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06.11
Taking
Responsibility for Technology
By Don Shafer
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| This article is
based on a keynote of the same title presented
at the IEEE-USA Annual Meeting in Austin, Texas,
5 March 2011 [watch
video]. Further information
on the Macondo Incident background was first
introduced in Computing Now.
[i] |
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My focus on responsible
technology development may differ
slightly from that of most IEEE members. I’m
the chief technology officer of a Texas
company of around 60 engineers that work
offshore on oil and gas exploration and
production vessels ensuring that the
control systems are functioning
correctly. Offshore oil and gas
exploration has driven technology in
metallurgy, chemistry, manufacturing,
electronics and computing. It has also
provided areas where the technology has
rapidly gotten away from us. The Macondo
Well incident [ii]
of April 2010 is an
excellent example of not taking
responsibility for technology.
Safety is a critical component
of the culture of oil and gas workers. To that
end we need to begin with a safety minute.
A Safety Minute
Basic Offshore Technology
Source:
http://www.seton.com/knife-safety-signs-safety-first-91822.html
For years, most people working
in the oil and gas field — whether in an office,
on a drilling rig or in the field — carried a
pocket knife. As a leading cause of personal injuries,
however, pocket
knives were banned from all rigs operated by
Transocean, the
offshore drilling contractor responsible for
managing the Deepwater Horizon. Eleven crew members were
killed in the explosion and fire
that decimated the rig on 20 April 2010.
Improbable as it may sound, the absence of
pocketknives could have contributed to even more
deaths aboard the Horizon. Here's a quote from
Horizon survivor Mike Williams, the rig's chief
electronics technician:
The life raft was at a
45-degree angle to the water. There's
something called a painter line that these
life rafts attach to the rigs. We had pulled
all that tight. And no one had ever cut it.
So we're tied to the rig and we're dumping
people out of the life raft. Transocean has
a no-knife policy. No pocketknives of any
kind. No one had a knife to cut this line.
— Mike
Williams
Chief Electronics Technician, Deepwater
Horizon
[extended
60 Minutes
interview]
Deepwater Horizon Explosion and Sinking –
April 2010
Source:
http://blog.al.com/wire/2011/04/deepwater_horizon_owner_transo.html
http://www.nytimes.com/2010/07/20/science/20lesson.html
Luckily for Mike and the others
on the raft, some fishermen who were helping
with the rescue got close enough to the raft to
throw a knife. The painter was cut and the raft
got away.
IEEE Code of Ethics
As members of the IEEE, we
ascribe to the Code of Ethics shown below. This
is a good starting place to discuss our
responsibilities as engineers to the technology
we build, deliver and use.
We, the members of the IEEE, in
recognition of the importance of our
technologies in affecting the quality of life
throughout the world and in accepting a personal
obligation to our profession, its members and
the communities we serve, do hereby commit
ourselves to the highest ethical and
professional conduct and agree:
-
to accept responsibility in making
decisions consistent with the safety, health and
welfare of the public, and to disclose promptly
factors that might endanger the public or the
environment;
-
to avoid real or perceived conflicts of
interest whenever possible, and to disclose them
to affected parties when they do exist;
-
to be honest and realistic in stating
claims or estimates based on available data;
-
to reject bribery in all its forms;
-
to improve the understanding of
technology, its appropriate application, and
potential consequences;
-
to maintain and improve our technical
competence and to undertake technological tasks
for others only if qualified by training or
experience, or after full disclosure of
pertinent limitations;
-
to seek, accept, and offer honest
criticism of technical work, to acknowledge and
correct errors, and to credit properly the
contributions of others;
-
to treat fairly all persons regardless of
such factors as race, religion, gender,
disability, age, or national origin;
-
to avoid injuring others, their property,
reputation, or employment by false or malicious
action;
-
to assist colleagues and co-workers in
their professional development and to support
them in following this code of ethics.
We will discuss the implications
of these three highlighted aspects of the code.
Rule #1:
To accept responsibility in making decisions
consistent with the safety, health and
welfare of the public, and to disclose
promptly factors that might endanger the
public or the environment
Although Macondo was the
stimulus for this article, it was not the first,
nor will it be the last technology disaster. As
engineers we need to always take responsibility
for our decisions. Those decisions must be in
concert with health, safety and the environment.
We need to be the “truth tellers” in informing
the public about any of the results, actual or
possible, of the technology that can lead to
diminished health, safety or environment.
Where are those areas where we
can fail?
1. Always, give the King what he asks for.
Title: Vasa Sinking, August 1628
Source: Vasa Museum
http://www.vasamuseet.se/en/The-Ship/The-sinking/
Further Information: http://en.wikipedia.org/wiki/Vasa_(ship)
What do you do when you have a
powerful, overbearing — but technically ignorant
— boss or customer? You say yes and do what they
want, right? Wrong! Minutes after her grand
launching, with all Stockholm watching, the Vasa
heeled, listed and sank, killing about 50. King
Gustavus Adolphus in his effort to make Sweden
the world’s superpower ordered four new warships
built fast. Remember, this is 1628. Von Leibnitz
did not publish his differential calculus until
1784 [iii].
There were no modeling tools other than those
rendered into wood.
Workmen were already laying the
Vasa's keel when the king ordered its length
extended. The master shipwright agreed and then
died. His inexperienced assistant then took
over. The king ordered a second gun deck. The
result was the most heavily armed warship of its
day, but too long and too tall too heavy for its
beam and ballast. When the standard stability
test of the day, 30 sailors running from side to
side, perilously tilted the Vasa, the test was
canceled and the ship readied for launch. They
would test the ship “in production.”
2. Communication? What communication?
Hyatt Regency walkway collapse – July 1981
Source:
http://en.wikipedia.org/wiki/Hyatt_Regency_walkway_collapse
Communication among all the
stakeholders in a project is critical to the
project’s success. When the designers, builders
and inspectors failed to communicate the
changing requirements, design challenges and
changing calculations, a recipe for disaster was
in the making. On 17 July 1981, approximately
1,600 people gathered in the Hyatt Regency
Kansas City atrium to participate in and watch a
dance competition. The fourth floor walkway
collapsed onto the second floor and both
walkways then fell to the lobby floor below,
resulting in 114 deaths and 216 injuries.
When three "floating walkways"
crashed to the floor of Kansas City, MO's swank
new Hyatt Regency on 17 July 1981, speculation
first fixed on the patrons who'd been dancing on
them: perhaps their high-stepping had set off a
harmonic wave that made the sky bridges buckle
and crumble. First, blame the victims! The basic
problem was a lack of proper communication,
failure to review the initial design thoroughly,
and failure to perform basic calculations that
would have revealed its serious intrinsic flaws
— in particular, the doubling of the load on the
fourth-floor beams. Miscommunication and lack of
attention to detail by the engineers resulted in
114 people perishing in the deadliest structural
failure in U.S. history.
3. Technology’s will solve our most pressing
problems.
Iroquois Theater Blaze – December 1903
Source:
http://www.listzblog.com/top_ten_deadly_fires_history_list.html
The burning of Chicago's
Iroquois Theater — a supposedly indestructible,
up-to-the-minute design-in this case, a theater
advertised as "absolutely fireproof" — killed
602 people, more than twice the toll of "the
Great Chicago Fire" 32 years earlier. The
Iroquois' owners acted with as much haste and
hubris as their Titanic counterparts would in
the near future. They installed no firefighting
equipment, eliminated fire drills and opened for
business before the sprinkler system was ready.
Instead, they relied on a single technological
magic bullet: an asbestos curtain that would
drop down and shield the audience in the (rather
common) event of a backstage fire. As could be
predicted, a fire started. The asbestos curtain
started dropping on cue but caught on a stage
light. Crew and cast opened the stage door to
flee, admitting a powerful gust that sent
fireballs shooting out over the unshielded
audience. Fleeing patrons either found the doors
barred or could not operate the new door
latches.
4. Why, that could never happen!
Atlantic Empress/Aegean Captain Collision –
July 1979
Source:
http://planetgreen.discovery.com/feature/planet-100/worst-oil-catastrophes.html
http://www.globalarchitectsguide.com/library/Atlantic-Empress.php
The ocean is an enormous
expanse. Even when you take into account the
size of super tankers, why the ocean is still
big enough. Two could never collide. A super
tanker can stretch over 400 meters, weigh more
than 400,000 metric tons and require five
kilometers to stop. By design, they have minimal
crew, have no margin of error in their power
plant and do not prepare for unexpected
problems. Where many smaller ships use multiple
propellers to steer and brake, most tankers have
just a single massive propeller. The technology
that helps compensate for these limitations can
contribute to a false sense of security. Highly
effective, navigation radar provides a false
sense of security allowing tankers to travel too
fast to break from a collision course. Remember,
it takes 5 kilometers to stop. On 19 July 1979,
what could never happen, happened! The Atlantic
Empress and the Aegean Captain collided near
Tobago in a light rainstorm. They lost 26
crewmembers and spilled more than 2,105,000
barrels of oil, more than four and a half times
as much as the Exxon Valdez spilled in 1989.
5. Future changes can only enhance the quality
of the product.
Minneapolis I-35W Bridge Collapse – August
2007
Source:
http://designcrave.com/2010-06-11/5-design-flaws-that-led-to-disaster-2/
The I-35W Mississippi River
bridge was an eight-lane, steel truss arch
bridge that carried Interstate 35W across the
Mississippi River in Minneapolis. During the
evening rush hour on 1 August 2007, it suddenly
collapsed, killing 13 people and injuring 145.
NTSB found the primary cause was the under-sized
gusset plates. Contributing to that error was
the fact that 2 inches of concrete were added to
the road surface over the years, increasing the
dead load by 20%. Also contributing was the
extraordinary weight of construction equipment
and material resting on the bridge just above
its weakest point at the time of the collapse.
6. We need reliable workers. Training is
secondary.
Chernobyl – April 1986
Source:
http://designcrave.com/2010-06-11/5-design-flaws-that-led-to-disaster-2/
The catastrophic meltdown at the
Chernobyl nuclear power station occurred on 26
April 1986, when one of the reactors overheated
rapidly, leading to a meltdown. The accident was
rated 7 on the International
Nuclear Event Scale (INES),
which runs
from 0 (an abnormal situation with no safety
consequences) to 7 (an accident causing
widespread contamination with serious health and
environmental effects). Until the March 2011
nuclear accidents in Fukushima, Japan, Chernobyl
was the only level-7 incident. Chernobyl
released an enormous cloud of radioactive
fallout, simultaneously endangering the lives of
hundreds of thousands of people in surrounding
areas. It is
estimated that 4,000
people may die due to cancer from
the radiation released during the Chernobyl
meltdown. As it stands today, Chernobyl has a
17-mile radius “Exclusion Zone” which is
considered too hazardous to live in. Based on
the half-life of Plutonium 239, the exclusion
zone will not be safe to inhabit for 24,100
years.
The immediate
cause of the Chernobyl accident
has been linked to an ill-advised electrical
power generation experiment conducted by
engineers with no experience in reactor physics.
Instead of powering down reactor 4, which was
running dangerously low on coolant, the
engineers increased the reactor's power, causing
it to rapidly overheat.
Additional factors
which helped precipitate the event were the
unstable design of the reactor itself and the
absence of a strong safety culture at the plant.
7. Well, it’s only Excel!
Maersk Line – 18 Containers lost overboard –
October 2009
Source:
www.maib.gov.uk/publications/completed_preliminary_examinations/husky_racer.cfm
The preliminary examination of
the accident found that the inaccurate container
weights were on the loading plan because of a
system shortcoming that did not update the
operations department when the shipper provided
more accurate contents details to the carrier.
Further investigations showed that the Microsoft
Excel worksheet that calculated the loading
order sorted the containers from lightest to
heaviest. Then it started at the top of the
list, the lightest, and placed them first in the
ship. The lightest containers were placed on the
bottom. Eventually, the bottom containers,
collapsed under the weight causing the stacks to
fall over.
8. We’ll test it later, in production.
Control System Failure - December 2009
Source:
http://stepchangeinsafety.net/stepchange/SingleItem_Incident.aspx?ID=5824
A control system failure
occurred on a large, construction vessel. Two
control units were restarted twice,
unsuccessfully. A blinking red lamp on the PLC
indicated that a memory reset was required, even
though a memory reset had NEVER been requested
by control system diagnostics during equipment
operations. As soon as the hydraulic power
packs started, a loud bang was heard. A
quadruple joint of pipe dropped approximately
one meter to the welding deck below. A second
quadruple joint of pipe in the pipe elevator was
released (all clamps opened and the hydraulic
safety stop swung away) and fell the full length
of the tower, smashing through a crowded access
platform to the deck below.
The initialization instruction
was pre-loaded in PLC EPROM memory and the
initialization included instructions to OPEN ALL
CLAMPS.
Eight personnel were injured —
four fatally. All were located on the access
platform and several were thrown overboard by
the impact.
Rule #3:
To be honest and realistic in stating claims
or estimates based on available data
How many of us when asked for
the status of a project has said, “It’s 90%
complete”? Especially in software, that’s a
common response. What about when health, safety
and the environment are closely impacted? As our
view of our responsibility to changing
technology evolves after the Macondo incident,
we may need to address what happens when, as
engineers, we are honest in our answers but our
managers bury the information. Below are ten
opportunities that were lost in preventing the
Deepwater Horizon oil spill. These are just a
handful of opportunities lost. This list and the
following graphic emphasize that not only were
these known, but the solutions were industry
standard practices that were not followed.
Referring back to point number one in our Code
of Ethics, as engineers they voiced their
concerns but did not inform the affected
parties.
Macondo Opportunities Lost [iv]
-
22
June 2009 - Mark E. Hafle, a senior
drilling engineer at BP, warns that the metal
casing for the blowout preventer might collapse
under high pressure.
-
March
2010 - An accident damages a gasket on the
blowout preventer on the rig.
-
1
April 2010 - Halliburton employee Marvin Volek
warns that BP's use of cement "was against our
best practices.“
-
6
April 2010 - MMS issues permit to BP for the
well with the notation, "Exercise caution while
drilling due to indications of shallow gas and
possible water flow."
-
9
April 2010 - BP drills last section with the wellbore 18,360 feet below sea level but the
last 1,192 feet need casing. Halliburton
recommends liner/tieback casing that will
provide 4 redundant barriers to flow. BP chooses
to do a single liner with fewer barriers that is
faster to install and cheaper ($7 to $10
million).
-
15
April 2010 - Morel informs Halliburton
executive Jesse Gagliano that they plan to use 6
centralizers. Gagliano says they should use 21.
-
15
April 2010 - Gagliano also recommends to
circulate the drilling mud from the bottom of
the well all the way up to the surface to remove
air pockets and debris which can contaminate the
cement, saying in an email, at "least circulate
one bottoms up on the well before doing a cement
job." Despite this recommendation, BP cycles
only 261 barrels (41.5 m3) of mud, a
fraction of the total mud used in the well.
-
17
April 2010 - Gagliano now reports that using
only 6 centralizers "would likely produce
channeling and a failure of the cement job."
-
18
April 2010 - Gagliano's report says, "well is
considered to have a severe gas flow problem."
-
20
April 2010 at 7 am - BP cancels a
recommended cement bond log test.
Warning Signs Ignored
Source:
http://www.saveusenergyjobs.com/2010/06/bp-step-by-step-to-disaster/#section3
Conclusion
It is our responsibility as
engineers and members of IEEE to remember the
fifth rule of our code of ethics:
Rule #5:
to improve the understanding of technology,
its appropriate application, and potential
consequences
To that end you, the reader,
need to search your experiences and decide how
to pass along your hard earned experiences.
Teach a course within your company, at your alma
mater or a local community college. Write a
paper for a professional society’s magazine or
journal. Give a talk. Do something to get your
colleagues and new engineers to take
responsibility for this wonderful technology all
of us are developing.
[i]
"The BP Oil Spill: Could Software be a Culprit?,"
by Don Shafer and Phillip A. Laplante,
http://www.computer.org/portal/web/computingnow/bp-spill
[ii]
As a point of irony, the name Macondo is the same name as the fictitious cursed
town in the novel "One Hundred Years of Solitude" by Colombian Nobel
Prize-winning writer Gabriel Garcia Marquez.
http://en.wikipedia.org/wiki/Macondo_Prospect
[iii]
Leibniz is credited, along with Sir Isaac Newton, with the inventing of
infinitesimal calculus (that comprises differential and integral calculus). This
cleverly suggestive notation for the calculus is probably his most enduring
mathematical legacy. Leibniz did not publish anything about his calculus until
1684. http://en.wikipedia.org/wiki/Gottfried_Leibniz#cite_note-29
[iv] Timeline of the Deepwater Horizon Oil Spill,
http://en.wikipedia.org/wiki/Timeline_of_the_Deepwater_Horizon_oil_spill
As cofounder and chief
technology officer, Don Shafer developed Athens
Group’s oil and gas practice and leads engineers
in delivering software services for exploration,
production, and pipeline monitoring systems for
clients such as BP, Chevron, ExxonMobil,
ConocoPhillips, and Shell. He led groups
developing and marketing hardware and software
products for Motorola, AMD, and Crystal
Semiconductor. Shafer managed a large PC product
group producing award-winning audio components
for Apple. From the development of low-level
software drivers to the selection and monitoring
of semiconductor facilities, he has led key
product and process efforts.
He received a BS from the
United States Air Force Academy and an MBA from
the University of Denver. Twice treasurer of the
IEEE Computer Society Board of Governors, past
editor in chief and chair of the IEEE Computer
Society Press, an IEEE senior member, and a
Golden Core member, he is an adjunct professor
of engineering at the University of Texas at
Austin. Shafer has contributed to three books,
written more than 20 published articles, and is
coauthor of Quality Software Project Management,
published by Prentice-Hall. He is a contributor
to the 2010 edition of the Encyclopedia of
Software Engineering and is a Certified Software
Development Professional. His current projects
include the development of a multi-volume set of
Software Engineering Proven Practices for the
oil and gas industry based on more than a decade
of extensive engineering work done at Athens
Group.
For more on Shafer's
background, please reference:
http://www.computer.org/portal/web/buildyourcareer/mypath/shafer
Comments may be submitted to
todaysengineer@ieee.org.
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