BP 'slipped and tripped' to Macondo disaster
31 Jul 2012
Houston, Texas – Prior to the Deepwater Horizon explosion in the Gulf of Mexico, BP, Transocean, trade associations and US regulators largely judged the safety of offshore facilities by focusing on personal injury and fatality data, the US Chemical Safety Board (CSB) has found.
This focus on incidents such as dropped objects and slips, trips, and falls) overshadowed the use of leading indicators more focused on managing the potential for catastrophic accidents, the CSB said in the preliminary findings of its investigation into the disaster.
Expanded use of process safety indicators was first recommended by the CSB in its 2007 report on the March 2005 BP Texas City refinery disaster.
In the offshore arena, potential indicators - such as timely checks on safety critical equipment and response to well control events - would provide an assessment of the health of their safety management systems.
“These type of indicators may be precursors to the kind of tragedy that took eleven lives on the Deepwater Horizon drilling rig following the Macondo well blowout on April 20, 2010,” said the CSB.
The CSB is examining the need for the US offshore drilling and production industry - and the agencies that regulate it - to develop process safety indicators that will result in safety improvements and reduce the likelihood of major accidents.
“A number of past CSB investigations have found companies focusing on personal injury rates while virtually overlooking looming process safety issues - like the effectiveness of barriers against hazardous releases, automatic shutoff system failures, activation of pressure relief devices, and loss of containment of liquids and gases,” said CSB chairperson Dr. Rafael Moure-Eraso.
The CSB had also found failures by companies to implement their own recommendations from previous accidents involving, for example, leaks of flammable materials, he noted.
In its investigation of the Macondo disaster, the CSB found that BP and its contracted drilling rig operator, Transocean, were focused on personal safety issues such as worker injury rates, rather than broader safety issues involving the process of drilling for oil using a complex rig.
Noting a lack of sustained focus on process safety at BP and its contracted drilling rig operator, Transocean, CSB investigator Cheryl MacKenzie described an “eerie resemblance” between the 2005 explosion at the BP Texas City refinery and the explosion aboard the Deepwater Horizon.
At the BP Texas City refinery on March 23, 2005, contract workers had just returned to temporary trailers at the plant after attending a celebratory lunch commending an excellent personal injury accident record. Shortly after lunch, an explosion occurred during process startup, killing 15 and injuring 180 others.
At Macondo, BP and Transocean officials were in the process of lauding operators and workers for a low rate of personal injuries on the very day of that tragedy. Company VIP’s had flown to the rig in part to commend the workforce for zero lost-time incidents.
“Companies need to develop indicators that give them realistic information about their potential for catastrophic accidents,” said MacKenzie. “If companies are not measuring safety performance effectively and using those data to continuously improve, they will likely be left in the dark about their safety risks.”
For example, the bridging document that sought to harmonise safety controls between BP and Transocean was a minimal document that focused only on six personal safety issues such as minimum heights for employing fall protection equipment. The document did not address major accident hazards like the potential for loss of well control.
Hazard assessments of major accident risks on the Deepwater Horizon relied heavily on prompt, correct manual intervention by the rig crew to prevent a catastrophe, for example to divert the flow of flammable hydrocarbons away from the rig during a blowout.
Depending on a human reaction alone during an emergency situation - with many distractions - is not a reliable safety layer. A comprehensive hazard assessment should have identified this risk.
On the Deepwater Horizon, a little over a month before the Macondo blowout, there was a delay by operators in responding to a “well kick” - an unanticipated, hazardous influx of hydrocarbons into the wellbore that can precede a blowout.
BP investigated the incident but after informal verbal discussions with Transocean, evidence indicates that Transocean did not implement changes based on the findings.
A robust system of process safety indicators might have revealed such management system deficiencies before the disaster occurred, according to CSB investigators.
CSB’s MacKenzie noted that Transocean primarily measured safety performance through two metrics: total recordable injuries and the “Total Potential Severity Rate.”
Although Transocean gave itself a zero score for total recordable injuries following the tragedy, its scoring on the potential severity rate enabled top-level management at Transocean to receive financial bonuses for safety performance.
The investigation is also looking at the role US regulators and regulations played in the time preceding to the accident.
The CSB found that BP was a finalist for a safety award from the Minerals Management Service (MMS), the former Department of the Interior agency overseeing offshore oil exploration and production, and that a total of 15 safety awards had been given to BP and Transocean over a period of years.
The CSB investigation team presented eight conclusions from the investigation to date:
1. Transocean and BP had multiple safety management system deficiencies that contributed to the Macondo incident.
2. Before the Macondo blowout, the safety approaches and metrics used by the two companies and US trade associations did not adequately focus on major accident hazards. Recently BP officials informed CSB investigators that they are working to develop a more comprehensive offshore indicators program using leading and lagging metrics to help drive performance improvements.
3. Systems used for measuring safety effectiveness in the offshore industry focused on personal safety and infrequent lagging indicators.
4. The US offshore regulator, the Department of the Interior, can achieve a greater impact on major accident prevention through the development of a leading and lagging process safety indicator program.
5. Despite some significant progress with process safety indicator implementation in the downstream oil industry, in the offshore sector BP, Transocean, industry associations, and the regulator had not effectively learnt critical lessons of Texas City and other serious process incidents at the time of the Macondo blowout.
6. Companies and trade associations operating in other regulatory regimes outside the US have developed effective indicator programs, recognising the value of leading indicators, and using those indicators to drive continuous improvement.
7. Trade associations and many of the same companies that operate in the US are partnering with the regulators in other countries in advancing safety indicators programs.
8. In the aftermath of the Macondo blowout, companies and trade associations in the U.S. are initiating efforts to advance the development of offshore major accident indicators.
