In collaboration with

University of Sunderland


Name SEGI ID UOS ID Lecturer Date

: Johnin Taimin : SJCJ-0012043 : : Miss Ida Fahani Md Jaye : 29th November 2011

4 The happening.2 Objectives of the Management Industrial processes Causes of accident 4.1 The Management and its structures 2.Table of Contents Page No Abstract 1.0 8.0 6.0 7 8 5.2 Design and process 6.0 3.0 9.1 Management and human resources 6.1 Objective 1.1 Root and human factors 4. Viper plagiarism report 1 1 2 4 6 2.0 10 10 7.3 Safety and health Conclusion List of references Appendix i.2 General background about Piper Alpha 1.2 Design and process factors Consequences of the effect of the accident Improvement and prevention 6.0 11 12 .0 4.3 General purposes of the platform 1.0 Introduction 1. effect and recovery of the incident Management and operation 2.

We believe we’re cleverer stronger and faster than we actually are. our friends. despite our best intentions with all these things can end up putting us. One of the worst accidents has happened was the Piper Alpha Incident. determines the story behind the incident and indentifies all the causes and effects of the incident. This report would examine the company general background and purposes. Our attention span is limited. The accident that occurred on board the offshore platform Piper Alpha in July 1988 killed 167 peoples and cost billions of dollars in property damages. our colleagues and other people at risk and lead it to accident.Abstract We’re all human. Unfortunately. We overlook crucial evidence in making decisions. We make mistakes and forget things. .

Peru. On July 6th 1988. and the United Kingdom [3]. For the next 10 years. Such as accident progression started before the first explosion occurred until at last fire and smoke engulfed the platform. Armand Hammer was elected as president and CEO. studying the processes and operations of the platform and also evaluating the happening and risks in all areas that lead to the accident. Venezuela. Other than that.0 Introduction 1. . the company discovered the second largest natural gas field in California in the Arbuckle area of the Sacramento basin at Lathrop. identify the causes and consequences from all occurred effects of the accident.1 Objective The purposes of this report are to examine the general backgrounds and structures about the management of Piper Alpha Platform. operated by Occidental Petroleum (Caledonia) Ltd in the UK North Sea. Trinidad. It was founded in 1920.2 General background about Piper Alpha Piper Alpha was a North Sea oil production platform fully managed and operated by Occidental Petroleum (Caledonia) Ltd subsidiaries of Occidental Petroleum Corporation (Oxy). Oxy is a California based company in oil and gas exploration and production with operations in the few countries. Occidental expanded internationally with operations in Libya. sacrificed 167 peoples life in now remains the world's most deadly offshore disaster. In 1957. Bolivia. Dr.1. 1. an explosion and subsequent inferno on the Piper Alpha platform. Then. In 1961. It lead Occidental to the won exploration rights in Libya in 1965 and operated there until all activities were suspended in 1986 after the United States imposed economic sanctions on Libya [4]. According to the official investigation report written by Lord Cullen. it was the failures of company’s management on safety on the Piper Alpha Platform.

3 General Purpose of the platform operation Figure 1 : Piper Alpha field location [18] The Piper Alpha offshore platform was located in the British sector of the North Sea oil field approximately 120 miles from Aberdeen Scotland (Figure 1). the oil platform that .1. It was accounted for around ten per cent of the oil and gas production from the North Sea at that time. Figure 2 Piper Alpha Platform before engulfed in a catastrophic fire [9] The platform began production in 1976 at first as an oil platform and then converted to gas production. By the year 1988. It is the major Northen Sea Oil and Gas for drilling and production that time.

The Tartan field also fed oil to Claymore and then onto the main line to Flotta.762 meters in diameter of main oil pipeline which ran 127 miles (205 km) from Piper Alpha platform to Flotta terminal. 000 barrels of oil every day [5]. Claymore and Tartan where each with its own platform (Figure 3).6 kilometers) to the west. As we can see the platform actually acted as a hub for importing and exporting oil and gas operated by 226 workmen who lived and worked on the platform and at the same time running production of the platform. .The Flotta oil terminal in the Orkney Islands will receive and process oil in these fields. Figure 3 The Piper Field of oil and gas extraction and processing [10] The platform belonged to oil and gas production area consisting of the fields Piper. with a short oil pipeline from the Claymore platform joining it some 21.5 miles (34. There were one 0. There were also 46 centimeters in diameter separated gas pipelines which run from Piper to the Tartan platform and from Piper Alpha to the gas compressor platform MCP-01 around 30 miles (48 kilometers) to the Northwest.had once been the world’s single largest oil producer was starting to show its age produced 317.

effects and recovery of the incident Figure 5 References to the investigation described in the Postmortem Analysis of Technical and Organizational Factors by M. Module C and Module D. They didn’t know that the Pump ‘A’ shut down for maintenance which the . Figure 4). Module B. 1988 work began on one of two condensate-injection pumps. On 6 July. It was started with process disturbance to the operation. There were two works permits were taken but the shift supervisor was not able to complete the maintenance work in the shift and gave them to the contractor but the contractor did not read it and signed off the permit for the work.Figure 4 Piper Alpha Platform [10] Piper Alpha platform generally can be divided into Module A. Module D involves production and generation of oil and gas. Elisabeth Pate – Cornell each events are subsequent ones which lead to the further events (figure 5). designated A and B. which were used to compress gases in the gas compression module of the platform prior to transport of the gas to Flotta (Module C. There were two redundant and condensate pumps inoperative in Module C which involves with gas compression.4 The happening. 1. Primary Initiating event was the first explosion. Module C and B are gas Gas compression and separation while Module A was the Wellheads (also known as Christmas Tree) of the Platform. During the evening of 6 July the next shift personnel came and started continuing operation for compressor Pump ‘A’ since Compressor Pump ‘B’ is tripped and could not be restarted. The redundant Pump ‘A’ was shut down for maintenance and the condensate pump ‘B’ tripped.

Tertiary initiating event was the third violent explosion which collapses the structures of the platform. Then the gas ignited and exploded. which fueled an extremely intense fire under the deck of Piper Alpha. One of the main pipes in module B also ruptured which projectile from Module B/C fire wall. it followed by the ruptured of riser from Tartan to Piper Alpha platform caused by the pool fire beneath it. Once the pump was operational. The fire pump was malfunction where the automatic pumps been turned off and manual pump diesel powered in Module D are also damaged by the failure of Modules C/D fire wall. The pipe steel strength reduced because of the too high temperature and some more induced by internal pressures. The fire instantly spreads back into Module C through a breach in Module B/C firewall and to 1200 barrels of fuel which stored on the deck above Modules B and C. causing fires and damage to other areas with the further release of gas and oil. Around 10:20pm. Then. large crude oil leaked in Module B and lead to the huge fireball and deflagration. a jet fire from broken riser. Secondary initiating event were the second major explosion few seconds after the first explosion and propagation of the fire to the Module B (Gas separation). followed by the eventual platform structural collapse (figure 6) of a significant proportion of the installation and killed 165 workmen on the board and two men on board of a fast rescue vessel. Then intense impinged jet fire under the platform and MCP-01 gas risers failed was lead to the third violent explosion and makes the whole platform engulfed by fire. That fire impinged on a gas riser from another platform.valve of the piping was replaced by two blind flanges and there was no pressure release valve. . [10]. It was started from fire that licked the wall of Modules B/C and ruptured it. Figure 6 Next morning platform structural collapse [1] Then explosions ensued. the gas detector and emergency shutdown were malfunctioned and lead it to the first ignition and explosion [2]. Then. a steady gas condensate vapors leaked into the air around 45kg which filled 25% of the Module C volume from the two blind flanges at around 10pm. On that time.

On the same time. One of the objectives of the management was ensuring that all objectives of the subordinates are linked to the organization’s objectives. .2. Then some confusion which leads to restarted of Condensate Pump A which resulted from failures to adhere the Permit To Work (PTW) system. At the Primary Initiating Events. decision.1 The management and its structures Organizational Level Decision and actions level Basic Events (component failures and operator errors) Figure 7 Hierarchy of root system failures [2] The management and structures of an organizational is very important. It started from management decisions on how the leader doing his planning.0 Management and operation 2. faulted the company’s management of safety on Piper Alpha. For each of any basic events. and assigning peoples. coordination and interaction between superiors and subordinates helps to solve any problems. The official investigation report written by Lord Cullen.E Pate Cornell in his risk analysis on probabilistic approach and application to offshore platform. 2.2 Objective of the management Generally. the superintendent of the platform (Offshore Installation Manager or OIM) panicked. was totally ineffective almost from the beginning. Managers will give order to operator on the board. for better communication. The shift supervisors suppose to explain the permit before pass it to contractor and the contractor cannot simply write it off without reading it. Main element of the accident sequence is based on the organizational level. according to the management structure for any actions or decision made on the platform of Piper Alpha at that time at first started from managers. Figure 7 is hierarchy of root system failures which been analyzed by M. the human decision and actions will influence to their occurrences.

There were drilling. . The wellheads controlling the flow of the material extracted from the reservoir and also isolating the reservoir as required. The reservoir fluids were mixtures of crude oil. It was located in cabinets about twelve feet high and most of the east end of Module D was occupied by these. As designed there were two compressing pumps known as Pump A and Pump B. First would be the reservoir and Module A (Wellheads). The module D was located at the north end of the platform. Generally. Next to the west within an enclosed area there was a diesel-driven firewater pump and adjacent to it was an electric-driven firewater pump which used to drew water from below the sea level. water and sand. The main function of the equipment in Module B (Separation) was to separate gas and produce water from the crude oil. The process equipment in Module C was designed to process the gas produced by the production from Module C (Separation). While the produced water being heavier than oil dropped to the bottom of the separators and interface between water and oil in the separators was regulated by a level control system and disposed of into the sea. the Piper Alpha Platform can be divided into four modules (Refer Figure 4). At the eastern end of the module were the John Brown Turbines A and these were substantial pieces of equipment generating 13800 volts. production. There were separated manifolds for each of the production separators and a third for the test separator. The test separator will check the flow rate and composition of the well fluids so that at regular intervals oil from each well was routed into the test separators. Then the oil is thereafter transferring back to the production separator by a transfer pump. gas. There was the fuel gas heater in the adjacent to the C/D firewall at the eastern end. The produced water was diverted to the water treatment package. It been used to remove the condensate from the gas thus increase the pressure of the gas.3 Industrial Processes There were some activities before the primary initiating events occurred. The outline of the process in Module B was the gas that cooled and a small quantity of condensate which been collected and transfer it back to the production separators. The gas compression was achieved by the use of centrifugal and reciprocating compressors. Then the gas routed into Module C (Gas Compression) for further processing. Then it will be brought to the surface through pumping a proportion of the 34 wells which connected the reservoir to the platform. The extracted materials then transferred via pipeline to the manifold in modules B. inspection and maintenance by some workmen and divers. The contents of the reservoir were kept in liquid state by the intense pressures generated there but by the time they had reached the surface during the extraction they had become gas and fluid. Each of the separate flow lines from the wellheads in Module A passed through A/B firewall into manifolds in module B.

there were inadequate communications which had contributed to fatalities and a civil conviction for the company but remedial actions have not been taken. In the Piper Alpha case. It can be blame from the peoples who design and build the platform but anything would start from decisions and actions. Then. Some workers even have not been shown the location of their life boat.1. They did not knew that Pump A under maintenance and accidently turn it to operational. some decisions or actions are clear errors and others may be acceptable based on the judgments at that time they made it. . Basically their judgments in making decisions and actions can be labeled in four phases (figure 8). Seconds.1 Root and human factors The root factor of the incident was the company’s management of safety on the platform as stated in the official investigation report of the Piper Alpha Disaster written by Lord Cullen. Then next shift workmen came and found out that Pump B was tripped and could not be started. Figure 8 [2] 4. The management has not given any emergency response training to new workers on the platform. platform management reluctant to shut down or stop the operation after the first explosion occurred. 4. Pump A was shut down for maintenance but the PTW was been simply signed off by the contractor.4 Causes of accident There are several causes that lead to the tragic accident.1 Failures in the Management First failure of the company’s management on safety was the Permit to Work (PTW) system did not used properly. As we know. It can be said that the command system failed during an emergency. As been discussed earlier in the Primary Initiating Events. Most of the platform managers also have not been trained well on how to respond to emergencies. The superintendent of the platform (Offshore Installation Manager or OIM) was panicked and did not have authority to stop exporting. root factor would be discussed together with the human factor because both of these factors are related. Human factor which involved with human actions linked to basic event of the accident are one of the main causes that lead to the tragic occurred. every single action we did will lead to some events which start from basic events. In this report. Each of these basic events have been influenced a number of decisions and actions.

fire pumps or emergency lighting do not seem to have received proper attention. There were also designed bad location of the radio room and lack of redundancies in the communication system.2 Failures during operation (Maintenance and Inspection) The most critical maintenance problem was the failure of the Permit To Work system (PTW). The Fire water system also been set on manual which was not proper way of starting it in an emergency. The permit supposes to be explained by the Shift Manager and the contractor also must read it first. First was location of the detector module rack. The Public address system was entirely dependent on electricity coupling among the backups of electric power supply caused a power failure then lead it to no sound. The night shift was not informed of the situation and tried to restart the pump in which initially gas leak started. Second. fire protection (deluge) and emergency shutdown systems because of these some design systems deficiency.4. gas alarm were received in the main control room but because of the display of the signals origins in the detector module rack. Life rafts. On the Primary Initiating Events. the PTW has been signed off by the contractor without reading it. control and loss of electrical power the system was technically decapitated. there was no automatic fire protection upon gas detection in west half of module C and primary automatic trip functions did not exist for operation safety in Phase 1of Modules C. . The location of the control room next to the production modules created failure dependencies such that the fire and blast at Initial Primary Initiating events had a high probability of destroying the control room.2 Design and Process Factors Prior to the initial explosion. the operator did not check where they came from since it was a false alert. With loss of command. The platform also was under operationally with lacking in inspection particularly in safety equipment. 4. The failure of gas detectors. Another most critical maintenance problem was the carelessness with flange assembly without proper tagging. thereby putting Pump A out of service. Lack of redundancies in the commands made it extremely difficult at that time to manually control the equipment. The assembly work was not inspected and therefore the leakages were not detected.1. The platform also has inadequate refuge area and refuge system.

people’s feeling and suffering. most of the consequences of the accident cannot be valued it by money. actions and control the output.1 Management and Human Resources    Any recruitment of new workers shall be exposing to the safety training and emergency response training. We may not predict precisely when the accident will be happen but we can minimize the risk and avoid any accident to be happen. there was US$ 3. According to the Cullen’s report. An accident is started from decisions which lead to the actions. We cannot be too easily satisfied on any whatever we have. As discussed earlier. We did not know their sufferings and feelings. people’s life. Roughly.  .0 Consequences of all the effects of the accident The most invaluable prices as the consequences of the accident was life of 165 workmen (out of 226) on board and 2 men from the fast rescue boat which been sacrificed.4 billion cost in property damage and around 100 kg of hydrocarbons loss which containment to the marine but it only insured around US$ 1. All workers must been Training in use of the Short Messaging System (SMS) and training in understanding the risks of the operation. So. 6. Practice of Permit To Work (PTW) system must be put on high priority with regular audit and review of the system to make sure it is being used and is effective. some of them really badly injured and loss parts of their body. It around 70% peoples on the platform dead resulted from the tragic accident.0 Improvement and prevention Any accident can happen in anywhere at any time. It can happen.4 billion by the Insurers Lloyd of London. We may not know how the families of peoples who died on the accident continuing their life. Platform managers must be train on how to respond to emergencies on other platforms and give order to the workmen on the board. we are one who the making the decisions. Such as. a tragic accidents start from basic events which resulted from our actions. There were 167 families loss one of their siblings on the accident.5. 6. has happened can be happen again. It has make it at that time the largest insured man-made catastrophe [6]. There were no injuries been reported but according to the people who survived from the incident.

All new recruitment or existing employee must be exposed on emergency response training either twice or once a year.0 Conclusion It was 23 years ago. blast walls. protected control rooms and muster areas Active and passive fire protection systems Riser ESDVs properly positioned and protected A variety of evacuation and escape systems. has happened and can be happen again. culture. which was not result of an unpredictable ‘act of God’ but an accumulation of errors and questionable decisions. Regularly auditing and inspection on safety and health in the working places. .g.2 Design and Process         Use tools such as QRA and ALARP to understand the risks and hazards Segregation of hazardous areas from control rooms and accommodations.6.3 Safety and Health   7. ladders & nets Provide annual safety training. Temporary Safe Refuge (TSR) to Prevent smoke ingress. design and structure and the procedures of Occidental Petroleum. 6. 167 peoples killed and cost billions of dollars in properties damages in a most tragic oil and gas accident. and deficient learning mechanisms. All of these events that led to the Piper Alpha accident rooted in the management. the system had been made without sufficient feedback and understanding of their effects on the safety of operations. some of which are to large segments of the oil and gas industry and to other industries as well. Must be more than one route. It can happen. Other than that. The maintenance error that eventually led to the initial leak was the result of inexperience. Provide secondary escape equipments e. Enforcement of law in workers Safety and Health. It was the companies’ responsibilities to expose their employees to be always prepared for any accident or unwanted events occur with safety training and emergency response training. At the heart of the problem was a philosophy of production first and a production situation that was inappropriate for the personnel’s experience. The improper structural design was then lead difficulty if the worker to save their own life. We hope any companies’ management will not take any measures in order to save money in the short term which can lead to understaffed facilities and less experienced and overworked operators. It was caused by a massive fire. : ropes. poor maintenance procedures. With these condition operators are unable to focus specifically on accident prevention. use of firewalls. 8.12 http://e-stud.4 http://en.9 http://www.13 http://edition.14 %2FCCPS%2FResources%2FKnowledgeBase%2FPresentation_Rev_newv4. ISBN -978-0-33047193-0 8.ppt&ei= 0ajHTuPUO4nrrQfhw_ynDg&usg=AFQjCNGY5kjEhiB3UNu4eHMxjve6_rUknA 8.accidents/index.html?ire f=allsearch 8.15 http://news.2 http://www.dailymail.56783&lang=en&id=4722 8.7 http://wn.11 http://www. stm 8.10 Fire in the night.scribd.0 List of reference 8.5 &cd=1&ved=0CBsQFjAA& 8.8 8.17 8. The Piper Alpha Disaster by Stephen 8.cnn.html .