THE explosion and fire that occurred on the Piper Alpha rig in the North Sea changed many aspects of what we now do in process safety. Much has been written on the sequence of events, and on the 30th anniversary it is important for us to reflect and think about the 167 souls that lost their life that day. It can be said that a significant systemic failure in this incident was due to the permit-to-work system and inadequate handover communication, there were several other factors which played a part in the escalation of the incident.
Management of change also played a part, as the rig had originally been designed to handle oil and was converted to handle gas as well, without the fire walls being changed to blast walls. In addition to this, the workers were not clear on how to evacuate from the rig in an instance like this one. They waited in the accommodation deck to be rescued by helicopter, but no helicopters were able to land because of the smoke and fire. There were also cultural elements present with the interconnected rigs continuing to pump oil and gas to Piper Alpha when they could not reach them on the radio or phone and felt unable to make the decision to stop pumping without instruction. The fire pumps were also temporarily inhibited at the time of the incident.
This tragedy led to implementation of safety case legislation in the UK North Sea, and this has flowed to a number of locations around the world. Accepted practices and standards have also evolved. Permit-to-work systems have become more thorough, and shift communications have been a constant focus on facilities, both on shore and off. The management of fire protection systems as well as the standard platform designs have evolved to address elements of the Piper Alpha accident. For example, when inhibiting fire protection systems, a number of insurance companies now require written notification when this is put in place and removed, thus raising the focus on the serviceability of the systems.
While we have not seen anything of the magnitude of Piper Alpha, sadly we are still seeing significant offshore incidents occur internationally, where lives are being lost and the environment is being harmed.
So the question here is why have we not learnt from this and other tragedies? What is it about how we take in and process information that prevents us from taking every action to not make the same mistake? Humans seem to have a preference to learn from experience, but when it comes to process safety this can often be tragic, with multiple fatalities.
There is no shortage of lessons and case stories available, yet we seem to fall into the trap of thinking “it won’t happen to me because I would never make that mistake”.
In IChemE we have been doing some work on trying to give people an experience by focussing them on the context behind decisions rather than just the decision. The medium for this has been the ISC Case Studies, where the audience plays a role as the event unfolds by watching short videos, and then asks them to make a key decision, without disclosing the consequences of the decision. This creates the experience where the participant has made the same decisions that triggered the incident, without the pain of the consequences.
“For a long time, people were saying that most accidents were due to human error and this is true in a sense but it's not very helpful. It's a bit like saying that falls are due to gravity.”Trevor Kletz
This same process can be used within your own organisation, but challenging what the drivers for decisions were. So in Piper Alpha, what context and organisational factors led to it being acceptable to not fully blank the pipe where the relief valve had been removed? Focussing on the human error aspect of this is not helpful in preventing it occurring again. As Trevor Kletz once said: “For a long time, people were saying that most accidents were due to human error and this is true in a sense but it's not very helpful. It's a bit like saying that falls are due to gravity.”
We need to get better at this learning, because as Sir Brian Appleton reminded us in the Piper Alpha inquiry: “Safety is not an intellectual exercise to keep us in work. It is a matter of life and death. It is the sum of our contributions to safety management that determines whether the people we work with live or die.”
The next time you do an accident investigation in your organisation, ask yourself, what was the context in which the fateful decisions were made. Once you understand that context, that is something you can take remedial action on.
We have added fresh perspectives each day in the run up to the 30th anniversary of the Piper Alpha tragedy. Read the rest of the series here.