The Piper Alpha’s tragic chain of events occurred because of a number of safety procedures were not met or implemented. The almighty dollar was given preference over the safety of hundreds of lives. We found a number of unsafe situations that could have been avoided if the right Safety management system was in place. These are our findings.
1. The oil rig recently introduced a new gas pipeline in the weeks leading up to the disaster. The rig wasn’t designed to be a gas provider in the original building stage. The one meter wide pipes weren’t designed well enough to cope with 1000-degree heat. No risk assessment was conducted on the quality of the pipes.
2. The oil pipeline was not shut down as the work upgrade on the gas pumps continues. Several small leaks were noted, but not concerned about. Procedures were over looked, as this risk was a common occurrence.
3. Pressure valve was removed from pump A during servicing and replaced with a thin plate. Time was up on that shift and the engineer wasn’t prepared to do over time to replace valve. Costs were put before safety.
4. Engineer filled out the permit to work form; this is to let everyone know that pump A was out of action. Two permits were filled out that day and they became separated. The permit that had the information on it about the valve only made it to the Shift supervision desk and not acknowledged by the supervisor as receiving it. The communication from the engineering was unacceptable because he was too impatient to wait a few minutes to correctly inform the supervisor of the situation. (Engineer was to caught up in finishing his shift to worry about the safety of others).
5. The automatic fire pump system was switched over to manual override position while the maintenance on the valve was taking place. This was to protect divers in the water from getting sucked up during a fire. The risk should have been known before hand and the divers should be aloud to dive while