Safety Flash

IMCA Safety Flash 05/17 March 2017

These flashes summarise key safety matters and incidents, allowing wider dissemination of lessons learnt from them. The information below has been
provided in good faith by members and should be reviewed individually by recipients, who will determine its relevance to their own operations.
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Association or its members.

Focus: Diving Safety

The first incident is a clarification and reissue by NOPSEMA of their Safety Alert 63 regarding quality assurance of
diving system audits. The other two incidents are diving-related near miss incidents, covering firstly, suspected
high levels of C02 in diver breathing gas, and secondly, bailout cylinder and pillar valve compatibility failures.

1 Clarification from NOPSEMA: Quality Assurance of Diving System Audits

The National Offshore Petroleum Safety and Environmental Management Authority (NOPSEMA) of Australia
published Safety Alert 63 regarding the quality assurance of diving system audits.

This was passed on to IMCA members as IMCA SF 03/17 – Incident 2 – Quality assurance of diving system audits.
Additional information drawn to the attention of NOPSEMA has made some changes necessary. The alert has now
been re-issued as Safety Alert 63 Rev. 1.

“A number of NOPSEMA inspections have identified a trend in the standard of audits conducted on diving systems
and equipment. Specifically, a number of operators of diving projects and diving contractors have failed to ensure
diving system audits have been conducted to an appropriate standard. While reviewing the audits conducted by
the diving project operators and the diving contractors, NOPSEMA’s inspectors identified the following deficiencies:
 Man-riding wire destructive test certification was not adequately assessed, resulting in the failure to identify
that the percentage deterioration was greater than that permitted by the relevant International Marine
Contractor’s Association (IMCA) code/guidelines and therefore should have been replaced;
 Inappropriate application of a management of change process to justify the deferral of man-riding wire
destructive tests;
 Failure to make an emergency services umbilical available for SPHL connection to its life support package;
 A high pressure (200 bar) flexible oxygen hose was found during a NOPSEMA inspection to be too long, made
up with joins and was damaged, however it was marked as compliant during an earlier audit;
 Older diving systems built to class have not been upgraded, where practicable, to meet current class
requirements e.g. fire suppression systems within diving chambers unable to be externally actuated.
Each of the deficiencies outlined above should have been identified and rectified as a result of the third party or in-
house audits.”

NOPSEMA notes that: “Failure to identify audit non-conformances associated with safety-critical elements of a
diving system may result in an increased level of risk to the air and saturation divers. The non-conformance
examples provided above have the potential to compromise the integrity of the system components and reduce
functionality in an emergency. Any loss of integrity or system redundancy has the potential to result in serious injury
or fatalities to divers and others involved in diving operations.”
2 Near Miss: Suspected High Levels of CO2 in Diver Breathing Gas
A member has reported an incident where there was an elevated level of CO2 in the divers reclaim breathing gas
during saturation diving operations. A dive team was performing diving operations with two divers working on the
seabed at an approximate depth of 92m. The bellman was within the diving bell supporting the two divers in the
water.

While working on the seabed the divers began to experience breathing difficulties but this was not reported to the
Dive Supervisor. On return to the bell for his hydration break, one of the divers experienced difficulties climbing
his umbilical to return to the bell but put this down to his own level of fitness. He mentioned this to the bellman
during the hydration break but this was not reported to the Dive Supervisor. On his return to the worksite the diver
again experienced breathing difficulties and asked the Dive Supervisor if everything was OK with the reclaim system.
On checking the topside reclaim system and discussing his concerns with the bellman, he reported back to the diver
that all was OK.

A short while later an alarm sounded on the CO2 analyser for the divers reclaim return. The Dive Supervisor noted
the analyser was displaying an incorrect reading. The divers then subsequently advised the Dive Supervisor of the
problems they were experiencing, including; agitation, breathing difficulties and headaches.

The Dive Supervisor requested the divers flush their helmets, go on open circuit, return to the bell stage and
changed the divers onto a secondary breathing mix. The Dive Supervisor also raised concerns regarding the analyser
and requested that the analyser was changed. The Soda Sorb was also replaced in the divers reclaim system.
Following the change of analyser, it was noted that the CO2 reading displayed was out with normal operating
parameters.

Both divers were subsequently recovered to the bell and the dive was aborted with no further ill effects experienced
by either of the divers.

A formal investigation was initiated and a report was submitted to the regulatory authorities.
Soda Sorb is used within the diver reclaim system and absorbs CO2 exhaled by the divers. This reclaimed gas is then
recirculated through the topside process system and subsequently resupplied back to the divers.
In this incident, the Soda Sorb within the reclaim towers which absorbs the CO2 was allowed to saturate. This
resulted in elevated levels of CO2 entering the reclaim loop and the divers experiencing symptoms indicative of an
elevated level of CO2 within their breathing gas.
 Our member suggested that the following things went wrong:
 it appears a mistake had been made in calibrating the analysers which resulted in them not alarming at the
expected threshold levels
 the vessel specific dive system operating procedures did not contain sufficient detail on how to calibrate
and set the alarms for the CO2 analysers
 industry practice is that Soda Sorb is changed based on the monitoring of the CO2 alarms
 the symptoms experienced by the divers at the time were not considered initially by the diver or supervisor
significant enough to cause alarm
 the incorrectly calibrated CO2 analyser indicated a fault code. This was not known as a fault code and its
significance was not recognised.
 Our member made the following observations:
 it is essential to ensure manufacturers equipment guidance is up to date and available to all relevant
personnel on board. Key information provided by the manufacturer must also be reflected in the operating
processes and procedures to ensure the safe maintenance and operation of plant and equipment
 it is essential to ensure persons responsible for the set up and calibration of equipment are familiar with
the procedures for safety critical equipment
 it is essential that persons in safety critical roles understand the importance of systems that have single
point failures and the value of establishing effective risk control and mitigating barriers
  the importance of effective training, competency and on-going assessment for personnel performing a
safety critical role. This should include practical competence assessment, especially if the person
performing the safety critical role has been absent from the worksite for an extended period of time
 the importance of ensuring that sufficient detail is captured within dive system operating procedures, on
how to calibrate and set up analysers including setting of alarms
 the importance of ensuring that manuals used across multiple assets are consistent to ensure the same
practices are applied.
 Our member took the following actions:
 raising of awareness across the fleet of the key learning points identified during the course of this enquiry
 engagement with equipment manufacturers to ensure up to date information is available, current and
consistent
 development of systems to ensure the dissemination of critical changes distributed by manufacturers or
equipment suppliers are issued to appropriate onshore and offshore personnel
 thorough review of diving operating manuals to ensure reflection of manufacturer’s current
recommendations
 thorough review of diving emergency and contingency manuals to ensure scenarios of high CO2 are
captured and that the appropriate actions to be taken are fully detailed. This will include contaminated gas
scenarios which must be incorporated into the emergency response drill matrix and practices at regular
intervals
 revision of the competency systems to identify all diving safety critical roles, specification of safety critical
modules within the competency system to ensure all those personnel in safety critical roles are competent
in using and calibrating safety critical equipment under their control
 review and amendment of fleet failure modes, effects and criticality analysis (FMECA) documents to include
scenarios of high CO2 in divers breathing gas
 all possible mitigations identified in the FMECA to be put in place to ensure risks are managed to as low as
reasonably practicable.

Members may wish to refer to the following incidents (search words, diver, faint, gas):
 IMCA SF 04/15 – Incident 4 –Diver fainted;
 IMCA SF 01/16 – Incident 3 – High potential near miss: poor o2 content in supplied air - diver temporarily lost
consciousness.
3 Bailout Cylinder and Pillar Valve Compatibility Failure
A member has reported a near miss incident in which there were failures of pillar valves. The incident occurred
during visual inspection of bailout cylinders, when it was identified that six out of the twelve pillar valves tested,
with GO/NO-GO thread gauges, failed the GO thread gauge test.

Of the six cylinders that passed the original test, four cylinders were rechecked at the next six-monthly planned
maintenance check, and two of the pillar valves failed the GO gauge thread test. A possible cause of the later failure
may have been wear & tear, continual emptying & recharging to 200 bar (at 200 bar there is almost 1 tonne of force
on the pillar valve).

Our member has introduced a quality check of cylinder threads and pillar valves whereby GO/NO-GO thread gauges
are used before accepting any new stock. When recently purchasing new cylinders and additional pillar valves the
pre-acceptance tests were performed. It was identified that there was a surprisingly high failure rate when testing
the new pillar valves. Of six pillar valves purchased, four failed the GO thread gauge test. It is to be noted that
similar failure rate has also been the case with subsequent purchases of pillar valves.

Attached are photographs of both the six pillar valves which failed during the original test and two other, order
replacement pillar valves which also failed the test. Also attached are photos of a new pillar valve with packaging
and demonstration photos of successful & unsuccessful GO thread gauge tests.

All tests were conducted by a technician who is qualified as an “ASSET” Part 1 & Part 2 Cylinder Inspector using
recently calibrated GO/NO-GO thread gauges.

Example of a GO Gauge PASS Example of a GO Gauge FAIL

New Pillar Valve with Packing Example of New Pillar Valves that FAILED
 GO or NO-GO thread ring gauge

A thread RING gauge is used to check

the accuracy of an outside thread.

The GO thread ring gauge should easily

and completely slide over the outside
Six In-Service Pillar Valves that FAILED thread. The NO-GO thread ring gauge
should not be able to slide over more
Our member’s recommendations and lessons learnt were: than 3 threads, if it does the outside
 It is recommended that organisations using Bailout Cylinders: thread is too small.
 establish a planned maintenance system procedure whereby on all
6 monthly internal visual inspections the cylinder and pillar valves
threads are checked using the GO/NO-GO thread gauges
 ensure that cylinders and pillar valves are checked when purchased
and before putting into service to ensure correct fitting using
calibrated GO/NO-GO thread gauge and by a trained technician
 implement a method of marking the pillar valves so that a register GO or NO-GO thread plug gauge
can be created to record or link a particular pillar valve to a
particular cylinder by serial number. A thread PLUG gauge is used to check
the accuracy of a threaded hole.
Members may wish to refer to the following incidents:
The longer end of the tool will be the GO
 IMCA SF 12/09 – Incident 1 – Pillar valve failure; end, while the shorter end is NO-GO.
The longer end should be able to thread
 IMCA SF 19/14 – Incident 1 – Injuries due to failure of diver’s emergency
into the threaded hole easily and
gas cylinder; completely. If not the hole is too small.
 IMCA SF 01/16 – Incident 2 –Injuries due to failure of divers emergency The NO-GO end should not enter
gas cylinder – use of incompatible threads. beyond the third thread, if it does the
threaded hole is too large.