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Cause Mapping Example:
The Deepwater Horizon oil rig was in the final stages of exploratory drilling at the Macondo well in the Gulf of Mexico when disaster struck. On April 20, 2010, the rig exploded, killing 11 workers and forcing the evacuation of the rig. It quickly became clear that the emergency measures taken prior to evacuation had not sealed the well and that great amounts of oil were leaking into the Gulf of Mexico.
Immediately, plans were developed to stop the oil leaking from the well while attempting to avoid anything that might cause the leak to expand. This delicate balancing act – and a host of other factors from a hurricane to political wrangling – meant that it would take nearly 3 months before the leak was stopped, and nearly 5 months before the well was declared effectively dead.
The months between the beginning and end of the leak were defined by contingency plan after contingency plan. We’ll examine this incident closer to look at what happens when your original solution doesn’t solve the problem.
We’ll use the Cause Mapping process to provide an analysis of the issues related to the Deepwater Horizon explosion and oil spill. The Cause Mapping method utilizes three steps: 1) Define the problem, 2) Conduct the analysis and 3) Identify the best solutions. Each step will be discussed below.
Step 1. Define the Problem
The first step of the Cause Mapping approach is to define the problem by asking the four questions: What is the problem? When did it happen? Where did it happen? And how did it impact the goals? One person may say that the problem was the well blowout. Another person might say that the problem was the explosion on the rig, and a third person could say that the problem was the worker fatalities. We can write down these three “problems” on the first line. In the Cause Mapping methodology the facilitator anticipates that the group may disagree so all three responses are written down. There is no need to spend time debating the problem. The magnitude of this incident is defined by the impact to the goals.
The second question is the “When?” which is the date and time of the incident. When captures the timing of the issue and also has a line for what was different or unusual in this occurrence. The question of what was different is fundamental in any investigation. On the Deepwater Horizon issue we capture the date as April 20, 2010 and the time of 9:49 PM when the first explosion occurred. An important difference was confusing test pressure results.
In an investigation there can be several pieces of information that need to be captured when specifying the location. At a minimum the physical/geographic location and the process should be captured. The physical location is where geographically the incident happened. In this case, the incident occurred in Macondo Prospect in the Gulf of Mexico on the Deepwater Horizon oil rig. At the time of the explosion, the rig was performing the final phase of drilling an exploratory well.
The next part of the outline captures the impact to the overall goals. According to the operator of Deepwater Horizon, “Our goals are simply stated. No accidents, no harm to people, and no damage to the environment.” Clearly the 11 fatalities and 17 injures are an impact to the safety goal. The ~4.9 million barrels (by government estimate) of oil spilled is an impact to the environmental goal. There were other goals that were affected but the magnitude of the loss of life makes any other goals less significant. The two impacted goals that we will use for our analysis are the safety goal and the environmental goal.
Step 2. Identify the Causes (The Analysis)
The analysis step is where the incident is broken down into causes which are captured on the Cause Map. The Cause Map starts by writing down the goals that were affected as defined in the problem outline. For Deepwater Horizon, the safety goal was impacted because of the1 1 lives that were lost and 17 injures. The environmental goal was impacted because of the spill. These are the first two cause-and-effect relationships in the analysis.
The analysis can continue by asking “Why” questions and moving to the right of either of the cause-and-effect relationships above. In this example we’ll examine the spill, which was caused by damage to the riser. Additionally, the magnitude of the spill directly resulted from (was caused by) the blowout preventer (BOP) not sealing the well, as designed, for reasons that are not entirely clear. Because both of these causes were necessary for the oil spill to occur, they are joined with “AND”.
We can begin by providing more detail by asking more “Why” questions about the riser damage. The riser damage was caused by the explosion, which resulted from hydrocarbons flowing onto the platform (the fuel) and causing an engine overspeed (the ignition source).
Hydrocarbons flowed onto the platform when they flowed up riser. The mud-gas separator (MGS) became overwhelmed when the crew vented to the MGS for unknown reasons. The MGS was not designed for large flow rates.
The uncontrolled flow up the riser (blowout) was caused by a failure of the well seat due to an ineffective cement job and failure of the barriers in the shoe track, which allowed the hydrocarbons to enter the production casing, for unknown reasons. Additionally, the crew did not recognize there was a problem until the blowout occurred. (A well control problem is known as a “kick”.) This is because the ambiguous pressure test results we talked about earlier were misinterpreted. The test guidelines did not clearly specify success and failure criteria.
The amount of detail provided in an analysis must be adequate to determine effective solutions in reducing the impacts to the goals. In the case of Deepwater Horizon, the immediate solutions focused on stopping the oil flow out of the damaged riser. The rig itself capsized and sank, and will not be used again.
During the course of the internal investigation, eight key findings were identified. These eight key findings can be addressed in a Cause Map with a higher level of detail. To view a PDF showing the eight key findings, click here or on the button above.
Step 3. Select the Best Solutions (Reduce the Risk)
Once the Cause Map is built to a sufficient level
of detail with supporting evidence the solutions step can be started. The Cause Map is used to identify all the possible solutions for given issue so that the best solutions can be selected. The possible solutions can also provide backup plans in case the initial solutions selected didn’t work, as happened in this case.
Plan A: The first plan (action item) was to attempt to use functionality within the blowout preventer (BOP) which had failed to seal the well. A remote-operated vehicle (keep in mind that all the equipment and functionality were either at the bottom of the Gulf of Mexico or on an evacuated oil rig spewing thousands of gallons of oil) would be used to activate the BOP’s auto-shear mechanism, which should cut and block the pipe delivering oil from beneath the gulf to the surface. It didn’t work. Attempts to intervene with the BOP ended May 5th.
Plan B: Plan B involved the installation of a cofferdam, a dome that would be placed over the leak and divert the oil to a surface ship. The cofferdam reached the bottom of the Gulf May 7th, got clogged with hydrates (a byproduct of the process) and couldn’t be forced down over the leak.
Plan C: The next plan was to use a Riser Insertion Tube Tool (RITT) that would siphon some of the flow from the end of the riser and redirect it to a surface ship for collection. The RITT was partially successful. It did divert some of the flow from the leak. But not all. More solutions were still needed.
Plan D: The next plan aimed to end the flow from Macondo well by ramming heavy mud and cement directly into the well itself. This was known as a “top kill”. The top kill began on May 26th. Three days later, the operation was stopped when it became clear the top kill was no match for the flow from the well.
Plan E: The plan designed to capture ALL the flow was a 3-ram capping stack, or “sealing cap”. This cap was designed to seal tightly, capture all the oil and divert it to two surface ships. Also at the ready were other caps in case the capping stack couldn’t be seated properly. The cap was finally placed on July 12th and the flow was choked on July 15th. Now the flow was controlled, but the Macondo well was still releasing oil at a high rate.
Plan F: I’m calling this plan F because it was what finally ended the issue after attempts at Plans A-E. However, Plan F had been a long time in coming. This involved the drilling of relief wells. The first relief well had begun May 2nd. The relief wells were dug in with the plans of intercepting and pumping mud, then cement, down into the Macondo reservoir, a permanent fix to the spill (known as a “static kill”). This, like all the other tasks involved with shutting down the Deepwater Horizon leak, as not an easy task. The static kill was completed on August 4th. That still wasn’t the end. The last cement was placed on September 18th and it was announced that the well was ‘effectively dead’.
Response, recovery and investigation into the Deepwater Horizon incident continues. Some of the specifics may never be known as the evidence required is lost with the rig and the workers who were killed. The reminders of the tragedy will remain, and hopefully the lessons learned will be applied to other incidents to ensure that safety is maximized in difficult environments in the future.
Click on “Download PDF” above to download a PDF showing the Root Cause Analysis Investigation.
The information used to make this Cause Map was obtained from:
A Hole at the Bottom of the Sea: The Race to Kill the BP Oil Gusher by Joel Achenbach
Internal Accident investigation Report
CSB Investigation on the Macondo Blowout and Explosion
Deepwater Horizon Study Group’s Final Report on the Investigation of the Macondo Well Blowout
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Case Study: BP Oil Spill
This lesson has addressed the key components of ethical principles in crisis communication, including the ethical principles of responsibility, accountability, and humanistic care. The case of BP oil spill in 2010 provides an important example for understanding how these principles are valued by public opinion in a crisis situation, and how the communication actions by a corporation in this type of circumstances might have long-term effect on the brand image of the organization.
On April 20, 2010, a BP’s Deepwater Horizon oil rig exploded, causing what has been called the worst environmental disaster in U.S. history and taking the lives of 11 rig workers. For 87 straight days, oil and methane gas spewed from an uncapped wellhead, 1 mile below the surface of the ocean. The federal government estimated 4.2 million barrels of oil spilled into the Gulf of Mexico.
Mistakes in Initial Response
According to NPR, BP’s action has become a textbook example of how not to do crisis management. BP executives declared it was not their accident, blamed their contractors and made the company look arrogant and callous. CEO Tony Hayward repeated insensitive comments in public, like this one: “There’s no one who wants this thing over more than I do. You know, I'd like my life back.” He also suggested that the environmental impact of the spill would be “very, very modest.” Images of Hayward attending a yacht race just 48 hours after a hostile interrogation by a US congressional committee on the oil spill, provoked sharp criticism on both sides of the Atlantic. Although the company, formerly British Petroleum, officially changed its name to BP in 2001, Americans consider it a foreign company even though it has just as many American shareholders as British ones, and its biggest operations are in the United States.
To sooth angry Americans, BP aired a multimillion-dollar national TV spot in June in which Hayward pledges: "We will make this right." Hayward also promised BP would clean up every drop of oil and “restore the shoreline to its original state.” President Barack Obama said the money spent on the ads should have gone to cleanup and compensating devastated fisherman and small business owners. The ad indicated that the company didn't even follow its own internal guidelines for damage control after a spill. Its own spill plan, filed the year before with the federal government, says of public relations: “No statement shall be made containing any of the following: promises that property, ecology or anything else will be restored to normal.”
BP also bought online ads that pop up when people search for information about the oil spill on Google and Yahoo. The ads, which link to BP's own oil-response sites, typically appear above or to the right of other search results. BP said the idea was to help people on the Gulf find the right forms to fill out quickly and effectively. However, many people suggest it's a move to steer searchers away from bad press for BP.
Crisis management experts stated the only reliable way to repair BP's badly tarnished image should be the obvious one — to plug the hole where oil was still leaking out. It would take nearly 3 months before the leak was stopped, and nearly 5 months before the well was declared effectively dead. Public relations experts pointed out that BP ran its crisis communications in the same “ham-fisted” manner they’ve run the clean-up operation in the Gulf.
"BP's handling of the spill from a crisis management perspective will go down in history as one of the great examples of how to make a situation worse by bad communications," said Michael Gordon, of New York-based crisis PR firm Group Gordon Strategic Communications. “It was a combination of a lack of transparency, a lack of straight talking and a lack of sensitivity to the victims. When you're managing an environmental disaster of this magnitude you not only have to manage the problem but also manage all the stakeholders.”
BP attempts to convince people that it appears the Gulf of Mexico is healing itself after a while. In 2015, BP released PR materials that highlight the Gulf’s resilience, as well as a scientific report showing the area is making a rapid recovery. But evidence is mounting that five years after millions of gallons of oil spilled into the Gulf, wildlife there is still struggling to rebound.
In June 2016, BP issued its final estimate of the cost of the spill, the largest in U.S. history. The total amount for the cost of the 2010 oil spill in the Gulf of Mexico was $61.6 billion. Under the settlement with BP, five states in the Gulf area and local governments will receive payments over the next dozen years. The funds will enable them to ramp up vital restoration work along the coast. BP continues to settle claims from business owners and residents who say they were harmed.
Moral of the Story
In conclusion, this is a classic case example of why organizational decision making in crisis situations should be based on ethical principles such as accountability and responsibility. Public criticism and outrage following the incident not only focused on the oil spill, but on the lack of remorse and sincerity from the top management in crisis response, particularly the lack of sympathy to the victims of the disaster. The failure by BP’s leadership to respond to the disaster with sufficient speed and attention demonstrates that crisis preparedness and ethical guidelines should become part of the organization culture.Next Page: Lesson 1 Assessment