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PIPER ALPHA, Vessel-602350 , Piper Alpha was an oil platform located…
PIPER ALPHA
Event Sequence
The diesel and electric saltwater pumps were switched from automatic to manual control as it was found they may prove hazardous if they were activated whilst platform divers were in the water. These pumps fed the platforms on-board fire-fighting system from the ocean
Nightshift staff were unable to restart the primary condensate pump after it tripped out. The spare condensate pump was re-commissioned to restart operations when it was under maintenance
Spare condensate pump/valves were removed for a large overhaul and was additional work to what was initially scheduled for maintenance
Due to work policies, the contractors working on the large overhaul paused the job at 6pm to complete the next morning which made the pump maintenance incomplete
Due to workload, the contractors were unable to speak to the operations manager directly to explain the work was incomplete and the permit-to-work system (on additional works) so they left it on the manger's desk
Operations manager was unaware that the contractors did additional works on the spare pumps/valves that was not completed
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Gas alarms in the control room started to sound to warn leaking gas in low lying areas that indicated propane
Leaking condensate ignited causing an explosion in the gas compression module. Various firewalls and communication equipment was destroyed
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A gas pipe carrying compressed gas from the other two platforms burst causing explosion and gas fire
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Module (D), including the fireproofed accommodation block, slips into the sea
System life cycle
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Maintenance
Servicing
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Generator, electrical systems and electric motors
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Commissioning
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Transportation
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Platform parts (decks, jackets, appurtenances fastened to barge
Motions of heave, pitch, roll and yaw is considered
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Installation
Structural sections must be able to withstand upending, uprighting and lifting/launching and other stresses
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Operation
Onboard facilities
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Small movie theatres, pool tables, air hockey, video game consoles on some rigs
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Concept Detailed Design
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Geotechnical perimeters
Seabed soil mixture eg. sand, clay, silt
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System parts
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Staff
Training
If a newcomer had worked offshore before, then training was brief to the point of non-existent
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Discrepancies between what the safety department intended to convey, and what they actually conveyed
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Attitudes
Work ethic among the platform had disintegrated; with workers only working to complete tasks before changeovers
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Workplaces
Workplace factors
The gas and condensate operational elements were not included in the design plans therefore it could only manage the safety of the gas production
The pressure relief valves for the condensate injection pumps were located one floor above the pumps
In order to reinstate condensate injection pump A, two separate actions would have been required: reinstate electrical power and open the gas-operated suction and discharge valves
Valve should be placed as close to condensate unit as possible however it was placed 8 metres above and 15 metres away from the pump
No locking of isolation valves, spading or double-block-and-bleed were used to prevent re-pressurisation of a system isolated for maintenance
Equipment design
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To activate the fire-fighting system, the pumps had to be started locally
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Due to display of non-critical alarm sounds and signals coming from the detector module rack, the gas alarms sounding in the control room were not acknowledged by the operator as associated with gas hazard alarms
Wilkinson et al. (2000) discusses the operation of critical alarms and the need to consider staffing levels and work loading conditions through unforeseeable conditions like normal, through upset, shutdown, start-up and emergency. The alarm systems can only operate effectively if those factors are taken into consideration in the design process including shift lengths, fatigue factors and operational training
Equipment was challenging to control during the emergency as there was a lack of redundancy controls
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The primary emergency evaluation method was via helicopters and boats and no other transportation method was included.
Inadequacies in the layout of the platform as there was only one access route to the lifeboats and this was obstructed with thick black smoke from the explosions
When the fire and black smoke broke out, no workers could get to the helipad
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Most workers were sleeping in the accommodation quarters where the explosion occurred due to fire which was located close to the explosion
Work environment
The workers onboard the platform at the time of the emergency began to seek shelter in the crew quarters. Due to a lack of emergency training, the workers seeking refuge in the crew quarters were constantly opening and closing the doors; exposing themselves to fatal levels of the smoke from the explosions
Management
Organisational factors
Operational Routine
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The assessment of risk was focused on turning off the pumps to protect divers from being sucked into pipes instead of prioritising the 226 men unprotected from fire
Marsden (2019) states that earlier audits of the automatic firefighting system (both electric and diesel seawater pumps) recommended that this should not be disabled while diving operations were underway as this presents major hazards in the case of an emergency.
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Financial pressures
Control room operators did not believe they had the authority to cease productions and stop pumping oil
Oil continued to be produced and exported into the line to for approximately an hour after the first explosion
Superintendent in the control room did not believe he had the authority to stop the exportation processes from the platform
Job design
When the fire broke out, the pumps had to be started locally to activate the fire-fighting
Impairment of performance and inability to complete maintenance before shift changeover could be attributed to tiredness from long shifts
Long shifts for the workers on the platform could have attributed to poor performance when undertaking maintenance activities
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Information transfer
Handover of information was inadequate between shifts, crew and disciplines
No communication between the contractors and management to discuss the unfinished work & removal of the spare condensate pump/valves
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While bespoke communications can have some benefits, minimum standards were not set or met.
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People
Team factors
Teams on other platforms surrounding Piper Alpha continued to pump oil to it even though it was visibly on fire
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Individual factors
Supervisors/Management
Management of Piper Alpha viewed emergency training as 'cursory' and did not account for catastrophic events including the one that destroyed the platform
Safety advisor signed off Permit to Work without inspecting the job site where routine maintenance was being conducted
The previous shift supervisors failed to communicate to the supervisor on the consecutive shift that there was ongoing maintenance being conducted on Condensate Pump A
The control room operators did not believe they had the authority to cease productions and stop pumping oil to Piper Alpha due to a lack of command among platforms
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Management would assume that if no issues were reported by crew then they did not independently review operations or the Permit to Work system
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Workers/Operators
No one received accurate training as they did not challenge management's viewers that emergency training was cursory
Due to a number of other non-critical alarms constantly sounding, the operators ignored the gas alarms that were sounding in the control room
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Workers were constantly exposing themselves to fatal levels of smoke as they constantly opened and closed the door to the crew quarters
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Piper Alpha was an oil platform located approximately 120 miles north-east of Aberdeen, Scotland in the North Sea. The platform later added gas and condensate production. A series of explosions broke out before the platform was engulfed in fire killing 167 people on the 6-7 July 1988
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Bull, A & Love, M 2019, ‘Worldwide oil and gas platform decommissioning: A review of practices and reefing options’, Ocean & Coastal Management, vol. 168, no. 1, pp. 274-306Chao, L & Ishii, K 2003, Design process error-proofing: Development of automated error-proofing information systems, paper presented at ASME Design Engineering Technical Conferences, 2-6 September, viewed 13 August 2020, https://www.researchgate.net/publication/267198001_Design_Process_Error-Proofing_Development_of_Automated_Error-Proofing_Information_SystemsCopello, S n.d, Life-cycle assessment of offshore platforms, viewed 10 September 2020, http://www.aiom.info/documentsfordownloads/STUDI_AIOM_GENOVA_2015/presentazioni/sessione3/copello.pdfCraig, B 2008, ‘Materials for deep oil and gas well construction’, Advanced Materials and Processes, vol. 166, no. 5, pp. 33-35Deniz, S 2013, Environmental & socio-economic drilling rig impact assessment, viewed 11 September 2020, https://www.bp.com/content/dam/bp/country-sites/en_az/azerbaijan/home/pdfs/esias/sd/sd2/5_project_description.pdfMacleod, F & Richardson, S 2018, Piper Alpha: The disaster in detail, viewed 11 September 2020, https://www.thechemicalengineer.com/features/piper-alpha-the-disaster-in-detail/Marsden, E 2019, The Piper Alpha disaster, viewed 13 September 2020, https://risk-engineering.org/concept/PiperAlphaOccupational Safety and Health Administration n.d, Maintenance activities, viewed 11 September 2020, https://www.osha.gov/SLTC/etools/oilandgas/drilling/maintenance_activities.htmlOnshore Operations Subgroup 2011, ‘Life cycle of onshore oil and gas operations’, The National Petroleum Council North American Resource Development Study viewed 10 September 2020, https://www.npc.org/Prudent_Development-Topic_Papers/2-26_Life_Cycle_of_Onshore_Operations_Paper.pdfSadeghi, K 2007, ‘An overview of design, analysis, construction and installation of offshore petroleum platforms suitable for cyprus oil/gas fields’ Offshore Platforms, viewed 12 September 2020, https://www.researchgate.net/publication/229036270_An_Overview_of_Design_Analysis_Construction_and_Installation_of_Offshore_Petroleum_Platforms_Suitable_for_Cyprus_OilGas_FieldsSkogdalen, J, Khorsandi, J & Vinnem, J 2012, ‘Evacuation, escape, and rescue experiences from offshore accidents including the Deepwater Horizon’, Journal of Loss Prevention in the Process Industries, vol. 25, no. 1, pp. 148-158Wilkinson, J & Lucas, D 2000, Better alarm handling - a practical application of human factors, paper presented at IBC Alarms Conference, June, viewed 11 September 2020, https://journals.sagepub.com/doi/pdf/10.1177/002029400203500204