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On July 6, 1988, a series of
catastrophic explosions and fires destroyed the platform. Of the 226 people
on the platform at the time of the event, 165 died along with two emergency
response personnel during a rescue attempt. The platform was totally
destroyed.
Investigation was hindered by
a lack of physical evidence. Based upon eyewitness accounts it was concluded
that a release of light hydrocarbon occurred when a pump was restarted after
having been prepared for maintenance. Unknown to the workers starting the
pump, a relief valve in the pump discharge had been removed for maintenance.
A blank had been loosely installed in place of the relief valve at a location
which was not readily visible from the pump vicinity. When the pump was
started this blank leaked, producing a flammable cloud, which subsequently
found an ignition source. The pump was started at about 10 PM, and by 1 AM,
three hours later, the platform had been entirely destroyed and most of its
occupants had been killed.
As would be expected in a
disaster of this magnitude, the investigation identified many root causes
related to design operation, safety culture, emergency response, and
training. Two issues are highlighted below which are particularly relevant to
all oil and gas plant operators.
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What went wrong:
·
In adequate
maintenance and safety procedures.
·
Poor
communication between operators.
·
Lock out/Tag
out are not properly followed.
·
Failure to
comply permit to work system.
WHAT CAN YOU DO:
Working with a Permit to Work:
·
Strict
adherence to the requirements of the Permit to Work.
·
No alterations
to the Permit to Work after issuance.
·
Displayed in
the workplace.
·
Cancelled when
changes to the agreed Safe Systems of Work are needed.
·
Returned to
permit issuer on task completion or when time limit is reached.
·
Lost Permits to
be reported to permit issuer immediately.
·
Supervisor/
Management to monitor implementation of permit systems at all times.
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