Feed Forward: Safety in Process Automation

The New York Timesconducted an analysisof the second part of the Deepwater Horizon disaster. The first part was the blowout. The second was the destruction of the rig. Based on interviews of people who survived plus recorded testimony of most of the survivors, the Times asked why the disaster happened when the rig had very sophisticated safety systems with up-to-date training.

The Times concluded, "The paralysis had two main sources, the examination by The Times shows. The first was a failure to train for the worst. The Horizon was like a Gulf Coast town that regularly rehearsed for Category 1 hurricanes but never contemplated the hundred-year storm. The crew members, though expert in responding to the usual range of well problems, were unprepared for a major blowout followed by explosions, fires and a total loss of power."

"They were also frozen by the sheer complexity of the Horizon’s defenses, and by the policies that explained when they were to be deployed. One emergency system alone was controlled by 30 buttons."

These are certainly lessons for us all to consider as we evaluate our safety systems. I know that technology developers and users have been studying the problem for a long time. We have the Center for Operator Performance, Abnormal Situation Consortium and Human-Centered Design. We have improved simulation and training. Are these enough? Are we implementing them smartly? What else do we need to do?

Feed Forward Blog
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