Synopsis/Executive summary
This study will examine two incidents which have occurred with catastrophic results; Buncefield Oil Storage Depot in the UK in 2005 and at the Deepwater Horizon Drilling Rig in the Gulf of Mexico in 2010.
The purpose of the case study is to provided analysis framework of the two cases and compare and contrast the root causes of the incidents and responses taken to the emergencies, the study will identify common themes and lessons learned from the incidents. In particular, issues relating to inherent safety of the design, operating procedures, human factors and the preparedness for protection of staff and emergency responders.
Overview
Both Buncefield & Deepwater Horizon fall within the oil and gas industry and the study identifies findings that are lacking within a multibillion dollar industry and which could and should have been prevented.
Early in the morning of Sunday the 11th December 2005 an explosion, followed by a fire engulfed the Buncefield fuel storage depot, the fire was to turn out as Britain’s biggest peacetime blaze. Unleaded fuel was being pumped into one of the storage tanks on the site, safeguards on the tanks failed, none of the duty staff were aware that the capacity of the tank had been breached. The site is situated near the town of Hemel Hempstead, 25 miles northwest of London; it is sited in a residential and small industrial business area. The site and surrounding area was destroyed, there were casualties but no loss of life.
On the 20th April 2010 a catastrophic explosion occurred and tore through the Deepwater Horrizon Drilling Rig, which at the time was operating in the Gulf of Mexico. The explosion happened as the crew of the rig was completing the final stages of the drilling an exploratory well. It incident caused 11 deaths and the sinking of the platform there was then a subsequent oil discharge from the well. The position of the rig was forty miles of the cost of Louisiana, USA.
Outline
The findings of the study in both cases show Management failings and a distinct lack of Management commitment to Health and Safety of its staff, facilities, the general public and the environment. The incidents show a lack of Safety culture in/on both facilities and the companies involved.
Theory
The document will draw its conclusions from Investigation reports, identifying what the author believes to be key issues examined by key experienced investigative body.
Findings Buncefield
Root causes of the incidents
(COMAH, 2005, p.4 para 4) Failures of design and maintenance in both overfill protection systems; the independent high-level switch (IHIL) & automatic tank gauging system (ATG) and liquid containment systems were the technical causes of the initial explosion.
Underlying immediate failings, lay root causes based in broader management failings: Management systems were in place but were not good enough for the task and even then were not followed, Management of Change was not conducted on the installation of the IHIL and the ATG which could have identified problems, pressure on staff had increased and they had little control over the receipt of fuel, the throughput had increase but there was little engineering support for the site. Management should have been aware of this but showed a disregard for the safety of its personnel and the site.
(BSTG, 2006, sect 2) States; there was overfilling of a large storage tank with fuel which led to the fuel overflowing. Risk assessments should have been conducted for filling operations, there is no doubt that Risk Assessments were carried out but the findings were not followed or acted upon, as an example; you would not turn on taps in your bath and leave it to run if there was not an overflow and you didn’t know where the water went. Risk Assessments are an inextricable part of the planning process but have to be followed and need reviewed not only for the content but to ensure that they are being followed.
Preventative maintenance, Tanks and Bunds, (COMAH, 2005, p.21) these areas of protection to the site and personnel were in disrepair and identified, bad or no maintenance this lead to the leaking of fuel from one of the tanks and to the breach of the bunds. Preventative maintenance is an integral part of any Safety Management Systems; no maintenance can lead to catastrophic failure and cause an incident as well as adding to the result of an incident, as in this case.
Responses taken to the emergencies.
(BMIIB2a) states that the overall response to the incident was impressive. But the authors belief is this was down to the professionalism of the emergency services, they had to deal with a fire in an area which needed to be contained and had no immediate supply of emergency water on site. Onsite fire systems were not available due to the pump house for the water being rendered inoperable by the first explosion; this was due to the sighting of the pump house next to the fuel tanks. (TBI, 2008 p.13) states the recommendations and changes in sites in future. If a risk assessment had been conducted these recommendations would have been identified prior to the incident.
Common themes and lessons learned from the incidents.
(BMIIB2a. 2006, sect 4.Initial report, Annex 5) We have to look at other incidents and not assume that no lessons were learned, we have to say that there was a total disregard for the other incidents and no action taken to identify similar situations that could happen at Buncefield, there is proof of seven similar incidents which had taken place and it seems that these were not acted upon? The question now is can this industry learn from Buncefield or are we waiting for another incident.
Issues relating to inherent safety of the design, operating procedures, human factors.
9 Risk criteria for land use planning in the vicinity of major industrial hazards
HSE Books 1989 ISBN 978 0 11 885491 7
(BMIIB1, 2008. P.43. para )
Findings Deepwater Horizon
Root causes of the incidents
The direct cause of the Deepwater Horizon rig explosion and subsequent fire and sinking of the platform was a Blowout but (Deep Water p. 122 para 2) states that even though this was the case it was the Management failings that led to the Blowout and therefore were the root cause of the incident. It seems that the problems stem first and foremost from no Management of Change (MOC) procedure for drilling, well design went through stringent MOC and peer review. But drilling had no such reviews under MOC and therefore no one knew exactly what to do when the time came for a reaction in a serious situation, because the drilling operation was not discussed there was no review of past experience that the company had. If this had been discussed and researched BP would have known that there had beein a similar incident in the North Sea on one of its own rigs.
(Deep Water p.104 para 4) tells us that numerous changes to the operation in drilling had taken place but had not gone through any sort of Risk Assessment or again Management of change. This is differs from the Buncefield incident as Assessments were conducted there but not followed. In the case of Deepwater Horizon, the assessments were not carried out. How did they expect to manage the risk if it has not been, identified. BP has always been known as a company that takes risk where others don’t; Risk is acceptable if the Risk is managed.
Failure of the BOP, (Deep Water p.114 para 6) even after initiating the emergency disconnect procedures for the BOP the system failed. Even though this should have triggered the dead man system this failed also, the investigation panel assumes that this could have been due to bad maintenance again aligning with the bad Preventative Maintenance schedule that Buncefield suffered.
Responses taken to the emergencies.
Common themes and lessons learned from the incidents.
(Deep Water p.124 para 2) Transocean failed to notify its employees of a similar incident which occurred on one of its Oil Rigs in the North Sea; again this raises the point that communication plays a vital part in the operations. Identification of problems, near misses and occurred incident root causes could and usually do prevent incidents happening if details are passed on so engineers can look if there are similar situations in their operations.
Issues relating to inherent safety of the design, operating procedures, human factors.
Preparedness for protection of staff and emergency responders.
Summary/Conclusion
Let’s Manage the Change
After the Buncefield incident in 2005 and the Gulf Horizon in 2010 and many more incidents that could be named. There is the need for an independent international body to police the Oil & Gas industry such as International Maritime Organisation (IMO) for the shipping industry. Who insist on 3rd Party Audits for all vessels? Oil and Gas Producers (OGP) currently have this responsibility for their own industry, but how can we have an industry police itself when in all cases of incident; it is proved that they are not following their own procedures.
There were so many mistakes in both cases, mistakes that should not occur because procedures were in place and should have been followed.
Systems and procedures for Managing were not fully implemented, there was lack of engineering support, a culture had developed which showed that production was more important than safety and providing experienced resources was judged on cost and the bottom line and if the worst happened there was inadequate arrangements for containment and protection of the environment. There are failings to update and monitor systems after an incident or near misses have occurred, so no lessons are learnt.
Incidents and the industry need an effective auditing system this needs to be set in place to test the Management Systems and ensure that procedures are being followed.
In 1988 an explosion and subsequent blaze destroyed the Oil drilling platform Piper Alpha costing 167 men their lives. In November 1990 the Cullen report severely criticised Safety proceedings on the Oil Platform. The report changed the face of Health and Safety throughout all industry, but had it biggest effect on the Oil and Gas Industry. Or did it?
Governments Health and Safety Executives are now in the position to enforce the changes required to ensure that the industry follow the procedures that are laid down and change the way the Oil and Gas industry conduct their business.
Fines that are given for total disregard of procedures causing death and destruction are inadequate in today’s society and are not a deterrent to the rich Oil and Gas Industry; this is a failure by our governments to provide effective regulatory body to oversee a total reform which is required by an HSE agency
References:
(BMIIB) Buncefield Major Incident Investigation Board (2008) Recommendations on land use planning and the control of societal risk around major hazard sites. Retrieved September 19, 2012, from the Government Buncefield Investigation website. http://www.buncefieldinvestigation.gov.uk/reports/comahreport3.pdf
(BMIIB1) Buncefield Major Incident Investigation Board. (2008).The Buncefield Incident
11 December 2005. The final report of the Major Incident Investigation Board
Volume 1. Retrieved September 19, 2012, from the Government Buncefield Investigation website. http://www.buncefieldinvestigation.gov.uk/reports/volume1.pdf (BMIIB2a) Buncefield Major Incident Investigation Board. (2008).The Buncefield Incident 11 December 2005. The final report of the Major Incident Investigation Board
Volume 2a. Retrieved September 19, 2012, from the Government Buncefield Investigation website. http://www.buncefieldinvestigation.gov.uk/reports/volume2a.pdf
(BMIIB2b) Buncefield Major Incident Investigation Board. (2008).The Buncefield Incident 11 December 2005. The final report of the Major Incident Investigation Board
Volume 2b. Retrieved September 19, 2012, from the Government Buncefield Investigation website. http://www.buncefieldinvestigation.gov.uk/reports/volume2b.pdf
(BSTG) Buncefield Standards Task Group (2006). Initial report - recommendations requiring immediate action. Retrieved October, 2nd, 2012 from http://www.hse.gov.uk/comah/buncefield/bstg1.htm
(COMAH) Control of Major Accident Hazards (2005). Buncefield, Why did it happen, The underlying causes of the explosion and fire at the Buncefield oil storage depot, Hemel Hempstead, Hertfordshire on the 11th December 2005. Retrieved 15th September 2012 from the HSE Government website: http://www.hse.gov.uk/comah/buncefield/buncefield-report.pdf
Deepwater Horizon
(Deep Water) National Commission of the BP Deepwater Horizon Oil Spill and Offshore Drilling. (2011). The Gulf Oil Disaster and the Future of Offshore Drilling, Reported to the President. Retrieved September 19th 2012 from Oil Spill Commission Government website: http://www.oilspillcommission.gov/sites/default/files/documents/DEEPWATER_ReporttothePresident_FINAL.pdf
(TBI) UK Government (2008) The Buncefield Investigation, The Government and Competent Authority’s Response. Retrieved October, 3rd 2012 from http://www.dwp.gov.uk/docs/buncefield.pdf
