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 PERMITS AND AUDITS A 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 TRAINING Good 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 COMMUNICATION Clear 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