1988: Piper Alpha Oil Rig

Ablaze
CHEN 655 Project:
Syed Quraishy
Tasmia Tahsin Priyanka
Piper Alpha-Location
At around 110 miles north-east of Aberdeen in the North
Sea.
Claymore and Tartan were the two other platforms
connected to Piper which were also operated by
Occidental.

http://www.brighthubengineering.com/marine-history/116049-piper-alpha-oil-rig-disaster
Piper Alpha-Background
Owned by a consortium consisting of
-Occidental Petroleum (Caledonia)
-Texaco Britain Ltd
-International Thomson Plc
-Texas Petroleum Ltd
Oil Production in 1976 about 250,000 barrels
per day increasing to 300,000 barrels later.
In 1980 a gas recovery module was installed .
Production declined to 125,000 in the year
1988.



Piper Alpha-Background
The production deck level consisted of four
Modules:
Module A: Well head
Module B: Oil Separation
Module C: Gas compression
Module D: Power generation and Utilities


Piper Alpha-Background
Piper Alpha Platform: West
Elevation
(Lees Loss Prevention in Process industries, Volume 3)
Piper Alpha Platform: Production deck on 84 feet level
Piper Alpha-Timeline
Incident Investigation
1 hr. 35 min before disaster:

All gas alarm came from
module C
Captain in one of the nearby
ship had seen a blue flame
coming underneath the module
C
Convinced the investigator that
module C was starting point of
the explosion
Analyzing 3 products of Piper
Alpha they were confirmed that
condensate started the fire.

Incident Investigation
Analyzed the pattern of the gas
alarm & suspected a condensate
release in the eastern end of
module C.
Only source of condensate in
module C is two PSVs; designed
to withstand twice the operating
pressure.
PSV-504 was taken out for a
maintenance work, replaced by a
blind flange/metal disk
Incident Investigation
Workers had installed the metal disk by
hand tight.
PSV-504 was connected with a condensate
pump which was shut down for an
overhauling job.
Standby pump (Pump-B) tripped that night
and the lead operator (unaware about the
PSV maintenance work) had swapped the
pump & introduced condensate for priming
before startup.
Later when they had started the pump the
leak was larger and triggered multiple gas
alarms including the High gas alarm
1 hr. 30 min before disaster:

Module C was protected by fire walls
designed to resist intense flames up
to 6 hrs. but not explosion proof.
Destroyed the fire panels of the fire
walls which had flown like projected
missiles.
Damaged another condensate
pipeline in module B.
This leak aided a second explosion
which was an oil explosion resulted
in an evanescent fire ball.

Incident Investigation
Incident Investigation
1 hr. 10 min before disaster:

Colossal explosion from the bottom of
module B had shaken the platform
Oil was dripping below the module B did
not dripped directly to the sea but it
settled
Divers placed rubber matting over the
gratings to avoid the sharp edge on their
bare feet
Dripped oil had formed a small pool and
this pool fire had heated up a high
pressure gas line from Piper alpha to
another rig named Tartan.
The pool fire, weak metal, high pressure
heated up gas caused the huge
explosion and around 150m (as per
Cullen Report) fire ball
Incident Investigation
HP gas pipeline to Claymore destroyed
Living quarter dislodged to the sea with
all the crew
Failure Analysis & Mitigation
PTW System
Multiple PTW should be kept at a common place
Proper hand over between shifts
Effective site auditing regarding specialized permit
Appropriate equipment specific isolation procedure
Fire wall and
Layout
Conducting a design safety review before any
modification and analyzing the requirement of passive
fire protection (blast proof walls) due to the new
modification.
Conducting Explosion Overpressure Study to check
the extent to which the walls could withstand
explosion
Failure Analysis & Mitigation
Automatic
water deluge
system
Putting the critical safety equipment always on
automatic mode
Production-
Safety Conflict
People > Environment > Asset > Revenue
OSHA PSM Elements Failure
The 14 key elements of OSHA PSM are as
follows:
Employee participation
Process safety information
Process hazard analysis (PHA)
Operating procedures
Training
Contractors
Pre-start up safety review
Mechanical integrity
Hot work permits
Management of change
Incident investigations
Emergency planning and response
Audits
Trade secrets
OSHA PSM Elements Failure
The 14 key elements of OSHA PSM are as
follows:
Employee participation
Process safety information
Process hazard analysis (PHA)
Operating procedures
Training
Contractors
Pre-start up safety review
Mechanical integrity
Hot work permits
Management of change
Incident investigations
Emergency planning and response
Audits
Trade secrets
Accidents and disasters are
common events in chemical, oil
& gas, manufacturing, and
nuclear industry.
Piper Alpha Disaster was
initiated & propagated by faulty
actions of human.
In our study of this incident we
have focused on Human Error.
Our Approach
Human Error
Departure from acceptable or desirable
practice on the part of an individual that can
result in unacceptable or undesirable results
1

Intentional & unintentional manmade mistakes
that cause injury to people, environment
pollution, economical loss and reputational
damage.

It is a concept for explaining breakdowns,
accidents or other inadvertent consequences .

1
Bea, Holdsworth, and Smith, Human and Organization Factors in the Safety of Offshore Platforms
Human error includes:

Failing to execute or omitting a task
Accomplishment of the task inaccurately
Performing an additional or non-required
task
Performing tasks out of sequence
Failing to perform the task within time limit
linked with it
Failing to respond effectively to an
emergency

Human Error
Human Error Classification
Unsafe Acts
Intended Action
unintended Action
Slip
Laps
Mistake
Violation
Attentional Failure
Intrusion
Omission
Reversal
Misordering
Mistiming
Memory Failure
Omitted Planned items
Place-losing
Forgetting intensions
Rule-based Mistakes
Misapplication of good rule
Application of bad rule
Knowledge-based Mistakes
Many variable forms
Routine Violation
Exceptional Violation
Art based mistakes
Fig. 1: Unsafe Acts taxonomy (Reason 1990)
Slips: Errors associated with the execution of faulty action.

Lapses: Errors is caused by memory failure.

Mistakes: Error occurs perfect execution of a task but wrong
planning.

Violations: Errors associated with deliberately avoiding
organizational rules and regulations.
Human Error Classification
Human Error Classification


Human Error
Handling Error
Maintenance Error
Assembly Error
Design Error
Installation Error
Inspection Error
Operator Error
Control Error
Fig. 2: Human Error in Different Phase of a Project
Contributors to Human Error
Performance requirements that exceed
human capability
Design that promotes fatigue
Inadequate facilities or information
Difficult/ Dangerous/ Unpleasant/
Repetitive tasks
Tasks at odds with the person's aptitude
Stress, Illness, Sleep Deprivation, Injury.

Human Error Management
Reduce error vulnerabilities to tasks/task
elements
Determine, asses & eliminate error
producing factors within the workplace
Identify organizational factors that create
error producing conditions within the
individual, team, task & workplace
Enhance error detection
Increase the error tolerance of the system
Improve the organization resistance to
human fallibility
HEART: Human Error Assessment &
Reduction Technique
Established by J.C. Williams (1986)
Procedural technique that attempts to
calculate human error.
Data based structured approach to human
error quantification
Uses its own values of reliability & also
factors of effect for a certain number of
error producing conditions
Start
Analyze task by
using HTA
Take the first/next
task step from the
HTA
Assign a HEART
generic category to
the task step in
question
Assign a nominal
human error
probability (HEP) to
the task step in
question
Select any relevant
error producing
conditions (EPCs)
Take the first/next
EPC
Determine the
assessed proportion
of effect of the EPC
on the nominal HEP
Are there any
more EPCs?
Y
N
Calculate the final
HEART HEP for the
task step in question
Are there any
more task steps?
N Y
Stop
HEART Methodology
Step 1: Categorized task
Analysis (HTA)
Step 2: The HEART Selection
Process
Step 3: Classification of task
unreliability
Step 4: Identifying Error
Producing Conditions (EPC)
Step 05: Assessed proportion
of effect
Step 06: Explanation of
remedial measures
Step 07: Documentation

Human Errors in Piper Alpha
Performing a maintenance work without
following appropriate procedure
Faulty warning system & read out problems
in the control board panel due to design of
the panels or action of board operator
Put the automatic (electricity driven)
firefighting pumps turned off
Philosophy of production first rather than
safety first
Action of a less trained people as major
decision maker

Assumed Scenario
A key overhauling work, already in backlog
No practice of cross referencing between
works
Possibility weather condition change
Complacent attitude in the auditing &
inspection practice.
Non redundant methanol system (hydrate
inhibitor) needs troubleshooting
Recently promoted OIM having no
experience in managing crisis condition as
an incident commander.

General task category
Type of task (E)

Routine, highly practiced, rapid task Involving
relatively low level of skill

Nominal Human Unreliability 0.02


Error Producing Conditions
EPC HEART
effect (E)
Assessed Proportion
(P)
Assessed effect
A.E=((E-1) x P) + 1
No means of conveying spatial
and functional information to
operators(in this case
maintenance crew) in a form
which they can readily assimilate
X 8.0 0.15 2.05
The need to transfer specific
knowledge from task to task
without loss
X 5.5 0.2 1.9
Little or no independent
checking or testing of output
X 3.0 0.5 2
Ambiguity in the required
performance standards
X 2.5 0.35 1.525
A need for absolute judgments
which are beyond the
capabilities/experience of the
performer
X 1.6 0.25 1.150
No obvious way to keep track of
progress during an activity
X 1.4 0.5 1.2
Human Error Probability
Nominal likelihood of failure
P = 0.02 2.05 1.90 2.0 1.525
1.150 1.2 = 0.3279
Calculated Human Error Probability (HEP) is
nearly 33% for this particular task
Remedial Measures
Spatial & Functional Incompatibility Such incompatibilities should not occur. If there is any doubt
expert opinion should be obtained to run the task in
appropriate manner
Knowledge Transfer Reliance should not be placed on operators transferring
their previous knowledge without loss of precision or
meaning-if such perfect transfer is required suitable job aids
should be provided as reference.
Inadequate Checking When high reliability is paramount, independent checking on
a proper accuracy level by people & systems that do not
have any vested interest in the success/failure of an
individual. Blame game is strictly prohibited.
Ambiguity It needs to be ensured that all the performers of a particular
task are well aware of the codes & standards. There should
not be any chance of relying on substandard information
Requirement of absolute judgment Task performer should not be placed in the position of
taking decision about issues which are outside the span of
their experience. Task analysis will help to figure out the
time when this sort of situation arises & management should
have contingency plan. Brain storming or problem solving
sessions can help to tackle this bizarre condition.
Lack of progress tracking Job aids (checklist/electronic mimic) need to be supplied in
order to ensure that performers do not go out of step with
the task in hand.
HEART at a glance
HEART method was used for error
probability assessment & error reduction.
HEART provided valued awareness
regarding industrial parameter
Aided to figure out appropriate defenses
against human error in both qualitative &
quantitative level.


Aftermath
Immediate wide ranging assessments of the installation
and management system carried.
Official public inquiry of the disaster was done by Lord
Cullen came up with 106 recommendations.
The Offshore Installations (Safety Case) Regulations
came into effect 1992
The Offshore Installation and Pipeline Works
(Management and Administration) Regulations 1995
The Offshore Installations (Prevention of Fire and
Explosion, and Emergency Response) Regulations 1995
(PFEER)
The Offshore Installations and Wells (Design and
Construction, etc) Regulations 1996
Survivors Psychology
Professor David Alexander carried out a study
on the long-term psychological and social
effects of Piper Alpha on the survivors.
Around 70% survivors had psychological and
behavioral symptoms of post-traumatic stress
disorder.
They had difficulty in finding employment.
Employers regarded Piper Alpha survivors as
Jonahs bringers of bad luck.
Family members of the dead and survived
victims suffered psychological and social
problems.
Piper Alpha Today
Platform that used to produce 10 percent of the North Seas
oil , today only a wreck buoy of it is all that is visible.
A memorial sculpture showing three oil workers was
founded in the Rose Garden within Hazlehead Park in
Aberdeen.
A scholarship was launched on April 20th 2011 by Industry
Skills and Safety Body OPTIO as a tribute to the heroes of
Piper Alpha who lost their lives.
Pound for Piper Memorial was launched on the 28th of
May 2012 to raise 1m for maintenance of the Piper Alpha
Memorial garden.
A three-day event to be held at Aberdeen which will be
chaired by Oil & Gas UK chief executive, Malcolm Webb to
mark 25 years of Piper Alpha disaster




This Presentation is dedicated to all the
survivors- When I stand before thee at the day's
end, thou shalt see my scars and know that I had my
wounds and also my healing.-Rabindranath Tagore