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(Workplaces, Management, People), Marsden, E 2019, The Piper Alpha…

- - - - All controls were located in the control room. There were no sub-sea controls (Lord Cullen )
      - All controls were located in the control room. There were no sub-sea controls (Lord Cullen)
      - Fire controls located in a single location and where inaccessible when control room was lost
  - - - there was no alternative arrangement for control of plant if control room was lost. nasa
      - coupling- network piping connecting Tartan and Claymore to Piper Alpha platform (Pate-Cornell 1993)
      - no separation hazardous and sensitive areas ( NASA 2013)
      - gas compression module in close proximity to control room
      - Poor design of evacuation routes (Pate-Cornell 1993)
      - Location of accommodation close to production areas
    - - inadequate fireproofing of structure ( Marsden 2019 )
      - no blast proof between control room and production areas
      - no mechanisms built into system to shut-off connection with other platforms in case of an accident.
      - No spark arrestors in the system to prevent ignition, (Cornell)
      - Firewalls between modules B and C unable to withstand explosion
- - - - No central management for the interconnected platforms
      - failed to empower workers to make decisions during periods of crisis
      - Delayed evacuation of workers
      - decision to leave the fire suppression system on manual
      - decision to continue production during major overhaul. nasa
      - management did not plan for abandonment of platform despite 1986 report
      - Management from other platforms did not shut down the pipelines feeding into the platform
    - - permit system and isolation
        
        no information labelling was used to identify isolated equipment
        
        No training in the permit system
        
        The permit system was localised and as a result there were 2 permits for work on Pipe A.
        
        There was no serious regard for the permit system (Lord Cullen).
        
        Blind flange not properly secured.
        
        Permit procedures were not followed, tags, task description etc.
    - - workers' complaints about safety not acted upon
      - failed to learn from fatality the previous year
      - recommendation to keep water pumps on automatic at all times ignored (NASA 2013)
      - skewed personal safety vs process safety trade-off led to water fire fighting equipment being left on manual
      - no measures taken for decoupling of Tartan and Claymore despite acknowledgement of risk potential caused by the large interconnecting pipes (NASA 2013)
    - - inadequate emergency procedures, there were no re evacuation procedure, workers waited for instructions in living areas
      - life rafts did not inflate, life boats could not be launched
      - fire system set to manual
      - operators from Tartan and Claymore did not know if they had authority to shut production in emergency. nasa
      - fire system not in serviceable condition
  - - - no inspections carried out on pipes before start up
      - no inspections conducted on emergency equipment (Pate-Cornell 1993)
    - - inadequate transfer of information between lead workers during shift handovers (Pate-Cornell)
    - - ineffective communication with workers during evacuation (Lord Cullen)
      - poor communication between Piper Alpha and the other platforms (Cullen )
  - - - no worker supervision
    - - Workers started task late in the day as such could not finish work on Pipe A
      - Maintenance allowed to occur at the same time as major rebuilds- resulted in opening of two permits for Pipe A which resulted in the confusion about its status (Marsden 2013)
- - - - Workers
        
        no knowledge of the plant layout (Lord Cullen)
    - - operators
        
        workers' limited knowledge of risk. could have physically checked condition of pump A
        
        inexperienced operators (Pate-Cornell 1993)
        
        failure to understand alarm signals (Pate-Cornell)
        
        failure to fix warning system after it gave out false warning signals. This caused the real signals to be ignored.
      - maintenance crew
        
        incorrect isolation procedure
      - OIM
        
        inexperienced (Lord Cullen)