Deepwater Horizon and New Social Science of DIsaster

[QUOTE=powerabout;191124]I see the instant blackout by a DP3 vessel due to poor DP3 engine room ventilation specifications seems to have been lost…
USCG asked the question…oops ABS
Plenty of DP2 vessels with separated engines rooms would have survived longer…not that might have made any difference but?[/QUOTE]

well there are combustible gas detectors at each of the intakes to the enginerooms which are supposed to automatically close shutters on the intakes if gas is detected specifically to prevent exactly what happened on the DWH which leads to infer that those did not work which points to poor testing and maintenance by DWH people.

what we do have is the knowledge that there was three minutes between the initial blowout and the engines exploding. we also have knowledge that the rig did not go into full emergency status during those three minutes which points many fingers at the master. we know that many people experienced gas surrounding the decks of the rig during those three minutes which should have triggered a full blown emergency long before the explosion. when did the master arrive on the bridge and what did he do to prevent the cataclysm? the hearings held afterward did not paint the master’s actions in a very positive light. I know it is hard to declare a major emergency when it seems that conditions might not escalate to what they became but if gas alarms were sounding around the rig it seems rather counterintuitive to not declare that the rig was in a full emergency situation which would have meant close blind shear rams, initiate emergency disconnect sequence and quite possibly go to full machinery shutdown (although I can see a great reluctance to go that final measure until at least disconnected). one of the biggest questions to ask is if this might have worked if initiated before the explosion? obviously afterwards there was no chance at all

To help the conversation along I have added pictures of the drill shack and the BOP control panel to our blog, along with a link to the Sperry Sun telemetry plots on the USCG site:

http://www.boebertandblossom.com/?p=270

Cheers,

Earl

An article from Fuel Fix that links to the Slate article in post #1 and talks about the DWH movie.

[QUOTE=Earl Boebert;191134]To help the conversation along I have added pictures of the drill shack and the BOP control panel to our blog, along with a link to the Sperry Sun telemetry plots on the USCG site:

http://www.boebertandblossom.com/?p=270

Cheers,

Earl[/QUOTE]

I read your book, superb. I wish the CSB had done as good a job but in recent years they appear to have sold their souls.
That the combination of Transocean and BP resulted in such a catastrophe was no surprise to anyone who knows both of them. In the grand scheme of things little has changed but the offshore industry in the USA is always dragged kicking and screaming into any change. The “git 'er done” mindset will not alter without a complete change of mindset and enforced regulations by regulators who are well educated and experienced in the challenges of deepwater drilling. BP remains primarily a financial corporation as their activity in the oil futures markets clearly shows. They operate as a hedge fund company disguised as an oil company. The drilling contractors will do as they are told just to keep their heads above water.
Thank you for your book. Should be required reading for anyone in the industry or those that purport to regulate them.

[QUOTE=tengineer1;191165]I read your book, superb. I wish the CSB had done as good a job but in recent years they appear to have sold their souls.
That the combination of Transocean and BP resulted in such a catastrophe was no surprise to anyone who knows both of them. In the grand scheme of things little has changed but the offshore industry in the USA is always dragged kicking and screaming into any change. The “git 'er done” mindset will not alter without a complete change of mindset and enforced regulations by regulators who are well educated and experienced in the challenges of deepwater drilling. BP remains primarily a financial corporation as their activity in the oil futures markets clearly shows. They operate as a hedge fund company disguised as an oil company. The drilling contractors will do as they are told just to keep their heads above water.
Thank you for your book. Should be required reading for anyone in the industry or those that purport to regulate them.[/QUOTE]

I agree, very worthwhile book. The abstract “systems approach” concepts are explained in common sense terms and the technical details on drilling are illustrated with drawings. The book pulls it all together in a very readable package.

Earl,

One early reaction I had to this thread was sort of a knee jerk repulsion from the whole “new social science” label. Is everything “new” now? I owe Leveson a more careful reading but new? It just sounds like good engineering effort to me. But I digress plus you made me think twice with this:

[QUOTE=Earl Boebert;191093]Sure. What you point out is what I regard as the central problem in achieving (as opposed to talking about) systems safety: how to bridge the gap between analytic models, which look at life backwards, and the needs of practitioners, who must live life in the forward direction. I’ve not seen any easy answers.
[/QUOTE]

So got your book late Monday.

I am a marine engineer from the Garden State so I am a cynic by both nature and nurture and wasn’t sure what to expect.

I am also someone who reads with a dictionary, a highlighter, sticky tags, a notepad and pen so lets just say I read slowly and yet here we are on Thursday evening and I have finished it.

Agree with the above reviews, a tremendous book. Highly recommended to anyone working in the drilling industry or working on/with any complex systems.

Now for the questions.

Are the MDL 2179 exhibits available on line?

Throughout the book you speak of “brittle organizations”. I get the meaning from context but if you had to list the characteristics or traits of such an animal what would that list look like?

Sort of same question about “contextual review”. What is your definition of a contextual review? Multidisciplinary? Different than what many of us know as risk assessments? A more intense search for hazards? More complicated hazards? Less obvious hazards? Performed by someone other than the designer?

Again wonderful book.

Ok ok ok. I’m going to the library. With this many thoughtful guys loving it, I need to find a copy myself.

Edit: I checked the catalog, we don’t have it. I filled out the buy-request form and emailed the librarian at the marine campus library. I heard a rumor that they haven’t spent their new books budget yet, and that they were soliciting sugestions. I feel like a very powerful person right now.

Edit again: The library enthusiastically approved my request. I told them to get two, so that we don’t have to share ours with the main campus. Earl, when you come to Vancouver you can sign our copy and remit my kickback. :wink:

just buy a copy on amazon

[QUOTE=KPChief;191928]Earl,

One early reaction I had to this thread was sort of a knee jerk repulsion from the whole “new social science” label. Is everything “new” now? I owe Leveson a more careful reading but new? It just sounds like good engineering effort to me. [/QUOTE]

The thread title wasn’t my idea :slight_smile: And yes, much of what she says is what people of our generation would call good engineering, but which has dropped out of the collective memory under pressure from the financial community, management consultants, and business schools.

[QUOTE=KPChief;191928]Earl,
Now for the questions.

Are the MDL 2179 exhibits available on line?

Throughout the book you speak of “brittle organizations”. I get the meaning from context but if you had to list the characteristics or traits of such an animal what would that list look like?

Sort of same question about “contextual review”. What is your definition of a contextual review? Multidisciplinary? Different than what many of us know as risk assessments? A more intense search for hazards? More complicated hazards? Less obvious hazards? Performed by someone other than the designer?

[/QUOTE]

The MDL 2179 material is still up at http://www.mdl2179trialdocs.com/index.php?page=phase1

It’s a mountain of stuff, about 4K emails, 300 depositions and so forth. Also not indexed or in any particular order. It took me a couple of months after the end of the trial just to organize it.

Characteristics of a brittle organization: Understaffed and underexperienced from a cost-driven management that views employees as liabilities instead of assets and lays off senior people first. No meaningful mentoring. Lack of unit cohesion generated by evaluation/compensation practices that promote internal competition (google on “stack ranking” if you want to see a really stupid form of this).

Contextual review: yes, multidisciplinary, involving outsiders, combining traditional design reviews with updating the risk register. Exxon Mobil’s “cold eyes” reviews are a kind of example. Thanks for asking this, I’ll work a clarification into the corrections somewhere. And thanks for your kind words about the book.

Cheers,

Earl

[QUOTE=Flyer69;191942]just buy a copy on amazon[/QUOTE]

I’m a student on the ramen noodle budget.

Didnt the DWH report just say cowboys in cowboy land behave like cowboys because they can?

I was doing a reference check for an article and came across a couple of papers from Leveson’s outfit that might be of interest:

Analysis of a DPS system (not an accident): http://sunnyday.mit.edu/papers/Navy-Final-Report-2016-Feb-17.pdf

Sewol-Ho ferry accident: http://sunnyday.mit.edu/papers/Kwon-Thesis.pdf

And to address the issue of how do you get it right before you start bolting stuff together:

http://sunnyday.mit.edu/STAMP/Fleming-Leveson-INCOSE-2015.pdf

Cheers,

Earl

Earl, few more thoughts…
On page 11 (top) you speak about the dangers of complex systems operating safely in one environment being moved to a new environment without adequate “re-thinking”. Agree with you on that point. Perhaps this is more a a nit being picked but while you can certainly plainly see two different environments between land based drilling and offshore as you write in this section, I would say another line that was crossed was after the mid-70’s.

Some really good engineering was done to get to floaters and then the first generation of DP vessels. I have a built in bias towards SEDCO but that place had an engineering culture at the highest levels. The success of the 135’s and 700 series semis not to mention the drill ships 445, 471 and 472 were some remarkable vessels. More importantly than their features SEDCO nearly always responded to unanticipated events with swift, engineering problem solving. Yes they were pioneers but they were engineering it as they went, not faking it to make it.

Seems to me somewhere about the late 70’s (drilling capabilities of water depths to 2000 to 3000 feet of water) the engineering facts were changing and instead of “re-thinking” it at that time they just started plugging new/bigger numbers into old formulas and hoping for the best or assuming it would work.

Somewhat related, on page 183 you discuss the balance of safety culture with engineering culture and I would suggest this analysis should not be restricted to BP but the drilling contractors themselves as well. From the glory days of having SEDCO and say Earl & Wright and various equipment makers engineers be very real presences in the operating of DP floaters/ships there was steady decline in in-house engineering talent and then even the willingness to involve outside engineering. Perhaps complacency derived from relatively good safety records or the management trends towards financialization (who needs to know what you’re talking about, just get an MBA). I think the loss of engineering culture was also masked by the endless mergers each of which made it easier to ignore the basic fact that offshore drilling is an engineering heavy human endeavor. And made it easier to think only in terms of drilling KPI’s or ROI’s or safety systems divorced from operations.

Still I am not (completely) one of those “in the gold days” guys. Nothing, even the past is perfect, to wit. Your account of the Macondo well failure sent me back to the 1979 Ixtoc (summary here) blowout. Fragile formation, loss of circulation, BOP failure. I am not sure of the relationship between SEDCO and PEMEX at the time but wonder about the competency of that operator as well.

Then again the more things change… here is a purely anecdotal account of a well control situation from 1985. The write up is from 2010 and the author seems like he was trying to make a point about what might be wrong with the Macondo well (eerie that it was also a Mississippi Canyon lease). Putting aside the hydrates angle, if true it does show a more conservative, step by step approach to the problem. Was Exxon under the same pressures as BP? Have no idea but seems the combination of Exxon engineers and SEDCO worked the problem successfully in that case (even though it was after the mid-70’s!)

This is probably only of interest to those who have read the book, but here’s our latest blog entry covering the testimony from the February trial of the Well Site Leader. No show-stoppers, but a couple of interesting new pieces of evidence:


Background

In February of 2016 one of the last trials arising from the Deepwater Horizon incident was held in New Orleans. This was a criminal trial, which began in Novevmber 2013 when the Federal Government indicted the two on-duty Well Site Leaders (WSLs) for eleven counts of Seaman’s Manslaughter and eleven counts of Ordinary Manslaughter each, plus violation of the Clean Water Act. The two WSLs were the lowest-ranking BP employees associated with the event, and the indictments were made with great fanfare, Attorney General Holder travelling to New Orleans to announce them.

Seaman’s Manslaughter (technically, “Ship Officer’s Manslaughter”) is an 1852 act passed in response to large casualties incurred in the wrecks resulting from racing passenger steamboats, and requires only the showing of ordinary negligence to convict; Ordinary Manslaughter, a charge based on the deaths of the same eleven crewmembers, requires the stricter showing of gross negligence. Based on prior agreements with their employees, BP paid for their defense attorneys.

In March of 2015 the U.S. Court of Appeals dismissed the Seaman’s Manslaughter charges, ruling the statute only applied to employees on the marine side of the rig and did not apply to drilling operations. After three changes in prosecution team, the Department of Justice voluntarily dismissed the Ordinary Manslaughter charges in December 2015, leaving only a charge of misdemeanor violation of the Clean Water Act, something ship captains typically get charged with when they discharge oily bilge water into the ocean.

The on-shift WSL pled guilty, agreed to testify for the Government, and was sentenced to probation and community service. The off-shift WSL, who had gone to his cabin three hours before the blowout, chose to fight the misdemeanor charge and was acquitted. Some facts of interest came up during the testimony in his trial and are summarized here. None of them contradict conclusions in our book, but they add extra detail.

The 8:52 PM Phone Call to Town

One hour before the blowout, the on-shift WSL (not the one being tried) called the BP Houston office to discuss the results of the second negative test, the one that was declared a success despite 1400 psi pressure showing on the drill pipe. The senior drilling engineer, who after the incident exercised his Fifth Amendment rights and to our knowledge has never spoken publicly since, was assumed by many (including ourselves) to have been looking at the real-time Sperry Sun telemetry on BP’s internal network when he was discussing the pressure anomaly with the on-shift WSL. This turns out not to have been the case.

Immediately after the incident the FBI took forensic images of a number of BP computers, including that of the senior drilling engineer. This is standard practice after an event that may have criminal aspects. The image, a copy of the contents of the computer, is kept as a master copy and copies distributed so that there is no possibility of the data being inadvertently or maliciously changed.

The defense in the WSL trial obtained a copy of the image and had it analyzed by an expert in forensic expert in computer analysis. This expert testified that the the image showed that during the time of the telephone call the senior drilling engineer was disconnected from BP’s internal network and connected to the open internet, where he was booking a vacation flight.

If the expert was correct, this means that the only description of the pressure anomaly that the senior engineer had available to him during the call was the verbal discription given by the on-shift WSL — he had no ability to examine the shape of the pressure or other curves, or move back in time to the first negative pressure test. As a consequence it is unlikely that he would have been able to apply the the full scope of his expertise to the problem the on-shift WSL was describing.

Limitations of the Sperry Sun Telemetry

In a discussion outside the hearing of the jury, the Halliburton-Sperry employee who specialized in interpreting Sperry Sun data was quoted as saying in his deposition

“I don’t believe the data we were able to collect during the negative test would allow for an accurate analysis of the negative test, whether or not there was communication with the wellbore at the time.”

This opinion reinforces the need for more comprehensive event data recording on these rigs.

The Kill Line Valve

The person leading the engineering side of the BP internal investigation (the so-called Bly report) testified that the investigation team regarded a closed kill line valve as being equally probable to a plugged kill line as a cause of the zero pressure seen on the kill line during the second negative test. He also testified that the team thought that if a kill line valve were closed, it would be the upper (surface) one closed inadvertently, instead of (as we have surmised) the lower one closed by some sort of malfunction.


Cheers,

Earl

In the last chapter, Earl talks about the lessons we can take away from this and who those lessons are aimed at.

I could add one more, based on my reading. I would add that studying this case is useful for young people because it will help to be able to recognize ‘go fever,’ ‘brittle organizations,’ and see the importance of safety culture. Earlier in the book, he mentions that BP had too many bright young ambitious people and not enough mentors for them. I’ve seen organizations that operate that way before, and I’ve seen the consequences myself. But if I had read something like this when I was first entering the workforce, I might not have been such a True Believer for so long. Better to have your eyes open than to trust in the full-colour-glossy-colour-coordinated system that they try to sell you on during your indoctrination.

@Kennebec_Captain @Earl_Boebert1

This is an older title I picked up in mid 90’s and just re-read. On the theoretical side of managment ideas but examining management systems or approaches from quantum view point was interesting and thought provoking. Perhaps you’d find interesting as well.

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I guess that’s one of the most expensive oil spills ever. I don’t really recall estimations for the Exxon Valdez disaster at the time.

BP oil spill did $17.2 billion in damage to natural resources, scientists find