Investigative panel releases Deepwater Horizon report–points finger at policy and practice

The Deepwater Horizon Joint Investigation Team (JIT), comprised of representatives from the Coast Guard and the Bureau of Ocean Energy Management, Regulation and Enforcement, Friday released Volume I (PDF) of its exhaustively titled “Report of Investigation into the Circumstances Surrounding the Explosion, Fire, Sinking and Loss of Eleven Crew Members Aboard the Mobile Offshore Drilling Unit Deepwater Horizon in the Gulf of Mexico, April 20 – 22, 2010.”

This first volume of the report, coming in at a hefty 288 pages, including appendices, is the result of a year-long investigation of the Deepwater Horizon disaster and looks mainly at the causes and immediate effects of the explosion, rather than the enduring environmental consequences of around 200 million gallons of oil gushing into the Gulf.

The report knocks a lack of proper oversight from the Republic of the Marshall Islands, the Micronesian island chain under whose flag the Deepwater Horizon operated, as well as the fact that firefighting efforts were overly focused on search and rescue rather than actually putting out the fire on the site. However, it reserves its strongest condemnation for Transocean, the company that owned and operated the Deepwater Horizon oil rig under contract with BP.

The JIT’s findings are in stark contrast with Transocean’s own annual report, which crowed that 2010 was “the best year in safety performance in our company’s history.”

Ultimately, the JIT report concludes:

Although the events leading to the sinking of DEEPWATER HORIZON were set into motion by the failure to prevent a well blowout, the investigation revealed numerous systems deficiencies, and acts and omissions by Transocean and its DEEPWATER HORIZON crew, that had an adverse impact on the ability to prevent or limit the magnitude of the disaster. These included poor maintenance of electrical equipment that may have ignited the explosion, bypassing of gas alarms and automatic shutdown systems that could prevent an explosion, and lack of training of personnel on when and how to shutdown engines and disconnect the MODU [Mobile Offshore Drilling Unit] from the well to avoid a gas explosion and mitigate the damage from an explosion and fire. These deficiencies indicate that Transocean’s failure to have an effective safety management system and instill a culture that emphasizes and ensures safety contributed to this disaster.

Over the course of its 130 pages of non-appendix content, the report goes into greater detail on all points. It highlights the company’s failure to prepare for the possibility of the rig sinking and points out five distinct actions undertaken in the critical initial hours of the disaster that contributed to total system failure.

More significantly, the report provides several major areas of Transocean policy and practice that led to the total failure of the rig. Among them:

  • Several maintenance audits, including one performed just weeks before the disaster, found Transocean was not doing its job in monitoring and maintaining conditions on Deepwater Horizon and other vessels.
  • Deepwater Horizon had two separate system failures in the summer of 2008 that were never investigated.
  • Transocean had no system to communicate emergencies across all workers on the rig.
  • Deepwater Horizon’s management and crew were ill trained in disaster preparedness. Just 63 percent of the crew had even gone through safety training prior to the explosion.

In a later section, the JIT indicts the corporate culture within Transocean:

Transocean also did not create a climate conducive to such analysis and reporting of safety concerns. In March 2010, Transocean hired Lloyd’s Register, a classification society, to conduct a SMS Culture/Climate Review which included auditors conducting surveys at Transocean offices and vessels over a two week period. The results indicated that “a significant proportion (43.6%) of the personnel participating in the perception survey reported that they worked with a fear of reprisal if a casualty or near miss occurred. This issue is strongly related to the company’s casualty investigation process, which nearly 40% of the participants believed was applied to apportion blame.”

At a company where employees fear reprisal for whatever reason and when there are significant costs associated with any unscheduled shutdown or delay of drilling activities, it is unlikely that the crew would report safety issues even if it identified risks.

The report goes on to detail eight pages of “Examples of Transocean’s Non-compliance with the International Safety Management Code” in an appendix. Volumes II through V of the report are scheduled to be released by July.

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