
The Oil Disaster Is About Human, Not System, Failure - revorad
http://online.wsj.com/article/SB10001424052748703303904575293270746496824.html?KEYWORDS=Samson
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rauljara
This article points out that people screwed up, which is fine, and also pretty
obvious, considering the size of the screw up. But what about BP's corporate
culture that would allow people to screw up this badly, and this many times?
Isn't that indicative of systemic failure?

Or is it just that people just screw up, no matter the system? If that is the
case, and no matter how good the system is, eventually there will be another
drilling disaster like this one, it begs the obvious question of whether there
should ever be this sort of drilling again.

~~~
brown9-2
Just want to point out this is a letter to the editor, not a WSJ-authored
article.

As to BP's corporate culture, who is to blame for it's failures - isn't the
culture created by humans?

I think the distinction being made here between "human failure" and "systemic
failure" is incredibly subtle, since any system has to be created by humans in
the first place.

~~~
hugh3
I think many people would really _like_ to blame BP's corporate culture, since
it puts the blame on the shoulders of somebody with deep pockets instead of
some random schmo with two kids and a mortgage. In fact, I'm certain that this
is where the blame is going to wind up, regardless of the merits.

~~~
knowtheory
I think you're losing the forest for the trees. Corporations are made up of
individuals. Individuals who bear the responsibility and power invested in
them by the corporation for whom they work.

If the individual is liable, the corporation is liable, both for having
initiated the project in the area, as well as imbuing the individual with the
power and responsibility they have.

That's why it's a total non-starter that BP, Transocean and Halliburton appear
to be trying to make responsibility evaporate (much like the hydrocarbons on
the Gulf) by passing the buck to other parties.

The contract for drilling is in BPs name. It doesn't matter if they hired
incompetent drillers (Transocean) to do the drilling. They did the hiring,
it's their responsibility.

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CapitalistCartr
Questions of system versus human failure are not as fuzzy as they first seem.
Systems are just rules-based solutions. If following the rules wouldn't result
in the desired outcome, that's clearly a system failure. If the rules are not
fault-tolerant, such as when a mistake causes substantial harm, that's a
failure of the system; no redundancy.

When the people operating the entire system simply disregard the rules in a
massive scale, that's a human failure. No rules-based solution can work, or be
blamed, if the people are ignoring it, and "flying by the seat of their
pants." All good systems have redundancy/fault-tolerance built in, and will
tolerate some cheating. When the people, including the auditors (government
employees) choose to throw out the rules, that's a human failure.

~~~
skybrian
That's a good first step, but the next step is to ask why people didn't follow
the rules. What sort of pressure were they under and what were their
incentives? That's when you start asking questions about corporate culture.

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gaius
The company is not called British Petroleum since '98 when it changed its name
to just BP. It is a true multinational which employs a substantial number of
Americans and pays more in tax to the US government than it does to the UK.
That rather glaring mistake early indicates the author is not as familiar with
the background as perhaps he ought to get published in the WSJ.

~~~
skmurphy
There is a short bio for Terry Barr at
[http://www.samsonoilandgas.com/IRM/content/aboutus_boardandm...](http://www.samsonoilandgas.com/IRM/content/aboutus_boardandmanagement.html)
he seems to have considerable experience in oil and gas. He only uses the name
British Petroleum once and refers to it as BP thereafter, seven times in total
in the letter.

    
    
       Mr Barr was appointed Managing Directors of the Company on 25 January 2005.  
       Mr Barr is a petroleum geologist with over 30 year's experience, including 
       11 years with Santos.  In recent years, Mr Barr has specialised in tight 
       gas exploration, drilling and completion and is considered an expert 
       in this field. Prior to joining Samson, Mr Barr was employed as Managing 
       Director by Ausam Resources from 1999 to 2003 and as was the owner of Barco 
       Exploration from 2003 to 2005.

~~~
gaius
In that case it's a propaganda piece.

~~~
skmurphy
What are the counterfactual statements that the article makes? What key facts
have been omitted?

I don't understand what in the article leads you to the conclusion that it's
propaganda.

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hga
Very good, and limiting itself entirely to hard facts.

Backing up those facts are e.g. the reports on the top Transocean guy on the
rig, Jimmy Harrell. Another worker has reported that after the meeting with BP
where the latter decided to remove the mud Harrell said "Well, I guess that's
what we have those pinchers for" (the BOP shears that failed for one reason or
another).

A less well sourced report has him saying this while on a boat to someone in
Houston:

" _Are you fucking happy? Are you fucking happy? The rig's on fire! I told you
this was gonna happen.

"I am fucking calm. "You realize the rig is burning?_"

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Ratufa
There are a few components involved in this disaster:

1) The "system" which, in the article, refers to the standard procedures and
best practices one should follow when monitoring and running an oil well of
this type. From what the author said, it appears that if the people at the
well had followed these procedures the blowout wouldn't have happened.

2) Human error -- people being careless, rushed, drunk, tired, not
understanding procedures, etc. This is the "people aren't immune to screw-ups"
factor. It's not clear how much this applies to this particular incident.

3) There's another sort of "system" that 1) and 2) are embedded in, and that
is the system of incentives in which people operate. This includes things like
your manager pressuring you to "do it anyway", or knowing that your promotion
depends on cutting corners and being under budget. I suspect that this is the
root of the problem, in this case.

One reason these incentives are the way they are is because they often work
--- the company saves money (or the individual gets his promotion) and even
when things go wrong the cost of the failure may be less than the money saved
(though, that likely won't be true in the case of BP). Other reasons may
involve not fully understanding the risks, or principal/agent issues.

------
MichaelSalib
The WSJ editor who picked the headline doesn't understand anything about
systems. There exists a plausible explanation by which any system failure can
be described as a human failure. Just say that one of the human designers
screwed up!

Despite the headline, the article itself is good.

~~~
extension
That's a bit pedantic. What I would consider the key difference between
systematic and human failure is whether or not there was actually a system in
place to prevent the failure, that humans simply failed to work within. That
was clearly the case here.

Systems themselves are sometimes inadequate to prevent failure, but this
follows from a lack of human creativity, rather than the inability to follow
straightforward rules.

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joezydeco
What about the platform itself? An explosion and fire is one thing, but is
that enough to sink the platform and cause the pipe to snap?

Is it normal procedure to flood the platform with water when there's a fire?
Can enough water sprayed on a platform make it capsize? I guess if the blowout
preventer fails, there's no other choice to put out the fire. Who oversaw the
recovery mission after the explosion?

~~~
hga
Without breaking the riser pipe connection to the rig an uncontained fire like
this is pretty clearly going to sink it, boats next to it aren't going to be
able to keep it cool enough (you have seen pictures of the fire, haven't
you?).

I think the Coast Guard oversaw the initial recovery, although many are
questioning the decision to put out the fire and the failure of the Federal
government to keep in stock fire booms as called for by a 1995? or so
government study/recommendation for Gulf oil well blowouts.

~~~
joezydeco
Yeah, I've seen the fire. If you can't tame it like a land-based well blowout
and let it burn, how does it sink the platform? The fire's hot enough to melt
the metal and lose water-tightness?

Why not let it burn while trying to figure out how to clinch the pipe from
below?

~~~
hga
Asymmetrical fire can destroy a steel structure by warping it. According to
one analysis by a MIT materials science professor I've read of the fall of the
WTC towers, what ultimately killed them was the difference in heat between the
side that was facing the wind and the back side. The difference in expansion
stressed the already weakened by heat floor supports to the point where
cascading failures occurred.

And as I noted, many people are asking the latter question, alhtough once the
riser pipe detached and formed a shape like this (inverted V)_ on the sea
floor that became much less clean of an option, one the Feds weren't in
position to reconsider after putting it out due to their failure to procure
fire booms ahead of time.

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ams6110
The whole scenario plays out a lot like what led up to the Chernobyl
explosion. Even after problems became evident there were several chances to
shut down and avoid a catastrophe, but the safeguards, standard procedures,
and warnings were ignored.

~~~
hga
In all fairness the operators at Chernobyl were running an experiment that had
been done all of 3 or so times before at reactors of this design. The biggest
failing was the design of the reactor (positive void coefficient (illegal to
build in the US) and slow moderator tipped control rods) and their not knowing
or realizing that their deviations from the experiment's known safe procedure
could have such disastrous consequences.

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wanderr
All disastrous human failure _is_ system failure. If the system allows human
failure to cause a massive disaster, the system is flawed.

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c00p3r
What else WSJ (BP) would say? =)

