Failure of people and systemsLost opportunities to take action in saving lives...On February 25, 2022, when five divers were sucked into a pipeline, they had only about nine hours—until midnight—to live.
This was one of the findings of the commission of enquiry (CoE) report into the diving disaster.
It examined the failures of people and systems to rescue the men and the several opportunities lost to take action from when they became trapped in the pipeline.
On that tragic day, five LMCS divers—Christopher Boodram, Fyzal Kurban, Rishi Nagassar, Kazim Ali Jr and Yusuf Henry—went to No 36 sealine riser on the Berth 6 offshore platform at Pointe-a-Pierre to conduct maintenance works.
Only Boodram survived after crawling through the dark 30-inch pipe for nearly three hours. The CoE was chaired by Jerome Lynch, KC, and included commissioner sub-sea specialist Jerome Wilson.
The commission’s lead attorney was Ramesh Lawrence Maharaj, SC.
The commission’s 520-page report was laid in the Parliament on Friday by Energy Minister Stuart Young, who disclosed that it had also been forwarded to the Director of Public Prosecutions (DPP).
The report recommended that Paria Fuel Trading Company be charged with corporate manslaughter due to gross negligence.
“The Commissioners believe that by midnight on 25 February 2023, the men would have been dead and therefore what was done in those hours up to midnight was crucial,” stated the report.
There was criticism of Paria officials in the report, in particular its terminal operations manager Collin Piper who did not allow any diving rescue efforts to take place.
While the divers were trapped in the pipeline, with time and oxygen running out, Paria officials were slow to react.
The report noted that Paria officials would have been aware that by 2.45 p.m. the men were missing from the chamber in which they had been doing work.
The commissioners outlined the timeline of when professionals were contacted by Paria—hours later—and when they arrived on site:
i. Mitchell’s Professional Diving Services arrived at 8.40 p.m.
ii. Eastern Divers were not contacted until 11.40 p.m.
iii. OTSL (Offshore Technology Solutions Ltd) arrived at 8 p.m. with their ROV and camera, but it didn’t fit in the pipe and the light was not working.
iv. Hull Support Services was contacted at 4.30 p.m., but never went on the site.
v. Hummingbird was not contacted until 10.50 p.m.
vi. Atlantic LNG arrived at 9 p.m. with a pushrod camera, but it was not inserted until midnight.
vi. Professional Inspection Service Ltd came with their borescope camera at midnight, but was not deployed until 1 a.m.
viii. A crawler was inserted into the pipe at 3 a.m. and the same was done at Berth 5 at 6 a.m.
The report stated that apart from failed attempts to deploy cameras during the latter part of Friday evening, the dive teams contacted by Paria and Heritage were placed on standby and were not consulted until the early hours of Saturday morning (February 26, 2022).
The commission cited numerous “lost opportunities”, and again noted the time-frames and the delays in action.
(a) Rolph Seales, an experienced commercial diver assigned to Heritage from Kenson arrived at Paria at 8.20 p.m.
Piper did not speak to him until after 9.30 p.m.
(b) Paria and Heritage personnel commenced a risk assessment after 9 p.m. but that was abandoned, according to Osei Flemming-Helder, Heritage Petroleum operations HSSE manager, because he was called back to the ICT to listen to what Boodram had to say.
The risk assessment was not finished when Paria clearly determined it was both necessary and possible.
This was another wasted opportunity for the ICT to have a proper risk assessment in front of them prepared by their own people, the report stated.
(c) Catherine Balkissoon, Paria’s acting technical lead, did not speak to commercial diver Michael Kurban, and she did not take steps to view the GoPro which the log reveals was recovered by Kurban.
She did not seek to ascertain any detail of the method of rescue proposed by LMCS personnel after the support divers had arrived and who had expressed a willingness to effect a rescue, she gave little or any advice or opinion to the ICS bearing in mind her role as stated by Piper, the commission’s report noted.
(d) LMCS or Subsea Global Diving Solutions were not brought into the picture. They were not utilised, consulted or even put on standby. Subsea Global Solutions arrived at Berth #6 at 7.15 p.m.
They waited until 3 a.m. when they asked for permission to leave, but they were held on standby in case needed.
This was a wasted opportunity to utilise their equipment if not their divers. No one from Paria’s ICT spoke to them at all, the report stated.
(e) The ICT through Seales (Heritage dive supervisor Rolph Seales) and HSE should have engaged directly with divers, oil men and HSE officers on the site. If a timeous, safe conscious plan could not be formulated and executed then, it never could. The upshot of the evidence is that it is difficult to conceive of any other equipment that might have been obtained to attempt a rescue. There appeared to be a clear lack of understanding between the ICS and the men on the berth who were willing to carry out a rescue, the report said.
The report noted further that Paria’s Balkissoon was dispatched to Berth #6 and was said by Piper to be “performing a critical technical role in the assessment of the pipeline conditions and the execution of the recovery efforts”.
The commissioners stated that they were of the view that she too failed in this endeavour.
“Balkissoon was unable to stamp her authority on the site and that in turn had a detrimental effect on coordinating any kind of rescue between the company and the contractor. Each appears to be acting in silo and to a degree blaming each other for the failure to rescue,” stated the report.
It further stated that there was no revisiting of the no-dive policy.
The commissioners cast blame on Piper for the decisions he made and also the accuracy of his account that the no-dive instruction was given at 6.25 p.m.
The report stated that LMCS said it was told no diving before Boodram emerged from the pipeline.
It added that Piper in his witness statement said that at 6.26 p.m. he asked Paria’s security to secure the incident site and to stop divers from entering the pipeline.
The commissioners stated that a blanket declaration by Paria that there was to be no diving and Trinidad and Tobago Coast Guard seemingly authorised to enforce it was hardly going to lead to a spirit of cooperation.
“All the more reason for a direct intervention by the most senior men on each side Piper as the Commander of the ICS and Ali Snr (Kazim Ali Sr) as the owner of LMCS,” stated the report.
The report also pointed out that the chamber where the divers worked was effectively “abandoned” and at “bare minimum”, fresh communications, a camera and lights should have been positioned in the chamber.
Crucial minutesThe commissioners stated that Boodram may not have been in the best state of mind when he was finally brought to the surface; but apart from his own insistence that the men were rescued, no one sought, at that time, to ask him anything about the other divers, the conditions in the pipe or anything else pertaining to the event.
“That too was lamentable and was a lost opportunity to discover more in the crucial minutes and hours after he emerged from the pipeline,” stated the report.
The report detailed the failures of Paria’s Incident Command System (ICS) and an Incident Command Post (ICP).
“If the primary responsibility of the ICS and any emergency plan is to preserve life. It follows that the faster one acts the more likely the victims can be saved. As time ebbs away so too will the possibility of saving life. This was to prove important as the possible rescuers would have wanted some realistic prospect of successfully recovering live divers from the pipeline before risking their own lives,” stated the report.
The ICT, it noted, prohibited diving and never revisited that ban even when it had some camera footage.
Stated the report: “It never came up with a rescue plan at all even if the criteria could not have been fulfilled, assuming it considered at the time any of LMCS’ plans it rejected them all as inadequate without offering any alternative. It failed to utilise any of the diving resources that were available by around 7 p.m. that night and ultimately gave a disproportionately greater responsibility to the rescuers’ health than the lives of the divers in the pipeline especially given that no one was being ordered into the pipeline, it was only ever going to be voluntary.”
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