A news item in the The Wall street Journal reports the following:
"BP PLC came within 1.4 inches or less of preventing the worst offshore oil spill in U.S. history, say engineers studying the safety device that failed in last year's Gulf of Mexico disaster.
The device, known as a blowout preventer, was a massive set of valves that sat on the sea floor nearly a mile beneath the Deepwater Horizon drilling rig, which floated on the surface. It was equipped with powerful shears designed to cut through pipe and seal off the well in an emergency. Why the device failed has been one of the central mysteries of last year's disaster.
In a report released Wednesday, engineers hired by U.S. investigators say they have solved it: The force of the blowout bent the drill pipe, knocking it off-center and jamming the shears. Rather than seal the well, the blades got stuck 1.4 inches or less apart, leaving plenty of space for 4.9 million barrels of oil to leak out.
The investigators concluded the blowout preventer failed as a result of a design flaw, not because of misuse by BP or any of the other companies involved, and not because of poor maintenance. The fail-safe device, the last line of defense against a disaster, wasn't designed to handle a real-world blowout, according to investigators, who called for further study of the devices.
The report doesn't address what caused the blowout itself. That has been the subject of several other major inquiries, which all have found that a series of decisions by BP and its contractors set the disaster in motion.
Even if the device had worked, it wouldn't have saved the lives of the 11 rig workers killed in the accident. That's because no one even tried to activate the shears until after massive explosions killed the men and crippled the rig. But the device could have mostly prevented the oil spill that began when the Deepwater Horizon sank two days after the initial explosion".
How sure are you that your fail safe devices will work as intended? Today there are systems available to conduct a online partial stroke test of critical valves. But the test is done during normal operating conditions. In the case of a major upset or incident, conditions may prevent the fail safe devices from working.
Read the article in this link.
Showing posts with label BP Oil Rig Disaster. Show all posts
Showing posts with label BP Oil Rig Disaster. Show all posts
March 25, 2011
January 15, 2011
The report on the BP oil rig disaster - familiar lessons, familiar root causes
The Report to the President of USA by the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling has been released.
I have summarized the key points from the investigation report:
"The final moments:
Down in the engine control room, Chief Mechanic Douglas Brown, an Army veteran employed by Transocean, was filling out the nightly log and equipment hours. He had spent the day fixing a saltwater pipe in one of the pontoons. First, he noticed an “extremely loud air leak sound.” Then a gas alarm sounded, followed by more and more alarms wailing. In the midst of that noise, Brown noticed someone over the radio. “I heard the captain or chief mate, I’m not sure who, make an announcement to the standby boat, the Bankston, saying we were in a well-control situation.” The vessel was ordered to back off to 500 meters. Now Brown could hear the rig’s engines revving. “I heard them revving up higher and higher and higher. Next I was expecting the engine trips to take over. . . . That did not happen. After that the power went out.” Seconds later, an explosion ripped through the pitch-black control room, hurtling him against the control panel, blasting away the floor.
Brown fell through into a subfloor full of cable trays and wires. A second huge explosion roared through, collapsing the ceiling on him. All around in the dark he could hear people screaming and crying for help.
Steve Bertone, the rig’s chief engineer, had been in bed, reading the first sentence of his book, when he noticed an odd noise. “As it progressively got louder, it sounded like a freight train coming through my bedroom and then there was a thumping sound that consecutively got much faster and with each thump, I felt the rig actually shake.” After a loud boom, the lights went out. He leapt out of bed, opening his door to let in the emergency hall light so he could get dressed. The overhead public-address system crackled to life: “Fire. Fire. Fire.”
Root Causes (failures in industry):
BP’s management process did not adequately identify or address risks created by late changes to well design and procedures. BP did not have adequate controls in place to ensure that key decisions in the months leading up to the blowout were safe or sound from an engineering perspective. While initial well design decisions undergo a serious peer review process155 and changes to well design are subsequently subject to a management of change (MOC) process,156 changes to drilling procedures in the weeks and days before implementation are typically not subject to any such peer-review or MOC process. At Macondo, such decisions appear to have been made by the BP Macondo team in ad hoc fashion without any formal risk analysis or internal expert review. This appears to have been a key causal factor of the blowout.
Halliburton and BP’s management processes did not ensure that cement was adequately tested. Halliburton had insufficient controls in place to ensure that laboratory testing was performed in a timely fashion or that test results were vetted rigorously in-house or with the client. In fact, it appears that Halliburton did not even have testing results in its possession showing the Macondo slurry was stable until after the job had been pumped. It is difficult to imagine a clearer failure of management or communication.
BP, Transocean, and Halliburton failed to communicate adequately. Information appears to have been excessively compartmentalized at Macondo as a result of poor communication. BP did not share important information with its contractors, or sometimes internally even with members of its own team. Contractors did not share important information with
BP or each other. As a result, individuals often found themselves making critical decisions without a full appreciation for the context in which they were being made (or even without recognition that the decisions were critical).
Transocean failed to adequately communicate lessons from an earlier near-miss to its crew. Transocean failed to adequately communicate to its crew lessons learned from an eerily similar near-miss on one of its rigs in the North Sea four months prior to the Macondo blowout. On December 23, 2009, gas entered the riser on that rig while the crew was displacing a well with seawater during a completion operation. As at Macondo, the rig’s crew had already run a negative-pressure test on the lone physical barrier between the pay zone and the rig, and had declared the test a success.163 The tested barrier nevertheless
failed during displacement, resulting in an influx of hydrocarbons. Mud spewed onto the rig floor—but fortunately the crew was able to shut in the well before a blowout occurred.Nearly one metric ton of oil-based mud ended up in the ocean. The incident cost Transocean 11.2 days of additional work and more than 5 million British pounds in expenses.
Decision making processes at Macondo did not adequately ensure that personnel fully considered the risks created by time- and money-saving decisions. Whether purposeful or not, many of the decisions that BP, Halliburton, and Transocean made that increased the risk of the Macondo blowout clearly saved those companies significant time (and money)".
For those of you who are interested in reading the complete report, here is the link. (File is large, be patient...)
I have summarized the key points from the investigation report:
"The final moments:
Down in the engine control room, Chief Mechanic Douglas Brown, an Army veteran employed by Transocean, was filling out the nightly log and equipment hours. He had spent the day fixing a saltwater pipe in one of the pontoons. First, he noticed an “extremely loud air leak sound.” Then a gas alarm sounded, followed by more and more alarms wailing. In the midst of that noise, Brown noticed someone over the radio. “I heard the captain or chief mate, I’m not sure who, make an announcement to the standby boat, the Bankston, saying we were in a well-control situation.” The vessel was ordered to back off to 500 meters. Now Brown could hear the rig’s engines revving. “I heard them revving up higher and higher and higher. Next I was expecting the engine trips to take over. . . . That did not happen. After that the power went out.” Seconds later, an explosion ripped through the pitch-black control room, hurtling him against the control panel, blasting away the floor.
Brown fell through into a subfloor full of cable trays and wires. A second huge explosion roared through, collapsing the ceiling on him. All around in the dark he could hear people screaming and crying for help.
Steve Bertone, the rig’s chief engineer, had been in bed, reading the first sentence of his book, when he noticed an odd noise. “As it progressively got louder, it sounded like a freight train coming through my bedroom and then there was a thumping sound that consecutively got much faster and with each thump, I felt the rig actually shake.” After a loud boom, the lights went out. He leapt out of bed, opening his door to let in the emergency hall light so he could get dressed. The overhead public-address system crackled to life: “Fire. Fire. Fire.”
Root Causes (failures in industry):
BP’s management process did not adequately identify or address risks created by late changes to well design and procedures. BP did not have adequate controls in place to ensure that key decisions in the months leading up to the blowout were safe or sound from an engineering perspective. While initial well design decisions undergo a serious peer review process155 and changes to well design are subsequently subject to a management of change (MOC) process,156 changes to drilling procedures in the weeks and days before implementation are typically not subject to any such peer-review or MOC process. At Macondo, such decisions appear to have been made by the BP Macondo team in ad hoc fashion without any formal risk analysis or internal expert review. This appears to have been a key causal factor of the blowout.
Halliburton and BP’s management processes did not ensure that cement was adequately tested. Halliburton had insufficient controls in place to ensure that laboratory testing was performed in a timely fashion or that test results were vetted rigorously in-house or with the client. In fact, it appears that Halliburton did not even have testing results in its possession showing the Macondo slurry was stable until after the job had been pumped. It is difficult to imagine a clearer failure of management or communication.
BP, Transocean, and Halliburton failed to communicate adequately. Information appears to have been excessively compartmentalized at Macondo as a result of poor communication. BP did not share important information with its contractors, or sometimes internally even with members of its own team. Contractors did not share important information with
BP or each other. As a result, individuals often found themselves making critical decisions without a full appreciation for the context in which they were being made (or even without recognition that the decisions were critical).
Transocean failed to adequately communicate lessons from an earlier near-miss to its crew. Transocean failed to adequately communicate to its crew lessons learned from an eerily similar near-miss on one of its rigs in the North Sea four months prior to the Macondo blowout. On December 23, 2009, gas entered the riser on that rig while the crew was displacing a well with seawater during a completion operation. As at Macondo, the rig’s crew had already run a negative-pressure test on the lone physical barrier between the pay zone and the rig, and had declared the test a success.163 The tested barrier nevertheless
failed during displacement, resulting in an influx of hydrocarbons. Mud spewed onto the rig floor—but fortunately the crew was able to shut in the well before a blowout occurred.Nearly one metric ton of oil-based mud ended up in the ocean. The incident cost Transocean 11.2 days of additional work and more than 5 million British pounds in expenses.
Decision making processes at Macondo did not adequately ensure that personnel fully considered the risks created by time- and money-saving decisions. Whether purposeful or not, many of the decisions that BP, Halliburton, and Transocean made that increased the risk of the Macondo blowout clearly saved those companies significant time (and money)".
For those of you who are interested in reading the complete report, here is the link. (File is large, be patient...)
January 7, 2011
BP oil spill- Process safety and its Management
A news article mentions the following from the report of the presidential commission set up to investigate the BP oil sill disaster:
"A "complacent" attitude to safety and a cost-cutting culture by BP's management and that of its partners contributed to the oil spill that ravaged the Gulf of Mexico last year, the official US inquiry has ruled.
A pre-released chapter from the final report of the White House oil spill commission set up by President Barack Obama is scathing in its attack on management failure, warning that the cause of the crisis was "systemic" and that without reform of the industry a similar disaster "might well recur".
"Most of the mistakes and oversights at Macondo can be traced back to a single overarching failure – a failure of management. Better management by BP, Halliburton, and Transocean would almost certainly have prevented the blow-out," the report said.
It added: "Whether purposeful or not, many of the decisions that BP, Halliburton, and Transocean made that increased the risk of the Macondo blowout clearly saved those companies significant time (and money)."
BP staff are accused of making several critical mistakes, including the misinterpretation of a vital "negative pressure test" to check that the well had been properly sealed before removing the rig. The report said BP's "fundamental mistake" was its failure to exercise caution before relying on the cement as a barrier to the flow of oil and gas up the well.
BP's US partners, Halliburton and Transocean, do not escape censure either. Halliburton is criticised for failing to ensure the cement used to seal the well had been tested properly. Transocean, which owned and ran the rig, is attacked for not learning the lessons of a similar incident that almost led to an accident in the North Sea four months prior to the Macondo disaster".
Read the full article in this link.
"A "complacent" attitude to safety and a cost-cutting culture by BP's management and that of its partners contributed to the oil spill that ravaged the Gulf of Mexico last year, the official US inquiry has ruled.
A pre-released chapter from the final report of the White House oil spill commission set up by President Barack Obama is scathing in its attack on management failure, warning that the cause of the crisis was "systemic" and that without reform of the industry a similar disaster "might well recur".
"Most of the mistakes and oversights at Macondo can be traced back to a single overarching failure – a failure of management. Better management by BP, Halliburton, and Transocean would almost certainly have prevented the blow-out," the report said.
It added: "Whether purposeful or not, many of the decisions that BP, Halliburton, and Transocean made that increased the risk of the Macondo blowout clearly saved those companies significant time (and money)."
BP staff are accused of making several critical mistakes, including the misinterpretation of a vital "negative pressure test" to check that the well had been properly sealed before removing the rig. The report said BP's "fundamental mistake" was its failure to exercise caution before relying on the cement as a barrier to the flow of oil and gas up the well.
BP's US partners, Halliburton and Transocean, do not escape censure either. Halliburton is criticised for failing to ensure the cement used to seal the well had been tested properly. Transocean, which owned and ran the rig, is attacked for not learning the lessons of a similar incident that almost led to an accident in the North Sea four months prior to the Macondo disaster".
Read the full article in this link.
December 27, 2010
Defense Less? The story of Deepwater Horizons last moments
An investigation by the New York Times graphically depicts the last moments of the Deepwater Horizon oil rig.The article mentions the following:
"What emerges is a stark and singular fact: crew members died and suffered terrible injuries because every one of the Horizon’s defenses failed on April 20. Some were deployed but did not work. Some were activated too late, after they had almost certainly been damaged by fire or explosions. Some were never deployed at all.At critical moments that night, members of the crew hesitated and did not take the decisive steps needed. Communications fell apart, warning signs were missed and crew members in critical areas failed to coordinate a response.The result, the interviews and records show, was paralysis. For nine long minutes, as the drilling crew battled the blowout and gas alarms eventually sounded on the bridge, no warning was given to the rest of the crew. For many, the first hint of crisis came in the form of a blast wave.
The paralysis had two main sources, the examination by The Times shows. The first was a failure to train for the worst. The Horizon was like a Gulf Coast town that regularly rehearsed for Category 1 hurricanes but never contemplated the hundred-year storm. The crew members, though expert in responding to the usual range of well problems, were unprepared for a major blowout followed by explosions, fires and a total loss of power.They were also frozen by the sheer complexity of the Horizon’s defenses, and by the policies that explained when they were to be deployed. One emergency system alone was controlled by 30 buttons".
"The industry has long depicted blowout preventers as “the ultimate fail-safe.” But Transocean says the Horizon’s blowout preventer was simply incapable of preventing this blowout. Evidence is mounting, however, that the blowout preventer may have been crippled by poor maintenance. Investigators have found a host of problems — dead batteries, bad solenoid valves, leaking hydraulic lines — that were overlooked or ignored. Transocean had also never performed an expensive 90-day maintenance inspection that the manufacturer said should be done every three to five years. Industry standards and federal regulations said the same thing. BP and a Transocean safety consultant had pointed out that the Horizon’s blowout preventer, a decade old, was past due for the inspection.
Transocean decided that its regular maintenance program was adequate for the time being."
Read the full article in this link.
December 23, 2010
US Unions view of oil industry safety
An union in the US has told the CSB which is currently investigating the BP oil rig disaster about the following issues regarding safety:
"After the 2005 Texas City blast" which killed at least 15 people at BP's USW-represented Texas City, Texas refinery, "We got a federal grant to develop a process safety curriculum," he explained. "It was approved by OSHA and we offered it, for free, to the companies," where USW would train workers in safety, "if they would just pay the salaries of workers to come to it" for 3-day sessions, he added. They turned it down.
The industry's attitude extends down to the local level, the two Alaskans said. At Prudhoe Bay, until local management changed last year, bonuses depended on how few accidents managers reported. Health and safety data was "manipulated" and workers did not report accidents "for fear of being disciplined," Trimmer, Local 4959's secretary-treasurer, said. BP has "a safety matrix" for each pipeline work area, with standards set for how few accidents are allowed. Report more, the 30-year veteran said, and supervisors lose bonuses.
"One guy had a bad vehicle accident. He had a broken leg and didn't report if for three hours. When he finally had to and we asked him why he delayed, he responded that he feared being fired," Trimmer said. Overtime and fatigue are also problems: 18-hour days for 2-week stretches are technically banned, so workers toil 16 hours. Guenther, a 25-year chief steward at Prudhoe, said that from 1979 to 1994, management emphasized preventive maintenance on the pipeline, but things have gone downhill since. Workers left and were not replaced, while the oil field he worked at doubled in size. Only recently has new hiring exceeded retirements, Guenther added.
"We went from preventive maintenance to running around fixing problems at all hours of the day and night," even in Alaska's sub-zero cold, Guenther said. Problems pile up and are shoved into "a backlog." Structures at the pipeline are reaching the end of their useful working lives, 15-25 years old, developing cracks that are patched. And BP rejected the local's contract proposal for a full-time health and safety specialist.
"We have to fundamentally change how we regulate this industry - and there's an even wider gap between regulation and the industry" than elsewhere, Wright told the CSB. "What we need are effective management programs, with strong regulation, backed by strong unionization and strong worker involvement" in safety"
Read the article in this link
November 19, 2010
The familiar technical and safety failures
An article mentions the following about the BP oil rig disaster:
"A sorry catalogue of technical, safety and regulatory failures all contributed to the Deepwater Horizon oil spill in the Gulf of Mexico, according to an interim independent report commissioned by the US Department of the Interior and published today.
The oil spill began on 20 April when an uncontrolled release of oil and gas from an underwater well caused an explosion that engulfed the Deepwater Horizon rig, killing 11 crewmen on board. The leak continued until 15 July, releasing about 5 million barrels of oil into the Gulf, the largest accidental marine oil spill in history.
The report highlights a number of failures that led to the accident. It says the well had not been properly sealed with cement and that this allowed oil and gas to escape.
The "pivotal moment" came when workers carried out several pressure tests to check the integrity of the well but ignored the signs that something was wrong, said Paul Bommer, a petroleum engineer at the University of Texas at Austin and a member of the panel of experts that produced the report.
The report says the panel has not yet had time to work out why the blowout preventer, a giant valve on the seafloor which should have stopped the flow of oil as a measure of last resort, failed to activate".
Always, technical as well as safety failures occur for an incident to happen. Just by implementing management systems does not mean you can prevent an incident. Today, there is also a lot of talk about behavior based safety management systems, but as I have mentioned earlier, I am not a fan of this. It needs constant 24X7 safety oriented behaviour by top management, be it budget allocation, decision making, manpower allocation, gauging technical competency to manage cost cutting etc to ensure process safety is managed well.
Read the full article in this link.
"A sorry catalogue of technical, safety and regulatory failures all contributed to the Deepwater Horizon oil spill in the Gulf of Mexico, according to an interim independent report commissioned by the US Department of the Interior and published today.
The oil spill began on 20 April when an uncontrolled release of oil and gas from an underwater well caused an explosion that engulfed the Deepwater Horizon rig, killing 11 crewmen on board. The leak continued until 15 July, releasing about 5 million barrels of oil into the Gulf, the largest accidental marine oil spill in history.
The report highlights a number of failures that led to the accident. It says the well had not been properly sealed with cement and that this allowed oil and gas to escape.
The "pivotal moment" came when workers carried out several pressure tests to check the integrity of the well but ignored the signs that something was wrong, said Paul Bommer, a petroleum engineer at the University of Texas at Austin and a member of the panel of experts that produced the report.
The report says the panel has not yet had time to work out why the blowout preventer, a giant valve on the seafloor which should have stopped the flow of oil as a measure of last resort, failed to activate".
Always, technical as well as safety failures occur for an incident to happen. Just by implementing management systems does not mean you can prevent an incident. Today, there is also a lot of talk about behavior based safety management systems, but as I have mentioned earlier, I am not a fan of this. It needs constant 24X7 safety oriented behaviour by top management, be it budget allocation, decision making, manpower allocation, gauging technical competency to manage cost cutting etc to ensure process safety is managed well.
Read the full article in this link.
November 18, 2010
Do not ignore the warnings!
A news article mentions the following "BP and its contractors missed and ignored warning signs prior to the massive oil well blowout in the Gulf of Mexico, showing an "insufficient consideration of risk" and raising questions about the know-how of key personnel, a group of technical experts concluded.
In a 28-page report released late Tuesday, an independent panel convened by the National Academy of Engineering said the companies failed to learn from "near misses" and neither BP, its contractors nor federal regulators caught or corrected flawed decisions that contributed to the blowout.
Donald Winter, a professor of engineering practice at the University of Michigan and chair of the 15-member study committee, said in a statement that plugging of the well to seal it off for future oil and gas production continued "despite several indications of potential hazard."
No major accident happens without adequate warning. There will be enough signals that some thing disastrous is about to happen. Do not be risk blind. Read the full article in this link.
In a 28-page report released late Tuesday, an independent panel convened by the National Academy of Engineering said the companies failed to learn from "near misses" and neither BP, its contractors nor federal regulators caught or corrected flawed decisions that contributed to the blowout.
Donald Winter, a professor of engineering practice at the University of Michigan and chair of the 15-member study committee, said in a statement that plugging of the well to seal it off for future oil and gas production continued "despite several indications of potential hazard."
No major accident happens without adequate warning. There will be enough signals that some thing disastrous is about to happen. Do not be risk blind. Read the full article in this link.
November 5, 2010
What went wrong - the BP oil rig disaster
For those of you who are interested in what went wrong in the BP oil rig disaster in the Gulf of Mexico, see this excellent article.
October 14, 2010
Stronger Safety after an incident!
A news article mentions the following:
"Incoming BP boss Bob Dudley has announced the creation of a new safety division along with a management reshuffle that includes the departure of Andy Inglis, the head of the oil firm's key exploration and production division.
The group said the safety division would have "sweeping powers" to oversee and audit the company's operations around the world with the safety and operational risk department having authority to intervene in all aspects of its technical activities.
The powerful organisation is designed to strengthen safety and risk management across the group, following the Gulf of Mexico disaster that caused the biggest oil spill in US history. It will be headed by Mark Bly and report directly to incoming chief executive Dudley, who replaces Tony Hayward on Friday.
Dudley said: "These are the first and most urgent steps in a programme I am putting in place to rebuild trust in BP – the trust of our customers, of governments, of our employees and of the world at large. That trust is vital to the restoration of shareholder value which has been so adversely affected by recent events.
"Our response to the incident needs to go beyond deepwater drilling. There are lessons for us relating to the way we operate, the way we organise our company and the way we manage risk."
It is good that BP is reorganizing its safety functions. But in many companies, I keep hearing from the existing safety department that line managers do not pay heed to what they say! Look inwards into your organization and see if you are listening to you existing safety managers! They will have a lot to tell you. In fact prior to the BP Texas refinery disaster, it is reported that the safety manager had put up a slide on the key risks in which he mentioned "BP Texas refinery kills someone in the next few months"!
Read the news article in this link
"Incoming BP boss Bob Dudley has announced the creation of a new safety division along with a management reshuffle that includes the departure of Andy Inglis, the head of the oil firm's key exploration and production division.
The group said the safety division would have "sweeping powers" to oversee and audit the company's operations around the world with the safety and operational risk department having authority to intervene in all aspects of its technical activities.
The powerful organisation is designed to strengthen safety and risk management across the group, following the Gulf of Mexico disaster that caused the biggest oil spill in US history. It will be headed by Mark Bly and report directly to incoming chief executive Dudley, who replaces Tony Hayward on Friday.
Dudley said: "These are the first and most urgent steps in a programme I am putting in place to rebuild trust in BP – the trust of our customers, of governments, of our employees and of the world at large. That trust is vital to the restoration of shareholder value which has been so adversely affected by recent events.
"Our response to the incident needs to go beyond deepwater drilling. There are lessons for us relating to the way we operate, the way we organise our company and the way we manage risk."
It is good that BP is reorganizing its safety functions. But in many companies, I keep hearing from the existing safety department that line managers do not pay heed to what they say! Look inwards into your organization and see if you are listening to you existing safety managers! They will have a lot to tell you. In fact prior to the BP Texas refinery disaster, it is reported that the safety manager had put up a slide on the key risks in which he mentioned "BP Texas refinery kills someone in the next few months"!
Read the news article in this link
September 10, 2010
BP oil rig disaster internal investigation report
BP has released their internal investigation report of the oil rig disaster in the Gulf of Mexico. The report is obviously an initial investigation on the causes and does not go into why the failures occurred. This is stated by BP as follows:
It may also be appropriate for BP to consider further work to examine potential systemic issues beyond the immediate cause and system cause scope of this investigation. The summary of the report findings are given below:
1. The investigation team concluded that there were weaknesses in cement design and testing, quality assurance and risk assessment.
2. The investigation team concluded that hydrocarbon ingress was through the shoe track, rather than through a failure in the production casing itself or up the wellbore annulus and through the casing hanger seal assembly.
3.The investigation team has identified potential failure modes that could explain how the shoe track cement and the float collar allowed hydrocarbon ingress into the production casing.
4.The Transocean rig crew and BP well site leaders reached the incorrect view that the test was successful and that well integrity had been established.
5.The rig crew did not recognize the influx and did not act to control the well until hydrocarbons had passed through the BOP and into the riser.
6.If fluids had been diverted overboard, rather than to the Mud gas separator (MGS), there may have been more time to respond,and the consequences of the accident may have been reduced.
7.The design of the MGS system allowed diversion of the riser contents to the MGS vessel although the well was in a high flow condition. This overwhelmed the MGS system.
8.The heating, ventilation and air conditioning system probably transferred
a gas-rich mixture into the engine rooms, causing at least one engine to overspeed, creating a potential source of ignition.
9.Through a review of rig audit findings and maintenance records, the investigation team found indications of potential weaknesses in the testing regime and maintenance management system for the Blow out presenter (BOP).
Point no. 8 is a repeat of the ignition source in the BP Texas city refinery explosion where a pick up truck took in vapours through its air intake and triggered the initial explosion.Are we learning from our incidents?
Read the executive summary of the report in this link.
It may also be appropriate for BP to consider further work to examine potential systemic issues beyond the immediate cause and system cause scope of this investigation. The summary of the report findings are given below:
1. The investigation team concluded that there were weaknesses in cement design and testing, quality assurance and risk assessment.
2. The investigation team concluded that hydrocarbon ingress was through the shoe track, rather than through a failure in the production casing itself or up the wellbore annulus and through the casing hanger seal assembly.
3.The investigation team has identified potential failure modes that could explain how the shoe track cement and the float collar allowed hydrocarbon ingress into the production casing.
4.The Transocean rig crew and BP well site leaders reached the incorrect view that the test was successful and that well integrity had been established.
5.The rig crew did not recognize the influx and did not act to control the well until hydrocarbons had passed through the BOP and into the riser.
6.If fluids had been diverted overboard, rather than to the Mud gas separator (MGS), there may have been more time to respond,and the consequences of the accident may have been reduced.
7.The design of the MGS system allowed diversion of the riser contents to the MGS vessel although the well was in a high flow condition. This overwhelmed the MGS system.
8.The heating, ventilation and air conditioning system probably transferred
a gas-rich mixture into the engine rooms, causing at least one engine to overspeed, creating a potential source of ignition.
9.Through a review of rig audit findings and maintenance records, the investigation team found indications of potential weaknesses in the testing regime and maintenance management system for the Blow out presenter (BOP).
Point no. 8 is a repeat of the ignition source in the BP Texas city refinery explosion where a pick up truck took in vapours through its air intake and triggered the initial explosion.Are we learning from our incidents?
Read the executive summary of the report in this link.
September 8, 2010
The BP oil rig disaster
A presentation in the Global maritime Congress 2010 by Clay Maitland about the cause of the BP oil rig disaster mentions the following:
What were the underlying causes of the disaster?
• Complacency and routinism; the tendency of those within a large organisation to avoid testing established policies.
• “Bean-counteritis”; a failure to examine constraints on risk management budgets.
• Collectivism; a conviction that existing company policy is, by definition, the best that could possibly be. In American parlance, this is often called “drinking the company Kool-Aid.” It entails a rejection of rigourous analysis of internal management systems,and their appraisal for possible deficiencies.
• A failure, from top to bottom, to subject these systems to outside scrutiny, in the manner of the International Maritime Organisation’s Member State Audit Scheme.
• A tendency to stigmatise concern for the environment as something repugnantly radical, “Greenpeace Socialism”, “tree-hugging”, etc.
• Most significantly, the failure to establish a risk control or safety awareness mindset at all levels of the corporate hierarchy,particularly at middle-management levels, and to effectively offset a “get it done, at the lowest possible cost” attitude at the “coalface”.
Read the full presentation in this link
What were the underlying causes of the disaster?
• Complacency and routinism; the tendency of those within a large organisation to avoid testing established policies.
• “Bean-counteritis”; a failure to examine constraints on risk management budgets.
• Collectivism; a conviction that existing company policy is, by definition, the best that could possibly be. In American parlance, this is often called “drinking the company Kool-Aid.” It entails a rejection of rigourous analysis of internal management systems,and their appraisal for possible deficiencies.
• A failure, from top to bottom, to subject these systems to outside scrutiny, in the manner of the International Maritime Organisation’s Member State Audit Scheme.
• A tendency to stigmatise concern for the environment as something repugnantly radical, “Greenpeace Socialism”, “tree-hugging”, etc.
• Most significantly, the failure to establish a risk control or safety awareness mindset at all levels of the corporate hierarchy,particularly at middle-management levels, and to effectively offset a “get it done, at the lowest possible cost” attitude at the “coalface”.
Read the full presentation in this link
July 11, 2010
BP Oil Spill - an interesting take
I read an interesting article in Forbes.com where the writer mentions the following:
"The job of senior executives (or politicians and regulators) is to think the unthinkable. While few risks truly justify a "never failing" attitude, those that do should follow my five reliability principles:
1. Multiple things must line up before failure can occur (catastrophic failures are extremely rare).
2. Junior management error is the most frequent root cause. Why protect against something that probably won't happen?
3. Very carefully control configuration changes. In BP's case the drilling rig was being disconnected at the time of explosion.
4. Look for unintended interactions between adjacent systems. For instance, unexpected freezing conditions prevented the first BP well cap from working.
5. Be very, very careful toward the very end of long-term projects. On the day of the BP explosion plaques were being distributed to employees for seven years of uninterrupted safety".
Point number 2 in which the writer mentions that Junior management error is the most frequent cause is linked to organisational culture. With the Indian workforce becoming younger and younger, I observe a shift in the Plant manager's perception of risk. They are becoming more blind to risk due to inexperience and lack of training, and conflicting signals from top management (Top management talks about safety but does not back up its actions with resources). A recipe for disaster!
Read the full article in this link.
"The job of senior executives (or politicians and regulators) is to think the unthinkable. While few risks truly justify a "never failing" attitude, those that do should follow my five reliability principles:
1. Multiple things must line up before failure can occur (catastrophic failures are extremely rare).
2. Junior management error is the most frequent root cause. Why protect against something that probably won't happen?
3. Very carefully control configuration changes. In BP's case the drilling rig was being disconnected at the time of explosion.
4. Look for unintended interactions between adjacent systems. For instance, unexpected freezing conditions prevented the first BP well cap from working.
5. Be very, very careful toward the very end of long-term projects. On the day of the BP explosion plaques were being distributed to employees for seven years of uninterrupted safety".
Point number 2 in which the writer mentions that Junior management error is the most frequent cause is linked to organisational culture. With the Indian workforce becoming younger and younger, I observe a shift in the Plant manager's perception of risk. They are becoming more blind to risk due to inexperience and lack of training, and conflicting signals from top management (Top management talks about safety but does not back up its actions with resources). A recipe for disaster!
Read the full article in this link.
June 9, 2010
Decisions and Disasters -2
A friend of mine who is in top management in a large organization sent me this article about the BP oil spill, highlighting the following points:
"With the schedule slipping, Williams says a BP manager ordered a faster pace.Williams says going faster caused the bottom of the well to split open, swallowing tools and that drilling fluid called "mud."
We actually got stuck. And we got stuck so bad we had to send tools down into the drill pipe and sever the pipe,Williams explained.There's always pressure, but yes, the pressure was increased.He discovered chunks of rubber in the drilling fluid. He thought it was important enough to gather this double handful of chunks of rubber and bring them into the driller shack. I recall asking the supervisor if this was out of the ordinary. And he says, 'Oh, it's no big deal.' And I thought, 'How can it be not a big deal? There's chunks of our seal is now missing,'Williams told Pelley.
The BOP is operated from the surface by wires connected to two control pods; one is a back-up. Williams says one pod lost some of its function weeks before. "The communication seemed to break down as to who was ultimately in charge," Williams said. What strikes Bea is Williams' description of the blowout preventer. Williams says in a drilling accident four weeks before the explosion, the critical rubber gasket, called an "annular," was damaged and pieces of it started coming out of the well.
Investigators have also found the BOP had a hydraulic leak and a weak battery".
Read the full article in this link
"With the schedule slipping, Williams says a BP manager ordered a faster pace.Williams says going faster caused the bottom of the well to split open, swallowing tools and that drilling fluid called "mud."
We actually got stuck. And we got stuck so bad we had to send tools down into the drill pipe and sever the pipe,Williams explained.There's always pressure, but yes, the pressure was increased.He discovered chunks of rubber in the drilling fluid. He thought it was important enough to gather this double handful of chunks of rubber and bring them into the driller shack. I recall asking the supervisor if this was out of the ordinary. And he says, 'Oh, it's no big deal.' And I thought, 'How can it be not a big deal? There's chunks of our seal is now missing,'Williams told Pelley.
The BOP is operated from the surface by wires connected to two control pods; one is a back-up. Williams says one pod lost some of its function weeks before. "The communication seemed to break down as to who was ultimately in charge," Williams said. What strikes Bea is Williams' description of the blowout preventer. Williams says in a drilling accident four weeks before the explosion, the critical rubber gasket, called an "annular," was damaged and pieces of it started coming out of the well.
Investigators have also found the BOP had a hydraulic leak and a weak battery".
Read the full article in this link
May 29, 2010
Decisions and Disasters
An article titled "BP Decisions Set Stage for Disaster" alleges the following about the BP oil spill:
A Wall Street Journal investigation provides the most complete account so far of the fateful decisions that preceded the blast. BP made choices over the course of the project that rendered this well more vulnerable to the blowout, which unleashed a spew of crude oil that engineers are struggling to stanch.
BP, for instance, cut short a procedure involving drilling fluid that is designed to detect gas in the well and remove it before it becomes a problem, according to documents belonging to BP and to the drilling rig's owner and operator, Transocean Ltd.
BP also skipped a quality test of the cement around the pipe—another buffer against gas—despite what BP now says were signs of problems with the cement job and despite a warning from cement contractor Halliburton Co.
Once gas was rising, the design and procedures BP had chosen for the well likely gave this perilous gas an easier path up and out, say well-control experts. There was little keeping the gas from rushing up to the surface after workers, pushing to finish the job, removed a critical safeguard, the heavy drilling fluid known as "mud." BP has admitted a possible "fundamental mistake" in concluding that it was safe to proceed with mud removal, according to a memo from two Congressmen released Tuesday night.
Finally, a BP manager overseeing final well tests apparently had scant experience in deep-water drilling. He told investigators he was on the rig to "learn about deep water".
The last point mentioned scant experience. I am seeing a trend in many Indian Companies that indicates a steep decline in competency of personnel working in chemical industries. The lack of competency is acute at the manager level where decisions are taken during an emergency situation. With the advent of the software industry, many engineers prefer a "soft" job with them rather than sweat it out in a chemical industry! Is the stage set for another Bhopal??
Read more of the article in this link
A Wall Street Journal investigation provides the most complete account so far of the fateful decisions that preceded the blast. BP made choices over the course of the project that rendered this well more vulnerable to the blowout, which unleashed a spew of crude oil that engineers are struggling to stanch.
BP, for instance, cut short a procedure involving drilling fluid that is designed to detect gas in the well and remove it before it becomes a problem, according to documents belonging to BP and to the drilling rig's owner and operator, Transocean Ltd.
BP also skipped a quality test of the cement around the pipe—another buffer against gas—despite what BP now says were signs of problems with the cement job and despite a warning from cement contractor Halliburton Co.
Once gas was rising, the design and procedures BP had chosen for the well likely gave this perilous gas an easier path up and out, say well-control experts. There was little keeping the gas from rushing up to the surface after workers, pushing to finish the job, removed a critical safeguard, the heavy drilling fluid known as "mud." BP has admitted a possible "fundamental mistake" in concluding that it was safe to proceed with mud removal, according to a memo from two Congressmen released Tuesday night.
Finally, a BP manager overseeing final well tests apparently had scant experience in deep-water drilling. He told investigators he was on the rig to "learn about deep water".
The last point mentioned scant experience. I am seeing a trend in many Indian Companies that indicates a steep decline in competency of personnel working in chemical industries. The lack of competency is acute at the manager level where decisions are taken during an emergency situation. With the advent of the software industry, many engineers prefer a "soft" job with them rather than sweat it out in a chemical industry! Is the stage set for another Bhopal??
Read more of the article in this link
May 27, 2010
BP oil spill
An article in the Telegraph mentions that "Tony Hayward, whose leadership during the catastrophe has come under fire, insisted that his success at shaving $4bn off BP's costs last year had not contributed to lower safety standards.
"We have let people down in our defence of the shore, and we are going to redouble our efforts," he said, adding that cuts did "not have anything to do" with the accident". Read more in this link
"We have let people down in our defence of the shore, and we are going to redouble our efforts," he said, adding that cuts did "not have anything to do" with the accident". Read more in this link
May 24, 2010
Blowout Preventer
What is a blowout preventer? In the Deepwater Horizon oil rig disaster, it is suspected that the blowout preventer failed. Please see Wikepedia's explanation given below:
BOPs come in a variety of styles, sizes and pressure ratings, and usually several individual units comprise a BOP stack. Blind rams are designed to close an open wellbore. Pipe rams seal around tubular components in the well (drill pipe, casing, tubing, or coiled tubing). Shear-seal BOPs are fitted with hardened steel shearing surfaces that can actually cut through drill pipe and tool strings, if all other barriers fail. Since BOPs are important for the safety of the crew, as well as the drilling rig and the wellbore itself, BOPs are regularly inspected, tested and refurbished. Tests vary from daily test of functions of critical wells to monthly or less frequent testing of wells with low likelihood of control problems.Any of these BOPs may be installed underwater, normally with two hydraulic actuators.
Deepwater Horizon blowout
After the Deepwater Horizon drilling rig explosion on April 20, 2010, the blowout preventer should have activated itself automatically to avoid an oil spill in the Gulf of Mexico. Underwater robots were sent to manually activate the mechanism's switch, to no avail. As of May 2010[update] it is unknown why it failed.BP representatives suggested that the preventer could have suffered a hydraulic leak. Gamma-ray imaging of the preventer conducted on May 12 and May 13, 2010 showed that the preventer's internal valves were partially closed and were restricting the flow of oil. Whether the valves closed automatically during the explosion or were shut manually by ROV is unknown.
Please see this link for a pdf version powerpoint presentation of BOP (large file-be patient!).
BOPs come in a variety of styles, sizes and pressure ratings, and usually several individual units comprise a BOP stack. Blind rams are designed to close an open wellbore. Pipe rams seal around tubular components in the well (drill pipe, casing, tubing, or coiled tubing). Shear-seal BOPs are fitted with hardened steel shearing surfaces that can actually cut through drill pipe and tool strings, if all other barriers fail. Since BOPs are important for the safety of the crew, as well as the drilling rig and the wellbore itself, BOPs are regularly inspected, tested and refurbished. Tests vary from daily test of functions of critical wells to monthly or less frequent testing of wells with low likelihood of control problems.Any of these BOPs may be installed underwater, normally with two hydraulic actuators.
Deepwater Horizon blowout
After the Deepwater Horizon drilling rig explosion on April 20, 2010, the blowout preventer should have activated itself automatically to avoid an oil spill in the Gulf of Mexico. Underwater robots were sent to manually activate the mechanism's switch, to no avail. As of May 2010[update] it is unknown why it failed.BP representatives suggested that the preventer could have suffered a hydraulic leak. Gamma-ray imaging of the preventer conducted on May 12 and May 13, 2010 showed that the preventer's internal valves were partially closed and were restricting the flow of oil. Whether the valves closed automatically during the explosion or were shut manually by ROV is unknown.
Please see this link for a pdf version powerpoint presentation of BOP (large file-be patient!).
May 9, 2010
Process safety information and BP incident
A number of articles are going around on the BP oil spill incident. In one of them, a whistleblower is supposed to have raised safety concerns about BP Atlantis, the world’s largest and deepest semi-submersible oil and natural gas platform. In this article it mentions the following "It was then that the whistle-blower, who was hired to oversee the company’s databases that housed documents related to its Atlantis project, discovered that the drilling platform had been operating without a majority of the engineer-approved documents it needed to run safely, leaving the platform vulnerable to a catastrophic disaster that would far surpass the massive oil spill that began last week following a deadly explosion on a BP-operated drilling rig.
BP’s own internal communications show that company officials were made aware of the issue and feared that the document shortfalls related to Atlantis “could lead to catastrophic operator error” and must be addressed.“The risk in turning over drawings that are not complete are: 1) The Operator will assume the drawings are accurate and up to date,” the email said. “This could lead to catastrophic Operator errors due to their assuming the drawing is correct,” said Duff’s email to BP officials Bill Naseman and William Broman. “Turning over incomplete drawings to the Operator for their use is a fundamental violation of basic Document control, [internal standards] and Process Safety Regulations.” Read more of this article in this link.
BP’s own internal communications show that company officials were made aware of the issue and feared that the document shortfalls related to Atlantis “could lead to catastrophic operator error” and must be addressed.“The risk in turning over drawings that are not complete are: 1) The Operator will assume the drawings are accurate and up to date,” the email said. “This could lead to catastrophic Operator errors due to their assuming the drawing is correct,” said Duff’s email to BP officials Bill Naseman and William Broman. “Turning over incomplete drawings to the Operator for their use is a fundamental violation of basic Document control, [internal standards] and Process Safety Regulations.” Read more of this article in this link.
May 2, 2010
BP Oil Spill
The latest BP oil spill in the Gulf of Mexico could turn out to be bigger than the Exxon Valdez spill. The President of the US himself has flown to Louisana for a first hand look. One would have thought that after the BP Texas Disaster in 2005, many checks and balances would have been put to prevent another disaster. We will have to wait and see the results of the investigation...
See photos of the spill in this link
See photos of the spill in this link
April 22, 2010
Process Safety - oil rig explosion
An explosion has been reported at an oil rig contracted by BP. It appears that the CSB is considering investigating this incident. Please read full article in this link.
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