Trying to keep track of the Gulf Investigations

I began writing this post as an open letter to Senator Graham and Administrator Reilly as they embarked in their work as co-chairs of the Presidential Commission on the BP Deepwater Horizon oil rig catastrophe. I planned to urge them to read investigation reports on the BP Texas City disaster because both the US Chemical Safety Board and the Baker Panel challenged BP (and others in the oil and gas sector) from using "lost-time injury rates" to assess safety performance.

I quickly learned, however, that Mr. Graham and Mr. Reilly are not the only individuals who should read these reports. I've identified at least six groups involved in "investigating" the BP Deepwater Horizon disaster:

• Presidential Commission
• 30-day safety review
• Dept of Interior's new Outer Continental Shelf Safety Oversight Board
• National Marine Board, National Academies
• Departments of Interior and Homeland Security internal review
• National Academy of Engineering

So far, there's spotty information on the specific charges for each group. EmptyWheel has one of the best assessments to-date of the Presidential Commission's authority and scope of work. She calls into question the Administration's characterization that their Commission is "similar to the one" proposed by Congresswoman Lois Capps (D-CA) and Senator Sheldon Whitehouse (D-RI). EmptyWheel dissects the Commission's charter and finds plenty of significant differences including no subpoena power, and no prohibition from service of individuals who had relationships with MMS.

For the other five investigation parties I identified, there's little in the public domain about their specific assignments. This makes me wonder whether these announcements were made before the powers-that-be have really figured out the purpose of these various investigations. I, for one, want at least one of these teams to focus intently on the work organization and work processes on the rig and in the corporate offices that oversaw it. I have a haunting feeling that if skilled investigations, such as those at the CSB who investigated the March 25 BP Texas City disaster, asked the right questions and probe the records, similarities will abound.

The late Carolyn Merritt, former chair of the US Chemical Safety Board, said of the agencies 50 significant investigations, "none was more important" than the one examining the March 2005 BP Texas City refinery explosion. Fifteen workers were killed, making it one of the worst industrial disasters since 1990. Among the CSB's findings:

"operators involved in the startup were fatigues, having worked 29 straight days of 12-hour shifts. By the day of the start-up, the board operator had an accumulated sleep debt of 43 hours. Sleep deprivation and fatigue have been cited as important causes of accidents in many sectors...but the petrochemical industry lacks established guidelines for preventing worker fatigue."

The occupational health community knows that extended work shifts is associated with adverse health consequences and safety risks. Which, if any, of the six investigation teams will be asking questions about shift work on the BP Deepwater Horizon rig?

The CSB report also noted:

"...Like many other companies, BP relied excessively upon a single measurement ---occupational injuries and illnesses (the lost-time injury rate) ---to assess safety performance. In a complex facility like an oil refinery, the occupational injury rate is a measure of personal safety but does not predict the likelihood of a catastrophic process-related event."

When I listened to BP Deepwater Horizon rig survivor, Mike Williams, describe his experience on the rig, the work sounded as complex as what a worker would experience in a refinery.

Like the CSB, the Baker Panel made a similar conclusion about using injury rates as a measure of safety performance:

"BP's reliance on injury rates significantly hindered its perception of process risk. ...BP's corporate safety management system for its US refineries does not effectively measure and monitor process safety performance."

Fast forward to Transocean's website (which curiously has a URL with the phrase "deepwater"):

In 2009, Transocean recorded its best ever TRIR (no recordable incidents) in the company's history. ...Many challenges still remain ahead in 2010, but hope to continue this success and beat our record again! In addition to this achievement we celebrated the facts:

38 Rigs with Zero TRIR (no Recordable Incidents)
67 Rigs with Zero Serious Injury Cases
4 of our rigs achieved our Safety Vision of Zero incidents

When we challenge ourselves and ask if the Safety Vision is something we can achieve each day, these installations epitomize the total approach we take to QHSE leadership.

As I've written before, lost-time injury incidents are not an adequate metric for evaluating the overall safety performance of firms in many sectors, including oil, gas and other extraction industries. It's plain to see that Transocean relies heaving on injury-incident rates to characterize its safety culture. A quick search of its 2009 Annual Report for investors reveals how management bonuses are determined, in part, by these rudimentary measures of safety peformance:

"...through a combination of our total recordable incident rate ("TRIR"), and the total potential severity rate ("TSPR"), and through high-potential dropped objects ("HPDO"). ...HPDO is calculated by multiplying the mass of the object by the height dropped and then applying an industry standard formula to determine potential severity. ...The Committee set our TRIR target for 2009 at 0.82, our TPSR target at 30...which would result in a named executive officer receiving a payout of 20% of the target bonus amount for this performance measure."

Transocean's Annual Report goes on to explain that in 2009, they achieved their "best-ever" TRIR of 0.77.

They had four employees killed in 2009 on their rigs. So much for what a TRIR tells you about the firm's safety performance.

The Transocean annual report, dated March 24, 2010, says:

"...we have embarked on a thorough review of our safety systems across our fleet to help us enhance procedures and processes that will assist us in achieving this goal."

Which, if any, of the six investigation teams will be asking questions about their review of their safety systems? Does anyone know if any of the six investigation teams have been charged with examining the worker health and safety issues, including process safety? If any one of these teams wants to get to the bottom of what happened, they'll need to look at process safety:

"Process safety hazards can give rise to major accidents involving the release of potentially dangerous materials, the release of energy (such as fires and explosions), or both. Process safety incidents can have catastrophic effects and can result in multiple injuries and fatalities, as well as substantial economic, property and environmental damage. ...[It] involves the prevention of leaks, spills, equipment malfunctions, over-pressures, excessive temperatures, corrosions, metal fatigue, and other similar conditions. Process safety programs focus on the design and engineering of facilities, hazard assessments, management of change, inspection, testing, and maintenance of equipment, effective alarms, effective process controls, procedures, training of personnel, human factors." [Baker Panel, Jan 2007]

Here's what I've been able to pull together about these other investigations:

A 30-Day Safety Review by Dept of Interior: On April 30, ten days after the disaster, President Obama requested a 30-day safety review. The results of that review should be released at the end of this week; perhaps they will be similar to what the Labor Department prepared following the Massey Mine disaster.

Outer Continental Shelf (OCS) Safety Oversight Board: On May 18, Interior Secretary Ken Salazar said he created this group comprised of "top departmental officials" to "strengthen safety and improve overall management, regulation, and oversight of operations on the OCS."

Internal Investigation by Interior and Homeland Security: In testimony on May 18 before the Senate Committee on Environment and Public Works, Secretary Salazar said:

"We are carrying out, with the Department of Homeland Security, an investigation into the cause of the April 20th explosion, and will hold public hearings, call witnesses, and take any other steps needed to determine the cause of the spill."

National Academy of Engineering (NAE): At this same May 18 hearing, the Secretary announced that the NAE "agreed to my request to review the Deepwater Horizon spill. ...will bring a fresh set of eyes to this tragedy, and will conduct an independent science-based analysis of the causes of the oil spill."

National Marine Board, within the National Academies: At this same May 18 hearing, the Secretary said:

"I had previously asked the National Marine Board...to direct an independent review of MMS's inspection program for offshore facilities. The results of that review are due to us this Fall."

He noted that the expert panel visited in April the Minerals Management Services' (MMS) Pacific OCS region and was schedule to visit the MMS's Gulf of Mexico region during the first week of May. That meeting has been postponed due to the disaster. The National Marine Board's review will include:

• Examine changes in the inspection program and process since the Marine Board's 1990 study;
• Review available trend data on inspections, safety, and environmental damage;
• Examine analogous safety inspection programs in other regulatory agencies and other nations for lessons that could be applied to MMS inspections;
• Consider changes in industry's safety management practices since the 1990 report;
• Recommend changes to inspection program to enhance effectiveness.

After finding that at least six investigation teams have been convened to examine the BP Deepwater Horizon disaster, it seems that plenty of resources are being directed at trying to find its cause. The question I have is whether individuals with the skills and experience investigating workplace disasters are members of these teams. At a minimum, I hope that Secretary Salazar has already consulted with the expert federal investigators at the CSB who could probably give him an earful on why disasters happen in industrial workplaces.