THE UNIVERSITY OF DODOMA

COLLEGE OF EARTH SCIENCES AND ENGINEERING (COESE)

DEPARTMENT OF PETROLEUM AND ENERGY ENGINEERING.
COURSE TITLE: Health, Safety and Environmental Management

COURSE CODE: PE 423.

DEGREE PROGRAM: BSc In petroleum engineering.

INSTRUCTOR: Prof. Godlisten Kombe.

NATURE OF THE WORK: Group Assignment.

S/N MEMBER’S NAME REGISTRATION NO.

1 KIVANDIKO, SAFIYUNA M. T/UDOM/2020/05796
2 MSECHU, RAJABU H. T/UDOM/2020/09398
3 AMEIR, MARYAM H. T/UDOM/2020/09402

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Contents
ABSTRACT ................................................................................................................................................ 3
INTRODUCTION ....................................................................................................................................... 4
METHODOLOGY ...................................................................................................................................... 5
FINDINGS................................................................................................................................................. 6
1. BLIND OPERATIONS ..................................................................................................................... 6
2. DESIGN ........................................................................................................................................ 7
3. EXTERNAL CAUSES ...................................................................................................................... 9
4. INSPECTION AND MAINTENANCE ............................................................................................. 11
5. KNOWLEDGE AND TRAINING .................................................................................................... 12
6. HAZARD IDENTIFICATION (HAZID)............................................................................................. 14
7. MANAGEMENT OF CHANGE ..................................................................................................... 16
8. NOT LEARNING FROM NEAR MISSES ........................................................................................ 17
9. OPERATION PRACTICE ............................................................................................................... 19
10. PERMIT TO WORK SYSTEMS (PTWS). .................................................................................... 21
11. HUMAN FACTOR.................................................................................................................... 22
RECOMMENDATION .............................................................................................................................. 24
CONCLUSION ......................................................................................................................................... 26
References............................................................................................................................................. 27

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ABSTRACT
This study explores into the complexities of accident causation within the oil and gas industry.
By analysing a comprehensive database of oil spills, explosions, fires, and equipment failures,
the research dissects the underlying roots of these incidents, revealing a concerning interplay
of human error, equipment malfunctions, environmental factors, and organizational
shortcomings. Human error, often stemming from insufficient training, fatigue, or inadequate
situational awareness, emerged as a pervasive theme. Equipment failures, ranging from faulty
valves to lax maintenance practices, were recurrent contributors. The influence of
environmental forces, such as extreme weather or natural disasters, was also identified as a
potential catalyst for accidents. Notably, the study exposes the significant role of organizational
deficiencies, encompassing inadequate safety protocols, communication breakdowns, and
ineffective risk management systems, in fostering hazardous situations.

This investigation yields valuable insights for accident prevention and mitigation. The research
underscores the critical need for comprehensive training programs, a culture of safety, and
improved communication channels to minimize human error. The study emphasizes the
importance of robust equipment inspection protocols, enhanced maintenance practices, and the
adoption of advanced monitoring technologies. Additionally, it highlights the necessity for
designing infrastructure resilient to environmental risks and implementing well-defined
emergency response plans. Furthermore, the research advocates for organizational changes,
including the establishment of effective safety management systems, regular audits, and a
culture of accountability, to address accident risks arising from organizational shortcomings.

Beyond the immediate findings, the study emphasizes the importance of cross-industry
collaboration and knowledge sharing as a powerful tool for preventing future accidents. By
analysing and disseminating lessons learned from these incidents, the research aims to serve as
a valuable resource for policymakers, regulators, and industry stakeholders in developing more
effective safety standards and guidelines. Ultimately, this investigation strives to contribute to
a safer oil and gas industry, protecting workers, the environment, and the public from the
inherent hazards associated with its operations.

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INTRODUCTION
The oil and gas industry is a cornerstone of global energy production, yet it inherently operates
in a high-risk environment. Extracting and processing hydrocarbons involves complex
processes, powerful equipment, and often unforgiving natural conditions. Even minor slips in
safety protocols or unforeseen events can have catastrophic consequences for personnel, the
environment and surrounding communities.

Understanding the root causes of accidents in the oil and gas industry is essential for several
reasons: Preventing Future Incidents: By dissecting the contributing factors behind past
accidents, we can identify vulnerabilities and implement preventative measures. This
knowledge empowers the industry to establish strong safety protocols and operational practices
that minimize the risk of similar events recurring.

Enhancing Worker Safety: Every accident represents a potential injury or fatality. Identifying
the human factors and organizational shortcomings that contribute to accidents allows us to
prioritize worker safety through training initiatives, improved communication, and fostering a
culture of safety awareness.

Environmental Protection: Oil spills, explosions, and equipment failures can have devastating
environmental consequences. Understanding the causes behind these incidents allows us to
develop strategies for mitigating environmental impact, such as designing infrastructure
resilient to environmental threats and implementing effective emergency response plans.

Public Confidence: Accidents erode public trust in the oil and gas industry. By demonstrating
a commitment to safety through a thorough understanding of accident causation, the industry
can rebuild public confidence and ensure social acceptance of its operations.

This study delves into a comprehensive analysis of multiple accident cases within the oil and
gas industry. By examining these diverse events, we aim to uncover recurring patterns in
accident causation and extract valuable lessons that can be applied across the industry. This
multi-case approach allows for a more nuanced understanding of the complex interplay
between human error, equipment malfunctions, environmental factors, and organizational
deficiencies that contribute to accidents.

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METHODOLOGY
This study employs a multi-pronged approach to gather and analyse data on accident cases
within the oil and gas industry. The goal is to gain a comprehensive understanding of accident
causation and extract valuable lessons for future safety improvements.

Data Acquisition Strategies:

Literature Review: A thorough review of existing literature is conducted. This includes

academic journals, industry reports, and documented case studies pertaining to oil and gas
accidents. This initial research lays the groundwork for understanding historical trends and
identifying key incidents for further investigation.

Government and Regulatory Sources: Public databases and reports maintained by

government agencies and regulatory bodies overseeing the industry are explored. These
resources often provide detailed investigation reports, accident data, and safety
recommendations, offering valuable insights into the official perspective.

Industry-Specific Databases: Industry associations, research institutions, and safety

organizations often maintain specialized databases compiling accident data and incident
reports. Utilizing these resources allows for a comprehensive view of accidents within the
industry.

Company Reports and Internal Documents: Whenever possible, accident reports and
internal documents from oil and gas companies are obtained. These documents, subject to
confidentiality limitations, can shed light on specific incidents, offering a deeper understanding
of the company's perspective and response to the accident.

News and Media Monitoring: News outlets serve as a valuable source for initial reporting on
accidents and incidents. By monitoring news sources, both online and offline, we can identify
new cases for further investigation.

Case Study and Research Analysis: Existing case studies and research projects that delve into
specific oil and gas industry accidents are critically examined. These studies provide in-depth
analysis and offer valuable lessons learned, contributing significantly to the overall
understanding of accident causation.

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FINDINGS
1. BLIND OPERATIONS
The case study: Piper Alpha Platform Disaster (1988)

The Piper Alpha platform disaster is a horrific accident in the North Sea, this disaster serves as
a stark reminder in the oil and gas industry of the dangers of blind operations. The following
is a summary of the timeline of event leading up to the disaster:
July 6, 1988 (Morning): During maintenance, a condensate removal pump on Piper Alpha is
being prepared for removal. A temporary bypass line is installed to maintain production in the
meantime.
July 6, 1988 (Afternoon): Workers mistakenly remove the wrong spool piece creating a direct
connection between a high-pressure gas line and the condensate line.
July 6, 1988 (6:00 PM): The bypass line is activated, and due to the incorrect spool piece high-
pressure gas leaks into the condensate line. Alarms sound in the control room but the platform
operators are unaware of the severity due to incomplete procedures and lack of training on the
specific bypass operation.
July 6, 1988 (6:04 PM): An ignition source, possibly from ongoing maintenance work, triggers
an explosion. The force of the blast ruptures nearby pipelines causing a massive fire that engulfs
the platform.
July 6, 1988 (Night): Emergency response is hampered by the ongoing fire and the loss of
critical equipment. Nearby platforms are evacuated. On July 7, 1988, the fire continues to rage,
rescue efforts focus on survivors in lifeboats.
July 10, 1988: The fire is finally extinguished.
Aftermath: 167 personnel perish in the accident, making it the deadliest offshore oil rig disaster
in history.
Underlying Causes
The following causes contributed to the accident.
Communication Breakdown: Incomplete information about the bypass line status and the
severity of the leak contributed to the delayed response.
Inadequate Safety Measures: Insufficient training on emergency procedures and the lack of
a proper shutdown system hampered the initial response.
Focus on Production over Safety: Prioritizing production efficiency over safety protocols
may have influenced the decision to continue operations despite the leak.

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Key Lessons Learned
Procedures and Training: Comprehensive procedures for all operations, including non-
routine activities, are crucial. Rigorous training ensures personnel understand the risks and can
respond appropriately.
Communication and Information Sharing: Clear communication between personnel and
readily available platform information are essential for real-time situational awareness.
Safety Culture: A strong safety culture that prioritizes risk mitigation and incident reporting
over production pressure is vital.
Emergency Preparedness: Robust emergency response plans, trained personnel, and readily
available resources are critical for effective incident management.
Independent Review: Regular independent safety audits can identify potential hazards and
ensure adherence to best practices.
The Piper Alpha disaster serves as a tragic reminder of the catastrophic consequences that can
arise from blind operations in the oil and gas industry. By prioritizing safety protocols, clear
communication, and thorough training, similar accidents can be prevented.

2. DESIGN
Case Study: Deepwater Horizon Blowout (2010)

This case study examines the Deepwater Horizon blowout, a devastating accident in the Gulf
of Mexico that highlights the dangers of flawed design in the oil and gas industry. The
following is a summary of the timeline of event leading up to the blowout:
April 20, 2010 (Start): The Deepwater Horizon semi-submersible drilling rig begins drilling
operations on the Macondo Prospect well.

April 20 – April 22, 2010: Several critical safety tests are bypassed or inadequately performed
due to pressure to complete the well ahead of schedule. These tests included a negative pressure
test and a wellbore integrity test.

April 20, 2010 (Evening): While displacing drilling mud with lighter seawater in preparation
for well completion, a blowout occurs. Hydrocarbons surge up the wellbore, overwhelming the
blowout preventer (BOP) stack, a critical safety device designed to seal the well in case of
emergencies.

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April 20 – April 22, 2010: The uncontrolled well releases massive amounts of oil and gas into
the environment, initiating the largest accidental marine oil spill in history.

April 22, 2010: An explosion on the rig ignites the leaking oil, resulting in a fire that rages for
several days.

April 22 – July 15, 2010: Multiple failed attempts are made to contain the well blowout.

July 15, 2010: A relief well is finally drilled, intercepting the Macondo well and stopping the
flow of oil.

September 19, 2010: The well is permanently sealed.

Underlying Causes

Flawed Well Design: The well design lacked a secondary containment barrier, a crucial safety
feature that could have prevented the blowout.

Inadequate Blowout Preventer: The BOP stack was not properly maintained and lacked
redundancies to handle a major pressure surge.

Cost-Cutting Measures: Bypassing safety tests and prioritizing speed over well integrity
contributed to the accident.

Communication Breakdown: Insufficient communication between rig personnel and BP

management regarding safety concerns played a role.

Key Lessons Learned

Well Design Standards: Strong well design standards with mandatory secondary containment
barriers are essential.

Blowout Preventer Technology: Robust BOP stacks with redundancies and regular
maintenance are crucial for well control.

Safety Culture: A company culture that prioritizes safety over cost-cutting and encourages
open communication of concerns is vital.

Risk Assessment and Management: Comprehensive risk assessments and robust mitigation
strategies should be implemented for all drilling operations.

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Regulatory Oversight: Stronger regulatory oversight with stricter enforcement of safety
standards is needed.

The Deepwater Horizon disaster illustrates how design flaws and a disregard for safety
protocols can have devastating environmental and economic consequences. By prioritizing
well design, robust BOP technology, and a strong safety culture, the oil and gas industry can
strive to prevent similar tragedies from occurring.

3. EXTERNAL CAUSES
Case Study: Texas City Refinery Explosion (2005)

This case study examines the Texas City Refinery explosion, a catastrophic incident in the oil
and gas industry that highlights the dangers posed by external factors. The following is a
summary of the timeline of event leading up to the explosion:
March 21, 2005 (Morning): Maintenance work begins on a raffinate splitter, a vessel used to
separate gasoline components at the BP Texas City Refinery.

March 21, 2005 (Afternoon): During the hot work (welding) on the vessel, a highly flammable
liquid hydrocarbon mixture (isobutane) unexpectedly enters a partially open bypass line
connected to the vessel. This bypass line had been installed earlier for a planned future project
and inadvertently left open.

March 21, 2005 (3:18 PM): Ignition occurs, likely from the welding activity, triggering a
massive explosion. The blast destroys the raffinate splitter and damages nearby equipment,
causing a fire that engulfs the surrounding area.

March 21 – March 22, 2005: Emergency responders battle the fire and evacuate nearby
residents.

Aftermath: 15 workers are killed, and 170 are injured. The explosion also causes significant
environmental damage.

Underlying Causes

Inadequate Permitting and Planning: The hot work permit for the raffinate splitter did not
adequately address the risks associated with the open bypass line.

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Communication Breakdown: Communication failures occurred between maintenance crews
and process operators regarding the status of the bypass line.

Management System Deficiencies: Inadequate management oversight of safety procedures

and risk assessments contributed to the accident.

External Cause (Unforeseen Circumstance): The open bypass line, a result of unplanned
future project work, acted as an external factor that was not adequately considered in the hot
work permit and safety protocols.

Key Lessons Learned

Hot Work Permitting: Strict hot work permitting procedures with clear hazard identification
and mitigation plans are essential.

Communication Protocols: Robust communication protocols are needed to ensure all

personnel involved in operations understand potential risks.

Management of Change: A comprehensive management of change (MOC) process should be

implemented to identify and address potential hazards during modifications or future project
considerations.

Risk Management: Comprehensive risk assessments that consider both internal and external
factors are crucial for safe operations.

Emergency Preparedness: Continuous improvement of emergency response plans and

training is essential to minimize damage and casualties in case of accidents.

The Texas City Refinery explosion highlights the importance of considering all potential
hazards, including those arising from external factors, during planning and execution. By
implementing robust safety procedures, clear communication protocols, and a strong risk
management culture, similar tragedies can be prevented.

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 4. INSPECTION AND MAINTENANCE

Case Study: Piper Alpha Platform Gas Leak and Explosion (1988)

This case study revisits the Piper Alpha platform disaster (1988) but focuses on the role of
inspection and maintenance failures that contributed to the accident. The following is a
summary of the timeline of event leading up to the Gas Leak and Explosion:
Preceding Weeks: During routine maintenance on Piper Alpha, a condensate removal pump is
scheduled for replacement.
July 6, 1988 (Morning): Preparations for pump removal begin, including the installation of a
temporary bypass line to maintain production flow.

July 6, 1988 (Afternoon): A critical error occurs during the bypass line installation. Workers
mistakenly remove the wrong spool piece, creating a direct connection between a high-pressure
gas line and the condensate line.

July 6, 1988 (Inspection Failure): This crucial error goes unnoticed. Standard inspection
procedures for verifying the correct spool piece installation are either bypassed or inadequate.

July 6, 1988 (6:00 PM): The bypass line is activated, and due to the incorrect spool piece,
high-pressure gas leaks into the condensate line. Alarms sound in the control room, but the
platform operators are unaware of the severity due to incomplete procedures and lack of
training on the specific bypass operation.

July 6, 1988 (6:04 PM): An ignition source, possibly from ongoing maintenance work, triggers
an explosion. The force of the blast ruptures nearby pipelines, causing a massive fire that
engulfs the platform.

Aftermath: The accident resulted in the death of 167 personnel.

Underlying Causes

Inadequate Inspection Procedures: The established procedures for verifying the correct
installation of the bypass line spool piece were either insufficient or not followed properly.

Lack of Training: Maintenance personnel lacked adequate training on proper bypass line
installation and the potential hazards associated with errors.

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Focus on Production over Safety: There may have been pressure to complete maintenance
tasks quickly to minimize disruption to production, potentially leading to shortcuts in
inspection procedures.

Maintenance Program Deficiencies: The overall maintenance program may have lacked
sufficient oversight and risk assessment to identify potential hazards during bypass operations.

Key Lessons Learned

Robust Inspection Procedures: Implementing clear and comprehensive inspection

procedures for all maintenance activities, including bypass line installations, is crucial.

Competent Workforce: Ensuring maintenance personnel receive thorough training on proper

procedures and hazard identification is essential.

Prioritize Safety: A strong safety culture that prioritizes meticulous inspection and adherence
to procedures over production pressure is vital.

Risk-Based Maintenance: Developing a risk-based maintenance program that identifies and

prioritizes critical inspections based on potential hazards can help prevent accidents.

Independent Audits: Regular independent audits of maintenance programs and procedures

can help identify and address potential weaknesses.

The Piper Alpha disaster demonstrates the devastating consequences of failures in inspection
and maintenance practices within the oil and gas industry. By prioritizing robust procedures, a
competent workforce, and a safety-focused culture, similar tragedies can be avoided.

5. KNOWLEDGE AND TRAINING

Case Study: Montara Wellhead Platform Leak (2009)

This case study examines the Montara Wellhead Platform leak, an incident in the Timor Sea
that highlights the importance of knowledge and training gaps in preventing oil and gas
accidents. The following is a summary of the timeline of event leading up to the Wellhead
Platform Leak:

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August 21, 2009: During a routine well transfer operation on the Montara Wellhead Platform,
a leak develops at the wellhead due to a faulty well connector.

August 21, 2009 (Initial Response): Platform personnel attempt to contain the leak using
various methods, but due to a lack of understanding of the specific well connector design and
its failure mode, their initial efforts are unsuccessful.

August 21 – August 24, 2009: The uncontrolled well continues to leak condensate (light crude
oil) into the Timor Sea. Efforts to contain the leak continue with limited success.

August 24, 2009: A relief well is finally drilled, intercepting the leaking well and stopping the
flow of oil.

Aftermath: The leak spilled an estimated 430 million litres of oil, causing significant
environmental damage to the Timor Sea ecosystem.

Underlying Causes

Inadequate Knowledge of Wellhead Equipment: Platform personnel lacked sufficient

knowledge about the specific well connector design and its potential failure modes. This limited
their ability to effectively respond to the initial leak.

Insufficient Emergency Response Training: Training on emergency procedures for specific

wellhead equipment failures may have been inadequate, hindering the initial response and
containment efforts.

Communication Breakdown: Communication gaps between platform personnel and onshore

support teams may have hampered the flow of critical information and hindered decision-
making during the Incident.

Key Lessons Learned

Comprehensive Equipment Training: Personnel working with wellhead equipment require

thorough training on its operation, maintenance, and potential failure modes to ensure a proper
response during emergencies.

Scenario-Based Emergency Response Training: Regular emergency response training that

simulates specific scenarios, including wellhead equipment failures, can help prepare personnel
for effective response and decision-making.

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Knowledge Sharing and Continuous Learning: Encouraging knowledge sharing within the
organization and promoting continuous learning opportunities can ensure personnel stay
updated on best practices and potential hazards associated with specific equipment.

Clear Communication Protocols: Establishing clear communication protocols between

platform personnel and onshore support teams is critical for efficient information exchange
during emergencies.

Incident Investigation and Lessons Learned Implementation: Thorough investigation of

incidents like the Montara leak, followed by the implementation of lessons learned, is crucial
to prevent similar incidents in the future.

The Montara Wellhead Platform leak serves as a reminder that knowledge and training gaps
can significantly impact the response to oil and gas accidents. By investing in comprehensive
training programs, fostering a culture of knowledge sharing, and promoting clear
communication, the industry can create a more prepared and resilient workforce.

6. HAZARD IDENTIFICATION (HAZID)

Case Study: Guadalajara Pipeline Explosion (1992)

This case study analyses the Guadalajara pipeline explosion, a devastating accident in Mexico
that highlights the importance of Hazard Identification (HAZID) studies in preventing oil and
gas disasters. The following is a summary of the timeline of event leading up to the Pipeline
Explosion:

Preceding Years: A gasoline pipeline traverses a growing residential area in Guadalajara,

Mexico.

1992 (Uncertain Date): A leak develops on the gasoline pipeline, likely due to corrosion or
inadequate maintenance.

April 22, 1992 (Morning): The gasoline leak goes unnoticed, and vapors accumulate in the
subsurface and nearby sewers.

April 22, 1992 (Afternoon): An unidentified spark ignites the gasoline vapor cloud, triggering
a massive explosion. The blast destroys homes and businesses across a large area.

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April 22 – April 23, 1992: Emergency responders struggle to control the fire and rescue
survivors.

Aftermath: The explosion resulted in over 200 deaths, hundreds of injuries, and widespread
property damage.

Underlying Causes

Absence of a HAZID Study: The pipeline operator seemingly did not conduct a
comprehensive HAZID study to identify potential hazards associated with a gasoline pipeline
traversing a populated area.

Inadequate Pipeline Risk Assessment: Without a proper HAZID, the operator likely failed to
assess the risk of leaks and vapor accumulation in the densely populated area.

Lack of Public Awareness: The public residing near the pipeline were likely unaware of the
potential dangers and how to respond to a leak. This could have contributed to delayed
evacuation and increased casualties.

Key Lessons Learned

Mandatory HAZID Studies: Implementing mandatory HAZID studies for all oil and gas
projects, including pipeline routing, is crucial for early identification of potential hazards.

Risk-Based Pipeline Management: Utilizing risk-based pipeline management strategies that

consider population density and potential consequences of leaks can guide decisions on
pipeline maintenance and safety measures.

Community Awareness and Emergency Planning: Engaging communities residing near

pipelines in emergency preparedness exercises and public awareness campaigns about potential
hazards is essential.

Continuous Pipeline Monitoring and Maintenance: Regular pipeline inspections, leak

detection systems, and proper maintenance programs can help prevent accidents before they
occur.

The Guadalajara pipeline explosion serves as a stark reminder of the catastrophic consequences
that can arise from neglecting HAZID studies and risk assessments. By prioritizing these
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proactive measures, implementing robust pipeline management practices, and engaging with
communities, the oil and gas industry can work towards preventing similar tragedies.

7. MANAGEMENT OF CHANGE

Case Study: Buncefield Depot Explosion (2005)

This case study examines the Buncefield Depot explosion, a major incident in the United
Kingdom that highlights the importance of a robust Management of Change (MOC) process in
the oil and gas industry. The following is a summary of the timeline of event leading up to the
Depot Explosion:

Preceding Months: The operator of the Buncefield Depot, a major fuel storage facility, decides
to increase the capacity of a specific storage tank.

December 11, 2005 (Morning): A contractor is hired to perform cleaning activities on the newly
modified tank. However, crucial changes made to the tank’s internal pipework during the
capacity increase were not adequately documented or communicated to the cleaning crew.

December 11, 2005 (Afternoon): During the cleaning process, the cleaning crew unknowingly
opens a newly installed isolation valve, allowing petrol (gasoline) to flow into an incompatible
pipe containing aviation fuel.

December 11, 2005 (Evening): The incompatible fuel mixture ignites, triggering a series of
massive explosions that engulf the depot in flames. The fire burns for several days.

Aftermath: The Buncefield explosion caused significant environmental damage, economic

disruption, and several injuries.

Underlying Causes

Inadequate Management of Change Process: The MOC process failed to effectively identify,
document, and communicate the changes made to the tank’s internal pipework.

Lack of Communication: The cleaning crew was not informed about the modifications to the
tank, leading to a critical misunderstanding and unsafe operation.

Insufficient Risk Assessment: The potential hazards associated with the cleaning activities in
light of the tank modifications were not adequately assessed.

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Focus on Schedule over Safety: There may have been pressure to complete the cleaning
activity quickly, potentially leading to shortcuts in safety procedures.

Key Lessons Learned

Rigorous MOC Process: Implementing a rigorous MOC process that identifies all changes,
assesses associated risks, and ensures effective communication to impacted personnel is
crucial.

Pre-Job Briefings: Thorough pre-job briefings that clearly communicate any modifications
made to equipment or procedures are essential for safe work execution.

Risk-Based Approach: A risk-based approach to MOC that prioritizes the criticality of

changes and potential consequences is vital.

Competent Workforce: Ensuring personnel involved in maintenance and cleaning activities

are competent and understand potential hazards is essential.

Safety Culture: Fostering a strong safety culture that prioritizes open communication of
concerns and adherence to procedures over expedience is key.

The Buncefield Depot explosion demonstrates the potential consequences of a weak MOC
process in the oil and gas industry. By implementing robust MOC procedures, ensuring clear
communication, and prioritizing a risk-based approach, similar accidents can be prevented.

8. NOT LEARNING FROM NEAR MISSES

Case study: Buncefield Oil Depot Fire (2005), A Missed Opportunity to Prevent Disaster

The Buncefield Oil Depot fire, which occurred on December 11, 2005, in Hertfordshire,
England, stands as a chilling example of how failing to learn from near misses can contribute
to catastrophic accidents. The following is a summary of the timeline of event leading up to the
Depot fire:

Preceding Weeks: The depot had experienced several near misses involving leaking or
overflowing tanks in the weeks leading up to the fire.

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December 11th:

Morning: During a routine transfer of gasoline between storage tanks, a faulty pipe connection
failed.

Leakage and Delays: The leak went unnoticed for an extended period due to a malfunctioning
alarm system and a lack of regular tank level monitoring.

Ignition Source: The spilled gasoline vapors eventually reached an ignition source, possibly an
electrical spark, triggering a massive explosion and fire.

Aftermath: The fire raged for several days, causing widespread damage to surrounding
infrastructure and disrupting fuel supplies in the region.

Underlying Causes

Ignored Near Misses: Previous leaks and equipment malfunctions were not thoroughly
investigated or addressed, creating a sense of complacency and a failure to identify
potential hazards.

Inadequate Safety Culture: The focus on production and efficiency may have
overshadowed safety concerns, leading to a culture that tolerated near misses.

Equipment Failures: Malfunctioning alarms and potentially faulty pipe connections

contributed to the accident.

Insufficient Monitoring: Inadequate tank level monitoring and leak detection systems
allowed the spill to go unnoticed for a critical period.

Key Lessons Learned

Heed Near Misses: Every near miss is an opportunity to learn and improve safety
procedures. Thorough investigation and corrective actions are crucial to prevent future
incidents.

Strong Safety Culture: Cultivating a robust safety culture that prioritizes risk
identification, reporting, and mitigation of potential hazards.

Reliable Equipment: Investing in reliable equipment and implementing proper

maintenance programs to minimize the risk of equipment failures.

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 Comprehensive Monitoring: Implementing rigorous monitoring systems to detect leaks,
spills, and equipment malfunctions promptly.

Learning from the Past

The Buncefield fire serves as a stark reminder of the domino effect that can occur when near
misses are not addressed. It highlights the importance of a proactive safety culture, robust
incident investigation, and continuous improvement in safety protocols to prevent future
disasters.

9. OPERATION PRACTICE

Case study: Alexander L. Kielland Platform Accident (1980)

This incident, which occurred on March 27, 1980, in the North Sea, involved the partial
collapse of the Alexander L. Kielland platform, causing the tragic loss of 123 lives. The
following is a summary of the timeline of event leading up to the accident:

Prior to the Accident: The platform, designed for production and accommodation, had
undergone modifications to accommodate additional personnel. These modifications may have
compromised its structural integrity.

March 27th: A fatigue crack in a crucial brace supporting one of the platform's legs propagated
due to a combination of factors.

Triggering Event: A collision with a supply vessel, the supply ship "Viking Viking", further
stressed the already weakened brace.

Collapse: The brace failed catastrophically, causing one of the platform's legs to detach and the
platform to partially collapse.

Tragic Outcome: The collapse resulted in the detachment of lifeboats and the sinking of the
platform section, leading to the deaths of 123 people.

Underlying Causes

Structural Deficiencies: The platform modifications may have introduced weaknesses that
made it susceptible to fatigue cracks.

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Lack of Maintenance: There's a possibility that proper inspections and maintenance weren't
conducted to identify potential structural issues.

Operational Oversight: Failures in overseeing the platform's structural integrity and potential
overloading could have been a contributing factor.

Emergency Response Issues: The effectiveness of the emergency response, including lifeboat
deployment and rescue efforts, may have been compromised.

Key Lessons Learned:

Structural Integrity Assessments: The importance of thorough and ongoing assessments of

platform structures, especially after modifications.

Preventative Maintenance: Implementing rigorous preventative maintenance programs to

identify and address potential structural problems.

Operational Safety Management: The need for robust operational safety management
systems that prioritize platform integrity and emergency preparedness.

Effective Emergency Response Plans: Developing and practicing comprehensive emergency

response plans to ensure a swift and coordinated response in case of accidents.

The Alexander L. Kielland platform accident serves as a stark reminder of the importance of
safe operating practices in offshore oil and gas exploration. It highlights the need for rigorous
structural assessments, preventative maintenance, and effective emergency preparedness to
prevent such tragic events.

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 10. PERMIT TO WORK SYSTEMS (PTWS).

Texas City Refinery Explosion (2005)

This incident, which occurred on March 21, 2005, at the isomerization unit of the BP Texas
City Refinery, tragically resulted in 15 fatalities and over 170 injuries. The following is a
summary of the timeline of event leading up to the explosion:

Weeks Prior: A series of process safety incidents, including leaks and near misses, occurred in
the isomerization unit. These incidents were not adequately addressed.

Days Before: A turnaround (major maintenance project) began at the refinery, requiring
numerous permit to work systems (PTWs)

March 21st: During a PTW-authorized blind flange removal on a highly flammable

hydrocarbon line, a liquid level indicator malfunctioned. This malfunction gave a false reading,
indicating the line was empty when it actually contained liquid hydrocarbons.

Later that Day: When the blind flange was removed, the pressurized liquid hydrocarbons
erupted, igniting and causing a massive explosion that engulfed nearby units.

Underlying Causes:

Flawed PTW System: The PTW system did not effectively address the hazards associated
with blind flange removal, particularly relying on a single, malfunctioning instrument for liquid
level verification.

Process Safety Management Issues: The BP refinery exhibited a culture that prioritized
production over safety, leading to a disregard for process safety incidents and inadequate risk
management.

Communication Breakdown: There were communication gaps between operations and

maintenance personnel regarding the status of the hydrocarbon line.

Inadequate Training: Workers involved in the PTW process and blind flange removal may
not have received proper training on the specific hazards and safety protocols.

Key Lessons Learned:

PTW System Review: The importance of regularly reviewing and updating PTW procedures
to address potential hazards and ensure effectiveness.

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Process Safety Culture: The need for a strong process safety culture that prioritizes risk
management, incident investigation, and proactive safety measures.

Effective Communication: The importance of clear and consistent communication between

all personnel involved in hazardous operations.

Comprehensive Training: Ensuring all workers involved in PTWs and high-risk activities
receive thorough training on specific hazards, procedures, and emergency protocols.

The Texas City Refinery explosion serves as another example of how breakdowns in PTW
systems can contribute to catastrophic accidents. The lessons learned from this tragedy
continue to inform best practices for safe operations in the oil and gas industry.

11. HUMAN FACTOR

Case study: Exxon Valdez Oil Spill (1988)

The Exxon Valdez oil spill, which occurred on March 24, 1989, remains one of the worst
environmental disasters in U.S. history. It resulted from a confluence of human errors that
tragically unleashed millions of gallons of crude oil into the pristine waters of Prince William
Sound, Alaska. The following is a summary of the timeline of event leading up to the oil spill:

Night of March 23rd: The Exxon Valdez tanker departs the Alaskan port of Valdez en route to
California. Captain Joseph Hazelwood is in command, but has reportedly been drinking prior
to setting sail.

Early Morning of March 24th: The ship deviates significantly from its planned course, placing
it dangerously close to Bligh Reef. The under-rested and overworked crew fails to notice the
deviation or raise any alarms.

3:12 AM, March 24th: The Exxon Valdez collides with Bligh Reef, causing a massive gash in
the hull and spilling millions of gallons of crude oil into the pristine waters of Prince William
Sound.

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Underlying Causes:

Fatigue: The crew, including Captain Hazelwood, had reportedly been working long hours and
were likely fatigued. This can impair judgment and reaction times.

Impairment: Allegations of Captain Hazelwood's alcohol consumption prior to sailing raise

concerns about his ability to safely command the vessel.

Inadequate Monitoring: The bridge team failed to adequately monitor the ship's course,
leading to the deviation that resulted in the grounding.

Key Lesson Learned:

Human factors play a significant role in oil and gas accidents. The Exxon Valdez incident
highlighted the importance of:

Crew fatigue management: Implementing procedures to ensure crew members are well-
rested and alert during critical operations.

Substance abuse prevention: Having clear policies and testing protocols to address potential
impairment.

Bridge resource management: Training bridge teams on effective communication, situational

awareness, and decision-making to prevent accidents.

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RECOMMENDATION
These are recommendations for the Accident Prevention in the Oil and Gas Industry:

Addressing Human Error:

Comprehensive Training Programs: Implement training programs that address technical skills,
safety procedures, emergency protocols, and situational awareness for all personnel.

Fatigue Management Strategies: Enact policies to manage worker fatigue, including limitations
on shift lengths and mandatory rest periods.

Improved Communication: Foster a culture of open communication to encourage workers to

report safety concerns and near misses.

Mitigating Equipment Failures:

Robust Inspection Protocols: Establish and enforce stringent inspection schedules for all
equipment and infrastructure.

Enhanced Maintenance Practices: Implement preventive maintenance programs and utilize

advanced technologies for equipment monitoring and diagnostics.

Investment in Reliable Technology: Prioritize the use of high-quality, reliable equipment and
components.

Strengthening Resilience to Environmental Risks:

Infrastructure Design: Design and build infrastructure that can withstand extreme weather
events, natural disasters, and other environmental threats.

Emergency Response Planning: Develop and regularly practice comprehensive emergency

response plans for various disaster scenarios.

Environmental Risk Assessments: Conduct thorough environmental risk assessments at all

stages of operation and implement appropriate mitigation measures.

Addressing Organizational Shortcomings:

Effective Safety Management Systems: Implement and maintain robust safety management
systems that prioritize safety throughout the organization.

Regular Audits: Conduct regular safety audits to identify and address potential hazards and
ensure adherence to safety protocols.

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Culture of Accountability: Cultivate a culture of safety where all personnel are accountable for
following safety procedures and reporting concerns.

Collaboration and Knowledge Sharing:

Cross-industry Collaboration: Encourage collaboration between oil and gas companies to share
best practices, incident data, and lessons learned.

Knowledge Dissemination: Publish and disseminate accident reports and analysis findings to
inform broader safety improvements across the industry.

Industry Standards and Guidelines: Participate in the development and implementation of

stronger, evidence-based safety standards and guidelines.

By implementing these recommendations, the oil and gas industry can significantly reduce the
risk of accidents and create a safer work environment for its employees, a more secure
operation for the environment, and greater public trust in its practices.

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CONCLUSION
The oil and gas industry while crucial to modern society, faces inherent dangers. The accidents
explored here serve as stark reminders of the paramount importance of prioritizing safety
through robust procedures and risk management. Each incident offers invaluable lessons that
have significantly shaped industry practices and illuminated areas demanding further
improvement.

Human factors, as exemplified by the Exxon Valdez spill, demonstrate the devastating
consequences of fatigue, complacency, and insufficient training. These incidents underscore
the need for a culture that prioritizes safety, fosters clear communication, and emphasizes
comprehensive training with ongoing competency evaluations to mitigate human error.

Accidents like the Macondo Blowout and Piper Alpha, involving deficiencies in permit-to-
work systems, operating practices, and blind operations, highlight the critical need for rigorous
risk assessments, unwavering adherence to safety protocols, and robust monitoring systems.
Clear communication, meticulous equipment maintenance, and a commitment to continuous
improvement are essential to preventing accidents and ensuring effective emergency response.

The importance of thorough planning, comprehensive hazard identification (HAZID), and

proper risk management during operational changes cannot be overstated, as evidenced by
accidents stemming from management of change and a lack of HAZID processes. These
incidents emphasize the need for stringent procedures, independent reviews, and proactive
measures to guarantee safety is never compromised during organizational or operational shifts.

Furthermore, accidents related to design flaws, inadequate HAZID procedures, insufficient

knowledge and training, lax inspection and maintenance practices, external factors, and
equipment failures underscore the significance of meticulous design considerations, rigorous
safety standards, regular inspections, and robust maintenance programs. These incidents
highlight the importance of learning from past accidents, implementing effective safety
measures, and continuously improving industry practices.

The oil and gas industry has taken significant strides towards enhanced safety by learning from
these critical incidents. These lessons have spurred essential initiatives to prevent accidents and
lessen the environmental and human costs associated with them. The industry is on a path of
continuous evolution, implementing stricter regulations, enhancing safety practices, and
fostering a culture that prioritizes continuous learning and improvement.

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(CSB), C. S. (2007). Explosion and fire at the BP Texas City Refinery.

(HSE)., H. a. (2008). Buncefield depot fire: The final report of the major accident investigation team .

Cullen, W. D. (1994). The Piper Alpha disaster: A study of offshore safety management. HSE Books.

Dewan. (2010). The Oil Spill’s Money Squeeze. 70.

Directorate, N. P. (1981). Report of the inquiry into the Alexander L. Kielland accident (Report No.
NOU 1981: 8).

Konstantinidou, M. C. (2012). Safety of offshore oil and gas operations. 65.

Schleifstein, M. (2007). Breaux Act Anniversary Marks 20 Years of Coastal Restoration Progress,. 55.

Thompson, K. (2010). Waste from BP Oil Spill Cleanup Has Gulf Residents Near Landfills Concerned.
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