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

[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

[alfredos]

It is the same with aviation accidents. Sometimes it's just an individual screwing up, but that's the exception.

No, it's the norm if not always the reason

I agree a bit with that. But I also think that while NTSB investigation and reports are top notch, they suffer from being (unavoidably) within the same environment.

I'll give you an example. You can easily support, NTSB reports in hand, that flying by eye in meteorological conditions that are too hard for that (visual into IMC for you pilots out there) is one of the leading causes of accidents in light airplanes. That is too bad. Anybody can get some additional training and learn instrument flying. Well, if it's that easy why isn't it done in the first place? Why does not everybody get at least basic instrument training so that they can keep their act together when the shit hits the propeller? From there you can easily jump to a politics debate but keep with me for a moment. I'll give another example.

Another leading cause of light aviation accidents is loss of engine power. Now loss of power can be due to a number of reasons: You can run out of gas, for example. Or you can forget to adjust the mixture as you go up or down. Or your carburetor can get ice. There exists technology enough to eliminate or greatly reduce the danger in most of these causes. Why isn't it done? Well, firstly because a fully computerized control system for an aviation engine costs as much as a new car. Now you can argue that the pilot is putting his/her life to risk because of economical considerations, or you can look at the reasons why everything is so damned expensive in aviation. I'll leave it to you, but yes, it's as easy as it seems.

My point is that it's worth the effort to dig a bit more. You can't expect everybody to be fully proficient at everything they get into. Instead, however, helping environments become safer by promoting safe ideas, technologies, training and norms pays much more than blaming the individual and leaving it there.

Re:Complex environment, complex causes

[natehoy]

What *wasn't* in the NTSB report: the switch was behind him, in a tight space, and he couldn't see over his shoulder clearly enough to tell if the switch was in the proper place.

That WAS in the NTSB report, in fact Denver and a mechanic discussed it, the mechanic attempted to attach a pair of vice-grips as a workaround, and Denver said he'd use the autopilot to ensure straight-and-level if he had to mess with it in flight. He also refused a refuel stating that he'd be flying for an hour.

http://www.ntsb.gov/ntsb/GenPDF.asp?id=LAX98FA008&rpt=fa

But the engineer(s) who put the switch behind the pilot's seat are just as much, if not moreso, to blame

Actually, the aircraft wasn't engineered that way. Someone (apparently a previous owner) modified it. Denver was aware of the modification, aware of its shortcomings, had actually made arrangements to fix it permanently, attempted a failed temporary fix with an A&P mechanic, then decided to fly it anyway without making sure both tanks were full (in fact, the A&P interviewed stated that Denver had initially tried to start the engine on a tank that might have been empty, meaning Denver's attempts to change tanks would have been in vain since he switched to the only tank with an unknown quantity of fuel left before takeoff).

Sorry, John Denver was a great singer. But the blame for the crash rests firmly on his shoulders.

This is a perfect example of a "string of failures". Someone made an ill-considered modification to an aircraft that Denver (an experienced pilot) bought. This modification made it difficult to change tanks. Denver knew about the problem, but completely failed to mitigate it by:

1. Not making sure he had enough fuel on board in his chosen primary tank for a short flight,
2. Not making sure he would be able to switch the tanks while in flight,
3. Apparently not ensuring that his alternate tank had any fuel in it at all, so even if he did manipulate the switch he may well have been switching from one empty to another,
4. Insisting on a short flight before he would be taking a trip that would give his A&P plenty of time to fix the problem and relocate the switch where it belonged.

Proper handling of ANY of the four issues above could have turned the disaster into a safe flight (or at least a case of "being down here, wishing you were up there", which isn't usually fatal like "being up there, wishing you were down here" sometimes is).

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.

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.

Ohhhhhhhhh

[Sparckus]

Who lives in a pineapple under the sea

SPONGEBOB SQUAREPANTS!

Who died in an oil spill because of BP

SPONGEBOB SQUAREPANTS!

Re:Ohhhhhhhhh

[IrquiM]

Who died in an oil spill because of BP SPONGEBOB SQUAREPANTS!

Guess it wasn't as bad as I thought then....

Rebuttles

[Bill Dimm]

No surprise, Transocean finds fault with the report, as does Halliburton.

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

[ColdWetDog]

This is nice tear down of the executive summary. The Oildrum has had an excellent running commentary on the Macondo Spill. It's primarily a 'Peak Oil' site but it is done quite well. My favorite quote from some apparently ancient oil guy named 'Rockman' who's major failing in life seems to be a horrible addiction to Blue Bell ice cream:

Here's what I saw as critical aspects of the executive summary from the BP report. "Indications of influx with an increase in drill pipe pressure are discernable in real-time data from approximately 40 minutes before the rig crew took action to control the well. The rig crew's first apparent well control actions occurred after hydrocarbons were rapidly flowing to the surface. The rig crew did not recognize the influx and did not act to control the well until hydrocarbons had passed through the BOP and into the riser."



"Well control response actions failed to regain control of the well. If fluids had been diverted overboard, rather than to the MGS, there may have been more time to respond, and the consequences of the accident may have been reduced."

And a viable excuse offered: "The explosions and fire very likely disabled the emergency disconnect sequence, the primary emergency method available to the rig personnel, which was designed to seal the wellbore and disconnect the marine riser from the well.

Given a number of highly questionable decisions, BP appears to volunteer to take a few arrows themselves: "The team did not identify any single action or inaction that caused this accident. Rather, a complex and interlinked series of mechanical failures, human judgments, engineering design, operational implementation and team interfaces came together to allow the initiation and escalation of the accident. Multiple companies, work teams and circumstances were involved over time."

So BP may claim a collective blame but I go back to their lead off position: ""the crew... did not act to control the well". If you followed the debate between syn and I you can see how I take BP's report: yes...BP and others made mistakes. BUT the TO drill crew "did not act to control the well". And that lack of action allowed the kick to turn into a blow out that killed 11 hands and wrecked the GOM.

Opinions will vary, of course. And in the end there will be legal judgment rendered. But each person, including the surviving participants, will come to their own conlusions.

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".

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.

Re:On a side note

[chrb]

Since when has ocean drilling even a part of space exploration? Or any drilling for that matter?

One of the anticipated problems of future space missions is that humans will need to find resources outside of the Earth environment. The amount of energy required to lift materials out of the gravity well of our planet is huge, so it makes sense to explore other options. NASA has researched laser drilling, deep drilling Mars for water, Moon drilling, low energy mobile drilling etc. NASA's remit is not just shooting satellites into orbit, it is also to conduct early stage R&D for exactly this kind of stuff.

And why the FUCK is NASA the only expert around to be able to help the stranded miners?

NASA employs many experts with the skills to do detailed drilling, modelling and geologic and seismic analysis.

Why does NASA have not only the desire, expertise, or the capability to test a BOP?

Who would you rather have test it? Deep sea drilling is a tight-knit industry. I would be surprised if there were any independent testing labs for this technology.

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:Queue the Libertarian Rants!

[mcgrew]

From the Libertarian party's website:

We defend the right of individuals to form corporations, cooperatives and other types of companies based on voluntary association. We seek to divest government of all functions that can be provided by non-governmental organizations or private individuals. We oppose government subsidies to business, labor, or any other special interest. Industries should be governed by free markets.

Sure looks to me like they support them.

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.

Re:Bad link

[UnknowingFool]

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".

That's not how it works in the oil and gas business and I have many friends in the industry. The ultimate responsibility is in the hands of the well owner, not the rig owner. In this case that is BP because BP called all the shots. And that is the company people will sue. There are a number of things that BP did to bypass Transocean's safety protocols. While it appears that Transocean may have damaged the BOP before handling control to BP, you don't know if BP knew that. There is evidence BP pressured Transocean to finish off the well their way. Transocean wanted 3 concrete plugs with finishing mud in between. In order to save time, BP did not want the finishing mud. Professor Robert Bea who was asked to investigate the incident by the White House says if the mud had been left, there may have not been a blowout even if the BOP was damaged.