RISK MANAGEMENT FAILURE

(Case Study)

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
 Risk Management

Construction Operation Post

Design Phase Phase Phase incident

Safe Design Risk Control Rehabilitation

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
 Petrobras

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
 Risk Management

Construction Operation Post

Design Phase Phase Phase incident

Safe Design

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
"Petrobras has established new global benchmarks for the generation
of exceptional shareholder wealth through an aggressive and
innovative program of cost cutting on its P36 production facility.
Conventional constraints have been successfully challenged and
replaced with new paradigms appropriate to the globalize corporate
market place. Through an integrated network of facilitated workshops,
the project successfully rejected the established constricting and
negative influences of prescriptive engineering, onerous quality
requirements, and outdated concepts of inspection and client control.
Elimination of these unnecessary straitjackets has empowered the
project's suppliers and contractors to propose highly economical
solutions, with the win-win bonus of enhanced profitability
margins for themselves. The P36 platform shows the shape of
things to come in unregulated global market economy of the 21st
Century.”

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
 QUALITY
ASSURANCE
AND THE
SINKING
OF THE
LARGEST
OFFSHORE
OIL
PLATFORM
March 2001
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
 For those of you who may
be involved in project cost
control (at whatever level),

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
 please read this quote from a
Petrobras executive,

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
 extolling the benefits of
cutting quality assurance
and inspection costs,

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
on the project that
sunk into the Atlantic
Ocean off the coast of
Brazil in March 2001.

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
"Petrobras has established new
global benchmarks for the generation
of exceptional shareholder wealth

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
through an aggressive and innovative programme
of cost cutting on its P36 production facility.

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
Conventional constraints have been successfully challenged

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
and replaced with new paradigms appropriate to the
globalised corporate market place.

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
 Through an integrated network of
facilitated workshops,

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
the project successfully rejected the established constricting and
negative influences of prescriptive engineering,

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
onerous quality requirements, and
outdated concepts of inspection and
client control.

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
Elimination of these unnecessary straitjackets has empowered the
project's suppliers and contractors to propose highly economical
solutions,KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
with the win-win bonus of enhanced
profitability margins for themselves.
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
 And now you have seen
the final result of this
proud achievement by
Petrobras.

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
Case Study

GAS PIPELINE EXPLOSION

BELGIUM
June 30th 2004

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
 Risk Management

Construction Operation Post

Design Phase Phase Phase incident

Rehabilitation

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
Gas Pipeline Explosion

Date: June 30th 2004

Location: Gellingen, Belgium
Zeebrugge to France gas pipeline
Content: Natural Gas, 80-100kg/cm2
Cause: Rupture of pipeline
Ignition: Ignition after 1 hour
Fatalities: 20 - (All fire brigade killed instantly)
Damage: All nearby buildings destroyed

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
Gas Pipeline Explosion

The Fire

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
Gas Pipeline Explosion

The Cause

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
Gas Pipeline Explosion

The Damage

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
Gas Pipeline Explosion

The Casualties

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
Case Study:

GRANGEMOUTH
HYRDROCRACKER
EXPLOSION
(March 1987)

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
 Risk Management

Construction Operation Post

Design Phase Phase Phase incident

Risk Control

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
Case Study: Hydrocracker Explosion
Wax and heavy
feed
Feed
surge
drum
Recycle hydrogen gas
compressor
Reactor

Reactor Reactor
effluent Hydrogen make
up
HP
Reactor separator
Gas to
Reactor Fin fan HP/LP separator amine
cooler valve system sulphur
removal
Liquid plant
Heat exchangers LP separator
Recycle Fraction-
waxy ation Liquid To
residue fractionator
Light products

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
Case Study: Hydrocracker Explosion
Gas

Reactor Float & nucleonic HP/LP

effluent gauges
Separator
HP control
Separator
system
Liquid

Valve A
LP pressure relief
to flare

To amine plant
Gas
Bypass
LP
Separator

Liquid
To
Valve B fractionator

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
 Case Study: Hydrocracker Explosion

Investigation revealed that:

• valve A did not trip shut due to disconnected solenoid
• the solenoid on valve B was also disconnected
• alarm had failed bulbs, audible alarm regarded as spurious
• low low level inoperative due to poorly maintained switches
• not all interlocks & alarms on routine proof test

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
Case Study: Hydrocracker Explosion

Disconnection of valve solenoids is a plant change

and should have been subject to a
MANAGEMENT OF CHANGE PROCEDURE

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK
 THE END

KMI – RISK MANAGEMENT WORK SHOP – CASE STUDY Ir. Wito Sugiono MKKK