Industrial and

Environmental Safety
 Part 1:

Accident Timeline and Bow-Tie

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 Accident Timeline
• During the day shift on July 6, 1988, an engineer responsible for undertaking the safety valve recertification work removed Pump A’s
pressure safety valve for examination and maintenance.
• The work could not be completed before 6 P.M shift change, so the engineer, blocked off the pipe by a hand tightened “blind flange”.
• The engineer had completed a permit, stating that Pump A was not ready for operation and must not be activated.
• At 9:45 P.M., an alarm sounds in the control room, signaling an issue with a condensate pump. The second shift was faced with a hydrate
buildup that blocked the gas compression system and the blockage resulted in failure of Pump B.
• At 9:55 P.M, assuming the pump A to be safe to use, one of the production operators attempted to start Pump A, in order to prevent the
failure of the offshore platform’s entire power supply.
• When the pump was activated, the gas pressure it created started to leak out from the blind flange, resulting in a significant gas leak that
was audible throughout the platform by triggering 6 alarms.
• At 10:00 P.M, before anyone could react, the gas ignited, resulting in the initial explosion in module C, containing the condensate oil. A
nearby boat captain reports a flash of a blue flame projecting out from underneath the platform.
• At 10:20 P.M, the firewall between module B and C, which were designed to protect the modules from the burning oil, crumbled, and
resulted in rupture of several oil lines, started multiple oil fires.
• At 10:50 P.M, the third explosion happened, third location of fire was not in or adjacent to the aforementioned modules, but rather in the
deck below all of these modules.
• At 11:20 P.M, the platform begins to collapse.
• At 00:45 A.M, the vast majority of the platform crumbled into the North Sea.

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 Accident timeline with respect to bow-tie

Human Error 15-30 tons of gas

Explosion in fueled the fire
Module C
Usage of blind flange Several Oil fires
Design Issues The vast majority of
to seal the pipe A started in Module B
6 alarms ring in control the platform crumbled
room. into the sea
Location-based
Rubber matting placed
permit system Hand-tightening
on the grated flooring
the flange Firewall between module Explosion at the
Lack of communication Leakage of gas Cost
Human Error C and B, failed to cope Explosion in Collection of oil deck below of the
between shifts & crews condensate in $1,500.000,000
Pump A with explosion Module B dripping in rubber modules
Failure of pump B
matting
due to hydrate
Wrong guideline for Alarm.
buildup. Rupture of condensate Superheating the 167 life lost
emergency
pipe in module B high pressure gas
Maintenance and Running the pump A, pipeline
production works for not reducing the
productivity 61 survivors dealt
at the same time
with psychological
damage
Not finishing up the
valve maintenance
during first shift

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 Part 2:

Apply Checklists and What-If Analysis

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 Materials and Flowsheet

• What materials are hazardous? Are any prone to form vapor clouds?

❖ 1- Natural Gas(Methane) 2- Liquide Petroleum Gas(Condensate) 3- Crude Oil(Petroleum)

❖ Yes, Liquefied Petroleum Gas (LPG).

o Which ones are actually toxic? Crude Oil

o Which ones are chronically toxic, carcinogenic, mutagenic, or teratogenic? LPG is toxic and possibly carcinogenic. Crude oil is toxic and

causes cancer (carcinogenic), also it may affect the female reproductive system and therefore may be teratogenic.. Natural Gas doesn’t

have chronic health effects in long term and is not carcinogenic.

o Which ones are flammable? LPG, Crude oil, Natural Gas

o Which ones are combustible? LPG, Natural Gas

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 Apply what-if analysis
What if? Consequences/Hazards
What if the condensate Pause in all offshore production on
pump trips? the Piper Oilfield and reduction in
productivity
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What if condensate is The hazardous and highly flammable
released in the process LPG will rapidly fill the area, and with
area? trigger can combust and release into
other modules.
What if blast walls are The highly flammable condensate will
not installed? burst into the module B, which is a very
dangerous place for being exploded,
since it contains crude oil and it creates
black smoke which is highly toxic.
ALMA MATER STUDIORUM – UNIVERSITÁ DI BOLOGNA
Safeguards Recommendations
Alarm. Make sure of the both permits of the pump and safety
Pump A as substitution can valve. Check the presence of the safety valve. Check
be used. the tightness of flange.
A number of alarms ring in Make sure that the alarms work by frequent checks.
control room. Make sure that valves and flanges are durable, by
Durable safety valve and regular testing and maintenance.
flange. Make sure not to simultaneously do the maintenance
Blast walls. work with production.
Assure the blast walls are resistant to the combustion
as well as fire.
Change the design of the Make sure that the design of platform is regulated
platform, such that the with the standards of the process safety, not for
module containing crude maximizing the production.
oil, not be adjacent to the
condensate.
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