In 2016, the film Deepwater Horizon, based on the BP oil rig disaster in the Gulf of Mexico, was released, inspiring a seminar series providing insights into what contributed to the explosion.
Held by the Chemical and Biomolecular Engineering Foundation of the University of Sydney, in conjunction with the Safety Institute of Australia, the seminar was held in Sydney, Brisbane, Melbourne and Adelaide. It featured discussions from United States Chemical Safety and Hazard Investigation Board (CSB) investigator, Cheryl Mackenzie, and Noetic Group general manager of risk, Peter Wilkinson.
While the seminar briefly explained the cause of the rig failure, one of the main topics was the human and organisational factors that contributed to it.
Mackenzie explained that the CSB is a non-regulatory safety body that investigates incidents such as Deepwater Horizon, publicises the findings and makes recommendations to the parties involved to make improvements to help prevent a similar incident.
She said the board produced four volumes of information from its investigation of the disaster.
Mackenzie said the CSB identifies common themes with disasters such as Deepwater Horizon and one of the biggest is the gap between the ‘work as imagined’ and ‘work as done’ – what a company says it is going to do in a particular situation compared to what it actually does.
She emphasised that there was a gap between what was expected of workers on paper and what they were able to do in practice.
“When we investigate incidents we look at the policy on how you manage your hazards…and then we look at what we found in reality and what the actual practices were,” she told Australian Mining.
Mackenzie added that the gap provides an opportunity for companies to work on their policies and practices and identify what can be changed to ensure another event like Deepwater is prevented.
Mackenzie mentioned a key example following the disaster, where CEOs from other major oil companies were called to give a testimony that an incident such as Deepwater wouldn’t happen with their company.
While most of them suggested they had proper management systems in place, it was later discovered that the majority had almost exactly the same oil response plans, highlighting a potential failure in safety procedures.
“A lot of them had oil spill response plans that were almost identical and they were all almost identical in the inaccuracies contained within them,” Mackenzie said.
“They identified wildlife that could be impacted by an oil spill and it was animals that don’t exist in the Gulf.”
The CSB is also involved in following up with organisations that it makes recommendations to but Mackenzie said that in this situation, a lot of the focus was on their recommendations on the regulator and industry associations such as the American Petroleum Institute.
Because the findings were not unique to BP and Deepwater Horizon rig owner Transocean she believed that change could be created right across industry.
“We feel if they take up our recommendations, a larger audience is more likely to also respond to that and make some changes for safety purposes,” she said.
Lost Time Injuries
The explosion occurred shortly after BP celebrated seven years without a lost time injury (LTI).
While LTIs are a good measure of occupational safety, Mackenzie said they were not a good indicator of process safety.
She highlighted that occupational safety involved instances such as wearing the correct personal protective equipment (PPE) and ensuring proper handling of tools – issues that are high frequency and low consequence. Alternatively, process safety refers to the containment of extremely hazardous materials.
“In this case it would be hydrocarbons coming out of a well that could ignite and blow up; that’s a process hazard,” Mackenzie said.
Mackenzie added that it was easier to manage occupational safety issues as they are more observable compared to process safety issues.
“You can observe when someone’s not wearing their safety helmet or hardhat, you can observe when someone’s climbing at a height without the right fall protection but process safety hazard is ‘What are you doing to make sure, in this case, flammable material stays contained?’,” she said.
Mackenzie explained that while safety observation programs were well intentioned, they mainly focused on what was observable, potentially missing process issues.
“If that’s what your company’s looking at to try and manage your process hazards, that’s not going to be sufficient,” she said.
“You have to try to look at, ‘well what are the steps that we’re taking to ensure that we don’t have a lot of containment issues?’.”
It’s human nature
One of the main things Mackenzie said the film accurately depicted was the sense of chaos following the explosion.
She said the people responded the way they were trained to respond.
“That’s human nature. We’re trained a certain way; we have an expectation based on experience [and] we’re taught to expect certain things.”
Mackenzie highlighted that it was normal people doing normal work in an abnormal situation.
“People rely on rote memory and then they respond in a way almost automatically to what they already have been trained to do and know how to do,” she said.
“The evidence that we saw, they did what policy said they should have done, what they knew to do based on the information they had at the time and their natural human response to the situation that was occurring.”
Not so unique
During the event Peter Wilkinson, who was also an advisor to the CSB during the Deepwater Horizon investigation, mentioned another significant oil spill – the Piper Alpha disaster of 1988.
He told Australian Mining that during the incident, hydrocarbons flowed onto a burnt platform and fuelled the fire.
Wilkinson said the incident with the well kick that triggered the Deepwater disaster was a known hazard.
However, he warned that there is a danger with known hazards.
“The difficulty comes with well-known hazards which are relatively rare in terms of huge consequences and I think humans are much better at dealing with things were we get regular feedback,” he said.
Echoing Mackenzie, he said low probability, high consequence incidents do not give feedback by having disasters because they are harder to imagine.
He highlighted that Transocean had a well kick in the UK sector in the North Sea prior to Deepwater but it did not involve significant changes that could have been made if people envisaged what it could have led to.
Wilkinson said it played a role in helping shape safety in the oil and gas industry and highlighted the engineering changes made for production platforms, particularly in relation to using better quality emergency shut down systems.
Despite the difficulty in gaining support for regulatory changes following Piper Alpha, Wilkinson said Australia made changes without suffering a major disaster.
“An example of that was setting up the National Offshore Petroleum Safety and Environmental Management Authority which increased the pool of resources, both money and competence to regulate offshore petroleum.”
When bad news is good news
Wilkinson said that human and organisational factors cross boundaries regardless of the industry a person works.
He emphasised that while good news given by workers in any workplace should be celebrated, it is also important that companies are honest with themselves about what may be going wrong, to address safety issues.
“You cannot manage what you don’t know about,” he said, and added that management should consciously attend to it.
Cheryl highlighted the importance of learning from events such as Deepwater Horizon, particularly as organisational levels and certain organisational practices become more complex and interwoven.
“We need to continually advance our understanding of how these events occur in order to really prepare ourselves and remember that these incidents they are rare but they can happen.
“We can’t just sit back and hope it doesn’t happen, we actually have to do something about it.”