O OURO DE SHARPE PDF
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The Piper Alpha accident involved not only human errors and conflicting orders, but a long chain of events. The same authors point out that the disaster exposed the flaws in the offshore safety field.
Likewise, to understand the Gulf accident requires looking at the British Petroleum track record, since the accident with the Texas City refinery in Disasters and organizations: from lessons learnt to theorizing. Along the same line, to understand some aspects of the Fukushima tragedy Still, based on the analysis of the management of incidental and accidental situations, we believe it is important to examine the extent to which one can identify some of the organizational factors at the origin of actions and decisions that contributed to the accident, which the report by the Petrobras Internal Inquiry Commission Results and discussion Brief description of the accident On March 14, , two non-routine operations were being performed: emptying the emergency drain tank EDT on the aft port, beginning at hours, and preparation for inspection of the stability box.
It was then supposed to flow off, together with the production of hydrocarbons, to the process plant. The operator A claimed categorically that it was closed. The startup of the aft port EDT pump, after 54 minutes, considerably decreased the backflow of hydrocarbons.
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However, the water pumped out of the tank after the pump started also entered the aft starboard EDT, further increasing its pressure. Figure 1 Flowchart of the emergency drain tank process involved in the first explosion on the P rig.
This configuration resulted in the continuous pressurization of the aft starboard tank and its subsequent mechanical rupture some two hours after the beginning of the operation to empty the other tank aft port. At hours on March 15, , a huge tremor was felt, similar to dropping a heavy load on the deck, due to the mechanical rupture of the starboard EDT when it reached burst pressure.
Due to this and other damage, the fire ring was depressurized and the process plant automatically entered emergency shutdown mode. The gas released from the tank reached the internal area of the tank top and main deck, activating the gas sensors.
However, since the third- and fourth-level areas had not been classified as risk zones, the gas released after the explosion was not detected immediately in the tank compartment, which also explains why the oil and gas were not contained in this area, since there were no adequate containment devices or explosion-proof equipment Figure 2.
Figure 2 Illustration of the aft starboard column. The emergency brigade quickly deployed to the site, and some of the brigade members entered the column. The hatch from the third to the fourth level was opened for inspection of the lower compartments, where an intense hissing noise was detected, like leaking water, and plus a thick white mist with no heat or flames.
The inspection was hampered by lack of lighting in the area. Approximately 17 minutes after the aft starboard tank burst mechanically, at hours, there was a second, high-intensity explosion caused by the ignition of the natural gas released from the column, reaching the tank top and second deck.
The explosion killed 11 members of the fire brigade and caused major destruction to the area located above the aft starboard column. P plataforma que afundou.
From the importance of shared management in high-risk incidental and accidental situations… It is crucial to emphasize that the 11 dead crew members belonged to the brigade. Despite the intensity of the second explosion, it only hit those who had rushed to the immediate area of the accident, the brigade members.
The report by the Internal Commission It suggests such measures as the use of portable gas detectors and communications systems during emergencies. Such situations reveal the opacity of this kind of system and the related difficulties in interpretation by the operators Leplat J.
Aspectos da complexidade em ergonomia. There was also faulty classification of the risk areas, e. In this case, would it not have been more prudent for the brigade to avoid accessing the site? If each accident has specificities that make it a unique arrangement, we concede that it is impossible to determine in advance all the procedures to be adopted in future situations; otherwise we would be contradicting our basic frame of reference.
Still, this does not relieve management of the responsibility for mapping vulnerable points in its planning, identifying the existing gaps, in order to gather more elements to assist in the difficult task of managing incidental and accidental situations in which emergency decisions are made.
In this mapping process, who can contribute better than the workforce in listing, identifying, and discussing with managers the project gaps and flaws of an organizational nature , through shared decisions and collective analysis of risk situations, thereby exercising a more shared form of management? Rogalski J. In: Falzon P, organizador. The degree of tension can reach paroxysmal levels, and some managers become paralyzed, as Rogalski highlights, citing the article by Flin et al. Emergency decision making in the offshore oil and gas industry.
Hum Factors ; In addition, in an emergency, the alarms all sound at once, producing excessive information for the operators, compromising their cognitive capacity to interpret the unfolding phenomena, a classic problem identified by the Ergonomics of Activity in the control rooms of complex systems With the high degree of automation, frequently accompanied by complexification of decision-making, the operator does not always have timely access to adequate information.
Despite the long list of serious and fatal offshore accidents, the challenge here is not to conduct an inventory of deadly events, but to learn lessons from them to accumulate knowledge on accident prevention, more precisely on the management of incidental and accidental situations.
Our interview with operator A gave us a brief idea of the difficulties faced by the brigade after the first explosion. But after all, how can management gather such elements to minimize or partially offset the gaps in reliability that end up allowing to emerge situations that are difficult to reverse? Resilience engineering: concepts and precepts.
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