THE PERFECT STORM — EPILOGUE
What if we put this entire story into a Bow Tie?
In the previous posts, we went back to December 2011.
First, an inadvertent activation of the emergency disconnect system sent the BOP — the safety equipment that controls the well on the seabed — to the ocean floor.
Then, while recovering the LMRP, the upper disconnectable section of that system, we were repressurizing the high-pressure air accumulators of the rig’s motion compensation system.
A task was interrupted. A valve remained open. About two minutes later, a high-pressure line exploded.
Fortunately, no one was injured.
The explanation seemed simple: “the valve was left open.”
But the investigation revealed much more: pressure, temperature, materials, procedures, interruptions, competing priorities, and barrier architecture.
The design changed. New barriers were introduced.
To close the cycle, I propose looking at this story through a Bow Tie.
At the center is the moment we lose control. On one side are threats and preventive barriers. On the other, potential consequences and barriers to limit escalation.
In our case:
LOSS OF CONTROL OF THE ACCUMULATOR PRESSURIZATION AND THERMAL CONDITION
Before that point: rapid pressurization, simultaneous operations, task interruption, and a change in priority.
Cognitive load, reliance on memory, and a critical function concentrated in a single human action could degrade the defenses. The open valve then stops being simply “the cause” and becomes part of a broader sequence.
That is where the Bow Tie becomes powerful: it allows us to visualize which barriers existed, which could be degraded, and which needed strengthening or introduction.
On the other side are potential consequences: rupture, flying components, fire, personnel exposure, and potential fatality—along with barriers intended to limit escalation.
What can degrade each barrier?
Counting them is not enough. We need to understand what they do, what they depend on, how they lose effectiveness, and whether they are truly independent.
This is where different perspectives come together. HAZOP challenges deviations and safeguards; LOPA challenges the robustness and independence of protection layers; and Human Factors helps us understand how barriers interact with work as actually done.
People are also part of the defense. But critical systems must account for a human reality: we get interrupted, face competing priorities, and can forget an action.
So the question changes from: “Who left the valve open?”
to:
“What set of barriers should prevent a predictable human variation from finding an unobstructed path to a serious consequence?”
After four chapters, perhaps this is the best image to close the cycle:
At the center of the Bow Tie is the moment we lose control.
The barriers hold everything we learned to keep it from happening again.
#HereComesAStory #ProcessSafety #HumanFactors #HAZOP #LOPA
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