Pressure Safety Valve is removed from condensate pump A (Human Factors…
Pressure Safety Valve is removed from condensate pump A
Maintenance staff only tightened bolts on pressure safety valve hand tight (ACTIVE FAILURE).
Poor communication between maintenance and control room (LATENT FAILURE).
Operators did not shut down production when alarms for gas originally activated
Insufficient training on evacuation plan for catastrophic fire
Insufficient communication between outgoing and oncoming crews (LATENT FAILURE)
When pump B stopped working employees felt enormous pressure to keep production flowing (LATENT FAILURE).
Piper Alpha originally designed exclusively for oil production and then when laws change and Piper Alpha must utilise gas much retrofitting has to be done (Government legislates so system must change)
Firewalls designed to stop spread of oil fires not gas explosions (Design failure).
Firewalls shattered in initial small explosion
Gas processing module is next to control room
Piper Alpha not sufficiently retrofitted for safe gas production
Retrofitting more expensive than engineering controls at design phase according to Stone, Tumer and Stock (2004)
Safety design failures
Insufficient lifesaving devices on rig e.g. life rafts
No back up plan when helicopter cannot land because of fire or wind
Safety Pressure Valve that originally leaked was up off the ground and not obvious to anyone except if they had read work order that put it out if service
No ability to isolate and lock the pump that had the Pressure Safety Valve removed (ACTIVE FAILURE).
Control Room had to be evacuated because of the proximity of the fire. There was no back up plan to manage an emergency in this scenario.
Production placed as highest priority (LATENT FAILURE).
Safety systems are poor. Procedure for storing work permits in different area's of the rig directly contributed to rig's disaster (ACTIVE FAILURE).
Claymore and Tartan did not have authority to shut down gas production to stop feeding fire on Piper Alpha (Management Failure)
Management of Occidental did not seem to have any procedure for an event such as Piper Alpha occurring (Management Failure)
Automatic fire suppression system was set to manual because of divers in the water, according to NASA (2013)