Pillai Sreejith

PIPER ALPHA ACCIDENT CASE STUDY DISCUSSION
Source: BBC Video ‘Spiral to Disaster’ (total length: 30 minutes) Introduction: The 1988 Piper Alpha disaster was an eye opener to all offshore operators and was one of the key triggers for the safety improvements in offshore installations. There are plenty to learn from this great case study. The BBC docudrama on Piper Alpha disaster, ‘Spiral to Disaster’ can be effectively used as a group learning exercise with some specific discussion triggers. Learning Approach: • • • • • Show the video, stop at the identified discussion points; Assess the understanding of the participants in line with the text noted under each of the discussion points; If they do not get the point, make them understand the issue; Compare the Piper Alpha flaws with the participant installations; and Based on the identified triggers, take their views / opinion.

Group Learning: Introduction to Piper Alpha platform Discussion point 1: Fire walls and Layout Platform originally built for oil processing with 4 modules separated by fire-proof wallsLater Piper Alpha platform was modified for gas processing without modifications of the existing fire walls- originally drilling facilities were located away from accommodation block-gas compression facilities were located near sensitive areas such as control roomthis had tragic consequences on Piper as you will see in the subsequent video. Discussion Triggers: • • • • • In your offshore complex, do you know where the fire walls are? Are you sure of the integrity of these walls? Are there blast walls? Do you see the importance of layout review from the fire / explosion point of view? Do you appreciate the importance of assessing impairment of sensitive receivers from the fire and explosion point of view?

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Pillai Sreejith

Discussion point 2: Gas leaks & Welding Before 6th July, a new gas pipeline was installed which included welding works- platform continued its production-several gas leaks were reported and were considered not unusual. Discussion Triggers: • In your offshore complex, how are new jobs managed? Engineering Change Request? MoC? Comprehensive review before start of job?

Discussion point 3: PTW July 6, 6 pm The platform had 2 large gas compressors (A & B) that pump gas to onshoreCompressor A was taken out of service that morning and PSV was removed for servicing-the open pipe was temporarily sealed with a metal plate-PSV was meant to be replaced by the end of the day but the job overran and filled in the PTW form to inform all that the pump was out of action-In fact 2 work permits were taken for the job that morning (one for PSV and a routine overhaul that will last for 2 weeks which was yet to begin) and the 2 work permits got separated-at the end of the day, the engineer returned the PSV WP to the control room-Since the supervisor was busy, he signed off the WP & did not inform the supervisor that the PSV was off the compressor and went off-PTW for Piper Alpa was degraded and was not in good working condition for some months. Discussion Triggers: • • • • How are multiple work permits managed for jobs? Can the Piper PTW flaw happen at your installation? If not why not? Is the system working? Any audit findings?

Discussion point 4: Automatic Water Deluge System July 6, 7 pm Piper Alpha had automatic fire water deluge system- It was a normal practice to switch off the deluge pumps to manual mode to avert divers being sucked in by the fire water intake suction point, when the divers were very near the intakes-At Piper Alpha, the

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Pillai Sreejith

deluge system was kept on manual mode although divers were away from deluge water intake point Discussion Triggers: • • • • What is the practice in your offshore installation for deluge while diving or other operations are on? Who takes the decision? Based on what factors? Do you think water deluge can fight intense gas fires? How often if the fire water system tested?

Discussion point 5: Start-Up Procedures July 6, 9 45 pm The spiral to disaster began-Gas compressor B tripped-If gas compressor stops, then the GTs would stop and eventually the drilling also has to stop which was not acceptable-they could not get pump B started-engineer retrieves the WP for pump A overhaul maintenance without knowing the PSV (Pressure Safety Valve) permit and did not know the fact that the PSV was removed-Since the maintenance work on pump A was not started as per PTW (Permit To Work), he assumed that it is safe to start Pump A. Discussion Triggers: • • • What is the start-up procedure in your installation? Is this defined & practiced? How are permits managed? Isolation / LOTO reversals? Do you think this issue has resulted in an accident or a near-miss?

Discussion point 6: Taking wrong decision without considering all issues The crew prepared to re-start pump A-No one was aware of the removed PSV since the metal plate was 15’ up hidden by machinery- just before 10’O clock, Pump A was restarted-Pump B tripped causing an alarm in control room-gas leaked through the metal plate and gas detectors went off triggering alarms all over the placeFirst explosion affecting control room-main gas riser valves were shutdown by supervisor by hitting ESD button-this stopped the oil & gas production and should have isolated the rig-the blast blew down the fire walls to the oil separation area-this started an oil fire as shown in the footage-fire wall inadequacy was another major design flaw Discussion Triggers: • • How well are the log books maintained in your installation? If it a practice to maintain the log books with all events recorded?

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Pillai Sreejith

• • •

Do all shift personnel review the log book at the beginning of every shift? Are the log books audited by managers? Do you know the location of ESD (Emergency Shut Down) push buttons? Do you know the actions of SD (Shut Down)?

• • •

Fire wall adequacy assessment is critical Do you know where the fire walls are in your installation? In audits, are fire walls looked at from the integrity point of view?

Discussion point 7: Evacuation & ERP (Emergency Response Plan) July 6, 10.04 pm At this point of time, only 2 men were killed and situation was far from hopeless-Piper Alpha’s ERP collapsed since it was centered around the rig manager who was supposed to co-ordinate evacuation & fire fighting from radio room-but the radio room itself was damaged-PA system was not used to communicate to personnel for evacuation-Radio room was abandoned-men on board was not directed on what to do-as per the instructions they received, they were supposed to wait at the muster station which was at the lifeboat station- but the fire stopped the men from reaching the life boat stationthey went to the accommodation block and waited for instructions for evacuation using helicopter-over 100 men waited in the galley area just beneath the helideck, but the fire flames were blowing above the helideck making the helicopter access impossible. Discussion Triggers: • • • • Where are the emergency control centres located for your installations? Are the equipment in good condition? Are you aware of your role in the ERP? Are there drills conducted? What are the emergency evacuation instructions given to you? Do you abide by them firmly or will take a decision based on situation? • • Obeying procedures killed most of the men!! Do you understand what this meant? Smoke ingress analysis would have helped?

Discussion point 8: Evacuation & ERP Men were given no further instructions but to wait-they waited in smoke-filled room choking-all stayed in the galley which was getting filled with smoke.

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Pillai Sreejith

Discussion Triggers: • • • Can this situation of delayed / no instruction condition occur in your installation? Are the control room / accommodation block smoke-proofed? How long can you stay inside?

Discussion point 9: Use of ELSA (Emergency Life Saving Apparatus) instead of SCBA (Self-Contained Breathing Apparatus) When the fire water deluge system failed, 2 men bravely attempted to re-start the pumps manually wearing emergency breathing apparatus-they never made it. Triggers: • • Do you think this is a prudent and brave step? Do you have sufficient SCBAs?

(ELSA can supply Oxygen for around 15 minutes whereas SCBA can provide breathing air for around 30 minutes. They should not have gone out at all!!) Discussion point 10: Conflict between production and safety There were other 3 rigs in the Piper field (Tartan, Claymore) and all of them pumped oil onshore-the backpressure from other 2 rigs flowed to Piper Alpha-22 kms away, Claymore heard the first May day-they could not communicate to piper Alpha since the communication facilities were knocked off at Piper Alpha-Claymore continued to pump oil onshore thereby adding more fuel at Piper –The stand-by vessel Nautica was instructed to check the situation at Piper Alpha-Manager tried to contact Occidental Petroleum onshore control centre-manager decides not to shut down and continues pumping of oil-Meanwhile Tartan rig, located 12 miles away also continues to pump oilconflict between production and safety.

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Pillai Sreejith

Discussion Triggers: For managers / supervisors • • What will you do in this case? If your offshore installations are inter-linked, can there be a case similar to Piper Alpha of back-feeding? How? Is any risk assessment done? Discussion point 11: Smoke filled galley and Evacuation July 6, 10:18 pm At Piper, the gas from the long pipelines from other platforms added to the fire load-this fact was known to the management of Occidental Petroleum that if there is a gas fire, it will take long time to de-pressurize and will be nearly impossible to fight-nothing was done to strengthen or protect the pipeline. 10:20 pm The Tartan gas line burst with 3T of gas coming out every second from the ruptured pipeline- people were still alive (although overcome by smoke) in the accommodation block mainly due to the efficient fire cladding on the accommodation block-some of them went out and made the 10 story jump into the sea. Discussion Triggers: • • • • How much time will it take to de-pressurize gas risers on your offshore installations? Are the passive fire protection measures in place? How are risks managed? Which is the safest place in your installation in case of a major fire? Why?

Discussion point 12: Communication failure The second explosion knocked out the telephone link between Claymore and Occidental’s onshore control centre-at 10:30 pm, Claymore manager speaks to the OP emergency centre through satellite communication system-supervisor tries to convince the manager to shutdown. Discussion Triggers: • If you see an obvious problem (fire in the other installation, for example), what action will you take? • Are you authorized to take major decisions?

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Pillai Sreejith

Discussion point 13: Escape & Evacuation There was another chance of escaping without jumping into the sea-the gigantic safety vessel, Tharos, was anchored close to Piper Alpa by pure chance-Tharos wasted its water by turning on the water too fast-this waster 10 minutes of the time getting it restarted-Worst still, the extendable gangway proved very slow (5 m to move 2 feet) took 1 hr to extend full 30 m- at 10:50 pm, they ran out of time when the second gas pipeline burst-this threw Tharos back-then on the crew could only watch the platform melted and collapsed. Discussion Triggers: • • • Are the responsibilities of the support / supply vessel defined during emergency? Is its fire pump functional and tested periodically? Are support vessel personnel aware of the hazards and take part in selected rescue / emergency support activities? Discussion point 14: Finally Claymore shuts down- at 10:50 pm-If Tartan and Claymore had shut down after they heard the first Mayday (distress signal), this could have significantly reduce the consequences to a large extent. 11:20 pm After withstanding the intense heat from fire for over an hour, the accommodation block slid into the sea and most of the rig fell after it-rescue and evacuation measures-out of the 226 men on board Piper Alpha, 167 died and only 61 men survived- these people survived only since they ignored the little training they received!! Burning remains of Piper Alpha-3/4th of the original platform disappeared- the intense heat (over 1000 degree C) generated from gas fires melted steel platform legs Discussion Triggers: • Do you see some commonalities between your installation and Piper alpha?

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Pillai Sreejith

Piper Alpha Offshore complex consisting of inter-

Offshore Complex ?

connected platforms Pumps gas offshore Taros, MSV Oil to gas conversion Existence of fire walls Existence of fie water deluge Existence of gas compressors ? ? ? ? ? ?

Learning Points: There were lots of things that went wrong (PTW, layout, emergency response, fire water deluge, fire walls, communication, decision making, support vessels, training, safety systems, etc.) at Piper Alpha and if learn from them, then the installations will be much safer. Understanding the potential accidents and the associated barriers are the most important learning points!!

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