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# System prepended metadata

title: 6841 f11a week2

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# 6841 f11a week2

## Admin
* something awesome
    * documentation
    * marks
* open learning permissions
---

## Case Study
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### Question
In the wake of the Deepwater Horizon catastrophe, the US president has asked you to make a presidential inquiry.

Consider the main lessons that should be learned and
produce a short list of recommendations for actions to be taken to prevent future disasters.

The government, public and oil industry all support the inquiry and are prepared to devote considerable resources to implement your recommendations.

State your top 5 recommendations, listing them in decreasing order of importance. Give a clear, concise justification for each one.

You have until 12:15.

----
### Group 1
1. Stricter industry safety standard combined more government penalties for failure so that the cost of PR and the cost of cleaning is outweighed by the cost of the penalties.
    - Increase monetary incentives against BP being lazy regarding safety

2. Better industry management protocol:
    - The safety management people living on the oil rig should have ultimate safety decision relative to all other BP managers regardless of rank.

3. Better evacuation protocols with rigorous drills
    - This is to account for the unlikely chance that everything, regardless of how many redundancy, the oil rig was to break. This will at least reduce the number of casualties.

4. Better monitoring and testing industry standards
    - High monetary penalties for not following standard to the letter. (But this may place a price tag to their error which they can choose to ignore)

5. Blind Government Audits on both BP Management and oil rig:
    - Keep people from being complacent on both sides of the business
    - Auditing management involvement with safety
    - Auditing response to safety concern


- More redundancy even if that does not completely stop the accident


- Remote station to control oil rig so people are not in the "line of fire" so to speak
- Reduce 
time fatigue.
- Governments standards for negative pressure tests
- * Hindsight bias with all recommendation *
- Trade-off between power concentration and power distribution
----
### Group 2
- Remote shutoff capability
    - The latest technology
- Relief well capability
    - The latest technology
- Stronger concrete walls for the well
    - Better cement
    - Outsource to a proven/well-known cement organization
- include safety measures into daily quotas to encourage proactive maintanance, and reduce worker fatigue
- Monthly consultations with qualified engineers
    - Regular maintenance of drilling equipment
- Reduce pressure somehow, have management work closer to the workers on the drill
    -  better equipment and procedures for high-pressure remote operations
    - if problems are more visible to managers and engineers they can find problems earlier
    - and come have more understanding of the issues on the ground floor
- HR
    - Prevent worker fatigue
    - Improve HR management
- Ensure equipment isn't broken
    - Weekly/monthly checkups and maintenance
- Energy Legislation to reduce dependance on enviromentally unfriendly energy sources
    - move capital towards more sustainable
- Incentive Structures: Ethics, laws, money, 
    - What motivates people? To take risk?
        - Improve off-the job and on-the job training to boost confident
        - 
    - How do you change money so it motivates people towards safety?

Main Lessons Learnt
1) Do not get complacent (complacency is the defenders mindset)
2) Don't rush 
3) Have a contingency plan
4) Enforce a culture of tighter safety and more experienced regulators

Recommendations
1) 3rd party inspection committee who get bonuses for finding unreported accidents, penalties for oil rigs that score low on safety - should be unbiased and they would have an incentive to ensure there is a safe work culture - By having an unbiased viewpoint, accidents won't just be swept under the rug
2) Every time equipment is used, it gets serviced - compare to airplane industry; they are serviced everytime they land (proactive maintenance), ensures that no equipment will fail and cause disaster
3) Company fined per gallon for an oil spill - deincentivise emergencies happening in the first place, money is a big factor into decisions made by management, large oil companies that make many mistakes recieve huge fines and free market removes inneficient/harmful business
4) Anonymous reporting system for workers to bring up grievances such as too much pressure/accidents - increased pressure from management caused maintenance/issues to be disregarded despite concerns from crew/engineers
5) Drills for emergencies - they had no plan (told that nothing bad would happen and ended up panicking during disaster), drills could ensure if disasters happen (low probability, high impact),they are prepared to mitigate the disaster



----
### Group 3
1. Initialise a government authority that randomly and extensively checks safety on rigs (Potentially always stationed on-board)
    - incentivises stringent safety measures
    - Prevents a conflict of interest concerning the productivity of company operations
    - Offers an outlet for worker complaints on the safety of ongoing operations on any given oil rigs
    - Try make the authority less influenced by the party in charge, Obama put in restrictions then Trump eased  some of them. This ties into making the authority less prone to lobbying from oil companies, a quick google shows that they spend hundreds of millions of dollars on lobbying. This is quite unrealistic but in a perfect world, this would be the case.
2. Create an industry standard for testing and maintenance
    - Namely negative pressure tests
    - Necessary as one of the key issues in the Deepwater horizon incident was the lack of concrete standards for how tests were conducted and interpreted
    - Also because regular maintenance did not seem to be a major priority which led to the impairment of many fail safe features and also essential infrastructure going under the radar.
3. More accurate detection system for damages to key safety infrastructure (e.g. Blowout preventer, blind sheer ram)
    - New technology
    - Important in terms of the event as the only physical indication that the Blowout preventer was damaged was the rubber floating back up through the pipe, which was promptly discarded.
4. Mandatory reporting 
    - Cement bond logs
    - Any abnormalities e.g. the rubber coming back up through the pipe
    - Standardised, mandatory reporting was essential to run an accurate safety and risk report on the continuation of drilling
    - Also to pick up on and log any small details that may have significance, (considering the complexity of offshore rigs, everything would have significance)
5. More safety features on control equipment to prevent worker accidents. (e.g. different procedures to be taken before they can control the equipment)
    - Reduces the chance of a worker bumping into important controls
    - Set limits on things like speed controls, so we can't go over a safe limit even if pressured to do so.
    - Better communication from the different teams/companies that work on the rig so that the workers can understand how each equipment worked. (Knowledge to prevent some accidents)
    - Isolation of important infrastructure (such as the main engine) from high risky areas
        - This would prevent excess leakage of fuel into the main engine, causing it to operate even after shutdown

Overall Budgeting Cost: 7 billion usd

----
### Group 4
#### Random thoughts
- emergency practice drills?
- people were panicking in the disaster
- communication issues between the transocean and bp manager
- routine inspections from a third-party?
- ability for workers to anonymously report issues (addresses the fear of being fired)
- Invest into safer equipment that can easily detect breakages.
- mandatory fallback plans for each deadline?
- allow workers to anonymously apply for deadlines to be extended if there are safety concerns? a third-party authority would be responsible for reviewing these applications and enforcing them?

#### Technical notes on the disaster
- cement wasn't sealed properly in the well
- the gases escaped quickly but they didn't recognise them escaping as they put something in the bop to
- they didn't redirect the rig
- the gas went into the engine intake, caused the engine to go into overdrive, and caused a fire
- the switch to turn the engine off was manual
- there was a loss of power, which was disastrous as the rig needs power to remain on top of the well and secure the pipe
- the problem was slow to identify as monitoring equipment was faulty

#### Main lessons learnt
- Prioritisation of profit over safety have disastrous effects.
- Place safeguards so that such an event could be prevented from happening again (this was done by the Obama administration but progressively eased by the Trump administration :( )
- Even after the disaster, you shouldn't downplay the effects till absolutely sure (i.e. there is thought to be much more oil spilled than initially estimated)
- pressure on workers placed on by managers pressing for time

#### Final recommendations
1. Enforce routine/surprise third-party inspections on equipment, procedure, deadlines and working conditions (or even place a permanent unbiased third-party authority on the rig).
    - Greedy management decisions were at the root of the disaster. Ideally those sorts of decisions should never be made, but hoping for that is somewhat idealistic. Therefore we should assume those decisions will be made and schedule regular third-party checkups to identify and correct them.
2. Create a system that allows workers to anonymously report issues.
    - Workers on the rig knew about many safety concerns but sometimes refrained from communicating them out of fear of reprisal. For example, it was non unknown for someone to be fired for voicing an error that would delay drilling. Anonymous reports would make it impossible for such targeted reprisal to occur.
    - This could work well with recommendation 1 in that workers could anonymously report issues to the third-party.
3. Implement more well-designed monitoring equipment in areas prone to errors.
    - The problems precipitating the disaster came a while before the disaster actually occurred. More resources dedicated to monitoring would allow problems to be identified and preventative measures to be taken.
4. Enable workers to request to extend the deadline of the project if it risks their health or safety. These requests will be reported anonymously and reviewed/enforced by a third-party that has authority over the rig managers. (This may build on systems developed as part of recommendations 1 and 2).
    - The pressure of deadlines caused rash decisions and jeopardised safety. For example, the speed of drill on the Deepwater Horizon was increased to save time/money, which led to a split on the ocean floor that exacerbated the disaster. This recommendation aims to give power to the workers to extend deadlines.
5. Implement more failsafe protocols OR strengthen the current ones.
    - The rig's blowout preventer (BOP) was the main fail-safe protocol which relied on the "blind shear rams" (a massive set of blades) which were designed to slice the pipe which carried the oil BUT that itself had malfunctioned. 
    - Strengthen (i.e. better material) the blind shear rams or the root of the failsafe protocol.
    - Automatic failsafes should be implemented more consistently across the rig (?).

----
### Group 5

----

### All groups top recommendation

- Group 1 recommendation:
    - Stricter industry safety standard combined more government penalties for failure so that the cost of PR and the cost of cleaning is outweighed by the cost of the penalties.
        - Increase monetary incentives against BP being lazy regarding safety


- Group 2 recommendation:
    - 3rd party inspection committee who get bonuses for finding unreported accidents, penalties for oil rigs that score low on safety - should be unbiased and they would have an incentive to ensure there is a safe work culture - By having an unbiased viewpoint, accidents won't just be swept under the rug


- Group 3 recommendation:
    - 1. Initialise a government authority that randomly and extensively checks safety on rigs (Potentially always stationed on-board)
    - incentivises stringent safety measures
    - Prevents a conflict of interest concerning the productivity of company operations
    - Offers an outlet for worker complaints on the safety of ongoing operations on any given oil rigs
    - Try make the authority less influenced by the party in charge, Obama put in restrictions then Trump eased  some of them. This ties into making the authority less prone to lobbying from oil companies, a quick google shows that they spend hundreds of millions of dollars on lobbying. This is quite unrealistic but in a perfect world, this would be the case.

- Group 4 recommendation:
    - 1. Enforce routine/surprise third-party inspections on equipment, procedure, deadlines and working conditions (or even place a permanent unbiased third-party authority on the rig).
        - Greedy management decisions were at the root of the disaster. Ideally those sorts of decisions should never be made, but hoping for that is somewhat idealistic. Therefore we should assume those decisions will be made and schedule regular third-party checkups to identify and correct them.


## Review
- Useful XSS resouce: https://alf.nu/alert1

### Group 