Reports & recommendations

106 recommendations, each with the government response on the record. Filter by government response or delivery status.

Title Volume Publication Date Recommendations Links
The Public Inquiry into the Piper Alpha Disaster - 12 Nov 1990 106

Recommendations (106)

1

Operator to submit Safety Case

Recommendation
The operator should be required by regulation to submit to the regulatory body a Safety Case in respect of each of its installations. The regulation should be analogous to Reg 7 of the CIMAH Regulations, subject to recommendations 2–13 (paras …
2

Objectives the Safety Case must demonstrate

Recommendation
The Safety Case should demonstrate that certain objectives have been met, including the following:- (i) that the safety management system of the company (SMS) and that of the installation are adequate to ensure that (a) the design and (b) the …
3

Safety management system content

Recommendation
The SMS should be in respect of (a) the design (both conceptual and detailed) of the operator’s installations; and (b) the procedures (both operational and emergency) of those installations. In the case of existing installations the SMS in respect of …
4

Contents of the Safety Case

Recommendation
In furtherance of the objectives set out in para 2 above, the operator should be required to set out the following in the Safety Case:- (i) A demonstration that so far as is reasonably practicable hazards arising from the inventory …
5

Design accidental events and acceptance standards

Recommendation
For the purposes of the demonstration referred to in para (iii) of recommendation 4, the accidental events are to be identified by the operator. A design accidental event is an event which will not cause the loss of any of …
6

Temporary Safe Refuge as accommodation

Recommendation
The TSR should normally be the accommodation (paras 19.156 and 19.161). In the case of existing installations any requirement for the upgrading of the accommodation, escape routes and embarkation points should be determined on the basis of the Safety Case …
7

Safety Case specification of TSR and escape

Recommendation
In connection with the above the Safety Case should specify the following:- In respect of the TSR- — its function — the conditions which constitute its integrity — the conditions for integrity of its supporting structure — the events in …
8

Safety Case before installation operates

Recommendation
No fixed installation should be established or maintained in controlled waters; and no mobile installation should be brought into those waters with a view to its being stationed there or maintained in those waters unless a Safety Case in respect …
9

Date for submitting Safety Cases

Recommendation
As regards existing installations the date for submission of the Safety Case should be laid down by regulation. There is an urgent need for the submission of Safety Cases, but the date should be selected by the regulatory body. The …
10

Updating the Safety Case

Recommendation
A Safety Case should be updated:- (i) After a period of years from its last assessment (not less than 3, not more than 5, years). (ii) At the discretion of the regulatory body on the ground of a material change …
11

Modifications and the Safety Case

Recommendation
As regards modifications to installations or their equipment or procedures, the operator should, before putting the modification into effect, ascertain what effect, if any, it has on the relevant components of the Safety Case. An operator should be required to …
12

Regulations, guidance notes and Safety Cases

Recommendation
For the time being the acceptance by the regulatory body of Safety Cases should not be regarded as justifying the revocation of regulations or the withdrawal of guidance notes (para 17.67). Where an operator proposes to meet the objectives of …
13

Preliminary assessment at Annex B consent

Recommendation
The regulatory body should discuss with the industry whether it is desirable and practicable that at the stage of the application for Annex B consent (or its equivalent) there should be a procedure for submission by operators of a preliminary …
14

Operator audits of safety management

Recommendation

The operator should be required to satisfy itself by means of regular audits that its SMS is being adhered to (para 21.60).

15

Regulatory body review and inspection

Recommendation
The regulatory body should be required regularly to review the operator’s audit on a selective basis; and itself to carry out such further audit as it thinks fit; and by regular inspection verify that the output of the SMS is …
16

Review of the certification system

Recommendation
The regulatory body should consider (i) after the introduction of requirements for the demonstration of SMS and auditing of compliance with it; and (ii) after experience in the operation and effectiveness of such requirements whether and to what extent it …
17

Goal-setting regulations and guidance notes

Recommendation
(i) The principal regulations in regard to offshore safety should take the form of requiring that stated objectives are to be met (referred to as “goal-setting regulations”) rather than prescribing that detailed measures are to be taken (para 21.67). (ii) …
18

Offshore Acts as relevant statutory provisions

Recommendation
The provisions of the Mineral Workings (Offshore Installations) Act 1971 and the Petroleum and Submarine Pipe-lines Act 1975 which have the same general purposes as those of Part 1 of the Health and Safety at Work etc Act 1974 (HSWA), …
19

Replacement of existing offshore regulations

Recommendation
The Construction and Survey Regulations, the Fire Fighting Equipment Regulations, the Life-Saving Appliances Regulations and the Emergency Procedures Regulations should be revoked and replaced by- (i) Construction Regulations, covering inter alia the structure and layout of the installation and its …
20

Standards used to comply with goal-setting

Recommendation
Operators should be encouraged to specify the standards which they will use to comply with goal-setting regulations. For a given installation compliance may be demonstrated by reference to such standards, the terms of guidance notes and what is shown by …
21

Treatment of existing guidance notes

Recommendation
As regards existing guidance notes the regulatory body should consider whether and to what extent they should be treated without replacement or modification as giving non-mandatory advice in the sense set out in paragraph (ii) of recommendation 17; and should …
22

Consultation on guidance notes

Recommendation
In connection with the preparation of guidance notes the regulatory body should review the procedures for consultation so as to ensure that the views of the representatives of employers and employees involved in work offshore are adequately taken into account …
23

Single regulatory body for offshore safety

Recommendation

There should be a single regulatory body for offshore safety (para 21.62).

24

Scope of the regulatory body

Recommendation
The single regulatory body should discharge the safety functions in relation to fire-fighting equipment and life-saving appliances. As regards standby vessels it should discharge all functions, whether directly or through the agency of the Department of Transport (DoT), save those …
25

Offshore safety division within HSE

Recommendation
The functions of the Petroleum Engineering Division of the Department of Energy (DEn) which are concerned with the regulation of offshore safety should in future be discharged by a discrete division of the Health and Safety Executive (HSE) which is …
26

Specialist inspectorate and chief executive

Recommendation
This division should employ a specialist inspectorate and have a clear identity and strong influence in the HSE. It should be headed by a chief executive who should be responsible directly to the Director General of the HSE and should …
27

Workforce involvement in safety

Recommendation

The regulatory body, operators and contractors should support and encourage the involvement of the offshore workforce in safety. In particular, first line supervisors should involve their workforce teams in everyday safety (para 18.48).

28

Workforce involvement part of the SMS

Recommendation

The operator’s procedures included in line management of operations which are aimed at involving the workforce in safety should form part of its SMS (para 21.56).

29

Review of safety representatives regulations

Recommendation

The DEn’s intention to review the Offshore Installations (Safety Representatives and Safety Committees) Regulations 1989 after 2 years’ experience of their working is endorsed (para 21.85).

30

Protection of safety representatives

Recommendation

Safety representatives should be protected against victimisation by a provision similar to Sec 58(i)(b) of the Employment Protection (Consolidation) Act 1978 (para 21.86).

31

Training of safety representatives

Recommendation

The Offshore Installations (Safety Representatives and Safety Committees) Regulations 1989 should be modified to the effect that the training of safety representatives should be determined and paid for by the operator (para 21.87).

32

Permit to work part of the SMS

Recommendation

The operator’s permit to work system should form part of its SMS (para 21.56).

33

Training of contractors' supervisors

Recommendation

Operators and the regulatory body should pay particular attention to the training and competence of contractors’ supervisors who are required to operate the permit to work system (paras 18.17 and 18.29).

34

Harmonisation of permit to work systems

Recommendation
Standardisation of the permit to work system throughout the industry is neither necessary nor practicable. However, in view of the fact that there is much in common between the systems of different operators, the industry should seek to increase harmonisation, …
35

Contractors' supervisors as Performing Authorities

Recommendation
While it is not inappropriate for contractors’ supervisors to act as Performing Authorities, operators should be made responsible for ensuring that such supervisors are trained in the permit to work system for the installation where they are to act as …
36

Mechanical isolation procedure

Recommendation

All permit to work systems should incorporate a mechanical isolation procedure which involves the physical locking off and tagging of isolation valves (para 18.29).

37

Permits and isolations remain in force

Recommendation

A permit to work and its consequent isolations, both mechanical and electrical, should remain in force until the work is sufficiently complete for the permit to be signed off and the equipment returned to operation (para 18.8).

38

Display of issued permits to work

Recommendation
Copies of all issued permits to work should be displayed at a convenient location and in a systematic arrangement such that process operating staff can readily see and check which equipment is under maintenance and not available for operation (para …
39

Database of leaks, spills and ignitions

Recommendation
The regulatory body should be responsible for maintaining a database with regard to hydrocarbon leaks, spills and ignitions in the industry and for the benefit of the industry. The regulatory body should:- (i) discuss and agree with the industry the …
40

Process variables in the Control Room

Recommendation

Key process variables, as determined by the Safety Case, should be monitored and controllable from the Control Room (para 18.36).

41

Control Room manning and qualification

Recommendation

The Control Room should at all times be in the charge of a person trained and qualified to undertake the work of Control Room operator. The Control Room should be manned at all times (para 18.35).

42

Control Room operator emergency training

Recommendation

The training of Control Room operators should include instruction in an onshore course in the handling of emergencies (para 18.35).

43

Emergency Pipe-line Valve Regulations

Recommendation
The Emergency Pipe-line Valve Regulations should continue in force until they are subsumed in the Plant and Equipment Regulations. The provision in these regulations for there to be on each riser a valve with full emergency shutdown capability and located …
44

Subsea isolation valves

Recommendation
There should be no immediate requirement that a subsea isolation valve (SSIV) be fitted on a pipeline connected to an installation. The operator should demonstrate in the Safety Case that adequate provision has been made, including if necessary the use …
45

Studies on inventory and pipeline connections

Recommendation
Studies should be carried out with the following objectives:- (i) To explore the feasibility of dumping in an emergency large oil inventories, such as those in the separators, in a safe and environmentally acceptable manner, so as to minimise the …
46

Studies on riser protection and SSIVs

Recommendation
Studies should be carried out with the following objectives:- (i) To achieve effective passive fire protection of risers without aggravating corrosion (para 19.22). (ii) To improve the reliability and reduce the cost of SSIVs so that it is more often …
47

Emergency shutdown valve activation

Recommendation

The arrangements for the activation of the emergency shutdown valves (ESVs), and of SSIVs if fitted, on pipelines should be a feature of the Safety Case (para 19.42).

48

Vulnerability of emergency shutdown valves

Recommendation

Studies should be done to determine the vulnerability of ESVs to severe accident conditions and to enhance their ability to survive such conditions (para 19.43).

49

Fire risk analysis requirement

Recommendation

Operators should be required by regulation to submit a fire risk analysis to the regulatory body for its acceptance (para 19.90).

50

Approach to fire and explosion protection

Recommendation
The regulations and related guidance notes should promote an approach to fire and explosion protection:- (i) which is integrated as between - — active and passive fire protection — different forms of passive fire protection, such as fire insulation and …
51

Fire water deluge survivability

Recommendation

The ability of the fire water deluge system, including the fire pump system, to survive severe accident conditions should be a feature of the Safety Case (para 19.100).

52

Hydrocarbon fire test interpretation

Recommendation
The regulatory body should work with the industry to obtain agreement on the interpretation for design purposes of its interim hydrocarbon fire test and other similar tests. If in the view of the regulatory body there exists a need for …
53

Withdrawal of fire protection discussion document

Recommendation

The DEn discussion document on Fire and Explosion Protection should be withdrawn (para 19.102).

54

Immediate fire risk analysis by operators

Recommendation

The regulatory body should ask operators which have not already done so to undertake forthwith a fire risk analysis, without waiting for legislation (para 19.103).

55

Regulations on accommodation and escape routes

Recommendation

Provisions should continue to be made by regulations supported by guidance notes as to the construction of the accommodation; and as to escape routes and embarkation points (para 19.166).

56

Protection of accommodation

Recommendation
The regulations and the related guidance notes should promote an approach to protection of the accommodation:- (i) in which external fire protection is provided both to prevent breach of the accommodation and to maintain breathable air within it (para 19.170); …
57

Ventilation intakes and detectors

Recommendation
For the purpose of maintaining breathable air within the accommodation, it should be required by regulation that the ventilation air intakes should be provided with smoke and gas detectors and that on smoke or gas alarm the ventilation and dampers …
58

Escape routes to remain passable

Recommendation
The regulations and related guidance notes on escape routes should recognise that it may not be practicable to protect escape routes against all physical conditions; and accordingly should be based on the objective that they should remain passable (para 19.174).
59

Emergency lighting and signs

Recommendation

It should be required by regulation that escape routes are provided with adequate and reliable emergency lighting and with photoluminescent direction signs (para 19.175).

60

Immediate assessment of smoke ingress

Recommendation
The regulatory body should ask operators which have not already done so to carry out forthwith an assessment of the risk of ingress of smoke or gas into the accommodation; and to fit smoke and gas detectors and implement ventilation …
61

Studies on breathable air in the TSR

Recommendation

Studies should be carried out with the objective of assisting designers in predicting the breathability of air in a TSR where its external fire wall is subjected to a severe hydrocarbon fire (para 19.163).

62

Facilities for control of emergencies

Recommendation
It should be required by regulation that there should be available within the TSR certain minimum specified facilities for the monitoring and control of an emergency under hostile outside conditions (paras 19.178 and 19.182). These facilities should be in the …
63

Radio Room in the TSR

Recommendation
It should be required by regulation that a Radio Room with facilities for external communications should be located in the TSR (para 19.179). On existing installations where the Radio Room is not in the TSR, these facilities should be in …
64

Survivability of emergency systems

Recommendation
The regulations and related guidance notes should promote an approach to emergency systems:- (i) which provides to a high degree the ability of these systems to survive severe accident conditions (paras 19.188-189); and (ii) which applies to communications systems the …
65

Emergency systems in the Safety Case

Recommendation

The ability of emergency systems to survive severe accident conditions should be a feature of the Safety Case (para 19.189).

66

Status light systems

Recommendation

The regulatory body should work with the industry to promote the use of status light systems (para 19.192).

67

Standardisation of status lights and alarms

Recommendation

The regulatory body should work with the industry to achieve standardisation of status lights and of alarm systems for emergencies (para 19.194).

68

Studies on emergency system vulnerability

Recommendation

Studies should be done to determine the vulnerability of emergency systems to severe accident conditions and to enhance their ability to survive such conditions (para 19.190).

69

Immediate review of emergency systems

Recommendation

The regulatory body should ask operators which have not already done so to review forthwith the ability of emergency systems to withstand severe accident conditions (para 19.191).

70

Availability standards for protective systems

Recommendation

Where a regulation imposes a requirement for a major emergency or protective system, such as a fire deluge system, it should be required that the operator should set acceptance standards for its availability (para 19.199).

71

Review of pipeline emergency procedures

Recommendation
Operators should be required by regulation regularly to review pipeline emergency procedures and manuals. The review should ensure that the information contained in manuals is correct, that the procedures contained are agreed with those who are responsible for executing them …
72

Shutdown in emergency on connected installation

Recommendation
Operators should be required by regulation to institute and review regularly a procedure for shutting down production on an installation in the event of an emergency on another installation which is connected to the first by a hydrocarbon pipeline where …
73

Evacuation, escape and rescue analysis

Recommendation

Operators should be required by regulation to submit to the regulatory body for its acceptance an evacuation, escape and rescue analysis in respect of each of its installations (para 20.9).

74

Content of the analysis

Recommendation
The analysis should specify the facilities and other arrangements which would be available for the evacuation, escape and rescue of personnel in the event of an emergency which makes it necessary or advisable in the interests of safety for personnel …
75

Specific matters the analysis must cover

Recommendation
In particular the analysis should specify:- (i) The formal command structure for the control of an emergency affecting the installation; (ii) The likely availability and capacity of helicopters, whether in-field or otherwise, for the evacuation of personnel; (iii) The types, …
76

Immediate analysis without waiting for legislation

Recommendation
The regulatory body should ask operators which have not already done so to undertake an evacuation, escape and rescue analysis forthwith, without waiting for legislation. The timetable for completion of this analysis should be agreed between the regulatory body and …
77

Helicopter flight following system

Recommendation
Operators should adopt a flight following system for determining at short notice the availability and capacity of helicopters in the event of an emergency. This system could be either a system operated by the individual operator or a North Sea-wide …
78

TEMPSC capacity

Recommendation
The requirement by regulation that each installation should be provided with TEMPSC having in the aggregate sufficient capacity to accommodate safely on board 150% of the number of persons on the installation should be maintained (para 20.16). Such provision should …
79

Orientation of davit-launched TEMPSC

Recommendation

On new installations where the provision of davit-launched TEMPSC is acceptable to the regulatory body they should be oriented so as to point away from the installation (para 20.24).

80

Launching TEMPSC clear of the installation

Recommendation
The regulatory body should work with the industry to develop equipment and methods to enable TEMPSC to be launched clear of the installation including where, as on existing installations, they are oriented so as to point along the side of …
81

Free-fall TEMPSC

Recommendation
Reg 5 of the Life-Saving Appliances Regulations should be amended or replaced so as to enable free-fall TEMPSC to be installed on new and existing installations. It should remain for the operator to justify its choice of TEMPSC as being …
82

Life rafts

Recommendation
It should be required by regulation that each installation should be provided with life rafts having in the aggregate sufficient capacity to accommodate safely on board at least the number of persons on board the installation; along with suitable ropes …
83

Variety of means of descent to the sea

Recommendation
A variety of means of descent to the sea should be provided on all installations. In accordance with recommendation 75 the types, numbers and locations of facilities for this purpose should be specified in the evacuation, escape and rescue analysis; …
84

Escape chutes and collapsible stairways

Recommendation

The regulatory body should work with the industry to determine the practicability and safety of escape chutes and collapsible stairways (para 20.30).

85

Personal survival equipment for each person

Recommendation
Each individual on board an installation should be provided with:- (i) a personal survival (or immersion) suit; (ii) a life-jacket; (iii) a smoke hood of a simple filter type to exclude smoke and provide protection for at least 10 minutes …
86

Survival suits and life-jackets

Recommendation

The use of small transmitters or detectors on life-jackets in order to assist in the finding of personnel in the dark should be considered. Luminescent strips should be of a colour other than orange (paras 20.33-34).

87

Combined survival suit and life-jacket

Recommendation

Work should be carried out with the objective of combining the functions of a survival suit and a life-jacket in one garment (para 20.32).

88

Quality of standby vessels

Recommendation
Changes in the regulations and the code for the assessment of standby vessels should be aimed at an improvement in the quality of standby vessels, introducing basic standards for existing vessels and higher specifications for new vessels (para 20.41).
89

Standards for standby vessels

Recommendation
It should be required by regulations that each standby vessel should comply with the following standards:- (i) It should be highly manoeuvrable and able to maintain its position; (ii) It should provide full visibility of the water-line in all directions …
90

Revocation of Reg 10

Recommendation

Reg 10 of the Emergency Procedures Regulations should be revoked (para 20.39).

91

Withdrawal of areas of operation section

Recommendation

Sec 3 of the code for the assessment of standby vessels (areas of operation) should be withdrawn (para 20.39).

92

Weekly notification of standby vessel locations

Recommendation

The owners of standby vessels should be required to notify the regulatory body weekly as to the locations and functions of their vessels in the ensuing week. A copy of such notification should also be given to the DoT (para 20.54).

93

Crew numbers for standby vessels

Recommendation

As regards the appropriate numbers for the crew of standby vessels, the DoT should take into account the evidence given in the Inquiry when reviewing the code in this respect (para 20.50).

94

Standby vessel crew age and fitness

Recommendation

The proposals in the amended code as to age limit, medical examination and certification of fitness of members of the crew of standby vessels; and as to their periods of duty are endorsed (paras 20.51-52).

95

Training packages for standby crews

Recommendation
The regulatory body should work with the industry to obtain agreement as to adequate training packages for the crew of standby vessels. Such training should be administered, and records of training kept by the Offshore Petroleum Industry Training Board (OPITB) …
96

Special training for fast rescue craft crews

Recommendation

The coxwain and crew of fast rescue craft should receive special training for their duties, along with regular refreshers (para 20.55).

97

Command organisation part of the SMS

Recommendation

The operator’s formal command organisation which is to function in the event of an emergency should form part of its SMS (para 20.59).

98

Selection criteria for OIMs

Recommendation

The operator’s criteria for selection of OIMs, and in particular their command ability, should form part of its SMS (para 20.59).

99

Emergency exercises for OIMs

Recommendation

There should be a system of emergency exercises which provides OIMs with practice in decision-making in emergency situations, including decisions on evacuation. All OIMs and their deputies should participate regularly in such exercises (para 20.61).

100

Drills and exercises part of the SMS

Recommendation

The operator’s system for emergency drills and exercises should form part of its SMS (paras 20.61 and 20.64).

101

UKOOA guidelines for drills and exercises

Recommendation

Offshore emergency drills and exercises should be carried out in accordance with the UKOOA guidelines for offshore emergency drills and exercises on installations (paras 20.61 and 20.64).

102

One muster per tour of duty

Recommendation

All offshore staff should attend one muster per tour of duty (para 20.62).

103

Reporting precautionary musters

Recommendation

The circumstances of all precautionary musters and evacuations should be reported by operators to the regulatory body (para 20.62).

104

Lists of personnel on board

Recommendation
Operators should maintain lists of personnel on board by alphabetical order and also by reference to the names of contractors whose personnel are represented on board. These lists should be updated for every movement of personnel and copied immediately to …
105

UKOOA guidelines for emergency training

Recommendation
The UKOOA guidelines for offshore emergency safety training on installations should be a minimum requirement for survival, fire-fighting and other forms of training detailed therein for the relevant personnel employed offshore. Personnel who have not met the requirements of these …
106

Emergency training part of the SMS

Recommendation

The operator’s system for emergency training and its enforcement should form part of its SMS (para 20.64).