The Weekly Reflektion Week 40 / 2019

This week’s Reflektion is based on the Piper Alpha disaster and asks the question.

What do you do with important information presented at your meetings?

Do you just take note and move onto the next item on the agenda? Or do you take the information seriously?

The Piper Alpha disaster occurred on the 6th July 1988. The initial explosion was most likely due to a condensate leak from a flange that had not been secured properly following the removal of a pressure safety valve. The initial explosion caused a leak in pipework from the main separators and the separator inventory provided a significant amount of fuel for a sustained fire. The fire impinged on three high pressure gas risers, which subsequently ruptured and the resulting explosions and fire destroyed the platform. 165 people on board Piper Alpha died on that day as well as 2 people from a fast rescue craft engaged in picking up survivors that had jumped into the water.

Lord Cullen was responsible for the investigation into the disaster. Lord Cullen gave a speech at the opening of Oil & Gas UK’s Safety 30 conference in Aberdeen on 5 June 2018. The 30th anniversary of the disaster. Here is an extract from this speech.

The management could have been in no doubt as to the grave consequences to the platform and its personnel in the event of a prolonged high pressure gas fire. A report from consultants in 1986 had advised that such a fire would be almost impossible to fight and the gas pipelines would take hours to depressurise. Earlier in 1988, a report by the facilities engineering manager advised that if a fire was fed from a large hydrocarbon inventory, structural integrity could be lost within 10–15 minutes. A report in 1987 by a member of the loss prevention department pointed to an even greater hazard to personnel and plans for platform abandonment. In the event, these reports predicted what happened on the night of the disaster.

Management did not accept that this would happen. They had rejected the installation of sub-sea isolation valves and the fireproofing of structural members as impractical. They had relied on emergency shutdown valves and a limited deluge system, both of which were rendered useless by the initial explosion. They had not carried out a systematic identification and assessment of the potential hazards, or put in place adequate measures for controlling them, but had relied on merely a qualitative opinion. It showed, in my view, a dangerously superficial approach.

Occidental was the operator of Piper Alpha and the Occidental management were presented with information that described how the disaster could occur in advance of the disaster itself. They failed to take action in two important areas. Firstly, they failed to systematically identify the potential hazards and the measures in place to control them, as Lord Cullen states. Secondly, they failed to ensure that the measures actually in place to control the hazard associated with the gas risers would function as required. For example, the fire pumps that should have supplied the seawater for a deluge to cool the high pressure gas risers were often in manual due to diving operations. That is, they did not start automatically on fire detection.  

Management displaying a superficial approach to prevention of Major Accidents is a common factor in the investigation of Major accidents. You may think that the criticism of Occidental management for Piper Alpha in 1988, the London Underground management for the Kings Cross disaster in 1987, BP management for the Texas City refinery disaster in 2005, Exxon management for the Exxon Valdez disaster in 1989, the Townsend Thoresen management for the Herald of Free enterprise disaster in 1987s etc etc…would be enough for management not to have a superficial approach. History unfortunately tells another story. What would they say about you if a disaster occurred on your installation?

Thank you to everyone that attended our Breakfast Seminar on the 25th September. We hope you enjoyed the presentation and have now a better appreciation of ‘creeping change’ and how it may affect your organisation/installation.

Reflekt AS