Deepwater Horizon: Failure to Learn

Ten years later, its lessons remain critical.

On April 20, 2010, an explosion on the BP Deepwater Horizon drilling rig 49 miles off the coast of Louisiana in the Gulf of Mexico killed 11 men. The blowout of the well initiated the worst oil spill in U.S. history. Ten years later, five insights about organizational culture and cognitive biases remain evergreen for leaders of project-based organizations.[1]

An accident like Deepwater Horizon does not happen simply because individuals make poor decisions due to cognitive biases. Organizational culture sets the context and ultimately determines the damage that faulty decisions can cause. In this respect, organizations are like living organisms with immune systems. A dysfunctional culture compromises an organization’s immune system, creating a fertile breeding ground for poor decision-making processes. Three of the insights below address cultural dynamics, while two speak to cognitive biases.

1. Normalization of deviance is a ticking time bomb. “When you see something, however abnormal, often enough, you begin to think it’s normal,” former NASA Administrator Sean O’Keefe once said. NASA understands this better than most organizations. Sociologist Diane Vaughan coined the term “normalization of deviance” to explain the organizational dynamics that led NASA officials to launch the space shuttle Challenger on a freezing January day in 1986 despite a string of data points from previous missions that led engineers to warn of the likelihood of catastrophic failure.[2] Normalization of deviance is a cultural phenomenon-it’s a shared understanding of a new normal, regardless of data, processes, or procedures.

Evidence of the normalization of deviance on Deepwater Horizon extended to oil giant BP, owner of the well, and Halliburton, the contractor BP hired to cement each segment of the well in place. Halliburton prepared cement for this well that had repeatedly failed Halliburton’s own laboratory tests. Despite those test results, Halliburton managers onshore let its crew on Deepwater Horizon as well as the crews from BP and Transocean, the owner/operator of the rig, continue with the cement job.

On February 10, soon after Deepwater Horizon began work on the well, Halliburton engineer Jesse…