Safety, Efficiency, and Productivity: Conflict or Cooperative? The BP Deepwater Horizon Accident Personal Observations

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1 Safety, Efficiency, and Productivity: Conflict or Cooperative? The BP Deepwater Horizon Accident Personal Observations Najm Meshkati Professor Department of Civil/Environmental Engineering Department of Industrial & Systems Engineering University of Southern California 2012 Fifth International High Reliability Organizing (HRO) Conference Chicago, Tuesday May 22, 2012

of Civil/Environmental Engineering Department of Industrial & Systems Engineering University

2 BP Deepwater Horizon Accident April 20, 2010

3 BP Deepwater Horizon

4 BP Deepwater Horizon

5 BP Deepwater Horizon Accident April 20, workers lost their lives and 16 others were seriously injured. The flow continued for nearly 3 months before the well could be completely killed, during which time, nearly 5 million barrels of oil spilled into the gulf.

The flow continued for nearly 3 months before the well could be

6 National Academy of Engineering/National Research Council (NAE/NRC) Committee Committee for Analysis of Causes of the Deepwater Horizon Explosion, Fire, and Oil Spill to Identify Measures to Prevent Similar Accidents in the Future 6

the Deepwater Horizon Explosion, Fire, and Oil Spill to

7 Disclaimer When you speak, we d ask that you note the following in any written statement or as you answer questions orally: 1) Our final report was released to the public on December 14, The committee of which I was a member has been disbanded; we are not continuing to work on the Deepwater Horizon blowout. Free copies of our report (pdf) are available at 2) When you are answering a question, please make clear when you are speaking based on the committee s report and when you are answering based on your own personal experience and expertise. You may need to do this more than once during a public Q & A session. It is particularly important to do this clearly when in your answer to a single question you wish to speak about both what the report found and your own personal views or experience. 7

2) When you are answering a question, please make clear when you are speaking based on the committee s report and when you are answering based on your own personal experience and expertise.

8 Committee s Origin and Tasks Origin: Request from U.S. Department of Interior Secretary Salazar Study Tasks: Examine probable causes of the Deepwater Horizon incident in order to identify measures for preventing similar harm in the future. Committee Composition: 15 Members with expertise in geophysics, petroleum engineering, marine systems, accident investigations, safety systems, risk analysis, human factors and organizational behavior Process: Consensus report with peer review 8

to identify measures for preventing similar harm in the future.

9 NAE/NRC Committee s BP DWH Report Macondo Well Deepwater Horizon Blowout: Lessons for Improving Offshore Drilling Safety Released on Dec 14,

10 NAE/NRC BP DWH Committee Report December

11 The Deepwater Horizon

12 The Deepwater Horizon Rig Mobile Offshore Drilling Unit (MODU)

13 Deepwater Horizon s Org Chart

14 Company man (Well Site Leader), Offshore Installation Manager (OIM) & Master/Captain OIM and Master Two different Transocean employees were in charge of the rig at different times. Captain Curt Kuchta, Transocean s master, was in charge when the rig was moving from location to location. Once the rig arrived at a given site and began drilling or drilling-related operations, Jimmy Harrell, Transocean s offshore installation manager (OIM), took over.

Captain Curt Kuchta, Transocean s master, was in charge when the rig was moving from location to location.

15 Most Important Technical Contributing Causes of the DWH Accident Well design; Narrow drilling margins Cementing: Cement material Long string instead of a liner Number of centralizers NPT Misinterpretation BOP Failure Alarm Systems Mud-Gas Separator 15

Cement material Long string instead of a liner Number of

16 BP Deepwater Horizon Once well control was lost, the large quantities of gaseous hydrocarbons released onto the rig, exacerbated by low wind velocity and questionable venting selection, made ignition all but inevitable.

the rig, exacerbated by low wind velocity and

17 Personal Observations

18 The HOT Model, Safety Culture & Major Subsystems of a Complex, Large-scale Technological System (e.g., a nuclear power plant, refinery, chemical processing plant, hospital, or an offshore platform) 18

19 Interactive Effect Human Organization Technology Volume of Output 19

20 Interactive Effect Human Organization Technology Volume of Output 20

25 Meshkati s Observation Page 223 BP conducted its own accident investigation of Deepwater Horizon, but once again kept its scope extremely narrow.(31) Professor Najmedin Meshkati of the University of Southern California, Los Angles a member of the separate National Academy of Engineering committee investigating the oil spill criticized BP s accident report for neglecting to address human performance issues and organizational factors which, in any major accident investigation, constitute major contributing factors. He added that BP s investigation also ignored factors such as fatigue, long shifts, and the company s poor safety culture.(32)

26 Site Visit Deepwater Nautilus in the Gulf of Mexico 26

27 Deepwater Nautilus 27

28 28

29 29

30 30

31 BOP 31

32 BOP 32

33 BOP 33

34 BOP 34

35 NAE-NRC BP DWH Report s Specific Findings The actions, policies, and procedures of the corporations involved did not provide an effective systems safety approach commensurate with the risks of the Macondo well. The lack of a strong safety culture resulting from a deficient overall systems approach to safety is evident in the multiple flawed decisions that led to the blowout. Industrial management involved with the Macondo well-deepwater Horizon disaster failed to appreciate or plan for the safety challenges presented by the Macondo well. (Finding 5.1. p.77) 35

36 NAE-NRC BP DWH Report s Specific Recommendations Fostering Safety Culture Summary Recommendation 5.5: Industry should foster an effective safety culture through consistent training, adherence to principles of human factors, system safety and continued measurement through leading indicators. (p.82) 36

37 NAE-NRC BP DWH Report s Specific Recommendations Safety Culture Summary Recommendation 6.25: BSEE and other regulators should foster an effective safety culture through consistent training, adherence to principles of human factors, systems safety, and continued measurement through leading indicators. (p. 96) 37

38 38

39 The New York Times Editorial December 19, 2011 The lack of strong safety culture 39

40 Journal of Petroleum Technology May

41 JPT May

42 42

43 JPT, May 2012 (P. 49) 43

44 Global Implications About a 30% of the world s oil production presently comes from offshore projects and it will increase to about 50% in

45 Implications for the Gulf of Mexico: Cuba 45

46 Implications for the Gulf of Mexico: Mexico 46

47 Conclusion

48 Safety, Efficiency, and Productivity: Conflict or Cooperative?

49 A Requirement for Safety Culture: A Balanced Approach Toward Production and Safety Goals Economic/ Competitive Schedule Pressure Equilibrium Production Safety Political & Regulatory Env.; Senior Management s Biased Priorities, Policies, and Practices Inspired by Professor James Reason s Human Error (1990)

50 An Unbalanced Approach Toward Production and Safety Goals Equilibrium Political & Regulatory Env.; Senior Management s Biased Priorities, Policies, and Practices

51 Y Improvement Phase I Phase II? Phase III? Safety Quality/ Productivity/ Efficiency Initial State Time & Efforts X

52 Interactive Effect Human Organization Technology Volume of Output 52

53 Technological systems failures Accidents? or System designers ignorance to consider / incorporate HRO Characteristics + Managers incompetence + Regulators arrogance

54 A Robust/Stable Technological System

55 BP Refinery Accident March 23, 2005

56 Financial

58 58

National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling. Report to the President. www.oilspillcommission.

National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling Report to the President www.oilspillcommission.gov 1 Causes of Explosion The Deepwater Horizon disaster was foreseeable and