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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2016. Strengthening the Safety Culture of the Offshore Oil and Gas Industry. Washington, DC: The National Academies Press. doi: 10.17226/23524.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2016. Strengthening the Safety Culture of the Offshore Oil and Gas Industry. Washington, DC: The National Academies Press. doi: 10.17226/23524.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2016. Strengthening the Safety Culture of the Offshore Oil and Gas Industry. Washington, DC: The National Academies Press. doi: 10.17226/23524.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2016. Strengthening the Safety Culture of the Offshore Oil and Gas Industry. Washington, DC: The National Academies Press. doi: 10.17226/23524.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2016. Strengthening the Safety Culture of the Offshore Oil and Gas Industry. Washington, DC: The National Academies Press. doi: 10.17226/23524.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2016. Strengthening the Safety Culture of the Offshore Oil and Gas Industry. Washington, DC: The National Academies Press. doi: 10.17226/23524.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2016. Strengthening the Safety Culture of the Offshore Oil and Gas Industry. Washington, DC: The National Academies Press. doi: 10.17226/23524.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2016. Strengthening the Safety Culture of the Offshore Oil and Gas Industry. Washington, DC: The National Academies Press. doi: 10.17226/23524.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2016. Strengthening the Safety Culture of the Offshore Oil and Gas Industry. Washington, DC: The National Academies Press. doi: 10.17226/23524.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2016. Strengthening the Safety Culture of the Offshore Oil and Gas Industry. Washington, DC: The National Academies Press. doi: 10.17226/23524.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2016. Strengthening the Safety Culture of the Offshore Oil and Gas Industry. Washington, DC: The National Academies Press. doi: 10.17226/23524.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2016. Strengthening the Safety Culture of the Offshore Oil and Gas Industry. Washington, DC: The National Academies Press. doi: 10.17226/23524.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2016. Strengthening the Safety Culture of the Offshore Oil and Gas Industry. Washington, DC: The National Academies Press. doi: 10.17226/23524.
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13 For many decades, the U.S. federal government has leased portions of the U.S. Outer Continental Shelf (OCS), mainly the Gulf of Mexico and Alaska regions, to companies for the exploration, development, and production of oil and gas. According to the Minerals Management Service, which was reorganized and ultimately replaced in 2011 by the Bureau of Ocean Energy Management (BOEM), the Bureau of Safety and Environmental Enforcement (BSEE), and the Office of Natural Resources Revenue, more than 50,000 wells have been drilled in the Gulf of Mexico since 1947. Offshore regulation and company operations are conducted pursu- ant to the Outer Continental Shelf Lands Act (OCSLA) and several other laws that establish the salient institutional framework, proce- dures, and regulatory means and the decision criteria for their imple- mentation. With regard to the safety of operations, OCSLA mandates rulemaking and enforcement by the U.S. Department of the Interior, assigns offshore workplace safety responsibilities to the U.S. Coast Guard, requires cost-benefit analysis in safety-related rulemaking, and authorizes adoption of industry standards. It is within this framework that improvements to the safety of offshore oil and gas operations are considered in this report. Aside from supplying oil and gas to meet U.S. domestic needs, the off- shore oil and gas exploration activities in the OCS also contribute con- siderably to the U.S. economy. In 2009 alone, for example, offshore companies paid the U.S. government $6 billion in royalties on the sale of oil and gas produced in federal waters and provided 150,000 jobs (GAO 2010; Baram 2011). Royalties and payments collected by the Department of the Interior from oil and gas companies amounted to approximately $48 billion from 2009 through 2013 (GAO 2015, 94). Since 2010, leases in the OCS have been the source of approximately 2 billion barrels of oil and 6.2 trillion cubic feet of natural gas, account- ing for more than 19 percent of U.S. oil production and about 5 percent 1 | Introduction

14 Strengthening the Safety Culture of the Offshore Oil and Gas Industry of U.S. natural gas production.1At the same time, however, offshore oil and gas operations in the OCS (and elsewhere in the world) are highly complex and pose the risk of injury or death to workers, explosions, blowouts, and oil spills with associated contamination of the marine environment. STUDY ORIGINS In 2013, an assistant U.S. district attorney in charge of negotiating a settlement with a private oil and gas company operating in the Gulf of Mexico contacted BSEE about addressing the causes of accidents and spills in the offshore oil and gas industry. BSEE staff referred her to the National Academies of Sciences, Engineering, and Medicine because of efforts under way at the Marine Board to develop a project on safety culture in the offshore industry. The study was supported with funds designated for the National Academy of Sciences as a community ser- vice payment arising out of a plea agreement entered into between the United States Attorney’s Office for the Eastern District of Louisiana and Helmerich & Payne International Drilling Company. STUDY CHARGE AND APPROACH This study was carried out in accordance with the statement of task presented in Box 1-1. As part of its information-gathering activities, the study committee held five meetings; met with representatives of the dif- ferent sectors of the offshore oil and gas industry; and visited offshore oil and gas training and operations centers in Robert, Louisiana, and Houston, Texas. At its first meeting in April 2014, the committee met with representatives of BSEE, the Center for Offshore Safety, and the Pipeline and Hazardous Materials Safety Administration and learned about each agency’s perspectives on addressing safety in the U.S. off- shore oil and gas industry. The committee’s second meeting was held in August 2014, its third in October 2014, its fourth in January 2015, and its fifth in May 2015. The speakers and the agendas for the open ses- sions of the committee meetings are provided in Appendix A. 1 Statement of Lars Herbst, Regional Director, BSEE, U.S. Department of the Interior, before the Committee on Natural Resources, U.S. House of Representatives. https://www.doi.gov/ocl/energy-production. Accessed January 26, 2016.

Introduction 15 STUDY CONTEXT Offshore Work Environment The industry’s advance from shallow water into deep water (500 to 1,499 meters) and ultradeep water (1,500 meters or more), while crucial to meeting the nation’s demand for oil and gas, has increased the dangers to a workforce already engaged in an intrinsically haz- ardous occupation. Offshore drilling and production platforms in deep and deeper waters, where complex operations using increas- ingly sophisticated technology/equipment are regularly performed and increase opportunities for human and organizational error, are among the most extreme workplaces in the world. They are exposed to adverse marine conditions and are remote, reachable only by heli- copter or boat, features that introduce additional hazards into the work environment. BOX 1-1 Statement of Task In this project, an ad hoc committee will conduct a study to aid industry, government, and other stakeholder efforts to strengthen the offshore indus- try safety culture. The committee will gather information from safety culture experts, members of the industry, regulators, workers, and the public in order to identify the essential characteristics of a strong safety culture, barriers to achieving a strong safety culture in the offshore industry, and possible ways of overcoming these challenges. The committee will also identify potential strate- gies to measure and assess company and industry safety culture effectively. The role of the regulators in achieving a proper safety culture will also be considered. Because of the complexity of both the subject and the industry, the commit- tee may not be able to answer all of the questions about the offshore industry safety culture that will be raised during the course of the study. However, based on information gathered, literature reviews, lessons learned from implement- ing safety culture in other industries, and expert judgment, the committee will identify options for improving and promoting a safety culture for industry, regulators, and policy makers to consider. The committee will also identify and recommend specific areas of research and research projects to address gaps in knowledge identified through this process.

16 Strengthening the Safety Culture of the Offshore Oil and Gas Industry Workplaces in the offshore environment vary as different types of structures are employed in oil and gas drilling and production in shallow water, deep water, and ultradeep water. The types of offshore structures include conventional fixed platform, compliant tower, ver- tically moored tension leg and mini-tension leg platform, spar, semi- submersible, floating production, storage and offloading facility, and subsea completion and tie-back to host facility. These structures differ in the types of equipment and technology they employ. Operations required for offshore oil and gas drilling and produc- tion are not performed by a single company; instead, operators work with drillers and various contractors for the critical aspects of these operations. These workers can vary in knowledge, skills, and abilities, as well as primary language and culture. By current estimates, about 75 operators, 17 drilling contractors, and more than 1,000 contractors and subcontractors provide support to offshore drilling, production, and construction activities in the Gulf of Mexico. Contractors vary in size and financial resources; some are one-person specialized compa- nies, while others have several thousand employees. Safe operations among this complex blend of workforces from different companies operating on the same platform require effective contracts. The con- tract can establish standards and expectations, and it is typically accom- panied by a bridging document that specifies the responsibilities of each company for the various aspects of drilling operations and sets forth emergency procedures that operators and their contractors are expected to follow. As drilling operations move into deeper water and become more complex, specifying responsibilities for safety and liability through contracts and bridging documents has become a greater challenge. Offshore work environments vary depending on many factors, such as the type and size of facility or vessel and the technology and equip- ment on board; the mechanical and structural integrity of the facility or vessel; the number of companies involved in the operations and their goals related to profitability; the capabilities and cultural mix of per- sonnel; the operations performed; the leadership style of managers; and the policies, procedures, culture, and financial resources of the opera- tors, contractors, and subcontractors. All of these factors and the com- plex relationships among operators, contractors, and subcontractors can have profound impacts on the propagation of strong safety culture offshore (NAE and NRC 2011).

Introduction 17 Some production platforms have full operations around the clock, while others operate in a “run and maintain” mode, which means they are visited daily or a few times a week for monitoring. Small platforms may have as few as two people aboard, while large platforms and float- ing production facilities may have between 75 and 150 people aboard depending on the complexity of the equipment and operations. The smaller platforms usually have day crews only, but the larger ones may have larger day crews and some night crews. Mobile offshore drilling units, which move from site to site to conduct well-drilling operations, may have 50 to 125 people aboard. For long stretches of time, platform workers operate equipment to extract flammable hydrocarbons at high pressure. Shifts are typically 12 hours long. Many people work 14 days on and 14 days off, but sched- ules vary, with some crews working 14 days on and 7 days off, while others work 21 on and 14 off. Some workers may work overtime, but it is unusual for them to do so on an ongoing basis. Job performance is contingent on a number of factors. The skill sets required for performance—electrical; instrumentation; mechanical; maintenance; health, safety, and environment; drilling; mud engineer- ing; technician; general labor; and so forth—are task dependent, and some require company, industry, or regulatory certification. In some situations, critical operations, such as drilling, well servicing, welding, and diving construction, require management and regulatory approval before work can begin. Various kinds of training are mandated by BSEE regulations. In addition, companies may require additional training. Training is provided by the operators and service companies, using either internal or external resources. Each shift usually begins with a handover meeting from one crew to another (day to night and vice versa) that includes a toolbox safety meeting—a group discussion that focuses on a particular safety issue and is geared specifically to the workers who will undertake a particular task. In addition, supervisors may hold meetings, or members of a skill group (e.g., mechanics, welders) may be assembled to discuss work. After these meetings, employees pursue their individual work activities with varying amounts of supervision and autonomy. In some situations, employees are virtually on their own and are expected to do their jobs with minimal guidance from managers. In other situations, supervisors are present and direct the work.

18 Strengthening the Safety Culture of the Offshore Oil and Gas Industry Fatal and Nonfatal Injuries The nature of the work and the conditions under which work is per- formed in the OCS result in a substantial number of accidents that are sometimes accompanied by injuries and/or deaths. According to the BSEE annual report of 2014, a total of 43 deaths occurred in the OCS (Gulf of Mexico and Pacific OCS combined) between 2007 and 2014, with 2010 having seen the largest number of deaths (12 total, 11 resulting from the Deepwater Horizon accident) and 2014 having seen the fewest (only one fatality). For this time period, the leading causes of fatalities offshore were explosions and fires (44 percent), lifting (16 percent), helicopter accidents (12 percent), and diving (9 percent). The other causes were falls (during construction), personnel transfer, man falling overboard, electrocution, and accidents involving support vessel—anchor (see Figure 1-1). In terms of nonfatal injuries, the average number per year in the OCS (Gulf of Mexico and Pacific OCS combined) was 303 between 2007 and 2014 (BSEE 2014). Investigations of injuries reported in 2013 and 2014 revealed that 39 percent were due to human engineering problems (issues related to the human-machine interface, poor work- FIGURE 1-1 Causes of fatalities in the Outer Continental Shelf, 2007 to 2014. Source: Adapted from BSEE (2014). 44.00% 16.00% 12.00% 9.00% 5.00% 5.00% 5.00% 2.00% 2.00% Explosion and fires Liing Helicopter Diving Construcon fall Personnel transfer Man overboard Electrocuon Support vessel–anchor

Introduction 19 ing environments, system complexity, and non-fault-tolerant systems), and 32 percent were caused by problems in work direction (related to planning, site preparation, selection of workers, and supervision for a specific job or task). The BSEE annual report of 2014 does not indicate the causes of 29 percent of the nonfatal injuries that occurred offshore in 2013–2014. Low-Frequency, High-Consequence Events and Their Causes and Impacts The infrequent accidents that can cause massive oil spills and environ- mental damage (i.e., low-probability, high-consequence events) receive the most public attention and become the subject of investigation and analysis. The scale and consequences of such events worldwide are illus- trated by four major accidents: the Santa Barbara oil spill of 1969, the Piper Alpha explosion in the North Sea in 1988, the Montara blowout/ fire and oil spill in the Timor Sea in 2009, and the Macondo blowout– Deepwater Horizon fire and oil spill in 2010 (summarized in Table 1-1): • The Santa Barbara oil spill of 1969 was the largest oil spill in history in U.S. waters at that time and today ranks third in the amount of oil spilled, after the Deepwater Horizon and Exxon Valdez2 spills (Clarke and Hemphill 2002). The investigation into the Santa Barbara acci- dent indicated that the spill occurred as a result of a blowout caused by immense pressure in the well and a large volume of oil and gas being released simultaneously (Clarke and Hemphill 2002). • The Piper Alpha accident in 1998 caused more fatalities than any inci- dent in the history of offshore oil and gas operations and was considered the costliest man-made disaster at that time (Lloyd’s n.d.). In Novem- ber 1988, Britain’s Lord Cullen conducted a formal inquiry into the Piper Alpha accident for the British government. In his report, he identified two factors that contributed to the severity of the accident: human error and flaws in the design of the oil production platform (Cullen 1990). • The Montara oil spill of 2009 occurred after a blowout and fire on the Montara wellhead platform, located in a remote area of the Timor 2 The Exxon Valdez oil spill occurred when the tanker ran aground on Bligh Reef in Prince William Sound, Alaska, in March 1989, spilling more than 11 million gallons of crude oil.

20 Strengthening the Safety Culture of the Offshore Oil and Gas Industry (continued) TABLE 1-1 Four Major Offshore Accidents and Their Impacts Accident (date, name, and location) Casualties–Injuries, Environmental Impacts, and Claims of Illness by Emergency Responders and Cleanup Workers Cost January 29, 1969 Santa Barbara–Union Oil Company Platform 21A, located 6 miles off the coast of Summerland, California Human casualties: none Oil spilled: 80,000 barrels totala Environmental effects: 800 square miles of ocean affected; 35 miles of coastline coated with oil up to 6 inches thick (Friends of the California Archives 2014) Nearly 3,700 birds confirmed dead (NOAA 2014) A large number of seals and dolphins removed from the shoreline; spilled oil killed fish and intertidal invertebrates, damaged kelp forests, and displaced populations of endangered birds (Friends of California Archives 2014) Cleanup costs exceeded $4.5 million in 1969 dollars (Friends of the California Archives 2014) $6.5 million awarded to own- ers of beachfront homes, apartments, hotels, and motels (County of Santa Barbara Planning and Devel- opment Energy Division n.d.) $1.3 million awarded to com- mercial and recreational boat owners and nautical sup- pliers for property damage and loss of revenue (County of Santa Barbara Planning and Development Energy Division n.d.) $9.5 million paid by Union Oil to the state of California, the county of Santa Barbara, and the cities of Santa Barbara and Carpinteria for loss of property (County of Santa Barbara Planning and Devel- opment Energy Division n.d.) July 6, 1988 Piper Alpha offshore drilling platform oper- ated by Occidental Petroleum in the United Kingdom, North Sea Human casualties: 167 fatalities among men aboard the plat- form; 2 fatalities among men on a rescue ship Total insured loss: $3.4 billion (Center of Risk for Health Care Research and Practice n.d.) August 21, 2009 Montara platform–West Atlas rig operated by PTTEP AA, in Australia in the Timor Sea Human casualties: none Oil spilled: 30,000 barrels totalb $170 million spent on oil and gas leak until November 3 (Sonti 2009)

Introduction 21 Sea; 69 workers were evacuated from the rig.3 The formal inquiry conducted by the Australian government found that the immediate cause of the Montara blowout was failure of the cementing job done by Halliburton. The inquiry also found, however, that the compa- ny’s systems and processes were deficient, many of the workers were not capable of performing their jobs, and the regulatory regime was inadequate. • The Deepwater Horizon blowout and spill in 2010, which caused the worst oil pollution disaster to date in U.S. history, was investi- gated by the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling (National Commission), appointed by President Obama shortly after the accident occurred. The com- mission identified the cause of the blowout as a series of mistakes made by the owner (BP), the operator (Transocean), and the con- tractor that performed the cementing job (Halliburton)—mistakes viewed as indicative of systematic failures in risk management that 3 http://www.theoildrum.com/node/7193. Accessed September 4, 2015. TABLE 1-1 (continued) Four Major Offshore Accidents and Their Impacts April 20, 2010 Macondo–Deepwater Horizon platform oper- ated by BP in the Gulf of Mexico Human casualties: 11 fatalities; 17 injured Oil spilled: 3.19 million barrels (Schwartz 2015) Environmental effects: 650 miles of coastline oiled in Louisiana, 174 miles in Florida, 159 miles in Mississippi, and 90 miles in Alabama (Reuters 2012); more than 8,000 birds, sea turtles, and marine mam- mals found injured or dead in the 6 months after the spill; long-term damage caused by the oil and the nearly 2 million gallons (7.6 million liters) of chemical dispersants used on the spill may not be known for years (National Wildlife Federation n.d.) Cost to BP (Reuters 2012): $13.9 billion for individual liability; $14 billion for operational response; $4.5 billion to $17.6 billion in civil penalties; $5 billion to $15 billion in criminal penalties; $5 billion for environmental damage Estimated economic impact on U.S. Gulf fisheries (over 7 years) : $8.7 billion (Sumaila et al. 2012); loss of about 22,000 jobs in fisheries-related sectors a http://www.bsee.gov/BSEE-Newsroom/Offshore-Stats-and-Facts/Pacific-Region/Pacific-Facts- and-Figures/#How_much_oil_is_spilled_or__leaked__from_OCS. Accessed September 4, 2015. b http://www.theoildrum.com/node/7193.

22 Strengthening the Safety Culture of the Offshore Oil and Gas Industry call into question the safety culture of the offshore oil and gas industry (National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling 2011). Although these four major accidents in the global oil and gas indus- try in the last 50 years had different specific causes, they highlight the lack of an effective safety system for ensuring that equipment is work- ing properly and that workers are aware of safety risks and will take corrective action as needed. The committee chose these four accidents to illustrate the sever- ity of loss and damage that offshore accidents can cause. Other major accidents (e.g., the fire on Platform C at Main Pass 41 and the blowout and fire at Bay Marchand, both occurring in 1970) have not been as catastrophic as these four. In combination with the Santa Barbara oil spill, however, they led to changes in regulations and in the way the industry regarded safety and the environment (Arnold 2015). In 2011, the National Commission reached the following conclusion: Most, if not all, of the failures at Macondo can be traced back to under- lying failures of management and communication. Better management of decision-making processes within BP and other companies, bet- ter communication within and between BP and its contractors, and effective training of key engineering and rig personnel would have prevented the Macondo incident. BP and other operators must have effective systems in place for integrating the various corporate cultures, internal procedures, and decision making protocols of the many differ- ent contractors involved in a deepwater well. IMPORTANCE OF SAFETY CULTURE Reports produced by the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling (2011), the National Academy of Engineering and National Research Council (2011), the U.S. Coast Guard (n.d.), and the Bureau of Ocean Energy Management, Regula- tion and Enforcement (BOEMRE 2011) Joint Investigation Team all emphasize that compliance with government regulations alone is insuf- ficient to create and maintain a safe working environment offshore and that a fundamental transformation of the offshore oil and gas indus-

Introduction 23 try’s safety culture is needed to reduce the risk of offshore accidents. Yet while the importance of establishing a safe working environment is widely acknowledged, strengthening offshore safety culture and reduc- ing incidents across the industry needs to be a continuous improvement effort. In November 2012, an explosion and fire on an oil platform owned by Black Elk Energy Offshore Operations, LLC, killed three workers. While the third-party investigation of this accident, funded by Black Elk, focused blame on the contractor’s pipe-welding operation,4 a federal investigation found that Black Elk had failed “to establish an effective safety culture and communicate risks and precautions to its contractor.”5 Because of the U.S. demand for energy, substantial oil and gas explo- ration and production operations are likely to continue offshore despite the current downturn in crude oil prices. Thus, the safety of workers and avoidance of major catastrophes will remain significant concerns of the industry, its regulators, and the public until a vision for creating and sustaining a safer working environment is developed, executed, and shared by all parties. ORGANIZATION OF THE REPORT This report consists of six chapters. Chapter 2 defines safety culture, explains why such a culture is difficult to achieve, and identifies its essential elements. Chapter 3 details the history of developments and safety efforts in the offshore oil and gas industry. Chapter 4 describes safety regulations and safety management and safety culture initia- tives both domestically and abroad, and suggests what is needed to advance safety culture. Chapter 5 focuses on assessment and mea- surement of safety culture. Finally, Chapter 6 examines how change in offshore safety culture can be implemented. The committee’s find- ings, conclusions, and recommendations are presented at the end of Chapters 2 to 6. Knowledge gaps and research needs are identified in Chapters 2, 5, and 6. 4 http://fuelfix.com/blog/2013/08/21/black-elk-commissioned-investigation-blames-contractors-for- fatal-platform-explosion/?cmpid=eefl#8547101=0. Accessed January 27, 2016. 5 http://fuelfix.com/blog/2013/11/04/feds-blame-poor-decisions-and-communication-for-lethal-blast/ #8547101=0. Accessed January 27, 2016.

24 Strengthening the Safety Culture of the Offshore Oil and Gas Industry REFERENCES Abbreviations BOEMRE Bureau of Ocean Energy Management, Regulation, and Enforcement BSEE Bureau of Safety and Environmental Enforcement GAO U.S. Government Accountability Office NAE National Academy of Engineering NOAA National Oceanic and Atmospheric Administration NRC National Research Council USCG U.S. Coast Guard Arnold, K. 2015. First-Hand: History of Operational Safety Awareness in the US Gulf of Mexico 1964 to 2014: A Personal Recollection by Kenneth (KEN) Arnold. http://ethw.org/First-Hand:History_of_Operational_Safety_Awareness_ in_the_US_Gulf_of_Mexico_1964_to_2014:_A_personal_recollection_by_ Kenneth_E._(KEN)_Arnold. Accessed Oct. 23, 2015. Baram, M. S. 2011. Preventing Accidents in Offshore Oil and Gas Operations: The U.S. Approach and Some Contrasting Features of the Norwegian Approach. Boston University School of Law Working Paper No. 09-43. http://papers.ssrn.com/ sol3/papers.cfm?abstract_id=1705812. Accessed Sept. 16, 2015. BOEMRE. 2011. Report Regarding the Causes of the April 20, 2010, Macondo Well Blowout. http://www.bsee.gov/uploadedFiles/BSEE/BSEE_Newsroom/ Publications_Library/OCS_Archives/DeepwaterHorizon/DWHFINAL DOI-VolumeII.pdf. Accessed May 9, 2016. BSEE. 2014. 2014 Annual Report. http://www.bsee.gov/uploadedFiles/BSEE/ BSEE_Newsroom/Publications_Library/Annual_Report/BSEE%202014%20 Annual%20Report.pdf. Accessed Nov. 6, 2015. Center of Risk for Health Care Research and Practice. n.d. Piper Alpha Accident. http://www.smd.qmul.ac.uk/risk/yearone/casestudies/piper-alpha.html. Accessed Aug. 27, 2015. Clarke, K. C., and J. J. Hemphill. 2002. The Santa Barbara Oil Spill: A Retrospec- tive. In Yearbook of the Association of Pacific Coast Geographers (D. Danta, ed.), University of Hawaii Press, Honolulu. County of Santa Barbara Planning and Development Energy Division. n.d. Blowout at Union Oil’s Platform A. http://www.sbcountyplanning.org/energy/ information/1969blowout.asp. Accessed Aug. 27, 2015. Cullen, W. D. 1990. The Public Inquiry into the Piper Alpha Disaster. H.M. Stationery Office, London. Friends of the California Archives. 2014. January 28, 1969: An Ecological Disaster and an Impetus for a New Ethos. http://friendsofcalarchives.org/2014/01/january-

Introduction 25 28-1969-an-ecological-disaster-and-an-impetus-for-a-new-ethos. Accessed Aug. 27, 2015. GAO. 2010. Federal Oil and Gas Leases. Opportunities Exist to Capture Vented and Flared Natural Gas, Which Would Increase Royalty Payments and Reduce Green- house Gases. GAO-11-34. Washington, D.C., October. http://www.gao.gov/ new.items/d1134.pdf. Accessed Sept. 28, 2015. GAO. 2015. High-Risk Series: An Update. GAO-15-290. Washington, D.C., Feb. http://www.gao.gov/assets/670/668415.pdf. Lloyd’s. n.d. 1998 The Piper Alpha Explosion. https://www.lloyds.com/lloyds/ about-us/history/catastrophes-and-claims/piper-alpha. Accessed Oct. 26, 2015. NAE and NRC. 2011. Macondo Well–Deepwater Horizon Blowout: Lessons for Improving Offshore Drilling Safety. National Academies Press, Washington, D.C. National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling. 2011. Deepwater: The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President. U.S. Government Printing Office, Washington, D.C. National Wildlife Federation. n.d. How Does the BP Oil Spill Impact Wildlife and Habitat? http://www.energybc.ca/cache/oilspill/www.nwf.org/Oil-Spill/ Effects-on-Wildlife.html. Accessed May 13, 2016. NOAA. 2014. 45 Years after the Santa Barbara Oil Spill, Looking at a Historic Disaster Through Technology. http://response.restoration.noaa.gov/about/ media/45-years-after-santa-barbara-oil-spill-looking-historic-disaster- through-technology.html. Accessed Aug. 27, 2015. Reuters. 2012. Factbox: What’s BP’s Potential Price Tag for Macondo? http://www. reuters.com/article/2012/03/03/us-bp-costs-idUSTRE8220R320120303. Accessed Aug. 27, 2015. Schwartz, J. 2015. Judge’s Ruling on Gulf Oil Spill Lowers Ceiling on the Fine BP Is Facing. New York Times, January 15. http://www.nytimes.com/2015/01/16/ business/energy-environment/judge-sets-top-penalty-for-bp-in-deepwater- horizon-spill-at-nearly-14-billion.html?_r=0. Accessed March 11, 2016. Sonti, C. 2009. Oil Spill Finally Stopped: Company. WA Today, Nov. 3. http:// www.watoday.com.au/wa-news/oil-spill-finally-stopped-company-20091103- hv56.html. Accessed Aug. 27, 2015. Sumaila, U. R., A. M. Cisneros-Montemayor, A. Dyck, L. Huang, W. Cheung, J. Jacquet, K. Kleisner, V. Lam, A. McCrea-Strub, W. Swartz, R. Watson, D. Zeller, and D. Pauly. 2012. Impact of the Deepwater Horizon Well Blowout on the Economics of U.S. Gulf Fisheries. Canadian Journal of Fisheries and Aquatic Sciences, Vol. 69, No. 3, pp. 499–510. USCG. n.d. Report of Investigation into the Circumstances Surrounding the Explosion, Fire, Sinking and Loss of Eleven Crew Members Aboard the Mobile Offshore Drill- ing Unit Deepwater Horizon in the Gulf of Mexico April 20–22, 2010. http://www. bsee.gov/uploadedFiles/BSEE/BSEE_Newsroom/Publications_Library/ OCS_Archives/DeepwaterHorizon/2_DeepwaterHorizon_ROI_USCG_ Volume%20I_20110707_redacted_final.pdf. Accessed May 9, 2016.

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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 or the TR News article for a summary of the report.

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