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Columbia Gas of Massachusetts Case – Project Issue Analysis Report

Is it clear from reading your assignment that you read the case and understood what happened that led up to the mistakes that were made and that yielded the fires and explosions?
Did you ‘dig deeper’? Some people identify very technical issues – did you find the underlying reasoning – the project-level thinking that may have driven decisions to go a certain way technically?
Did you keep your writing concise and to the point? Part of the intent of this assignment is an exercise in expressing important ideas in as efficient a way as possible.
Was there a logical flow from your Issue Identification to your Proposed Solutions, to your Pros and Cons and to your conclusion?
If you did have ‘extra’ information to exhibit, did you put it in an Appendix rather than in the body of the text? Again, the focus is on a concise, crisp presentation of your arguments.

References and resources:

Did you provide several relevant references that helped make your points? Of course you can use the main Case as a reference, but did you reach out and find out more about the Columbia Gas incident from other sources? You really should at least investigate the references pointed to at the bottom of this Case at a minimum.

Other things to consider:

Did you add value from your own professional and/or personal experience?
Did you make appropriate use of figures and tables in an appendix? Don’t substitute quantity for quality here – one good, relevant, and meaningful small table is worth 100 randomly inserted graphs and charts.
Did you really take on the viewpoint of a project leader here, and consider the way the team was motivated, the way the different stakeholders communicated (or didn’t), the culture of the different companies?
Did you consider the different stakeholder interests?


Issue/Solution/Pros and Cons Idea Collector

Enter your information in the pastel-colored cells as appropriate

List your issues here – SEE IMPORTANT NOTE BELOW – these should be Project Management Issues

Issue 1:

Issue 2:

Issue 3:

Issue 4:

List your Solutions to the above issues Pros (positive aspects) of this Solution Cons (negative aspects) of this Solution

Solution(s)for Issue 1

Solution(s)for Issue 2

Solution(s)for Issue 3

Solution(s)for Issue 4

NOTE: Be sure that the issues you identify are MANAGERIAL issues, in fact Project Management issues, and not specific engineering or technical issues.

For example, don’t identify “use of older operating system” as an issue. DIG DEEPER! Ask this question of yourself: WHY was the operating system not updated?

If you have drafted an Executive Summary, you can copy and paste it below…

The BP Macondo Well Case

Executive Summary

The BP deepwater Horizon is one of the worst industrial catastrophes ever due to the oil rig explosion on April 20, 2010, in the Gulf of Mexico. Eleven people died in what has become the worst oil spill in the United States lasting 87 days with 507 million liters of oil spilled in the sea (US Environmental Protection Agency, 2017). Multiple failing went right up to the top management of the companies involved and multiple points at which it could have been averted. In this report we addressed three of their major issues:
· BP’s safety culture

· BP’s risk-seeking culture

· The lack of ethics values

Issues will be identified then practical solutions to these issues will be presented. Finally, recommendations will be made based on the pros and cons of each solution and thanks to the solution ranking matrix.


The BP deepwater Horizon is one of the worst industrial catastrophes ever due to the oil rig explosion on April 20, 2010, in the Gulf of Mexico. Eleven people died in what has become the worst oil spill in the United States lasting 87 days with 507 million liters of oil spilled in the sea (US Environmental Protection Agency, 2017).
A single cause is not at the origin of the tragedy of the Macondo well. It is rather a ‘collection’ of errors that led to the explosion and the fire of the platform. The leak was indisputably caused by technical failures, but those –in turn – could have been avoided or at least lessened in impact and probability if they had not had deeper organizational and systemic failures within BP. The US Federal investigation identified the technical failures that led to the blow out, it includes: the cement failing to seal the bottom of the well, lack of centralizers in order to center the pipe when pouring the cement, the blowout preventer malfunction, the high pressure in the drill and the cement formula that was not certified to function properly, etc.
However, multiple failure causes, in this author’s opinion, are traceable to project management issues, which in turn can be linked to the top management of the companies involved and multiple points at which it could have been averted. The three top issues that we can identify are BP’s safety culture, BP’s risk-seeking culture and the lack of ethics values.
I will discuss three major project issues that have been identified within the “BP and the Deepwater Horizon Disaster of 2010” that led up to the explosion and oil spill. Solutions and their pros and cons will then be introduced along with recommendations of how the disaster could have been avoided.

Issues Identification

Issue 1

The first issue and the most important concerns BP’s safety culture. In fact, despite the fact that BP had publicly declared its commitment for safety, BP had multiple issues with safety breaches. In a previous accident in BP’s Texas City refinery which killed 15 persons, the investigation report that they purposely cut back the maintenance and safety measures in order to limit costs.

Even after trying to improve personal safety, BP misunderstood that by decreasing and having a lower personal injury rates do not mean that safety process is well implemented. According to Ingersoll C. and al. (2012) U.S. refinery workforce believe that process safety is not a core value at BP. Meaning that in BP the workforce is not able to perceive a clear corporate message coming from BP’s executive.

In BP’s 18 values, only one concerns health and safety, it claims: “no accidents, no harm to people, and no harm to the environment” But nothing clear is stated concerning safety process and it has never been a real commitment for BP. They never tried to implement new safety policies and processes, it has been seen more as a way to communicate and articulate a “safety” message to maintain a respectable corporate image than a real way to establish long-term change into their safety process.

Issue 2

The second issue is BP’s corporate risk management appetite which is very risk-seeking. It has been stated that BP’s culture is one that values doing as much as they can for a minimum budget. It was expected that the Macondo well project had a budget of $96.2 billion and was scheduled to take place in 51 days. In addition, the well started to be functional in January of 2010 and the explosion occurred in April, so less than 3 months after the effort began.

Indeed, the project was six weeks behind schedule and $58 million over budget (National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, 2011), with such time and cost constraints we can surely imagine that decisions had been made in alacrity.

Moreover, with the technical issues that happen previously the blowout of Deep-Water Horizon, we can affirm that with a proper risk management it would have unquestionably reduced, if not eliminated, the probability of the blowout. In the conclusion stated in the National Commission’s report (2011), the explosive loss of the Macondo well could have been prevented. In fact, decisions made before and during the disaster were never subject to an official risk assessment.

Furthermore, BP was conscious that they needed to provide maintenance to their machinery in order to be in compliance. Indeed, a week before the accident, the blowout preventer (BOP) was accidentally deteriorating (Greene-Blose, 2015). As an example, one of the censors of the control pod was not working due to an emptied battery and the other was not working due to a defective solenoid valve (National Commission, 2011). In fact, no one in the Deepwater horizon workforce and executive took the necessary actions to solve this problem. According to Hillson R. & Webster M. (2005) what characterizes risk seekers’ is that they tend to downplay threats.

One week prior to the blowout, the project team had actually failed to identify risk triggers resulting in an extreme threat. Consequently, both the probability and impact of this risk has become more important, it is then too late for preventive action, the risk is accepted.

Issue 3

The third issue concerns the lack of ethics in BP’s core values.. Or at least the conveyance of those values to project team members. According to Jennings M. (2010): “BP’s management principles, business plans, and codes of ethics focused on safety and compliance, [but] something was

lost in translation between words and actions. The message in the written materials was not the message that the employees heard or followed.

There was a long-standing cultural disconnect between outward appearances and internal behaviors.” In fact, corporate ethics were sacrificed when it came to catch up their delay.

Moreover, Mr. Reilly, the former president of the United States environmental protection agency, denounced “a culture of complacency” among BP corporations, resulting in “bad decisions” as they were preparing to complete the drilling of the “Macondo” well at 1,500 meters below the sea surface. In fact, there has been precipitation in the realization of the well because on site asset managers were rushing in order to meet performance targets. Furthermore, they extended this practice among all employees working on the site, so employee compensation was tied to asset performance and the overall performance of the site. We can easily imagine how this manner to behave can impact the project quality and push employees to question the respect of ethics.

Leadership responsibility, which is receiving more attention, has been widely discussed in the context of large corporations that are suffering the consequences of their actions (or inaction). Managers are often accused of acting selfishly and sacrificing the company’s bottom line for their own benefit. Already in the 1970s, Jensen and Meckling (1976) were suggested ways to counter such behavior or to encourage managers to act in the interest of the company and the society.

In a general way, the CEO needs to enhance shareholder value, in line with the expectations of the shareholders and, respectively, the management committee. However, what we do not know is how it is supposed to achieve that goal, that is to say, what risks he must take. The CEO must therefore improve the security aspect so as to minimize operational risks and limit potential liabilities. In the case of BP, during the trial, Tony Hayward emphasized the $14 billion invested in security since his appointment as CEO, but he was not able to say how it was spent. That’s why it is important spending

the time needed in order to investigate even the most minor failure and then implementing the appropriate changes.

Proposed Solutions Table

Issues # – Solution # Solution


Create a company-wide initiative safety program that states clear safety practices and standards that must be respected, with sanctions in case of safety violation.


Training in order to educate the employee properly concerning the safety practices to be in compliance.


Value scope by shifting from a risk-seeking company to a risk-adverse company, this strategic change will impact positively BP company in a long- term vision.


Establish a thorough risk management by providing a Plan Risk Management in order to decrease the risk tolerance level, according to Greene-Blose, J.
M. (2015): “A simple cause and effect diagram (also known as a fishbone or Ishikawa diagram), useful for identifying, assessing, and understanding the root cause of risks (Project Management Institute, 2013, p. 236), may have provided the necessary insight into the appropriate risk quantification and response at BP.”


Establish thorough ERM throughout organization in order to reduce the risk of regulatory non-compliance and allow BP to provide maintenance for their equipment when it is needed.


Modify the policy concerning the asset federation model for meeting performance targets in order to not sacrifice quality and ethics over budget and time constraints.


Create a monitoring program and ethical training for all BP employees resulting in leadership empowerment.


Implement a company-wide communication plan and encourage whistle- blower in order to push employees to report unethical behavior.

Pros and Cons Matrix

Solution Pros Cons

1-1 Create a company-wide initiative safety program

· Impact future profit by reducing repair costs for major disaster

· Take time to be integrated in every employees’ behavior

1-2 Implement safety training and practices

· Fewer workplace incidents/ employees have better responses and behavior

· Take time to create those kings of a training
· Very costly to establish

2-1 Shifting from a risk-seeking company to a risk-adverse company

· Value and quality over cost and time constraints
· A better long-term vision

· Take time to realign corporate strategy
· Change is difficult to adopt

2-2Build a strong risk management

· Risk quantification
· Better responses in case of occurring

· Take time before the project execution

2-3 Establish thorough ERM through BP company

· Limit the risk to be in non- compliance
· Investments are made on purpose when needed

· Can be expensive to implement though the company

3-1 Modify asset federation model policy

· Limit the pressure for asset managers to meet the performance target
· Quality over Cost constraints

· Less decision making for the asset managers, limit their actions

3-2 Create a monitoring program and ethical training

· Improve leadership empowerment
· Encourage good behavior and positive management

· It is costly to create training all over the company
· Employees can be reluctant to change

3-3 Implement a company-wide communication plan

· Encourages open exchange of information and viewpoints
· Limit unethical behavior

· Whistle-blower may be misunderstood and seen as oppressive
· Take time to implement

Solution Ranking Table [NOTE: NOT REQUIRED]


Likelihood of Success

Difficulty Implementing

Solution Score

Solution Rank

1-1 Create a company-wide
initiative safety program





1-2 Implement safety
training and practices





2-1 Shifting from a risk- seeking company to a risk-
adverse company





2-2 Build a strong risk





2-3 Establish thorough
ERM through BP company





3-1 Modify asset federation
model policy





3-2 Create a monitoring
program and ethical training





3-3 Implement a company- wide communication plan






As a recommendation we can focus on the proposed solutions table and pros/cons matrix cross results. In the solution ranking table above, we can see that the solution with the highest likelihood of success (Create a company-wide initiative safety program) is also the most difficult challenging to achieve. However, it will allow BP to implement an efficient and durable vision in order to provide the necessary measures to prevent from future disaster. Moreover, if other major accidents happen in the upcoming years, BP will not be able to recover the important monetary debt and its reputation will be severely damaged. Furthermore, based on the solution ranking table, BP should focus, first of all, in some solutions that have priority for the reinstate their credibility. First of all, they have to create a

company-wide initiative safety program, secondly, they need to shift from a risk-seeking company to a risk adverse one and finally they need to implement safety practices and training for their employee. These three solutions, if prioritized immediately can really decrease and mitigate upcoming potential disasters.


Beever, J., & Hess, J. L. (2016). Deepwater Horizon oil spill: An ethics case study in environmental engineering. American Society for Engineering Education.

Graham, B., Reilly, W. K., Beinecke, F., Boesch, D. F., Garcia, T. D., Murray, C. A., & Ulmer, F. (2011). The National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling. Deep Water. The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.

Greene-Blose, J. M. (2015). Deepwater horizon: lessons in probabilities. Paper presented at PMI® Global Congress 2015—EMEA, London, England. Newtown Square, PA: Project Management Institute.

Hillson, D. A., & Murray-Webster, R. (2006). Understanding risk attitude. Association for Project Management (APM) Yearbook 2006/2007, 25-27.

Ingersoll, C., Locke, R. M., & Reavis, C. (2012). BP and the Deepwater Horizon Disaster of 2010. MIT Sloan School of Management, Case Study.


MANAGEMENT. Corporate Finance Review 15.2 (2010): 38-42. ProQuest. Web. 21 Apr. 2019.

Jensen, M. C., & Meckling, W. H. (1976). Theory of the firm: Managerial behavior, agency costs and ownership structure. Journal of financial economics, 3(4), 305-360.

Julie, C., (2016). A Case Study in Engineering Ethics: The Deepwater Horizon Disaster.

A SunCam online continuing education course, Case Study. Retrieverd 4/16/2019 from:

O’Connor, E. O. H. (2011). Organizational apologies: BP as a case study. Vand. L. Rev., 64, 1957.

US Environmental Protection Agency. (2017). Deepwater Horizon – BP Gulf of Mexico Oil Spill. Retrieved 4/15/2019 from:


Columbia Gas of Massachusetts – Project Issue Analysis

It was late in the afternoon of September 13, 2018. Professor Rich Maltzman looked up, startled, as three sharp raps on his car window interrupted the online course he was teaching from his car. Why from his car? Everyone in the town of Andover (Massachusetts, USA) had already been told to get out of their their homes, and they awaited word from the police – should they leave the town altogether?

Yes! The three raps were from the Professor’s wife, and she was animatedly and urgently conveying the message: “we have to LEAVE TOWN. NOW!”

The urgency was coming from the breaking story so well-summarized by the podcast series, “
Fire in the Valley
”. Fires and explosions were occurring in over 100 structures in the Merrimack Valley region of Massachusetts, north of Boston, in particular in the City of Lawrence and the towns of North Andover and Andover, Massachusetts, where the Professor and his family reside.
It was hard for residents to get the important details. Local news stations were covering the story, but the information was scattered and hard to decipher meaningfully. The Twitter feed from Columbia Gas of Massachusetts, the utility that operates the natural gas lines that were involved had this post on their web page for hours during the incident:

This was of little help – and if it wasn’t so sad, it would actually be funny.

The local police were doing a better job posting advice and making announcements and sending out reverse 911 calls to residents. This is what triggered the raps on the windows and yielded the decision for Professor Maltzman to prematurely end his class, which ironically was about qualitative decision making.

This tweet from the authorities made things much more clear:


So, the Professor and his family headed to Cape Cod to stay with relatives – they were very lucky to have this option available. Others were not so lucky. See

this video

from Rabbi Howard Mandell who tells his story, which starts with a 6- foot flame emanating from his boiler’s gas supply.

A tremendous write-up of the story comes from an article from the June, 2019 issue of Popular Mechanics – an article entitled, “The Day the Town Blew Up”.
Here the key extract:

…On the Salem Street side of the O’Connell South Common (in Lawrence, Massachusetts), a public park, a contractor removes a length of cast-iron pipe, caps it, and sets it aside.

Feeney Brothers Utility Services (“Providing Underground Utility Services since 1988”) has a permit to open up a two-foot-wide, 340-foot-long stretch of Salem Street, for the purpose of “completing gas main tie-ins and retirement of dual cast-iron gas mains.” Feeney Brothers is a family-owned operation with seven hundred employees. They’ve worked extensively not only for Columbia Gas but also for the region’s other major natural-gas supplier, Eversource. In recent years, gas utilities in Massachusetts have increasingly relied on contractors to carry out projects like this.

It’s usually cheaper.

The job today is to install new polyethylene pipeline and tie it into a new distribution main, also plastic. The Feeney Brothers contractor may or may not be aware that a regulator sensing line— a gauge that measures gas pressure—is attached to the pipe he had discarded. But it’s important to note that he and his crew are performing their duties as directed, under Columbia Gas supervision, and correctly following the steps in the work package Columbia Gas developed and approved. Columbia Gas’s work order doesn’t mention the sensor and was not prepared by a professional engineer. Until four years ago, a technician from the Meter and Regulation Department would have been assigned to the site to monitor pressure readings on the affected section of gas main, but Columbia Gas, for undisclosed reasons, has ended this practice.

The sensor on the discarded length of pipe thinks it’s still measuring the gas pressure in a vast underground network. In fact, it is measuring nothing: The pipe has been disconnected from the network. The sensor might as well be attached to a hot dog. But the sensor doesn’t know any of that, and there is no other sensor in this segment of the network to contradict it.

The sensor sends a message to the regulator valves in this segment of the network: Boost the pressure! Which they do. But the sensor, because it’s still attached to the dead piece of pipe,

doesn’t detect any of that. Instead, it registers a pressure drop, all the way down to 0.01 psi. More pressure, it tells the valves, until they have opened completely, and two distribution systems that were supposed to be segregated, cordoned off from each other, are instead tied directly into each other for twenty-six minutes.

A wave of high-pressure gas rushes into the regional gas-main system that serves Lawrence, Andover, and North Andover. In the older cast-iron segments of the network, the pressure rises to at least 6 psi, twelve times what the pipes are capable of handling.

At 4:04 p.m., the first high-pressure alarm is received by the NiSource monitoring station—in Columbus, Ohio. A second alarm is received at 4:05 p.m.

In the control room in Ohio, the NiSource employees have no capacity to control, let alone shut down, the gas flow. They can only contact the Meters and Regulations Group at Columbia Gas, which at 4:06 p.m. dispatches its entire team of inspectors to investigate—a total of two people, or approximately one per 2,494.75 miles of pipe.

The result of this over-pressurization: 141 fires, 5 explosions, 21 serious injuries, 1 death, many people displaced and/or without heat or the ability to cook – for months, and the bankruptcy of Columbia Gas of Massachusetts.
This was the incident. How about the cause?
The NTSB incident report summarized the case in the following way:

NTSB investigators learned that, until about 4 years ago, Columbia Gas required that a technician monitor any gas main revision work which required depressurizing the main. The technician—typically from the Meter and Regulation department—would use a gauge to monitor the pressure readings on the impacted main and would communicate directly with the crew making the change. If a pressure anomaly occurred, the technician could quickly act to prevent an overpressurization action. Columbia Gas offered no explanation as to why this procedure was phased out.

Although the Columbia Gas monitoring center in Columbus, Ohio, received high-pressure alarms and reported the event to the Meters and Regulations department two minutes after receiving the first alarm, there were no technicians prestaged or positioned to immediately close valves when the overpressurization occurred. Had Columbia Gas adequately performed MOC (Management of Change) and placed personnel at critical points along the system, Columbia Gas could have immediately addressed the issue and mitigated the consequences of the event. Therefore, the NTSB recommends that NiSource apply MOC processes to all changes to adequately identify system threats that could result in a common mode failure.
Additionally, the NTSB recommends that NiSource develop and implement control procedures during modifications to gas mains to mitigate the risks identified during MOC operations. Gas main pressures should be continually monitored during these modifications and assets should be placed at critical locations to immediately shut down the system if abnormal operations are detected.

NTSB Recommendations

In November 2018, the NTSB issued a series of “urgent”

safety recommendations

. The report contained four recommendations for NiSource, the parent company of Columbia Gas, and one for the state, seeking elimination of the professional engineer licensure exemption for public utility work and a requirement for a professional engineer’s seal on public utility engineering drawings.

The NTSB report recommends NiSource do the following:

· revise the engineering plan and constructibility review process across all subsidiaries;
· review all records and documentation of natural gas systems;
· apply management of change processes to all changes to identify threats that could result in a common mode failure;
· develop and implement control procedures during gas main modifications to mitigate risks.

See below for important references and resources.

References and Resources

NTSB Incident Report

Popular Mechanics article, “

The Day The Town Blew Up

Boston Magazine
article on the real story of the Merrimack Valley explosions

Fire in the Valley – Podcast – Four episodes

Episode 1:
The first minutes of a disaster

Episode 2: “
I had never gone toward explosions before

Episode 3:
The sun rises after a disaster

Episode 4:
Making the Valley whole again

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