BENG (HONS) ELECTRICAL & ELECTRONIC ENGINEERING (2+0)

In collaboration with

University of Sunderland

SUBJECT: INDUSTRIAL STUDIES SUBJECT CODE: EAT 221 REPORT TITLE: PIPER ALPHA DISASTER

Name SEGI ID UOS ID Lecturer Date

: Johnin Taimin : SJCJ-0012043 : : Miss Ida Fahani Md Jaye : 29th November 2011

Table of Contents
Page No Abstract
1.0 Introduction 1.1 Objective 1.2 General background about Piper Alpha 1.3 General purposes of the platform 1.4 The happening, effect and recovery of the incident Management and operation 2.1 The Management and its structures 2.2 Objectives of the Management Industrial processes Causes of accident 4.1 Root and human factors 4.2 Design and process factors Consequences of the effect of the accident Improvement and prevention 6.1 Management and human resources 6.2 Design and process 6.3 Safety and health Conclusion List of references Appendix i. Viper plagiarism report 1 1 2 4 6

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3.0 4.0

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Abstract
Were all human. We make mistakes and forget things. Our attention span is limited. We overlook crucial evidence in making decisions. We believe were cleverer stronger and faster than we actually are. Unfortunately, despite our best intentions with all these things can end up putting us, our friends, our colleagues and other people at risk and lead it to accident. One of the worst accidents has happened was the Piper Alpha Incident. The accident that occurred on board the offshore platform Piper Alpha in July 1988 killed 167 peoples and cost billions of dollars in property damages. This report would examine the company general background and purposes, determines the story behind the incident and indentifies all the causes and effects of the incident.

1.0 Introduction
1.1 Objective
The purposes of this report are to examine the general backgrounds and structures about the management of Piper Alpha Platform. Other than that, studying the processes and operations of the platform and also evaluating the happening and risks in all areas that lead to the accident. Such as accident progression started before the first explosion occurred until at last fire and smoke engulfed the platform. Then, identify the causes and consequences from all occurred effects of the accident.

1.2

General background about Piper Alpha

Piper Alpha was a North Sea oil production platform fully managed and operated by Occidental Petroleum (Caledonia) Ltd subsidiaries of Occidental Petroleum Corporation (Oxy). Oxy is a California based company in oil and gas exploration and production with operations in the few countries. It was founded in 1920. In 1957, Dr. Armand Hammer was elected as president and CEO. In 1961, the company discovered the second largest natural gas field in California in the Arbuckle area of the Sacramento basin at Lathrop. For the next 10 years, Occidental expanded internationally with operations in Libya, Peru, Venezuela, Bolivia, Trinidad, and the United Kingdom [3]. It lead Occidental to the won exploration rights in Libya in 1965 and operated there until all activities were suspended in 1986 after the United States imposed economic sanctions on Libya [4]. On July 6th 1988, an explosion and subsequent inferno on the Piper Alpha platform, operated by Occidental Petroleum (Caledonia) Ltd in the UK North Sea, sacrificed 167 peoples life in now remains the world's most deadly offshore disaster. According to the official investigation report written by Lord Cullen, it was the failures of companys management on safety on the Piper Alpha Platform.

1.3

General Purpose of the platform operation

Figure 1 : Piper Alpha field location [18] The Piper Alpha offshore platform was located in the British sector of the North Sea oil field approximately 120 miles from Aberdeen Scotland (Figure 1). It is the major Northen Sea Oil and Gas for drilling and production that time.

Figure 2 Piper Alpha Platform before engulfed in a catastrophic fire [9] The platform began production in 1976 at first as an oil platform and then converted to gas production. It was accounted for around ten per cent of the oil and gas production from the North Sea at that time. By the year 1988, the oil platform that

had once been the worlds single largest oil producer was starting to show its age produced 317, 000 barrels of oil every day [5].

Figure 3 The Piper Field of oil and gas extraction and processing [10] The platform belonged to oil and gas production area consisting of the fields Piper, Claymore and Tartan where each with its own platform (Figure 3).The Flotta oil terminal in the Orkney Islands will receive and process oil in these fields. There were one 0.762 meters in diameter of main oil pipeline which ran 127 miles (205 km) from Piper Alpha platform to Flotta terminal, with a short oil pipeline from the Claymore platform joining it some 21.5 miles (34.6 kilometers) to the west. The Tartan field also fed oil to Claymore and then onto the main line to Flotta. There were also 46 centimeters in diameter separated gas pipelines which run from Piper to the Tartan platform and from Piper Alpha to the gas compressor platform MCP-01 around 30 miles (48 kilometers) to the Northwest. As we can see the platform actually acted as a hub for importing and exporting oil and gas operated by 226 workmen who lived and worked on the platform and at the same time running production of the platform.

Figure 4 Piper Alpha Platform [10]

Piper Alpha platform generally can be divided into Module A, Module B, Module C and Module D. Module D involves production and generation of oil and gas. Module C and B are gas Gas compression and separation while Module A was the Wellheads (also known as Christmas Tree) of the Platform.

1.4

The happening, effects and recovery of the incident

Figure 5 References to the investigation described in the Postmortem Analysis of Technical and Organizational Factors by M. Elisabeth Pate Cornell each events are subsequent ones which lead to the further events (figure 5). Primary Initiating event was the first explosion. On 6 July, 1988 work began on one of two condensate-injection pumps, designated A and B, which were used to compress gases in the gas compression module of the platform prior to transport of the gas to Flotta (Module C, Figure 4). It was started with process disturbance to the operation. There were two redundant and condensate pumps inoperative in Module C which involves with gas compression. The redundant Pump A was shut down for maintenance and the condensate pump B tripped. There were two works permits were taken but the shift supervisor was not able to complete the maintenance work in the shift and gave them to the contractor but the contractor did not read it and signed off the permit for the work. During the evening of 6 July the next shift personnel came and started continuing operation for compressor Pump A since Compressor Pump B is tripped and could not be restarted. They didnt know that the Pump A shut down for maintenance which the

valve of the piping was replaced by two blind flanges and there was no pressure release valve. Once the pump was operational, a steady gas condensate vapors leaked into the air around 45kg which filled 25% of the Module C volume from the two blind flanges at around 10pm. Then the gas ignited and exploded, causing fires and damage to other areas with the further release of gas and oil. On that time, the gas detector and emergency shutdown were malfunctioned and lead it to the first ignition and explosion [2], [10]. Secondary initiating event were the second major explosion few seconds after the first explosion and propagation of the fire to the Module B (Gas separation). It was started from fire that licked the wall of Modules B/C and ruptured it. One of the main pipes in module B also ruptured which projectile from Module B/C fire wall. Then, large crude oil leaked in Module B and lead to the huge fireball and deflagration. The fire instantly spreads back into Module C through a breach in Module B/C firewall and to 1200 barrels of fuel which stored on the deck above Modules B and C. Tertiary initiating event was the third violent explosion which collapses the structures of the platform. Around 10:20pm, a jet fire from broken riser. The fire pump was malfunction where the automatic pumps been turned off and manual pump diesel powered in Module D are also damaged by the failure of Modules C/D fire wall. Then, it followed by the ruptured of riser from Tartan to Piper Alpha platform caused by the pool fire beneath it. The pipe steel strength reduced because of the too high temperature and some more induced by internal pressures. That fire impinged on a gas riser from another platform, which fueled an extremely intense fire under the deck of Piper Alpha. Then intense impinged jet fire under the platform and MCP-01 gas risers failed was lead to the third violent explosion and makes the whole platform engulfed by fire.

Figure 6 Next morning platform structural collapse [1] Then explosions ensued, followed by the eventual platform structural collapse (figure 6) of a significant proportion of the installation and killed 165 workmen on the board and two men on board of a fast rescue vessel.

2.0 Management and operation

2.1 The management and its structures
Organizational Level Decision and actions level

Basic Events (component failures and operator errors) Figure 7 Hierarchy of root system failures [2] The management and structures of an organizational is very important. Figure 7 is hierarchy of root system failures which been analyzed by M.E Pate Cornell in his risk analysis on probabilistic approach and application to offshore platform. Main element of the accident sequence is based on the organizational level. It started from management decisions on how the leader doing his planning, decision, and assigning peoples. For each of any basic events, the human decision and actions will influence to their occurrences. The official investigation report written by Lord Cullen, faulted the companys management of safety on Piper Alpha. At the Primary Initiating Events, the superintendent of the platform (Offshore Installation Manager or OIM) panicked, was totally ineffective almost from the beginning. Then some confusion which leads to restarted of Condensate Pump A which resulted from failures to adhere the Permit To Work (PTW) system. The shift supervisors suppose to explain the permit before pass it to contractor and the contractor cannot simply write it off without reading it.

2.2 Objective of the management

Generally, according to the management structure for any actions or decision made on the platform of Piper Alpha at that time at first started from managers. Managers will give order to operator on the board. One of the objectives of the management was ensuring that all objectives of the subordinates are linked to the organizations objectives. On the same time, for better communication, coordination and interaction between superiors and subordinates helps to solve any problems.

3 Industrial Processes
There were some activities before the primary initiating events occurred. There were drilling, production, inspection and maintenance by some workmen and divers. Generally, the Piper Alpha Platform can be divided into four modules (Refer Figure 4). First would be the reservoir and Module A (Wellheads). The reservoir fluids were mixtures of crude oil, gas, water and sand. Then it will be brought to the surface through pumping a proportion of the 34 wells which connected the reservoir to the platform. The wellheads controlling the flow of the material extracted from the reservoir and also isolating the reservoir as required. The contents of the reservoir were kept in liquid state by the intense pressures generated there but by the time they had reached the surface during the extraction they had become gas and fluid. The extracted materials then transferred via pipeline to the manifold in modules B. The main function of the equipment in Module B (Separation) was to separate gas and produce water from the crude oil. The produced water was diverted to the water treatment package. Each of the separate flow lines from the wellheads in Module A passed through A/B firewall into manifolds in module B. There were separated manifolds for each of the production separators and a third for the test separator. The test separator will check the flow rate and composition of the well fluids so that at regular intervals oil from each well was routed into the test separators. Then the oil is thereafter transferring back to the production separator by a transfer pump. While the produced water being heavier than oil dropped to the bottom of the separators and interface between water and oil in the separators was regulated by a level control system and disposed of into the sea. The outline of the process in Module B was the gas that cooled and a small quantity of condensate which been collected and transfer it back to the production separators. Then the gas routed into Module C (Gas Compression) for further processing. The process equipment in Module C was designed to process the gas produced by the production from Module C (Separation). It been used to remove the condensate from the gas thus increase the pressure of the gas. The gas compression was achieved by the use of centrifugal and reciprocating compressors. As designed there were two compressing pumps known as Pump A and Pump B. The module D was located at the north end of the platform. At the eastern end of the module were the John Brown Turbines A and these were substantial pieces of equipment generating 13800 volts. It was located in cabinets about twelve feet high and most of the east end of Module D was occupied by these. There was the fuel gas heater in the adjacent to the C/D firewall at the eastern end. Next to the west within an enclosed area there was a diesel-driven firewater pump and adjacent to it was an electric-driven firewater pump which used to drew water from below the sea level.

4 Causes of accident
There are several causes that lead to the tragic accident. Human factor which involved with human actions linked to basic event of the accident are one of the main causes that lead to the tragic occurred. It can be blame from the peoples who design and build the platform but anything would start from decisions and actions. As we know, every single action we did will lead to some events which start from basic events. Each of these basic events have been influenced a number of decisions and actions. In the Piper Alpha case, some decisions or actions are clear errors and others may be acceptable based on the judgments at that time they made it. Basically their judgments in making decisions and actions can be labeled in four phases (figure 8).

Figure 8 [2]

4.1 Root and human factors

The root factor of the incident was the companys management of safety on the platform as stated in the official investigation report of the Piper Alpha Disaster written by Lord Cullen. In this report, root factor would be discussed together with the human factor because both of these factors are related. 4.1.1 Failures in the Management

First failure of the companys management on safety was the Permit to Work (PTW) system did not used properly. Then, there were inadequate communications which had contributed to fatalities and a civil conviction for the company but remedial actions have not been taken. As been discussed earlier in the Primary Initiating Events, Pump A was shut down for maintenance but the PTW was been simply signed off by the contractor. Then next shift workmen came and found out that Pump B was tripped and could not be started. They did not knew that Pump A under maintenance and accidently turn it to operational. Seconds, platform management reluctant to shut down or stop the operation after the first explosion occurred. The superintendent of the platform (Offshore Installation Manager or OIM) was panicked and did not have authority to stop exporting. It can be said that the command system failed during an emergency. The management has not given any emergency response training to new workers on the platform. Some workers even have not been shown the location of their life boat. Most of the platform managers also have not been trained well on how to respond to emergencies.

4.1.2

Failures during operation (Maintenance and Inspection)

The most critical maintenance problem was the failure of the Permit To Work system (PTW). On the Primary Initiating Events, the PTW has been signed off by the contractor without reading it. The permit supposes to be explained by the Shift Manager and the contractor also must read it first. The platform also was under operationally with lacking in inspection particularly in safety equipment. Life rafts, fire pumps or emergency lighting do not seem to have received proper attention. Another most critical maintenance problem was the carelessness with flange assembly without proper tagging, thereby putting Pump A out of service. The night shift was not informed of the situation and tried to restart the pump in which initially gas leak started. The assembly work was not inspected and therefore the leakages were not detected. The Fire water system also been set on manual which was not proper way of starting it in an emergency.

4.2 Design and Process Factors

Prior to the initial explosion, gas alarm were received in the main control room but because of the display of the signals origins in the detector module rack, the operator did not check where they came from since it was a false alert. The failure of gas detectors, fire protection (deluge) and emergency shutdown systems because of these some design systems deficiency. First was location of the detector module rack. Second, there was no automatic fire protection upon gas detection in west half of module C and primary automatic trip functions did not exist for operation safety in Phase 1of Modules C. The location of the control room next to the production modules created failure dependencies such that the fire and blast at Initial Primary Initiating events had a high probability of destroying the control room. With loss of command, control and loss of electrical power the system was technically decapitated. Lack of redundancies in the commands made it extremely difficult at that time to manually control the equipment. The Public address system was entirely dependent on electricity coupling among the backups of electric power supply caused a power failure then lead it to no sound. There were also designed bad location of the radio room and lack of redundancies in the communication system. The platform also has inadequate refuge area and refuge system.

5.0 Consequences of all the effects of the accident

The most invaluable prices as the consequences of the accident was life of 165 workmen (out of 226) on board and 2 men from the fast rescue boat which been sacrificed. It around 70% peoples on the platform dead resulted from the tragic accident. According to the Cullens report, there was US$ 3.4 billion cost in property damage and around 100 kg of hydrocarbons loss which containment to the marine but it only insured around US$ 1.4 billion by the Insurers Lloyd of London. It has make it at that time the largest insured man-made catastrophe [6]. There were no injuries been reported but according to the people who survived from the incident, some of them really badly injured and loss parts of their body. Roughly, most of the consequences of the accident cannot be valued it by money. Such as, peoples life, peoples feeling and suffering. We may not know how the families of peoples who died on the accident continuing their life. We did not know their sufferings and feelings. There were 167 families loss one of their siblings on the accident.

6.0 Improvement and prevention

Any accident can happen in anywhere at any time. It can happen, has happened can be happen again. We cannot be too easily satisfied on any whatever we have. We may not predict precisely when the accident will be happen but we can minimize the risk and avoid any accident to be happen. An accident is started from decisions which lead to the actions. As discussed earlier, a tragic accidents start from basic events which resulted from our actions. So, we are one who the making the decisions, actions and control the output.

6.1 Management and Human Resources

Any recruitment of new workers shall be exposing to the safety training and emergency response training. Platform managers must be train on how to respond to emergencies on other platforms and give order to the workmen on the board. Practice of Permit To Work (PTW) system must be put on high priority with regular audit and review of the system to make sure it is being used and is effective. All workers must been Training in use of the Short Messaging System (SMS) and training in understanding the risks of the operation.

6.2 Design and Process

Use tools such as QRA and ALARP to understand the risks and hazards Segregation of hazardous areas from control rooms and accommodations, use of firewalls, blast walls, protected control rooms and muster areas Active and passive fire protection systems Riser ESDVs properly positioned and protected A variety of evacuation and escape systems. Must be more than one route. Temporary Safe Refuge (TSR) to Prevent smoke ingress. Provide secondary escape equipments e.g. : ropes, ladders & nets Provide annual safety training. All new recruitment or existing employee must be exposed on emergency response training either twice or once a year. Regularly auditing and inspection on safety and health in the working places. Enforcement of law in workers Safety and Health.

6.3 Safety and Health

7.0 Conclusion
It was 23 years ago, 167 peoples killed and cost billions of dollars in properties damages in a most tragic oil and gas accident. It was caused by a massive fire, which was not result of an unpredictable act of God but an accumulation of errors and questionable decisions. It can happen, has happened and can be happen again. All of these events that led to the Piper Alpha accident rooted in the management, culture, design and structure and the procedures of Occidental Petroleum, some of which are to large segments of the oil and gas industry and to other industries as well. At the heart of the problem was a philosophy of production first and a production situation that was inappropriate for the personnels experience. The maintenance error that eventually led to the initial leak was the result of inexperience, poor maintenance procedures, and deficient learning mechanisms. Other than that, the system had been made without sufficient feedback and understanding of their effects on the safety of operations. The improper structural design was then lead difficulty if the worker to save their own life. We hope any companies management will not take any measures in order to save money in the short term which can lead to understaffed facilities and less experienced and overworked operators. With these condition operators are unable to focus specifically on accident prevention. It was the companies responsibilities to expose their employees to be always prepared for any accident or unwanted events occur with safety training and emergency response training.

8.0 List of reference

8.1 Fire in the night, The Piper Alpha Disaster by Stephen McGinty, ISBN -978-0-33047193-0 8.2 http://www.stanford.edu/group/mse278/cgi-bin/wordpress/wpcontent/uploads/2010/01/Learning-from-Piper-Alpha.pdf 8.3 http://en.wikipedia.org/wiki/Piper_Alpha 8.4 http://en.wikipedia.org/wiki/Occidental_Petroleum#Safety_record 8.5 http://wn.com/oxychem 8.6 http://wn.com/Piper_Alpha_Disaster_1998 8.7 http://gcaptain.com/piper-alpha-disaster-19-year-anniversary-of-tragedy?231 8.8 http://www.google.com.my/url?sa=t&rct=j&q=nasa%20piper%20alpha&source=web &cd=1&ved=0CBsQFjAA&url=http%3A%2F%2Fwww.aiche.org%2FuploadedFiles %2FCCPS%2FResources%2FKnowledgeBase%2FPresentation_Rev_newv4.ppt&ei= 0ajHTuPUO4nrrQfhw_ynDg&usg=AFQjCNGY5kjEhiB3UNu4eHMxjve6_rUknA 8.9 http://www.scribd.com/doc/45024732/Piper-Alpha-Disaster-Slides 8.10 http://www.scribd.com/doc/5034444/Piper-Alpha-Case-Study 8.11 http://www.scribd.com/doc/5070962/Piper-Alpha-Discussion 8.12 http://e-stud.vgtu.lt/users/?p=78007.56783&lang=en&id=4722 8.13 http://www.youtube.com/watch?v=v6m_IGymWfw&feature=relmfu 8.14 http://www.youtube.com/watch?v=CBlgEpdlvUE&feature=relmfu 8.15 http://news.bbc.co.uk/onthisday/hi/dates/stories/july/6/newsid_3017000/3017294. stm 8.16 http://edition.cnn.com/2001/WORLD/americas/03/20/oil.accidents/index.html?ire f=allsearch 8.17 http://www.dailymail.co.uk/news/article-1031994/The-day-sea-caught-20-yearsPiper-Alpha-explosion-survivors-finally-able-tell-story.html