Friday, September 10, 2010

BP Oil Spill: Accident Investigation Report

BP released the report of its internal investigation team on the Deepwater Horizon accident on 8th September 2010 ( Media coverage of the report has made much of the alleged attempts to divert blame for the accident onto other companies; contractors involved in the operation and maintenance of the oil rig (e.g. Who’s blamed by BP for the Deepwater horizon oil spill -, BP oil spill report: the Deepwater horizon blame game-, BP oil spill: US reaction to the BP report - Robert Preston, the BBC’s business editor even dubbing BP as standing for ‘Blame Placing’ ( This blog looks at the report in context; a second blog will deal with the findings themselves.

The report itself is at pains to point out that it is own limitation. The second paragraph of the executive summary, for example, states:
“In preparing this report, the investigation team did not evaluate evidence against legal standards, including but not limited to standards regarding causation, liability, intent and the admissibility of evidence in court or other proceedings.”
Deepwater Horizon Accident Investigation Report: Executive Summary, 2010, p.2.

The report notes it had to work with the information available to it and draw interpretations from sometimes contradictory, unclear and uncorroborated evidence that used the ‘best judgement’ of the team, but from which others might draw different conclusions. The report even finishes with a section on what the team could not analyse. So is the report a PR exercise, an attempt to deflect blame or a genuine attempt to provide some rapid, informative answers to the questions about what caused a major environmental disaster.

The report needs to be considered in the light of how industries operate in the contemporary economic environment. I am not concerned with legal definitions of responsibility nor intend to discuss these or get into such a debate as I am sure that such heated deliberations will ensue once money comes to the fore. Robert Preston’s blog is useful in illustrating the ‘hollowing out’ aspect of modern large companies such as BP. Companies no longer do everything; contracting out aspect of their industry that they are either not good at or that other companies can do better or more cheaply has become a common practice. BP may be an oil company but it does not undertake every aspect of the oil industry in house.

Robert Preston’s blog provides a good analogy of a dodgy chicken tikka masala bought from a supermarket. If you are ill after eating the meal do you blame the supermarket or its contracted manufacturers? He states that most people would hold the supermarket accountable although the contracted company may have had the sloppy hygiene standards that produce the dodgy meal. In his blog he does point out that BP were the named party on the relevant oil lease and so assumed to exercise sufficient oversight.

My view is that the example is a little too simplistic to grasp the complexity of relationships that define a modern business enterprise. Imagine instead that you want to get to work every day to do what you are good at. You are not good at driving nor want the expense of owning a car, so you contract out both hiring a driver and leasing a car. You specify that you need a driver who can take orders and a car that is a reasonable car for your status. You tell the driver you leave a 08:10 and must be at work at 08:30. Everything seems to run smoothly, the driver is well turned out, the car is comfortable and you get to work on time. One day there is an accident as the car overturns taking a corner – who is to blame? It may seem simple, the driver is to blame, he was driving – he is the person immediately, obviously involved in the accident, its cause. BUT you specified the time; he has to drive to ensure you get there on time. Is it the pressure you put him under that caused the accident? Furhter investigation points to some mechanical problems with the brakes. Not enough on its own to cause the accident but a possible contriubting cause. The car is maintained by the leasing company, who are good at leasing but not at maintenance so contract that out. But you specified only a standard maintenance contract,you didn't specify that there would be undue wear on the brakes as you don't drive so don't know how different driving styles affect brake wear. The subcontractor states it is nothing to do with them as they maintained it to the standard specified. Where does the cause lie? With mechanical problems, with your communciation with your contractors, with your ability to specify exactly what you require or with your understanding of the context?

I hope you can start to see the problem. Such a complex web of relationships requires careful and thoughtful planning and overseeing. Relations and specifications need to be established carefully and maintained. Importantly, you may not realise there is a problem with the relations or specification until there is a problem. The problem itself highlights the errors, by which time it is too late. This does not absolve you of blame it just shows how difficult it is to pin down exactly who or what is the cause. Causation and blame may be different things entirely.

It is within this context of devolved tasks that the investigation team undertook the report. Central to this report, in fact any report, are the terms of reference, TOR, found in Appendix A of the report. The scope of the report is defined as finding facts surrounding the uncontrolled release of hydrocarbons and efforts to contain that release aboard the Transocean drillship Deepwater Horizon. More specifically, the team will determine the actual physical conditions, controls and operational regime related to the incident to understand a) the sequence of events, b) the reasons for initial release, c) the reasons for fire, d) efforts to control flow at the initial event. As well as a timeline for the event itself, the team were also tasked to described the event and identify critical factors, both immediate causes and system causes. As with any TOR, the terms are narrower than you might want to try to understand the event in totality and, as is common with such an event, the key focus is on the technical and procedural. The team are not tasked to apportion blame within their TOR, they are merely seen as reporting ‘the facts’. Clearly, ‘the facts’, as in people’s actions and recollections, depend on what they are told and upon who tells them, what hidden agendas each person might have. Instruments and equipment, where available, tell another set of stories which may at first seem more objective but once different experts begin to interpret the information may become almost as ambiguous as the recollections of fallible humans.

The focus on the initial release and the events leading up to the explosion of necessity spotlights the actions of individuals in the decision making at that time. Despite this, a number of issues concerning equipment, maintenance and instructions are highlighted as requiring improvement suggesting that systemic factors may be more important. In other words, the communication and relations between companies is as much at the heart of the event as the faulty decisions made at the time.

Interestingly, the investigation team had 5 specific terms of reference associated with administration, including the sanctioning of all activities by a team leader, the requirement of a BP person at each interview and on questions or tasks to BP contractors without BP approval. The impact of such administrative arrangements on the nature or scope of the questions asked is not discussed. How are these administrative requirements to be interpreted? As a standard implementation of policy in such investigations, as a check on the team adhering to the TOR or ensuring the TOR were clarified to the team when required? Your interpretation may depend on the degree of belief or trust in have in the internal report in the first place.

The complexity of the task of assigning causation and blame is highlighted by the team in the Executive Summary:
'The team did not identify any single action or inaction that caused this accident. Rather, a complex and interlinked series of mechanical failures, human judgments, engineering design, operational implementation and team interfaces came together to allow the initiation and escalation of the accident. Multiple companies, work teams and circumstances were involved over time.'
Deepwater Horizon Accident Investigation Report: Executive Summary, 2010, p.5.

But why produce and release the internal report to the public now? There are other reports in the pipeline, not the least the official report into the incident that will presumably form the basis for blame, responsibility and one would assume compensation claims. BP may be trying to show themselves as a responsible company, but there is also the possibility that they are putting the report out there as a marker, an anchor for further reports. Whatever the status of the BP internal report, it is now known and available, it provides information and interpretations that any other report will be compared to. BP have provided an anchor or a starting point for expectations. Other reports will need to refer to it, to agree or disagree with it, to confirm or reject its findings and assertions. BP might not have defined the agenda for the debate over responsibility that will develop but they have defined the starting points and details that all other reports will have to cover; so not a bad start to agenda setting.

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