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Lessons Learned from Investigations of Oil and Chemical Industry Events

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Disclaimer The PowerPoint presentation given by Mark Griffon, Board

Member, United States Chemical Safety & Hazard Investigation Board is for general informational purposes only. The presentation represents his individual views and all references, conclusions, or other statements regarding current on going CSB investigations are preliminary in nature and do not represent a formal adopted product of the full Board. Users of this presentation should also note the contents were compiled solely for this presentation. For specific and accurate information on completed investigations, please refer to the final printed version by going to the CSB website at www.csb.gov.

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WHAT IS THE CSB? • An independent U.S. federal agency

– investigating chemical accidents – promoting prevention – public knowledge

• Authorized by Congress in 1990 • Five Board Members; approx 45 staff • Modeled after NTSB

• Intent of CSB investigations are to get to root cause(s) and

make recommendations toward prevention

• Not regulatory; no enforcement authority

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CSB Investigation Approach • Formal analysis to identify underlying technical, human

factor, management system, organizational and regulatory causes of the incident. – Beyond immediate technical events and individual actions – Focus is on improving safety NOT assigning blame

• Addressing the immediate cause ONLY prevents that exact accident from occurring again.

January 23, 2013

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Investigative Approach • Analysis of Safety Systems

– Not just how they are set up but how the systems work in real life (interviewing employees at all levels within organization)

– Why conditions or decisions leading to accident were seen as normal, rational, or acceptable prior to the accident

• More emphasis on Organizational and Social Causes – Safety culture – Organizational Structure – Cost Pressures – Regulatory Gaps and ineffective enforcement – Performance Agreements or bonus structure

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Causal Analysis

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Societal Risk Tolerance; Econonmics

Government and Regulatory Regulatory gaps; enforcement

Industry Group Best Practices; Audit function

Company Organizational structure; decision making; communicatoins

Technical and Operational Management Safety Management Systems; Performance Metrics; monitoring and feedback loop

Physical Processes and Employee activities

Technical process and the human interaction with the systems

Equipment Designed for safety, maintenance

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BP Texas City • March 23, 2005

• Blowdown drum

• Liquid hydrocarbon

• Vapor cloud explosion • 15 deaths/180 injuries

• Baker Panel

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Baker panel findings • BP had not provided effective process safety leadership

• BP had not established an open trusting relationship between management and the workplace

• Lack of a unifying process safety culture • Personal Safety emphasis; not process safety

– Reliance on low LTIR gave misleading risk indicator • Cost cutting pressures seriously degraded infrastructure

– Mgmt failed to assess impact of cost and staff reductions on safety

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Lessons Learned (?) from BP Texas City Key Organizational Findings

• Personnel checked off safety procedures as done when incomplete

• An absence of reporting of abnormal situations for fear of blame, reprisals

• No emphasis on learning from mistakes to prevent worse incidents

• Failure to respond to multiple internal surveys revealing deep problems

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PSM in the Refinery Sector

• OSHA National Emphasis Program (initiated in 2007) • OSHA “deeply troubled by the significant lack of

compliance we are finding in our inspections, and with the number of serious refinery problems that continue to occur”

• Primary areas: – Mechanical Integrity – Process Safety Information – Operating Procedures – Process Hazard Analysis

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CURRENT REFINERY INVESTIGATIONS

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Chevron, Richmond CA

January 23, 2013

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Chemical Facility Incidents DuPont Yerkes New York Hot Work Incident

Found inadequate PHA January 23, 2013

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Deepwater Horizon (DWH) Incident • April 20th, 2010

• 11 deaths

• 17 serious Injuries

• ~5 million barrels of oil spilled in Gulf

• Tremendous Economic Impact

January 23, 2013

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Summary of Event

• 9:47 PM on April 20, 2010 a flow of hyrdrocarbons came up the riser and onto the Deepwater Horizon Drill rig from the Macondo Well (Depth - 5000 feet of water; depth of well 13,000 feet below sea floor • A series of two or more explosions and a massive fire occurred shortly after •The rig sank and bent the riser and drill pipe attached to the rig •Blow Out Preventer (‘Fail Safe Device’) did not stop the flow of oil •83 Days and 5 million gallons later the oil spill is stopped

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CSB Investigation • Examine specifics of organizational factors

– Staffing and organizational structure (changes) – Safety Metrics – Awards and Bonuses – Cost and Performance Pressures (cost and production goals)

• Human factors analysis of how mistakes occurred – Reliance on human intervention – Evidence / Explanations for “inexplicable” decisions leading up

to the incident – Control / display panels – Decision making process

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‘Inexplicable decisions’ • Examining the decision making process and the

interaction of the decision makers – Transocean (driller), BP, Halliburton, regulator – Off-shore and On-shore

• Examining the information available to the decision makers

• Considering the external factors which may have effected the interpretation of information

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Organizational Learning • Transocean incident in the North Sea

– Very similar to the Macondo incident – Internal investigation report written; message did not get

to the DWH crew • BP’s 2008 internal review of safety risk mgt in the GOM

– “Insufficient awareness (of major hazards) is leading to missed signals that precede incidents and response after incidents; both of which increases the potential for, and severity of, process safety related incidents”

POSC Chief Counsel Report

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Examination of consideration of Risks • High Hazard Risks

– Examining BPs approach for assessing the risk • Safety risk was considered to be low; low level review • Regulator review

• Personal Safety vs. Process Safety – Safety professionals focused on personal safety

• Commercial Risk vs. Safety Risk – Exploration Division : Big Risk – Big Reward – Examining decisions leading up to the event

• Decisions made to save time and money

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Personal vs. major hazard safety • BP and Transocean primarily measure safety

performance using worker injury data • BP executives on the rig to mark safety record • Safety bonuses and awards are largely based

on injury data

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Safety Culture • Big risk for big reward

– Commercial risk vs. safety • Plan for worst

– Considered ‘low’ safety risk; environmental mitigation focused on spill vs. stopping a well flow • Focus on personal safety • Pay attention to warning signs

– Prior incidents – Prior audit reports

• Question data and pay attention to anomalies • Raise concerns ; stop work authority • Complacency – no ‘big’ accidents so start to not be concerned with little things • Normalization of Deviance (acceptance of deviance)

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Safety Culture Model

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Will Off-Shore Drilling and Refinery Safety be transformed like the Nuclear Industry

• Nuclear Industry, post TMI, developed a real belief that “if one of us

fails, we all fail” • Nuclear Industry agreed to collect and share accident, near miss

and indicator data (thru INPO) • Unclear whether same climate exists in Oil and Gas Industry

– Deepwater was ‘just a rogue operator’ – Sharing of ‘lessons learned’, accident data, and near miss data is limited – Public Reaction

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Leadership Challenges • Safety requires passionate and effective leadership • Tone is set at the top of the organization • Not just slogans but real commitment • Setting priorities

– Adequate resources assigned / Asset integrity • Safety and productivity are not conflicting if take a

long-term view January 23, 2013

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Factors of Complacency • Discounting risk

• Over-relying on redundancy

• Unrealistic risk assessment

• Ignoring low-probability, high-consequence events

• Assuming risk decreases over time

• Ignoring warning signs January 23, 2013

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Visibility and Communication • Downward and upward communication

– Requires a positive, open, trusting environment – Need effective measurement , monitoring and

reporting of process safety performance (e.g., injury rates are not useful and are misleading)

• If managers do not want to hear, people stop talking

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It won’t happen to me....

January 23, 2013

When anyone asks me how I can best describe my experiences of nearly forty years at sea, I merely say uneventful. I have never been in an accident of any sort worth speaking about....I never saw a wreck and have never been wrecked, nor was I ever in any predicament that threatened to end in disaster of any sort.“

Edward J. Smith

(Captain of the Titanic)

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Contact the CSB

• Web site: www.csb.gov

• Mark Griffon

– Mark.griffon@csb.gov January 23, 2013