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Piper Alpha was a large North Sea oil platform that started production in 1976. It produced oil from 24 wells and in its early life it had also produced gas from two wells. It was connected by an oil pipeline to Flotta and by gas pipelines to two other installations. In 1988, Piper Alpha was operated by Occidental Petroleum (Caledonia) Ltd ("OpCal"), a wholly owned subsidiary of Occidental Petroleum Corporation. On 6 July 1988, there was a massive leakage of gas condensate on Piper Alpha, which was ignited causing an explosion which led to large oil fires. The heat ruptured the riser of a gas pipeline from another installation. This produced a further massive explosion and fireball that engulfed the Piper Alpha platform. All this took just 22 minutes. The scale of the disaster was enormous. 167 people died, 62 people survived. It is believed that the leak came from pipe work connected to a condensate pump. A safety valve had been removed from this pipe work for overhaul and maintenance. The pump itself was undergoing maintenance work. When the pipe work from which the safety valve had been removed was pressurised at start-up, it is believed the leak occurred.
Initial response from industry
As details of the causes of the disaster emerged, every offshore Operator carried out immediate wideranging assessments of their installations and management systems. These included: y y y y y y Improvements to the "permit to work" management systems Relocation of some pipeline emergency shutdown valves Installation of sub sea pipeline isolation systems Mitigation of smoke hazards Improvements to evacuation and escape systems Initiation of Formal Safety Assessments
The industry invested in the order of £1 billion on these and other safety measures before Lord Cullen's Public Inquiry into the disaster reported.
however. Preparing. with Lord Cullen¶s report being published in November 1990. which considered measures to prevent future major accidents. The safety case is a very comprehensive piece of work. The operators were responsible for 40. UKOOA. The safety case must give full details of the arrangements for managing health and safety and controlling major accident hazards on the installation. a safety case. was represented throughout but did not participate in Part I. The second made recommendations for changes to the safety regime. for their acceptance. By November 1993 a safety case for every installation had been submitted to the HSE and by November 1995 all had had their safety case accepted by the HSE. many being a direct result of industry evidence. revising and updating the Safety Case whenever needed throughout the full life cycle of an installation make considerable demands on the duty . for their acceptance. and provided 34 expert witnesses. Eight were for the whole industry to progress and the last was for the Standby Ship Owners Association. At the same time the Health and Safety Executive (HSE) developed and implemented Lord Cullen's key recommendation: the introduction of safety regulations requiring the operator/owner of every fixed and mobile installation operating in UK waters to submit to the HSE. It must demonstrate. all of which were accepted by industry. a safety case. provided a temporary safe refuge on the installation and has made provisions for safe evacuation and rescue. for example. the oil and gas production companies¶ trade association (now Oil & Gas UK). The inquiry began in November 1988. The Safety Case Regulations require the operator/owner (known as the 'duty holder') of every fixed and mobile installation operating in UK waters to submit to the HSE. that the company has safety management systems in place. The Health and Safety Executive (HSE) was to oversee 57. The Safety Case Regulations The Offshore Installations (Safety Case) Regulations came into force in 1992. has introduced management controls. The first was to establish the causes of the disaster. which was to establish the cause of the disaster. By 1993 all had been acted upon and substantially implemented. has identified risks and reduced them to as low as reasonably practicable. Responsibilities for implementing them were spread across the regulator and the industry.The Cullen Inquiry Lord Cullen chaired the official Public Inquiry into the disaster in two parts. Industry acted urgently to carry out the 48 recommendations that operators were directly responsible for. play a full role in Part II. It did. The Cullen Report Lord Cullen made 106 recommendations within his report.
The Offshore Installations (Prevention of Fire and Explosion. in light of 13 years of experience. safety legislation is "goal-setting" rather than prescriptive. Enforcement and workforce involvement The Health and Safety Executive's (HSE) Offshore Safety Division employs a team of inspectors who are . The legislation sets out the objectives that must be achieved. and for securing effective emergency response. y y There are a wide range of other regulations applicable to the offshore oil and gas industry. The Safety Case Regulations were revised in 2005. etc) Regulations 1996 these are aimed at ensuring the integrity of installations. display screen equipment. there may be particular hazards in the offshore environment that need special consideration. Health and safety legislation offshore In addition to the application of the Health and Safety at Work Act (1974).these set out requirements for the safe management of offshore installations such as the appointment of offshore installation managers (OIMs) and the use of permit-to-work systems. personal protective equipment (PPE).holder. The Offshore Safety Case Regulations are underpinned by more detailed regulations. manual handling and safety zones. There are therefore major sets of UK regulation applicable to the industry's operations. but allows flexibility in the choice of methods or equipment that may be used by companies to meet their statutory obligations.these provide for the protection of offshore workers from fire and explosion. safety representatives and safety committees. and Emergency Response) Regulations 1995 (PFEER) . These are: y The Offshore Installation and Pipeline Works (Management and Administration) Regulations 1995 . These include (but are not limited to): y y y y y y y The Management of Health and Safety at Work Regulations 1992 The Control of Substances Hazardous to Health Regulations updated in1999 The Noise at Work Regulations 1989 The Health and Safety at Work Act (1974) The Provision and Use of Work Equipment Regulations (PUWER) The Lifting Operations and Lifting Equipment Regulations (LOLER) The Dangerous Substances and Explosive Atmosphere Regulations (DSEAR) These regulations above are in addition to various regulations dealing with first-aid. In the UK. The Offshore Installations and Wells (Design and Construction. The objective of the revisions was to improve the effectiveness of the regulations whilst at the same time reducing the burden of three yearly resubmissions. and the safety of the workplace environment offshore. the safety of offshore and onshore wells.
The Safety Case Regulations require the operator both to demonstrate they have consulted with the workforce when preparing the Safety Case and to make copies of the accepted Safety Case available to them. Safety Representatives have made and continue to make a valuable contribution to safety offshore. They will investigate safety incidents. like Quality. a safety representative to represent them in dealings with the installation management on health and safety and to establish safety committees on each platform.responsible for enforcing both the offshore specific regulations and the general safety legislation common to all industries. Their work includes regular inspection visits to offshore installations. companies can choose the best methods or equipment available at the time. Oil & Gas UK publishes guidelines in accordance with this recommendation which are usually developed with other stakeholders. provide training. Systems Failure Analysis is based on the Deming philosophy that Occupational Safety & Health. select the equipment and tools used and provide the plant and the environment necessary to achieve high standards of occupational health and safety. For example. The Offshore Installations (Safety Representatives and Safety Committees) Regulations. The people who work in the system have little or no influence over 85+% of the causes of accidents that are built into the system. Safety Representatives from installations across the UKCS are actively engaged with the industry's Step Change in Safety campaign. via the Elected Safety Representative network set up to improve exchange of information and share best practice. only management action can change the system. The Operator has a duty to ensure and pay for the training of the Safety Representatives. . Employees can only be responsible for resolution of special safety problems caused by actions or events directly under their control. and prosecute if necessary. also provided a voice to the offshore workforce in the health and safety of their installation. Deming stresses that it is the "system" of work that determines how work is performed and only managers can create the system and improve it. The "goal-setting" approach to safety legislation differs from the prescriptive style in that rather than being given a fixed check list of things that must be done to meet a statutory requirement. which came into force in 1989. such as the Health and Safety Executive (HSE) and other industry trade associations. The guidelines are designed to identify and assess key areas of risk and provide guidance on the measures and procedures most suitable for controlling those risks. Secondly. Only managers can allocate resources. Establishment of safety guidelines Lord Cullen recommended that the industry specify the standards used to comply with goal-setting regulations. by secret ballot every two years. the workforce is involved in developing the Safety Case for an installation. Members of the offshore workforce have the right to elect. Oil & Gas UK (formerly UKOOA) guidelines aid this process by promoting best practice across the industry. is primarily the result of senior management actions and decisions and not the result of actions taken by "workers".
b) Prevent reoccurrence. nor will it suggest any area of management to take remedial action. Systems fail for a variety of reasons but usually due to a multiplicity of causes. Even the addition of a figure of $10. Corrective Action does just that ~ corrects the existing problem. must be. It is important to note too. but the extent of that loss is mostly chance. Collecting and analysing data on the distribution of accidents by "class" or "type" i. Many of the individual causes may have been built into the original systems and processes and lain unnoticed for many years. Managers must be concerned with collecting and analysing data about any accidents involving the people they supervise. that cost does not relate to the cause.000 loss from eye injuries does not offer any specifics for management on action to control the Loss. Large Losses do not necessarily reveal mismanagement. which may continue to re-occur. Preventive Action improves the systems and processes.Are accidents really such or are they more accurately described as performance imperfections of human and physical resources that should be under the control of a responsible management? What should be investigated? The message to managers. part of body injured.e. We know that accidents invariably produce a Loss. information. We need to accept the principle that the severity of personal harm or property damage should not dictate the intensity of the investigation. agency of injury etc. INTRODUCTION Using Systems Failure as working tool. that there is great potential in good incident/accident investigation for improving how managers manage. It does not provide causal information on which management can base decisions to act and evaluate progress on efforts expended to improve Health & Safety. This "class" and "type" information shows magnitude without the identification of cause. and very little insight (to management) into why the accidents are occurring. and c) Prevent potential accidents. rather than information on why it happened. does little to identify root cause(s). Before we can analyse the systems that have failed we need to clearly understand the subsystems involved in accidents and how they relate to each other. The result has little to do with cause. Many computerised analysis programs end up giving a great deal of accessible. For example. How useful is the accident data we currently collect? Most data recorded and analysed on accidents is based on OSH requirements requiring a detailed description of the circumstances surrounding the accident. nature of injury. The system of investigation must probe into the way management manages and look at the Systems that have Failed. who consider accident investigation just a tedious legal requirement to be avoided whenever possible. . We need to identify Corrective and Preventive Action(s) to: a) Eliminate the causes of the accident that occurred. accident type. the fact that 100 eye injuries occurred in a given plant may impress its management of the need for safety. But it does not point out any specific causes. but not useable.
modified procedures. It also provides feedback on the effective functioning. Subsequent investigations often reveal flawed systems that have never been previously or officially revealed (in writing) to Senior Management. catastrophe may result. This will involve using a Team of experienced people to reveal flaws. Preventive actions may involve a re-design of equipment. as well as the operational integrity of the Standards. If the quality of written Standards. we can then decide on: (a) (b) prompt and immediate corrective action(s). Note: Actions (a) and (b) may be different. Trends can also be measured which uncover repeated loss exposures. may be very different to the longer-term strategy that is then adopted. together with an investigation and follow-up of all accidents and mishaps.When a particular and unique set of conditions and circumstances arise however. of the Management System and/or Safety System through analysis of how and which part of the management system failed. Some of the problems. This is the reason that regular internal audits* should be conducted. Audits must be conducted by auditor(s) experienced in the processes being audited. Any such Audit must actively involve the employees working in the processes being audited in order to uncover any major flaws or shortcomings in their operation. to establish the root causes and actual consequences of the mishap (undesired event(s). and inadequate controls. then the only problem is usually one of individual compliance with the standard. Management Systems (oversights) From this systematic analysis of Accident Data. . If however the process has been changed for any reason. or otherwise. may actually have been unwittingly introduced by the employees themselves. improperly evaluated risks. and longer term preventive action(s). What is required. as they operate the system and related processes. the root cause(s) of the failure(s) can be established. then a complete re-evaluation will be required Carrying out Systems Failure Analysis Accident Investigation & Analysis involves the methodical and systematic examination of the sequence of events before. is regularly tested. in either hardware or software systems and/or procedures. Physical Systems (failures) and. to stop immediate recurrence of the mishap. The Systems Failure Analysis Tool These causes can be grouped under 3 headings: y y y Human Systems (errors). Audits Check for Compliance with Management Performance Standards. although the employees working in the process are often aware of the shortcomings. Following the analysis. purchase of new equipment. during and after a particular mishap.
through its original design and subsequent adaptation on several occasions. there was no condensate in this pipe. The blind flange was replacing a valve that had been removed for repair. One particular danger. who chaired the Court of Inquiry. was open to the possibility of accident should circumstances conspire as they did. Lord Cullen. The management system by way of ³Permit to Work´ was found to be ill monitored and the platform itself. The explosion in effect destroyed the platform¶s main power supplies and the control room. obvious examples are: The unavailability of a crane to replace the repaired valve before the night shift took over. [see also separtae more detailed entry for Piper Alpha] The Piper Alpha Oil Platform disaster was caused by the ignition of condensate flooding from a blind flange that could not withstand the pressure of condensate in the pipe it closed. which was still under maintenance and not in a state in which it could safely be put into service. Safety and Environmental (HSE) Systems in larger organisations will consist of dozens of processes and maybe as many as 175 related HSE practices. different training or re-training of staff and any one of a possible multitude of actions that may emerge from the systems failure analysis. more generally a series of incidents (each normally safe or even trivial in themselves) come together.recruitment changes. The evidence also indicated dissatisfaction with the standard of information which was communicated at shift hand-over´. the operators in the control room on the night shift were not properly informed by the day shift that the valve had been taken out for repair. operational irregularities occurred. Sophisticated Health. which led to the destruction of the platform and the tragic loss of 167 lives. The lack of knowledge of the absence of the valve by the men on the night shift. and The fact that the only valve available malfunctioned that night. and a series of serious consequences flowed from this. In the case of Piper Alpha. and the blind flange was not intended to withstand the pressure of the condensate. That night. At the time of removal of the valve. so establishing root causes may not be a simple task and therefore the corrective and preventive actions may also be multi-tiered. There is little doubt that the immediate cause of the disaster was human error but there is rarely one cause of a major accident. . against an existing background to cause it. and the potential for tragedy became a fact. The Piper Alpha Oil Platform disaster in the North Sea in 1988 ~A classic µSystems Failure¶ [The following information is used with the training video µSpiral to Disaster¶ as part of our training courses. A failure in any one or more of these practices could lead to a major mishap. which was relevant to the disaster. made the following observations: ³«The failure in the operation of the Permit To Work system was not an isolated mistake but that there were a number of respects in which the laid down procedure was not adhered to and unsafe practices were followed. However. was the need to prevent the inadvertent or unauthorised re-commissioning of equipment. The explosion occurred and led to a large crude oil fire. The operators took the natural action of leading the condensate into the alternative pipe.
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