Managing Complex Systems
The commission’s report made an observation that applies to many businesses and organizations, not just those involved in the lucrative but dangerous world of oil and gas exploration and production. The observation was: ‘Complex systems almost always fail in complex ways.’ The greater the complexity of any system the greater the need for business leaders to free their imagination and be willing to think of what might the worst thing that could happen.
The commission’s report provides expansive background information on the history of deepwater offshore drilling and the economic reasons why it has increasingly been part of the industry’s mode of exploration. The report, of course, detailed the reasons for the Macondo well blow out that led to the explosion, fire, loss of life, and oil spill. The operational reasons for the disaster are spelled out in chapter four of the report in remarkably precise detail. Though persons outside of the oil drilling business may not be familiar with the complicated process of using drilling ‘mud’ and cement as an important part of the operation and maintenance of a deepwater oil well, the report clearly explains how it should normally be done. The commission’s report also explains the risks inherent in the process.
A series of compromises made by BP during the mud and cement process are highlighted in the report. It also details the crew’s failure to properly monitor tests that would have provided critically important information about the pressure of the well. It was too late by the time the crew on the rig’s platform realized something was dangerously wrong with the well’s pressure. Though the platform crew was praised for their quick action once the dire nature of their circumstances was realized, by that point gas under a tremendous amount of pressure was accelerating uncontrollably up the drill shaft with such velocity that it was described in the report as having the effect of ‘a 550-ton freight train hitting the rig floor’.