The blame game - BP and the Gulf of Mexico disaster

Materials World magazine
,
3 Nov 2010

In my inaugural column (Materials World, June 2010), I wrote how inaccurately much of the media reported the events on the Deepwater Horizon well blowout in the Gulf of Mexico. Four months on and BP has published its own investigation report, which goes a long way towards explaining what happened and the lessons that can be learnt.

Predictably, many commentators dismissed it as a whitewash, claiming that BP was passing the blame onto the drilling contractor and rig owner, Transocean, and the Deepwater Horizon rig crew. Having read the report in full, my view is that BP has done a remarkable job in not only determining what led to the blowout, explosion and fire, but also evaluating the impact of factors, such as the well design, which were seized upon in initial press reports (and promulgated by the US Congressional Subcommittee on Oversight and Investigations).

Despite the political grandstanding and seeming desire of the sub-committee to pin the blame entirely on Tony Hayward, BP’s now ex-Chief Executive, not surprisingly, the company’s own investigation reaches a more measured conclusion. The report identifies eight critical factors and concludes that ‘if any of these factors had been eliminated, the outcome of Deepwater Horizon events on April 20, 2010, could have been either prevented or reduced in severity’.

Anyone familiar with major accident analysis will be aware of this so-called ‘Swiss Cheese’ model – an alignment of holes, or breakdowns, in the layers of barriers and safeguards designed to prevent such catastrophic outcomes. Deepwater Horizon is a classic example of this, and BP’s report should be required reading for anyone wishing to understand what happened, not least those of us working in drilling, completions or well integrity.

In common with other major accidents, each of these holes has a strong element of human factors, and it is obvious that some of the judgement calls taken during the course of events were incorrect. What is much harder to explain, and the report does not attempt to, is why certain individuals made the decisions that they did. Identifying these decisions as contributory factors is not the same thing as finding fault or apportioning blame, but understanding them is crucial to preventing future accidents. Tragically, some people paid for their decisions with their lives, and we will probably never fully understand.

The aviation industry has long understood the impact that ‘human error’ plays in air accidents, particularly the choices made by those with most influence to affect the outcome – the pilots. Indeed, the subject of Crew Resource Management, the study of communication, leadership and decision-making in the cockpit, is now an essential part of pilot training.

Air incidents are investigated by a body independent of aircraft manufacturers, operators, Government or legal bodies, such as the UK’s Air Accidents Investigation Branch. Its aim is to determine the causes, ‘not to apportion blame or liability’.

Unfortunately for the oil industry, the press, politicians and most of the general public only seem interested in blame and liability. The latter will only be determined after lengthy and expensive court proceedings, trials, appeals and judgements, none of which will further our comprehension of the human factors behind this disaster. In the blame game, we inevitably lose out on a deeper understanding.