# The Deepwater Horizon Explosion: Non-Technical Skills, Safety Culture, and System Complexity

*Reader & O'Connor · Safety & Error, Voice & Silence, Complexity & Systems · Journal of Risk Research · 2014 · Paywalled*

Reader and O'Connor take the Deepwater Horizon blowout of April 2010, which killed eleven people and produced the largest marine oil spill in history, and do what the official inquiries did not: they read it through a human-factors lens. Working from the National Oil Spill Commission's report, they analyse the disaster on three levels and then integrate them. First, non-technical skills, the social and cognitive competencies (decision-making, situation awareness, communication, teamwork, leadership) that underpin safe performance in complex work, and whose absence is visible throughout the final hours, most notoriously in the misreading of the negative pressure test, where anomalous readings that should have signalled a live well were explained away by a plausible-sounding rationalisation. Second, safety culture, the organisational and industry environment that shaped how risk was managed: the relentless pressure of a well running late and over budget, the diffusion of responsibility across BP, Transocean and Halliburton, and a climate in which raising concerns was not straightforwardly safe. Third, systems thinking, which they use to show that the mishap cannot be explained by any single failure but by the way the components interacted to escalate risk, a critique they level at accident narratives that stop at the last person to touch the equipment. The most instructive detail sits outside the technical chain of events entirely. On the day of the explosion, BP and Transocean executives were aboard the rig to congratulate the crew on seven years without a lost-time injury, and the regulator had recently described the Deepwater Horizon as a model for safety. A workforce survey conducted only weeks earlier had found the opposite: people were reluctant to report problems, and some were entering false data to circumvent the reporting system, so that, in the survey's own words, the company's perception of safety on the rig was distorted. The rig's safety statistics improved while its process safety decayed, and the better the numbers looked the harder it became to say anything that contradicted them. For this map the paper is the modern companion to Piper Alpha, and the echo is uncomfortable: two decades on, the same structure of causes recurs, production pressure meeting ambiguous authority meeting a workforce that could see something was wrong and could not make that seeing count. It also sits at the junction of three of this map's threads, the crew-resource-management tradition of non-technical skills, the safety-culture literature, and complexity, and argues that none of them alone explains the disaster. Its limits are those of a case study built on a public inquiry rather than primary fieldwork: it reinterprets an existing evidentiary record through a theoretical frame, which is illuminating but not independent confirmation. (Text drawn from the 2014 Journal of Risk Research paper, 17(3), pp. 405-424.)

- **This page:** https://explore.psychsafety.com/n/reader-oconnor-2014/
- **View the source paper:** https://doi.org/10.1080/13669877.2013.815652
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