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[HSE Expert]

The only good thing about an accident or incident is that people can learn from it and do not make the same mistake. There is a simple tool for incident investigation, initially developed for quality issues by Sakichi Toyoda, but now widely used for investigating health, safety and environmental incidents (HSE incidents) in order to determine the root cause. Once the root cause of an incident is known, it should be eliminated in order to prevent reoccurrence.

This method is called the "5 Why Method". Starting with the incident, the investigator will insistingly ask "why" several times (not necessarily 5 times) until he does not get any better answer and has found the fundamental cause that should be eliminated by suitable corrective action.

In order to show how the method works, I have applied it to the bp Deepwater Horizon disaster.

Incident: the installation exploded and sank on April, 20th, 2010, 11 workers were killed, up to 50,000 barrels of oil were leaking out per day in a depth of 1.6 km and massively polluted the Gulf of Mexico

WHY?

Immediate cause: a blow out occurred (a mixture of oil and gas was set free and caught fire)

WHY?

Underlying cause: the blow out preventer (BOP) had not closed the leak (BOP = installation on the ground of the ocean with several safety valves)

WHY?

Underlying cause: the battery in the blow out preventer was dead, furthermore, there was a leak in the hydraulic system and the BOP was not designed for a drill of that size (additional failures at bp: the alarm system on the Deepwater Horizon was switched off in order to prevent false alarms, the staff applied a fixation cement which did not solidify in time, Transocean only applied 6 alignment rings instead of 21 required to stabilize the drilling device, bp sent a safety inspection team from Schlumberger home some hours before the explosion, bp's emergency plan was full of mistakes and partly inoperable)

WHY?

Root cause at bp: deliberate toleration of carelessness in order to save time and money

WHY?

Underlying cause: the competent authority (Minerals Management Service, MMS) never checked Transocean's and bp's activities and did not – as required by law – ask for an environmental impact assessment and information on the suitability of the BOP

WHY?

Root cause at the enforcement authority: the MMS was responsible for issuing oil drilling licenses and supervising the environmental safety but also collected the corresponding fees (23 billion US$ per year) => conflict of interest at the authority

Corrective action at the enforcement authority: some of the MMS staff including the director was dismissed, the MMS was split into independent units which separately oversee safety enforcement and revenue collection

Corrective action at bp: ???

This tool is simple and effective, isn't it? I wonder if bp will ever be able to learn.

[Charlz]

Not only meant for bp, but also for all other participants. Thanks, i have learnt alot