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Macondo Findings: Focus on Injuries (Trees) Misses Catastrophe (Forest)

U.S. Chemical Safety Board (CSB) investigators examining the April 2010 Macondo well blowout and Deepwater Horizon platform explosion in the Gulf of Mexico (GOM) have concluded in a preliminary report that BP plc, Transocean Ltd. and other operators, along with trade associations and U.S. regulators, "largely judged the safety of offshore facilities by focusing on personal injury and fatality data (such as dropped objects and slips, trips and falls), that overshadowed the use of leading indicators more focused on managing the potential for catastrophic accidents."

The preliminary report was issued last Tuesday in Houston on the second day of a two-day hearing called by the CSB to examine the need for the U.S. offshore drilling and production industry -- and the agencies that regulate it -- to develop process safety indicators that could reduce the likelihood of major accidents. The independent federal agency is charged with investigating all aspects of chemical accidents, including physical causes such as equipment failure, inadequacies in regulations, industry standards and safety management systems. However, the CSB only recommends changes; it is not charged with authorizing any.

In 2007 the CSB recommended that the energy industry make better use of process safety indicators following an investigation of a March 2005 refinery disaster at a BP facility in Texas City, TX. Process safety indicator systems also should be implemented in the offshore industry, the board concluded.

"In the offshore arena, potential indicators -- such as timely checks on safety critical equipment and response to well control events -- would provide an assessment of the health of their safety management systems. These type of indicators may be precursors to the kind of tragedy that took 11 lives on the Deepwater Horizon drilling rig following the Macondo well blowout on April 20, 2010."

Several previous investigations by the board "have found companies focusing on personal injury rates while virtually overlooking looming process safety issues -- like the effectiveness of barriers against hazardous releases, automatic shutoff system failures, activation of pressure relief devices and loss of containment of liquids and gases," said CSB Chairman Rafael Moure-Eraso. "Furthermore, we have found failures by companies to implement their own recommendations from previous accidents involving, for example, leaks of flammable materials."

In the Macondo well blowout, BP and Transocean "were focused on personal safety issues such as worker injury rates, rather than broader safety issues involving the process of drilling for oil using a complex rig." BP was majority owner the operator of the Macondo well; Transocean owned the Deepwater Horizon and was contracting it to BP.

CSB investigator Cheryl MacKenzie said there was a "lack of sustained focus on process safety" in the Macondo blowout, and she described an "eerie resemblance" between BP's 2005 refinery explosion and the Macondo well blowout.

The March 23, 2005 explosion at the BP Texas City refinery unfolded as contract workers were returning to temporary trailers at the plant "after attending a celebratory lunch commending an excellent personal injury accident record. Shortly after lunch an explosion occurred during process startup, killing 15 and injuring 180 others. At Macondo, BP and Transocean officials were in the process of lauding operators and workers for a low rate of personal injuries on the very day of the blowout. Company VIPs had flown to the rig in part to commend the workforce for zero lost-time incidents," noted CSB.

The Department of Interior's offshore regulator the Bureau of Safety and Environmental Enforcement (BSEE) could achieve a bigger impact on major accident prevention by developing "a leading and lagging process safety indicator program," said the board. Even with the "significant" progress with process safety indicator implementation in the downstream oil industry, offshore sector operators, industry associations and regulators had not "effectively learned critical lessons" from the Texas City refinery explosion or other "serious process incidents" at the time of the Macondo blowout.

Operators and trade associations that operate outside the United States "have developed effective indicator programs, recognizing the value of leading indicators, and using those indicators to drive continuous improvement," the board concluded. In addition, trade associations "and many of the same companies that operate in the U.S. are partnering with the regulators in other countries in advancing safety indicators programs."

In Macondo's aftermath, U.S. operators and trade associations have begun to advance offshore major accident indicator development, noted the CSB. BP is working "to develop a more comprehensive offshore indicators program using leading and lagging metrics to help drive performance improvements."

Several preliminary findings related to "management system deficiencies" in the Macondo blowout, including that BP and Transocean hazard assessment systems were inadequate. For example, a bridging document used to "harmonize" safety controls between the operators was a "minimal document that focused only on six personal safety issues such as minimum heights for employing fall protection equipment." Major accident hazards like the potential for loss of well control were not addressed.

Investigators also reported that about a month before the Macondo blowout, there was a delay by operators on the Deepwater Horizon drilling platform to respond to a "well kick," which the CSB described as an "unanticipated, hazardous influx of hydrocarbons into the wellbore that can precede a blowout." BP investigated the incident, they said, "but after informal verbal discussions with Transocean, evidence indicates that Transocean did not implement changes based on the findings."

Beyond its focus on safety issues, the CSB also is investigating the role U.S. regulators and regulations played preceding the accident. For example, investigators said BP was a finalist for a safety award from Interior's former Minerals Management Service, and "a total of 15 safety awards had been given to BP and Transocean over a period of years. The criteria used to determine the award candidates focused on personal safety metrics and did not give an accurate measure of safety management system performance to control major accident hazards."

Since the tragic accident, some BSEE "reporting requirements have become mandatory, but the focus remains on reporting major accident events such as fires rather than predictive, leading indicators." In addition, "the onshore refining industry, responding to a previous CSB recommendation to the American Petroleum Institute (API) and the United Steelworkers Union, is moving toward the development of key safety performance indicators."

The CSB "would like to see API move even further and focus more on leading indicators to proactively measure safety system performance before accidents occur," said Moure-Eraso. "I believe the offshore drilling industry could benefit from such a program as well. Meantime, it is encouraging to see the industry move in this important direction, which will help prevent accidents and save lives."

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