The 1978 Star Canopus Accident

[Michael Smart]

Cut the hose! Cut the hose!


—— Supervisor Robert Kelly to the divers in the bell1

On November 26, 1978, the Diving Support Vessel Star Canopus was dynamically positioned on the northeast side of the Beryl Alpha platform conducting diving operations. Three hundred thirty‑four feet below, Michael Ward was working for Northern Divers about 60 feet off the seabed trying to connect a six-inch flowline to a riser flange protruding from the side of the concrete platform.

Oil production had declined that year,2 and with winter conditions upon them, subsea work had fallen behind schedule.3 There was “a lot of catching up to do,” the contracts manager for Northern Divers would say later,4 and Mobil Oil, like many operators, decided to allow the diving program to continue through the winter months to take advantage of available weather windows.

Earlier that evening, London Weather Center had predicted 40‑knot gusts between 1800 and midnight.5 That forecast proved to be correct. At 2030, and again at 2245, squalls reaching those speeds moved in and blew the Canopus off location.6 Shortly thereafter, Captain Roy Forsyth terminated diving operations.7

But when the 12‑hour shift change occurred at midnight, weather conditions had calmed. Coming on duty, Supervisor Robert Kelly was told by the superintendent that “the weather was reasonable to dive” and to continue with the dive program.8 Kelly went to the bridge to review the weather forecast, which predicted there would be a change in wind direction from west to north, and that conditions “would worsen later in the day” with wind speeds gusting to 35 knots.9 The Canopus was only a year old, and although it represented the latest and best technology of that era, the limits of her dynamic positioning system were 18-20 knots with the wind hitting her broadside.10

On the bridge, Kelly noticed the wind-speed indicator fluctuating between 15 to 20 knots. He walked outside to look at the weather firsthand. With the wind blowing from the west against his face, Kelly gazed across the dark sea. Standing alongside the Beryl platform, near where the Canopus would be commencing work, was the imposing silhouette of the Haakon Magnus, a Norwegian semi-submersible, with her massive anchor chains extended.

To Kelly, the weather looked suitable for diving. At 0240, he launched the bell with Tony Prangley and Michael Ward inside.11 At 0312, Ward locked out and found the pipe flange protruding from the wall of the platform base. Eight minutes later Captain Forsyth called Kelly on the ship’s intercom to alert him that a squall was approaching on the ship’s radar.12 Kelly ordered Ward back to the bell where he sat for the next 40 minutes. At 0400 Ward was back on the job. Then, at 0545, the wind suddenly shifted directions and began blowing from the north at a speed of 40 knots, hitting the Canopus on her beam, and overpowering her DP system. It was a sustained blow as one of the men would later testify.

“When this wind arrived, it arrived really without any warning and it was not like a sudden gust of wind or a passing squall which then died down, it started blowing suddenly at 40 knots and remained at that level for a considerable period of time thereafter. It was a very strange occurrence, to say the least.”13

In the bell van, Supervisor Kelly was at the control panel when an amber warning light came on followed by the klaxon of the ‘Dive Alert’ alarm. Then, Captain Forsyth’s voice came over the intercom: “Get the diver back in the bell please.”14 Kelly relayed the message to Ward who stopped what he was doing and swam back to the bell. In the trunking he took off his helmet as Prangley stacked his umbilical.

On the surface, the force of the wind had blown the Canopus sideways against the platform overhang, snapping off the ship’s mast which came crashing down onto the deck with a loud bang. At the same time, the wind was driving the ship backwards towards the Haakon Magnus. Captain Forsyth quickly took the ship off DP and tried to swing the bow outboard to keep the vessel from grounding on the submerged pontoons of the Magnus. Then he pressed the ‘Dive Abort’ alarm and called dive control.

In dive control, Kelly was waiting for Prangley and Ward to seal the bell when the red ‘Dive Abort’ indicator suddenly lit up. Captain Forsyth came on the intercom again, this time with noticeable urgency in his voice. “Get the bell up as soon as possible,” he said to Kelly.15 But when Kelly called down to the bell, he discovered that Prangley was having difficulty pulling in Ward’s umbilical; it was snagged on something outside the bell. He didn’t know on what, but now there was no way to shut the inside hatch until the umbilical was cleared. Ward wanted to lock out to fix the problem, but Kelly flatly forbade him to do so. Instead, he told Ward to throw the dive hat out of the bell, then pull in the umbilical; perhaps that would free it. But when this was tried, the umbilical remained snagged.16

Meanwhile, Kelly received another urgent message from Captain Forsyth asking if he had started recovering the bell yet.17 Kelly explained the delay and said he would notify the bridge when he started the recovery. Then he got on the comms and told the divers to stop what they were doing, and to cut the hose, and be quick about it. Several minutes later, as the bell smashed against the base of the platform, Prangley and Ward got a seal and notified topside.

In dive control, Kelly was watching his two divers on the video monitor while the bell was being raised. Prangley was calling out the depth every 10 meters. Eighty, seventy, sixty—when the bell was thirty meters from the surface, Prangley suddenly stood up, waved his fist shoulder high, and shouted, “All stop.”18 On the monitor, he appeared to be listening to something.

Supervisor Kelly did as he was told, and from the bell van, he had a clear view of the moonpool and could see that something was wrong. The bell umbilical and clump weight guide wires were not hanging straight down through the moonpool; they were leaning towards the bow of the ship. What’s more, the trolley that the wires were hanging from was violently shaking and vibrating.19 Suddenly the video monitor blacked out. The Star Canopus, with her human payload dangling thirty meters below, had been blown across the path of a Haakon Magnus anchor chain, completely severing all connections to the bell, including the life-support umbilical, the main lift wire, and the clump weight/guide wire recovery system. In that instant, the bell, with Prangley and Ward inside, began plummeting to the seabed below.

Miraculously both divers survived the 294‑foot fall, but now they faced a harrowing predicament. With their hot-water supply completely severed, the internal temperature began to drop rapidly. If rescuers didn’t arrive soon, their only recourse would be to release the drop weight. But Prangley and Ward couldn’t release the weight because it was externally secured to the bell frame with a set of “secondary locking pins.”20 And because the bell was not equipped with a stage to keep the bottom hatch out of the mud, Prangley and Ward had no way to get out to release them. Nor was the bell equipped with a strobe flasher to help rescue divers find it in the dark; and the crew of the Canopus had removed the bell transponder some time before the dive.21 Helplessly trapped, with nothing to keep them warm, and no way to release the drop weight, all they could do was huddle together and pray that rescuers would find them in time.

But time was not on their side. With a storm raging on the surface, it took rescuers more than thirteen hours to recover the stricken bell to the deck of the Canopus. By that time, Ward had died of hypothermia and Prangley had drowned.a


a) Although Prangley was suffering from hypothermia, too, his death was ruled as a drowning. When the bell was initially raised off the seabed, he fell out of the trunking and floated to the surface. Source: Prangley/Ward FAI, p. 152.
Endnotes:
1 Prangley/Ward Fatal Accident Inquiry (FAI), p. 475-476, 512.
2 Brown Book, 1980, p. 31.
3 Prangley/Ward FAI, p. 158, 180.
4 Prangley/Ward FAI, p. 180.
5 Prangley/Ward FAI, p. 176.
6 Prangley/Ward FAI, p. 123, 143.
7 Prangley/Ward FAI, p. 393-394.
8 Prangley/Ward FAI, p. 459-460.
9 Prangley/Ward FAI, p. 138, 460, 463.
10 Prangley/Ward FAI, p. 142.
11 Prangley/Ward FAI, p. 468.
12 Prangley/Ward FAI, p. 468-469.
13 Prangley/Ward FAI, p. 134.
14 Prangley/Ward FAI, p. 508.
15 Prangley/Ward FAI, p. 508.
16 Prangley/Ward FAI, p. 475, 511.
17 Prangley/Ward FAI, p. 475.
18 Prangley/Ward FAI, p. 483-484.
19 Prangley/Ward FAI, p. 483.
20 Prangley/Ward FAI, p. 374.
21 Prangley/Ward FAI, p. 431.

[the diving tiler]

great stories ta for sharing, some terrible working conditions

[Michael Smart]

great stories ta for sharing, some terrible working conditions
You're very welcome. Working conditions today in the North Sea have greatly improved for the diver.

Michael

[Frax]

So sad, what a horrible way to die; cold, frightened and at the bottom of the North Sea.

[Tim Digger]

When people are slagging off the HSE, it is as well to consider the work that that organisation did in the North Sea Oil industry to improve safety for divers. AND to reflect that in several areas around the world corners are still cut and working practices are such that accidents like that are still happening.

[Neil Brock]

When people are slagging off the HSE, it is as well to consider the work that that organisation did in the North Sea Oil industry to improve safety for divers. AND to reflect that in several areas around the world corners are still cut and working practices are such that accidents like that are still happening.

I suspect Tim that even as experience, evolution and attitudes changed over the years, the transition of oversight from DoE to the HSE in the very early 80's was probably the greatest single improvement in working diver safety !

Excellent little 'mini' series of write up's Michael, keep em coming, it shows where we are, where we have come from, and, some of what it cost in human tragedy.

Well done

[Michael Smart]

AND to reflect that in several areas around the world corners are still cut and working practices are such that accidents like that are still happening.

This is true. The Gold Standard today in terms of diver safety is the North Sea. Outside the North Sea, there are operations running in parts of the world, which are not monitored by any regulatory body. In that instance it is left up to the individual diving company, motivated by profit, to determine the level of safety subject to prevailing economic pressures.

In my opinion, the primary reason for today’s high safety standard in the North Sea is due to the Fatal Accident Inquiry process of conducting a public investigation, with witnesses under oath testifying to what happened. This transparency focuses a very sharp light on the actions of the companies, individuals, and policies that contributed to the accident. Without such transparency companies would simply carry on with their normal and accepted practices.

[Michael Smart]

I suspect Tim that even as experience, evolution and attitudes changed over the years, the transition of oversight from DoE to the HSE in the very early 80's was probably the greatest single improvement in working diver safety !


Yes, and that transition was hard fought.

In 1977, the 1974 Health and Safety at Work Act was finally extended to the Continental Shelf. The HSE should have taken over the DOE’s role, but the government left the responsibility for offshore safety in the hands of the DOE because “a special relationship was perceived between Energy as the Sponsor Department and the industry.” Details of this internecine war between the DOE and the HSE can be found in WG Carson’s book, The Other Price of Britain’s Oil. As Carson writes, “involvement of the HSC and the HSE in the regulation of offshore safety posed a substantial threat to the special relationship which had previously existed between the industry and the Department of Energy.” (p. 204). It was only until after the Piper Alpha disaster, and the public inquiry that followed, that Lord Cullen recommended that the responsibility for offshore safety be taken out of the hands of the Department of Energy.

[Tim Digger]

It is really interesting that in my own field of anaesthesia marked improvements in safety and survival have happened during my working life. This is due in large part to the use of what is now regarded as standard monitoring, IE ECG Pulse oximetry and gas monitoring of gases and gas exchange in the lungs. Such devices became widely available at the beginning of the 80s but I know I spent most of the 80s and early 90s fighting for purchase of this equipment in the NHS. Now it would be almost a capital offence to give an anaesthetic without such devices. In this case largely due to recommendations and published standards by professional organisations leading to successful litigation when such devices were not being used in adverse events.
The problem in the NHS at present is that too many committees have produced mandatory checks that multiple repetitions of what is effectively the same safety check are now required, it has not gone too far merely been poorly applied.

[Michael Smart]

It is really interesting that in my own field of anaesthesia marked improvements in safety and survival have happened during my working life. This is due in large part to the use of what is now regarded as standard monitoring, IE ECG Pulse oximetry and gas monitoring of gases and gas exchange in the lungs. Such devices became widely available at the beginning of the 80s but I know I spent most of the 80s and early 90s fighting for purchase of this equipment in the NHS. Now it would be almost a capital offence to give an anaesthetic without such devices. In this case largely due to recommendations and published standards by professional organisations leading to successful litigation when such devices were not being used in adverse events.
The problem in the NHS at present is that too many committees have produced mandatory checks that multiple repetitions of what is effectively the same safety check are now required, it has not gone too far merely been poorly applied.

Point taken Tim. I would also add that, with regulation, the regulatory body has to have the will to enforce the law. The biggest improvement in North Sea safety took place in 1974, which outlawed diving below 50 meters without the use of a diving bell and mixed gas. This was significant, and it saved many lives.

Then, in 1976, The Submarine Pipe-lines (Diving Operations) made it illegal to modify a diving plant and equipment, unless it was examined and tested before it was put back into service. (Regulation 17, 1] Despite this regulation, some diving superintendents ignored the law and did as they pleased which resulted in catastrophic accidents. And when the diving companies were caught violating the law, real punishment was rarely inflicted. Today, this has largely changed because the old “machismo” attitudes of yesterday have faded away with heavy penalties for infringement taking hold.

[Tim Digger]

A similar problem in Anaesthesia was known as The Westminster Incident. Anaesthetic gas pipeline supplies from central large automated cylinder banks or Liquid O2 containers were just coming in and being realised as safer than small cylinders of nitrous oxide and oxygen attached to anaesthetic delivery machines (largely because of missed change overs and delivery of gas without O2 to patients). A gang of plumbers were employed at the hospital to alter water pipes and in order to reach the pipes they needed to work on they disconnected two other pipes containing O2 and nitrous oxide, and reconnected them wrongly. This resulted in hypoxic deaths for three patients before it was realised what was happening.
Engineering regs and hospital engineering practices were rapidly modified including labelling of medical gas pipelines at 1m intervals and strict rules as to who could work on hospital pipelines. To our shame it was a further 2 decades before the final check of an Oxygen analyser was routine on all anaesthetic machines. To my knowledge a similar incident has not happened in the UK since. But multiple episodes of O2 pipeline contamination from upstream equipment forced the use of analysers eventually in the 90s.
When I lecture to anaesthetists on this subject I marvel at the changes that have had to be forced upon us over my working lifetime to prevent tragedies.

[Michael Smart]

A similar problem in Anaesthesia was known as The Westminster Incident. Anaesthetic gas pipeline supplies from central large automated cylinder banks or Liquid O2 containers were just coming in and being realised as safer than small cylinders of nitrous oxide and oxygen attached to anaesthetic delivery machines (largely because of missed change overs and delivery of gas without O2 to patients). A gang of plumbers were employed at the hospital to alter water pipes and in order to reach the pipes they needed to work on they disconnected two other pipes containing O2 and nitrous oxide, and reconnected them wrongly. This resulted in hypoxic deaths for three patients before it was realised what was happening.
Engineering regs and hospital engineering practices were rapidly modified including labelling of medical gas pipelines at 1m intervals and strict rules as to who could work on hospital pipelines. To our shame it was a further 2 decades before the final check of an Oxygen analyser was routine on all anaesthetic machines. To my knowledge a similar incident has not happened in the UK since. But multiple episodes of O2 pipeline contamination from upstream equipment forced the use of analysers eventually in the 90s.
When I lecture to anaesthetists on this subject I marvel at the changes that have had to be forced upon us over my working lifetime to prevent tragedies.

It’s great when regulation works and people obey the law. But when the regulatory arm of government stands idly by after an horrific accident such as Canopus, takes no corrective action, and defends the very practices that contributed to the fatalities (to accommodate industry), then the system is corrupt and part of the problem. This is, in fact, what happened to Richard Walker and Skip Guiel eight months after the Canopus accident.

[Chris Brown]

No way they should have been operating in those conditions. There was bad weather forecast and they already had over 20knt winds?!! Seas must have been over 10' before they started. God knows what 40knts gives you in the North Sea


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[Glos-Tech]

Michael what a fantastic book, Into the Lions Mouth, very sad in places, makes you realise how brave these guys were

I had the chance in the mid 70s to attend the commercial course then paid by the government called the tops scheme held at Fort William if memory serves me well it cost around £3000.
I often regretted not going but with a young family taking priority who knows

[Michael Smart]

Michael what a fantastic book, Into the Lions Mouth, very sad in places, makes you realise how brave these guys were

I had the chance in the mid 70s to attend the commercial course then paid by the government called the tops scheme held at Fort William if memory serves me well it cost around £3000.
I often regretted not going but with a young family taking priority who knows

Thank you for the compliment. It was eight long years of research all sparked by a chance conversation and my reading of the Walker/Guiel Fatal Accident Inquiry Findings written by Sheriff Douglas James Risk of Aberdeen. Were it not for his patience and persistence in allowing the truth to come forward, this book might never have been written.

I did my sat course at Fort William. Excellent training. Less than three weeks later, I was diving at 460 feet installing a 36-inch pipeline in the Ninian Field in the North Sea.