Learning from the Piper Alpha Accident: A Postmortem Analysis of Technical and Organizational Factors

ABSTRACT

The accident that occurred on board the offshore platform Piper Alpha in July 1988 killed 167 people and cost billions of dollars in property damage. It was caused by a massive fire, which was not the result of an unpredictable "act of God" but of an accumulation of errors and questionable decisions. Most of them were rooted in the organization, its structure, procedures, and culture. This paper analyzes the accident scenario using the risk analysis framework, determines which human decision and actions influenced the occurrence of the basic events, and then identifies the organizational roots of these decisions and actions. These organizational factors are generalizable to other industries and engineering systems. They include flaws in the design guidelines and design practices (e.g., tight physical couplings or insufficient redundancies), misguided priorities in the management of the tradeoff between productivity and safety, mistakes in the management of the personnel on board, and errors of judgment in the process by which financial pressures are applied on the production sector (i.e., the oil companies' definition of profit centers) resulting in deficiencies in inspection and maintenance operations. This analytical approach allows identification of risk management measures that go beyond the purely technical (e.g., add redundancies to a safety system) and also include improvements of management practices.