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Deepwater Horizon (EVENTS (12:35am: Halliburton contractors finish…

- - - - No safety culture
        
        Management procedures
    - - No checks were made to ensure that staff were correctly trained
        
        Management procedures
    - - No warning indicators or steps were evident to be used
        
        Management procedures
  - - - Installed the faulty concrete
        
        Aware that the mixture was unstable and would not set
        
        Management/Procedure Failure
        
        Knew of the danger signs and used mixture anyway
        
        Management/Procedure Failure
        
        Knew that mixture did not pass standards
        
        Management/Procedures Failure
      - Subcontracted by BP to install the concrete core
        
        Aware of the explosion on a BP well weeks before
    - - Cutting costs
        
        Stress on workers
        
        Added stress and pressure to working environment
        
        Failing expectations
        
        Organisational Failure
      - Changed procedures
        
        Impacted the quality of work and execution of tasks
        
        Organisational/Management Failure
      - Did not carefully check and approve the tasks completed by Halliburton
    - - Owners of the ship
- - - - Jobs were not completed properly, which caused the explosions to occur and the leaks from the wells.
        
        Design failure
    - - The lack of cameras, documentation and other forms of monitoring the wells,
        
        Management/Organisational Failure
  - - - Pressure test results were not considered
        
        Management/Procedure Failure
      - Was not made to withstand multiple explosions
        
        Design Failure
      - Procedures and standards not followed
        
        Management Failure
    - - Put pressure on wells
      - Previously activated
        
        Punctured pipe and bent pipe (Pallardly 2017).
        
        This meant that the stabilisers were unable to prevent the explosions (Pallardy 2017).
        
        Design Failure
      - Hand (2017), discusses the importance of human-machine collaboration and the different stages of collaboration.
  - - - Corners were cut to try to get back on schedule
      - The workers were not as precise when completing tasks correctly
    - - Atmosphere
      - Water
- - - - Cutting costs
        
        By cutting the costs, the equipment necessary, procedure requirements and the information needed about the system was not the main priority
        
        Management/Organisational Failure
      - Lack of crew management
        
        Management/Organisational Failure
      - Procedure changes
        
        Management/Procedure Failure
    - - It is evident that the current safety procedure was not appropriate for the mixture used on the day
      - The safety procedures were not refreshed regularly
        
        Policy and procedure failures
  - - - Procedures not followed correctly
        
        Management Failure
    - - Workers did not recognise the warning signs
        
        Training/Information Failure
      - Procedures were not followed
        
        Management/Procedure Failure
      - Workers were not aware of the importance of monitoring the system
    - - Workers were unaware of the requirements and necessities of their specific task
  - - - Communication breakdown
      - Policies and procedures not followed
        
        Health and safety risks
    - - This impacted their quality of work, motivation and accuracy
        
        Management/Procedural Failure
- - - - Instructions
      - Training
      - Standards
      - Health and Safety
      - Design
      - Cost
    - - Testing
        
        Standards
        
        Health and Safety Requirements
        
        Code of Practice
      - Inspections should be completed regularly
        
        Stabiliser was damaged and unable to work, this contributed to the multiple explosions
        
        No indication of damagers shown
      - Training must be provided on how to use the stabiliser
        
        Job description
    - - Cost
      - Health and Safety
      - Design
      - Standards and other relevant documentation
  - - - Rostering
      - Task requirements
      - Training
    - - Health and safety of workers
      - Standards are followed
      - Tasks are completed correctly
  - - - BP
      - Halliburton
      - Transocean
- - - - Reliable and stable to ensure no leaks occur.
        
        Design Failure
    - - Must be able to withstand an explosion if it was to occur.
        
        Design Failure
  - - - Workers
      - Parts
  - - - Making sure that the ship functions properly
      - Ensuring that the mixture for the cement adheres to the related standards.
    - - Ensuring that the cement mixture meets requirements
  - - - Required to correctly and safety seal well
        
        Concrete filling
        
        Monitoring
    - - Adhere to correct procedures outlined in the Standards, Code of Practice and other related documentation.
  - - - Eliminates health and safety risks that may arise
    - - Ensures the quality of the filling and monitors the reliability of the mixture
    - - Standards
      - Instructions / Procedures
      - Requirements