Silent killer on Deepwater Horizon

A couple years ago at a Safety Users Group (SUG) meeting in London, I asked a top official of the organisation how many end user companies were actually members of the group?

After a slight pause and a somewhat convoluted reply, it emerged that, while equipment, system and service suppliers were well represented, ’zero’ process operators had joined the California-based body – set up in 2000 to promote instrumented safety across the process industries, internationally.

This glaring membership gap, plus the SUG’s subsequent disappearance off our radar, suggests that when it comes to safety matters – cyber attacks, spills, blasts, near misses etc – the instinct of most process engineers and their bosses is to keep things under their hat if at all possible.

Not surprisingly, this deep-seated tendency has emerged as a contributing factor to the Deepwater Horizon disaster, which killed 11 people and caused massive environmental damage in the Gulf of Mexico.

According to the US Oil Spill Commission’s final report on the incident, BP, Transocean, and Halliburton failed to communicate adequately, with information “excessively compartmentalised” at the Macondo drilling site.

BP, it said, did not share important information with its contractors, or sometimes internally even with members of its own team, while the contractors did not share important information with BP or each other.

“As a result, individuals often found themselves making critical decisions without a full appreciation for the context in which they were being made, or even without recognition that the decisions were critical,” the Commission found.

For example, many BP and Halliburton employees were aware of the difficulty of the primary cement job, but did not communicate this to the rig crew monitoring the well.

Also left in the dark was Bob Kaluza, who was on his first spell as a well site leader on the Deepwater Horizon, while the on-shore team were not informed about anomalous pressure test data.

“Had they done so, the Macondo blowout may not have happened,” said the report.

More pointedly still, it emerged in the report that Transocean had failed to adequately communicate lessons learnt from an “eerily similar” near-miss on one of its rigs in the North Sea four months prior to the Macondo blowout.

On 23 Dec, 2009, gas entered the riser on that rig while the crew was displacing a well with seawater during a completion operation.

As at Macondo, the rig’s crew had already run a negative-pressure test on the lone physical barrier between the pay zone and the rig, and had declared the test a success.

The tested barrier nevertheless failed during displacement, resulting in an influx of hydrocarbons. Mud spewed onto the rig floor—but fortunately the crew was able to shut in the well before a blowout occurred.

Transocean subsequently created an internal PowerPoint presentation and sent out an “operations advisory” warning about the dangers highlighted by the incident and setting out “mandatory” precautionary measures to be taken during well completions.

The Commission concluded: “The basic facts of both incidents are the same. Had the rig crew been adequately informed [by Transocean] of the prior event and trained on its lessons, events at Macondo may have unfolded very differently.”

The Oil Spill Commission, goes on to list many recommendations towards preventing future disasters and restoring public confidence in the oil & gas exploration industry (see report).

To achieve these worthy goals, both industry and regulators must start by empowering/requiring process engineers to communicate any concerns they have about the safe running of their equipment and facilities.