accidents don’t have to happen

ACCIDENTS DON’T HAVE TO HAPPEN

Three elements of a successful safety process:

• Hazard analysis

• Pro-active planning

• Employee participation.

RECIPE FOR DISASTER

Piper Alpha was similar to other oil rigs. Yet there were some important differences:

• Design changes compromised crew and equipment safety.

• Changes to normal operating routine were normal practice.

• Few audits and quality checks to prevent unsafe practices.

RECIPE FOR DISASTER

• Limited personnel training on work permitting and emergency procedures

• Degraded work permit system

• Personnel not routinely drilled in emergency and disaster procedures.

continued

DESIGN CHANGES

When Piper Alpha was modified a hazard analysis would have shown:

• Potentially hazardous gas extraction equipment built close to the Control Room endangered people.

• Gas pipelines were installed close to oil piping.

• Blast walls were not installed.

NORMAL OPERATING PROCEDURES

• When divers worked near seawater intakes, fire control pumps had to be placed in MANUAL mode.

• But unlike other platforms, pumps were routinely switched from AUTO to MANUAL.

MANAGEMENT OF CHANGE

Two important processes were left out:

• Management of Change Procedure

• Process Hazard Analysis

WORK PERMITSAND AUDITSA strict work permit system with routine audits could have identified:

• Routine loss/misfiling of work permits

• Missing checks that ensured proper notification

• Weaknesses in personnel training

• Casual attitude toward work permits and safety

• Lack of communication between crucial personnel.

SAFETY – PART OF A PROCESS• Safety policies and procedures need to be

understood, followed and audited.

• Safety is everyone’s responsibility.

• Each time you act, weigh the risks of that action.

EMERGENCY ACTION PLAN

Regularly scheduled emergency and evacuation drills might have identified and corrected:

• Slowly operating extendable gangway on the Faros safety vessel

• No alternate escape routes in case of fire

• Not shutting down transfer operations on neighboring rigs

• No alternate emergency control space.

EMERGENCY ACTION PLAN

• Indecisive action in emergencies.

• Insufficient emergency evacuation training. Knowing your role in an emergency can save lives.

continued

IMPORTANCE OF TRAININGGood safety training covers:

• Work permit system

• Emergency and disaster action plans

• Changes to normal operating procedures

• Basic operational risk analysis

• Emergency shutdown procedures

• Roles, responsibilities and lines of authority.

LINES OF COMMUNICATIONClear lines of communication and authority are necessary in an emergency between:

• Maintenance and production personnel

• On-site and off-site facilities

• Emergency responders.

LINES OF COMMUNICATION

Routine emergency drills might have shown the need for better communication between all personnel.

Operating managers need authority to make difficult decisions quickly.

continued

SUMMARY

A complete safety program should include:

• Management of Change Procedures – for reviewing changes in design and to normal procedures

• Process Hazard Analysis (PHA) – to analyze risks and hazards of actions

• Work Permit System – strictly enforced and audited

SUMMARY

• Emergency and Disaster Plan – clearly defined steps and actions

• Training – classroom, hands-on and regularly scheduled emergency/evacuation drills

• Operational Risk Analysis – every worker, every day considering the risks of each action.

continued