Piper Alpha Tragedy Causes

2.0 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. 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.

2.1 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

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

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