The Bureau of Safety and Environmental Enforcement's Incident Investigations Program

Published by the Department of the Interior, Office of Inspector General on 2019-11-07.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                                            CLOSEOUT MEMORANDUM

               INSPECTOR GENERAL


Report No.: 2017-EAU-067
                -   -                                  November 2019
               OFFICE OF
               INSPECTOR GENERAL


To:             Scott A. Angelle
                Director, Bureau of Safety and Environmental Enforcement

From:           Amy R. Billings
                Central Regional Manager

Subject:        Closeout Memorandum – The Bureau of Safety and Environmental
                Enforcement’s Incident Investigations Program
                Report No. 2017-EAU-067

        We reviewed the Bureau of Safety and Environmental Enforcement (BSEE) to determine
what progress has been made in improving its incident investigations program since the
Deepwater Horizon incident in 2010. Overall, we learned that BSEE improved its incident
investigations program, but communication challenges were impacting the program.

        After the Deepwater Horizon incident, we conducted an extensive review 1 of Federal
offshore oil and gas operations, which included the incident investigations program (formerly
known as accident investigations). We found that organizational, procedural, and regulatory
issues impeded the incident investigation program’s effectiveness. Specifically: (1) the program
did not have sufficient full-time dedicated investigation personnel; (2) the guidelines for
investigations did not contain detailed requirements for planning investigations, gathering and
documenting evidence, and ensuring quality control; and (3) the district offices did not have
appropriate investigations training. We recommended restructuring of the incident investigation

        Since our last review, BSEE made progress in improving its incident investigations
program. Specifically, BSEE established a National Investigations Program, dedicated staff to
incident investigations, developed policies to address incident investigations, and created a basic
training program on conducting incident investigations. In addition, BSEE updated and finalized
its investigations policy 2, tiering policy 3, and handbook 4.

       While BSEE made improvements in these areas, we found communication issues that
were negatively impacting the incident investigations program. For example:

  OIG Evaluation Report, A New Horizon: Looking to the Future of the Bureau of Ocean Energy Management,
Regulation and Enforcement (Report No. CR-EV-MMS-0015-2010), December 2010
  National Investigations Policy, Directive Number: 590-MC, November 5, 2018
  Reportable Incident Notification and Investigation, Directive Number 593-MC, November 5, 2018
  National Investigations Handbook, Directive Number 590-HBK, November 5, 2018

                           Office of Audits, Inspections, and Evaluations | Lakewood, CO
      •   The BSEE regions did not fully implement the tiering policy. BSEE developed a new
          tiering policy in 2016 that established three investigative tiers determined by the severity
          and complexity of the incident being reported to determine the amount of resources
          necessary to investigate an incident. The Pacific region had not fully implemented the
          policy, and some Gulf of Mexico Region (GOMR) staff told us they relied on prior
          guidance that more clearly determines the type of investigation needed, a practice
          unbeknownst to BSEE Headquarters. To alleviate confusion over the tiering policy, the
          New Orleans District Office created its own standard operating procedure detailing how
          that district investigates incidents and how it deviates from the tiering policy. The Alaska
          region did not have any reported incidents during the scope of our review, so it did not
          have the opportunity to implement the tiering policy.

      •   BSEE did not communicate which version of the investigations handbook was the most
          current. BSEE issued a draft version of its handbook in September 2016 to ensure a
          consistent approach to incident investigations. Staff required to implement the guidance
          in the handbook shared that they were uncertain as to which version was the most current
          because the versions were not dated or numbered. BSEE managers told us that the
          handbook was considered a “living” document and changes would continue to occur as
          the National Investigations Program evolves. The handbook remained in draft status for 2
          years, until November 2018.

        Towards the end of our review, BSEE corrected these issues by updating and finalizing
its investigations policy, tiering policy, and handbook. The revised investigations and tiering
policies now include the Pacific Region Compliance Section, the Pacific region’s counterpart to
the GOMR’s Office of Incident Investigations. In the handbook, BSEE replaced the tiering
instructions with a reference to the revised tiering policy. The revised documents are now
included as chapters in the Bureau Manual. BSEE communicated these revisions with staff
during an all-hands meeting on October 25, 2018—BSEE’s first all-hands meeting since 2016.
During the meeting, the Chief of the Safety and Incidents Investigations Division said she hoped
to eliminate the tiering policy in the future.

        The U.S. Government Accountability Office’s (GAO) Standards for Internal Control in
the Federal Government 5 (Greenbook) identifies information and communication as one of the
five components of internal controls in the Federal Government. In addition, the Greenbook
specifically cites communication as critical to the success of achieving objectives at all levels of
an organization and states that management should communicate policies and procedures to
personnel so they can implement their assigned responsibilities. While BSEE made changes to
address the communication issues outlined above, we encourage BSEE to continue to improve its
communications in the incident investigations program.

       We conducted our evaluation in accordance with the Quality Standards for Inspection and
Evaluation as put forth by the Council of the Inspectors General on Integrity and Efficiency. We
believe that the work performed provides a reasonable basis for our conclusions and

    GAO’s Standards for Internal Control in the Federal Government (GAO-14-704G), September 2014

       We appreciate the cooperation and assistance provided by your staff during our review. If
you have any questions regarding this memorandum, please contact me at 303-236-9243.

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