CSB investigators blame Deepwater Horizon disaster on companies39 emphasis on personal safety rather than process safety CSB

CSB investigators blame Deepwater Horizon disaster on companies' emphasis on personal safety, rather than process safety.

CSB: Critical Lessons from 2005 BP Texas City Refinery Explosion Ignored

Citing progress overseas and in U.S. refining and chemical sectors, CSB investigators conclude offshore oil exploration and production safety will benefit from effective use of major accident indicators.

In preliminary findings released July 24 at a public hearing in Houston, U.S. Chemical Safety Board (CSB) investigators examining the Deepwater Horizon explosion in the Gulf report that companies like Transocean and BP, trade associations and U.S. regulators largely judged the safety of offshore facilities by focusing on personal injury and fatality data (such as dropped objects and slips, trips and falls), rather than using leading indicators more focused on managing the potential for catastrophic accidents.  

“A number of past CSB investigations have found companies focusing on personal injury rates while virtually overlooking looming process safety issues – like the effectiveness of barriers against hazardous releases, automatic shutoff system failures, activation of pressure relief devices and loss of containment of liquids and gases,” said CSB Chairman Dr. Rafael Moure-Eraso. “Furthermore, we have found failures by companies to implement their own recommendations from previous accidents involving, for example, leaks of flammable materials.”

Expanded use of process safety indicators was first recommended by CSB in its 2007 report on the March 2005 BP Texas City refinery disaster. In the offshore arena, potential indicators – such as timely checks on safety critical equipment and response to well control events – would provide an assessment of the health of their safety management systems. These types of indicators may be precursors to the kind of tragedy that killed 11 workers on the Deepwater Horizon drilling rig following the Macondo well blowout on April 20, 2010.

The preliminary findings were presented during the second day of a 2-day hearing called by the CSB to examine the need for the U.S. offshore drilling and production industry – and the agencies that regulate it – to develop process safety indicators that will result in safety improvements and reduce the likelihood of major accidents.  

"Eerie" Similarities

In its investigation of the Macondo disaster, the CSB found that BP and its contracted drilling rig operator, Transocean, were focused on personal safety issues such as worker injury rates, rather than broader safety issues involving the process of drilling for oil using a complex rig. Noting the lack of sustained focus on process safety, CSB Investigator Cheryl MacKenzie described an “eerie resemblance” between the 2005 explosion at the BP Texas City refinery and the explosion aboard the Deepwater Horizon.  

At the BP Texas City refinery on March 23, 2005, contract workers had just returned to temporary trailers at the plant after attending a celebratory lunch commending an excellent personal injury accident record. Shortly after lunch, an explosion occurred during process startup, killing 15 and injuring 180 others.

At Macondo, BP and Transocean officials were in the process of lauding operators and workers for a low rate of personal injuries on the very day of that tragedy. Company VIP’s had flown to the rig in part to commend the work force for zero lost-time incidents.  

“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,” said  MacKenzie. “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.”

 

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