Fish bone diagram & 6 sigma for piper alpha accident

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