Piper Alpha Oil Rig Fire - Assignment Example

 Piper Alpha Oil Rig Fire Executive Summary One hundred and sixty seven men lost their lives, including both crew and rescue personnel, on July 6, 1988 when the Piper Alpha Oil Rig experienced catastrophic explosions caused by management and process oversights. Piper Alpha had two condensate pumps, pump A and B, which carried compressed gas. The evening prior, maintenance to pump A had been authorised, however the repairs were left unfinished and a temporary seal was placed on Pump A along with a safety permit indicating the pump was not to be utilised. During the course of the evening, the permit and information about the dangers of Pump A had been misplaced, through the change of staffing which occurred overnight, thus the cause of the explosion when Pump A was turned on and gas began to leak out of the network of piping on the rig. Professor James Reason developed a model known as the Reason Error Prevention Model or the Swiss Cheese Model which suggests that gaps in process or management can lead to on-the-job hazards or accidents (in an environment such as Piper Alpha), with these gaps requiring closure in order to provide effective management and successful adherence to process guidelines. This report identifies certain managerial and process breakdowns which occurred in 1988 on Piper Alpha in order to highlight how better to manage organisational risks, especially in an environment prone to dangerous hazards. Piper Alpha managerial breakdowns Reason’s model suggests that human error is a natural evolution in any business environment and should be considered when creating a leadership or management model. Lack of concentration, carelessness or forgetfulness are human failings and are going to be present in the organisational design, thus leading to undesirable business outcomes. Further, Reason claims that “adverse events are the product of latent conditions (pathogens) within the organisational system” (Reason, 2008, p.7; Jeffries, 2005). By this, Reason means that even the most detailed and sophisticated management models, maintaining a strong focus on safety and adherence to policy, can still be interrupted by humans or organisational pathogens and lead to workplace hazards. At Piper Alpha, the disaster cost the company $1.4 billion in USD (Peterson, 1991). The pathogen which existed during this time period was failure for safety workers and managers to perform follow-up with on-duty managers after changing shifts overnight. Even though the permit system had been established to ensure that machinery experiencing maintenance was isolated and closed off, shift leaders did not record the event in any appropriate log nor was the maintenance of Pump A discussed during shift changeover. From a process perspective, the contractor working on Pump A had signed off on the work and indicated with an appropriate safety tag that the Pump should be isolated. However, managerial intervention eventually made this tag disappear from the organisational environment, thus the proverbial hole in the cheese. From Reason’s perspective, as a means of filling these gaps in process, there should be a stricter focus on training and ensuring that managers understand the tremendous risks involved with an oil rig safety process. What Piper Alpha had been utilising was a permit-to-work system which experienced a managerial breakdown, thus the next shift was completely unaware that turning on Pump A could cause a devastating explosion. The pathogen in this case was an ongoing failure of management to ensure that all aspects of safety were observed and failing to adhere to communications protocols between shifts. If Piper Alpha had been more safety focused and provided the knowledge and training necessary for managers to realise the importance safety auditing, accident causation, and the overall importance of having a safety culture, likely the holes in Piper Alpha’s management system could have been closed with more thoughtful managerial intervention. Christodoulou (2001) offers that if managers are informed of the tangible costs of accidents, it can provide a more safety-oriented culture. There is also a pathogen which existed at Piper Alpha involving the bureaucratic organisational structure governing the rig. Change in this type of organisation is top-down and tends to be inflexible, but can be dysfunctional in an unstable environment (Airline Pilots Association, 2006), such as a risk-filled oil platform. To the full knowledge of senior leaders at the time, Piper Alpha maintained a metallic structure with no fireproofing whatsoever where “structural integrity could be lost with 10-15 minutes if a fire was fed from a large pressurized hydrocarbon inventory” (CCPS, 2005, p.3). Senior decision-making, at the highest levels, regarding profitability versus expenditure put workers into an unsafe situation especially with the recent installation of gas pipelines from a rig which had originally been developed for oil extraction. The fire on Piper Alpha spread so quickly and could likely have met with much less loss of life had the structure, itself, been retrofitted with some sort of fireproofing to protect workers. The senior level pathogens were mentioned because it was already known that structurally, Piper Alpha was a danger in event of fire. Reason’s model was designed to offer insights into different holes in leadership and process which require filling in order to prevent workplace hazards. A form of internal analysis is required to make sure that these holes do not exist as part of a risk management focus and to protect business interests. Not long after the explosion, personal injury claims further complicated the legal process when an employee won an undisclosed settlement for post-traumatic stress disorder caused by experiencing the disaster (Parkes, 1996). There was clearly a dysfunction between senior management thinking in regards to ensuring a higher profit margin and reducing costs, therefore avoiding the much-needed retrofitting for fireproofing Piper Alpha. Had leadership realised that safety was more important than business economics, such safety improvements would have been considered prior to installing new gas pipelines which could have led to faster containment of the spreading fires. In this case, senior level oversight and distorted business focus led to long-term risks and heavy financial payouts for the business’ failures. Senior-level job role auditing could have been an internal defence against continuing operations on a rig not equipped with structural safety technologies. Evacuation drills also were not conducted according to policy at Piper Alpha, which should have been conducted weekly based on safety laws at the time (CCPS). This represents fundamental holes in the process of safety at the rig where managers either did not deem these drills vital to future safety or simply were complacent in their leadership efforts. The evacuation process, after the explosion, was complicated by many different problems, thus the loss of life was much larger than it needed to be. One year prior, senior leaders had read a report which warned that a gas fire could cause significant problems with successful evacuation, but this report was ignored (CCPS). The evidence suggests yet another senior-level pathogen in the system, under Reason’s model, where complacency and the assumption that operations will not steer toward disaster were holes in the process. Better crew management would have consisted of routine evacuation drills for different accident scenarios (such as gas versus oil leaks or explosions) to familiarise workers with their different evacuation options and strategies. In retrospect, auditing of employees and the system should have indicated that these evacuation drills were not being completed appropriately, thus closing the hole which ultimately led to disaster on Piper Alpha. “A key safety challenge now is asset integrity as platforms continue to work beyond their design life” (Izundu, 2008, p.26). Piper Alpha was constructed in 1976 and was solely designed for oil extraction from beneath the ocean floor. As the business began to diversify its business opportunities, this is what led to the implementation of natural gas pipelines, which was already identified as being irresponsible without the necessary safety retrofitting. Piper Alpha was already 12 years old and had been in continuous operation since its development, therefore requiring more maintenance to keep operational than other newer platforms. Legislators identified that poor plant design had been a catalyst which fuelled the explosion and made the resulting loss of life significantly higher (Hibbert, 2008). Under Reason’s model, even the best safety protocols and communications systems cannot be considered adequate if there are structural, age and design issues on an oil platform. These were realisations which were made after the explosion and nearly two years of investigation were conducted into what caused the problems. Had Reason’s model been a part of Piper Alpha’s management philosophy, internal analysis would have revealed design dysfunctions or created back-up plans in the event of catastrophic failure of both gas pipes. Successful operations as well as positive crew management start with ensuring that the environment is equipped for operating beyond its design life and is actually built to support radical new raw materials extraction processes. During the explosions, the control room was destroyed, therefore critical information needed to ensure that evacuation was successful could not be relayed to workers trying to escape the spreading fires. None of the manuals, safety or evacuation protocols took into consideration the possible event of control room destruction, therefore there was no back-up plan in place for communicating information to workers spread across the platform. It seems as though there was a sort of free-for-all in evacuation with no direction occurring. Reason’s model would represent this as a pathogen within the business, where contingencies have not been considered in all safety and evacuation scenarios. If the oil rig relies on information from a centralised source, it is not unrealistic to assume that this singular communication medium could be destroyed in a catastrophe on-board. An analysis of safety protocols could have created alternative communications efforts such as the use of pagers (which were common in the late 1980s) or alternative loudspeaker locations set up across the rig so that important communications can continue. There was no back-up communications system in place, yet another proverbial hole in the organisational system at Piper Alpha. Conclusion The largest problems at Piper Alpha were management oversight and failure to create contingency/back-up scenarios in all aspects of safety protocol and safety adherence. Clearly, senior level administration was complacent and/or focused on incorrect business strategy, thus they were not aware of the different holes which could, and did, eventually lead to an on-board catastrophe. Reason’s model might suggest that an overhaul of existing leadership to place a more competent and audit-focused group would be better to close the gaps between process and human effort. Failure to identify on-board activities using verbal and non-verbal (the logs) communication represented yet another fundamental problem which linked a hazardous outcome with organisational structure and process efficiency. It is imperative to understand what type of maintenance efforts are occurring on previous shifts and ensure that all members who have any type of contact with or responsibility for gas pumps understand how to continue operations safely after shifts have changed. However, there was a management complacency which existed at Piper Alpha which likely led to communications breakdowns, further holes in the rig’s organisational and safety policies. For better crew management, Piper Alpha leaders should have recognised where failures existed in relation to safety and devoted the financial resources necessary to develop training better, improve managerial communications, and ensure a tangible, safe environment for carrying out operations. Even though the permit-to-work system was already in place, it was human error and human distraction which led to the negative outcomes on this oil rig. It is likely that these barriers or pathogens could have been identified with a more thorough safety and managerial analysis to work these pathogens out of existing process and create a more efficient, non-complacent group of oil rig workers and leaders. References Airline Pilots Association. 2006. Background and fundamentals of the Safety Management System for Aviation Operations. 2nd ed. Accessed 7 Oct 2009 from http://ihst.rotor.com/portals/54/aviation%20SMS%20Background-fundamentals.pdf. CCPS. 2005. Building process safety culture: Tools to enhance process safety performance. Center for Chemical Process Safety. Accessed 8 Oct 2009 from http://www.aiche.org/uploadedFiles/CCPS/Resources/KnowledgeBase/Piper_Alpha.pdf Christodoulou, Andrew. 2001. Preventing disaster from the top. The Safety & Health Practitioner, Borehamwood. 19(8), pp.34-37. Hibbert, Lee. 2008. Averting disaster. Professional Engineering, St Edmunds. 21(11), pp.20-23. Izundu, Uchenna. 2008. UK oil industry reflects on Piper Alpha lessons. Oil & Gas Journal, 106(45), pp.26-28. Jeffries, Bill. 2005. Safety: The accidental organisation – Lessons from the transport sector, Is your organisation a pathological, bureaucratic or generative one? New Zealand Management, Auckland, p.40. Parkes, B. 1996. Psychiatric injury: Go ahead for stress claim made five years after Piper Alpha tragedy. IRS Employment Review, London. Iss. 603, p.H16. Peterson, Richard C. 1991. Putting risk managers on the solvency alert. Risk Management. 38(6), pp.26-31. Reason, James. 2008. Human Factors in Patient Safety. University of Manchester, UK. Accessed 8 Oct 2009 from http://www.patientsafetycongress.co.uk/files/james_reason.pdf Read More