Missing the 'bigger picture'

New findings claim industry overlooked broad safety hazards in favor of injury data in Deepwater Horizon explosion

Before the 2010 explosion aboard the Deepwater Horizon oil rig, BP and Transocean Ltd. were overly focused on personal safety metrics – such as slips, trips and falls – and gave inadequate attention to process safety hazards, according to preliminary findings from the Chemical Safety Board.

The findings were presented July 24 at a two-day CSB hearing on safety performance indicators.

CSB has been calling for expanded use of process safety indicators since its investigation into the 2005 explosion at BP’s Texas City refinery, and investigators said a strong system based on such indicators might have revealed deficiencies before the Deepwater explosion. The blast killed 11 workers and, by government estimates, spewed millions of gallons of oil into the Gulf of Mexico.

Daniel Horowitz, managing director of CSB, told Safety+Health that although nothing is wrong with working to reduce personal injury hazards, “the mistake that a lot of companies will make is assuming that if they’re bringing those numbers in the right direction, then by default they are controlling major accident hazards.”

Horowitz said infrequent catastrophic incidents are triggered by factors such as faulty design and deferred maintenance, which are different from the causes of individual worker injuries and require a higher level of attention.

In addition to blaming BP (majority owner of the oil well) and Transocean (which owned the rig being leased by BP), CSB faulted trade groups and U.S. regulators for largely focusing on personal injury data and other after-the-fact “lagging” indicators rather than using “leading” indicators to identify potential dangers.

Download papers and statements from CSB's hearing.
Download CSB's presentation (.pdf file) on the explosion.

In the case of BP, CSB investigator Cheryl MacKenzie noted an “eerie resemblance” between Deepwater and Texas City – in both cases, the company was celebrating a low injury rate shortly before the disaster occurred. “The emphasis on personal injury and lost work-time data obscures the bigger picture: that companies need to develop indicators that give them realistic information about their potential for catastrophic accidents,” MacKenzie stated in a press release. “How safety is measured and managed is at the very core of accident prevention. If companies are not measuring safety performance effectively and using those data to continuously improve, they will likely be left in the dark about their safety risks.”

Next steps

Several experts spoke during the hearing, including assistant OSHA administrator Jordan Barab, who gave an overview of the agency’s National Emphasis Programs on refineries and chemical plants.

Providing an international perspective, Andrew Hopkins, professor of sociology at the Australian National University in Canberra, pointed out that unlike Australian and Norwegian regulators, the United States does not require reporting of “well kicks.” A well kick is a hazardous influx of hydrocarbons into the wellbore (drill hole) that can be a precursor to a blowout.

CSB said a well kick occurred on the Deepwater Horizon oil rig one month before the explosion but went unnoticed for 33 minutes. BP investigated and discussed the issue with Transocean, but changes were not implemented.

Also during the hearing, CSB addressed the American Petroleum Institute’s response to the agency’s prior recommendation to develop process safety indicators for onshore industries. The Washington-based institute established Recommended Practice 754, which identifies leading and lagging indicators. CSB designated the action “open-acceptable,” meaning more work needs to be done to satisfy the recommendation.

Regarding the current investigation, Horowitz said CSB expects to issue a short report on safety indicators in a couple of months, followed by a report on blowout preventer failures in the fall and a final report on the explosion in early 2013.

While expressing confidence in CSB’s investigation, Najmedin Meshkati, professor of civil/environmental and industrial and systems engineering at the University of Southern California, offered a suggestion. In his opinion, reports from a presidential commission and National Academy of Engineering/National Research Council committee – of which he was a member – have thoroughly addressed the blowout preventer problems and most root causes. Rather than “duplicate” that work, Meshkati recommended CSB focus on issues such as workplace design, shift work, fatigue and organizational decision-making.

“They can do a great contribution to the country by concentrating on human-factors issues and safety culture issues,” he said.

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