Disastrous Decisions

The Human & Organizational Causes of the Gulf of Mexico Blowout by Andrew Hopkins

Its been 10 years since the infamous Macondo disaster on the 20th Apr 2010. Killing 11 people and injuring 17 individuals, this incident costed over US$260 billion to humanity… …although the true costs must be a order of magnitude higher.

Andrew craft fully presents the “Swiss Cheese Model” assessment of the incident with several contributory factors, but overwhelmingly HUMAN FACTORS was attributed to be the root cause. However, its important to note that not all barriers are truly independent. In Macondo, a number of post-blowout barriers (BOP, etc) were depending on the effectiveness of the pre-blowout barriers (volume control, etc). Inadequately thought through barriers and risk assessments will always have unintended consequences.

Tunnel vision engineering focusing on mitigating commercial risk and not safety risks is a failure of cumulative risk assessment that many engineers are guilty of. Not focusing on cumulative risk results in leaders being swept by “consensus” decision making. Decision making must be differentiated from “consultation”. Consensus decision making breeds confirmation bias where the group wants to be seen to make the right choices, even if counter indicators are evident.

Its important to focus on “listening” during “auditing” – especially when focusing on safety. It is important to be inquisitive, inquire minor “drifts” from policy and procedures, cross the barriers of language in international operations, and “feel” the coal face – whether at the smoke shacks or coffee rooms.

The history of industrial accidents, has shown that regulations typically lag behind events and can’t be relied upon to prevent them. Anomalies that resolve with limited to no consequence shouldn’t be ignored, these are precursors to future failures.

It easy to focus and measure Personal Safety. Process Safety is inherently difficult to measure and manage. The number of such events is rare and infrequent (thankfully!). Organisations need to learn quickly and maximize the effectiveness of the learning from such events. These generational events leave learning gaps in new employees who haven’t personally lived through such a catastrophe. Organizations that fail to capitalize on these learning are bound to learn the hard way. There is old adage that is so pertinent to this – a failure to learn is same as learning to fail!