Lesson Learned From Major Engineering Failures – Accident Mitigation For Hydrocarbon Industry

Muhammad Abduh (abduh@reksolindo.co.id)

Print Version Published for PetroEnergy February-March 2008 Edition

Remarkable fires and explosions to several production and processing sites in Cilacap, Tuban, and Belawan and also the remaining public controversy of Sidoarjo Mud Volcano recently should be learned within the industry to better manage engineering accidents. Every accident was triggered by multi-event of failures. Those failure events are contributed by faults of one or more elements that build the system (e.g. design, health and safety policy, operation and maintenance). Oil and gas industry that have of facilities with high pressure system, corrosive medium, and hostile environment have a large engineering failure experiences from the fire in Piper Alpha to the recently explosion of Texas City Refinery. This paper will present an overview of major engineering failures in oil and gas and hydrocarbon industry and to look for an alternative perspective for the mitigation management in Indonesia.

cilacap_2008.jpg belawan_2008.jpg

Figure 1. Cilacap Pipeline Fire 2008 and Belawan Pipeline Fire 2008 (liputan6.com)

I. Major Engineering Failures (1977-2007)

Compilation of engineering failures that has significant impact both in economic and personnel safety have been already developed by several integrity engineering companies, government bodies, health and safety authorized body, engineering risk consultants, insurance companies, and loss adjusters Table 1.



Every failure is an unexpected event. But if it happened, we can track back to find out the failure path, contributing events, and root causes. This methodology in broader term will refer as failure analysis. In the development failure analysis methodologies, there are several approach to express the structure of failures including root cause analysis (RCA), failure mode effect analysis (FMEA), event tree analysis (ETA), and fault tree analysis (FTA). One recent development in failure analysis is the expanding of the failure elements domain to the overall company organization (e.g. HSE, Human Resources, Quality Policy) and the socio-economic environment (regulatory systems, societal), Figure 2 .


Figure 2. Failure Map

Expanding the Root Cause

Engineering failure is triggered by multi-event of failures. The term of root cause then becomes relative. As we can see from above figure, surrounding societal aspects that include regulatory system can trigger the failure. Technical investigation to find out the nature of the accident should be beneficial in order to make necessary improvement in technical regulation. As we know that the first issue of American Society of Mechanical Engineer (ASME) Code for Boiler and Pressure Vessel was driven by the explosion of shoe factory in Boston in 1914. United States regulation on pipeline safety 49 CFR 192 has been already amended for several times following previously some significant pipeline explosions. The amendment was expected the close the void in the regulation that makes the accident occurred.


Technical measures which failed or were not adequately implemented in each of the accidents are:

Inadequate Design that includes: materials selection, pipework design codes, corrosion protection system, plant siting and layout, pipeline and underground conduit layout;
Defective Manufacture: material quality control, welding quality,
– Inability to predict and to Prevent; inspection (NDT, Assessments), risk assessments; maintenance procedures, emergency response,gas leak detection, spill control,isolation; and warning systems.

Figure 3. Accident Mitigation Scheme


Accident mitigation differs in every country. In several countries regulatory system defines and provides the procedure for the formation of an investigation authority. In United Kingdom the formation of this official investigation body is ruled under COMAH (Control of Major Hazard) Regulation 1999. The competent authority under this regulation minimally consists of Health and Safety Executive (HSE) and Environment Agency. Additionally, in United States the investigations are performed by several government agency including Chemical Safety Board (CSB), Pipeline Hazardous Material Safety Administration (PHMSA), and National Transportation Safety Board (NTSB) supported by third party investigation company (e.g. integrity engineering, explosion engineering, failure analyst, risk analyst, loss adjustor). In other case like P-36 Sinking, Petrobras performed an in-house investigation and the results were validated by third party company.

The investigation authorities performed task as follows:

Find out the root cause, contributing event, chronology;

Give necessary recommendation for the company to prevent the occurrence of the failure;

To propose amendment in regulation;

To propose revision for technical code and designs;

To publish neutral public information;

One important action in accident mitigation is technical investigation. Technical investigation is an activity to find out the technical nature of the accident that includes failure analysis. Outputs expected from technical investigation are:

Independent judgment on the nature of accident is important to avoid the public miss-perception, and political distortion;
Recommendation for regulatory amendment;
Independent judgment for contractual disputes;
Necessary corrective action for the companies


From engineering accident experience, stakeholders in oil and gas industry have an opportunity to develop better managed accident mitigation. Reference shows that more managed accident mitigation action will reduce non-technical excess of the accident (e.g. public miss-perception, distortion of information), improvement in technical code and design regulations, and to solve legal or contractual disputes.


  1. The 50 Major Engineering Failures (1977-2007) in Oil and Gas and Hydrocarbon Industry, Reksolindo Publication, 2008;
  2. The 100 Largest Losses 1972-2001 Large Property Damage Losses in the Hydrocarbon-Chemical Industries, Marsh Risk Consulting 20th Edition: February 2003;
  3. www.hse.gov.uk
  4. http://www.antara.co.id/en/arc/2008/3/10/pertamina-refinery-fires-death-toll-rises-to-three
  5. http://www.metrotvnews.com/berita.asp?id=52489
  6. http://www.tempointeraktif.com/hg/nasional/2008/03/09/brk,20080309-118872,id.html
  7. http://www.liputan6.com/news/?id=156080&c_id=7

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