“...a succession of interrelated well design, construction, and temporary abandonment decisions that compromised the integrity of the well and compounded the risk of its failure…”** (p. 10)
Note, their report did not place the focus on the “attitudes, beliefs or values” of BP personnel or rig workers, and really did not let their conclusions drift into the fuzzy answer space of “safety culture”. In fact the only mention of safety culture in their 200+ page report is in reference to a U.S. Coast Guard (USCG) inspection of the drill rig in 2009 which found:
“outstanding safety culture, performance during drills and condition of the rig.” (p. 201)
There is no mention of how the USCG reached such a conclusion and the report does not rely on it to support its conclusions. It would not be the first time that a favorable safety culture assessment at a high risk enterprise preceded a major disaster.***
We also found the following thread in the findings that reinforce the importance of recognizing and understanding the impact of underlying constraints on decisions:
“The decisions, many made by the operator, BP, in the two weeks leading up to the incident, were driven by BP’s knowledge that the geological window for safe drilling was becoming increasingly narrow.” (p.10)
The fact is, decisions get squeezed all the time resulting in decisions which may be reducing margins but arguably are still “acceptable”. But such decisions do not necessarily lead to unsafe, much less disastrous, results. Most of the time the system is not challenged, nothing bad happens, and you could even say the marginal decisions are reinforced. Are these tradeoffs to accommodate conflicting priorities the result of a weakened safety culture? Perhaps. But we suspect that the individuals making the decisions would say they believed safety was their priority and culture may have appeared normal to outsiders as well (e.g., the USCG). The paradox occurs because decisions can trend in a weaker direction before other, more distinct evidence of degrading culture become apparent. In this case, a very big explosion.
* B. Casselman and A. Gonzalez, "Transocean Puts Blame on BP for Gulf Oil Spill," wsj.com (June 23, 2011).
** "Macondo Well Incident: Transocean Investigation Report," Vol I, Transocean, Ltd. (June 2011).
*** For example, see our August 2, 2010 post.