Title:

Major Accidents - Can we Learn?

Synopsis:

Major accident hazards will always be present wherever oil or gas is produced,

transported or stored. Despite improvements in technical safety and sophisticated

integrity management systems, major accidents continue to occur. Possible reasons for

this are reviewed and improvements recommended based on the author's experience of

32 years studying major accidents and practical risk assessment.

Talk will last 40-50 minutes with questions at the end but I am happy to take questions

during the talk to clarify any points. I cannot go into great detail on the accidents

described in the time available but would welcome more detailed discussion outside the

meeting.

1

Title:

Major Accidents - Can we Learn?

Synopsis:

Major accident hazards will always be present wherever oil or gas is produced,

transported or stored. Despite improvements in technical safety and sophisticated

integrity management systems, major accidents continue to occur. Possible reasons for

this are reviewed and improvements recommended based on the author's experience of

32 years studying major accidents and practical risk assessment.

Talk will last 40-50 minutes with questions at the end but I am happy to take questions

during the talk to clarify any points. I cannot go into great detail on the accidents

described in the time available but would welcome more detailed discussion outside the

meeting.

2

Main headings in the talk.

Hope to show that whilst major accident hazards will always be present in the oil & gas

industry the risk of major accidents can be reduced by learning the lessons from the

past, understanding why they happened and taking care that all decisions are made with

due consideration as to their impact on risks from major hazards.

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Much has been written on past accidents and what we should learn but despite this……

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…. Accidents continuing to occur – many with the potential to kill tens, if not hundreds

of people and cause great environmental damage.

5

The list of past accidents includes major pipeline accidents. The required prevention

measures should be familiar to this audience.

6

Helps to define the most significant terms used when discussing major hazards.

Hazard refers to a situation with the potential for harm, risk is the likelihood of a

specified level of harm occurring expressed as a frequency or probability of, for example,

death. As in risk of death at a particular location is one in a million per year from a

major accident on a pipeline.

7

Perhaps the starting point for major hazard regulation and process safety development

in the UK although the Engineering Department at ICI would have disputed this as they

started – Hazard Studies in the 1960s

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What happened?

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Lessons learned – immediate reports and then the ACMH reports and eventually Seveso

1.

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World attention focussed on major accidents in the process industry.

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Process Safety Management regs in US, Major Hazards regulations in Australia and India,

Responsible Care started in Canada – World Bank Guidelines.

12

There were previous major accidents offshore but most involved structural or naval

engineering issues (Ocean Ranger). First major platform incident and the worst fire and

explosion offshore.

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The facts

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Deductions from the investigation and Inquiry.

15

Inquiry delved deeper into fundamental causes showing that Safety Critical Functions

were not identified as such and so not maintained, or even not considered.

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Lack of care by management – did not take account of what could happen.

NB First QRA studies on need for SSIVs etc were undertaken in 1984.

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Safety requirements based on key risk management principles, guided by specific

assessment / demonstration requirements

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17 years later – a galley worker on an Indian offshore platform cut his finger and this was

the result. Why?

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No helicopter available for evacuation so decided to take him off by boat which collided

with the riser… unaware of risks of platform design and previous recomendations

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Pipelines crossing foreshore in close proximity in tropical cyclone zone. ….

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Installed at different times – possible coating damage during installation of later lines.

Change in corrosion protection from imposed current to sacrificial anodes – no

assurance of complete coverage, consultants reports on need for checks ignored,

regulatory requirement / commitment to regular checks not followed – no follow-up by

regulator.

Lost gas supply to Western Australia – particularly mining areas around Kalgoorlie.

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Lessons learned from Flixborough – potential for blast effects from gas leaks. Codes not

adequate – consider hazard potential first then look at risk reduction. Inherent safety

principle – eliminate, then reduce potential – one way is to increase separation but still

may have some overpressure – don’t let building collapse / damage injure people.

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Integrity Management System did not consider accumulation of risks and concentration

because of plant layout. Not all hazards identified. Gaps in technical knowledge of

operators on site

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Not the first overfilling incident – similar problems at Pembroke Refinery in 1994, also

lessons from Longford not learned. Big issue of designers not understanding what

operators might do to their plants – gaps left in instrumentation that could have

diagnosed and given warning.

Local vents not replaced according to plan.

25

Several contraventions of company procedures and standards but allowed to happen by

management

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Summed up by lack of leadership in process safety

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From the various reports, including BP’s own.

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Rehearsal for Macondo

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Report Published June 2010 but facts were known before April.

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In many ways similar to Montara except major quantities of oil released.

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Just a few months after Montara which shared several contractors with Macondo

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It seems that hard won lessons from onshore accidents such as safety reviews of

proposed changes – ignored.

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Diverter not used early

Training for emergencies?

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Management of Change and Control of Wok processes not applied.

Other priorities – based decisions on perception not analysis.

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Risk increased by working practices rather than decreased

36

Process industry not alone.

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Some projects did learn (see also SAGE gas plant earlier)

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Other industries’ projects have set standards for care and consideration

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Unfortunately organisations do not have good memories and underlying causes of

accidents are not avoided for long. I am still saying

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Some improvements – Technical fixes are better and we are more aware of need to

improve human factors but other priorities sometimes allowed to take precedence and

erode process safety.

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Technical fixes

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Management and other human inputs.

Be aware of the major accident potential then reduce the risk – use inherent safety

methods in both technical and human factors improvements.

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Process Safety has high priority – at least as high as occupational safety

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Mindfulness - from CEO and CFO through leadership team, in design operations,

procurement and finance all decisions / actions can affect major accident risk.

Remember the chef’s cut finger?

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