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Jan 4, 2017

Work as Imagined vs. Work as Done: Presentation Highlights CSB’s Macondo Findings

On 20 April 2010, a multiple-fatality accident occurred at the Macondo oil well approximately 50 miles off the coast of Louisiana in the Gulf of Mexico. Eleven people were killed, and 17 were seriously injured. The US Chemical Safety Board (CSB) released its final investigation report from this incident in April 2016. Mary Beth Mulcahy, an investigator with the CSB, will present the results of the investigation at a meeting of the SPE Gulf Coast Section (GCS) Safety and Environmental Study Group on 10 January in Houston.



When conducting an investigation, the CSB builds on previously published investigation reports by analyzing evidence that, in some respects, became available only following their publication. An overview of the event and investigation report recommendations are available on the CSB website. This site also includes all four detailed reports. Given the global interest in this topic, SPE will also provide access to the event via webinar for any members interested in the topic but unable to attend in person. To register for the presentation or find more information about the webinar, visit the SPE GCS website.

Mulcahy’s presentation will provide highlights regarding the drilling contractor/operator relationship. The drilling contractor brings the infrastructure (drilling rig), supplies the majority of the workforce, and has more direct control over the primary operations (drilling) and emergency response (well control). The operator, though, is responsible for the well’s design and drilling program, which form the basis for establishing safe drilling operations, and should account for site-specific conditions that could increase the risk or complexity of the contractor’s various drilling and well control operations. As exemplified at Macondo, the operator and drilling contractor must actively work to bridge the gap between “work as imagined” in the drilling program and “work as done” by the well operations crew.

An excerpt from the executive summary of the report follows. The executive summary also provides a much more detailed listing of the key investigative findings and conclusions that highlights the complex, closely connected interplay of technical, human, organizational, and regulatory factors.

Recommendations Summary
In Volumes 1 and 2 of the CSB Macondo Investigation Report, the CSB issues two recommendations to the Bureau of Safety and Environmental Enforcement (BSEE) within the US Department of Interior, recommending requirements for managing safety-critical elements and developing guidance to fulfill those new regulatory obligations.

The CSB also issues two recommendations to the American Petroleum Institute, recommending the publication of an offshore standard for the effective management of technical, operational, and organizational safety critical elements and revisions to API Standard-53 requirements for testing and monitoring of blowout prevention systems.

Volume 3 contains six recommendations. The CSB issues one to the American Petroleum Institute to revise API Recommended Practice 75 to expand Safety and Environmental Management Systems (SEMS) responsibilities beyond just the operator; include explicit and expanded responsibilities for human factors, corporate governance, workforce involvement, contractor oversight, and key performance indicators; and incorporate the principles of a risk reduction concept [e.g., as low as reasonably practicable (ALARP)] and the hierarchy of controls.

Three recommendations to the US Department of Interior concern developing industry guidance on human factors and corporate governance and establishing a process safety culture improvement program.

The CSB issues one recommendation to the Sustainability Accounting Standards Board (SASB) to update, strengthen, and finalize the SASB’s provisional Oil and Gas Exploration and Production Sustainability Accounting Standard to expand its reporting recommendations to include disclosure of additional leading and lagging indicators, safety goals based on annual statistical analysis of industry data, and emphasis on the preventive value of leading and process safety indicators and the active monitoring of barrier effectiveness.

Finally, the CSB issues one recommendation to the Ocean Energy Safety Institute to conduct further study on riser gas unloading scenarios and publicize those learnings to advance industry understanding of this well operations risk.

Volume 4 issues five recommendations to the Department of Interior. In brief, the CSB recommends revision and augmentation of existing offshore oil and gas safety regulations, including the SEMS Rule, to a more robust risk management regulatory framework that embodies key regulatory attributes found in other global offshore regions, including but not limited to systematic analysis and documentation by the responsible companies that risks have been reduced to ALARP and barriers are effective to manage major accident hazards.

The other four recommendations involve

  • Augmenting the capabilities and functioning of BSEE to empower it with the explicit regulatory authority to proactively assess industry safety management programs and practices before major accidents occur through preventive inspections, audits, and review and acceptance of regulatory-required safety management documentation
  • Expanding BSEE staff to increase collective experience, diversity, and competencies in technical and safety-critical fields of study, including human and organizational factors and process safety
  • Improving the offshore safety regulatory reporting program to focus on leading process safety indicators and barrier performance metrics that drive continual safety improvements of industry through specific indicator data trending, goal-setting, and transparency
  • Strengthening regulatory requirements to improve worker engagement in major accident safety management, including but not limited to workforce-elected safety representatives and committees; authority and opportunity to interact with management and the regulator on safety concerns through proactive mechanisms; tripartite collaboration between workforce, industry, and regulator; and worker protections to encourage all such activities

Download the complete executive summary here (PDF).