Learning from the Learning from the Macondo Deepwater Horizon Macondo Deepwater Horizon

blow outblow out

Feedback from the CSB Public Hearing Feedback from the CSB Public Hearing

23-24 July, 201223-24 July, 2012

Safety Performance IndicatorsSafety Performance Indicators

Preliminary Findings from the Macondo/Deepwater Horizon Preliminary Findings from the Macondo/Deepwater Horizon

AccidentAccident

The risk/reward equations on which the individual decisions seem to have been taken look as though they were strongly weighted towards getting things done quicker, and thus cheaper. The commission tabulates nine decisions where higher-risk options were chosen over lower ones; in seven of them the riskier option was also the time-saving one (in the other two the implications for time-saving are not clear). Poor management meant that there was no overall view of how the decisions interacted and thus no good sense of how these risks added up. Poor communication meant that key people on the rig were unaware of the increased risk some of those decisions were seen as entailing.

Jake Molloy, Regional Organiser National Union of Rail, Maritime and Transport

Workers (RMT)

• RMT fully supports the use of meaningful and effective indicators. However, we must emphasise the word ‘effective’, as all too often we find the actual ‘effectiveness’ of well intentioned schemes can very rapidly be diminished as managers seek to influence outcomes and meet targets.

Dangerous’ aspects of setting Key Performance Indicators

• KPI’s create a divisive environment where short cuts and non-reporting are common place, but not spoken about. In April 2012 we received £700 bonus before tax and our sister platform received just £120. I think that’s probably because the management team on our sister platform are a bit more honest than the team I work with.

Dangerous aspects of setting Key Performance Indicators

• KPI’s linked to incentives can very quickly lead to a situation where senior management believe that safety and productivity performance is good, when in fact the opposite is the case.

• production and maintenance reports are distorted or even falsified; there can be widespread under reporting or even non-reporting and this quickly becomes institutionalised;

• Transocean and BP had multiple safety management system deficiencies that contributed to the Macondo incident.

• Before the Macondo blowout, the safety approaches and metrics used by the two companies and U.S. trade associations did not adequately focus on major accident hazards. Recently BP officials informed CSB investigators that they are working to develop a more comprehensive offshore indicators program using leading and lagging metrics to help drive performance improvements.

• Systems used for measuring safety effectiveness in the offshore industry focused on personal safety and infrequent lagging indicators.

• The U.S. offshore regulator, the Department of the Interior, can achieve a greater impact on major accident prevention through the development of a leading and lagging process safety indicator program.

• Despite some significant progress with process safety indicator implementation in the downstream oil industry, in the offshore sector BP, Transocean, industry associations, and the regulator had not effectively learned critical lessons of Texas City and other serious process incidents at the time of the Macondo blowout.

• Companies and trade associations operating in other regulatory regimes outside the U.S. have developed effective indicator programs, recognizing the value of leading indicators, and using those indicators to drive continuous improvement.

• Trade associations and many of the same companies that operate in the U.S. are partnering with the regulators in other countries in advancing safety indicators programs.

• In the aftermath of the Macondo blowout, companies and trade associations in the U.S. are initiating efforts to advance the development of offshore major accident indicators.

“The emphasis on personal injury and lost work-time data obscures the bigger picture: that companies need to develop indicators that give them realistic information about their potential for catastrophic accidents. How safety is measured and managed is at the very core of accident prevention. If companies are not measuring safety performance effectively and using those data to continuously improve, they will likely be left in the dark about their safety risks.”

CSB investigator Cheryl MacKenzie