Deepwater Horizon and New Social Science of DIsaster

A good article using the movie about the Deepwater Horizon disaster to discuss Organization Accidents.

Blame BP for Deepwater Horizon. But Direct Your Outrage to the Actual Mistake.

This new social science of disaster helps explain why the people involved never seem to see the accident coming. The people working in these cultures don’t [I]think[/I] they are being reckless; they don’t recognize all the ways they’ve normalized deviance and let risks creep up. When the disaster finally strikes, they are as stunned as anyone. These findings also show why disasters are so hard to predict: According to Dekker, “Accidents can happen without anything breaking, without anybody erring, without anybody violating the rules they consider relevant.” The disaster, in other words, is not a violation of the daily routine, but a product of it. Some disaster researchers call these sorts of incidents“normal accidents” or “organizational accidents” to stress the way they emerge from the normal operation of the organization.

That article was good, but seriously incomplete. I say this as somebody who spent five years digging into this event:

Ask me anything :slight_smile:

Cheers,

Earl

Here’s another read on the issue from the Washington Post:

‘Deepwater Horizon’ movie gets the facts mostly right, but simplifies the blame

P[QUOTE=Kennebec Captain;190979]A good article using the movie about the Deepwater Horizon disaster to discuss Organization Accidents.

Blame BP for Deepwater Horizon. But Direct Your Outrage to the Actual Mistake.[/QUOTE]

Interesting theory. The other day I did some research in the sinking of the Free Enterprise, a Victory C1-B, back in 1951. It was loaded, amongst other things, with 762.6 tons of pig iron in No. 2 lower hold and 508 tons of the same in No. 4 hold. The iron in 4 was evenly spread out but in No. 2 hold it was piled pyramidically as dumped by the grappling cranes. To ‘control’ the pile of you might say loose bricks it was more or less covered with sacks of coffee beans and other stuff as well… The bosun had objected to the loading plan which made use of only two holds and proposed to transfer iron from 2 and 4 holds into No. 3 hold. The chief mate relayed this to the captain but he decided against it, probably in view of the extra costs.


The ship is lying high in the water, it was carrying cargo which amounted to one third of the loading capacity.

No longitudinal bulkheads were present. This type of stowage was ‘normal’ in those days, probably due to the fact that no serious calamities had occurred so far. During the hearings the Coast Guard did remark about the stowage of the pig iron cargo in #2 hold and noted that it was not leveled out as was the pig iron in #4 hold but was stacked in a pyramid shape. The report stated that this did constitute a certain hazard as to shifting, however, this type of stowage was a common practice at the time and had been sanctioned by the shipper, underwriter, owner and the master.

During a storm a tremendous wave hit the ship and caused it to sway 60° - 70° after which the ship had developed a permanent list of 25° probably due to the shifting of the pig iron cargo in No. 2 hold. Later on the list increased as more cargo shifted.

This also seems to be a typical case of not seeing the accident coming while it was evident that any big or rogue wave would shift such a pile of pig iron.

Another mistake in my opinion is the fact the Carlssen decided to great circle to New York during WNA instead of sailing south and then make the crossing, especially with this kind of cargo loading. But then again nothing was wrong…

It has nothing to do with the above but it seems that the ship had a secret cargo, probably zirconium in the same shape as the pig iron and mixed with it. I understand that the Nautilus project was delayed by the loss of this metal which is only a little bit lighter in weight than iron. It could explain the continuous presence of American war ships and the rather strange tenacity of Carlssen to stay on board a lost ship.

I just saw the movie and it was fairly accurate on the DP, Company Man, Fouchon, and the mix of people we work with. I don’t know anything about MODU units but it looked like someone researched into the details about them.

[QUOTE=Dutchie;190986]Interesting theory. The other day I did some research in the sinking of the Free Enterprise, a Victory C1-B, back in 1951. It was loaded, amongst other things, with 762.6 tons of pig iron in No. 2 lower hold and 508 tons of the same in No. 4 hold. The iron in 4 was evenly spread out but in No. 2 hold it was piled pyramidically as dumped by the grappling cranes. To ‘control’ the pile of you might say loose bricks it was more or less covered with sacks of coffee beans and other stuff as well… The bosun had objected to the loading plan which made use of only two holds and proposed to transfer iron from 2 and 4 holds into No. 3 hold. The chief mate relayed this to the captain but he decided against it, probably in view of the extra costs.

No longitudinal bulkheads were present. This type of stowage was ‘normal’ in those days, probably due to the fact that no serious calamities had occurred so far. During the hearings the Coast Guard did remark about the stowage of the pig iron cargo in #2 hold and noted that it was not leveled out as was the pig iron in #4 hold but was stacked in a pyramid shape. The report stated that this did constitute a certain hazard as to shifting, however, this type of stowage was a common practice at the time and had been sanctioned by the shipper, underwriter, owner and the master. [/QUOTE]

We should start a thread for this. I recently reread Mowat’s The Serpent’s Coil, which is the story of a Sam-type Liberty ship who was very nearly lost in 1948 because of… Should I spoil it? It’s directly in line with the case that you have been researching. Lots of Sam-types had mysteriously disappeared prior to this event, and the near-loss of this ship (Leicester), taught us a lot about how and why this kind of thing happens. I strongly recommend this book: it’s a bloody nail biter, and a fascinating disaster investigation mystery. Let’s do have a ‘stability accident’ thread.

(This book might also be interesting to people who are interested in hurricane prediction and ship-based weather decision-making. This story features 3 hurricanes, and several organized extra tropical storms. It describes one of the early meteorological flights into a hurricane. It also talks about how choices are made on a ship’s bridge based on imperfect data in these situations. Certain of you cough Kennebec Captain cough might find it within your bailiwick.)

[QUOTE=Emrobu;190990]We should start a thread for this. I recently reread Mowat’s The Serpent’s Coil, which is the story of a Sam-type Liberty ship who was very nearly lost in 1948 because of… Should I spoil it? It’s directly in line with the case that you have been researching. Lots of Sam-types had mysteriously disappeared prior to this event, and the near-loss of this ship (Leicester), taught us a lot about how and why this kind of thing happens. I strongly recommend this book: it’s a bloody nail biter, and a fascinating disaster investigation mystery. Let’s do have a ‘stability accident’ thread.

(This book might also be interesting to people who are interested in hurricane prediction and ship-based weather decision-making. This story features 3 hurricanes, and several organized extra tropical storms. It describes one of the early meteorological flights into a hurricane. It also talks about how choices are made on a ship’s bridge based on imperfect data in these situations. Certain of you cough Kennebec Captain cough might find it within your bailiwick.)[/QUOTE]

It is a fantastic book with my favorite part being an age when ships without radars would detect an unlit hulk of a wreck in the middle of the Atlantic and casually report it by MF/HF as a hazard to navigation. Then the salvage tugs would be racing on a wild goose hunt for the prize. Truly amazing seamen back then.

[QUOTE=Earl Boebert;190984]That article was good, but seriously incomplete. I say this as somebody who spent five years digging into this event:

Ask me anything :slight_smile:

Cheers,

Earl[/QUOTE]

much as I enjoy the FLYING ENTERPRISE or the LEICESTER stories let’s stay on track with this one. Earl, I am all ears sir. Please give us the summation of the “immediate events” that led to the DEEPWATER HORIZON’s loss. Did it all come down to a mere two minutes and a couple of drillers in the cabin watching the freight train headlight coming straight at them but not doing anything to make it stop? too stoopified by the glare or simply not believing what they were seeing? or was it people not wanting to be responsible for activating the BOP?

WTF really happened on there?

[QUOTE=Earl Boebert;190984]That article was good, but seriously incomplete. I say this as somebody who spent five years digging into this event:

Ask me anything :slight_smile:

Cheers,

Earl[/QUOTE]

Why have other investigations accepted BP denials with regards to Kaskida?

BP was at risk of losing its lease to Kaskida if the company did not meet a regulatory deadline for drilling there, and the Horizon was the only rig BP had available for that task. BP executives have steadfastly denied that Kaskida was a factor in the blowout, and both official and unofficial investigations have accepted their denials. Despite that, we believe that such an extreme and widespread epidemic of go fever could arise only from the fear of losing a prize the size of Kaskida.

[QUOTE=c.captain;190993]Please give us the summation of the “immediate events” that led to the DEEPWATER HORIZON’s loss. Did it all come down to a mere two minutes and a couple of drillers in the cabin watching the freight train headlight coming straight at them but not doing anything to make it stop? too stoopified by the glare or simply not believing what they were seeing? or was it people not wanting to be responsible for activating the BOP?

WTF really happened on there?[/QUOTE]

Over the last couple of decades sociologists have changed the way some researchers view accidents of the type that occurred on the Deepwater Horizon. There has been a reduction of focus on workers closest in time and distance to events at the heart of the incident and more attention to the larger picture, the actions and events that put workers in that position.

An earlier and well known example isProfessor Diane Vaughn’s book on the Challenger disaster.

Turns out that a post about the Deepwater Horizon and Social Science will flush out the scientist and forum member that cowrote the book on the Deepwater Horizon disaster, Earl Boebert.

Deepwater Horizon: A Systems Analysis of the Macondo Disaster

Just read a sample, looks very interesting and readable, I have downloaded a copy and plan to read it.

The blame came is on, but who or what is really to blame? Here is one opinion: http://www.slate.com/articles/health_and_science/science/2016/09/bp_is_to_blame_for_deepwater_horizon_but_its_mistake_was_actually_years.html

Having worked around rigs for 40 years I have seen the change from the cowboy days in the 1970’s to the so called safety culture of today. Much of that time on rigs belonging to the companies that went into what is today T/O, and on the same rigs after they joined the T/O fleet.

At the time of the blow-out there was a celebration going on the DWH to mark 7 years of no LTA, which is admirable.
This was achieved by everybody following safety rules of wearing PPE, writing Stop-cards and paying homage to the “Pyramid”. (Old T/O hands will know what I’m talking about)

But is it REAL safety that is being promoted? Not really. Real safety is more then ensuring that nobody loose fingers or toes. It costs money and involve having the best available equipment, with proper training in how to use it.

On DWH the BOP was not equipped with acoustic remote closing facilities, although such equipment has been available for years and compulsory in many other locations. It would NOT have worked in this case, since there were not enough accumulator pressure to operate the rams due to lack of maintenance.

In this case short cuts were made, both operational and on maintenance of critical equipment. Who’s to blame, BP as the Operator, T/O as the Drilling Contractor and Owner of the unit?

My answer is both; BP because they did not have sufficient control of their Contractors and had not managed to instigate their normal very strict safety culture on their US operation, which was originally AMOCO.

T/O because they did not spend enough money on upgrading and maintaining equipment, but most of all to instigate a proper attitude towards maintenance routines and risk assessment.
The OIM is legally “Person-in-Charge” on the rig. He has the authority to override the Companyman, at least in theory.
If he does so and thus nothing bad happen, he would probably be fired, however.

11 people died on the DWH, but at least they did so with their fingers and toes intact.

When this happened, I remember that blame was split between the BOP and the contractor that was doing the cementing job. It was said that the blowout could have been prevented if the cementing was correct (and that the reason for using the wrong cement were these familiar sociological/risk comfort/cheap-out ones) I haven’t heard anyone talk about the cement in years, has it been eliminated as a contributing factor?

[QUOTE=Emrobu;191003]When this happened, I remember that blame was split between the BOP and the contractor that was doing the cementing job. It was said that the blowout could have been prevented if the cementing was correct (and that the reason for using the wrong cement were these familiar sociological/risk comfort/cheap-out ones) I haven’t heard anyone talk about the cement in years, has it been eliminated as a contributing factor?[/QUOTE]

Point is the framework used, as far as the cause, Earl wrote the book. I’ll read it and get back to you.

[QUOTE=Kennebec Captain;190994]Why have other investigations accepted BP denials with regards to Kaskida?[/QUOTE]

Good question. The only outside investigation that went into enough organizational depth to do so was the Chief Counsel’s Report. They were aware of Kaskida because of a Washington Post report (possible the result of an inside tip) but relegated it to an Appendix and said they didn’t believe it.

There are a couple of possible explanations for this. One is that the Republican caucus in the Senate blocked the Chief Counsel’s subpoena power, so his team only had access to material BP chose to provide to them. The relevant internal documents were not in that set. The other explanation is that interpreting those documents requires a moderate amount of experience with engineering project management, and the CC team may not have had that. My co-author and myself have, for better or worse, lived through more cost overruns than we choose to remember, and the pattern of unconcern by BP and their funding partners Anadarko and MOEX was pretty obvious to us. We go through this in detail in the book.

Cheers,

Earl

[QUOTE=c.captain;190993]much as I enjoy the FLYING ENTERPRISE or the LEICESTER stories let’s stay on track with this one. Earl, I am all ears sir. Please give us the summation of the “immediate events” that led to the DEEPWATER HORIZON’s loss. Did it all come down to a mere two minutes and a couple of drillers in the cabin watching the freight train headlight coming straight at them but not doing anything to make it stop? too stoopified by the glare or simply not believing what they were seeing? or was it people not wanting to be responsible for activating the BOP?

WTF really happened on there?[/QUOTE]

There’s no short answer to that question. The best I can come up with is this: A long series of seemingly innocuous decisions made by a range of organizations spread all over the map piled risk upon risk. The men in the drill shack were sitting on top of the resulting risk pyramid, one whose scope and detail was largely unknown to them. They were under a great deal of explicit and implicit pressure to get off that well. The (de facto) Big Kahuna for BP was visiting the rig. There had been an almost total breakdown of communication between BP and TO on the details of what was to be done. The crew were working at a level of simultaneous operations that the mud logger said he had never seen in 18 years offshore.

On top of all this, they were part of a feedback control system that was giving mixed green and red light signals. They chose green. Senior oilfield professionals who have absorbed this whole picture disagree as to whether that choice was reasonable. As authors we have tried to stay as far away from “coulda woulda shoulda” analysis as we can, so we take no position on the matter. For those who choose to judge, we think it is important to remember that those crew members died at their posts battling the consequences of that decision.

Earl

[QUOTE=Earl Boebert;191016]Good question. The only outside investigation that went into enough organizational depth to do so was the Chief Counsel’s Report. They were aware of Kaskida because of a Washington Post report (possible the result of an inside tip) but relegated it to an Appendix and said they didn’t believe it.

There are a couple of possible explanations for this. One is that the Republican caucus in the Senate blocked the Chief Counsel’s subpoena power, so his team only had access to material BP chose to provide to them. The relevant internal documents were not in that set. The other explanation is that interpreting those documents requires a moderate amount of experience with engineering project management, and the CC team may not have had that. My co-author and myself have, for better or worse, lived through more cost overruns than we choose to remember, and the pattern of unconcern by BP and their funding partners Anadarko and MOEX was pretty obvious to us. We go through this in detail in the book.

Cheers,

Earl[/QUOTE]

could you be a little more specific on the regulatory deadline? Seems to me they got the lease in 2003, not sure how long a term but if current guide is any indicator they would have got 8-10 years to drill, but they had drilled and found oil, once with DWH once with another rig. What deadline was relevant?

[QUOTE=Earl Boebert;191019]There’s no short answer to that question. The best I can come up with is this: A long series of seemingly innocuous decisions made by a range of organizations spread all over the map piled risk upon risk. The men in the drill shack were sitting on top of the resulting risk pyramid, one whose scope and detail was largely unknown to them. They were under a great deal of explicit and implicit pressure to get off that well. The (de facto) Big Kahuna for BP was visiting the rig. There had been an almost total breakdown of communication between BP and TO on the details of what was to be done. The crew were working at a level of simultaneous operations that the mud logger said he had never seen in 18 years offshore.

On top of all this, they were part of a feedback control system that was giving mixed green and red light signals. They chose green. Senior oilfield professionals who have absorbed this whole picture disagree as to whether that choice was reasonable. As authors we have tried to stay as far away from “coulda woulda shoulda” analysis as we can, so we take no position on the matter. For those who choose to judge, we think it is important to remember that those crew members died at their posts battling the consequences of that decision.

Earl[/QUOTE]

but certainly, the gas rising up the well bore was seen by someone at some point where a sane person with fear in their eyes would know that there was going to be a blowout if the blindshear rams weren’t immediately closed…

yes, that person or persons died when that cataclysmic explosion erupted but still we can infer that the loss of control of that well was first seem imminently before the gas reached the diverter and the rotary? how could no man, no matter what other pressures being placed on him by outside forces not react to save his own life?

here I point to the culture of not wanting to take the responsibility and thus not acting until the point is reached when no action can be taken. now I cannot recall, did the ontour toolpusher die or was he enroute to the drillfloor when the explosion occurred? Did the driller ontour simply refuse to activate the BOP in adequate time to save the rig? why would any man not save himself unless he was stoopid the danger and risk involved? most here know I hold little regard for the intelligence of drillers. most are bayoo bubbas with high school diplomas if they are lucky when their position should involve licensing just like bridge and engineering officers.

no matter any and all actions which implicate BP compromising the integrity of the well cementing job, there is a last line of defense which rests with the ontour toolpusher, driller and assistant driller. One of those three had to see the eruption emerging and had time and ability to push the red button and make it all stop in its tracks but they didn’t and thus died plus caused a massive and catastrophic environmental disaster on top of nearly killing a hundred more on that rig that night while happy celebrations of trifling achievement were occurring a hundred or so feet away…

blame BP for setting them up with the dynamite but it was TO’s people who pushed down the plunger which detonated the rig…SIMPLY HIDEOUS to my eyes!

[QUOTE=c.captain;191033]but certainly, the gas rising up the well bore was seen by someone at some point where a sane person with fear in their eyes would know that there was going to be a blowout if the blindshear rams weren’t immediately closed…

yes, that person or persons died when that cataclysmic explosion erupted but still we can infer that the loss of control of that well was first seem imminently before the gas reached the diverter and the rotary? how could no man, no matter what other pressures being placed on him by outside forces not react to save his own life?

here I point to the culture of not wanting to take the responsibility and thus not acting until the point is reached when no action can be taken. now I cannot recall, did the ontour toolpusher die or was he enroute to the drillfloor when the explosion occurred? Did the driller ontour simply refuse to activate the BOP in adequate time to save the rig? why would any man not save himself unless he was stoopid the danger and risk involved? most here know I hold little regard for the intelligence of drillers. most are bayoo bubbas with high school diplomas if they are lucky when their position should involve licensing just like bridge and engineering officers.

no matter any and all actions which implicate BP compromising the integrity of the well cementing job, there is a last line of defense which rests with the ontour toolpusher, driller and assistant driller. One of those three had to see the eruption emerging and had time and ability to push the red button and make it all stop in its tracks but they didn’t and thus died plus caused a massive and catastrophic environmental disaster on top of nearly killing a hundred more on that rig that night while happy celebrations of trifling achievement were occurring a hundred or so feet away…

blame BP for setting them up with the dynamite but it was TO’s people who pushed down the plunger which detonated the rig…SIMPLY HIDEOUS to my eyes![/QUOTE]

There was a very complex sequence of events in the last few minutes, but yes, the toolpusher, driller, and assistant driller died on the drill floor, and yes, they were trying to shut in the well in the last moments. It takes, like, a whole chapter to describe. And it wasn’t just one red button to shut in the well, it was a specific sequence because the blind shear ram was not sufficient to cut the size drill pipe they were using by itself. And it was TO’s policy to have the BOP control panel operated by the subsea supervisors, not the drillers, because of its complexity. The subsea supervisor was not in the drill shack at the time. And given the open loop, bang-bang nature of the BOP control system and TO’s “run it until it breaks” maintenance practices it’s quite possible the crew did everything right on the floor and nothing happened down at the mud line. Definitely not a prima facie case of somebody being slow at the switch.

Earl

Earl, if everyone and everything associated with the rigfloor was violently destroyed when that massive explosion occurred, what evidence survived to tell us what actions were attempted and when? there is no data recorder for cyber chairs! over clearcomm with the DPO?

there was a pretty good pressure leak from the BOP hydraulics as they kept topping it up and it was coming up close to rig nearby so a guy on the nearby rig told me several days after the bang.