Commission Implementing Regulation (EU) No 1112/2014 of 13 October 2014 determining a common format for sharing of information on major hazard indicators by the operators and owners of offshore oil and gas installations and a common format for the publication of the information on major hazard indicators by the Member States Text with EEA relevance

22.10.2014	EN	Official Journal of the European Union	L 302/1

THE EUROPEAN COMMISSION,

Having regard to the Treaty on the Functioning of the European Union,

Having regard to Directive 2013/30/EU of the European Parliament and of the Council of 12 June 2013 on safety of offshore oil and gas operations and amending Directive 2004/35/EC ¹, and in particular Articles 23(2) and 24(2) thereof,

Whereas:

• (1) Member States are required to ensure that operators and owners of offshore oil and gas installations provide the competent authority, as a minimum, with the data on major hazard indicators as specified in Annex IX to Directive 2013/30/EU. That information should enable Member States to provide advanced warning of the potential deterioration of safety and environmentally critical barriers, and should enable them to take preventive action, including in light of their obligations under Directive 2008/56/EC of the European Parliament and the Council (Marine Strategy Framework Directive) ².

• (2) The information should also demonstrate the overall effectiveness of measures and controls implemented by individual operators and owners, and the industry as a whole, to prevent major accidents and to minimise risks for the environment. In addition, the information and data provided should ensure that the performance of individual operators and owners can be compared within the Member State and the performance of the industry as a whole can be compared between Member States.

• (3) The sharing of comparable data between Member States is rendered difficult and unreliable due to the lack of a common data reporting format across all Member States. A common format for the reporting of data by operators and owners to the Member State should provide transparency of the safety and environmental performance of operators and owners and should provide Union-wide comparable information on safety of offshore oil and gas operations and should facilitate dissemination of lessons learned from major accidents and near misses.

• (4) To facilitate public confidence in the authority and integrity of offshore oil and gas operations in the Union, Member States should periodically publish the information referred to in point 2 of Annex IX of Directive 2013/30/EU pursuant to Article 24 of Directive 2013/30/EU. A common format and details of information to be made publicly available by the Member States should enable easy cross-border comparison of data.

• (5) The measures provided for in this Regulation are in accordance with the opinion of the Advisory Committee on Safety of Offshore Oil and Gas Operations,

HAS ADOPTED THIS REGULATION:

Article 1

Subject matter and scope

This Regulation specifies common formats in relation to:

• (a) reports from operators and owners of offshore oil and gas installations to competent authorities of Member States in accordance with Article 23 of Directive 2013/30/EU;

• (b) publication of information by Member States in accordance with Article 24 of Directive 2013/30/EU.

Article 2

Reporting reference and remittance dates

Article 3

Details of information to be shared

Annex I sets out the details of information to be shared in accordance with point 2 of Annex IX of Directive 2013/30/EU.

Article 4

Entry into force

This Regulation shall enter into force on the twentieth day following that of its publication in the Official Journal of the European Union.

This Regulation shall be binding in its entirety and directly applicable in all Member States.

Done at Brussels, 13 October 2014.

For the Commission

The President

José Manuel BARROSO

ANNEX I

Common data reporting format for incidents and major accidents in the offshore oil and gas industry

(As required by Article 23 of Directive 2013/30/EU)

General remarks on the details of information to be shared

• a. The details of information to be shared are in relation to point 2 of Annex IX to Directive 2013/30/EU on the safety of offshore oil and gas operations and in particular to the risk of a major accident as defined within that Directive.

• b. Annex IX, point 2, to Directive 2013/30/EUcontains leading and lagging key performance indicators (KPI's) in order to provide a good picture about offshore oil and gas safety within a Member State and in the European Union, but some of the KPI's have a warning function like failures of safety and environmental critical elements (SECE) and fatalities.

• c. Pursuant to Article 3, paragraph 4, of the Council Directive 92/91/EEC ³, the employer shall, without delay, report to the competent authorities any serious and/or fatal occupational accidents and situations of serious danger. This data shall be used by the competent authority to report the information required under Annex IX, point 2, letters (g) and (h) of Directive 2013/30/EU.

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Event date and time

(a) Event date: (dd/mm/yyyy)

(b) Event time: (hh:mm)

Details of the location and of the person reporting the event

Operator/owner

Name/type of the installation:

Field name/code (if relevant):

Name of the reporting person:

Role of the reporting person

Contact details:

Telephone number:

E-mail address:

Event categorisation (2)

What type of event is being reported? (More than one option might be chosen)

A.

Unintended release of oil, gas or other hazardous substances, whether or not ignited:

(a) not ignited natural gas or evaporated associated gas if mass released ≥ 1 kg

(b) not ignited liquid of petroleum hydrocarbon if mass released ≥ 60 kg;

B.

Loss of well control requiring actuation of well control equipment, or failure of a well barrier requiring its replacement or repair:

(2) According to Annex IX of Directive 2013/30/EU.

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C.

Failure of a safety and environmental critical element:

Any loss or non-availability of a SECE requiring immediate remedial action.

D.

Significant loss of structural integrity, or loss of protection against the effects of fire or explosion, or loss of station keeping in relation to a mobile installation:

Any detected condition that reduces the designed structural integrity of the installation, including stability, buoyancy and station keeping, to the extent that it requires immediate remedial action.

E.

Vessels on collision course and actual vessel collisions with an offshore installation:

Any collision, or potential collision, between a vessel and an offshore installation which has, or would have, enough energy to cause sufficient damage to the installation and/or vessel, to jeopardise the overall structural or process integrity.

F.

Helicopter accidents, on or near offshore installations:

Any collision, or potential collision, between a helicopter and an offshore installation.

G.

Any fatal accident to be reported under the requirements of Directive 92/91/EEC

H.

Any serious injuries to five or more persons in the same accident to be reported under the requirements of Directive 92/91/EEC

I.

Any evacuation of personnel:

Any unplanned emergency evacuation of part of or all personnel as a result of, or where there is a significant risk of a major accident

J.

A major environmental incident:

Any major environmental incident as defined in Article 2.1.d and Article 2.37 of Directive 2013/30/EU

Remarks:

If the incident falls into one of the abovementioned categories, the operator/owner shall proceed to the relevant section(s), hence a single incident could result in completing multiple sections. The operator/owner shall submit the filled in sections to the competent authority within 10 working days of the event, using the best information available at that time. If the event reported is a major accident, the Member State shall initiate a thorough investigation in accordance with Article 26 of Directive 2013/30/EU.

Fatalities and serious injuries are reported under the requirements of Directive 92/91/EEC.

Helicopter incidents are reported under CAA regulations. If a helicopter accident occurs in relation to Directive 2013/30/EU, section F shall be completed.

Taking into account Member States’ obligations to maintain or achieve Good Environmental Status under Directive 2008/56/EC (3), if an unintended release of oil, gas or other hazardous substance, or the failure of a safety and environmental critical element results in or is likely to result in degradation of the environment, such impacts should be reported to the competent authorities.

(3) Directive 2008/56/EC of the European Parliament and of the Council of 17 June 2008 establishing a framework for community action in the field of marine environmental policy (Marine Strategy Framework Directive) (OJ L 164, 25.6.2008, p. 19).

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SECTION A

UNINTENDED RELEASE OF OIL, GAS OR OTHER HAZARDOUS SUBSTANCES, WHETHER OR NOT IGNITED

A.1. Was there a release of hydrocarbon substances? Yes No

If yes, fill in the following sections.

I. Hydrocarbon (HC) released: (Tick appropriate box)

NON PROCESS: (Specify)

PROCESS: Oil Condensate Gas 2-Phase

For gas or 2-Phase, state level of H2S: (estimated ppm)

II. Estimated quantity released:

(Specify units, e.g. tonnes, kg, Nm3)

III. Estimated initial release rate:

(Specify units, e.g. tonnes/day, kg/s, Nm3/s)

IV. Duration of leak: (seconds/minutes/hours)

(Estimated time from discovery, e.g. alarm, electronic log, to termination of leak)

V. Location of leak:

VI. Hazardous area classification: (i.e. zone at location of incident)

(Tick appropriate box) 1 2 Unclassified

VII. Module ventilation? Natural Forced

How many sides enclosed?

(Insert the number of walls, including floor and ceiling)

Module volume: (m3)

Estimated number of air changes (if known):

Specify hourly rate

VIII. Weather conditions:

Wind speed: Wind direction:

(Specify units, e.g. mph, m/s, ft/s) (Specify heading in degrees)

Provide a description of other relevant weather conditions:

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IX. System pressure:

Design Pressure: Actual Pressure:

(Specify units, e.g. bar, psi or other) (i.e. at time of release)

X. Means of detection: (Please tick type of detector or specify as appropriate)

Fire

Gas

Smoke

Other

XI. Cause of leak: (Please give a short description and complete the ‘Cause’ checklist below)

XII. Did ignition occur? (Please tick appropriate box)

Yes No

If yes, was it: Immediate: Delayed: Delay time: (sec)

Was there: (add sequence of events by numbering appropriate boxes in order of occurrence)

A flash fire

An explosion

A jet fire

A pool fire

XIII. Ignition source (if known)

Provide a description of the ignition source.

XIV. What emergency action was taken? (Please tick appropriate box)

Shutdown

Automatic

Manual

Blowdown

Automatic

Manual

Deluge

Automatic

Manual

CO2/Halon/inerts

Automatic

Manual

Call to muster

At stations

At lifeboats

Other, specify

XV. Any additional comments:

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CAUSE OF LEAK CHECKLIST (See point A.1.XI ‘Cause of leak’)

(Please indicate those items which come nearest to pinpointing the cause of the leak)

Indicate the cause(s) of the release.

From each of the following categories tick the appropriate boxes.

(a) Design:

Failure related to design

(b) Equipment:

Internal corrosion

External corrosion

Mechanical failure due to fatigue

Mechanical failure due to wear out

Erosion

Material defect

Other, specify:

(c) Operation:

Incorrectly fitted

Left open

Improper inspection

Improper testing

Improper operation

Improper maintenance

Dropped object

Other impact

Opened when containing HC

Other, specify:

(d) Procedural:

Non-compliance with procedure

Non-compliance with permit-to-work

Deficient procedure

Other, specify:

Indicate the operational mode in the area at the time of release:

Choose one parameter from the following categories, and tick the appropriate boxes.

Operational mode in the area at the time of release:

Drilling:

Well operations (specify actual operation, e.g. wire line, well test, etc.):

Production

Maintenance

Construction

Pipeline operations including pigging

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A.2. Description of circumstances, consequences of event and emergency response

A.2.1 Was there a release of a non–hydrocarbon hazardous substance?

Yes No

If yes, specify the type and quantity of released substance:

(Type) (Quantity, specify units)

A.2.2 Was there a non-hydrocarbon fire (e.g. electrical) with a significant potential to cause a major accident?

Yes No

Describe circumstances:

A.2.3 Is the incident likely to cause degradation to the surrounding marine environment?

Yes No

If yes, outline the environmental impacts which have already been observed or are likely to result from the incident:

A.3. Preliminary direct and underlying causes (within 10 working days of the event)

A.4. Initial lessons learned and preliminary recommendations to prevent recurrence of similar events (within 10 working days of the event)

The competent authority shall further complete this section.

Is this considered to be a major incident?

yes

no

Give justification:

END OF THE REPORT

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SECTION B

LOSS OF WELL CONTROL REQUIRING ACTUATION OF WELL CONTROL EQUIPMENT, OR FAILURE OF A WELL BARRIER REQUIRING ITS REPLACEMENT OR REPAIR.

B.1. General information

(a) Name/code of well:

(b) Name of drilling contractor (if relevant):

(c) Name/type of drilling rig (if relevant):

(d) Start and end date/time of loss of well control:

(e) Type of fluid: brine / oil / gas / (if relevant)

(f) Well head completion: surface / subsea:

(g) Water depth (m):

(h) Reservoir: pressure / temperature/depth

(i) Type of activity: normal production/drilling / work over / well services

(j) Type of well services (if applicable): wire line / coiled tubing / snubbing / …

B.2. Description of circumstances, consequences of event and emergency response

Blowout prevention equipment activated:

yes

no

Diverter system in operation:

yes

no

Pressure build-up and/or positive flow check:

yes

no

Failing well barriers

(a)

(b)

(c)

Description of circumstances

Further Details (specify units)

Duration of uncontrolled flow of well-fluids:

Flowrate:

Liquid volume:

Gas volume:

Consequences of event and emergency response

(E.g.; 1. jet fire/ 2. first explosion / 3. second explosion, etc.)

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B.3. Preliminary direct and underlying causes (within 10 working days of the event)

B.4. Initial lessons learned and preliminary recommendations to prevent recurrence of similar events (within 10 working days of the event).

The competent authority shall further complete this section.

Is this considered to be a major incident?

yes

no

Give justification:

END OF THE REPORT

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SECTION C

FAILURE OF A SAFETY AND ENVIRONMENTAL CRITICAL ELEMENT

C.1. General information

(a) Name of the independent verifier (if applicable):

C.2. Description of circumstances, consequences of event and emergency response

C.2.1. Description of SECE and circumstances

Which Safety and Environmental Critical systems were reported by the independent verifier as lost or unavailable, requiring immediate remedial action, or have failed during an incident?

Origin: Report Independent verifier: details (report nr. / date / verifier / )

Failure during major accident: details (date / accident description / )

Safety and Environmental Critical elements concerned

(a) Structural integrity systems

Topside structures

Subsea structures

Cranes & lifting equipment

Mooring systems (anchorline, dynamic positioning)

Other, specify:

(b) Process containment systems

Primary well barrier

Secondary well barrier

Wireline equipment

Mud processing

Sand filters

Pipelines & risers

Piping system

Pressure vessels

Other, specify:

Well control process equipment - BOP

(c) Ignition control systems

Hazardous area ventilation

Non-hazardous area ventil.

ATEX certified equipment

Electrical tripping equipment

Earthing/bonding equipment

Inert Gas system

Other, specify:

(d) Detection systems

Fire & gas detection

Chemical injection monitor

Sand

Other, specify:

(e) Process containment relief systems

Well control process equipment — diverter

Relief systems

Gas tight floors

Other, specify:

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(f) Protection systems

Deluge

Helideck foam system

Fire water pumps

Firewater system

Passive fire protection system

Fire/blast walls

CO2 / Halon fire-fighting system

Other, specify:

(g) Shutdown systems

Local shutdown system (LSD)

Process shutdown system (PSD)

Emergency shutdown system (ESD)

Subsea isolation valve (SSIV)

Riser ESD valve

Topsides ESD valve

Blowdown

Other, specify:

(h) Navigational aids

Aircraft navig. aids

Seacraft navig. aids

Other, specify:

(i) Rotating equipment — power supply

Turbine P.M. for compressor

Turbine P.M. for generator

Other, specify:

(j) Escape, evacuation and rescue equipment

Personal safety equipment

Lifeboats / TEMPSC

Tertiary escape means (lifecraft)

Temporary refuge/Muster area

Search & rescue facilities

Other, specify:

(k) Communication systems

Radios / telephones

Public address

Other, specify:

(l) Other, specify

C.2.2. Description of consequences

Is the incident likely to cause degradation to the surrounding marine environment?

Yes No

If yes, outline the environmental impacts which have already been observed or are likely to result from the incident.

C.3. Preliminary direct and underlying causes (within 10 working days of the event)

C.4. Initial lessons learned and preliminary recommendations to prevent recurrence of similar events (within 10 working days of the event).

Describe any important lessons learned from the event. List recommendations to prevent the recurrence of similar events.

The competent authority shall further complete this section.

Is this considered to be a major incident?

yes

no

Give justification:

END OF THE REPORT

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SECTION D

SIGNIFICANT LOSS OF STRUCTURAL INTEGRITY, OR LOSS OF PROTECTION AGAINST THE EFFECTS OF FIRE OR EXPLOSION, OR LOSS OF STATION KEEPING IN RELATION TO A MOBILE INSTALLATION

D.1. General information

(a) Name of vessel (if applicable)

D.2. Description of circumstances, consequences of event and emergency response

Indicate the system that failed and provide a description of the circumstances of the event / describe what has happened including weather conditions and sea state

D.3. Preliminary direct and underlying cause (within 10 working days of the event)

D.4. Initial lessons learned and preliminary recommendations to prevent recurrence of similar events (within 10 working days of the event)

The competent authority shall further complete this section.

Is this considered to be a major incident?

yes

no

Give justification:

END OF THE REPORT

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SECTION E

VESSELS ON COLLISION COURSE AND ACTUAL VESSEL COLLISIONS WITH AN OFFSHORE INSTALLATION

E.1. General information

(a) Name/ Flag State of vessel (*):

(b) Type/tonnage of vessel (*):

(c) Contact via AIS?:

(*) If applicable

E.2. Description of circumstances, consequences of event and emergency response

Indicate the system that failed and provide a description of the circumstances of the event / describe what has happened (minimum distance between vessel and installation, course and speed of vessel, weather condition)

E.3. Preliminary direct and underlying causes (within 10 working days of the event)

E.4. Initial lessons learned and preliminary recommendations to prevent recurrence of similar events (within 10 working days of the event)

The competent authority shall further complete this section. Is this considered to be a major incident?

yes

no

Give justification:

END OF THE REPORT

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SECTION F

HELICOPTER ACCIDENTS, ON OR NEAR OFFSHORE INSTALLATIONS

Helicopter incidents are reported under CAA regulations. If a helicopter accident occurs in relation to Directive 2013/30/EU, section F shall be completed.

F.1. General information

(a) Name of helicopter contractor:

(b) Helicopter type:

(c) Number of persons on board:

F.2. Description of circumstances, consequences of event and emergency response

Indicate the system that failed and provide a description of the circumstances of the event / describe what has happened (weather conditions)

F.3. Preliminary direct and underlying causes (within 10 working days of the event)

F.4. Initial lessons learned and preliminary recommendations to prevent recurrence of similar events (within 10 working days of the event)

The competent authority shall further complete this section. Is this considered to be a major incident?

yes

no

Give justification:

END OF THE REPORT

Sections G and H shall be reported under the requirements of Directive 92/91/EEC.

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SECTION I

ANY EVACUATION OF PERSONNEL

I.1. General information

Start and end date/time of evacuation:

I.2. Description of circumstances, consequences of event and emergency response

Was the evacuation precautionary or emergency?

Precautionary Emergency Both

Number of persons evacuated:

Means of evacuation: (e.g. helicopter)

Indicate the system that failed and provide a description of the circumstances of the event / describe what has happened, unless already reported in a previous section of this report.

I.3. Preliminary direct and underlying causes (within 10 working days of the event)

I.4. Initial lessons learned and preliminary recommendations to prevent recurrence of similar events (within 10 working days of the event)

END OF THE REPORT

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SECTION J

A MAJOR ENVIRONMENTAL INCIDENT

J.1. General information

(a) Name of contractor (if applicable)

J.2. Description of circumstances, consequences of event and emergency response

Indicate the system that failed and provide a description of the circumstances of the event / describe what has happened. What are or are likely to be the significant adverse effects on the environment?

J.3. Preliminary direct and underlying causes (within 10 working days of the event)

J.4. Initial lessons learned and preliminary recommendations to prevent recurrence of similar events (within 10 working days of the event)

END OF THE REPORT

ANNEX II

Common Publication Format

(As required by article 24 of Directive 2013/30/EU)

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SECTION 1

PROFILE

Information on Member State and Reporting Authority

(a) Member State:

(b) Reporting period: (Calendar Year)

(c) Competent authority:

(d) Designated Reporting Authority:

(e) Contact details

Telephone number:

E-mail address:

SECTION 2

INSTALLATIONS

2.1. Fixed installations: Please provide detailed list of installations for offshore oil and gas operations in your country (on first of January of the reported year), including their type (i.e. fixed manned, fixed normally unmanned, floating production, fixed non-production), year of installation and location:

Table 2.1

Installations within jurisdiction on 1 January of the reporting period

Name or ID

Type of installation, i.e.

Fixed manned installation (FMI);

(Fixed) normally unmanned (NUI);

Floating production install. (FPI)

Fixed non-production install. (FNP)

Year of installation

Type of fluid, i.e.

Oil; Gas; Condensate; Oil/Gas; Oil/Condensate

Number of beds

Coordinates

(longitude-latitude)

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2.2. Changes since the previous reporting year

(a) New fixed installations: Please report the new fixed installations, entered in operation during the reporting period:

Table 2.2.a.

New fixed installations entered in operation during the reporting period

Name or ID

Type of installation, i.e

Fixed manned installation (FMI);

(Fixed) normally unmanned (NUI);

Floating production install. (FPI)

Fixed non-production install. (FNP)

Year of installation

Type of fluid, i.e.

Oil; Gas; Condensate; Oil/Gas; Oil/Condensate

Number of beds

Coordinates

(longitude-latitude)

(b) Fixed Installations out of operation: Please report the installations that went out of offshore oil and gas operations during the reporting period:

Table 2.2.b.

Installations that were decommissioned during the reporting period

Name or ID

Type of installation, i.e

(Fixed attended;

Fixed normally unattended;

Floating production installation;

Fixed non-production installation.)

Year of installation

Coordinates

(longitude-latitude)

Temporary / Permanent

2.3. Mobile installations: Please report the mobile installations carrying out operations during the reporting period (MODUs and other non-production installations):

Table 2.3

Mobile Installations

Name or ID

Type of installation, i.e

Mobile offshore drilling;

Other mobile non-production

Year of

construction

Number of beds

Geographical area of operations (e.g. South North Sea, North Adriatic); and Duration

Area 1

Duration

(months)

Area 2

Duration

(months)

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2.4. Information for data normalisation (1) purposes. Please provide the total number of actual offshore working hours and the total production in the reporting period:

(a) Total number of actual offshore working hours for all installations:

(b) Total production, in kTOE:

Oil Production (specify units):

Gas Production (specify units):

(1) For the purpose of this Implementing Regulation, normalisation means a transformation applied uniformly to each element in a set of data so that the set has some specific statistical property. For example, a number of reported events (i.e. loss of well control) might be normalised by dividing each one by the total number of wells in that Member State.

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SECTION 3

REGULATORY FUNCTIONS AND FRAMEWORK

3.1. Inspections

Number and offshore inspections performed during the reporting period.

Number of offshore inspections

Man-days spent on installation (travel time not included)

Number of inspected installations

3.2. Investigations

Number and type of investigations performed during the reporting period.

(a) Major accidents:

(pursuant to Article 26 of Directive 2013/30/EU):

(b) Safety and environmental concerns:

(pursuant to Article 22 of Directive 2013/30/EU):

3.3. Enforcement actions

Main enforcement actions or convictions performed in the reporting period pursuant to Article 18 of Directive 2013/30/EU:

Narrative:

3.4. Major changes in the offshore regulatory framework

Please describe any major changes in the offshore regulatory framework during the reporting period.

(include e.g. rationale, description, expected outcome, references)

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SECTION 4

INCIDENT DATA AND PERFORMANCE OF OFFSHORE OPERATIONS

4.1. Incident data

Number of reportable events pursuant to Annex IX:

of which identified to be major accidents:

4.2. Annex IX Incident Categories

Annex IX categories

Number of events

Normalized number of events

(a) Unintended releases

Ignited oil/gas releases — Fires

Ignited oil/gas releases — Explosions

Not ignited gas releases

Not ignited oil releases

Hazardous substances released

(b) Loss of well control

Blowouts

Activation of BOP / diverter system

Failure of a well barrier

(c) Failure of SECE’s

(d) Loss of structural integrity

Loss of structural integrity

Loss of stability/buoyancy

Loss of station keeping

(e) Vessel collisions

(f) Helicopter accidents

(g) Fatal accidents (*)

(h) Serious injuries to 5 or more persons in the same accident (*)

(i) Evacuations of personnel

(j) Environmental accidents

(*) Only if related to a major accident.

4.3. Total number of fatalities and injuries (**)

Number

Normalized value

Total number of fatalities

Total number of serious injuries

Total number of injuries

(**) A total number as reported pursuant to 92/91/EEC.

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4.4. Failures of Safety and Environmental Critical Elements (SECEs)

SECE

Number related to major accidents

(a) Structural integrity systems

(b) Process containment systems

(c) Ignition control systems

(d) Detection systems

(e) Process containment relief systems

(f) Protection systems

(g) Shutdown systems

(h) Navigational aids

(i) Rotating equipment — power supply

(j) Escape, evacuation and rescue equipment

(k) Communication systems

(l) other

4.5. Direct and Underlying causes of major incidents

Causes

Number of incidents

Causes

Number of incidents

(a) Equipment-related causes

(c) Procedural / organisational error

Design failure

Inadequate risk Assessment/perception

Internal corrosion

Inadequate instruction/procedure

External corrosion

Non-compliance with procedure

Mechanical failure due to fatigue

Non-compliance with permit-to-work

Mechanical failure due to wear-out

Inadequate communication

Mechanical failure due to defected material

Inadequate personnel competence

Mechanical failure (vessel/helicopter)

Inadequate supervision

Instrument failure

Inadequate safety leadership

Control system failure

Other

Other

(b) Human error – operational failure

(d) Weather-related causes

Operation error

Wind in excess of limits of design

Maintenance error

Wave in excess of limits of design

Testing error

Extremely low visibility in excess of system design

Inspection error

Presence of ice/icebergs

Design error

Other

Other

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4.6. Which are the most important lessons learned from the incidents that deserve to be shared?

Narrative:

END OF THE REPORT