On Sunday (September 26th, 2010) the lead investigator for the Deepwater Horizon oil spill was questioned by a National Academy of Engineering committee. The committee brought up concerns that the investigation that had been performed was not adequate to address all the causes of the spill. Said the lead oil spill investigator: “It is clear that you could go further into the analysis . . . this does not represent a complete penetration into potentially deeper issues.”
Specifically, the committee was concerned that the study focused on decisions made on the rig (generally by personnel who worked for other companies) but did not adequately consider input from these companies. The study also avoided organizational issues that may have contributed to the spill.
In circumstances such as this one – where an extremely complicated event requires an organization to spend most of its resources fixing the immediate problem, an interim report – which may not delve deeply into underlying organizational issues or obtain a full spectrum of interviews – may be appropriate. However, it’s just an interim report and should not be treated as the final analysis of the causes relating to an issue. The organizations involved need to ensure that after the immediate actions – stopping the spill, completing the cleanup, and compensating victims – are complete, an in-depth report commensurate with the impact of the issue is performed.
In instances such as these, causes relating to an incident need to be unearthed ruthlessly and distributed freely. This is generally why a governmental organization will perform these in-depth reviews. The personnel involved in the investigation must not be limited to only one organization, but rather all organizations that are involved in the incident. Once action items that will improve safety and processes have been determined, they must be freely distributed to all other organizations participating in similar endeavors. The alternative – to wait until similar disasters happen at other sites – is unacceptable.