Falling Dominos The failure of the defence in depth in the Macondo disaster

Andrew Hopkins Australian National University

2

3

Blowout

Wall of well

Steel casing (tube)

Oil and gas sand layers

Annulus

Figure 5: Final intended location of cement (diagonals)

Mud

Mud

Sea surface

Sea floor BoP

Blow out

Hydro carbons

Multiple fatalities

Environ. disaster

Poor engineering decisions

Decentral- isation

Factors leading to poor engineering decision making

CEO

Business unit leader

Sub-business unit leader

Engineer

Senior engineers

Figure 1 Base level engineer reports to sub-business unit leader a decentralised organisation

CEO

Business unit leader

Sub business Unit leader

Engineer

Senior engineers

Engineer

Figure 2 - Base level engineer reports to more senior engineer

CEO

Business unit leader

Sub business Unit leader

Engineer

Engineer

Engineer

Figure 3 Engineering line reporting to CEO a centralised organisation

VP Exp and Production- GoM

Simplified version of Org structure for Exp & App, post April 14 2010, with focus on the Macondo well

Ops Mgr

Macondo well team ldr

E&A drilling eng team ldr

E&A drilling engineers

Wells Mgr- GoM

VP Drilling and Completions - GoM

Drilling Eng Mgr - GoM

VP Exp and Production- Global

Group CEO

Poor engineering decisions

Decentral- isation

Unconstrained Cost Pressure

No focus on major hazard risk

Safety = occup safety

Factors leading to poor engineering decision making

Safety metrics for GoM

Personal Safety - RIF (Recordable Injury Frequency) Process safety LOPC (Loss of Primary Containment)

Significance of LOPCs

In petroleum industry generally, LOPC (loss of primary containment) is a precursor to MAE (major accident event)

In drilling industry

LOPC is not a precursor to MAE (blowout)

Focus on LOPCs does not drive down risk of blowout

Poor engineering decisions

Decentral- isation

Unconstrained Cost Pressure

No focus on major hazard risk

Safety = occup safety

Failure to adapt process safety to drilling

Factors leading to poor engineering decision making

Failure of pressure testing

Failure to understand defence in depth

Normal- isation

Group think

Inadequate mental model

Lack of behavioural safety for MH risk

Absence of engineers on site/ limited competency

Factors leading to failure of pressure testing

Belief that well was safe (confirmation bias)

Human factors

Is confirmation bias a problem here? What can we do about it?

Is groupthink a problem a problem here? What

can we do about it? Is normalisation of deviation or partial

malfunction a problem here? What to do?

Slide Number 1Slide Number 2Slide Number 3Slide Number 4Slide Number 5Slide Number 6Slide Number 7Slide Number 8Slide Number 12Slide Number 13Slide Number 14Slide Number 15Slide Number 16Slide Number 17Safety metrics for GoMSignificance of LOPCsSlide Number 20Slide Number 22Slide Number 24Human factors