Year one - Case Studies, Piper Alpha accident, Centre of Risk for Health Care Research and Practice

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Tuesday, October 13, 2015

Piper Alpha accident

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The Piper Alpha was a North sea oil

production platform operated by Occidental
Petroleum (Caledonia) Ltd. It accounted for
around ten per cent of the oil and gas
production from North sea at the time.
Located about 120 miles north-east of
Aberdeen, The platform began production in
1976 first as an oil platform and then later
converted to gas production. A sub-sea
pipeline, shared with the Claymore
platform, connected Piper Alpha to the
Flotta oil terminal on the Orkney Islands.
Piper Alpha also had gas pipelines
connecting it to both the Tartan platform
and to the separate MCP-O1 gas processing
platform. In total, Piper Alpha had four
main transport risers: an oil export riser,
the Claymore gas riser, the Tartan gas riser and the MCP-01 gas riser. An explosion and
resulting fire destroyed it on July 6, 1988, killing 167 men. Total insured loss was $ 3.4 billion.
To date it is the worlds worst offshore oil disaster. The disaster began with a routine
maintenance procedure. On the morning of the 6th of July, a backup propane condensate pump
in the processing area needed to have its pressure safety valve checked. The work could not be
completed by 18.00 and the workers asked for and received permission to leave the rest of the
work until the next day. The tube was sealed with a plate.
Later in the evening during the next work shift, the primary condensate pump failed. None of
those present were aware that a vital part of the machine had been removed and decided to
start the backup pump. Gas products escaped from the hole left by the valve. Gas audibly
leaked out at high pressure, ignited and exploded, blowing through the firewalls. The fire
spread through the damaged firewalls, destroyed some oil lines and soon large quantities of
stored oil were burning out of control. The automatic deluge system, which was designed to
spray water on the fire, was never activated because it had been turned off.
Before the first explosion, gas alarms were received in the main control room but due to design
error of the detector the operator did to check where it originated from.
About twenty minutes after the initial explosion, at 10:20, the fire had spread and become hot
enough to weaken and then burst the gas risers from the other platforms. These were steel
pipes of a diameter from 24 to 36 inches, containing flammable gas products at two thousand
pounds per square inch of pressure. When these risers burst, the resulting jet of fuel
dramatically increased the size of the fire.
The generation and utilities module, which included the fireproofed accommodation block,
slipped into the sea. The largest part of the platform followed it. The nearby diving support
vessel Lowland Cavalier reported the initial explosion just before 22:00, and the second
explosion occurred twenty two minutes later. By the time civil and military rescue helicopters
reached the scene, flames over one hundred metres in height and visible as far as one hundred
km away prevented safe approach. The whole accident took place in 22 minutes.

Contributing risk factors

The Cullen enquiry was set up in November 1988 to establish the cause of the disaster. In
November 1990, it concluded that the initial condensate leak was the result of maintenance
work being carried out simultaneously on a pump and related safety valve. However, there
were a number of factors contributed to the severity of the Piper alpha accident:
Human error
Oil production platform design

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Year one - Case Studies, Piper Alpha accident, Centre of Risk for Health Care Research and Practice

Human error
Lord Cullen identified a number of human errors that contributed to the severity of the incident.
Including deficient analysis of hazards, deficiencies in the permit to work system, inadequate
training in the use of permits and emergency response procedures. There was a breakdown of
the chain of command and lack of any communication to the platform's crew. The continued
pumping of gas and oil by the Tartan and Claymore platforms was not shut down due to a
perceived lack of authority, even though personnel could see the Piper burning.
After the investigation was completed it was discovered that the pump had been turned off was
a failure of permit-to-work system that did not ensure proper communication. This was the
critical factors that lead to the disaster. The change of shift was not systematically done. There
was a failure of communication when writing the work-to-permit. This was a system of
paperwork designed to promote communication between all parties affected by any maintenance
procedure done on the platform. The system on Piper Alpha had become too relaxed. Employees
relied on too many informal communications and communication between shift changes was
lacking. If the system had been implemented properly, the initial gas leak never would have
occurred.
There was blind flange that was installed in place of pressure valve was not made tight. The
blind flange could not stand the high pressures. It was found that there was no inspection after
fitting of this blind flange. This could have led to earlier leaks.

Oil production platform design

In the control room the monitoring panels were not clearly visible and operators could not tell
were the alarms originated from. Also in the control room there were a number of non critical
alarms that lead the operator to ignore the series of alarms after the first explosion. The
location of the pressure valve was out of sight for the nightshift workers. When designing a
critical component, it should have not been out of arms reach for the operator. The design of
the manual fire fighting system also failed to follow the accessibility guidelines. The presence of
fire walls and the lack of blast walls - the fire walls predated the installation of the gas
conversion equipment and were not upgraded to blast walls after the conversion. The
accommodations were not smoke-proofed, and the lack of training that caused people to
repeatedly open and shut doors only worsened the problem. Conditions got so severe in the
accommodations area that some people realized that the only way to survive would be to
escape the station immediately. They, however, found that all routes to lifeboats were blocked
by smoke and flames, and in the lack of any other instructions, they made the jump into the
sea hoping to be rescued by boat. Sixty-two men were saved in this fashion; most of the other
167 who died suffocated on carbon monoxide and fumes in the accommodations area.
There should have been sufficient protection against and mitigation of fire and explosions as
well as fire fighting are of particular importance as there is no possibility to rely on outside
assistance, such as the fire brigade. Furthermore, there should have been more than one route
to helicopters and lifeboats and the route must be accessible at any given time to ensure
evacuation of the platform in a crisis situation. To aid escape from a hazardous situation,
luminescent strips and heat shielding provide visibility in smoke and protection from flames,
respectively. Secondary escapes such as ropes, ladders, and nets are also available as backup
for the more sophisticated escape methods.

The aftermath
The Cullen enquiry concluded that the initial condensate leak was the result of maintenance
work being carried out simultaneously on a pump and related Safety valve. The enquiry was
critical of Piper Alpha's operator, Occidental, which was found guilty of having inadequate
maintenance and safety procedures. But no criminal charges were ever brought against it.
The second phase of the enquiry made 106 recommendations for changes to North Sea safety
procedures, all of which were accepted by industry. Most significant of these recommendations
was that the responsibility for enforcing safety in the North Sea should be moved from the
Department of Energy to the Health and Safety Executive as having both production and safety
overseen by the same agency was a conflict of interest.
The disaster led to insurance claims of approximately US$ 1.4 billion, making it at that time the
largest insured man-made catastrophe. The insurance and reinsurance claims process revealed
serious weaknesses in the way insurers at Lloyd's of London and elsewhere kept track of their
potential exposures, and led to their procedures being reformed.
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Year one - Case Studies, Piper Alpha accident, Centre of Risk for Health Care Research and Practice

Barts and The London School of Medicine and Dentistry, QM

Innovation Building, Walden Street, London

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