONG - a radio operator admin. employed by
Universal Sodexho who was on board Brent Bravo on
59. HUGH MUIRHEAD McCUE - the father of Sean McCue.
60.
DERK KAPPELLE -
a director of Shell U.K. Limited, the owners of the Brent Bravo Offshore
Platform who spoke to the location of the platform in the
61. SIMON DAVID REID - a chartered mechanical engineer employed by Bureau Veritas as a senior verification engineer and was in 2003 the verification focal point for the Brent Field verification.
The Brent
Bravo platform is a concrete platform structure built to the Condeep design and
installed in the Brent field complex in the mid 1970s. The complex comprises four production
platforms, namely Alpha, Bravo, Charlie and Delta. The Brent field is located in Quadrant 211,
Block 29 of the
The oil produced by the Brent field is exported, via the Cormorant A platform, to Sullum Voe. The produced gas is exported via the Brent system to St Fergus.
The topside and process facilities of the platform are supported by a concrete gravity structure sitting on the seabed and comprises of nineteen compartments, or cells, three of which extend upwards as legs, or shafts, in order to support the topside structure. The three legs measure some 170 metres in height.
Sixteen of the compartments provide a storage and settlement system for the produced oil and liquids and hold 159,000 m3 of oil and water.
The two southern legs contain production well conductors and are filled with water to sea level. These two legs are not normally accessed.
The northern leg, or utility shaft, contains pipework and pumps for the oil storage and export system. The water level in the utility shaft is normally maintained at about 74.5 metres above the leg base. A minicell is located at the base of the utility shaft and is normally flooded but can be dewatered.
The concrete structure requires to remain in compression for structural stability and the cells are maintained full of liquid with oil on top, water below, with a settlement interface. The structure is subject to constant pressure from the internal column of water and a header tank.
The upper section of the utility shaft contains piping systems and pumps for (i) sea water cooling (service water), (ii) five pumps, (iii) produced water and (iv) crude oil export. Oil lines in the utility shaft transport produced oil and water to the storage cells. There is a platform at the 157.4 metre level,, a platform at the 101.2 metre level which supports the drawdown header tank and a platform at the 96.2 metre level which supports the storage water pumps.
The mid section of the utility shaft controls the production storage and distribution. The oil rundown lines enter the 24 inch manifold situated on the 81.2 metre level which also supports the oil booster pumps. The crude oil export lines terminate at the 81.2 metre level. A platform at the 76.7 metre level supports the storage manifold and below this the cell fill lines distribute stored production to the surrounding concrete cells.
The lower section of the utility shaft, the bilge, is normally filled with water to 74 metres and is not accessed. It contains a central circular structure known as the minicell. The storage water is routed through the minicell and out to the base of the concrete cells. In addition to the functional storage water lines a number of redundant lines associated with the platform installation remain in place and were cement filled after the platform base was grouted to the seabed.
The utility shaft may be accessed either by means of the lift, which terminates at the 81.2 metre level, or by 90 metres of stairs.
(i)
Three main generators,
(ii)
The back-up power supply is by means of two diesel
fuelled
(iii) Thirdly, there is an emergency diesel generator, which on sensing there is no power automatically, within a minute, runs up and closes on to the switchboard in order to supply power for essential systems such as light, radios etc. The running of the emergency generator will depend on the gas situation on board the platform.
(iv) Finally, there is a system known as the uninterrupted power supply (U.P.S.) which operates on batteries in the event of loss of A.C. power on the platform, and supplies communications and other systems in order to facilitate the emergency response and the resumption of main power generation.
The identifiable pipework systems contained within the utility shaft are, firstly, the three 8 inch oil rundown lines which transfer crude oil from the platform process system to the concrete storage cells at the base of the platform. The oil rundown lines enter the 24 inch manifold independently and are fitted with isolation and level control valves.
Secondly, the storage manifold which is located at the 76.7 metre level and allows the flow from the oil rundown lines to be diverted to the selected cell storage system and individual cells. The storage manifold is also used to reverse the flow to the oil export lines.
Thirdly, the cell fill lines which route the flow from the utility shaft to selected external storage cells which are clustered around the three platform legs.
Fourthly, the oil export lines which allow, when required, the stored oil to be pumped to the export flowline.
Fifthly, the storage water lines which can be used to introduce water to, or draw water from, the cells so as to maintain the water levels within the storage cells.
Sixthly, an independent service water system which provides seawater for the required platform functions.
Seventhly, an independent fire water system which provides seawater for the platform fire and deluge systems.
Eighthly, the ballast lines which were designed for use during the installation operations and are now redundant and are grouted and isolated.
In addition to the three 8 inch oil rundown lines four other lines from services located on the platform topside, connect to the 24 inch manifold. Firstly, the redundant drain line from the Brent Alpha platform. Secondly, the closed drain line from the process drains degasser vessel located at the 158.2 metre level in the utility shaft. Connected to the closed drain degasser rundown line, by means of an equal 4 inch tee and a 6 inch by 4 inch reducer, is the open drain line from tanks located on the lower deck of the platform. Also connected to the closed drain degasser rundown line, with an isolation valve, is a line from the caisson pumps on the level below. The closed drain degasser rundown line is fitted with isolation valves, a level control valve and a non-return valve. Finally, the condensate line routed from the low pressure flare knock-out drum located on the south face of the platform connects to the 24 inch manifold but is split and enters the manifold at two points. Both branches of the condensate line are fitted with isolation valves and level control valves.
Within the utility shaft is a fixed fire (both flame and smoke detection) system and a gas detection sys