Was Deepwater Horizon / Macondo blowout a ‘systems’ accident?

Not much to say here – just an extract from a paper that modelled the accident using a control structure.

** PS. Check out my YouTube: https://youtube.com/@safe_as_pod?si=nrKljK0AeUZXTOgd

Some quotes:

· “Figure 1 finds no single root-cause or chain of behaviours to have caused the accident”

· “Although the failure of the blowout preventer is often seen as the core failure underlying the oil spill (and remains the focus of technical and non-technical research on safety interventions), a combination of interlinked events that occurred simultaneously underlie the incident”

· “These led to the earlier described non-technical skills and safety culture problems” [** SC problems…meh]

· “Many of the accident mechanisms (e.g. the unsuccessful cement job) leading to the blowout emerged from separate and distinct failures (e.g. flaws in the cement design, inappropriate foam cement slurry)”

· “It is not clear whether ameliorating these individually would have prevented the accident mechanisms from occurring, or whether the deeper-lying conditions (flaws in the design of the well, poor information sharing between contract and operating companies) would simply have created alternative accident mechanisms”

· “the conditions leading to the DH mishap can be seen as manifestations of systemic factors or “system migration to states of higher risk”

· E.g. “the lack of industry regulation for running safety critical processes created risks across the offshore system, including negating the need for formal risk assessments in the design of the well, training for managing the NPT and emergency scenarios, and maintenance and inspection routines”

· “in terms of the decision-making and risk assessment of operators, the analysis shows how ‘errors’ were shaped. In particular, the drilling crews monitor ing the progress of the well were unaware of the problems with the NPT, and their attention was split across different tasks”

Ref: Reader, T. W., & O’Connor, P. (2014). The Deepwater Horizon explosion: Non-technical skills, safety culture, and system complexity. Journal of Risk Research, 17(3), 405-424.

Study link: https://doi.org/10.1080/13669877.2013.815652