Cheryl Mackenzie

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Cheryl Mac 150Ms. MacKenzie has been an investigator with the CSB since September 2004. She has been involved in numerous CSB incident investigations, including the 2005 BP Texas City refinery explosion, the 2007 Xcel Energy penstock fire, natural gas explosion events at both the ConAgra Foods facility in 2009 and Kleen Energy natural gas plant in 2010, the Texas Tech University laboratory explosion in 2010, the Macondo well blowout that same year, and the 2013 West Fertilizer Plan explosion, among others.

Prior to her CSB work, Ms. MacKenzie conducted extensive study and research in the fields of anthropometrics, biomechanics, human information processing, and design. She has directed numerous usability assessments for clients in office, industrial, and virtual-world work settings. Ms. MacKenzie is a graduate of Cornell University with a Master’s degree specializing in Human Factors and Ergonomics.

Presentation Title

Human Factors and the Macondo Blowout – A CSB Perspective


The Macondo incident yields many lessons, with a primary one being the importance of human factors in drilling and completions operations. The reliance upon human detection, decision-making, and intervention is crucial for successful and safe work.

Yet multiple significant human factors challenges presented themselves to the Deepwater Horizon well operations crew and, in some cases, the onshore personnel meant to interact with them. I will present the human factors analysis of the U.S. Chemical Safety and Hazard Investigation Board’s investigation of the Macondo event, exploring these challenges and their applicability beyond Macondo. As part of this review, I will also describe some of the systemic and organisational factors of this incident that are inextricably linked to human performance.

This presentation will delve into the concepts of organizational complexity, resiliency, and performance reliability. Potential opportunities to further advance human performance in the dynamic and complex offshore work environment will be discussed, including non-technical skills development and minimising the gap between work-as-imagined versus work-as-done.

Date & place

19 - 21 April 2016
Staverton Park, Daventry, Northamptonshire

Organised by

Join delegates from:

Institute of Occupational Medicine
Royal Air Force
Health and Safety Executive
Office of Rail and Road
Rail Safety and Standards Board
Greenstreet Berman
The Keil Centre
DCA Design
and many more