Andrew Hopkins

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Andrew Hopkins

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<ul><li><p>Falling Dominos The failure of the defence in depth in the Macondo disaster </p><p>Andrew Hopkins Australian National University </p></li><li><p>2 </p></li><li><p>3 </p></li><li><p>Blowout </p></li><li><p>Wall of well </p><p>Steel casing (tube) </p><p>Oil and gas sand layers </p><p>Annulus </p><p>Figure 5: Final intended location of cement (diagonals) </p></li><li><p>Mud </p><p>Mud </p><p>Sea surface </p><p>Sea floor BoP </p></li><li><p>Blow out </p><p>Hydro carbons </p><p>Multiple fatalities </p><p>Environ. disaster </p></li><li><p>Poor engineering decisions </p><p>Decentral- isation </p><p>Factors leading to poor engineering decision making </p></li><li><p>CEO </p><p>Business unit leader </p><p>Sub-business unit leader </p><p>Engineer </p><p>Senior engineers </p><p>Figure 1 Base level engineer reports to sub-business unit leader a decentralised organisation </p></li><li><p>CEO </p><p>Business unit leader </p><p>Sub business Unit leader </p><p>Engineer </p><p>Senior engineers </p><p>Engineer </p><p>Figure 2 - Base level engineer reports to more senior engineer </p></li><li><p>CEO </p><p>Business unit leader </p><p>Sub business Unit leader </p><p>Engineer </p><p>Engineer </p><p>Engineer </p><p>Figure 3 Engineering line reporting to CEO a centralised organisation </p></li><li><p>VP Exp and Production- GoM </p><p>Simplified version of Org structure for Exp &amp; App, post April 14 2010, with focus on the Macondo well </p><p>Ops Mgr </p><p>Macondo well team ldr </p><p>E&amp;A drilling eng team ldr </p><p>E&amp;A drilling engineers </p><p>Wells Mgr- GoM </p><p>VP Drilling and Completions - GoM </p><p>Drilling Eng Mgr - GoM </p><p>VP Exp and Production- Global </p><p>Group CEO </p></li><li><p>Poor engineering decisions </p><p>Decentral- isation </p><p> Unconstrained Cost Pressure </p><p>No focus on major hazard risk </p><p>Safety = occup safety </p><p>Factors leading to poor engineering decision making </p></li><li><p>Safety metrics for GoM </p><p> Personal Safety - RIF (Recordable Injury Frequency) Process safety LOPC (Loss of Primary Containment) </p></li><li><p>Significance of LOPCs </p><p> In petroleum industry generally, LOPC (loss of primary containment) is a precursor to MAE (major accident event) </p><p> In drilling industry </p><p> LOPC is not a precursor to MAE (blowout) </p><p> Focus on LOPCs does not drive down risk of blowout </p></li><li><p>Poor engineering decisions </p><p>Decentral- isation </p><p> Unconstrained Cost Pressure </p><p>No focus on major hazard risk </p><p>Safety = occup safety </p><p>Failure to adapt process safety to drilling </p><p>Factors leading to poor engineering decision making </p></li><li><p>Failure of pressure testing </p><p>Failure to understand defence in depth </p><p>Normal- isation </p><p>Group think </p><p>Inadequate mental model </p><p>Lack of behavioural safety for MH risk </p><p>Absence of engineers on site/ limited competency </p><p>Factors leading to failure of pressure testing </p><p>Belief that well was safe (confirmation bias) </p></li><li><p>Human factors </p><p> Is confirmation bias a problem here? What can we do about it? </p><p> Is groupthink a problem a problem here? What </p><p>can we do about it? Is normalisation of deviation or partial </p><p>malfunction a problem here? What to do? </p><p>Slide Number 1Slide Number 2Slide Number 3Slide Number 4Slide Number 5Slide Number 6Slide Number 7Slide Number 8Slide Number 12Slide Number 13Slide Number 14Slide Number 15Slide Number 16Slide Number 17Safety metrics for GoMSignificance of LOPCsSlide Number 20Slide Number 22Slide Number 24Human factors</p></li></ul>