On June 14, I published a question:
How Long Must We Wait To Learn?
I asked: “Do we need to wait for the completion of the Presidential Commission’s investigation to learn from the BP Deepwater Horizon Accident?”
OK … I know I will make some people mad with this answer but … Here’s the answer none-the-less.
NO – WE DON’T NEED TO WAIT TO LEARN.
First, let me say that as the many official investigations continue, we will learn more about the technical details of what happened. The equipment failures that cause the failure of the blowout preventer. The details of the tests that were performed and misused to justify replacing the mud with seawater. The design basis for the well design and construction decisions that turned out to be inadequate to prevent a blowout.
These are things that we will learn with time.
Thus, people aren’t completely wrong when they say – “Wait until the official investigations are completed.” “We don’t want to jump the gun and jump to conclusions without the facts.”
That’s sentiment is well and good.
But, they are missing my point.
We already know enough about some parts of the accident to be able to learn some important lessons. Lessons that we need to learn RIGHT NOW.
The first, and biggest, thing we can learn is that SAFETY CULTURE MAKES A DIFFERENCE.
We already knew that drilling in deepwater is dangerous. We knew this before the BP Deepwater Horizon accident. We certainly know it now.
The risk of a failure in deepwater is more than the risk of drilling on land or in shallow water. The deeper you go, the more complex it gets. Also, the higher the technology that you use. These facts make it more important to understand what makes a high reliability organization tick – what produces a good safety culture for these demanding environments.
I think everyone will agree with the previous paragraph.
Yet, BP did NOT take extra precautions in designing or constructing the well being drilled by the Deepwater Horizon. In fact (and we know this to be a fact from testimony already given), they didn’t take precautions that other companies take and are “standards” for drilling in deepwater.
What shortcuts did they take? Here are five that I think have already been proven:
1. The choice of the cheaper, but less safe design using a single liner for well completion. BP says this design had longevity advantages. But it was mainly FASTER and CHEAPER. This choice obviously was not about safety first. A well that experiences a catastrophic failure doesn’t need to be designed to last longer.
2. Using too few hangers to center the casing. I’m not a drilling expert but the experts TOLD BP that the six hangers were WAY TOO FEW and would make it almost impossible to get a good cement job.
3. Failure to circulate the mud fully prior to cementing. Fully circulating the mud is required by an API standard. Not circulating the mud fully was a safety shortcut (but it saved them time and, therefore, money).
4. Failure to run a cement bond log. If this was a standard well and everything had gone right, you might skip this safety step. But on a well that is deep, with a single casing, with too few hangers, and with a bad first test, skipping this test was inexcusable. They were leaving safety to luck. And they ran out of luck that day.
5. Failure to deploy the casing hanger lockdown sleeve. I haven’t heard why this wasn’t done. But BP and the Coast Guard/MMS investigators already know about it. I just haven’t been able to find the testimony (which is on line).
These are facts.
Of course, BP argues that MMS approved these shortcut. But errors at MMS don’t mean that BP was right and had a safe well design. The mistakes at MMS, if and when they occurred, are just additional failed safeguards that allowed the accident to progress.
Therefore, I’m not saying that these are all the shortcuts. There are MORE.
I’m saying that these shortcuts are sufficient to prove that, at least for this well’s safety, BP’s practices WERE NOT to make safety the highest priority.
The question remaining is … “Is this the BP culture or were the people drilling this well ‘outliers’ – rouge engineers and supervisors who were working outside BP’s culture.”
This is where I make a fairly safe assumption.
This well was so deep and so important that it couldn’t (and shouldn’t) slip underneath the radar of BP’s management. Fairly senior management (maybe not the CEO, but certainly some high up folks) must have known about the design decisions. In fact, I believe investigators will be able to show significant management pressure to get the well complete and move on to the next well. This pressure – without enough consideration for safety as an overriding priority – is the current safety culture at BP.
Thus even though they talk about ” …focusing on safety like a laser” and “We don’t do anything unless it is safe.” … the reality, which is reflected by the practices in the field, is quite different.
When I heard the BP America President say in Congressional testimony that:
“We don’t do anything unless it is safe.”
I knew that he didn’t really understand safety. Why? Because safety is never absolute. Everything we do has some risk.
Therefore, we can learn NOW. We can learn that SAFETY CULTURE IS IMPORTANT.
And there are important lessons that are common practice in high reliability organizations that all organizations facing high risk, high complexity operations must learn.
How do I know about these lessons?
I worked in a high reliability organization. The Nuclear Navy. And I “got it.”
I also studied human factors and organizational design and I understand why a high reliability organization function successfully.
But obviously, not everyone gets it.
I say obviously because repeated major accidents are proof that somebody doesn’t get it.
Therefore, from the “evidence” of their repeated serious accidents, I conclude that BP senior management doesn’t get it.
What can I do? I’m going to share what I know with anyone willing to listen and learn. BP if they are willing. Or any other company that faces potentially catastrophic damage if they are not highly reliable.
At the 2010 Summit in San Antonio on October 27-29, I will provide two presentations that takes learning about safety culture and performance improvement to the next level.
The first talk is a Keynote address to the entire Summit audience titled:
“Taking Improvement to the Next Level”
I already have part of this presentation developed but I’m adding to it daily. If you are responsible for improving safety, quality, equipment reliability, or production, you need to be at this talk.
The second talk is much more focused on safety culture and the secrets behind a high reliability organization. It is titled:
“Lessons Learned About Excellence & Safety From Admiral Rickover”
This presentation takes the PhD complexity of safety culture and high reliability organizations and makes it understandable and practical. This presentation details what’s made the Nuclear Navy work for all these years. It’s the secrets that Admiral Rickover understood (and many others in the Navy didn’t understand).
This second presentation is part of the Improvement Program Track. if you are interested in high reliability organizations and safety culture, make sure to sign up for it when you register for the Summit.
So, here is my overall advice …
Don’t wait to learn.
Start reviewing the facts that are available now and learn as much as you can as fast as you can.
Also, plan to attend the Summit in October (register now). The lessons you can learn there are too important to miss. They can help you save lives, your company’s reputation, and all sorts of headaches.
[...] This post was mentioned on Twitter by Jay Rohman, TapRooT® RCA. TapRooT® RCA said: Lessons About Safety Culture from the BP Deepwater Horizon Accident that We Can Learn NOW http://bit.ly/bPP3HX [...]
I don’t agree with the article , since , as for me ,you have to wait till the full investigation completed.
Othervise the conlcusions that you have drawn from the incident before the full investigation completed, could mislead you , because of the full investigation may reveal a lot of facts that might change final conclusion about causal or root causes of the incident.
In every post factum incident analysis you have the transient time between the hypothestical state and the proven state to answers or causes. The more information is gathered the more hypotheses are rejected or proven.
So in my opinion we should learn as fast as possible ESPECIALLY for high risk activities and best BEFORE the incidents/accidents.
A risk analysis where you consider the worst case of some hypothesises is therefor always a must. If you don’t do that you can get the worst consequences and people start to wonder (with reason) about your safety culture
Some interesting points raised by Mark.
I don’t understand the argument that “A well that experiences a catastrophic failure doesn’t need to be designed to last longer.” You could argue that BP were preventing a future catastrophic failure of the well by designing it for longevity.
How many other wells are there out there with a similar design? Naturally other oil companies, with 20/20 hindsight, would say “We wouldn’t have done it that way”.
But my concern is this. Like chunks of insulation falling off the shuttle became normal, like “O” ring wear on the booster rockets was accepted, the design of this well was probably influenced by the designs of predecessors. Each one slightly different but not so different so as to fail. This well probably incorporated too many changes and so the design was flawed.
But BP is not alone in failing to learn. From Challenger to Columbia; from Thresher to Greeneville, organisations fail to learn from themselves and others. Why?
Now – if we can solve that…….
Mark
I’m quite surprised that you would publish such an article given you are an investigation professional. Investigations are difficult enough even when you have the available evidence right in front of you, the fact that you are coming to judgemental conclusions from so remote a position from the evidence absolutely astounds me. You are basically repeating the conclusions the international media are promoting as the main story (i.e. BP are to blame). There are a myriad of companies and regulators involved in this incident and they all had a role to play in preventing an incident of this nuature.
On a similar basis I could argue that there is no point in investigating any incidents as they all boil down to a root cause of safety culture anyway, and what use is that sweeping conclusion to anyone? Investigations are there to surgically analyse what actually happened so that we don’t make sweeping conclusions or let our opinions tell the story of what we think might have happened without carefully using the evidence to steer the investigation.
If this is the foundation of how you run your investigation courses that you are advertising here, I will not be going on one, it sounds like a “black magic” method to get to investigation conclusions quickly, sorry but you did invite critisism when you published this. I’d advise you to wait till all the investigations are complete before forming an opinion yourself.
If you intend to defend yourself, please also publish your taproot analysis of the evidence you have analysed for the Deepwater Horizon Incident and show how you reached your conclusions without speculation from that analysis.
Regards
Mike
I totally agree with your comments. If BP are as they say committed to Health & Safety, then why do these incidents still occur?
How long must we wait to learn with the focus on learning – I fully support this article – Organizational Weaknesses do not manifest as events in a learning organization as a surprise. Learning should therefore even take place before the event – in this case ASAP to prevent common cuase. I bet BP already took action to address some Org. Weaknesses.
If it cultural issues you might need a wake-up call as many organisations are not aware of cultural issues and some external assessment is needed.
I usually never respond but I thought this one deserved a response. I think you should write about why people feel the need to personally attack your credibility when they disagree with your opinion on an issue. I guess it also throws me that anyone would say that they can’t learn a lesson until they get all the facts.
I thought your article was right on track.
I’m reading Mark’s article and the reply’s sitting in my office in Valdez Alaska. To date, the exact lessons learned, conclusions, and international regulations influenced by the Exxon Valdez oil spill in 1989 are still being fine tuned and adjusted. The oil and marine industry in Alaska, and for the most part the entire West Coast began implementing changes from initial casual factors (drinking, watch standing, vessel escorts) well before the official investigation was completed. If we always wait until the Legislative brances of our government came to a final conclusion of their investigations, changes and improvements would serioulsy fall behind.
To Mike McCartney and others who think that I jumped to conclusions without facts and investigation to support my results …
I appreciate your feedback but the reason I wrote this article was NOT to jump the gun … but to show what we could learn with the information that is ALREADY available.
For those not up to speed on what is available, start by watching the publicly available “interviews” that are being done in the joint Coast Guard/MMS investigation. See:
http://www.taproot.com/wordpress/2010/06/22/joint-coast-guard-mms-deepwater-horizon-joint-investigation-web-site/
for a sample and then follow the link to the site for the rest. There is extensive information there (you will spend several days going through it all).
Next, watch the Congressional hearings and download that information. See:
http://www.taproot.com/wordpress/2010/06/17/well-design-construction-causal-factors-of-the-deepwater-horizon-accident/
for Causal Factors based on Congressional investigator’s analysis of the well design.
Also, the Wall Street Journal has been a good source of information. A letter to the editor there laid out some of the Causal Factors immediately prior to the well blowout. See:
http://www.taproot.com/wordpress/2010/06/11/great-letter-to-the-editor-in-the-wall-street-journal-lays-out-causal-factors-immediately-before-the-well-blowout/
Once you’ve seen the information available, you may think that there is already a wealth of information available to start analyzing.
However, I agree that I don’t have enough information yet to take all the Causal Factors through the Root Cause Tree®. I don’t even know all the Causal Factors (there is much to learn about the failure of the blowout preventer). I said that in the article above. But I do think that we have enough information to START looking beyond the immediate causes (root causes) and still LEARN something that we can apply now.
This is a different approach than I normally take. A different approach than I normally teach. But I think we can learn from what we already know (facts that are available through public sources).
This learning comes from the FIVE SHORTCUTS that were taken in the well design and completion that I mentioned in the article above. These shortcuts were supervised and directed by BP. (That is a fact in the record.) These shortcuts were sometimes over the objections of Transocean and Halliburton employees who were experts in their field. (That is a fact in the record as well.)
These five shortcuts (and, as I said, not all the shortcuts that were taken) show a pattern of choosing the cheaper/faster method rather than the more robust, resilient, safer method. This is what I am using to draw conclusions about the safety culture and, hopefully, LEARN.
One person has objected to one of the shortcuts – the single liner design for well completion. But I’ve seen several experts say that it would be almost impossible to get a good cement job with this design. Thus I conclude that “longevity factors” are irrelevant if you can’t get a reliable well to start with.
No one has disagreed with any of the other short cuts.
Finally, I admit that I made an assumption. I spelled out my assumption. I didn’t see anyone yet disagree with it. The assumption is that BP’s management had to know about the shortcuts being taken.
I suggest we learn NOW from the information that’s available and the assumption. The slow, formal investigations will eventually catch up.
Of course, my assumption may be wrong. In that case, BP’s management didn’t know about the shortcuts. In that case, they didn’t know about something that they should have known about. If you think this likely, I would suggest trying to learn from that too.
So Mike (and others), please don’t assume that this article is typical of a TapRooT® investigation. If we had started a TapRooT® investigation 60 days ago, we would have many answers that are still not clear because of the way we gather and organize evidence and then analyze the root causes of what happened.
In fact, if BP had been using TapRooT® proactively, they may have been able to identify the problems that caused this accident and correct them before they became an accident and, thus, prevent the spill from ever happening.
Therefore, I suggest you attend a course and learn about the “Black Magic” that we teach. I think you will find it very helpful and effective in your next investigation.
One other comment to JEFF PRICE about:
“But BP is not alone in failing to learn. From Challenger to Columbia; from Thresher to Greeneville, organisations fail to learn from themselves and others. Why? Now – if we can solve that…….”
I’m very interested in learning why BP didn’t learn from previous incidents including BP Texas City. I think if we dive in deep enough, we will find that large corporate cultures are very set in their ways and very difficult to change. People at the top have to conclude that things must be done differently and they must make their ideas known down throughout the organization. It is very hard to change from an organization that deals with normal risk to a high reliability organization in a high risk environment.
High reliability organizations and system are not easy to create. They are different than your everyday manufacturing company. Probably different than your everyday oil company. Most business leaders have zero experience in high reliability organizations. And the secrets of how they work are the topic of my talk at the Summit titled –
“Lessons Learned About Excellence & Safety From Admiral Rickover”
I’m still working on getting this all put together but I think it will be very interesting and useful. Maybe we can learn why organizations don’t learn.
Best Regards to All,
Mark
If BP put safety first, their track record would be much different. One must remember that BP’s Texas City accidents have recieved the largest fines to yet be levied by OSHA.
More importantly, for the folks whose livelihood may be taken away if the ill-conceived moratorium of drilling continues, an early analysis could indicate that the drilling process can be done safely if done properly. Once the rigs up anchor and leave to west Africa or other locations to drill, it will be a long time before we can reduce our dependence on foreign oil and the experts that we had working on all the rigs that didn’t ever have a catastrophic release will be working elsewhere.
“I think if we dive in deep enough, we will find that large corporate cultures are very set in their ways and very difficult to change.”
Exactly true. For that reason, pace Mike McCartney, I almost think that “corporate culture” is not by itself a root cause, so much as a feature of the environment. (In the same way, when looking for the root cause of a fire one doesn’t settle on “oxygen in the atmosphere” even though that is obviously a necessary precondition.)
Yes, corporate cultures can be changed, but only slowly and at great cost. Preventive action based on root cause analysis should typically be faster than that.
Great article, by the way.
Sam makes a good point about not waiting on the legislative branch to complete its work. The Warren Commission took 10 months to issue its report following the JFK assassination which was was caught on film and had hundreds of witnesses. Fifteen years later, they conducted another investigaion and report. As Mark previously pointed out the Blue Ribbon panel lacks expertise. I would have thought some engineering and safety folks would have been better choices. Why not have some NTSB folks on the panel. Seems to me a panel with a current or ex NTSB investigator has more creditbility and has a leg up on what has to be done.
Mark
Thanks for your considered and respectful reply.
I think I now know where you are coming from on this, I just urge caution about linking it to the investigation when we are so far removed from the actual evidence. Also remember that each separate investigation body will also be subject to its own natural bias and potentially uncovering its own failings and those lines of enquiry may not be objectively pursued or indeed may be excluded from terms of reference (I know myself from having conducted many investigations how much I have to try to control my own natural bias ..its not easy).
If your original article were more generic about how industry/organisations can better set up cultures to help prevent incidents like Deepwater Horizon, Columbia, Challenger, Valdez, Braer, Flixborough, Sveso, Chernobyl, Three mile island, Buncefield, Longford, Piper Alpha, Texas City, Bhopal, Connecticut power plant gas explosion, friendly fire fatalities in military operations etc etc I would not have had any issue, but it seemed unfair to lay the whole topic at the feet of bp. Major accidents like this are not the sole preserve of bp and the deepwater Horizon is just the latest in a long string of major accidents across many companies and industry sectors. Please also note that Texas City was acquired as part of the Amoco merger in 2001 and as Michael Mills points out above that it takes a long time to change a safety culture. Texas City had a sorry history of accidents (some fatal) prior to bp merging with Amoco.
If safety were easy none of these accidents would happen, no one would get killed driving on the roads and people wouldn’t trip and fall down stairs.
I know what the inside of bp looks like and I know the people there and I know there is a huge commitment, budget and effort dedicated towards the HSE agenda (I was a part of it at one time). Are they perfect?, of course not, neither is anyone else, but are they trying to be the best on HSE?, most definitely. bp will be hugely shocked that this could have happened to them after all they have done on HSE to date.
Some of the comments above would seem to indicate that no other organisations have accidents ever because they simply put safety as number one priority. I think this is bp’s own policy that if there is ever a conflict between schedule/production and safety, safety always takes priority. Seriously have you had no accidents in your own companies? Do priorities never get compromised at any time within every team within your organisations?
Some of the answers to where you are eluding on a general organisational level are presented in James Reason’s book “The Human Contribution”. I think many organisations suffer these “cancers” and I’ve certainly never worked anywhere where they couldn’t improve their safety standards. In saying that industry takes safety a LOT more seriously than it ever did and accident trends are proof of that, so at least we are on the right path and there is a genuine committment to get better with safety, but its a gritty journey to improve safety in any organisation and there is no “magic bullet”.
The big question for me is how are we as a profession are going to start the drive to move to the next level when major accidents (all accidents for that matter) can really become a thing of the past. Its obvious that in 2010 we are still no where near where we need to be in terms of safety and I mean that across many companies and industry sectors, but the solution is like trying to sqaure the circle and the closer you get to zero accidents the harder you realise the next step closer will be.
Deepwater drilling does not have to be dangerous, just as drilling any well or going to the moon does not have to be dangerous providing you put the right safety precautions in place, but activity is never risk free either. Drilling in deepwater is now a necessity for Western Oil production, part of good safety management is being able and willing to cope with the new safety challenges presented by the new challenges and technologies of an ever changing competitive business environment.
One last thing, Transocean can veto any client decision on their rig on any grounds not least safety, they are the installation duty holder and operator at all times similar to the way the master of a marine vessel remains in full charge of their ship at all times never mind who is asking them to go faster. They are also very well versed in the techniques and safe practices associated with drilling oil & gas wells and the hazards of not following those safe practices, after all they do operate drilling rigs and contract themsleves out as a competent and safe service provider. The oil industry is full of time pressures and cost pressures and safety issues and quality issues and organisational issues. these things are a normal and healthy part of the business, they are not in themselves a cause of accidents. If you were paying a contractor $500,000 a day to fix up your house you’d want them to work as damned quickly as they could but of course without compromising safety. Cotractors employed by the major oil compaines must have the ability to properly balance progress with safety considerations and know when to say STOP and to actually STOP when its necessary. Production and safety rarely conflict with each other and as I said earlier on the few occasions where they do SAFETY is always the top priority.
Cheers
Mike
Mike – A couple of quick comments …
1. I might give BP a pass of Texas City if they had increased spending and the accident still happened. Instead they cut spending more dramatically than pre-merger cuts by AMOCO. Thus, they were not correcting any problem that was left behind by AMOCO – they were making it worse. That’s the message of the Baker Commission and the CSB investigation.
2. I agree that there are good people at BP. That’s not the problem. There were good people at Texas City. The problem is how they manage high risk activities. The problem starts with senior managers – corporate level folks – not rank and file safety folks.
3. Not all accidents are created equal. Industrial safety and process safety aren’t the same. Therefore, efforts to improve industrial safety don’t necessarily improve process safety. I learned that at Du Pont. I’ll try to explain it simply and clearly at the Summit.
4. Your comment: “… industry takes safety a LOT more seriously than it ever did and accident trends are proof of that, so at least we are on the right path …”. However, serious accident trends, although infrequent, are not positive. Thus, process safety and high reliability organizations are not becoming the norm across high risk industries.
5. Deepwater drilling is inherently dangerous. Forget that and you open the door to the Deepwater Horizon accident.
6. Transocean did say no. The Company Man argued for an hour with the top Transocean guy until he decided to do it the BP way. Watch the testimony of the surviving witness to the argument. The BP Company man refused to testify exercising his 5th amendment rights to avoid self incrimination.
That’s it for tonight!
Best Regards,
Mark
Thanks for the insight and wonderful artical on the issue, I do agree …
Waiting for final investigation is the great tool with people now days to escape at least for time being and most cases people had short memories particularly those who are non sufferer,
In the BP case it’s time for them to check…..
Is BP rewarding for task accomplished as per target or for profit inspite of safety shortcuts?
Are people at all levels empowered for unsafe task suspension?
How often shop floor people give suggestions informally for safety improvement?
Is shop floor people feeling respected and honored for giving safety suggestion?
If no positive answer to the above then here it comes to safety culture, then it’s really matter for concern.
Mark, Mike, all,
Very good article and comments – extremely insightful and thought provoking. You have provoked me to share some of my thoughts on this.
To Mark: I think you are not only on the right track, but very close to the essence of the issue. But there may be an important obstacle and cause of the current corporate culture that I do not see expressed above. You and others talk about “safety culture”, but what does this really mean to the largest percentage of our corporate leaders? You mention “high reliability organizations”, and I have read enough and rubbed elbows with representatives of these to “get it”, and I enthusiastically agree that you are right on with the connection here. So the answer to proper “safety culture” already exists and is well-published; so why does the predominance of our corporate leadership not “get it”? Why do the predominance of our politicians not “get it”?
I also recognize and completely agree with the connections in your article and comments by Mike and others regarding the current deep-water tragedy and Bhopal, Challenger, etc.
So here are my thoughts: How many of our renowned business schools have courses or degree programs with subjects or titles such as “Corporate Safety Culture”, or “Process Safety Management”? How about Harvard? Yale? Wharton? Cambridge? Just name a few top institutions who focus on these themes to help me recognize I am wrong.
On the converse side of the problem, how many feature philosophies of “taking risk”, or based on such hollow slogans as “nothing significant is ever gained without taking a chance”, or “no guts no glory”? A few years ago I was privileged to attend a Wharton evening seminar with the theme of “the only worthy purpose of corporations is to maximize profit and return to shareholders”. Yes, really. The presentation was of course impressive, quoting notable leaders of corporate and American public leadership to make substantiate the primary importance of corporations to “maximize profit”. This was a traveling guest lecture topic that was making the rounds to all the top business schools – with great fanfare and notoriety.
I see a strong connection between our corporate leadership being taught this way by the most renowned academic institutions, having this way of thinking reinforced by the predominance of our political leadership, and generally having this exist as the norm of our culture. Think about what Mike Mills states above: “…I almost think that “corporate culture” is not by itself a root cause, so much as a feature of the environment.” Wow!
By the way – to Mark – in a separate blog regarding the “Blue Ribbon Panel” you made profound observations about one of the important connections of all of the members: “…time at Harvard or Yale…”. I don’t have any expectations of anything important being discovered or learned/shared by that team.
So I guess my thoughts can be summed up something like this: High reliability organizations “get it”, and they have the answer to the problem. But the predominance of the rest of our corporate and political leadership is not capable of “getting it”, since our academic culture is teaching the opposite.
So BP will be condemned and blamed extensively, mostly as a way of the academic culture reaffirming that “the problem is them, but not us”. My concern is that BP is really not that much different – and maybe in many ways better – then the rest of corporate leadership and culture. Maybe they are just not very lucky – but given enough time we will all be unlucky at some point since the predominance of corporate leadership will fail to learn from this. Just as they failed to learn from all of the other horrible disasters that have come before the current Gulf crisis. To be blunt: I believe the real reasons why these things happen is due to all of us: academia, corporate leadership, political leadership, and those of us contributing to this blog. It is not that change is very slow; it will take an overall revolution in our cultural values, thinking, and acceptance of disgusting (selfish, greedy, etc.) beliefs. Except for those few high-reliability organizations, we should generally be ashamed of our generation.
Mark – I have no doubt that the paper you are preparing and the presentation you will be making at the Summit will be profound and insightful toward the solution to our problem. How many corporate CEO’s will be there? How many Deans of the Business Schools of academia will be there? How many of our elected politicians will be there? Will any of them read the paper? Will you or any of us on this blog be invited to testify before Congress? In the end we are all preaching to the choir – the people who need to learn this stuff are not listening and have little or no incentive to listen. It is so much easier to blame BP for being a “bad company” and enable the rest of the clan to continue with business as usual.
Thank you to Mark and the others on this blog for provoking my thoughts and provoking me to take the time to share my personal testimony. Let’s keep working on this and some day we may succeed.
I have had enough – I need a beer!
Food for thought, Art
Art
Thanks for the thought provoking comment.
Here are two ideas…
1. Let’s work on getting some top level managers to the Summit. If everyone reading would work on getting their VP there … we could make a dent.
2. I’ll work on getting the word out beyond the Summit after the Summit. I’m open for ideas for places to talk and will welcome invitations from conferences and “elite” institutions.
Other ideas???
Mark:
Your statement “This well was so deep and so important” which is the basis for the assumption that upper management should have been intimately involved in the design, is based on what other facts or assumptions? I was not aware that this particular well was substantially different from the median of other deepwater wells.
The statement makes it appear that this well was unusual. If on the other hand, it was part of the norm, say inside the 85th percentile, then your conclusion as to how much involvement there should have been from upper management would not be a sequitur.
Also, considering all the proposals to strengthen the MMS, to divide agencies, to create new regulatory bodies, etc., I think that more emphasis should be given to the classification of the role of the regulatory/oversight/permitting agents as “broken safeguards” vs. actors who are part of mangement system. If in fact, their approval or non-approval of methods and practices affect the design and/or flow of porcesses, cannot the argument be made that the agencies form part of the management system and/or culture? If such a conclusion could be supported, then they would themselves be subject to the in-depth analysis of their failure modes – what went wrong with MMS?
Charles
Thanks for the reply.
I agree completely that MMS failures could be other causal factors. That is a topic of a different post. See:
http://www.taproot.com/wordpress/2010/06/08/interesting-analysis-of-regulatory-process-in-the-off-shore-oil-industry-what-do-you-think/
As for management’s awareness, I’ve read that this was one of the deepest wells being drilled in the gulf and had been a “problem well” before the accident. The cost overruns alone should have drawn management’s attention.
And for those that say this is only a problem in America, read this report:
http://www.cbsnews.com/stories/2010/06/22/opinion/main6605248.shtml
And finally, see this report about management attention on costs vs safety:
http://www.taproot.com/wordpress/2010/06/30/the-wall-street-journal-reports-safety-and-cost-drives-clashed-as-ceo-hayward-remade-bp/
I’m not trying to beat up BP. Just trying to see why the accident occurred where it did in what seems like a series of accidents with very similar causes.
And here’s one more “preliminary report” that is well worth reading:
http://www.taproot.com/wordpress/2010/07/06/heres-a-pdf-of-robert-beas-preliminary-findings-about-the-bptransocean-deepwater-horizon-accident/
Very insightful and informative piece and for the most part the same can be said for the comments. The question now is will there be a open investigation, and if Marks’ theory is correct, will the recommendations that come forth be implemented, by force of law if neccessary? Or will it be the same old, same old, with lawyers on both sides of the issue muddying the waters ensuring that many years go by before any steps are taken to correct the mistakes and omissions that led to this catastrophe?
Hi Mark and all,
Great Blog. Anyone who had done extensive root cause work would agree that there are lessons that can be learned early in an investigation and many times must be acted on immediately to start the process of preventing recurrrence. It appears to me that you have worked hard to develop your facts from which you have drawn your preliminary conclusions. Nicely done.
Examination of the 5 facts you present indicated to me that it is highly likely that the BP decision makers did not understand WHY the attributes they elected to eliminate from the well design were important. If they did understand the attributes of each, perhaps they did not understand the cumulative effect of omitting all 5. Working in the nuclear industry for 31 years, 6 of which were on Admiral Rickover’s staff at NAVSEA 08, I learned early in my career that a good engineer would not make a change to a design without understanding not only the benefit of the proposed change, but also the potential consequences of making the change. You must also look athe the cumulative effect of all changes that are made. There is always two sides to the balance sheet. When decisions are driven by preceived financial benefit, the negative side of the balance sheet (risk of potential negative consequences) is often overlooked. This is why folks without the appropriate technical training should never make techincal decisions such as omitting important design attributes.
If the techical folks were consulted and failed to identify the potential negative consequences, one must ask why. Was it because they did not know why the attributes were included in other wells of this type or was it because they were afraid to raise their hand to be heard.
One must always ask “What is the worst thing that can happen if I do this?” Upon answering this question, if you cannot live with the potential consequence, you must not take the action. You are obligated to make the decision makers aware of your concerns and you must not stop until you are certain they understand you. Folks in the nuclear navy learn this and this is expected of all. Proceding in the face of uncertainty is unacceptable and ofter results in bad outcomes.
Good article.
Some individuals just don’t realize, like my neighbor who couldn’t visualise the practical substance of this line on your post “…. The equipment failures that cause the failure of the blowout preventer. The details of the …” it makes me to feel more knowledgable after reading it.