Analysis of human failure contribution to process risk – The Case of Blowout in the Gulf of Mexico
Abstract
The Gulf of Mexico is considered to have accounted for roughly 90% of the complete offshore drilling in the United States of America in terms of the oil volume that is extracted. This number can be further equated to approximately one-third of the total production of oil in the United States of America. There are more than 50, 000 wells that have been drilled here since the year 1947 and of these 4,000 wells were dug deeper than 1, 000 ft. of water. As of date, more or less 80% of the total offshore drilling happens at a depth of over 1000 ft. of water. The blowout of BP in the Macondo, in the Gulf of Mexico was regarded to be the most drastic environmental calamities to have occurred in history. A plethora of reasons can be ascribed to the prevalence of this catastrophic adversity. Tis essay analyses the complete disaster by initially offering a run-up to the disaster, progressing ahead with the analysis and finally presenting the inferences. The run-up to the disaster starts with the presentation of the various happening starting from the initiation of digging the well using Transocean’s ‘Deepwater Horizon’ till the conclusion of the disaster and analyses the root cause for the disaster. Furthermore, a few recommendations have also been offered for avoiding similar kinds of catastrophes in the future.
The BP oil spill situated in the Gulf of Mexico is intended to take its place as one of the supreme ecological catastrophes in the American history, or the same can be referred as the worst disaster in the entire planet. Like many other similar disasters on that list, it was completely avoidable.
In the initial exploration plan that BP presented to the MMS, it was believed to have attested that the company has got the ability to take action to any probable catastrophe, necessarily a spill. If such a blowout and spill occurs, then the same was estimated to be 162,000 BPD (barrels per day). However, in the plan that was proposed by BP the likelihood of a spill coupled with a blowout was assessed to be “implausible” and a situation for a probable blowout was considered “unnecessary.” The ecological impact study also came out with a conclusion that there were no vital ecological impacts that is being expected out of this drilling. BP’s proposal was approved by the MMS during April 2009.
After getting the approval from MMS, BP started working with the dynamically positioned floating drill unit of Transocean which is called as the
“Deepwater Horizon.” BP shortly completed the record setting Tiber in Mexico’s northern Gulf. BP, with the help of the “Deepwater Horizon” managed to drill to the depth of more than 40000 ft of water out of the total water depth of 35, 000ft. The Tiber well infiltrated a reservoir which according to estimated reports had reserves worth more than 3 billion barrels of oil. This was the most significant discovery of this entire disaster.
Run-up to the Mishap
On the 6th of February, the drilling of the Macondo well was resumed by the Deepwater Horizon. As the work progressed, a leak was detected on the yellow pod of the blowout preventer (BOP). The BOP contained two independent pods, one blue pod, and one yellow pod. These pods are believed to stimulate hydraulic control devices which would in turn lose the different devices on the BOP. According to the version of BP, the leak was abridged after switching from the yellow pod to the blue pod. It was later revealed that there was inadequate charge on the blue pod’s battery bank. Failures in both of the pods entail that the BOP is not possible to be activated in case of any emergency.
The Deepwater Horizon was under contract with BP as the company sought to replace Marianas with Deepwater Horizon. On the 14th of January, 2010, the MMS gave its approval for BP’s Application for Revised New Well, and the Macondo Well plan was restructured according to the substitution of the Marianas by the Deepwater Horizon. On January 31st, 2010, the Deepwater Horizon arrived on the location of the Macondo Well.
As part of the proposed plan of BP to terminate the digging of the well any further, it was intended that a 300ft cement plug be installed in the well in a depth of 3,300 ft below the seafloor. The intention behind this was to prevent wellhead seal area getting contaminated and also to offer adequate weight from the strings of the drill to keep the locking down seal intact. According to the guidelines of the MMS, it was mandatory to plug in the production casing is set below 1,000ft of the seafloor and not more than that. There were two significant interconnected operations that were to be done simultaneously. They are:
- Displacing the drilling mud with the seawater, &
- Offloading the drilling mud on to a sea vessel.
At approximately 9.47 PM CST on the evening of the disastrous blowout (20th April, 2010), an uncontrolled flow of water, oil mud, oil gas, and various other materials erupted out of the drilling riser and probably the drill pipe of the dynamically positioned drilling vessel of Transocean – Deepwater Horizon that was under a contract with BP for drilling the Mississippi Canyon 252 #1, the Macondo Well. Shortly after the outflow of oil mud, oil gas, and other materials as stated above, two explosions clubbed with a huge fire broke out. This fire which broke out continued unabated for two complete days.
The Various Failures in the BP Oil Spill
As mentioned earlier in this essay in various instances, the accident occurred on the 20th of April at the time when the whole team was aboard the Deepwater Horizon and was preparing to briefly abandon a well that was earlier drilled about 70 km away from the coast of the United States. One day prior to the accident, the entire crew had thrust cement to the bottom of the well’s borehole. This actually is a standard procedure aimed at preventing leakage of oil out of the well. On the day the mishap happened, the team were carrying out their routine checks for ascertaining that everything was fine and the well was sealed in a proper manner.
There were a couple of different issues related to safety that were identified to be the ones that resulted in such a catastrophic mishap. Each one of them are briefly described below.
1. Dodgy Cement – It was identified that the cement that was used to seal the bottom of the well was not of good quality and this poor quality cement failed to seal the bottom of the well properly, thus resulting in the leakage of both oil as well as gas.
2. Failure of the Valve - The foot of the pipe to the exterior layer was sealed using two different methods. Even this pipe was filled with cement, it had two mechanical valves that were designed for ensuring that oil and gas did not flow out of the pipe. In the case of the mishap, both these mechanical valves incidentally failed, consequently resulting in both oil and gas to travel upwards to the surface of the pipe.
3. Misinterpretation of the Pressure Test – A plethora of pressure tests were conducted by the crew aboard as part of the routine checks to ensure if the well was sealed properly or not. However, the results of such pressure tests were misinterpreted, thus resulting in the crew assuming that everything with the well was fine.
4. Leak Spotted rather slow – Irrespective of the well, being or not being, under control, the crew working in the bottom should be capable enough to detect the upward flow of oil and gas by looking at the unexpected escalation of pressure. Even though such unexpected escalation of pressure occurred exactly 50 minutes before the accident, the same was not identified and interpreted to be a leak and something wrong.
5. Second failure of Valve – Just about 8 minutes prior to the accident, a mixture of both mud and gas started pouring out on the rig’s floor. At that instance, the crew immediately tried closing a valve named the blowout preventer that is placed exactly on top of the well bore hole atop the ocean surface. This valve failed to function in the way it was supposed to.
6. Separator having been overloaded – The crew had an alternative to divert the mixture of mud and gas that poured out on the rig’s floor, away from the rig by way of venting it out through pipes in a safe manner. Rather, they diverted this mixture onto a device on the rig whose purpose was to separate small amounts of gas from a mud flow. Because of momentous increase in the mixture that was diverted, the pressure on this device increased and eventually the gas resulted in the rig to catch fire.
The Aftermath
Unnoticed, a massive quantity of hydrocarbons got into the bottom of the well as the well was being prepared for a brief abandonment. Several tests were unsuccessful in disclosing the violation or the entrance of hydrocarbons into the well. As a result of the disarticulation within the well of the upper 8,300 ft of heavy drilling fluids that contained lighter seawater, there was large diminution in pressures within the well which permitted considerable quantities of gases to develop from the hydrocarbons.
As the gases augmented within the well bore, they quickly stretched in volume as they got into the lower pressures close to the surface. There were massive amount of hydrocarbons coming out of the Macondo Well as a result of this blowout. The Deepwater Horizon was deserted shortly after the breakout of the fire, but 11 out of the total 126 crew members aboard perished. About 36 hours later the fire was put out and the vessel sank into the sea. The riser and drill pipe within twisted at the top of the subsea Blowout Preventer (BOP) and eventually slumped and creased on the seafloor, churning out gas and oil.
The oil-gas separator was aimed at preventing the seawater from getting contaminated with the oil-based drill mud and also the various other well fluids and gases which were rerouted overboard. Amidst these, due to increased volume and pressure of the fluids on the separator, emergency alarms and other shut-down equipment and procedures stopped functioning. The gas burst into flames eventually resulting in a couple of explosions that in due course reached the drill deck and killing the eleven workers who were striving to prevent the blowout. Seawater, drill mud, and other fluids in the well bore were pushed ahead of the rising and expanding gases. This stream of gases and fluids were followed by high-pressure oil, gases, and other fluids from the reservoir.
Final attempts were made on the floor of the Deepwater Horizon to reroute the gases, oil, and other fluids of the well into equipment that separates oil and gas separator. This preference was made rather than rerouting the blowing out well directly overboard.
An In-depth Overview
BP, as an organization and also the operating teams it had, lacked the functional Safety Culture and this also can be quoted as one of the contributing factors for the disaster. The system of BP was not propelled in the direction of the goal of utmost safety in all of its demonstrations but was rather geared en-route for a trip-and-fall compliance attitude rather than paying attention on the actual expedition.
There were a number of organizational issues that aided in the disaster and the same are believed to be deep rooted in the culture and history of the offshore oil and gas industry. These issues were also supported by the poor governance that is offered by the public regulatory agencies. The fundamental aspects in this regard were the BP failed to adhere to the existing progressive guidelines and relevant safety practices, namely the BAST (Best Available and Safest Technology).
Unfortunately, the three major companies that were involved in the April 20th Gulf of Mexico, Maconda oil well blowout and deep water horizon rig explosion, which took away the lives of 11 men have been pointing fingers at each other. The surprising comment that came from the Presidential Commission that went into the analysis and went into the investigation that went deeply into the disaster that created the largest oil spill ever in the history of the United States said that all the three companies have taken the right stance and that all three of them are to be blamed along with the government regulator.
The panel shared jointly by the former U.S. Senator Bob Graham and a former EPA administrator William K. Reilly sounded an ominous warning that another similar spill could happen even today if the administration does not tighten its oversight of off-shore drilling options. The Commission has gone on record stating all the three companies that were involved in the blowout cases – British Petroleum, which is the major shareholder, Halliburton that was pushing cement into the well when the blowout occurred, as well as Trans-Ocean – the drilling contractor took uneasy short guts simply to save time and money. This was done when much less riskier options were available and could have been used to prevent the blowout.
Another important reason that seemed to have caused this problem was that these three major companies and their sub-contractors were not communicating effectively with each other, and this improper communication caused the well to erupt, rig to explode, followed by five million barrels of oil going into the sea.
The systems of BP were not insightful of one having up to date, exposure, or just organizational cultures. BP’s system displayed very little substantiation of being a high-reliability organization that possesses a fast learning culture that had the enthusiasm and proficiency to make the appropriate inferences and eventually make the right decisions from the safety signals indicated by the system.
Better management controls by BP, Trans-Ocean as well as Halliburton would have definitely prevented and mitigated the blowout by adopting simple improvisations and empowering individuals involved in the operations directly to identify as well as quantify the risks that they faced in the day-to-day operations.
There was definitely a process requirement to be able to evaluate, effectively communicate the same, as well as addressing them in a timely manner in order to prevent the loss of 11 precious lives and also untold harm and damage to the local environment. There is also a saying which says that deep water horizons blowout preventer was failed, and had not been deployed on the sea floor. This is one of those classic low probability and high impact incidents, improbable but possible. This blowout seems to have happened when the natural gas and oil escaped from the well, shooting up through the well pipe, expanding and igniting.
Blowout preventers usually sit on the well head and are supposed to automatically shut-off the flow and tamp the well. However, on deep water horizon, both switches – the manual as well as the automatic switch, seemed to have failed automatically. This certainly indicates directly with the systemic problems and not just to the mechanical failure of these switches. These failures happen way beyond the mechanical issues, and encompass people working on the platform, corporate hierarchies as well as bureaucratic systems that oversee the operations of such large and sensitive work.
Inference
There were multiple occasions and chances to correctly judge the probabilities and repercussions of organizational decisions with regard to Risk Assessment and proper Management, that were presumably driven by the desire of the management of BP to “seal the competitive space” and improve the organizational bottom-lines and performance. As a result, despite having had multiple chances to do the right things in the right manner at the right times, the perspective that the management of BP was futile in identifying and admitting its own fallibilities regardless of a record of latest accidents in the United States and a sequence of promises to change the safety culture of the organization.
The various failures pertaining to contain, manage, alleviate, plan, and crackdown which stretched out and in due course drove this tragedy seem to be profoundly rooted in a multi-decade record of organizational failures and lack of forethought.
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