Among the physical causes of the initial process safety incident, maintenance should be at the top of the list. That basic safety management failure struck the first match.

How tightly does a flange have to be bolted to prevent vapor leaks on a condensate line pressurized to 650 psi? Most people that have been in an oil production environment understand how critical that answer is.

The problem is that on the Piper Alpha platform, a PSV (pressure safety valve) had been removed and a blind flange put in its place, and indications are that the bolts were only finger tight. The maintenance person left it that way and no supervisor or process safety engineer came back to check it, so it stayed that way. The most basic oil and gas safety protocols was not implemented.

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