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          In the late evening of 20th April 2010 there was an explosion and fire on the semi-submersible Deepwater Horizon, which was completing a well for BP, 50 miles from the edge of the Mississippi delta in the Gulf of Mexico. Eleven of the personnel on board the rig unfortunately lost their lives. Nine of them were employed by Transocean, the owners of the rig, and two of them by MI-Swaco, a service company. The rest of the crew successfully evacuated mostly by lifeboat and were subsequently recovered to the Tidewater platform ship, Damon B Bankston. They were finally landed in Port Fouchon twenty-seven hours after the incident. The rig continued to burn and gradually took on an increasing list, and slipped under the waves on 22nd April. The BOP was still in position on the wellhead and the riser, the pipe connecting the well to the rig was only destroyed as the rig sank in 5000 feet of water. Subsequently the well belched forth hydrocarbons, and it took the operator weeks to get the release under control. The resulting pollution with the inevitable claims, counterclaims, and government intervention kept the event on the front pages of the American newspapers for months. I followed the journalism, the senate committee interviews and the Coastguard investigation as they were taking place, and wrote a number of articles to enlighten and inform any readers I might have. What follows is the final article I wrote after the President’s investigation had been published. Elsewhere on this site I have combined the other articles into a single document for those who interested in the event.

          Towards the end of January 2011 President Obama’s National Commission on the Deepwater Horizon Oil Spill presented its report. It runs to over 300 pages, and covers much else besides the actual  Deepwater Horizon disaster itself. It is an extensive piece of investigative reporting and all of it is worth reading.

            When investigating accidents there is much talk about looking for “root causes”, and the commission  determined that the failures that resulted in the loss of the Deepwater Horizon and the lives of eleven of the personnel who worked on it, were due to problems endemic in the industry and the manner in which it has been regulated. Within a few days of the accident the Marine Management Service had been effectively disbanded to be replaced by the Bureau of Ocean Energy Management, Regulation and Enforcement, amid accusations that the now defunct body had been in the hands of the operators, and lurid accounts of the exchange of favours of all sorts in return for agreements, acceptances and approvals. However, the commission found that the MMS had been starved of funds for years, which resulted in a lack of both numbers of personnel and expertise. The dual role of the MMS as the overseer for safety and the collection of revenues was also criticised for their lack of compatibility. Of course as far as the rig guys were concerned they were just a part of the normal inspection process which involved the MMS, the Coastguard, the classification societies and flag state. All of these bodies had received nothing more than the usual courtesies while on board. Now, visiting BOEMRE inspectors are only allowed to accept water. They even bring their own food.

There is little doubt that the for many years the industry has seen regulations as nothing more than an impediment to the potential success of what-ever operation they happened to be carrying out, and therefore any action or intervention to circumvent the intent of any regulatory requirements was deemed to be acceptable. Probably a good example of this, as far as the Deepwater Horizon is concerned, was the Environmental Spill Plan lodged with the authorities by BP. It cited as their major source of expertise a gentleman who had been dead for five years, and mentioned, as did the plans for a number of other operators, that they intended to safeguard varieties of wildlife completely unknown to the Gulf of Mexico. Sometimes it appears that it is solely the boredom of the routines required to ensure that the processes remains safe that cause people to neglect or circumvent them. One cannot readily see why Halliburton should have doubted their own tests on the nitrogen cement, and carried out a second one, or why BP went ahead with the cement job before the second set of tests were completed, other than the underlying view that such activities were not really necessary. And it may be the whole attitude of “we know best” which answers the question posed by the managing director of BP, Tony Hayward.

            “What have we done to deserve this?” he asked in the aftermath of the Deepwater Horizon disaster. And even without the commission report there is a body of opinion amongst those who have had contact with BP that they are disinterested in the views, or opinions of others, even if the others are experts in their fields. It seems that BP, like many large corporations, have such a sense of the rightness of everything they do, that they are unwilling to accept any sort of alternative view. It could be this sense of rightness that resulted in the onshore staff deciding that it was acceptable to install production casing with only 9 instead of 26 centralisers, a decision which may have been one of the reasons for the  reduced the integrity of the cement job. Also for complex reasons in the temporary abandonment process, they chose to set the cement plug at 3000 feet down in the well instead of near the surface, a process outwith the existing MMS regulations.

The perception in large organisations that they know everything can result in relatively junior members of staff taking attitudes, which in some environments, might be considered to be bullying. There is anecdotal evidence that prior to the disaster Transocean staff argued with the senior BP representative on the rig as to possible next actions, but that in the end the BP rep’s requirements were accepted. Indeed some American offshore workers believe that the reason the drill crew of the Deepwater Horizon did not abandon the drill floor, when it might have been prudent to do so, was because they feared for their jobs. Whether this is true or not, it shows that the threat of being NRB’d, Not Required Back, still hangs in the air in the Gulf of Mexico.

            The report also touches on a point which has been made by one or two academics over the last few years, and which was highlighted by the investigation into the Texas City Refinery disaster, another BP misfortune, where 15 people died in 2005. This is that there is now little relationship between occupational accident and “process failures”, i.e major accidents. The accepted safety mantra in years gone by, was that if you prevented minor accidents from taking place then the major accidents would also be prevented. Even in UK, where the safety case regime has been in place for 13 years, it appears to some safety engineers that the industry concentrates on occupational accidents, such as slips trips and falls, to the point that major accidents, the events which will result in multiple deaths if not prevented, are more or less ignored. Some have said that it would take another Piper Alpha to sort this out, but it never occurred to them that this would take place in the Gulf of Mexico. This is starkly illustrated by the fact that when the Deepwater Horizon blew up there were a number of Transocean and BP executives on board to celebrate the rig’s achievement of seven years without a lost time accident. A lost time accident? This is the industry’s traditional measurement of safety, and is an accident where the unfortunate injured person cannot continue working due to the severity of the injury. In the reception areas of the rig owners and operators all over the world there used to be boards on the walls presenting the days since the last lost time accident on every one of their installations. Imagine the situation where there has been 1000 days since the last LTA and some-one trips over a door sill and twists their ankle so that they can no longer carry on working. The 1000 days are wiped out and they start again. One day, two days, three days and so on! It would be heartbreaking. The President’s commission found that even though fatalities are twice as high in the Gulf of Mexico as they are in Europe, there would appear to be far fewer injuries. This is because the LTA structure discourages reporting, resulting in a distorted view of safety in the offshore environment. European safety specialists would be amazed to find that since 2001 there have been a stunning 948 fires and explosions in the Gulf. Not far off 100 a year.

What else did the commission report? It identified the fact that the crew on the rig did not accept the signs that were presented to them that all was not well. This is not solely a problem for the offshore industry. We, as human beings, are reluctant to accept information which does not fit into our perception of what should be happening. This has been a feature of many offshore accidents, and can be identified as a component of human behaviour elsewhere. When the IRA blew the front off Harrods in December 1983 the people in the restaurant tried to pay their bills before leaving. They insisted on maintaining their normal patterns of activity in the face of evidence that they should have been getting out of there as quickly as possible. The failure to accept the evidence presented to them on board the Deepwater Horizon was manifest most notably during the testing of the cement plug. At that time, when there should have been no pressure above the cement, a pressure gauge indicated otherwise, but rather than accepting the evidence, the team on the rig decided that the gauge was faulty. There were also other unaccountable differences in pressure, which caused them to carry out a second test after they had accepted that the first might have failed. On the evening of 20th April the second negative pressure test continued to show differences in pressure between the kill line and the drill string, but this was explained away by one of the team as a known anomaly.

            People who are used to presenting UK safety cases are accustomed to having to identify a TR Temporary Refuge in which people could muster safely before taking further action to save themselves. This is of course as a result of Lord Cullen’s recommendation from the Piper Alpha enquiry, and was based on the fact that 70 people in the platform’s accommodation died in the disaster. So the safety case process would generally identify the accidents which could result in fires and explosions and then show how the TR, usually all or part of the accommodation would protect people for a period to time which would allow them to get organised for their next move. This all seems eminently sensible, and it is probable that such an emergency process was initiated when Transocean suffered from a very similar well control problem (thankfully with a different outcome) in the North Sea. However, despite the fact that these emergency procedures have been in place for years in the North Sea, and have been accepted as “best practice”, elsewhere in the world it is more likely that when the alarm bells ring the crew will muster on the open deck and get into the lifeboats. So are the risks in the Gulf of Mexico, and Nigeria and the Far East different from those in the North Sea and the UK Atlantic margin? Of course not, only the perception is different.

            The witness testimony from the BOEMRE/Coastguard investigation, which has yet to report also indicated confusion on the part of many of the rig crew as to who was in charge as the disaster developed. This is in part as a result of the drilling industry view that the person in charge of an oil rig should be a “driller”, a person who has worked up through the ranks of the drilling fraternity to eventually attain a senior position on the rig, or in their view, the most senior. This is because much of the industry believes that only drilling people can talk to other people about the main task of the rig – drilling holes in the seabed, and the fact that it is a floating object is a secondary consideration. Only a few drilling rig owners have taken the step of putting a mariner in charge at all times, even though the ISM (International Ship Management) code requires that one should be in charge when a dynamically positioned semi-submersible is “under way”. And here it appears that Transocean felt that when the Deepwater Horizon was connected to the seabed by the riser, even though its position was being maintained by its marine propulsion system, it was not under way, since the OIM, who was a driller, was in charge. There was a moment during the developing emergency when the Captain should have taken over, but it appears to have been undefined, so that even he was confused. The rig was fitted with an EDS (Automatic Disconnect System). This was a single button in the Pilot House, which when pressed would have disconnected the riser, and therefore the rig, from the BOP, and allowed it to move away. But even though the Captain was supposed to take charge during an emergency, the crew had the impression that they required the permission of the OIM to carry out the action. When he did give permission and the button was finally pressed nothing happened, probably because the connection with the subsea equipment had been destroyed by the explosions.

            And finally, and outwith any observations made by anyone in the investigations into this disaster, it is possible that constant exposure to difficulties and dangers causes one to develop a tolerance for situations which, under normal circumstances, would be unacceptable. When drilling and circulating was taking place at Macondo it seemed that the mud weight was always on the cusp, if it was too heavy it would leak away into the formation and there would be a tendency for the well to flow. As the drilling progressed it became more and more difficult to maintain this balance and over the duration of the well 3000 barrels of mud were lost to the formation, creating constant problems for the guys on the drill floor. But, they had overcome the difficulties, and it may have been the confidence developed by these successes that made the crew continue to battle with the blowout when they should actually have chosen “flight” rather than “fight”.

            There is one more report to come, that of the Coastguard/BOEMRE which is likely to be presented in March 2011. The president’s commission has already used some of the testimony in its report, and indeed the testimony has also been referenced extensively elsewhere. There are a number of possible directions to be taken by the American regulatory authorities there-after, one of which might be the introduction of a safety case regime, or something like it. But the safety case is not a silver bullet. It requires the active co-operation of everyone involved, and an honest approach to the problem of keeping the workforce alive and uninjured in what is accepted as being a dangerous environment. Everyone must take responsibility for their own safety and, possibly more importantly, the safety of others commensurate with their training, skills and responsibilities. It does not actually need a safety case to achieve this. It only requires a change of attitude.

 This will be my last comment about the Deepwater Horizon disaster, and it is my earnest hope that everyone involved in oil and gas exploration and production will take to heart all the recommendations made by the investigators, so that working offshore will become safer, not only in the Gulf of Mexico, but everywhere in the world.

 Victor Gibson. February 2011.


I have commented on the progress of the attempts to stem the leak from the Macondo well, and the investigations into the disaster elsewhere on the site. Click here to access this report.



Deepwater Horizon -The President's Report
Deepwater Horizon - The Progess of the Event

The KULLUK Grounding
The Costa Concordia Report
The Costa Concordia Grounding
The Elgin Gas Leak
The Loss of the Normand Rough
The Bourbon Dolphin Accident
The Loss of the Stevns Power
Another Marine Disaster
Something About the P36
The Cormorant Alpha Accident
The Ocean Ranger Disaster
The Loss of the Ocean Express

The Life of the Oil Mariner
Offshore Technology and the Kursk
The Sovereign Explorer and the Black Marlin

Safety Case and SEMS
Practical Safety Case Development
Preventing Fires and Explosions Offshore
The ALARP Demonstration
PFEER, DCR and Verification
PFEER and the Dacon Scoop
Human Error and Heavy Weather Damage
Lifeboats & Offshore Installations
More about PFEER
The Offshore Safety Regime - Fit for the Next Decade
The Safety Case and its Future
Collision Risk Management
Shuttle Tanker Collisions
A Good Prospect of Recovery

The History of the UT 704
The Peterhead Connection
Goodbye Kiss
Uses for New Ships
Supporting Deepwater Drilling
Jack-up Moving - An Overview
Seismic Surveying
Breaking the Ice
Tank Cleaning and the Environment
More about Mud Tank Cleaning
Tank Cleaning in 2004
Glossary of Terms

An Unusual Investigation
Gaia and Oil Pollution
The True Price of Oil
Icebergs and Anchor-Handlers
Atlantic SOS
The Greatest Influence
How It Used to Be
Homemade Pizza
Goodbye Far Turbot
The Ship Manager
Running Aground
A Cook's Tale
Navigating the Channel
The Captain's Letter

The Sealaunch Project
Ghost Ships of Hartlepool
Beam Him Up Scotty
The Bilbao OSV Conference