[SystemSafety] Indian Train Crash + Boebert and Blossom on Deepwater Horizon

[Prof. Dr. Peter Bernard Ladkin]

1. Indian Train Crash

Horrific.

 From The Guardian today 
https://www.theguardian.com/world/2023/jun/04/india-train-disaster-cause-of-crash-under-investigation-as-rescue-work-finishes-with-death-toll-passing-300 


[begin citation]

Preliminary investigations revealed that a signal was given to the Coromandel Express to enter the 
main track line but the signal was later taken off. The train entered another line, known as the 
loop line, and crashed into a goods train parked there, the Press Trust of India news agency reported.

[end citation]

2. Deepwater Horizon: A Systems Analysis of the Macondo Disaster, Earl Boebert and James M. Blossom, 
Harvard U.P 2016.

The incident is 13 years ago now (April 10, 2010). Boebert and Blossom explain (a) the equipment 
used, what it is supposed to do (and not do) and how it works, as well as (b) reconstruct the events 
and how and why they occurred as well as possible, largely from court submissions.

It turns out that many accounts I had read of (a) were wrong in significant respects. If you want to 
know how this kit works and don't have time to take courses on it, this book is where you can find out.

Concerning (b), it turns out that the information available is far too sparse to allow any kind of 
technical analysis such as WBA or STAMP. Better said, application of such analytical methods will 
not tell you much, or anything, that is not evident from the prose report. It will likely astonish 
most (or all) readers of this list how little information appears to be available about the state of 
the well being drilled -- much of it is inferred from the behaviour of on-board systems rather than 
being derived from sensorics. The lack of appropriate control structures, such as a safety 
management system, in the organisations involved will likely astonish those working in other 
industries with safety-related aspects. As far as I can tell, it can only be explained through 
complacency engendered by decades of routine operations without an accident such as this.

When I write "without an accident such as this", the question arises: what about the Piper Alpha 
disaster of 6 July, 1988? The answer may be: Piper Alpha was an accident caused directly by actions 
of the crew in a condition of failed situational awareness about the state of the rig systems; 
whereas Deepwater Horizon was caused by a failure to control the environment, namely the state of 
the Macondo well itself (both the engineered kit in it and the geology).

There is a wealth of difference between the Cullen report on Piper Alpha and the sparse information 
Boebert and Blossom have been able to put together from the court proceedings around the Deepwater 
Horizon disaster. B&B explain in some detail the diffused nature of responsibilities for Macondo 
well operations between the client BP, the operator Transocean, and various other organisations, as 
well as the separate command responsibilities for Deepwater Horizon in its operation as a marine 
vessel, and drilling operations.

BTW, I came across this 2020 account of Piper Alpha from a chemical engineer, Marc Reid, whose 
father was aboard Piper Alpha and was injured: https://pubs.acs.org/doi/10.1021/acs.chas.9b00022

PBL

Prof. i.R. Dr. Peter Bernard Ladkin, Bielefeld, Germany
Tel+msg +49 (0)521 880 7319  www.rvs-bi.de