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 walls-
Later 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 room-
this 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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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 onshore-
Compressor 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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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 re-
started-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 place-
First 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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• 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 station-
they 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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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 oil-
conflict between production and safety.

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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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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 re-
started-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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Piper Alpha Offshore Complex

Offshore complex consisting of inter- ?
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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