CLOSEOUT MEMORANDUM OF INSPECTOR GENERAL U.S.DEPARTMENT OF THE INTERIOR THE BUREAU OF SAFETY AND ENVIRONMENTAL ENFORCEMENT’S INCIDENT INVESTIGATIONS PROGRAM Report No.: 2017-EAU-067 - - November 2019 OFFICE OF INSPECTOR GENERAL U.S.DEPARTMENT OF THE INTERIOR Memorandum 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 program. 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: 1 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 2 National Investigations Policy, Directive Number: 590-MC, November 5, 2018 3 Reportable Incident Notification and Investigation, Directive Number 593-MC, November 5, 2018 4 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 recommendations. 5 GAO’s Standards for Internal Control in the Federal Government (GAO-14-704G), September 2014 2 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. 3 Report Fraud, Waste, and Mismanagement Fraud, waste, and mismanagement in Government concern everyone: Office of Inspector General staff, departmental employees, and the general public. We actively solicit allegations of any inefficient and wasteful practices, fraud, and mismanagement related to departmental or Insular Area programs and operations. You can report allegations to us in several ways. By Internet: www.doioig.gov By Phone: 24-Hour Toll Free: 800-424-5081 Washington Metro Area: 202-208-5300 By Fax: 703-487-5402 By Mail: U.S. Department of the Interior Office of Inspector General Mail Stop 4428 MIB 1849 C Street, NW. Washington, DC 20240
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)