BP's Gulf Spill Report Shows String of Failures

eldavojohn writes "News is out of BP's report on the gulf spill that shifts some of the blame on to other companies like Transocean that worked with BP in erecting the Deepwater Horizon rig. If you were affected by the spill, you might find the video, executive summary and 193-page report an interesting read. The summary outlines six or seven major failures in safety and engineering that all built up to the deaths of eleven workers and widespread contamination of the gulf. From incorrectly using seawater instead of drilling fluid to misinterpreting pressure test results, this report is just BP's side of the story as the blowout preventer has been pulled up and is still on its way to NASA where it will be analyzed by government investigators who will be able to compile their own report."

Comments

Complex environment, complex causes

[alfredos]

It is the same with aviation accidents. Sometimes it's just an individual screwing up, but that's the exception. Usually there are multiple causes as well as contributing factors. Unfortunately that doesn't mix well with the mainstream media, which wants a three-word expanation so that they can print in big letters on page one. I have learnt that if I want to know something about a mishap in a complex environment, either I read the whole 196-page document, or it's better if I don't learn anything at all.

Re:Complex environment, complex causes

[dkleinsc]

On the flip side, the multiple causes from multiple organizations frequently lead to each organization completely absolving itself by saying "well, if the other team's stuff had worked properly, there wouldn't have been a problem." While true, it also means that they will avoid fixing their piece of the problem (and do their best to avoid legal responsibility as well).

Re:Complex environment, complex causes

[cgenman]

Usually when you talk about complex causes, you mean that factors A, B, C, and D all interacted in unexpected ways to cause a failure, but that most of those factors on their own are basically innocuous. This can be the case in aviation, which a century out remains a tricky human endeavor.

Here, we're talking about several major failures, any one of which would be bad on their own. You can't write it off as a "complex cause" when the safety failed because it was improperly maintained, then the safety person failed because he was improperly trained, then the backup safety failed because nobody installed it, etc. The cause is very simple: cutting too many corners.

Re:Complex environment, complex causes

[causality]

most private pilots aren't the independently wealthy individuals you seem to think we are

My comment about wealth was to be understood within the context of a discussion about John Denver. As a famous, successful musician, he certainly was independently wealthy. Most of the plane crashes that are very well-known tend to involve people who are celebrities or businessmen who don't precisely have money problems, which is what I meant by "these". Right or wrong, the working stiff who can barely afford aviation and has a crash doesn't seem to get discussed years after the event.

Regarding private pilots in more general terms... unless you are a professional pilot working for i.e. the military or a commercial airliner, then you have disposable income. You have merely chosen to allocate it towards aviation. The cost of one personal parachute should be negligible compared to what you would already invest in the airplane, hangar space, training, etc.

You gave me a very good explanation of why parachutes probably would not result in more lives saved. They clearly are not such a great idea. However, if they would be a really good idea, then I don't know about you but personally, I am willing to go into debt if necessary when I firmly believe it's a matter of life and limb.

Otherwise, I found your comment refreshing to say the least. It's clear that you and pilots in general have their priorities straight. There's something noble and admirable about going down with the plane if it means you can protect innocent third parties. Other than the volunteer firefighters I personally know, that isn't the sort of heroism I hear so much of these days. Thank you for that.

Re:Complex environment, complex causes

[thegarbz]

Every major incident has a complex cause, maintaining safety devices has nothing to do with it. In all major industrial accidents there are multiple failures that all need to align perfectly in order for something to go wrong. Yes each on it's own right has the potential to cause a problem, but not usually on the scale of hitting the world media.

For example using drilling mud instead of seawater could have prevented the issue due to better pressure control.
Operators not waiting to sound the alarm could have mitigated much of the incident and loss of life
A BOP that had a working battery and front panel meant the well could have leaked for a day not 4 months.

For a major industrial incident all the ducks need to be lined up in one often very unlucky row.

Re:Complex environment, complex causes

[Your.Master]

You are reducing cgenman's repeated and coherent explanations to a soundbite that confirms your worldview: "Two Minutes Hate". Yet your position seems to be that reducing arguments to a soundbite is a bad argument.

Please be consistent. Or explain how your seemingly-hypocritical position here is consistent.

Re:Complex environment, complex causes

[Bigjeff5]

Go find the video for the Texas City oil refinery accident - it's another BP fuckup (this one they were entirely to blame for from start to finish).

The brief rundown is as follows:

Sensors on a particular tank were not adequate for the purposes of that tank. Basically two sensors were used to measure the fluid level, but as the fluid was never supposed to exceed a certain level sensors were never placed above that level. In other words once the fluid went above the allowed level there was no way to tell what the fluid level actually was. Start-up was a bit of an exception, and fluid levels regularly rose above the sensor level, but before too long returned to normal levels. As a result the instruments regularly went into alarm due to high-levels at start-up. Rather than fix the instruments, it became standard procedure to ignore the high level alarms during start-up.

The operator room was supposed to be staffed by two operators, but because of recent schedule/employment changes there was only one operator on duty per shift. Also, because it was start-up (shut-down and start-up are a very big deal in any major processing facility) the operators had been working longer hours than normal, and were generally fatigued. This caused poor notes to be passed between the night shift operator and the day shift operator, and the day shift operator re-started or continued a procedure that should have been finished by the time he was on shift, and the fact that it was not was a major warning sign and should have resulted in an immediate shut-down. This confusion allowed fluid levels in the tank to rise 5-10 times safe levels, but because it was standard operating procedure to ignore the alarm, and because the sensors did not give a full picture of the situation, the operators continued unaware there was a problem. Eventually the fluid overflowed, after which there was nothing the operator could have done to fix the problem even if he was aware of it.

The final piece of the puzzle, the mechanical safety system that triggered after the tank over-flowed, was a retrofit and as such was simply inadequate to handle the amount of fluid coming through, and the emergency vent let out a giant plume of gas, which turned to vapor and grew until it reached a truck that had been left running in the parking lot. The truck backfired due to the extra gas in the air and ignited the plume. The resulting explosion basically killed anything within 100 feet of the plant, which included a set of temporary offices and 20-30 people who had absolutely no business being anywhere near the refinery.

The cause of the explosion was primarily the sensors on the tank, followed by over-worked and too few operators, followed by an inadequate safety system, followed by employees not following established procedures (leaving the truck running in the parking lot was against company policy). The reason so many people died was because of idiotic decisions - like putting temporary office trailers right next to a potentially dangerous phase of the refining process, which was also against company policy.

I imagine something similar happened on DWH, except there are three or four companies involved instead of just one. It is the same kind of thing, people who should know better maintaining the status quo instead of raising hell. In the Texas City incident, the operators should have been raising hell about the inadequate sensors. The operators and their managers should have been raising hell about being over-worked and understaffed. The safety personnel should have been raising hell about the inadequate safety relief system. Plant management and the operators both should have been raising hell about the office trailers right outside a potentially dangerous area. Everyone should have been raising hell about the common but frowned upon practice of leaving vehicles running in the parking lot.

Yet nobody did, and many people died because of it. It took a lot of things to go wrong, but wrong they went. This is how major industrial accidents happen almost every time.

String of Failures

[c 0xFF]

Of course it was a string of failures. I don't care if it's an oil rig or a software bug, it usually takes more than one failure before a problem actually surfaces. It's usually a combination of physical defects, human error, and process failures ... but it takes the entire sequence to fail before something goes wrong.

The longer it takes for a problem to be discovered, the more failures probably exist in the chain. Honestly, I'd be more scared if only a couple things went wrong.

Re:String of Failures

[BuckaBooBob]

But Seriously... In the end it was a lack of BP's oversight to watch over everything to prevent this type of disaster.. This is probably the biggest thing that wrong with big business and politics.. There is no accountability anymore (If there ever was). This appears to be a PR Campaign to draw attention away from BP's faults.. In the end the only lesson that will be learned will be that a good PR campaign after a disaster can work wonders.

Just like Clemens...

[PmanAce]

There is nothing surprising about an entity shifting the blame onto others to try and save their own asses, human nature. "From incorrectly using seawater instead of drilling fluid" I can't even imagine how dumb one must be to substitute one fluid for the other. That would be like a mechanic using gasoline instead of wiper fluid, something that you just don't do or think about, period. Even if heads roll, are oil companies going to change?

Re:Bad link

[lgw]

Any major disaster is at the end of a long chain of fuckups (this applies to /. stories as well of course). No doubt there's plenty of blame here - many people need to cooperate to keep the chain of fuckups going to where multiple safety and contingency systems fail.

Did they list corruption?

[DoofusOfDeath]

You know, the sex and other perks that bought off the regulators?

Or the part where they pencilled in the report forms on behalf of the inspectors, who would then trace them over in pen?

I can see how that would slip their minds.

Re:Queue the Libertarian Rants!

[bill_mcgonigle]

Don't be a moron, libertarians don't support corporations.

there's another way to say it.

[swschrad]

"But Ma, everybody did it."

BP, you're still getting a spanking. you're supposed to set an example, not lead a gang.

Re:there's another way to say it.

[Stevecrox]

I read the BBC article on the spill, they hardly said that. Halliburton apparently installed sub standard concrete which should have failed inspection but was somehow passed. Transocean/BP made a number of procedural failures and and a pressure test showed the problem days before it happened and was missed by drilling crew and BP.

How does that translate to "everybody's doing it?".

Considering it was a rig owned by BP, operated by Transocean and installed by Haliburton, with parts made by dozens of other companies it would be pretty impressive if the cause was purely BP's fault.

I still think the US government lept on a bandwagon in order to install a US CEO, who amusingly was far more involved with the rig than the then CEO.

It wasn't failure

[countertrolling]

It's company policy to forgo safety for increased profits. History is full of this. They took a gamble and got beat by a pair of deuces. But they have accountants to take care of it all. The main issue hasn't changed, and we'll be speculating on the the next disaster soon enough.

Re:Bad link

[mcgrew]

Well, at least the summary didn't kill anybody.

TFS: The summary outlines six or seven major failures in safety and engineering

Yet nobody's in prison for negligent manslaughter. But if I'm not paying attention and run over a single person, I go to prison. Must be nice to be so rich you're above the law.

Snore

[kenp2002]

Until people go to jail for the deaths what point or purpose does any of this mean? Wealth clearly puts a person above the law and above manslaughter charges. It's that simple. Arguing the fingerpointing is wasted energy since, regardless of the fault, no one will be held accountable. The government will take a bribe in the form of a penalty\fine and all the PEOPLE who lead to the deaths will walk free. The only time the wealthy suffer consequences is when they harm other wealthy people.

Re:Bad link

[Coren22]

Or to be a corporation that cannot be held liable as a person can.

Re:Queue the Libertarian Rants!

[enjerth]

The libertarian principle is more like giving the least trust to those with the greatest power. It's not in support of anything except personal freedom. It just happens that you get the worst of both worlds when you introduce regulation as the government selects "qualified" individuals, such as former CEO's of industry leaders, to give regulatory power to in their given field. I wouldn't want them selecting unqualified individuals, but the qualified ones have a history of personal investment and are likely quite partial. They don't make for impartial regulators.

Such as Michael Taylor, former VP of Public Policy at Monsanto Corp. and Monsanto lobbyist, appointed to senior FDA food safety adviser. Or Roger Beachy, former president of the Danforth Plant Science Center, another branch of the Monsanto Corp., is now heading the National Institute of Food and Agriculture.

You don't trust corporations, but you refuse to realize that regulation just supports more corporatism?

Your government only gives you the illusion of protection and safety. You are really on your own in this world. We'd just like to have the government acknowledge that fact.

Re:Bad link

[DragonWriter]

Summary of the Summary: BP did a bunch of stupid things, but it was TO's (Trans Ocean - the rig owner) responsibility to control the well even if BP purposely designed the rig to fail. They didn't do that. And Boom. IMHO this is not a shot across the bow of Transocean...it's an arrow aimed straight at their heart: "the crew... did not act to control the well".

Summary^3: BP's report says "That sucked. But it was mostly someone else's fault."

Big surprise.

Re:Bad link

[thegarbz]

They didn't do that. And Boom. IMHO this is not a shot across the bow of Transocean...it's an arrow aimed straight at their heart: "the crew... did not act to control the well".

This is how all these investigations work. Nearly every major incident has such a multitude of failures in defence mechanisms leading up to it that it is actually quite easily to say "It's not my responsibility because if X happened then the entire situation could have been avoided." For example:

The Texas City incident could have been avoided by operations not overfilling the column. Damn operations. Or it could have been avoided if the high level switches in the column worked. Damn maintenance. Or it could have been avoided by the blowdown stack being connected to the flare relief line (the piping ran very close so this wasn't an expensive option). Damn engineers. How about a culture of routine complacency in the workplace? Damn Management!

Could apply the same thing to Three Mile Island. Operators should have realised there was no water in the cooling system and not cut the feed. Damn Operations. The PORV should have properly autoreclosed and not jammed open. Damn Maintenance. etc etc.

Chernobyl? Operators should not have shutdown the SCRAM shutdown system, engineering should have an interlock that prevents the removal of control rods so far out of the reactor and the sudden re-insertion etc. etc. etc.

This was Transocean's fault. It was Haliburton's fault. It was definitely BP's fault too.