THE DEEPWATER HORIZON
ACCIDENT
In the late evening of 20th April 2010 there was an
explosion and fire on the semi-submersible Deepwater
Horizon, which was completing a well for BP, 50 miles
from the edge of the Mississippi delta in the Gulf of
Mexico. Eleven of the personnel on board the rig
unfortunately lost their lives. Nine of them were
employed by Transocean, the owners of the rig, and two
of them by MI-Swaco, a service company. The rest of the
crew successfully evacuated mostly by lifeboat and were
subsequently recovered to the Tidewater platform ship,
Damon B Bankston. They were finally landed in Port
Fouchon twenty-seven hours after the incident. The rig
continued to burn and gradually took on an increasing
list, and slipped under the waves on 22nd April. The BOP
was still in position on the wellhead and the riser, the
pipe connecting the well to the rig was only destroyed
as the rig sank in 5000 feet of water. Subsequently the
well belched forth hydrocarbons, and it took the
operator weeks to get the release under control. The
resulting pollution with the inevitable claims,
counterclaims, and government intervention kept the
event on the front pages of the American newspapers for
months. I followed the journalism, the senate committee
interviews and the Coastguard investigation as they were
taking place, and wrote a number of articles to
enlighten and inform any readers I might have. What
follows is the final article I wrote after the
President’s investigation had been published. Elsewhere
on this site I have combined the other articles into a
single document for those who interested in the event.
Towards the end of January 2011 President Obama’s National
Commission on the Deepwater Horizon Oil Spill presented
its report. It runs to over 300 pages, and covers much
else besides the actual Deepwater Horizon disaster
itself. It is an extensive piece of investigative
reporting and all of it is worth reading.
When investigating accidents there is much talk
about looking for “root causes”, and the commission
determined that the failures that resulted in the loss
of the Deepwater Horizon and the lives of eleven of the
personnel who worked on it, were due to problems endemic
in the industry and the manner in which it has been
regulated. Within a few days of the accident the Marine
Management Service had been effectively disbanded to be
replaced by the Bureau of Ocean Energy Management,
Regulation and Enforcement, amid accusations that the
now defunct body had been in the hands of the operators,
and lurid accounts of the exchange of favours of all
sorts in return for agreements, acceptances and
approvals. However, the commission found that the MMS
had been starved of funds for years, which resulted in a
lack of both numbers of personnel and expertise. The
dual role of the MMS as the overseer for safety and the
collection of revenues was also criticised for their
lack of compatibility. Of course as far as the rig guys
were concerned they were just a part of the normal
inspection process which involved the MMS, the
Coastguard, the classification societies and flag state.
All of these bodies had received nothing more than the
usual courtesies while on board. Now, visiting BOEMRE
inspectors are only allowed to accept water. They even
bring their own food.
There
is little doubt that the for many years the industry has
seen regulations as nothing more than an impediment to
the potential success of what-ever operation they
happened to be carrying out, and therefore any action or
intervention to circumvent the intent of any regulatory
requirements was deemed to be acceptable. Probably a
good example of this, as far as the Deepwater Horizon is
concerned, was the Environmental Spill Plan lodged with
the authorities by BP. It cited as their major source of
expertise a gentleman who had been dead for five years,
and mentioned, as did the plans for a number of other
operators, that they intended to safeguard varieties of
wildlife completely unknown to the Gulf of Mexico.
Sometimes it appears that it is solely the boredom of
the routines required to ensure that the processes
remains safe that cause people to neglect or circumvent
them. One cannot readily see why Halliburton should have
doubted their own tests on the nitrogen cement, and
carried out a second one, or why BP went ahead with the
cement job before the second set of tests were
completed, other than the underlying view that such
activities were not really necessary. And it may be the
whole attitude of “we know best” which answers the
question posed by the managing director of BP, Tony
Hayward.
“What have we done to deserve this?” he asked in
the aftermath of the Deepwater Horizon disaster. And
even without the commission report there is a body of
opinion amongst those who have had contact with BP that
they are disinterested in the views, or opinions of
others, even if the others are experts in their fields.
It seems that BP, like many large corporations, have
such a sense of the rightness of everything they do,
that they are unwilling to accept any sort of
alternative view. It could be this sense of rightness
that resulted in the onshore staff deciding that it was
acceptable to install production casing with only 9
instead of 26 centralisers, a decision which may have
been one of the reasons for the reduced the integrity
of the cement job. Also for complex reasons in the
temporary abandonment process, they chose to set the
cement plug at 3000 feet down in the well instead of
near the surface, a process outwith the existing MMS
regulations.
The
perception in large organisations that they know
everything can result in relatively junior members of
staff taking attitudes, which in some environments,
might be considered to be bullying. There is anecdotal
evidence that prior to the disaster Transocean staff
argued with the senior BP representative on the rig as
to possible next actions, but that in the end the BP
rep’s requirements were accepted. Indeed some American
offshore workers believe that the reason the drill crew
of the Deepwater Horizon did not abandon the drill
floor, when it might have been prudent to do so, was
because they feared for their jobs. Whether this is true
or not, it shows that the threat of being NRB’d, Not
Required Back, still hangs in the air in the Gulf of
Mexico.
The report also touches on a point which has
been made by one or two academics over the last few
years, and which was highlighted by the investigation
into the Texas City Refinery disaster, another BP
misfortune, where 15 people died in 2005. This is that
there is now little relationship between occupational
accident and “process failures”, i.e major accidents.
The accepted safety mantra in years gone by, was that if
you prevented minor accidents from taking place then the
major accidents would also be prevented. Even in UK,
where the safety case regime has been in place for 13
years, it appears to some safety engineers that the
industry concentrates on occupational accidents, such as
slips trips and falls, to the point that major
accidents, the events which will result in multiple
deaths if not prevented, are more or less ignored. Some
have said that it would take another Piper Alpha to sort
this out, but it never occurred to them that this would
take place in the Gulf of Mexico. This is starkly
illustrated by the fact that when the Deepwater Horizon
blew up there were a number of Transocean and BP
executives on board to celebrate the rig’s achievement
of seven years without a lost time accident. A lost time
accident? This is the industry’s traditional measurement
of safety, and is an accident where the unfortunate
injured person cannot continue working due to the
severity of the injury. In the reception areas of the
rig owners and operators all over the world there used
to be boards on the walls presenting the days since the
last lost time accident on every one of their
installations. Imagine the situation where there has
been 1000 days since the last LTA and some-one trips
over a door sill and twists their ankle so that they can
no longer carry on working. The 1000 days are wiped out
and they start again. One day, two days, three days and
so on! It would be heartbreaking. The President’s
commission found that even though fatalities are twice
as high in the Gulf of Mexico as they are in Europe,
there would appear to be far fewer injuries. This is
because the LTA structure discourages reporting,
resulting in a distorted view of safety in the offshore
environment. European safety specialists would be amazed
to find that since 2001 there have been a stunning 948
fires and explosions in the Gulf. Not far off 100 a
year.
What
else did the commission report? It identified the fact
that the crew on the rig did not accept the signs that
were presented to them that all was not well. This is
not solely a problem for the offshore industry. We, as
human beings, are reluctant to accept information which
does not fit into our perception of what should be
happening. This has been a feature of many offshore
accidents, and can be identified as a component of human
behaviour elsewhere. When the IRA blew the front off
Harrods in December 1983 the people in the restaurant
tried to pay their bills before leaving. They insisted
on maintaining their normal patterns of activity in the
face of evidence that they should have been getting out
of there as quickly as possible. The failure to accept
the evidence presented to them on board the Deepwater
Horizon was manifest most notably during the testing of
the cement plug. At that time, when there should have
been no pressure above the cement, a pressure gauge
indicated otherwise, but rather than accepting the
evidence, the team on the rig decided that the gauge was
faulty. There were also other unaccountable differences
in pressure, which caused them to carry out a second
test after they had accepted that the first might have
failed. On the evening of 20th April the second negative
pressure test continued to show differences in pressure
between the kill line and the drill string, but this was
explained away by one of the team as a known anomaly.
People who are used to presenting UK safety
cases are accustomed to having to identify a TR
Temporary Refuge in which people could muster safely
before taking further action to save themselves. This is
of course as a result of Lord Cullen’s recommendation
from the Piper Alpha enquiry, and was based on the fact
that 70 people in the platform’s accommodation died in
the disaster. So the safety case process would generally
identify the accidents which could result in fires and
explosions and then show how the TR, usually all or part
of the accommodation would protect people for a period
to time which would allow them to get organised for
their next move. This all seems eminently sensible, and
it is probable that such an emergency process was
initiated when Transocean suffered from a very similar
well control problem (thankfully with a different
outcome) in the North Sea. However, despite the fact
that these emergency procedures have been in place for
years in the North Sea, and have been accepted as “best
practice”, elsewhere in the world it is more likely that
when the alarm bells ring the crew will muster on the
open deck and get into the lifeboats. So are the risks
in the Gulf of Mexico, and Nigeria and the Far East
different from those in the North Sea and the UK
Atlantic margin? Of course not, only the perception is
different.
The witness testimony from the BOEMRE/Coastguard
investigation, which has yet to report also indicated
confusion on the part of many of the rig crew as to who
was in charge as the disaster developed. This is in part
as a result of the drilling industry view that the
person in charge of an oil rig should be a “driller”, a
person who has worked up through the ranks of the
drilling fraternity to eventually attain a senior
position on the rig, or in their view, the most senior.
This is because much of the industry believes that only
drilling people can talk to other people about the main
task of the rig – drilling holes in the seabed, and the
fact that it is a floating object is a secondary
consideration. Only a few drilling rig owners have taken
the step of putting a mariner in charge at all times,
even though the ISM (International Ship Management) code
requires that one should be in charge when a dynamically
positioned semi-submersible is “under way”. And here
it appears that Transocean felt that when the Deepwater
Horizon was connected to the seabed by the riser, even
though its position was being maintained by its marine
propulsion system, it was not under way, since the OIM,
who was a driller, was in charge. There was a moment
during the developing emergency when the Captain should
have taken over, but it appears to have been undefined,
so that even he was confused. The rig was fitted with an
EDS (Automatic Disconnect System). This was a single
button in the Pilot House, which when pressed would have
disconnected the riser, and therefore the rig, from the
BOP, and allowed it to move away. But even though the
Captain was supposed to take charge during an emergency,
the crew had the impression that they required the
permission of the OIM to carry out the action. When he
did give permission and the button was finally pressed
nothing happened, probably because the connection with
the subsea equipment had been destroyed by the
explosions.
And finally, and outwith any observations made
by anyone in the investigations into this disaster, it
is possible that constant exposure to difficulties and
dangers causes one to develop a tolerance for situations
which, under normal circumstances, would be
unacceptable. When drilling and circulating was taking
place at Macondo it seemed that the mud weight was
always on the cusp, if it was too heavy it would leak
away into the formation and there would be a tendency
for the well to flow. As the drilling progressed it
became more and more difficult to maintain this balance
and over the duration of the well 3000 barrels of mud
were lost to the formation, creating constant problems
for the guys on the drill floor. But, they had overcome
the difficulties, and it may have been the confidence
developed by these successes that made the crew continue
to battle with the blowout when they should actually
have chosen “flight” rather than “fight”.
There is one more report to come, that of the
Coastguard/BOEMRE which is likely to be presented in
March 2011. The president’s commission has already used
some of the testimony in its report, and indeed the
testimony has also been referenced extensively
elsewhere. There are a number of possible directions to
be taken by the American regulatory authorities
there-after, one of which might be the introduction of a
safety case regime, or something like it. But the safety
case is not a silver bullet. It requires the active
co-operation of everyone involved, and an honest
approach to the problem of keeping the workforce alive
and uninjured in what is accepted as being a dangerous
environment. Everyone must take responsibility for their
own safety and, possibly more importantly, the safety of
others commensurate with their training, skills and
responsibilities. It does not actually need a safety
case to achieve this. It only requires a change of
attitude.
This
will be my last comment about the Deepwater Horizon
disaster, and it is my earnest hope that everyone
involved in oil and gas exploration and production will
take to heart all the recommendations made by the
investigators, so that working offshore will become
safer, not only in the Gulf of Mexico, but everywhere in
the world.
Victor
Gibson. February 2011.
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