April 20, 2012 | Mark Paradies

US Chemical Safety Board Announces That They Plan to Release an Interim Report on the Deepwater Horizon Accident This Year – CSB Press Release Attached

How much time does it take to investigate an accident?

The US CSB has announced that they are continuing to investigate the Deepwater Horizon (Macondo Well) Accident and will release a preliminary report in July of 2012 and a final report in 2013.

Today is the two year anniversary of the blowout and explosion that killed 11 aboard the Deepwater Horizon. Of course the resulting oil spill continued for months.

An investigation that concludes more than two years after an accident seems too slow to me … but perhaps the results will be worth the wait?

From the information in the CSB press release, the CSB seems to believe that additional regulation – especially developing a safety case – would have prevented the accident. In their press release (see below), they said:

Investigation findings to date indicate a need for companies and regulators to institute more rigorous accident prevention programs similar to those in use overseas.

They also say:

In December 2010, a CSB public hearing in Washington featured international regulators, companies, trade associations and union representatives discussing the “safety case” regulatory approach for offshore safety, a concept widely used in the North Sea and Australia and supported by a number of the participants.

To me this seems strange. Transocean had a similar near-miss incident in the North Sea and there have been major spills in exploration covered by Australian regulations (those “overseas” regulations). But people in Washington seem to always believe that more regulation – rather than better management – will keep everyone safe.

I’ve never really believed that regulations are the answer to safe performance. The the press release, CSB says:

Process safety regulations and standards utilized by oil companies in refineries and process plants in the continental U.S. have a stronger major accident prevention focus, CSB investigators have determined. Unlike the U.S. offshore regulatory system, the “onshore” process safety requirements are more rigorous and apply both to operators and key contractors.

But refineries and plants covered by the process safety regulations continue to have deadly fires and explosions, showing that adherence to regulations is not enough to prevent accidents. (A subject of my talk at the 2012 TapRooT® Summit – CLICK HERE to watch all three parts of the talk.)

The press release also contains some comments that I believe are right on target from my review of previous Deepwater Horizon accident reports.

First, they say they are looking into the human factors of well control. The release says:

The issue of human factors in offshore drilling and well completion is particularly important as offshore well control programs currently rely to a large extent on manual control, procedures and human intervention to control hazards…“.

When reviewing the displays available to the operators monitoring the control of the well, I thought – poor human engineering! (See pictures below of what the operators were suppose to catch.)

April20Flowinflowout-1

April20Drillpipepressure-1

April20Normalabnormalflow-1

I haven’t seen pictures of the types of actual instrumentation that was used (all now at the bottom of the sea), but I imagine similar equipment is used throughout the industry. If the drawings of what was supposed to be observed look like real time detection would be error prone, I can only guess that the actual equipment is as hard or harder to use.

The next “human factors” issue that the CSB is investigating is fatigue. The press release says:

…we are investigating whether fatigue was a factor in this accident. Transocean’s rig workers, originally working 14-day shifts, had been required to go to 21-day shifts on board. CSB is examining whether this decision was assessed for its impact on safe operations.

Of course, fatigue could be an issue in a 14 day or a 21 day shift. I hope they are using a systematic process like FACTS to evaluate the possibility of fatigue being a potential cause of operator errors.

Here is the entire CSB press release …

 Userfiles Chemsafety Image Template1 Prnt-Hdr-29

CSB Investigation into Macondo Blowout and Explosion in Gulf of Mexico Continues; Two Public Hearings and Interim Reports Scheduled for this Year

April 19, 2012

Washington, DC, April 19, 2012 — The U.S. Chemical Safety Board (CSB) announced today that its investigation into the April 20, 2010 Macondo well blowout, explosion and fire in the Gulf of Mexico is progressing, with two interim reports with findings and recommendations to be released this year. A final report is expected to be completed in early 2013.

Investigation findings to date indicate a need for companies and regulators to institute more rigorous accident prevention programs similar to those in use overseas. The CSB announcement was made approaching the second anniversary of the tragedy, which took eleven lives and caused the worst environmental disaster in U.S. history,

Process safety regulations and standards utilized by oil companies in refineries and process plants in the continental U.S. have a stronger major accident prevention focus, CSB investigators have determined. Unlike the U.S. offshore regulatory system, the “onshore” process safety requirements are more rigorous and apply both to operators and key contractors.

To date, the CSB has conducted numerous interviews, examined tens of thousands of documents from over 15 companies and parties, gathered data from two phases of blowout preventer (BOP) testing, and conducted a public hearing on international regulatory approaches.  Recommendations targeting specific reforms are contemplated for release as early as August of this year.

CSB Chairman Rafael Moure-Eraso said, “Our final report on the tragic accident that occurred two years ago, will, I believe, represent an opportunity to make fundamental safety improvements to offshore oil and gas exploration to prevent future catastrophic accidents.”

Dr. Moure-Eraso continued, “The CSB is not a regulatory agency; our job is to convey information and recommendations to improve safety in the oil and chemical industries and protect workers and the environment. In our view, while previous investigations of the Macondo blowout have produced useful information and recommendations, important opportunities for change have not been fully addressed.  And these are critically important for major accident prevention.” 

Don Holmstrom, manager of the CSB Western Regional Office in Denver, whose team is conducting the investigation, announced a timeline calling for the final report release in early 2013, with the first of several public meetings to be held by the CSB likely in July 2012 in Houston, addressing use of leading and lagging indicators by companies and regulators to improve safety performance.

The CSB anticipates releasing preliminary findings and safety recommendations at the meeting, and to hear experts testify on the need for the offshore drilling industry to utilize safety performance indicators like hydrocarbon leaks and maintenance of safety critical equipment to drive safety improvements and to prevent major accidents.

Dr. Moure-Eraso said the CSB’s investigation is taking a broad look at causal issues of the Macondo blowout and the subsequent massive release of flammable hydrocarbons which resulted in an explosion.  “These issues include the manner in which the industry and the regulating agencies learn or did not learn from previous incidents. They also include a lack of human factors guidance, and organizational issues that impaired effective engineering decisions,” he said.

The issue of human factors in offshore drilling and well completion is particularly important as offshore well control programs currently rely to a large extent on manual control, procedures and human intervention to control hazards, said CSB Investigator Cheryl MacKenzie.  She observed “There are no human factors standards or regulations in U.S. offshore drilling that focus on major accident prevention. As an example, we are investigating whether fatigue was a factor in this accident. Transocean’s rig workers, originally working 14-day shifts, had been required to go to 21-day shifts on board. CSB is examining whether this decision was assessed for its impact on safe operations.” 

The CSB investigation team participated in the examination of the blowout preventer (BOP) in Louisiana last year.  As has been reported, the BOP – a massive device designed to shear off the well pipe and stop the flow of volatile hydrocarbons — failed.  The CSB is currently evaluating BOP deficiencies as reflecting larger needed improvements in offshore risk management.  These include lack of safety barrier reliability/ requirements, inadequate hazard analysis requirements for evaluating BOP equipment design, and insufficient management of change requirements for controlling hazards.

The CSB is conducting additional computer modeling of the BOP and assessing the capability of the BOP to close and which functions specifically led to its failure. The agency is also exploring new issues and “near miss” deficiencies that did or could have compromised the ability of the BOP to function properly, including the failure of the annular preventer to seal the well, the impact of drill pipe size, and the performance of the BOP hydraulic accumulators.

Finally, the CSB is carefully examining the physical causes of the drill pipe buckling that other investigations previously concluded may have prevented the BOP’s blind shear rams from functioning correctly.  The CSB is evaluating different mechanisms that could have led to the drill pipe buckling.

CSB Chairman Moure-Eraso said the CSB is examining whether further changes to offshore safety regulations and industry standards are needed.  “While important regulatory changes have occurred, we are examining whether these changes that have been made are sufficient for preventing major accidents.  In December 2010, a CSB public hearing in Washington featured international regulators, companies, trade associations and union representatives discussing the “safety case” regulatory approach for offshore safety, a concept widely used in the North Sea and Australia and supported by a number of the participants.

In addition, Chairman Moure-Eraso noted that the CSB investigation is also examining the implementation of effective corporate governance and sustainability standards to address safety and environmental risk, organizational issues that impaired effective engineering decisions, and the consideration of past safety performance in lease allocation decisions and contractor selection.

The CSB investigation into the accident has been delayed on occasion as the Board sought to work out mutually acceptable access and investigation agreements with other investigative groups that had different missions.  The Department of Justice has filed an action against Transocean in federal court and has requested that the Court order Transocean to comply with the CSB subpoenas. Following a hearing last week, the CSB anticipates a decision from the Court in the near future.

Chairman Moure-Eraso said, “The CSB investigation of this tragedy will, we believe, offer unique findings and recommendations that, if adopted, would provide significantly safer operations during vital offshore drilling and production activities.

The CSB is an independent federal agency charged with investigating chemical accidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit our website, www.csb.gov.

For more information, contact Communications Manager Hillary Cohen at 202.446.8094 or Sandy Gilmour at 202.251.5496.

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