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Deepwater Horizon Picture Deepwater Horizon (Nature of the system and…

- - - - Acitive failure.
      - Cement contained voids.
        
        Inadequate concrete testing.
        
        Latent failure.
        
        Precondition
    - - Active Failure.
      - BOP failed to seal the well once hydrocarbons had escaped and applied excessive pressure
        
        Precondition.
        
        Lack of testing under extreme conditions (U.S. Chemical Safety and Hazard Investigation Board 2016a, p. 8).
        
        Latent failure.
        
        The drill pipe buckled under pressure after the well had been compromised. The buckling moved the pipe outside the envelope in which the BOP could effectively shear and safely seal off the well (U.S. Chemical Safety and Hazard Investigation Board 2016a, p. 8).
        
        Latent failure.
    - - Active failure.
      - The oil rig had already experienced an explosion of hydrocarbons
        
        EDS was not designed to handle an extreme explosion.
        
        Latent Failure
        
        Precondition.
      - The automated function was hindered by a flat battery and a poorly wired connection (U.S. Chemical Safety and Hazard Investigation Board 2016a, p. 12).
        
        Precondition.
        
        Lack of testing and maintenance of the equipment. Lack of skill and/or qualification of the person wiring the safety device.
        
        Latent failure.
        
        Regulations did not require testing of the equipment (U.S. Chemical Safety and Hazard Investigation Board 2016a, p. 13).
        
        Latent failure.
  - - - All materials and manufacturing standards are to be met to suit the design requirements and allow for the system to fail safe in the event of a problem.
    - - Components to be transported to a difficult and remote marine environment.
    - - Components to be commissioned in a difficult and remote marine environment.
    - - All operator must be suitably skilled and trained for their roles.
      - Lines of reporting must be clear.
      - Operation manuals and standard operating procedures must be concise and up to date.
    - - Oil rig must be adequately maintained for continual fitness for purpose during the whole life cycle.
    - - Eventual decommissioning of an oil rig should cause minimal or no degradation to the environment and sea life.
      - Oil rig to be designed to be safely and efficiently decommissioned. Components should be designed and maintained to withstand a harsh and corrosive marine environment.
- - - - Regulations did not enforce risk management tools (U.S. Chemical Safety and Hazard Investigation Board 2016a, p. 16).
- - - - A process called a negative pressure test was conducted to establish the structural integrity of the oil well and to ascertain that there is no leakage of hydrocarbons into the well. High pressure readings indicated that the process had failed and that well integrity had been compromised. The negative pressure test had failed however Transocean rig crew and BP site leaders had erroneously concluded that the testing had been successful (BP 2010, p. 10).
        
        Active failure
        
        Bias was applied by all personnel concerned.
        
        Staff may have felt pressured as the project was running late.
        
        Possible latent failure.
        
        Precondition.
        
        This created a delay in the activation of the Blow Out Preventer. Early activation by human detection may have prevented the disaster (U.S. Chemical Safety and Hazard Investigation Board 2016a, p. 6).
        
        Most accidents are caused by human factor failures (Havliklova et al. 2013, p. 346).
        
        Precondition.
        
        When human intervention is a critical barrier for failure prevention effective safety management systems are required (U.S. Chemical Safety and Hazard Investigation Board 2016a, p. 13).
        
        Latent failure
    - - Potential for long shifts and lack of recreation which could cause fatigue.
    - - Potential for employees to have elevated stress levels due to working in an isolated remote location away from family.
      - Potential for high stress situations when there is a problem or delays on the oil rig.
    - - Job design potentially requires good physical fitness.
  - - - Must be specific and suitable for offshore drilling.
    - - Remote and harsh marine location.
    - - Drilling is deep into the ocean and far away from the operator vantage point.
        
        Control room must have simple and functional human interface.
        
        Feedback displays and warning mechanisms needed for oil rig operators.
    - - Potential for noise, poor lighting, temperature extremes and exposure to the elements.
      - Potential for extreme weather events.
  - - - Resourcing.
        
        Adequate resources required to manage the rig and combat employee fatigue.
      - Procedures.
        
        Adequate and up to date procedures would be required for technical aspects of the work involved on the oil rig.
      - Policies.
        
        More emphasis was placed on personal safety performance indicators than system process safety (U.S. Chemical Safety and Hazard Investigation Board 2016a, p. 9).
        
        Corporate policy differed to actual work practices (U.S. Chemical Safety and Hazard Investigation Board 2016a, p. 15).
      - Organisation of work.
        
        Work needs to be organised so that there is a clear line of reporting between white and blue collar workers.
        
        Shift work would require effective handover of duties and daily events on board the rig at the time of roster change.
      - Leadership style.
        
        Leadership style will inevitably influence the work practices and culture on the oil rig.
    - - Communication.
        
        Poor communication between all companies involved.
      - Work instructions.
        
        Complexity between full time operations and contract workers can make responsibilities ambiguous (U.S. Chemical Safety and Hazard Investigation Board 2016a, p. 10).