Accident Investigation & Process Safety Lessons Learned from Deepwater Horizon & Texas City

Mark Paradies President System Improvements, Inc. 238 S Peters Road Knoxville, TN 37923"865-539-2139 www.taproot.com

Deepwater Horizon & Texas City What should we learn about accident

investigation and process safety?

Mark Paradies President, System Improvements

•  US Nuclear Navy & Du Pont prior to starting SI in 1988 •  Co-Developer of the TapRooT® System •  Co-Author of the TapRooT® Book •  2 US & Foreign Patents for Root Cause Software •  Editor of the Root Cause Network Newsletter •  IEEE Root Cause Analysis Standard Committee •  Co Author of CCPS book Guidelines for Investigating

Chemical Process Incidents •  MS Nuclear Eng with Emphasis on Human Factors •  Engineer Qualified (NavSea 08) •  Certified Professional Ergonomist

This Session is •  NOT a complete review of each accident •  NOT a critique of previous investigations •  NOT an all encompassing report

•  A view of lessons NOT learned in previous reports

•  A critique of the failure to learn and prevent accident reoccurrence

•  Suggestions to improve investigations

© Copyright 2013 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. 3

BP Texas City Explosion Sources of Information

•  BP Texas City Preliminary Report •  BP Texas City Final Report •  The Baker Panel Report •  The Bonse Disciplinary Report to BP •  CSB Texas City Final Report •  Discussions with a CSB Investigator •  Press Reports on Texas City Explosion •  Watching Two Days of Texas City Deposition Videos •  Reading other Texas City Depositions •  Discussions with Plaintiff Lawyers


Deepwater Horizon Accident Sources of Information

•  Watching Multiple Days of Coast Guard / MMS Investigation Interview Videos

•  Combined Coast Guard/MMS Report •  Republic of the Marshall Island’s Report •  President’s Commission Report •  BP Accident Report Presentation •  BP Accident Report •  Transocean Accident Report •  Congressional Testimony •  Press Coverage


Investigation Problems

•  Operator tells different stories •  Witnesses dead •  Company man lawyers-up


Investigation Problems Why did he start filling the plant

when the level was already 98%?


•  Operator tells different stories •  Witnesses dead •  Company man lawyers-up



•  Need video/audio recordings of key stations in control room + data recording

•  If facility can be destroyed … need off-site back-up/storage of data

•  Primary use of videos & data is learning from everyday events/near-misses


Human Factors Causes Texas City Display

Human Factors Causes

Couldn’t obtain a picture or video of displays used but … high likelihood that detecting a “kick” could be made more apparent to drilling team.

•  Deepwater Horizon Display


Human Factors Underappreciated

•  If plant / drilling response is easy to understand … NO ACCIDENT

•  However, bad human factors treated as a minor point that operators should overcome by…

- being more careful, or with - more training, or with - better procedures / compliance

Procedure Problems •  Texas City

- Two different procedures - Neither procedure worked

•  Deepwater Horizon - Procedure written the night before - Procedure doesn’t match permit - Procedure not received until ~ 4 AM - Procedure not specific enough * cementing process * negative pressure test


Good Procedures

• Good procedures are a key part of process safety

• What is a good procedure? See your Root Cause Tree®!

• Procedure compliance isn’t possible with bad procedures


Management Doesn’t Understand •  Learning from Accidents



• “Had the six operators and one supervisor assigned to the start-up of the refinery's isomerization unit been doing their jobs, the explosion would not have happened, 15 people would not have been killed and more than 170 would not have been injured,” said Ross Pillari, President of BP Products North America.

• "The mistakes made during the start-up of this unit were surprising and deeply disturbing," Pillari said during a news conference in which BP released a 47-page interim report on its investigation.

• “The core issue here is people not following procedures," Pillari said.

• Immediate action: 5 operators and supervisors fired.

INTERIM INVESTIGATION REPORT BP Press Statement (now retracted)

Management Doesn’t Understand

•  Procedures

•  Human Factors

•  Investigations Techniques

•  Not learning across organization

•  Culture didn’t change


Management Doesn’t Understand •  Process Safety


Texas City

•  Baker Report shows lack of understanding of Process Safety

23 © Copyright 2013 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.

But Later - Joke Too Close to Reality

Management Doesn’t Understand 6 Months Before the Accident

(from the Financial Times)

But BP’s shares rose 5 per cent to 597.4p on the news because the overall results were 30-50 per cent higher than analysts had expected. Analysts said the results reflected the impact of cuts and operational improvements under chief executive Tony Hayward. In the past 18 months, BP has shed 6,500 jobs, significantly more than the 5,000 it had announced it would cut. Much of the other cost saving came from favourable exchange rate movements and lower energy bills for BP itself. Thomas Pearmain, analyst at IHS Global Insight, the consulting group, noted that it was two years since Mr. Hayward had announced a major restructuring of BP and a fundamental shift in the way the company operates. The results had shown that Mr Hayward had put his stamp on the company. “Cash costs are down by more than $3bn compared with the same period last year, which indicates that the efficiency drive that Hayward has implemented since taking over as chief executive is making strong progress,” Mr Pearmain said.

Deepwater Horizon Causal Factors •  Decide to continue drilling dangerous well (cost) •  Decide to bring in cheaper completions rig after

abandoning well by cementing and removing mud and unbalancing well (single safeguard) (cost)

•  Decide to use only 6 spacers (cost)

•  Decide to use nitrified cement (cost) •  Fail to stop at first negative pressure test failure (cost)

•  Use kill line leakage test as a successful negative pressure test (but kill line is plugged/missaligned … test not accurate) (?) - (cost)

•  Miss early indications of a blowout (?) (Cost?) •  Use wrong path for routing blowout overboard (?)

•  Blowout preventer fails to stop blowout (?)

BP Investigation & Presentation

•  Limited investigation to “immediate” causes

•  Emphasized blame on others

•  Less than forthcoming with other investigations

•  Presentation to industry misses all management system causes


Process Safety

• Placing cost ahead of complex process safety is a loser

• What does it take to have world-class process safety?

- Rickover & Nuclear Navy

• BP “co-priorities” did NOT work


© Copyright 2013 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.

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Accident Investigation & Process Safety Lessons Learned from Deepwater Horizon & Texas City