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transportation research board | special report 321 Strengthening the Safety Culture of the Offshore Oil and Gas Industry Transportation Research Board Washington, D.C. 2016 www.TRB.org Committee on Offshore Oil and Gas Industry Safety Culture Transportation Research Board Marine Board Board on Human-Systems Integration Division of Human Behavioral and Social Sciences and Education

Transportation Research Board Special Report 321 Subscriber Categories Administration and management; energy; safety and human factors Transportation Research Board publications are available by ordering individual publications directly from the TRB Business Office, through the Internet at www.TRB.org or nationalacademies. org/trb, or by annual subscription through organizational or individual affiliation with TRB. Affili- ates and library subscribers are eligible for substantial discounts. For further information, con- tact the Transportation Research Board Business Office, 500 Fifth Street, NW, Washington, DC 20001 (telephone 202-334-3213; fax 202-334-2519; or e-mail TRBsales@nas.edu). Copyright 2016 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the National Academy of Med- icine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to the procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the National Academy of Medicine. Design by Beth Schlenoff, Beth Schlenoff Design Typesetting by Circle Graphics, Inc. Cover photo credits: (top and lower row, center) Melissa Phillip, © Houston Chronicle, used with per- mission; (lower row, left) Dan Bannister, Getty Images; (lower row, right) Berndt Åkesson, Getty Images Library of Congress Cataloging-in-Publication Data Names: National Academies of Sciences, Engineering, and Medicine (U.S.). Committee on U.S. Offshore Oil and Gas Industry Safety Culture, author. | National Research Council (U.S.). Board on Human-Systems Integration, author. | National Research Council (U.S.). Marine Board, author. | National Research Council (U.S.). Transportation Research Board, issuing body. Title: Strengthening the safety culture of the offshore oil and gas industry / Committee on U.S. Offshore Oil and Gas Industry Safety Culture: A Framing Study, Transportation Research Board, Marine Board, Board on Human-Systems Integration, Division of Human Behavioral and Social Sciences and Education, The National Academies of Sciences, Engineering, and Medicine. Other titles: Special report (National Research Council (U.S.). Transportation Research Board) ; 321. Description: Washington, D.C. : Transportation Research Board, 2016. | Series: Transportation Research Board special report ; 321 | Includes bibliographical references. Identifiers: LCCN 2016024798 | ISBN 9780309369862 Subjects: LCSH: Offshore oil industry—United States—Safety measures. | Offshore oil industry—Safety regulations—United States. | Offshore gas industry—United States—Safety measures. | Offshore gas industry—Safety regulations—United States. | Industrial safety—United States. | System safety. Classification: LCC HD9560.5 .S7946 2016 | DDC 363.11/9622338190973—dc23 LC record available at https://lccn.loc.gov/2016024798

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.national-academies.org. The Transportation Research Board is one of seven major programs of the National Academies of Sciences, Engineering, and Medicine. The mission of the Transportation Research Board is to increase the benefits that transportation contributes to society by providing leadership in transportation innovation and progress through research and information exchange, conducted within a setting that is objective, interdisciplinary, and multimodal. The Board’s varied committees, task forces, and panels annually engage about 7,000 engineers, scientists, and other transportation researchers and practitioners from the public and private sectors and academia, all of whom contribute their expertise in the public interest. The program is supported by state transportation departments, federal agencies including the component administrations of the U.S. Department of Transportation, and other organizations and individuals interested in the development of transportation. Learn more about the Transportation Research Board at www.TRB.org.

Reports document the evidence-based consensus of an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and committee deliberations. Reports are peer reviewed and are approved by the National Academies of Sciences, Engineering, and Medicine. Proceedings chronicle the presentations and discussions at a workshop, symposium, or other convening event. The statements and opinions contained in proceedings are those of the participants and have not been endorsed by other participants, the planning committee, or the National Academies of Sciences, Engineering, and Medicine. For information about other products and activities of the Academies, please visit nationalacademies.org/whatwedo.

Marine Board James C. Card (Vice Admiral, U.S. Coast Guard, retired), Independent Consultant, Chair Mary R. Brooks, Dalhousie University, Vice Chair Edward N. Comstock, Independent Consultant (retired from Raytheon and Naval Sea Systems Command) Elmer P. Danenberger III, Independent Consultant Samuel P. De Bow, Jr. (Rear Admiral, National Oceanic and Atmospheric Administration, retired), Lynker Technologies Thomas J. Eccles (Rear Admiral, U.S. Navy, retired), USJ-IMECO Holding Company Martha R. Grabowski, LeMoyne College Jeanne M. Grasso, Blank Rome, LLP Stephan T. Grilli, University of Rhode Island John M. Holmes (Captain, U.S. Coast Guard, retired), Independent Consultant Thomas A. Jacobsen (Captain), Jacobsen Pilot Service, Inc. Donald Liu, NAE, American Bureau of Shipping (retired) Richard S. Mercier, Texas A&M University Edmond (Ned) J. Moran, Jr., Moran Towing Corporation Ali Mosleh, NAE, University of California, Los Angeles John W. Murray (Captain), Hapag-Lloyd USA, LLC Karlene H. Roberts, University of California, Berkeley Richard D. Steinke, Moffatt & Nichol Engineers Peter K. Velez, Peter Velez Engineering, LLC Richard D. West (Rear Admiral, U.S. Navy, retired) Transportation Research Board 2016 Executive Committee Officers James M. Crites, Executive Vice President of Operations, Dallas–Fort Worth International Airport, Texas, Chair Paul Trombino III, Director, Iowa Department of Transportation, Ames, Vice Chair Susan Hanson, Distinguished University Professor Emerita, Graduate School of Geography, Clark University, Worcester, Massachusetts, Division Chair for NRC Oversight Neil J. Pedersen, Transportation Research Board, Executive Director

Board on Human-Systems Integration Nancy Cooke, Cognitive Engineering Research Institute, Arizona State University, Chair Ellen J. Bass, Department of Systems and Information Engineering, Drexel University Sara J. Czaja, Departments of Psychiatry and Behavioral Sciences and Industrial Engineering, University of Miami Francis T. Durso, Department of Psychology, Georgia Institute of Technology Andrew S. Imada, Principal, A. S. Imada & Associates, Carmichael, California Edmond Israelski, Human Factors Program, AbbVie, Abbott Park, Illinois Elizabeth Loftus, Criminology, Law and Society; Cognitive Sciences; School of Law, University of California, Irvine Frederick L. Oswald, Department of Psychology, Rice University Karl S. Pister, Department of Civil and Environmental Engineering, University of California, Santa Cruz David Rempel, Division of Occupational Medicine, University of California, San Francisco Emilie M. Roth, Principal, Roth Cognitive Engineering, Menlo Park, California Barbara Silverstein, Safety and Health Assessment and Research for Prevention Program, Washington State Department of Labor and Industries David H. Wegman, School of Health and Environment, University of Massachusetts, Lowell Poornima Madhavan, Director

Committee on Offshore Oil and Gas Industry Safety Culture Nancy T. Tippins, CEB, Greenville, South Carolina, Chair Deborah A. Boehm-Davis, George Mason University, Fairfax, Virginia John S. Carroll, Massachusetts Institute of Technology, Cambridge Elmer P. Danenberger III, Independent Consultant, Reston, Virginia David A. Hofmann, The University of North Carolina at Chapel Hill William C. Hoyle, U.S. Chemical Safety and Hazard Investigation Board (retired) Robert Krzywicki, DuPont (retired), Independent Consultant, Ocean Isle Beach, North Carolina Todd R. LaPorte, University of California, Berkeley (emeritus) Karlene H. Roberts, University of California, Berkeley (emerita) Peter K. Velez, Peter Velez Engineering, LLC, Houston, Texas Timothy Vogus, Vanderbilt University, Nashville, Tennessee James A. Watson IV (Rear Admiral, U.S. Coast Guard, retired), American Bureau of Shipping, Houston, Texas Warner Williams, Chevron Corporation (retired), Warner M. Williams, LLC, Covington, Louisiana Marine Board Liaison James C. Card, U.S. Coast Guard (retired), Independent Consultant, Houston, Texas Transportation Research Board Staff Stephen R. Godwin, Director, Studies and Special Programs Camilla Y. Ables, Study Director Beverly Huey, Senior Program Officer Amelia Mathis, Administrative Assistant

ix Since the term “safety culture” was coined after the Chernobyl disaster in Ukraine almost 30 years ago, it has been cited as a factor in many other catastrophic accidents worldwide, including the Macondo well blowout–Deepwater Horizon explosion and oil spill of 2010. That accident represents the worst environmental disaster in the history of the United States and an enduring reminder of the haz- ards of offshore oil and gas exploration and production and the serious consequences of accidents offshore. Since it occurred, it has been the subject of several investigations and studies. It also has spurred action from the government and the offshore oil and gas industry aimed at improving safety culture and safety within the industry, including a number of initiatives and new regulations issued after 2011. However, more work remains to be done to effect positive change in the safety culture of the entire U.S. offshore oil and gas industry. In this context, the National Academies of Sciences, Engineer- ing, and Medicine convened the Committee on Offshore Oil and Gas Industry Safety Culture to conduct a framing study on safety cul- ture and safety in the offshore oil and gas industry and prepare this report. The objective of the committee’s efforts was to assist the off- shore industry, government, and other stakeholders in strengthening the industry’s safety culture. The committee members were selected for their expertise in the areas of industrial and organizational psychology, safety program management, safety culture, high-reliability organiza- tions, offshore industry operations, industrial safety, safety regulations and policy, human factors and applied cognition, and organizational change (biographical information on the committee members is pro- vided at the end of this report). This study was initiated in March 2014. The committee held five meetings, made four site visits, and held several information- gathering sessions with various members of the offshore oil and gas industry to obtain the information needed to carry out the study. We are Preface

x Strengthening the Safety Culture of the Offshore Oil and Gas Industry grateful for the valuable information and insights provided by Charlie Williams II (Center for Offshore Safety [COS]); Doug Morris and Staci Atkins (Bureau of Safety and Environmental Enforcement [BSEE]); Jeff Wiese (formerly with the Pipeline and Hazardous Materials Safety Administration [PHMSA]); Rear Admiral Paul F. Thomas (U.S. Coast Guard [USCG]); Andy Eckel (Chevron); Joel Plauche (Fieldwood Energy); David Hensel (Ensco); Ricky Britt (Danos); Kevin Graham (M&H); Steve Arendt (ABS Consulting); John Coryell (Conoco/ DuPont, retired); Thor Gunnar Dahle, Elise Jorunn Tharaldsen, and Irene Dahle (Petroleum Safety Authority Norway [PSA]); James Ellis (formerly with the Institute of Nuclear Power Operations [INPO]); Tom Krause (BST); Billie Garde (Clifford & Garde); Mark Steinhilber (California State Lands Commission [CSLC]); Capt. Jason Neubauer (USCG); Christopher Hart (National Transportation Safety Board [NTSB]); Lois Epstein (The Wilderness Society); and David Hammer (WWL-TV New Orleans). We also benefited greatly from our interactions with the training staff and trainees at the Shell Robert Training Center in Robert, Louisiana, and the PetroSkills Oil and Gas Training Facility and the Diamond Offshore Drilling Train- ing and Simulation Center, both in Katy, Texas; with personnel at the Shell Drilling Real Time Operations Center in Houston, Texas; and with third-party inspectors with Offshore Technical Compliance, LLC. The committee also is grateful for the assistance provided by the staff of the National Academies of Sciences, Engineering, and Medi- cine. We particularly wish to acknowledge the support of Stephen Godwin, Camilla Y. Ables, Beverly Huey, Amelia Mathis, and Mark Hutchins. Finally, I thank all the members of the study committee for their efforts throughout the study and the preparation of this report. Nancy Tippins, PhD, Chair Committee on Offshore Oil and Gas Industry Safety Culture ACKNOWLEDGMENTS This study was performed under the overall supervision of Stephen R. Godwin, Director, Studies and Special Programs, Transportation Research Board. The committee acknowledges the work and support

Preface xi of Camilla Y. Ables, who served as study director and assisted the commit- tee in the preparation of its report, and Beverly Huey, who assisted in the early phases of the project. The committee also acknowledges the work and support of Karen Febey, Senior Report Review Officer, who man- aged the report review process. Rona Briere edited the report, and Alisa Decatur provided word processing support. Jennifer J. Weeks prepared the manuscript for prepublication web posting, Janet M. McNaughton handled the editorial production, and Juanita Green managed the book production and design, under the supervision of Javy Awan, Director of Publications. Amelia Mathis assisted with meeting arrangements and communications with committee members. A draft version of this report was reviewed by individuals chosen for their diverse perspectives and technical expertise in accordance with the procedures of the Report Review Committee (RRC). The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evi- dence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. The committee thanks the following individuals for their review of this report: Ken Arnold, Independent Consultant, Houston, Texas; Khalid Aziz, Stanford University (emeritus); Michael Baram, Boston University School of Law (emeritus); Dennis Bley, Buttonwood Consulting, Inc., Albuquerque, New Mexico; Mark Fleming, Saint Mary’s University (Canada); Patrick Hudson, Delft University of Technology (Netherlands) (emeritus); Craig Philip, Vanderbilt University; and Edgar Schein, Massachusetts Institute of Technology (emeritus). Although these reviewers provided constructive comments and suggestions, they were not asked to endorse the report’s conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Susan Hanson,

xii Strengthening the Safety Culture of the Offshore Oil and Gas Industry Clark University (emerita), and Robert Frosch, Harvard Univer- sity. They were responsible for making certain that an independent examination of this report was conducted in accordance with insti- tutional procedures and that all review comments received full consid- eration. Responsibility for the final content of this report rests entirely with the authoring committee and the National Academies of Sciences, Engineering, and Medicine.

xiii ABS American Bureau of Shipping AER after event review ANPRM Advance Notice of Proposed Rulemaking APD Application for Permit to Drill API American Petroleum Institute BOEM Bureau of Ocean Energy Management BOEMRE Bureau of Ocean Energy Management, Regulation, and Enforcement BSEE Bureau of Safety and Environmental Enforcement BV Bureau Veritas CCPS Center for Chemical Process Safety CFR Code of Federal Regulations COS Center for Offshore Safety DNV Det Norske Veritas DOI Department of the Interior DWOP Deepwater Operations Plans EIA Energy Information Administration FR Federal Register HCA high-consequence area HSE health, safety, and environment HSQE health, safety, quality, and environmental IACS International Association of Classification Societies IADC International Association of Drilling Contractors IAEA International Atomic Energy Agency ILO International Labor Organization IMO International Maritime Organization INPO Institute of Nuclear Power Operations IOGP International Association of Oil & Gas Producers IRF International Regulators’ Forum ISM International Safety Management ISO International Organisation for Standardization MMS Minerals Management Service MOA memorandum of agreement Acronyms and Abbreviations

xiv Strengthening the Safety Culture of the Offshore Oil and Gas Industry MODU mobile offshore drilling unit MOU memorandum of understanding NASA National Aeronautics and Space Administration NPDES National Pollutant Discharge Elimination System NPRM Notice of Proposed Rulemaking NRC National Research Council NTL Notice to Lessees OCS Outer Continental Shelf OCSLA Outer Continental Shelf Lands Act OMB Office of Management and Budget OOC Offshore Operators Committee OSHA Occupational Safety and Health Administration OTA Office of Technology Assessment PHMSA Pipeline and Hazardous Materials Safety Administration PSA Petroleum Safety Authority (Norway) PSMS pipeline safety management system PTP Prevention Through People RP Recommended Practice SEMP Safety and Environmental Management Program SEMS Safety and Environmental Management Systems (rule) SLA Submerged Lands Act SPE Society of Petroleum Engineers USCG U.S. Coast Guard U.S. DOT U.S. Department of Transportation USGS U.S. Geological Survey U.S. NRC U.S. Nuclear Regulatory Commission

Summary 1 1 Introduction 13 Study Origins 14 Study Charge and Approach 14 Study Context 15 Importance of Safety Culture 22 Organization of the Report 23 2 Safety Culture 26 Definition of Safety Culture 26 Why a Strong Safety Culture Is Difficult to Achieve 32 Elements of a Strong Safety Culture 34 Findings, Conclusions, and Recommendations 52 Directions for Future Research 52 3 History of the Offshore Oil and Gas Industry and the Development of Safety Efforts 64 1890s to 1940s: Coastline and Offshore Oil and Gas Exploration 64 1950s to 1960s: The Dangers and Challenges of Moving Farther Offshore 65 1965 to 1990: Improving the Safety of Offshore Operations 69 1990s: Promoting Offshore Safety and Environmental Protection 74 2000s to the Present: Deepwater Discoveries and Explorations and the Aftermath of a Catastrophic Blowout 77 Summary 83 Findings and Conclusions 84 Contents

4 U.S. Offshore Safety Regulation Pertaining to Safety Culture 89 Federal Safety Management and Safety Culture Initiatives 94 Industry Self-Regulation and Third-Party Initiatives 117 International Regulation of Offshore Oil and Gas Operations 122 Approaches for Advancing Safety Culture 129 Findings, Conclusions, and Recommendations 131 5 Safety Culture Assessment and Measurement 138 Safety Culture and Its Organizational Context 138 Assessing and Managing Safety Culture 140 Findings, Conclusions, and Recommendations 160 6 Implementing Change in Offshore Safety Culture 171 Change Principles 172 Challenges in Changing Offshore Safety Culture 183 Conclusions and Recommendations 194 Appendixes A Open Session Agendas 200 B Regulators, Trade Associations, and Advisory and Other Groups with Offshore Safety Oversight 205 Study Committee Biographical Information 214

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TRB Special Report 321: Strengthening the Safety Culture of the Offshore Oil and Gas Industry offers recommendations to industry and regulators to strengthen and sustain the safety culture of the offshore oil and gas industry. A supplemental product titled Beyond Compliance provides an executive-level overview of the report findings, conclusions, and recommendations.

The committee that prepared the report addresses conceptual challenges in defining safety culture, and discusses the empirical support for the safety culture definition offered by the Bureau of Safety and Environmental Enforcement, the nine characteristics or elements of a robust safety culture, methods for assessing company safety culture, and barriers to improving safety culture in the offshore industry.

The committee’s report also identifies topics on which further research is needed with respect to assessing, improving, and sustaining safety culture. Download the Report in Brief for a summary of the report.

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