MEMO

TO ACE Internal; OMT;

FROM N Burnett, HSEQ Manager
DATE 12 April 2013
RE ACE/0395/11 – CC43 - Incident Investigation Summary

Date of Incident: 15 March 2013

Location: Technip, Malaysia
Location of Incident: MMHE yard
Failure Focal Point: ACE469 – 83Te WLL Hydraulic Drum Winch

Summary
The wire rope on the winch was over-spooled instead of under-spooled as required by the client. This
problem was identified at the client work site and actions taken to rectify this. The winch wire was changed
to under-spooled in the Swee Bee yard in Singapore using a spooling machine provided by Franklin.

The spooling machine was set up approximately 20m from the winch to allow for adequate fleeting angles.
Suitable ballast was used to anchor both the winch and spooling machine. The wire rope was spooled off
the winch onto the spooling machine. Three wire rope wraps were laid onto the spooling machine before
rope tension was increased slightly. Then at five wraps tension was raised to 5 tonnes. This tension was
maintained throughout the transfer of the remainder of the wire rope from the winch to the spooling
machine.

The winch was turned around to allow the wire rope to be under-spooled. The wire rope wraps on the
winch were laid with minimal tension until a total of five wraps were on the winch and the wire rope
tension was increased to 5 tonnes. Wire rope was laid at this tension until the last five wraps on the
spooling machine when the tension was reduced until the wire rope was released from the spooling
machine drum. The remaining 20m of wire rope was spooled onto the winch with no tension other than a
nylon rope restraint for guidance.

The combination of 20m between the winch and the spooling machine and the last five wraps from the
spooling machine laid down with decreasing tension resulted in approximateky 35m of wire rope slack
spooled on the winch drum.

Two technicians from ACE Winches were mobilised to conduct the on-site load testing of the winch.

Winch acceptance testing was carried out on site by a full capacity loading of the winch. As part of the set
up for the load test, 25m of wire rope was paid off through a snatch block down to the j-tube anchor point
where the wire rope was connected to for load testing. This left the wire on the drum at the last wrap
before climbing to the next layer. The test load was increased to the final load required in three stages;
20Te, 40Te amd 55Te. As the test load increased, the wire rope was pulled down into the narrowing gap
of the final wrap the layer below. This resulted in the rope jamming between the winch drum flange and the
space on the last wrap before continuing the next layer (Photographs 1 and 2).

CC43: Incident & Investigation Summary 12/4/13 - 2

 Photograph 1 Photograph 2

Immediate action

To release the jammed wire rope, it was re-connected to the anchor point at the j-tube and a two tonne
chain block was used to pull the wire rope free. The wire rope was visually inspected by both V Ronald and
D Collins (certification of rope inspection attached) and was found to have a slight kink as seen in
Photograph 3. There was no evidence of broken wire damage or crushing to the wire rope.

The winch load testing and release of the jammed rope was conducted under the supervision of Benoit
Gourguechon of Technip.

Photograph 3

Investigation and analysis

The wire rope was jammed between the rope layer and the winch drum flange due to the fact that the
outer wraps of the wire rope were spooled slack and the position of the wire rope on the drum when load
was applied.

A root cause analysis of the incident was completed using the TapRooT Root cause Analysis technique. The
output is shown in the TapRooT chart (Attachment 1) and TapRooT table (Attachment 2).

CC43 Incident Investigation Summary 12/4/13 - 2 Page 2 of 3

Initial causes
These are identified as black triangles on the TapRooT chart.

1. The winch mobilisation order did not stipulate under-spooling requirement.

2. The wire rope was not packed for the load test and the load test was conducted with the wire rope at
the winch drum flange.

Root Causes
From the analysis of the initial causes the basic causes and root causes were indentified. The root causes as
follows.

For initial cause 1

• The spooling requirement was not communicated and error was not detected
• The spooling requirement was not successfully communicated
• The Mobilisation Order form did not have a means to positively identify spooling requirement

For initial cause 2

• The winch Operating Manual did not include specific instructions for wire rope positioning and
packing during testing in this situation
• Wire rope will cut into lower layers when wrapped loosely and cannot be simply reversed
• The winch technician training materials did not include specific effects of wire rope tension and
positioning during testing in this situation
• Paperwork for field testing did not include a check on wire rope tension / position prior to winch
testing

Actions

For initial cause 1

• Amend the Mobilisation Order form to include positive identification of winch spooling
requirements.

For initial cause 2

• Amend the Operating Manual templates to include specific instructions on wire rope positioning on
the drum during test and wire rope protection when testing with loose wire rope.
• Amend winch technician training materials to include / emphasise the importance and effects of
wire rope positioning on the drum during test and wire rope protection when testing with loose
wire rope.
• Amend field paperwork forms to include a positive check on wire rope tensions, positioning and
protection during testing.
• Issue a HSEQ Alert on this topic to all ACE Winches field technicians.

Recommendations

The visual inspection of the wire rope shows no damage which should affect its capacity and it is suitable
for continued use at its original capacity.

The project is due to be carried out in September / October 2013 and the wire rope will require re-
certification before 28 October 2013 when current certification expires.

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