Environment Systems and Decisions

, Volume 34, Issue 2, pp 194–207 | Cite as

Learning from the BP Deepwater Horizon accident: risk analysis of human and organizational factors in negative pressure test



According to several seminal investigation reports on the BP Deepwater Horizon (DWH) accident, misinterpretation of a critical test, called negative pressure test (NPT), was a major contributing cause of that disaster. NPT, according to many credible references, is the primary step to ascertain well integrity during any offshore drilling. This paper introduces a three-layer, conceptual risk analysis framework to assess the critical role of human and organizational factors in conducting and interpreting a negative pressure test. This framework has been developed by generalizing the risk assessment model that was proposed by the authors for the analysis of the conducted NPT by the DWH crew. In addition, the application of the introduced framework in this study is not limited to NPT misinterpretation. In fact, it can be generalized and be potentially useful for the risk analysis of future oil and gas drilling as well as other high-risk operations. Analysis of the developed framework in this paper confirms the results of previous studies by indicating that organizational factors are root causes of accumulated errors and questionable decisions made by personnel or management. Further analysis of this framework identifies procedural issues, economic pressure, and personnel management issues as the organizational factors with the highest influence on misinterpreting a negative pressure test. It is noteworthy that the captured organizational factors in the introduced conceptual framework are not only specific to the scope of the NPT. The three aforementioned organizational factors have been identified as common contributing causes of other offshore drilling accidents as well.


Risk analysis Offshore drilling safety Human and organizational factors Negative pressure test Deepwater Horizon 


  1. Aven T, Sklet S, Vinnem JE (2006) Barrier and operational risk analysis of hydrocarbon releases (BORA-Release); part i: method description. J Hazard Mater 137(2):681–691CrossRefGoogle Scholar
  2. Bea R (1998) Real-time prevention of drilling and workover blowouts: managing rapidly developing crises. J Drill Eng Soc Petrol EngGoogle Scholar
  3. Bea R (1999) A structured method and software to assess human and organizational errors in the life-cycle of offshore structures. In: Proceedings of the 18th international conference of offshore mechanics and arctic engineering, safety and reliability symposium, American Society of Mechanical Engineers. July 11–16, St. John’s Newfoundland, CanadaGoogle Scholar
  4. Bea R (2002) Human and organizational factors in design and operation of deepwater structures. In: Proceedings of the offshore technology conference. May 6–9, Houston, TXGoogle Scholar
  5. Bea R (2006) Reliability and human factors in geotechnical engineering. J Geotech Geoenviron Eng 132(5):631–643CrossRefGoogle Scholar
  6. Bea R (2011a) Personal communication. University of California Berkeley. Member of the National Academy of Engineering. 28 SeptGoogle Scholar
  7. Bea, R (2011b) Personal communication. University of California Berkeley. Member of the National Academy of Engineering. 6 DecGoogle Scholar
  8. BOEMRE report (2011) Report regarding the causes of the April 20, 2010 Macondo well blowout. The Bureau of Ocean Energy Management, Regulation, and Enforcement. September 14Google Scholar
  9. BP report (2010) Deepwater Horizon accident investigation report. British PetroleumGoogle Scholar
  10. Cai B, Liu Y, Liu Z, Tian X, Zhang Y, Ji R (2012) Application of Bayesian networks in quantitative risk assessment of subsea blowout preventer operations. Risk Anal. 10.1111/j.1539-6924.2012.01918.x
  11. Cai B, Liu Y, Zhang Y, Fan Q, Liu Z, Tian X (2013) A dynamic Bayesian networks modeling of human factors on offshore blowouts. J Loss Prev Process Ind. 10.1016/j.jlp.2013.01.001
  12. Chief Counsel’s report (2011) Macondo, the Gulf Oil Disaster. National Commission on the BP Deepwater Horizon Oil Spill and Offshore DrillingGoogle Scholar
  13. Christou M, Konstantinidou M (2012) Safety of offshore oil and gas operations: lessons from past accident analysis: ensuring EU hydrocarbon supply through better control of major hazards. Publication JRC77767. Joint Research Centre. European Commission, http://publications.jrc.ec.europa.eu/repository/handle/111111111/27463. Accessed 27 Feb 2014
  14. Curole MA, McCafferty D, McKinney A (1999) Human and organizational factors in deepwater applications. OTC 10878. Proceedings of the Offshore Technology Conference. May 3–6, Houston, TXGoogle Scholar
  15. de Morais M, Pinheiro C (2011) Application of the 17 practices of the management system for operational safety on marine installations for drilling and production of oil and natural gas in Brazil. OTC 22685. In: Proceedings of the offshore technology conference. October 4–6, Rio de Janeiro, BrazilGoogle Scholar
  16. Deepwater Horizon Study Group (DHSG) report (2010) The Macondo Blowout. 3rd ProgressGoogle Scholar
  17. Gentile G (2013) Regulations & environment: a deep-rooted cause of Macondo is raised. Oilgram New Column. November 4, http://blogs.platts.com/2013/11/04/macondo-why/. Accessed 28 Jan 2013
  18. Ghosh ST, Apostolakis GE (2005) Organizational contributions to nuclear power plant safety. Nucl Eng Technol 37(3):207–220Google Scholar
  19. Goh YM, Love PED, Brown H, Spickett J (2012) Organizational accidents: a systemic model of production versus protection. J Manage Stud 49(1):52–76CrossRefGoogle Scholar
  20. Hopkins A (2001) Was three mile island a ‘Normal Accident’? J Conting Crisis Manag 9(2):65–72CrossRefGoogle Scholar
  21. Hopkins A (2011) Management walk-arounds: lessons from the Gulf of Mexico oil well blowout. Saf Sci 49(10):1421–1425CrossRefGoogle Scholar
  22. Hopkins A (2012) Disastrous decisions: the human and organizational causes of the Gulf of Mexico Blowout, CCH Australia LimitedGoogle Scholar
  23. International Energy Agency (IEA) (2010) 2011: forecasters see higher crude oil prices and lower U.S. Crude Oil Production. Institute for Energy Research. October 19, http://www.instituteforenergyresearch.org/2010/10/19/2011-forecasters-see-higher-crude-oil-prices-and-lower-u-s-crude-oil-production/. Accessed 23 Jan 2013
  24. Johnsen SO, Okstad E, Aas AL, Skramstad T (2012) Proactive indicators to control risks in operations of oil and gas fields. SPE Econ Manag 4(2):90–105Google Scholar
  25. Lootz, E, Ovesen, M, Tinmannsvik, RK, Hauge, S, Okstad, EH, and Carlsen, IM (2013) Risk of major accidents: causal factors and improvement measures related to well control in the petroleum industry. SPE 163775, Society of Petroleum Engineers Americas E&P Health, Safety, Security, and Environmental Conference. March 18–20, Galveston, TXGoogle Scholar
  26. Martins MR, Maturana MC (2009) Application of Bayesian networks in the analysis of human contribution in collision accidents. In: Proceedings of the 28th conference on ocean, offshore, and arctic engineering (OMAE). May 31–June 5, Honolulu, HawaiiGoogle Scholar
  27. Martins MR, Maturana MC (2010) Human error contribution in collision and grounding of oil tankers. Risk Anal 30(4):674–698CrossRefGoogle Scholar
  28. NAE/NRC report (2011) Macondo well-deepwater horizon blowout: lessons for offshore drilling safety. National Academy of Engineering and National Research Council. The National Academies Press, WashingtonGoogle Scholar
  29. Nickerson RS (1998) Confirmation bias: a ubiquitous phenomenon in many guises. Rev Gen Psychol 2(2):175–220CrossRefGoogle Scholar
  30. Papazoglou IA, Bellamy LJ, Hale AR, Aneziris ON, Ale BJM, Post JG, Oh JIH (2003) I-risk: development of an integrated technical and management risk methodology for chemical installations. J Loss Prev Process Ind 16(6):575–591CrossRefGoogle Scholar
  31. Pate-Cornell E (1990) Organizational aspects of engineering system safety: the case of offshore platforms. Science 250(4985):1210–1217CrossRefGoogle Scholar
  32. Pate-Cornell E (1993) Learning form the piper alpha accident: a platform analysis of technical and organizational factors. Risk Anal 13(2):215–232CrossRefGoogle Scholar
  33. Perrow C (1984) Normal accidents: living with high-risk technologies. Basic Books, New YorkGoogle Scholar
  34. Rasmussen J, Svedung I (2000) Proactive risk management in a dynamic society, 1st edn. Raddningsverket. Risk and Environmental Department, Swedish Rescue Services Agency, KarlstadGoogle Scholar
  35. Reason J (1997) Managing the risks of organizational accidents. Ashgate Publishing Limited, UKGoogle Scholar
  36. Ren J, Wang J, Jenkinson I, Xu DL, Yang JB (2007) A Bayesian network approach for offshore risk analysis through linguistic variables. China Ocean Eng 21(3):371–388Google Scholar
  37. Ren J, Jenkinson I, Wang J, Xu DL, Yang JB (2008) A methodology to model causal relationships on offshore safety assessment focusing on human and organizational factors. J Safe Res 39(1):87–100CrossRefGoogle Scholar
  38. Ren J, Jenkinson I, Wang J, Xu DL, Yang JB (2009) An offshore risk analysis method using fuzzy bayesian network. J Offshore Mech Arctic Eng 131(4):041101-1:041101-12Google Scholar
  39. Report to the President (2011) Deep water; the Gulf Oil disaster and the future of offshore drilling. National Commission on the BP Deepwater Oil Spill and Offshore Drilling. JanuaryGoogle Scholar
  40. RNNP project (2011) The petroleum safety authority Norway. Trends in Risk Level in the Norwegian Petroleum Activity 2011. Main Report. http://www.ptil.no/risikonivaa-rnnp/rapporter-fra-risikonivaa-i-norsk-petroleumsvirksomhet-rnnp-2011-article8458-20.html. Accessed 29 May 2013
  41. Shaughnessy JM, Romo LA, Soza RL (2003) Problems of ultra-deep high-temperature, high-pressure drilling. SPE 84555. SPE Annual Technical Conference and Exhibition. October 5–8, Denver, ColoradoGoogle Scholar
  42. SINTEF Executive Summary (2011) The Deepwater Horizon accident: causes, learning points and recommendations for the Norwegian continental shelf. MayGoogle Scholar
  43. SINTEF report (2011) The Deepwater Horizon accident: causes, learning points and recommendations for the Norwegian continental shelf. MayGoogle Scholar
  44. Sklet S, Aven T, Hauge S, Vinnem JE (2005) Incorporating human and organizational factors in risk analysis for offshore installations. In: Proceedings of the European safety and reliability conference. June 27–30, Tri City, Poland, 1839–1848 ppGoogle Scholar
  45. Skogdalen JE, Vinnem JE (2012) Quantitative risk analysis of oil and gas drilling, using deepwater horizon as a case study. Reliab Eng Syst Safe 100:58–66CrossRefGoogle Scholar
  46. Tabibzadeh M (2014) A risk analysis methodology to address the critical role of human and organizational factors in offshore drilling safety: with an emphasis on negative pressure test. Doctor of Philosophy Dissertation. University of Southern California, Los Angeles, CAGoogle Scholar
  47. Tabibzadeh M, Meshkati N (2013a) A proposed “Standard” framework for conducting negative pressure test. J Petrol Technol (In Press) (Submitted November 20, 2013)Google Scholar
  48. Tabibzadeh M, Meshkati N (2013b) A risk analysis framework to understand and assess interoperation of multiple organizations: adopting Rasmussen’s model to the BP deepwater horizon accident case study. Safe Sci (In Press) (Submitted October 17, 2013)Google Scholar
  49. Tabibzadeh M, Meshkati N (2014) A risk analysis study to systematically address the critical role of human and organizational factors in negative pressure test for the offshore drilling industry: policy recommendations for HSE specialists. SPE International Conference on Health, Safety, and Environment, March 17–19, Long Beach, CAGoogle Scholar
  50. Transocean report (2011) Macondo Well Incident. Transocean Investigation Report. Volume I. JuneGoogle Scholar
  51. Trucco P, Cango E, Ruggeri F, Grande O (2008) A Bayesian belief network modeling of organizational factors in risk analysis: a case study in maritime transportation. Reliab Eng Syst Safe 93(6):823–834CrossRefGoogle Scholar
  52. Vinnem JE (2007) Offshore Risk assessment; principles, modeling, and applications of QRA studies, 2nd edn. Springer, LondonGoogle Scholar
  53. Visser RC (2011) Offshore accidents, regulations, and industry standards. SPE 144011, Society of Petroleum Engineers Western North American Regional Meeting. May 7–11, Anchorage, AlaskaGoogle Scholar
  54. Walker SJ (2006) Three mile island: a nuclear crisis in historical perspective. University of California Press, USAGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Epstein Department of Industrial and Systems EngineeringUniversity of Southern CaliforniaLos AngelesUSA

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