CSB Investigation into Macondo Blowout and Explosion in Gulf of Mexico Continues; Two Public Hearings and Interim Reports Scheduled for this Year

April 19, 2012
                Washington, DC, April 19, 2012 — The U.S. Chemical Safety Board (CSB) announced today that its investigation into the April 20, 2010 Macondo well blowout, explosion and fire in the Gulf of Mexico is progressing, with two interim reports with findings and recommendations to be released this year. A final report is expected to be completed in early 2013. 

Investigation findings to date indicate a need for companies and regulators to institute more rigorous accident prevention programs similar to those in use overseas. The CSB announcement was made approaching the second anniversary of the tragedy, which took eleven lives and caused the worst environmental disaster in U.S. history,

Process safety regulations and standards utilized by oil companies in refineries and process plants in the continental U.S. have a stronger major accident prevention focus, CSB investigators have determined. Unlike the U.S. offshore regulatory system, the “onshore” process safety requirements are more rigorous and apply both to operators and key contractors.  

To date, the CSB has conducted numerous interviews, examined tens of thousands of documents from over 15 companies and parties, gathered data from two phases of blowout preventer (BOP) testing, and conducted a public hearing on international regulatory approaches.  Recommendations targeting specific reforms are contemplated for release as early as August of this year.

CSB Chairman Rafael Moure-Eraso said, “Our final report on the tragic accident that occurred two years ago, will, I believe, represent an opportunity to make fundamental safety improvements to offshore oil and gas exploration to prevent future catastrophic accidents.”

Dr. Moure-Eraso continued, “The CSB is not a regulatory agency; our job is to convey information and recommendations to improve safety in the oil and chemical industries and protect workers and the environment. In our view, while previous investigations of the Macondo blowout have produced useful information and recommendations, important opportunities for change have not been fully addressed.  And these are critically important for major accident prevention.”   

Don Holmstrom, manager of the CSB Western Regional Office in Denver, whose team is conducting the investigation, announced a timeline calling for the final report release in early 2013, with the first of several public meetings to be held by the CSB likely in July 2012 in Houston, addressing use of leading and lagging indicators by companies and regulators to improve safety performance. 

The CSB anticipates releasing preliminary findings and safety recommendations at the meeting, and to hear experts testify on the need for the offshore drilling industry to utilize safety performance indicators like hydrocarbon leaks and maintenance of safety critical equipment to drive safety improvements and to prevent major accidents.

Dr. Moure-Eraso said the CSB’s investigation is taking a broad look at causal issues of the Macondo blowout and the subsequent massive release of flammable hydrocarbons which resulted in an explosion.  “These issues include the manner in which the industry and the regulating agencies learn or did not learn from previous incidents. They also include a lack of human factors guidance, and organizational issues that impaired effective engineering decisions,” he said.  

The issue of human factors in offshore drilling and well completion is particularly important as offshore well control programs currently rely to a large extent on manual control, procedures and human intervention to control hazards, said CSB Investigator Cheryl MacKenzie.  She observed “There are no human factors standards or regulations in U.S. offshore drilling that focus on major accident prevention. As an example, we are investigating whether fatigue was a factor in this accident. Transocean’s rig workers, originally working 14-day shifts, had been required to go to 21-day shifts on board. CSB is examining whether this decision was assessed for its impact on safe operations.”  

The CSB investigation team participated in the examination of the blowout preventer (BOP) in Louisiana last year.  As has been reported, the BOP – a massive device designed to shear off the well pipe and stop the flow of volatile hydrocarbons -- failed.  The CSB is currently evaluating BOP deficiencies as reflecting larger needed improvements in offshore risk management.  These include lack of safety barrier reliability/ requirements, inadequate hazard analysis requirements for evaluating BOP equipment design, and insufficient management of change requirements for controlling hazards.

The CSB is conducting additional computer modeling of the BOP and assessing the capability of the BOP to close and which functions specifically led to its failure. The agency is also exploring new issues and “near miss” deficiencies that did or could have compromised the ability of the BOP to function properly, including the failure of the annular preventer to seal the well, the impact of drill pipe size, and the performance of the BOP hydraulic accumulators. 

Finally, the CSB is carefully examining the physical causes of the drill pipe buckling that other investigations previously concluded may have prevented the BOP's blind shear rams from functioning correctly.  The CSB is evaluating different mechanisms that could have led to the drill pipe buckling.

CSB Chairman Moure-Eraso said the CSB is examining whether further changes to offshore safety regulations and industry standards are needed.  “While important regulatory changes have occurred, we are examining whether these changes that have been made are sufficient for preventing major accidents.  In December 2010, a CSB public hearing in Washington featured international regulators, companies, trade associations and union representatives discussing the “safety case” regulatory approach for offshore safety, a concept widely used in the North Sea and Australia and supported by a number of the participants. 

In addition, Chairman Moure-Eraso noted that the CSB investigation is also examining the implementation of effective corporate governance and sustainability standards to address safety and environmental risk, organizational issues that impaired effective engineering decisions, and the consideration of past safety performance in lease allocation decisions and contractor selection.

The CSB investigation into the accident has been delayed on occasion as the Board sought to work out mutually acceptable access and investigation agreements with other investigative groups that had different missions.  The Department of Justice has filed an action against Transocean in federal court and has requested that the Court order Transocean to comply with the CSB subpoenas. Following a hearing last week, the CSB anticipates a decision from the Court in the near future. 

Chairman Moure-Eraso said, “The CSB investigation of this tragedy will, we believe, offer unique findings and recommendations that, if adopted, would provide significantly safer operations during vital offshore drilling and production operations. 

             The CSB is an independent federal agency charged with investigating chemical accidents. The agency's board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit our website, www.csb.gov. 

For more information, contact Communications Manager Hillary Cohen at 202.446.8094 or Sandy Gilmour at 202.251.5496.


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