The DWH incident was a classic example of a cascading failure, in which one thing leads to another until catastrophe ensues; in CRM terms, it's an "error chain." It is always possible to take one element of the chain and assert that it is the only one that matters: "if x had/hadn't done y, none of this would have happened." Collapsing a chain of factors down into one is called "root cause seduction," and it has been depreciated for decades by safety specialists. The problem with thinking this way is that:
It doesn't help us differentiate between important and unimportant factors. The "if x" statement can be made about any element in the chain.
It promotes complacency by fooling us into thinking we have found the "answer" to a complex problem.
That complacency, in turn, leads to a disregard of factors that may have been minor or irrelevant in this chain of errors but which, if unaddressed, could be an element in the next one.
Your repeated assertion that the incident was the result of crew action, all crew action, and only crew action is a textbook example of root cause seduction. Perhaps the most striking thing about your position is that one can search in and out of the Internet and find few, if any people who agree with you. Not even BP believes in a single-factor explanation:
"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." [BP, Deepwater Horizon Accident Investigation Report]
Continuing the exchange, my original in italics, alcor's response in bold, my rebuttal in plain
I do wish you would carefully read what I wrote. Stating that something influences an incident does not imply an intent to excuse.
Except that you continuously suggest the other guy did it!
I suggest, imply or state no such thing. For the empty-umpth time, observing that something may be a factor in an event does not constitute either blame or excuse.
Fact is that all the bullshit surrounding centralisers, long string versus liner etc...are diversions from the truth.
I never suggested they were factors. I stated that, in my opinion as an experienced practitioner and teacher of project management, the manner in which the centralizer decision was made indicated disorganized and tentative decision-making. I stand by my statement.
The people controlling the well made the decision to continue, and they did this knowing sweet FA about what they were doing. This sums up the culture, put your hand in the fire when told to do so....without any understanding of the consequences.
I would appreciate pointers to evidence of this culture and how widespread it may. I know how to use Google, so just a few keywords will do.
My statement was that the shoreside management did not help and probably made life more complicated for the crew.
The crew have escaped any criticism, and by crew I mean the guys sitting in the doghouse, the logger and the mud engineer. Any way you look at this, incompetence prevailed, and yet, no-one speaks of it.
Well, if you feel so strongly about that, get off your duff and do something. The whole Internet is at your disposal. Submit an edit to the Wikipedia page (anybody can), put up a Facebook page, write a blog and publicize it in comments here and elsewhere. Volunteer to be an expert witness for BP. Write an op-ed for the New York Times. Just be sure to explain how an obsession with blame advances the cause of safety.
Whatever shoreside did or didn't do is irrelevant.
Only if you subscribe to the simplistic and dead-end view that this was a single-factor event. If you take a wider and more nuanced view then the confusion about the temporary abandonment plan and the poor supervision of the Halliburton marketing guy are clearly factors. Not indictments, not excuses, not the whole story. Just things that need to be kept in mind when attempting to understand all that was involved the event.
The crew had successfully run the casing and placed cement on bottom.
I don't think you'll find many people who will agree that the cement job was successful.
Their only responsibility is to monitor the well, to interpret the data and signals from the well and above all take the required action to shut in when it became obvious that the well was flowing. When was it obvious? The very first time they opened the well and discovered excess flow. All they had to do was calculate the volume to bleed off and allow for a small amount of thermal expansion.
Please tell us the specific point in the timeline when, if you were in the doghouse, it would have been obvious to you that the well was flowing, and what values would give you that indication.
Then monitor the displacement which the mud engineer did not participate in other than to write a plan for displacement which appears to have ignored any control of volume.
It is my understanding that the plan for displacement was written by the shoreside drilling engineer (who was on the rig up to 11:15 AM the day of the blowout -- he left with the Schlumberger cement logging team). Please cite your evidence that I am mistaken.
That mud engineer visits Exxon rigs too!
And I am quite confident that if and when he does, his actions take place in the context of a strong, top-down risk management structure. A structure that either did not exist or was not exercised in BP Houston.
So, what management had to do with any of these decisions is very questionable. The crews are expected to have the training to deal with the protection of all personnel on the vessel. If an idiot Co Man doesn't know how to interpret the well's pressure then the crew are supposed to react. They deal with pressure and signals from the well each and every day. To dismiss their responsibility and suggest onshore management 'made life more complicated' is clutching at untruths. This is a pressure job which has to be handled one stage at a time.
I think I've stated my position on the blame/excuse game enough that I don't need to repeat it here.
I'm not impressed by sweeping generalizations about GOM-wide practices. I find it hard to believe that an ExxonMobil rig crew would exhibit the behavior we saw on DWP. More to the point, I find it hard to believe that an ExxonMobile Drilling Engineer would get away with sending six revisions to a temporary abandonment plan in eight days without performing either a risk assessment or management of change step on any of them.
You'll just have to accept that the industry has its frustrating moments and they all have these experiences despite your unwillingness to believe.
I don't believe anything without evidence. Please cite a case where ExxonMobil after 2008 failed to invoke its risk management process.
The guy actually had to be reminded to include the negative pressure test.
And the TO OIM's statement in the morning suggested 'we've always got the pinchers'! I assume he was prepared to continue with operations rather than contest any decisions. And, why the hell wasn't he in the heart of the action? Because of the officials on the vessel? C'mon, he always insisted on negative tests. Couldn't he just have relayed some of his experience where negative tests went wrong? His crew needed guidance and he was nowhere to be seen to hel with interpretation.
For the record, the OIM denied under oath making the "pincers" statement that day -- he said it was the previous day. There clearly was tension between him and at least one of the company men. And the degree of faith the OIM had in the toolpusher's judgement was definitely a factor.
And do you actually think any other operator would send out a company man who not only had never been on a rig before but who accepted the "bladder effect" explanation so thoroughly that even after he was fished out of the water and got back to the office he sent out emails promoting it?
I assume he was listening to the toolpusher who was just about to become the TO training Instructor for well control. Slightly ironic wouldn't you say?
Aside: I was wrong in stating that the new company man had never been on a rig -- he had never been on a drilling rig, but came from a production rig. I find it strange that a company man would unquestioningly accept such an explanation, but then I find it hard to figure out what the company men on that rig did for a living in the first place.
It is definitely the case that BP botched the takeover of Amoco and Arco. You think it's a Brit/American thing; I think it was more a finance/operations thing (I have lived through a major takeover -- they almost never work). BP's numbers-driven managers forced out all the senior Amoco/Arco managers because they were too expensive. Here's what Bob Bea, who was hired directly by Lord Browne to advise them on the takeover, said about that decision:
Obama, made it a Brit/American thing and the whole country listened to the media spouting untruths about BP. The lynch mob mentality started in the White House and they needed a culprit quickly to appease a nation who had just lost 11 of their sons due to the ineptitude of BP in London, apparently! So, they decided on Hayward as an easy target. The attack on his character can only be likened to the mentality of the muslims in Egypt leaving the Mosque to fight the infidel after being 'instructed' and 'directed' by the holier than thou Mullahs!
Every time you launch into one of these chauvinistic rants I find myself humming "He Is An Englishman" from HMS Pinafore And I've already told you how you can come to Hayward's defense.
"You're screwed. You just early-retired your memory. You early-retired the people who remember all those mistakes you've ever made, and you've left all the bright young people without adequate mentors." Bea further said that BP was too enthusiastic with its downsizing and left it with a "brittle organization" "When you put them under stress they tend to collapse." The beancounters "stripped away all the robustness. BP became defect intolerant. The problem is, life is full of defects."
Mistakes are made in every organisation!
Well, this is something you and I can agree on. Throwing away the experience base of an organization in order to improve your numbers definitely qualifies as a mistake. Here's how Karlene Roberts, Bob Bea's co-author on the BP "Refining and Pipeline Leadership Field Book" describes the beancounter-driven management under Browne:
"They trained their refinery guys in the language of the book and then told them 'It's up to you to implement this in each refinery,' Roberts said, 'But, you have to do this within your budget, and by the way, we're cutting your budget.'" [Reed and Fitzgerald] The decentralized, numbers-driven management of Browne-era BP worked directly against any effective process safety. Process safety, by it's very nature, has to be imposed top-down by senior managers whose range of visibility into the organization lets them see multiple relevant factors at once. No person at the bottom of an organizational stovepipe, no matter how smart, diligent, and responsible, can do it because they aren't aware of things that may effect the degree of risk they are in.
Is any of this relevant to the inept actions on the vessel?
I've addressed that above.
[I]BP Houston/ex-Amoco/ex-Arco was a mess. Here's the content of an April 17 email between the Wells Team Leader (who had just received a de facto demotion) and the Drilling Operations Manager:
"[DOM], over the past four days there have been so many last minute changes to the operation that the WSL’s have finally come to their wits end. The quote is ‘flying by the seat of our pants.’ More over, we have made a special boat or helicopter run everyday. Everybody wants to do the right thing, but this huge level of paranoia from engineering leadership is driving chaos. This operation is not Thunderhorse. [The Drilling Engineer] has called me numerous times trying to make sense of all the insanity. Last night’s emergency revolved around the 30 bbls of cement spacer behind the top plug and how it would affect any bond logging (I do not agree with putting the spacer above the plug to begin with). This morning [the Drilling Engineer] called me and asked my advice about exploring opportunities both inside and outside of the company.[/I]
I take it that he was looking for a job elsewhere! And remember, the casing was put in place successfully. The only thing that went wrong was the action of the personnel on the vessel. There are so many cement jobs that fail but they must be recognised especially during an inflow test. Where was the goddam OIM who insisted on taking the inflow test and where was his instruction to maintain volume control?
I think it's obvious that the comment about looking for a job is the reaction of a junior person (he only had four years on the job, if I recall correctly) who is very frustrated at the lack of leadership in his organization -- leadership that the beancounters pushed out the door.
What is my authority? With the separation of engineering and operations I do not know what I can and can’t do. The operation is not going to succeed if we continue in this manner."
Isn't that a question a driller and Toolpusher should also make? Am I going to continue blind and not tell anyone I don't understand what's going on.
Yes. And the Drilling Engineer. And the Company Men. And everybody else involved.
Finally, I think it is good for your industry and society as a whole that there are people inside API, IADC, COS and the operating companies who have refused to accept the proposition that once you have placed the onus on the crew there is nothing more to learn.
But, it might help if people could understand that the personnel on the vessel obviously had no idea what they were dealing with......and didn't seek clarification or shout STOP. Remember, this was over 1000 barrels before anyone attempted to shut in. I believe this is the largest ever undetected influx! API, IADC, COs all have a part to play in ensuring Drillers and Toolpushers know a little more than closing the pinchers! If they want to set standards then they need to make sure they aren't 'voluntary'.
Once again, and probably not for the last time, I believe blame is the enemy of safety. And "each and every one" includes everybody from the CEO on down.