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deepwater-horizon-burning (WHAT HAPPENED (drilled to desired depth,…

- - - - 700 kms offsite
        
        communicated about lack of centralisers
        
        management stopped ordering additional centralisers due to design flaw
        
        boasted about it being alright because its already done now
        
        productivity over safety culture
    - - shift change over
        
        interpreted test results differently
        
        ignored irregular readings
        
        failed to shut down operations
      - Kariuki & Lowe (2007) state that human factors can influence behaviour at work in a way that can affect health and safety.
  - - - shift ending
      - pressure tested and found irregularities
    - - shift starting
      - last shift on rig
        
        finishing project to never return
        
        relaxed attitude towards possible blowout
    - - calculated 21 centralisers required
        
        15 sent to oil rig without ensuring they are the correct ones
        
        only 6 used due to wrong centralisers being sent
        
        lead to failed cement plugging of well
        
        70% of offshore blowouts occur due to human error, the other 30% is due to technical errors (Cai et al. 2013)
- - - - Perera et al. (2016) discusses how failed maintenance systems can lead to catastrophic system failures.
  - - - accident occured at night
    - - methane and hyrdocarbons leaked out of well
    - - constantly moving
  - - - LTA maintenance
      - LTA inspections
- - - - engineers needed to be on the oil rig
    - - allowed poor decisions to be made by night shift staff
        
        Lack of leadership, improper maintenance and communication and wrong engineering judgements contributed to the disaster (Pranesh et al. 2017)
  - - - ignored regulators recommendations to use newer BOP model as 50% of that model had failed
      - BP ignored engineers on how many centralisers to be used
        
        cost cutting
        
        The accident investigation team concluded that there were weakness in the design and testing of cement, risk assessment and quality assurance. The rig crew conducted a LTA cementing job of the well.
        (Executive Summary, 2010).
      - chose cheaper design to operate and drill oil well
      - BP overruled Transocean to use inferior cement design
      - Halliburton tested cement design and concluded it was not the best method but failed to pass on that information to BP or Transocean
    - - 43 days behind schedule
      - shift change over
        
        pressure test was conducted near shift end and night shift supervisor chose to interpret test in an implausible way
        
        Time management is critical to decision making particularly if negative consequences can result. Inefficiency in such situations tends to increase (Kerstholt, 1994)
    - - 7 year accident free history
        
        positive safety culture
        
        According to Skogdalen, Utne & Vinnem 2011, the Deepwater horizon drilling rig was thought to be safe as no reported injuries or technical faults recorded for the past seven years.
- - - - LTA cement design for seal
    - - The well integrity plan was not properly designed and executed by the drilling crew on the rig, the design flaw lead to a critical component failing and subsequently failed to prevent the disaster (Norwegian Oil Industry Association 2004)
    - - communication barriers
  - - - seven year period of no recorded incidents
- - - - old computing system used
    - - LTA maintenance
      - schedule maintenance due to location of rig
  - - - secure and cap well with cement
    - - drilling plan type
      - meet regulations and standards
  - - - meets required demands
    - - impact on environment and wildlife
  - - - disassembled and moved onto next project