U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD INVESTIGATION REPORT VOLUME 3 DRILLING RIG EXPLOSION AND FIRE AT THE MACONDO WELL (11 Fatalities, 17 Injured, and Serious Environmental Damage) DEEPWATER HORIZON RIG MISSISSIPPI CANYON 252, GULF OF MEXICO KEY ISSUES: APRIL 20, 2010 • HUMAN FACTORS • ORGANIZATIONAL LEARNING • SAFETY PERFORMANCE INDICATORS • RISK MANAGEMENT PRACTICES • CORPORATE GOVERNANCE • SAFETY CULTURE REPORT NO. 2010-10-I-OS 4/17/2016 Macondo Investigation Report Volume 3 4/17/2016 [This page left intentionally blank.] 2 Macondo Investigation Report Volume 3 4/17/2016 Contents VOLUME 3 – INTRODUCTION .............................................................................................................. 15 Moving Beyond the Blowout Preventer ...................................................................................................... 19 Volume Overview ....................................................................................................................................... 20 1.0 HUMAN FACTORS ..................................................................................................................... 21 1.1 Macondo Temporary Abandonment Personnel ............................................................................. 25 1.2 Macondo Temporary Abandonment Activities: Four Phases ........................................................ 26 1.2.1 Phase 1: Presetting of the Diverter System Route ............................................................ 27 1.2.2 Phase 2: Displacement of the Drilling Mud from the Drillpipe and Upper Wellbore ...... 27 1.2.3 Phase 3: Monitoring Pressure in the Underbalanced Well ............................................... 30 1.2.4 Phase 4: Displacement of the Riser .................................................................................. 33 1.2.5 Human Performance at Macondo ..................................................................................... 34 1.3 Phase 1 – Organizational Influence on Human Performance ........................................................ 35 1.3.1 Diverter Dual Role: Operational and Emergency Mitigation Device ............................... 36 1.3.2 Organizational Policy and Practice Influence Human Performance ................................. 38 1.3.3 Diverter System Design Required Multi-Step Process to Divert Fluids Overboard ......... 41 1.3.4 Needed Improvements in Detecting Gas Influx Prior to Reaching Riser ......................... 45 1.4 Phase 2 – Seemingly Insignificant Decisions can have Great Impact in Complex Systems ......... 47 1.5 Phase 3 – Evidence of Confirmation Bias ..................................................................................... 54 1.5.1 Potential Influence of Distraction and Fatigue ................................................................. 59 1.5.1.1 Fatigue ........................................................................................................... 60 1.5.1.1 Distraction ..................................................................................................... 63 1.6 Phase 4 – Troubleshooting, Multiple Activities, and Communication Gaps Obscure Well Conditions ................................................................................................................................................... 63 1.7 Competency and Non-technical Skills ........................................................................................... 66 1.7.1 Case Study for NTS: Pressure Discrepancies between Drillpipe and Kill Line ............... 70 1.7.1.1 Role of Mudlogger ........................................................................................ 72 1.7.2 Case Study for NTS: Conversation between Well Site Leader and Onshore Engineer .... 76 1.7.3 Integration of Non-technical Skills ................................................................................... 81 1.8 Work-as-Imagined Versus Work-as-Done: The Operator/Drilling Contractor Gap ...................... 83 1.8.1 BP’s Development and Communication of the Temporary Abandonment Plan .............. 85 1.8.2 Gap between ‘Work as Imagined’ and ‘Work as Done’ at the Macondo Well ................ 91 3 Macondo Investigation Report Volume 3 4/17/2016 1.8.3 Transocean Procedural Development Policies .................................................................. 93 1.8.4 Lack of Written Transocean Procedures and Work Instructions at Macondo .................. 95 1.9 Management of Change (MOC) .................................................................................................. 102 1.9.1 Management of Change: A Missed Opportunity ............................................................ 103 1.9.2 MOC Regulatory Requirements and Good Practice Guidance ....................................... 107 1.9.2.1 Regulatory Requirements for an MOC Safety Management System .......... 107 1.9.2.2 Multi-party MOCs are an International Concern ........................................ 109 1.10 Inadequate Requirements for Incorporating Human Factors in US Offshore Operations ........... 110 1.10.1 After Macondo, Limited US Offshore Regulatory Requirements Remain for Including Human Factors .................................................................................................................................. 111 1.10.2 Good Practice Techniques and Guidance on Human Factors ......................................... 112 1.10.3 International Offshore Regulatory Requirements and Guidance .................................... 114 1.11 Conclusion ................................................................................................................................... 117 2.0 ORGANIZATIONAL LEARNING FROM INCIDENT INVESTIGATIONS .......................... 119 2.1 Joint Incident Investigations and Challenges to Disseminating Lessons Learned Between Companies................................................................................................................................................. 119 2.2 Challenges to Disseminating Lessons Globally ........................................................................... 121 2.3 Expanding Beyond Immediate Causes and Implementing Change ............................................. 126 2.4 Effectiveness of post-Macondo SEMS Requirements for Incident Investigation ........................ 127 2.5 Conclusion ................................................................................................................................... 131 3.0 SAFETY PERFORMANCE INDICATORS ............................................................................... 132 3.1 Process Safety Performance Indicators for High-hazard Work Environments ............................ 133 3.2 BP’s Selection and Use of Performance Indicators ..................................................................... 137 3.2.1 BP Corporate Policies Reflect a Focus on Production, Personal Safety, and Lagging Indicators 137 3.2.2 Individual Performance Plans Lacked Process Safety Metrics ....................................... 139 3.3 Transocean’s Selection and Use of Performance Indicators ........................................................ 143 3.3.1 Transocean Recognized Need for Process Safety Performance Indicators .................... 146 3.3.2 Transocean Bonus Awards Insufficiently Focused on Performance Relating to Process Safety and MAP ................................................................................................................................ 148 3.4 Advancing the Development and Use of Process Safety Performance Indicators ....................... 149 3.4.1 CSB Efforts to Advance Understanding and Use of Process Safety Performance Indicators 150 3.4.2 Selection of Effective Performance Indicators ............................................................... 152 4 Macondo Investigation Report Volume 3 4/17/2016 3.5 Process Safety Metrics Gleaned from the Macondo Blowout ..................................................... 157 3.5.1 Real-time Indicators for Safety Critical Elements .......................................................... 158 3.5.1.1 Well Kicks ................................................................................................... 159 3.5.2 Slow Moving Indicators for SMS Elements ................................................................... 160 3.5.2.1 Emerging MOCs Themes ............................................................................ 160 3.5.2.2 Cross Reference Indicators Between the Operator/Drilling Contractor ...... 164 3.6 Regulatory Requirements for Indicators Reporting ..................................................................... 165 3.7 Conclusion ................................................................................................................................... 166 4.0 INEFFECTIVE RISK MANAGEMENT APPROACHES AT MACONDO AND THE CHALLENGES OF THE MULTI-EMPLOYER OFFSHORE WORK ENVIRONMENT .................... 167 4.1 BP and Transocean Risk Reduction Goal: ALARP ..................................................................... 168 4.2 Contractor Safety Management Guidance Calls for Clear Definition of Roles and Responsibilities 170 4.3 Transocean did not apply its More Rigorous Corporate Risk Management Policies to the Deepwater Horizon and Macondo Well .................................................................................................... 171 4.3.1 Transocean Lacks Implementation Guidance