The document provides background information on the Piper Alpha oil production platform disaster that occurred in 1988, killing 167 people. It discusses the platform's management and operations, industrial processes, and identifies multiple causes of the accident. The primary initiating event was an explosion caused by a condensate pump startup during maintenance, which allowed gas to leak and ignite. This led to secondary and tertiary explosions as fires spread and structures collapsed. Root causes included failures in the company's management of safety systems like permit-to-work and a lack of emergency response training and authority. Human errors also contributed through improper maintenance procedures and sign-offs.

1. 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 : Johnin Taimin
SEGI ID : SJCJ-0012043
UOS ID :
Lecturer : Miss Ida Fahani Md Jaye
Date : 29th November 2011

2. Table of Contents
Page No
Abstract
1.0 Introduction
1.1 Objective 1
1.2 General background about Piper Alpha 1
1.3 General purposes of the platform 2
1.4 The happening, effect and recovery of the incident 4
2.0 Management and operation 6
2.1 The Management and its structures
2.2 Objectives of the Management
3.0 Industrial processes 7
4.0 Causes of accident 8
4.1 Root and human factors
4.2 Design and process factors
5.0 Consequences of the effect of the accident 10
6.0 Improvement and prevention 10
6.1 Management and human resources
6.2 Design and process
6.3 Safety and health
7.0 Conclusion 11
8.0 List of references 12
9.0 Appendix
i. Viper plagiarism report

3. Abstract
We’re all human. We make mistakes and forget things. Our attention span is limited. We
overlook crucial evidence in making decisions. We believe we’re 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.

4. 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 company’s management on safety on the Piper Alpha Platform.

5. 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

6. had once been the world’s 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.

7. 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 didn’t know that the Pump ‘A’ shut down for maintenance which the

8. 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.

9. 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 company’s
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 organization’s objectives.
On the same time, for better communication, coordination and interaction between
superiors and subordinates helps to solve any problems.

10. 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.

11. 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 company’s 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 company’s 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.

12. 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.

13. 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 Cullen’s 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, people’s life, people’s 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.

14. 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
6.3 Safety and Health
 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.
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
personnel’s 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.

15. 8.0 List of reference
8.1 Fire in the night, The Piper Alpha Disaster by Stephen McGinty, ISBN -978-0-330-
47193-0
8.2 http://www.stanford.edu/group/mse278/cgi-bin/wordpress/wp-
content/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-years-
Piper-Alpha-explosion-survivors-finally-able-tell-story.html