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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"
• 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!
Jon Espen Skogdalen

 Jon.espen.skogdalen@gmail.com
           (+47)99024171
http://no.linkedin.com/in/skogdalen
Press this key for full-size view
http://www.oilspillcommission.gov/
http://www.deepwaterinvestigation.com
http://www.restorethegulf.gov/
http://www.cspan.org/Topics/Oil-Spill/
http://www.nytimes.com/2010/12/26/us/26spill.html
http://www.csb.gov/investigations/detail.aspx
?SID=96&Type=1&pg=1&F_All=y
http://www.bp.com/sectionbodycopy.do?cate
goryId=41&contentId=7067505
http://ccrm.berkeley.edu/deepwaterhorizonst
udygroup/index.shtml
“The worst environmental
  disaster America has
      ever faced.”

15 June 2010, President Barack Obama
“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
“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
Gulf of Mexico and BP
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/
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/
Challenges deepwater
•   huge costs,
•   complex casing programs,
•   narrow drilling margins,
•   high pressures,
•   high temperatures,
•   difficult formations,
•   uncertain seismic
•   lack of experienced personnel
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/
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/
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/
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
Macondo well
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/
•   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
• 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
http://www.onepetro.org/mslib/servlet/onepe
tropreview?id=OTC-20399-MS&soc=OTC
http://www.rigzone.com/news/article.asp?a_i
d=79954

  http://www.deepwater.com/fw/main/IDeepwa
  ter-Horizon-i-Drills-Worlds-Deepest-Oil-and-
  Gas-Well-419C1.html?LayoutID=6
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/
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/
”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/
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/
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/
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/
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/
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/
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/
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/
Cementing
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/
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/
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/
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/
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/
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/
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/
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/
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/
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/
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/
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/
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/
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/
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/
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/
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/
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/
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/
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/
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/
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/
Source: US Coastguard
Source: US Coastguard
Source: US Coastguard
Source: US Coastguard
Source: US Coastguard
“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
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
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
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
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
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
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
”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/
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/
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/
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/
“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/
“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/
“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/
“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/
“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/
•   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/
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/
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/
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/
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/
• http://www.nrk.no/nett-tv/prosjekt/1933/
Film
http://www.bp.com/sectionbodycop
y.do?categoryId=41&contentId=7067
                505
“…in the worst case, loss of a significant
portion of the 110-million-barrel reservoir into
                   the Gulf”
http://www.sciencedirect.com/science/article/
pii/S0925753511000828

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The Macondo blowout

  • 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
  • 4. Press this key for full-size view
  • 13. “The worst environmental disaster America has ever faced.” 15 June 2010, President Barack Obama
  • 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
  • 16. Gulf of Mexico and BP
  • 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/
  • 19. Challenges deepwater • huge costs, • complex casing programs, • narrow drilling margins, • high pressures, • high temperatures, • difficult formations, • uncertain seismic • lack of experienced personnel
  • 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
  • 29. http://www.rigzone.com/news/article.asp?a_i d=79954 http://www.deepwater.com/fw/main/IDeepwa ter-Horizon-i-Drills-Worlds-Deepest-Oil-and- Gas-Well-419C1.html?LayoutID=6
  • 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/
  • 91. “…in the worst case, loss of a significant portion of the 110-million-barrel reservoir into the Gulf”