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Ishikawa diagram of human errors in Piper Alpha accident

Patricia Fleitas's picture
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Patricia Fleitas's picture

Despite the fact of all the effort that the industry makes to ensure the correct design by following international standards, still accidents can happened. Furthermore, analysing the correlation between Accidents and Time, Step Change Safety pointed out that overtime when the mechanical issues of new equipment is proven on working correctly and the procedures used are according with a high safety performance, then the human safety behaviour has a huge influence on the overall process. As a result, the root of causes of human mistakes must be analysed carefully.

In order to analyse the influence of human error, the following Ishikawa diagram was developed to find out how the perception, memory, decision making and action process ended on the catastrophic Piper Alpha accident (figure 1).  The example bellow doesn’t take into account all the human error, but it gives a clear introduction on how these key human mistakes contributed with the spiral of the disaster. Nevertheless, after the principal human error that initiate the emergency situation (work permits), design of the installations for a quick response under an emergency situation was the underlying causes that contributed with the escalation of the situation (Accommodation modules located close to processing modules).
However, the mentioned human error are not “individuals error”, it is mostly the result of safety culture into the organization. Hopkins A. (2002) pointed out that when the company has safety polices on their core values, then the atmosphere of safety culture is spread to every level of the organization and individual applies it as full time activity including outside of work. Once, the individual is formed under the culture of safety of the organization; then the management mindset is required to ensure the identification, develop of procedures and commitment to ensure that the work place is safe. The process is a continuous learning and improvements (closed loop).


1) Step Change Safe. “Changing minds: a practical guide for behavioural change in the oil industry” Accessed on 19/11/12.
2) Hopkins A. (2002), “Working paper. Safety, culture, mindfulness and safe behaviour: covering ideas”. Australian National University.

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