This systems analysis is focused on the Deepwater Horizon blowout, based on the Report to the President made by the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling.
The root technical cause of the Macondo blowout was that the cement pumped by BP and Halliburton to the bottom of the well did not seal off hydrocarbons. Yet the Macondo accident cannot be accounted to single causation. The role played by human and organisational influences on safety becomes relevant in this instance, in understanding how different system levels interact together and creating a clear causal picture of the accident.
Swiss Cheese model of the DWH accident.
Human factors issues present in different system levels acting as significant contributory factors to the DWH accident are discussed.
An examination of the combination of human, organisational and technological factors and their interactions were made through the development of an Accimap and a Swiss Cheese Model of the Macondo disaster to best illustrate contributory factors. Actionable SMART recommendations are then given.
