Deepwater Horizon: A Systems Analysis of the Macondo Disaster

Confronted with the snarl of conflicting, contradictory and missing information that is the Deepwater Horizon, Boebert and Blossom wade in with sieves and scales, and after much sorting and weighing, make as much sense of it as anyone is ever likely to.As you read Deepwater Horizon, many accounts written as the disaster was unfolding or in its immediate aftermath suddenly snap into focus, their implications finally clear. 'My God,' you find yourself saying again and again, 'so that is what that was all about.'Boebert and Blossom lay out their terms in an introductory chapter. They are going to discuss the Deepwater Horizon as a "system," they say, a system so complex that no one individual or entity truly understood it. They will not be looking for a root cause of the disaster. Rather, they say, the blowout was a result of a combination of decisions, actions and component attributes rather than the result of a single act or failure.Moreover, they are going to be taking a "scholarly" rather than a "judicial" approach to the evidence, since their goal is to understand, rather than to place blame. For this reason, none of the actors is named, even when they are as easily identifiable as the chief executive of British Petroleum at the time of the disaster.Remarkably--given these and other narrative (or anti-narrative) decisions--Deepwater Horizon is an engaging and ultimately gripping read, at first illuminating and then impossible to put it down, even if you do have to go to work the next day.To me one of the most fascinating elements of this story is how little information the crew on the rig actually had about what was happening more than a mile beneath them at the bottom of a hole in the ocean floor. The authors explain that, as far as physics is concerned, the well is essentially a big U-shaped tube stuffed with heavy drilling mud to prevent lighter hydrocarbons from rising to the surface prematurely. The crew monitored the hidden state of the well by comparing the amount of mud they were pushing down to the amount coming back up.So mud is the ground truth, the ultimate finger on the pulse of the well. But during the procedure that led to the blowout--a crucial test of the integrity of the cement seal at the bottom of the well--the mud loggers couldn't, or thought they couldn't, monitor the volume of mud in the storage pits because other crew members were moving the mud from storage pit to pit before transferring it overboard.What's worse, nobody did the predictive well-control calculations that would have showed the procedure they were undertaking would bring the well close to the edge; the point where the push of the mud would be unable to oppose the shove of the hydrocarbons. Nobody, in other words, was saying I'm not going to do something I don't understand, and everyone was just following orders in the belief that someone else understood.Boebert and Blossom are right to insist are no heroes and no villains in this tragedy. Nobody quit his job to prevent the disaster but nobody acted maliciously either. But everyone who has ever worked in a large organization will recognize two 'types' in the story: those who know what they are doing and those who don't.The person you hope is sitting next to you is a senior guy with a lot of experience, "the ability to draw conclusions from incomplete and conflicting information" and "the moral fiber to act." A few of them turn up in Deepwater Horizon, asking inconvenient questions and refusing to proceed until conditions are met (we've all been in that meeting, silently cheering them on). But the system rolls over them: They are bypassed, or don't have the authority, or are given the day off.In any case they are vastly outnumbered by the other guys, the ones who don't care or don't care enough, who are just doing a job, just trying to get by. There's the vendor's rep who was known for 'just in time delivery' of test results, thereby depriving other people of the time to think them through; or the guy who created a design document consisting of lots of canned output by pushing the "generate report" button on the computer. We've all worked with people like this. silently fixed the broken things they leave in their wakes and fervently hoped never to work with them again.What matters in the end, however, what saves the reader and comforts her, despite her smoldering anger at the stupidity of it all, is the narrative voice: the calm, thorough, persistent, intelligent voice of the authors and their unstated code of respect for competence, for intellectual honesty, and for taking responsibility.To some extent what happened on the Deepwater Horizon was technology specific. For a science writer like me, one of the pleasures of this book is clarity of the descriptions of deep-water drilling technology, the many technical illustrations, and the appendices on topics such as cementing mechanisms or low returns during displacement. It's not really possible to understand what happened without getting into the details.On the other hand, the Deepwater Horizon is also a type, or exemplar, of the many sporadically lethal "systems" that are part of our lives today-- such as the U.S. heath-care system, the Internet, the U.S. government, and the global climate system--all of which we seem hell-bent on running close to the edge.We would all be better off is more of us thought, when we were under pressure to go forward assuming the best, that one day someone might write a book like this one about what we were doing.

I'm used to reading science fiction and fantasy, so this book is reading more like a text book, at least to me. I know the author is the reason for the purchase. It is interesting reading, some of the facts mentioned, I don't recall being mentioned by the news during the actual event.

The authors of this book do a fine job of explaining exactly what went wrong with the Deepwater Horizon. It's easy to read and understand, and I found it to be fascinating. They apply a thorough, rigorous approach to analysing every single factor that led to the Macondo well blowout and subsequent destruction of the Deepwater Horizon rig. As with most things on life, things were not as simple as they seemed, and the causes of the accident were numerous. I thought the authors did a really fantastic job and the book was worth the high price. I read it on the Kindle and the diagrams were easily readable.

This was actually a present for my brother, ( whom I consider an authority in offshore petroleum engineering) a specific request. he is currently reading it for a second time. He really enjoys the detailed engineering and physics and chemistry of the event, and says this book does an exemplary job of explaining all of the dynamic factors and outcomes. Fairly technical if that is not for you, then I would try a different one. But reads like an engineering book of catastrophic errors or a root cause analysis.

While the book itself is commendable, the KINDLE presentation is awkward. The only suggestion for the authors is that a page or so with the frequently used abbreviations would be helpful. Otherwise the book was quite well done.

I liked the manner in which the story was laid out! I worked offshore for 12 years, the last nine on a deep water production platform and we had the SAME struggles with safety, production, and managerial issues!!

I'm not an engineer, but have some oil and gas litigation background. Ordered this after watching the film. With a few reread sections and occasional reference to the web, I was able to get through it. Well sourced with many further references if you wish to dive deeper

Accidents in complex systems often have root causes that stem from organizational or even cultural problems. This analysis of the Deepwater Horizon disaster steps back to examine the context for this "emergent event". The details of rig operations and onboard decision-making ring true from my limited experiences, but more importantly, the generalities of disorganization, miscommunication, and human psychology are applicable to systems far beyond the oil industry.

I initially started reading this when a former colleague lent his (autographed) copy to me. I immediately had to buy my own. This review will focus on a different aspect of the book than others. Yes, it is an amazing review of the disaster but it is more than that and its applicability is wider.This book attempts to piece together the various contributing causes of the Deepwater Horizon disaster. As an IT engineer (and sometimes engineering manager) I found myself relating to much of the material far more than I expected. Time pressure, some of which could have been avoided, leading to bad engineering decisions. Organisational chaos, people charged with things they were not ready for. All these things reminded me of things I had experienced before over and over.Ultimately a lot of the issues found here are relatable in other fields. For those of us who are tasked with keeping things running, whether they are IT environments, power plants, airline pilots, or oil rigs, this book has a lot to offer. The same goes for doctors, nurses, airline pilots and aerospace engineers. Many of us do have to think about safety engineering and this book is a goldmine in this field.

Looking from system theory perspective, authors have laid bare the multiple pathways that led to this disaster.Much like Nimrod disaster, this book is a must for anyone who is interested in learning more from an incident than purely using human error label .

Excellent read

Probably the most definitive technical account and analysis of this event that we are likely to read. Much of the information on the event that analysts might wish for is simply unavailable, sparse enough that technical accident analysis methods such as WBA or STAMP cannot really be applied. Deep sea drilling appears to be different in this respect from other critical engineering industries such as aerospace, transport, nuclear, and other process industries. Boebert and Blossom explain the operation and the equipment in detail for those unfamiliar. Much, even most, of the information on the event comes from legal submissions to court.