Loss of Petrobras P-36

That Sinking Feeling

Loss of Petrobras P-36

Budgets cuts and downsizing are a reality in every industry, but it is critical to maintain the integrity of safe operations through these times, especially with human space flight. While cost-cutting can drive many innovative solutions, a blind focus on financial performance can compromise safety considerations, forfeit thorough testing and result in poor decisions with catastrophic outcomes. Petrobras management had taken a clear stance to eliminate many standard engineering practices, redefine safety requirements and reduce inspections openly with the goal of improving financials. As a part of efforts to save cost and space on its Platform 36, the Emergency Drain Tanks (EDTs) were placed inside of the two aft support columns adjacent to the seawater service pipes. When one of the EDTs burst from over-pressurization, this set off a violent chain of events, including the rupture of the seawater pipe, massive flooding of the column and an incendiary explosion on the upper levels, ultimately resulting in the total loss of the world's largest offshore oil production platform and the lives of 11 crew members. The investigation found that no design testing or analysis had ever been performed on the EDT configuration. At NASA, we must impose a consistently high level of rigor to all of our testing plans and treat even common reconfigurations the same as we would a new design.