Feedback from the CSB Public Hearing 23-24 July, 2012 Safety Performance Indicators Preliminary Findings from the Macondo/Deepwater Horizon Accident

1. Learning from the
Macondo Deepwater Horizon
blow out
Feedback from the CSB Public Hearing
23-24 July, 2012
Safety Performance Indicators
Preliminary Findings from the Macondo/Deepwater Horizon
Accident

48. The risk/reward equations on which the individual decisions
seem to have been taken look as though they were strongly
weighted towards getting things done quicker, and thus
cheaper. The commission tabulates nine decisions where
higher-risk options were chosen over lower ones; in seven
of them the riskier option was also the time-saving one (in
the other two the implications for time-saving are not clear).
Poor management meant that there was no overall view of
how the decisions interacted and thus no good sense of
how these risks added up. Poor communication meant that
key people on the rig were unaware of the increased risk
some of those decisions were seen as entailing.

58. Jake Molloy, Regional Organiser
National Union of Rail, Maritime and Transport
Workers (RMT)
• RMT fully supports the use of meaningful
and effective indicators. However, we
must emphasise the word ‘effective’, as all
too often we find the actual ‘effectiveness’
of well intentioned schemes can very
rapidly be diminished as managers seek
to influence outcomes and meet targets.

59. Dangerous’ aspects of setting Key Performance Indicators
• KPI’s create a divisive environment where
short cuts and non-reporting are common
place, but not spoken about. In April 2012
we received £700 bonus before tax and
our sister platform received just £120. I
think that’s probably because the
management team on our sister platform
are a bit more honest than the team I work
with.

60. Dangerous aspects of setting Key Performance
Indicators
• KPI’s linked to incentives can very quickly lead
to a situation where senior management believe
that safety and productivity performance is good,
when in fact the opposite is the case.
• production and maintenance reports are
distorted or even falsified; there can be
widespread under reporting or even non-
reporting and this quickly becomes
institutionalised;

62. • Transocean and BP had multiple safety management system
deficiencies that contributed to the Macondo incident.
• Before the Macondo blowout, the safety approaches and metrics
used by the two companies and U.S. trade associations did not
adequately focus on major accident hazards. Recently BP officials
informed CSB investigators that they are working to develop a more
comprehensive offshore indicators program using leading and
lagging metrics to help drive performance improvements.
• Systems used for measuring safety effectiveness in the offshore
industry focused on personal safety and infrequent lagging
indicators.
• The U.S. offshore regulator, the Department of the Interior, can
achieve a greater impact on major accident prevention through the
development of a leading and lagging process safety indicator
program.

63. • Despite some significant progress with process safety indicator
implementation in the downstream oil industry, in the offshore sector
BP, Transocean, industry associations, and the regulator had not
effectively learned critical lessons of Texas City and other serious
process incidents at the time of the Macondo blowout.
• Companies and trade associations operating in other regulatory
regimes outside the U.S. have developed effective indicator
programs, recognizing the value of leading indicators, and using
those indicators to drive continuous improvement.
• Trade associations and many of the same companies that operate
in the U.S. are partnering with the regulators in other countries in
advancing safety indicators programs.
• In the aftermath of the Macondo blowout, companies and trade
associations in the U.S. are initiating efforts to advance the
development of offshore major accident indicators.

64. “The emphasis on personal injury and lost work-
time data obscures the bigger picture: that
companies need to develop indicators that give
them realistic information about their potential
for catastrophic accidents. How safety is
measured and managed is at the very core of
accident prevention. If companies are not
measuring safety performance effectively and
using those data to continuously improve, they
will likely be left in the dark about their safety
risks.”
CSB investigator Cheryl MacKenzie