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a study on Piper Alpha Accident and come out with fish bone diagram and 6 sigma to analyse the details.
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Piper Alpha Disaster: Fire in The Night
CHEMICAL ENGINEERING
NIK ALIFF SYAZREEN BIN SABRI 13526
MOHAMAD RAZLAN BIN MD RADZI 13545
AMIRUL HAFIZ BIN RUSNAN 13663
AHMAD HISSAMUDDIN B ZULKIFLI 13604
NUR HIDAYAH SHAHRUL AMAR 13590
ENGINEERS IN SOCIETYDr Usama Eldemerdash
Six Sigma Concept
• DMAIC • Define customers and requirements• Measure things critical to quality• Analyze baseline, opportunities, objectives, and
root causes• Improve the process• Control the process
Define
• Customer• Offshore personnel(technicians, operators,
engineers etc)
• Requirement• Organized and supervised equipment (pump)
maintenance.
Measure
• Form/Permit• Thoroughly inspected and revised• Has proper LOA
• Start-up procedure of pump• Previous repairs/modifications to the system should be
analyzed and confirmed
• Emergency response – should be faster and efficient.
Analyze
• Baseline• Most workers did not know fully exposed to proper
evacuation
• Opportunities• Objectives• Supervised jobs hand-over and adequate safety
trainings.
• Root Cause • Fish Bone Diagram
Decision error
Memory error Perception error
Failure to identify a hazard.
Remove the pressure safety valve on
condensate pumps
Shutdown production of
connected platforms Claymore, Tartan and MCP-01 to avoid accident
escalation.
Action error
Restart pump to continue the
condensate injection without verifying that it was out of
service
Forgot to notify to the team
Lifeguard float tied and lack of tools to
cut the rope
Piper Alpha Disaster
Piper Alpha Disaster Root Cause
Improve
Decision error
Memory error Perception error
Failure to identify a hazard.
Remove the pressure safety valve on condensate pumps
Shutdown production of connected platforms
Claymore, Tartan and MCP-01 to avoid accident
escalation.
Action error
Restart pump to continue the condensate injection without verifying that it
was out of service
Forgot to notify to the team Lifeguard float tied and lack of tools to
cut the rope Piper Alpha Disaster
Ensure all worker are given adequate safety trainings
Life-saving equipment should be easily reached
Should always make a black and white copy of any task
Awareness is extremely important
Establishment of good and clear communication is highly crucial for
any events
Workers must always follow the proper procedure for any
repair/maintenance
Control
• Supervisor• Evaluation/tests of workers performance.
• Operator• Assist to provide a proper maintenance/repairing.
• Technician• Always follow and refer to guidelines for standard
procedure..
Six Sigma
• Pump is manufactured with operating specification at 650psi. • Lower specification limit: 620 psi• Upper specification limit: 680 psi
• The desired chance of a product produced out of pressure specification is 2 out of a billion.
• This means that 680psi is 6×σ far from mean
• 5psi• The equipment must be reliable that the products
produced does not vary more than standard deviation of 5psi
0.0000063
0.00000000124
LSL=620psi HSL=680psi650psi
• The chance of an event out of specification boundaries is 5080 times less than chance of event out of control limit, where alarms will ring
• = 5080
THANK YOU