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8 FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS In response to the request of the Minerals Management Service (MMS), the committee evaluated the present outer continental shelf (OCS) inspection program and identified ways to improve it. The committee's assessment of the current inspection program and five alternative programs (alternatives 1 through 5) against a variety of considerations led to the following findings, conclusions, and recommendations. FINDINGS AND CONCLUSIONS 1. The current inspection program satisfies the literal requirements of the Outer Continental Shelf Lands Act (OCSLA) for annual and unannounced inspections of each OCS facility. In this sense, it fulfills MMS's statutory mission. On the other hand, the OCSLA carries a broad mandate to promote safety of life and property and to protect the environment. The committee believes that by this measure the MMS effort is not totally successful, particularly in the light of greater public expectations regarding safety and environmental protection that have emerged since the OCSLA was amended in 1978. In any event, changes in the OCS operating environmentincluding aging platforms, more complex systems and operations, activities in deeper water at greater distances from shore, and changing characteristics of operating companies-have created a need to upgrade the MMS inspection program in order to sustain in the future the generally good safety and environmental record of the past. 2. The core of the present MMS inspection program is ensuring compliance with a large number of hardware-oriented requirements compiled in a list of "potential incidents of non-compliance," the PING list. The MMS's overriding emphasis on this list tends to lead operators to concentrate their safety activity on items they expect the MMS to inspect, i.e., the items on the PINC list. The net result is that to some extent the program fosters an attitude that "compliance equals safety." This "compliance mentality" is of concern to the committee because it can diminish the operator's recognition of his primary responsibility for safety. 3. There is a considerable degree of variability among offshore operators regarding the amount of emphasis that each places on safety programs. The safety attitude of some operators is reflected in a failure to institute adequate safety programs, to maintain important safety equipment systematically, and to encourage good safety attitudes and practices among operating personnel. 4. The current MMS inspection program does not incorporate satisfactory means to specifically identify, measure, or react administratively to the evidence of insufficient emphasis on 80

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81 safety programs, where it exists. Nor does it lead MMS to vary the level of its inspection activity to focus greater attention on facilities operated by lax operators. Presently, PINC G-400, dealing with whether operations are conducted in a Safe and workmanlike manner," provides the only vehicle for MMS inspectors to cite subjective observations regarding poor operator attitudes toward safety. In itself it is an insufficient basis for remedial action. 5. The majority of accident events occurring on the OCS in a representative year (1982) were related to operational and maintenance procedures or human error that are not addressed directly by the hardware-oriented PINC list. In its close examination of the 1982 data only one of the 11 events leading to fatalities were found by the committee to be related even remotely to a hardware PINC. None of the fatalities was caused by the failure of a safety device whose testing must be witnessed by MMS inspectorsalthough witnessing tests currently is the principal inspection activity of the MMS inspection program. Similarly, of 263 events in 1982 involving injuries, fires, and pollution on or from production facilities, only two probably were due to failure of a safety device. 6. Most accident events occurring on the OCS result only in minor personal injury, small flash fires, and small oil spills. MMS focuses its attention primarily on "major accidents"-those that result in significant injuries, deaths, and large spills. However, low-level mishaps often are precursors to major disasters. To reduce the risk of major disasters it is necessary also to study and understand the root causes of low-level mishaps. 7. As a previous Marine Board report pointed out (National Research Council, 1984), the MMS needs to improve its data collection and safety analysis effort to meet modern standards for a safety program. While MMS has made progress in data collection over the past several years, its organization and analysis of those data is not sufficient to meet the needs of a safety program which goes beyond inspection of specific devices and controls. The present program incorporates no mechanism or analytical basis for systematically upgrading safety requirements for OCS operations. For example, the committee found no indications that the MMS analyzes data to identify safety trends, collects data consistently across operators and facilities that would permit such analyses, documents operator safety histories, or cross-references PINCs and incidents of non-compliance (INCs) to events (accidents). 8. The present checklist approach to inspection and testing does not encourage MMS inspectors to be alert to, or to report on, emerging safety risks due to changing technologies, procedures, or operating environments. Yet these unrecognized risks could present significant threats to safety on the OCS, and an effective inspection program must seek to identify them, using guidelines which will preclude arbitrary inspection activity. 9. Based on these findings, the committee concludes that more inspections of the type that currently are being conducted (i.e., alternative 1) would yield no substantive improvement in safety. Such an expansion would require additional personnel and involve greater travel costs, while increasing the tendency of operators to abdicate their safety responsibility to the MMS inspectors. 10. On the other hand, the presence of government inspectors on the OCS is important for conveying a sense of oversight and for providing impetus to marginal and inexperienced operators to meet federal safety standards. Third-party inspection by private sector contractors (alternative 4) would not diminish and would probably increase the tendency of operators to abdicate safety responsibility to the inspecting organization. It would greatly alter the role and function of MMS inspectors, requiring extensive retraining and new criteria for hiring MMS personnel. It would present a strong potential for conflict of interest on the part of the third-party organization. And it

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82 would almost certainly increase the cost of the inspection program. Self-inspection (alternative 5), while it would pinpoint the operator's responsibility, would be unsuitable because the MMS oversight function would be too tenuous. In the event of a major accident MMS would be vulnerable to charges that it had abdicated its responsibility. 11. The present inspection program can be modified to enhance its effectiveness at present levels of personnel and funding. The committee concludes that the effectiveness and efficiency of inspections to ensure compliance with regulations could be substantially improved by immediate adoption of an inspection program (alternative 2) utilizing modern sampling techniques to select items for inspection and, potentially, to select facilities to be spot inspected on a priority basis. This approach would free inspector resources for necessary complementary activities not now being carried out that would improve, to a significant degree, the content and implementation of the inspection program and thus meet the broad mandate of the OCSLN RECOMMENDATIONS 1. The committee's overall recommendation is that the MMS should maintain the presence of an inspector force on the OCS. The resource level of the inspection program should not be reduced. However, those resources should be utilized more effectively in an inspection program that permits more controlled and deliberate assessment and management of safety risks on the OCS. 2. To that end, the committee recommends adoption of a modified inspection program (alternative 2) for production platforms in which a facility-specific sampling of PINCs is selected for inspection during the annual inspection, based on a formal sampling plan. Sampling plans would be developed for each facility on the basis of a prior review ashore of records submitted by the operators as well as the results of prior inspections and industry-wide experience. Some of the inspector resources made available by witnessing fewer tests should be redirected toward increased spot inspections, instituted systematically on the basis on analysis of inspection results, operator safety histories, interviews with key operator personnel, and analysis of data to identify emerging safety problems and general safety trends. This alternative program would require the operators to perform and record in a prescribed format all the scheduled inspections themselves (both those specified by MMS and those in the operators' own facility inspection program) with only selective verification inspections being performed by MMS in accordance with a sampling plan. Ultimately, as experience and confidence in the validity of the sampling plans is developed, the inspection program might be modified further to use sampling theory to select OCS facilities for a full annual inspection, as described in Chapter 4 (alternative 3~. (Implementation of the latter alternative might require legislative action to amend the OCSLA requirements regarding annual inspections.) 3. The foregoing recommendation applies only to production operations. The committee recommends that the MMS's current "high visibility" program of frequent and comprehensive inspections of facilities engaged in drilling and workover operations, and the drilling and workover operations themselves, be continued because of (1) the high frequency of events per unit for these facilities as compared to production facilities, and (2) the large population of workers on each facility engaged in drilling and workover operations. Moreover, MMS should introduce the upgraded data collection and safety analysis features recommended by the committee for production platforms into its inspection program for drilling operators. 4. The committee recommends that the MMS begin collecting the types of data that will provide the basis for facility-specific sampling plans. This includes data on operator safety histories (consistently across facilities and operators), on PINCs and INCs as a function of accident events

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83 and mishaps, on operator inspection and test results over time, on training programs, and on the condition of safer and environmental control systems. The safety analysis program should include monitoring and review of operator records ashore, and analysis of data and subjective observations to uncover safety trends. 5. The committee recommends that MMS place its primary emphasis on detection of potential accident-producing situationsparticularly those involving human factors, operational procedures, and modifications of equipment and facilitiesrather than scattered instances of non- compliance with hardware specifications. One reason for improving the inspection process should be to provide data that can be used to verify the relationship between items on the PINC list and accident prevention. 6. The committee recommends that MMS encourage its inspectors to uncover emerging kinds of safety risks and changing risks on OCS facilities. The position description, job assignments and reward structure for MMS inspectors should be modified to reflect the importance of uncovering and reporting safety risks. An important step is to extend the definition of a "mishap" to include near misses, i.e., drilling or production disruptions, and events that prompt the operator or an MMS inspector to shut down operations and require investigation of these less serious occurrences as well as events (accidents). Information on events and mishaps should be disseminated in a manner similar to safety alerts, and should be used, where appropriate, in formulating changes in approvals, training requirements, and/or regulations.