Becoming more socially responsible through failure: An illustrative example of a systems engineering failure analysis and corrective action report on the Deepwater Horizon disaster

摘要

As system complexity increases, system unpredictability and potential for failures that can be difficult to understand increase. These conditions increase the importance of applying systems engineering approaches, such as failure analysis and corrective action reporting, which can enable learning and the chance to become successful through failure. Such outcomes are particularly important when system failures can result in extreme and wide-spread harm to individuals, societies, and environments. Guidance for creating a failure analysis and corrective action report is provided through an illustrative example of such a report on the British Petroleum (BP) Deepwater Horizon disaster. Proximal and distal causes of this tragedy and appropriate placement of responsibility are considered. The discussion focuses on the roles of technical, human, and social factors in causing the disaster. These factors include cement barrier and blowout preventer failure, extreme environmental conditions, delayed problem detection by the crew, and poor institutional oversight, political climate, and corporate culture. Possible corrective actions to prevent similar disasters are provided.