Anyone who thought safety culture and safety decision making was an institutional artifact, or mostly a matter of regulatory enforcement, might want to take a close look at what is happening on the BP/Deepwater Horizon front these days. Three BP employees have been criminally indicted - and two of those indictments bear directly on safety in operational decisions. The indictments of the well-site leaders, the most senior BP personnel on the platform, accuses them of causing the deaths of 11 crewmen aboard the Deepwater Horizon rig in April 2010 through gross negligence, primarily by misinterpreting a crucial pressure test that should have alerted them that the well was in trouble.*
The crux of the matter relates to the interpretation of a pressure test to determine whether the well had been properly sealed prior to being temporarily abandoned. Apparently BP’s own investigation found that the men had misinterpreted the test results.
The indictment states, “The Well Site Leaders were responsible for...ensuring that well drilling operations were performed safely in light of the intrinsic danger and complexity of deepwater drilling.” (Indictment p.3)
The following specific actions are cited as constituting gross negligence: “...failed to phone engineers onshore to advise them ...that the well was not secure; failed to adequately account for the abnormal readings during the testing; accepted a nonsensical explanation for the abnormal readings, again without calling engineers onshore to consult…” (Indictment p.7)
The willingness of federal prosecutors to advance these charges should (and perhaps are intended to) send a chill down every manager’s spine in high risk industries. While gross negligence is a relatively high standard, and may or may not be provable in the BP case, the actions cited in the indictment may not sound all that extraordinary - failure to consult with onshore engineers, failure to account for “abnormal” readings, accepting a “nonsensical” explanation. Whether this amounts to “reckless” or willful disregard for a known risk is a matter for the legal system. As an article in the Wall Street Journal notes, “There were no federal rules about how to conduct such a test at the time. That has since changed; federal regulators finalized new drilling rules last week that spell out test procedures.”**
The indictment asserts that the men violated the “standard of care” applicable to the deepwater oil exploration industry. One might ponder what federal prosecutors think the “standard of care” is for the nuclear power generation industry.
Clearly the well site leaders made a serious misjudgment - one that turned out to have catastrophic consequences. But then consider the statement by the Assistant Attorney General, that the accident was caused by “BP’s culture of privileging profit over prudence.” (WSJ article) Are there really a few simple, direct causes of this accident or is this an example of a highly complex system failure? Where does culpability for culture lie? Stay tuned.
* U.S. District Court Eastern District of Louisiana, “Superseding Indictment for Involuntary Manslaughter, Seaman's Manslaughter and Clean Water Act: United States of America v. Robert Kaluza and Donald Vidrine,” Criminal No. 12-265.
** T. Fowler and R. Gold, “Engineers Deny Charges in BP Spill,” Wall Street Journal online (Nov. 18, 2012).
Tuesday, November 20, 2012
BP/Deepwater Horizon: Upping the Stakes
Posted by
Bob Cudlin
Labels:
BP,
Decisions,
Deepwater,
Safety Management Decisions
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It is difficult from my perspective to understand how a federal prosecutor can assert that a "standard of care" applies to an industry in which there are no operator or manager licensing requirements. While the accused are said not to have consulted with "offshore engineers" why not indict the managers further up the line from the platform leadership who didn't send the extra engineers out to the platform to double check this highly important test?
ReplyDeleteThis would have made sense to me at points earlier in my career if I had a project 60+ days behind schedule and under a lot of pressure to wrap things up quickly.
Or why not indict the three senior and operations experienced executive that flew to the site to present safety awards and were in the pit on the day of the accident but didn't intervene.
Rickover talked about the Concept of Total Responsibility - given the long tangled management structure over this project it seems a very misguided signal to pick out two people close to the tragedy and force them to trial - no doubt at their own expense.