Responding to consultant Ian Fitzsimmons' recent remarks in OE about BP's accident investigation report on the Gulf of Mexico's Macondo well disaster, drilling specialist Dr John Thorogood argues that it's time to stop pointing the accusatory finger and start learning the human factors lesson.
Ian Fitzsimmons' article Macondo – the unfolding aftermath (OE November 2010) deserves comment. His is a viewpoint that polarises views on a complex issue and provides little insight into the underlying causes of the tragedy. There appears to be a desire to blame BP through criticism of the long string casing design and the technically incorrect use of the word 'reckless'. However, his final comments at the end of the article point in a promising direction.
The leak path through the shoe-track negates the assertion that the design itself was a contributory cause of the accident, refuting his assertion of a 'glaring omission'. Cement testing even at simulated downhole conditions may not be conclusive. Shoe tracks fail for a variety of reasons, not all related to the cement formulation. Possible causes of failure include, for example, over-displacement of the slurry, failure of plugs, or obstructions in the float equipment.
In addition to the well-known 'Swiss cheese' model, Professor James Reason also formulated the 'just culture' model to provide an objective means of testing the motivation behind people's actions. Without the benefit of hindsight, it is not possible to assert that the actions of the people involved would have failed the 'substitution test'. Certainly, they do not fall anywhere near the region of negligence or deliberate sabotage, which would be required to prove recklessness.
Professor Andrew Hopkins observes in his book Failure to learn that blame is the enemy of understanding. Fitzsimmons falls into precisely the trap of pointing fingers rather than shedding light. As Professor Hopkins explains, the investigator must continue asking 'why?' until the causal trail is exhausted. Whilst much may be going on behind the scenes, certainly there is, as yet, no evidence in the public domain to suggest that this trail has been followed to its end. Only after such an investigation has been undertaken can solutions be developed to reduce the potential for similar incidents in the future.
Ultimately, multiple barriers are required to prevent catastrophe and these include the mindfulness, risk awareness, skills and knowledge, vigilance and competence of the people on the rig. Fitzsimmons steered away from considering the reasons why the crew made the selection of flow diverter routing, but he suggested that external pressures might have contributed to the misinterpretation of the pressure test results and, implicitly, the subsequent failure to recognise the signs of a massive influx until it was too late. In their defence, one might speculate that, in part, the selection may have been driven by an overriding instinct not to discharge hydrocarbons deliberately into the sea. This impulse is strongly reinforced by the severe regulatory consequences of reporting overboard spills, however small.
These types of questions must be investigated by trained and competent specialists to determine where failures in the barriers occurred, and to identify lessons for the future.
The real tragedy, as Professor Hopkins notes, is that there is no such thing as a new industrial accident. They have all happened somewhere else; so it may be with Macondo. As widely reported in the media, including the New York Times, BBC news, the Daily Telegraph and Aberdeen Press & Journal, an eerily similar precursor to Macondo occurred on 23 December 2009 in the UK North Sea involving Transocean and Shell. In this case, a downhole barrier was compromised and a potentially catastrophic event was averted only at the last moment when mud from the well was gushing way up the derrick; the incident being halted by one of the final 'barriers' on this occasion.
The PTTEP Montara blowout in the Timor Sea (OE December 2009), just eight months before Macondo, is another example of the consequences of blindness to the risks of shoe-track integrity. It is, perhaps a missed opportunity, that all the final recommendations on that event also focused on the technical and regulatory aspects of the disaster and not on the evident human factors issues.
The common factor in these three incidents was that they all took place in cased hole in a supposedly safe situation and all in well regulated areas. There is no obvious explanation as to why? In all three cases the warning signs were missed. To explain this incident, and its precursors in the North Sea and Timor Sea, in a way that we can take effective steps to prevent a repetition, it will be necessary to go beyond the obvious regulatory and technological responses now being pursued. It is probable that in the fullness of time it will be recognised that the industry has a fundamental gap in the realm of human factors, in terms of crew resource management and nontechnical skills.
It is not simply a matter of flogging the offshore workforce with the mantra of 'competence'. Competence and human factors are fundamentally different. Competence does not explain why highly skilled, trained, professional and regularly checked aircrew fly perfectly serviceable aircraft into the ground. Human factors analysis does.
Fitzsimmons is correct in observing that other communities have well-developed training procedures. However, these training procedures are the product of extensive research into accident causation in the domain and also to the human factors issues. In aviation, the training is not simply around competency testing, but also checking and testing the nontechnical aspects, the Crew Resource Management skills. For drilling operations, it will be necessary to train in relation to critical influences, such as the trade-off between complying with regulations, such as not venting overboard, against managing a rapidly evolving situation. Such instances do not need more procedures. Drilling teams must be equipped with knowledge about decision making and critical influences, assessing situations and managing surprises. There are no instant answers, the industry will have to devote time and people to examining the human factors issues before it can define what sorts of training, simulation or testing of nontechnical skills are appropriate.
If problems are only viewed through a technical lens, then technical solutions are the only answer; to make progress, both the technical and non-technical issues must be equally addressed. It is to be hoped that the drilling community will learn the lessons from high hazard industries such as aviation, nuclear and other process industries where the human factors approach has been adopted and look much further and deeper into the realms of safety culture and human factors to find a fuller and more meaningful explanation for these tragedies. OE
About the Author
Dr. John Thorogood is an independent consultant after a 34-year career with BP in drilling operations, technology and exploration project management. In 2002-2003 he undertook research with the University of Aberdeen Department of Psychology and published work on drilling teams and decision making and human factors. He is the 2011 recipient of the Society of Petroleum Engineers International Drilling Engineering Award, a former technical director of the SPE and author of more that 40 technical papers and articles on drilling engineering. He has BA and PhD degrees in Engineering from the University of Cambridge.