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Macondo Blowout and Explosion
FINAL REPORT: Macondo Investigation Report Volume 1
FINAL REPORT: Macondo Investigation Report Volume 2
Accident Occurred On: 04/20/2010
Accident Type: Oil and Refining - Fire and Explosion

statistics

Total # of Recommendations
4
Total # of Open Recommendations
4
Total # of Closed Recommendations
0
Total % of Open 100 vs. Closed 0

investigation information

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Accident Description
On April 20, 2010, a sudden explosion and fire occurred on the oil rig. The accident resulted in the deaths of 11 workers and caused a massive, ongoing oil spill into the Gulf of Mexico. The rig was located approximately 50 miles southeast of Venice, Louisiana, and had a 126-member crew onboard. The CSB will be holding a public hearing in Houston, Texas on July 23 and 24 in support of the board's continued analysis of effective safety performance indicators and to release preliminary findings into the agency’s investigation of the Macondo well blowout, explosion and fire in the Gulf of Mexico. The CSB’s two day hearing will be in downtown Houston at the Hyatt Regency Hotel located at 1200 Louisiana Street.
Investigation Status
The CSB's investigation is currently underway.


 

Recommendations

American Petroleum Institute (API)
2010-10-I-OS-3

Publish an offshore exploration and production safety standard for the identification and effective management of safety critical elements (SCEs)— technical, operational, and organizational— with the goal of reducing major accident risk to As Low As Reasonably Practicable (ALARP), including but not limited to:
a. development and implementation of a SCE management system that includes the minimum necessary “shall” requirements in the standard to establish and maintain effective safety barriers to prevent major accidents;
b. methodologies for (1) the identification of SCEs and (2) the development of performance standards of each SCE, including its functionality, availability, reliability, survivability, and interactions with other systems;
c. establishment of assurance schemes for continuous active monitoring of all identified SCEs throughout each SCE’s lifecycle;
d. fulfillment of independent verification requirements and use of those verification activities to demonstrate robustness of the SCE management process;
e. development of process safety key performance indicators pertaining to the effective management of SCEs to drive continuous improvement.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2010-10-I-OS-4

Revise Blowout Preventer Equipment System for Drilling Wells (API Standard-53, 4th edition) to establish additional testing or monitoring requirements that verify the reliability of those individual redundant blowout prevention systems that are separate from the integrated system tests currently recommended.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Bureau of Safety and Environmental Enforcement
2010-10-I-OS-1

Augment 30 C.F.R §250 Subpart S to require the responsible parties, including the lessee, operator, and drilling contractor, to effectively manage all safety critical elements (SCEs)— technical, operational, and organizational—thereby ensuring their effective operation and reducing major accident risk to As Low As Reasonably Practicable (ALARP).  At a minimum, require the following improvements:

a. Written identification of all safety critical elements for offshore operations through hazard analysis. This list will be made available for audits and inspections performed by the responsible parties, external entities (e.g., independent competent parties, third-party auditors), and the regulator, and it will be shared among the lessee, operator, and drilling contractor. Identifying all safety critical elements shall ensure the establishment and maintenance of effective safety barriers to prevent major accidents;

b. Documented performance standards (as defined in Section 5.2 of the CSB Macondo Investigation Report Volume 2) describing the required performance of each SCE, including its functionality, availability, reliability, survivability, and interactions with other systems;

c. Augmentation of 30 C.F.R §250.1916 to include requirements for all responsible parties, including contractors, to conduct monitoring for continuous active assurance of all identified SCEs through each SCE’s lifecycle (as described in Section 5.0 of the CSB Macondo Investigation Report Volume 2);

d. Documented independent verification scheme for the identified SCEs reported to and subject to review by the regulator (as described in Section 5.5 of the CSB Macondo Investigation Report Volume 2), where:

1. the independent party meets BSEE criteria that guarantees its competence and independence from the company or facility for which it is providing verification;
2. the independent verification occurs prior to commencement of the offshore drilling or production activity and periodically, as defined by BSEE;
3. all resulting assessments of the independent verification activities will be tracked in a formal records management system; and
4. corrective action shall be taken to address negative verification findings and non-compliance. Verified noncompliance shall be tracked by the responsible party as a process safety key performance indicator and be used to drive continuous improvement.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2010-10-I-OS-2

Publish safety guidance to assist the responsible parties in fulfillment of regulatory obligations stipulated in R1 for the identification and effective management of safety critical elements (SCEs)—technical, operational, and organizational— with the goal of reducing major accident risk to As Low As Reasonably Practicable (ALARP), including but not limited to each of the identified minimum requirements (See R1, items a-d).

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

 
 

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