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Deepwater Horizon Accident - 2010 Deepwater-Horizon (SYSTEM PARTS…

- - - - Combustible Gas Detectors (CGD)
        
        27 CGD's located across the rig. Each CGD had an audio system and a visual indication. The design showed that there was an alarm at each location.
        
        13 of the 27 CGD's were equipped to have an automatic response to an indication. This meant that if there was a detection of some kind, instead of just alarming the surrounding crew members, it would set actions such as closing vents to stop the spreading of fires and fumes (NAENRC 2012).
        
        The CGD in the engine room, which has a high chance of igniting a flammable gas, only had a basic unit (only visual and audio) and did not contain any automatic response. This meant that it required a crew member to confirm and action the response (NAENRC 2012).
        
        The reason for having a non-automated CGD in the engine room, is that if it were to be activated, for any reason, it could disrupt the current procedure and the rig might have to emergency disconnect from the well if it were to activate (NAENRC 2012). This means that the thought process behind the system was more based on the economic destructive outcomes, over the physical destruction that could come from an ignition in the engine room.
      - Integrated Alarm and Control System (IACS)
        
        The IACS is a system that combines all alarm and indication systems into displays that can be monitored on the bridge. That way, all systems can be monitored at once, in one location.
        
        'Human-out-of-the-loop syndrome'
        
        Porathe (2017) defines the human-out-of-the-loop syndrome as an operator having a delayed response in reacting to an unusual situation due to the fact that that operator is not in direct interactions with the operations. It takes time for the operator to be able to engage and then react to the alert.
    - - 4-8 people to a room in bunk beds
    - - TV Room
      - Games room
  - - - It was discovered that the watch officers were not properly trained to react to the warning signs and conditions of this accident (NAENRC 2012).
    - - It was also found that crew members dealing with the situation, were not trained to be able to understand all systems and components. This meant that crew members would have lacked the ability to identify and respond to events (NAENRC 2012).
    - - Once systems started to fail, there was no chain of command. Everyone acted on their own, and this lack of procedure lead to a lack of understanding of the situation and overall resulted in the 11 deaths that night
- - - - Calm sea
      - Large Waves
      - Heavy Rain / Hail
      - Storms
    - - Combustible Gas Detectors in the engine room did not operate as an automatic response. They had to be initiated by an operator (NAENRC 2012).
    - - 100+ confined to a floating platform
  - - - Material
      - Construction workers
      - Money # # #
        
        The whole rig costed roughly $350 million to build. It took from December 1998 until February 2001 to construct (Nguyen, T, Mohamed, I 2014).
      - Time
    - - Lead to stresses on the strict timeline
    - - User interface
      - Interactions with humans
      - How to deal with failures
  - - - BP rented the Deepwater Horizon at a cost of $500,000 per day (Nguyen, T, Mohamed, I 2014)
  - - - Stresses to operate to its full ability
        
        Errors made or procedures not followed
  - - - International Maritime Organizations
      - American Bureau of Shipping
      - United States Coast Guard
      - DNV Classification
      - Health, Safety and Environmental (HSE) Standards
      - (Lifecycle Engineering 2018) # # # # #
- - - - The crew monitoring the test failed to pick up on any warning signs that were present
        
        No alert system to show that systems had failed
      - Participating crew members failed to identify the wrong identification
    - - Workers were under the same mindset that they were working in a very safe environment and this can lead to the idea that nothing will happen because nothing already has happened
        
        4 Senior BP members flew in prior to the accident to congratulate and celebrate the long term safety record (Barstow, D et al 2010).
    - - Crew members operated 12 hours a day and had a 12 hour break before operating again
        
        Mix of day and night shifts
      - Crew members are at work for anywhere between 2-6 weeks at a time before getting time off (Living on an offshore oil rig 2016)
      - Potential influence on the ability to think and operate under fatigue # #
- - - - Workers on offshore oil rigs typically work at a period of between 2 and 6 weeks before returning home and getting time off (Living on an offshore oil rig 2016).
      - 12 hours on / 12 hours off mixed between day and night shift (Living on an offshore oil rig 2016)
      - Inability to maintain a set body cycle leading to fatigue #
        
        Poor decision making
      - The crew members in charge of monitoring systems had been under-trained. They were expected to know and understand all systems on board so that they could react accordingly to any unusual responses by any system (NAENRC 2012).
    - - The role of a supervisor is to watch over all operations, and have the ability to step in and make decisions if something goes wrong.
        
        When everything was going wrong on this evening, no one took charge, everyone panicked and worked on their own and without someone giving directions or orders
      - In the investigation, it was discovered that there was a change of supervisor shift right before one of the major testing operations.
  - - - Halliburton proved that 21 cement centralizers were required for this deep water operation (Merchant, B 2010).
        
        BP declined this proposal and continued the operation with the only centralizers onboard the rig, which happened to be 6. That is 15 short of the calculated amount (Merchant, B 2010).
    - - When the first test failed, there should have been procedure set in place to recorrect the situation. #
      - When events started getting serious, there should have been an assigned emergency crew to deal with the situation. There should have been set procedure to follow rather than everyone acting on their own without instruction #
      - Shift changes of any sort should not occur right before or during any major task #
    - - On the day of the disaster, the Deepwater Horizon was over 50 days behind schedule (Hammer, D 2010).
        
        At a rental of $500,000 per day, this would mean that BP was over $25 million behind schedule and an enormous pressure would be put on the workers to make up for any lost time
  - - - No one spoke up even though they did not agree with the assumption
        
        Lack of communication between crew members
    - - Potential to lead to confusion on the day
- - - - Some warning systems, however, required a worker to act on the warning, rather than having an automatic response by the system when activated (NAENRC 2012).
        
        One of which was in the engine room, meaning that when the combustible gas detectors went off, the engines were able to keep running (NAENRC 2012).
    - - In both tests conducted, one failed. Yet it was based on the interpretation from the crew to determine the results.
        
        This can lead to disagreements amongst crew members, and potentially lead to a false interpretation
    - - After investigations, it was discovered that there was a damaged solenoid on one side of the BOP, and the batteries on the other system were flat (British Petroleum 2010).
        
        None of these discoveries were made prior to the accident. This means that there were no systems in place to provide warning of such failure.
        
        There was no procedure followed to check these batteries and systems to ensure that if it was required, it would be operational.
  - - - Floating platform in the middle of the ocean
        
        Added risk of having to escape overboard in an incident
      - All systems are confined in a close space
        
        Combustible gas was able to access dangerous areas