Episode 12 – Piper Alpha

Piper Alpha Overview On the 25th Anniversary of the destruction of the Piper Alpha oil platform, everyone is discussing the importance of not forgetting the lessons of Piper Alpha. What are those lessons though? Hindsight bias can often let us believe that accidents are caused by extreme incompetence or reckless disregard for safety. These simplistic explanations convince us that disaster could never happen to us. After all, we do care about safety. We do try to do the right thing. We have good safety management, don't we? The scary truth is that what we believe about our own organisations, Occidental Petroleum believed about Piper Alpha. As well as the usual description of the accident, this episode separately delves into the design and management of Piper Alpha. In each segment, we extract themes and patterns repeated across multiple systems, multiple procedures, and multiple people. Design From a design point of view, there were four major failings on Piper Alpha, all teaching lessons that are still relevant. Failure to include protection against unlikely but foreseeable events An assumption that everything would work, with no backup provision if things didn’t work. Inadequate independence, particularly with respect to physical co-location of equipment A design that didn’t support the human activity that the design required to be safe Organisation There are three strong patterns in the management failings of Piper Alpha. A lack of feedback loops, and an assumption that not hearing any bad information meant that things were working. A tendancy to seek simple, local explanations for problems, rather than using small events as clues for what was wrong with the system An unwillingness to share and discuss information about things that went wrong Additionally, there were severe problems with the regulator - not a shortage of regulation, but a shortage of good regulation. Transcript for this episode is here.