Cause & Effect Analysis

As an operator who works in oil and gas industry, I will present a life incident in one of the oil and gas location called Piper Alpha disaster UK. Piper Alpha was a North Sea oil production platform operated by Occidental Petroleum (Caledonia) Ltd. The disaster began with a routine maintenance procedure. On the morning of the 6th of July, a certain backup propane condensate pump in the processing area needed to have its pressure safety valve checked. The work could not be completed by 18.00 and the workers asked for and received permission to leave the rest of the work until the next day. The tube was sealed with a plate. Later in the evening during the next work shift, the primary condensate pump failed. None of those present were aware that a vital part of the machine had been removed and decided to start the backup pump. Gas products escaped from the hole left by the valve and lead to an explosion and resulting fire that destroyed the platform on July 6, 1988, killing 167 men, with only 59 survivors. The death toll includes 2 crewmen of a rescue vessel. Total insured loss was about £1.7 billion (US$ 3.4 billion). The generation and utilities module, which included the fireproofed accommodation block, slipped into the sea. The largest part of the platform followed it; the whole accident took place in 22 minutes. That was the end of Piper Alpha.

What went wrong? The fishbone diagram identifies some possible cause and effect.

METHOD/PROCEDURE
ENVIRONMENT
MATERIAL
MANPOWER
MACHINE
Poor leadership
Poor maintenance
PTW risk assessment use incorrect
Absence of blast wall
Inadequate maintenance/safety procedure
Poor practice /audit complacency Lack of communication between crew shift
Lack of training
Deluge fire system turnoff
Primary condensate pump failed
No quality checking on production line
Poor production planning
Poor isolation of maintenance
Heat, smoke and fire
Hazardous area
Carbon monoxide/fumes
Piper Alpha disaster UK