Piper Alpha

LESSON LEARNED DOCUMENT

Place : Piper Alpha, North Sea
Date : 06.07.1988
Substance Involved : Oil, Gas
Event : Explosions & Fires
Loss :
- Killed : 167
- Injuries :-
- Financial : $ 1,860,000,000
Plant Unit Involved : compression unit, drilling platform
 Explosion
• Condensate leaks caused the explosion in the gas
compression and separation module at 10.00 PM
• Deficient PTW (Permit-to-Work) System
• no cross reference among all parties involved in the
maintenance operations
• no system for handover to the next shift
• Deficient Training on the PTW System
• no the PTW system training for contractors for
maintenance job
• no the PTW system training for all operations personnel
 Prolonged Oil Fire
The explosion blew down the fire wall and damage the
equipment at the oil separation section and started the oil fire
which a thick black smoke
• Deficient Hazards Analysis
• at the design stage, a risk of fire was recognized
• but not the explosion hazards.
• Deficient Training
• no inter-platform emergency communication exercise
• the adjacent platform kept sending their product to
alpha, because the communication system had been
destroyed by the explosion
 Dead in Accommodation
In the evening , majority of the crew were in the accommodation . The thick
black oil smoke caught in the accommodation and majority of people died
from carbon monoxide poisoning.
Deficient Hazards Management
The accommodation was design to provide some resistance for
some time to fire.
It was not set up to prevent the egress from the thick black oil
smoke.
Deficient Training
The offshore installation Manager was never been trained in any
simulation exercise in handling emergency
People who put him on the job should be able to recognize the
need for such training.
 Safety Auditing
Deficient of Quality Audit
• there was sufficient safety monitoring and auditing conducted in Piper
• it was not effective because it was not on the right quality
• Every single day, a full time safety operator was dedicated to watch
the PTW system. There was no significant fault found in the PTW
System based on that daily monitoring. There was no report saying
that practices are different with what said in the paper
• Each year , there was a fire insurance audit and there was no
single report on the blockage of the water deluge system
 Gas Fire
Gas lines of 2000 psi from the adjacent platforms to Alpha were caught in
the oil fire and burst due to excessive heat.
Deficient hazard Management
• management never discussed the hazard of gas pipe line riser fails
•The study disclosed that when the gas pipelines riser fails, no fire fighting
would be effective and the lost of life could be enormous.
•
 Fire Fighting
At the time of disaster, the water deluge system did not work. The initial
explosion destroyed the main power supply to the electric driven fire pump
By design , the diesel driven back-up pump was installed in an automatic
start when the electric driven pump does not work.
•Deficient Quality Decision
• Management decided to put the diesel driven fire pump on manual
start when the drivers are in the water.
• Hazards to driver is more in priority compare to number of people
stay at the platform.
• Deficient Safety Management
• A frequent problem of blockage of the deluge systems due to
corrosion and many years back management decided to replace it
with non-corrosive material
• Only one of the deluge systems had been replaced with non-
corrosive material and it was at the drilling module which had not
been in fire.