Dear Readers,

With the problems in the Gulf, equipment problems are (again) back in focus.  While many of the investigations are looking deeply at the safety culture of BP, I noticed that there is a good bit of emphasis being placed on the blowout preventer (BOP) problems.  And yet, even with this increased scrutiny, it seems like the investigations are still focusing on who to blame for the failure. 

Was it Cameron's fault, because they manufactured it? 

Was it BP's fault, because their prints weren't up-to-date and they had possibly authorized modifications? 

Is it Transocean's fault, because they didn't adequately test the equipment? 

Is it a regulatory failure, because the MMS did not have strict enough requirements? 

Everyone seems to be focusing on who should be made accountable.  Of course, this is what grabs the best headlines in the newspaper and the best sound bites during the Congressional hearings, but are these questions really going to fix the problem?

At least, with this spotlight placed on these issues, maybe we will get around to actually addressing the mechanical failure problems.  I just hope they are able to dig down to the real root causes of the failure, and look at those root causes in context with the rest of the incident.  When your last safeguard fails, it may seem like the most important problem, but the entire birds-eye view is really required if you hope to isolate the human errors and then target effective corrective actions.

Best regards,   

Ken Reed
Equifactor® Program Manager
System Improvements, Inc.
238 South Peters Road, Suite 301
Knoxville, TN  37923
ken@taproot.com