The Full Macondo

And now the full and final commission report to the president on the BP Deepwater Horizon disaster, including the Chapter 4 on the blow-out failure itself, reviewed previously.

Finally, to the American people, we reiterate that extracting the energy resources to fuel our cars, heat and light our homes, and power our businesses can be a dangerous enterprise. Our national reliance on fossil fuels is likely to continue for some time—and all of us reap benefits from the risks taken by the men and women working in energy exploration. We owe it to them to ensure that their working environment is as safe as possible. We dedicate this effort to the 11 of our fellow citizens who lost their lives in the Deepwater Horizon explosion.

I have to say, my general feeling, is the quality of the investigation and reporting seems excellent. I sincerely hope the findings and recommendations – technical and rhetorical – are fully understood and actioned accordingly, avoiding knee-jerk “never again” simplistications.

As the Board that investigated the loss of the Columbia space shuttle noted, “complex systems almost always fail in complex ways.” Though it is tempting to single out one crucial misstep or point the finger at one bad actor as the cause of the Deepwater Horizonexplosion, any such explanation provides a dangerously incomplete picture of what happened—encouraging the very kind of complacency that led to the accident in the first place.  Consistent with the President’s request, this report takes an expansive view.

And as a little context, beyond this drilling operation, and beyond BP:

Since 2001, the Gulf of Mexico workforce—35,000 people, working on 90 big drilling rigs and 3,500 production platforms—had suffered 1,550 injuries, 60 deaths, and 948 fires and explosions.

[Post Note : Just assembling a collection of all my blog links on this subject:
11th Jan 2011 this post https://www.psybertron.org/?p=3699
10th Jan 2011 https://www.psybertron.org/?p=3694
6th Jan 2011 https://www.psybertron.org/?p=3689
2nd Nov 2010 https://www.psybertron.org/?p=3598
30th Sep 2010 https://www.psybertron.org/?p=3548
8th Sep 2010 https://www.psybertron.org/?p=3534
10th Jun 2010 https://www.psybertron.org/?p=3426
28th Apr 2010 https://www.psybertron.org/?p=3312

Remember, despite blaming no single failure above:

… the failures at Macondo can be traced back to
underlying failures of management and communication.

Must collate a coherent summary report of my main proposals – the communication of information supporting management decisions at all levels, particularly the criticality of information in context driving the escalation of levels of management to be informed and involved in those decisions.]