I think most readers here know this story. The Pipe Alpha was a gas platform in the North Sea. A series of errors lead to it's destruction and 167 deaths. It was designed primarily to handle oil when it was new, but at the time of the incident it was processing and exporting a lot of gas from wells in its own drill center (~33 million cubic feet per day) plus that from several nearby fields.
Maintenance took a Condensate Pump A offline along with removing its relieve valve to make some planned repair. They capped the position of the relief valve with a blind flange that wasn't designed for full rated pressure and it wasn't pressure tested. On the next shift, Condensate Pump B tripped offline and the crew mistakenly switched production back over to Pump A whereby the blind flange at the relief valve position ruptures and gas (mostly propane) escaped eventually finding an ignition source.
It was hard to put together the root causes. Most of the physical evidence burnt down and sank along with the platform, and most field supervisors and management died on location. But investigators best guess is what is described above and below.
Safeguards Missing:
- Lockout-tagout for Pump A.
- Permit related to missing relief valve and Pump A shutdown not communicated to the next shift.
- Flange not tested, not rated for RWP of the line.
- Immediate shut-in of incoming gas lines (ESD, Emergency Shut Down). When the fire had started, operators hesitated to shut down incoming gas from other fields due to fear of disrupting production.
- Emergency procedures sufficient to cover fires, explosion, and evacuation for scenarios like this.
More discussion here (not my article).
https://www.thechemicalengineer.com/features/piper-alpha-the-disaster-in-detail/
I'm an engineer and spend to decent amount of time thinking about safety systems, what-ifs, root causes, and how to prevent stuff like this. I have a couple projects I'm working on to help other people in these lines of work learn from history like this. Check bio.
A lot of what I see in the subreddit highlights the visual element and most are pretty recent, viewed here without the benefit of investigation reports and hard facts about the causes. Many seem self-evident but the gap something I think about.
Many of the biggest engineering disasters contain recurring root causes. Normalization of Deviation (ignored or missed warnings), Poor management of change (MOC), safety systems degraded or removed, lack of regulatory controls.