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Piper Alpha Oil Rig explosion (People (individual factors) (lack of…
Piper Alpha Oil Rig explosion
Management
Information transfer
Safety handbook was misleading
poor permit to work system
supervisors did not inspect workplace before shift change
no verbal communication during handover
"At shift changeover lead production operators would not review or discuss the active or suspended permits." - Department of Energy 1990
lack of method of isolation like tagging and locking off on when valve are closed or opened
Organisational/systems factors
poor planning for evacuation routes (Pate-Cornell, E 1993, p.223)
written procedures were not displayed at workplace
Procedures were disregarded
a large number of suspended permits in safety office but no procedure were made to improve them
Workplace
Workplace factors
no fire proof structure
Design of firewall were insufficient
not explosion proof
Inadequate electric power system
emergency lighting, public addressing system failed (Pate-Cornell, E 1993, p.221-222)
Design of having fuel storage above production modules (Pate-Cornell, E 1993, p.221)
Control room was placed next to production modules meaning when accidents happen it will destroy it. (Pate-Cornell, E 1993, p.222)
Not enough room in control room
suspended permits not kept in control room but in safety office
"active permits were made more difficult by the fact that in the safety office suspended permits were not filed according to location but according to the trade involved. - Department of Energy 1990
Equipment design
failure of emergency lighting (Pate-Cornell, E 1993, p.222)
poor design of manual fire-fighting system
poorly located and vulnerable to fires and explosions (Pate-Cornell, E 1993, p.221)
no system to ensure fire and gas panel to reactivate after finishing locking them off. Only the operator in control room or designate authority can reactivate it. - Department of Energy 1990
People (individual factors)
lack of training
managing maintenance
emergency and evacuation procedure (Pate-Cornell, E 1993, p.223)
Offshore installation manager fail to give orders of evacuation (Pate-Cornell, E 1993, p.216)
Mr Lockwood - assumes that other operators follow the log and procedures - Department of Energy 1990