Piper Alpha Appleton BBC

00:46:28
https://www.youtube.com/watch?v=S9h8MKG88_U

الملخص

TLDRLa prezento esploras la katastrofon sur la Piper Alpha platformo en 1988, analizante la kaŭzojn de la tragedio kaj la lecionojn pri sekureco. La prezentanto priskribas la strukturojn de la platformo, la publikan enketon post la katastrofo, kaj ses kritikajn faktorojn kiuj kontribuis al la perdo de vivoj. La konkludo emfazas la gravecon de administrado en sekureco, sisteman aliron, kaj la kvaliton de sekureca administrado, substreke ke sekureco estas afero de vivo kaj morto.

الوجبات الجاهزة

  • 🔍 La Piper Alpha estis offshore petrolplatformo.
  • 💥 La katastrofo okazis la 6-an de julio 1988.
  • ⚖️ Publika enketo estis gvidata de Lord Cullen.
  • 📉 Ses faktoroj kontribuis al la alta mortoprocento.
  • 📋 Manko de trejnado estis grava problemo.
  • 🚨 Sekureco estas respondeco de la administrado.
  • 🔧 Kvalito de sekureca administrado estas esenca.
  • 📊 Auditoj devas esti altkvalitaj.
  • 🛑 Manko de sistemaj aliroj kaŭzis problemojn.
  • 🌊 La 'bottom line' de sekureco estas vivo kaj morto.

الجدول الزمني

  • 00:00:00 - 00:05:00

    La prezento temas pri la katastrofo sur la Piper Alpha platformo en 1988, kun la celo disvolvi fundamentajn lecionojn pri sekureco. La prezentanto klarigas la strukturo de la platformo, ĝian funkciadon, kaj la unikajn defiojn, kiujn alfrontis la laboristoj en kazo de urĝa situacio, komparante ĝin kun surtera industrio.

  • 00:05:00 - 00:10:00

    La katastrofo rezultigis 167 mortojn, kio kondukis al publika enketo gvidata de Lord Cullen. La enketo celis identigi la kaŭzojn de la katastrofo kaj fari rekomendojn por eviti similan okazaĵon en la estonteco. La prezento emfazas, ke la enketo ne celis kulpigi individuojn, sed kompreni la okazaĵon.

  • 00:10:00 - 00:15:00

    La eksplodo okazis en la gas-kompresia modulo, kaŭzita de malfunkciado de pumpilo, kiu ne estis adekvate prizorgita. La malbona komunikado inter la teamoj kaj la manko de kono pri la duobla prizorgado de la pumpilo estis kritikaj faktoroj, kiuj kondukis al la katastrofo.

  • 00:15:00 - 00:20:00

    La enketo malkovris, ke la permeso por labori ne estis ĝuste administrita, kun mankoj en la sistemoj, kiuj devus certigi sekurecon. La manko de trejnado por la supervizoroj kaj la neefika administrado de la permesoj estis gravaj kaŭzoj de la katastrofo.

  • 00:20:00 - 00:25:00

    La eksplodo kaŭzis nur kelkajn mortojn, sed la sekva oleo-fajro, kiu daŭris pli longe ol atendite, kaŭzis la plimulton de la viktimoj. La manko de sistemiga analizo de danĝeroj en la projektado de la platformo estis grava manko.

  • 00:25:00 - 00:30:00

    La administrado de la aliaj platformoj ne haltis la produktadon, supozante, ke Piper Alpha kontrolos la situacion. Tio montras la mankon de trejnado kaj simulado de krizaj situacioj inter la platformoj, kio plifortigis la katastrofon.

  • 00:30:00 - 00:35:00

    La akvo-sistemo por fajro-fighting ne funkciis, ĉar la rezervaj pumpiloj ne estis agorditaj por aŭtomata starto. La decido de la platforma administranto ne estis sufiĉe kvalita, kio kondukis al neefikeco en la fajro-fighting sistemoj.

  • 00:35:00 - 00:40:00

    La plimulto de viktimoj mortis en la loĝejo pro karbona monoksido, ĉar la evakuado ne estis organizita. La manko de trejnado por la administranto de la platformo kaj la neefika komunikado inter la teamoj kaŭzis la malfruan reagon al la katastrofo.

  • 00:40:00 - 00:46:28

    La prezento finas kun kvar fundamentaj lecionoj pri sekureco: la respondeco de la administrado, la bezono de sistemiga aliro, la graveco de kvalito en sekureca administrado, kaj la neceso de alta kvalito en sekureca revizio. La rakontoj de du supervivantoj emfazas, ke sekureco estas demando de vivo kaj morto, kaj la sumo de individuaj kontribuoj determinas la sekurecon de ĉiuj laboristoj.

اعرض المزيد

الخريطة الذهنية

فيديو أسئلة وأجوبة

  • Kio estis la Piper Alpha?

    Piper Alpha estis granda offshore petrolplatformo situanta ĉirkaŭ 100 mejlojn de Aberdeen, produktanta petrolon, gason, kaj kondensaton.

  • Kio okazis la 6-an de julio 1988?

    La 6-an de julio 1988, Piper Alpha suferis eksplodon kaj sekvan fajron, rezultigante la morton de 167 homoj.

  • Kio estis la rolo de la publika enketo?

    La publika enketo, gvidata de Lord Cullen, celis determini la kaŭzojn de la katastrofo kaj fari rekomendojn por eviti ripetiĝon.

  • Kio estis la ĉefaj faktoroj kontribuantaj al la katastrofo?

    Ses faktoroj estis identigitaj, inkluzive mankojn en la permeso por labori, trejnado, kaj sistemaj mankoj en sekureca administrado.

  • Kio estas la 'bottom line' de sekureco?

    La 'bottom line' de sekureco estas ke sekureco ne estas intelekta ekzerco, sed afero de vivo kaj morto, kaj la kvalito de individuaj kontribuoj determinas la sekurecon de kolegoj.

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الترجمات
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التمرير التلقائي:
  • 00:00:09
    afternoon the purpose of my presentation
  • 00:00:12
    is to develop some fundamental lessons
  • 00:00:15
    about safety and I want to do that by
  • 00:00:19
    considering the
  • 00:00:21
    circumstances surrounding the disaster
  • 00:00:24
    that struck the piper Alpha platform in
  • 00:00:28
    1988 my presentation is in five
  • 00:00:33
    stages I want to tell you first what was
  • 00:00:36
    Piper and what happened to
  • 00:00:38
    it and then I'll explain a little bit
  • 00:00:40
    about the public
  • 00:00:42
    inquiry which was really an accident
  • 00:00:46
    investigation and the major part of my
  • 00:00:48
    talk is to consider six factors that I
  • 00:00:52
    believe crucially bore on the loss of
  • 00:00:55
    life in the
  • 00:00:58
    disaster and from those
  • 00:01:00
    I want to develop lessons about managing
  • 00:01:04
    safety and finally I'll close my
  • 00:01:07
    presentation and what I believe is the
  • 00:01:09
    bottom line of safety so let's start
  • 00:01:12
    with what was Piper and what happened to
  • 00:01:16
    it Piper was a large offshore oil rig
  • 00:01:20
    located about 100 miles offshore from
  • 00:01:22
    abdine uh it had a traditional
  • 00:01:26
    layout at the South End the drilling
  • 00:01:28
    Derek in the middle
  • 00:01:31
    a processing unit separating oil gas
  • 00:01:33
    condensate and at the far end the white
  • 00:01:36
    building the accommodation block with
  • 00:01:37
    the helicopter pad on top and Piper
  • 00:01:40
    produced oil gas and condensate
  • 00:01:44
    condensate mainly
  • 00:01:46
    propane it exported oil both to Shore
  • 00:01:49
    and gas to Shore and condensate to Shore
  • 00:01:52
    and crucially it was linked to two other
  • 00:01:55
    platforms by both oil pipelines and gas
  • 00:01:59
    pipelines
  • 00:02:05
    my life was spent in the onshore
  • 00:02:07
    chemical industry and therefore when I
  • 00:02:10
    joined the public inquiry into the
  • 00:02:12
    disaster and started to think about an
  • 00:02:14
    oil rig out in the North Sea in terms of
  • 00:02:18
    emergency there were three things that
  • 00:02:20
    struck me straight
  • 00:02:22
    away first one was the fact that it was
  • 00:02:24
    surrounded by water and therefore the
  • 00:02:27
    people who worked on it did not go home
  • 00:02:30
    at night like the do on land and
  • 00:02:32
    therefore in any emergency the number of
  • 00:02:35
    people that are at risk were massively
  • 00:02:38
    greater than an
  • 00:02:40
    onshore Refinery or chemical plant
  • 00:02:43
    roughly 20 times as many
  • 00:02:48
    people the second factor that struck me
  • 00:02:51
    was the question of escape on sure if we
  • 00:02:54
    have an emergency on a
  • 00:02:57
    plant the means of Escape is the surface
  • 00:03:00
    of the
  • 00:03:01
    land and the means of Transport are our
  • 00:03:04
    own legs we just run away and within 10
  • 00:03:06
    or 15 seconds we can be out of danger
  • 00:03:09
    but with an offshore rig Escape has to
  • 00:03:12
    be
  • 00:03:13
    organized information is needed will
  • 00:03:16
    helicopters arrive when will they arrive
  • 00:03:19
    are the ships stood by an escape has to
  • 00:03:22
    be led it requires leadership to take
  • 00:03:26
    those decisions that are necessary do we
  • 00:03:28
    wait for helicopter do we take to the
  • 00:03:32
    water and the third crucial differences
  • 00:03:34
    on Shore was in terms of handling any
  • 00:03:38
    emergency on Shore the first thing we
  • 00:03:40
    call up is the local fire brigade they
  • 00:03:43
    come with first class equipment
  • 00:03:45
    well-trained Crews and experienced
  • 00:03:48
    officers to lead them but on an offshore
  • 00:03:51
    rig you cannot whistle up the fire
  • 00:03:53
    brigade you tackle any emergency with
  • 00:03:57
    what you got on the rig and with the
  • 00:03:59
    people you employ if you have a fire
  • 00:04:02
    it's the built-in Firewater system that
  • 00:04:05
    you use and it's the part-time fireman
  • 00:04:08
    there may be processed workers or
  • 00:04:10
    Fitters management of any sort so three
  • 00:04:14
    crucial differences with the onshore
  • 00:04:16
    plant which you will see as the disaster
  • 00:04:20
    develops uh played a critical part what
  • 00:04:23
    happened to
  • 00:04:25
    Piper well at 10:00 on the evening of
  • 00:04:28
    6th of July 1988
  • 00:04:30
    there was an
  • 00:04:31
    explosion and a subsequent fire and in
  • 00:04:35
    just a few
  • 00:04:38
    hours that platform was reduced to
  • 00:04:41
    this just the base of the um drilling
  • 00:04:45
    ring end of the
  • 00:04:46
    platform 12,000 tons of steel was 454 ft
  • 00:04:51
    down on the bottom of the North
  • 00:04:53
    Sea but more crucially in just that few
  • 00:04:57
    hours 166 men
  • 00:05:01
    died the total death toll was 167 one
  • 00:05:05
    more died of his injuries the next
  • 00:05:09
    day and it is because of that large
  • 00:05:11
    death toll that there was a public
  • 00:05:14
    inquiry into the
  • 00:05:17
    disaster what's a public inquiry
  • 00:05:21
    like it's a court of
  • 00:05:24
    law it's led by a judge in this case
  • 00:05:27
    Lord Cullen a very senior Scottish judge
  • 00:05:31
    parties are represented by Council by
  • 00:05:33
    legal council so for instance the
  • 00:05:36
    operator was represented by Council uh
  • 00:05:39
    the survivors were represented by their
  • 00:05:40
    own Council the trade unions
  • 00:05:43
    represented uh some of the equipment
  • 00:05:46
    suppliers were
  • 00:05:47
    represented because they felt their
  • 00:05:49
    equipment might be implicated in the
  • 00:05:51
    causes of the disaster
  • 00:05:55
    itself Witnesses presented evidence and
  • 00:05:58
    they were cross-examined by both both
  • 00:05:59
    the council and the
  • 00:06:05
    judge but the inquiry was still an
  • 00:06:08
    accident investigation and therefore it
  • 00:06:11
    had exactly the same objectives as we
  • 00:06:15
    have throughout the organization in any
  • 00:06:18
    accident and that is to determine the
  • 00:06:22
    causes of the accident in this case the
  • 00:06:25
    causes of death and secondly to make
  • 00:06:28
    recommendations to avoid a
  • 00:06:36
    repetition as I develop this
  • 00:06:40
    presentation and develop in particular
  • 00:06:43
    the causes of
  • 00:06:44
    death you will be able to interpret what
  • 00:06:47
    I said as criticism of parts of an
  • 00:06:51
    organization or
  • 00:06:53
    individuals that is not the purpose of
  • 00:06:55
    my presentation and it was not the
  • 00:06:58
    purpose of the public
  • 00:07:00
    inquiry public inquiry just had to
  • 00:07:03
    determine what happened why it happened
  • 00:07:06
    and make recommendations to avoid a
  • 00:07:09
    repetition so just like an accident
  • 00:07:12
    investigation run like a court of law
  • 00:07:15
    but differing crucially from a court
  • 00:07:18
    case we're all used to reading the
  • 00:07:21
    newspapers and the prosecuting Council
  • 00:07:23
    gets up and in
  • 00:07:25
    effect sets out for the court what the
  • 00:07:29
    prosecution the police believe happened
  • 00:07:33
    they worked it out from the evidence
  • 00:07:35
    then the case is defended but in a
  • 00:07:37
    public inquiry no one gets up and says
  • 00:07:40
    we've investigated we've worked out what
  • 00:07:43
    happened on Piper Alpha we can tell
  • 00:07:45
    you the inquiry itself does that piece
  • 00:07:49
    of detective work as you go along and by
  • 00:07:52
    the inquiry I mean the judge and the
  • 00:07:55
    three
  • 00:07:57
    assessors I was one of those Assessor
  • 00:08:00
    I said there were three of us with three
  • 00:08:02
    different industrial backgrounds our
  • 00:08:05
    sole job was to help the judge help him
  • 00:08:08
    with the detective work to determine
  • 00:08:10
    what happened and why help him to
  • 00:08:12
    formulate
  • 00:08:13
    recommendations and thirdly help him
  • 00:08:16
    write the
  • 00:08:18
    report so there's the public inquiry let
  • 00:08:21
    me now move on to the events of the
  • 00:08:25
    night and the six factors that bore on
  • 00:08:28
    the high death t
  • 00:08:30
    as I've told you at 10:00 there was an
  • 00:08:36
    explosion we knew it was 10:00 because
  • 00:08:39
    one Manet switched on the television
  • 00:08:41
    news and the television announcer hadn't
  • 00:08:44
    yet said anything so we knew it was
  • 00:08:47
    within seconds of
  • 00:08:50
    10:00 we knew where it was and that was
  • 00:08:54
    in the gas compression module in the
  • 00:08:56
    middle of the
  • 00:08:57
    platform in part because the Iver said
  • 00:09:00
    well I felt a Bang from that direction
  • 00:09:02
    or I heard a Bang from this and we
  • 00:09:05
    could uh cross the lines but crucially
  • 00:09:09
    the control room operator
  • 00:09:12
    survived uh and about 30 seconds maybe a
  • 00:09:15
    minute before the explosion he had a
  • 00:09:17
    series of gas alarms from that gas
  • 00:09:20
    compression
  • 00:09:23
    module and the third reason we could
  • 00:09:25
    home in where it started was from the
  • 00:09:28
    survivors describing damage damage to
  • 00:09:31
    walls so we knew it was 10:00 we knew
  • 00:09:34
    where it
  • 00:09:35
    was all the gas alarms that came up were
  • 00:09:38
    low-lying in the
  • 00:09:40
    module and therefore what had leaked was
  • 00:09:44
    heavier than air not natural gas lighter
  • 00:09:48
    so it was propane that
  • 00:09:50
    leaked and it is for that reason that
  • 00:09:53
    the inquiry concentrated its attention
  • 00:09:56
    on what we've been happening to the
  • 00:09:58
    condensate system
  • 00:10:00
    in the period before the
  • 00:10:05
    explosion everything was running
  • 00:10:07
    normally until about 50 minutes before
  • 00:10:10
    9:45 and at that time the pump that
  • 00:10:14
    pressured up condensate to about 1,000
  • 00:10:17
    PSI to inject it into the oil export
  • 00:10:20
    line to go to shore tripped
  • 00:10:25
    out the night shift tried to restart the
  • 00:10:27
    pump and failed
  • 00:10:31
    but there was an installed spare
  • 00:10:34
    pump now the night shift knew that
  • 00:10:36
    during that day that spare pump had been
  • 00:10:39
    taken for
  • 00:10:40
    maintenance it had been taken for a
  • 00:10:42
    major overhaul done once every two
  • 00:10:46
    years but they also knew very little had
  • 00:10:49
    been done to the spare pump yes it had
  • 00:10:51
    been electrically
  • 00:10:53
    isolated suction and delivery valves
  • 00:10:55
    closed the propane blown down from the
  • 00:10:58
    pump
  • 00:10:59
    but no pipe work had been opened up no
  • 00:11:02
    slip plates had been fitted so it should
  • 00:11:05
    be a relatively easy and quick job to
  • 00:11:08
    recommission the spare
  • 00:11:11
    pump reconnect electricity Supply open
  • 00:11:14
    suction and V vales start the pump
  • 00:11:17
    on but the night shift were not aware
  • 00:11:21
    that there was a second maintenance job
  • 00:11:22
    that had been started that day on that
  • 00:11:25
    pump on its delivery pip work there was
  • 00:11:27
    a relief valve
  • 00:11:30
    and that relief valve had been taken off
  • 00:11:32
    that day for an annual overhaul and a
  • 00:11:34
    check of its set
  • 00:11:37
    pressure the work on the valve was not
  • 00:11:40
    complete by
  • 00:11:41
    6:00 uh the platform was trying to
  • 00:11:44
    reduce overtime and the contractor's
  • 00:11:47
    employees who were doing the relief
  • 00:11:50
    valve
  • 00:11:51
    overhaul uh decided they would finish
  • 00:11:53
    the job the next morning
  • 00:12:00
    the Twan contractor team one was a
  • 00:12:02
    supervisor it was his first time ever
  • 00:12:04
    acting as a
  • 00:12:06
    supervisor
  • 00:12:07
    and at 6:00 he took the permit to work
  • 00:12:11
    for the reli work back to the control
  • 00:12:15
    room the process Supervisor was busy
  • 00:12:19
    with his Handover 6:00 was a shift
  • 00:12:23
    change so the contractor's supervisor
  • 00:12:26
    signed the permit and left it on the
  • 00:12:28
    desk
  • 00:12:34
    he did not check the job site before he
  • 00:12:37
    did
  • 00:12:41
    that so here were two maintenance jobs
  • 00:12:43
    the process team knew about one they
  • 00:12:45
    were confident they could recommission
  • 00:12:47
    the spare pump they did not know about a
  • 00:12:49
    second which crucially was on the
  • 00:12:53
    delivery side of the pump before the
  • 00:12:56
    delivery valve when they attempted to
  • 00:12:59
    recommission the spare
  • 00:13:01
    pump condensate
  • 00:13:03
    leak from where that relief valve had
  • 00:13:07
    been taken off yes blank flanges should
  • 00:13:12
    have been fitted they cannot have been
  • 00:13:14
    fitted fully and
  • 00:13:22
    well why didn't the process supervisors
  • 00:13:26
    know about that relief valve the permit
  • 00:13:29
    to work system is designed to do just
  • 00:13:32
    that to make sure that everybody who
  • 00:13:34
    needs to know does
  • 00:13:37
    know when the inquiry examined what had
  • 00:13:41
    been happening in permits to work that
  • 00:13:43
    day we found there were faults in the
  • 00:13:46
    permit to work system on that fatal
  • 00:13:48
    Wednesday
  • 00:13:51
    evening as I said the contractor
  • 00:13:53
    supervisor did not talk to the process
  • 00:13:56
    supervisor he did not in uh respect the
  • 00:13:59
    job site the two permits one for the
  • 00:14:02
    major pump overhaul the second one for
  • 00:14:04
    the relief valve were not cross
  • 00:14:06
    reference one to the
  • 00:14:12
    other and they were faults on the night
  • 00:14:15
    when we invested the background to that
  • 00:14:18
    these were not unusual
  • 00:14:22
    faults common jobs on the same piece of
  • 00:14:24
    equipment on Piper Alpha the permits
  • 00:14:27
    were never cross reference one to the
  • 00:14:31
    other it was common practice for
  • 00:14:34
    maintenance supervisors to return
  • 00:14:36
    permits to the control room not speak to
  • 00:14:39
    the process supervisor and leave them
  • 00:14:41
    lying on the
  • 00:14:44
    desk process
  • 00:14:46
    supervisors quite frequently would sign
  • 00:14:49
    off a
  • 00:14:50
    permit accepting the job back and the
  • 00:14:53
    equipment back prior to inspecting the
  • 00:14:56
    job site to satisfy themselves the work
  • 00:14:59
    was complete and entirely
  • 00:15:07
    safe the contractor supervisor I told
  • 00:15:10
    you was a new one his first time ever as
  • 00:15:12
    a supervisor he'd had no training in the
  • 00:15:16
    permit to work system whatsoever yes
  • 00:15:19
    he'd seen the supervisor he worked for
  • 00:15:22
    in days gone by use the permit system
  • 00:15:25
    but he'd had no
  • 00:15:27
    training but that was wasn't too unusual
  • 00:15:29
    on
  • 00:15:30
    Piper nobody
  • 00:15:32
    else had received regular and formal
  • 00:15:36
    training in the operation of the permit
  • 00:15:38
    to work
  • 00:15:40
    system everything was learning on the
  • 00:15:43
    job the problem with learning on the job
  • 00:15:46
    is you perpetuate and accumulate
  • 00:15:57
    errors so here was
  • 00:16:01
    explosion at the heart of it was a lack
  • 00:16:04
    of
  • 00:16:05
    knowledge at the heart of it was a
  • 00:16:08
    breakdown in a permanent to work
  • 00:16:10
    system and it wasn't just an error on
  • 00:16:13
    the night it was Perman work that way
  • 00:16:16
    the men on Piper Alpha did not work the
  • 00:16:19
    permit to work system as the management
  • 00:16:22
    had laid
  • 00:16:26
    down and that was in in part dependent
  • 00:16:30
    on the lack of
  • 00:16:32
    training so an explosion and two
  • 00:16:34
    deficiencies deficient permit to work
  • 00:16:36
    system deficient
  • 00:16:38
    training I said the inquiry's role was
  • 00:16:40
    to look to the causes of death um the
  • 00:16:43
    explosion caused very few deaths we
  • 00:16:47
    think maybe
  • 00:16:52
    two but after the explosion there was an
  • 00:16:56
    an oil fire
  • 00:17:00
    the explosion of the gas compression
  • 00:17:02
    module blew down the
  • 00:17:04
    firewall and damaged equipment in the
  • 00:17:07
    oil separation unit and there was an
  • 00:17:10
    almost immediate very large oil
  • 00:17:17
    fire I said it Brew down the
  • 00:17:21
    firewalls so obviously in the design of
  • 00:17:23
    the plant it had been considered that
  • 00:17:27
    the chances of a fire in the compression
  • 00:17:29
    module was sufficiently large to Warrant
  • 00:17:32
    a
  • 00:17:35
    firewall it seems
  • 00:17:39
    inconceivable uh in a gas compression
  • 00:17:42
    module handling natural gas and
  • 00:17:43
    condensate that the likelihood of an
  • 00:17:46
    explosion was any less than the
  • 00:17:48
    likelihood of a
  • 00:17:49
    fire but no explosion walls were
  • 00:17:52
    installed between the modules
  • 00:17:59
    on Piper in his design phase there had
  • 00:18:02
    never been a systematic assessment of
  • 00:18:05
    all potential
  • 00:18:08
    hazards and therefore no identification
  • 00:18:11
    that an explosion was just as likely as
  • 00:18:13
    a
  • 00:18:18
    fire so there was deficient Hazard
  • 00:18:25
    analysis the oil fire was prolonged
  • 00:18:29
    in fact it lasted longer than the
  • 00:18:31
    inventory of oil on Piper would permit
  • 00:18:35
    it I told you earlier that Piper was
  • 00:18:38
    connected to two other platforms by oil
  • 00:18:40
    pipelines and the production from those
  • 00:18:43
    pip pipelines was put to shore via
  • 00:18:50
    Piper after the initial explosion on
  • 00:18:53
    Piper and during the subsequent fire the
  • 00:18:56
    other two pip uh platforms went on
  • 00:19:01
    producing and in effect they were
  • 00:19:03
    pumping their oil to the fire on
  • 00:19:10
    Piper when the inquiry asked the
  • 00:19:13
    managers of the other platforms why they
  • 00:19:15
    went on producing instead of shutting
  • 00:19:18
    down they said that um they
  • 00:19:22
    assumed that Piper would bring its
  • 00:19:24
    emergency under control they'd heard the
  • 00:19:27
    maydays they'd heard ships broadcasting
  • 00:19:30
    that had been attracted round same
  • 00:19:31
    Pipers on fire but they
  • 00:19:34
    assumed that they would bring it under
  • 00:19:36
    control the initial explosion
  • 00:19:40
    unfortunately put out a commission all
  • 00:19:42
    the means of communication on Piper so
  • 00:19:45
    they could not talk to Piper
  • 00:19:50
    directly but they really had no evidence
  • 00:19:53
    on which to make that assumption that it
  • 00:19:55
    would be brought under
  • 00:19:56
    control and therefore no real
  • 00:19:59
    justification for going on
  • 00:20:03
    producing but when we examine the
  • 00:20:06
    background to that issue we found that
  • 00:20:10
    there had never been any training or
  • 00:20:12
    simulated exercises in an interplatform
  • 00:20:17
    emergency the three platforms connected
  • 00:20:20
    together by both oil and gas pipes
  • 00:20:22
    formed one system and if one was in
  • 00:20:24
    trouble there must be a reaction on the
  • 00:20:26
    other
  • 00:20:27
    two but had never been a simulation
  • 00:20:31
    exercise so managers could work out what
  • 00:20:34
    they might do in the face of different
  • 00:20:36
    emergencies so prolonged oil
  • 00:20:39
    fire division Hazard analysis no
  • 00:20:42
    explosion walls and again deficient
  • 00:20:46
    training but even the oil fire killed
  • 00:20:49
    very few
  • 00:20:51
    people what did it look like like
  • 00:20:56
    this a large fire fire but not totally
  • 00:21:00
    engulfing the
  • 00:21:02
    platform unfortunately it produced
  • 00:21:04
    massive amount of thick black smoke that
  • 00:21:07
    swept to the North End of the platform
  • 00:21:09
    where all the lifeboats were located and
  • 00:21:11
    no one could reach a
  • 00:21:16
    Lifeboat but it's doubtful whether that
  • 00:21:18
    oil fire on its own in the fire killed
  • 00:21:21
    many people maybe
  • 00:21:23
    want but it was followed by a gas fire
  • 00:21:30
    the gas pipes connected Piper to the
  • 00:21:33
    other two platforms and to shore came up
  • 00:21:37
    in Piper in the middle of the oil
  • 00:21:42
    fire and as that fire played on those
  • 00:21:45
    pipes they gradually weakened the gas
  • 00:21:48
    was at about 2,000 PSI and
  • 00:21:52
    eventually they burst successively one
  • 00:21:55
    after about 25 minutes the other two are
  • 00:21:57
    about another half hour
  • 00:22:03
    later was the hazard of the gas pipes
  • 00:22:07
    recognized well yes it was and in
  • 00:22:10
    particular on Piper just 12 months
  • 00:22:13
    before a young chemical engineer had
  • 00:22:15
    been asked to consider whether it was
  • 00:22:17
    worth renewing the contract for the
  • 00:22:20
    small firefighting ship that stood by
  • 00:22:24
    Piper um it could spray water onto Piper
  • 00:22:28
    but it wasn't very effective at fighting
  • 00:22:30
    a fire but this young chemical
  • 00:22:32
    engineer in studying this issue uh
  • 00:22:36
    examined all the potential fires that
  • 00:22:38
    could occur on paper and in doing so he
  • 00:22:41
    examined what the fire would be like if
  • 00:22:44
    a gas Riser
  • 00:22:46
    broke and what he wrote about that was
  • 00:22:50
    that if a gas Riser fails into a
  • 00:22:54
    fire the fire will be enormous there
  • 00:22:57
    will be no no means of containing
  • 00:23:00
    it and the loss of life will be very
  • 00:23:05
    large at the meeting of senior managers
  • 00:23:08
    to consider his report about renewing
  • 00:23:11
    the contract for the firefighting ship
  • 00:23:14
    that paragraph about the potential
  • 00:23:16
    Hazard of the gas risers was never
  • 00:23:20
    raised no one commented on it no one
  • 00:23:24
    questioned it
  • 00:23:29
    so here was a known
  • 00:23:33
    Hazard a massive Indy of gas in those
  • 00:23:37
    long large pipelines aimed at the
  • 00:23:41
    platform and the hazard was not managed
  • 00:23:44
    it wasn't a question of identification
  • 00:23:46
    it was a question of managing it could
  • 00:23:48
    anything have been
  • 00:23:50
    done well yes you could have had water
  • 00:23:53
    sprays specifically on the risers that
  • 00:23:56
    would have bought some time you could
  • 00:23:58
    have insulated the Rises that would pose
  • 00:24:01
    problems because of corrosion underneath
  • 00:24:03
    the insulation but again you could have
  • 00:24:05
    bought time might have bought some hours
  • 00:24:08
    that might have been crucial on that
  • 00:24:10
    fatal
  • 00:24:12
    night what did the gas fire look like
  • 00:24:17
    look like
  • 00:24:19
    this as you can see very different from
  • 00:24:22
    the oil
  • 00:24:23
    fire the platform engulfed in fire but
  • 00:24:26
    this slide gives you a very poor
  • 00:24:28
    impression of what it was like um and
  • 00:24:32
    what I want to do is to show you a very
  • 00:24:34
    small piece of
  • 00:24:35
    video um in one of the ships near Piper
  • 00:24:38
    on that evening a Norwegian sailor had a
  • 00:24:41
    video camera and he was taking shots for
  • 00:24:43
    his child school
  • 00:24:45
    project and he took film of the disaster
  • 00:24:49
    and what I want to show you is about 30
  • 00:24:51
    40 seconds of film which starts with the
  • 00:24:54
    oil
  • 00:24:55
    fire and you then see the first gas
  • 00:24:59
    Riser
  • 00:25:01
    [Music]
  • 00:25:04
    blow
  • 00:25:05
    incredibly some men escaped after that
  • 00:25:09
    gas Riser blow and through those
  • 00:25:17
    Flames I said earlier that uh a North
  • 00:25:20
    Sea platform has to fight a fire with
  • 00:25:22
    whatever it's
  • 00:25:23
    got and on Piper
  • 00:25:30
    it had quite a lot in particular it had
  • 00:25:33
    a water delu system that sprayed a
  • 00:25:37
    defined amount of water over every area
  • 00:25:41
    that could contain
  • 00:25:47
    hydrocarbons on the night of the
  • 00:25:50
    disaster the water supply system did not
  • 00:25:53
    work at all now the initial explosion No
  • 00:25:57
    Doubt destroyed the main power
  • 00:26:00
    supply and therefore put out a
  • 00:26:02
    commission the water pumps that supplied
  • 00:26:05
    that water delude system but the
  • 00:26:08
    designers of the platform had foreseen
  • 00:26:10
    that possibility and had therefore
  • 00:26:14
    installed emergency water pumps diesel
  • 00:26:17
    driven that started up
  • 00:26:20
    automatically when the W the electrical
  • 00:26:22
    driven pumps failed but on the night of
  • 00:26:25
    the disaster the diesel driven drump
  • 00:26:28
    pumps were not on automatic start they
  • 00:26:31
    were on manual
  • 00:26:35
    start they were on manual start because
  • 00:26:38
    of a problem with diver
  • 00:26:42
    safety the water pumps took their
  • 00:26:44
    suction from below the
  • 00:26:46
    platform and if a diver was close to the
  • 00:26:49
    pump suction when it started up
  • 00:26:52
    automatically he or these feeder lines
  • 00:26:55
    could be sucked into it and the diver
  • 00:26:57
    could die
  • 00:26:58
    and this issue was raised with the
  • 00:27:00
    platform
  • 00:27:03
    manager quite rightly raised with him
  • 00:27:05
    and he
  • 00:27:06
    decided that the diesel driven pumps
  • 00:27:10
    would be on manual start whenever the
  • 00:27:12
    divers were in the water note not when
  • 00:27:15
    they were near the pump intake whenever
  • 00:27:17
    they were in the water and on Piper in
  • 00:27:20
    the summer months diving took place for
  • 00:27:22
    12 hours each
  • 00:27:25
    day so in the summer months The crucial
  • 00:27:29
    backup fire water pumps were on manual
  • 00:27:31
    start for half the
  • 00:27:38
    time platform manager absolutely right
  • 00:27:41
    to consider
  • 00:27:42
    the the problem with the divver safety
  • 00:27:45
    what was wrong was the quality of the
  • 00:27:48
    decision he took in the face of that
  • 00:27:51
    problem on his assist the platform they
  • 00:27:53
    only put the diesel pumps on manual
  • 00:27:55
    start when the divers were close to pump
  • 00:27:58
    suction
  • 00:28:00
    Intex and that was
  • 00:28:06
    infrequent but even if the pumps had
  • 00:28:08
    started up it is most unlikely that the
  • 00:28:11
    Deluge system would have worked properly
  • 00:28:14
    because there had been a
  • 00:28:15
    problem with blocking of the Deluge
  • 00:28:20
    heads the seawater corroded the Deluge
  • 00:28:23
    pipe work the products of corrosion were
  • 00:28:25
    carried forward and bed the small holes
  • 00:28:28
    in the Deluge
  • 00:28:32
    heads first attempt to cure this uh was
  • 00:28:35
    by more frequent cleaning of the pipe
  • 00:28:38
    work but that didn't work it just
  • 00:28:40
    presented bare metal to be
  • 00:28:43
    corroded second method tried was to put
  • 00:28:46
    in larger heads with larger holes in
  • 00:28:48
    them that didn't work either the
  • 00:28:51
    corrosion products block those and
  • 00:28:53
    finally it had been decided to replace
  • 00:28:55
    all the Deluge pipe work in
  • 00:28:57
    non-corrosive material
  • 00:28:59
    unfortunately by the time of the
  • 00:29:01
    disaster the only module that had been
  • 00:29:04
    so converted was the drilling module and
  • 00:29:07
    that was the one that didn't really
  • 00:29:09
    catch
  • 00:29:09
    fire now I think you'd agree
  • 00:29:12
    that's a quite logical way of tackling
  • 00:29:15
    that problem try one method try
  • 00:29:19
    increasing the holes and finally facing
  • 00:29:21
    the large expans of replacing the PIP
  • 00:29:24
    work but what was not acceptable was
  • 00:29:28
    that the problem of blocking deluse
  • 00:29:30
    heads had been identified 4 years before
  • 00:29:34
    the
  • 00:29:35
    disaster and after 4 years it had not
  • 00:29:39
    been
  • 00:29:43
    solved so in terms of
  • 00:29:47
    firefighting the diesel driven pumps
  • 00:29:49
    being on
  • 00:29:50
    manual was
  • 00:29:52
    a a deficiency of quality of safety
  • 00:29:55
    decision
  • 00:29:59
    the spray heads not being fully
  • 00:30:01
    functional working well was a de
  • 00:30:05
    deficiency of Safety Management it was
  • 00:30:07
    well known throughout the company but it
  • 00:30:10
    had not been solved in any kind of
  • 00:30:12
    reasonable time
  • 00:30:16
    period as I told you the inquiry has to
  • 00:30:20
    determine the causes of death and the
  • 00:30:24
    bulk of the people on Piper Alpha died
  • 00:30:28
    in the accommodation
  • 00:30:32
    block as the explosion took place at
  • 00:30:34
    10:00 at night uh most of the onboard
  • 00:30:37
    crew were already in the accommodation
  • 00:30:39
    block and many of those working made the
  • 00:30:42
    way there through the smoke Through the
  • 00:30:44
    flames and they did that because the
  • 00:30:46
    normal means of transportation was by
  • 00:30:48
    helicopter and they expected Rescue
  • 00:30:51
    helicopters to come in and take them off
  • 00:31:00
    but they died in that accommodation and
  • 00:31:02
    they died of carbon monoxide poisoning
  • 00:31:04
    from
  • 00:31:07
    smoke because
  • 00:31:10
    although the ventilation system on the
  • 00:31:14
    uh accommodation block had dampness that
  • 00:31:17
    would close on high
  • 00:31:19
    temperature people kept opening doors to
  • 00:31:22
    see what was happening kept breaking
  • 00:31:25
    Windows to see if they could Escape
  • 00:31:29
    some fire doors had been permanently
  • 00:31:32
    hooked open to facilitate passage had
  • 00:31:35
    been like that for weeks so there was no
  • 00:31:38
    discipline in the face of that fire and
  • 00:31:41
    the smoke and gradually the
  • 00:31:45
    accommodation filled up with thick smoke
  • 00:31:48
    and the people died we know that because
  • 00:31:51
    one part of the accommodation block was
  • 00:31:52
    recovered from the Bottom of the Sea and
  • 00:31:54
    there were 80 bodies in it
  • 00:32:00
    but they also died because they stayed
  • 00:32:08
    there within minutes of the initial
  • 00:32:11
    explosion it must have been very evident
  • 00:32:14
    that no helicopter had any chance of
  • 00:32:17
    landing on Piper in the face of the
  • 00:32:19
    flames and the
  • 00:32:21
    smoke the only chance anybody in the
  • 00:32:24
    accommodation has and it was a lousy
  • 00:32:28
    chance was to leave the accommodation
  • 00:32:31
    fight the way through the smoke and the
  • 00:32:33
    flames and jump in the sea and hope to
  • 00:32:36
    be picked up and there were many ships
  • 00:32:39
    around doing exactly
  • 00:32:42
    that
  • 00:32:45
    unfortunately no decision was
  • 00:32:49
    taken to tell the men in the
  • 00:32:51
    accommodation block to take that
  • 00:32:54
    terrible chance but it was a chance and
  • 00:32:57
    they stay stayed and
  • 00:33:01
    died none of us
  • 00:33:04
    know how we will react under the stress
  • 00:33:07
    of a major emergency if we were in
  • 00:33:09
    charge we can't forecast
  • 00:33:11
    that but what the inquiry
  • 00:33:14
    noted was that the offshore installation
  • 00:33:18
    manager had had inadequate training in
  • 00:33:22
    handling
  • 00:33:24
    emergencies he hadn't gone through any
  • 00:33:26
    simulation exercises
  • 00:33:28
    of the types of emergencies that might
  • 00:33:30
    develop on an offshore
  • 00:33:33
    rig not his
  • 00:33:37
    fault if a man is appointed to a job and
  • 00:33:41
    training is needed to fit him for that
  • 00:33:43
    job it is the senior Management's
  • 00:33:46
    responsibility to provide that training
  • 00:33:48
    that training was not
  • 00:33:53
    provided it was a poor chance of
  • 00:33:56
    survival
  • 00:33:58
    but it was possible 28 men left the
  • 00:34:04
    accommodation fought the way through the
  • 00:34:06
    flames and smoke jumped in the sea and
  • 00:34:08
    they were picked
  • 00:34:15
    up the final factor I want to touch on
  • 00:34:18
    about the
  • 00:34:22
    disaster it's about auditing the
  • 00:34:24
    deficiencies I've told you about um
  • 00:34:29
    they were not difficult to find in the
  • 00:34:32
    inquiry the problems of the permit to
  • 00:34:35
    work system we ran over in the first
  • 00:34:38
    fortnite so if we found them so easily
  • 00:34:41
    why is it the management had not notice
  • 00:34:44
    them during the operation of
  • 00:34:48
    Piper our way of knowing what's
  • 00:34:50
    happening in all our
  • 00:34:52
    organizations um is by auditing now we
  • 00:34:55
    do it required by law to do it for
  • 00:35:00
    finances and equally we
  • 00:35:03
    audit safety practices and on Piper
  • 00:35:06
    there was a lot of
  • 00:35:08
    auditing more than I'd been used to in
  • 00:35:11
    my previous career in
  • 00:35:14
    chemicals for example each day one of
  • 00:35:18
    the safety operators on the
  • 00:35:21
    platform was required to monitor the
  • 00:35:23
    operation of the permit to work system
  • 00:35:25
    and he went around looking what people
  • 00:35:27
    were doing an examine permit to work
  • 00:35:29
    forms things like
  • 00:35:32
    that no Faults were ever reported on the
  • 00:35:35
    permit to work system on Piper
  • 00:35:40
    Alpha just 6 months previously there had
  • 00:35:43
    been an Inc company audit of Piper they
  • 00:35:46
    chose three or four subjects to audit
  • 00:35:47
    one again was the permit to work
  • 00:35:50
    system that in company
  • 00:35:54
    audit said there were no Faults in the
  • 00:35:56
    operation of the firm to work system on
  • 00:35:58
    Piper
  • 00:36:04
    Alpha problem with the delug heads been
  • 00:36:07
    running for four
  • 00:36:09
    years it was an annual fire Insurance
  • 00:36:12
    audit the inquiry read the reports for
  • 00:36:14
    the four years not a single report noted
  • 00:36:18
    the problem of the Deluge heads but it
  • 00:36:21
    was a fire Insurance AIT
  • 00:36:28
    so a lot of auditing on
  • 00:36:32
    Piper but deficient quality
  • 00:36:37
    auditing and when you have deficient
  • 00:36:39
    quality auditing it has a double Hazard
  • 00:36:43
    are you miss things that you want to
  • 00:36:44
    pick up and
  • 00:36:46
    correct but secondly it lulls the
  • 00:36:49
    management into a false sense of
  • 00:36:51
    security as one very senior manager said
  • 00:36:53
    to the inquiry I knew everything was all
  • 00:36:57
    right right because I got no reports of
  • 00:37:00
    things being wrong from safety
  • 00:37:04
    auditing I my
  • 00:37:06
    experience that's not real life safety
  • 00:37:10
    isn't like that there are always things
  • 00:37:13
    that you can find that can be improved
  • 00:37:16
    and if you get reports that give
  • 00:37:17
    continuous good marks you smell
  • 00:37:25
    it so there are six factors
  • 00:37:29
    and the backgrounds to them that bore on
  • 00:37:31
    the death toll on Piper
  • 00:37:34
    Alpha what I want to do now is extract
  • 00:37:37
    lessons from
  • 00:37:40
    those clearly there are lessons to learn
  • 00:37:43
    about the detailed design and operation
  • 00:37:45
    of permit work systems for
  • 00:37:48
    example um equally there are lessons
  • 00:37:51
    peculiar to the offshore industry like
  • 00:37:54
    planning evacuation and means of Escape
  • 00:37:59
    but all history teaches us that the
  • 00:38:01
    detailed circumstances of any major
  • 00:38:04
    accident never repeat themselves and
  • 00:38:07
    it's for that reason that we try to get
  • 00:38:10
    to the root causes of any
  • 00:38:15
    accident and when we look at the list of
  • 00:38:19
    deficiencies that I've developed
  • 00:38:23
    today we can bring out four lessons
  • 00:38:31
    all the divisiones I've talked about
  • 00:38:33
    were the responsibility of
  • 00:38:36
    management so the first lesson is that
  • 00:38:39
    safety is the responsibility of
  • 00:38:41
    management no one else it's not the
  • 00:38:42
    responsibility the regulator or safety
  • 00:38:45
    committees or anything like that it is
  • 00:38:47
    the responsibility of management
  • 00:38:49
    management is a very wide term let's get
  • 00:38:53
    more specific it is the responsibility
  • 00:38:56
    of line manager
  • 00:38:58
    M it is not the responsibility of the
  • 00:39:01
    safety department safety department has
  • 00:39:04
    a crucial role to play it has things it
  • 00:39:06
    must do but it is not responsible for
  • 00:39:10
    safety performance that is the line
  • 00:39:13
    management and it is the line management
  • 00:39:16
    from top to bottom from the chief
  • 00:39:19
    executive to the lowest
  • 00:39:21
    supervisor and in particular the chief
  • 00:39:25
    executive he has to be totally committed
  • 00:39:28
    and visibly
  • 00:39:30
    committed so that's the first lesson I
  • 00:39:33
    would extract from Piper
  • 00:39:36
    Alpha the second lesson is that safety
  • 00:39:39
    needs a systematic approach if you look
  • 00:39:41
    at all those
  • 00:39:43
    deficiencies they were failures in
  • 00:39:45
    systems either there was a system it
  • 00:39:48
    didn't work well for instance there was
  • 00:39:50
    a permit work system but it didn't work
  • 00:39:55
    properly or there wasn't a system where
  • 00:39:58
    there should have
  • 00:40:00
    been there was no systematic assessment
  • 00:40:03
    of major hazards in the design of Piper
  • 00:40:05
    Alpha there should have
  • 00:40:08
    been so safety needs a systematic
  • 00:40:14
    approach third lesson I extract
  • 00:40:19
    is it is the quality of Safety
  • 00:40:21
    Management which is crucial to
  • 00:40:24
    you the offshore installation manager
  • 00:40:26
    facing the the problem with the divers
  • 00:40:28
    with the pump
  • 00:40:29
    intakes right to face it he had to
  • 00:40:32
    decide what was wrong was the quality of
  • 00:40:34
    his decision another example from the
  • 00:40:37
    same manager he he told us that he he
  • 00:40:41
    walked around the platform for about an
  • 00:40:42
    hour an hour and a half each day and he
  • 00:40:45
    did that to keep his finger on the pulse
  • 00:40:46
    and in particular to keep a feel of
  • 00:40:49
    safety check on permits to work look how
  • 00:40:51
    people were doing jobs and I think
  • 00:40:53
    you'll all agree that was a right thing
  • 00:40:55
    for the leader to do
  • 00:40:58
    but he told us he did that at 7:00 at
  • 00:41:01
    night and he did it at 7:00 at night
  • 00:41:05
    because that was the only time he had
  • 00:41:07
    available offshore installation manager
  • 00:41:09
    is a very busy man but then the bulk of
  • 00:41:12
    the work finished at
  • 00:41:17
    6:00 so it it is not just putting the
  • 00:41:21
    effort into Safety Management it is the
  • 00:41:24
    quality of what each one of us do
  • 00:41:30
    and the final lesson is about
  • 00:41:37
    auditing we have to
  • 00:41:40
    know that things we decide must be done
  • 00:41:43
    a certain way to be safe are done that
  • 00:41:46
    way every single time every single
  • 00:41:52
    day and our way of doing that is by
  • 00:41:56
    safety your
  • 00:41:58
    ating and it must be high quality safety
  • 00:42:03
    auditing so there are four fundamental
  • 00:42:06
    lessons I would draw out of the disaster
  • 00:42:09
    on Piper and his
  • 00:42:13
    background but I told you at the start
  • 00:42:17
    that my final section of the
  • 00:42:18
    presentation was what I call the bottom
  • 00:42:21
    line of
  • 00:42:25
    safety and where I to cover that is to
  • 00:42:28
    tell you of two short episodes told To
  • 00:42:32
    Us by two of the survivors from
  • 00:42:36
    pipo they were both relatively young men
  • 00:42:39
    around
  • 00:42:40
    30 and the first one was very
  • 00:42:43
    unlucky he arrived on Piper just 6 hours
  • 00:42:46
    before the explosion at 4:00 in the
  • 00:42:48
    afternoon it was the first time he' ever
  • 00:42:50
    been on Piper Alpha in fact it was the
  • 00:42:54
    first time he'd ever worked offshore
  • 00:42:59
    he had a short safety introduction
  • 00:43:01
    course he had a meal as he was starting
  • 00:43:04
    a to go to work at 6:00 in the morning
  • 00:43:07
    he decided to go to bed early and he did
  • 00:43:08
    about
  • 00:43:09
    8:00 and he was woken by the
  • 00:43:14
    explosion and he then tried to tell the
  • 00:43:17
    inquiry how he escaped but he suffered
  • 00:43:21
    from a major problem at no instant had
  • 00:43:25
    he any idea where he was
  • 00:43:28
    he never been on the thing
  • 00:43:30
    before Council kept saying where were
  • 00:43:33
    you then I don't know I couldn't
  • 00:43:37
    see and eventually he found himself on a
  • 00:43:41
    walkway and he was surrounded by Thick
  • 00:43:45
    Smoke and then large Flames came up with
  • 00:43:49
    the smoke
  • 00:43:50
    itself and he told the inquiry I decided
  • 00:43:53
    to jump off the
  • 00:43:55
    walkway and the C
  • 00:43:57
    asked him why decided to do that and he
  • 00:44:01
    said I decided it was to better better
  • 00:44:05
    to die hitting the deck than to be burnt
  • 00:44:10
    alive he did jump he fell straight in
  • 00:44:13
    the sea and was rescued until to this
  • 00:44:16
    day neither he nor we know where he
  • 00:44:20
    jumped
  • 00:44:23
    from the second episode
  • 00:44:28
    this from a man who worked for the
  • 00:44:30
    drilling contractor bordon he was on
  • 00:44:32
    night shift when the explosion took
  • 00:44:34
    place he was at the drilling
  • 00:44:37
    rig and he fought his way through the
  • 00:44:39
    flames and the smoke to the
  • 00:44:41
    accommodation
  • 00:44:43
    block and that took him some
  • 00:44:45
    time and by the time he got there the
  • 00:44:48
    accommodation block was full of the
  • 00:44:51
    thick black smoke and when he got inside
  • 00:44:54
    he could see nothing and he could see no
  • 00:44:56
    one
  • 00:44:58
    and he told the inquiry he called out is
  • 00:45:01
    anybody from bordon here when Council
  • 00:45:04
    asked him why did you call that
  • 00:45:08
    out he said I didn't want to die
  • 00:45:13
    alone and I tell you those two
  • 00:45:17
    stories because we must always remember
  • 00:45:21
    that safety is not an intellectual
  • 00:45:24
    exercise it's not something to keep
  • 00:45:27
    safety departments in work or the reason
  • 00:45:30
    to go to conferences or hear
  • 00:45:33
    presentations safety is truly a matter
  • 00:45:36
    of life and
  • 00:45:41
    death and the sum and quality of all our
  • 00:45:45
    individual contributions to the
  • 00:45:48
    management of
  • 00:45:49
    safety determines whether the colleagues
  • 00:45:52
    we work with live or die
  • 00:45:57
    and on Piper Alpha on the 6th of July
  • 00:46:01
    1988 they died
  • 00:46:17
    [Music]
الوسوم
  • Piper Alpha
  • katastrofo
  • sekureco
  • publika enketo
  • permeso por labori
  • trejnado
  • hazardanalizo
  • administrado
  • fajro
  • evakuado