Last May President Obama established the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling to unravel the circumstances that led to the April 20, 2010 disaster in the Gulf. Hundreds of hours of study and nearly three quarters of a year later, the commission has reached its conclusion. The full report will be released on Jan. 11, and it is expected to be damning. But the sneak-peek chapter made public on Wednesday—which levied harsh criticism in the starkest and most official terms yet—didn’t actually conclude anything new.
In fact, while the wording might have seemed spectacular and quotable in the present moment, reading the 48-page chapter was more like déjà-vu. It was packed with blunt criticisms that were refreshing after months of rhetoric about what really happened in America’s southern waters. But hadn’t we read this before?
It turns out the report—at least the language dedicated to the disaster’s most prominent miscreant, BP—echoes both public and private analysis done after a series of BP accidents, small and large, over the last decade. It also reaches strikingly similar overall conclusions. These likenesses indicate that BP’s most significant cultural deficiency is not necessarily its now well-documented lax oversight of safety, anemic risk planning and poor communication, but the corporation’s institutional inability to learn from its mistakes.
Here are just a few items that jumped out from our close reading:
From the 2011 National Commission report, following the explosion and sinking of the Deepwater Horizon rig and the subsequent oil spill:
“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.”
“Most of the mistakes and oversights at Macondo can be traced back to a single overarching failure—a failure of management. … BP’s management process did not adequately identify or address risks created by late changes to well design and procedures. BP did not have adequate controls in place to ensure that key decisions in the months leading up to the blowout were safe or sound from an engineering perspective.”
“Information appears to have been excessively compartmentalized at Macondo as a result of poor communication. BP did not share important information with its contractors, or sometimes internally even with members of its own team. … Individuals often found themselves making critical decisions without a full appreciation for the context in which they were being made (or even without recognition that the decisions were critical).”
“Decision-making processes at Macondo did not adequately ensure that personnel fully considered the risks created by time- and money-saving decisions. … There is nothing inherently wrong with choosing a less-costly or less-time consuming alternative—as long as it is proven to be equally safe. The problem is that, at least in regard to BP’s Macondo team, there appears to have been no formal system for ensuring that alternative procedures were in fact equally safe.”
“None of BP’s decisions … appear to have been subject to a comprehensive and systematic risk-analysis, peer review, or management change of process.”
From the 2007 reports from the U.S. Chemical Safety and Hazard Investigation Board, which also refers to “systemic failures,” and from the BP-sponsored review led by former Secretary of State James Baker following the 2005 explosion at BP’s Texas City refinery, which killed 15 people.
“The panel found instances of a lack of operating discipline, toleration of serious deviations from safe operating practices, and apparent complacency toward serious process safety risk.” (Baker Panel)
“BP did not take effective steps to stem the growing risk of a catastrophic event. … Supervisors and operators poorly communicated critical information regarding the startup during the shift turnover; BP did not have a shift turnover communication requirement for its operations staff. … These lapses in communication were the result of BP management’s lack of emphasis on the importance of communication. BP had no policy for effective shift communication.” (CSB)
“Cost cutting, failure to invest and production pressures from BP Group executive managers impaired process safety at Texas City.” (CSB)
From the 2003 report from the Scottish Environment Protection Agency following a series of accidents and fires at BP’s huge refinery in Grangemouth, Scotland, in 2000.
The “incidents would not have occurred if BP’s high standards and policies and procedures been followed consistently across the complex.” (Sic)
“The tendency was to place relatively high emphasis on short-term benefits of cost and speed and to be readier to make compromises over longer term issues like plant reliability. Management was perceived by technicians as hurried, and managers expressed similar concerns about technicians.”
“The company did not adequately measure the major accident hazard potential. … BP did not apply the required degree of expertise to some key technical tasks and had no overall plan as to what resources of technically competent people were required to manage the major accident hazards effectively.”
“Control of major accident hazards requires a specific focus on process safety management over and above conventional safety management. … The investigation also found that there was a more optimistic perception of safety performance than might be borne out.”