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Piper Alpha Oil Rig falls to the sea floor (Piper Alpha Oil Rig explodes…

- - - - Tired staff
        
        Latent failure: Management job design
        
        Safe Work Australia, 2019
      - poor shift design
        
        Latent failure: Management job design
        
        Safe Work Australia, 2019
  - - - Failure at design stage
        
        SWA 2019
      - Fire wall tiles become projectiles and blew into section B rupturing a pipe with LPG in it
        
        Latent failure: Workplace design
        
        HSE UK Gov
        
        poor design and use of materials
        
        Failure at design stage
        
        SWA 2019
        
        Failure at design stage
        
        SWA 2019
    - - Inadequate way for divers to move around below the oil rig
        
        Failure at design stage
        
        SWA 2019
        
        Latent failure: workplace design
        
        HSE UK Gov
      - Latent failure: Management policy
        
        Health and safety authority 2019
  - - - The crew at the muster point didn't have a view of the helicopter pad
        
        Latent failure: workplace design
        
        SWA 2019
      - Latent failure: Management policy and procedure
        
        Business Victoria 2019
    - - Unclear instructions
        
        Latent failure: Information transfer failure
        
        HSE UK Gov
      - Failure at design stage
        
        SWA 2019
      - Latent failure: Workplace design
        
        HSE UK Gov
  - - - Latent failure: Workplace site design
        
        SWA 2019
      - Production crew did not inspect pump
        
        Not production crews duties to inspect the pump
        
        Latent failure: Management policy and procedure
        
        WorkCover 2014
      - No indication lights at pump for when there is no safety valve
        
        Failure at design stage
        
        SWA 2019
        
        Failure at commissioning stage
        
        Mike Lohr, 2002
    - - poor permit to work organisation system in place
        
        Latent failure: Management decision
        
        Health and safety authority, 2019
    - - Production crew unaware on how to repair pump
        
        Not their responsibility
        
        Latent failure: Management job design
        
        WorkCover NSW 2014
      - Poorly maintained equipment
        
        Failure at operation stage
        
        SWA 2019
    - - Unclear permit system
        
        Latent failure: Management decision
        
        Health and safety authority, 2019
        
        Latent failure: Information transfer
        
        Health and safety authority, 2019
      - Time pressures
        
        Latent failure: Management decision
        
        Health and safety authority, 2019
    - - Precondition failure: Information transfer
        
        WorkCover NSW 2014
  - - - Maintenance crew took shortcuts
        
        Time pressures
        
        Latent failure: Management job design
        
        HSE UK Gov
        
        No inspection of maintenance crews work
        
        Management procedure failure
        
        SafeWork QLD 2013
        
        Latent failure: Inadequate supervision
        
        HSE UK Gov
        
        No fail safe system in place for steel plate on pipe
        
        Latent failure: Workplace fixed plant design
        
        John Spacey, 2016
        
        Failure at design stage
        
        John Spacey, 2016
        
        Failure at commissioning stage
        
        Mike Lohr, 2002
        
        Poor health and safety culture
        
        Latent failure: Management decision
        
        SafeWork QLD 2013
      - Latent failure: Workplace fixed plant design
        
        SWA 2019
      - Failure at operation stage
        
        WorkSafe QLD, 2019
      - Active failure: Expectation
        
        HSE UK Gov
    - - Latent failure: Management decision
        
        WorkCover 2014
      - stress of losing power to the oil rig
        
        Time pressures
        
        Latent failure: Management decision
        
        Health and safety authority, 2019
        
        Loss of production
        
        Latent failure: Management decision
        
        Health and safety authority, 2019
  - - - Failure at the design stage
        
        SWA 2019
      - Workplace equipment design failure
        
        SWA 2019
      - Frequent dives are done on the oil rig for safety reasons it was switched to manual
        
        Latent failure: workplace fixed plant design
        
        HSE UK Gov
    - - Active failure: Expectation
        
        HSE UK Gov
      - Common practice to ignore minor alarms
        
        Latent failure: Management procedure
        
        SafeWork QLD 2013
        
        No automated system for alarms
        
        Failure at the design stage
        
        Michael Villalba 2018
        
        Latent Failure: Workplace fixed plant design
        
        Michael Villalba 2018
        
        Failure at commissioning stage
        
        Mike Lohr, 2002
    - - Emergency alarm panel was destroyed in the explosion
        
        Failure at the design stage
        
        Mike Lohr 2002
        
        Latent failure: Workplace equipment design
        
        HSE UK Gov
        
        No other back up system in place
        
        Failure at design stage
        
        John Spacey, 2016
      - Failure at workplace site design
        
        SWA 2019