The following guest post is by Ian Sutton, a Risk Management Engineer in the Process Industries – both onshore and offshore. Ian publishes books and articles on safety management at Sutton Technical Books and suttonbooks.wordpress.com.

Introduction

Almost two years have passed since the explosion and fire on Deepwater Horizon drilling rig. But most of us still vividly remember the tragedy in which eleven men died and almost a billion dollar’s worth of equipment went to the bottom of the ocean. The ruptured well then leaked around 6 million barrels of oil into the Gulf of Mexico for a period of about two months, leading to extensive environmental damage and economic loss. (The event also further established the authority of The Oil Drum; the timeliness and quality of its postings and comments were unrivaled.)

Incidents of the magnitude of Deepwater Horizon (DWH) often lead to a fundamental rethink in the affected industry as to how such an event could have happened and what needs to be done to prevent a recurrence. The manner in which such a rethink is organized is often along the following lines.

1. What happened? What was the timeline of events that led to the catastrophe? This phase of the investigation requires deductive analysis (think Sherlock Holmes or Hercule Poirot) and is generally much more difficult than it sounds, not least because most people jump to an early conclusion and then fixate on that conclusion regardless of what later facts tell them.
2. What were the immediate causes of failure? These can include equipment failure, instrument malfunction and operating error. (The phrase operating error is used in preference to operator error in order to minimize the tendency to blame the supervisors and front-line technicians; the event probably was caused by a series of failures along the way — the front-line personnel were simply the last people on the bus.)
3. How did the management systems fail? For example, in the case of DWH what led to the failure of the Blowout Preventor (BOP)? Specifically:
   1. Were the proper standards for the design of BOPs followed, and are those standards good enough for current and future conditions given that we are working in ever more challenging environments?
   2. Was the procedure for selecting the BOP for this service properly followed?
   3. Was the BOP properly manufactured and installed?
   4. Were the technicians and supervisors properly trained to operate and maintain the BOP?
   5. Were management and supervisors trained in what to do should the BOP or any other equipment fail to operate properly?
4. If any of the answers to Question 3 are “no” then how should we update our management systems to make sure that this accidents such as this do not recur?
5. Are the government regulations sufficiently stringent and up to date, and are the regulatory agencies doing their work properly?

With regard to DWH/Macondo the answers to the first two questions can be found in various reports that analyze the incident in detail. Before discussing the response to Questions 3 through 5 it is first useful to consider the question of risk and risk analysis in an industrial context.