Article from Industrial Week 12 January 2011 by Peter Schmitt and Les Goldberg
In the past, NASA's design effort has been focussed on flight operations. As a result, very little consideration was given to manufacturing processes or human factors engineering. The argument was "If you're spending money on ground operations, you're not spending it on in-space operations."
The scenarios that resulted from this included:
* A spacecraft would be built without any thought given to how it would be transported to the launch site
* Ground operations were only developed after the spacecraft had been built and transported to the launch site
* Engineers had to develop "work-arounds" for nearly every task required to prepare the vehicle for launch, making the space shuttle very expensive to operate.
The article says that the availability of 3D digital manufacturing software to simulate operations at all stages of the operation have led to significant improvement. I think I would argue that, whilst the technology must have helped, it would have required a significant cultural change to start thinking about human factors for the whole project.
Examples of improvements that have been achieved include:
* Simulating a welding process identified that the welding head would collide with other hardware. Parts were changed during the design, avoiding problems during manufacture.
* Simulating how a person would interact with a vehicle to secure it to a barge for transport allows features to be incorporated to ensure that humans have access to, and can reach the hardware they need to perform tie-down operations.
* Simulating a two crane lifting operation allowed detailed instructions to be developed prior to the operation, validating its safety.
Introducing these tools at the outset of a program reduces manufacturing and ground operations costs, and fundamentally changes the way NASA engineers operate.
It has improved relationships between engineers at different facilities. Money saved on manufacturing and ground operations can be spent on exploration and in-flight activities.
Thursday, January 13, 2011
LSE says human error, not sabotage, caused crash
Article from Reuters 11 January 2011 by Luke Jeffs
Having initially citing "suspicious circumstances" and calling the police, the LSE has now announced that "The investigation found the incident was the result of human error and the incident has now been closed." No further details were provided.
I am not sure if we are supposed to be reassured by this statement. Have any system or organisational changes been made to prevent a recurrence? Or have they just reprimanded the human who made the error?
Having initially citing "suspicious circumstances" and calling the police, the LSE has now announced that "The investigation found the incident was the result of human error and the incident has now been closed." No further details were provided.
I am not sure if we are supposed to be reassured by this statement. Have any system or organisational changes been made to prevent a recurrence? Or have they just reprimanded the human who made the error?
Tuesday, January 11, 2011
Oil Spill Commission - Final Report
Published 11 January 2011 and available at http://www.oilspillcommission.gov/sites/default/files/documents/DEEPWATER_ReporttothePresident_FINAL.pdf
Publishing a report that is nearly 400 pages long, it may be concluded that the Commission is trying to cover up information by overwhelming us with data. The early release of a single chapter a week earlier may be further evidence of some slight of hand going on.
The report reads almost like a novel in places, and includes a lot of history of the oil industry going right back to the 1890s. The fact that the Commission chose to title the report "Deep Water" does little to reassure me that we are receiving an objective or useful view of what caused the disaster, and how it can be avoided in the future.
I've only skimmed through the report. Below are a few sections I have picked out that appear to be particularly interesting or useful. I have included page numbers so that you can find the sections in the report if you wish.
The Blow Out Preventer did not work, and I was aware that there were some issues regarding previous modifications. This is covered on Page 137 of the report:
As the National Incident Command took shape in early May, BP’s efforts to stop the flow of oil continued to focus on actuating the BOP, which BP still believed was the best chance of quickly shutting in the well. These efforts were plagued by engineering and organizational problems. For instance, it took nearly 10 days for a Transocean representative to realize that the stack’s plumbing differed from the diagrams on which BP and Transocean were relying, and to inform the engineers attempting to trigger one of the BOP’s rams through a hydraulic panel that they had been misdirecting their efforts.
(Without properly recording the change, Transocean had reconfigured the BOP; the panel that was supposed to control that ram actually operated a different, “test” ram, which could not stop the flow of oil and gas. BP Vice President Harry Thierens, who was BP’s lead on BOP interventions, stated afterward that he was “quite frankly astonished that this could have happened.”) While this and other problems delayed BP’s efforts, the flow of oil and sand continued to wear down the BOP’s parts, making closure more difficult.
One thing I wanted from the report was clear indication of how bad the environmental damage really was as a result of the oil spill. The report suggests that it was far less than was often suggested. In fact it appears to me that American politicians may have been tempted to exaggerate in an effort to put more pressure on BP.
Page 155 of the report includes the following from a Gulf resident. "What’s funny,” Lindsay said, “is we only had about three bad weeks where oil was washing on shore and BP was staging clean-up on the beach. That was in June. The rest of the summer the beaches were pretty much clean but folks still didn’t come down.”
The report gives some idea of the the impact on nature. There does not seem to be anything like a clear picture, partly because conditions prior to the disaster where not known in any detail. Page 174 of the report includes the following.
"The Deepwater Horizon oil spill immediately threatened a rich, productive marine ecosystem. To mitigate both direct and indirect adverse environmental impacts, BP and the federal government took proactive measures in response to the unprecedented magnitude of the spill. Unfortunately, comprehensive data on conditions before the spill—the natural “status quo ante” from the shoreline to the deepwater Gulf—were generally lacking. Even now, information on the nature of the damage associated with the released oil is being realized in bits and pieces: reports of visibly oiled and dead wildlife, polluted marshes, and lifeless deepwater corals. Moreover, scientific knowledge of deepwater marine communities is limited, and it is there that a significant volume of oil was dispersed from the wellhead, naturally and chemically, into small droplets. Scientists simply do not yet know how to predict the ecological consequences and effects on key species that might result from oil exposure in the water column, both far below and near the surface.
Much more oil might have made landfall, but currents and winds kept most of the oil offshore, and a large circulating eddy kept oil from riding the Loop Current toward the Florida Keys. Oil-eating microbes probably broke down a substantial volume of the spilled crude, and the warm temperatures aided degradation and evaporation—favorable conditions not present in colder offshore energy regions. (Oil-degrading microbes are still active in cold water, but less so than in warmer water.) However widespread (and in many cases severe) the natural resource damages are, those observed so far have fallen short of some of the worst expectations and reported conjectures during the early stages of the spill. So much remains unknown that will only become clearer after long-term monitoring of the marine ecosystem. Government scientists (funded by the responsible party) are undertaking a massive effort to assess the damages to the public’s natural resources. Additionally, despite significant delays in funding and lack of timely access to the response zone, independent scientific research of coastal and marine impacts is proceeding as well.
Page 176 of the report
The oil that made landfall was fairly “weathered,” consisting of emulsions of crude oil and depleted of its more volatile components. More than 650 miles of Gulf coastal habitats— salt marsh, mudflat, mangroves, and sand beaches—were oiled; more than 130 miles have been designated as moderately to heavily oiled. Louisiana’s fragile delta habitats bore the brunt of the damage, with approximately 20 additional miles of Mississippi, Alabama, and Florida shorelines moderately to heavily oiled. Light oiling and tar balls extended east to Panama City, Florida. Except for occasional tarballs, Deepwater Horizon oil never reached Texas or the tourism centers along the southwest Florida coast.
Page 189
In early May, to show that their pristine beaches were still sugary white, “We started filming daily and sometimes twice daily a video for YouTube called Shore Shots. It involved one of my employees standing in front of the camera and showing the Gulf of Mexico and the lack of oil despite being told otherwise. . . . It was not always well received. We were called liars when we said we didn’t have oil on the beaches and told we were poisoning people with Corexit for our own greedy gain. It was definitely tough. “By July the oil was here. No way I could prevent it from coming on – revenue dropped significantly. By August it was awful. No one, I mean no one, believed that we weren’t covered in oil similar to the Exxon Valdez.”
Is it a coincidence that negative information about Transocean and Haliburton is hidden over 200 pages into the report?
Page 224 of the report shows that Transocean's culture and systems may have had some serious weaknesses.
A survey of the Transocean crew regarding “safety management and safety culture” on the Deepwater Horizon conducted just a few weeks before the accident hints at the organizational roots of the problem. The research, conducted at Transocean’s request, involved surveys and interviews with hundreds of employees onshore and on four rigs, including Deepwater Horizon, which was surveyed from March 12 to March 16. The reviewers found Deepwater Horizon “relatively strong in many of the core aspects of safety management.” But there were also weaknesses. Some 46 percent of crew members surveyed felt that some of the workforce feared reprisals for reporting unsafe situations, and 15 percent felt that there were not always enough people available to carry out work safely. Some Transocean crews complained that the safety manual was “unstructured,” “hard to navigate,” and “not written with the end user in mind”; and that there is “poor distinction between what is required and how this should be achieved.” According to the final survey report, Transocean’s crews “don’t always know what they don’t know. [F]ront line crews are potentially working with a mindset that they believe they are fully aware of all the hazards when it’s highly likely that they are not.”
Also, on the same Page 224 there appears to be some really damming information about Halibuton's cementing
Halliburton prepared cement for the Macondo well that had repeatedly failed Halliburton’s own laboratory tests (see Chapter 4). And then, despite those test results, Halliburton managers onshore let its crew and those of Transocean and BP on the Deepwater Horizon continue with the cement job apparently without first ensuring good stability results.
Halliburton also was the cementer on a well that suffered a blowout in August 2009, in the Timor Sea off Australia. The Montara rig caught fire and a well leaked tens of thousands of barrels of oil over two and a half months before it was shut down. The leak occurred because the cement seal failed, the government report into the accident found. However, the report said it would not be appropriate to criticize Halliburton, because the operator “exercised overall control over and responsibility for cementing operations.” The inquiry concluded that “Halliburton was not required or expected to ‘value add’ by doing
more than complying with [the operator’s] instructions.” In this, Montara offers yet another example of a lack of communication between operators and service providers and of the gaps between the silos of expertise that exist in the deepwater oil and gas industry.
The final section I have copied here seems to suggest that that American Petroleum Institute (API) were to blame for poor regulation. I'm not sure I quite follow the logic behind the text on Page 228 of the report
For years, API also led the effort to persuade the Minerals Management Service not to adopt a new regulatory approach—the Safety and Environmental Management System (SEMS)—and instead has favored relying on voluntary, recommended safety practices.
Safety and environmental management systems are used in similar forms in other parts of the world and many credit them with the better safety records achieved outside U.S. waters (see Chapter 3). Beginning early in the last decade, the trade organization steadfastly resisted MMS’s efforts to require all companies to demonstrate that they have a complete safety and environmental management system in addition to meeting more traditional, prescriptive regulations—despite the fact that this is the direction taken in other countries in response to the Piper Alpha rig explosion in the late 1980s. Indeed, many operators in the Gulf were used to this safety-based approach on their rigs in the North Sea and Canada. It was not until this past September—after the Macondo blowout—that the Department of the Interior was finally able to announce a new, mandatory Safety and Environmental Management System: almost two decades after the approach was adopted in the United Kingdom, where it is called the “safety case.” Moreover, API opposed revisions to the incident reporting rule that would have helped better identify safety risks
Publishing a report that is nearly 400 pages long, it may be concluded that the Commission is trying to cover up information by overwhelming us with data. The early release of a single chapter a week earlier may be further evidence of some slight of hand going on.
The report reads almost like a novel in places, and includes a lot of history of the oil industry going right back to the 1890s. The fact that the Commission chose to title the report "Deep Water" does little to reassure me that we are receiving an objective or useful view of what caused the disaster, and how it can be avoided in the future.
I've only skimmed through the report. Below are a few sections I have picked out that appear to be particularly interesting or useful. I have included page numbers so that you can find the sections in the report if you wish.
The Blow Out Preventer did not work, and I was aware that there were some issues regarding previous modifications. This is covered on Page 137 of the report:
As the National Incident Command took shape in early May, BP’s efforts to stop the flow of oil continued to focus on actuating the BOP, which BP still believed was the best chance of quickly shutting in the well. These efforts were plagued by engineering and organizational problems. For instance, it took nearly 10 days for a Transocean representative to realize that the stack’s plumbing differed from the diagrams on which BP and Transocean were relying, and to inform the engineers attempting to trigger one of the BOP’s rams through a hydraulic panel that they had been misdirecting their efforts.
(Without properly recording the change, Transocean had reconfigured the BOP; the panel that was supposed to control that ram actually operated a different, “test” ram, which could not stop the flow of oil and gas. BP Vice President Harry Thierens, who was BP’s lead on BOP interventions, stated afterward that he was “quite frankly astonished that this could have happened.”) While this and other problems delayed BP’s efforts, the flow of oil and sand continued to wear down the BOP’s parts, making closure more difficult.
One thing I wanted from the report was clear indication of how bad the environmental damage really was as a result of the oil spill. The report suggests that it was far less than was often suggested. In fact it appears to me that American politicians may have been tempted to exaggerate in an effort to put more pressure on BP.
Page 155 of the report includes the following from a Gulf resident. "What’s funny,” Lindsay said, “is we only had about three bad weeks where oil was washing on shore and BP was staging clean-up on the beach. That was in June. The rest of the summer the beaches were pretty much clean but folks still didn’t come down.”
The report gives some idea of the the impact on nature. There does not seem to be anything like a clear picture, partly because conditions prior to the disaster where not known in any detail. Page 174 of the report includes the following.
"The Deepwater Horizon oil spill immediately threatened a rich, productive marine ecosystem. To mitigate both direct and indirect adverse environmental impacts, BP and the federal government took proactive measures in response to the unprecedented magnitude of the spill. Unfortunately, comprehensive data on conditions before the spill—the natural “status quo ante” from the shoreline to the deepwater Gulf—were generally lacking. Even now, information on the nature of the damage associated with the released oil is being realized in bits and pieces: reports of visibly oiled and dead wildlife, polluted marshes, and lifeless deepwater corals. Moreover, scientific knowledge of deepwater marine communities is limited, and it is there that a significant volume of oil was dispersed from the wellhead, naturally and chemically, into small droplets. Scientists simply do not yet know how to predict the ecological consequences and effects on key species that might result from oil exposure in the water column, both far below and near the surface.
Much more oil might have made landfall, but currents and winds kept most of the oil offshore, and a large circulating eddy kept oil from riding the Loop Current toward the Florida Keys. Oil-eating microbes probably broke down a substantial volume of the spilled crude, and the warm temperatures aided degradation and evaporation—favorable conditions not present in colder offshore energy regions. (Oil-degrading microbes are still active in cold water, but less so than in warmer water.) However widespread (and in many cases severe) the natural resource damages are, those observed so far have fallen short of some of the worst expectations and reported conjectures during the early stages of the spill. So much remains unknown that will only become clearer after long-term monitoring of the marine ecosystem. Government scientists (funded by the responsible party) are undertaking a massive effort to assess the damages to the public’s natural resources. Additionally, despite significant delays in funding and lack of timely access to the response zone, independent scientific research of coastal and marine impacts is proceeding as well.
Page 176 of the report
The oil that made landfall was fairly “weathered,” consisting of emulsions of crude oil and depleted of its more volatile components. More than 650 miles of Gulf coastal habitats— salt marsh, mudflat, mangroves, and sand beaches—were oiled; more than 130 miles have been designated as moderately to heavily oiled. Louisiana’s fragile delta habitats bore the brunt of the damage, with approximately 20 additional miles of Mississippi, Alabama, and Florida shorelines moderately to heavily oiled. Light oiling and tar balls extended east to Panama City, Florida. Except for occasional tarballs, Deepwater Horizon oil never reached Texas or the tourism centers along the southwest Florida coast.
Page 189
In early May, to show that their pristine beaches were still sugary white, “We started filming daily and sometimes twice daily a video for YouTube called Shore Shots. It involved one of my employees standing in front of the camera and showing the Gulf of Mexico and the lack of oil despite being told otherwise. . . . It was not always well received. We were called liars when we said we didn’t have oil on the beaches and told we were poisoning people with Corexit for our own greedy gain. It was definitely tough. “By July the oil was here. No way I could prevent it from coming on – revenue dropped significantly. By August it was awful. No one, I mean no one, believed that we weren’t covered in oil similar to the Exxon Valdez.”
Is it a coincidence that negative information about Transocean and Haliburton is hidden over 200 pages into the report?
Page 224 of the report shows that Transocean's culture and systems may have had some serious weaknesses.
A survey of the Transocean crew regarding “safety management and safety culture” on the Deepwater Horizon conducted just a few weeks before the accident hints at the organizational roots of the problem. The research, conducted at Transocean’s request, involved surveys and interviews with hundreds of employees onshore and on four rigs, including Deepwater Horizon, which was surveyed from March 12 to March 16. The reviewers found Deepwater Horizon “relatively strong in many of the core aspects of safety management.” But there were also weaknesses. Some 46 percent of crew members surveyed felt that some of the workforce feared reprisals for reporting unsafe situations, and 15 percent felt that there were not always enough people available to carry out work safely. Some Transocean crews complained that the safety manual was “unstructured,” “hard to navigate,” and “not written with the end user in mind”; and that there is “poor distinction between what is required and how this should be achieved.” According to the final survey report, Transocean’s crews “don’t always know what they don’t know. [F]ront line crews are potentially working with a mindset that they believe they are fully aware of all the hazards when it’s highly likely that they are not.”
Also, on the same Page 224 there appears to be some really damming information about Halibuton's cementing
Halliburton prepared cement for the Macondo well that had repeatedly failed Halliburton’s own laboratory tests (see Chapter 4). And then, despite those test results, Halliburton managers onshore let its crew and those of Transocean and BP on the Deepwater Horizon continue with the cement job apparently without first ensuring good stability results.
Halliburton also was the cementer on a well that suffered a blowout in August 2009, in the Timor Sea off Australia. The Montara rig caught fire and a well leaked tens of thousands of barrels of oil over two and a half months before it was shut down. The leak occurred because the cement seal failed, the government report into the accident found. However, the report said it would not be appropriate to criticize Halliburton, because the operator “exercised overall control over and responsibility for cementing operations.” The inquiry concluded that “Halliburton was not required or expected to ‘value add’ by doing
more than complying with [the operator’s] instructions.” In this, Montara offers yet another example of a lack of communication between operators and service providers and of the gaps between the silos of expertise that exist in the deepwater oil and gas industry.
The final section I have copied here seems to suggest that that American Petroleum Institute (API) were to blame for poor regulation. I'm not sure I quite follow the logic behind the text on Page 228 of the report
For years, API also led the effort to persuade the Minerals Management Service not to adopt a new regulatory approach—the Safety and Environmental Management System (SEMS)—and instead has favored relying on voluntary, recommended safety practices.
Safety and environmental management systems are used in similar forms in other parts of the world and many credit them with the better safety records achieved outside U.S. waters (see Chapter 3). Beginning early in the last decade, the trade organization steadfastly resisted MMS’s efforts to require all companies to demonstrate that they have a complete safety and environmental management system in addition to meeting more traditional, prescriptive regulations—despite the fact that this is the direction taken in other countries in response to the Piper Alpha rig explosion in the late 1980s. Indeed, many operators in the Gulf were used to this safety-based approach on their rigs in the North Sea and Canada. It was not until this past September—after the Macondo blowout—that the Department of the Interior was finally able to announce a new, mandatory Safety and Environmental Management System: almost two decades after the approach was adopted in the United Kingdom, where it is called the “safety case.” Moreover, API opposed revisions to the incident reporting rule that would have helped better identify safety risks
Thursday, January 06, 2011
Commission Releases Chapter on BP Well Blowout Investigation in Advance of Full Report
6 January 2011
Summary of the Chapter available here
Full chapter available here
Key messages include:
"The well blew out because a number of separate risk factors, oversights, and outright mistakes combined to overwhelm the safeguards meant to prevent just such an event from happening. But most of the mistakes and oversights at Macondo can be traced back to a single overarching failure—a failure of management. Better management by BP, Halliburton, and Transocean would almost certainly have prevented the blowout by improving the ability of individuals involved to identify the risks they faced, and to properly evaluate, communicate, and address them."
". . .the Macondo blowout was the product of several individual missteps and oversights by BP, Halliburton, and Transocean, which government regulators lacked the authority, the necessary resources, and the technical expertise to prevent.”
“The blowout was not the product of a series of aberrational decisions made by rogue industry or government officials that could not have been anticipated or expected to occur again. Rather, the root causes are systemic and, absent significant reform in both industry practices and government policies, might well recur."
I'm not really sure why this chapter has been released early. It doesn't seem to say much that was not covered in BP's own report, which they published four months ago in September 2010.
I can't help thinking there is a political motive. The summary released seems to be leading up to the a change of emphasis, from blaming BP for the accident to a shared responsibility. Equally I note that the name of the disaster changes from "BP Well Blowout" to "Macondo blowout" depending on the message.
I am still waiting to see reports from Transocean and Haliburton. Surely they have had the time to write them!
Summary of the Chapter available here
Full chapter available here
Key messages include:
"The well blew out because a number of separate risk factors, oversights, and outright mistakes combined to overwhelm the safeguards meant to prevent just such an event from happening. But most of the mistakes and oversights at Macondo can be traced back to a single overarching failure—a failure of management. Better management by BP, Halliburton, and Transocean would almost certainly have prevented the blowout by improving the ability of individuals involved to identify the risks they faced, and to properly evaluate, communicate, and address them."
". . .the Macondo blowout was the product of several individual missteps and oversights by BP, Halliburton, and Transocean, which government regulators lacked the authority, the necessary resources, and the technical expertise to prevent.”
“The blowout was not the product of a series of aberrational decisions made by rogue industry or government officials that could not have been anticipated or expected to occur again. Rather, the root causes are systemic and, absent significant reform in both industry practices and government policies, might well recur."
I'm not really sure why this chapter has been released early. It doesn't seem to say much that was not covered in BP's own report, which they published four months ago in September 2010.
I can't help thinking there is a political motive. The summary released seems to be leading up to the a change of emphasis, from blaming BP for the accident to a shared responsibility. Equally I note that the name of the disaster changes from "BP Well Blowout" to "Macondo blowout" depending on the message.
I am still waiting to see reports from Transocean and Haliburton. Surely they have had the time to write them!
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