EDITORIAL COMMENTS: Invisible fog of doom

October 7, 2010

Let’s put aside the inflammatory accusations of BP’s blunder in the Gulf, summarized in Mother Jones, magazine’s September/ October issue cover story: the company “has to lie, cheat and stall its way out of a problem;” scientists have been bribed to keep their research secret; fishermen have been paid off to avoid rioting; BP’s Gulf oil-spill plan included a wildlife assessment for walruses and an on-call expert who has been dead for years.

OK, we get the picture.

And let’s back off from conclusions reached in an Associated Press article published this summer: 1) disasters of all sorts result from the acts of stupid, thoughtless, arrogant, people; 2) a cycle of hubris is more or less a hopeless condition of human nature.

BP: Such an easy target

Damning critiques could fill a library since the Deepwater Horizon rig went down on April 20. We’ll let investigators tackle the big picture. What is important for safety and health pros with day-to-day responsibilities is the question posed by The Wall Street Journal:

“Why didn’t the crew recognize the warning signs in the final hours?”

For safety and health pros, the event might be a collapsing trench, a hole in a roof, a forklift in reverse, an explosion from accumulated dust, a shirt caught on a conveyor, a crane that tips over, trash that catches fire, a car wreck, a slip on ice.

If the signs were present, why didn’t someone catch them?

Actions in the final hours before virtually any high-consequence incident (in aviation, the nuclear industry, oil and chemical processing industries, etc.) are connected to so-called upstream organization issues: management decisions gone wrong, corporate hubris, maintenance cuts. Those are often easier to document with a paper trail of emails, etc. than what went down in the final hours. That can be shrouded in an invisible fog of botched communications and misunderstandings, much to the frustration of professionals looking for answers.

Fatal alignment

The fog descends in the form of disruptions, distractions and disagreements, for example. Workers become disoriented, perhaps worsened by fatigue.

In the case of the Deepwater Horizon rig, the fog built up gradually throughout the day of April 20. How? For one thing, key changes took place, changes to a critical safety test of the well’s stability that were “unorthodox,” not well-explained nor understood on the rig, according to The Wall Street Journal report. There was disagreement about the need for and timing of making the change. Control room operators struggled to interpret test readings.

A critical shift change occurred at 6 p.m. on April 20. The dayshift tool pusher supervisor who said “something wasn’t right” with the drilling operation was replaced by the nightshift supervisor who said “nothing unusual” was going on.

“Management of change,” a critical component of process or system safety, was poorly executed. It contributed to the developing fog.

Conditions for catastrophe

There were other contributors:

Key managers were out of the loop for part of the day. The BP manager of the rig was onshore attending a training class, with his cell phone off.
Two Transocean managers were tied up hosting executives on the rig for a safety awards ceremony.
Accountability was unclear and diffused. Who was in charge of the rig: Transocean or BP? Decisions were made at BP headquarters in Houston, and on the rig 50 miles off the Louisiana coast.
Ironically, accountability and chain of command were undermined by a culture of employee empowerment, according to the testimony of one BP official. Asked repeatedly at a federal hearing in August to name one person on board the rig on April 20 to enforce BP’s so-called “golden rules of safety,” BP’s Senior Vice President Kent Wells would only reply, “Our culture is meant that everyone is supposed to feel responsible.”
Employees did take responsibility. A 54-yearold Transocean worker, the most senior of the 79 Transocean workers aboard the rig, protested in a morning meeting about the procedural changes to testing the well. “This is how it’s going to be,” he was told by a BP manager, according to The Wall Street Journal.

Mike Williams, a Transocean employee in charge of maintaining the rig’s electronic systems, protested to a supervisor after discovering the physical alarm system had been disabled a full year before the disaster, and a crucial safety device designed to shut down the rig’s control center in the case of dangerous gas levels being detected had been bypassed. “Damn thing has been in bypass for five years,” he was told, according to The Journal.
Workers out on the isolated drill platform were continually multi-tasking, tired and bored, all at the risk of missing signs that the well was slipping out of control. “I was so tired,” 23-year-old Chris Choy, a roustabout, told PBS TV after finishing another 12-hour shift on April 20. Fatigue fogs thinking and reactions.
Fear fogs thinking, too. According to The New York Times, workers on the Deepwater Horizon were afraid to report mistakes for fear of reprisals. Or losing bonus money. Incentive performance targets that determined bonuses for top managers and low-level employees took into account the number of days it took to drill 10,000 feet, idle time (or downtime), and output in terms of barrels per day, according to The Wall Street Journal.
The culture of total safety described by the BP VP was not the only culture at work on the Deepwater Horizon. Press reports tell of a culture of competitiveness that bred impatience and insecurity. The pressure was on to keep BP the number one oil producer in the Gulf, as it was in 2009. Pressure was ongoing to catch up to Royal Dutch Shell and Exxon Mobil in the global market. Insecurity came by way of workers knowing that their rig was known as a “nightmare well” among BP colleagues - the least efficient BP rig working in the Gulf, $29 million over budget for 2010, with 44 percent of its day non-productive, according to a BP chart as reported by The Journal.

So out of this clash of cultures, poor communication, pressure, impatience, confusion and fatigue a fog enveloped the Deepwater Horizon on April 20.

Common root causes

In the 1990s, Dr. Edward Zebrowski studied the Chernobyl nuke meltdown the Piper Alpha oil rig fire, the Bhopal gas release, and the Challenger space shuttle explosion. He categorized common contributors to the fog of doom, many on display in the Gulf on April 20:

Diffuse responsibilities. Dissent not allowed. Safety subordinate to other performance goals. Undefined responsibility and authority for safety.

The 126 Deepwater Horizon workers were not stupid and arrogant people in the final hours. They were caught in a quickly mushrooming fog.

Check your incident reports and investigative findings. How often are perceptions and recollections of what happened clouded or contradictory? What contributed to the fog? And if a culture of safety has somehow diffused accountability to the point no one is in charge, you need a culture change - immediately.