Here are the links to the reports:
Collision between a freight wagon door and signal in Kilsby Tunnel, 15 March 2010
Serious injury to a loader at Hoo Junction, Kent 14 April 2010
Archive for the ‘Investigations’ Category
UK Rail Accident Investigation Branch Releases Two Reports Detailing the Root Causes of Recent Rail Accidents
Wednesday, July 21st, 2010
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Wall Street Journal Reports on Mistake Made in Final Hours before the BP/Transocean Deepwater Horizon Blowout
Monday, July 19th, 2010The Wall Street Journal article discusses twenty “anomalies” signaled that a blowout could be coming and unexpected pressure increase triggered disagreements between BP and Transocean employees. See:
Third Round of Hearings by the Joint Panel of Coast Guard & Bureau of Ocean Management, Regulation and Enforcement into the Causes of the BP/Transocean Deepwater Horizon Blowout, Explosion, & Spill Start Today
Monday, July 19th, 2010
(hearing photo)
Today was the day that BP Well-Site Manager Don Vidrine was suppose to testify. However, he was removed from the list of witnesses. Later this week the other Well-Site Manager, Robert Kaluza, is scheduled to testify. Previously, he “took the fifth” (self incrimination) and declined to testify.
These hearings, although probably the worst way to interview witnesses, are still extremely interesting.
For an article about today’s hearings, see:
http://blogs.chron.com/newswatchenergy/archives/2010/07/update_coast_gu.html
Here’s the investigations web site where you can see live and recorded testimony:
Monday Accident and Lessons Learned: OGP SAFETY ALERT NO. 225: PIPE HANDLING OPERATIONS RESULT IN FATALITY
Monday, July 19th, 2010SAFETY ALERT NO. 225: PIPE HANDLING OPERATIONS RESULT IN FATALITY
Country: USA
Location: OFFSHORE : Other offshore
Type of Activity: Lifting, Crane, Rigging, Deck operations
Type of Injury: Caught In, Under or Between
Function: Drilling
Applicabale Filter Categories: Caught between
Recently a fatality occurred during pipe handling operations on a deepwater drilling unit. A rig employee’s head was caught between the pipe handler’s lower travel assembly and a vertical support stanchion (pinch/crush point of 4 inches) as the pipe handler was being traversed across the pipe bay to the catwalk to retrieve a joint of pipe. The deceased was acting as a spotter for the pipe handler operator at the time of the incident and the pipe handler operator did not observe the incident due to his obstructed view of the spotter.
What Went Wrong?:
The BOEM (formerly MMS) investigation revealed that unidentified crush points existed between the lower travel assembly and the vertical support stanchions of the trolley system. It was concluded in part, from the investigation that the pipe handler operator failed to confirm an “all clear” with the spotter and failed to exercise his Stop Work authority when he lost site of the spotter. The Lessee/Operator failed to provide the necessary additional oversight to ensure that the pipe handler operation was conducted in accordance with their lifting policy. The drilling company’s line management also failed to:
Provide a more formalized training program to include the hazards associated with the operation of the pipe handler.
Identify the specific pipe handler operational tasks, hazards and respective mitigations in order to develop and implement guidelines for personnel working around the strong-back area.
Provide additional onsite supervision to both the Operator and Spotter during the pipe handler operation.
Properly implement their Management of Change policy with respect to new personnel in new positions. The company’s Management of Change policy was also identified as being too complex to implement.
Corrective actions and Recommendations:
Therefore, BOEM recommends the following to Lessees/Operators and their Drilling Contractors for any type of overhead trolley beam mounted crane (trolley crane) operation, including but not limited to a pipe handler:
Inspect trolley crane operations with the intent to identify all potential hazards and mitigations (including pinch/crush points), and communicate these findings with all necessary personnel.
Review Stop Work authority programs with their personnel, while stressing the importance of the individual’s responsibilities and authority to exercise Stop Work as necessary.
Review trolley crane training programs to ensure that the program covers not only the proper operation of the equipment, but also includes the limitations, capabilities and potential hazards. If the training includes onsite hands-on training, the verification/certification should be done by senior facility management.
Review the Management of Change policy for clarity and to ensure the program recognizes and manages changes, conditions and inactions in a given situation or unexpected events.
Install and maintain safety barriers (signage, red zones, tiger striping, temporary barrier tape, handrails, etc.) to prevent access to the trolley crane’s traversing path.
Clear the trolley crane’s path of general storage. Telephone, intercoms or stored items located under the trolley crane should be removed and relocated to a safer area.
Consider the feasibility of installing cameras or mirrors in areas where the trolley crane operator’s view is obstructed.
Consider the feasibility of re-engineering the trolley crane to possibly eliminate any additional Spotter involvement.
Conduct pre-tour meetings for all tours, including short change crews. The short change crew involves multiple employees filling new roles and/or not working on their normal crew shift.
A Press Release from the Deepwater Horizon Joint Investigation
Saturday, July 17th, 2010Witness lists of fact-finding joint investigation available for July 19-23, 2010
NEW ORLEANS – The following are links to witness lists for July 19-23, 2010 for the third round of public hearings in this fact-finding joint investigation. The purpose of this joint investigation is to develop conclusions and recommendations as they relate to the Deepwater Horizon MODU explosion and loss of life on April 20, 2010. The facts collected at this hearing, along with the lead investigators’ conclusions and recommendations will be forwarded to Coast Guard Headquarters and BMOE for approval. Once approved, the final investigative report will be made available to the public and the media. No analysis or conclusions will be presented during the hearing.
Click on the dates to link to individual witness lists:
For Deepwater Horizon joint investigation information: www.deepwaterinvestigation.com
For Deepwater Horizon oil spill response information: www.deepwaterhorizonresponse.com
Wall Street Journal reports: “Oil Industry To Form Accident Group Following BP Spill”
Thursday, July 15th, 2010For details, see:
Wall Street Journal Takes Up Qualifications of the President’s Independent Commission to Investigate the BP Deepwater Horizon Accident
Thursday, July 15th, 2010On June 16th, we published a blog article about the qualifications of the President’s Independent Commission to investigate the BP Deepwater Horizon accident. Many of the readers here commented on the qualifications and the overall response was that they didn’t seem particularly well qualified to find the root causes of the well blowout, explosion, and spill. See the comments here:
Last week, the Wall Street Journal published an article, “The White House Get’s Drilled,” that pointed out the bias of the Commission. It said:
“By contrast, the President’s seven-member commission contains not a single expert on drilling or petroleum engineering and is instead loaded with such anti-oil and antidrilling activists as Natural Resources Defense Council President Frances Beinecke and former Florida Senator Bob Graham.”
The also quoted Louisianna Democratic Senator Mary Landrieu, who said:
“I would suggest to my Democratic friends that if the shoe were on the other foot, and President Bush was the President and he had submitted a list of names like this to us and everyone was related to the defense of oil companies, we would say this is not fair.”
In reviewing the commissions qualifications, the Journal article points out the following:
About Commissioner Reilly: “Mr. Reilly is well known as a green activist who once ran the World Wildlife Fund, which is precisely what made him attractive as a GOP political appointee and for ConocoPhillips. Both were looking for environmental cover.”
About Commissioner Beinecke: “‘Offshore drilling is a needless risk,’ said Ms. Beinecke in 2008, as part of her push for cap-and-trade legislation.”
About Commissioner Boesch: “‘We should be redoubling our efforts to get off oil,’ said fellow commission member Donald Boesch in May. He wants ‘transportation not powered by liquid petroleum.’”
About Commissioner Garcia: “Appointee Terry Garcia of the National Geographic Society rapped the Bush administration in 2008 for not doing more to ‘protect’ oceans from ‘commercial and recreational fishing, oil and gas exploration or deep-sea mining.’”
About Commissioner Murray: “Harvard’s Cherry Murray is president of the American Physical Society that recently rejected calls from 160 physicists to alter its doomsday position on climate change, which demands immediate reductions in greenhouse-gas emissions to avoid ’significant disruptions in the Earth’s physical and ecological systems, social systems, security and human health.’”
About Commissioner Ulmer: “The University of Alaska’s Fran Ulmer is on the board of the Union of Concerned Scientists, which wants the U.S. to curb its ‘oil addiction’ by requiring that cars get at least 42 miles to the gallon.”
The article goes on to comment of the Commission’s new Executive Director, Richard Lazarus. The article says:
“Underscoring its biases, the President’s commission has chosen prominent environmental litigator Richard J. Lazarus as its staff director. Mr. Lazarus has made a career out of suing private companies and governments to impose stricter environmental regulation.”
This week, the Commission’s Executive Director wrote back to the Wall Street Journal. In an editorial, published today, he said:
“The commission is co-chaired by two highly regarded public servants, former Sen. Bob Graham and former EPA Administrator Bill Reilly. They are individuals of enormous integrity and highly respected by industry, by members of Congress and by state officials, regardless of formal political affiliation.”
He also said:
“You may also note that the commission recently named Richard Sears, a widely respected oil industry expert with 35 years experience, as its adviser on science and engineering, to augment the oil industry expertise of Mr. Reilly, who has served on the Conoco-Phillips board for over 15 years.”
So, I thought I would look for Bio’s of Mr. Lazarus and Mr. Sears. Here’s what I found…
First, Mr. Lazarus. Here’s a link to his bio:
http://www.sandiego.edu/law/academics/faculty/bio.php?id=749
The bio seems to confirm the Wall Street Journal’s rhetoric.
Next, Mr. Sears. The first thing I found was this presentation he gave at TED:
The I found a bio attached to a Washington Post Viewpoint paid discussion. I quote it here:
“Richard Sears is Vice President and Extra-mural Research Coordinator for Shell International Exploration and Production Inc. He is currently on loan to MIT for a period of three years, where he serves as Visiting Scientist in the Laboratory for Energy and the Environment. The intent is to create a research and technology relationship model for Shell with major US universities and manage Shell energy research activities at MIT as well as other research relationships in the Americas.”
“In his more than 30 years with Shell, Richard has gained significant domestic and international experience, frequently representing Shell to partners, governments and national oil companies, including presentations to governmental authorities and ministers of eleven countries. He has been an invited and keynote speaker at industry conferences in the US, UK, Africa and Asia.
Prior to his current assignment, he shared responsibility for developing Shell strategy for deepwater exploration and development worldwide and was one of three vice presidents within Shell E&P responsible for the work of over 800 technical professionals across the globe from over 15 distinct geoscience, engineering and business disciplines.”
“Previous positions within Shell have included exploration geophysicist, technical instructor, economist, strategic planner, and general management.”
“He is the author of numerous internal publications including field studies and case histories, geophysical research reports, and technical training manuals.”
“Richard has been a member of the Stanford University School of Earth Sciences Advisory Board since 2004. He is a Licensed Professional Geoscientist in the State of Texas, an active member of the Society of Exploration Geophysicists and a member of the American Association of Physics Teachers.”
“He earned his Master of Science degree in Geophysics and his Bachelor of Science degree in physics from Stanford University.”
To me, he seems well qualified. But I wish I knew more about his oil drilling (not just oil exploration geophysical) experience and his experience leading accident investigations.
With that said, what influence does a consultant to the Commission have? He isn’t a commission member. I guess his influence is yet to be seen.
What do you think?
Does a well qualified consultant change your opinion on the qualifications of the President’s Independent Commission to investigate the BP Deepwater Horizon accident? Let me know by posting your comments here.
Monday Accident & Lessons Learned – BP/Transocean Deepwater Horizon Explosion & Spill
Monday, July 12th, 2010We’ve been posting lots of information about this accident since it happened. It’s now been over two months and the question I would like to ask is …
WHAT HAVE WE LEARNED?
Here’s a review of what’s been posted so far. Review it and then leave a comment with what you think we can learn so far.
APRIL
First Coverage on the TapRooT® Blog
Amazing New Root Cause on Oil Rigs: “Human Error”
First Estimates of Cost – $1.6 Billion
Slow Motion Disaster in the Gulf
New Idea: Consider Oil Company’s Environment and Safety Record When Leasing Drilling Rights
Cost of an Accident: Legislative Costs
MAY
TV News Coverage of the Oil Spill Off Louisiana
BP/Transocean Rig Explosion: Amazing Accident Pictures and Interview with Survivor
Blame Before the Investigation: Looking for Villians Before the Oil Stops Flowing
More Blame and Reprecussions: BP/Transocean Rig Explosion and Oil Spill
BP/Tranocean Rig BOP Failure: The Smoking Gun Paper
BP/Transocean Rig Explosion: Interview with Survivors on ABC
Very Critical Article of Offshore Drilling
Interesting Blog Article about BP/Transocean Rig Accident
BP “Culture of Incompetence” says Congressman Bart Stupack
Is This an Investigation Technique or a Liability Reduction Technique
First Congressional Hearings – McKay
60 Minutes Report on the BP/Transocean Deepwater Horizon Explosion
Newspaper Calls for Investigation of “Safety Culture” at BP
The Cost of an Accident: More Lawsuits for BP
Monday Accident & Lesson Learned: Either You Are Leading the Solution or You Are Part of the Problem
MSNBC Investigates Scandal of BP Deepwater Horizon Incident – Corporate Homicide?
Top Kills Fails – BP to Try New Plan
Bad News After an Accident: BP Can’t Get Much Worse Press Than This…
For Those Who Want to Know More About Cementing
JUNE
Interesting Analysis of Regulatory Process in the Off-Shore Oil Industry … What Do You Think?
CNN Reports on “Criminal” Conduct by BP in Story Titled: “Rig survivors: BP ordered shortcut on day of blast”
Great Letter to the Editor in the Wall Street Journal Lays Out Causal Factors Immediately Before the Well Blowout
How Long Must We Wait to Learn?
The Cost of an Accident – Your Reputation and $20 Billion Dollars
Well Design & Construction Causal Factors of the Deepwater Horizon Accident
More Bad PR for BP – CNN Story: “BP documents highlight PR strategy after deadly Texas blast”
Second Congressional hearings – Hayward
How Bad is the BP PR Impact? It Can’t Get Much Worse Than This…
Do Exxon and BP Take Different Approaches to Risk?
Cost of an Accident: Costs Sometimes Go Far Beyond the Company Involved
Are We Blaming BP Rather Than Learning From What Went Wrong?
CSB Press Release: CSB to Investigate Root Causes of BP Deepwater Horizon Blowout Accident
Joint Coast Guard & MMS Deepwater Horizon Joint Investigation Web Site
Lessons About Safety Culture from the BP Deepwater Horizon Accident that We Can Learn NOW
Columnist Laura Parker Comments on Multiple Deepwater Horizon Investigations
CBS News Reports: “BP’s Disaster: No Surprise to Folks in the Know”
The Wall Street Journal Reports: “Safety and Cost Drives Clashed As CEO Hayward Remade BP”
JULY
BP Investigation Presentation from the Deepwater Horizon Accident
BP Deepwater Horizon Fault Tree
Here’s a PDF of Robert Bea’s Preliminary Findings About the BP/Transocean Deepwater Horizon Accident
Anadarko Withholds Payment of BP Spill Bill
That catches us up with what is known so far.
Now tell me what we can learn by leaving your ideas as a comment here…
Anadarko Withholds Payment of BP Spill Bill
Sunday, July 11th, 2010The Houston Chronicle reports that Anadarko Petroleum is withholding payment on a bill sent by BP to help pay for the spill.
The article says:
“The company has argued that it’s not responsible for costs arising from an operating partner’s ‘negligence’ or ‘willfull misconduct’ — something it accuses BP of in relation to the spill.”
The article also said:
“Last month, Anadarko CEO James Hackett said BP should shoulder the costs of the spill. BP has said it strongly disagreed with Anadarko’s allegations.”
For more info, see:
New BP Spill – This one in Michigan
Tuesday, July 6th, 2010Here’s a PDF of Robert Bea’s Preliminary Findings About the BP/Transocean Deepwater Horizon Accident
Tuesday, July 6th, 2010Click the document below to open…
My evaluation of the preliminary findings is that they are at the level of the causal factors. Still more work to be done to get to root causes.
Robert Bea’s Investigation
Tuesday, July 6th, 2010Here’s a video about the preliminary findings of Robert Bea’s investigation of the BP/Transocean Deepwater Horizon accident.
Visit msnbc.com for breaking news, world news, and news about the economy
Monday Accident & Lessons Learned: Run Over by Equipment Video
Monday, July 5th, 2010Union Calls for Root Cause Analysis of Fatal Accident in Guyana
Saturday, July 3rd, 2010Here’s a quote from the West Indian News:
“As the worst accident in the Kwakwani area, resulting in deaths, critical injuries and traumatized workers, it cannot be swept under the carpet as a simple road accident. While the Union is encouraged at the efforts made to save lives, it will not be satisfied to be told that this is as far as it goes. We need a root cause analysis to determine all factors contributing to this very sad loss of lives and injury and immediate short and long term measures to be implemented so that such situations of hazards are removed or minimized in the daily lives of bauxite workers.”
See the whole article at:
BP Deepwater Horizon Fault Tree
Thursday, July 1st, 2010A TapRooT® Instructor forwarded this to me. What do you think? Does this add to your knowledge of the accident?
BP Investigation Presentation from the Deepwater Horizon Accident
Thursday, July 1st, 2010Here’s a PDF of the preliminary BP Investigation downloaded from the House of Representatives Energy and Commerce web site:
Review the slides and see what you think.
Compare their four “critical factors” to the multiple Causal Factors at these two links:
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/
http://www.taproot.com/wordpress/2010/06/17/well-design-construction-causal-factors-of-the-deepwater-horizon-accident/
What are they missing if they don’t look at additional Causal Factors?
Anything else that you see about this investigation presentation that makes it easy or hard to understand?
Please leave your comments.
The Wall Street Journal Reports: “Safety and Cost Drives Clashed As CEO Hayward Remade BP”
Wednesday, June 30th, 2010A very interesting article in The Wall Street Journal. See:
http://online.wsj.com/article/SB10001424052748703964104575335154126721876.html
Some interesting quotes…
“Meanwhile, company officials continued hammering home the message on costs. Mr. Shaw, the Gulf of Mexico head, made the point at a meeting for top managers in Phoenix in April 2008. His aim, according to an internal BP communication, was to instill a ‘much stronger performance culture’ in the organization, based on strictly managing costs and ‘this notion that every dollar does matter.’”
- – -
“A former BP engineer who retired last year said the Gulf of Mexico operation under Mr. Shaw became focused on meeting performance targets, which determined bonuses for top managers and low-level workers alike. The engineer says even small costs got targeted: BP no longer provided food at lunch meetings, and eliminated the fruit bowls that were offered as part of a healthy-living drive a few years earlier.”
- – -
Talking about pipeline leaks in Alaska … “The state [Alaska] also said it was ‘deeply concerned with the timeliness and depth of the incident investigation’ conducted by BP. It took four months to provide a report that other oil companies typically submit in two weeks.”
- – -
“Some think the cost drive affected safety. Workers had ‘high incentive to find shortcuts and take risks,’ says Ross Macfarlane, a former BP health and safety manager on rigs in Australia who was laid off in 2008. ‘You only ever got questioned about why you couldn’t spend less—never more.’ BP vigorously denies putting savings ahead of safety.”
- – -
“In a different context, BP had questioned the impact of its cost-cutting in the Gulf. After the 2008 incident on the Atlantis platform, BP’s internal report warned of lax safety oversight and tight budgets.”
“It concluded: ‘A key question to ask, especially with apparently minor and disconnected defects, is ‘What’s the worst thing that could happen?””
CBS News Reports: “BP’s Disaster: No Surprise to Folks in the Know”
Tuesday, June 29th, 2010Here’s the link to read what was said:
http://www.cbsnews.com/stories/2010/06/22/opinion/main6605248.shtml
Saudi Food and Drug Authority take the Lead in Investigating Medical Device Failures
Tuesday, June 29th, 2010
The newly developed SFDA (Saudi Food and Drug Authority) located in Riyadh, Saudi Arabia, has taken the lead in medical oversight of conformity; not only by creating a Medical Devices Sector, but also by ensuring that their Medical Device team has a thorough understanding of human error and equipment failure and has the best tool to investigate it with, TapRooT® Root Cause Analysis.
Here are few pictures taken during the onsite 2-Day TapRooT® Incident Investigation and Root Cause Analysis, 1-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis, Stopping Human Error, and 1-Day Evidence Gathering Courses held in June.
If you look closely you can see that they are using the new individual software… (another user test to make sure it is ready to go out to all users)
Rent a TapRooT® Trained Senior Detective to Help Facilitate A Tough Accident Investigation
Tuesday, June 29th, 2010
Alan Smith and Mhorvan Sherret are retired Senior Detectives located in Scotland. They are also Certified TapRooT® Instructors. That makes a great combination if you need unbiased help facilitating a difficult investigation. Mhorvan and Alan are close by for any investigation in Europe & the Middle-East. But they will travel anywhere you need them around the world.
Need someone closer to your site? We have excellent TapRooT® Facilitators in:
Africa,
Australia,
Brazil,
Canada,
Columbia,
Korea,
Mexico, and
the United States.
To get help fast, call 001-865-539-2139. Or e-mail info@taproot.com.
Monday Accident & Lessons Learned: How Many Accidents Before a Corrective Action is Needed?
Monday, June 28th, 2010A road in Nevada had a truck “run away” in 1990. The runaway ramp failed to stop it. No corrective actions were taken.
Now a similar accident happens with a bigger truck and there’s more damage. The article says:
“State transportation officials say they’ll study the latest accident to determine if any changes are needed with the ramp.”
What do you think? How many fatal accidents should it take to cause corrective actions to be taken?
Columnist Laura Parker Comments on Multiple Deepwater Horizon Investigations
Sunday, June 27th, 2010Laura Parker, an independent columnist, has written an interesting article about the problems with multiple investigations of the BP Deepwater Horizon accident. See the full article at:
The story starts with:
“When a little-known federal agency with just 14 investigators joined the growing list of government probes into the Deepwater Horizon disaster, it renewed cries from the Gulf of Mexico — and beyond — that no one seems to be in charge.”
A quote from the story about the Joint Coast Guard/MMS investigation:
“In addition, the panel’s public questioning of witnesses has come in for criticism from the Interior Department’s acting inspector general, Mary Kendall. Because the MMS lacked clear guidelines for conducting accident investigations (they are summed up in a scant five paragraphs of regulations), the Coast Guard’s more substantial procedures are guiding the probe. The Coast Guard rules ‘are comprehensive,’ Kendall told a House committee, ‘but in my view, completely backwards, gathering evidence via public hearing, rather than developing evidence to culminate in a public forum.’”
Read the rest at the link above.
Link to the Executive Order that Establishes the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling
Sunday, June 27th, 2010Lessons About Safety Culture from the BP Deepwater Horizon Accident that We Can Learn NOW
Friday, June 25th, 2010On 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.
Corporate Homicide – Death in the Workplace
Thursday, June 24th, 2010When the unthinkable happens will you be ready?
Open the PDF and see what you can learn before the Summit.
Here’s the link to register for the course:
Joint Coast Guard & MMS Deepwater Horizon Joint Investigation Web Site
Tuesday, June 22nd, 2010I’m slow to find this site but there’s lots of information for anyone who wants to learn from the accident.
The investigation home site address is:
http://www.deepwaterinvestigation.com
There are videos of witness interviews, transcripts of interviews, and witness lists.
Here’s a sample of a few of the videos…
My favorite interviews were Jimmy Harrell’s. That’s the kind of interview you appreciate after an accident.
The Washington Post Reports: “Since Red Line crash, efforts to improve Metro safety have lost momentum”
Tuesday, June 22nd, 2010The story starts with:
“A year after the deadliest accident in Metro’s history, the transit authority’s safety record has worsened, and officials acknowledge that there has been too little progress.”
Read the rest of the story at:
http://www.washingtonpost.com/wp-dyn/content/article/2010/06/21/AR2010062104703.html
CSB Press Release: CSB to Investigate Root Causes of BP Deepwater Horizon Blowout Accident
Monday, June 21st, 2010
CSB to Investigate Root Causes of BP Deepwater Horizon Blowout Accident; Announcement Made in Letter by Chairman John Bresland to Chairman Henry Waxman of House Energy and Commerce Committee and Chairman Bart Stupak of Subcommittee on Oversight and Investigations
Here’s a link to the letter by Chairman John Bresland:
Are We Blaming BP Rather Than Learning From What Went Wrong?
Monday, June 21st, 2010Most investigators agree that blame makes an accident investigation more difficult. If someone thinks they are going to be blamed (and perhaps fired), they often provide less information than if they were in a non-blame environment.
Might the same concept be true for companies?
For example, did sending the Attorney General to the Gulf to start a criminal investigation of BP make BP less cooperative?
If you were a senior executive and you might face charges (environmental or corporate manslaughter), would you be open in a Congressional hearing?
It seems we are in the middle of “blame season” for the BP/Transocean Deepwater Horizon accident. But there is so much that could be learned about how an organization can prevent people putting cost and time pressure above safety. It seems a shame that blame should get in the way.
I understand the need for justice and the desire to punish corporate criminals, but if we start down this road, are we missing a chance to learn and prevent similar corporate culture accidents in the future?
Leave a comment … Let me know what you think …
Monday Accident & Lessons Learned: Fatal Tram Pedestrial Accident Investigation is an Interesting Investigation and Good Recommendations
Monday, June 21st, 2010For the investigation report from the UK RAIB about an accident in Norbreck, UK, see:
http://www.raib.gov.uk/cms_resources.cfm?file=/100603_R092010_Norbreck.pdf
UK RAIB Accident Report on Train Collision at Exeter St Davids Station
Monday, June 21st, 2010Qualifications of the Independent Commission to Investigate the BP Deepwater Horizon Accident
Saturday, June 19th, 2010Posted this blog entry so the qualifications would be easier to find on Google. Here’s the link to the qualification summary:
Sky News Reports: BP Chairman Says “… embattled chief executive Tony Hayward is to have a changed role in dealing with the oil spill.”
Friday, June 18th, 2010See:
http://blogs.chron.com/newswatchenergy/archives/2010/06/bp_chairman_say.html
The BP Chairman told Sky News that comments by Mr Hayward have had detrimental effects as the company seeks to control the fallout from the disaster. BP Chairman Carl-Henric Svanberg said: “It is clear Tony has made remarks that have upset people.”
This morning on CNBC the commentators said that it was rumored that the BP Chairman was looking for new people qualified for the CEO job at BP.
The article says:
“Mr Svanberg admitted the rig blowout is turning from an industrial accident into a broader political concern with questions of the company’s ongoing viability being raised.”
“I still strongly believe in BP and that we will come through this,” the Chairman said.
As I said in an earlier blog posting, “You are either leading the solution or part of the problem.”
Here’s the whole interview …
and here is a previous report about BP CEO being “denounced.”
NTSB Press Release: UPDATE ON NTSB’S INVESTIGATION OF THE MAY 8 STATEN ISLAND FERRY ACCIDENT
Friday, June 18th, 2010************************************************************
NTSB ADVISORY
************************************************************
National Transportation Safety Board
Washington, DC 20594
June 18, 2010
************************************************************
UPDATE ON NTSB”S INVESTIGATION OF THE MAY 8 STATEN
ISLAND FERRY ACCIDENT
************************************************************
On Saturday, May 8, 2010, the National Transportation Safety Board
launched a team to the New York City Borough of Staten Island to
investigate an accident involving a Staten Island ferry. The passenger
ferry, Andrew J. Barberi, departed Whitehall Ferry Terminal in lower
Manhattan for its regularly scheduled voyage to St. George’s Ferry
Terminal, Staten Island. At approximately, 9:19 a.m. (EDT), the vessel
struck the boarding apron and transition bridge on slip No. 5 of the pier
on Staten Island. At the time of the accident, there were 18 crewmembers,
2 New York City police officers, 2 concessionaires and 244 passengers on
the ferry. Forty-eight persons reported minor injuries. The NTSB’s on-
scene investigation was completed on Saturday, May 15. Below is an
update on the Safety Board’s ongoing investigation.
The last U.S. Coast Guard inspection on the vessel was its quarterly
inspection on April 15, 2010.
Drug and alcohol tests of the crew were negative for alcohol and illegal
drugs.
Investigators visited the Coast Guard’s Vessel Traffic Service and
obtained a copy of the vessel track line. The track line shows the Andrew
J. Barberi abeam of the KV buoy with a Course over Ground (COG) of
230 degrees and a Speed over Ground (SOG) of approximately 16 knots.
From the midpoint of the KV buoy to the entrance to slip No. 5, the vessel
has a COG of 227 degrees and a SOG of about 14 knots.
A preliminary review of the pilot-house close-circuit television (CCTV)
video of the entire transit from Whitehall to St. George indicates the
voyage was uneventful until the approach to slip No. 5. At that time the
video shows crew members taking actions consistent with attempting to
slow the vessel prior to entering the slip.
Investigators interviewed the deckhand at slip No. 5 who operated the
transition bridge, which allows passengers to embark and disembark from
the vessel to the terminal. According to the deckhand, he noticed the
speed of the ferry was faster than usual as it entered the slip. As a result,
he positioned the transition bridge to align with the main deck (which is
also performed in a normal docking), believing this action would lessen
the damage to the ferry and injury to passengers. Both the interview and
preliminary review of the CCTV video indicate he was at the operator
station and aligned the bridge to the main deck of the vessel prior to the
accident.
The Emergency Preparedness and Response Group has interviewed eight
passengers, one police officer, and five New York DOT employees. The
Andrew Barberi video shows passengers jostled in their seats and some
standing passengers falling to the deck during the accident. Some of the
passengers stated that there may have been more injuries if it had not been
drizzling as the ferry neared St. George; instead of standing outside near
the Staten Island end of the vessel in preparation for disembarking, many
passengers remained inside the vessel.
Some of the injured passengers stated they heard a warning over the public
address system just before the accident, while others did not recall hearing
a warning.
The Engineering Group interviewed 10 persons, including all the
engineering crew on watch at the time of the accident and several port
engineers.
At the time of the accident the Chief Engineer was on duty in the engine
control room below decks. He was first aware of a problem when he heard
the engine audible pitch increase. He looked at the CCTV and noticed the
vessel was in the slip and moving too fast. He instructed the engine crew
in the engine control room to brace for impact.
The vessel is a “double-ender”, symmetric about the midpoint with pilot
houses located at each end (named Staten Island and New York ends).
The named ends in the forward or bow of the vessel during transit to the
respective dock location. At the time of the accident the crew was
controlling the vessel from the Staten Island end pilot house.
The vessel is propelled by cycloidal propulsion units, one mounted at each
end of the vessel (two diesel engines are coupled to drive each propulsion
unit). The two diesel engines driving the Staten Island end propulsion unit
stopped at the time of or immediately following the collision. The engines
were not stopped manually by the crew. The New York end cycloidal
propulsion unit was still being driven and operating at 50 to 60% ahead
thrust after the accident.
Preliminary results of post accident testing of the Staten Island and New
York end propulsion systems indicated that the Staten Island end
propulsion unit operated satisfactorily, while the New York end propulsion
unit was not responding properly to commands from the Staten Island end
wheelhouse. Following a propulsion control system assessment, the
investigation team was able to replicate the control issue on the New York
end propulsion unit. Certain propulsion control components on the New
York end propulsion unit were identified as possibly defective and
replaced. After replacement, preliminary dockside testing showed the
propulsion unit to be working properly. Investigators sent the removed
propulsion control components and oil samples to NTSB headquarters for
further analysis.
Following structural and mechanical repairs to the propulsion system,
multiple sea trials have been conducted under the regulatory oversight of
the Coast Guard and American Bureau of Shipping, a classification society
that is responsible for development and verification of standards for the
design, construction and operational maintenance of marine vessels.
Investigators from the NTSB also attended the initial sea trial in early
June.
-30-
NTSB Media Contact: Terry N. Williams
(202) 314-6100
williat@ntsb.gov
More Bad PR for BP – CNN Story: “BP documents highlight PR strategy after deadly Texas blast”
Thursday, June 17th, 2010Bad PR is gift that just keeps giving. With the new Gulf spill, old BP documents and stories about the BP Texas City refinery explosion are again making the headlines. See:
http://www.cnn.com/2010/US/06/16/bp.refinery.reaction/index.html
Well Design & Construction Causal Factors of the Deepwater Horizon Accident
Thursday, June 17th, 2010In an earlier posting, we laid out the Causal Factors immediately before the well blowout as described by Terry Barr.
Now someone else has helped us identify the Causal Factors associated with the well design and construction. The Committee on Energy and Commerce investigation into the well blowout has identified 5 Causal Factors in a letter to Tony Hayward dated June 14, 2010. That letter is also covered in a Wall Street Journal article.
I’ll summarize the Causal Factors here and let you read the details in the letter liked to above.
Well Design and Construction Causal Factors
- Choice of the cheaper, but less safe, well completion liner option to complete the well.
- Using to few casing centralizers for the well design.
- Failure to perform a cement bond log.
- Failure to circulate the mud prior to cementing per the API standard.
- Failure to deploy the casing hanger lockdown sleeve prior to replacing the mud with seawater.
That makes a total of 12 Causal Factors for the incident BEFORE the blowout preventer failed.
The blowout preventer failure will have one or more Causal Factors and the failures to contain and cleanup the spill and minimize environmental damage will have multiple Causal Factors. Of course, the multiple number of failures is “normal” in an accident of this significance. And when all these Causal Factors are analyzed for their root causes, there will be a significant number of ways that BP, and perhaps the industry, can learn from this accident and improve performance so that we don’t have to kill 11 workers and cause an environmental nightmare ever again.
One last note … All the Causal Factors mentioned here are based on publicly available information. We haven’t done any interviews or collected any first-hand information. It would be nice to see a fully qualified investigative team use advanced tools to perform a real root cause analysis on the first-hand data.
Also, I have posted the Congressional Letter below to make sure that it is available to those reviewing this article in the future…
President Names “Independent” Blue Ribbon Commission to Investigate Gulf Oil Spill – Are They Qualified?
Wednesday, June 16th, 2010Here are the names released by the White House:
Co-chairmen:
Bob Graham
William K. Reilly
Other Commission Members
Frances Beinecke, President of the Natural Resources Defense Council;
Donald Boesch, President of the University of Maryland Center for Environmental Science;
Terry Garcia, a Vice President of the National Geographic Society;
Cherry Murray, Dean of the Harvard School of Engineering and Applied Sciences;
Frances Ulmer, Chancellor of the University of Alaska Anchorage.
Under their charter from the President, the panel has six-months to find out what led to the blowout of the Macondo Prospect (Deepwater Horizon) well and to make recommendations for future drilling practices.
Since the mission of this body is so important to the energy future of the US, I thought I’d dig deeper into the commission members backgrounds. I’ve written a short summary for each of the members of what I found on line…
- – -
Bob Graham, is a Democrat and former Florida Governor and Senator. He has a BA from the University of Florida and a Law Degree from Harvard. He is a member of the Council on Foreign Relations and the New Democrat Network,
As a Senator, Governor, and Presidential candidate, Bob Graham opposed offshore drilling. However, after he was appointed to the commission he is quoted as saying:
“I don’t think my designation sends any signal. We should be in a position to have good information about the situation and based on that, come to a solid judgment and conclusion.”
William K. Reilly was the head of the EPA during the Exxon Valdez spill cleanup. He has a BA in History and a Law Degree from Harvard and a Masters Degree in Urban Planning. Before becoming the head of the EPA, William Reilly’s main jobs were with environmental groups including The National Urban Coalition, The Conservation Foundation, and the World Wildlife Fund. He was also the lawyer for the President’s Council on Environmental Policy where he drafted environmental legislation. Now William Reilly is a board member at several large companies including Du Pont, ConocoPhillips, and Royal Caribbean Cruises. He is also an advisor to TPG Capital, an international investment firm where he was involved in the purchase of Texas Utilities (TXU) by TPG and KKR. He negotiated with TXU to reduce their plans for coal fired power plants from 11 to 3. He now serves on the Sustainable Energy Advisory Board for the company.
In a June 16 article in the Wall Street Journal, William Reilly is quoted as saying that the oil industry needs an organization like INPO (the Institute of Nuclear Power Operations) to help the industry improve operations the way the nuclear industry did after Three Mile Island.
Frances Beinecke, President of the Natural Resources Defense Council (NRDC), has an undergraduate degree from Yale, a Master’s Degree in Forestry and Environmental Studies from Yale. The NRDC web site says the following about Frances Beinecke:
“Under Frances’s leadership, the organization sharply focuses on curbing global warming, developing a clean energy future, reviving the world’s oceans, saving endangered wild places, stemming the tide of toxic chemicals and accelerating the greening of China. With Bob Deans, Frances recently co-authored the book Clean Energy Common Sense: An American Call to Action on Global Climate Change, which shows how we can secure a clean and sustainable energy future that will help put Americans back to work, reduce our reliance on foreign oil and create a healthier future for ourselves and our children.”
Also, back in May (after the spill started), she wrote an editorial that said:
“The best protection we have against offshore accidents is to end our dependence on oil. We simply don’t have to jeopardize our oceans, fishing industry, tourism business, and rich coastal ecosystems in order to fuel our cars and trucks. We can pass clean energy and climate legislation – legislation that will slash our oil reliance by spurring innovation in cleaner solutions – things like more efficient cars and plug-in hybrids.”
She went on to suggest a three point plan:
1. Impose a moratorium on all new offshore oil drilling activities.
2. Ensure rules for future drilling reflect the lessons of Deepwater Horizon.
3. Initiate an independent investigation.
She was also quoted by the New York Times as saying that the independent commission should determine:
“…whether, when, where and under what circumstances new offshore drilling operations should be allowed.”
Donald Boesch is President of the University of Maryland Center for Environmental Science. He has a PhD in Marine Science from the College of William and Mary. He has a long career as an academic. The University of Maryland web site says:
“Dr. Boesch is a biological oceanographer who has conducted research in coastal and continental shelf environments along the Atlantic Coast and in the Gulf of Mexico, eastern Australia and the East China Sea. He has published two books and more than 85 papers on marine benthos, estuaries, wetlands, continental shelves, oil pollution, nutrient over-enrichment, environmental assessment and monitoring and science policy. Presently his research focuses on the use of science in ecosystem management.”
Terry Garcia is Vice President of Mission Programs at the National Geographic Society. He has a Bachelor’s Degree in International Relations and a Law Degree from The George Washington University.
Before becoming a VP at National Geographic, Garcia was an Assistant Secretary of Commerce for Oceans and Atmosphere, the Deputy Administrator for the National Oceanic and Atmospheric Administration (NOAA), General Council for NOAA (where he oversaw the implementation of the oil spill recovery efforts under the Exxon Valdez Oil Spill Restoration Plan for the Prince William Sound and the Gulf of Alaska), and a partner in the law firm Manatt, Phelps & Phillips in Los Angeles.
The National Geographic web site says:
“Executive Vice President, Mission Programs, National Geographic Society
Terry D. Garcia is responsible for the Society’s core mission programs: the Committee for Research and Exploration, the Geographic Education Outreach program, the Education Foundation, and the Society’s Development Office, Explorers Hall museum, and lecture program.”
Cherry Murray is the Dean of the Harvard School of Engineering and Applied Sciences. She has a BS, Masters, and PhD in Physics from MIT.
Before becoming a Dean at the Harvard School of Engineering and Applied Sciences, she was the Principal Associate Director for Science and Technology at Lawrence Livermore National Laboratory. She also worked at Bell Labs.
This is how the Harvard web site describes her research:
“A celebrated experimentalist, Murray is well-known for her scientific accomplishments using light scattering, an experimental technique where photons are fired at a target of interest. Scientists can then gather insights into surface physics and photonic behavior by analyzing the spray of photons in various directions from such collisions.”
“She is also a leader in the study of soft condensed matter and complex fluids, hybrid materials that show properties of different phases of matter. The control of suspensions, foams, and emulsions has application for the development of everything from novel drug delivery systems to “lab-on-a-chip” devices.”
“Among other diverse topics in condensed matter physics, Murray has studied semiconductors’ optical phenomena, nanostructures, phase transitions, and controlled self-assembly of optical materials — all critical for the advancement of quantum optics, engineered semiconductors, and tools such as optical tweezers.”
Frances Ulmer is Chancellor of the University of Alaska Anchorage. She has a BA in Political Science and a Law Degree from the University of Wisconsin.
Before becoming the Chancellor of the University of Alaska Anchorage, Frances was a Democrat elected to a variety of offices in the state of Alaska as well as appointed governmental positions that include: Director of Policy Development for the State of Alaska (managing diverse programs, including coastal management, intergovernmental coordination, and public participation initiatives); serving as a member of the North Pacific Anadromous Fish Commission; the Federal Communications Commission’s State and Local Advisory Committee; and the Federal Elections Commissions Committee. She also has held academic positions including being a Fellow at the Institute of Politics at Harvard University’s Kennedy School of Government and a Distinguished Visiting Professor of Public Policy at the Institute of Social and Economic Research.
Currently, she serves on the Board of Trustees of the National Parks Conservation Association, the Advisory Board of the Union of Concerned Scientists, and the Alaska Nature Conservancy Board.
- – -
That’s it.
What did I notice?
Not an engineer among them.
No petroleum engineers. No geologists.
No one with any real oil drilling experience (unless you count being on the Board of Directors of ConocoPhillips as oil drilling experience).
Has any of the commission members even slept on an offshore rig overnight?
Also, no one with any experience investigating accidents (at least no experience that I can find in their publicly available bios).
Also, no one with any “high reliability” organization experience.
What do they have?
Lots of law degrees
Time at Harvard or Yale
Lots of “government” experience
Environmentalist backgrounds
To me it seems they are most qualified to investigate the problems with the spill response.
But they don’t seem qualified to investigate why a well blowout occurred.
I’m not trying to imply that any of the commission members aren’t highly qualified for their current jobs or aren’t wonderful people. They just aren’t the folks I would go see if I wanted to find out why BP drilled a bad oil well that killed 11 people and started an environmental disaster.
What do you think? Is this Bipartisan, Independent, Blue Ribbon, Presidential Commission qualified to do it’s job?
Dig some more into the commission member’s backgrounds and let me know by leaving a comment here.
How Long Must We Wait to Learn?
Monday, June 14th, 2010I keep seeing comments by BP, other oil executives, and even environmental activists that we have to wait until the investigation is complete before we take action to prevent future spills in the Gulf.
Oil execs say that the proposed six month deepwater drilling moratorium is overkill. They believe they already have safeguards in place that go beyond the actions taken by BP. They argue that waiting for a final investigation is an unnecessary waste of time and a burden for those who will lose their jobs. They also explain that if rigs are moved to other non-US locations, that drilling could be disrupted for years.
However, environmental activists are saying the the drilling moratorium should cover all offshore drilling activities and should be extended until the blue ribbon Presidential Commission has completed their work. It took the CSB three years to complete their investigation of the BP Texas City explosion. Could we really wait three years to resume offshore drilling?
To me, it seems that there is lots of information already available. People who know our TapRooT® Instructors/Facilitators can understand how in a couple of weeks a dedicated, facilitated team could have a preliminary set of causal factors determined, identify areas where there is any uncertainty, and identify the root causes of problems where uncertainty is limited. This would provide significant learning without waiting years. The lessons could provide a basis for resuming drilling with interim compensatory corrective actions to assure better safety and environmental stewardship. I hate to see people lose their jobs and environmentally sound drilling be put off for no good reason.
What do you think? Do we have to wait for a Presidential Commission to learn? Or are there lessons learned that could be analyzed and applied now?
Let me know your thoughts by leaving a comment here.
Houston Chronicle Story Says Criminal Charges Likely for BP the Corporation but NOT for BP Executives
Monday, June 14th, 2010Monday Accident & Lessons Learned: OGP Safety Alert – Fan Partially Amputates Hand
Monday, June 14th, 2010SAFETY ALERT NO. 222: WORKER’S HAND PARTIALLY AMPUTATED FROM CONTACT WITH FAN BLADE
Country: CANADA
Location: ONSHORE : Other onshore
Type of Activity: Maintenance, Inspection, Testing
Type of Injury: Caught between
Applicabale Filter Categories: Caught between,Struck by,Human error,System/Equipment failure
Description:
As the worker was cleaning the building walls, he noticed a small amount of oil below the generator fan guard.
The worker folded a small rag and attempted to clean the area, while the generator was running. A small opening on the fan guard, which allows for removal of the guarding during servicing, allowed the rotating fan blades to grab the rag, which pulled the workers hand into fan blades.
This resulted in a partial amputation of the workers hand.
What Went Wrong?
Rotating equipment guard did not completely mitigate the rotating hazard allowing contact with the worker when not isolating the equipment.
Hazard of loose rag being drawn into rotating fan not recognized.
Failure to follow procedures – administrative control requires equipment to be isolated prior to servicing.
Corrective actions and Recommendations:
Evaluate rotating equipment has complete guarding to prevent access. If inadequate, consider implementation of administrative controls. Procedures for working on or near rotating equipment to also include hazard assessment of inadequate guarded equipment.
Work with rotary equipment suppliers to ensure adequate guarding in place prior to installation or constructed prior to start up.
Evaluate the need for isolation procedures to ensure equipment is isolated and de-energized prior to attempting any housekeeping tasks on running equipment.
Source Contact:
For more information of event, please contact safety@enform.ca
This alert is being distributed via a partnership between the International Association of Oil and Gas Producers (http://www.ogp.org.uk/) and Enform (http://www.enform.ca/).
27 May 2010
OGP Safety Incident Reports http://info.ogp.org.uk/safety/
