Safety Moment #1: Mumbai High North - A Discouraging Sameness
Mumbai High North was an oil and gas platform located about 160 km offshore, west of the city of Mumbai, India. The platform was destroyed in an explosion and fire in the year 2005; the incident took the lives of approximately 22 men and injured many others. The YouTube video describes this event (the matching storyboard is here).
We show how similar this event is to the Piper Alpha catastrophe that took place 17 years earlier, which is why the words ‘A Discouraging Sameness’ are shown; it sometimes seems as if we never learn.
Safety as a Cause of Catastrophic Incidents
One important lesson that crops up time and time again is that a root cause for major events is that someone, somewhere was trying to improve safety. In this case, the attempt to provide medical treatment to the galley worker who had seriously injured his thumb resulted in the death of twenty two men and the loss of a major facility.
We see the same issue with Piper Alpha. One of the causes of that event was that management decided to remove a critical pressure safety relief valve for bench testing onshore. This is obviously an important safety measure — it is vital that relief valves work on demand. But it meant that the item that it was protecting (a pump handling highly flammable hydrocarbons) had to be shut down and was not available for use. It turned out that the pump was not properly secured. A process upset required that the pump be put into service; the resulting leak was the initiating event for the catastrophe.
Other examples of safety work being a cause of serious incidents include the following:
- On an offshore platform a maintenance technician was replacing stair treads (a routine task) in order to ensure that no one slipped when walking on the stairs. During the course of his work the technician fell through a gap in the stairs and later died of his injuries.
- Sometimes it is the need to improvement environmental performance that leads to a serious incident. On another offshore platform a technician was preparing to stop a very small leak that was creating a near-trivial environmental problem. As he was preparing to start work a corroded drain valve fell out and he was seriously injured.
- It has been found that launching lifeboats during evacuation drills can be risky. Indeed, in one such drill a man died.