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PIPER ALPHA, Vessel-602350, Piper Alpha was an oil platform located…

- - - - Hell deck
      - Top deck
      - Quarters
      - Power generation
      - Drilling rig
      - Crane
      - Flare boom
      - Production equipment
    - - Rig inspections
      - Drill pipe inspection/tubular inspection
      - Non-destructive testing (NDT techniques)
      - Mobile hard banding
    - - Nickel based alloys
      - Titanium alloys
      - Duplex & martensitic stainless steel
  - - - Conversion of decommissioned gas and oil platforms can be turned into particular reefs. In the Gulf of Mexico, as much as 11% of platforms have been converted into reef (Bull & Love 2019)
  - - - Drilling line maintenance
      - Wire rope maintenance
      - Mud circulating system
        
        Hoses
        
        Hose connections
        
        Pop-off values
        
        Shale shakers
        
        Belts
        
        Guards
        
        Mud pumps
      - Generator, electrical systems and electric motors
      - Engines
      - Rig floor
        
        Rotary
        
        Catheads
        
        Tongs
        
        Wire rope
        
        Drawworks
        
        Air hoists
      - Derrick equipment maintenance
        
        Travelling block
        
        Swivel packing replacement
        
        Crown block
        
        Swivel
    - - Not accurately updated to suit new operational requirements eg. gas
  - - - Processing equipment and utilities tested onshore and pre-commissioned where possible
      - Hydrotesting of pressurised gas tests and pipework (1% helium and nitrogen for trace for detection)
      - Onshore hydrotesting of the topside performed with potable water
      - Vessels fire fighting systems
    - - On board a vessel
      - Stresses checked
      - Seafastening analysis is performed
      - Platform parts (decks, jackets, appurtenances fastened to barge
      - Motions of heave, pitch, roll and yaw is considered
      - Seastate analysis compare with worst of the year
    - - Structural sections must be able to withstand upending, uprighting and lifting/launching and other stresses
      - Jackets are self supporting during pile drive and installation
  - - - Onboard wifi
      - Accommodation quarters
      - Television
      - Small movie theatres, pool tables, air hockey, video game consoles on some rigs
      - Music rooms
      - Laundry
      - Kitchen
      - Sometimes fire rooms/own fire fighting crew
    - - Can be 200 people working and living on a rig at one time
      - Helipad
        
        Used to fly in hundreds of workers constantly via helicopters
        
        Approx. 90 min turnaround on flight
      - Oil rig operational 24 hours a day
    - - Complete sea survival training
      - Medical examinations
    - - Automated drilling system
      - Integrated drilling controls system
      - Equipment integration
      - Drilling control rooms
      - Data Mate System (DMS)
  - - - Fatigue analysis
      - In-place analysis
      - Earthquake analysis
      - Installation analysis
      - Transportation analysis
      - Upending analysis
      - Appurtenances analysis
      - Loadout analysis
      - Impact analysis
      - Stability analysis
      - Pile and conductor pipe drivability analysis
    - - Helicopter landing pads/decks must conform to legislation
      - Wave height analysis
      - Water depth
      - Wind velocities
      - Tide analysis
      - Minimum air gaps between decks
      - Load weight of onboard equipment
    - - Seabed soil mixture eg. sand, clay, silt
      - Load bearing of tension and compression
      - Sheer resistances
      - Load-deflection characteristics
    - - Accommodation allocation
      - Safety features and emergency provisions eg. lifeboats
      - Materials used
      - Layout of rig
- - - - Condensate Pump A
      - Condensate Pump B
      - Pipeline terminations
      - Pig Traps
    - - SW Flare Boom
      - SE Flare Boom
    - - Control Room
    - - Main escape route for emergencies not sufficient
    - - East
      - West
  - - - If a newcomer had worked offshore before, then training was brief to the point of non-existent
      - Incoming crews were supposed to be given safety induction training by the safety department
      - Discrepancies between what the safety department intended to convey, and what they actually conveyed
      - Some staff didn't know the location of the lifeboats
    - - Work ethic among the platform had disintegrated; with workers only working to complete tasks before changeovers
  - - - The safety induction was too simplistic. Staff were handed booklet and told to read it, much of the information was out of date or inapplicable to Piper Alpha
      - Managers on board the platform had minimal training
        which resulted in poor practices and ineffective audits
      - Management viewed safety training as “cursory” and did not train new workers in emergency responses. Witnesses reported that some workers were not shown where the lifeboats were on the platform
    - - Safety culture complacency and everything is fine attitude
        
        Macleod et al. (2018) states that when people are encouraged to think that safety can be ensured by roles that are enforced by inspectors, they become complacent and it is impossible to cover eventualities in a set of general rules
      - Personal safety over process safety eg. fire water pumps on manual start to protect divers
    - - Shift changeovers
        
        At shift changeover lead production operators would not review or discuss suspended permits
        
        Operators were busy with their own handovers at the shift change on the day
        
        Shift handover was a busy time
      - Policies and procedures
        
        Lack of adherence to the standard operating procedures associated with the PTW system
        
        Procedure required maintenance and operations to meet, inspect the work site and sign off permits together however did not occur on the day of the accident
        
        Operators kept a log but often failed to record maintenance activities
        
        Procedure if management were busy was for maintenance to sign off the work permit and leave it in the control room or safety office
    - - Emergency procedures that existed, did not account for any catastrophic events, such as the one that destroyed the platform
      - Main evacuation was via helicopter (helideck as it was believed to be the last place to be damaged if an accident occurred). Within the first minute of the explosion, the helideck was covered in black smoke
        
        Skohdalen et al. (2012) explains the requirement of extensive installation, evacuation, escape and rescue (EER) operations for safeguarding the lives of personnel onboard offshore drilling rigs. The requirement to design the platform to have numerous different escape methods and specific placement of lifeboats across the rig has been shown in major accidents in history. Helicopter evacuation cannot be used as the primary method in situations involving fire, gas and smoke.
      - Some staff did not know the location of the lifeboats therefore it hindered their escape when the explosions began
      - The Piper Alpha platform did not have an adequate refuge area and refuge system
      - 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 were reluctant to shut down the operations onboard
      - Superintendent in the control room did not believe he had the authority to stop the exportation processes from the platform
      - Management in the surrounding platforms did not believe they had authority to stop the constant supply from their platforms
- - - - 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
  - - - Extensive modifications required due to afterthought to introduce export of gas
        
        Retrofitting was in several phases - separation of condensate and then production of export-quality gas
        
        Retrofitting causes non-ideal design solutions to make it work
      - The new facility was located right beside accommodation modules, radio room, under the electrical power and beside the control room which caused a disastrous situation
        
        The explosions caused a loss of command, control and electrical power among the platform, leaving the system essentially decapitated
        
        Communications between the platforms were lost when the first explosions occurred. This delayed shut-down on the other platforms, particularly on Claymore and Tartan.
        
        The location of the control room next to the oil and gas production modules had a high probability of destroying the control room and created high failure dependencies if any fires and blasts occurred
      - The platform was never upgraded to be equipped with emergency response mechanisms for gas situations; therefore the firewalls were never upgraded to withstand gas-related fires and explosions of that nature
        
        Safety design rested (fire) was not revisited effectively when the platform was modified to treat gas with additional risk of explosion.
    - - The oil from Claymore and Titan took the easier reverse route to Piper Alpha because the emergency shutdown valve on the Piper Alpha oil export line failed to close tightly
    - - 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
    - - No way of contacting the surrounding platforms to cease their supplies to the platform
      - The lack of communication system redundancies when these were destroyed during initial explosions
    - - 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
- - - - Contract rigger killed in an accident a few years prior
        
        Prior warnings regarding issues with the organisations low quality safety management systems long before the accident
        
        Chao et al. (2003) states that the use of root-cause analysis, failure modes and effects analysis (FMEA) can provide comprehensive predictions of future errors and casual factors from comparisons of historical errors. If these prior warnings would be have been acknowledged, management would have identified areas where the safety management system was lacking.
        
        Highlighted inadequacies of both the permit to work and the shift handover procedures however nothing was changed
      - 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.
    - - The deluge nozzles were often blocked with scale and the fire-water pipework was undergoing phased replacement
      - The platform was underperforming operationally after an inspection was conducted on the safety equipment
    - - 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
- - - - 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
      - Management were reluctant to shut down operations onboard after the first explosion
      - Management would assume that if no issues were reported by crew then they did not independently review operations or the Permit to Work system
      - Fire-fighting systems were not activated when fires began as it was turned to manual control
    - - No identification of the risks associated with loosely fitting the blind flange
      - Did not inform management of unfinished works or additional maintenance work was undergone
      - Maintenance log not filled in
      - No out of order signs/tag out on pump undergoing maintenance
      - Left works for the following day instead of delegating the task
    - - 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
      - Not trained in emergency evacuation procedures
      - Workers were constantly exposing themselves to fatal levels of smoke as they constantly opened and closed the door to the crew quarters