Deep Water Horizon

Topics: Drilling rig, Reliability engineering, Petroleum Pages: 12 (5674 words) Published: April 21, 2014
Deepwater Horizon Study Group
Working Paper – January 2011

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A High Reliability Management Perspective on the
Deepwater Horizon Spill, Including Research Implications
Emery Roei and Paul R. Schulmanii

Abstract
Looking back on events leading up to the Deepwater Horizon Spill raises questions about how the Spill is currently portrayed. We run the risk of focusing too narrowly on a sequence of particular events as the main culprit when the accidents and failures that did not happen are just as important to understand in drawing the right policy implications. Looking forward means we also have to better understand how and why “better regulation” can‟t be the only or even primary answer to more reliable deepwater drilling. Research is proposed detailing these issues from a high reliability management perspective. That research would include identification and tracking of indicators of real-time reliability from rig and drilling operators in the deepwater drilling and exploration sector.

i
ii

Center for Catastrophic Risk Management, University of California, Berkeley, CA. Professor of Government, Mills College, Oakland, CA.

1

Deepwater Horizon Study Group – Working Paper
A High Reliability Management perspective on the Deepwater Horizon Spill, Including Research Implications

Table of Contents
1.

Introduction ....................................................................................................................................... 3

2.

Control Rooms and High Reliability Management ...................................................................... 5

3.

First-Order Questions ...................................................................................................................... 7

4.

Second-Order Questions.................................................................................................................. 9

5.

Third-Order Questions ..................................................................................................................10

6.

Conclusion and Proposed Research .............................................................................................11

7.

References ........................................................................................................................................12

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Deepwater Horizon Study Group – Working Paper
A High Reliability Management perspective on the Deepwater Horizon Spill, Including Research Implications

1. Introduction
We may never know all the events that led up to the Deepwater Horizon Oil Spill, but that will not stop decisionmakers from having to explain what happened. The outlines of their storyline are already clear. The Spill was the culmination of multiple failures, human and technical. 1 What could have been prevented by way of better technology, drilling practice, industry standards, corporate responsibility and government regulation wasn‟t, and as a result a catastrophe like this became all but inevitable.

The problem with the storyline isn‟t the facts about the casing, blow-out preventer, cement, saltwater replacing the mud, and more. The real issue for us is the premature policy implications that are now being―and are going to be―drawn from this sequence of mistakes. A blame scenario built around mistake-after-mistake is one that invariably scapegoats the lack of government regulation as the ultimate culprit. For it is government regulation that ensures oversight to prevent error, and a storyline that is a catalogue of preventable error after preventable error is one that nearly always ends up at regulation‟s front door.

You see this kind of blame scenario everywhere today. Just as it is now argued that mortgage companies and investment firms were “acting rationally” in the face of government‟s failure to regulate the banking and finance sector, so too increasing numbers will be arguing that oil companies were actually...

References: 1. S. Kirchgaessner, “Mystery over crew‟s reaction times to disaster,” Financial Times, May 28,
2010, 3.
2. C. Perrow, The Next Catastrophe: Reducing Our Vulnerabilities to Natural, Industrial, and
Terrorist Disasters (Princeton, NJ: Princeton University Press, 2007), 9-10.
3. E. Roe and P.R. Schulman, High Reliability Management (Stanford, CA: Stanford University
Press, 2008).
4. J. Gapper, “BP is drilling itself into deep water,” Financial Times, May 6, 2010, 11.
6. D. Kahneman and G. Klein, “Conditions for intuitive expertise,” American Psychologist, 64
(2009): 515-526.
7. G. Klein, Sources of Power: How People Make Decisions (Cambridge MA: MIT Press, 1999).
9. D. Woods and E. Hollnagel, Joint Cognitive Systems (Boca Raton: CRC Press, 2006).
S. Tremblay (Great Britain: Ashgate Publishing, 2004).
11. E. Roth, J. Multer, and T. Raslear, “Shared situation awareness as a contributor to high reliability
performance in railroad operations,” Organization Studies 27(7), (2006): 967-987.
12. E. Rosenthal, “Our fix-it faith,” New York Times Week in Review (2010): WK 1.
Horizon, with Loss of Life in the Gulf of Mexico, 21-22 April 2010,” (July 23, 2010), 5-241. See
http://www.wadisasternews.com/external/content/document/3043/856507/1/7-23-10.pdf
15. R. Gold and G. Chazan, “BP tries to shift blame to Transocean,” Wall Street Journal, May 2223, 2010, A4.
19. I. Urbina, “Documents show earlier fears about safety of offshore well,” New York Times, May
30, 2010; 1, 16.
21. D. Hoyos, “The rig‟s blow-out preventer holds the key to what went wrong and why,” Financial
Times, May 7, 2010, 7.
22. R. Samuelson, “Oil spill reveals dangers of success,” Washington Post, June 7, 2010, A17.
23. D. Brooks, “Drilling for certainty,” New York Times, May 28, 2010, A23.
25. D. Vaughan, The Challenger Launch Decision: Risky Technology, Culture, and Deviance at
NASA (Chicago: University of Chicago Press, 1996).
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