After the spill: safety standards and metrics

Article by Kristen Kulinowski and Mark Kaszniak

Ten years after Macondo, US offshore drilling safety improvements remain elusive

IN the wake of the Deepwater Horizon incident at the Macondo well, the US Chemical Safety and Hazard Investigation Board (CSB) issued a series of recommendations to bolster safety. These have yet to be fully implemented. As such, offshore drilling in the US remains an unacceptably hazardous operation.

The CSB is a non-regulatory federal government agency that conducts investigations to determine the causal factors leading to major industrial chemical incidents where the release of a hazardous substance resulted in loss of life, serious injury or substantial property damage. Being apart from the industry and other regulatory agencies affords us the independence to examine incidents from a systems perspective, identifying gaps in safety management systems and regulations broadly, and issue recommendations to prevent their reoccurrence or mitigate their consequences.

The Macondo investigation was a multi-year effort for the CSB, and one of the most challenging experiences in agency history. Our investigation commenced several months post-incident after we received requests from the US Congress to apply the same rigour to this complex incident as the agency had to its investigation of the 23 March 2005 explosions and fire at the BP America refinery in Texas City, TX.

Then followed lengthy litigation against Transocean, the drilling contractor and entity with the most eyewitnesses on the rig, for failure to provide key document and interview subjects. The agency prevailed after four-and-a-half years, during which time the CSB’s investigation focussed where it could with the cooperation of other entities. The magnitude of the case, and its technical complexity, challenged an agency with limited resources. Nevertheless, we persisted, ultimately issuing four volumes containing 16 safety recommendations. While many official entities investigated this incident, the CSB’s reports cover aspects not addressed by these other bodies, most of whose work had concluded before the final phases of testing of the blowout preventer and the conclusion of litigation revealed new insights.

The CSB issued four volumes and an executive summary on the incident:

  • Volume 1 (released 5 June 2014) contains a summary of information on drilling and well completion activities leading up to the explosions and fire.
  • Volume 2 (released 5 June 2014) contains technical findings related to the blowout preventer, a key system for preventing a loss of well control, including failures in its design and in the safety management systems meant to ensure its effective use as a barrier.
  • Volume 3 (released 17 April 2016) describes human and organisational factors, including aspects of decision-making by the well operations crew, the operator-contractor relationship, and the role of boards of directors, shareholders, and the Securities and Exchange Commission’s reporting requirements in establishing and assessing corporate governance good practice for major incident prevention.
  • Volume 4 (released 17 April 2016) assesses the role of the Bureau of Safety and Environmental Enforcement (BSEE), the safety regulator which oversees offshore drilling activities in the US.

Full details can be found here


The CSB’s primary lever for driving safety change is our recommendations, which stem from our investigation findings. It is through our recommendations that we drive safety change and through their adoption that we measure success. When we identify safety gaps whose absence could have prevented the incident or mitigated its consequences, we issue a specific recommendation to a recipient to close the gap so a future incident with a similar fact pattern doesn’t occur or isn’t as catastrophic. Recommendations are only issued for outstanding gaps made at the time our final report is issued; if safety change was made during our investigation then what might have been a recommendation is no longer needed. This is, of course, a desirable outcome.

Given the length of this investigation, other official reports on the incident, and industry efforts to understand and address known issues, one might have hoped that few CSB recommendations would be needed because the desired safety changes would have been made in the time between the incident and the publication of Volumes 1 and 2 (>4 years post-incident) and Volumes 3 and 4 (6 years post-incident). Yet the CSB identified 16 recommended actions that the Board deemed essential for improving safety that had not yet been taken. They include:

  • requirements by the regulator for managing safety-critical elements and development of guidance to fulfill those new regulatory obligations;
  • development by the regulator of industry guidance on human factors and corporate governance and establishment of a process safety culture improvement programme;
  • revision and augmentation of existing offshore oil and gas safety regulations, including BSEE’s Safety and Environmental Management Systems (SEMS) Rule, to a more robust risk management regulatory framework that embodies key regulatory attributes found in other global offshore regions;
  • the publication of an offshore standard for the effective management of technical, operational, and organisational safety critical elements and revisions to API Standard-53 requirements for testing and monitoring of blowout prevention systems; and
  • revision of API Recommended Practice 75 to expand SEMS responsibilities beyond just the operator – to include explicit and expanded responsibilities for human factors, corporate governance, workforce involvement, contractor oversight, and key performance indicators; and incorporate the principles of a risk reduction concept (eg ALARP) and the hierarchy of controls.

The text of each recommendation can be found here

After CSB recommendations are published, our staff track them through periodic communication with the recipient to encourage their adoption. Progress toward implementation is assessed by the Board, which then votes to change the status of a recommendation. Ultimately, we drive recipients toward full implementation of the recommendation, but we also measure progress made along the way, and may accept alternative actions if they meet the intended goal. The current status of our recommendations reveals that change continues to come slowly. Ten years after the incident, and 4–6 years after they were issued, only four CSB recommendations have been closed and of those only one has been closed acceptably. Two have been "Closed – Reconsidered/Superseded", meaning the Board retracted the recommendation upon new information or additional analysis. One has been "Closed – Unacceptable Action/No Response Received".  Most remain "Open – Awaiting Response" or "Evaluation/Approval of Response" indicating either that the recipient has not yet communicated their intentions regarding the recommended action, or the Board has not yet evaluated its response.

The one acceptably closed recommendation was to the Sustainability Accounting Standards Board (SASB). The following text is from the Board’s Recommendation Status Change Summary:

As a part of its investigation, the US Chemical Safety and Hazard Investigation Board (CSB) analysed the current regulatory oversight of US offshore oil and gas operations. The CSB determined that few specific data points relevant to a company’s health, safety, and environmental operations are specifically required for disclosure to shareholders of companies trading in the US under regulations promulgated by the Securities and Exchange Commission (SEC) pursuant to the Securities and Exchange Act of 1933 or 1934, Sarbanes-Oxley, Dodd-Frank, or any other existing financial law or regulation. As the SASB has created health, safety, and emergency management reporting standards for both onshore and offshore operations, the Board voted to issue a recommendation to the SASB.

In June of 2016, SASB began the process of modifying its Oil & Gas – Exploration & Production Sustainability Accounting Standard. SASB published the final standard on its website on 8 November 2018, along with an accompanying “Basis for Conclusions” document that outlines the new standard’s rationale, supporting analysis, market input and benefits.

The Board voted to change the status of CSB Recommendation No. 2010-10-I-OS-R9 to: “Closed – Acceptable Alternative Action” on 15 April 2019 because while the SASB’s new standard for the Oil & Gas – Exploration & Production Sector does not add additional leading and lagging indicators to actively monitor major accident safety barriers and the management systems for ensuring their effectiveness, it does require reporting a description of process safety related management systems, including safety barriers, used to identify and mitigate catastrophic and tail-end risks in periodic mandatory filings with the SEC, such as the Form 10-Q, Form S-1, and Form 8-K. The new SASB standard also emphasises and promotes the concept that personal safety metrics are important but separate from process safety performance indicators by requiring them to be reported as separate metrics.

Positive signs

There are also positive signs that other recommendations will be adopted. The clearest comes from the Ocean Energy Safety Institute, to whom the CSB issued a recommendation to: Conduct further study on riser gas unloading scenarios, testing, and modelling and publish a white paper containing technical guidance that communicates findings and makes recommendations for industry safety improvements.

The CSB determined that the Macondo incident “progressed from a gas-in-riser event ultimately to an uncontrolled blowout after the crew’s well control actions and the physical well barriers (eg the blowout preventer and diverter system) were unable to mitigate the hazardous conditions created once hydrocarbons entered the riser” and noted that “this is a hazardous situation because riser gas migration toward the rig may be nearly undetectable and can rapidly change from a seemingly stable condition to an extremely high flow rate, releasing large amounts of gas on the drilling rig that can ignite and explode.” [CSB Macondo Report, Volume 3. Section 1.3, page 35.] Therefore, a recommendation was made to OESI to study various scenarios and publish technical guidance for industry action.

Recommendation No. 2010-10-I-OS-10 to the OESI was made an “Open –  Acceptable Response or Alternative Response” by the Board on 29 January 2020 as its ongoing research work on studying riser gas unloading scenarios, testing. Modelling is actively underway and it anticipates publishing a white paper containing technical guidance that communicates findings and makes recommendations for industry safety improvements, in 2021.

The Board also remains optimistic about the eventual closure of 2010-10-I-OS-5, which calls for the American Petroleum Institute to revise API RP 75: Recommended Practice for Development of a Safety and Environmental Management Program for Offshore Operations and Facilities to require a specific focus on major accident prevention. API has revised this recommended practice, and the CSB, which participated in its revision and advocated for inclusion of the elements contained in this recommendation, is now evaluating it for potential closure.

Even after a recommendation has been closed unacceptably, the CSB continues to advocate its adoption. Such is the case for recommendation 2010-10-I-OS-7, which calls upon the US Department of the Interior: Drawing upon best available global standards and practices, develop guidance addressing the roles and responsibilities of corporate board of directors and executives for effective major accident prevention. Among other topics, this standard shall provide specific guidance on how boards and executives could best communicate major accident safety risks to their stakeholders, as well as corporate level strategies to effectively manage those risks.

The Bureau of Safety and Environmental Enforcement, responding on behalf DOI, initially disagreed with CSB’s assignment of this recommendation to DOI. The conversation continues. In an effort to demonstrate our commitment to the importance and positive impact of our recommendations and based upon BSEE’s decision not to implement recommendation 2010-10-I-OS-7, the Board committed to developing the recommended guidance itself.  As a result, our agency recently released the CSB product entitled “CSB Best Practice Guidance for Corporate Boards of Directors and Executives in the Offshore Oil and Gas Industry for Major Accident Prevention.” 

In the aftermath of the explosions and fire came the sinking of the Deepwater Horizon and the largest accidental marine oil spill in history, with environmental and economic costs that reverberate today that threaten the lives and livelihood of workers and communities.

CSB recommendations provide practicable actions that drive safety change.

This article is part of series called Deepwater Horizon: a Decade On. Read the rest of the series here

Article By

Kristen Kulinowski

Board Member, US Chemical Safety and Hazard Investigation Board

Mark Kaszniak

Senior Recommendations Specialist, US Chemical Safety and Hazard Investigation Board

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