exxon valdez final report
TRANSCRIPT
Exxon Valdez Human Error and Complex System Failure
Cooper Green Daniel Kilcullen
Greg Long Damiete Samuel-Horsfall
Andrew Schanne
University of Michigan Industrial and Operations Engineering IOE 434: Winter 2016
4/14/2016
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Table of Contents The Exxon Valdez ..................................................................................................................... 3
Operating the Exxon Valdez ..................................................................................................... 4
Alaska and the Trans-Alaska Pipeline System ......................................................................... 5
Broken Promises ...................................................................................................................... 6
Accident Analysis: Government and Exxon Culpability ................................................................ 7
Government Culpability ............................................................................................................ 7
Exxon Management of the Captain .......................................................................................... 7
Exxon Management of Third Mate ............................................................................................ 8
Exxon Reduced Ship Manning Policy ....................................................................................... 8
Exxon Record Manipulation Policy ........................................................................................... 9
Accident Analysis: Coast Guard Culpability ................................................................................. 9
Manning Standards ................................................................................................................... 9
VTS involvement on the Night of Accident ............................................................................... 9
Organizational Issues that led to Loss of Situational Awareness and Vigilance ..................... 10
Accident Analysis: Design Induced and Human Error ................................................................ 12
Design Induced Error .............................................................................................................. 12
Human Error ........................................................................................................................... 12
Pilot Error ................................................................................................................................ 12
Captain Hazelwood Culpability and Error ............................................................................... 13
Third Mate Cousins Culpability and Error ............................................................................... 14
Spill Response and Cleanup ...................................................................................................... 15
Promised Clean-up Response ................................................................................................ 16
Initial 72 Hour Response ........................................................................................................ 16
Day One .............................................................................................................................. 16
Day Two .............................................................................................................................. 18
Day Three ........................................................................................................................... 19
Analyzing the Regional Response Team’s Decisions ......................................................... 19
Long Term Impact of the Oil Spill ........................................................................................... 20
Recommendations and Conclusions .......................................................................................... 20
Conclusion .............................................................................................................................. 22
Internal Oversight ................................................................................................................... 22
Nuclear Model ......................................................................................................................... 22
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Appendix 01 – Double Hull Tankers ........................................................................................... 24
Appendix 02 – EXXON VALDEX Route the night of 23 March 1989 ........................................ 25
Appendix 03 – Steering Console Design .................................................................................... 26
Appendix 04 – Human Culpability .............................................................................................. 27
Appendix 05 – Busby Island Light .............................................................................................. 28
Appendix 06 – How to take a paper fix ....................................................................................... 29
Appendix 07 – Oil Recovery Methods ........................................................................................ 30
Mechanical Skimming ............................................................................................................. 30
Chemical Dispersants ............................................................................................................. 30
In-Situ Burning ........................................................................................................................ 31
Appendix 08 - Event Timeline of The Exxon Valdez Oil Spill Response - Initial 36 Hours ......... 32
References ................................................................................................................................. 33
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Background Shortly after midnight on March 24, 1989, the Exxon Valdez oil tanker ran aground on Bligh Reef in
Prince William Sound, Alaska, and began leaking oil. The captain of the tanker was possibly drunk, and
had left the bridge to go to his private stateroom, where he told the deck watch officers that he would be
filing reports to Exxon. The third mate, a lookout, and the helmsman were the only crew members on the
bridge after the captain left. The third mate had just worked almost 12 consecutive hours, had only slept
approximately five hours in the last twenty-four, and was very inexperienced. However, he was
attempting to navigate the Exxon Valdez through Prince William Sound and plot the position of the oil
tanker by himself through the darkness. The third mate had intentionally deviated from the predetermined
route the tanker was supposed to follow, and the Coast Guard knew. However, the Coast Guard stopped
monitoring the location of the ship.
After failing to begin turning the Exxon Valdez early enough, the third mate collided the oil tanker into
Bligh Reef. Immediately he called the captain, who returned to the bridge from his stateroom. After
unsuccessfully attempting to free the tanker from the reef for approximately 22 minutes, the captain
notified the Coast Guard that there had been an accident and oil was leaking. However, it took hours for
oil containment and cleanup equipment to be mobilized and arrive at the scene of the accident. Most of
the equipment had either broken in the past and not been fixed, or was covered in snow.
According to local experts in Valdez, Alaska, the Exxon Valdez oil spill should have been very easy to
contain and cleanup. The weather conditions were ideal; the sea was very calm. However, no one was
prepared for an accident of that magnitude, so there were significant delays in mobilizing the necessary
equipment, and the response was completely inadequate. On the third day of the cleanup, a major storm
hit Prince William Sound, spreading the spilled oil over long distances, and making the spill significantly
harder to clean up. A total of 11.6 million gallons of oil were spilled in the accident (National
Transportation Safety Board, 1989).
The Exxon Valdez Constructed from 1985 to 1986 in San Diego, California, the Exxon Valdez was the largest ship ever built
on the west coast of the United States at the time of its construction. The ship was 987 feet long and 166
feet wide. For comparison, the Empire State Building in New York City is just over 1,400 feet from base
to tip. The deck of the Valdez is long enough to hold three football fields and one basketball court.
(Gordon, 2003)
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Every oil company that owned tankers similar to the Exxon Valdez had two goals: carry the greatest
possible volume of oil, and deliver that oil to its final destination as quickly as possible. The Valdez had a
capacity of 62 million gallons of oil, weighed 214,000 tons when completely full, and sat 65 feet beneath
the water. The ship was also a single hulled tanker. This means that the Valdez only had one hull
separating the sea water on the outside of the ship from the oil inside of the ship. In the case of an
accident where the hull is breached, such as the Exxon Valdez, oil spills directly into the ocean. In
contrast, some oil tankers are double hulled. In double hulled tankers, there is an outer hull that is in
contact with the seawater, then a gap of approximately 10 feet of air or ballast, then an inner hull that is in
contact with the oil inside of the ship. Double hull tankers are much safer than single hull tankers because
in order for an accident to occur, two hulls need to be breached instead of one. However, as mentioned,
oil companies designed tankers to carry as much oil as possible, and having a double hull significantly
reduced the amount of oil the tanker could carry when compared to having a single hull (see Appendix
01). Additionally, in the 1980s, hiring a single hulled tanker costed oil companies 20% less than a double
hulled tanker (Gordon, 2003).
The equipment aboard the Valdez was as basic as possible to minimize costs. The tanker had a single
engine, single rudder, and single propeller. Not only did this simplicity reduce the overall cost of the ship
and allow it to carry more oil, but it also reduced the number of crew members required to operate the
ship. Although it was such a massive ship, the Valdez was designed for a crew of 34. However, there
were only 20 crew members on the night of the accident, and there were plans to further reduce this crew
to 16 in future voyages. It was standard practice for the crew to work 20 hour shifts (Gordon, 2003).
Operating the Exxon Valdez During transit through Prince William Sound, a pilot was supposed to be on the bridge (the platform or
room from where the ship is commanded), but was not during the accident (Gordon, 2003). A pilot is an
expert of the local area who helps ships navigate through difficult areas close to the port. Prior to the
vessel entering open water, the pilot leaves the ship and the captain takes over.
The hierarchy on the Exxon Valdez also played a key role in the accident. There were four deck watch
officers on the ship during the accident: the third mate, second mate, chief mate, and captain. The third
mate is the officer with the least amount of training and experience. Training and experience increases as
one moves from third mate to second mate, second mate to chief mate, and finally chief mate to captain.
The captain is the deck watch officer in command of the vessel and has the most responsibility for
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ensuring a safe and timely completion of the ship’s journey. The two key members of this hierarchy
regarding the Exxon Valdez oil spill were the captain and the third mate.
Captain Joseph Hazelwood was a highly skilled and experienced captain. He obtained his Master’s
license in 1977 and had competed over 100 voyages through Prince William Sound. Hazelwood was
considered to be one of Exxon’s best captains, but was becoming unhappy with Exxon trying to control
his ship at sea, demanding additional paperwork, and pressuring him to rush. Still, Hazelwood was an
excellent captain, particularly in difficult and high stress situations. As a result of his skill, Hazelwood
received Exxon’s most prestigious safety awards in 1987 and 1988.
Although he was an outstanding captain, Hazelwood had a history of alcohol abuse. As a result of his
drinking, his wife left him and he entered rehab, where he was described as depressed and demoralized. In
his home state of New York, Hazelwood had his driver’s license suspended three times and received two
DUI’s, one of which occurred in 1988, the year before the Exxon Valdez accident. Additionally,
Hazelwood had been known to drink while on board his ships. Although his superiors knew of his alcohol
abuse, his behavior was never monitored (Gordon, 2003).
Gregory T. Cousins was the third mate of the Exxon Valdez. He was promoted to this role in 1987, and
had only completed six round trips to Valdez with Captain Hazelwood. Cousins was the least trained and
least experienced officer on the Exxon Valdez. According to the NTSB report, Cousins’ performance
reviews said “he seems reluctant or uncomfortable in keeping his superior posted on his progress and/or
problems in assigned tasks.”(National Transportation Safety Board, 1989). At the time of the accident,
Cousins was the only deck watch officer on the bridge, although he had the least training and experience,
and was attempting to monitor the ship’s course and navigate the ship through Prince William Sound by
himself.
Alaska and the Trans-Alaska Pipeline System In 1973, the highly controversial Trans-Alaska Pipeline Authorization Act was passed. The original plan
for the pipeline was for it to begin in Prudhoe Bay in the North Slope of Alaska, cut through Canada, and
end in the Midwest Region of the United States. However, the U.S. Department of the Interior determined
that the pipeline could be completed two years earlier if it was built through Alaska rather than through
Canada. Therefore, the original plan to build through Canada was scrapped and a new plan to build an
800 mile long pipeline from Prudhoe Bay to Valdez was approved. This new plan would also allow
America to be energy independent, since Canada would not own any part of the pipeline, allow oil to
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reach the U.S. west coast faster and cheaper, and allow Alaska to start earning mineral revenues as soon
as possible (Gordon, 2003). The Trans-Alaska Pipeline System (TAPS) was completed in 1977 and began
pumping 1.6 million barrels of oil per day from Prudhoe Bay to Valdez. Had the original plan to build the
pipeline through Canada been followed through, there would have never been oil in Valdez, meaning
there never would have been oil tankers in Prince William Sound, and the Exxon Valdez oil spill accident
never would have occurred.
Broken Promises When oil was discovered, Alaska rushed to launch the oil industry to provide desperately needed income
to the poor state and took shortcuts regarding safety as a result. While working with the federal
government and private oil companies, Alaska was assured that safety would be a top priority; however,
none of the promises made by the oil companies were put in writing. Therefore, there was no way of
enforcing these promises, and the oil companies were free to follow their own industry safety standards.
For example, the federal government and oil companies initially supported double hulled tankers in the
Port of Valdez. However, when Alaska passed its own law requiring double hulled tankers, the oil
industry sued Alaska, saying the law infringed on federal authority. The oil companies won the suit, and
double hulled tankers were not required.
Additionally, the oil companies fought Alaska in court for the freedom to determine the location of the
navigation channel in Prince William Sound. The navigation channel, also known as the shipping lanes,
can be thought of as a divided highway for large commercial ships, such as oil tankers. In the southbound
shipping lane, full oil tankers were heading out of Prince William Sound toward the Pacific Ocean. In the
northbound lane, empty tankers were heading to the Port of Valdez to fill up with oil. When TAPS first
opened, the Coast Guard closely monitored tankers, and tankers rarely left the designated shipping lanes.
When the shipping lanes were full of ice from the nearby Columbia Glacier, oil tankers were supposed to
slow down and stay within the lane. However, since the goal of the major oil companies was for their
tankers to deliver oil to their final destination as quickly as possible, the companies began pressuring the
Coast Guard to permit tankers to leave the shipping lanes to avoid ice so they did not have to slow down.
As seen in Appendix 02, the Exxon Valdez deviated from its shipping lane to avoid ice and maintain a
higher speed. Had they followed the original requirement and stayed in the shipping lane, the accident
likely never would have occurred (Fountain, 2013).
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Accident Analysis: Government and Exxon Culpability
The culpability for the grounding of the Exxon Valdez and the subsequent failure in cleanup efforts is
shared by several key players, all having partially contributed to the accident. These key players include
the Alaska State and U.S. Federal government, Exxon Corporation, the U.S. Coast Guard, the crew of the
Exxon Valdez, and Alyeska, the company tasked with spill response around Valdez.
Government Culpability The federal government's culpability can be traced back over a decade prior to the grounding of the ship.
In 1974, the double hulls, which were previously required to enhance ship safety, were determined by the
federal government to be economically infeasible due to increased construction costs and restrictions in
oil tanker cargo capacity. The reversal in the double hull policy may be traced back to substantial
lobbying and pressure from oil companies. Three years later, in 1977, the U.S. Congress passed the Clean
Water Act. This act dictated how oil spill cleanup response should be conducted, but was not seriously
enforced.
In 1973, the boat used to pilot oil tankers from the Port of Valdez to the entrance of Prince William Sound
became non-operational and instead of repairing the boat or purchasing a boat with comparable
capabilities, the State of Alaska Board of Marine Pilots acquired a smaller, less capable boat and moved
the pilot station closer to the Port of Valdez, thus requiring the oil tanker crews to navigate the ship
through an increased amount of difficult water. In 1980, the Coast Guard was assigned drug enforcement
duties on U.S. coastal waters. This additional responsibility did not include an increase in budget or
staffing levels, and the Coast Guard was required to divert resources from other responsibilities, including
its vessel traffic services operation at Valdez. In 1987, the U.S. government required Alyeska to
demonstrate how they would conduct a 200,000-gallon spill response. Alyeska believed conducting a spill
response of this magnitude was unnecessary and did not comply with the requirement. The federal
government never enforced this requirement.
Exxon Management of the Captain The NTSB concluded that “Exxon should have removed the captain from seagoing employment” due to
his alcohol problem. Exxon management was aware of Captain Hazelwood’s alcohol problems and
provided him with a 90 day leave to attend a rehabilitation recommended by the medical staff. The
captain accepted the 90 day leave; however, no documentation exists determining whether he completed
or even attended the rehabilitation program. Additionally, the management and medical staff never
informed the Hazelwood’s supervisor about the captain’s condition, nor did management contact an
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alcohol expert to determine appropriate methods for further monitoring the captain’s sobriety and how to
alter his work duties to assist in supporting his sobriety. A breakdown at boundaries occurred, because
there was a substantial lack of communication between different contingents of Exxon (medical,
management, supervisory) to inform each other about the captain’s condition. Furthermore, Exxon failed
to revise its assessment of the master’s ability to maintain seagoing employment and his employment
duties even after receiving information regarding his alcoholism.
Exxon Management of Third Mate U.S.C. 8104 requires that the Deck Watch Officer controlling of the ship has been off-duty for at least six
of the twelve hours prior to the ship leaving the port; however, the third mate had been working for eleven
of the twelve hours prior to the Exxon Valdez leaving port. Additionally, the third mate only rested
approximately five hours in the previous 24 hours before the accident. U.S.C 8104 also states that a
licensed individual is not required to work more than eight hours in a day, yet the third mate did not
follow this directive either. Due to this excessive workload, fatigue became a factor in the third mate’s
performance. Additionally, prior voyages of the Exxon Valdez included four mates instead of three to
reduce the workload burden. Exxon requiring the third mate to work inappropriate hours is a violation,
because the company knowingly ignored the policy required by U.S.C. 8104.
Exxon Reduced Ship Manning Policy After world oil prices crashed in 1986, Exxon began reducing crew sizes on ships to save money. Despite
the smaller crews, no policies were implemented to account for the increased responsibilities of the
remaining crew. The Exxon Valdez was transporting oil to Long Beach, California; however, the ship was
manned according to guidelines for transit from Valdez to Panama. The route was shortened, but the
required ship maintenance remained constant. Therefore, crew members had to replace rest time with
maintenance work. Furthermore, with the shortened route, there was less time to rest between the arduous
tasks of loading and unloading the oil. Drift toward failure in the face of production pressure occurred,
because there was increased pressure to reduces expenses due to reduced revenues from the crash of
world oil prices and Exxon’s response was to subject the crew to a potentially harmful situation of having
an overworked and fatigued crew. Additionally, Exxon failed to revise its crew manning when the route
was changed and failed to revise the assessment of crew workload when the number of employees was
reduced.
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Exxon Record Manipulation Policy To allow for the previously mentioned reduced ship manning, overtime records for crew workload were
routinely manipulated. A company memo directed the officers to disingenuously minimize equipment
maintenance and overtime reports. This record manipulation policy is an optimizing violation, because
Exxon knowingly ignored laws to achieve a non-functioning goal of operating a ship with a severely
understaffed crew.
Accident Analysis: Coast Guard Culpability
The two major aspects of the Coast Guard’s culpability in this accident were the manning standards which
they used to tolerate reduced ship crews and organizational issues within the Vessel Traffic System (VTS)
that lead to a loss of situational awareness and a breakdown in their defenses against potential disaster in
Prince William Sound.
Manning Standards The Coast Guard was under pressure with regards to their policies regarding minimum crew sizes on
ships due to the conflicting rationales from ship owners and labor unions. However, their primary
justifications for allowing reduced crews to the level as at the time of the accident was that there would be
reliable labor-saving equipment onboard the ships, which meant not as much manpower was needed.
This conclusion was an oversimplification of the issue because there was not a substantial amount of
labor-saving equipment onboard the Exxon Valdez to justify the reduced crews. More importantly, the
Coast Guard overlooked the amount of work that was done by crew members at the port, which was
significantly more than that which was done at sea. As a result of this, members of reduced crews on
ships were working near their physical capacity and hence along the boundaries of safe operation. This
was problematic because the potential for disaster such as an oil spill was increased by the presence of
fatigued crew members participating in sensitive cargo transfer operations at sea.
VTS involvement on the Night of Accident On the night of the accident, the 1600-2400 VTS radar watchstander noticed that the Exxon Valdez was
no longer available on the radar at about 5.5 miles from the grounding site. His attempts to reacquire radar
contact with the vessel using the No. 3 radar on the 12-mile range scale were unsuccessful; however, he
made no mention of the settings he used for the No.1 radar. He assumed that the radar was not working
properly, but only informed the relieving watchstander that the vessel was no longer available on the
radar. The relieving watchstander noticed that the range scale on the No. 1 radar was set to the 3-mile
range scale when he arrived at about 2330.
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While it was true that the radar sometimes did not function adequately due to the deterioration of the
system over time, the assumption by the first watchstander that the radar was not functioning correctly on
the night of the accident was an availability heuristic because it was the most easily accessible diagnosis
of the problem at hand. Therefore, undue weight was ascribed to it and very little to other factors that may
have caused the loss of radar contact.
In reality, the No.1 radar being set to the 3-mile range scale, while accurate for monitoring vessels
transiting the Valdez Narrows, was not sufficient to monitor the Exxon Valdez to the point it reached
shortly after radar contact had been lost. In short, the reason why the radar contact was lost was simply
because the No. 1 radar was not on the correct setting at the time and that its setting as of 2330 when the
second watchstander arrived contributed or perhaps even caused the loss of radar contact.
In summary, the first watchstander had a faulty mental model of the radar system, which drove an
incorrect top-down assessment of the problem (loss of radar contact), because he did not change the radar
settings for the No. 1 radar. Additionally, the second watchstander made no further attempts to reacquire
the vessel’s location on the radar, although there was no policy which required either watchstander to do
so. This made it very difficult for the VTS to have intervened and prevented the accident from happening,
constituting in a breakdown in their defenses on the night of the accident.
Organizational Issues that led to Loss of Situational Awareness and Vigilance The VTS comprised of the Vessel Traffic Center (VTC) and its communication systems. The VTS was in
the operations department that was under the authority of the Marine Safety Office (MSO). This meant
that the duties in the VTS did not involve watchstanding. Duties were assigned at the discretion of the
Commanding Officer (CO) of the MSO.
Budget cuts within the VTS lead to the loss of personnel and the expansion of officer duties to non-VTS
related duties. This meant a reorganization in the structure of the VTS, as the duties did not decrease
along with the amount of personnel. In addition to this, the radar system in PWS had greatly deteriorated
and hence was usually affected by adverse weather conditions to the point where it was a known fact
across the VTS that the radar systems where no longer reliable.
Due to the budget cuts and the diminished personnel, the duties of the Commanding Duty Officer (CDO)
and the Officer of the Day (OOD) were merged and called the OOD. The CDOs were officers that were
well experienced with watchstanding and were in charge of supervising the VTC watchstanding activities.
A significant number of the OODs were enlisted personnel who were junior to the VTC watchstanding
officers that they were now in charge of supervising. A large portion of the OODs had no experience with
watchstanding, yet they were in charge of supervising watchstanding operations and relaying relevant
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information to the CO, such as when permission would be required for a vessel to leave its designated
shipping lane. This meant the supervision of the VTC was ineffective and the communication between the
VTC and the CO was hindered.
The VTS did not defer to expertise because the individuals who were in charge of supervising VTC often
did not even have as much experience as the watchstanders they supervised, nor did they have enough
experience in watchstanding activities in general to be in charge of those duties.
Regarding the plotting of vessels, on August 31, 1987 a memorandum was issued by the senior
watchstander that eliminated the requirement of vessels outside of the Valdez Narrows to be plotted by
VTC watchstanders. At the time, this meant that range and bearing data for vessels in the Valdez Arm
were no longer being recorded into the VTC data sheet. This lowered the awareness of the officers as to
how the vessels were moving; hence, there was a lack of redundancy present on the system that would
have required the watchstanders to maintain working knowledge of the vessel locations in the event that
the ship operators failed in navigation and operation as was the case with the Exxon Valdez.
Despite the fact that ships regularly deviated from their shipping lanes, the CO stated that a vessel
requesting deviation from the lanes was requesting something out of the norm. He made this statement in
lieu of knowledge of just how frequently vessels deviated from the lanes. The fact that this happened
often without knowledge meant the VTC watchstanders were regularly granting permission to ships to
deviate from the lanes without informing the CO, which would constitute a routine violation. The
combination of the poor communication between the VTS and the CO, as well as the removal of plotting
requirements, are probably what led to the CO’s lack of knowledge about the vessels frequently leaving
the shipping lanes. The sum of this was a lack of sensitivity to operations on the on the part of the CO,
even though it was caused by an increased amount of workload and poor communication.
With regards to ice reporting, the VTS did not provide accurate or timely reports to ships to give them a
complete picture of the ice situation in Prince William Sound. The reports provided by the VTS were
retransmissions of the reports given by vessels that had previously transited the shipping lane. The
retransmissions were provided often hours after they were originally received by the VTS, making them
inaccurate since the ice would most likely have changed locations. Ships often left the shipping lanes to
avoid ice, but there was no effort made in order to consolidate and analyze the ice report information to
provide the vessels with a reliable and dynamic assessment. This means that the VTS exhibited a failure
to revise assessments as they continued to receive new information about the presence of ice. (National
Transportation Safety Board, 1989)
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Accident Analysis: Design Induced and Human Error
Poor design of various features on the Exxon Valdez and the actions of various crew members created the
potential for errors were major contributors to the accident.
Design Induced Error The autopilot design for the ship, while relatively simple, had one flaw that may have contributed to the
accident. There were two modes on the system, manual and gyro, or “autopilot”. In gyro mode, a course
is selected and the system will adjust the rudder to steer that course. Manual mode requires a helmsman to
actively control the rudder and make adjustments to steer the ship. Also on the helm console, pictured in
Appendix 03, are two gauges. The bottom gauge directly above the wheel is a mechanical indicator
connected to the wheel to indicate the amount of rudder that is applied. If 20 degrees of right rudder is
ordered, the helmsman would turn the wheel until the mechanical indicator indicates 20 degrees. The top
gauge displays the actual position of the rudder since there is a delay from when the wheel is turned and
the rudder moving to the desired rudder amount. Once the wheel is turned to achieve the desired rudder
position, the helmsman must watch the top gauge to ensure the rudder goes to the correct position.
However, if the system is in gyro mode, the helmsman can turn the wheel and the mechanical indicator
will move, but the actual rudder will not. The only way to tell if the command was carried out is to verify
on the top gauge. No alarm will indicate that the intended command will not be carried out because the
system is in gyro mode. This lack of feedback is normally caught by the helmsman checking the top
gauge, but if the helmsman forgets to verify, it could lead to disaster.
Human Error Unfortunately, by the time of the Exxon Valdez grounding, all other safety aspects of the system1 had
been removed, leaving the safe transit of a ship up to a captain and his crew through complex and
challenging waters. If a navigation mistake was made, there was no outside intervention to alert the crew
before it was too late. Dr Riki Ott had come to this realization when she gave a speech to local fisherman
the night of the grounding saying: “Given current practices and pressures in Prince William Sound, a
catastrophic accident involving an oil tanker has become inevitable.”
Pilot Error On the evening of the grounding, the pilot boarded the Exxon Valdez and headed to the bridge to await
the ship's departure. He smelled alcohol on the captain’s breath, but failed to report it and did nothing to
prevent the ship from leaving port. Failure to report intoxication is a violation of federal law. The pilot
1 System – The transfer of oil out of Valdez Alaska by oil tanker – Parties involve include: Federal Government, Oil Companies, U.S. Coast Guard, Shipping Companies, Oil Tankers and their crews.
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was overconfident that the captain would not be drunk while operating a vessel, and looked for signs to
confirm his belief by observing the Captain’s speech and movements to confirm his belief that the captain
was not intoxicated. This is overconfidence bias and confirmation bias, as the pilot believed the captain
would never be drunk on the job, and the pilot sought evidence to confirm his conclusion.
Captain Hazelwood Culpability and Error In studying accidents, it is important to avoid simply blaming a human operator and look for the
underlying causes of the accident. However, even after removing all hindsight bias and using the
substitution test, the captain of the Exxon Valdez is highly responsible for this accident. In the maritime
community, it is the captain’s responsibility to ensure safe operation of his vessel. On March 23, 1989
when the Exxon Valdez left the Port of Valdez, safety was not Captain Hazelwood’s first priority. The
first breakdown in a long chain of events was drinking alcohol throughout the day and evening of the
ship’s departure, which was a violation of federal law. As shown in Appendix 04, a graph of diminishing
culpability, using an unauthorized substance is the second highest only behind intended sabotage.
After the pilot left the ship, the captain and third mate remained on the bridge to drive and navigate the
ship. Shortly after entering the shipping lanes, the captain alerted the Coast Guard that the Exxon Valdez
was coming to a course of 200 degrees true to avoid ice. However, immediately after talking to the Coast
Guard, Captain Hazelwood ordered the helmsman to come to a course of 180 degrees true. While twenty
degrees may seem small and insignificant, a course of 200 degrees would have kept the ship in the
inbound shipping lane as the captain had told the Coast Guard he would do, and would have not required
the ship to turn to avoid Bligh Reef. However, the course of 180 degrees true brought the ship out of the
shipping lanes and directly toward Bligh Reef. This navigation error may have been a slip due to the
captain being tired and possibly intoxicated, or he may have deliberately told the Coast Guard the wrong
information. The Coast Guard may have challenged a course change to 180 degrees true, knowing it
would put the ship on a collision course with Bligh Reef.
The next and probably most contributing factor to the accident was that Captain Hazelwood left the
bridge, leaving the third mate to do the job of two people: navigate and drive the ship, for a complex
transit through Prince William Sound at night. The NTSB report concluded that “there were demanding
conning, lookout, and navigation functions that required the presence of an experienced conning officer
assisted by a competent navigation watch officer…demanded the captain’s presence on the bridge.”
(National Transportation Safety Board, 1989) For this reason, Exxon policy required either the captain or
chief mate to be on the bridge when operating near land. Additionally, federal law required that the
captain be on the bridge during near coastal transit, because he was the only crew member with a Valdez
Pilot License, which was required to operate in Prince William Sound. By leaving the bridge the captain
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violated of both Federal and Exxon policies. As shown in Appendix 04, between the drinking and this
violation, the Captain bears a great deal of responsibility in this accident.
Prior to leaving the bridge, the captain had the helmsman put the ship in autopilot, which was a violation
of Exxon policy because autopilot was only supposed to be used in open waters (usually greater than 5
nautical miles from shore). While this was a violation, it may have been a slip or capture error caused by
the captain’s tired and possibly intoxicated state where he thought the ship was farther from shore than it
actually was, or just did so out of habit, as the ship is in autopilot most of the time the ship is underway.
Lastly, the captain never should have left the bridge with the ship’s crew being extremely novice. The
third mate was the most inexperienced and least trained Deck Watch Officer and the helmsman was not
known as an exceptional helmsman. Prior evaluations reports had noted that the helmsman, “needs
practice [helmsmanship] before sailing” (National Transportation Safety Board, 1989). Additionally, the
third mate was known for being reluctant to ask for help when needed. This oversight of the captain may
have been caused by the availability heuristic, since the crew had recently been performing well, so that
was what came readily to the captain’s mind. However, the captain forgot that this crew was not his best
ship drivers.
Third Mate Cousins Culpability and Error Upon arriving to the bridge to take his watch during the outbound transit from Valdez, Alaska, the third
mate had been awake since 0520 on March 23, after going to bed at 0100. At 2350, the third mate learned
from the off going helmsman that the ship was in autopilot. At 2352 the captain left the bridge after
giving instructions to turn back towards the shipping lanes when the ship was abeam of Busby Island
Light. At this point, the third mate was responsible for navigating and driving the ship by himself on the
bridge, although both a helmsman and lookout were on duty. At 2355, the third mate stated that the ship
was abeam of Busby Island Light and took a fix. While taking the fix, he observed a white light from
Busby Island Light, indicating that the tanker was sufficiently far from Bligh Reef. Busby Island Light
was a directional light that showed red when a ship was within a danger area around Bligh Reef, and
showed white when a ship was safe (See Appendix 05). Shortly after noticing the white light, the third
mate went back to the chart table to plot his fix (Outlined in Appendix 06). While he was plotting, the
lookout reported that there was a red flashing light off the starboard bow and that the light should be on
the port side. The third mate ignored the lookout’s report and continued with his fix. This was the due to
the anchoring heuristic, because he had just seen the white light from Busby Island Light and maintained
that he was still in safe water. This mistake is also confirmation bias because he justified that he had seen
the light on his radar and that everything was ok.
15
Unfortunately, this was the last point at which the Exxon Valdez could have avoided hitting Bligh Reef.
If the third mate had reacted with the appropriate actions on hearing that the light was on the wrong side
of the ship and put the rudder over, the ship would have missed the reef. After not responding with any
corrective action, there was nothing the third mate or any operator could have done to prevent the ship
from hitting the reef. After the accident, the third mate testified that after plotting his fix, he ordered the
helmsman to put on 10 degrees of right rudder, which would cause the ship to turn. For some reason, the
ship did not start to turn until 0001.5 on March 24. The third mate claimed that the fix took about a
minute and the rudder was put over immediately after.
There are three possible scenarios for why the ship did not turn. One, the ship was still in autopilot mode
and when the helmsman turned the wheel, nothing happened because of the design induced error
discussed earlier. It then took the third mate about 5 minutes to realize that the ship was not turning. This
would be a lapse since the third mate forgot to turn the autopilot off before the turn, probably caused by
his lack of sleep. The second scenario is that it took the third mate much longer to take the fix than he
thought, and he applied the rudder at 0001.5 after completing the fix. This would be a loss of situational
awareness caused by his lack of sleep. Lastly, the third mate may have thought he told the helmsman to
put the rudder over but never actually did, due to a loss of activation and lapse from the high demands of
trying to navigate and drive a ship at night combined with a lack of sleep. The third mate finally realized
that the vessel was not turning and attempted to change its direction too late, and the vessel ran aground at
0005 on March 24.
There were two additional errors that contributed to the accident. First, the third mate was reluctant to call
for help, caused by overconfidence in his abilities. Second, he was over-reliant on radar, which was partly
due to the situation he was in, trying to do the job of two people. The radar gave him the timeliest
information; however, it did not display the location of the reef. This is a selectivity failure because the
third mate choose the most salient data rather than the most important data, which would have been the
external navigation aids and the chart he used to plot his fix.
Reviewing the human culpability chart in Appendix 04, all of the third mate’s culpability stems from
system induced violations. He was not provided with adequate rest and was left alone with the almost
impossible task of simultaneously navigating and driving the ship.
Spill Response and Cleanup
Three cleanup methods were used following the accident for the response effort: mechanical skimming,
chemical dispersants, and in-situ burning. An explanation of each method can be found in Appendix 07.
The oil industry operates in a complex environment with potential for disaster. Extra production
16
pressures, increasing technologies, monetary compensation, and governmental pressures all combine to
create a highly complex environment that only increases in complexity when cleanup is necessary.
Promised Clean-up Response Alyeska Pipeline Service Company was the entity responsible for any spill response in the Prince William
Sound area. From 1976 to 1977 when the Trans-Alaskan pipeline was finished with construction,
Alyeska’s oil spill recovery plan was under criticism for a lack of thoroughness and clarification. Multiple
Alaskan officials, including the Department of Environmental Conservation (DEC) wrote reports trying to
convince Alyeska to edit their recovery plan to make it sufficient to handle the risks that would become
present after the finishing of the pipeline in Valdez. For example, within the contingency plan, Alyeska
promised to be on site of any spill in the Prince William Sound area within five hours of a spill occurring.
Rear Admiral J.B. Hayes of the 17th Coast Guard District stated that this was an extreme overestimate of
Alyeska’s capabilities, stating that response times for vessels stationed in Valdez would take 7 to 8 hours
to respond.
In addition to their questionable contingency plan, Alyeska was pressured into eliminating their dedicated
spill response team by the Reagan administration in 1981. Under the initial contingency plan, Alyeska
had a contractor force that would respond to every oil spill. During the first four years after the pipeline
became operational, there was a large number of responses. After 1981, however, the number of
responses decreased significantly, not due to the fact of spilling less oil, but because once the spill
response duties were internalized, they were severely neglected in favor of profit driving activities.
Initial 72 Hour Response The initial response during the first 72 hours were the most significant, because a storm hit Prince
William Sound at the end of the third day and spread the oil over 800 miles of coastline. The night before
the grounding, March 23, 1989, Alyeska held its annual safety awards ceremony. The highlight of the
night was the successful cleanup of the Thompson Pass spill, BP’s tanker that spilled 71,000 gallons of oil
in the Valdez port. Alyeska classified this as a “textbook” cleanup response recovery. This resulted in
Alyeska using past successes as a reason for confidence, leading them to put their response barge in dry
dock for cleaning and repairs (when it was still seaworthy), without taking the appropriate actions to
ensure a oil spill response could still be properly executed.
Day One After the grounding of the Exxon Valdez at 0005 on March 24, 1989, Captain Hazelwood attempted to
free the ship from the reef for 22 minutes before notifying the Coast Guard of the accident. Had he been
17
successful in freeing the ship, it may have broken apart and spilled an additional 40 million gallons due to
its damaged structural integrity. It was not until two hours later at 0200 that Alyeska’s response barge
finally arrived at the Valdez Terminal to begin loading in an effort to respond to the spill. Alyeska failed
to be preoccupied with failure in Valdez; their barge was out of water and the spill response equipment
was either buried in snow or in storage. Additionally, facing massive production pressures from the
government, Alyeska had to internalize their previously separate response team into the terminal crew
that performed day to day operations. Of the 26 people at the terminal, only 12 were available to mobilize
the response without ceasing terminal operations. Furthermore, of the 12 available, only one crew
member was certified to operate the crane and the forklift, which were both needed to transport the
equipment to the dock and load it onto the response barge. Alyeska failed to build excess capability
through multi-function training, which led to the slow mobilization of a response barge that was already
90 minutes behind schedule. This is an example of how production pressures can drive organizations to
omit preoccupation with failure, failure to diversify training, and not have the required manpower to
operate under the appropriate conditions.
At 0414, the lag in the response became even worse. After structural calculations were performed on the
Exxon Valdez, On Scene Coordinator (OSC) Steve McCall made the decision to make lightering of the
Exxon Valdez a high priority item. Lightering involves transferring the cargo from one ship onto another.
In this case, oil from the Exxon Valdez was moved to the Exxon Baton Rouge. In order to comply with
this priority item, the crew at the Valdez terminal, which now had roughly 38 individuals working on the
response mobilization, had to split their efforts between the current loading of the response barge and the
loading of a tug with the lightering equipment needed to lighter the Exxon Valdez. When McCall made
this decision, he was under the perception that Alyeska’s response barge was fully loaded and underway,
as was stated in their contingency plan. This was a breakdown in communication that lead to a decision
being made at the wrong level. Although this was a priority item, McCall was unaware that this would
slow the response time of Alyeska’s barge even further.
At 0800, with the response barge still in port (over two hours after it was supposed to arrive on scene),
Alyeska began requesting permission from the federal government to use chemical dispersants on the
continuously growing oil slick. This would consequently bring up the dichotomy between expertise and
experience within the oil industry and the environmental experts. The oil industry, with their claimed
experience in the matter, thought that chemical dispersants were a highly effective method that should be
utilized. However, the toxicology experts claimed that these dispersants would cause more harm to the
environment than the potential positive impact that the oil industry claimed they would have.
18
While the loading of the lightering response tug began roughly two hours after the loading of the response
barge, it arrived at the scene of the grounding at 1205, two hours and fifty minutes before the response
barge. At this time, an estimated 8 million gallons of oil had spilled from the Exxon Valdez. Over the
next two hours, an additional 2.5 million gallons spilled into the Sound before Alyeska’s response barge
finally arrived at the grounding site at 1454, nine hours and twenty-four minutes after the promised
response time of five hours.
Three hours later, experience triumphed over expertise, and the first chemical dispersant test was
conducted in Zone One of the spill. Under the contingency response plans, the government split up Prince
William Sound into three zones, with Zone One allowing use of chemical dispersants only under the
approval of the OSC. While the oil companies received the results of their test at 1800, the results were
extremely poor due to the calm weather and lack of wave movement to mix the dispersant. At 1910,
skimming operations by Alyeska officially ceased due to the accompanying skimming vessels reaching
their capacity of 210 gallons of recovered oil (less than 10% of the oil spilled). (National Transportation
Safety Board, 1989)
Day Two To begin the second day of clean-up efforts, a second response barge arrived on site at 0015 on March 25,
with a capacity of 30,000 gallons to allow skimming operations to resume. Although the lightering
equipment arrived at 1205 the previous day, lightering of the Exxon Valdez did not actually begin until
0736 on the second day. While Alyeska was responsible for the initial clean-up efforts, at 0945 on the
second day, they turned over all of their responsibilities to Exxon, a more experienced company greater
resources. This is a direct reflection of deference to expertise.
It was not until 35 hours after the spill that the Exxon Valdez was fully surrounded by oil containment
booms. While the containment booms would not stop the oil from leaking, they would have helped
contain the oil spill. An hour after the containment booms were put into place, the oil spill was reported to
be 10 miles long and fluctuated between three and seven miles wide. Around 1425, another 3,500 gallon
dispersant test was approved in Zone One, which was also found to be ineffective.
At 2045, near Goose Island, 15,000 gallons of oil was successfully burned, resulting in 100 square feet of
tar residue that was immediately cleaned up. As the second day concluded, only 50,400 gallons of oil had
been recovered from the water (0.86% of the total amount spilled). In addition, 504,000 gallons had been
19
lightered off the Exxon Valdez, leaving 98% of the remaining cargo still onboard, at risk of being spilled
into Prince William Sound and adding to the 11 million gallons of oil already in the water. (Alaska Oil
Spill Commission, 1990)
Day Three Up until mid afternoon, the battle between experience and expertise continued. The weather in the Sound
was worsening, and as winds began to pick up, the successful burning test was deemed infeasible due to
the risk of the fire spreading in an uncontrollable manner. However, the wind led to more wave action,
and Exxon finally conducted multiple successful chemical dispersant tests throughout the afternoon.
After a discussion between Exxon, the Coast Guard, and the OSC Steve McCall, use of chemical
dispersants was authorized on the majority of the oil slick.
However, the early success of the newly approved dispersants would prove to be futile. At 1830 on the
third day, Alaskan Governor Steve Cowper declared the spill as a state disaster. By this time, the oil slick
had spread in amoeba-like fashion to cover more than 50 square miles of water, and was continuing to
spread. Later than evening, a storm hit Prince William Sound, bringing 70 mph winds and spreading the
oil more than 40 additional miles. The violent weather turned the oil into a “mousse” like froth, making
burning and chemical dispersants no longer effective and greatly hindering mechanical skimming
progress. Throughout the months to follow, the 11.6 million gallons of spilled oil would end up polluting
over 800 miles of coastline. (Alaska Oil Spill Commission, 1990)
Analyzing the Regional Response Team’s Decisions Reflecting back on the first 72 hours of cleanup efforts, very few things were done correctly; however,
one entity that did follow some of the key principles of high reliability organizations (HROs) was the
Regional Response Team (RRT). The RRT was a multi-faceted team of experts from various areas of
government that acted as the federal governing body in charge of overseeing the cleanup efforts. They
met multiple times throughout the clean-up effort to discuss the use of alternative cleanup methods. This
showed that they recognized the importance of reassessing the situation and their reluctance to simplify
this oil spill as “just another spill”. They understood that this was a unique situation in a dynamic
environment that needed to be dealt with unlike any previous spill. Lastly, since the RRT had federal
authority, they had the ability to federalize the entire cleanup effort. However, they made the correct
decision by deferring to expertise, allowing Exxon to take complete control of the cleanup effort. Exxon
had the resources, manpower, experience, and mobilization capacity that could be utilized in a timely
manner that the federal government did not have.
20
Long Term Impact of the Oil Spill As Exxon began mobilization of long-term cleanup efforts that would last for months after the spill, the
communities around Prince William Sound began to experience adverse effects. Populations doubled or
tripled, with Valdez experiencing a population increase of 5 times its original size. This population
increase put intense strain on the economic, political, and social infrastructure of these normally small
towns. Crime increased by 300%, housing quantities became inadequate, social service organizations
were put under immense pressures, and the health, sewer, and garbage agencies could not keep up with
the massive scaling of these towns.
Over the next two years following the spill, the local economies experienced an estimated $330 million in
economic damages, and over 32,000 fishermen were affected. Additionally, Exxon experienced $4.1
billion in cleanup costs. Costs included $1.1 billion for environmental damages paid in 1991, $2 billion
paid in cleanup costs, and $1.1 billion paid in economic compensation between 2006 and 2008. Also,
following the oil spill, South Central Alaska experienced a 8% drop in tourism, and South West Alaska
experienced a 35% drop.
Perhaps the most direct negative effect of the oil spill was seen in the environment. While the plant life
was significantly affected, the wildlife was affected the most. Throughout the duration of the cleanup
efforts, the carcasses of 35,000 seabirds and 1,000 sea otters were collected. However, experts estimate
that 250,000 seabirds, 2,800 sea otters, 300 harbor seals, 250 bald eagles, up to 22 killer whales, and
billions of salmon and herring eggs were killed in this disaster. It is important to note that salmon
populations were not seriously affected by the oil because local fishermen banded together to surround
key inlets with containment booms to prevent three major hatcheries from being damaged. (Exxon Valdez
Oil Spill Trustee Council, n.d.)
Recommendations and Conclusions
After the Exxon Valdez accident, many safety measures were implemented to avoid further accidents.
The Oil Pollution Act of 1990 required double hulls in oil tankers, which were initially promised, then
deemed economically infeasible by the federal government. To enhance ship monitoring, the Coast Guard
VTS in Valdez was provided additional personnel for radio and radar duties and a new radar system was
provided. To enhance ship guidance through Prince William Sound, the pilot station was moved back to
Rocky Point, south of Bligh Reef. This allowed for increased pilotage distances of ships leaving the port
and navigating through the narrows. Navigation aids, such as buoys, were also added. To ensure the
21
ability of ship employees, stricter alcohol policies for commercial ship crews were implemented.
Additionally, to reduce the impact of an accident after it already had occurred, Alyeska provided greater
assurances that their spill response teams would be readily available to handle future accidents and their
capability was sufficient for larger scale accidents.
Despite substantial changes to existing policies for all of the key players, oil spills still continue. Twenty-
four major oil spills have occurred since the grounding of the Exxon Valdez and approximately 1.3
million gallons of oil are spilled in U.S. waters annually. Oil companies still have strong lobbying
organizations, which have substantial influence in state and federal legislation. Prior to the Exxon Valdez
accident, this influence was utilized to block requests for double hulled tankers and reduce manning on
ships to unsafe levels. Currently, this influence is still present and frequently utilized.
Oil spills will also continue due to production pressures and lack of preoccupation with failure. To
prevent future oil spills, oil companies need to become HROs, with a focus on mindfulness. A
preoccupation with failure will force oil companies to understand how newly implemented policies create
new pathways for accidents. Biannual unannounced spill response drills should be required by the Coast
Guard to ensure the readiness of oil spill cleanup companies, such as Aleyska. An unannounced drill will
force the company to have a complete, fully prepared complement of employees and fully functional
equipment.
Additionally, the Coast Guard and Federal government must compel the oil companies and Aleyska to
expand operations, so their response capacity may exceed the magnitude of future disasters. Even if
Aleyska were completely prepared to recover oil from the Exxon Valdez and was functioning at full
capacity, the response would have been substantially insufficient. The spill response capability
enhancements should not just be limited to Aleyska’s capacity to burn and skim oil. Oil spill response
time and Exxon’s ability to lighter excess oil off a grounded ship should also be expanded.
Finally, vessel monitoring should be expanded. All commercial vessels should utilize navigational
devices to indicate position and velocity. The Coast Guard and other monitoring agencies should dedicate
staff and technology to constantly monitoring ships near potential areas of danger. The Coast Guard, oil
companies, spill response companies, the government, and the local population also must improve
communication to understand each other’s capabilities and what policies need to be implemented at
responsibility boundaries between entities. Increased communication will allow entities to determine
whether the other agencies are adequately prepared and suggest changes to policies to enhance readiness.
22
Conclusion In the wake of Exxon Valdez, there were many promises from the government for better oversight of the
oil and gas industry to prevent an accident from happening again. However, in 2010, BP’s Deepwater
Horizon exploded and released millions of gallons of oil into the Gulf of Mexico. A look at phenotype
causes (safety overlooked in quest for profit, inadequate legislative mandates for safety, number of
workers reduced) is similar to the Exxon Valdez. A look at the genotype causes illustrates that same
problems that led to the Exxon Valdez also caused Deepwater Horizon and that nothing really changed:
violations, overconfidence, taking past success as a reason for confidence, failure to revise assessment,
and drift towards failure due to production pressure. The question then becomes, how can adequate
oversight of this industry be put in place?
Internal Oversight Prior to Deepwater Horizon, in 2007, BP hired a new CEO with two goals: improve safety and reduce
costs. In his quest for safety, he founded a new school at MIT for management to attend. The curriculum
focused on the following subjects, which closely correlate to mindfulness: small incidents are warning
signs that conditions are ripe for a disaster, it’s essential to maintain multiple safeguards against an
accident (preoccupation with failure), anomalies need to be clearly resolved (reluctance to simplify), it is
dangerous to change operating plans on the fly (sensitivity to operations), and long stretches without a
serious accident breeds complacency. Additionally, an Operating Management System was established
which was a group to focused on looking at unsafe practices occurring in the organization and report upon
them. However, while the organization did an excellent job at identifying and integrating safety problems
into the planning stage, they had no authority to guide decisions during operations. Many of the problems
were discovered, but nothing was done to solve them. Proof that internal oversight did not work is the
Deepwater Horizon accident. Additionally, it is key to note that the new CEO was able to reduce costs by
$8 billion, indicating the there was a drift towards failure due to production pressure. The two goals of
safety and cost cutting ultimately contradict each other, and in the end, cost cutting often wins. (Peter
Elkind, 2011)
Nuclear Model The oil industry has continued to demonstrate that they are incapable of being regulated by the
government or themselves. Following the 1979 Three Mile Island accident, some of the same conclusions
were drawn about nuclear power and the industry was told to, “dramatically change its attitudes toward
safety and regulations” (National Commission on the BP Deepwater Horizon, 2011). The Nuclear
industry banded together to form and implement the Institute of Nuclear Power Operations (INPO), a
nonprofit organization funded by the industry that oversees and inspects nuclear power plants to ensure
23
the plants are following all regulations and safety protocols. Inspections are performed every two years
and each nuclear power plant’s insurance rates are dependent on the results of their inspection, giving
motivation to do well and operate safely. Their reports also directly connect senior management's actions
and policies to the day to day operations.
Some similarities between the oil and nuclear power industry include: dependence on highly sophisticated
and complex systems, culture of complacency in the absence of major accidents, and the government not
being able to afford high salaried private sector experts. For these reasons, it is recommended that the oil
industry ban together to form a similar non-profit oversight organization to ensure all responsible parties
are following the regulations. As was seen from Deepwater Horizon, one company’s actions can have a
direct effect on other company’s profit and operations since BP’s failures resulted in the ban on drilling in
the Gulf of Mexico. This new organization would help the industry police its own standards and ensure
effective management and safe operations of all companies, therefore becoming an HRO. An HRO has no
choice but to function reliably and they operate in unforgiving environments that are full of potential for
error and no room for experimentation. While the oil industry learned in the short run, history shows that
over time people forget and safety standards are pushed aside in the quest for profit. Only an independent
third party organization can ensure the industry continues to remember and enforce all safety standards.
(National Commission on the BP Deepwater Horizon, 2011)
24
Appendix 01 – Double Hull Tankers
Pictured on the left, a single hull tanker has only the hull between the tank where the oil is stored and the ocean. In a double hulled tanker pictured on the right, there are essentially two hulls between the oil and the sea water. Due to the required space between the hull and the tanks in a double hull tanker, they carried less oil and therefore made less profit per trip. Additionally, these ships cost more to build making oil companies argue strongly against them. However, if an accident is to happen, they are one the best protective measures to preventing oil from spilling into the ocean.
25
Appendix 02 – EXXON VALDEX Route the night of 23 March 1989
The trip out of Valdez Alaska was routine until 2339 when the Captain turned the ship to a course of 180° true to avoid the ice coming out of Columbia Bay. After that turn, the ship continued to follow the course until it was too late, and there was nothing that could be done to save the ship. The Third Mate was supposed to alter course at 2355 back towards the shipping lanes, but failed to do so.
26
Appendix 03 – Steering Console Design
1. Rudder actual position 2. Where the rudder will go - mechanical indicator 3. Selector switch for steering mode
Important: If the ship is in autopilot, the helmsman can turn the wheel and watch the mechanical indicator move; however, the rudder will not change and no alarm will sound – Design Induced Error – Error Mode
1
2
3
27
Appendix 04 – Human Culpability
Master’s Culpability in the accident:
Third Mate’s Culpability in the accident:
28
Appendix 05 – Busby Island Light
The red lines show the area where Busby Island displayed red light to mariners and outside this area, the light was white. As seen from the photo, at 2355 the 3rd Mate saw a white light, but it was right on the danger area where the light turned red.
29
Appendix 06 – How to take a paper fix
In the picture, the two blue circles are the Navigation Objects chosen since they are visible both from the bridge of the ship and on the paper chart. To take a fix, a person would use an alidade to shoot a bearing to the objects and then draw a line from the object on that bearing across the chart. The operator would then use the radar to get a range to the object and an arc would be drawn on the chart of that range on the chart. Were all these lines and arc intersect is the location of the ship when that fix was taken. This is a time consuming process for one person especially at night when they are tired.
30
Appendix 07 – Oil Recovery Methods
Mechanical Skimming
Mechanical skimming is the favored method by environmentalists and initial clean-up response teams;
skimmers can be easily attached to already existing vessels to provide a quick response. To provide a
better understanding of how they work, a ship will use a floating boom (or barrier) and place it in a U-
shape. This U-shape configuration is dragged through the oil slick, creating a concentrated pool of oil in
the back of the configuration. A skimmer is placed within this concentrated pool. A skimmer is a pump
that resides just below the surface of the water and is connected to the accompanying vessel. The skimmer
pumps the oil from the surface of the water onto the vessel. This method is favored by environmentalists
because it has a very low potential for environmental harm. However, skimmers have numerous
limitations. They can only be used in relatively calm waters and can only operate at a certain speed,
heavily limiting the rate that oil can be removed from the environment. The most significant limitation
however is the accompanying vessels. Vessels and bladders can only hold a certain amount of oil; thus
when the vessels are full, there is no longer any space and often times skimming operations will cease, as
was the case in the Exxon Valdez response.
Chemical Dispersants
Chemical dispersants are favored by the oil companies partaking in oil spill cleanup efforts. This method
was tested three separate times during the first 72 hours of the cleanup efforts of the Exxon Valdez spill.
The results were not promising and there was not enough available equipment for this technique to be
effective. Chemical dispersants can reduce the appearance of oil floating in water much quicker than other
solutions. This method is so effective because dispersants break up the spilled crude oil into smaller oil
droplets that are dispersed in the upper water column. This removes the spill from the surface, but the
toxins are spread throughout a larger area where microorganisms can break the toxins into natural
byproducts. This could be a very effective method if the microorganisms work quickly enough; however,
micro droplets of oil can be inhaled by other sea creatures, beginning a toxic reaction throughout the food
chain. In addition to the high potential for environmental harm is posses, chemical dispersants can only be
used in certain conditions. First, there needs to be wave action in order to “mix” the dispersant with the
31
crude oil. Also, this method is time sensitive, because chemical dispersants will not work if the oil
becomes too mixed with water or too aerated.
In-Situ Burning
Similar to chemical dispersants, in-situ burning is often heavily disputed by environmentalists. To begin
in-situ burnings, vessels drags fireproof booms through the oil spill to concentrate the oil in one area.
Once this oil is concentrated to a depth of 3mm or more, it is lit on fire. Burning of oil creates a thick
black cloud of smoke that causes significant air pollution. Once the burning is finished, a significantly
smaller volume of a tar like residue is left on the surface of the water. This residue must be cleaned up
before it sinks and causes more environmental harm. While additional environmental risks are imposed
by conducted in-situ burning, it can be a very successful method in calm waters, with the capability to
remove large amounts of oil relatively quickly.
32
Appendix 08 - Event Timeline of The Exxon Valdez Oil Spill Response - Initial 36 Hours
Key Events Day Time Event
3/24/1989
0005 Exxon Valdez runs aground Bligh Reef
0027 Captain Joseph Hazelwood officially informs the VTC (Vessel Traffic Control) that they are grounded and leaking some oil
0030 Valdez terminal begins mobilizing the clean-up response. 0200 Alyeska Response barge arrives at the Valdez terminal for loading. Was in dry dock for repairs 0249 Coast Guard Pacific Area Pollution Strike Team's assistance was requested. Based out of San Fransisco 0350 Commanding Officer of the Coast Guard boards the Exxon Valdez to begin inspection and investigation 0414 Lightering of the Exxon Valdez made a "High Priority" 0435 Exxon elevates their response team to the highest level and begins mobilizing a response 0600 All members of the Regional Response Team have been notified 0610 Fisherman's offer for assistance in clean-up effort rejected by Exxon and Alyeska 0830 First request to use chemical dispersants issued 1010 Tug SeaFlyer with lightering equipment departs Valdez Terminal to start lightering operations 1137 Alyeska response barge leaves Valdez Terminal 1200 First requeset for In-situ burning requested 1205 Lightering equipment arrives at the grounding sight 1454 Alyeska reponse barge arrives at the Exxon Valdez 1800 First dispersant test was conducted in Zone 1, tests proved to be unsatisfactory 1910 Skimming operations cease due to the lack of capacity to hold anymore recovered oil
3/25/1989
0736 Lightering of the Exxon Valdez to the Exxon Baton Rouge begins 1100 Exxon Valdez fully surrounded by containment booms 1110 1551 Second dispersant test was conducted, tests proved to be unsatisfactory 2045 In-situ burning test was conducted on 15,000 gallons. Results proved this method to be effective
3/26/1989 0530 Coast Guard Pacific Area Pollution Strike Team arrive and begin assisting in clean up efforts 1830 Governor Cowper declares the spill as a state disaster
Spill Size Reference Day Time Oil Spill Size
3/24/1989 0350 5,796,000 gallons of oil have been spilled from the Exxon Valdez 0727 Oil slick reported to be 1,000 ft wide and 4 to 5 miles long 1310 8,400,000 gallons of oil have been spilled from the Exxon Valdez 1459 10,500,000 gallons of oil ahve been spilled from the Exxon Valdez 3/25/1989 1230 Oil slick reported to extend 10 miles from the tanker with a width of 4 to 7 miles
33
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