June 25, 2010 | Mark Paradies

Lessons About Safety Culture from the Deepwater Horizon Accident

Deepwater Horizon licensed from CANVA

What Can We Learn NOW?

On June 14, I published a question:

How Long Must We Wait To Learn?


I asked: “Do we need to wait for the completion of the Presidential Commission’s investigation to learn from the BP Deepwater Horizon Accident?”

OK … I know I will make some people mad with this answer, but … Here’s the answer nonetheless.



First, let me say that as the many official investigations continue, we will learn more about the technical details of what happened. The equipment failures that cause the failure of the blowout preventer. The details of the tests that were performed and misused to justify replacing the mud with seawater. The design basis for the well design and construction decisions turned out to be inadequate to prevent a blowout.

These are things that we will learn with time.

Thus, people aren’t completely wrong when they say…

“Wait until the official investigations are completed.”

We don’t want to jump the gun and jump to conclusions without the facts.”

That’s sentiment is well and good. But they are missing my point.

We already know enough about some parts of the accident to be able to learn some important lessons. Lessons that we need to learn RIGHT NOW.

First Lesson That Should Be Learned NOW! (Safety Culture)

The first and biggest thing we can learn is that SAFETY CULTURE MAKES A DIFFERENCE.

We already knew that drilling in deepwater is dangerous. We knew this before the BP Deepwater Horizon accident. We certainly know it now.

The risk of failure in deepwater is more than the risk of drilling on land or in shallow water. The deeper you go, the more complex it gets. Also, the higher the technology that you use. These facts make it more important to understand what makes a high-reliability organization tick – what produces a good safety culture for these demanding environments.

I think everyone will agree with the previous paragraph.

Yet, BP did NOT take extra precautions in designing or constructing the well being drilled by the Deepwater Horizon. In fact (and we know this to be a fact from testimony already given), they didn’t take precautions that other companies take and are “standards” for drilling in deepwater.


What shortcuts did they take? Here are the five that I think have already been proven:

1. The choice of the cheaper but less safe design using a single liner for well completion. BP says this design had longevity advantages. But it was mainly FASTER and CHEAPER. This choice obviously was not about safety first. A well that experiences a catastrophic failure doesn’t need to be designed to last longer.

2. Using too few hangers to center the casing. I’m not a drilling expert, but the expert TOLD BP that the six hangers were WAY TOO FEW and would make it almost impossible to get a good cement job.

3. Failure to circulate the mud fully prior to cementing. Fully circulating the mud is required by an API standard. Not circulating the mud fully was a safety shortcut (but it saved them time and, therefore, money).

4. Failure to run a cement bond log. If this was a standard well and everything had gone right, you might skip this safety step. But on a well that is deep, with a single casing, with too few hangers, and with a bad first test, skipping this test was inexcusable. They were leaving safety to luck. And they ran out of luck that day.

5. Failure to deploy the casing hanger lockdown sleeve. I haven’t heard why this wasn’t done. But BP and the Coast Guard/MMS investigators already know about it. I just haven’t been able to find the testimony.

These are facts.

Of course, BP argues that MMS approved these shortcuts. But errors at MMS don’t mean that BP was right and had a safe well design. The mistakes at MMS, if and when they occurred, are just additional failed safeguards that allowed the accident to progress.

Therefore, I’m not saying that these are all the shortcuts. There are MORE.

I’m saying that these shortcuts are sufficient to prove that, at least for this well’s safety, BP’s practices WERE NOT to make safety the highest priority.

What is the Safety Culture?

safety culture

The question remaining is …

“Is this the BP culture, or were the people drilling this well ‘outliers’ –
rouge engineers and supervisors who were working outside BP’s culture.”

This is where I make a fairly safe assumption.

This well was so deep and important that it couldn’t (and shouldn’t) slip underneath the radar of BP’s management. Fairly senior management (maybe not the CEO, but certainly some high-up folks) must have known about the design decisions. In fact, I believe investigators will be able to show significant management pressure to get the well completed and move on to the next well. This pressure – without enough consideration for safety as an overriding priority – is the current safety culture at BP.

Thus, even though they talk about…

” …focusing on safety like a laser”


“We don’t do anything unless it is safe.”

… the reality, which is reflected by the practices in the field, is quite different.

When I heard the BP America President say in Congressional testimony that:

“We don’t do anything unless it is safe.”

I knew that he didn’t really understand safety. Why? Because safety is never absolute. Everything we do has some risk.

Therefore, we can learn NOW. We can learn that SAFETY CULTURE IS IMPORTANT.

High-Reliability Organizations

And there are important lessons that are common practice in high-reliability organizations that all organizations facing high-risk, high-complexity operations must learn.

How do I know about these lessons?

I worked in a high-reliability organization. The Nuclear Navy. And I “got it.”

I also studied human factors and organizational design, and I understand why a high-reliability organization functions successfully.

But obviously, not everyone gets it.

I say obviously because repeated major accidents are proof that somebody doesn’t get it.

Does BP’s Senior Management Get It?

Therefore, from the “evidence” of their repeated serious accidents, I conclude that BP senior management doesn’t get it. They don’t understand the safety culture that they created.

What can I do? I’m going to share what I know with anyone willing to listen and learn. BP if they are willing. Or any other company that faces potentially catastrophic damage if they are not highly reliable.

At the 2010 Summit in San Antonio on October 27-29, I will provide two presentations that take learning about safety culture and performance improvement to the next level.

The first talk is a Keynote address to the entire Summit audience titled:

“Taking Improvement to the Next Level”

I already have part of this presentation developed, but I’m adding to it daily. If you are responsible for improving safety, quality, equipment reliability, or production, you need to be at this talk.

The second talk is much more focused on safety culture and the secrets behind a high-reliability organization. It is titled:

“Lessons Learned About Excellence & Safety From Admiral Rickover”

This presentation takes the Ph.D. complexity of safety culture and high-reliability organizations and makes it understandable and practical. This presentation details what’s made the Nuclear Navy work for all these years. It’s the secrets that Admiral Rickover understood (and many others in the Navy didn’t understand).

This second presentation is part of the Improvement Program Track. If you are interested in high-reliability organizations and safety culture, make sure to sign up for it when you register for the Summit.

Learn NOW!

So, here is my overall advice …

Don’t wait to learn.

Start reviewing the facts that are available now and learn as much as you can as fast as you can.

Also, plan to attend the Summit in October (register now). The lessons you can learn there are too important to miss. They can help you save lives, your company’s reputation, and all sorts of headaches.

Accident, Investigations, Process Safety, Safety
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