1. The Macondo blowout
"But, who cares, it's done, end of
story, [we] will probably be fine and
we'll get a good cement job"
2. • This presentation summarizes the main topics
from the Safetec seminars held in week 20-21
in Oslo, Trondheim, Stavanger and Bergen,
(Norway).
• Do not hesitate to contact me if you have
questions!
3. Jon Espen Skogdalen
Jon.espen.skogdalen@gmail.com
(+47)99024171
http://no.linkedin.com/in/skogdalen
14. “Nearly 400 feet long, the Horizon had formidable and redundant
defenses against even the worst blowout. It was equipped to divert
surging oil and gas safely away from the rig. It had devices to
quickly seal off a well blowout or to break free from it. It had
systems to prevent gas from exploding and sophisticated alarms
that would quickly warn the crew at the slightest trace of gas. The
crew itself routinely practiced responding to alarms, fires and
blowouts, and it was blessed with experienced leaders who clearly
cared about safety.”
http://www.nytimes.com/2010/12/26/us/26spill.html
15. “What emerges is a stark and singular fact: crew
members died and suffered terrible injuries
because every one of the Horizon’s defenses failed
on April 20. Some were deployed but did not
work. Some were activated too late, after they
had almost certainly been damaged by fire or
explosions. Some were never deployed at all.”
http://www.nytimes.com/2010/12/26/us/26spill.html
17. Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
18. Deepwater technology
• drilling from 5,000 to 10,000 feet of water, and
from 20,000 to 30,000 feet of sub-seafloor depth:
– New directional drilling techniques,
– information from deep inside wells, using
“measurementswhile-drilling” tools and sensors that
provided position, temperature, pressure, and
porosity data while the borehole was being drilled.
– Improvements in marine risers using lightweight
composite materials and tensioners,
– new methods for preventing oil from cooling and
clogging in deepwater pipelines,
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
20. Started in the 1980s?
“The mid-1980s collapse in oil prices also ruined many
companies’ appetite for further leasing in the
deepwater Gulf of Mexico. But Shell and others chose
to take a longer-term view —a decision reinforced by
the failures in Alaska. Additional reinforcement came in
1987, when the Minerals Management Service reduced
the minimum bid for deepwater tracts from $900,000
to $150,000—enabling companies to lock up entire
basins for 10 years for only a couple million dollars.
During the next five years, despite flat oil and gas
prices, the industry acquired 1,500 tracts in
deepwater.”
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
21. 1998 - The supermajors
• In 1998, BP acquired Amoco.
• The next year, Exxon merged with Mobil in an $80
billion deal to create the world’s largest company.
BP-Amoco countered by acquiring ARCO;
• Total merged with Fina and Elf (renamed Total in
2003);
• Chevron combined with Texaco;
• finally, Conoco and Phillips joined to create the
sixth “super major” (along with Royal Dutch
Shell).
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
22. BP and Gulf of Mexico
• In August 2002, BP’s CEO Browne:
– spend $15 billion during the next decade on drilling
and developing these discoveries
– BP had become the largest-acreage holder in the
deepwater Gulf, with more than 650 tracts in water
depths greater than 1,500 feet,
– in possession of one-third of all deepwater reserves
then discovered.
– The deepwater Gulf of Mexico, Browne asserted,
would be the “central element” of BP’s growth
strategy.
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
23. Systemic corporate culture issues
• Grangemouth Refinery complex –2000
• Forties Alpha Production Platform –2003
• Texas City Refinery –2005
• Thunder Horse Platform -2005
• Prudhoe Bay Pipeline -2006
• Deepwater Horizon -2010
• Texas City Refinery (again) -2010
• BP pipelines across Alaska –2010
25. Macondo partners
• In February 2010, Deepwater Horizon
commenced drilling an exploratory well at the
Macondo Prospect (Mississippi Canyon Block
252), about 66 km off the southeast coast of
Louisiana, at a water depth of approximately
1,500 m
• BP (65%), Anadarko (25%) and MOEX Offshore
2007 (10%)
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
26. • one of the world's largest offshore drilling contractors
• based in Vernier, Switzerland
• offices in 20 countries
• 25,000 people worldwide
• fleet of 139 offshore drilling units
• hire out floating mobile drill rigs, along with the equipment
and personnel for operations, to oil and gas companies
• average daily rate of US$142,000 (2006)
• US$650,000 for its deepwater drillships
• 2007, Transocean announced a merger with GlobalSantaFe
Corporation for US$17 billion
• In 2009, revenues of $11.6 billion
27. • is the world's second largest oilfield services
corporation
• operations in more than 70 countries 52000
employees
• Main office Houston, Texas and Dubai, United
Arab Emirates
• Halliburton's major business segment is the
Energy Services Group
• provides technical products and services for
petroleum and natural gas exploration and
production
30. DH – best of safety!
• BP’s Patrick O’Bryan (vice-president for drilling
and completions, Gulf of Mexico Deepwater.);
• "the Deepwater Horizon was the best performing
rig that we had in our fleet and in the Gulf of
Mexico. And I believe it was one of the top
performing rigs in all the BP floater fleets from
the standpoint of safety and drilling
performance.”
• they had not had a single “lost-time incident” in
seven years of drilling.
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
31. Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
32. ”The well from hell”
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
33. Bartlit, J.F.H., Sankar, S.N., Grimsley, S.C., (2011). Macondo - The
Gulf Oil Disaster - Chief Counsel’s Report National Commission
on the BP Deepwater Horizon Oil Spill and Offshore Drilling,
Available at: http://www.oilspillcommission.gov/
34. Kick response
After the March 8 kick on the Deepwater Horizon, Guide (BP)
asked Transocean rig manager Paul Johnson to consider
how to improve the rig crew‘s hazard awareness. He
responded in an email:
“I thought about this a lot yesterday and asked for input from
the rig and none of us could come up with anything we are
not already doing.... You can tell them what the hazards
are, but until they get used to identifying them their selves,
they are only following your lead.... Maybe what we need is
a new perspective on Hazard recognition from someone
outside the industry.”
Bartlit, J.F.H., Sankar, S.N., Grimsley, S.C., (2011). Macondo - The Gulf Oil Disaster - Chief Counsel’s Report
National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, Available at:
http://www.oilspillcommission.gov/
35. Well design
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
36. Organization onshore
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
37. Organization offshore
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
38. Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
39. Centralizers
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
41. Risk factors - cementing
• Difficult drilling conditions, including serious lost
returns in the cementing zone;
• Difficulty converting float equipment and low
circulating pressure after conversion;
• No bottoms up circulation;
• Less than recommended number of centralizers;
• Low rate of cement flow;
• Low cement volume.
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
42. Halliburton cement design
• began pumping the Macondo job without carefully reviewing laboratory foam
stability data and without solid evidence that the foamed cement design would be
stable;
• reported foam stability data to BP selectively, choosing in February not to report
the more unfavorable February 13 test, and choosing in April not to report the
more unfavorable April 15 test result (although Halliburton contends these results
were erroneous);
• selected the pre-test conditioning time informally, choosing different conditioning
times (ranging from no time to three hours) in each of the four foam stability tests
without any stated explanation;
• assumed, without apparent scientific basis, that conditioning the base slurry
before foaming was scientifically equivalent to foaming the cement then pumping
it down the well; and
• recommended a cement design without conducting any formal internal review of
that design. Notably, the only design element that Halliburton manipulated
between February and April was retarder concentration, even though BP‘s well
design changed significantly during that period and even though bottomhole well
conditions were unknown in February. Halliburton has provided no evidence that a
supervisor or senior technical expert ever reviewed the final cement slurry design.
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
43. The temporary abandonment
procedure
1. Perform a positive-pressure test to test the integrity of the
production casing;
2. Run the drill pipe into the well to 8,367 feet (3,300 feet
below the mud line);
3. Displace 3,300 feet of mud in the well with seawater,
lifting the mud above the BOP and into the riser;
4. Perform a negative-pressure test to assess the integrity of
the well and bottom-hole cement job to ensure outside
fluids (such as hydrocarbons) are not leaking into the well;
5. Displace the mud in the riser with seawater;
6. Set the surface cement plug at 8,367 feet;
7. Set the lockdown sleeve.
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
44. Positive test
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
45. Negative test
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
46. Actions after the negative test
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
47. Kick detection
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
48. Kick detection
Bartlit, J.F.H., Sankar, S.N., Grimsley, S.C., (2011). Macondo - The Gulf Oil Disaster - Chief Counsel’s Report
National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, Available at:
http://www.oilspillcommission.gov/
49. Bartlit, J.F.H., Sankar, S.N., Grimsley, S.C., (2011). Macondo - The Gulf Oil Disaster - Chief Counsel’s Report
National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, Available at:
http://www.oilspillcommission.gov/
50. Bartlit, J.F.H., Sankar, S.N., Grimsley, S.C., (2011). Macondo - The Gulf Oil Disaster - Chief Counsel’s Report
National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, Available at:
http://www.oilspillcommission.gov/
51. Communication – special risk
“BP did not adequately inform Transocean about
the risks at the Macondo well, particularly the
risks of a poor bottomhole cement job.Transocean
argues that if BP had done so, its crew might have
demonstrated ―heightened awareness. But it is
unlikely that this particular communication failure
compromised kick detection; the crew would
probably have dismissed warnings about cement
risks anyhow after the successful negative
pressure test.”
Bartlit, J.F.H., Sankar, S.N., Grimsley, S.C., (2011). Macondo - The Gulf Oil Disaster - Chief Counsel’s Report
National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, Available at:
http://www.oilspillcommission.gov/
52. Human ergonomic and factor
“The well monitoring equipment on the
Deepwater Horizon was inadequate. For
example, the data displays depended not only
on the right person looking at the right data at
the right time, but also that the person
understood and interpreted the data
correctly.”
Bartlit, J.F.H., Sankar, S.N., Grimsley, S.C., (2011). Macondo - The Gulf Oil Disaster - Chief Counsel’s Report
National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, Available at:
http://www.oilspillcommission.gov/
53. Experience/training
Transocean leaves open the possibility that its
rig crew ―did not have the experience‖ or
training to interpret pressure anomalies
during the negative pressure test. If true, then
the crew likely did not have sufficient training
or ability to interpret the recurrence of those
anomalies during the final displacement.
Bartlit, J.F.H., Sankar, S.N., Grimsley, S.C., (2011). Macondo - The Gulf Oil Disaster - Chief Counsel’s Report
National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, Available at:
http://www.oilspillcommission.gov/
54. Lack of Training at Macondo
“Transocean has argued that the members of its
rig crew were tradesmen, not engineers, and
could not have been expected to interpret the
complex results of the Macondo negative
pressure test. Transocean’s training approach
certainly supports that view.”
Bartlit, J.F.H., Sankar, S.N., Grimsley, S.C., (2011). Macondo - The Gulf Oil Disaster - Chief Counsel’s Report
National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, Available at:
http://www.oilspillcommission.gov/
55. Communication – Well monitoring
“The pre-job meetings should also have informed
well monitoring personnel that certain kick
indicators such as pit gain and flow-out would be
compromised or unavailable during the planned
operations. Well monitoring personnel should
have been told that, as a result, they would need
to perform volumetric calculations to keep track
of pit gain, pay special attention to other
parameters (such as drill pipe pressure), and
conduct visual flow checks whenever the pumps
were stopped”
Bartlit, J.F.H., Sankar, S.N., Grimsley, S.C., (2011). Macondo - The Gulf Oil Disaster - Chief Counsel’s Report
National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, Available at:
http://www.oilspillcommission.gov/
56. Communcation - anomaly
“Even after the Transocean crew shut down the
pumps to investigate an anomaly, they did not
inform the Sperry Drilling mudlogger, senior
Transocean personnel, or the BP well site
leader of the anomaly or ask for their help in
resolving it.”
Bartlit, J.F.H., Sankar, S.N., Grimsley, S.C., (2011). Macondo - The Gulf Oil Disaster - Chief Counsel’s Report
National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, Available at:
http://www.oilspillcommission.gov/
57. Human intervention
“People especially mattered at Macondo because BP,
Transocean, and Halliburton placed heavy reliance on
human judgment. For instance, during displacement of the
riser with seawater, BP relied on the bottomhole cement as
the only barrier in the wellbore. But awareness of whether
that barrier was in place—because of the negative pressure
test—depended on human judgment. Another barrier, the
blowout preventer (BOP), also relied on human judgment
because of the importance of kick detection and kick
response. Yet, the companies failed to provide the rig crew
and well site leaders exercising that judgment with
adequate training, information, procedures, and support to
do their jobs effectively.”
Bartlit, J.F.H., Sankar, S.N., Grimsley, S.C., (2011). Macondo - The Gulf Oil Disaster - Chief Counsel’s Report
National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, Available at:
http://www.oilspillcommission.gov/
58. Risk assessment
• Problems with risk assessment practices appear to
have affected decision making at Macondo in a number
of ways.
– First, they allowed decision makers to avoid systematically
identifying the risks their procedures created and the steps
necessary to mitigate those risks.
– Second, the absence of formal risk assessment enabled
late and rushed decision making.
– Third, the lack of rigorous risk assessments led decision
makers to solve problems in isolation instead of
considering the cumulative impact their solutions might
have on the rest of the project.
Bartlit, J.F.H., Sankar, S.N., Grimsley, S.C., (2011). Macondo - The Gulf Oil Disaster - Chief Counsel’s Report
National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, Available at:
http://www.oilspillcommission.gov/
59. Gas on its way!
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
60. Bartlit, J.F.H., Sankar, S.N., Grimsley, S.C., (2011). Macondo - The Gulf Oil Disaster - Chief Counsel’s Report
National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, Available at:
http://www.oilspillcommission.gov/
61. Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
62. Managment findings
• BP’s management process did not adequately identify
or address risks created by late changes to well design
and procedures.
• Halliburton and BP’s management processes did not
ensure that cement was adequately tested.
• BP, Transocean, and Halliburton failed to communicate
adequately.
• Transocean failed to adequately communicate lessons
from an earlier near-miss to its crew.
• Decisionmaking processes at Macondo did not
adequately ensure that personnel fully considered the
risks created by time- and money-saving decisions.
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
68. “if the tour wasn’t going on, if there wasn’t
visitors, would you have stayed [on the Drill
Floor],”
“Yes, sir. And I wouldn’t be here talking to you.”
Miles Ezell – Senior Toolpusher Transocean
http://www.c-spanvideo.org/program/Eze
69. Key Investigative Findings
• Failure to Use the Diverter Line
• Hazardous Electrical Equipment
• Gas Detectors
• Bypassed Systems
• Design of the Main and Emergency Power
Sources
• Crew Blast Protection
• Command and Control
USCG, (2011). Report of Investigation into the Circumstances Surrounding the Explosion, Fire, Sinking and
Loss of Eleven Crew Members Aboard the Moblie Offshore Drilling Unit Deepwater Horizon in the Gulf of
Mexico April 20-22, 2010.United States Coast GuardAvailable at: http://www.deepwaterinvestigation.com
70. Key finding
“The master was not aware that he had the
authority to activate the Emergency
Disconnect System, a critical step to cut off
the flow of flammable gases to the MODU,
and the official who received gas alarms was
unaware of procedures relating to the
activation of the emergency shutdown
system in response to such alarms, even
though shutting down the engines could have
averted an explosion.”
USCG, (2011). Report of Investigation into the Circumstances Surrounding the Explosion, Fire, Sinking and
Loss of Eleven Crew Members Aboard the Moblie Offshore Drilling Unit Deepwater Horizon in the Gulf of
Mexico April 20-22, 2010.United States Coast GuardAvailable at: http://www.deepwaterinvestigation.com
71. Shortly thereafter, the on-watch subsea
supervisor arrived in the CCR and advised the
master, “I’m EDSing.” The master responded,
“No, calm down. We’re not EDSing.”
USCG, (2011). Report of Investigation into the Circumstances Surrounding the Explosion, Fire, Sinking and
Loss of Eleven Crew Members Aboard the Moblie Offshore Drilling Unit Deepwater Horizon in the Gulf of
Mexico April 20-22, 2010.United States Coast GuardAvailable at: http://www.deepwaterinvestigation.com
72. Notification of Emergency
At approximately 2150 …the on-watch dynamic positioning officer (DPO) yelled, “We’re
in a well control situation.” Soon thereafter, there were explosions causing a fire
and a loss of electrical power on board DEEPWATER HORIZON. The first official
notice of the emergency to the MODU crew came from the general alarm, which
was activated by the DPO. Simultaneously, the on-watch SDPO verbally announced
over the MODU’s public address system, “This is not a drill … muster at your
emergency stations.” A mud engineer on board later testified that he heard an
announcement, “Fire, fire, fire, this is not a drill … report to secondary muster
stations, do not go outside.”
The standard procedure for alerting the crew to flammable gas emergencies required
the onwatch DPO to manually activate the general alarm (GA) system after two or
more gas detectors were activated.240 In this case, multiple gas alarms had been
activated and acknowledged, but the GA was not sounded until the explosions
occurred. When asked why the GA was not immediately sounded after the first
alarms were received, the on-watch DPO stated, “It was a lot to take in. There was
a lot going on.”
USCG, (2011). Report of Investigation into the Circumstances Surrounding the Explosion, Fire, Sinking and
Loss of Eleven Crew Members Aboard the Moblie Offshore Drilling Unit Deepwater Horizon in the Gulf of
Mexico April 20-22, 2010.United States Coast GuardAvailable at: http://www.deepwaterinvestigation.com
73. Key finding
“In 2008, DEEPWATER HORIZON had two
significant incidents which could have
seriously affected the safety of the vessel or
the environment – a loss of power that
jeopardized the MODU’s ability to maintain its
position above the well and the flooding of a
compartment resulting from a failure to close
valves. Neither of these incidents was properly
investigated and addressed.”
USCG, (2011). Report of Investigation into the Circumstances Surrounding the Explosion, Fire, Sinking and
Loss of Eleven Crew Members Aboard the Moblie Offshore Drilling Unit Deepwater Horizon in the Gulf of
Mexico April 20-22, 2010.United States Coast GuardAvailable at: http://www.deepwaterinvestigation.com
74. Key Recommendations
• Requiring that MODUs have available a non-
electrically powered fire pump to provide fire
main pressure during a loss of electrical power;
• Requiring a fixed water deluge system to fight
fires on or near the Drill Floor, which may
automatically activate upon gas detection;
• Requiring hydrocarbon fire-resistant bulkheads
between the drilling area, adjacent
accommodation spaces, and spaces housing vital
safety equipment.
USCG, (2011). Report of Investigation into the Circumstances Surrounding the Explosion, Fire, Sinking and
Loss of Eleven Crew Members Aboard the Moblie Offshore Drilling Unit Deepwater Horizon in the Gulf of
Mexico April 20-22, 2010.United States Coast GuardAvailable at: http://www.deepwaterinvestigation.com
75. ”The root cause”
The most significant failure at Macondo—and the clear root
cause of the blowout—was a failure of industry
management. Most, if not all, of the failures at Macondo
can be traced back to underlying failures of management
and communication. Better management of
decisionmaking processes within BP and other companies,
better communication within and between BP and its
contractors, and effective training of key engineering and
rig personnel would have prevented the Macondo incident.
BP and other operators must have effective systems in
place for integrating the various corporate cultures, internal
procedures, and decisionmaking protocols of the many
different contractors involved in drilling a deepwater well.
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
76. The Commission - Key findings
• The Macondo well blowout was the product of human error, engineering
mistakes, and management failures, including the following:
– Failure adequately to evaluate and manage risk in late-stage well-design decisions.
– Failure to redesign cement slurry in response to tests that repeatedly demonstrated
problems with the slurry design.
– Failure to recognize that the critical “negative pressure test”—a key test used to
determine the integrity of the cement job that seals off the well—signaled that the
cement at the well-bottom had failed to seal off hydrocarbons.
– Failure to recognize that the temporary well-abandonment procedures, which BP
changed repeatedly in the days leading up to the blowout, unnecessarily increased the
risk of a well blowout.
– Failure to recognize and respond to early warning signals of the hydrocarbon influx (or
“kick”) that eventually became the blowout.
– Failure to respond appropriately to the blowout once it began, including but not limited
to the failure of the rig’s blowout preventer to shut in the well.
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
77. Main conclusions - 1
• The explosive loss of the Macondo well could have been prevented.
• The immediate causes of the Macondo well blowout can be traced to a
series of identifiable mistakes made by BP, Halliburton, and Transocean
that reveal such systematic failures in risk management that they place in
doubt the safety culture of the entire industry
• Deepwater energy exploration and production, particularly at the frontiers
of experience, involve risks for which neither industry nor government has
been adequately prepared, but for which they can and must be prepared
in the future.
• To assure human safety and environmental protection, regulatory
oversight of leasing, energy exploration, and production require reforms
even beyond those significant reforms already initiated since the
Deepwater Horizon disaster. Fundamental reform will be needed in both
the structure of those in charge of regulatory oversight and their internal
decisionmaking process to ensure their political autonomy, technical
expertise, and their full consideration of environmental protection
concerns.
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
78. Main conclusions - 2
• Because regulatory oversight alone will not be sufficient to ensure
adequate safety, the oil and gas industry will need to take its own,
unilateral steps to increase dramatically safety throughout the
industry, including self-policing mechanisms that supplement
governmental enforcement.
• The technology, laws and regulations, and practices for containing,
responding to, and cleaning up spills lag behind the real risks
associated with deepwater drilling into large, high-pressure
reservoirs of oil and gas located far offshore and thousands of feet
below the ocean’s surface. Government must close the existing gap
and industry must support rather than resist that effort.
• Scientific understanding of environmental conditions in sensitive
environments in deep Gulf waters, along the region’s coastal
habitats, and in areas proposed for more drilling, such as the Arctic,
is inadequate. The same is true of the human and natural impacts
of oil spills.
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
79. “BP did not adequately identify or address risks created by
last-minute changes to well design and procedures. BP
changed its plans repeatedly and up to the very last minute,
sometimes causing confusion and frustration among BP
employees and rig personnel.”
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
80. “When BP did send instructions and procedures to rig
personnel, it often provided inadequate detail and
guidance.”
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
81. “It is common in the offshore oil industry to focus on
increasing efficiency to save rig time and associated costs.
But management processes must ensure that measures
taken to save time and reduce costs do not adversely affect
overall risk. BP‘s management processes did not do so.”
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
82. “Halliburton appears to have done little to supervise the
work of its key cementing personnel and does not appear to
have meaningfully reviewed data that should have prompted
it to redesign the Macondo cement slurry.”
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
83. “Transocean did not adequately train its employees in
emergency procedures and kick detection, and did not
inform them of crucial lessons learned from a similar and
recent near-miss drilling incident.”
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
84. • BP did not adequately identify or address risks created by last-minute changes to
well design and procedures. BP changed its plans repeatedly and up to the very
last minute, sometimes causing confusion and frustration among BP employees
and rig personnel.
• When BP did send instructions and procedures to rig personnel, it often provided
inadequate detail and guidance.
• It is common in the offshore oil industry to focus on increasing efficiency to save
rig time and associated costs. But management processes must ensure that
measures taken to save time and reduce costs do not adversely affect overall risk.
BP‘s management processes did not do so.
• Halliburton appears to have done little to supervise the work of its key cementing
personnel and does not appear to have meaningfully reviewed data that should
have prompted it to redesign the Macondo cement slurry.
• Transocean did not adequately train its employees in emergency procedures and
kick detection, and did not inform them of crucial lessons learned from a similar
and recent near-miss drilling incident.
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
85. The Commission - Key findings
“These errors, mistakes, and management failures
were not the product of a single, rogue company,
but instead reveal both failures and inadequate
safety procedures by three key industry players
that have a large presence in offshore oil and gas
drilling throughout the world”
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
86. The Commission - Key findings
“Just as this Commission learned from the
experiences of other nations in developing our
recommendations, the lessons learned from
the Deepwater Horizon disaster are not
confined to our own government and industry,
but relevant to rest of the world.”
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
87. The Commission - Key findings
“The immediate causes of the Macondo well
blowout can be traced to a series of
identifiable mistakes made by BP, Halliburton,
and Transocean that reveal such systematic
failures in risk management that they place in
doubt the safety culture of the entire industry.”
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/
88. The Commission - Key findings
“Changes in safety and environmental practices,
safety training, drilling technology, containment
and clean-up technology, preparedness, corporate
culture, and management behavior will be
required if deepwater energy operations are to be
pursued in the Gulf— or elsewhere.”
Graham, B., Reilly, W.K., Beinecke, F., Boesch, D.F., Garcia, T.D., Murray, C.A., Ulmer, F., (2011). Deep Water.
The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.the National Commission on
the BP Deepwater Horizon Oil Spill and Offshore Drilling. Available at: http://www.oilspillcommission.gov/