Thursday, May 27, 2010

BP's Deepwater Horizon Blowout -- Critical Thinking Failure-- Part I

Scott Pelley interviewed BP explosion survivor Mike Williams on 60 Minutes (5-16-2010). Watch the entire interview.     Williams, the Chief Electronics Technician for Transocean, the builder of the rig, related how the Blow Out Preventer (BOP) was apparently damaged 4 weeks before the Deepwater Horizon oil rig blew up and sank on April 20.   The BOP is a rubber annular ring that surrounds the drilling pipe.   "It is the most vital piece of safety equipment" on the rig.   It acts as a gasket that prevents oil and gas, normally under enormous pressure, from coming back up the drilling pipe.   "It seals the well shut in order to test the pressure and integrity of the well, and in case of a blowout, it is the crew's only hope".  During a test 4 weeks before the disaster, while the gasket was tightly closed, the drill pipe was accidentally moved through the closed BOP.  "Later they discovered a double handful of chunks of rubber in the drilling fluid".  Mr. Williams stated that his supervisor responded to the rubber chunks in the drilling fluid -- "It's no big deal".   

A billion dollar project, that was costing $1million per day, manuals full of policies and procedures, safety drills, and I am sure, many hours of scenario planning by the engineers and builders -- does it all come down to one person making a horrendous critical decision?  This disaster wasn't just an equipment failure--it was a human failure.   Humans have been making poor decisions forever -- this is nothing new.  What is new is the complexity of our decisions, and the scope of impact.  Our decisions now impact Millions and cost Billions.  What is not new, and is the reason that bad decisions will continue, is that our hard wired "humaness" allows us to make bad decisions--our human qualities of denial, gambling on outcomes, trying to plug unique situations into old learned patterns, and making decisions on inadequate data.

If the supervisor indeed wrote off the chunks of rubber as "no big deal", he was then a victim of classic "Shuttle Thinking"  --  A unique, once in a lifetime situation, inadequate data as to the amount of BOP damage, a bit of denial that the situation was serious, all leading to a gamble of "its probably not going to be a problem".

Part II  A discussion on Dr. Robert Bea's comments on 60 Minutes.  Dr. Bea, a professor of engineering, investigated the Columbia Space Shuttle disaster for NASA as well as the Hurricane Katrina Disaster for the National Science Foundation.  The White House has asked Dr. Bea to investigate the Deepwater Horizon Blowout.

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