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THEBUREAUOFOCEANENERGYMANAGEMENT,

REGULATIONANDENFORCEMENT

REPORTREGARDINGTHECAUSESOFTHEAPRIL20,2010
MACONDOWELLBLOWOUT


September14,2011


TABLEOFCONTENTS

ExecutiveSummary ................................................................................................1
I. Introduction ..................................................................................................... 10
A. TheInvestigation ......................................................................................... 10
B. BackgroundRegardingDeepwaterDrillingintheGulfofMexico ............ 13
C. CompaniesInvolvedintheMacondoWell .................................................. 16
D. TheDeepwaterHorizon............................................................................... 18
E. TheMacondoWell ....................................................................................... 19
F. TheBlowout ................................................................................................. 23
II. WellDesign...................................................................................................... 25
A. CostoftheMacondoWell............................................................................ 25
B. DrillingMargin........................................................................................... 27
C. CasingProgram ........................................................................................... 31
D. MudProgramandType .............................................................................. 32
E. MudLosses .................................................................................................. 33
F. WellBallooning ........................................................................................... 34
G. PlannedandActualTotalDepth................................................................. 34
H. DesigningtheProductionCasingLongStringversusLiner................... 36
III. Cementing ........................................................................................................ 40
A. CementingProcess....................................................................................... 40
B. CementDesignandModeling ..................................................................... 41
C. GasFlowPotential....................................................................................... 46
D. Centralizers.................................................................................................. 47
E. FloatCollar .................................................................................................. 49
F. CementingtheMacondoProductionCasing .............................................. 53
G. IndustryStandardsforCementing.............................................................. 57
IV. PossibleFlowPaths ........................................................................................ 61
V. ConclusionsonWellDesign,Cementing,andFlowPath ........................ 68
A. CauseoftheFailureoftheCementBarrier.................................................. 68
B. ContributingCausesoftheCementBarrierFailure ................................... 68
C. PossibleContributingCausesoftheCementBarrierFailure ..................... 70
D. FlowPathCause .......................................................................................... 73
VI. ChallengesattheMacondoWell .................................................................. 75
A. KicksandStuckDrillPipe .......................................................................... 75
B. SchedulingConflictsandCostOverruns.................................................... 78
C. PersonnelChangesandConflicts ................................................................ 79
D. SafetyStanddown....................................................................................... 83
VII. TemporaryAbandonmentoftheMacondoWell ....................................... 85

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A. InstallingtheLockDownSleeve ................................................................. 85
B. SettingtheCementPlug.............................................................................. 86
C. TheUseofLostCirculationMaterialasSpacer.......................................... 87
D. WellIntegrityTesting ................................................................................. 88
VIII. KickDetectionandRigResponse................................................................. 98
A. KickDetectionMethodsandResponsibilities.............................................. 98
B. MultipleSimultaneousOperationsThatHamperedtheCrewsAbilityto
DetectKicks ................................................................................................. 99
C. RigFloorResponse .................................................................................... 103
D. TheUseoftheMudGasSeparator............................................................ 104
E. ActivityontheBridge................................................................................ 106
F. EmergencyDisconnectSystem.................................................................. 107
IX. ConclusionsonTemporaryAbandonment,KickDetection,andthe
EmergencyResponse................................................................................... 109
A. KickDetectionandResponseFailureCause ............................................. 109
B. KickDetectionFailureContributingCauses ............................................ 109
C. KickDetectionFailurePossibleContributingCauses .............................. 110
D. ResponseFailureContributingCauses ..................................................... 112
E. ResponseFailurePossibleContributingCauses ....................................... 113
X. IgnitionSource(s)andExplosions .............................................................. 115
A. MainEnginesandEngineSwitchGearRooms ........................................ 115
B. MudGasSeparator.................................................................................... 119
C. OtherPossibleIgnitionSources ................................................................ 122
XI. ConclusionsonIgnitionSourceandExplosion........................................ 125
A. IgnitionSources......................................................................................... 125
B. ContributingCausesoftheExplosion ....................................................... 125
C. PossibleContributingCausesoftheExplosion ......................................... 126
D. OtherPossibleIgnitionSources ................................................................ 127
XII. TheDeepwaterHorizonBOPStack............................................................... 129
A. DesignandConfiguration ......................................................................... 129
B. ControlandPowerSystems....................................................................... 132
C. EmergencyDisconnectSystem.................................................................. 133
D. AutomaticModeFunction(Deadman) ................................................. 134
E. AutoshearFunction ................................................................................... 134
F. ForensicExaminationoftheBOP ............................................................. 135
G. ExaminationMethodsUsedbyDNV........................................................ 137
H. DNVsForensicExaminationFindings .................................................... 138
I. EvaluationofOtherPossibleFailures ....................................................... 142
J. StudiesEvaluatingtheReliabilityofBOPs .............................................. 144
K. MaintenanceoftheDeepwaterHorizonBOP........................................... 146

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L. BOPSystemLeaks..................................................................................... 151
M. ROVInterventions .................................................................................... 153
XIII. BOPStackConclusions ................................................................................ 155
A. CauseoftheBOPStackFailure................................................................. 155
B. BOPStackFailureContributingCauses .................................................. 155
C. BOPStackFailurePossibleContributingCauses..................................... 155
XIV. RegulatoryFindings ..................................................................................... 157
A. PermittingProcess..................................................................................... 158
B. WellActivityReports ................................................................................ 161
C. MacondoDeparturesandAlternativeProcedures .................................... 161
D. MMSDrillingInspections ........................................................................ 162
E. PotentialIncidentofNoncomplianceGuidelines ...................................... 162
F. InspectionForms........................................................................................ 164
G. MMSDeepwaterHorizonInspectionsatMC252 ................................... 164
H. SafeDrillingMargin ................................................................................. 165
I. WellControl............................................................................................... 165
J. SubseaBOPRegulatoryRequirements ..................................................... 167
K. RegulatoryImprovements ......................................................................... 172
L. IncidentsofNonCompliance .................................................................... 173
XV. PoliciesandPracticesofInvolvedCompanies ......................................... 175
A. BPsPoliciesandPractices ........................................................................ 175
B. TransoceansPracticesandProcedures..................................................... 185
C. BPandTransoceanBridgingDocument................................................... 189
D. StopWorkAuthority ................................................................................. 189
XVI. ConclusionsRegardingInvolvedCompaniesPractices......................... 191
XVII. SummaryofPanelConclusions .................................................................. 194
A. WellDesignandCementing...................................................................... 194
B. FlowPath ................................................................................................... 195
C. TemporaryAbandonment,KickDetection,andEmergencyResponse ..... 195
D. IgnitionSource .......................................................................................... 197
E. BlowoutPreventer ..................................................................................... 198
F. CompanyPractices .................................................................................... 199
XVIII. Conclusion ..................................................................................................... 200
XIX. Recommendations......................................................................................... 202
A. WellRecommendations.............................................................................. 202
B. KickDetectionandResponseRecommendations ...................................... 203
C. IgnitionSourceRecommendations ............................................................ 205
D. BlowoutPreventerRecommendations....................................................... 206
E. RegulatoryAgencyRecommendations...................................................... 207
F. OCSCompaniesPracticesRecommendations.......................................... 209

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Dedication .............................................................................................................211
Acknowledgement ...............................................................................................212

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ExecutiveSummary

Atapproximately9:50p.m.ontheeveningofApril20,2010,whilethe
crewoftheDeepwaterHorizonrigwasfinishingworkafterdrillingtheMacondo
exploratorywell,anundetectedinfluxofhydrocarbons(commonlyreferredtoas
akick)escalatedtoablowout.Shortlyaftertheblowout,hydrocarbonsthat
hadflowedontotherigfloorthroughamudgasventlineignitedintwo
separateexplosions.Flowinghydrocarbonsfueledafireontherigthat
continuedtoburnuntiltherigsankonApril22.Elevenmendiedonthe
DeepwaterHorizonthatevening.Overthenext87days,almostfivemillion
barrelsofoilweredischargedfromtheMacondowellintotheGulfofMexico. 1

AfteranextensiveinvestigationconductedbytheJointInvestigation
TeamoftheBureauofOceanEnergyManagement,RegulationandEnforcement
(BOEMRE)(formerlytheMineralsManagementServiceorMMS)andthe
UnitedStatesCoastGuard,theBOEMREpanelofinvestigators(thePanel)has
identifiedanumberofcausesoftheMacondoblowout.

ThePanelfoundthatacentralcauseoftheblowoutwasfailureofa
cementbarrierintheproductioncasingstring,ahighstrengthsteelpipesetina
welltoensurewellintegrityandtoallowfutureproduction.Thefailureofthe
cementbarrierallowedhydrocarbonstoflowupthewellbore,throughtheriser
andontotherig,resultingintheblowout.Theprecisereasonsforthefailureof
theproductioncasingcementjobarenotknown.ThePanelconcludedthatthe
failurewaslikelydueto:(1)swappingofcementanddrillingmud(referredtoas
fluidinversion)intheshoetrack(thesectionofcasingnearthebottomofthe
well);(2)contaminationoftheshoetrackcement;or(3)pumpingthecementpast
thetargetlocationinthewell,leavingtheshoetrackwithlittleornocement
(referredtoasoverdisplacement).

ThelossoflifeattheMacondositeonApril20,2010,andthesubsequent
pollutionoftheGulfofMexicothroughthesummerof2010weretheresultof
poorriskmanagement,lastminutechangestoplans,failuretoobserveand
respondtocriticalindicators,inadequatewellcontrolresponse,andinsufficient

1Thisestimateisbaseduponpressurereadings,data,andanalysisconductedbyU.S.scientific
teamscommissionedbytheNationalIncidentCommander.See
http://www.doi.gov/news/pressreleases/USScientificTeamsRefineEstimatesofOilFlowfrom
BPWellPriortoCapping.cfm.

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emergencybridgeresponsetrainingbycompaniesandindividualsresponsible
fordrillingattheMacondowellandfortheoperationoftheDeepwaterHorizon.

BP,asthedesignatedoperatorunderBOEMREregulations,was
ultimatelyresponsibleforconductingoperationsatMacondoinawaythat
ensuredthesafetyandprotectionofpersonnel,equipment,naturalresources,
andtheenvironment.Transocean,theowneroftheDeepwaterHorizon,was
responsibleforconductingsafeoperationsandforprotectingpersonnelonboard.
Halliburton,asacontractortoBP,wasresponsibleforconductingthecementjob,
and,throughitssubsidiary(SperrySun),hadcertainresponsibilitiesfor
monitoringthewell.CameronwasresponsibleforthedesignoftheDeepwater
Horizonblowoutpreventer(BOP)stack.

Atthetimeoftheblowout,therigcrewwasengagedintemporary
abandonmentactivitiestosecurethewellafterdrillingwascompletedand
beforetheDeepwaterHorizonleftthesite.InthedaysleadinguptoApril20,BP
madeaseriesofdecisionsthatcomplicatedcementingoperations,added
incrementalrisk,andmayhavecontributedtotheultimatefailureofthecement
job.Thesedecisionsincluded:

Theuseofonlyonecementbarrier.BPdidnotsetanyadditionalcementor
mechanicalbarriersinthewell,eventhoughvariouswellconditions
createddifficultiesfortheproductioncasingcementjob.

Thelocationoftheproductioncasing.BPdecidedtosetproductioncasingin
alocationinthewellthatcreatedadditionalriskofhydrocarboninflux.

Thedecisiontoinstallalockdownsleeve.BPsdecisiontoincludethesetting
ofalockdownsleeve(apieceofequipmentthatconnectsandholdsthe
productioncasingtothewellheadduringproduction)aspartofthe
temporaryabandonmentprocedureatMacondoincreasedtherisks
associatedwithsubsequentoperations,includingthedisplacementof
mud,thenegativetestsequenceandthesettingofthesurfaceplug.

Theproductioncasingcementjob.BPfailedtoperformtheproduction
casingcementjobinaccordancewithindustryaccepted
recommendations.

ThePanelconcludedthatBPfailedtocommunicatethesedecisionsand
theincreasingoperationalriskstoTransocean.Asaresult,BPandTransocean

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personnelonboardtheDeepwaterHorizonontheeveningofApril20,2010,did
notfullyidentifyandevaluatetherisksinherentintheoperationsthatwere
beingconductedatMacondo.

OnApril20,BPandTransoceanpersonnelonboardtheDeepwaterHorizon
missedtheopportunitytoremedythecementproblemswhenthey
misinterpretedanomaliesencounteredduringacriticaltestofcementbarriers
calledanegativetest,whichseekstosimulatewhatwilloccuratthewellafterit
istemporarilyabandonedandtoshowwhethercementbarrier(s)willhold
againsthydrocarbonflow.

Therigcrewconductedaninitialnegativetestontheproductioncasing
cementjobthatshowedapressuredifferentialbetweenthedrillpipeandthekill
line,whichisahighpressurepipeleadingfromtheBOPstacktotherigpumps.
Thiswasaseriousanomalythatshouldhavealertedtherigcrewtopotential
problemswiththecementbarrierorwiththenegativetest.Aftersome
discussionamongmembersofthecrewandasecondnegativetestonthekill
line,therigcrewexplainedthepressuredifferentialawayasabladdereffect,a
theorythatlaterprovedtobeunfounded.Around7:45p.m.,afterobservingfor
30minutesthattherewasnoflowfromthekillline,therigcrewconcludedthat
thenegativetestwassuccessful.Atthispoint,therigcrewmostlikely
concludedthattheproductioncasingcementbarrierwassound.

Thecementintheshoetrackbarrier,however,hadinfactfailed,and
hydrocarbonsbegantoflowfromtheMacondoreservoirintothewell.Despitea
numberofadditionalanomaliesthatshouldhavesignaledtheexistenceofakick
orwellflow,thecrewfailedtodetectthatthewellwasflowinguntil9:42p.m.
Bythenitwastoolatethewellwasblowingdrillingmudupintothederrick
andontotherigfloor.Ifmembersoftherigcrewhaddetectedthehydrocarbon
influxearlier,theymighthavebeenabletotakeappropriateactionstocontrol
thewell.TherewereseveralpossiblereasonswhytheDeepwaterHorizoncrew
didnotdetectthekick:

Therigcrewhadexperiencedproblemsinpromptlydetectingkicks.The
DeepwaterHorizoncrewhadexperiencedakickonMarch8,2010thatwent
undetectedforapproximately30minutes.BPdidnotconductan
investigationintothereasonsforthedelayeddetectionofthekick.
TransoceanpersonneladmittedtoBPthatindividualsassociatedwiththe
March8kickhadscrewedupbynotcatchingthekick.Tenofthe11

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individualsondutyonMarch8,whohadwellcontrolresponsibilities,
werealsoondutyonApril20.

Simultaneousrigoperationshamperedtherigcrewswellmonitoringabilities.
Therigcrewsdecisiontoconductsimultaneousoperationsduringthe
criticalnegativetestsincludingdisplacementoffluidstotwoactivemud
pitsandcleaningthepitsinpreparationtomovetherigcomplicated
wellmonitoringefforts.

Therigcrewbypassedacriticalflowmeter.Atapproximately9:10p.m.,the
rigcrewdirectedfluiddisplacedfromthewelloverboard,which
bypassedtheSperrySunflowmeter,whichisacriticalkickdetectiontool
thatmeasuresoutflowfromthewell.TheDeepwaterHorizonwas
equippedwithotherflowmeters,butthePanelfoundnoevidencethat
thesemeterswerebeingmonitoredpriortotheblowout.

Oncethecrewdiscoveredthehydrocarbonflow,itsenttheflowtoamud
gasseparator,apieceofequipmentnotdesignedtohandlehighflowrates.The
mudgasseparatorcouldnothandlethevolumeofhydrocarbons,andit
dischargedagasplumeabovetherigfloorthatignited.

ThePanelfoundevidencethattheconfigurationoftheDeepwaterHorizon
generalalarmsystemandtheactionsofrigcrewmembersonthebridgeofthe
rigcontributedtoadelayinnotifyingtheentirecrewofthepresenceofvery
highgaslevelsontherig.TransoceanhadconfiguredtheDeepwaterHorizons
generalalarmsystemininhibitedmode,whichmeantthatthegeneralalarm
wouldnotautomaticallysoundwhenmultiplegasalarmsweretriggeredin
differentareasontherig.Asaresult,personnelonthebridgewereresponsible
forsoundingofthegeneralalarm.Personnelonthebridgewaited
approximately12minutesafterthesoundingoftheinitialgasalarmstosound
thegeneralalarm,eventhoughtheyhadbeeninformedthatawellcontrol
problemwasoccurring.Duringthisperiod,therewereapproximately20
alarmsindicatingthehighestlevelofgasconcentrationindifferentareasonthe
rig.

TheDeepwaterHorizonsBOPstack,amassive,360tondeviceinstalledat
thetopofthewell,wasdesignedtoallowtherigcrewtohandlenumeroustypes
ofwellcontrolevents.However,onApril20,theBOPstackfailedtosealthe
welltocontaintheflowofhydrocarbons.Theexplosionslikelydamagedthe
DeepwaterHorizonsmultiplexcablesandhydrauliclines,renderingthecrew

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unabletoactivatetheBOPstack.TheBOPstackwasequippedwithan
automaticmodefunction,whichuponactivationwouldtriggertheblindshear
ram(BSR),twometalblockswithbladesontheinsideedgesthataredesignedto
cutthroughthedrillpipeandsealthewellduringawellcontrolevent.

ThePanelconcludedthatthereweretwopossiblewaysinwhichtheBSR
mighthavebeenactivated:(1)onApril20,bytheautomaticmodefunction,
immediatelyfollowinglossofcommunicationwiththerig;or(2)onApril22,
whenaremotelyoperatedvehicletriggeredtheautoshearfunction,whichis
designedtoclosetheBSRifthelowermarineriserpackagedisconnectsfromthe
restoftheBOPstack.RegardlessofhowtheBSRwasactivated,itdidnotseal
thewell.

AforensicexaminationoftheBOPstackrevealedthatelasticbucklingof
thedrillpipehadforcedthedrillpipeupagainstthesideofthewellboreand
outsidethecuttingsurfaceoftheBSRblades.Asaresult,theBSRdidnot
completelyshearthedrillpipeanddidnotsealthewell.Thebucklingofthe
drillpipe,whichlikelyoccurredatornearthetimewhencontrolofthewellwas
lost,wascausedbytheforceofthehydrocarbonsblowingoutofthewell;bythe
weightofthe5,000feetofdrillpipelocatedintheriserabovetheBOPforcingthe
drillpipedownintotheBOPstack;orbyacombinationofboth.Asaresultof
thefailureoftheBSRtocompletelycutthedrillpipeandsealthewell,
hydrocarbonscontinuedtoflowaftertheblowout.

PriortotheeventsofApril20,BPandTransoceanexperiencedanumber
ofproblemswhileconductingdrillingandtemporaryabandonmentoperations
atMacondo.Theseproblemsincluded:

Recurringwellcontroleventsanddelayedkickdetection.Atleastthree
differentwellcontroleventsandmultiplekicksoccurredduring
operationsatMacondo.OnMarch8,ittooktherigcrewatleast30
minutestodetectakickinthewell.ThedelayraisedconcernsamongBP
personnelabouttheDeepwaterHorizoncrewsabilitytopromptlydetect
kicksandtakeappropriatewellcontrolactions.Despitetheseprior
problems,BPdidnottakestepstoensurethattherigcrewwasbetter
equippedtodetectkicksandtohandlewellcontrolevents.AsofApril20,
TransoceanhadnotcompleteditsinvestigationintotheMarch8incident.

Schedulingconflictsandcostoverruns.Atthetimeoftheblowout,
operationsatMacondoweresignificantlybehindschedule.BPhad

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initiallyplannedfortheDeepwaterHorizontomovetoBPsNilewellby
March8,2010.Inlargepartasaresultofthisdelay,asofApril20,BPs
Macondooperationsweremorethan$58millionoverbudget.

Personnelchangesandconflicts.BPexperiencedanumberofproblems
involvingpersonnelwithresponsibilityforoperationsatMacondo.A
reorganizationthattookplaceinMarchandApril2010changedtheroles
andresponsibilitiesofatleastnineindividualswithsomeresponsibility
forMacondooperations.Inaddition,thePanelfoundevidenceofa
conflictbetweentheBPdrillingandcompletionsoperationsmanagerand
theBPwellsteamleaderandevidenceofafailuretoadequatelydelineate
rolesandresponsibilitiesforkeydecisions.

Atthetimeoftheblowout,bothBPandTransoceanhadextensive
proceduresinplaceregardingsafedrillingoperations.BPrequiredthatits
drillingandcompletionspersonnelfollowadocumentedandauditablerisk
managementprocess.ThePanelfoundnoevidencethattheBPMacondoteam
fullyevaluatedongoingoperationalrisks,nordiditfindevidencethatBP
communicatedwiththeTransoceanrigcrewaboutsuchrisks.

Transoceanhadanumberofdocumentedsafetyprogramsinplaceatthe
timeoftheblowout.Nonetheless,thePanelfoundevidencethatTransocean
personnelquestionedwhethertheDeepwaterHorizoncrewwasadequately
preparedtoindependentlyidentifyhazardsassociatedwithdrillingandother
operations.

EveryoneonboardtheDeepwaterHorizonwasobligatedtofollowthe
TransoceanstopworkpolicythatwasinplaceonApril20,whichprovided
that[e]achemployeehastheobligationtointerruptanoperationtopreventan
incidentfromoccurring.DespitethefactthatthePanelidentifiedanumberof
reasonsthattherigcrewcouldhaveinvokedstopworkauthority,noindividual
ontheDeepwaterHorizondidsoonApril20.

ThePanelfoundevidencethatBPand,insomeinstances,itscontractors
violatedthefollowingfederalregulations:

30CFR250.107BPfailedtoprotecthealth,safety,property,andthe
environmentby(1)performingalloperationsinasafeandworkmanlike
manner;and(2)maintainingallequipmentandworkareasinasafe
condition;

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30CFR250.300BP,Transocean,andHalliburton(SperrySun)failedto
takemeasurestopreventtheunauthorizedreleaseofhydrocarbonsinto
theGulfofMexicoandcreatingconditionsthatposedunreasonablerisk
topublichealth,life,property,aquaticlife,wildlife,recreation,navigation,
commercialfishing,orotherusesoftheocean;

30CFR250.401BP,Transocean,andHalliburton(SperrySun)failedto
takenecessaryprecautionstokeepthewellundercontrolatalltimes;

30CFR250.420(a)(1)and(2)BPandHalliburtonfailedtocementthe
wellinamannerthatwouldproperlycontrolformationpressuresand
fluidsandpreventthereleaseoffluidsfromanystratumthroughthe
wellboreintooffshorewaters;

30CFR250.427(a)BPfailedtousepressureintegritytestandrelated
holebehaviorobservations,suchasporepressuretestresults,gascut
drillingfluid,andwellkickstoadjustthedrillingfluidprogramandthe
settingdepthofthenextcasingstring;

30CFR250.446(a)BPandTransoceanfailedtoconductmajor
inspectionsofallBOPstackcomponents;and

30CFR250.1721(a)BPfailedtoperformthenegativetestprocedures
detailedinanapplicationforapermittomodifyitsplans.

AlthoughthePanelfoundnoevidencethatMMSregulationsineffecton
April20,2010wereacauseoftheblowout,thePanelconcludedthatstronger
andmorecomprehensivefederalregulationsmighthavereducedthelikelihood
oftheMacondoblowout.Inparticular,thePanelfoundthatMMSregulationsin
placeatthetimeoftheblowoutcouldbeenhancedinanumberofareas,
including:cementingproceduresandtesting;BOPconfigurationandtesting;
wellintegritytesting;andotherdrillingoperations.Inaddition,thePanelfound
thattherewereanumberofwaysinwhichtheMMSdrillinginspections
programcouldbeimproved.Forexample,thePanelconcludedthatdrilling
inspectionsshouldevaluateemergencydisconnectsystemsand/orotherBOP
stacksecondarysystemfunctions.BOEMREhasalreadyimplementedmanyof
theseimprovements.

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ThisReportsetsforthindetailthePanelsinvestigativefindings,
conclusions,andrecommendations.ThePanelsfindingsandconclusionsare
presentedinthefollowingsubjectareas:welldesign;cementing;possibleflow
paths;temporaryabandonmentoftheMacondowell;kickdetectionandrig
response;ignitionsourceandexplosion;thefailureoftheDeepwaterHorizon
blowoutpreventer;regulatoryfindingsandconclusions;andcompanypractices.

ThisReportconcludeswiththePanelsrecommendations,whichseekto
improvethesafetyofoffshoredrillingoperationsinavarietyofdifferentways:

Welldesign.Improvedwelldesigntechniquesforwellswithhighflow
potential,includingincreasingtheuseofmechanicalandcementbarriers,
willdecreasethechancesofablowout.

Wellintegritytesting.Betterwellintegritytestpractices(e.g.,negativetest
practices)willallowrigcrewstoidentifypossiblewellcontrolproblemsin
atimelymanner.

Kickdetectionandresponse.Theuseofmoreaccuratekickdetectiondevices
andothertechnologicalimprovementswillhelptoensurethatrigcrews
candetectkicksearlyandmaintainwellcontrol.Bettertrainingalsowill
allowrigcrewstoidentifysituationswherehydrocarbonsshouldbe
divertedoverboard.

Rigengineconfiguration(airintakelocations).Assessmentandtestingof
safetydevices,particularlyonrigswhereairintakelocationscreate
possibleignitionsources,maydecreasethelikelihoodofexplosionsand
fatalitiesintheeventofablowout.

Blowoutpreventers.ImprovementsinBOPstackconfiguration,operation,
andtestingwillallowrigcrewstobebetterabletohandlewellcontrol
events.

Remotelyoperatedvehicles(ROVs).StandardizationofROVintervention
panelsandinterventioncapabilitieswillallowforimprovedresponse
duringablowout.

ThePanelbelievesthattheadoptionoftheproposedrecommendations
willimprovethesafetyofoffshoreoperationsandwillhelptoreducethe

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likelihoodoftheoccurrenceofanothertragiceventsimilartotheMacondo
blowout.

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I. Introduction

A. TheInvestigation

OnApril27,2010,theSecretariesoftheDepartmentofHomelandSecurity
andtheDepartmentoftheInteriorconvenedajointinvestigationofthe
explosionandsinkingofthemobileoffshoredrillingunitDeepwaterHorizon 2by
theBureauofOceanEnergyManagement,RegulationandEnforcement
(BOEMRE)andtheUnitedStatesCoastGuard(USCG).TheConvening
OrderdirectedtheJointInvestigationTeam(JIT)toissueajointreportwithin
ninemonths.ThisdeadlinewasextendedtoallowtheJITtocompletethe
investigation.

OnApril29,2010,anMMSAssociateDirectorappointedtheMMS(now
BOEMRE)membersoftheJIT. 3ThisReportisbasedontheinvestigativerecord
developedbytheJITandcontainsthePanelsfindingsandconclusions.
BOEMREsInvestigationsandReviewUnit(IRU),inclosecoordinationwith
thePanel,hadasubstantialroleinthedraftingandpreparationoftheReport. 4

TheConveningOrderprovidesthatrelevantstatutesandregulations
relatingtoboththeUSCGandBOEMREgoverntheJITandthattheJITspublic
hearingsbeconductedinaccordancewiththeUSCGsrulesandprocedures
relatingtoMarineBoardsofInvestigation.Undertheserules,theJITwas
requiredtoformallydesignatecertaincompaniesandindividualsinvolvedwith
theDeepwaterHorizonoperationatthetimeoftheblowoutaspartiesininterest
(PIIs)andalsoretainedtheauthoritytodesignateotherPIIsatitsdiscretion.
TheJITdesignatedthefollowingentitiesandindividualsasPIIs:BP,Transocean,
Halliburton,MISWACO,Weatherford,AnadarkoPetroleum,MOEXUSACorp.,
DrilQuip,JimmyHarrell(Transocean),CurtKuchta(Transocean),Douglas
HaroldBrown(Transocean),SteveBertone(Transocean),MikeWilliams

2JointDepartmentoftheInteriorandDepartmentofHomelandSecurityStatementofPrinciples
andConveningOrderRegardingInvestigationintotheMarineCasualty,Explosion,Fire,
Pollution,andSinkingofMobileOffshoreDrillingUnitDeepwaterHorizon,withLossofLifein
theGulfofMexico,April2122,2010(theConveningOrder).ByorderoftheSecretaryofthe
Interior,datedJune18,2010,BOEMREreplacedtheformerMineralsManagementService
(MMS)astheUnitedStatesoffshoreresourcemanagerandsafetyauthority.
3PanelmembersincludedDavidDykes(cochair),GlynnBreaux,JohnMcCarroll,Kirk

Malstrom,andJasonMathews.
4IRUmembersincludedMichaelFarber,LisaScanlon,andKishanNair.

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(Transocean),PatrickOBryan(BP),andRobertKaluza(BP). 5UndertheMarine
Boardrulesandothergoverningauthorities,thePIIspossessedcertainrights
relatingtotheinvestigation. 6

UndertheConveningOrder,theJITwasgiventhefullinvestigative
authorityofboththeDepartmentoftheInteriorandtheDepartmentof
HomelandSecurity. 7TheJITheldsevenpublichearingsandheardtestimony
frommorethan80witnesses. 8Threewitnesseswhosetestimonywassoughtby
theJITinvokedtheirFifthAmendmentrightsagainstselfincriminationand
refusedtotestifyduringtheJIThearings,andtwootherwitnessesclaimedthey
wereunabletotestifyformedicalreasons. 9Inadditiontothepublichearings,
BOEMREinvestigatorsalsoconductedinterviewsofmorethan25individuals
throughouttheinvestigation.

TheJITcollectedandreviewedlargevolumesofelectronicandwritten
material,includingdata,emailsandotherrecordsrelatedtothePIIsequipment,
managementsystems,supervisionofemployeesandcontractors,
communications,performanceandtrainingofpersonnel,relevantcompany
policiesandpractices,andworkenvironment.TheJITissuedmorethan90
subpoenasfordocumentsandotherinformationandcollectedover400,000
pagesofevidence.

Duringthecourseoftheinvestigation,theJITcommissionedseveral
entitiesandqualifiedindividualstoconductexpertanalysesofevidence.Dr.
JohnSmith,apetroleumengineerwithPetroleumConsultingLLC,reviewed

5AttherequestoftheRepublicoftheMarshallIslands,theJITdesignateditasaSubstantially
InterestedState.TheDeepwaterHorizonwasaforeignflaggedvesselthat,atthetimeofthe
blowout,wasflaggedundertheRepublicoftheMarshallIslands.
6See46U.S.C.6303;46CFR.4.0310,4.0735,4.0915.

7ConveningOrder,at1.

8RetiredUnitedStatesDistrictJudgeWayneAndersen,whoservedwithoutcompensation,

joinedtheJITinAugust2010topresideoversubsequenthearings.BOEMREisgratefulforJudge
AndersensassistanceduringthehearingsandinmeetingswithcounselforthePIIs.
9BrianMorelandRobertKaluzaeachinvokedhisFifthAmendmentRightsandrefusedtotestify

duringJIThearings.Aftertestifyingatonehearing,MarkHafleinvokedhisFifthAmendment
Rightsandrefusedtotestifyasecondtime.Throughhisattorney,DonaldVidrineclaimedthat
hecouldnottestifyduetomedicalreasons.EachofthesefourindividualswasaBPemployeeat
thetimeoftheblowoutandcontinuestobeemployedbyBP.Inaddition,twoTransocean
witnessesdeclinedtocooperatewiththeinvestigation,citingtechnicalreasonsfortheirdecisions
nottotestify.Transoceandeclinedtoencouragethesewitnessestocooperatewiththe
investigation.

11
wellconditiondatacollectedbySperrySunduringthetemporaryabandonment
procedureandreportspreparedbytheInternationalAssociationofDrilling
Contractors(IADC)tohelpreconstructandidentifykeyissuesduringthe24
hoursimmediatelypriortotheblowout.KeystoneEngineeringconducteda
casingbuoyancyanalysis. 10OilfieldTestingandConsultingconductedacement
blendanalysisonsamplesprovidedbyHalliburton.DetNorskeVeritas
(DNV)conductedtheforensicexaminationoftheDeepwaterHorizonsBOP
stackandsectionsofdrillpipeandprovidedaforensicanalysisreportdetailing
theinformationandconclusionsdevelopedbasedonthisexamination.11These
expertreportsareattachedasappendicestothisReport.

Thepurposeofthisinvestigationwastoidentifythecausesofthe
Macondoblowoutandissuerecommendationsinordertoreducethelikelihood
ofasimilareventinthefuture.Throughoutthisreport,thePanelclassifiesthe
factorsthatcontributedtotheblowoutinthefollowingcategories:

Causesarethosefactorsthatmostimmediatelyandproximatelycaused
theblowout;thatmostdirectlyledtothecircumstancesunderlyingthe
blowout;orthatallowedtheblowouttohappen.Butforthesefactors,
therewouldnothavebeenablowout.Thesefactorsmaybespecific
eventsorconditionsthatexistedinthewellorontherigatthetimeofthe
blowout.

ContributingCausesarethosefactorsthatalonewouldnothaveledto
theblowout,butthatweresignificantincontributingtotheeventsor
conditionsthatgaverisetotheblowout.Forafactortobeclassifiedasa
contributingcauseofanevent,theremustbecompellingevidence
supportingboththeexistenceofthefactorandthatitmaterially
contributedtotheoccurrenceorseverityoftheevent.

PossibleContributingCausesarethosefactorsthateitherwereminor
contributingcausesoftheblowoutorforwhichtheevidencesuggeststhe
factorscontributingroleintheblowoutisweakerorlesscompelling.

10Thecasingbuoyancyanalysisevaluatedwhethertheproductioncasingfloatedupthewellbore
aresultoftheblowout.
11
Asdiscussedinmoredetaillaterinthisreport,aBOPstackisalargedevicethatsitsontopofa
wellandisdesignedtoassistrigcrewsinmaintainingcontrolofthewell.VariousBOPstack
componentscanbemanuallyorautomaticallyoperatedtosealthewellandprotectagainsta
blowout.ThecentralissueinvestigatedbytheJITregardingtheDeepwaterHorizonBOPwaswhy
theBOPfailedtostoptheflowofhydrocarbonsfromtheMacondowell.

12

B. BackgroundRegardingDeepwaterDrillingintheGulfof
Mexico

Thegoalofdeepwaterdrillingoperationsistolocateandextractoiland
gas(collectivelyreferredtoashydrocarbons)fromreservoirslocatedbeneath
theseafloor.Insomereservoirs,thehydrocarbonsbecometrappedbeneath
impermeablerock;whenthishappens,thehydrocarbonsseepintosurrounding
porousrock.Drillingoperationsseektopenetratetheimpermeablerocktogetto
hydrocarbonbearingreservoirsorpayzones.

TheGulfofMexicoishometoalargenumberofhydrocarbonreservoirs.
Since1947,morethan50,000wellshavebeendrilledintheU.S.GulfofMexico.
Approximately97%oftheoilproducedontheU.S.OuterContinentalShelf
(OCS)isproducedintheU.S.GulfofMexico.Therearecurrentlynearly7,000
activeleasesintheU.S.GulfofMexico,64%ofwhichareindeepwater.12

Since1995,deepwaterdrillingactivityhasincreasedsignificantlyinthe
Gulf.In2001,U.S.deepwateroffshoreoilproductionsurpassedshallowwater
offshoreoilproductionforthefirsttime.AsofMay2010,operatorsdrilled
approximately700wellsinwaterdepthsequaltoorgreaterthan5,000feet,the
approximatedepthoftheMacondowell. 13Deepwaterreservoirscanyieldahigh
volumeofoilandgas.Productionratesfordeepwaterwellsaretypicallymuch
higherthaninshallowwaterwells.

Theinitialwellorwellsdrilledintoaformationarereferredtoas
exploratorywells,whichanoperatordrillstodeterminewhetherareservoir
containssufficientvolumesofhydrocarbonstowarrantinvestmentinthe

SeeDepartmentofInterior,IncreasedSafetyMeasuresforEnergyDevelopmentontheOuter
12

ContinentalShelf,(May27,2010).Althoughthereisnosingleaccepteddefinitionof
deepwater,acommonuseofthetermistorefertolocationswherethewaterdepthisatleast
1,000feet.
13Id.Operatorsarethepersonsthelessee(s)designatesashavingcontrolormanagementof
operationsontheleasedareaoraportionthereof.Anoperatormaybealessee,theMMS
approveddesignatedagentofthelessee(s),ortheholderofoperatingrightsunderanMMS
approvedoperatingrightsassignment.Lesseemeansapersonwhohasenteredintoalease
withtheUnitedStatestoexplorefor,develop,andproducetheleasedminerals.Thetermlessee
alsoincludestheMMSapprovedassigneeofthelease,andtheownerortheMMSapproved
assigneeofoperatingrightsforthelease.30CFR250.105.

13
installationofequipmentrequiredforproduction.Atthisstage,theoperator
mayhavelimitedinformationaboutthegeologicalcharacteristicsofthereservoir
andsurroundingformations.Suchinformation,includingdataaboutthe
surroundingformations,porepressures, 14reservoirconfigurationandreservoir
volumes,isdevelopedduringtheexploratorydrillingoperationandmayleadto
changesinthedrillingplanandwelldesignastheoperationproceeds.

Onceanoperatorfinishesdrillinganexploratorywellandperformingits
initialevaluationofthewell,ittypicallysealsthewellbypumpingcementand
installingmechanicalplugs.Thisprocedureiscommonlyreferredtoas
pluggingandabandoningthewell.Iftheoperatorbelievesthatiteventually
willbeabletoproducehydrocarbonsfromtheexploratorywell,itmaychooseto
performtemporaryabandonmentprocedures,whichareproceduresthatallow
thedrillingrigtomoveoffofthewellsothattheoperatorcanreturnatalater
datetocompletethewellandprepareitforproduction.

Atypicaldeepwaterwellisdrilledusingthefollowingprocess:

Adrillingrigmovesonthelocationofthewell.Manyrigsoperatingin
deepwateraredynamicallypositioned,whichmeansthattheyarenot
mooredtotheseafloorbutinsteadholdtheirpositionoverthewell
throughacombinationofsatellitetechnologyanddirectionalthruster
activity.TheDeepwaterHorizonwasadynamicallypositionedrig.

Theriglowersdrillpipe(alsoknownasadrillstring)withadrillbit
attachedtoitsend.Thedrillbitboresintotheseafloorandthesubsea
formationtomakeahole.Thatholeisreferredtoasthewellbore.

Theriginstalls,orsets,alargediameterpipeknownascasinginto
thewellboretoestablishabarrierbetweenthewellboreandthe
surroundingformationandtoensurethatcontinueddrillingdoesnot
resultinthecollapseofthewellbore.Theinitialcasingthatissetinthe
wellboreiscalledconductorcasing.

Therigthenusesthemarineriserorriser,whichisalargepipethat
surroundsthedrillpipe,tolowerthesubseaBOPstackontothewell.
ThesubseaBOPislatchedtothewellheadontheconductorcasing.

14Porepressureisthepressureoffluidswithintheporesofareservoir.

14
Asdrillingprogresses,therigsetsadditionalcasings(sectionsofpipe)
thatareslightlysmallerindiameterthantheholecreatedbythedrillbit.
Thecombinationofcasingsisreferredtoasthecasingstring.The
casingsarebondedintoplaceusingcement.Thecasingstringmaintains
theintegrityofthewellborebyprotectingthesidesofthewellborefrom:
(1)pressureexertedfromthedrillingmud;(2)collapseoftheholealready
drilled;and(3)influxoffluidsfromthesurroundingformation.

Theoutermostcasingnearthetopofthewellcanbeuptofourfeetin
diameter,andtheinnermoststringofcasingnearthebottomofthewell
canbelessthansixinchesindiameter.Thesizeoftheinitialandfinal
casing,thetypesofcasing,andthetypeofcementusedaredetermined
bytheprofileofthewellbeingdrilled,includingfactorssuchaswell
depth,temperatures,andwellpressures.Oncethewellisinproduction,
hydrocarbonsareextractedthroughatubingstringthatisrundown
throughthemiddleoftheproductioncasingstring.

Duringdrilling,therigcrewpumpsafluid,calleddrillingmudor
muddownthedrillpipeandthroughthedrillbitnozzles.Althoughthefluid
isreferredtoasmud,itisactuallyacomplexsystemcomprisedofcomponents
thataredesignedinlightof,andtailoredto,avarietyofwellconditions.The
mudsprimaryfunctionistoassistdrillcrewsinmaintainingwellcontrol.
Drillingmudexertshydrostaticpressureinthedrillpipeandannulus(thespace
betweenthedrillpipeandthewallsofthecasingstringsoropenhole)thatis
equaltoorgreaterthanthepressuresencounteredinthewellbore,thereby
keepingthewellbalancedandundercontrol.Drillingmudalsocoolsthedrill
bitandliftscuttingstothesurfaceasthemudiscirculatedduringdrilling. 15By
closelymonitoringwellpressure,rigcrewsmaintainthewellborefluidpressure
sothatitisequaltoorslightlygreaterthanthepressuresfromtheformation.
Thistypeofpressurebalanceisreferredtoasanoverbalancedcondition.By
contrast,awellisinanunderbalancedconditionwhentheformationpressures
exceedthewellboredrillingfluidpressures.Rigcrewsrelyuponanumberof
indicatorstotrackfluidpressures. 16

15Operatorsroutinelyrelyupondrillingmudsupplierstoprovideassistancewithchoosingan
appropriatedrillingmud.Drillingrigcrewsincludemudloggerswhomonitordrillingmud,
wellborepressures,andotherdata.
16Thisprocessofmonitoringwellpressuresisreferredtoasmeasurementwhiledrilling.

Operatorsalsoroutinelyrelyupondrillingmudsupplierstoprovideassistancewithchoosingan
appropriatedrillingmudandtoprovidemudloggersontherigtomonitordrillingmud,
wellborepressures,andotherdata.

15

Cementingisanimportantfactorinwelldesignandtheexecutionofa
safedrillingprogram.Aftereachcasingstringisset,cementispumpeddown
thedrillstring,outthebottomofthecasingandbackupintotheannularspace.
Thecementreinforcesthecasingstringandsealsofftheannularspace,
preventinghydrocarbonsfromflowingthroughthespace.Aproperlycemented
annularspaceissaidtohaveachievedzonalisolation.Operatorsoftenwork
withcontractorsthatpossessspecificcementingexpertisetodeveloptheoptimal
typeofcementforaparticulardrillingoperation.Cementingcompaniesalsocan
helpmodeldifferentanticipatedwellconditionstohelpdrillingengineersto
designasuccessfulcementjob.Thereareanumberofdifferentteststhatcanbe
performedtoassessthequalityofacementjob.

Duringthedrillingprocess,pocketsofoil,naturalgas,orwaterthatare
encounteredinporouslayersoftheformationcanexertpressureintothe
wellborethatmaysuddenlyforcemudbackupthewellborewithconsiderable
forcethisiscommonlyreferredtoasakick.Tohandlekicksandtomaintain
wellcontrol,drillingcrewsusevariousmechanisms,including,underextreme
circumstances,activationoftheBOPstackanddiverters.Ifakickoverwhelms
thecontrolmechanisms,ablowouttheuncontrolledflowofhydrocarbons
throughthewellborecanoccur.

C. CompaniesInvolvedintheMacondoWell

BPandTransoceanweretheprimarycompaniesinvolvedindrillingthe
Macondowell.BPwasthemajorityowneranddesignatedoperatorofthelease.
BPidentifiedtheprospectanddesignedandplannedthewell.Transoceanwas
thedrillingcontractorengagedbyBPtodrilltheMacondowellandprovidethe
DeepwaterHorizon,adynamicallypositioned,mobileoffshoredrillingunit(DP
MODU),aswellasthedrillingpersonnel.

BPisaglobaloilandgascompanyheadquarteredinLondon,England.
BPoperatesinmorethan80countriesandisinvolvedinoilandgas
exploration,production,andrefining,aswellastheoperationof
servicestationsworldwide.BPholdsmorethan500activeleasesin
theGulfofMexico,morethananyotherlessee.From2005through
2009,BPwastheleadingproducerofoilandgasintheGulfofMexico,
producing559,336,436barrelsofoiland846,352,047MCF(thousand
cubicfeet)ofgasduringthatperiod.

16
Transoceanistheworldslargestoffshoredrillingcontractor.Basedin
Switzerland,Transoceanownsmorethan140drillingrigsandoperates
inthemajoroffshoreoilandgasfieldsintheworld.Transoceanhas
grownsubstantiallythroughaseriesofcorporateacquisitions,
includingtheacquisitionofReading&BatesFalcon(R&BFalcon)in
2000andGlobalSantaFein2007.TransoceanownedtheDeepwater
Horizonrig,whichwasunderalongtermleasetoBPatthetimeofthe
Macondoblowout.TheleaseagreementrequiredTransoceanto
manageandoperatetheDeepwaterHorizononbehalfofBP.

Offshoredrillingoperationsarecomplexandnormallyinvolvethework
ofmanydifferentspecialists.InadditiontoBP,theleaseholderandthe
designatedoperatoroftheMacondowell,andTransocean,thefollowing
companiesalsohadsignificantrolesintheoperation:

Halliburton,whichprovidesproductsandservicestotheenergy
industryworldwideandisoneoftheworldslargestcementing
contractorstotheoilandgasindustry,providedcementplanning,
products,andservicesatMacondo.

AnadarkoE&PCompanyLP,AnadarkoPetroleumCorporationand
MOEXwereBPspartnersintheMacondowell.AnadarkoE&P
CompanyLPowned22.5%,andAnadarkoPetroleumCorporation
owned2.5%. 17BothAnadarkocompaniesareU.S.oilandgas
explorationcompanies. 18MOEXOffshore2007,aJapaneseoil
explorationfirm,owneda10%shareofthewell. 19Thecompanies
sharedinBPscoststodrilltheMacondowellandwouldhaveshared
inanyprofitsfromthewell.

Cameron,whichisaTexasbasedmanufacturerofoilandgaspressure
controlequipment,manufacturedtheDeepwaterHorizonsBOPstack.

MISWACO,whichprovidesdrillingsuppliesandservices
worldwide,developedthemudprogramandprovideddrillingmud
andpersonneltooperatetheDeepwaterHorizonrigsmudsystem.

17
BP-HZN-MBI-00192559.
18BPHZNMBI00177777.
19Id.

17
Schlumberger,whichprovidesoilfieldservicesthroughouttheworld,
providedwellloggingservicesfortheMacondowell.

SperryDrilling(SperrySun),asubsidiaryofHalliburtonthat
providesdrillingdatasystemsandpersonneltothedrillingindustry,
equippedtheDeepwaterHorizonwithSperrydatasensorsandSperry
mudloggerstomonitorandevaluatewellconditiondata.The
DeepwaterHorizonwasalsooutfittedwithTransoceanpaddleflow
meterstomonitorflow.

Weatherford,whichprovidesavarietyofdrillingservicesand
components,providedthecasing,casingcentralizers,andfloat
conversionequipmentusedontheDeepwaterHorizon.

D. TheDeepwaterHorizon

TheDeepwaterHorizonwasadeepwater,columnstabilized,semi
submersibleDPMODU,designedtodrillsubseawellsforoilandgas
explorationanddevelopment.TheDeepwaterHorizonwasbuiltforR&BFalcon
(whichlaterbecamepartofTransocean)byHyundaiHeavyIndustriesinUlsan,
SouthKorea.ConstructionstartedinDecember1998,andtherigwasdelivered
onFebruary23,2001,afterTransoceanacquiredR&BFalcon.Atthetimeofthe
blowout,theDeepwaterHorizonwasregisteredinMajuro,MarshallIslands,and
leasedtoBP.

TheDeepwaterHorizonsdayrateatthetimeoftheblowoutwas$533,495
andtherigstotalestimateddailyoperatingcostswereapproximately$1
million. 20Asiscommonintheindustry,underitscontractwithBP,Transocean
wasallowedaspecificamountoftime(inthiscase,uptotwentyfourhoursper
calendarmonth)formechanicaldowntimetoperformmaintenanceandrepairs
withamaximumaccumulationof12daysofdowntimeperyear. 21Transocean
wasnotpaiditsdayrateiftherigwasnotoperationalduetoequipmentrepairs
fortimeperiodsbeyondthisallotment. 22

20TRNUSCG_MMS00040941.
21TRNUSCG_MMS00040482.
22Id.

18
E. TheMacondoWell

BPacquiredLeaseOCSG32306inanMMSCentralGulfofMexicolease
saleonMarch19,2008.Thisleasecovers5,760acresandextendsfor10years,
beginningonJune1,2008.BPisthedesignatedleaseoperatorandshares
ownershipoftheleasewithAnadarkoandMOEX.

TheMacondowellislocatedapproximately48milesfromthenearest
shoreline,114milesfromtheshippingsupplypointofPortFourchon,Louisiana,
and154milesfromtheHouma,Louisianahelicopterbase.BPbegandrillingthe
Macondowell(referredtoasspuddingthewell)onOctober7,2009,using
TransoceansMarianasrig.AftertheMarianassustaineddamageduring
HurricaneIdainNovember2009,BPmovedtheDeepwaterHorizontothe
Macondowell.TheDeepwaterHorizoncrewresumeddrillingoperationsat
MacondoinFebruary2010.

BPandTransoceanexperiencedseveralchallengesindrillingthe
Macondowell.InOctober2009,thewellexperiencedakickduringdrilling
operations. 23ThedrillingcrewexperiencedanotherkickonMarch8,2010.Asa
resultoftheMarch8kick,thedrillpipebecamestuckinthewellbore,andtherig
crewcouldnotpullthepipefree. 24Thecrew,therefore,hadtoseverthedrill
pipeanddrillabypassaroundtheportionofthewellwiththestuckpipe. 25The
wellalsoexperiencedseverallostreturnincidentsduringdrilling,when
drillingmudpumpeddownthewellboredidnotreturntothesurfaceas
expectedbecausesomevolumeofthemudflowedintoandwaslostinthe
formation. 26Lostreturnsarenotuncommonandcanoccurforavarietyof
reasons,suchasafractureintheformationordrillinginoverbalanced
conditions. 27Becauseoftheseandotherchallenges,onApril20,2010,the
Macondowellwasabout38daysbehindscheduleandapproximately$58
millionovertheoriginalbudget. 28

23MC252WellActivityReport,10/25/2009.
24IADCReports,3/8/103/12/10.
25Abypassisasecondarywellboredrilledawayfromtheoriginalhole.Itisnotuncommonfor

anoperatortodrillabypasswhileexperiencingproblemsduringthedrillingofawell.
26IADCReports,3/8/103/12/10.
27
AsdiscussedthroughouttheReport,thelostreturnsattheMacondowellwereofnotebecause
oftheirfrequencyandbecausetheyoccurredalongwithotheranomalies.
28BPHZNMBI00125958;BPHZNMBI0019553;BPMBHZN00192599.

19
Despitetheseproblems,byApril14,theDeepwaterHorizoncrew
successfullydrilledtotheM56sand,oneofthehydrocarbonbearingzones
thatBPgeologistsandengineershadtargetedforthewell. 29Althoughthe
originalwellplanwastodrillapproximately1,800additionalfeet,theBPdrilling
teaminHoustonoptedtostopdrillingthewellatatotaldepthof18,360feet
becauseBPbelievedthewellhadreachedthebaseofthetargetreservoirandthat
ithadrunoutofdrillingmargin. 30Inotherwords,BPconcludedthatitcouldno
longersafelydrillintotheformationwithoutcreatinganunderbalancedwell(if
themudwastoolight)orriskingfracturingtheformationandthreateningwell
integrity(ifthemudwastooheavy).BPplannedtorunproductioncasingand
temporarilyabandonMacondobysealingitwithasurfacecementplugsothat
anotherrigcouldreturntothewelllaterandtakethestepsnecessarytocomplete
thewellforproduction.

OnApril19,theDeepwaterHorizoncrewrantheproductioncasingstring
intothewell. 31BPsengineeringteamhadengagedinsignificantdebateoverthe
appropriatedesignofthecasingtoruninthefinalwellsection.Therewas
additionaldebateamongBPpersonnelaboutthenumberofcentralizers,which
arepiecesofequipmentusedtokeepthecasingcenteredinthewell,touseon
thefinalcasingstring.Thecrewpumpedcementintotheannulusandintothe
shoetrack,thesectionofthecasingbetweenthebottomofthewellandthefloat
valveinstalledinthewell(alargevalvedesignedtoallowfluidstoflowdown
thewellwhilepreventingfluidsfromflowingbackupthewellboreduring
cementingoperations).

Thepurposeofthecementjobwastoestablishanisolationbarrieracross
thehydrocarbonzoneatthebottomofthewellsothathydrocarbonscouldnot
enterthewell.InthelatehoursofApril19andintothemorningofApril20,the
rigcrewandBPscementcontractor,Halliburton,pumpedcementintothe
Macondowelltoisolatethehydrocarbonzones. 32BasedondataprovidedbyBP,
Halliburtondesigned the cement slurry, whichisamixtureofcement,waterand

29BPHZNMBI00126338.
30Id.AsdiscussedindetaillaterinthisReport,drillingmarginisthedifferencebetweenthe
weightofthemudusedtodrillrelativetotheporepressuresandthefracturegradientofthe
formation.Commonindustrypracticeistouseadrillingmarginof0.5ppgmudweightunder
thefracturegradient.
31IADCReport4/19/10.

32HalliburtonPostJobCementReport,BPHZNCEC011406.

20
assorteddryandliquidadditives. 33 After BP approved the design, Halliburton
began pumping the cement.

Inadditiontocementing,theprocessofpreparingawellfortemporary
abandonmentincludesfurtherprocedurestosecurethewellsothattherigsBOP
stackandrisercanberemovedastherigpreparestomoveoffthelocation.BP
engineersinHoustondevelopedtemporaryabandonmentprocedures(different
fromtheMMSapprovedprocedure)fortheMacondowellthatincludedthe
followingsteps:performingapositivepressuretest; 34displacingmudinthewell
from8,367feettothewellhead;performinganegativepressuretest; 35settinga
300footcementpluginthewellapproximately3,300feetbelowtheseafloorand
settingalockdownsleevetolockthefinalcasingintoplace. 36BPengineers
changedtheorderofthesestepsseveraltimesinthedaysbeforethetemporary
abandonment.

Duringallwellactivities,includingtemporaryabandonment,crew
membersmonitorvarioussensorsontherigthatshowfluidvolumesandwell
pressures. 37Thesesensorsproviderealtimedatatothecrew,whichmonitors
andanalyzesthedataonelectronicdisplaystoidentifypotentialkicks,among
otherthings.Earlykickdetectioniscriticaltomaintainingwellcontrol.

OnApril20,thecrewconductedteststoevaluatetheintegrityofthe
productioncasingcementjob.ThetestswerebasedonMMSapproved
proceduresthataBPdrillingengineerhadsenttotherigthatmorning. 38The
crewfirstconductedapositivepressuretesttoevaluatewhetherthewellcasing
couldsustainpressureexertedonitfromtheinsideofthewellandreceived
favorableresults. 39Onthesameafternoon,thecrewcirculatedmudupfromthe

33
Additivesareusedtotailorthecementtotheneedsofawell.Forexample,aweighting
materialmightbeaddedtoacementslurrywhenahigherdensitycementisneeded.
34Apositivepressuretestisconductedbypumpingfluidintothewellaftersealingtheblind

shearrams.Therigcrewmonitorsthewelltodeterminewhetherpressuresinthewellremain
static.
35Anegativepressuretestseekstocreateconditionsthatsimulatewhatwilloccurwhenthewell

isabandoned.Therigcrewdisplacesdrillingmudwithotherfluids,resultinginthewellbore
beingunderbalancedagainsttheformationpressures.Therigcrewthenmonitorspressuresand
flowtodeterminetheintegrityofthebarrierbeingtested.
36BPHZNMBI00129108.EachofthesestepsisdiscussedindetailinSectionIofthefindings

andconclusionsinthisReport.
37Fluidincludesanyfluid(mud,spacer,seawater)comingoutofthewelloracrosstherig.

38BPHZNMBI00021237.

39BPHZNMBI00136947.

21
well,andpumpedtherecoveredmudontotheDamonBankston,avesselworking
alongsidetheDeepwaterHorizonatMacondo.Becauseofthemovementofthe
mud,itwasdifficultforthecrewtotrackfluidvolumesinthewellboreandin
themudpitsontherig. 40

Next,crewmembersturnedtoconductingnegativepressuretestsonthe
well,whichwouldgivethecrewinformationaboutwhethertheproduction
casingcementjobwascapableofkeepinghydrocarbonsoutofthewellbore.The
crewrantwoseparatenegativetestsusingdifferentproceduresforeachtest.
Justpriorto8:00p.m.onApril20,theBPwellsiteleaderondutyontherig,
DonaldVidrine,andTransoceancrewmembersconcludedthatthesecond
negativetestshowedthatthefinalcementjobwassuccessful. 41Vidrinealso
calledMarkHafle,aBPengineerinHouston,around8:50p.m.todiscussthe
surfaceplug.Duringthiscall,Vidrinedescribedtheresultsofthenegativetests.
HaflequestionedVidrineabouttheresultsofthenegativetest,buthechosenot
toinvestigatefurtherbyaccessingandreviewingtheavailablerealtimedata.
Instead,HaflechosetorelyuponVidrinesassurancethattherigcrewhad
successfullyperformedanegativetest. 42

DuringtheeveningofApril20,theDeepwaterHorizoncrewcontinued
withthetemporaryabandonmentprocedurebyopeningtheBOPandpumping
seawaterdownthedrillpipetodisplacemudandaspacerfromtheriser. 43
Duringthesewellactivities,thewellexperiencedsignificantchangesinpressure.
Personnelresponsibleformonitoringtheconditionofthewell,however,didnot
recognizethesechangesassignsofakick.Thecrewmembersshutdownthe
wellaround9:15p.m.toperformasheentestonthespacerthattheyplannedto
sendoverboardasitwasdisplacedfromthewell. 44Thedecisiontosendthe
displacedspaceroverboardrenderedSperrySunpersonnelunabletomeasure
returnsononeoftherigsflowmeters.Duetotheplacementoftheflowmeters,

40BPHZNMBI00021238.
41TestimonyofJimmyHarrell,JointInvestigationHearing,May27,2010,at9091;Testimonyof
MilesEzell,JointInvestigationHearing,May28,2010,at279282.
42BPHZNBLY00125470.

43Spacerreferstomaterialthatrigcrewspumpintoawelltoseparatethedrillingmudfrom

seawater.Displacementofmudandspacerarepartofthetemporaryabandonmentprocedures
discussedindetailinSectionIVofthefindingsandconclusions.
44SperrySunrigdata,April20,2010.Thecrewperformedasheentesttoconfirmthatallofthe

oilbasedmudhadbeendisplacedfromtheriser.Asheentestisintendedtoindicatethe
presenceoffreeoilwhendrillingfluid,drilledcuttings,deckdrainage,welltreatmentfluids,
completionandworkoverfluids,producedwaterorsandorexcesscementslurryaredischarged
intooffshorewaters.

22
theSperrySuncrewcouldonlymeasurereturnssenttothemudpitsandcould
notmeasureflowvolumessentoverboard. 45

F. TheBlowout

OnApril20,2010,ataround9:40p.m.,powerfulpressuresfromthewell
causedmudtoflowupfromthewell.Mudspilledontherigfloorasthewell
begantoblowout.Thecrewrespondedtothesituationbydivertingtheflowto
themudgasseparator,partofthedivertersystemtowhichthecrewcoulddirect
fluidscomingupfromthewell. 46Atthistime,crewmemberslikelyrealizedthat
theyhadlostcontrolofthewellandattemptedtoregaincontrolofthewellby
activatingtheBOPstacksupperannularpreventerandtheuppervariablebore
ram. 47

Themudgasseparator,towhichthecrewhaddivertedflowfromthe
well,wasquicklyoverwhelmedandfailed,causingagasplumetofilltherig
floor.Thegasquicklyignited,causingthefirstexplosionontherigat9:49p.m.
Approximatelytensecondslater,asecondlargerexplosionoccurredandthefire
onboardtherigspreadrapidly.Shortlyafterthesecondexplosion,theriglost
powerandexperiencedatotalblackout.

Atapproximately9:56p.m.,therigssubseaengineerattemptedto
activatetheBOPstacksemergencydisconnectsystemfromtheBOPpanelonthe
rigsbridge.TheemergencydisconnectsystemisdesignedtoactivatetheBOP
stacksblindshearramanddisconnecttherigslowermarineriserpackage
(LMRP)fromthewell.TheBOPpanelapparentlyindicatedthatthe
emergencydisconnectsystemwasactivated,buttherigremainedconnectedto
thewellandhydrocarbonscontinuedtoflowuncontrolledfromthewell. 48
Aboutfourminutesaftertheattempttoactivatetheemergencydisconnect
system,personnelontheDeepwaterHorizonsbridgemanuallysoundedthe
generalalarmandmadeamustercallforpersonneltogatheratdesignated

45TestimonyofJosephKeith,JointInvestigationHearing,December7,2010,at135.
46Themudgasseparator,andtherigcrewsdecisiontouseittohandletheinfluxof
hydrocarbonsfromthewell,isdiscussedindetailinSectionVDofthefindingsandconclusions.
47DNV,ForensicExaminationofDeepwaterHorizonBlowoutPreventer,March20,2001,(DNV

Report)at4.AsdiscussedinlaterinthisReport,theupperannularpreventerandtheupper
variableboreramaretwoBOPstackcomponentsthatareusedbyrigcrewsinwellcontrol
events.Neithercomponent,however,isdesignedtoshearthedrillpipeandcompletelysealthe
welltheblindshearramontheBOPstackisdesignedtoperformthesefunctions.
48
TestimonyofChrisPleasant,JointInvestigationHearing,May28,2010,at123.

23
lifeboatstations.Personnel,includingcrewmembers,contractorsandvisiting
executivesfromBPandTransocean,evacuatedtherigontwolifeboatsandalife
raft.Atleastsixpeoplejumpedfromtherigintothewater.

At10:00p.m.,theDamonBankston,whichpriortotheexplosionshadbeen
directedbytheDeepwaterHorizontomove500metersawayfromtherig,
receiveddistresscallsfromtheDeepwaterHorizonandprepareditsfastrecovery
craftforlaunchandrescueofthosewhohadabandonedtherig.TheDamon
Bankstonretrievedsixpeoplefromthewaterandrecoveredanother108people
fromthetwolifeboatsandliferaft.Uncontrollablefirescontinuedtoblazeon
theDeepwaterHorizon,andtherigsankonthemorningofApril22.

Elevenmendiedasaresultoftheblowoutandsixteenotherswere
injured.EstimatesarethattheMacondowellspilledclosetofivemillionbarrels
ofoilintotheGulfofMexicoduring87daysbetweentheblowoutandwhenthe
wellwassuccessfullycappedonJuly15,2010.Aftermonthsofadditional
interventionwork,thewellwaspermanentlysealedonSeptember19,2010.

24
II. WellDesign

Welldesignisafundamentalandimportantphaseofoffshoredrilling
operations.Operatorsmustconsidersitespecificfactors,includingflows,
pressurizedformationflows,reservoirnaturalgasandoiltype,reservoir
lithology(formationcharacteristics),reservoirstructure,andtheanticipated
volumeofhydrocarbonstodeterminethebestwaytodrilltothetargetreservoir
andtoconfigurecasingtoallowproductionfromthewell.Duringthedesign
process,engineersuseallavailabledatatodetermineplannedtotaldepth
(sometimesreferredtoasTD)ofthewell,casingpointselections,required
casingspecifications,casingpressureratings,cementslurrydesign,mudweight,
andriskfactorsparticulartothewell. 49

Developmentwellsaretypicallydesignedanddrilledbasedinparton
datafromnearbywells,referredtoasoffsetwelldata.Inthecaseofexploratory
wells,suchasMacondo,operatorshavelimitedoffsetwelldataavailable,
makingitmoredifficulttoanticipatewellconditionspriortothespudofthe
well.Asaresult,designprocessesinexploratorywellsaresubjecttochange.
Operatorstypicallydealwithwelldesignchangesduringdrillingoperations
throughdocumentedmanagementofchangeprocesses,whichareintendedto
aidpersonnelinsystematicallyidentifyingandmitigatingtherisksassociated
withthechanges.

TheBPwellengineeringteamandtheBPsubsurfaceteamwereinvolved
indevelopingtheMacondowelldesign.Theteamsreferredtovarious
documentsandmanualswhiledesigningtheMacondowell,includingBPs
internalcasingdesignmanual,drillingwelloperationspolicy(DWOP),
advancedguidelinesfordeepwaterdrillingandotherguidance. 50

A. CostoftheMacondoWell

BPexceededitsoriginalcostestimatesfordrillingtheMacondowell.To
obtainadditionalfundsandcontinuedparticipationfromitspartnersinthe
Macondoproject,BPsubmittedtoAnadarkoE&PCompanyLPandAnadarko
PetroleumCorporation(collectivelyAnadarko)andMOEXseveral

49Casingpointisthedepthatwhichdrillingaparticularwellborediameterwillendsothat
casingofagivensizecanberunandcemented.
50BPHZNMBI000010362.

25
AuthorizationsforExpenditures(AFEs),whichincludedwrittendescriptions
oftheprojectandcostestimatesforproposedwellactivitiesandoperations. 51

UndertheiroperatingagreementwithBP,AnadarkoandMOEXcould
choosetoparticipateintheactivitiesandoperationsdescribedintheAFEand
therebycommittothefundingnecessarytocontinuetheoperation;theycould
proposeanalternativeoperatingplan;ortheycouldendtheirparticipationinthe
Macondoproject. 52

BPsubmittedtoAnadarkoandMOEXaninitialAFEfortheMacondo
wellinAugust2009,estimatingthatthetotalcostsofthewellwouldbeabout
$96.1million.BothAnadarkoandMOEXapprovedtheoperationand
expenditures. 53BPsoughtitsfirstsupplementalAFEforapprovalofan
additional$27.9millioninJanuary2010,whichthepartnersacceptedinFebruary
2010. 54InMarch2010,BPsoughtauthorizationforanadditional$27million,
explainingthatithadexceededthefirstsupplementalAFEduetounexpected
lostcirculationandwellcontrolevents. 55AnadarkoandMOEXapprovedthe
expenditureandofferednoalternativeoperatingplan. 56

OnApril14,afterBPhaddrilledtotheMacondowellsrevisedtarget
depth,itsoughtafinalAFEfor$3.5milliontofundsettingtheproductioncasing
inconnectionwiththetemporaryabandonmentofthewell.Anadarkoand
MOEXapprovedtheAFEanddidnotproposeanyalternativeoperatingplan. 57
Intotal,thecompaniesallocated$154.5milliontodrillingtheMacondo
exploratorywell,anamountwellinexcessoftheoriginalestimatedcostof
$96.16millionandthenottoexceedcostof$139.5million.

UndertheiroperatingagreementwithBP,AnadarkoandMOEXhad
accessto,andinfactreviewed,dataandfilesrelatedtotheMacondowellthatBP
madeavailabletothemthroughsharedwebsites.ThePanelfoundnoevidence,
otherthanreviewingthisinformationandapprovingtheAFEs,indicatingthat

51BPHZNMBI000173275.
52BPHZNMBI00173275.
53BPHZNMBI00192546,BPHZNMBI00192549.

54BPHZNMBI00192552,BPHZNMBI00192553.

55BPHZNMBI00192557.

56BPHZNMBI00192558.

57BPHZNMBI00192559,BPHZNMBI00192561.

26
AnadarkoorMOEXweredirectlyinvolvedindecisionsrelatedtothedesignor
drillingoftheMacondowell. 58

B. DrillingMargin

Drillingengineersmustdesignawelltomanageporepressureand
fracturegradientsatdifferentwelldepths.Porepressureisthepressureexerted
byfluidsintheporespaceoftheformationbeingdrilled.Fracturepressureis
thepointatwhichpressureexertedbythedrillingfluidinthewellwouldcause
thesurroundingformationtofracture.Thefracturegradientplot,expressedasa
calculatedequivalentmudweight,isacurvethatshowsthewellsestimated
fracturegradientbydepth.Duringwelldesign,engineerstypicallyusea
graphicalrepresentationoftheestimatedporepressure,mudweight,and
fracturegradient,whichtogetherdefinetheappropriatedrillingmargins.

Drillingengineersconductaleakofftesttodeterminethestrengthor
fracturepressureoftheopenformation.Thistestisusuallyconducted
immediatelyafterdrillingpastthecementedcasingshoeinthewell. 59During
thetest,thewellisshutinandfluidispumpedintothewellboretogradually
increasethepressurethattheformationexperiences.Atacertainpressure,fluid
pumpedintothewellwillentertheformation,orleakoff,bymovingthrough
permeablepathsintherockorbycreatingaspacebyfracturingtherock.Ifthe
pressureisincreasedbeyondtheformationfracturepoint,fracturingofthe
formationcanoccur.Theresultsoftheleakofftestdictatethemaximum
pressureormudweightthatmaybeappliedtothewellduringdrilling
operationsbeforetheformationcanbeexpectedtotakefluid.

BOEMREregulationsrequirethat[w]hiledrilling,youmustmaintainthe
safedrillingmarginidentifiedintheapprovedAPD[ApplicationforPermitto
Drill].Whenyoucannotmaintainthissafedrillingmargin,youmustsuspend
drillingoperationsandremedythesituation. 60Safedrillingmargincanbe
maintainedbyensuringthatthemudweightremainsbetweenthekick
toleranceorkickmargin,whichistypically0.5poundspergallon(ppg)

58DataobtainedfromHalliburtonshowedthatrepresentativesofAnadarkoandMOEX
periodicallyreviewedinformationrelatedtotheMacondowellduringdrilling.
59Thecasingshoeisashortsteelcollarthatistypicallyattachedtothebottomofthecasing

string.Ithelpstoestablishproperpositioningofthecasingstringinthewellbore.
60
30CFR250.427(b).BOEMREregulationsdonotspecifywhatasafedrillingmarginis.
Theremaybeinstanceswhereasafedrillingmargincanbemaintainedoutsidethekickor
swabmargins.

27
belowthefracturegradient,andtheswabmargin,whichistypically0.2ppg
abovetheporepressure.Inshort,themudmustbeheavyenoughtocontrolthe
porepressureandensurethattheformationfluids(includinghydrocarbons)do
notenterthewellbore,whilenotsoheavythatitfracturestheformation. 61

BOEMREregulationsrequireoperatorstoprovidevariousdatatothe
Agencydemonstratingthattheoperatorismaintainingasafemargin.For
example,operatorsmustshow,inasinglegraphicplot,porepressures,mud
weightsandfracturegradientsforthefullextentofthewell. 62Theplotteddata
reflectsforecasteddatabasedon3Dseismicandoffsetwelldata. 63When
operatorsencounterunexpectedpressuresthatdifferfromtheirforecasts,
applicableregulationsrequiretheoperatortoreviseitscasingdesignandapply
totheAgencyforapprovalofthemodification. 64

ThefinalestimatedMacondowellporepressure,mudweight,and
fracturegradientplotsubmittedtoMMSonMarch26isshownatFigure1.The
verticalaxisofFigure1showsthedepthofthewell.Thehorizontalaxisshows
themudweight.TheredlinedepictsBPsplannedmudweight,whichwas
designedtobebetweenthekickmarginandtheswabmarginidentifiedin
Figure1.

61Maintainingmudweightinthisrangeisanindustryacceptedpracticebutisnotspecifically
requiredbyBOEMREregulations.
62
30CFR250.413and414.
63Offsetwelldataaredataobtainedfromwellsthataredrilledinanareaclosetothetarget

well.
64
30CFR250.427(b).

28

Figure1MacondoWellPorePressureFractureGradientPlot 65

AsseeninFigure2,theformationintegritytestatthe97/8inchlinershoe
locatedat17,168feetyieldedresultsof15.98ppg(asidentifiedintheIADCdaily
reports,whicharecompletedbytherigcrewtodocumentdailyoperations)and
16.22ppg(identifiedinBPsDailyOperationReport).ThePanelfoundthatthis
integritytestmayhavecreateduncertaintybecause(1)itwas1.0ppghigherthan
anticipatedand(2)therewasapossibilitythatthetestresultsdidnotreflecta
truetestoftheformationbelowthe97/8inchlinershoe.Althoughthisfracture
gradienttestwasquestionable,BPchosenottoretestthefracturegradientatthe
shoeanddecidedtodrillahead.AfterdrillingtheM57Csandinterval,BP

65 API608174116901,March26APD(RevisedBypass)fortheMacondoWell.

29
conductedaGeotapsurveytodeterminethesandporepressure.Thesandpore
pressurewasdeterminedtobe14.15ppg.BPalsoconvertedthisporepressure
toanestimatedfracturegradientof15.0ppg.Theopenholesectiondrilled
utilizedasurfacemudweightrangeof14.114.5ppg,whichallowedforasafe
drillingmargintobemaintainedbetweenporepressureandfracturegradient.
Throughoutthisinterval,however,BPencounteredmultipleproblems
associatedwithbothlostreturnsandregressingporepressures(1.9ppg
difference)between17,001and18,066feet.BPlostapproximately4,000barrels
(bbls)ofmudintheproductionopenholeinterval.BPutilizedlosscirculation
materialinthisintervaltoattempttocontroltheselosses.


Open Hole Interval below 9 7/8-in Liner @ 17,168 - FIT 15.98 PP 13.9
Date Depth MW Losses PP Remarks Hydrocarbon Zones
2-Apr 17,007 - 17,321 14.3 17,168 FIT 16.22 PPG 17,684 - 17,693 M-57C 14.1 PPG
3-Apr 17,321 - 17,835 14.5 233 bbls 17,723 - GeoTap 14.15 ppg (PP) 17,786 - 17,791 M-56A 13.1 PPG
3-Apr 17,835 - 17,909 14.3
4-Apr 17,909 - 18,195 14.3 12.58 @ 18,089 Schematic - 12.6 ppg at 18,066 18,061 - 18,223 M-56E 12.6 PPG
4-Apr 18,215 - 18,250 14.4 639 bbls Lost full returns
5-Apr 18,260 14.0 1263 - Total
6-Apr 14.0 1586 - Total
7-Apr 14.0
8-Apr 14.0
9-Apr 18,360 14.0 called TD

Figure2DrillingmargindatafromIADCreportsandBPDailyReports

BPcontinueddrillinguntilitconcludedithadrunoutofdrillingmargin
betweenmudweightandformationporepressure.RobertBodek,BPGeological
OperationsCoordinator,emailedMichaelBierne,anotherBPemployee,onApril
13,2010,andexplainedthereasonswhyBPconcludedthatithadrunoutof
drillingmarginat18,360feet.Hesaidthattheteamdecidedtostopdrilling
becauseithadbecomeawellintegrityandsafetyissue. 66Theemailalsostates:

Wehadonemajorproblemhowever:thesandthatwetooktheinitial
GeoTappressureinwasmeasuredat14.15ppg.Theabsoluteminimum
surfacemudweightwecouldusetocovertheporepressureinthissand
was14.0ppg.Thiswouldgiveusapproximatelya14.2ppgESDoverthe
aforementionedsand.Ifweweretodrillaheadwitha14.0surfacemud
weight/14.2ESD,ourequivalentcirculatingdensity(ECD)wouldbe
approximately14.414.5ppg.Wehadalreadyexperiencedstaticlosses
witha14.5ppgESD!Itappearedasifwehadminimal,ifany,drilling
margin...Drillingaheadanyfurtherwouldunnecessarilyjeopardizethe
wellbore.Havinga14.15ppgexposedsand,andtakinglossesina12.6

66BPHZNMBI00126338.

30
ppgreservoirinthesameholesectionhadforcedourhand.Wehad
simplyrunoutofdrillingmargin.

C. CasingProgram

Casingprogramsdescribethenumberandsizesofthecasingstringstobe
setinthewellboreandarebaseduponporepressureandfracturegradientplots.
Casingprogramsaredesignedbasedonanumberoffactors,includingburstand
collapsepressures, 67tensilestrength, 68drillbitsize,anticipatedhydrocarbon
flow,andhydrocarbontype.BPoriginallydesignedtheMacondowellto
includesevencasingstringstoreachthetargetwelldepth.However,basedon
theactualconditionsencounteredduringdrilling,BPusedninecasingstringsto
reachtotaldepth.

Conditionsencounteredduringdrillingcandrivechangesincasing
programs.Forexample,circulationlosseventsoccurredintheopenholesection
oftheMacondowell.Lostcirculationisthelossofdrillingfluids(suchas
drillingmudandspacer)intotheformation.Thislossofdrillingfluidis
observedduringthecirculationofdrillingfluids.Whenlessfluidisreturnedup
thewellannulusthanwaspumpedintothewellthroughthedrillstring,this
meansalossofdrillingfluidlostreturnshasoccurred.Theselostreturns
wereafactorinBPsdecisiontolimitthewelltotaldepthto18,360feet(shortof
the20,200feetoriginallyplanned)andalsoledBPtorevisethewellscasing
designprogramtoaccountformudweightandfracturegradientdrillingmargin
issues.Specifically,BPmodifieditscasingprogramseveraltimesbecauseof:(1)
awellcontroleventinMarch2010thatresultedinthedrillpipebecomingstuck;
(2)changesinporepressureestimates;and(3)wellballooning. 69AfterBP
reviseditscasingprogram,itsubmittedarevisedApplicationforPermittoDrill
toMMSforapproval. 70

67Burstpressureisthetheoreticalinternalpressuredifferentialatwhichajointofcasingwillfail.
Collapsepressureisthepressureatwhichatubeorvesselwillcatastrophicallydeformasaresult
ofdifferentialpressurebetweentheoutsideandtheinsideofthetubeorvessel.Schlumberger
OilfieldGlossary.
68Tensilestrengthistheforceperunitcrosssectionalarearequiredtopullasubstanceapart.

SchlumbergerOilfieldGlossary.
69Ballooning,inwhichtheformationabsorbsdrillingmudwhiletherigspumpsareactivated

andthenreleasesthemudbackintothewellwhenthepumpsarenotactive,canbe
misinterpretedasakick.
70MMSapproved:BPsApplicationforPermittoBypass,whichaddedanadditionalcasing

string,onMarch15,2010;BPsRevisedApplicationforPermittoBypass,whichaddedaliner,on

31

D. MudProgramandType

Drillingmudprovideshydrostaticpressurepressureexertedbyafluid
atequilibriumduetotheforceofgravitytopreventformationfluidsfrom
enteringthewellbore.Drillingmudalsokeepsthedrillbitcoolandcleanduring
drilling,carriesdrilledcuttingsoutofthewellandsuspendsthedrillcuttings
wheneverdrillingispaused.

Operatorshavemultipleoptionsforthetypeofmudtouseduringthe
drillingofawell,includingoilbasedmud,syntheticoilbasedmudandwater
basedmud.Dependingonreservoirconditions,operatorsassesswhichmud
typeismostappropriateforthespecificwellbeingdrilled.

FortheMacondowell,BPchoseasyntheticoilbasedinvertmudsystem,
asysteminwhichsyntheticoilinthemudremainsinacontinuousfluidphasein
thelowerholesectionsofthewell.BPchosethissystemforseveralreasons:(1)
toenhancetheabilitytomaintainconsistentfluidpropertiesindependentofthe
temperatureandpressureconditionsofthewell;(2)toimproveholecleaning
andminimizebaritesag,controlofpressurespikes,andgaininggelstrengths; 71
and(3)todealwithotherproblemsthatresultwhenbalancingequivalent
circulatingdensity(ECD). 72Inselectingthesyntheticoilbasedmud,BPalso
soughttoreducefluidlossinordertominimizeformationdamagewhile
maintainingahigherdrillingefficiency.

Syntheticoilbasedmud,suchasthetypeBPusedintheMacondowell,
hasmanypositivefeaturesasdescribedabove.However,thistypeofmudalso
presentsrisksrelatingtoitseffectonthecrewsabilitytoaccuratelydetect
naturalgasinflux(kicks)intothewell.Arecentstudyofdrillingfluidmixtures
andwellcontrolfoundthatdrillersmighthaveahardertimedetectingkicks

March26,2010;andBPsRevisedApplicationforPermittoBypass,whichincludedaproduction
casing,onApril15,2010.
71SocietyofProfessionalEngineers,SPE116013PAStudyofthePVTPropertiesofGasSynthetic

DrillingFluidMixturesAppliedtoWellControl(2009).Baritesagisthesettlingofbariteparticles
(orotherweightingmaterials),whichcanresultinfluctuationsindrillingfluiddensity.When
thisoccursindrillingmud,themudlosesitsintegrityandcanonlybeatemporarybarrierinthe
well.Gaining,orprogressive,gelstrengthstypicallyrequirehigherpumppressurestobreak
circulation.
72ECDisthetotaleffectivepressurethatacolumnofdrillingmudexertsonaformationasthe

mudiscirculatedthroughthedrillstringandbackupthewellbore,accountingforfrictional
forcesthroughoutthecirculatorysystem.

32
whenusingsyntheticoilbasedmud.Thestudystatedthatanimportantaspect
thatshouldbeaddressedwhendrillingwithasyntheticfluidisthepeculiarities
concernedwithwellcontrol.Becauseofthesolubilityofformationgasinoil
basedfluids,itcouldbecompletelydissolvedinthemudatbottomhole
temperatureandpressureconditions,makingkickdetectionverydifficult. 73
ThePanelfoundnoevidencethatBPandMISWACOdiscussedwhether
theuseofsyntheticoilbasedmudwouldaffecttherigcrewsabilitytodetect
kicksduringdrillingoperationsatMacondo.Evenso,thePanelfoundno
evidencethatthespecificmudprogramusedbyBPandMISWACOwasacause
oftheblowout.

E. MudLosses

ThroughoutthedrillingoftheMacondowell,BPexperiencedmultiple
incidentswheremudwaslostintotheformation.Whilethelossofmudduring
drillingoperationsisnotuncommon,itisakeyindicatortodrillingengineers
thattheymustmonitorthewellcloselytoensurethatwellandformation
integrityarebeingmaintainedproperly.Abnormalpressurezonesidentifiedas
aresultofmudlosseventsoftenleaddrillingengineerstochangethewelldesign
andcasingsettingpoints.

BPdrilledtheMacondowelltoameasureddepthof18,360feet.Thecrew
seta97/8inchlinerinplaceat17,168feetmeasureddepthpriortodrillingthe
productionsection,whichwasthefinalsectionofthewell.Thelastsectionwas
difficulttodrillduetoadecreaseinthefracturegradientatthebottomofthe
wellbore.ThisconditionrequiredBPtocarefullyselectthecorrectmudweight
necessarytomaintainoverbalancerelativetotheformationwhileavoidingfluid
lossestothewell.

AccordingtoIADCdailyreports,thewellexperiencedmudlossesof
approximately3,000bblsacrossthehydrocarbonzonesofinterestduringthe
drillingoftheproductioncasingopenholesection.Thecrewcontrolledthese
losseswiththeadditionoflostcirculationmaterial(LCM)pillsandarelatively
smallquantity(lessthan200bbls)ofaspecialblendofdrillingfluid,whichhelp
retardthelossofmudintofracturesandhighlypermeableformations.Fromthe
timetheDeepwaterHorizonmovedontolocationatMacondo,atotalof

73Id.

33
approximately15,500bblsofdrillingfluidswerelostduringdrilling,running
casingandcementingoperations. 74

F. WellBallooning

Wellballooningisacommonphenomenoninwhichtheformation
absorbsdrillingmudwhiletherigspumpsareactivatedandthenreleasesthe
mudbackintothewellwhenthepumpsarenotactive.Wellballooningis
significantbecauseitcanmimicakick.Rigcrewscanthereforemisscriticalkick
indicatorsiftheymistakenlybelievethatballooningisoccurringinthewell.

MudloggingdatafortheMacondowelldemonstratedthattheproduction
casingzonestartedballooningbetween17,530feetand17,761feet.Thedaily
IADCreportsalsoshowthatthewellflowedbackduringflowchecksfollowing
mudlossatthosedepths.

G. PlannedandActualTotalDepth

Indesigningawell,engineerscalculateaplannedtotaldepthofthewell.
BPsFebruary2009ExplorationPlanestimatedthewelldepthatapproximately
20,200feettrueverticaldepth.Duetoanarroweddrillingmargin,BPultimately
decidedtostopdrillingthewellat18,360feet.

BPsetacasingstringat17,168feetmeasureddepth(sometimesreferredto
asMD)andthencontinuedtodrillthefinalproductionsectionofthewell.In
thesectionbelowthelasttwocasingstrings,thewelllostreturns,indicating
possiblefracturingorformationpressureregression.Inresponse,thecrew
stoppeddrilling,pumpedinlostcirculationmaterialstosealthefracture,and
restoredmudcirculation. 75Inthisopenholeinterval(wherenocasingstring
hadbeensetyet)theporepressuredecreasedfrom14.5ppgto12.6ppgbetween
thesandintervalat17,233feetmeasureddepthandtheM56targetformationat
18,083feetthrough18,206feet.Becauseofthedecreasingporepressureatthis
depthofthewell,therewasnodrillingmarginintheopenholesectionofthe
well,whichmeantthatthemudweightnecessarytopreventtheformationfrom
flowingattheupperportionoftheopenholecouldresultintheformation
fracturinginthelowersection. 76BPexplainedtoitspartners,MOEXand

74BPHZNMBI00304121.
75BPHZNMBI00126338.
76Id.

34
Anadarko,thatitchosetoterminatethewellat18,360feetMD,basedon
concernsaboutwellintegrityandsafetyrelatedtothislossofdrillingmargin. 77

Byterminatingthewellwhereitdid,BPsetthetotaldepthofthewellina
laminatedsandshaleinterface. 78BPinternalguidelinesfortotalwelldepth
specifythatdrillingshouldnotbestoppedinahydrocarboninterval,unless
necessaryduetooperational,pressureandsafetyissues. 79Typically,totaldepth
isnotcalledinasandsectionbecauseplacingthecasingshoethesectionofthe
casingbetweenthebottomofthewellboreandthefloatvalveinalaminated
sandshalezoneincreasesthelikelihoodofcementchannelingorcontamination
duetowashout,andcreatesdifficultiesinloggingwelldata. 80Figure3depicts
theplacementoftheMacondowellshoetrack.

77Id.BPsSeptember2009PreDrillingDataPackagealsoindicatedthat,ifafterdrillingthe
primaryM56objectivetherewasanonsetofpressurerequiringanewcasingstring,nofurther
drillingwouldbefeasible.SeeBPHZNMBI00013494.
78Sandismorepermeablethanshale.Therefore,whencasingissetinsand,lostreturnsare

morelikely.
79BPHZNMBI00013494.
80
Cementchannelingoccurswhenthecementslurryintheannulusdoesnotriseuniformly,
leavingspacesandthereforepreventingastrongbond.

35

ML @ 5067' MD/TVD

36" @ 5,321' MD/TVD (254' bml)

9 7/8 Liner 17,168


28" @ 6217' MD/TVD (1150' bml)

7,567' MD - Bot of 5-1/2" 21.9 ppf S-135 (3450' of pipe)

14.1 ppg 17,684-17,693


M57C sand (brine)

22" @ 7937' MD/TVD (2891' bml)


13.1 ppg 17,786-17,791
M56A sand
8,367' MD (3-1/2" - 800' pipe)

18" @ 8969' MD/TVD (3902' bml)


18,061-18,073
12.6 ppg
18,104-18,175
M56E sand
18,202-18,223 16" @ 11,585 MD / TVD (6518' bml)

XOVER 12,487.64'

13-5/8" @ 13,145' MD / 13,133' TVD

7 shoe 18,304

11-7/8" Liner @ 15,103' MD / 15,092' TVD

Float Collar
18,115
9-7/8" Liner @ 17,168' MD / 17,157' TVD

TD @ 18,360' MD / 7" Shoe @ 18,303.92' MD


Figure3MacondoWellShoeTrackandHydrocarbonIntervals

H. DesigningtheProductionCasingLongStringversusLiner

BPdrilledtheMacondowelltoahydrocarbonbearingzoneandplanned
toreturntothiszoneatalaterdatetocompletetheMacondowellfor
production.BeforemovingtheDeepwaterHorizonrigoffoftheMacondowell,
BPchosetosetaproductioncasingthatwouldbeusedtoextracthydrocarbons
atalaterdate.

36
Theproductioncasingrunsfromthebottomofthewelluptothe
wellhead.Therearetwogeneraldesignoptionsforproductioncasingsalong
stringdesignoralinerdesign.Alongstringcasingdesignconsistsofa
productioncasingthatextendsfromthebottomofthewelltothetopofthe
wellbore.Alinercasingdesignconsistsofacasingthatisanchoredor
suspendedfrominsidethebottomofthepreviouscasingstringanddoesnot
extendtothetopofthewellbore.Thelinerdesignhastheoptionofbeingtied
backtothetopofthewellhead.

Ingeneral,bothlongstringandlinerproductioncasingshavetwo
annulusbarriers:cementacrossthehydrocarbonzonesandthemechanicalseal
atthetopofeachstring.Themechanicalsealinalongstringcasingincludesthe
wellheadcasinghangersealassembly.Alinerdesignusesalinertoppacker
assembly.Thelinertiebackprovidestwoadditionalbarriers:thelinertieback
cementandthetiebacksealassembly.However,theuseofalinertieback
designalsoinvolvesrisksassociatedwiththepossibilityofmechanicalintegrity
failureatthetiebackjunction,aswellasthepotentialforincreasedannular
pressurebuildup,whichcouldoccurasaresultofannularfluidexpansion
causedbyheattransferduringthewellsproductionphase.Annularpressure
buildupincreasestheriskthattheproductioncasingortiebackstringwill
collapseifannulusfluidsorpressurebecometrappedbytheassemblywithno
outletforbleedoff.

BPswellengineeringteampreparedanundatedForwardPlanReview
addressingproductioncasingandtemporaryabandonmentoptionsforthe
MacondowellandcirculateditwithinBPinApril2010.Theforwardplan
recommendedagainstusingthelongstringdesignbecauseoftherisksdescribed
abovethatareassociatedwiththattypeofdesign.Thisdocumentstatedthat,
whilethelongstringof97/8x7inchcasingwastheprimaryoption,theuseof
a7inchlinerwasnowtherecommendedoptionforthefollowingreasons:
cementsimulationssuggestedthatcementingthelongstringwasunlikelytobe
successfulduetoformationbreakdown;usingalongstringwouldpreventBP
frommeetingregulatoryrequirementsof500feetofcementabovethetop
hydrocarbonzone;thelongstringwouldresultinanopenannulustothe
wellhead,withhydrocarbonzones(s)opento97/8inchsealassemblyastheonly
barrier;andthepotentialneedtoverifythecementjobwithabondlogandto
performoneormoreremedialcementjobspriortothetemporaryabandonment
ofthewell. 81

81BPHZNMBI00020910.

37

BPalsoidentifiedadvantagesofusingalinerdesign,includingthatthe
linerhangerwouldactassecondbarrierforhydrocarbonsintheannulus;the
primarycementjobonthelinerhadaslightlybetterchanceforsuccessfulcement
liftduetolowerECD; 82anditwouldbeeasiertojustifypostponinganyremedial
cementjobuntilafterthetemporaryabandonmentprocedurewascompleted. 83

BPemployeesevaluatedtheseapproachestodesigningtheproduction
casing.Forexample,onApril14,BPDrillingEngineerBrianMorelemaileda
colleague,RichardMiller,abouttheoptions.Inhisemail,Morelreferredto
Macondoasanightmarewellwhichhaseveryoneallovertheplace.Miller
respondedtoMorelsemail,advisingMorelthathehadupdatedhiscalculations
andmodel,whichindicatedthatbothproposalsfortheproductioncasingdesign
werefine. 84

Whenearlycementmodelingresultssuggestedthatthelongstringcould
notbecementedreliably,BPsdesignteamswitchedtoalinerdesign.However,
onApril13,MorelaskedEricCunningham,aninhouseBPcementingexpert,to
reviewHalliburtonscementingrecommendationsandmodeling.Cunningham
determinedthatcertaincementmodelingparametersusedbyHalliburton
shouldbecorrected.TheresultsoftherevisedmodelingcausedBPtoswitch
backtotheuseofalongstringastheprimaryoptionfortheproductioncasing.

Ultimately,BPchosetoinstallalongstringproductioncasinginthe
Macondowellinsteadofusingalinerandtieback.ABPManagementof
Changedocumentstatedthatthisdecisionwasbasedonthefollowingfactors:
thelongstringprovidedthebesteconomiccaseandwellintegritycasefor
futurecompletionsoperations;therecentcementmodelingshowedthatthe
longstringcouldbecementedsuccessfullyand,whileuseofalinerisalsoan
acceptableoption,doingsowouldadd$710milliontothecostofcompleting
thewell. 85

ThePanelfoundnoevidencethatthelongstringproductioncasingdesign
wasacauseoftheblowout.

82
Cementliftisincreasedpumppressurethatresultswhencementthatispumpeddownthewell
beginstoflowbackupwardagainstgravity.
83BPHZNMBI00020910.

84BPHZNCEC000021857.

85BPHZNMBI00143292.ManagementofChangeisBPsformalprocessforevaluatingand

approvingoperationaldecisions.

38

BPhadathirdoption(otherthaninstallingalongstrongproduction
casingoralinertieback)itcouldhavetemporarilyabandonedtheMacondo
wellwithoutsettinganyproductioncasing,whichisanoptionforwellswith
zerodrillingmargin.Forexample,inJanuary2009,onawellBPdrilledpriorto
Macondo,theKodiakwellatMC727Number2,theDeepwaterHorizoncrew
temporarilyabandonedthewellwithoutrunningproductioncasing.InAugust
2009,BPandtheDeepwaterHorizoncrewalsotemporarilyabandonedtheTiber
well,KC102Number1,whichhadsimilardrillingmarginhazardstothe
Macondowell,withoutsettingaproductioncasing. BPacknowledgedthisthird
optioninalateriterationofthetemporaryabandonmentandproductioncasing
ForwardPlandiscussedabove,whichstatedthatthecompanycouldplugthe
openholeandtemporarilyabandonthewell.BPnotedthatthiswasanoptionif
holeconditionsgosouth. 86Whilealloftheprimarywellobjectiveshadbeen
achieved,andalthoughBPcouldhaveminimizedanyadditionalimmediate
spendingonthewell,thethirdoptionwouldhaveincreasedcompletioncostsby
$10to$15millionbecauseBPwouldatafuturetimehavehadtodrilloutthe
cementplugs,redrilltheproductionhole,andrelogthewelldata. 87Forthese
reasons,thiswasBPsleastpreferredoption.

IfBPhadtemporarilyabandonedtheMacondowellwithoutrunningthe
productioncasing,asithaddonewithpriorwellswithnarrowdrillingmargins,
BPwouldlikelyhavehadanopportunitytoconsiderotheroptionsforsetting
thecasing,suchassidetrackingthewellandsettingthecasinginalocationwith
alowerpotentialforlostreturns.Inaddition,asdiscussedbelow,ifBPhad
temporarilyabandonedtheMacondowellwithoutsettingaproductioncasing,it
wouldnothavetakenstepstosetalockdownsleeveandcouldhavesetthe
surfaceplughigherinthewell.

86 BPHZNMBI00143295.
87 Id.

39
III. Cementing

Themainpurposeofcementwithinawellistoachievezonalisolation.
Cementreinforcesthecasingandpreventstheflowofhydrocarbonsthroughthe
annularspace.Thissectiondiscussesthecementingofthefinalproduction
casingintheMacondowell.

A. CementingProcess

Priortocementingawell,therigcrewconditionsthewellboreby
circulatingmudthroughit.Thisconditioningcleansoutanycuttingsorother
debrisinthecasing,drillpipeandwellborethatcouldinterferewithcement
placement.Whenmudiscirculatedcompletelythroughthecasing(sothatthe
mudonthebottomofthewellreturnstothesurface),operatorshaveachieveda
completebottomsup.Byperformingacompletebottomsup,thecrewnot
onlycleansoutthewellbore,butcanalsoanalyzethemudthathadbeenonthe
bottomofthewelltodeterminewhetherhydrocarbonsarepresentbefore
cementing.

Aftercirculatingmud,thecrewpumpsthevolumeofcementmodeledfor
thejobdownthewell,followedbythedrillingmudthatispumpedbehindthe
cementtopushthecementtoitsplannedlocation.Dartsandwiperplugs
separatethecementfromthemudtopreventtheoilbasedmudfrommixing
with,andpossiblycontaminating,thecement. 88AtMacondo,thecrewfirst
pumpedbaseoil(syntheticoilwithnoadditives)aheadofawaterbasedspacer
(aspacerisafluidmixturethatkeepsthemudandcementseparated).The
spacerwasfollowedbyabottomdart,thecement,thetopdartandmorespacer.
Afterthesecondspacer,thecrewpumpeddrillingmudtopushthematerialsin
frontofitdownthedrillpipe.

Whenthedartsreachtheendofthedrillpipe,thedartslaunchbottom
andtopwiperplugsthatseparatethecementfromtheothermaterialstraveling
downthewell.Whenthebottomplugreachesthetopofthefloatcollar,
pressurecausestheplugtorupture,andcementpassesthroughtheplugintothe
shoetrack.Afterallofthecementhasmovedthroughthebottomplugandinto
thetrack,thetopwiperpluglandsonthefloatvalves.Thetopplugisnot

Adartisadevicepumpedthroughatubingstringtoactivatedownholeequipmentand
88

tools.Awiperplugisaplasticcomponentthattravelsdownthewelltoseparatethespacer
andthecement.

40
designedtorupturebutinsteadremainsintacttopreventmudorspacerfrom
flowingdownthewell.Ifthecementjobhasgoneasplanned,thecementshould
beinthecorrectplaceintheannulusandshouldfilltheshoetrackwhenthetop
pluglands.

B. CementDesignandModeling

BPworkedwithHalliburtontodesigntheparametersoftheMacondo
cementjob.BecauseofthelostreturnsBPhadencounteredthroughoutthe
drillingoftheMacondowell,BPfocusedonreducingthechanceofadditional
lossesduringthefinalcementjob.BPsoughttominimizetheselossesby
reducingthevolumeofcementitpumpedintothewell,loweringtherateat
whichcementwaspumpedintothewellandusinganitrifiedcementslurryfor
partofthecementjob.Asdiscussedfurtherbelow,useoflowerdensitynitrified
foamcementofferedadvantagesintermsofreducingtheriskofformation
breakdown,butalsopresentedtechnicalchallengesinensuringthatthecement
mixtureisstable.89

1. CementVolume

BPchosetolimittheheightofthecementintheannulusbecausethe
highertheannularcementcolumn,themorepressurethecementwouldexerton
theformationbelow,increasingthelikelihoodofadditionallostreturnsand
potentialforfracturing.BPengineersproposedtosetthetopofthecementin
theannulusatabout17,300feettotaldepth,whichwasapproximately500feet
abovetheuppermosthydrocarbonzone. 90MMSregulationsrequiredthe
cementedannularspaceinaproductioncasingjobtobe500feetabovethe
uppermosthydrocarbonzone. 91

89OnAugust1,2011,OilfieldTestingandConsulting(OTC)completedaforensicanalysisof
thecementsamplesmixedtoreplicatethecementslurriesthatwerepumpedintotheMacondo
well.OTCsanalysisrevealedarangeofpotentialcementsettingtimesforthefoamedand
unfoamedcement.Severalofthesamplestestedrevealedsettingtimesgreaterthan18hours(the
timeperiodbetweenthecompletionofthecementjobandthestartofthenegativetests).See
OTCReportatpage30.ThePanel,however,foundthattherewasstrongevidencethatthe
cementhadsetpriortothetimetherigcrewperformedthenegativetest.See
http://www.oilspillcommission.gov/sites/default/files/documents/Chevron%20letter%2010%2026
%2010.pdf.
90BPHZNMBI0023746.Topofcementisthedepthinthewellwherethecementthathas

alreadybeensetinthewellends.
9130CFR250.421.

41
Halliburtonpumpedatotalof51bblsofcementfortheproductioncasing
cementjob,consistingof5.26bblsofleadcement,38.9bbls(47.74bblswhen
foamed)offoamedcement,and6.93bblsoftailcement. 92BPdidnotplanto
pumpcementabovethetopwiperpluginordertopreservetheabilitytoruna
cementevaluationlog(discussedbelow),ifnecessary.Cementabovethewiper
plugwouldhaveprovidedanadditionalbarriertohydrocarbonflow.

2. PumpTimeandRate

BPplannedtopumpthecementintothewellatarelativelylowrateof
fourbarrelsaminuteinordertoreducepressureontheformationthatcould
resultinlostreturns.Thisstrategycarriedriskssinceahigherpumpingrate
generallywouldhaveincreasedthelikelihoodthatcementwoulddisplacemud
fromtheannulusandtherebywouldhaveincreasedthelikelihoodofa
successfulcementjob.

BPwasawarethatitwasusingalowpumprate,soitwantedtobeableto
maximizetheamountoftimeitcouldrunthepumpwithoutthecementsetting
uporfracturingtheformation.BrianMorel,BPDrillingEngineer,expressedthis
inanemailtoJohnGuide,BPwellsteamleader,onApril17,whichstated:I
wouldprefertheextrapumptimewiththeaddedriskofhavingissueswiththe
nitrogen.Whatareyourthoughts?Thereisntacompressivestrength
developmentyet,soitshardtoensurewewillgetwhatweneeduntilits[sic]
done. 93

3. NitrifiedCement

AnotherwayinwhichBPsoughttoreduceadditionallostreturnsduring
thecementjobwasbyusinganitrifiedorfoamedcementslurryintheannular
space(thetailcementfortheshoetrackwasunfoamedcement).Cement
specialistsmakenitrifiedorfoamedcementbyinjectingcementwithnitrogen
bubbleswhilethecementisbeingpreparedontherig.Nitrifiedcementisless
densethanunfoamedcementandthereforeexertslesspressureontheformation.
However,theuseoffoamedcementcreatestheriskofnitrogenbreakoutifthe
nitrogenbubblesinthecementbreakoutofsuspensionwhichcanresultin
inconsistentcementplacementanddensities.Theuseofnitrifiedcementin

92BPHZNCEC011406.
93BPHZNMBI00255923.

42
deepwaterwellsistypicallyaviableoption;however,careshouldbetakenwhen
designingandexecutingthejobtopreventnitrogenbreakout.

Testingthestabilityoffoamcementbeforeitisusedinanoffshorecement
jobiscommonpracticeintheindustry.Consistentwiththispractice,Halliburton
shippedsamplesoftheMacondocementtoitslaboratoryinadvanceofthedate
onwhichthecementcomponentsweretobeusedontheMacondowelland
retainedsurplussamplesfromthetestingprogram.Halliburtonconductedpre
jobtestingofthemixtureofingredientstobeusedintheMacondocementslurry
toassesswhetherthecementcouldbepumpedandwouldsetupproperlyunder
conditionssimulatedtomatchthosedownthewellbore.

WhileHalliburtonconductedseveralprejobcementtests,itdidnotfinish
itsfinalcompressivestrengthanalysisforthecementusedontheproduction
casingstring.Compressivestrengthanalysesdeterminethelengthoftimefor
thecementslurrytodevelopsufficientstrengthtoachievezonalisolationand
providesufficientsupporttothecasing.OnApril19,JesseGagliano,the
Halliburtoninhousecementingengineer,toldtheBPwellsiteleadersandBrian
Morelthatthecompressivestrengthanalysisforthecementjobhadnotbeen
completed. 94Nevertheless,BPcontinuedthecementjobwithoutthis
information.ThePanelfoundnoevidencethatBPorHalliburtonevershared
thecementstabilityresultsortheOptiCemreports(showinggasflowpotential)
withTransoceanpersonnelontheDeepwaterHorizonorintheHoustonoffice.

HalliburtonspostblowoutlaboratoryworksheetsdatedMay26,2010,
showthatthefoamslurrycementdidnotmeetAmericanPetroleumInstitute
RecommendedPractice(APIRP)65. 95Additionally,laboratorytests
conductedbyChevrononbehalfoftheNationalCommissionontheBP
DeepwaterHorizonOilSpillandDeepwaterDrilling(Presidential
Commission)showedthatthefoamedcementslurryusedontheMacondowell
wasnotstable.

4. CementingaLongString

Asdiscussedabove,BPdebatedinternallywhethertousealongstringor
linerwithtiebackasthefinalproductioncasing.BPhaddifficultieswiththe
cementinoneofthetwolongstringsitranintheMacondowellpriortothe

94BPHZNMBI00192892.
95HAL0050590.

43
productioncasing.WhenBPdrilledoutthecementjobonthe16inch
intermediatelongstring,itdiscoveredthattheconditionoftheshoetrack
suggestedthatthecementhadnotsetupproperly,leadingthecementtochannel
andresultinlostreturns. 96

5. CementModeling

Offshoreoperatorsusecementmodelstocalculaterealtimeequivalent
circulatingdensitiesbasedonactualcementvolumes,ratesandfluiddensities.
Bymodelingvariousinputs,operatorscanassess,amongotherthings,the
likelihoodthatchannelinginthecementwilloccurasitsetsup.Channelingin
cementisaproblembecauseitcanprovideanopportunityforgastoflow
throughthecement,whichisquantifiedasgasflowpotential.

FortheMacondowell,BPusedHalliburtonsOptiCemprogramtomodel
pumpingsequencesofvariousfluiddensitiesandvolumestodeterminewhether
theminimumformationfracturepressurewouldbeexceeded.Inall,Halliburton
developedatleast30to40modelsforthecementtobeusedwiththeMacondo
productioncasing. 97Indevelopingthesemodels,BPandHalliburtonfrequently
changedassumptionsaboutthecasingstringandnumberofcentralizerstobe
used.Forexample,HalliburtongeneratedanOptiCemmodelonApril15at3:30
p.m.,whichshowedthatchannelingcouldresultifonlytencentralizerswere
installedinthewell.Themodelcalledfortencentralizerstobeinstalledbetween
18,300feetand17,811feetmeasureddepth,usingapproximately45footspacing
andanapproximate80%standoff. 98Theresultinggasflowpotential(GFP)
wasmoderateatareservoirzoneof18,200feetmeasureddepth.

LateronApril15,Halliburtonranasecondmodelusing21centralizers
installedbetween18,300feetand17,400feetmeasureddepth,using45foot
spacingwitha70%topofcentralizedintervalstandoff.Thismodelpredicted
thatchannelingwouldnotoccur;theresultinggasflowpotentialwasminor.
Basedonthisreport,BPordered15additionalcentralizerstosupplementthesix
centralizersalreadyontheDeepwaterHorizon.BPsdecisionmakingwithrespect

96BPHZNMB100036098.Cementchannelingisafailureduringthecementingofthecasingto
theformationinwhichthecementslurryleavesopenspaceswherehydrocarbonscanpotentially
flow.Theshoetrackisthespacebetweenthefloatcollarandapieceofequipmentcalleda
reamershoe(locatedatthebottomofthecasing).
97TestimonyofJesseGagliano,JointInvestigationHearing,August24,2010,at245.

98Standoffisthesmallestdistancebetweenthecasingandthewellborewall.Thestandoffratiois

theratioofthestandofftotheannularclearanceforaperfectlycenteredcasing.

44
totheinstallationofcentralizersduringthetemporaryabandonmentprocedure
isdiscussedinmoredetailbelow.

OnApril18,2010,Halliburtonmodeledthewellwithsevencentralizers
installedbetween18,305feetand18,035feetmeasureddepth,with45foot
spacing.Theresultinggasflowpotentialwassevereatareservoirzoneof18,200
feetmeasureddepth.

Atapproximately8:58p.m.onApril18,JesseGagliano,aHalliburton
cementingengineer,sentanemailtoseveralBPandHalliburtonpersonnel
attachingthisversionoftheOptiCemmodel,alongwithpartiallabresultson
compressivestrengthandHalliburtonsrecommendedcementingprocedurefor
theMacondowellcementjob. 99

BPusedtheApril18OptiCemreportasthebasisfortheactualcementjob
itperformedonApril19.

6. WeaknessesintheCementModeling

ThePanelidentifiedthefollowingincorrectassumptionsintheApril18
OptiCemmodel:

Themodelassumedaporepressureof13.97ppgforthehydrocarbon
zoneat18,200feetbasedonalinearprofilebetween17,700feetand18,305
feet.Thiswasinconsistentwiththemeasuredporepressurevalueofthis
zone,whichwas12.5to12.6ppg.

Halliburtonsreportusedincorrectcentralizerdata.Themodeluseda
nominaldiameterof8.622inches,buttheinstalledcentralizershadan
actualdiameterof10.5inches.Themodelalsospacedthecentralizers45
feetapartinsteadofusingtheactual,variablecentralizerspacingBP
specifiedtoHalliburton. 100Themodelalsoassumedsevencentralizers
ratherthanthesixthatactuallywereusedintheMacondoproduction
casingcementjob.

99BPHZNMBI00128708.
100BPspecifiedthatcentralizerswouldbespacedatvaryingintervals.SeeBPHZNMBI00127389.

45
WhileHalliburtonmodeledthemudasanoilbasedmudwithaconstant
densityof14.17ppg,thesyntheticoilbasedmudactuallyusedinthewell
wascompressibleandhadavariabledensity.

Halliburtonscementjobdesignincludedusingbaseoilwithadensityof
6.7ppg.BPactuallyusedthe6.7ppgdensitybaseoilinthefinalcement
job,butHalliburtonsApril18modelassumedthatthebaseoilwould
havea6.5ppgdensity.

IntheApril18model,Halliburtonassumed135Fasthebottomhole
circulatingtemperature,butBPmodelingshowedthatcirculating
temperatureduringcementingwouldbe140F.

ThePanelfoundnoevidencethat,despitetheinconsistenciesdescribed
above,BPquestionedthedataintheApril18modelbeforetheblowout.Nordid
thePanelfindanyevidencethatBPsharedtheOptiCemmodelinformationwith
theTransoceancreworpersonnelonshore.Giventheimportanceofthe
productioncasingcementjobtotheintegrityofthewell,accesstoOptiCemdata
wascriticaltoallowingtherigcrewtofullyunderstandtherisks.

C. GasFlowPotential

BPwitnessestestifiedthattheywerenotawareof,nordidtheyreview,
thegasflowpotentialcalculationsincludedintheOptiCemmodelreport.Brett
Cocales,aBPoperationsengineer,testifiedthathewasnotfamiliarwithgas
flowasitrelatestocementing. 101TestimonyfromBPpersonneldemonstrated
thattheydidnotfullyunderstandthegasflowpotentialoutputsreflectedinthe
OptiCemmodelsandinsteadonlyconsideredtheECDchartsinevaluatingthe
cementmodelresults. 102

IntheOptiCemmodels,gasflowpotentialhigherthansevenistypically
consideredsevere.DespitetheseveregasflowpotentialindicatedbyitsApril18
OptiCemmodel,Halliburtonemployeesprovidedthefollowingtestimony
demonstratingthattheybelievedtheOptiCemmodelsdidnotraiseimmediate
safetyconcerns:

TestimonyofBrettCocales,JointInvestigationHearing,August27,2010at155.
101

CocalesTestimonyat22;TestimonyofDavidSims,JointInvestigationHearing,August26,
102

2010at223.

46
NathanielChaisson,acementingengineer,statedthatpoorcentralization
doesnotequatetocompleteblowout; 103
JesseGagliano,acementingengineer,statedthatchannelingdoesnot
equalablowout; 104and
VincentTabler,acementer,statedthat,inameetingonApril19,noone
raisedconcernsabouttheriskassociatedwiththeproductioncasing
cementjob. 105

ItisnotcommonforoperatorsintheGulfofMexicotocompletecement
jobsthatpresentaseveregasflowpotential,althoughcementjobswiththese
conditionshavebeencompletedsuccessfullyinthepast.Halliburtonprovided
thePanelwithinformationaboutthenumberofcementjobsitconducted
betweenJanuary1,2005andApril20,2010wherethegasflowpotentialwas
calculatedtobesevere.ThePanelreviewedrecordsforjobsperformedinthe
GulfofMexico,andoffshoreinBrazil,NorwayandtheUnitedKingdom,which
showedthat53ofthesejobshadseveregasflowpotential.Elevenofthese53
cementjobswereperformedinthedeepwateroftheGulfofMexico.BPwasthe
operatorontwoofHalliburtonsseveregasflowpotentialcementjobs
conductedinthedeepwaterGulfofMexico.

D. Centralizers

Acentralizerisadevicethatfitsaroundacasingstringorlinertoensure
centeringofthecasinginanopenhole.Centralizationofcasingstringsand
linersfacilitatestheefficientplacementofcementaroundthecasingstring.Even
thoughtheMacondowellwasastraighthole,BPusedcentralizersbecausethe
diameteroftheproductioncasingdoesnotalwaysalignexactlywiththecenter
ofthewellboreand,therefore,withoutcentralizerstheproductioncasingcould
restalongthesidesofthewellbore.Casingstringcontactwiththesideofthe
wellborecanleadtovoidspacesinthecementjob(referredtoaschanneling).

OnApril14,fourdaysbeforetheproductioncasingwasscheduledtobe
run,BPhadonlysixcentralizersavailableontheDeepwaterHorizonforthe
productioncasingcementjob.Thesixcentralizersalreadyontherighadbuiltin
stopcollars.Stopcollarspreventacentralizerfrommovingupanddownthe
casingandbuiltinstopcollarsareintegratedintothecentralizer.Other

103TestimonyofNathanielChaisson,JointInvestigationHearing,August24,2010,at419.
104Gagliano,testimonyat264.
105TestimonyofVincentTabler,JointInvestigationHearing,August25,2010,at1213.

47
centralizersusestopcollarsthatareseparatecomponentsandslipontothe
centralizers.BecausetheApril15OptiCemreportpredictedlesschannelingwith
atotalof21centralizers,theBPMacondowellteamlocated15additional
centralizersfromWeatherford,anoilfieldservicecompany,andarrangedfor
themtobesenttotheBPshorebaseinHouma,Louisiana,fromwhichthe
centralizerswouldbeflowntotherig. 106

AWeatherfordrepresentative,DanielOldfather,however,testifiedhe
couldnotlocateallthecentralizermaterialsattheBPshorebase. 107Whilethe15
centralizerswereatHouma,additionalcentralizercomponents,includingstop
collarsandepoxywerenotavailable. 108OldfatherfurthertestifiedthataBP
representativetoldhimthattheadditionalcomponentswouldbeshippedtothe
rigbyboat. 109OnApril16,OldfatherflewtotheDeepwaterHorizonwiththe15
centralizersandwaitedfortheothercentralizercomponentstoarrive. 110When
the15centralizersarrivedontherig,BrianMorelexaminedthemandtoldJohn
Guide,theBPwellsteamleader,thatthe15centralizersdidnothavestopcollars
onthembutthattheywouldhaveplentyoftimeforthestopcollarstobe
deliveredtotherig. 111BPhadplannedtosendtheadditionalcentralizer
componentsbyboat,whichwastoarrivetheafternoonofApril16.By10:00p.m.
onthatdate,theboathadnotarrived. 112OnthemorningofApril17,Moreltold
OldfatherthatBPwouldrunonlythesixcentralizerswithbuiltinstopcollars
thatBPalreadyhadavailableontherig.Oldfathertestifiedthathenever
determinedwhethertheshipmentwiththeadditionalcentralizercomponents
arrivedontheDeepwaterHorizon. 113

GuideexplainedinanemailandinhistestimonybeforetheJITthe
rationaleforBPsdecisiontouseonly6centralizersratherthanthe21
centralizersthatbeenplanned.AccordingtoGuide,BPbelievedbasedonits
previousexperiencethatthe15centralizersdeliveredtotherig,whichhad
separatestopcollarsthatneededtobeslippedontothecentralizers,mightcome
apartandclogthewellbore. 114Finally,Guidenotedthatitwouldhavetakenan

106TestimonyofDanielOldfather,JointInvestigationHearing,October7,2010,at7.
107Id.
108Id.at89.

109Id.

110Id.at912.

111BPHZNMBI000255668.

112Oldfathertestimonyat1112.

113Id.at1213.

114Guidetestimony,July22,2010at6768.

48
additional10hourstoinstall21ratherthan6centralizers,andhestatedthatthe
earlierdecisiontouse21centralizerswasmadebyGreggWalz,BPdrilling
engineerteamleader,andothersinhisabsence. 115

ThePanelfoundnoevidencethatBPsdecisiontouse6centralizersrather
thanthe21recommendedbyHalliburtonwasacauseoftheblowout.

E. FloatCollar

1. FloatCollarFunction

Floatcollarsareonewayvalvesinstalledatornearthebottomofthe
casingstring.Whenafloatcollarhasbeensuccessfullyconverteditwillallow
fluidstoflowinonlyonedirection.Aconvertedfloatcollarallowscementand
otherfluidstobepumpeddownthewellwithoutreversingdirectionand
comingbackupthecasing.BPusedaWeatherfordModelM45APmidbore
autofillfloatcollarintheMacondowell,whichisdepictedinFigure4below.

Thefloatcollarusesadoublecheckvalveamechanicalvalvethat
permitsfluidtoflowinonedirectionthatisheldopenbyanautofilltube.
Whenrunningthecasingintothewell,theautofilltubeallowsmudtoflowinto
thecasing,therebyreducingtheforceexertedbythemudontheformationand
helpingtopreventlossoffluidsintotheformation.Toconvertthefloatcollar,a
ball(inthiscaseanAllamonballbecausethefloatcollarwasmanufacturedby
Allamon)restsintheautofilltubewhenrunningthecasingintothewelland
whenmudpumpingstartsitrestrictstheflowofmudbydivertingthemud
throughtwosmallportsintheautofilltube.Circulationthroughtheseports
createsadifferentialpressureinthefloatcollar,forcingtheautofilltubeoutof
thefloatcollarandallowingthecheckvalvestoclose.Indoingso,afloatcollar,
whichissetnearthebottomofthecasingstring,actsasacheckvalveand
preventscementthatispumpeddownthroughthecasingfromflowingback
intotheshoetrack(whichisthedistancebetweenthefloatcollarandendofthe
casing)oncethecementisinplace.Ifthefloatcollarfailstoconvert,itispossible
forreversefloworutubingflowtooccurfromthebottomofthecasingup
thewellboretowardtherig.

115BPHZNCEC022433.

49

Auto-Fill Ball

Float Check Valve


Auto-Fill Tube

Circulation Port


Figure4FloatCollarUtilizedintheMacondoWell

Asdiscussedabove,thefloatcollarwassetat18,115feetmeasureddepth,
withintheprimaryhydrocarbonreservoirsands(seeFigure2,above).Typically,
anoperatorsetsthefloatcollarbelowtheprimaryhydrocarbonsandstoallow
forperforationofthepayzonewithouttheneedtodrilloutthefloatequipment
togetbelowthepayzoneduringthecompletionofthewell.Inaddition,the
lowerprimarysandwaslessthan100feetfromthebottomoftheproduction
casingshoe. 116Normally,anoperatorwouldsettheproductioncasingshoe200
to300feetbelowtheprimarysandtoimprovethechancesofproperisolationof
thepaysand.

116 BPHZNMBI00018459.

50

2. FloatCollarConversionAttempts

OnApril18,atapproximately3:30a.m.,theDeepwaterHorizoncrew
startedrunningthe97/8x7inchlongstringproductioncasingandfinishedthe
procedureat1:30p.m.onApril19. 117Afterthecasingstringlanded,thecrew
attemptedtoconvertthefloatcollarsinpreparationforpumpingproduction
casingcementintothewell.BasedoninformationthatWeatherfordsupplied,
thefloatcollarconversionshouldhaveoccurredwithadifferentialpressureof
between400and700poundspersquareinch(psi),whichrequiredacalculated
pumprateoffivetosevenbarrelsperminute(bpm).Asuccessfulconversionof
thefloatcollarwouldresultinthefloatcollarstwocheckvalvesmovingintoa
closedposition,whichshouldpreventflowofcement(orotherfluids)upthe
casing.

Thecrewmadenineattemptstoestablishcirculationthroughthefloat
collarinanefforttoconvertthefloatcollar,increasingpressureoneachattempt.
Thecrewfinallyestablishedcirculationontheninthtry,atpressureof3,142psi.
Aftercirculationwasestablished,thecirculationpressurewasonly340psi,
whichwaslowerthanthepressureof570psipredictedbyHalliburtons
computermodel.Thepumpraterequiredtomovemudintothewelland
throughtheshoetrack(circulatingpressure)neverexceededapproximately4
bpm,whichwaslessthanthefivetosevenbpmthatWeatherforddetermined
wasnecessaryforfloatcollarconversion.

BecauseBobKaluza,theBPwellsiteleader,wasconcernedaboutthelow
circulatingpressure,hedirectedtherigcrewtoswitchcirculatingpumpsto
determinewhetherdoingsowouldimprovecirculatingpressure.They
eventuallyconcludedthatthepressuregaugetheyhadbeenrelyingonwas
inaccurate. 118

NathanielChaisson,anonsiteHalliburtonengineer,testifiedthat,after
circulationwasestablished,KaluzasaidImafraidthatweveblownsomething
higherupinthecasingjoint.ChaissonunderstoodKaluzatomeanthathe
believedtheyhadnotbeencirculatingmudfromthebottomofthewellup,but

117 BPDailyDrillingreports4/19,4/10(BPHZNMBI000136936;BPHZNMBI000136946).
118 Cocalestestimonyat7175.

51
ratherwerecirculatingitfromsomepointhigherinthewellcasing. 119According
tonotesofKaluzasinterviewwithBPinternalinvestigators,Kaluzadiscussed
withGuideandKeithDaigle,aBPwelloperationsadvisor,whatKaluza
consideredtobetheanomalyofthelowcirculationpressureaftercirculationwas
established.Inthatconversation,GuidedirectedKaluzatopumpcementand
didnotinstructhimtoredotestsortotakeanyotherprecautions(forexample,
settinganothercementbarrierontopofthewiperplugormoreclosely
monitoringwellflowsandpressuresaftercompletionofthecementjob). 120

DespiteKaluzasmisgivingsaboutlowcirculatingpressure,theBPteam
ontheDeepwaterHorizonconcludedthatthefloatvalveshadinfactconverted
andthereforecontinuedtothecementpumpingphaseofthetemporary
abandonmentoperation.

3. ProblemswithFloatCollarConversion

Thecementingcrewbelievedthatthefloatvalvesconvertedand,
therefore,proceededtopumpcementintothewell,eventhoughtherewas
evidencethattheconversionneveroccurred.Withoutproperconversionofthe
floatcollar,cementandotherfluidswouldhaveapathtoflowbackupthe
casingtotherigfloor.Followingtheblowout,BPcontractedStressEngineering
toconductapostincidentanalysisonfloatcollarssimilartothatusedonthe
Macondowell. 121StressEngineeringsreportconcludedthatthewell
experiencedablockagethatpreventedthefloatcollarfromconvertingduring
steadystateflow. 122DataanalyzedbyStressEngineeringsupportedthe
likelihoodthatablockagewaspresentfromasearlyaswhenthediverterwas
closedusingtheAllamonball,upthroughBPsfinalattempttoconvertthefloat
collar. 123StressEngineeringcouldnotdeterminewhethertheblockageoccurred
atthefloatcollaroratthereamershoe. 124

119NathanielChaissontestimonyat432433.
120BPHZNMBI00021271.
121HorizonIncidentFloatCollarStudyAnalysis,StressEngineeringServices,November22,2010

(BPHZNMBI00262898).
122Id.

123Id.

124Thefloatcollarandthereamershoewerethetwolikelylocationsforblockagebecausethey

eachhaveflowdirectedportsthatcanbecomeblockedwithlostcirculationmaterialorother
debris.Thereamershoeportscanalsobecomepluggedastheyareloweredintothehole.When
lowered,theshoeportscanscrapeagainsttheopenholesection,whichcanforcedebrisintothe
shoeportsandclogthem.BPsBrianMoreltoldBPinvestigatorsthathebelievedatthetimeof
theattemptedfloatcollarconversionthatthereamershoewasplugged.BPHZNMBI00021304.

52

ThePanelfoundadditionalevidencethatablockagemayhavebeen
presentatthebeginningoftheproductioncasingcementjob. 125Earlierinthe
procedure,thecrewlandedabottomwiperplugonthefloatcollarinorderto
establishaseparationbetweenfluids(spacerandmud)alreadypresentinthe
wellandinordertopreventcontaminationofthecement.Afterthewiperplug
landedonthefloatcollar,pressurewasappliedtoruptureaburstdiskinthe
wiperplug,whichwouldallowcirculationofthecementjobtocontinue.The
burstdiskwasdesignedtoruptureatbetween900psiand1,100psi,butthedisk
didnotactuallyruptureuntilthepressurereached2,900psi.

BPmighthavebeenabletoreducethelikelihoodoffloatcollarblockage
byinstallingafloatcollarthatwasmoredebristolerantthanthefloatcollarused
ontheMacondowell.Becauseofthenumerouslostcirculationeventsinthe
well,BPhadtouselostcirculationmaterialseveraltimes.Whenthereissuch
materialinthewell,drillerssometimesusedebristolerantfloatcollarstoreduce
thechancesthatthematerialmightleadtoablockage.Indeed,duringthe
attemptedfloatcollarconversion,oneofBPscontractorssuggestedtoMark
Hafle,aBPdrillingengineer,thatBPuseamoredebristolerantfloatcollarinthe
future. 126Haflesresponsewasthatthefloatcollarshiftedat3140psi.Orwe
hopeso. 127ThisresponsesuggeststhatHaflecouldnotverifythatthefloat
collarhadconverted,norcouldheexplainwhyittooksomanytriestoconvert
thefloatcollar.

ThePaneldidnotfindsufficientevidencetodeterminewhatcausedthe
blockagethataffectedthefloatcollar.

F. CementingtheMacondoProductionCasing

TheApril19cementjobwasperformedaccordingtotheprocedures
detailedintheApril18OptiCemreport. 128However,BPusedonlysix
centralizersinthewell,ratherthanthesevencentralizersrecommendedand
assumedintheApril18model.Priortocementing,BPdidonlyapartial

Areamershoeisapieceofequipmentthatguidescasingtowardsthecenteroftheholeasitis
lowereddownthewellbore.
125IADCreport4/19/10;SperrySunrigdata.

126BPHZNMBI00257031.

127Id.

128BPHZNCEC000011406.

53
wellborecirculationbecauseitwasconcernedaboutadditionallostreturnsthat
couldresultfromacompletebottomsupcirculation. 129

OnApril19,Halliburtonpumpedthefollowingfluidsdownthewellbore:
baseoil,spacerfluid,unfoamedleadcement,foamed(ornitrified)cementthat
wouldgointheannulus,tailcementandadditionalspacer. 130Afterpumping
thesefluids,Halliburtonpumpedmuddownthewelltomovethecementinto
place. 131Afteraboutthreeandahalfhours,thecementcrewcompleted
displacement,andbothplugslanded,orwerebumped,withanestimated100
psiofliftpressure(350psicirculatingto450psi)beforebumpingthetopcement
plug. 132Thecrewconductingthecementjobbelievedtheyhadreceivedfull
returnsthroughoutthejob,meaningthatthecrewbelievedthatlittleornomud
hadbeenlostintotheformationduringthecementjob. 133BrianMorel,whowas
usuallybasedinHouston,hadbeenontherigduringthecementjobandsentan
emailbeforehelefttherig,sayingthatthecementjobwentwell.Pressures
stayedlow,butwehadfullreturnstheentirejob,saw80psiliftpressureand
landedoutrightonthecalculatedvolume. 134

1. FloatCheck

Afterfinishingthecementjob,thecementingcrewconductedafloatcheck
intendedtoconfirmthatthefloatvalveshadproperlyclosedand,therefore,
wouldpreventanyflowbackupthewell.VincentTabler,theHalliburtoncrew
cementerandLeeLambert,aBPwellsiteleadertrainee,stoodatthecementunit
(avesselontherigthatinjectscementintothewell)toverifythatthechecks
wereholding.Theyallowedmudtoflowbackuntilitwasprobablywhatwe
callapencilstream,andthenitquitforalittlewhile,andthenwhentherig
wouldheave,itwouldgiveanotherlittlepencilstream,Tablersaid,Iknowit
wasagood15,20minutesthatwewatchedit. 135Attheconclusionofthefloat
check,thecrewconcludedthatthefloatvalveswereholding.Thecementing
crewcompletedthisjobapproximatelytwohoursafterthecementplacement.

129Guidetestimony,July22,2010,at150151.
130SeeHalliburtonpostjobnitrifiedcementingreportandjoblog(AppendixF).
131BPHZNMBI00137365.

132Bumpingthecementplugs,referstotheprocessbywhichtherigcrewtestswhetherthe

cementplugsareintheproperplace.Thecrewpumpsfluidandlooksforapressurespikethat
indicatesthatthecementplughaslandedinplace.
133NathanielChaissonemailtoJesseGagliano,April20,2010.

134BPHZNMBI00129052.

135Tablertestimonyat22.

54

2. CementJobReturns

Duringthecementingoperationfortheproductioncasing,rigpersonnel
continuouslymonitoredfluidsbeingpumpedintoandflowingoutofthewell.
Therigcrewcalculatedthequantityoffluidspumpedintothewellusingthe
pumpspistonvolumeoutputandefficiency.Pistonvolumeiscalculatedusing
thepumpslinerinsidediameterandstrokelengthefficiency.Sensorsonthe
pumpmeasurehowfastthepumpismovinginsteadofdirectlymeasuringthe
volumeoffluidbeingpumped.FlowoutoftheMacondowellcouldbe
measuredseveralways,includingbymonitoringpitvolumes, 136monitoring
Transoceansflowpaddles, 137ormonitoringthesonicandradarsensors(flow
outmeters)locatedinthereturnflowline. 138Monitoringthereturnflowline
wouldprovidethemostaccuratemeasureoffluidvolumesoutofthewell.The
flowoutmeterhasa10percentmarginoferrorandmustbebasedonproperly
calibrateddevices.Recalibrationoftheflowoutmeterisfrequentlynecessary
duetorigmovement,ballasting,craneoperations,seamovement,andother
factors.

Therigcrewobservedthatcementdisplacementoccurredatarateof
approximately4bpm,andtheybelievedthatfullreturnswereachievedwhile
circulating. 139Dr.JohnSmith,anexpertretainedbythePanel,calculatedthat
boththemainpitvolumerecordandthecalculatedcumulativeflowoutversus
flowinindicatedthatabout2.3bblsofmudwaslostduringthecementjob.John
GisclairofSperrySunperformedapostjobreviewoftheflowinandflowout
dataandagreedwithDr.Smithsreportthatifthesensorsandpaddleshadbeen
properlycalibrated,theaccuracyoftheflowoutvolumesshouldhavebeen
within5to10percentoftherecordeddata. 140Intestimony,however,Gisclair
cautionedthatflowoutisneverintendedtobeanactualmeasurementof
volume.Ifyouwanttoseethevolume,theactualamountsofagainoraloss,

136Pitvolumereferstotheamountofmudinanyoftherigsmudpitsatagiventime.
137TransoceansHitecmonitoringsystemontherighadpaddletypesensors.Asfluidrushed
past,thefluidpushedandliftedthepaddle.Thesystemcalculatedflowratebasedonhowmuch
thepaddlemoved.
138Thereturnflowlinewastheconduitwithinthepitsystem.

139BPHZNMBI137370.

140TestimonyofJohnGisclair,JointInvestigationHearing,October8,2010,at100.

55
youwouldalwaysusethepitvolumes,youwouldneverusetheflowoutovera
giventime. 141

ThePanelindependentlyassessedthedifferencebetweentheflowinand
flowoutdataandcalculatedthatamaximumofapproximately80bblsoffluids
(+/10percentbasedontheflowinandflowoutdata)couldhavebeenlost
duringthecementingjob.UsingSperrySundataofflowinandflowout,
measuredingallonsperminuteandrecordedeveryfiveseconds,thePanel
generatedaflowoutvs.flowinchart(Figure5).ThePanelconvertedthe
SperrySundatafromgallonsperminutetobarrelsperminute.Thechartsx
axisshowsthetime(hours/minutes/seconds)duringwhichthecementjob
occurredattheMacondowell.Ontheyaxis,theflowinvaluewasplotted
againsttheflowoutvalueinbarrelsperminute.Thedifferencebetweenthe
flowinandflowoutvaluesthroughoutthedurationofthecementjobwas
approximately80barrels.Assuminga10%marginoferrorintheflowout
meter,thePanelcalculatedthatanestimated72to88bblsoffluidscouldhave
beenlostduringtheproductioncasingcementjob.

Thispossiblerangeoflossexceededtheentirevolumeofcementpumped
duringtheproductioncasingcementjob.Thiscouldindicatethatover
displacementofcementoccurredintheshoetrack.Inotherwords,thecement
couldhavebeenpumpedintothewell,pasttheshoetrack,whichwouldhave
leftspacerandnocementintheshoetracktoisolatethecenteroftheproduction
casing.Ifoverdisplacementoccurred,itwouldhaveresultedininsufficient
cementcoverageintheshoetrack.

141 Id.at100101.

56

Figure5Flowoutvs.FlowinontheProductionCasing
CementJob(CalculatedbyPanel)

G. IndustryStandardsforCementing

APIRP65containsrecommendedpracticesfocusedonthedrillingand
cementingofcasingsintheshallowsedimentsofdeepwaterwellsinwhich
highlypermeableandoverpressuredsandsarefound. 142Inconnectionwiththe
productioncasingcementjobontheMacondowell,BPdivergedfromanumber
ofAPIRP65recommendedpractices.

APIRP65Section7.5providesthefollowingguidanceonpreventing
cementfrombeingdisplacedbydrillingmud:

Ifcasingisnottoberuntobottom,theratholeshouldbefilledwitha
higherweightmudtopreventcementfromfallingintotheratholeand
displacingratholefluidintothecementcolumn,thuscompromisingthe
cementsproperties.Thefluidshouldbeofadequatedensityand
propertiesthattherewillnotbeatendencyforthefluidtoswapwiththe
cementasitisbeingplaced.

142 APIRP65(2002).

57
NotwithstandingthespecificguidanceprovidedbyAPIRP65,therigcrewfilled
theratholeintheMacondowellwith14.0ppgsyntheticoilbasedmud(SOBM)
thatwaslighterthanthecementslurrydesign. 143Thetailcementwas16.74
ppg. 144Therefore,thedensityofthemudtherigcrewpumpedintothewellwas
notadequatetopreventthetypeoffluidinversion(swappingoffluidand
cement)thatcouldcompromisetheintegrityofthecementjob.

APIRP65Section8.2addresseswellpreparationusingconditioning
fluids.Itstatesthat:

Wellpreparation,particularlycirculatingandconditioningfluidsinthe
wellbore,isessentialforsuccessfulcementingCommoncementingbest
practiceistocirculatetheholeaminimumvolumeofonebottomsup
oncecasingisonbottom.

Asdiscussedindetailabove,BPonlypartiallycirculatedtheMacondowellprior
tocementing. 145

1. HalliburtonsPrimaryCementingBestPractices

ConsistentwithAPIRP65,Halliburtonsinternalcementingbestpractices
documentalsoadvisesthatfullwellcirculationbeperformedpriortocementing,
thatlighterweightfluidbeusedintherathole,andthatadequatecentralization
beinstalledinthewell.Halliburtonalsorecommendsthat,toimprovethe
probabilityofsuccessintheprimarycementingjob,[t]hebestmud
displacementunderoptimumratesisachievedwhenannulartolerancesare
approximately1.5to2.0inches.Asdiscussedabove,theannulartoleranceon
theMacondowellwasonlyinchesfortheproductioncasing.

Halliburtonsbestpracticesdocumentalsoaddressesgasflowpotential.
Itstates:

Althoughgasflowmaynotbeapparentatsurface,itmayoccurbetween
zones,whichcandamagethecementjobandeventuallyleadtocasing

143
A ratholeistheextraspacedrilledbeyondthelasthydrocarbonzoneofinterestsothat
loggingtools(usedtoevaluatethezoneofinterest)canberun.
144BPHZNCEC0011406.

145BPHZNMB100021304.

58
pressureatthesurface.TheOptiCemprogramcanbeusedasatoolto
determinethegasflowpotentialofanyprimarycementjob.

WhileBPusedHalliburtonsOptiCemmodel,itdidnotfocusonthegas
flowpotentialissuesraisedbythemodel.Inaddition,Halliburtonsbest
practicesdocumentrecommendsthatacementevaluationlogberuntoevaluate
thequalityofthecementjob. 146Asdiscussedbelow,BPdidnotrunacement
evaluationlogfortheMacondowell.

2. BPCementEvaluationLogRequirement

Inanticipationofpotentialfluidlossesduringtheproductioncasing
cementjob,theBPMacondowellteampositionedaloggingcrewandevaluation
toolsontherigtorunacementevaluationlog.Acementevaluationlogisused
toenableacrewtoevaluatethequalityofacementjobandwhetherthecement
intheannularspacesetupsuccessfully.Ifthelogindicatesproblemswiththe
cement,thecrewcanpumpadditionalcementtoremediatetheprimarycement
job.

BPsMarkHaflepreparedadecisiontreetodeterminewhetherBPwould
runthecementevaluationlog. 147Accordingtothedecisiontree,rigpersonnel
weretodeterminewhetherthecementplacementwentasplannedbychecking
forliftpressureofapproximately100psi(60psimorethanexpected)and
evaluatingwhethertherehadbeenanyapparentfluidlosses.Rigpersonnel
observedtheseindicatorsandconcludedthatthecementjobhadgoneas
planned.OnthemorningofApril20,theBPMacondowellteamdecidednotto
runacementevaluationlog. 148

BPsengineeringtechnicalpracticesrequirethatpersonneldeterminethe
topofcementbyaprovencementevaluationtechniqueifthecementisnot
1,000feetaboveanydistinctpermeablezones. 149Theacceptableproven
techniquesidentifiedinBPsinternalguidelinesarecementevaluationlogs,
cementcolumnbackpressure,andtemperaturelogs.BPsguidelinesdonot

146HalliburtonDeepwaterPrimaryCementing:BeyondtheShallowWaterFlows,Chapter7:PostJob
ProceduresandAnalysis(1997).
147BPProductionCasingandTAForwardPlanningDecisionTree,April14,2010.(BPHZN

MBI00010575)(AppendixL).
148Guidetestimony,July22,,2010,at4344.

149BPETPGP1060ZonalIsolationRequirementsDuringDrillingOperationsandWell

AbandonmentandSuspension(BPHZNMBI00193549).

59
identifyliftpressureorlostreturnstobeproventechniquesforevaluatinga
cementjob. 150Thus,HaflesdecisiontreeonwhethertodirecttheSchlumberger
crewtorunthecementevaluationlogwasinconsistentwithBPsown
guidelines.

SchlumbergertoldthePanelthatitisuncommonbutnotunheardoffor
operatorstocancelorderedservices,suchascementevaluationlogs,afterthe
crewarrivesatthefacility.Schlumbergerrevieweddeepwaterstatisticsfora30
monthperiodandfoundthatSchlumbergeractuallyperformed71ofthe74
cementevaluationsoriginallyorderedbyoperatorsduringthatperiod.

SincethePanelconcludedthatthecementinannulusdidnotfail,itfound
thatBPsdecisiontonotperformacementevaluationlogwasnotacauseinthe
wellfailure.

150Id.

60
IV. PossibleFlowPaths

ThePanelidentifiedthreepossiblepathsbywhichhydrocarbonscould
haveflowedupthewelltotherigduringtheinitialstageoftheblowout:(1)up
theproductioncasingannuluscementbarrierandupwardthroughtheannulus
andthewellheadsealassembly; 151(2)uptheproductioncasingandrelated
componentsfromabovethetopwiperpluglocatedonthefloatcollarat18,115
feet;or(3)upthelast189feetoftheproductioncasing(theshoetrack).

Scenario1:ProductionCasingAnnulusCementBarrierandtheWellheadSeal
Assembly

Underthisscenario,hydrocarbonswouldhaveflowedfromthereservoir
upthebacksideofthetaperedcasingstring,andthroughthesealassemblyinto
theriser.Ifthishadoccurred,thenitrifiedannularcementintendedtoisolatethe
hydrocarbonzone(s)attheproductionintervalwouldhavefailed,thecasing
wouldhaveliftedorfloated,andthesealassemblywouldhavefailedin
conjunctionwiththecasinglifting.Thispotentialflowpathisillustratedin
Figure6,below.



Figure6FlowUptheAnnulusandThroughtheSealAssembly

Thesealassemblyisametalelementthatistheinterfacebetweenthecasinghangerandthe
151

wellhead.

61

OnApril19,thedaybeforetheblowout,BPpumpedcementdownthe
productioncasingandupintothewellboreannulusabovetheuppermost
hydrocarbonreservoirtopreventhydrocarbonsfromenteringthewellbore.As
discussedabove,theannuluscementthatwasplacedacrossthemain
hydrocarbonzonewasalowerdensity,nitrified(foam)cementslurry.Atthe
timeoftheblowout,thesealassemblyhadnotyetbeenmechanicallylockedto
thewellheadhousing.

ToanalyzetheprobabilityofthisscenariothePanelcommissioned
KeystoneEngineeringInc.(Keystone)toconductabuoyancycasinganalysis.
Keystoneanalyzedeightproductioncasingstaticforceconditionsthatcould
haveactedupontheproductioncasingandwellheadhanger,andpossibly
resultedinmovementofthecasing.Keystonesanalysisfoundthatsixofthese
eightscenarioswereunlikelytohaveoccurred.Keystonepresentedtwo
remainingpossiblescenariosunderwhichsealmovementcouldhaveresulted
fromwellpressureandforces.However,thePanellaterruledoutbothofthese
scenariosbecausewellinterventionoperationsfollowingtheblowoutshowed
thatthewellheadsealassemblyhad,infact,remainedintactduringthe
blowout. 152

WhentheMacondowellwassecuredaftertheblowout,interventionwork
beganunderthedirectionandsupervisionoftheUnifiedAreaCommandwith
inputfromBOEMRE,includingthePanelandotherfederalagencies. 153This
interventionworkrequiredtheparticipationofcompaniesinvolvedinthe
drillingoftheoriginalMacondowell.

Duringthewellinterventionoperations,observationsusingremotely
operatedvehicles(ROVs)foundthattheMacondowellheadsealassemblywas
intact.OnSeptember9,2010,techniciansfromDrilQuipInc.,acontractor
involvedintheinterventionoperations,usedaleadimpressiontooltotakean
impressionofthehangerandsealassembly.Aleadimpressiontoolisahigh
tolerancemeasurementtoolthatisabletoabletodetectchangesinequipmentto
withinfractionsofaninch.Basedonthisleadimpression,thetechniciansonthe
DevelopmentDrillerII(DDII)reliefwelloperationconcludedthatthe97/8inch

KeystoneReport,September2010.
152

TheUnifiedAreaCommandreferstotheunified,interagencyresponsetotheDeepwater
153

Horizonoilspill.

62
hangerandsealassemblyremainedproperlyseatedinthe183/4inchhigh
pressurehousing,whereithadbeenplacedonApril19priortotheblowout. 154

Additionalevidencefromtheinterventionoperationsalsotendsto
eliminatethisfirstwellflowscenario.OnSeptember10,duringthewell
interventionoperation,BPconductedapositivepressuretestofthe97/8inch
productioncasingintheMacondowellbypumping6bblsof13.2ppgdrilling
muddowntheBOPkilllineandreachedaninstantaneousshutincasing
pressure(ISICP)of4,270psi.Thekilllinewasthenshutinand,after30minutes,
theshutinpressureremainedat4,158psi,thereforerevealingnoflowthrough
theannulus.

OnSeptember11,followinginstallationofthelockdownsleeve,BP
successfullypressuretestedthelockdownsleevesealto5,200psi,which
indicatedthatthewellhangerwasproperlyseatedbecauseotherwise,annular
flowwouldhaveliftedthehanger. 155

OnSeptember22,Schlumbergerusedanisolationscannertooltologthe
characteristicsoffluidintheannulusbetweenthemudlineand9,318feet
measureddepth. 156Thislogevaluated,amongotherthings,whetherthefluidin
theannulusincludedfreegas.Basedontheloggingdata,Schlumberger
determinedthatfreegaswasnotpresentintheannulusbelowtheBOP.The
absenceoffreegasintheannulusprovidesstrongevidencethathydrocarbons
werenotpresentintheannulusduringtheblowout.

OnOctober7,theinterventionteamperforatedthe97/8inchproduction
casingbetween9,176feetand9,186feettomonitorpressureandreturns. 157The
drillingmudintheinteriorofthecasingatthetimewasapproximately14.3ppg
syntheticbasedmud(SBM).Hydrocarbons,ifpresentintheannulus,would
haveexhibitedamuchlowerdensity.Whenfluidsofdifferentdensitiesmeetat
anopening,gravityandtheutubeeffecttypicallycausethemoredensefluid

154 DDIIIADCReport,9/11/10(TRNUSCG_MMS00043342).
155DDIIIADCReport,9/11/10(TRNUSCG_MMS00043342).Awellhangerisalongstringof
productioncasingthathangsfromacasinghangerinsidethewellhead.
156DDIIIADCReport9/22/10TRNUSCG_MMS00043388.Anisolationscannertoolisusedto

evaluateacementjobbytakingmeasurementstohelpdistinguishsolidsfromliquidsinthe
wellbore.Thetoolcanidentifypotentialchannelingandcanevaluatewhetheracementjobhas
achievedzonalisolation.
157DDIIIADCReport10/7/10(TRNUSCG_MMS00043449).Thiswasdoneusingaperforating

gunandwelltestingequipment.

63
toflowintothespaceoccupiedbythelowerdensityfluid.Noutubeflowof
the14.3ppgmudfromthecasingtotheannulusoccurredonOctober7,
indicatingthathydrocarbonswerenotpresentintheannulus. 158

AftertheBOPstackwasrecoveredfromtheseabed,picturestakenfrom
theDDIIreliefwellrigofthehangerandsealassemblyshowednoerosion.Had
hydrocarbonsfloweduptheannulus,theoutsideofthehangerandseal
assemblylikelywouldhaveshowneffectsoferosionduetohydrocarbonflow.

Becausetheevidencedoesnotsupportthetheorythathydrocarbons
floweduptheannulus,thePanelconcludedthatthenitrifiedcementslurryused
intheannuluslikelydidnotfail.

Scenario2:ProductionCasingandRelatedComponentsfromabovetheTop
WiperPlugat18,115feet

Underthisscenario,hydrocarbonswouldhaveflowedfromthereservoir
throughthecrossoverjointofthetaperedcasingstring,intothewellandupthe
risertotherig.ThePanelconsideredthecrossoverpointtobeapossiblesource
offlowbecauseitwasmanufacturedseparatelyfromtheothertubularelements
inthewell.Ifhydrocarbonshadflowedinthispath,itwouldmeanthatthe
annularcementisolatingthehydrocarbonzonesattheproductionintervalhad
failedandthecasinghadfailedatthecrossoverjoint.Thesefailureswouldhave
resultedinhydrocarbonflowoutofthewellanduptheriser.Thisscenariois
depictedinFigure7below:

158Utubing,orreverseflow,occurswhenfluidsflowinthereversedirectionandbackupthe
insideofthecasing.Theutubeeffectisthepracticeofputtingadensesluggingpill(mudthat
ismoredensethanthemudinthedrillpipeandthewellboreannulus)intothedrillpipeinorder
topulladrystring.Thepillispumpedtothetopofthedrillstringtopushmuddownward,out
ofthepipe,thuskeepingtheupperstrandsofthepipeempty.

64

Figure7FlowUptheAnnulusandThroughProductionCasingCrossoverJoint

Aftercementingtheproductioncasing,theDeepwaterHorizoncrew
conductedasuccessful2,500psipositivecasingtestagainstthetopwiperplug. 159
Althoughthispressuretest(250psilow/2,500psihigh)didnotconfirmaseal
belowthetopwiperplugatthetopofthefloatcollar,itdidprovideevidence
thatthe97/8x7inchproductioncasingandrelatedcomponentsthatcomprise
thisstringabovethetopwiperplugweremostlikelyleakfree.

LikeScenario1,Scenario2positsthathydrocarbonsflowedthroughthe
annulus.Forensicevidencegatheredduringwellinterventioneffortscasts
substantialdoubtonthistheory.Asdiscussedabove,thePanelfoundno
evidenceoferosionofthehangerandseatassembly.Hadhydrocarbonsflowed
alongthispath,erosioneffectslikelywouldhavebeenvisible.Inaddition,as
mentionedabove,loggingdatashowthatfreegaswasnotpresentintheannulus
belowtheBOP.

Forallofthesereasons,thePaneldoesnotbelievethatScenario2
representsalikelyexplanationfortheflowpathofhydrocarbonsduringthe
blowout.

159 SmithReportat8.

65

Scenario3:ProductionCasingShoeTrack

Underthisscenario,hydrocarbonswouldhaveflowedfromthereservoir
throughthecasingshoe,intothewellanduptherisertotherig.Forthisflow
pathtohaveoccurred,theshoetrackcementwouldhavefailed.Anumberof
factorscouldhavecausedtheshoetrackcementtofail.First,mudinthe
wellborecouldhavecontaminatedtheshoetrackcementandcausedthecement
nottosetproperly.Second,theshoetrackcementmighthaveswappedoutwith
thelighterdrillingfluidintherathole.Third,someoftheshoetrackcement
couldhavebeenlostintotheformation.Finally,thefailureoftheshoetrack
couldhaveresultedfromacombinationofthesefactors.Thisscenariois
representedinFigure8below.


Figure8FlowuptheProductionCasingShoeTrack

Theapproximately189footbottomsectionofthecasinginthewell,called
theshoetrack,consistedofsectionsofcasingwithareamerguideshoeatthe
bottomandadualflapperfloatcollarontop.Thesesectionsofcasingthatmake
uptheshoetrackaremeanttocontainthetop,ortailcement,whichinthe
Macondowellwasunfoamedcement.

66
Theshoetrackwasdesignedtopreventutubingintwoways:(1)the
presenceof189feetofcementasabarrierand(2)thefloatcollarsflowdual
flappervalvesweredesignedtoallowonlyonewayflowafterconversion.

Thefloatcollardualflapperarrangementisdesignedtocloseafterthe
cementisinplace(andstartssettingup)topreventanyflowbackintothecasing
(andupthewell)causedbyhydrostaticpressuredifferencesbetweenthedense
cementanddrillingmudontheoutsideofthecasingandthelessdense
displacementfluidontheinside.Thefloatcollaralsoactsasthelandingpoint
forthecementingplugsusedduringthejob.Thefloatcollaremployeda
differentialfilltubethatallowedmudtoflowintothecasingasitwasruninto
thewell.Thefilltubeinthiscasewasdesignedtobepumpedoutofthefloat
collarifthepumpratewashigherthanfivebarrelsperminute.Thepositionof
thetopofthefloatcollarlocatedat18,115feetplacedthefloatcollaracrossthe
productivereservoirbetween18,083feetand18,206feetmeasureddepth.

Asdescribedabove,thecrewhaddifficultyconvertingthefloatcollarand
maynothaveachievedconversiondespitemakingnineattempts.Thereare
threepossiblereasonsforthefailureofthefloatcollar:(1)thehighload
conditionsrequiredtoestablishcirculationdamagedthefloatcollar;(2)thefloat
collarfailedtoconvertduetoinsufficientflowrate;and(3)thecheckvalveson
thefloatcollarfailedtoseatduetodamage,contamination,orthepresenceof
debris.Noneofthesefloatcollarfailurescenariosexcludesthepossibilitythat
thecementcouldhavefailedduetodefectivecementdesign,contaminationof
thecementbymudinthewellbore,comminglingofcementwithnitrogendueto
nitrogenbreakoutfromthenitrifiedfoamcementslurry,swappingoftheshoe
tracktailcementwiththeheaviermudintherathole,acloggedreamershoethat
possiblyalteredcementflowoutofthereamershoe,orsomecombinationof
thesefactors.

TheforensicexaminationoftheBOPstackfoundinteriorerosionofthe
blindshearrams,whichsupportsthisflowpathasthemostlikelyscenario.This
erosiondetectedontheblindshearramslikelyresultedfromthehighpressure
flowofhydrocarbonspasttheramsasaresultoftheblowoutandindicatesthat
hydrocarbonsflowedupthewellafterenteringthroughtheshoetrack.

67
V. ConclusionsonWellDesign,Cementing,andFlowPath

A. CauseoftheFailureoftheCementBarrier

Contaminationordisplacementoftheshoetrackcement,ornitrogen
breakoutormigration,couldhavecausedtheshoetrackcementbarriertofail.
ThePanelfoundevidencethatthemostlikelyreasontheshoetrackcement
slurryfailedisduetocontaminationintheratholeportionofthewellboreand
inversionoffluidsduetodifferentdensities(themudintheshoetrackwas
lighterthantheunfoamedcementslurry).However,thePanelcouldnot
definitelyruleoutnitrogenbreakout,migration,oroverdisplacementinthe
shoetrack.ThePanelconcludedthatacombinationofcontamination,over
displacement,and/orpossiblynitrogenbreakoutoftheshoecementwere
causesoftheblowout.

Contaminationofthefoamedcementintheannulusbythemud,baseoil
orcementspacercouldhaveresultedinnitrogenbreakout,leadingtoafailureto
achievezonalisolationofhydrocarbonsintheannulus.ThePanelconcluded,
baseduponitsreviewofforensicevidencethatestablishedtheabsenceoffree
gasintheannulus,thatcontaminationornitrogenbreakoutdidnotaffect
zonalisolationintheannulus.

B. ContributingCausesoftheCementBarrierFailure

Macondowasanexploratorywellwithlimitedoffsetdata,andthe
differencesbetweencalculatedandactualporepressurescausedBPtomake
revisionstothedrillingprogramandcasingsettingdepths,includingthedepth
atwhichBPsettheproductioncasing.BPsinternalguidelinesstatedthat
drillingwouldnotbestoppedinahydrocarboninterval,unlessdoingsowas
necessarybecauseofoperational/pressure/safetyissues.BPsdecisiontosetthe
casingwasbasedonwellintegrityconcernsandapotentialsafetyissue
associatedwithazerodrillingmarginbasedon14.1ppgpressuredformation
sandcombinedwitha12.6ppgformationpressuredzoneinthesameopenhole
sectiontakinglosses.Additionally,theproductioncasingstringshoewassetin
alaminatedsandshaleinterfaceat18,304feetmeasureddepth,insteadofata
consolidatedshalestrata.Placementoftheshoeinalaminatedsandshalezone
increasedthelikelihoodofchannelingorcementcontamination.Thedecisionto
settheproductioncasinginalaminatedsandshalezoneinthevicinityofa
hydrocarbonintervalwasacontributingcauseoftheblowout.

68
Themudlossesofapproximately15,500bblsduringdrillingatMacondo
indicatedthatBPshouldhavetakenadditionalprecautionsduringthe
productioncasingcementingoperation.Withtheknownlossesexperiencedin
thewell,BPsfailuretotakeadditionalprecautions,suchasestablishing
additionalbarriersduringcementing,wasacontributingcauseoftheblowout.

Asdiscussedabove,APIRP65containsrecommendedpractices
regardingcementingoperationsthat,atthetimeoftheMacondoblowout,were
usedbymanyoperatorsdrillingwellsindeepwaterintheGulfofMexico.Some
ofthestepsthatBPtookduringthecementingoftheMacondoproductioncasing
werenotconsistentwithAPIRP65recommendedpractices,includingthe
following:

BPdidnotcirculateaminimumvolumeofonebottomsup(thevolume
neededtobepumpedtopushthemudatthebottomofthewellboreto
thesurface)oncethecasingwasonbottom,andthemudconditioning
volumewaslessthanoneannularvolume;

Withthecasingshoenotruntothebottom,BPdidnotfilltherathole
withahigherweightmudcapableofpreventingcementfromfallinginto
theratholeandtherebydisplacingratholefluidintothecementcolumn
andcompromisingthecementsproperties;and

Theholediameterwaslessthanthreeinchesgreaterthanthecasing
outsidediameter.

Withrespecttotheproductioncasingcementjob,BPandHalliburtondid
notemploytheindustryacceptedrecommendedpracticesdescribedabove.BP
andHalliburtonsfailuretoperformtheproductioncasingcementjobin
accordancewithindustryacceptedrecommendationsasdefinedinAPIRP65
wasacontributingcauseoftheblowout.

BPchosetolandthefloatcollaracrossahydrocarbonbearingzoneof
interestintheMacondowell,insteadofatthebottomoftheshoe.Ifthefloat
collarhadbeenatthebottomoftheshoe,thecementjobwouldlikelyhavebeen
moreoverbalanced(i.e.,greaterpressurefromthecementrelativetothe
pressuresfromthewell).Thisincreasedoverbalancewouldlikelyhaveallowed
therigcrewmoretimetorecognizethathydrocarbonswereflowinginthewell
andmoreopportunitiestotakemeasurestocontrolthewell.BPsdecisiontoset

69
thefloatcollaracrossthehydrocarbonbearingzonesofinterest,insteadofat
thebottomoftheshoe,wasacontributingcauseoftheblowout.

ThePanelfoundnoevidencesuggestingthatBPsharedwiththe
DeepwaterHorizonrigcreworTransoceanshorebasedpersonnelanyofthe
informationavailabletoBPregardingspecificrisksassociatedwiththeMacondo
productioncasingcementjobincludingthedecisionsnotedabovethatthe
Paneldeterminedwerecausesorcontributingcausestotheblowout.BPs
failuretoinformthepartiesoperatingonitsbehalfofallknownrisks
associatedwithMacondowelloperationswasacontributingcauseofthe
blowout.

BPmadeaseriesofdecisionsduringthedaysleadinguptotheblowout
withouthavingappropriatelyanalyzedallavailableinformationorhavingfirst
developedcertaincriticalinformation,including:(1)goingforwardwiththe
productioncasingcementjobwithoutanalyzingcompressivestrengthresults
fromHalliburton;(2)proceedingwiththecementjobdespitefailingtofully
analyzeandevaluatethegasflowpotentialvaluesinHalliburtonsOptiCem
reports;and(3)directingtherigcrewtopumpcementintothewellwithout
referringtodataavailabletoengineersonshorethatblockageinthecollarmay
havebeenpresentduringfloatcollarconversion.BPsfailuretoappropriately
analyzeandevaluaterisksassociatedwiththeMacondowellinconnection
withitsdecisionmakingduringthedaysleadinguptotheblowoutwasa
contributingcauseoftheblowout.

BPdidnotplaceanycementontopofthewiperplug.Thisadditional
cementwouldhavecreatedanotherbarriertopreventflowuptheproduction
casingthatcouldhavebeenpressureandweighttested.BPsfailuretoplace
cementontopofthewiperplugwasacontributingcauseoftheblowout.

C. PossibleContributingCausesoftheCementBarrierFailure

ThefloatcollarmodelusedintheMacondowellwasnotasdebris
tolerant(andthereforewasmoresusceptibletoblockages)asothermodelsthat
wereavailableandwouldhavebeenmoresuitableinlightoftheknown
challengeswiththeMacondowell.BPsdecisiontouseafloatcollarthatwas
notsufficientlydebristolerantwasapossiblecontributingcauseofthe
blowout.

70
OntheMacondowell,BPhadtheoptiontotemporarilyabandonthewell
withoutsettingaproductioncasing,asithaddonepreviouslywiththeKodiak,
MC727,Number2andTiber,KC102,Number1wellswhenfacedwithsimilar
narrowdrillingmarginsandlostreturnsattotaldepth.BPsdecisiontoset
casingintheproductionintervalwithknowndrillingmarginlimitsattotal
depthwasapossiblecontributingcauseoftheblowout.

Duringtheproductioncasingcementingoperation,rigpersonnel
continuouslymonitoredthefluidsthattheypumpedintoandthatflowedout
ofthewell.Butratherthanmeasuringflowindirectly,rigpersonnel
calculatedflowinbasedonthepumpspistonvolumeoutputandefficiency.
ThecrewmeasuredflowoutbasedontheTransoceanflowmeterpaddlesand
theSperrySunflowlinesonic/radarsensors.Thecrewalsomonitoredflowout
bypitgainvolumes.Asdiscussedabove,evenwithproperlycalibratedflow
measurementdevices,therewouldhavebeena10percentmarginoferrorinthe
flowoutcalculations.Dr.Smith,theexpertretainedbytheJIT,usedboththe
mainpitvolumedataandthecalculatedcumulativeflowoutversusflowindata
toestimatethatapproximately2.3bblsofmudwerelostduringtheproduction
casingcementingoperation.ThePanelusedactualflowvaluestocalculatethat
thelossesamountedtoapproximately80bbls(+/10%basedonflowin/flow
outdata).ThefactthattheDeepwaterHorizoncrewdidnothaveavailableto
themaccurateandreliableflowlinesensorsduringcementingoperationsin
ordertodeterminewhethertheywereobtainingfullreturnswasapossible
contributingcauseoftheblowout.

Therewereanumberoflimitationsinthecementingplanthatcouldhave
contributedtothecompromiseofthecementjob,includingthefollowing:

Reducingthebottomsupcirculationfrom2,760bblstoapproximately350
bblscouldhaveincreasedthelikelihoodofchannelingbecause:a)there
waslesscleaningofthewellbore,andb)thereducedbottomsup
preventedrigpersonnelfromexamining,priortocementing,themudfor
potentialcontaminationbyhydrocarbons;

Pumpingcementattherelativelylowflowrateof4bpmcouldhave
decreasedtheefficiencywithwhichcementdisplacedthemudfromthe
annularspace,therebyincreasingthepotentialforchanneling;and

71
Limitingthevolumeofcementtoapproximately51bblsmeantthatany
contaminationofthecementbymudcouldreducetheeffectivecoverage
ofannularand/orshoetrackcement.

ThesedecisionsbyBPandHalliburtonwithrespecttoplanningand
conductingtheMacondoproductioncasingcementjobwerepossible
contributingcausesoftheblowout.

BPswellsiteleadersandtheDeepwaterHorizonrigcrewfailedto
recognizetheaccumulatingriskassociatedwithseveralpossibleanomaliesthat
couldhavecontributedtotheshoetrackcementsfailuretopreventhydrocarbon
ingressintothewell.Theseproblemsinclude:

Thehigherpressureneededtoconvertthefloatcollarfromfillto
check(3,142psiinsteadofamaximumof700psi)couldhavedamaged
componentsofthefloatcollar(includingtheautofilltubeandshearpins);
Thefloatcollarmaynothaveconvertedbecausethecrewusedan
insufficientflowrateandpressure.Thefloatcollarwasdesignedto
convertatarangebetween5bpmand7bpm,whiletheactualflowrate
neverexceeded4.3bpm;
Thebottomcementwiperplugthatlandedonthefloatcollarrequired900
psito1,100psitoburstthedisk.However,theburstdiskdidnotrupture
until2,900psiwasapplied,whichindicatedthattheremayhavebeena
blockageinthefloatcollar;
Thecheckvalvesonthefloatcollarmaynothaveproperlysealedasa
resultofdamagetotheflappervalvepins,orrelatedcomponents,ormay
haveonlypartiallysealedasaresultofdebrisacrossthesealareas;
Lostcirculationmaterialorotherdebrisinthemudsystemcouldhaveled
totheneedtouseincreasedpressuretoconvertthefloatcollar.Ifdebris
waspresent,therewouldbenoassurancethatconversioncouldbe
achievedevenwiththeuseofhigherpressures;
Theshoetrackcementmayhavebeencontaminatedbymudintherat
holeswappingoutwiththecement,duetoadensitydifferencesbetween
thecementandthemud;and
Exceptforacoupleofsurgesorspikes,theflowrateusedbythecrewwas
toolowtoconvertthefloatcollar.

ThefailureofBPswellsiteleadersandtheTransoceanDeepwaterHorizonrig
crewtorecognizetherisksassociatedwiththesemultipleproblemsthat

72
occurredbetweenApril19andApril20wasapossiblecontributingcauseof
theblowout.

D. FlowPathCause

1. ProductionCasingAnnulusCementBarrierandthe97/8Inch
WellheadSealAssembly

Asdiscussedabove,thefollowingevidenceweighsagainstthepossibility
thathydrocarbonsflowedthroughtheproductioncasingannuluscementbarrier
andthe97/8inchwellheadsealassembly:

1) OnSeptember9,2010,DrilQuiptechniciansconfirmedwithalead
impressiontoolthatthe97/8inchwellheadsealassemblyremained
properlyseatedinthe183/4inchhighpressurehousing,whereithad
beenplacedonApril19,2010priortotheflowofhydrocarbons.
2) OnSeptember10,BPconducteda30minutepressuretestofthe97/8inch
productioncasingannulusthatconfirmedthelackofannular
communication.
3) OnSeptember11,thelockdownsleevesealwassuccessfullypressure
testedto5,200psi,whichtendedtoprovethatthehangerwasproperly
seated.
4) OnSeptember22,Schlumbergersloggingdatadeterminedthatfreegas
wasnotpresentbelowtheBOPto9,318feetmeasureddepth.
5) OnOctober7,BPsperforationofthe97/8inchcasingbetween9,176feet
and9,186feetfoundthatnoutubeflowoccurredfromthecasingto
annulus.
6) Duringwellinterventionoperations,ROVobservationdeterminedthe
wellheadsealassemblywasintact.Inaddition,subsequenttoremovinga
portionofthe97/8inchproductioncasing,original13.814.0ppgmud
wasdiscoveredbetweenthe16inchintermediatecasingand97/8inch
productioncasing.
7) PicturestakenfromtheDDIIreliefwellrigatthetimethehangerandseal
assemblywereextractedfromoutsidehangerandsealassemblyshowed
nosignsoferosionfromannularflow.

Basedonthisevidence,thePanelconcludedthathydrocarbonsdidnotflow
fromtheproductioncasingannuluscementbarrierandthe97/8inchwellhead
sealassemblyduringtheblowout.

73
2. ProductionCasingandRelatedComponentsfromabovetheTop
WiperPlugat18,115Feet

The97/8x7inchproductioncasingandrelatedcomponents(including
the97/8x7inchcrossoversubandcentralizersubs)weresuccessfullypressure
tested(250psilow/2,500psihigh)fromabovethetopwiperplugat18,115feet.
OnSeptember10,BPconducteda30minutepressuretestofthe97/8inch
productioncasingannulusthatconfirmedthelackofflowfromtheannulus.On
October7,2010,BPperforatedthe97/8inchcasingbetween9,176feetand9,186
feetanddeterminednoutubeflowoccurredfromthecasingtoannulus.Based
onthisevidence,thePanelconcludedthatthewellflowdidnotoccurfrom
insidethe97/8x7inchproductioncasingoritsrelatedcomponents(including
the97/8x7inchcrossoversubandcentralizersubs)fromabovethetopwiper
plugat18,115feet.

3. 97/8InchProductionCasingShoeTrack

Basedontheeliminationofthepotentialflowpathsfromtheprevious
scenarios,theexaminationoftheblindshearramsthatshowedinteriorerosion,
presumablyfromthehighpressureflowofhydrocarbonspasttheramsinthe
periodafterthewellevent,andthefindingscontainedintheKeystone
EngineeringReport,thePanelconcludedthatthemostlikelypathof
hydrocarbonsduringtheblowoutwasthroughtheshoetrack.ThePanel
concludedthathydrocarbonflowduringtheblowoutoccurredthroughthe9
7/8x7inchproductioncasingfromtheshoetrackasaresultoffloatcollarand
shoetrackfailure.

74
VI. ChallengesattheMacondoWell

BPandTransoceanencounteredanumberofproblemsduringdrilling
andtemporaryabandonmentoperationsattheMacondowellincludingkicks,
stuckpipe,lostreturns,equipmentleaks,costoverruns,wellschedulingand
logisticalissues,personnelchangesandconflicts,andlastminuteprocedure
changes.TheseproblemsledrigpersonnelandotherstorefertoMacondoasthe
wellfromhell. 160

A. KicksandStuckDrillPipe

BPcompanyrecordsandtestimonyfromrigpersonnelestablishthatat
leastthreewellcontroleventsandmultiplekicksoccurredduringdrillingand
temporaryabandonmentoperationsattheMacondowell.Thefirstwellcontrol
eventoccurredonOctober26,2009,whenthewellwasbeingdrilledby
TransoceansMarianasrig.ThesecondwellcontroleventoccurredonMarch8,
2010,aftertheDeepwaterHorizonhadreplacedtheMarianasandresultedina
stuckdrillpipe.

Ittookthecrewatleast30minutestodetecttheMarch8kick. 161This
delayraisedsignificantconcernsamongBPpersonneloverseeingtheoperation
abouttheabilityofpersonnelontheDeepwaterHorizontopromptlydetectkicks
andtakeappropriatewellcontrolactions.

Inapostblowoutinterview,JohnGuide,aBPwellsteamleader,stated
that,atthetime(March2010)hewasconcernedthattheDeepwaterHorizonteam
hadbecometoocomfortablewithitselfbecauseofitsgoodtrackrecordfor
successfullydrillingdifficultwells,andthatitsmembersmissedpotential
indicationsofproblemsduringtheMarch8eventthattheyshouldhave
caught. 162

OtherindividualsresponsibleforoperationsatMacondoexpressed
concernabouttheeventsofMarch8:

160TestimonyofMikeWilliams,JointInvestigationHearing,July23,2010,at35(statingthatthe
DeepwaterHorizoncrewhadusedthenamewellfromhellonapriorwellandalsousedthe
termontheMacondowellbecauseonbothwellsthecrewencounteredsimilarlostcirculation,
stuckpipe,andkickproblems).
161BPHZNMBI00221686.

162BPHZNBLY00125447.

75
DavidSims,BPdrillingandcompletionsoperationsmanager,expressed
concernabouttheBPwellsiteleaderswellcontrolabilitiesinanemail
writtenfollowingtheMarch8kick.Hestatedthatthewellsiteleaders
arenotwellcontrolexperts.Theyarefantasticdrillersthebestinthe
SPU[BPdrillingunit],ifnottheindustry.However,theydonotcirculate
outkicksforaliving,especially1200feetoffbottomwithmany
unknowns. 163

MarkHafletoldBPinvestigatorsinapostblowoutinterviewthathe
believedsomeoftheSperrySunmudloggersdidnotunderstandhowto
monitorthewellproperly,andthattheSperrySunpersonnelwere
stretchedtoothinanddidnothaveenoughqualifiedmudloggers. 164

NotwithstandingthehighlevelofconcernabouttheMarch8kickandthe
rigcrewsresponsetothekick,BPdidnotconductthetypeofinvestigationof
theincidentrequiredbyBPsownpolicies.BPsdrillingandwelloperations
proceduresrequireawellcontrolincidentreporttobecompletedand
documentedinBPsinternalreportingsystem 165andprovidethatsuchincidents
shouldbeinvestigatedtodeterminerootcausesandtoidentifywaystoprevent
reoccurrence. 166ThePanelfoundnoevidencethatBPdocumentedtheMarch
wellcontroleventinitsinternaltrackingsystemorthatitconductedapost
incidentinvestigationtodeterminetherootcauseofthedelayedkickdetection.

Insteadofconductingaformalinvestigation,Guidehaddiscussionswith
theBPwellsiteleadersandtheTransoceanrigleadersabouttheeventandthe
drillingcrewsresponse.GuidetoldBPinvestigatorsinapostblowout
interviewthathebelievedmembersoftherigcrewunderstoodtheir
responsibilitiesandadmittedtohimthattheyhadscrewedupbynotcatching
thekick.GuidealsotalkedtotheSperrySunmudloggersaboutthedetectionof
flow. 167

BPsinhousegroupofgeologicalexperts,theTotallyIntegrated
GeologicalandEngineeringResponseteam(theTIGERteam),conductedan

163BPHZNMBI00222540.
164BPHZNBLY00125470.AsdiscussedpreviouslyinthisReport,mudloggershavea
responsibilitytomonitortheconditionsinthewellduringdrillingoperations.Monitoringfor
potentialkicksisamongthemudloggersmostimportantresponsibilities.
165BPDWOPManual,Section15.2.12,BPHZNMBI00130846.

166BPDWOPManual,Sections3.1.5,BPHZNMBI00130817.

167BPHZNBLY00125447.

76
analysisoftheMarch8kick.Thiswasnotthetypeofincidentinvestigation
requiredbytheDWOP,butratherastudyoftheporepressureandother
geologicalconditionsencounteredinthewell.Inanemailreevaluatinghow
wemanagerealtimeporepressuredetectionforMacondotypewells,aBP
geologiststatedthatweneedtohavePP[porepressure]conversationsassoon
asANYindicatorshowsachangeinPPandweneedtobepreparedtohave
somefalsealarmsandnotbeafraidofit. 168Healsonoted:

Betterlinesofcommunication,bothamongsttherigsubsurfaceand
drillingpersonnel,andwithHoustonofficeneedtobereestablished.
Precedingeachwellcontrolevent,subtleindicatorsofporepressure
increasewereeithernotrecognized,ornotdiscussedamongstthegreater
group.ItistheresponsibilityofthemudloggersandwellsitePP/FG
personneltoopenlycommunicatewiththewellsitegeologist. 169

ThisanalysisbytheTIGERteam,whichwasfocusedongeologicalconditionsin
theMacondowell,wasnotintendedtoaddressthespecificwaysinwhichtherig
crewshouldmonitorthewell.Morel,HafleandCocalespresentedadocument
totheTIGERteamonMarch18thataddressedsomeoftheeventsofMarch8,
butthisdocumentdidnotincludeadiscussionofanymeasurestobe
implementedtoensurethattherigcrewcoulddetectkicksmorequicklyand
effectively. 170ThePanelfoundnoevidencethatMorel,Hafle,andCocales
presentedinformationrelatedtotheMarch8kickdetectionproblemstoanyone
elseinvolvedinoperationsatMacondo.

AftertheMarch8incident,BPhadtoabandonthewellbore(leaving
behindanumberofcostlydrillingtools)andperformabypasstocontinue
drillingthewell. 171Respondingtothekickandconductingthebypassoperation
resultedinadditionalcostandtimingdelayfortheMacondowell.

Exceptforoneperson,therigpersonnelinvolvedinkickdetectionand
responseonMarch8,includingamudlogger,drillers,assistantdrillers,asenior
toolpusher,andtoolpushers,werethesameindividualsondutyonApril20
whentheblowoutoccurred. 172

168BPHZNMBI00113015.
169BPHZNMBI00113017.
170BPHZNBLY00036098.

171Abypassorsidetrackoperationisperformedbydrillingadirectionalholetobypassan

obstructioninthewell.
172OneofthemudloggersondutyonApril20wasnotinvolvedintheMarch8kick.

77

B. SchedulingConflictsandCostOverruns

AstheDeepwaterHorizoncrewpreparedtocompleteoperationsatthe
Macondowell,theyweresignificantlybehindschedule.BPstated,ina
submissiontoMMS,thattheDeepwaterHorizonwouldarriveatBPsNilewell
(thenextwellafterMacondothattheDeepwaterHorizonwasscheduledtowork
on)byMarch8,2010. 173Byearly2010,itbecamecleartoBPthatthisschedulefor
theDeepwaterHorizonrigwouldnothold.

Inaddition,asdiscussedpreviouslyinthisReport,bythetimeofthe
blowout,BPhadexceededitsoriginalbudgetfortheMacondowellby$58.34
million.ThePanelcollectedandreviewedevidenceshowingthatBPpersonnel
wereawareofthecostoverrunsandwereconcernedaboutincurringadditional
coststhattheydeemedunnecessary.JohnGuidestestimonysuggeststhathis
effectivenessatreducingcostswaspartoftheevaluationofhisperformanceas
wellsteamleader. 174CorrespondencebetweenGuideandotherssuggestedhis
awarenessofothersevaluationofhiseffectivenessincontainingcosts.For
example,onApril20,GuiderespondedtoanemailrequestfromRossSkidmore,
aBPcontractor,toconductastandardprocedurethatwouldincreasethe
likelihoodofasuccessfullockdownsleeveinstallationawashrunthat
wouldavoidabadLIT[leadimpressiontool]impressionbysaying[w]e
willneverknowifyourmilliondollarflushrunwasneeded.Howdoesthisget
ustosectorleadership. 175

ThePanelfoundevidencethatBPsdecisiontohavetheDeepwaterHorizon
crewinstallthelockdownsleeve,discussedinmoredetailbelow,wasmotivated
bycostsavings.Alockdownsleeveisapieceofequipmentnecessaryforthe
productionofawell.Itconnectsandholdstheproductioncasingtothe
wellheadduringproduction,therebyprotectingtheconnectionfromthe
pressuresgeneratedbyaflowingwell.Lockdownsleevesareofteninstalledby
lowercostrigsthatareusedmainlyforcompletionworkinsteadofbyadrilling
rigliketheDeepwaterHorizon.EmailcorrespondencerevealsthatBPdidnot
initiallyintendtohavetheDeepwaterHorizoninstallthelockdownsleeve,but
thenchangedcoursewhenitwasshownthatdoingsowouldlikelysave5.5days

173APMsubmittedbyBPtotheMMS(AgencyTrackingID:EWLAPM123805).
174GuideTestimony,October7,2010,at14243.
175BPHZNMBI00258507.

78
ofrigtimeandapproximately$2.2million. 176Asdiscussedbelow,thiscost
savingdecisionmayhaveledtofurthercomplicationsencounteredduringthe
temporaryabandonmentproceduresthatwereunderwaywhentheblowout
occurred.

C. PersonnelChangesandConflicts

DuringthedrillingoftheMacondowell,BPexperiencedanumberof
personnelissuesrelatedbothtoarecentreorganizationofoperationalfunctions
andpersonnelandtopersonalconflictsamongemployeeswithsignificant
responsibilitiesfordrillingoperationsatMacondo.

InApril2010,BPbegantoimplementareorganizationthatinvolved
multiplepersonnelchangesamongthosewithresponsibilitiesforoperationsat
Macondo.Thereorganization,amongotherthings:(1)eliminatedthewells
directorposition;(2)changedthereportingresponsibilitiesofthewellsteam
leader;and(3)movedanoperationsengineerunderthedirectsupervisionofthe
drillingengineerteamlead.Atthetimeoftheblowout,nineBPemployeeswith
responsibilitiesfordrillingoperationsattheMacondowellhadbeenintheir
currentpositionsforlessthansixmonths. 177

BPwitnessestestifiedthatthereorganizationdidnotaffecttheirrolesor
responsibilities.Informationfromcontemporaneousdocumentsandwitness
interviews,however,telladifferentstory.FromFebruarythroughApril2010,a
numberofdifferentindividualswithresponsibilityfortheMacondodrilling
operationsexpressedconcernsaboutthereorganizationingeneraland,in
particular,aboutJohnGuidesroleinlightofthereorganization.Guidehad
previouslybeenatthesamelevelasDavidSims,BPdrillingandcompletions
operationsmanager,butafterthereorganizationhereportedtoSims.

TwoofGuidescolleaguesexpressedconcernsabouthisreactiontothe
reorganization.AccordingtointerviewnotesfromBPsinvestigation,Gregg
Walz,aBPdrillingengineerteamleader,statedthatGuideputOpsfirstand
wasconcernedaboutdistractionsassociatedwiththefunctional
reorganization. 178JonSprague,BPdrillingengineeringmanagerfortheGulfof

176BPHZNMBI00097490.
177Thevicepresidentofdrillingandcompletions;wellsmanager;drillingengineeringmanager;
drillingandcompletionsoperationsmanager;drillingengineerteamlead;drillingengineer;two
wellsiteleadersattheDeepwaterHorizon;andthefuturewellsiteleaderattheDeepwaterHorizon.
178BPHZNBLY00061325.

79
Mexico,testifiedthathewasconcernedthatJohn[Guide]maynotbe
comfortablewiththeneworganization. 179

InMarch2010,aroundthetimeofthesecondlossofwellcontrolat
Macondo,therewastensionbetweenSimsandGuide.InanemaildatedMarch
13,GuidecomplainedtoSimsandaccusedhimofmakinguphismindon
correctiveactionswithoutlisteningtoinputfromthewellsiteleaders.In
response,SimssaidthatwecannotfightabouteverydecisionandthatIwill
handthiswellovertoyouinthemorningandthenyouwillbeabletodo
whateveryouwant.Iwouldstronglysuggest,foreveryonessake,thatyou
makelogicaldecisions,basedonfacts,afterweighingalltheopinions. 180

SimsalsodraftedanemailthatwasaddressedtoGuidebutwasnever
sent.Intheemail,SimsstatedthefollowingaboutGuide:

Youseemtolovebeingthevictim.Everythingissomeoneelsesfault.
Youcriticizenearlyeverythingwedoontherigbutdontseemto
realizethatyouareresponsibleforeverythingwedoontherig.

Youwillnotcalltherigintheopsroom.Youhavetosneakoutofthe
roomandcallthemonyourcellphoneorgobacktoyourofficewhile
everyoneisintheopsroom.

Youcantsitinameetingandlistentoothersopinionswithout
arguingwiththem.Youthinkwhensomebodyhasanopinionthat
theyaredemandingaction.Youcomplainthatabunchofyoung
engineersarethrowingoutallkindsofwildideasandthatitisdriving
youcrazy.Youdontlisten.Youkeyonarandomwordorphraseand
thenyoufixateonthatanddonthearanythingelse.Youarealways
defensiveandthevictim.Youseemtonotwanttomakeadecisionso
thatyoucancriticizeitlater. 181

Duringtheweeksleadinguptotheblowout,Guideappearedtohave
problemshandlinghisresponsibilitiesforoperationsatMacondo.
Notwithstandingthefactthat,atthetime,hewasveryupsetabouttheMarch

179TestimonyofJonSprague,JointInvestigationHearing,December8,2010,at246.
180BPHZNMBI00222521.
181BPHZNMBI00222540.

80
8kickevent, 182Guidedidnottakestepstoensurethatitwasfullyinvestigated.
AccordingtoSims,Guidewasnotappropriatelyengagedintheeffortstodeal
withthestuckdrillpipeafterthekick. 183

ThePanelfoundnoevidencethatSimstookaffirmativeorspecificstepsto
addresstheproblemsheidentifiedwithGuidesperformance.Instead,Sims
simplymadeageneralpleatoGuide,askinghimtomakelogicaldecisions,
basedonfacts,afterweighingalltheopinions. 184

InadditiontothetensionbetweenSimsandGuide,therewereother
organizationalchallengesthatfrustratedpersonnelwithresponsibilitiesfor
Macondooperations.Forexample,justdaysbeforetheblowout,Guidesaid,
[w]iththeseparationofengineeringandoperationsIdonotknowwhatIcan
andcantdo.Theoperationisnotgoingtosucceedifwecontinueinthis
manner. 185Additionally,BrettCocalestestifiedaboutconcernsrelatedtohis
transfertotheengineeringdepartment. 186Cocalestestifiedthathisupcoming
transferwouldmoveresourcesfromtheoperationsgrouptotheengineering
group.

RecognizingtheorganizationalchallengespresentwiththeMacondo
team,onMarch21,2010,PatOBryan,BPsVicePresidentofdrillingand
completions,emailedBPdrillingandcompletionspersonnelandaskedthemto
bepreparedtodiscussoperationsissues,includingthechallengesthatweve
hadoverthelastfewweeks.Intheemail,OBryanlistedseveralitemshe
wantedtodiscuss,andoneoftheitemswasjustintimedeliveryofwellplans.
SimsdraftemailresponsestatedNothingisgoingtochange!Allleadership,
OpsDEs,etc.Lotsofstressinthesystem. 187

IntheweeksleadinguptoApril20,BPmadefurtherchangestothe
Macondowellteam.InearlyMarch,BPwellsmanagerIanLittlewasoutofthe
office,aswasSims.LittledelegatedhisdutiestoGuide.Guidesdutiesatthe
timeincludedtheresponsibilityforensuringaninvestigationintothecausesof
theMarch8kickwasconducted. 188CocalesassumedGuidesresponsibilities

182BPHZNMBI00125458(postincidentinterviewnotes).
183BPHZNMBI00222540.
184BPHZNMBI0022252.

185BPHZNMBI00255906.

186Cocalestestimonyat27172.

187BPHZNMBI00265306.

188TestimonyofIanLittle,JointInvestigationHearing,April7,2011,at38.

81
whenGuidetooktimeoffafterhisfathersdeath.189Thoseresponsibilities
includedinvestigationoftheMarch8kickincident.

OnApril6,KeithDaigle,BPwelloperationsadvisor,notifiedGuidethat
BobKaluzawouldreplaceRonnieSepulvadoasoneofthetwoBPwellteam
leadersontheDeepwaterHorizonsothatSepulvadocouldattendwellcontrol
training. 190Kaluzahadfouryearsofdeepwaterdrillingexperiencebutminimal
experiencewiththeDeepwaterHorizonrig.

Meanwhile,theproblemofjustintimedeliveryofwellplans,which
OBryanexpressedconcernsabout,continued.Inapostblowoutinterview,
GreggWalzstatedthat,atthetime,hewasconcernedaboutlastminute
changesandhewantedtogetworkdoneearlier. 191OnApril12,Sepulvado
emailedBrianMoreltoaskfortemporaryabandonmentprocedures. 192Morels
subsequentemailsrevealedthathestillhadnotcompletedthetemporary
abandonmentproceduresandwasstillnotsurewhethertheMacondodrilling
teamwouldsetthelockdownsleeveduringtemporaryabandonment. 193

TherewasevidencethatmembersoftheMacondoteamwereconcerned
aboutoperationsatMacondo.MorelemailedhiswifeonApril14thathehadto
gooffshoretotheDeepwaterHorizonrigbecauseournormalWSL[wellsite
leader]isheadinginandthenewguyisgood,butnotintunewiththewellsoI
needtogooutandmakesuretheyfolloweverystepasanydeviationscould
leadtousnotgettingagoodcementjobandhavingtodoalotofremedial
operations. 194

Inthedaysimmediatelypriortotheblowout,thecontentiousemails
betweenGuideandSimscontinued.OnApril15,SimsemailedGuidetoseeif
hecouldmeetwithhimthefollowingmorning,andGuiderespondedbyasking
Simsifhewasgoingtobefired.Inthesameemail,Simsaskedwhetherhe
neededtodelegateGuidesworksinceGuidehadbeenoutoftheofficeand
Simsdidnotknowwherehewas. 195Atthistime,theMacondoteamwas
workingoncriticalcementingproceduresandneededinputfromGuide.

189BPHZNMBI00214540.
190BPHZNMBI00241455.
191BPHZNBLY00061325.

192BPHZNMBI00199122.

193BPHZNMBI00126145;BPHZNMBI00126333.

194BPHZNMBI00329028.

195BPHZNMBI002543828;BPHZNMBI00254858.

82

OnApril17,GuidewrotetoSims:

David,overthepastfourdaystherehavebeensomanylastminute
changestotheoperationthattheWSLshavefinallycometotheirwits
end.Thequoteisflyingbytheseatofourpants.Moreover,wehave
madeaspecialboatorhelicopterruneveryday.Everybodywantstodo
therightthing,butthishugelevelofparanoiafromengineering
leadershipisdrivingchaos.ThisoperationisnotThunderhorse.Brian
hascalledmenumeroustimestryingtomakesenseofalltheinsanity.
Lastnightsemergencyrevolvedaroundthe30bblsofcementspacer
behindthetopplugandhowitwouldaffectanybondlogging(Idonot
agreewithputtingthespacerabovetheplugtobeginwith).Thismorning
Briancalledmeandaskedmyadviceaboutexploringopportunitiesboth
insideandoutsideofthecompany.

Whatismyauthority?Withtheseparationofengineeringandoperations
IdonotknowwhatIcanandcantdo.Theoperationisnotgoingto
succeedifwecontinueinthismanner. 196

ThePanelfoundnoevidencethatanyoftheissuesraisedbySimsand
GuideregardingGuidesperformance,thelackofclearauthorityandreporting
lines,andmanagementofchangestotheoperationwereresolvedoreven
meaningfullyaddressedpriortoApril20.

D. SafetyStanddown

EventsaroundaproposedsocalledsafetystanddownontheDeepwater
Horizonreinforcedthefactthatthereweresignificantproblemswithoversightof
rigoperationsandcommunications.RonnieSepulvado,oneoftheBPwellsite
leadersontherigatthetime,notifiedGuideonApril10ofafirstaidincident
aboardtheDeepwaterHorizon,whichinvolvedaroustaboutsustaininganinjury
tohisleftlegfromaloadbeingliftedbyacrane.GuideandSimsdiscussedthe
incident,andGuidesuggestedasafetystanddowntomorrowsowecangetour
acttogether.Simsagreedwiththeideaofastanddown,andheadded

BPHZNMBI00255906.Theallocationofresponsibilitiesbetweenoperationsandengineering
196

wereoutlinedinadocumentthatBPreferredtoasaRACIchart.SeeAppendixK.

83
[h]appytotakeasmuchtimeasyouthink.2firstaidsand2dropsin2weeksis
worthatimeout. 197

Followingthediscussionaboutthestanddown,Guidesentanemailto
PaulJohnson,aTransoceanrigmanagerwithresponsibilityfortheDeepwater
Horizon,informingJohnsonthatitwasprobablytimetostepbackforanhouror
two.Letsmakesurethecrewisengaged.JohnsonagreedandtoldGuidethey
wouldhaveasafetystanddownwithbothcrewstodiscussplanning. 198The
Panelfoundnoevidencethatindicatedasafetystanddownactuallyoccurred
outsideofthecrewsdailysafetymeeting,whichgenerallylastedonlyafew
minutes.

197 BPHZNMBI00249509.
198 BPHZNMBI00249524.

84
VII. TemporaryAbandonmentoftheMacondoWell

Attheendofdrillingoperations,therigcrewneedstosecurethewell
priortoleavingthesite.Temporaryabandonmentreferstotheprocessby
whichtherigcrewinstallscementplugsinthewellandpullstheriserand
blowoutpreventertothesurfacetomovetoanotherlocation.Pressuretesting
(calledpositiveandnegativetests)isakeycomponentoftemporary
abandonmentproceduresbecauseitseekstoensurewellintegrityandthat
hydrocarbonsarenotleakingintothewell.

A. InstallingtheLockDownSleeve

BPsplannedtemporaryabandonmentproceduresfortheMacondowell
werenotcompleteduntilApril12,andsubsequentlychangedanumberoftimes
beforeApril20.Theinitialplanincludedthesettingofalockdownsleeveprior
todisplacingdrillingmudfromtheriser.

Temporaryabandonmentproceduresdonotalwaysincludeinstallationof
alockdownsleeve.Correspondencefromlate2009andearly2010showsthat
BPdecidedtoinstallthelockdownsleeveaspartofitstemporaryabandonment
proceduresontheMacondowelltosavecosts.InJanuary2010,MerrickKelley,
BPsubseawellsteamleader,exchangedanumberofemailswithBPdrilling
engineerMarkHafleabouttheinstallationofalockdownsleevebythe
DeepwaterHorizoncrew.Kelleycalculatedthatthiswouldsave$2.2millionin
incrementalcosts: 199

199 BPHZNMBI00097490.

85

HaflediscussedthisfurtherwithDavidSims,andtheyagreedthatthe
DeepwaterHorizoncrewshouldmoveforwardwiththeinstallationofthelock
downsleeveaspartofitstemporaryabandonmentprocedures. 200BPchosetodo
thiseventhoughtheDeepwaterHorizonwasarigthatconductedexploratory
drillingoperationsoperationsthatdidnottypicallyincludethesettingofa
lockdownsleeve,whichwastypicallydonebyarigthatspecializesin
completionoperations.Indeed,thePanelconcludedthatnoneoftheBP
personnelontherigonApril20hadexperiencesettingalockdownsleeve. 201
Commonindustrypracticeis,duetosafetyconcerns,tosetthelockdownsleeve
inmudpriortodisplacementandsettingofthecementplug.Althoughthecrew
displacedthemud,thecrewnevergottothepointofsettingthelockdown
sleeve.

ThePanelfoundnoevidencethatBPassessedtherisksassociatedwithits
decisiontosetthelockdownsleeve.Thisdecisionincreasedtheriskassociated
withsubsequentprocedures,includingthesettingofthesurfaceplug,the
displacement,andthenegativetestsequence.Inalllikelihood,hadthelock
downsleevebeensetatalatertime,thesurfaceplugwouldnothavebeensetas
deep;thesurfaceplugwouldhavebeensetsooner;anddisplacementwouldnot
haveresultedinalowerpressuredifferentialinthewell.

Notwithstandingthefactthatthecrewwasunfamiliarwithsettingthe
lockdownsleeveandthatthisprocedurewouldincreaseoperationalrisk,there
isevidencethatmembersofthecrewmighthavebecomecomplacentafter
drillingwascompleted.BPcontractorRossSkidmore,whenaskedabouthis
concernsonthetimingofsettingthelockdownsleeve,testifiedthatwhenyou
gettothatpoint,everybodygoestothemindsetthatwerethrough,thisjobis
done. 202

B. SettingtheCementPlug

OnApril16,BPsubmittedtoMMS,andMMSapproved,arevised
temporaryabandonmentplanstatingthatthelockdownsleevewastobeset

200BPHZNMBI100446.Onereasontosetthelockdownsleeveduringtemporaryabandonment
istoenhancesafetybyprotectingtheproductioncasingagainstupliftforcesthatmightoccur
duringproductionasaresultofhydrocarbonsflowingupthewellbore.Thepanel,however,
foundnoevidencethatBPdecidedtosetthelockdownsleevewhenitdidoutofsafetyconcerns.
201TestimonyofMerrickKelley,JointInvestigationHearing,August27,2010,at28990.

202TestimonyofRossSkidmore,JointInvestigationHearing,July20,2010,at26364.

86
afterthedisplacementofthemudfromthewellbore.Theplanalsoincreasedthe
depthofthecementplugtobesetinthewellasabarriertoflow.BPchoseto
hang3,000feetofdrillpipebelowthelockdownsleevetoweighitdown. 203
Havingchosentodothis,BPbelievedthatitneededtosetthecementplug
deeperthannormaltoincreasetheamountofweightonthelockdownsleeve.
Theapprovedplanalsocalledfortwonegativetests.Thefirstnegativetestwas
tobetothewellheadwithaseawatergradientonthekillline.Thesecond
negativetestwastobeconductedafterdisplacingwithseawaterdownto8,367
feet.Further,theapprovedplancalledforthecementplugtobesetinseawater
afterdisplacementofmudfromthewellbore.

BPstemporaryabandonmentplanalsocalledforthecementplugtobe
setinseawaterafterdisplacementofmudto3,300feetbelowthemudline.This
createdariskysituationafterdisplacementofthemud,thewellwouldbeinan
underbalancedconditionandatriskofawellcontrolevent.Inaddition,BPhad
alreadyeliminatedthesecondcementbarrierthatwouldnormallybesetabove
thetopcementwiperplug.Thisfurtherincreasedthewellcontrolrisks.

C. TheUseofLostCirculationMaterialasSpacer

BPsplansfordisplacementofthemudfromtheriserattheMacondowell
calledfortheuseofspacerfluid,whichisusedtoseparatethedrillingmudfrom
theseawaterduringdisplacement.Theplansincludedtheuseoftwodifferent
pillsofspacer.Thepillstobeusedwereablendofleftoverlostcirculation
materialthathadbeenmixedontherig.Thelostcirculationmaterial(material
providedbyMISWACOwiththetradenamesFormASetandFormA
Squeeze)hadbeenprimarilyusedtopreventadditionallostreturnsatthewell.
BPhadneverusedthistypeofspacerbefore,anditdidnotknowwhetherthe
spacerwouldbecompatiblewiththesyntheticbasedmudthatitwasdisplacing.
BPalsodidnothaveanyinformationaboutthelongtermstabilityofthe
interfacebetweenthespacerandtheseawater. 204ThePanelfoundnoevidence
thatBPhadprovidedtherigcrewwithdesignspecificationsforthespacer.

ThePanelreviewedevidence,includingBPinternalemails,thatindicated
thatBPchosetousethelostcirculationmaterialsasaspacertoavoidhavingto
disposeofthematerialsonshore. 205Ifthematerialswerecirculatedthroughthe

203TestimonyofRonaldSepulvado,JointInvestigationHearing,July20,2010,at145.
204TestimonyofSteveRobinson,JointInvestigationHearing,December8,2010,at114.
205BPHZNMBI00262887.

87
well,therequirementtodisposeofthematerialsonshorecouldbeavoided
becausetheapplicableregulationsprovideanexemptionprovidedforwater
baseddrillingfluidsandallowsuchfluidstobedisposedoverboard. 206

BPpersonnelandMISWACOpersonnelagreedontheuseofthelost
circulationmaterialpillsasspacer. 207OnApril20,therigcrewblendedthe
spacerfromthelostcirculationmaterialstoa16.0ppgdensity.Therigcrew
pumped454barrelsofspacerintothewell,morethantwiceasmuchmaterialas
istypicallyused.ThePanelfoundnoevidencethatBPconsideredthepossibility
thatpumpingalargeamountof16.0ppglostcirculationmaterialintothewell
mightriskcloggingthechokelineorthekillline.NordidthePanelfind
evidencethatBPdiscussedthispossibilitywiththerigcrew.Acloggedchoke
lineorkilllinewouldleadtopressuredifferentialswiththedrillpipeandwould
complicateanynegativetestproceduresusingeitherline.

Initspostblowoutinvestigation,BPconcludedthatthepresenceofthis
spacerallowedforviscousmaterialtobepresentacrossthechokeandkilllines
duringthenegativetestandthatthispossiblypluggedthekillline.208Thisisa
possibleexplanationforthepressuredifferentialbetweenthedrillpipeandkill
line.

D. WellIntegrityTesting

1. NegativePressureTestPlannedProcedures

Anegativepressuretestiscriticalbecauseitteststheintegrityofthe
bottomholecementjob,thewellheadassembly,thecasing,andallofthesealsin
thewell.Thenegativetestseekstocreateconditionsthatsimulatewhatwill
occurafterthewellistemporarilyabandoned.Heavydrillingmudisdisplaced
withspacerfluidandseawater.Thedisplacementinvitesthewelltoflowasa
wayoftestingwellintegrity. 209Thewellborefluidsarereplacedsuchthatthe
wellboreisunderbalancedagainsttheformationpressuresforthepurposeof
testingthebarriersthatareinplace.Thereareanumberofalternativewaysarig

206See42U.S.C.69216939f(theResourceConservationandRecoveryAct)and40CFR
261.4(b)(5)(exemptionfordrillingfluids).
207Lindnertestimonyat296298.

208Robinsontestimonyat96.

209ReviewofOperationDataPrecedingExplosiononDeepwaterHorizoninMC252,Dr.John

Smith,7/1/10(SmithReport).

88
crewcanconductanaccuratenegativetest.InthecaseoftheMacondowell,the
barrierbeingtestedwasthecementintheshoetrackofthewellbore.

BPconsideredmultiplenegativetestproceduresinthedaysleadingupto
April20.NeitherBPnorTransoceanhadpreexistingnegativeteststandards
andprocedures.AsofApril2010,MMSdidnotrequirethatoperatorsconduct
negativetests,and,consequently,didnotspecifyhowsuchtestsshouldbe
performed.

InanApril18,2010emailentitledNegativeTestfromBrianMorelto
JohnGuide,Morelbrieflyexplainedthenegativetesttobeconducted,stating
thatthe[p]lanistodoanegativetestwithbaseoilonthebottomplug.Then
wewilldisplace(asecondnegativetesttogreatervaluewillhappen)and
followingthatsetthecementplug. 210MorelthenaskedGuide:

Areyouokwiththis,ordoyouthinkweshouldremovethefirstbaseoil
testandjustusethedisplacementasanegativetest(shutdownattheend
anddoaflowtest)?...Ihavegotdifferentopinionsfromeveryoneonthe
team.Thewaywecurrentlyhaveitsetupisthestandardwehavebeen
using,butthisoneisslightlydifferentbecausetheplugissodeepand
baseoildoesntachievethefullnegativeloadthewellborewillsee.Don
[Vidrine]andBob[Kaluza]dontseemtohavestrongopinionseither
way. 211

Guiderespondedbysaying,Iwouldusetheseawaterdisplacementas
thenegativetest,asyoustated,shutdownattheendanddoaflowtest.
Twentyminuteslater,Morelreplied,withoutelaborationoranyevidenceof
deliberation,[d]one. 212NeitherGuidenorMorelinformedtherigcrewthat
thesechangesgreatlyincreasedtherisksofawellcontrolevent.

Transoceanpersonnelwereawareoftheimportanceofconductinga
successfulnegativetest.JimmyHarrell,Transoceanoffshoreinstallation
manager,testifiedthat[t]hefirstplanIseen[sic]didnthaveanegativetestin
it.SoItoldhim[Vidrine]itwasmypolicytodoanegativetestbeforedisplacing
withseawater. 213

210BPconsideredanumberofdifferentnegativetestproceduresinthedaysleadinguptoApril
20.ThedifferentnegativetestvariationsthatBPconsideredaredetailedinAppendixG.
211BPHZNMBI00256247.

212Id.

213Harrelltestimonyat26.

89

Whenaskedhowhewouldtypicallylineupthepipingandvalve
arrangementsforconductinganegativetest,Harrelldescribedanothermethod
forperforminganegativetest.Heexplainedthat[y]oudoitbyleading
[bleeding]offbacktoHalliburtonandupyourdrillpipe.Youpumpseawaterto
theendofyourtailpipeandallthewaybackuptoaboveyourannularwith
yourspacerYouholdthemudintheriserwiththeannularclosedYouhave
seawaterinthedrillpipeandyouhaveseawaterinthekilllineandeitherone
wouldbeseeingthesamepressure 214

LeoLindner,anemployeeofMISWACO,testifiedthatonthemorningof
April20,2010,hehadtwoseparateconversationsregardingthenegative
pressuretest,onewithKaluzaandonewithMorel.Lindnerstated:

He[Kaluza]wantedtogooverthemethodbywhichtherighadbeen
doingitsnegativetestanddisplacing.IexplainedIexplainedittohim.
Heseemedsatisfiedwithit.Shortlyafterthat,IwascalledbyMr.Brian
Morel.Wehadbasicallythesameconversation.Heseemedsatisfiedwith
it.Heinformedmetheyweregoingtobedisplacingfurtherdownthe
holethanusual.Usuallyits300feetbelowthemudline,butthiswas
goingtobeat8,367feet[3,367belowthemudline].IlefttheofficeandI
makemycalculations.Itypeupadisplacementprocedure. 215

Lindnersprocedurespecificallyinstructed,assteptwo,to[d]isplace
choke,kill,andboostlinesandcloselowervalvesaftereach. 216Theprocedure
didnotinstructthepersonneltoreopenthechokeandkilllines,whichwouldbe
necessarytoperformanegativetestoneitherline.Inanyevent,Lindner
prescientlynotedattheendoftheprocedurethat[g]oodcommunicationwillbe
necessarytoaccomplishasuccessfuldisplacement.Ifyouarenotsure,stopand
ask. 217

Theonlyinstructiongiventotherigpersonnelinevaluatingthenegative
testwastomonitorthewellfornoflow.Noinstructionsweregiventoreopen
thechokeandkilllines,tomonitordrillpipepressure,ortoevaluateand
investigateanypressuredifferentials.TestimonyandinterviewnotesfromBP

214Harrelltestimonyat33.
215Lindnertestimonyat272.
216BPHZNMBI00133083.

217Id.

90
personnelrevealedthattheyhadanoversimplifiedviewofwhatconstituteda
successfulnegativetesttheyeachbelievedthattheyonlyhadtocheckforflow
toevaluatewhetheranegativetesthadbeensuccessful.Specifically,whenasked
whatasuccessfulnegativetestwasfortheMacondowell,Guidesaid[a]
successfultestneedstoberunfor30minuteswithnoflowfromthewell. 218In
responsetothesamequestion,Morelsaid[n]oflowfor30minutes, 219and
DonaldVidrine,aBPwellsiteleader,respondedthatasuccessfulnegativetest
required[c]heck[ing]forflowornoflow. 220

GuideandMorelappearedtohaveagreeduponasimplifiedapproachto
thenegativetestthatconverteditfromthepreviouslyapprovedmultistep
process.WhenaskedinapostblowoutinterviewwhyBPmadethechangefrom
theApril16approvedproceduretotheapproachreflectedinMorelsApril20
OpsNote,Kaluzaresponded,maybe[GuideandMorelwere]tryingtosave
time. 221

MorelhadpreviouslyarticulatedconcernsaboutKaluzasabilityto
executeprocedures.PriortoarrivingattheDeepwaterHorizon,Morelstatedthat
Kaluzawasnotintunewiththewell.Morelsaidthathehadtogoout[tothe
DeepwaterHorizon]andmakesurethey[thecrewunderKaluza]followevery
step. 222MoreltraveledtotheDeepwaterHorizonandwasonboardonApril20.
However,notwithstandinghisstatedconcernsaboutthecementjob,about
Kaluzaslevelofexperienceasthewellsiteleader,andaboutthemultiple
changestoproceduresthatincreasedtherisksofawellcontrolevent,Morel
departedtheDeepwaterHorizonpriortotheperformanceofthecriticalnegative
tests.

2. PositivePressureTestConductedonApril20

Anothermethodoftestingwellintegrityisapositivepressuretest,which
isatestthatisconductedbypumpingadditionalfluidintothewellaftersealing
theblindshearrams.Therigcrewthenmonitorsthewelltodeterminewhether
thepressuresinthewellremainstatic.Asdescribedpreviously,theDeepwater
Horizoncrewperformeda2,500psipositivepressuretestbetween10:30a.m.and

218BPHZNBLY00124455.
219BPHZNMBI00021336.
220BPHZNMBI00021424.

221BPHZNMBI000021237.

222BPHZNMBI00329028.

91
noononApril20.Thepressuresinthewellremainedconstantduringtesting. 223
Dr.Smith,anexpertretainedbytheJITtoreviewtestdataandother
information,foundthepositivepressuretesttobeacceptable. 224

3. NegativeTestsConductedonApril20

Withoutmuchtimetoconsiderchangesinthetemporaryabandonment
procedures,onApril20theDeepwaterHorizoncrewbeganworktoward
conductingthecriticalnegativetesttoevaluatewellintegrity.Beforestartingthe
test,thecrewdisplacedmudfromthewellborewithseawater,whichwould
simulatewellconditionsafterthewellhadbeentemporarilyabandoned.

Thefirststepofthenegativetestwastodisplacetheriserboostline,the
chokeline,andthekilllinewithseawater. 225Theseeffortsbeganat
approximately4:00p.m.onApril20.Overthenext30minutes,thecrew
pumpedthe454bblsofspacer(consisting,asdiscussedabove,ofmixedlost
circulationmaterials).Around4:30p.m.,thecrewthenpumpedapproximately
352barrelsofseawaterintothewellbore,whichtookapproximately25minutes.
Afterpumpingthespacerandseawater,seawatershouldhavebeenlocated
downtheworkstringandinthewellborefrom8,367feetto5,117feettotaldepth
andthespacershouldhavebeenlocatedjustabovetheseawaterfrom5,117feet
to3,707feet. 226

Afterthedisplacement,therigcrewshouldhaveseenadrillpipepressure
of1,610psi,basedonhydrostaticfluidcalculations.However,theelectronicdata
indicatesthatthedrillpipepressurewas2,339psi.Thisreadingwasmorethan
700psihigherthanitshouldhavebeen.Ifthecrewsawthisinformation,they
shouldhavetakenmeasuretoresolvethisanomalybecauseitmayhave
indicatedthatthespacerremainedbelowtheBOPstack(andcouldhaveclogged
thechokeorkilllines).227Thisproblemcouldhavebeenresolvedbycontinuing
thedisplacement(throughthechokeline)toensurethatallmudandspacerhad
beenremovedfromthewellborebelowtheBOPstack.Thismethodofcleaning
upthewellwouldnothavecompromisedthefunctionofthespacerbecause
mostofthespacerwasalreadyintheriserabovetheBOPstack. 228

223SmithReportat7;DeepwaterHorizonIADCDailyDrillingReport,April20,2010.
224SmithReportat8.
225ThisfirststepwasdifferentfromthefirststepintheMMSapprovedAPM.

226Id.at9.

227Id.

228Id.at1819.

92

Thereisnoevidencethattherigcrewdetectedorattemptedtoaddress
thisanomaly.Instead,thecrewproceededtoattempttoconductthefirst
negativetest.Welldataandtestimonyestablishthattherigcrewclosedthe
annulararound5:00p.m.andattemptedtoconductanegativetestbyfirst
bleedingoffthedrillpipepressurefrom2,324psito1,427psi.

Therigcrewthenopenedthekilllinevalve,presumablytotrytobalance
thekilllineanddrillpipepressure.Asthekilllinepressurefellto0psi,thedrill
pipepressureremainedat458psi,thusindicatingthatthecrewmaynothave
fullydisplacedthespacerfrombelowtheBOPstack.Atapproximately5:05
p.m.,thecrewshutinthedrillpipe,andconcurrentlythedrillpipepressure
increased.Theincreaseindrillpipepressureisevidenceofanunsuccessful
negativetestandshowedthatthewellwaspossiblyflowing.Inaddition,the
factthatthechokepressureremainedlessthan0psishowsthatthenegativetest
waslikelyeitherunsuccessfulor,attheveryleast,inconclusive. 229At5:25p.m.
thenegativetestconcluded.

Sometimebetween5:17p.m.and5:27p.m.,JimmyHarrell(Transocean),
RobertKaluza(BP),DonaldVidrine(BP)andothermembersofthedrillcrew
discussedthefirstnegativetest.AccordingtoKaluza,thisdiscussionaboutthe
pressureonthedrillpipewaslong. 230KaluzastatedthatJasonAnderson,
Transoceanassistanttoolpusher,explainedthatthepressurewasduetoa
bladdereffect,andthatthishappenseverytime.BrianMorel,aBPdrilling
engineerwhohadpreviouslyraisedconcernsaboutKaluzasabilitiestoexecute
procedures,wasnotontherigatthetime(hehaddepartedhoursearlier)tobe
consultedonthedrillpipepressureandotheranomalies. 231

Inaddition,nooneinvolvedinthislongdiscussionaboutthenegative
testconsultedanyoftheexecutivesvisitingtherigatthetime,eventhoughthese
BPofficialshadmorethan50yearsofdrillingexperience.Atthattime,the
executives,includingDavidSimsandPatOBryan,wereonboardconductinga
rigtourandwerepresumablyavailableforconsultation. 232Thereisevidence

229AreadingoflessthanzeroPSIsuggestsinstrumenterrorand/oraninaccuratetest.
230
BPHZNMBI00021237.
231
Id.
232ThegroupincludedPatOBryanandDavidSimsfromBPandDaunWinslowandBuddy

TrahanfromTransocean.Theyplannedtodiscussanumberofitemswiththerigcrew,
including(intheeyesofBPandTransocean)therigsrecordofexcellentcommunicationandlow

93
thatSimsandOBryanmetwithKaluzaatsomepointtodiscussthepositive
pressuretestandhowthecrewwouldbeliningupforthenegativetest. 233But
thecrewdidnotconsultOBryanorSimsabouttheactualnegativetestresults. 234

Around5:30p.m.,afterthefirstunsuccessfulnegativetest,therigcrew
begantosetupforanothernegativetest,whichbeganbybleedingoffthedrill
pipeandclosinganinternalvalveinthedrillpipefor20minutes.Oncethis
valvewasclosed,thecrewwasnolongercapableofmonitoringthedrillpipe
pressure.

Around6:00p.m.,thecrewbledthepressurefromthedrillpipetothe
cementingunit.Atthattime,thedrillpipewasshutinatthecementingunit,
andthepressureonthedrillpipeincreasedto1,400psiafter30minutes.Asthe
pressureonthedrillpipeincreased,thekilllinepressurealsosteadilyincreased
butonlyto140psi.Thispressuredifferentialbetweenthedrillpipeandthekill
linewasanotherindicatorthatthenegativetestwasnotsuccessful.

Around6:45p.m.,thecrewpumpedasmallamountoffluidintothekill
linetomakesureitwasfullforanothernegativetest.Atapproximately7:15
p.m.,thecrewopenedthekilllinetomonitorforpressure/flowconsistentwith
theAPMapprovedbyMMS.Afterapproximately40minutesofnoflowor
pressureobservedonthekillline,thecrewandtheBPwellsiteleadersdeemed
thenegativetestsuccessfulandbeganoperationstocompletethedisplacement
ofdrillingmudwithseawater.Notwithstandingmultipleanomaliesthatthe
crewencounteredduringtheseveralfailednegativetestattempts,thedrillcrew
andtheBPwellsiteleadersdecidednottoflushthesystemandconductanew
negativetest.

Testimonyfromrigpersonnelinvolvedwiththenegativetestreflectsthat
theybelievedthattheyhadsuccessfullytestedtheintegrityofthewellby
checkingforflowonthekillline.Kaluzastatedthat[i]twasnot
flowingAbsolutelynoflow. 235MilesEzell,Transoceanseniortoolpusher,
testifiedthatJasonAndersontoldhimthat[i]twentgood...Webleditoff.We

rateofdaysawayfromwork.Theyalsoplannedtodiscusstherigsfinancialperformance
(costscomparedtoAFEs)andongoingriskandhazardrecognition.SeeBPHZNMBI129014.
233TestimonyofPatrickOBryan,JointInvestigationHearing,August26,2010,at360,374;Sims

testimony,May292010,at178.
234OBryantestimonyat443;Simstestimony,May29,2010,at179.

235BPHZNMBI00021264.

94
watcheditfor30minutesandwehadnoflow. 236ChrisPleasanttestifiedthat,
[d]uringthenegativetestwedidntseeanyanythingflowback. 237

Thecrewapparentlydismissedthephenomenonofthepressure
differentialonthedrillpipeandkilllineasabladdereffectorannular
compression.Kaluzaattemptedtoexplainthebladdereffectinanemailsenton
April25. 238

Ibelievethereisabladdereffectonthemudbelowanannularpreventer
aswediscussed.Asweknowthepressuredifferentialwasapproximately
14001500psiacrossan18rubberannularpreventer,14.0SOBMplus
16.0ppgSpacerintheriser,seawaterandSOBMbelowtheannular
bladder.Duetoabladdereffect,pressurecanandwillbuildbelowthe
annularbladderduetothedifferentialpressurebutcannotflowthe
bladderpreventsflow,butweseedifferentialpressureontheothersideof
thebladder.

OnApril27,MikeZanghi,BPvicepresidentfordrillingandcompletions,
forwardedKaluzasdescriptionofthesocalledbladdereffecttoOBryan,who
respondedasfollows: 239

236Ezelltestimonyat282.
237TestimonyofChrisPleasant,JointInvestigationHearing,May28,2010,at118.
238BPHZNMBI00262896.

239Id.

95
Around8:52p.m.onApril20,aboutanhourafterthesecondnegative
test,DonaldVidrine(whowasontherig)calledMarkHafle(whowasatBPs
Houstonoffices)totalkaboutwhethertotestthesurfaceplugusingapressure
testoraweighttest.Duringtheconversation,VidrinealsotalkedtoHafleabout
thenegativeteststhattherigcrewhadjustconducted.VidrinetoldHaflethat
thecrewobservedzeropressureonthekillline,buttherewaspressureonthe
drillpipe.Haflerespondedthatasuccessfulnegativetestcouldnotresultin
pressureonthedrillpipeandzeropressureonthekillline.HetoldVidrineto
considerwhetherpressurewastrappedinthelineorperhapsavalvewasnot
properlylinedup.VidrinereportedtoHaflethathewasfullysatisfiedthatthe
rigcrewhadperformedasuccessfulnegativetest. 240

AtthetimeoftheconversationwithVidrine,Haflewasinhisoffice,
wherehecouldaccessrealtimedataatanytimethroughasystemcalledInsite
Anywhere.Indeed,HafleloggedontotheInsiteAnywheredatabaseat1:25:39
p.m.onApril20andaccessedMacondowellinformationviaat4:13:58p.m.241
ThefileheaccessedwasCementingXYTimeLog,andheremainedlogged
intothesystem(InsiteAnywhere)until5:27:35p.m. 242(RefertoFigure9Insite
AnywhereAccessLogforApril20,2010).However,Haflechosenottoaccess
availablerealtimedatatohelpinterpretthenegativetestresults.Instead,Hafle
apparentlyacceptedVidrinesexplanationwithoutreviewingdatafromthewell
ontheanomalousnegativetests.ThePanelfoundevidencethatHafleremained
attheofficeonApril20untilabout10:00p.m.CST,whichwasjustafterthe
discussionwithVidrine.Aftertheblowout,hesentanemailtohimselfdetailing
hisactivitiesthatday. 243

240BPHZNBLY00125475.
241InsiteAnywhereisadatabaseownedbyHalliburton,accessiblebyBPpersonnel.
242HAL50546.
243
BPHZNMBI00327757.

96

Figure9InsiteAnywhereAccessLogforApril20,2010

97
VIII. KickDetectionandRigResponse

Akickduringdrillingoperationsistheunwantedinfluxofformation
fluids,suchashydrocarbons,intothewellbore.Anundetectedkickcanleadtoa
lossofwellcontrol.AsstatedbySteveRobinson,BPvicepresidentofwellsin
Alaska,[t]hekeytowellcontrolisearlydetection.Itsgettingitshutin
quickly. 244Monitoringawellforkicksinvolvesobservationofanumberof
indicatorsandaconstantawarenessofwellconditions.

A. KickDetectionMethodsandResponsibilities

Certainrigpersonnel,includingthedriller,assistantdrillerand
mudloggershavespecificresponsibilitiesformonitoringthewelltodetectkicks,
amongotherthings. 245BPswellcontrolmanualprovidesthatthewellsite
leaderisresponsiblefordeveloping,monitoring,andsupervisingwellcontrol
procedures.Thecompanydrillingengineerisresponsibleforproviding
technicalsupporttothewellsiteleader.Theseniorcontractorrepresentativehas
overallresponsibilityforactionstakenontherig.Thecontractortoolpusherhas
overallresponsibilityforimplementingthewellcontroloperationandfor
ensuringthatthedrillerandthedrillcrewarecorrectlydeployedduringthewell
controloperation. 246

Personnelresponsibleforwellmonitoringuseanumberofmethodsto
determinewhetherthewellisstable.Onemethodismonitoringpitgain,which
involvestrackingfluidgainsinthepitsthatmightindicateflowfromthewell.
Anothermethodistheanalysisofflowoutversusflowindatawhichshould
beequalifthewellisstable.AsdiscussedbyDr.JohnSmithinhisreport,these
twomethodspitgainandcomparisonofflowintoflowoutarecriticalto
effectivewellmonitoring. 247Inaddition,otherdata(includingdrillpipepressure
changesandgascontentinformation)canalsoindicateifawellisflowing.A
warningfromanyoftheseindicatorsshouldpromptpersonneltostop
circulatingfluidandtoperformaflowcheck.Ifflowcontinues,thewellshould
beshutinusingtheBOP. 248

244Robinsontestimonyat44.
245TransoceanWellControlManual,TRNUSCG_MMS00043810.
246BPHZNMBI00000001.

247SmithReportat21.

248Id.at22;SeeAPIRP59;IADCDeepwaterWellControlGuidelines.

98
Becauseoftheimportanceofkickdetection,themembersoftherigcrew
shouldbeinconstantcommunicationwithoneanotheraboutpossiblekick
indications,oranyothercriticalobservationsbasedonwellmonitoring.Onthe
DeepwaterHorizon,thewellsiteleaderwasresponsibleforoverseeingallwell
operations,includingwellmonitoring.TheTransoceantoolpusherandsenior
toolpusheroversawthedrillingpersonnelandshouldbeawareofrigoperations
thatmightaffectthecrewsabilitytomonitorforkicks.TheTransoceanoffshore
installationmanager(sometimesreferredtoastheOIM)hadresponsibilityfor
theentireTransoceancrew. 249

Muchofwellmonitoringisdonethroughreviewofrealtimedatathatrig
personnelaccessoncomputerconsoles.SperrySunsentmudloggerstothe
DeepwaterHorizonandalsoprovidedrealtimedatathatwasaccessibletotherig
crew.RigpersonnelalsohadaccesstocertainrealtimedatafromTransocean.
Inaddition,videocamerasontherigallowedthecrewtomonitorcertain
activities,suchasflowbeingreturnedtothepits.BPanditsoperatingpartners
hadaccesstotherealtimedatathroughInsiteAnywhere,BPselectronicdata
systemthatprovidesrealtimeflowinandflowoutdata,gasanalysisdata,
standpipepumppressures,andotherdata.

MMSregulationsrequiredoperatorstousethebestavailableandsafest
technologytomonitorandevaluatewellconditionsandtominimizethe
potentialforawelltofloworkick. 250Theregulationsalsorequiredtheoperator
toensurethatthetoolpusher,operatorsrepresentative,oramemberofthe
drillingcrewmaintainscontinuoussurveillanceontherigfloorfromthe
beginningofdrillingoperationsuntilthewelliscompletedorabandoned,unless
theyhavesecuredthewellwithaBOP,bridgeplug,cementplugorapacker.

B. MultipleSimultaneousOperationsThatHamperedtheCrews
AbilitytoDetectKicks

OnApril20,afterperformingthenegativepressureteststhatwere
incorrectlyinterpretedassuccessful,therigcrewturnedtocompletingthe
temporaryabandonmentprocedures.Therigcrewdecidedtoperformmultiple
operationsoverashortperiodoftime,whichlikelylimitedtheirabilityto
effectivelymonitorthewell.Atthistime,BobKaluzaandDonaldVidrinewere
theBPwellsiteleaders.BrianMorelwastheBPdrillingengineer,buthehad

249TransoceanWellControlManual,TRNUSCG_MMS00043810.
250
30CFR250.401.

99
departedtheDeepwaterHorizonpriortothenegativetests.JimmyHarrellwas
theoffshoreinstallationmanagerandwastheseniorTransoceanrepresentative
ondutyatthetimeoftheblowout.MilesEzell,theseniortoolpusher,was
attendingameetingwithvisitingexecutivesandassignedJasonAnderson,an
assistanttoolpusher,tooverseethetemporaryabandonmentwork.ThePanel
foundnoevidencethatHarrell,EzellorKaluzawereontherigfloorduring
temporaryabandonmentoperationsontheeveningofApril20.

Therigcrewcomplicateditswellmonitoringeffortsbydisplacingmudto
twoactivepits(pits9and10)insteadofone.Thisdecisionlefttherigcrew
unabletoaccuratelymonitorwelloutflowbecausewhenfluidismoved
throughoutthesurfacesystem(tootherequipmenttanks,filling/drainingsurface
lines,generalsemisubmersiblerigmovement,etc.),subtlegainsorlossesinthe
triptanksorpitsaremoredifficulttoaccuratelymonitor.

CathleeniaWillis,aSperrySunmudlogger,describedtherigactivityas
follows:

They[therigcrew]weregettingpreparedtodisplaceanddiscussedthe
program.Atthesafetymeetingtheysaidtheywoulddisplacebacktothe
boat.AD[AssistantDriller]saidtheywouldcallherbecauseshesaidshe
couldnotmonitordisplacementbacktotheboat.WhenJoe[Keith]came
ontowerhesaidheneededtotalktothemaboutdisplacingtotheboat
andhewasnothappywiththis.

[Willis]toldJoeKeithinhandoverwhatwashappeningandhewasnot
happyaboutdisplacementtotheboat. 251

They[rigcrew]werefillinganddumpingthetriptanksbetween4:00p.m.
and6:00p.m.At628strokesADtoldhertozerooutthestrokes,thiswas
duringthetriptanktransfers.Shegotthestrokesfromthechokeandkill
lineandADsaiditwasokaytozerooutthestrokecounter. 252

Transoceanspolicy,asstatedinitsWellControlManual,Section1.2.2.1,
requireswheneverpossible,[to]limitcirculationtoasingleactivepit.Strictly

251Handoverinthiscontexttypicallyreferstothetransferofresponsibilitiesfromonepersonto
another.
252BPHZNMBI00129630.

100
enforcepitmanagement,andcarefullymonitorforanydiscrepanciesduring
trips. 253

JosephKeith,aSperrySunmudlogger,testifiedthattherigcrewwas
movingalotofmudaroundfromdifferentpits,reservepits,activepits,trip
tanks[and]sandtraps.Theyweremovingalotofmudaround. 254Keith
testifiedthathewasconcernedaboutthisbecausehecouldntreallymonitor
thevolumesinthepitscorrectly. 255Keithalsotestifiedthattheactivities
occurringonboardtheDeepwaterHorizonwerenotconsistentwithTransoceans
kickpreventionprocedures. 256Nevertheless,atnopointpriortotheblowout,
didKeithissueastopworkorderbecause,accordingtohistestimony,hejust
didntthinkofitatthetime. 257Keithtestified,however,thatthehighlevelof
mudmovingactivitiesshouldhaveresultedinastopworkorderfromsomeone
ontherig. 258

Dr.Smithanalyzedavailabledataand,inhisreport,detailedwhatKeith
andtherestofthecrewwouldhaveobservedhadtheyproperlymonitoredthe
well.Justafter8:00p.m.,anincreaseofmainpitvolumeby500barrels,likelythe
resultofthetransferofseawaterintothemainpit,precludedthecrewfrom
usingpitgainasamonitoringtool.AccordingtoDr.Smith,nothavingthistool
availablecomplicatedkickdetectioneffortsandwasnotconsistentwithproper
pitmanagementandmonitoring. 259

Dr.Smithconcludedthatthecrewcouldnotproperlymonitorthewell
anddetectkicksfrom8:38p.m.to8:56p.m.onApril20.Duringthistime,the
flowoutwassignificantlylessthantheflowin,inasituationwherelostreturns
wereunlikely.Atthesametime,thetriptankvolumewasincreasingrapidly,
andthedatashowedthattherewassomevolumeincreaseinthemainpits.
Giventhecomplicationscreatedbyconductingmultipleoperations
simultaneously,itisunlikelythatthecrewwasabletoevaluatethesesignalsthat
akickwasinprogress. 260

253TRNUSCGMMS00043810.
254Keithtestimonyat39.
255Id.at98.

256Idat.39.

257Id.at81.

258Id.at82.

259SmithReportat22.

260Id.

101
At8:58p.m.,flowoutincreasedsignificantlyandthepitlevelroseby
approximately100barrelsin15minutes.AccordingtoDr.Smith,atthispoint
thecrewshouldhaverecognizedthisasawarningsign,stoppedcirculationand
performedaflowcheck.Dr.Smithstatedthat[t]hesefailurestorespondtokick
warningsignsareindirectviolationofstandardindustrypracticeandMMS
requirements.Dr.Smithconcludedthatthewellcontinuedtoflowafterthe
pumpswereturnedoffat9:09p.m.Thiscontinuedflowwasaconclusive
indicatorthatakick[was]inprogress,i.e.,thatformationfluids[were]flowing
intothewell. 261

Keith,amudloggerwith18yearsofexperiencewhohadresponsibilities
formonitoringthewell,testifiedthathewentonafivetoeightminutebreakto
thecoffeeshopandthesmokingroomareaatapproximately9:00p.m.
AccordingtoKeithstestimony,afterthecrewshutdownthepumpsat9:09p.m.,
helookedatthevideofeedanddidnotseeanyflow. 262Keithtestifiedthat,at
thistime,hewasnotawareofincreasedpressureonthedrillpipe,whichwas
anotherindicatorthatakickwasinprogress. 263

At9:10p.m.,havingobservednoneoftheseveralindicationsthatakick
wasinprogress,thecrewreroutedreturnsfromthewelloverboard,which
causedthereturnstobypasstheSperrySunflowoutmeter.Thismeantthat
SperrySunmudloggersnolongerhadconventionalkickdetectionmethodsatits
disposal.Dr.Smithobservedthat[i]nitiatingthisactionwithoutinsuringthat
thewellwasundercontrolviolatesallindustrypracticesandregulatory
requirements. 264

Keithtestifiedthathedidnotknowthewellwasflowinguntilit
soundedlikeitwasrainingoutsideandhestartedsmellinggascomingthough
[his]purgesystem. 265

Itisnotclearwhatwellcontrolinformation,ifany,thedrillcrewwas
monitoringontheeveningofApril20.At9:18p.m.,thedriller,DeweyRevette,
sentrigcrewmemberstorepairapressurereliefvalveononeofthepumps.
ThisissignificantbecauseitisunlikelythatRevettewouldhavesentanycrew
memberstothepumproomifhebelievedthatthewellwasflowing.At

261Id.
262Keithtestimonyat50,118120.
263Id.at184.

264SmithReportat23.

265Keithtestimonyat32.

102
approximately9:20p.m.,JasonAnderson,thetoolpusher,toldMilesEzell,the
seniortoolpusher,thatthedisplacementwasgoingfine.Ivegotthis. 266Ezell
testifiedthatAndersonhadmoreexperienceasfarasshuttinginforkicksthan
anyindividualontheDeepwaterHorizon. 267ThePanelfoundevidencethata
significantvolumeofhydrocarbonshadalreadyenteredthewellbore,butthe
PanelfoundnoevidencethattheTransoceanrigcrewhadanyawarenessthat
thewellwasflowingorexperiencingakickatthistime.

C. RigFloorResponse

Atapproximately9:30p.m.,Revetteidentifiedapressuredifference
betweenthedrillpipeandthekilllineandshutdownthepumpstoinvestigate.
TheSperrySundataindicatedthatthedrillpipepressureinitiallydecreased
whenthepumpsshutdown.However,thedrillpipepressurethenincreasedby
approximately550psiduringthenextfiveminuteswhilethekilllinepressure
remainedlower.Onecrewmembertestifiedthatthedrillerandthetoolpusher
hadconcernsaboutthispressuredifferential. 268

Therigcrewthenattemptedtobleedoffthedrillpipe(i.e.,openthewell)
toeliminatethepressuredifferential,whichbrieflycausedthedrillpipepressure
todecrease. 269Giventhattherigcrewatthistimedecidedtobleedoffthedrill
pipepressure,theylikelystilldidnotunderstandthatthewellhadbegunto
flow.Bleedingoffdrillpipepressureduringakickisnotanindustryaccepted
practice.

At9:38p.m.,thedrillpipepressurebegantobuildbackup.Dr.Smith
concludedthat,atthistime,therigcrewroutedflowtothetriptanktocheck
whetherthewellwasflowing. 270Atapproximately9:42p.m.,thecrewdetected
flowanddivertedthegastothemudgasseparator.Atthesamemoment,or
shortlythereafter,therigcrewactivatedtheupperannularpreventer,afterthe
mudfromthewellwasalreadyflowingontherigfloor.TheSperrySundata
indicatestheannularpreventerwasactivatedat9:43p.m.,andby9:47p.m.,the
variableboreramhadbeenactivated.Bythistime,therigcrewknewthatawell
controleventwasoccurring.TheTransoceanwellcontrolmanualprovidesthat
thecrewshouldactivatetheBOPsblindshearram(BSR)asthelaststepin

266Ezelltestimonyat282.
267Id.at311.
268TestimonyofDavidYoung,JointInvestigationHearing,May27,2010,at25859.

269Robinsontestimonyat28485.

270SmithReportat14.

103
respondingtoawellcontrolevent,butthePanelfoundnoevidencethattherig
crewdidsoatthetime.

D. TheUseoftheMudGasSeparator

Amudgasseparatorisusedonadrillingrigtocaptureandseparategas
fromthedrillingfluidreturnedfromthewell.Afterseparation,themudflows
downintothepitsandthegasisventedupinthederrick.Amudgasseparator
istypicallyusedtodivertsmallvolumesofhydrocarbonsduringakick.Ifa
largeflowissenttothemudgasseparator,thereisariskthatthevesselwillfail
andcreatethepossibilityofgasignition.Ifthereispotentialforalargeflow,the
saferoptionistodiverttheflowoverboardusingoneoftwodiverterlines.The
diverterlineistypicallyusedduringawellcontroloperationwhen:(a)thegas
flowrateistoohighforthemudgasseparator;(b)hydratesareforminginthe
gasventlinefromthemudgasseparator;(c)thegasisfoundtocontain
hydrogensulfide;or(d)themudsystemisoverloaded. 271

BPswellcontrolmanualstatesthatthemudgasseparatorshouldbelined
upatalltimeswhenakickisbeingdisplaced,butthereisalimittothevolume
ofgasthateachmudgasseparatorcansafelyhandle. 272Transoceanswell
controlhandbookindicatesthatifgashasmigratedorhasbeencirculatedabove
theBOPstackbeforethewellisshutin,thechokemanifoldandmudgas
separatormaynolongerbeavailabletocontroltheflowrateswhenthegasinthe
riserreachesthesurface. 273Bothcompaniesrecommendusingthediverterlines
whenflowratesaretoohighforthemudgasseparator.

Specialprecautionsandproceduresarenecessarytoavoidtheeffectsof
therapidexpansionofgasintheriser,particularlyindeepwateroperations.
AccordingtotheTransoceanwellcontrolmanual,thereisapproximatelyfour
timesthemassofgasina15barrelinfluxin6,000feetofwaterasthereisinthe
sameinfluxin1,500feetofwater. 274Earlyrecognitionofthewarningsignalsand
rapidshutinarethekeytoeffectivewellcontrol. 275Bytakingwellcontrol
actionsquickly,thecrewcanminimizetheamountofformationfluidthatenters
thewellbore.AccordingtotheTransoceanwellcontrolmanual,therigcrewcan

271Hydrogensulfideisachemicalcompoundthatishighlyflammable.
272BPHZNMBI0000006061(pages144and145).
273BPHZNMBI0013162830(pages21and23).

274Id.(Section8,Subsection4,page22of28).

275Id.(Section3,Subsection2,page1of2).Thisisduetogasexpandingasitmovestowardsthe

surfaceandascompressivepressuredecreases.

104
calculatetheestimatedmaximumgasandfluidflowratesandwellhead
temperaturethatcouldresultfromanuncontrolledflowfromthezoneofthe
highestpressurethroughtheopenchokemanifold. 276Themaximumkick
volume(kicktolerance)shouldalsobecalculatedtoensurethatgasliberationat
reasonablekillrateswillnotoverloadthemudgasseparator.Priortothe
beginningofdrillingoperations,specificplansmustbemadeandwritten
instructionsgiventoallpersonnelconcerningnonstandardactions/procedures
tobeperformedtopreventorreacttoanywellcontrolproblems. 277

TheTransoceanwellcontrolmanualprovidedthatthechokeandkill
manifoldlowpressurevalvesmustbelineduptodirecttheflowofthewell
throughtheMudGasSeparator(MGS). 278Witnesstestimonyestablishesthat,at
approximately9:41p.m.,mudfromthewellbeganflowingontotherigfloorand
therigcrewroutedtheflowcomingfromtheriserthroughthedivertersystem
intothemudgasseparator. 279Atroughly9:45p.m.,StephenCurtis,theassistant
driller,calledEzell,theseniortoolpusher,totellhimthatthewellwasblowing
out,thatmudwasgoingintothecrown,andthatthedriller(Anderson)was
shuttingthewellin. 280

MicahSandell,acraneoperator,testifiedaboutwhathesaw:

AfterIsawthemudshootingupitwasjustseveralsecondsandthenit
justquit.Itwentdownand,atthattime,Iyelledatmyroustaboutstogo
tothefrontoftherig.Now,whethertheyheardmyradioImnotsure,
butitwasjustseveralsecondsafterthatItookadeepbreaththinking
thatOh,theygotitundercontrol.Thenallthesuddenthedegaseris
mudstartedcomingoutofthedegaser.Andthedegasersontheand
ImsureIdontknowifyallknowitsonthestarboardaftofthederrick
anditsinagooseneckanditpointsbackdowntothedeck.Anditcome
outofitsostrongandsoloudthatitjustfilledupthewholebackdeck
withagassysmokeanditwasloudenoughthatitsliketakinganair
hoseandstickingittoyourear.Thensomethingexploded.Imnotsure
whatexploded,butjustlookingatit,itwaswherethedegaserwassitting,

276Id.(Section8,Subsection5,page1of17).
277TransoceanWellControlManual,TRNUSCG_MMS00043810.
278Id.(Section4,Subsection1page4of4).

279TestimonyofMicahSandell,JointInvestigationHearing,May29,2010,at912;Young

testimonyat264.
280Ezelltestimonyat283.

105
itsabigtankanditgoesintoapipe.Imthinkingthatthetank
exploded. 281

StevenBertone,thechiefengineerontheDeepwaterHorizon,likenedthe
gasenteringtherigtoafreighttraincomingthroughmybedroom. 282The12
inchmudgasseparatoroutletventandthe6inchvacuumbreakerventwere
gooseneckedanddivertedflowbackdownwardtowardtherig,creatingagrave
riskofexplosiondirectlyabovetherig.

E. ActivityontheBridge

Atapproximately9:48p.m.,asmalljoltwasfeltonthebridgeofthe
DeepwaterHorizon,andsimultaneouslyseveralofthegasalarmswentoff. 283
Transoceansseniordynamicpositioningofficer,YancyKeplinger,wasonduty
atthetime,andhisresponsibilitiesincludedmonitoringtherigsdynamic
positioningsystemtoensurethesafetyofthevessel.Alsoondutywas
Transoceansdynamicpositioningofficer,AndreaFleytas,whoassisted
Keplinger.Twodynamicpositioningofficerswereondutyatalltimesoneon
thedeskwherethesystemis,andoneoffthedesk.Atthetimeoftheblowout,
Fleytaswasonthedesk. 284

Keplingertestifiedthathebelievedtheinitialgasalarmswerecoming
fromtheshaleshakerhouse,anareaoftherigwheredrilledsolidsareremoved
fromthemud. 285Fleytasalsotestifiedthatthegasalarmfortheshaleshaker
housewentofffirst,followedbythealarmforthedrillfloor. 286Accordingto
Fleytas,thegasalarmsilluminatedinmagenta,whichreflectsthehighestlevelof
gasconcentration.Subsequently,approximately20ormoremagentagasalarms
illuminated,indicatingthehighestamountofcombustiblegasthesensorscould
detect. 287

Keplingertestifiedthathewenttothevideomonitoronthebridge
(camera6),whichwasfocusedinthestarboardaftdirectionandsawlarge
quantitiesofmudbeingejected,butcouldnottellwhetherthemudwascoming

281Sandelltestimonyat1011.
282TestimonyofStephenBertone,JointInvestigationHearing,July19,2010,at34.
283TestimonyofAndreaFleytas,JointInvestigationHearing,October5,2010,at13.

284TestimonyofYancyKeplinger,JointInvestigationHearing,October5,2010,at128129.

285Id.at151.

286Fleytastestimonyat13.

287Id.at18,5455.

106
fromthediverteroranothersource. 288Shortlyafterwards,Fleytasreceivedacall
fromthedrillfloor,andsomeoneontherigcrewinformedherthattheyhada
wellcontrolsituation. 289Fleytastestifiedthatshereceivedaphonecallfrom
someoneintheenginecontrolroom,andsheinformedhimthattherigwasina
wellcontrolsituation. 290Aftertheinitialexplosion,thecameramonitorsshowed
flamesonthedrillfloorandanumberofadditionalgasalarmswentoff.During
thecall,Fleytasdidnotinformpersonnelintheenginecontrolroomofthegases
intheirimmediatevicinity. 291

Atapproximately10:00p.m.,thegeneralalarmandthefirealarmonthe
DeepwaterHorizonsounded.Keplingermadeanannouncementoverthepublic
addresssystem,instructingthecrewtogatheratemergencystationsandstating,
[t]hisisnotadrill. 292ThegeneralalarmontheDeepwaterHorizonwas
configuredtobeamanuallyoperatedsystem.MikeWilliams,thechief
electronicstechnicianontheDeepwaterHorizon,testifiedthatTransoceanhadset
thegasdetectorsininhibitedmodeandthatthiswasstandardpractice. 293In
theinhibitedmode,themultiplemagentagasalarmswerenotsetto
automaticallytriggerthegeneralalarmandtherefore,therewasnoalarm
configuredtoimmediatelywarnpersonnelinthepumproomoftheurgentneed
togotoemergencystations.

Fleytasactivatedthegeneralalarm,butonlyaftertheexplosionandafter
talkingtothecrewontherigfloorandtheenginecontrolroomandresponding
tothegasalarms. 294Fleytastestifiedthatshehadneverreceivedtrainingonhow
torespondtomultiplehighgasconcentrationalarmsgoingoffinmultipleareas
ontheDeepwaterHorizon. 295

F. EmergencyDisconnectSystem

Theemergencydisconnectsystemactivatestheblindshearramsonthe
BOPstackanddisconnectstheriser,allowingtherigtomoveoffofthewell.The
emergencydisconnectsystemismanuallyinitiatedbut,onceactivated,performs
thevariousdisconnectfunctionsinanautomaticsequence.

288Keplingertestimonyat150.
289Fleytastestimonyat13.
290Id.at1314.

291Id.at40.

292Keplingertestimonyat152.Thisistypicallyreferredtoasmustering.

293Williamstestimonyat3034.

294Fleytastestimony,at1314.

107

TransoceansDeepwaterHorizonemergencyresponsemanualprovides
guidanceforwhentoactivatetheemergencydisconnectsystem.TheTransocean
wellcontrolmanualoutlinesthedifferentalertlevelsthatreflectthedynamic
positioningstatusoftherig.Thegreenlevelmeansthatthedynamic
positioningsystemsisfunctioninginnormaloperations;theyellowlevel
meansthestationkeepingability(theabilitytokeeptheMODUonposition)is
deterioratingandthatpreparationstodisconnectshouldbegin;andthered
levelsignalsthatdisconnectionisnecessaryduetocontinuingdeteriorationof
stationkeepingabilities.Transoceansmanualstatesthatthereisredundant
communicationinthedrillersconsoleandonthebridgetoensurethatthedriller
andcrewonthebridgecancommunicateinthecaseofanyemergency. 296

Transoceanswellcontrolemergencyresponsemanualrequiresdrill
crewstodiscusspossibleemergencydisconnectactions.Themanualdoesnot
providetherigsmasterwithdefinedemergencydisconnectresponsibilities. 297
Thedrillingcrew,notthemaster,willtypicallybeinthebestpositiontoevaluate
possibleemergencydisconnectactionsinadrillingrelatedemergency.An
expertretainedbytheJIT,CaptainCarlSmith,testifiedthat,asamaster,he
wouldrelyontheexperienceofthepeopleonthedrillfloortodetermine
whentoinitiateemergencydisconnectactions. 298

ThePanelfoundnoevidencethattherewasanyattempttoactivatethe
blindshearramsortheemergencydisconnectsystemfromthedrillerspanel.
ChrisPleasant,theTransoceansubseaengineer,attemptedtoinitiateemergency
disconnectactionsfromthebridgeandsaid,everythinginthepaneldidlikeit
wassupposedtoatthepanelIhadnohydraulics. 299Pleasantsaidthatthe
panelwentthroughitssequenceaftertheexplosions,buttherigwasunableto
disconnecttheriserandlowermarineriserpackagefromtheBOPstack.

296TransoceanWellControlManual,TRNUSCG_MMS00043810.
297TransoceanWellControlManual,TRNUSCG_MMS00043810.
298TestimonyofCarlSmith,JointInvestigationHearing,October8,2010,at21.

299Pleasanttestimonyat123.

108
IX. ConclusionsonTemporaryAbandonment,KickDetection,
andtheEmergencyResponse

A. KickDetectionandResponseFailureCause

Atapproximately9:42p.m.,thecrewdetectedflowanddivertedthegas
influxfromthewelltothemudgasseparatorinaccordancewiththeTransocean
wellcontrolmanual.Shortlythereafter,therigcrewactivatedtheupperannular
preventersandtheuppervariableboreram,aftermudejectedfromthewellwas
alreadyontherigfloor.ThefailureoftheDeepwaterHorizoncrew(including
BP,Transocean,andSperrySunpersonnel)todetecttheinfluxof
hydrocarbonsuntilhydrocarbonswereabovetheBOPstackwasacauseofthe
wellcontrolfailure.

BPsnegativetestproceduresinstructedpersonneltomonitorthewellfor
noflowandnopressureonthekillline.Accordingtopersonnelmonitoringthe
well,thewellwasnotflowingfor30minutesandtherewasnopressureonthe
killline.Butanomaliespresentduringthenegativetests,suchasthepresenceof
drillpipepressurewhenthekilllinepressurewaszero,shouldhaveprompted
therigcrewtoinvestigatetheresultsfurther.TheDeepwaterHorizoncrews
(BPandTransocean)collectivemisinterpretationofthenegativetestswasa
causeofthewellcontrolfailure.

B. KickDetectionFailureContributingCauses

Pitvolume(flowout)dataismoreaccuratemeasureofflowthan
calculatingvolumefrompumpoutputstrokesandefficiency(flowin)andisthe
preferredmethodformeasuringflow.Duringcriticalcementtesting,thecrew
wasusingactivepitsnumber9andnumber10totransferfluidstootherpits,
whileatthesametimetransferringfluidsfromtherigtotheDamonBankston.
DuetotheactivitiesonboardtheDeepwaterHorizon,themudloggerswere
concentratingontheflowoutandflowinmeters.TheDeepwaterHorizon
crewsinabilitytoaccuratelymonitorpitlevelswhileconducting
simultaneousoperationsduringthecriticalnegativetestwasacontributing
causeofthekickdetectionfailure.

109
C. KickDetectionFailurePossibleContributingCauses

OnMarch8,2010,theDeepwaterHorizoncrewexperiencedawellcontrol
eventthatwentundetectedfor30minutes.Tenoftheelevenindividualson
dutyonMarch8duringtheundetectedkickandwellcontroleventwerealsoon
dutyduringtheApril20blowout.AccordingtoJohnGuide,Transoceanrig
managementpersonneladmittedtohimthatthoseindividualsinvolvedwiththe
March8incidenthadscrewedupbynotcatchingthekick.AlthoughBPhas
internalrequirementstoconductinvestigationsintoalldrillingincidents,BPdid
notdosofortheMarch8incident.BPsfailuretoperformanincident
investigationintotheMarch8,2010wellcontroleventanddelayedkick
detectionwasapossiblecontributingcausetotheApril20,2010kickdetection
failure.

ThePanelfoundnoevidencethat,duringcementpumping,BPshared
informationwitheithertheDeepwaterHorizonrigpersonnelorTransoceanshore
basedemployeesabouttheincreasedrisksassociatedwiththeMacondo
productioncasingcementoperations,suchas,thedecisionnottoincludea
secondcementbarrierabovethewiperplugandtheanomaliesencountered
duringcementpumping.BPsfailuretoinformthepartiesoperatingonits
behalfofallknownrisksassociatedwiththeMacondowellproductioncasing
cementjobwasapossiblecontributingcauseofthekickdetectionfailure.

BPdecidedtocombinetwolostcirculationmaterialpills,andusethis
combinedmaterialasaspacerintheMacondowell.Thepresenceofthisspacer
allowedviscousmaterialtobeacrossthechokeandkilllinesduringthenegative
testandpossiblypluggedthekillline.Ifthekilllinewasplugged,itcouldhave
ledtothepressuredifferentialbetweenthedrillpipeandkillline.BPsuseof
thelostcirculationmaterialpillsasaspacerintheMacondowelllikely
affectedthecrewsabilitytoconductanaccuratenegativetestonthekillline
andwasapossiblecontributingcauseofthekickdetectionfailure.

JohnGuide,theBPwellteamleader,believedthattheDeepwaterHorizon
crewhadbecometoocomfortablebecauseofitsgoodtrackrecordfordrilling
difficultwells.RossSkidmore,aBPcontractorontherigonApril20,testified
thatthecrewbecamecomplacentaftercompletingdrillingbecausewhenyou
gettothatpoint,everybodygoestothemindsetthatwerethrough,thisjobis
done.ThecomplacencyontheDeepwaterHorizoncouldbeattributabletothe
crewnothavingaccesstoallofthewelldata(OptiCemreports)availabletoBP
personnelonshoreandthewellsiteleadersontherig.Theoverallcomplacency

110
oftheDeepwaterHorizoncrewwasapossiblecontributingcauseofthekick
detectionfailure.

BPdrillingengineer,MarkHafle,allowedthetemporaryabandonment
operationsontheDeepwaterHorizontoproceedeventhoughhetoldDonald
Vidrine,theDeepwaterHorizonwellsiteleader,thatyoucanthavepressureon
thedrillpipeandzeropressureonthekilllineina[negative]testthatisproperly
linedup.Furthermore,Hafledidnothingtoinvestigateorresolvethepressure
differentialissueeventhoughheremainedinBPsofficeuntil10:00p.m.the
eveningofApril20andhadaccesstorealtimewelldata(whichheloggedoutof
at5:27:35p.m.).Haflesfailuretoinvestigateorresolvethenegativetest
anomaliesnotedbyVidrinewasapossiblecontributingcauseofthekick
detectionfailure.

PatrickOBryan,vicepresidentofdrillingandcompletions,andDavid
Sims,drillingandcompletionsoperationsmanager,werebothonboardthe
DeepwaterHorizonduringthenegativetestonApril20.Betweenthetwo
managers,theypossessedapproximately50yearsofdrillingexperience.Neither
VidrinenorRobertKaluzaconsultedwiththeirmanagersaboutthenegative
tests,theirinterpretation,oranyotheranomaliesthatoccurredontheeveningof
April20.Further,HaflewarnedVidrinethattheremighthavebeenaproblem
withthenegativetest.Thefailureofthewellsiteleaderstocommunicatewell
relatedissueswiththemanagersonboardtheDeepwaterHorizonwasa
possiblecontributingcauseofthekickdetectionfailure.

ThePanelidentifiedfivenegativetestproceduresthatBPdeveloped
betweenApril12andApril20.Inaddition,LeoLindnerofMISWACO
developedanegativetest,andtherigcrewperformedanegativetestthrough
thedrillpipe.Also,onApril17,GuidesentanemailtoSimsstatingthatthere
hadbeensomanylastminutechangestotheoperationthattheWSLshave
finallycometotheirwitsend.Thequoteisflyingbytheseatofourpants.
BPsfailuretoprovidecompleteandfinalnegativetestprocedurestotherigin
atimelyfashionwasapossiblecontributingcauseofthekickdetection
failure.

A15bblsinfluxin6,000feetofwatercontainsapproximatelyfourtimes
themassofgasofthesameinfluxin1,500feetofwater.Earlyrecognitionofthe
warningsignalsandrapidshutinarethereforecrucialtowellcontrolindeep
water.Takingactionquicklyminimizestheamountofformationfluidthat
entersthewellbore.Therigcrewfirstobservedthedrillpipepressureanomalies

111
atabout5:52p.m.andattemptedtobleedoffthedrillpipepressure.Afterthree
unsuccessfulattempts,thecreweventuallyjustifiedthepressureasabladder
effect.Therigcrewdidnotrealizethewellwasflowinguntilmudwas
dischargingontotherigfloor.TheDeepwaterHorizoncrewshesitancetoshut
intheBOPimmediatelywasapossiblecontributingcauseofthekick
detectionfailure.

TheMMSapprovedAPMcalledfortwonegativetests.Thiswouldallow
forthegreateropportunitytodetecthydrocarboninfluxinastagedtestsincethe
firsttestwouldhavebeentothewellheadandthesecondtestwouldhavebeen
tothedepthof8,367feet.BPsfailuretoconductthefirstofthetwonegative
testswasapossiblecontributingcauseofthekickdetectionfailure.

WhentheDeepwaterHorizoncrewresumedpumpingthereturns
overboardat9:15p.m.,theflowbypassedtheSperrySunmeterduetoits
downstreamlocationofftheflowreturntrough.Consequentlyflowoutdata
couldnotbeadequatelymonitoredbypersonnel,suchastheSperrySun
mudloggers,whowereresponsibleformonitoringthesedata.Therigcrews
decisiontobypasstheSperrySunflowmeterwhilepumpingthespacer
overboardwasapossiblecontributingcauseofthekickdetectionfailure.

Wellcontroltraininghistoricallyhasnotaddressedsituations,suchas
conductinganegativetestinthatoneisinvitingawellcontroleventtooccur.
Additionally,displacementoperationsthatputthewellinanunderbalanced
conditionshouldbecloselymonitoredthroughoutdisplacementoperations.The
failureofBPsandTransoceanswellcontroltrainingandMMSrequirements
toaddresssituations,suchasnegativetestsanddisplacementoperations,was
apossiblecontributingcauseofthewellcontrolfailure.

D. ResponseFailureContributingCauses

Therigcrewsdecisiontousethemudgasseparatorinsteadofthe
diverteracceleratedthelikelihoodthatthegasontherigwouldignite.The
decisiontousethemudgasseparatorduringthewellcontroleventwasa
contributingcauseoftheresponsefailure.

Oncemembersofthedrillcrewidentifiedtheincreaseindrillpipe
pressure,theycheckedthewellforflow.Atapproximately9:42p.m.,thecrew
detectedflowanddivertedthegastothemudgasseparator.Therigcrewwas
notabletodeterminethemagnitudeoftheflowwhenitmadethedecisiontogo

112
tothemudgasseparator.Transoceanswellcontrolmanualdidnotclearlystate
togotothediverterifthefloweventisunknown.Theambiguitywithinthe
Transoceanwellcontrolmanualonwhentousethediverterandnotthemud
gasseparatorwasacontributingcauseoftheresponsefailure.

Atapproximately9:48p.m.,severalofthegasalarmssounded.Within
minutes,approximately20gasalarmsweresounding,theresultofextremely
highlevelsofgasconcentration.YancyKeplinger,theseniordynamic
positioningofficer,wenttothevideomonitorandsawlargeamountsofmud
beingejected.Shortlyafterwards,AndreaFleytas,thedynamicpositioning
officer,gotacallfromtherigfloor,whichinformedherthattherewasawell
controlproblem.FleytastoldthePanelshereceivedaphonecallfromthe
engineroom,butshenevertoldtheengineroompersonneltoperforman
emergencyshutdown.Theinitialexplosionoccurredapproximately30seconds
toaminuteafterthefirstgasalarm.Atapproximately10:00p.m.,thegeneral
alarmandfirealarmontheDeepwaterHorizonsoundedandtherigbegantolist
tooneside.OnlythendidKeplingermakeanannouncementtomusterand
preparetoevacuate.Personnelwerenottoldtoevacuateuntilapproximately
twelveminutesafterthefirstgasalarmwentoff.Thefailureofthepersonnel
ontheDeepwaterHorizonbridgemonitoringthegasalarmstonotifythe
DeepwaterHorizoncrewintheenginecontrolroomaboutthealarmssothat
theycouldtakeactionstoshutdowntheengineswasacontributingcauseof
theresponsefailure.

E. ResponseFailurePossibleContributingCauses

Thecrewwasunawareofthevolumeofthehydrocarboninfluxassociated
withtheblowout.Therigfloorcrewsinabilitytodeterminethelocationof
thekickinrelationtotheBOPstackandthevolumeofhydrocarbonscoming
totheriginamatterofsecondswasapossiblecontributingcauseofthe
responsefailure.

ThePanelfoundnoevidencethatJasonAnderson,Transoceandriller,
whowasidentifiedintheTransoceanproceduresastheindividualwhoshould
initiatetheemergencydisconnectsystem,attemptedtodosooncethe
hydrocarbonswerepastthestack.Thereisevidencethattherigcrewactivated
theupperannularanduppervariableboreramwhenthehydrocarbonswere
pastthestack.ThereisalsoevidencethatChrisPleasant,Transoceansubsea
engineer,attemptedtoactivatetheemergencydisconnectsystemsometimeafter
theexplosionshaddisabledcommunicationswiththeBOPstack.Therigcrews

113
failuretoinitiatetheemergencydisconnectsystemuntilafterthe
hydrocarbonswerepasttheBOPstackwasapossiblecontributingcauseofthe
responsefailure.

TheDeepwaterHorizonoperatedamanuallyfunctionedgeneralalarm
system.IfthegeneralalarmoftheDeepwaterHorizonhadbeensetto
automaticallysoundwhenhighhighgasalarmssoundedinmultiple
compartmentsoftherig,personnelinthepumproomlikelycouldhavemoved
toalocationwheretheirchancesofsurvivalweregreater.Theinhibited
generalalarmsystemwasapossiblecontributingcauseoftheresponsefailure.

Transoceansseniordynamicpositioningofficeranddynamicpositioning
officerwerenottrainedfortheeventstheyfacedonthebridgeontheeveningof
April20,2010.Transoceansfailuretotrainthemarinecrewtohandleserious
blowouteventswasapossiblecontributingcauseintheDeepwaterHorizon
incident.

114
X. IgnitionSource(s)andExplosions

Twoexplosionsoccurredalmostimmediatelyaftertheblowoutwhenthe
largegasplumethathaddevelopedovertherigcameincontactwithoneor
moreignitionsourcesontherig.ThePanelconsideredthefollowingpossible
sourcesofignition:(1)mainenginesandengineswitchgearrooms;(2)mudgas
separator;(3)electricalequipmentinhazardousareas;(4)frictionandmechanical
sources;(5)nonhazardousareasources;and(6)electrostaticdischarge.

Itisnotpossibletodeterminewithcertaintythesourceofignitionbecause
muchofthephysicalevidencerelevanttomakingsuchadeterminationwaslost
withtherigorotherwiseisnotavailable.Baseduponitsreviewofwitnesses
testimonyandotherevidence,thePanelconcludedthatthemainengines(and
switchgearrooms)andthemudgasseparatorwerethemostlikelyignition
sources.

A. MainEnginesandEngineSwitchGearRooms

1. ConfigurationofEngineRoomsontheRig

TheDeepwaterHorizonhadsixengineslocatedonthethirddeckoftherig.
Eachenginewasinanengineroomthatwasequippedwithairintakesystems.
Eachairintakesystemdrewairfromventslocatedintheengineroominwhichit
sat.Eachengineroomhadanengineswitchgearroomattachedtoit.

TheDeepwaterHorizonsengineroomsandswitchgearroomswere
locatedinunclassifiedareas,whichwereareasthatdidnotrequireexplosion
proofenclosures,intrinsicallysafeequipment,and/orpurgedandpressurized
equipment.Theenginesandswitchgearsinthenonclassifiedareaswerenot
designedortestedtoensurethattheywouldnotinitiateanexplosion.

Theengineshadmultipleredundantsafetysystemsandshutdown
devicesdesignedtoshutdowntheenginesinanoverspeedsituation.Engine
overspeedisaconditionwhereanenginesrevolutionsperminute(rpms)
exceedtheirnormaloperatingspeed.Thisconditioncanoccurwhen
combustiblegasisdrawnintotheintakesystem.Topreventthis,theairintake
systemsincludedashutoffdevice(sometimesreferredtoasarigsaver)that

115
soughttoensurethattheenginewouldnotoverspeedafteringesting
combustiblegases.300

Thedesignofengineshutdownmechanismsondynamicallypositioned
rigs,suchastheDeepwaterHorizon,isdifferentfromtheshutdownsystemsin
mooredorjackuprigs. 301Insteadofthesingletoplevelshutdownofallengines,
adynamicallypositionedrigistypicallydesignedtoallowtherigtoactivatean
emergencydisconnectsystemtoseparatefromthewellheadandallowtherigto
escapethehazardousareaintheeventofanuncontrolledblowoutorother
emergency.Thisdesignalsoallowsforcontinueduseoftheenginesinan
emergencysuchasafire. 302Manualactivationoftheemergencydisconnect
system,requiredonadynamicallypositionedrig,canaddcomplexitytoarig
crewsresponsetoawellcontroleventandcanalsocreateapossibleignition
sourceduringthepresenceoffreegasontherig.

2. TestingoftheOverSpeedDevices

ArepresentativeofWartsila,themanufactureroftheDeepwaterHorizon
engines,toldthePanelthatallautomaticstopdevicesshouldbefunctiontested
atleastonceevery1,000hoursofengineoperationandthattheoverspeedtrip
devicesbecheckedevery2,000hours. 303HealsostatedthattheDeepwater
Horizonengineswerenotconfiguredtorunonnaturalgasandthatifthey
ingestednaturalgastheywouldmechanicallyfail(butnotexplode). 304

ThePanelfoundnoevidenceestablishingwhether,andhowoften,the
engineoverspeeddevicesandindividualenginecomponentsweretestedbythe
AmericanBureauofShipping(ABS).ABSconductedyearlyinspectionsofthe
overspeeddevicesduringtheircontinuousmachinerysurveys.Theseyearly
inspectionsincludedanevaluationofapproximately20%oftheoverspeed
devicesontherig,withthegoalofinspectingalldeviceswithina5yearperiod.

300KMI_PI001156RBS8D.Thedrillerwasresponsibleforshuttingintheengineairintakeonthe
DeepwaterHorizon.Thedrillersotherresponsibilitiesincluded:drillingthewellandknowingthe
drillingoperations;monitoringrealtimedataofthewell;insuringthesafetyofrigfloor
personnelworkinginaconfinedspace;investigatingwellflowissuesandrespondingtowell
controlevents;communicatingwiththeSubseaEngineer;andactivatingtheEDSifnecessary.
301Amooredrigisheldinplacebycablesattachedtogiantanchors;ajackuprigistowedonto

locationandissupportedbymechanicallegsloweredtotheseafloor.
302KMI_PI001156RBS8D.

303BOEMREinterviewofBobMiller(Wartsila)(November16,2010).Anoverspeedtripdevice

isasafetydevicethatisdesignedtorestricttheuncontrolledaccelerationoftheengine.
304Id.

116
Unfortunately,ABSinspectorsdidnotrecordwhichdevicesweretestedeach
year,whichmeantthattherewasnowaytoensurethatdifferentoverspeed
devicesweresubjecttoinspectioneachyearandthateachdeviceovertimehad
beeninspected. 305

TheDeepwaterHorizon,asdiscussedearlierinthisReport,wasavessel
flaggedundertheRepublicoftheMarshallIslands.Foreignflaggedvesselsare
subjecttoUSCGCertificateofComplianceinspections.Theseinspectionsdo
notnormallyincludetestingofoverspeeddevicesunlessthereissomeevidence
toindicatethattheymightnotfunctionproperly.OneoftheUSCGinspectors
whoconductedtheinspectionoftheDeepwaterHorizonstatedthattheengine
roomsandallmachinerycontainedthereinappearedtobewellmaintained.The
inspectordidnotdeemitnecessarytotesttherigsoverspeeddevicesbecause:
(1)asaforeignflaggedvessel,inspectionisnotrequired;and(2)conductingany
testoftheoverspeeddevicecouldnotbedonewithoutinterruptingdrilling
operations.

3. EvidenceRelatingtotheEngineRoomsasaPotentialIgnition
Source

Enginesnumber3andnumber6wereonlineatthetimeoftheblowout.
Theairintakesforengineroom3werelocatedapproximately60feetfromtherig
floorinthecenterofthemaindeck.

PersonnelontheDeepwaterHorizontestifiedaboutwhattheysawand
heardonApril20intheimmediatevicinityoftheenginerooms.Douglas
Brown,thechiefmechanicontheDeepwaterHorizon,whowasintheengine
controlroomatthetimeoftheblowout,testified:

AndrightuponthattheenginesRPMstartedincreasing.Iheard
themrevvinguphigherandhigherandhigher.NextIwas
expectingtheenginetripstotakeover,suchastheoverspeed,
andthatdidnothappen.AfterthatthepowerwentoutandI
wasassumingthatwasourhighfrequencytripandwewereput
indark,andrightontheendofthatwasthefirstexplosion.

* * *

305TestimonyofArinjitRay,JointInvestigationHearing,May26,2010,at297.

117
Imgoingtosaybothofthemrevvedupatthesametime,andwe
hadengines3and6onlineatthetime.Andinmyopinion,Im
goingtosaythatEngine3mostlikelyblewup,simplybecause
theexplosioncamefromtheportside,whichEngine3waspretty
muchlocatedrightnexttotheenginecontrolroomdownone
level.AndIreallycantsaywhichonerevvedupfirst,causeto
meitsoundedlikebothofthemdid. 306

MikeWilliams,thechiefelectronicstechnician,whowasintheelectronic
techniciansroomatthetimeoftheblowout,testified:

...Iknewwhichengineswereonlineatanygiventime.Icould
hearEngineNumber3starttorevup,anditsnormaloperating
RPMstowayabovewhatIeverhearditrunbefore,andits
continuouslysteadilyrising,andIknewthenthatwewerewe
werehavingaproblem.AsIstartedtopushbackfrommydesk,
thecomputermonitorexplodedinfrontofme.Allthelightsin
myshoppopped.Thelightbulbsthemselvesphysicallypopped.
NowIknowwereintrouble.Ireacheddowntograbmydoor,
andatthesimultaneouslyofgrabbingthehandle,theengine
goestoalevelthatishigherthanIcanevendescribeit.Its
spinningsofastthatitjustItstoppedspinningandtheresa
hugeexplosion. 307

OnceWilliamsmadeittothebridge,heexplainedtoCaptainKuchta,
masteroftheDeepwaterHorizon,[y]ouneedtounderstand.Wehavenoengine
controlroom].Itsgone.Ithasblownup.EngineNumber3forsurehasblown
up. 308

WillieStoner,amotorman,whowasintheenginecontrolroom,
testified:

Asitwasroaring,theNumber3engineyoucouldhearthe
Number3engine,whichwouldberighthere(indicating)started
revvingup.And,assoonasitstartedrevvingup,itstarteda
loaddownchangeover.Inotherwords,itssupposedtokickoff

306TestimonyofDouglasBrown,JointInvestigationHearing,May26,2010at9394,97.
307Williamstestimonyat13.
308Id.at18.

118
theline[a]nd,assoonasitdidthat,Icouldseewell,Doug
[Brown]saidSomethingaintright.And,ashesaidthat,about
thatassoonashestatedthat,heturnedandcamerightoverto
theconsolejusttolookatthescreen.And,withinsecondsofthat,
Isawroughlythree,maybefive[emergencyshutdowns]onthe
verybottomofthepanelstartflashing.Idontknowifsomebody
setthemofforifThatsemergencyshutdowns.Itssupposed
tobeactuallyfordampenersandtothateffectiftheresafireor
somethingtothateffect.Okay.Theystartedflashing,within
secondsofthattherewasabigexplosion,aloudBang,itgot
black.Theportdooronthishereside(indicating)blewin.As
soonasitblewinwithinamatterofsecondsthestarboardside
blewinassoonasyouheardthesecondexplosion. 309

PaulMeinhart,amotorman,whowasalsointheenginecontrolroom,
testified:

ThefirstexplosionIwasstandingwithmybacktotheportside
next to a door. The door on the port side of the engine control
roomgotblowin.So,Ibelievethatitcamefromtheportsideof
thevesselfromwherewewereat.

* * *

ThesecondexplosionatthattimeIhadjustmovedover,butIstill
had my back to the port side. But theres another door coming
fromthecenteroftherig.Duringthesecondexplosionthatdoor
gotblownopen. 310

The above witness testimony suggests that one or more of the explosions
occurredinthevicinityofengines3and6.

B. MudGasSeparator

AsdiscussedpreviouslyinthisReport,immediatelyfollowingthe
blowouttherigcrewdecidedtosendthehydrocarboninfluxtothemudgas

309Id.at342.
310TestimonyofPaulMeinhart,JointInvestigationHearing,May29,2010at3233.

119
separator,whichcouldhavecausedthecatastrophicfailureofthedevice. 311The
Panelfoundevidencethattheconfigurationofthemudgasseparatorsystem
directedtheventinggasbacktowardstherigfloor.A12inchdevicecalleda
mudgasseparatoroutletventwaslocatedatthetopofthederrickandwas
configuredsothatthepiperanbacktowardtherig.Thisgooseneckpiping
directedanyventinggasandfluidsbackdowntotherigfloor.Anotherdevice
calledavacuumbreakerwasconfiguredinasimilarmanner,butlocatedat
approximatelyonethirdoftheheightofthederrick.

AnumberofindividualsonboardtheDeepwaterHorizonatthetimeofthe
blowouttestifiedaboutwhattheysawinthevicinityofthemudgasseparator.

MicahSandell,acraneoperator,whowasintheportaftdeckgantry
crane,testifiedthatallthesuddenthedegasserismudstartedcomingoutof
thedegasserandit[came]outofitsostrongandsoloudthatitjustfilledup
thewholebackdeckwithagassysmokeanditwasloudenoughthatitslike
takinganairhoseandstickingittoyourear.Thensomethingexploded. 312

PaulErickson,adynamicpositioningofficer,whowasonthebridgeofthe
DamonBankston,testified:

Shortlyafter9:30,Iobservedacascadeofliquidcomingoutoftherig,the
areaofthedrillinggear.

* * *

Shortlyaftertheafter9:30,afterthe,Isawtheliquidcomingoutthe
bottomoftherig,IheardwhatIthoughtatthetimewasapressuretank
unloading.Itsnotuncommontodumptheairoutofapressuretank,but
itlastedmaybe20,30seconds,whichwasnotanunusualoccurrence,butI
mentallycategorizeditasanunloading,whichwasnotanexception.In
fact,itescapedmymindbecauseitseemedtobeoneofthefairlyroutine
thingstohappen.

311Asdiscussedintheprevioussection,themudgasseparatorisadeviceusedtoseparategas
fromdrillingfluid.Itisnotdesignedtohandlehighvolumeflow.Thepanelcalculatedthatthe
possibleinstantaneousflowratewasapproximately129.6millioncubicfeetperday
(MMCFPD)basedonfactthattheSperrySundatashoweda150bblinflux.
312Sandelltestimonyat1011.Agantrycraneisalargecranethatisonahorizontaltrackandcan

moveacrossthemaindeck.

120
* * *

Shortlyafterthat,Isawaneruptionoffluidoutoftheaftendofthe
derrickonthemaindeckoftherigandtheCaptainhadbeenontheradio
totherigtellingthemwewerebeingcoveredwithmudandtheyhad
respondedthattheywerehavingawellcontrolproblemandshortlyafter
thatweweretoldthatweoughtgetoutoftheway.

Somewhereinthatinterval,theeruptionofliquidandtheaftendofthe
rigbehindtheaftofthederrick, 313therewasaflashoffireandIhollered,
Fireontherig,fireontherig,andheadedforthegeneralalarmandafter
thatitgotprettychaotic. 314

AlwinLandry,thecaptainoftheDamonBankston,whowasalsoonthe
bridgeofthatvessel,testified:

Andhe[Erickson]advisedmethattherewasmudorsomethingcoming
outfromundertherig.IstartedtoturntolookandIseenmudfallingon
thebackhalfofmyboat,kindoflikeablackrain.AndIwasalittle
annoyedatfirstbecauseIthoughtitmighthavebeenarupturedhose
throughaprocessupthere.SowhenIseenthemagnitudeofthemud
comingdownweinstinctivelyclosedthewheelhousedoors.Iwenttothe
portsideandIlookedoutupatthederrickandthatswhenIseenthe
mudcomingoutthetopofthederrick.Icamebacktothecenterofthe
ship,establishedcontactwiththeHorizonandaskedthemwhatwas
goingon.Imgettingmudonme.Iwasadvisedthattheywashaving
troublewiththewell.Momentarilyafterthat,anothervoicecameoverthe
radioaskingmetogoto500meterstandby.IadvisedthemIstillhada
transferhoseonboard.Therewasapauseandaresponseandthen
shortlyafterthat,thefirstexplosionattherigoccurred.

* * *

Atthatpoint,myfocuswasontopthederrick.Atthatpoint,itwasmy
concernformycrew,also,becauseIknewitwascomingupaftdeckandI
couldntseerightbehindmycabinonthelowerlevels.Sosimultaneously

313Thelocationdescribedisthesameareawheretheairintakesforenginerooms3and4were
located.
314TestimonyofPaulErickson,JointInvestigationHearing,May11,2010,at22832.

121
workingradiosandItalkedtothebridge.Iinformedmyguystocome
insideawayfromthedeckarea.Somyfocuswasthereanditwasnt
nowhereelseontheriguntilIfeltandheardtheexplosionofftheport
sidethere. 315

Thesewitnessestestifiedthattheysawmudflowingandpossiblyagassy
smokeinthevicinityoftheairintakeforengineroom3andthemudgas
separatorpriortotheexplosions.Thissuggeststhatengineroom3orthemud
gasseparatorwasapossibleignitionsource.

C. OtherPossibleIgnitionSources

1. ElectricalEquipmentinHazardousAreas

Hazardousareaclassificationisbasedontheidentificationofareasor
zonesaccordingtothelikelihoodofthepresenceofsensitiveflammablegasor
vaporconcentrations.Themostlikelylocationforunguardedelectrical
equipmenttoigniteflammablegasistheareaonornearthedrillfloor.
TransoceanclassifiedthedrillfloorontheDeepwaterHorizonasaZone2
hazardousarea.Zone2denotesanareawhereexplosivegas/airmixturesarenot
likelytooccur,butiftheydooccur,theyareexpectedtobepresentforonlya
shortperiodoftime.

Electricalequipmentindesignatedhazardousareasmustbesubjecttothe
followingsafeguards:(1)explosionproofenclosures;(2)intrinsicallysafe
equipment(doesnothavesufficientenergytoigniteflammablegases);and(3)
purgedandpressurizedequipment(containedwithinenclosuressuppliedwith
freshairfromasafelocationatapressurehigherthanthepressureofthe
surroundingarea).

ThePanelfoundnoevidencethatelectricalequipmentindesignated
hazardousareaswasanignitionsource.MMSinspectorsconductedthree
inspectionswhiletheDeepwaterHorizonwasonlocationattheMacondowell,
andtheyissuednoIncidentsofNonCompliance(INCs)followinginspection
ofrigfloorelectricalequipment.Nowitnesstestimonyorotherevidence
identifiedanyfailurebyTransoceantosubjecttheelectricequipmentin
designatedhazardousareastotheappropriatesafeguards.

315TestimonyofAlwinLandry,JointInvestigationHearing,May11,2010,at99100.

122
2. FrictionandMechanicalSources

Mechanicalsparksoccurwhenthereisexcessivefrictionbetweenmetals
orextremelyhardsubstances.Asthetwosubstancesrubagainsteachother,
smallparticlesaretornfromthesurfaces. 316

Atthetimeoftheblowout,therigfloorcrewwasinvestigatingthedrill
pipepressuredifferential,anactivitynotlikelytocausefriction.ChadMurray,
chiefelectricianontheDeepwaterHorizon,wasintheelectricalshopontheport
sideofthethirddeck.Murraysawothersworkingonthenumber2mudpump
priortotheexplosion. 317Theelectricalshopisapproximately50feetawayfrom
thenumber2mudpump.Noneoftheindividualsworkingonthenumber2
mudpumpsurvivedtheexplosion.ThePanelbelievesthatitwasunlikelythat
themembersofthecrewwhowereworkingonthenumber2mudpump
continuedtoworkasthewellblewoutandgasrushedontotherig.Ifinfact,as
thePanelbelieves,theseindividualsstoppedworkimmediately,therewould
havebeennomechanicalfrictionignitionsourceinthearea.

3. OtherNonHazardousAreaSources

Ifflammablegasesdispersedbeyondthehazardousareasontherigto
otherdecklevelswithunclassifiedequipment,thenotherignitionsourceswere
possible.ThePanel,however,foundnoevidencethatthesourceofignitionwas
locatedinanyofthenonhazardousareasoftherig.

4. ElectrostaticDischarge

Electrostaticchargeorstaticelectricityoccursinmanyindustrial
operations.Staticdischargesareresponsibleformanyindustrialfiresand
explosions.Hydrocarbongasesareextremelyvulnerabletostaticdischarge
ignitionsthatmayoftenbeundetectablebyhumansightorhearing. 318ThePanel

316Forametaltospark,itmustsatisfythreeconditions.First,theenergythatcausesparticlesto
betornfreemustbesufficienttoheatthemetaltohightemperatures.Softermetalsusually
deformbeforetheyspark.Second,themetalmustbeabletooxidizeandburneasily.Generally,
ametalssparkingtemperatureisthesameasitsburningtemperature.Andthird,themetal
musthaveaspecificheatthatallowsittospark.Ametalwithalowspecificheatwillreacha
highertemperatureforthesameamountofenergyinput.
http://www.firesandexplosions.ca/hazards/ignition_sources.php.
317TestimonyofChadMurray,JointInvestigationHearing,May27,2010,at336.

318StaticElectricityGuidanceforPlantEngineers,GrahamHearn,2002.

123
couldnotruleoutelectrostaticdischargeasapossibleignitionsource,butit
foundnoevidencedirectlysupportingthistheory.

124
XI. ConclusionsonIgnitionSourceandExplosion

ThePanelconcludesthatthereweretwoplausibleignitionsourcesatthe
timeoftheblowout:(1)engineroomsnumber3and/ornumber6(andassociated
electricalswitchgearrooms);or(2)themudgasseparatorlocatedneartherig
floor.TheevidencethatsupportsthePanelsconclusionisdiscussedbelow.

A. IgnitionSources

Themostprobableignitionsourcewasengineroomnumber3and/or
number6.Theconclusionissupportedby:(1)witnesstestimony;(2)thelocation
oftheairintakesintotheenginerooms;(3)engineandelectricalswitchgear
roomsthatwereunclassifiedareaswithnumerouspotentialignitionsourcesthat
couldinitiateanexplosion;(4)asadynamicallypositionedrig,theDeepwater
Horizonmaynothavebeendesignedtoimmediatelyshutdownwhenhigh
levelsofgasaredetected;(5)thePanelfoundnoevidencethattheoverspeed
devicesproperlyfunctionedandfoundevidencethatsuchdevicesmaynothave
beeninspected.

AsmentionedpreviouslyinthisReport,thehydrocarboninfluxquickly
overwhelmedthemudgasseparator.Witnesstestimonysupportsthefactthat
therewasaflashexplosionneartheairintakeofengineroomnumber3andthe
mudgasseparatorshortlyafterthegascameontotherig.Thecatastrophic
failureofthemudgasseparatorcreatedapossibleignitionsourcewiththegas
plumereleasedontotherigfromthewell.

B. ContributingCausesoftheExplosion

Theairintakeforengineroomnumber3islocatedinthecenterofthe
deckjustaftoftherigfloor,whiletheairintakeoftheengineroomnumber6is
outboardonthestarboardsideoftherigaftoftherigfloor.ThePanelconcluded
thatthedelayedexplosionbetweenenginesnumber3andnumber6wasdueto
thedifferenceinthedistancebetweentheairintakesandthegasflow.The
locationoftheairintakesfortheengineroomnumber3andnumber6wasa
contributingcauseoftheDeepwaterHorizonexplosion.

ThePanelfoundnoevidencethattherigsaverfunctionoftheover
speeddevicessuccessfullyshutdownengines3and6.Thefailureoftheover

125
speeddevicestoinitiateshutdownoftheengineswasacontributingcauseof
theDeepwaterHorizonexplosion.

Thegooseneckconfigurationofthemudgasseparatorventallowedfor
theventingofhydrocarbonsbackontotherig.Thisincreasedtheriskofignition.
Thelocationanddesignofthemudgasseparatoroutletventswasa
contributingcauseoftheDeepwaterHorizonexplosion.

Priortothetwoexplosions,approximately20gasalarmswentoff
indicatingthehighestlevelofgasconcentrationontherig.AndreaFleytas,the
dynamicpositioningofficer,testifiedthatshereceivedaphonecallfromthe
engineroom,butsheneverinformedthemtoinitiatetheemergencyshutdown
sequenceorthattherewasawellcontrolevent.Fleytasfailuretoinstructthe
DeepwaterHorizonengineroomcrewtoinitiatetheemergencyshutdown
sequenceafterreceiving20gasalarmsindicatingthehighestlevelofgas
concentrationwasacontributingcauseintheDeepwaterHorizonexplosion.

C. PossibleContributingCausesoftheExplosion

Neithertheengineroomnortheswitchgearroomwasaclassifiedarea.
Therefore,theequipmentwasnotrequiredtobeexplosionprooforintrinsically
safe.Noristherearequirementthattheareabepurgedorpressurized.The
classificationofengineroomsnumber3andnumber6asnonclassifiedareas
wasapossiblecontributingcauseoftheDeepwaterHorizonexplosion.

TheDeepwaterHorizonhadmultipleinspectionsandsurveysduringthe
tenyearperioditwasoperatingintheGulfofMexico.ThePanelfoundno
evidencethatanyoneidentifiedthelocationoftheengineairintakesasa
potentialsafetyissue.Thefailuretoidentifytherisksassociatedwithlocating
theairintakeofengineroomnumber3incloseproximity(approximately60
feet)tothedrillfloorwasapossiblecontributingcauseoftheDeepwater
Horizonexplosion.

ThegassensorsintheenginecompartmentroomsoftheDeepwater
Horizondidnotautomaticallyshutdowntheengineswhentherewerehigh
levelsofgaspresentontherig.Theabsenceofemergencyshutdowndevices
thatcouldbeautomaticallytriggeredinresponsetohighgaslevelsontherig
wasapossiblecontributingcauseoftheDeepwaterHorizonexplosion.

126
TheDeepwaterHorizonhadmultipleinspectionsandsurveysthatshould
haveincludedtheinspectionoftheengineoverspeedshutdowndevices.The
panelhasbeenunabletoascertainexactlywheneachoverspeeddevicewas
tested.Accordingly,ABSindicatedthatitinspects20%eachyear;however,
neitherABSnorTransoceandocumentwhichdevicesaretestedtoensurethat
thesamedeviceisnottestedeachyearandthatalldevicesgettestedwithinthe
rotationfrequency.ThefailureofABSandTransoceantodocumentwhich
devicesaretestedtoensurealldevicesaretestedisapossiblecontributing
causeoftheDWHexplosion.

TheemergencyshutdownresponseonaDPMODUutilizesadifferent
operatingphilosophythanemployedonmooredMODUs.Insteadofthesingle
toplevelshutdownofallengines,theDPMODUrigisdesignedwithan
emergencydisconnectcapabilityfromthewellheadinordertoescapethe
hazardousareaintheeventofanuncontrolledblowout.Basedonthismindset,
theenginesshouldnotbeshutdownbecauseoftheneedforDPpower.Evenif
theprocessofmanualactivationisfullyunderstoodbythoseresponsibleforit
onaDPMODU,itaddsadditionalcomplexitytoresponseofthewellcontrol
event.Further,thephilosophycreatesaconflictsincetherigneedstomaintain
powertogetofflocationwhilemaintainingthatpowercreatesapossibleignition
sourceduringthepresenceoffreegasontherig.TheDPMODUoperating
philosophywhenconsideringtheperformanceofanEmergencyShutdown
(ESD)isapossiblecontributingcauseintheDeepwaterHorizonexplosion.

D. OtherPossibleIgnitionSources

1. ElectricalEquipmentinHazardousAreas

Themostlikelylocationfortheignitionofflammablegasbyunguarded
electricalequipmentwouldbeintheareaonornearthedrillfloor.The
DeepwaterHorizondrillfloorrequiredtheuseofproperlymaintainedand
certifiedexplosionproof,intrinsicallysafe,orpurgedandpressurized
equipment,whichshouldhavepreventedtheignitionofflammablegasesbyany
electricalequipmentinstalledinthisarea.ThePanelfoundnoevidencethatthe
electricalequipmentlocatedonornearthedrillfloorshazardousareawasa
causeoftheignition.

127
2. MechanicalSources

Formechanicalsparksresultingfromfrictiontohaveoccurred,theremust
bemovementofequipment.Atthetimeoftheblowoutnorigflooroperations
werebeingconductedoutsideoftheinvestigationintothedrillpipepressure
differential.ThePanelfoundnoevidencethatthemechanicalequipmenton
therigfloorwasacauseoftheignition.

3. OtherNonHazardousAreaSources

Iftheflammablegasclouddispersedbeyondthehazardousareasonthe
rigtootherdecklocationswithunclassifiedequipment,thenthoseignition
sourcescouldhavesparkedanexplosion.Anyunclassifiedequipment,suchas
anelectricaloutlet,wouldnotresultinignitionunlessasparkwasavailable.
Additionally,theelectricalequipmentlocatedontheweatherdeck(topdeck)is
typicallysealedagainsttheexposureoftheoffshoreenvironment.ThePanel
foundnoevidencedthatnonhazardousareasourceswerethecauseofthe
explosion.

4. ElectrostaticDischarge

Electrostaticchargeorstaticelectricityoccursinmanyindustrial
operations.Staticdischargesareresponsibleformanyindustrialfiresand
explosionscausedbystaticelectricity.Hydrocarbongasesareextremely
vulnerabletostaticdischargeignitionsthatmayoftenbeundetectablebyhuman
sightorhearing.TherePanelfoundnoevidenceofelectrostaticdischarge,but
itcannotberuledoutasapossiblesourceofignitionintheexplosion.

128
XII. TheDeepwaterHorizonBOPStack

ABOPstackisaseriesoframsandannularssituatedatthetopofawell
thattherigcrewcancloseifitlosescontrolofformationfluids.BOPscomeina
varietyofconfigurations,sizesandpressureratings.SomeBOPcomponentsare
designedtosealanopenwellbore,somearedesignedtosealaroundtubular
componentsinthewell,somearefittedwithhardenedsteelshearingsurfacesto
cutthroughdrillpipeorcasing,andothersaredesignedtocutthroughdrillpipe
andsealthewellbore.

A. DesignandConfiguration

CameronmanufacturedtheBOPstackusedduringdrillingoperationsby
theDeepwaterHorizon.CameronoriginallysoldtheBOPtoR&BFalcon,which,
asdiscussedpreviously,wasacquiredbyTransocean. 319Camerondeliveredthe
finalassembledBOPstack,whichweighedapproximately650,000pounds,to
R&BFalconinApril2000. 320

R&BFalconprovidedCameronwithspecificationsforrequiredfunctions
andthepreferredconfigurationofthedesiredBOPstack. 321DavidMcWhorter,
Cameronvicepresidentofengineeringandquality,testifiedthatCameron
assembledthestackaccordingtoR&BFalconsdesignspecificationsandin
compliancewithAPIspecifications. 322McWhorterindicatedthatCameron
designedandtesteditsequipmentinaccordancewithAPISpecification16A.
CamerondoesnotsubjectitsBOPstodynamicflowtesting,norissuchtesting
requiredinAPISpecification16A. 323

TheDeepwaterHorizonBOPassemblyconsistedoftwomajorsections:the
stackandthelowermarineriserpackage(seeFigure10).Atthetimeofthe
blowout,themajorcomponentsoftheDeepwaterHorizonmainstackconsistedof
thefollowing:

Wellheadconnector,whichconnectedtheBOPstacktotheMacondo

319In1999,whenitmanufacturedtheBOP,CameronwastheCameronDivisionoftheCooper
CameronCorporation.
320CAMCG00002843;TRNUSCGMMS00014355.

321CameronCommunicationtoJIT.

322TestimonyofDavidMcWhorter,JointInvestigationHearing,April8,2011,at112,117.

323McWhortertestimonyat153.DynamicflowtestingistestingoftheBOPstackunder

conditionsthatsimulatepressuresthatmightbegeneratedbyablowout.

129
wellhead.
Twovariableborerams(VBRs)designedtosealaroundseveral
differentsizesofdrillpipebutdonotshearorotherwiseaffectthedrill
pipe.
Testram(convertedVBR),whichisaninvertedVBRthatisdesigned
toonlyholdpressurefromthetopdown. 324
Casingsheardesignedtocutthroughdrillstringorcasing.It
consistedofacuttingelementonly,andwasnotdesignedtoseal.
Blindshearram(sometimesreferredtoasBSR)consistingofbotha
cuttingandsealingelementanddesignedtocutthedrillpipeandseal
thewell.
Chokeandkilllines,whicharehighpressurepipesthatledfroman
outletontheBOPstacktotherigpumps. 325Typically,thechokedoes
notconnecttotherigpumps,however,theDeepwaterHorizonBOP
couldusethechokeandkilllinesinterchangeably.
Remotelyoperatedvehicle(ROV)panelsoperatingpanelsthat
allowanROVloweredtotheseafloortoactivatecertainfunctionon
theBOPstack. 326
Accumulatorbottles,whichprovidedhydraulicfluidusedtooperate
thevariousBOPelements.

Atthetimeoftheblowout,themajorcomponentsofthelowermarine
riserpackageconsistedofthefollowing:

Twoannulars(upperandlower),whicharerubbermetalcomposite
elementscapableofclosingaroundthedrillpipetosealtheannulus.
Blueandyellowpods,tworedundantcontrolpodsusedtooperatethe
BOPcomponents.
Multiplexconnector,thepointatwhichthemultiplexlinesconnectto
theBOPstack.
ROVhotstabpanels,whichareoperatingpanelsthatallowanROV
loweredtotheseafloortoactivatecertainfunctionontheBOPstack.
Accumulatorbottles,whichprovidedhydraulicfluidusedtooperate
thevariousBOPelements.

324BPHZNMBI000136647;BPDeepwaterHorizonAccidentInvestigationReport,172.
325Duringwellcontroloperations,rigcrewspumpkillfluidthroughthedrillstringandannular
fluidisremovedfromthewellusingthechokeline.
326TohotstabistoinsertanROVsroboticarmintoahydraulicportontheBOPstacktopump

hydraulicfluidintotheBOPramclosingsystem.

130

FlexJoint

Upper Annular
Prevente r

Lower Annular
Prevente r
Kill Side

Choke Side
Blind Shear Ra m
Kill Valve

Casing She ar Ram

Upper Variable
Bore Ram

Choke Valves
Middle Variable
Bore Ram

Lower V ar iable
Bore Ram

Kill Valve

P ort Side

Figure10SchematicoftheDeepwaterHorizonBOPStack

Thetablebelowidentifiestheinstallationdatesofthefollowing
DeepwaterHorizonstackcomponents: 327

327 TRNUSCG_MMS00097144.

131
Component DateInstalled
LowerPipeRam August2000 328
MiddlePipeRams August2000
UpperPipeRams August2000
Shearing/BlindRams April2007
CasingShearRams September2009
LowerAnnular OverhauledOctober2007
UpperAnnular OverhauledOctober2007
UpperKillFailsafeValve October2007
LowerKillFailsafeValve December2006
UpperChokeFailsafe June2005
Valve
LowerChokeFailsafe January2006
Valve
BleedKillFailsafe August2009
MudBoostValve June2004
LMRPConnector January2005
WellheadConnector OverhauledOctober2009
Cameron
Figure11BOPComponentInstallmentDates

B. ControlandPowerSystems

TheDeepwaterHorizonhadamultiplexcontrolsystemthatusedboth
subseaandsurfaceequipmenttooperatetheBOPstack.Thecontrolsystemwas
designedtooperateandmonitortheclosingmechanismsintheBOPstack.The
systemusedbothhydraulicandelectricalpowertocontroldifferentelements.

ThehydraulicpowerunitlocatedontheDeepwaterHorizonprovidedthe
hydraulicpowerfluidthatcouldoperatethedifferentfunctionsontheBOPstack
andtheLMRP.Accumulatorbottlesbothonthesurfaceandsubseaprovided
hydraulicpowertothesystem.Thehydraulicpowerunitandtheaccumulators
hadsufficientfluidcapacitiestobeabletooperatethevariousBOPstack
functions. 329

328Aspreviouslynoted,thiswassubsequentlyconvertedtoatestram.
329CAMCG00000236.ThesevolumeswereconsistentwithAPIspecifications.

132
ThemicroprocessorbasedcontrolsystemontheDeepwaterHorizonBOP
stackreceivedACpowerfromanuninterruptablepowersupplyunit,whichwas
designedtokeepsurfaceandsubseaequipmentoperationalunderallconditions.
AllprimaryfunctionsoftheBOPstackwerecontrolledthroughthemultiplex
cables,whichconnectedtherigtotheBOPstack.Asaresult,thelossofthe
multiplexcableswouldresultinlossofpowerandlossofcontrolofthese
functions.ToensureoperationalredundancyandACpowersupply,the
uninterruptablepowersupplyunitincludedabatterysystemabletoprovide
powertothepanels,divertercontrols,eventloggerandpodsforatleasttwo
hoursofnormaloperation. 330

Cameronoffersanoptionforarigtohavetheabilitytomonitoreach
podsbatteryvoltagesfromanycontrolpanel.TheDeepwaterHorizondidnot
havethisadditionalCamerontechnology,whichwouldhaveenabledtherig
crewtomonitorbatteryvoltages.

C. EmergencyDisconnectSystem

Theemergencydisconnectsystemisasystemthatcanallowtherigto
separatefromtheBOP.Thissystemcanbeactivatedfromthreedifferent
locations:(1)thedrillerscontrolpanel;(2)thebridge;or(3)thesubseaengineer
controlroom.TheBOPhadtwoemergencydisconnectsystemssequencing
options,referredtoasEDS1andEDS2.Bothemergencydisconnectsystem
optionsweredesignedtoclosetheBSRs,closethechokeandkillvalves,and
unlatchtheLMRPConnector,alongwithchokeandkillconnectors.EDS2,
however,wouldalsoactivatethecasingshearram. 331Thestepbystep
sequencesfortheDeepwaterHorizonsemergencydisconnectsystemarein
AppendixH.

Thehydraulicpowertoperformtheemergencydisconnectsystem
sequencecameprimarilyfromtheconduit. 332Uponactivation,however,two
functionsthehighpressureclosingoftheBSRandofthecasingshearram
wouldreceivetheirhydraulicpowerfromtheBOPstackmountedaccumulators.

330Id.
331BPHZNMBI00010443.
332Id.Theconduitinturnreceiveditssupplyfromthehydraulicpowerunitfromthesurface.

Thisunithadatleasttwotriplexpumpstosupplythepressuretotheaccumulatorbankthrough
theconduit.

133
Themultiplexumbilicalcablesprovidedtheelectricalpowerand
communicationtothepods.Theelectricalpoweroriginatedfrompowerand
communicationcabinetslocatedonthesurface.Thecabinethasadedicated
uninterruptablepowersupplythatprovidedelectricalpowertosubseasystems
foraminimumoftwohoursifmainpowerfromtherigwasinterruptedor
removed.Therewerecontrolpanelsontherigthatwouldallowtherigcrewto
sendemergencydisconnectcommandstothesubseaequipment.Thecommands
weretransferredtotheBOPstackthroughcontrolpodsthatwereconnectedto
therigbymultiplexumbilicalcables. 333

D. AutomaticModeFunction(Deadman)

Theautomaticmodefunction(AMF)ordeadmansystemisdesigned
toclosetheBSRintheeventthattheLMRPsuffersthelossofelectricalpower,
thelossoffiberopticcommunicationwiththerig,andthelossofhydraulic
pressurefromtherig.TheaccumulatorbottleslocatedonthelowerBOPstack
providedthehydraulicpowerfortheAMF. 334ThestepbystepAMFsequence
fortheDeepwaterHorizonisinAppendixH.

TheAMFreliedupontworedundantcontrolpodsabluepodanda
yellowpod.Undernormaloperations,thepodswerepoweredthroughAC
cablesfromthesurface.Intheeventofalossofpowerfromthesurface,the
powersupplyforeachofthecontrolpodswasmaintainedthroughbatteries
locatedinthesubseaelectronicsmodule(SEM)inthemultiplexsectionofeach
pod.ThepodswerelocatedonoppositesidesoftheLMRP.Eachfunctioned
independentlyandeachhaditsownpowersupplyandbatteries.Eachpod
includedsolenoidvalves,whichweredevicesthatopenedandclosedin
responsetoelectricalsignals.Thesolenoidsweredesignedtocommunicatewith
theBOPelementsandtriggerthedeliveryof4,000psiclosingpressuretothe
BSRsthroughthededicatedaccumulatorbottleslocatedonthelowerBOPstack.

E. AutoshearFunction

TheautoshearfunctionisdesignedtoclosetheBSRintheeventofan
unplanneddisconnectoftheLMRPfromthelowerBOPstack.Apoppetvalve

Id.
333

Id.TheAMFisusuallydesignedforeventssuchastheriserparting.Iftheriserpartsatthe
334

lowerflexjointorsomeotherpartoftherisersystem,theAMFsequenceisdesignedtoactivate
tosealthewell.

134
waslocatedbetweentheLMRPandthelowerBOPthatwouldfireintheevent
theLMRPwasraisedaccidentally.Thisenabled4,000psiclosingpressuretobe
appliedtotheBSRthroughthededicatedaccumulatorbottleslocatedonthe
lowerBOPstack.Thiswouldsealthewellboreinspiteofthelossofconduit
supplypressurefromthesurface.

F. ForensicExaminationoftheBOP

1. RetrievalandTransportoftheBOPtoMichoud

AftertheuncontrolledflowofhydrocarbonsfromtheMacondowellwas
stopped,ateamdirectedbytheUnifiedAreaCommandandtheJITworkedto
retrievetheDeepwaterHorizonBOPstackfromtheseafloor,usingtheQ4000
vessel.TheteamsuccessfullyretrievedtheBOPstackonSeptember4,2010.

TheJITtookanumberofstepsimmediatelyfollowingtheBOPsretrieval
designedtopreservetheconditionoftheBOPstack.Thegoalofthese
preservationmeasureswastodisplaceseawaterandBOPstackfluidswithinthe
BOPcontrolsystem,thehydraulicoperatingsystem,andthestackcavitiesto
minimizecorrosionoftheBOPstackuponexposuretotheatmosphere.Todo
this,itwasnecessarytofunctionanumberoftheBOPstackcomponents;
however,threesectionsofdrillpipewerediscoveredinsidetheBOPstack.The
sectionsofthedrillpipewereremovedandpreservedforfurtheranalysis.The
JITmodifiedthepreservationprocedurestopreventdisturbanceofthe
additionaldrillpipefoundinsidetheBOPstack,andimmediatelytookstepsfor
wellborepreservationstepsinpreparationfortransporttoshore.

Afterthepreservationstepswerecompleted,abargetransferredtheBOP
stacktotheNationalAeronauticsandSpaceAdministration(NASA)Michoud
AssemblyFacilityinNewOrleans.TheMichoudfacilityisasecurefederalsite
wheretheexaminationcouldbeconducted.Sitepreparationactivitiesincluded
constructingatestpadcapableofsupportingtheapproximately325tonBOP
stack,deploymentofenvironmentalcontainmentequipment,andconstructionof
atemporarystructuretohousetheBOPstack.

2. ScopeoftheForensicExamination

TheJITretainedDetNorskeVeritas(DNV)toprepareaforensictesting
plan,toconducttheforensicexamination,andprepareareportcontaining
detailedfindingsbasedontheforensicexaminationoftheBOPstack.The

135
objectivesoftheforensicexaminationweretodeterminehowtheBOPstack
performedduringtheblowout,identifyanyfailuresthatmayhaveoccurred,
determinethesequenceofeventsleadingtoanypotentialfailuresoftheBOP
stack,andevaluatetheeffects,ifany,ofaseriesofmodificationstotheBOPstack
thatBPandTransoceanofficialshadimplementedbeforetheblowout.

Theexaminationwasdesignedtoevaluate:(1)whetherleaksontheBOP
stackwerefactorsintheBOPstacksperformanceduringtheblowoutand
duringtheROVinterventionefforts;(2)whetheranymodificationsmadetothe
controllogicandstackadverselyaffectedtheBOPstacksperformance;and(3)
whetheranyotherrelevantfactor,includingmanufacturingdefects,deferralof
necessaryrepairsaffectingfunctionality,andmaintenancehistoryaffectedthe
BOPsabilitytooperateasintended.

Theforensicexaminationsoughttorecreatethepreblowoutconditionsof
theBOPstack.Twomethodswereusedtoachievethis:(1)workingbackwards
fromthecurrentconditionoftheBOPstackthroughalloftheinterventions;and
(2)comparingtheasreceivedconditionoftheBOPstackwithdrawingsand
recordsreflectingthestateoftheBOPstackpriortoApril20,2010.

DNVsinvestigativeprocesswasaniterativeprocessthatintegratedthe
BOPstackfunctiontesting,thecollectionofevidence,preservationofevidence
(especiallythedrillpipecontainedinthewellboresoftheBOPandLMRP),
examinationofmaterials,damageassessmentandvideoandphoto
documentation.

3. TheForensicExaminationTechnicalWorkingGroup

Duringinterventionoperations,thecompaniesfamiliarwiththeDeepwater
HorizonBOPstackidentifiedmanymodificationsmadetothestacksinceits
originaldeliverybyCameron.Asaresult,technicalconsultationwith
TransoceanandCameronwascriticalforboththeeffectivenessofexamination
andforthesafetyoftheexaminers.Recognizingthis,atechnicalworkinggroup
(TWG)wasestablishedtoprovideDNVwithtechnicalsupportandexpertise
asDNVconducteditsforensicexamination.TheTWGincludedoneexpertand
onealternativeeachfromCameron,TransoceanandBP;anexpertworkingfor
theUnitedStatesDepartmentofJustice;twoexpertsrepresentingtheplaintiffsin

136
themultidistrictlitigation;andanexpertnominatedbytheChemicalSafety
Board. 335

ThemembersoftheTWGprovidedDNVwithinputandsuggestionsfor
testingprotocolsandothertechnicalsupport.DNVhelddailymorningmeetings
withtheTWGtodiscusseachdaysplannedforensictestingactivities.Through
participationinmorningmeetingsandobservationofDNVswork,TWG
memberswereabletomonitoralldaytodayforensictestingactivities.

G. ExaminationMethodsUsedbyDNV

1. ForensicTestingPlan

AttherequestoftheJIT,DNVdevelopedandsubmittedforJITapproval
aforensictestingplan.Theplanincludedforensictestingproceduresforthe
BOPstackanditscomponentsinaccordancewithestablishedandaccepted
protocols,methods,andtechniques. 336DNVsforensictestingplanwasalso
submittedtotheTWGandthepartiesininterest(PIIs)forreviewand
comment.Whereappropriate,DNVreviseditstestplanstoaddresscomments
received.TheJITapprovedDNVsrevisedforensictestingplanonOctober27,
2010. 337

2. BOPStackTesting

AftertheBOPstackarrivedattheMichoudtestingsite,DNVvisually
inspectedthestackandrecordedallvisiblenumbersincludingserialnumbers.
DNVexaminedinternalcomponentsusingacameraandvideoborescope.DNV
thencompletedthefollowingtasks:(1)determinationofthefinalpositionofthe
annularpreventersandrams;(2)examinationoftheconditionoftheBOPand
theLMRP;(3)removalofthedrillpipefromtheBOPandtheLMRP;(4)removal

335TheU.S.ChemicalSafetyBoard(CSB)isanindependentfederalagencychargedwith
investigatingindustrialchemicalaccidents.
336Theprotocolsincludedprofessionalvideorecordingoftheentireexaminationandcomplete

photographicdocumentation.
337TheprotocolsinDNVsforensictestingplanwerenotmeanttobeastepbystepsetof

procedures.Aswithmanyforensicexaminations,thetestplanprovidedaroadmapformeeting
theobjectives,butneededtobeadaptedasthetestingprogressed.DNVsubmittedadditional
protocolsthatwereoutsideofthescopeoutlinedintheoriginaltestingplantoTWGforreview
andcommentandtotheJITforapproval.

137
oftheramblocks;and(5)functiontestingofcriticalfunctionsandcircuitsthat
wereinvolvedintheattemptstocontrolthewellduringthefirsttwodays
followingtheblowout. 338

3. MaterialsEvaluationandDamageAssessment

AnothercriticalpartofDNVsforensicworkwasmaterialsevaluationand
damageassessment.Materialsevaluationincluded:(1)cleaningandexamining
theBOPrams;(2)cleaningandexaminingdrillpipesegmentsremovedfromthe
BOPstackandtheriser;(3)cleaningandexaminingcomponentsextracted
duringtheremovaloftherams;and(4)collectingandcleaningallsolidobjects
foundwithinthedifferentramcavities.

DNVassessedthedamagetotheBOPstackinthreedifferentways:(1)
visualinspectionandphotodocumentation;(2)dimensionalmeasurements;and
(3)threedimensionallaserscanning.Inaddition,DNVusedstructuralanalysis
andmodelingtosimulatedrillpipebehaviorinthewellbore. 339

4. ROVInterventionOperationsReview

DNVreviewedvideofootageandstillphotographstakenfromanumber
ofdifferentROVsthatwereusedduringattemptstostopthewellflow.This
reviewallowedDNVtoassesstheconditionoftheBOPstackwhenitwasstill
submergedandtotrytodeterminetheoriginofleaksintheBOPshydraulic
circuitry.ThisreviewalsoallowedDNVtoassesstheimpactofvariousROV
interventionsontheconditionoftheBOPstack. 340

H. DNVsForensicExaminationFindings

DNVsforensicexaminationfoundthat,astheBSRwasclosed,thedrill
pipewaspositionedsuchthattheoutsidecorneroftheupperBSRblade
contactedthedrillpipeslightlyoffcenterofthedrillpipecrosssection.A
portionofthepipecrosssectionwasoutsideoftheintendedBSRshearing
surfacesandwouldnothaveshearedasintended.AstheBSRclosed,aportion
ofthedrillpipecrosssectionbecametrappedbetweentheramblockfaces,
preventingtheblocksfromfullyclosingandsealing.

338DNVReport,Vol.1,at2324.
339Id.at23.
340Id.at24.

138

DNVsforensicexaminationfoundthatthemainfailureoftheDeepwater
HorizonBOPstackwascausedbyaportionofthedrillpipebeingtrapped
outsideoftheblindshearramcuttingsurfaces,whichpreventedtheblindshear
ramsfromfullyclosingandsealing.DNVwasabletoreconstructthesegments
ofrecoveredpipethroughanalysisofthesegmentsofpipeandtooljointsthat
werelocatedthroughouttheBOPandriser,includinganalysisofwearpatterns,
drillpipedimensions,damageanddeformationmarkings,shearedendsof
recovereddrillpipe,andphysicaldifferencesbetweenthetworecoveredjointsof
drillpipe.DNValsodeterminedthatatooljointhadbeenlocatedintheupper
annularwhileflowwaspresent.DNValsonotedtheasreceivedconditionof
manyBOPstackcomponents,i.e.,blueandyellowpodbatteryvoltagesand
variousrampositions.DNVsreportisincludedatAppendixD.

1. SequenceofEventsRelatedtotheBlindShearRams

Therearetwopossiblescenariosforhowtheblindshearramswere
activatedandclosed:(1)theautoshearcircuitwasactivatedonApril22,by
cuttingthepoppetvalvebetweentheLMRPandlowerBOPstack;or(2)the
automaticmodefunctionhadbeenactivatedbylossofthemultiplexand
hydrauliclinesonApril20.InitsreportspreparedforBOEMRE,DNVpresented
findingswithrespecttobothofthesescenarios.However,DNVconcludedthat
themostlikelyscenariofortheactivationoftheblindshearramwasfromthe
autoshearcircuit. 341

BythetimetheBSRwasactivatedandclosed,thedrillpipewas
positionedoutsideoftheBSRbladesurfaces.AstheBSRclosed,thisportionof
thedrillpipebecametrappedbetweentheramblockfacesandpreventedthem
fromfullyclosingandsealing.Thisresultedina2.8inchgapbetweenthe
blocks,asestimatedbyaDNVmodel.

DNVconcludedthat,atthetimeoftheblowout,therewasadrillpipetool
jointlocatedbetweentheclosedupperannularandtheclosedupperVBR,which
thePanelconcludedwereproperlyspacedout.ThePanelbelievesthattherig
crewmanuallyclosedtheupperVBRbecausetheupperVBRcannotberemotely
activatedfromthehotstabpanel.Duringthepostblowoutwellintervention

Initsreport,DNVstatedthatitcouldnotruleoutthepossibilitythattheBSRswereclosed
341

throughactivationoftheAMFcircuits.

139
operation,oncethepodshadbeenpulledandrerun,only2.3gallonsof
hydraulicfluidwerepumpedtoclosetheupperVBR.Thiswouldhavebeenan
insufficientamountoffluidtoclosetheVBRhaditbeeninanopenstate.
Furthermore,DNVfoundnocutupperVBRhydraulichosesduring
intervention.TheVBRwasalsofoundtobeintheclosedpositionatMichoud.

DNVfoundthatmultipleforcesacteduponthedrillpipeduringthe
blowout,resultingintheelasticbucklingofthedrillpipe.Elasticbucklingcan
occurwhenastructuralelementlosesstabilitywhenforceisapplied.Oncethe
forcecausingthebucklingisremoved,theobjectrevertstoitsoriginalform.

ThePaneldeterminedthateitherofthefollowingscenarios,orsome
combinationofthem,ledtotheelasticbucklingofthedrillpipeatthetimethe
blindshearramactivated,whichcontributedtothefailureoftheblindshearram
tocutthedrillpipeandsealthewell:

Theforcesfromtheblowoutactingonthedrillpipepushedthetooljoint
into(orfurtherinto)theupperannularelement.Thedrillpipewasthen
unabletomoveupwardattheupperannularbutwasabletomove
upwardattheupperVBR;and/or

Thedrawworks(theequipmentontherigthatsupportsthedrillpipethat
isloweredintotheriser)collapsedshortlyaftertheexplosions,thus
allowingapproximately150,000lbsofunsupporteddrillpipetoactasa
downwardforceagainsttheupperVBR. 342

Regardlessoftheconditionsthatledtotheelasticbuckling,DNV
concludedthat,baseduponthephysicalevidenceofthedrillpipe,wellbore,and
theBSRblocks,thedrillpipebecametrappedbetweentheBSRfaces,which
preventedtheBSRfromfullyclosing. 343SeeFigure12below.DNVfoundthat
theseconditionslikelyoccurredfromthemomentthewellbeganflowingand
wouldhaveremaineduntileithertheendconditionschanged(changeinUpper
AnnularorUpperVBRstate)orthedeflecteddrillpipewasphysicallyaltered
(sheared). 344

342TestimonyofDaunWinslow,JointInvestigationHearing,August23,2010,at452.
343
AddendumtoFinalReportforUnitedStatesDepartmentoftheInteriorBureauofOcean
EnergyManagement,RegulationandEnforcementForensicExaminationoftheDeepwater
HorizonBlowoutPreventer(April30,2011)(AddendumtoDNVReport)at11.
344DNVReport,Vol.1at4.

140

Figure12Offcenterdrillpipe(Source:DNV)

2. ActivationoftheCasingShearRams

Duringinterventionefforts,onApril29,thedrillpipewasshearedusing
thecasingshearram(CSR). 345DNVfoundthattheshearingofthedrillpipe
changedtheflowpatternwithinthewellbore.AttheBSR,theflowhadbeen
throughthepartiallysheareddrillpipe;thenewpathallowedflowuptheentire
wellbore,startingattheCSRthroughthe2.8inchgapalongtheentirelengthof
theblockfaces.

3. AutomaticModeFunction

DNVconcludedthatitcouldnotruleoutthepossibilitythattheBSRwas
closedthroughactivationoftheautomaticmodefunctioncircuits. 346DNVfound
thattherewasevidencethatconditionsnecessaryforAMF/Deadman(lossof
power,communicationandhydraulicpressure)existedimmediatelyfollowing
theexplosion/lossofrigpowerandpriortoROVintervention. 347DNVstated
thatitsfunctiontestingdemonstratedthattheAMFcircuitswithinbothpods
activatedwhenthelossconditionsweresimulated.Functiontestingontheblue

345DNVReport,Vol.1at5.
346Id.
347Id.at169.ModificationstotheBOPstackareincludedinatimelineatAppendixFoftheDNV

Report,Vol.2(AppendixDofthisReport).

141
podshowedthat,initsasreceivedcondition,the27voltbatteriesontheblue
poddidnothaveenoughpowertocompletetheAMFsequence. 348

Functiontestingoftheyellowpodyieldedinconsistentresultsduetoone
ofthesolenoids(solenoid103Y). 349Asolenoidvalve,inresponsetoanelectrical
signal,opensorclosesahydrauliccircuittofunctionBOPstackcomponents.
ThisfunctioningallowshydraulicfluidtoclosetheBSR.

I. EvaluationofOtherPossibleFailures

DuringtheROVinterventions,therewerereportsofleaksinvarious
hydrauliccircuits.DNVfoundthattheevidenceindicatesthereportedleaksin
thehydrauliccircuitswerenotacontributortotheBlindShearRamsbeing
unabletoclosecompletelyandsealthewell. 350

DNVreviewedvariousmodificationsmadetothecontrollogicortothe
BOPstackpriortotheblowout.DNVfoundthatthereisnoevidencethese
modificationswereafactorintheabilityoftheBlindShearRamsbeingableto
closefullyandsealthewell. 351

DNVtestedtheperformanceofsolenoid103Ythatwasremovedfromthe
yellowpodandobtainedinconsistentresults.DNVobservedthat,whenboth
coilswithinthesolenoidwereactivated(whichiswhatshouldhappenifthe
solenoidwasactivatedbytheAMFcircuits),thesolenoidfunctionedproperly.
Butwhenonlyoneofthecoilswasactivated,thesolenoidfailedtofunction
properly.DNVpositedtwotheoriesforwhythisoccurred.First,thesolenoid
wasremovedinMay2010butwasnottesteduntilMarch2011.DNVfoundthat
itwaspossiblethatseawaterdepositsorhydraulicfluidbuildupwasthecause
oftheinconsistentresults.Second,itwaspossiblethatthesolenoidhada
manufacturingdefect.DNVstatedthatitdidnotidentifyanyotherissuesor
evidencethatmanufacturingdefectsofoneformoranothercontributedtothe
BlindShearRamsnotclosingcompletelyandsealingthewell. 352

348However,thePanelfoundthatthiswasnotconclusivebecausethebluepodmayhave
performedtheAMFsequencesometimeafterthelossofwellcontrol,whichmayhavecausedits
asreceivedcondition.
349DNVReport,Vo1.1,at17172.

350Id.at171.

351Id.at172

352Id.

142
DNVstatedthatitstestsofthebluepodinitsasreceivedcondition
demonstratedthatthe27VoltbatteryintheBluePodhadinsufficientchargeto
activatethesolenoid103B.DNVnotedthattherewerenorecordsshowingthat
thebatteriesintheAMFsystemweretestedduringafactoryacceptancetestin
June2009. 353DNVfurthernotedthattestsforthe27voltbatteryconductedin
July2010(whentheBOPwasretrieved)reportedthebatteryleveltobeoutof
specification. 354

TheDeepwaterHorizoncrewdidnothavetheabilitytomonitorthesubsea
electronicmodule(SEM)batterypowersupply,althoughthePanelisawareof
technologythatexiststhatwouldallowTransoceantoperformthismonitoring.
IfthecrewhadbeenabletomonitortheSEMpowersupply,theycouldhave
knowntherealtimeconditionoftheAMFbatteries.

TwoothertheoriesregardingthefailureoftheBOPstackwereadvanced
duringJIThearings.ThefirstisthatthehydraulicsystemsthatpoweredtheBSR
didnothaveenoughpowertocausetheblindshearramstofullycloseandseal.
ACameronrepresentativestated:

Thereisapossibilitythattheshearramcouldhavebeenfunctionednot
throughthehighpressurecircuitbutthroughthemanifoldpressure,
whichwouldbe1,500PSI,anditspossiblethatifthathappened,we
wouldnthavenearenoughhydraulicforcepressureyoucouldnot
generateenoughforcewiththatpressuretocutthepipe.Infact,itsvery
likelythatthepipewouldonlybedentedandnotshearalltheway
through,exposingtheramtotheflowsthatweallhaveheardabout.Its
alsopossiblethatforwhateverreasonthehydraulicsystemwasntupto
thegamethatdayanddidnthavesufficientpressuretocloseit.Itis
possiblethatthesolenoidvalve,whichwhentestedbyDNVinMichoud,
operatedintermittently,sometimesitwouldntoperateatallandother
timesitwouldoperateforahandfulofseconds.Anditispossiblethatif
thedeadmanfiredandthesolenoidvalvedidexactlywhatitdidat
Michoud,thattheramcouldhavepartiallydeployedandnotgoneallthe
wayacross. 355

353Id.
354Id.at170.
355McWhortertestimonyat14445.

143
DNVdiscountedthistheoryforanumberofreasons.First,underthis
theory,someoneonthebridgewouldhavehadtoactivatetheBSRnormalclose
functionfromthetoolpusherscontrolpanelorthedrillerscontrolpanel.DNV
concludedthatnowitnesstestimonysupportedthis.Second,DNVpointedto
thetestimonyofChrisPleasant,theTransoceansubseaengineer,whotestified
thattheBSRwasinanopenstatewhenhearrivedatthebridgeat
approximately9:56p.m.Thiswasfurtherevidencethatnoonehadactivatedthe
closefunction.

Thesecondtheoryadvancedwasreferredtoasthedoubleclutch
theory,whichpositedthatthesolenoidoftheROVsuppliedjustenough
pressuretothehydraulicportontheBOPtocausetheBSRtogoonlypartially
intothewellbore. 356TheCameronrepresentativedescribedthisasfollows:

Also,therewereatleastahandfulofcasesduringthecourseofthe
interventioninwhichtheshearramsweredoubleclutched.Inother
words,pressurewasappliedtotheBOPandthenitwasrelieved.Itwas
appliedandrelieved.Therewereatleastahandfuloftimesinwhichthat
happened... 357

DNVconcludedthat[t]heoverallcontributionofthisdoubleclutching
phenomenoncannotinDNVsopinionbeofsignificancecomparedtothe
contributionofthetrappedpipebetweentheramblocks. 358

J. StudiesEvaluatingtheReliabilityofBOPs

Withinthelastdecade,MMS,throughitsTechnologyAssessmentand
ResearchProgram(TA&R),fundedorcofundedvariousstudiesregardingthe
reliabilityofBOPsystemsindeepwaterapplications,shearramcapabilities,and
theevaluationofsecondaryinterventionmethodsinwellcontrol. 359Someof
thesestudiespointedoutdeficienciesinBOPsystemsandmadesuggestionsto
changeMMSregulationsand/orindustrystandards.

356TheROVhasaroboticarmthatfitsintoahydraulicportontheBOPstacktopumphydraulic
fluidintotheBOPtoclosetheramblocks.
357McWhortertestimonyat145.

358AddendumtotheDNVReport,at10.

359TheTA&RProgramsupportsresearchassociatedwithoperationalsafety,pollutionprevention

andoilspillresponseandcleanupactivities.

144
Ofparticularnotewerethe2004WestEngineeringServicesstudiesReview
ofShearRamCapabilitiesandEvaluationofShearRamCapabilities(TARstudies455
and463). 360Themaingoalofthesestudieswastoanswerthefollowingquestion:
canarigsBOPequipmentshearthepipetobeusedinagivendrillingprogram,
atthemostdemandingconditiontobeexpected,and,ifso,atwhatpressure?
Beforeansweringthisquestion,oneofthestudiesnotedthat[s]hearramsmay
beadrillingoperationslastlineofdefenseforsafetyandenvironmental
protection.Inarrivingatseveralconclusionsandrecommendations,thereport
describedafailurerateof7.5%wheretheramstestedfailedtoshearpipewhile
workinginamaximumclosingforcepressureof3,000poundspersquareinch.

Ina2003WestEngineeringServicesstudyfundedbyMMS,thestudy
acknowledgedthatshearramblockswerenotdesignedtocloseandsealunder
highrateconditionsifclosurerateswereslow.ThestudyalsonotedthatAPI
Specification16Adidnotrequiretestingforramsunderdynamicflowing
conditions.TheMMSregulatoryresponsewastorequireoperatorstosubmit
documentationshowingthattheshearramsthattheyusedintheirBOPwere
capableofshearingpipeintheholeundermaximumanticipatedsurface
pressures.





ThisstudyfollowedanMMSfundedresearchprojectin2003(TARstudynumber431)that
360

evaluatedsecondaryinterventionmethodsinwellcontrol.Thegoaloftheresearchwasto
evaluatethecapabilitiesofthesecondaryBOPinterventionsystemsinplaceatthetimeofstudy,
andidentifythebestpracticesinuseandnotyetinuse.Theobjectivesofthestudywereto
compareandcontrastthecapabilitiesofavailablesecondaryinterventiontechnologies;review
andcontrastexistingsecondaryinterventionsystemsinplaceondeepwaterdrillingrigs;discuss
possibleenhancementstoexistingsystems,theirbenefits,andtheircosts;andrecommendthe
bestpracticesforoperationsinlessthanandgreaterthan3,500waterdepth.Forariginthe
dynamicallypositioned(DP)modeoperationwithamultiplexBOPcontrolsystem,likethe
DeepwaterHorizon,thestudyrecommendedthefollowingsecondarysystems:anemergency
disconnectsystem,adeadmansystemtosupplementtheEDSsystem,theadditionofan
autoshearcircuittoarigthathadanAMFsystem,andanROV.TheDeepwaterHorizonwas
equippedwithanemergencydisconnectsystem,adeadmansystem,anautoshearsystem,
andROVinterventioncapabilities.

145
K. MaintenanceoftheDeepwaterHorizonBOP

ThefollowingsectionsprovidedetailsaboutTransoceansmaintenanceof
theDeepwaterHorizonBOPstackandtheBOPstacksconditionatthetimeofthe
blowout.

1. TransoceanMaintenancePlans

TransoceanbegantouseamaintenancetrackingsystemcalledRMSII
shortlyafteritsmergerwithGlobalSantaFein2007.TheRMSIIsystemis
designedtoautomaticallyflagcomponentsinneedofscheduledmaintenance,to
orderparts,andtocreateworkorders.

TransoceanseniorsubseaengineerMarkHaydescribedtheRMSIIsystem
asapreventativemaintenancesystemusedtotelltherigpersonnelwhich
piecesofequipmentweredueformaintenance.Transoceanusedthis
maintenancetrackingsystemtodeterminethedifferenttypesofworkthat
neededtobedoneontheDeepwaterHorizonBOPstack. 361Transoceanhad
procedurestotrackmaintenanceonBOPcomponentswithintheirRMSII
system;however,theCompanydidnoteffectivelytrackmaintenanceworkon
eachspecificcomponent.

ThepreventativemaintenanceordersgeneratedfromwithintheRMSII
systemaredevelopedusingitemssuchasoriginalequipmentmanufacturer
(OEM)recommendationsforreplacingequipmentbasedonlifetimeservice
hours,loadsandpressures,routinerigmovemaintenanceworklists,the
365/1095/1825daypreventativemaintenanceworklists,aswellasthesubsea
maintenancephilosophy.

2. TransoceanSubseaMaintenancePhilosophy

TransoceanreliedonadocumententitledTransoceanRecommended
Practices,SubseaMaintenancePhilosophythatcontainedthecompanys
maintenancephilosophyforsubseaequipment. 362Inthedocument,
Transoceanprovidedguidanceforsubseaplannedmaintenancetasksandfor
planningformaintenancetobecompletedwhiletheBOPstackwasbeingmoved

TestimonyofMarkHay,JointInvestigationHearing,August25,2010,at237.
361

TransoceanRecommendedPractices,SubseaMaintenancePhilosophy,May2007,HQSOPS
362

RP400001.

146
fromonewelltoanother.Thedocumentalsosetsforthrequireddocumentation
includingmaintenancerecords,pre/postdeploymentsignoff,andcomponent
conditionevaluation.Thedocumentalsocoveredtheactualmaintenance,
overhaulandtestingofthesubseaequipment.Section8ofthedocument
requiredfullfunctiontestingoftheequipmentpriortodeployment.

Transoceanrequiredtwoformstobecompletedandstoredelectronically:
apredeploymentsignoffsheetandacomponentconditionevaluationform.
TransoceanprovidedthePanelwiththreepredeploymentsignoffsheets.
However,Transoceanwasunabletoproducecopiesofthecomponentcondition
evaluationformsorsimilardocuments.363MichaelFry,aTransoceanequipment
manager,testifiedaboutwhythecomponentconditionevaluationformwasnot
utilized:

Whenthesubseamaintenancephilosophywasoriginallycreated,the
thoughtprocessbehindthisformwastoestablishmeantimebetween
failuresanddocumentingproblemsthatwewerehavingwithequipment
thatwehadfailureswith.Thisdocumentwasntreallyutilized,because
whatweendedupdoingwasthemajor[originalequipment
manufacturers]haveforms,likediscrepancyforms,thatwhenyousendin
apieceofequipmentCameron,forexample,useswhatscalledanFPR
form,Ibelieveitsfieldperformancereport,

Wefeltlateronitwasbesttojusthavetheequipmentsentbacktothe
OEMandletthemdoaformalinvestigationofanyfailuresandtohave
themsubmittheinspectionreportsbacktous. 364

AlthoughFrytestifiedthatTransoceanreliesuponthesereportstomake
changestotheirmaintenanceandshouldhavereadyaccesstothem,thePanel
foundthatthecomponentconditiondocumentationfortheDeepwaterHorizon
waskeptontherig,andTransoceandidnotappeartoelectronicallystorethe
reportselsewhere.365

Section10ofthemaintenancephilosophydocumentfurtherexplained
thatallsubseaequipmentwassubjecttoanapproved1,825daytestand
inspection/surveyand,fortheGulfofMexico,the1,825dayoverhaulwas

363TRNUSCG_MMS00097219.
364TestimonyofMichaelFry,JointInvestigationHearing,April6,2011,at4950
365Id.at50.

147
dependentonthefindingsofthemajorsurvey.DuringJIThearings,Frywas
askedabouttheconfusionsurroundingtheverificationofthe1,825daymajor
overhaulstartdateandhowthePanelcoulddeterminewhentheDeepwater
HorizonsBOPstackcomponentswereinstalled.Fryresponded:

Ramblocks,recertificationoframblocksImean,aramblockthatgets
inspectedgetsinspectedfordamage.Itgetsahardnesscheck.Itgetsa
nondestructivetestinginspectiondoneonit.Iftheresnodamagetoit,
again,theresnorequirementforamandatoryrecertificationofit.
Normally,tokindofexpandonyourquestion,thestartdateisfromthe
dateoftheCOC. 366

Acertificateofconformityorcertificateofcompliance(COC)was
issuedbytheOEM.ThePanelcouldnotlocateanyCameronCOCfortheVBR
bonnetssincetheinstallationdatein2000.Transoceanalsosubmitted
documentationstatingtheVBRramblockshadnotbeencompletelyoverhauled
sinceinstallationin2000. 367

ThePanelalsoneverreceiveddocumentationontherequired1,825day
inspection,whichshouldhavebeendonein2005fortheVBRbonnets.
AccordingtoTransoceanssubseaitemsscheduledtobeworkedonduringthe
2011shipyardvisit,theywerescheduledtoreplaceorrebuildall6bonnetson
piperams. 368

3. ConditionBasedMonitoringandMaintenance

Intestimony,TransoceanpersonnelarticulatedanapproachtoBOPstack
maintenancethattheyreferredtoasconditionbasedmonitoringorcondition
basedmaintenance.Transoceansubseasuperintendant,WilliamStringfellow,
describedthisapproachasfollows:

Again,weuseconditionbasedmonitoring,andwelookat[API]RP53as
arecommendedpractice.Usingourconditionbasedmonitoringand
testingofoursystems,wecandeterminewhatkindofconditionthose
BOPsareactuallyin.Andwehavehistorytobackthisupthrough
weveactuallypulledBOPsdownwithinthistimeframeandtherenotbe

366Frytestimonyat46.
367TRNUSCG_MMS00097144.
368TRNUSCG_MMS00096390.

148
anythingwrongwiththem.Youputnewsealsinthem,youputthem
backtogether,andtheyregoodtogo.

Andwedeterminedthatbyperformingconditionbasedmonitoring,and
inseeinganychanges,whetheritbethroughreactiontimesorpressure,
thatwecandeterminewhetherthisisworthyforworkorwhetherwe
needtobelookingatreplacingthispieceofequipment. 369

Stringfellowfurtherexplained:

Totakesomeofthisequipmentanddisassembleitandinspectitandthen
putitbackintoserviceyouhavetolookatmaintenancehistory,and
thatssomethingthatIthinkthat,youknow,thatyourenotawareof,of
thethingsthatweveseeninthepasttobuildthisconditionbased
monitoring,whichweputalotoftimeandeffortintoforthisequipment.

Bydoingthis,wefeelthatwecutriskoftakingwevehadbrandnew
piecesofequipmentgointoserviceandfail.Itscalledinfantmortality. 370
Andandandwecangetoffintothisandintomuchdeepertalkyou
know,discussions.But,again,whatweseerighthereinthewaythat
weredoingthis,wefeelthatwehaveapieceofequipmentdownthere
thatwilldowhatitsdesignedtodo. 371

MostofthemaintenancedonebyTransoceanasaresultofcondition
basedmonitoringoccurswhenadrillingrigmovesfromonelocationto
another. 372Thisminimizesrigdowntimeandthecostsassociatedwith
performingthemaintenance.Stringfellowtestified:

TakingBOPbodiescompletelyapart,andsay,checkingthesealingareas
ofringgaskets.Wefoundthatbydisassemblingtheseareas,todoan
inspectiononthemandthenputthembacktogether,wehavemoreissues
withthemthanafterwedisassemblethemthanwedobefore.Imean,we
neverhadaproblem.

369TestimonyofWilliamStringfellow,JointInvestigationHearing,August25,2010at35859.
370Onewitnessdescribedtheinfantmortalityconceptthatequipmentcanfailsoonerfrom
performingtoomuchmaintenance,disassembly,andoverhaulofequipment.FryTestimonyat
69.
371Stringfellowtestimonyat37576.

372Haytestimonyat255.

149
* * *
So,Imean,youretalkingaboutpullingtherigoutofserviceandand,
thereagain,thepracticalityofdoingthisandwhatyougainbydoingthis
isweighedout. 373

MarkHay,Transoceansubseasuperintendent,testifiedthatitwaswell
knownamongthetoplinesupervisorsontheDeepwaterHorizonthattheBOP
stackwasoutsideofitsthreetofiveyearmajorinspectionrequirement,and
insteadTransoceanwasrelyinguponitsconditionbasedmaintenance. 374

4. Planned2011ShipyardMaintenance

TransoceanplannedtobringtheDeepwaterHorizoninformaintenanceata
shipyardinearly2011.Theplannedmaintenanceincluded:(1)replaceorrebuild
all6bonnetsonpiperams;(2)replaceboth28inchsupershearrambonnets;(3)
replaceCameronhighcapacityriserconnector;(4)completelyreplacelower
annularwithrebuiltannular;(5)replaceallcontrolhosesonBOP;(6)replace
diverter;(7)replacediverterflexjoint;(8)blastandpaintbothstackandLMRP
frames;(9)changeoutallanodes;(10)rebuildallshuttlevalves;and(11)replace
orrebuildriserspiderandgamble. 375

5. DeferringMaintenanceontheBOPStack

ThePanelfoundthat,lessthanaweekbeforetheblowout,BPinformed
Transoceanthatitwantedtodefermaintenancetotheupperandlowerannulars
(partsoftheBOPstack)andagreedtoacceptliabilityifthelowerannularfailed
priortotheperformanceofmaintenancework.

BrettCocalesemailedJohnGuideonApril15todiscussStuffforPaul
[Johnson,rigmanager].CocalesinformedGuidethatPaul[Johnson]neededa
coupleofthingsfromusfortheupcomingendofwellworklist.Thefirstitem

373Stringfellowtestimonyat379.
374Haytestimonyat20506.Transoceanwasusingconditionedbasedmaintenanceapproach
notwithstandingthefactthat,in2006,MMSciteditsextendeduseoftheBOPwithout
inspection/maintenanceasacontributingcauseofa2006pollutionevent.MMSrecommended
thatAnnularBOPmaintenanceshouldbeconductedperTransoceanScheduleandcriteriato
reducewellboreseal,wear,anddamage.MMSfoundthatTransoceanhadrecommendeda
maintenanceschedule,butthecrewhadfailedtofollowit.See
http://www.goboemre.gov/homepg/offshore/safety/acc_repo/2006/060212.pdf.
375TRNUSCG_MMS00096390.

150
stated,Heneedsanemailfromyouthatstateswedontwanttochangethe
annularsbeforetheNileandwillacceptthatliabilityifbothfailduringNileand
wehavetopulltheBOP.Weallagreethisisalowriskofhaving2failures.This
iscomingfromhisuppermanagementthattheyjustwantedourconfirmation
withanemail. 376

Onthesameevening,justminutesafterreceivingtheemailfromCocales,
GuidesentPaulJohnsonanemailsayingheconcurredwithnotchangingthe
annularelementspriortostartingtheNilewell.Theemailstated,B[P]accepts
responsibilityifbothannularsweretofailandthestackhadtobepulledto
repairthem. 377WhilethePaneldidnotfindthatafailureoftheannulars
contributedtothefailureoftheBOPstacktosealthewell,itdidfindthatGuide
decidedtoacceptliabilityonbehalfofBPforanyannularfailureswith
apparentlylittleornoanalysisoftheconditionsoftheequipment.

6. EffectsoftheBOPMaintenanceRecordonPerformance

ThePanelfoundthattheTransoceanssubseamaintenanceplanswere
generallyinaccordancewithCameronsmaintenancerequirements. 378Asnoted
previouslyinthisReport,thePanelfoundnoevidencethatTransoceanhad
submittedthevariableboreramstoamajorinspection(asdefinedinAPIRP53)
anytimesinceinstallationin2000.

ThePaneldidnotfindanyevidenceofanactualdeficiencyin
TransoceansmaintenanceoftheBOPstackthatplayedaroleinthefailureofthe
BSRtoshearthedrillpipeandsealthewell.

L. BOPSystemLeaks

BOPsystemsmaydevelophydraulicfluidleaksintheirvarious
components.PartofregularBOPstackmaintenanceistoidentifyandassessthe
seriousnessofleakstohosesandvalves.WhileTransoceanassertsthatthere
werenoleaksontheDeepwaterHorizonBOPstackwhenitwasdeployedatthe

376BPHZNMBI00254566.
377BPHZNMBI00254591.
378CameronSpecialProceduresidentifiedinEB902D,CAMCG00003345.

151
Macondowell,rigpersonnelidentifiedthreeleaksonthestackpriortothe
blowout. 379

Thefirstleakwasaverysmallleakonthecontrolhosefortheupper
annularsurgebottlethatresultedfromaloosefitting. 380Theleakwasdiscovered
abouttwoweeksaftertheDeepwaterHorizonsBOPstackwaspositionedonthe
Macondowell. 381Thesecondleakwasinthelowerannular;thecrewnever
determinedwherefluidwascomingfrombutthroughtestingruledouta
numberofcomponentsrelatedtotheannular. 382Thethirdleakwasinthelower
testramarisingfromtheoneofthesolenoidsontheyellowpod. 383Thecrew
functionandpressuretestedtheBOPstackaftertheseleakswerediscoveredand
thosetestsweresuccessful. 384

MarkHayexplainedTransoceansprocessforassessingleaks.Whena
leakisdiscovered,hesaidthatyouwouldtalktothemaintenancesupervisor
andOIMandthenyouwoulddoariskassessmentontherig,andthentherig
teamwouldmakeadecision,andyouwouldgivefieldsupportacallwithyour
findings,yourleakratesandallthat,andtheywoulddetermineifitisdeemed
necessarytopullandmakerepairs. 385

BPnotedtheleakonthelowertestraminitsinternaldailyoperations
reportfromFebruary23untilMarch13. 386Despiteidentifyingthisleak,BPdid
nottakestepstoensurethatTransoceanreportedthatleakintheIADCdrilling
report. 387Transoceandidnotrecordtheleakontheupperannularcontrolhose
ontheIADCdrillingreport. 388BPsJohnGuidedidnotbelievetheleakonthe

379Haytestimonyat242;Pleasanttestimonyat113.Inaddition,responsepersonnelidentified
BOPsystemleaksduringeffortstoshutthewellin.Itisnotknownwhetherthoseleaks
developedpostblowoutorexistedbeforetheblowoutandwerenotidentifiedbythecrew.
380Haytestimonyat193194.

381Id.at244.

382Id.at193,195.

383Id.at193194,196.

384Id.at249.

385Id.at243.

386BPsDailyOperationsReports,02/23/1003/13/2010.

387Id.

388Id.

152
lowertestramneededtobereportedtoMMSbecausetheleakdidnotaffectthe
functionofthestack. 389

Theleaksidentifieddidnotimpedetheclosingabilityoftheannularor
rampreventers.TheseleaksdidrequiretheplacementoftheBOPcontrolsinto
theblock/neutral/ventpositioninordertostoporslowthehydraulicleak.The
PanelconcludedthattheseleaksdidnotimpedethefunctionalityoftheBOP
stack.

M. ROVInterventions

NumerousattemptsweremadetoshutinthewellusingROVsafterthe
rigwasevacuated.OnApril21,BPinitiallyattemptedtoactivatethemiddle
piperam;however,personnelexperiencedproblemswithinsufficientROV
pumpvolumesandhotstabtools.

OnApril22,BPusedanROVtotrytoactivatetheautoshearfunction,
whichwouldhaveclosedtheBSR.TheROVwasunabletosufficientlycutthe
poppetvalvetoactivatetheautoshear. 390ThenextROVattempt,onApril22,to
closetheBSRbyhotstabbingwasnotsuccessfuleither. 391Thisattemptwas
hamperedbythefactthattheBOPstackhadbeenmodifiedtoconvertavariable
boreramintoatestramatBPsrequest. 392Theresponseteamwasnotawareof
thisuntilearlyMayandthusmademultipleeffortstohotstabthetestramunder
thebeliefthattheywerehotstabbingapiperam. 393

AgainonApril22,BPsuccessfullycutthepoppetvalvefortheautoshear.
ThisisthescenariothatthePanelandDNVReportconcludelikelyclosedthe
BSR,butfailedtosealthewell.FromApril25throughMay5,BPtried17
additionalROVinterventionstoclosevariousBOPramsandannularpreventers.
EventhoughBPwasabletooperatemanyoftheBOPcomponents,noneofthe
attemptswassuccessfulinshuttinginthewell.

389Guidetestimony,July22,2010at229.However,oneoftheBPwellsiteleadersontherig,
RonaldSepulvado,testifiedthathebelievedtheleakshouldhavebeenrecordedintheIADC
Report.Sepulvadotestimonyat2627.
390DNVReport,Volume1at135.

391Id.Tohotstabistoinsertahydraulicpump,bymeansofanROVsroboticarm,intoa

hydraulicportontheBOPstacktopumphydraulicfluidintotheBOPramclosingsystem.
392BPHZNMBI00136647;BP,DeepwaterHorizonAccidentInvestigationReportat172.

393TestimonyofHarryThierens,JointInvestigationHearing,August25,2010at103105.

153
FromtheoutsetofROVinterventions,Transoceancouldnotproducethe
redline(asbuilt)drawingstoknowhowtheBOPcomponentsworkedandwere
configured.Throughouttheintervention,drawingshadtobeupdatedin
accordancewithwhatwasobservedfromROVfootage.Accordingto
Transocean,theykepttheredlinedrawingsontheDeepwaterHorizonandthe
documentswentdownwiththerig.

154
XIII. BOPStackConclusions

ThePanelconcludedthatonApril20,2010,theDeepwaterHorizoncrew
closedtheupperannularontheBOPstackat9:43p.m.aspartofitsinitialefforts
tocontrolthewell.At9:47p.m.,thecrewclosedtheuppervariableboreramsas
partoftheircontinuingeffortstocontrolthewell.Whenthewellblewout,there
wasadrillpipetooljointlocatedbetweentheclosedupperannularandthe
closeduppervariableborerams.

A. CauseoftheBOPStackFailure

ThePanelconcludedthattherearetwopossiblescenariosforwhenthe
BSRwasactivated.First,theBSRcouldhavebeenactivatedbytheAMFwhile
thepipewasplacedincompressionbytheupperannularpreventerimmediately
followinglossofcommunicationwiththerig.Second,theBSRcouldhavebeen
activatedbytheautoshearonApril22,whilethepipewasplacedincompression
bytheweightofthedrillpipeandupwardforcesofthewell.Undereither
scenario,theBSRfailedtoshearthedrillpipeandsealthewellborebecausethe
pipewasplacedincompressionoutsideofthecuttingsurfaceoftheBSRblades.
ThePanelconcludedthatfailureoftheBOPtoshearthedrillpipeandsealthe
wellborewascausedbythephysicallocationofthedrillpipeneartheinside
wallofthewellbore,whichwasoutsidetheBSRcuttingsurfaceduring
activationonApril20orApril22.

B. BOPStackFailureContributingCauses

TheBSRcouldnotfullycloseandsealbecauseaportionofthedrillpipe
becametrappedbetweentheBSRblockfaces.Theelasticbucklingofthedrill
pipeforcedthedrillpipetothesideofthewellboreandoutsideoftheBSR
cuttingsurface,andwasacontributingcauseoftheBOPfailure.

C. BOPStackFailurePossibleContributingCauses

Approximately28feetofdrillpipebetweentheupperannularandthe
uppervariableboreramelasticallybuckledwithinthewellbore,causingthat
portionofthedrillpipetobeoffcenter.Eitherofthefollowingscenariosor
somecombinationthereof,ledtoelasticbucklingofthispipeinthislocation:

155
Scenario1:Flowfromthewellforcedthesectionofdrillpipe
locatedbetweentheclosedVBRandtheclosedupperannularup
intotheclosedupperannulartoapointwhereatooljointstopped
againsttheclosedupperannular.Wellboreconditionsproduced
enoughforcetocausethepipetoelasticallybuckleinthisarea.

Scenario2:Flowfromthewellandweightoftheunsupported5,000
feetof65/8inchdiameterdrillpipeabovetheclosedVBRforced
thesectionofdrillpipelocatedbetweentheupperVBRandthe
upperannularintoanelasticallybuckledstate.

Theforcesdescribedabove,whichledtotheelasticbucklingofthedrillpipe,
constitutedapossiblecontributingcauseoftheBOPfailure.

156
XIV. RegulatoryFindings

Thissectionaddressesregulatoryrequirementsthatwereineffecton
April20,2010. 394

UndertheOuterContinentalShelfLandsAct(OCSLA),theSecretaryof
theInteriorisauthorizedtomanageandregulatetheleasing,exploration,
development,andproductionofresourcesontheOuterContinentalShelf
(OCS).TheSecretaryhasdelegatedthisauthoritytoBOEMRE(MMSatthe
timeoftheMacondoblowout).395

OCSLAprovidesthatleaseorpermitholdershaveanaffirmativedutyto:

(1)maintainallplacesofemploymentwithintheleaseareaorwithinthe
areacoveredbysuchpermitincompliancewithoccupationalsafetyand
healthstandardsand,inaddition,freefromrecognizedhazardsto
employeesoftheleaseholderorpermitholderorofanycontractoror
subcontractoroperatingwithinsuchleaseareaorwithintheareacovered
bysuchpermitontheOCS;

(2)maintainalloperationswithinsuchleaseareaorwithinthearea
coveredbysuchpermitincompliancewithregulationsintendedto
protectpersons,propertyandtheenvironmentontheOCS;and

(3)allowpromptaccess,atthesiteofanyoperationsubjecttosafety
regulations,toanyinspector,andtoprovidesuchdocumentsandrecords

394SinceApril20,2010,BOEMREhasimplementedanumberofregulatoryreformsaimedat
improvingdrillingandworkplacesafety.OnSeptember30,2010,BOEMREimplementedthe
InterimFinalRule(sometimesreferredtoastheDrillingSafetyRule)andtheWorkplaceSafety
Rule(sometimesreferredtoastheSEMSRuleforSafetyandEnvironmentalManagement
Systems).TheInterimFinalRulecreatednewstandardsforwelldesign;casingandcementing;
andwellcontrolproceduresandequipment,includingblowoutpreventers.TheWorkplace
SafetyRulerequiredoperatorstosystematicallyidentifyandaddressrisksinordertoreducethe
humanandorganizationalerrorsthatlieattheheartofmanyaccidentsandoilspills.Effective
November11,2011,operatorsintheU.S.willberequiredtohaveacomprehensiveSEMS
programthatidentifiesthepotentialhazardsandriskreductionstrategiesforallphasesof
activity,fromwelldesignandconstruction,tooperationandmaintenance,andfinallytothe
decommissioningofplatforms.
395EffectiveOctober1,2011,BOEMREwillbereorganizedintotwobureaustheBureauof

OceanEnergyManagementandtheBureauofSafetyandEnvironmentalEnforcement.

157
whicharepertinenttooccupationalorpublichealth,safetyor
environmentalprotection,asmayberequested. 396

UndertheregulationsapplicableatthetimeoftheMacondoblowout,
operatorswerethepersonsthelessee(s)designatedashavingcontrolor
managementofoperationsontheleasedareaoraportionthereof.Anoperator
couldbealessee,theMMSapproveddesignatedagentofthelessee(s),orthe
holderofoperatingrightsunderanMMSapprovedoperatingrightsassignment.
AlesseewasapersonwhohadenteredintoaleasewiththeUnitedStatesto
explorefor,develop,andproducetheleasedminerals.Thetermlesseealso
appliedtotheMMSapprovedassigneeofthelease,andtheownerortheMMS
approvedassigneeofoperatingrightsforthelease. 397

MMSwasresponsibleforenforcingregulationsgoverningdrilling
operationscontainedin30CFRPart250.SubpartDcoveredmanyaspectsof
drillingoperations,includingpermitting,casingrequirements,cementing
requirements,divertersystems,BOPsystems,drillingfluidsrequirements,
equipmenttesting,andreporting. 398MMSregulationsmadeclearthatlessees,
designatedoperators,andpersonsactuallyperformingactivitiesontheOCS
werejointlyandseverallyresponsibleforcomplyingwithanyregulationthat
requiresthelesseetomeetarequirementorperformanaction. 399

A. PermittingProcess

Priortodrillingawellorsidetracking,bypassing,ordeepeningawell,the
operatorhadtoobtainwrittenapprovalfromMMS.Toobtainapproval,the
operatorhadto:

(a)Submittheinformationrequiredby30CFR250.411through250.418;
(b)IncludethewellinitsapprovedExplorationPlan(EP),Development
andProductionPlan(DPP),orDevelopmentOperationsCoordination
Document(DOCD);(c)Meettheoilspillfinancialresponsibility
requirementsforoffshorefacilitiesasrequiredby30CFRPart253;and(d)

39643U.S.C.1348(b).
397See30CFR250.105.
398SubpartDappliestolessees,operatingrightsowners,operators,andtheircontractorsand

subcontractors.30CFR250.400.Foreaseofreference,thisportionofthereportwilluse
operatortomeanalloftheseentities,unlessotherwisespecified.
39930CFR250.146(c).

158
SubmitthefollowingformstotheDistrictManager:(1)Anoriginaland
twocompletecopiesofFormMMS123,ApplicationforaPermittoDrill
(APD),andFormMMS123S,SupplementalAPDInformationSheet;(2)
AseparatepublicinformationcopyofformsMMS123andMMS123S
thatmeetstherequirementsof250.186;and(3)paymentoftheservicefee
listedin250.125. 400

UponreceiptoftheAPD,MMSpersonnelreviewedittodetermine
whetheritwascomplete,satisfiedtherelevantregulatoryrequirementsand
containednoerrors.MMSpersonnelalsoassessedwhethertheapplicantsoil
spillfinancialresponsibilitycoveragewascurrent.

MMSusedasecure,electronicfilingsystemcalledeWelltoprocessand
reviewAPDs.MMSdistrictengineerswereresponsibleforreviewingAPDs
submittedthroughtheeWellsystem.Reviewbyadrillingengineerwasdone
onaprioritizedbasis,dependingonrigstatusandotherfactors.

MMSstaffcheckedtheproposeddrillingrigsmaximumoperatinglimits
fordrillingdepthandwaterdepthtoensureappropriatenessfortheproposed
wellprogram.Thereviewincluded,butwasnotlimitedto,theproposed
procedure,welllocationanddirectionalprogram,geologicalandgeophysical
hazards,subsurfaceenvironmentforporepressureandfracturegradient,
wellboredesignandschematic,designcalculationsforpressurecontainment
duringdrillingandcompletion,cementvolumes,andtestingpressuresforthe
wellcontrolequipment,casingandcasingshoe.Thisreviewwasperformedfor
shallowanddeepwaterdrillingoperations,andahurricaneriskassessmentwas
performedduringhurricaneseason.

MMSpersonnelreviewedAPDstodeterminewhethertheproposed
operationsatisfied30CFR250.420bymeetingtheobjectiveofsafelyreachinga
targeteddepth.Thisreviewincludedanassessmentof:wellcasingsetting
depthsdeterminedbyformationstrength;predictedformationfluidpressure;
drillingmudweightlimits;anyanticipatedsubsurfacehazards;effectivenessof
wellcasingstrengthforpressurecontainmentatitsspecifieddepth;effectiveness
ofcementingthewellcasingaftersuccessfullysecuringandisolatingthe
hydrocarbonzonesoranyencounteredsubsurfacehazards;andmaintaining

400 30CFR250.410.

159
wellcontrolbyadjustingdrillingmudpropertiesandtheuseofwellcontrol
equipmentsuchasdivertersandBOPstacks.

ThedrillingengineerapprovedtheAPDonbehalfoftheDistrictManager
afterheorshereviewedtheitemslistedaboveandafterplanapprovalswere
verifiedbytheMMSPlansUnit.AMMSDistrictManagergrantedapprovalsof
APDs,withallapplicablecautionsandconditionsasnecessaryfromtheMMS
GeologicalandGeophysicalunit.IftheAPDdidnotsatisfyallofthereview
itemslistedabove,thedrillingengineerreturnedtheAPDtotheoperatorwith
commentsdocumentingthedeficienciesthatneedtobecorrectedpriortoAPD
approval.

Operatorsroutinelygatheredinformationandformulateddrilling
programsthatweremuchmoredetailedthantheinformationrequiredinthe
APDsubmittedtoMMS.Forexample,thedrillingprognosissubmittedwiththe
MacondoAPDwascondensedtoasinglepage,whilethefullBPdrilling
programwasmorethan100pageslong.

IfanoperatorchangeddrillingplansaftersubmissionofanAPD,itwas
requiredtosubmitanapplicationforpermittomodify(APM). 401TheAPM
wasrequiredtoincludeadetailedstatementoftheproposedworkthatwould
materiallychangefromtheapprovedAPD. 402

MMSsGulfofMexicoregionwasdividedintofivedistricts.The
MacondowellislocatedintheMississippiCanyonBlock252,whichiscovered
bytheNewOrleansDistrict.FrankPatton,anMMSdrillingengineerintheNew
OrleansDistrict,approvedtheMacondoAPDonbehalfofDavidTrocquet,the
NewOrleansDistrictManager.

ThePanelfoundthatPattondidnotrecognizethatBPfailedtosubmit
supportingdocumentationthattheblindshearramintheBOPstackhadthe
abilitytoshearthedrillpipeintheholeundermaximumanticipatedsurface
pressuresper30CFR250.416(e).However,thePanelreviewedevidencethat
CameronandTransoceanbothdetermined,priortotheAPDsubmittal,thatthe
DeepwaterHorizonBOPstackhadtheabilitytoshearthedrillpipeinuse.

30CFR250.465.
401

Id.WhenAPMsaresubmittedthroughtheewellsystemtorevisethepermittodrill,theyare
402

submittedasarevisedpermittodrill(RPD).BPsubmitteditsrevisedpermittodrillthrough
theewellsystem.

160

PattonalsoapprovedtheAPMsandRPDsthatBPsubmittedtoMMSfor
theMacondowell,includingtheAPMsrelatedtoBPstemporaryabandonment
ofthewell.BPsubmittedthelastAPMonApril16andprovidedanoverviewof
BPsplannedtemporaryabandonmentprocedures.BPstateditsintenttoseta
cementplugatadepthof8,367feetto8,067feet,andexplainedthatitneededto
settheplugdeepertominimizethechancesofdamagingthelockdownsleeve.
Pattontestifiedthathewasnotawareofevidenceofanyproblemswiththe
MacondowellandthathebelievedthatBPhadmetallapplicableregulatory
requirementsinsubmittingtheAPDtheAPMs,andtheRPDs. 403ThePanel
concludedthatPattonsreviewandapprovaloftheAPDwasnotacauseofthe
Macondoblowout.

B. WellActivityReports

AfterreceivingMMSapprovalofanAPD,pursuantto30CFR
250.468(b),thedesignatedoperatorhadtosubmitaweeklyWellActivityReport
(WAR)totheagencytoreportallofthespecificoperationsatthewell.The
operatorhadtosubmittheWARintoeWellweeklyfromthewellsspud(start)
datetotheendofdrillingoperationsatthewell.Thedrillingengineerreviewed
theWARforconsistencywiththereviewedpermitandtoidentifyanyanomalies
thatwarrantpossiblerevisionstothepermitorissuanceofincidentsof
noncompliancewiththeregulations.TheWARdidnotproviderealtime
information,rather,itwasasnapshotofthepriorsevendaysactivities.The
MMSdrillingengineerswhoreviewedtheWARsontheMacondowell,Patton
andPeterBotros,notednodeficienciesontheWARsduringthedrillingofthe
Macondowell.

C. MacondoDeparturesandAlternativeProcedures

IntheAPDprocess,operatorscouldseekauthorizationfromMMSto
departfromthedrillingrequirementssetoutin30CFRPart250. 404MMScould
alsoallowoperatorstoconductalternativeproceduresifthoseproceduresare
deemedtobesaferorassafeastherequirementssetforthin30CFRPart250.
MMSgrantedmultiplerequestsfordeparturesandalternativeproceduresatthe
MacondowellintheMacondoAPD(seeAppendixI).ThePanelfoundthatthese

403 TestimonyofFrankPatton,JointInvestigationHearing,May11,2010,at26869.
404 See30CFR250.142;30CFR250.409.

161
departuresfromtheregulationsoralternateprocedureswerenotacauseofthe
Macondoblowout.

D. MMSDrillingInspections

AnMMSdrillinginspectionroutinelyinvolvedareviewofrequired
documentsandrecords,awalkthroughvisualinspectionofthefacility,and
testingofequipment.Recordsreviewedduringatypicalinspectionincluded:
surveys;safetydeviceinformation;recordsofBOPtestsandinspections;records
ofdivertertests;recordsofwellcontroldrills;documentationofmaximum
pressureshandledbytheBOPstack;recordsreflectingtheconditionofthe
drillingmud;formationintegritytestresults;recordsofleakofftests;
applications;permits;andanyevidenceofunreportedpollutionincidents.

Visualinspectionstypicallyincludedavisualassessmentof:thediverter
system;classifieddrillingfluidhandlingareas;housekeepingandgeneralsafety
conditions;safetyvalvesontherigfloor;conditionsofmanliftandairhoistwire
ropes;safeweldingareaandequipmentinthearea(toensuretheabsenceof
flammablematerial);groundingofelectricalbuildingsandequipment;
emergencyshutdownfordieselengines(airshutoff);andoperableBOPremote
controlstations.

MMSinspectorstestedthefollowingequipmentduringatypical
inspection:crownblocksafetydevice;backupBOPaccumulatorcharging
system;degasserfunction;mudpitlevelalarms;flowshowalarm;gasdetection
system;ventilationsystemandalarms;andmudloggershackalarms.Duringthe
inspectionsofdrillingrigs,MMSinspectorswerenotrequiredtofunctiontest
theemergencydisconnectsystems,lowermarineriserpackages,orBOPstack
secondarycontrolsystems.

E. PotentialIncidentofNoncomplianceGuidelines

Toensureconsistencyintheagencysinspectionprogram,MMS
inspectorsperformedOCSinspectionsusinganationalchecklistcalledthe
PotentialIncidentofNoncompliance(PINC)list.Thislistisacompilationof
yes/noquestionsderivedfromsafety,environmentalandregulatory
requirementsrelatingtooilandgasoperationsontheOCS.

Upondetectingaviolation,theMMSinspectorissuedanIncidentof
Noncompliance(INC)totheoperatorandusedoneofthreemainenforcement

162
actions(warning,componentshutin,orfacilityshutin),dependingonthe
severityoftheviolation.Iftheviolationwasnotsevereorthreatening,a
warningINCwasissued.Theviolationhadtobecorrectedwithinareasonable
amountoftime,whichwasspecifiedonthewarningINC.TheshutinINC
couldbeforasinglecomponent(aportionofthefacility)ortheentirefacility.
Theviolationhadtobecorrectedbeforetheoperatorwasallowedtocontinuethe
activityinquestion.

Inadditiontotheenforcementactionsspecifiedabove,MMScouldassess
acivilpenaltyofupto$35,000perviolationperdayif:1)theoperatorfailedto
correcttheviolationinthereasonableamountoftimespecifiedontheINC;or2)
theviolationresultedinaseriousharmordamage,orathreatofseriousharmor
damagetohumanlife,propertyortheenvironment. 405

Figure13presentsanexampleofPINCguidanceaboutsubseaBOPstacks
canbefoundbelow:


Figure13ExampleofNationalPINCGuidanceforDrillingInspection

ThePaneldeterminedthattherewasnoPINContheinspectorschecklist
for30CFR250.446(a)atthetimeoftheMacondoblowout.Thatprovision
requiresanoperatortoconductamajorinspectionofBOPstackcomponents
everythreetofiveyears.BecausenoPINCexistedforthisrequirement,MMS
inspectorsdidnotregularlyverifythatthemajorinspectionrequirementshad
beenmetduringdrillinginspections.

43U.S.C.1350(b);30CFR250.1403.1404.ForviolationsthatoccurafterJuly30,2011,the
405

maximumcivilpenaltyperdaywillbe$40,000perdayperviolation.

163
F. InspectionForms

MMSinspectionsofdrillingrigsinvolvedacompleteinspectionassetout
inaPINClistwhichwas,asdescribedintheprevioussection,usedasa
checklistofitemsthatinspectorscheckedduringaninspection. 406ThePINClist
wasnotacomprehensivelistofallpotentialviolations.

Inspectorsrecordedcertaininformationonaninspectionform,including
identifyingdataabouttherig,leaseandoperator,buttheydidnotrecordwhat
testingwasconductedduringtheinspection,unlessaviolationwasidentified. 407
AllinformationonINCsissuedasaresultofinspectionswascapturedina
centralMMSdatabase,regardlessofwhetherthedistrictsinspectionformswere
originallyinelectronicorpaperform.ThePanelfoundthatnotallMMSdistricts
usedthesameinspectionform,andthattheformsvariedinlengthacrossthe
districts.

G. MMSDeepwaterHorizonInspectionsatMC252

WhiletheDeepwaterHorizonwasonlocationatMC252,MMSperformed
threedrillinginspectionsontherig.TheseinspectionsoccurredonFebruary17,
March3,andApril1.MMSinspectors,BobNealandEricNeal,identifiedno
majordeficienciesandissuednoINCsduringtheseinspections.

ThelastinspectionwascompletedbyEricNeal,aninspectorwhohad
beenwiththeagencysince2003.EventhoughNealhadpreviouslyparticipated
in73drillinginspections,hetestifiedthathewas[o]nlyintrainingfordrilling
inspections. 408DuringthelastinspectionoftheDeepwaterHorizon,Nealusedthe
PINCguidelinestoassisthimduringhisinspectionandfoundnobasistoissue
anyINCs. 409ThePanelfoundnoevidencethattheMMSinspectionsofthe
DeepwaterHorizonconductedin2010wereincomplete.ThePanelfoundno
evidencethattheMMSinspectionsoftheDeepwaterHorizonwhileonlocationat
Macondowereacauseoftheblowout.

406TestimonyofRobertNeal,JointInvestigationHearing,May11,2010,at350351;Testimonyof
EricNeal,JointInvestigationHearing,May11,2010at326.
407EricNealtestimonyat326329;334336.

408 EricNealtestimonyat316.

409Id.at325,336.

164
H. SafeDrillingMargin

MMSregulationsrequiredthat[w]hiledrilling,youmustmaintainthe
safedrillingmarginidentifiedintheapprovedAPD[ApplicationforPermitto
Drill].Whenyoucannotmaintainthissafemargin,youmustsuspenddrilling
operationsandremedythesituation.410 Thesafedrillingmarginreferencedin
theregulationisthedifferencebetweenthefracturegradientandthemud
weight.Theregulationdidnotdefinesafedrillingmargin,buttypically,the
industryacceptedsafedrillingmarginwas0.5ppg.Thisdrillingmarginwas
consideredsufficienttoallowtherigcrewtocirculateoutakickduringthe
drillingprocess.

I. WellControl

30CFR250.401requiresanoperatortotakenecessaryprecautionsto
keepthewellundercontrolatalltimes.Thisprovisionidentifiedfivespecific
wellcontrolrequirements:

Usethebestavailableandsafestdrillingtechnologytomonitorand
evaluatewellconditionsandtominimizethepotentialforthewelltoflow
orkick;
Haveapersononsiteduringdrillingoperationswhorepresentsthe
lesseesinterestandcanfulfillthelesseesresponsibilities;
Ensurethatthetoolpusher,operatorsrepresentative,oramemberofthe
drillingcrewmaintainscontinuoussurveillanceontherigfloorfromthe
beginningofdrillingoperationsuntilthewelliscompletedorabandoned,
unlesstheoperatorhassecuredthewellwithBOPs,bridgeplugs,cement
plugs,orpackers;
UsepersonneltrainedaccordingtotheprovisionsofSubpartOof30CFR
Part250;and
Useandmaintainequipmentandmaterialsnecessarytoensurethesafety
andprotectionofpersonnel,equipment,naturalresources,andthe
environment. 411

30CFRPart250SubpartOregulationsgoverningwellcontroland
productionsafetytrainingrequireoperatorstoestablishandimplementtraining
programsthattrainemployeestocompetentlyperformtheirassignedwell

410 30CFR250.427(b).
411 30CFR250.401.

165
controlduties.412MMScouldevaluateoperatorwellcontroltrainingprograms
byauditingtheoperatorstrainingprogram,conductingwrittenandhandson
testing,witnessingwellcontroldrills,andothermethods. 413

PriortoAugust2000,theregulationsregardingwellcontroltrainingwere
prescriptive.Theruleprescribedthecontentofthewellcontroltraining
curriculumandthelengthofthetrainingclassthateachindividualwasrequired
tocompleteaccordingtoresponsibilities.Additionally,MMSrequiredthatall
wellcontroltrainingprovidersneededtobeapprovedbyMMS.

InAugust2000,MMSpromulgatedaperformancebasedrulethat
requiredlesseestodevelopandimplementtheirtrainingprograms.This
regulation,whichbecameeffectiveonOctober13,2000,requiredeachoperator
toprepareatrainingplanlayingoutthecompanystrainingphilosophy
includingthetype,method,length,frequencyandcontentofitstraining
program.Underthisrule,MMSdidnotreviewandapprovethetraining
providersnordiditspecifythecontentofthetrainingprogram.Rather,the
lessee/operatorwasresponsiblefordeterminingthecontent,length,and
frequencyoftrainingprograms.

Sinceimplementingthisperformancebasedapproach,MMShasuseda
seriesofmeasurestoperiodicallyassessthequalityofoperatorandcontractor
trainingprograms.Suchassessmentshaveincludedareviewofoperator
trainingplans,records,andmethods.MMShasalsoreviewedthewaysinwhich
operatorsverifiedthetrainingconductedbycontractors.

AftertheMacondoblowout,BOEMREreviewedBPstrainingplan,on
linetrainingrecords,themethodsbywhichBPevaluatedTransoceanandthe
methodsbywhichBPverifiedthatcontractpersonnelweretrained.BOEMRE
alsoreviewedthecontractorevaluationofTransocean.BPrequiredall
individualswithwellcontrolresponsibilities(bothBPemployeesandcontractor
employees)tobetrainedeverytwoyears.BOEMREreviewedthetraining
recordsofalldrillingpersonnelstationedontheDeepwaterHorizonandallBP
personnelwhohadwellcontrolresponsibilities.ThePanelconcludedthatBPs

41230CFR250.1503.
41330CFR250.1507.

166
trainingprogramcompliedwith30CFRPart250SubpartOandthat
TransoceanstrainingprogrammetthestipulationsdictatedbyBP. 414

BP,however,didnotrequirethemudloggersmonitoringtherigdatatobe
trainedinwellcontrol,andsuchtrainingisnotrequiredbySubpartO.The
mudloggersonintheDeepwaterHorizonwereemployeesofSperrySun,a
subsidiaryofHalliburton.Halliburtonhasawellcontroltrainingprogramforits
ownpersonnel,butitstrainingprogramdidnotrequiremudloggerstobe
trainedinwellcontroloperations,includingkickdetection. 415

AsnotedpreviouslyinthisReport,thePanelfoundevidencethatBP,
Transocean,andHalliburtonviolated30CFR250.401byfailingtotake
necessaryprecautionstokeeptheMacondowellundercontrolatalltimes.As
providedin30C.F.R.250.146,operatorsandcontractorsarejointlyand
severallyliableforthefailuretocomplywithallapplicableregulations.

J. SubseaBOPRegulatoryRequirements

MMSregulationsestablishedcertainrequirementsrelatedtoBOPstack
maintenance,testing,recordkeepingandinspections.Someoftheseregulations
incorporatedbyreferenceAPIRecommendedPractices(RP),whichmeantthat
compliancewithanincorporatedAPIRPwasrequiredasdirectedbythe
regulation. 416ThissectiondiscussesrelevantMMSregulationsinplaceatthe
timeoftheblowout.

1. GeneralBOPRequirements

30CFR250.440requiredoperatorstodesign,install,maintain,testand
usetheBOPsystemandsystemcomponentstoensurewellcontrol.The
workingpressureratingofeachBOPcomponenthadtoexceedmaximum
anticipatedsurfacepressures.TheBOPsystemincludestheBOPstackand
associatedBOPsystemsandequipment.BPcalculatedtheMacondowell
maximumanticipatedsurfacepressure(MASP)tobe6,153psiusingthewells
estimatedporepressureatthewellsplannedtotaldepthof20,200feet.BPalso

414ThePanelmakesrecommendationstoimprovetheregulationsat30CFR250.1500(SubpartO)
relatingtowellcontroltraining.
415BPHZNMBI00328704.

4161CFR51.9(b)(3).

167
calculatedthemaximumanticipatedwellheadpressure(MAWP)atthe
mudline(orBOP)was8,404psi. 417

2. RequiredSystemsandEquipment

IfanoperatoroptedtouseasubseaBOPstack,ithadtofulfilltheMMS
requirementssetforthin30CFR250.442.Therequirementswere:

TheoperatorhadtoinstalltheBOPsystembeforedrillingbelow
surfacecasing.
Thesubseastackhadtoincludeatleastfourremotecontrolled,
hydraulicallyoperatedBOPsconsistingofanannularBOP,twoBOPs
equippedwithpiperams,andoneBOPequippedwithblindshear
rams.
Theoperatorhadtoinstallanaccumulatorclosingsystemtoprovide
fastclosureoftheBOPcomponentsandtooperateallcriticalfunctions
incaseofalossofthepowerfluidconnectiontothesurface.The
accumulatorsystemhadtomeetorexceedtheprovisionsofSection
13.3inAPIRP53,RecommendedPracticesforBlowoutPrevention
EquipmentSystemsforDrillingWells.
TheBOPsystemhadtoincludeanoperabledualpodcontrolsystemto
ensureproperandindependentoperationoftheBOPsystem.
Beforeremovingthemarineriser,theoperatorhadtodisplacetheriser
withseawater.Theoperatorhadtomaintainsufficienthydrostatic
pressureortakeothersuitableprecautionstocompensateforthe
reductioninpressureandtomaintainasafeandcontrolledwell
condition.

Additionally,allsubseaBOPsystemswererequiredtomeetthe
conditionssetforthin30CFR250.443.Thisregulationrequiredallsystemsto
include:

Anautomaticbackuptotheprimaryaccumulatorchargingsystem;
AtleasttwoBOPcontrolstations(onestationonthedrillfloorandthe
otherinareadilyaccessiblelocationawayfromthedrillfloor);
SideoutletsontheBOPstackforseparatekillandchokelines;
AchokeandkilllineontheBOPstack(eachtohavetwofullopening
valves,andbothtoberemotecontrolledifitissubsea).Thechokeline

417BPsApril15,2010APD.

168
hadtobeinstalledabovethebottomram,thekilllinecouldbe
installedbelowthebottomram;
AfilluplineabovetheuppermostBOP;
LockingdevicesinstalledontheramtypeBOPs;and
Awellheadassemblywitharatedworkingpressurethatexceedsthe
maximumanticipatedsurfacepressure(MASP). 418

3.RequiredMaintenanceandInspections

30CFR250.446identifiedBOPstackmaintenanceandinspection
requirements.ThisprovisionrequiredmaintenanceofBOPsystemstoensure
thattheequipmentfunctionedproperly.Italsorequiredtovisualinspectionsof
thesubseaBOPsystemandriseratleastonceeverythreedaysifweatherandsea
conditionspermitted.SubseaBOPstackmaintenancewasrequiredtomeetor
exceedAPIRP53Sections18.10,18.11and18.12.

a. APIRP53Section18.10

Section18.10ofAPIRP53generallyprescribedrecommendedpractices
forwellinspectionsandmaintenanceandrequiredthatallleaksand
malfunctionswerecorrectedbeforeBOPequipmentwasplacedintoservice.API
RP53Section18.10.3recommendedamajorinspectionoftheBOPstackafter
everythreetofiveyearsofservice.Duringthemajorinspection,theBOPstack,
chokemanifold,anddivertercomponentswererecommendedtobe
disassembledandinspectedinaccordancewiththemanufacturersguidelines. 419

b. APIRP53Section18.11

Section18.11.3ofAPIRP53addressedBOPmaintenance.Ofparticular
relevancehere,Section18.11.3requiredthatsparepartsbedesignedforintended
use.Theoperatorwasrequiredtoconsulttheoriginalequipmentmanufacturer
regardingreplacementparts,andifpartswereacquiredfromanonoriginal
equipmentmanufacturer,thepartsshallbeequivalenttoorsuperiortothe
originalequipmentandbefullytested,designverified,andsupportedby
traceabledocumentation. 420

418TheJITconcludedthatthecurrent30CFR250.443containsanerror;itbelievesthatthis
provisionshouldrefertomaximumallowableworkingpressure(MAWP),notMASP.
419APIRP53,Section18.10.3.

420APIRP53,Section18.11.3.

169

ThePanelfoundnoevidencethatBPconsultedwithCameronabout
modifyingtheBOPstackwithpartsfromanonoriginalequipment
manufacturer.

c. APIRP53Section18.12

Section18.12ofAPIRP53requiredalesseetohaveoneachrigaplanned
maintenancesystem,withequipmentidentified,tasksspecified,andthetime
intervalsbetweentasksstated.Maintenanceandrepairrecordswererequired
toberetainedonfileattherigsiteorreadilyavailable.

4. BOPPressureTests

30CFR250.447requiredtheoperatortopressuretesttheBOPsystem
(chokemanifold,valves,insideBOP,anddrillstringsafetyvalve):

Wheninstalled;
Before14dayselapsedsincethelastBOPpressuretest;and
Beforedrillingouteachstringofcasingoraliner. 421

Whileperforminga14dayBOPpressuretest,theoperatorwasrequired
tocomplywith30CFR250.448.Thisregulationrequiredtheoperatorto
conductbothalowpressureandahighpressuretestforeachBOPcomponent.
Thelowpressuretesthadtobeconductedbeforethehighpressuretest.Each
individualtesthadtoholdpressureforfiveminutes.Examplesofapproved
testswere:

421
TheMMSDistrictManagerhadtheoptiontoallowlesseestoomitthelasttestingrequirement
iftheydidnotremovetheBOPstacktorunthecasingstringorlinerandiftherequiredBOPtest
pressuresforthenextsectionoftheholewerenotgreaterthanthetestpressuresfortheprevious
BOPpressuretest.

170
LowpressureTest Between200and300psi
HighpressureTestforramtypeBOPs, Ratedworkingpressureofequipment;
thechokemanifold,andotherBOP or
components 500psigreaterthanthecalculated
MASPfortheapplicableholesection
(withMMSapprovalofthosetest
pressures)
HighpressureTestforannulartype 70percentoftheratedworking
BOPs pressureoftheequipment;ora
pressureapprovedintheAPD
Figure14BOPPressureTests

Iftheequipmentfailedtoholdtherequiredpressureduringanyofthesetests,
theoperatorwasrequiredtocorrecttheproblemandretesttheaffected
component.

5. AdditionalBOPTests

Atthetimeoftheblowout,theregulationincludedadditionalsubsurface
BOPtestingrequirements,includingthefollowing:

StumptestofasubseaBOPsystemwithwaterbeforeinstallation;
Alternatetestbetweencontrolstationsandpods;
PressuretestoftheBSRduringstumptestandatallcasingpoints;
AnintervalbetweenanyBSRpressuretestnotexceeding30days;
Apressuretestoftestvariableborepiperamsagainstthelargestand
smallestsizesofpipeinuse,excludingdrillcollarsandbottomholetools;
ApressuretestofaffectedBOPcomponentsfollowingthedisconnection
orrepairofanywellpressurecontainmentsealinthewellheadorBOP
stackassembly;
Afunctiontestofannularsandramseverysevendaysbetweenpressure
tests;and
Actuationofsafetyvalvesassembledwithpropercasingconnections
beforerunningcasing.

171
6. BOPRecordkeeping

30CFR250.450.requiredlesseestorecordthetime,dateandresultsof
allpressuretests,actuationandinspectionsoftheBOPsysteminthedrillers
report.Thelesseewasalsorequiredto:

RecordBOPtestpressuresonpressurecharts;
RequireonsiterepresentationtosignanddateBOPtestchartsandreports
ascorrect;
DocumentthesequentialorderofBOPandauxiliaryequipmenttesting
andthepressuredurationofeachtest(subseaBOPsrecordclosingtimes
forannularandramBOPs);
Identifythecontrolstationandpodusedduringthetest;
IdentifyanyproblemsorirregularitiesobservedduringBOPsystem
testingandrecordactionstaken;and
Retainallrecordsatthefacilityforthedurationofdrillingthewell.

Additionally,operatorshadtomaintaincompleteandaccuraterecordsofallwell
activitiesincludingrecordsofanysignificantmalfunctionorproblem. 422

K. RegulatoryImprovements

AtthetimeoftheMacondoblowout,MMSdidnothaveacomprehensive
setofregulationsspecificallyaddressingdeepwatertechnology,drilling,orwell
design.Regulationsapplicableatthattimetobothshallowwateranddeepwater
drillingoperationswerecapturedin30CFR250.400490(SubpartD).

Asdrillingoperationshavemovedintodeeperwater,operationalissues
havebecomefarmorecomplex.Thisincreasedcomplexitydemandsappropriate
regulatoryimprovements.ThePanelconcludedthattheregulationsineffectat
thetimeoftheMacondoblowoutcouldbestrengthenedinanumberofways
andthatregulatoryimprovementsmayhavedecreasedthelikelihoodofthe
Macondoblowout.

TheRecommendationssectionofthisReportcontainsanumberof
proposedregulatoryimprovementsthatthePanelbelieveswouldaddressthe
followingareas:cementbarriersinhighflowpotentialwells;negativetest
procedures;specificcementingrequirements;guidanceonlockdownsleeve

42230CFR250.466.

172
installation;dynamicflowtestingofBOPstacks;guidanceonramconfiguration
onBOPstacks;andimprovementsinanumberofBOEMREinspectionpractices.

L. IncidentsofNonCompliance

Duringitsinvestigation,thePanelfoundevidencethatBP,andinsome
instancesitscontractors,violatedthefollowingregulationsineffectatthetimeof
theblowout: 423

30CFR250.107BPfailedtoprotecthealth,safety,property,andthe
environment.BPandTransoceandidnot:(1)performalloperationsina
safeandworkmanlikemanner;or(2)maintainallequipmentandwork
areasinasafecondition.

30CFR250.300BP,Transocean,andHalliburton(SperrySun)didnot
preventconditionsthatposedunreasonablerisktopublichealth,life,
property,aquaticlife,wildlife,recreation,navigation,commercialfishing,
orotherusesoftheocean.

30CFR250.401BP,Transocean,andHalliburton(SperrySun)failedto
takenecessaryprecautionstokeepthewellundercontrolatalltimes.

30CFR250.446(a)BPandTransoceanfailedtomaintaintheBOP
systeminaccordancetoAPIRP53section18.10and18.11.

30CFR250.420(a)(1)and(2)BPandHalliburtondidnotcementthe
wellinamannerthatwouldproperlycontrolformationpressuresand
fluids;andpreventthedirectorindirectreleaseoffluidsfromanystratum
throughthewellboreintooffshorewaters.

30CFR250.427(a)BPfailedtousepressureintegritytestandrelated
holebehaviorobservations,suchasporepressuretestresults,gascut
drillingfluid,andwellkickstoadjustthedrillingfluidprogramandthe
settingdepthofthenextcasingstring.

ThislistofviolationsisbasedupontheevidencegatheredbytheJITduringitsinvestigation
423

anduponthePanelsfindingsandconclusions.Additionalevidencemayrevealfurther
violations.AfterthisReportisreleased,BOEMREwillissueIncidentsofNonCompliancebased
uponevidencecontainedinthisReportand/orotherrelevantevidence.

173

30CFR1721(a)BPfailedtoconductthenegativetestonApril20in
accordancewiththenegativetestprocedureapprovedintheApril16
APM.

174
XV. PoliciesandPracticesofInvolvedCompanies

A. BPsPoliciesandPractices

ThePanelsinvestigationfoundthat,atthetimeoftheblowout,BPhada
numberofcarefullydocumentedpoliciesandpracticesaddressingdrilling
operations,changemanagement,safetyandriskmanagement.

AccordingtoBP,during2010itwasintheprocessofimplementinga
comprehensive,companywideapproachtomanagementcalledtheOperating
ManagementSystem(OMS).OMSwasandisintendedtoprovidea
standardizedapproachthatpromoteseffectiveandconsistentriskmanagement
acrossthecompany. 424

UnderBPsOMS,localbusinessunitsareresponsibleforimplementing
theirownOMS.BPsdrillingandcompletionsunitintheGulfofMexicoissued
itslocalOMSinNovember2009. 425GulfofMexicodrillingoperationsarealso
guidedbyBPsDWOPmanualanditsBeyondtheBestmanual.BPdrilling
operationsmustalsofollowtheCompanysgoldenrulesofsafety.

1. BPsRiskAssessmentPolicies

BPhasrecognizedthat[t]heidentificationandmitigationofoperating
riskisakeyelementofOMSandhastoutedanumberofitsriskassessmentand
managementtools. 426InJanuary2009,BPissuedacompanystandardon
assessment,prioritizationandmanagementofrisk(January2009standard).This
documentrecognizesthat[i]nconsisentorineffectiveidentificationand
assessmentofrisktohealthandsafetyofpeople,theenvironmentandoperating
performancecancreatemanyissuesfortheorganization. 427Thestatedpurpose
ofissuingtheJanuary2009standardwastoprovideaconsistentapproachto
riskmanagementtotargetresourcesmosteffectivelyforcontinuousrisk
reduction. 428

424BPSubmittaltotheNationalCommissionontheBPDeepwaterHorizonOilSpillandOffshore
Drilling,entitledBPsCommitmenttoSafety(BPCommitmenttoSafetySubmission).
425BPHZNMBI00208572.

426BPCommitmenttoSafetySubmission.

427BPHZNMBI00195284.

428Id.

175
TheJanuary2009standardprovidesthateachBPfacilitymaintainarisk
registerthatcontainsadescriptionofidentifiedrisksandthedevelopmentofan
actionplantomanagethoserisks.ItalsomakesclearthatBPentitiesshouldseek
toidentifywheretheworkforcemayhavebecomeaccustomedtothepresenceof
therisk,ortoweaknessesinsafetycontrols. 429

FormerBPexecutivevicepresident,JamesKentWellssummarizedthe
companysOMSsystemasfollows:

Wehaveanumberofsystems.DWOP,forone,givesusguidance.We
haveasystemthatwevebeenworkingonforthelastseveralyearscalled
OMS,whichisouroperationalmanagementsystem.

Andthepurposeofthatsystemistosortofbringtogethersowerevery
systematicandconsistentacrossthewholecompanythewayweexpect
thingstobedone.Anditsetsoutwehavesomestandardsinthere.

Andwhatwedoisweusethattosettheguidelinesforactivitywemight
do,andthenalsotoworkwithourcontractorsthatprobablyalreadyhave
theirownsafetymanagementsystemstomakesurethatwebelievetheir
systemsareadequate. 430

AsnotedbyWells,therequirementsintheJanuary2009standardwere
supplementedbyrequirementsintheDWOP.BPsDWOPrequiredthatBP
employeesbepresentateverywellsiteandthattherebeadequateproceduresin
placetoensuresafedrillingoperations.

BPsDWOPalsocoveredthemanagementofrisk.Specifically,it
providedthat[a]ll[drillingandcompletion]operationsshallfollowa
documentedandauditableriskmanagementprocesstoincludeidentification,
assessment,prioritizationandaction. 431TheDWOPrequiredspecific
documentationandstatedthattherecommendedtoolfordocumentingand
managingdrillingandcompletionsriskwasawebbasedtoolcalledtheBPrisk
assessmenttool(RAT).

429BPCommitmenttoSafetySubmission.
430TestimonyofJamesWells,JointInvestigationHearing,August26,2010,at2324.
431BPHZNMBI00130820.

176
ThePanelsinvestigationfoundthatBPdrillingengineersdidnotevaluate
orcommunicatetheongoingriskassociatedwiththefollowing:

Theproductioncasingshoewassetinalaminatedsandshaleinterface
inlieuofaconsolidatedshale;
Decidingnottosetanadditionalproductioncasingbarrier,suchas,
settingaretainerand/orcementplugabovethefloatcollar;
Substantial(greaterthan3,000bbls)mudlosseshadoccurredinthe
openholeproductioninterval,whichindicatedpotentialcementing
problems;
Theplannedpositivetestingofthecasingwouldhaveonlytestedthe
topwiperplugandnotthecementcasingtrackbelowtheplug;
Thefloatcollarwasnotamechanicalbarriertowellflow;
Nocementwasleftabovethefloatcollarsothattherewouldbe
enoughroomtorunacementevaluationlog;thelogwasneverrun;
TheM56AandM56Esandswerepotentiallyunstablebecauseofa
differenceinporepressures;and
Therewasapotentialforballooningintheopenholeproduction
intervalfrom17,168feetto18,360feet.

Insteadofusingtherecommendedriskassessmenttool(theBPRAT
system),theMacondoengineeringteamusedariskregister,whichwasa
spreadsheetthattheteamcreatedtoanticipaterisksandtoidentifyindividuals
assignedtomitigaterisks.

JohnGuidetestifiedthataregisterorledgerwasusedthroughoutthe
processofdrillingthewell. 432TheMacondoteamdidnotperformanyrisk
analyses(ormitigationanalyses)usingtheriskregisterafterJune20,2009. 433
Thus,theriskregisterwasonlyutilizedduringtheMacondowelldesignphase
andnotduringBPsexecutionofdaytodayoperationsatthewell.

Intheriskregister,BPpersonnelidentified23riskswhileplanningthe
well.BPpersonnelplacedtheserisksintoonlythreedifferentcategoriescost,
productionandscheduleandchosenottocategorizeanyofthemashealth
andsafetyrisks.Forexample,BPpersonnelidentifiedawellcontrolproblemas
acostandnotahealthandsafetyrisk.Theriskcategoriesavailableinthe

432Guidetestimony,July22,2010,at64.
433BPHZNMBI00269180;seeAppendixJ.

177
riskregisterwere:healthandsafety,environmental,reputation,cost,schedule,
production,reserves,andnetpresentvalue.

AnotherexampleofthefailureoftheMacondoteamtofullyassessrisks
wasitsdecisiontoonlyusesixcentralizers(asdiscussedinSectionI).Inemail
aboutthisdecision,BrettCocaleswrote:

Butwhocares,itsdone,endofstory,wellprobablybefineandwellget
agoodcementjob.Iwouldratherhavetosqueezethangetstuckabove
theWH.SoGuideisrightontherisk/rewardequation. 434

Cocalestestifiedthattherisk/rewardequationdidnothaveaspecific
meaningwithinBP. 435ThePanelfoundnoevidencereflectingaBPrisk/reward
calculationonthedecisionofhowmanycentralizersshouldbeusedinthewell
design.

ThePanelfoundthatintheweeksleadinguptotheblowoutonApril20,
theBPMacondoteammadeaseriesofoperationaldecisionsthatreducedcosts
andincreasedrisk.ThePaneldidnotfindanyexplicitstatementsbyBP
personnelthatanyofthesedecisionsweremadeaspartofaconsciouscost/risk
tradeoff.However,theevidencethePanelreviewedsuggeststhattheMacondo
teammadeaseriesofdecisionsthatcutcostsandsavedtime.Moreover,the
Panelfoundnoevidencethatthecostcuttingandtimesavingdecisionswere
subjectedtothevariousformalriskassessmentprocessesthatBPhadinplace
(e.g.,riskregister,BPRAT,etc.).Examplesofsuchdecisionsarecontainedinthe
belowchart:

434BPHZNMBI00128409.
435Cocalestestimonyat24.

178

BPDecision LessCostto LessRig Greater
BP Time Risk
6versus21Centralizers Yes Yes Yes
CementBondLog Yes Yes Yes
FullBottomsUpon4/19 Yes Yes Yes
LongStringversusLiner Yes Yes
TimingofLockDownSleeve Yes Yes Yes
InstallationAftertheNegative
Test
Pumpingmudtoboatwhile Yes Yes Yes
displacing
Lostcirculationmaterial(LCM) Yes Yes Unknown
pillscombinedforSpacer
Figure15BPDecisionsandAssociatedCost,TimeandRisks

2. ManagementofChangeDrillingOperations

BPsDWOPrequiredthatanysignificantchangestoadrillingplanshall
bedocumentedandapprovedviaaformalmanagementofchange(MOC)
process. 436ThisrequirementwasreinforcedbytheBPgoldenrules,which
requirethatworkarisingfromtemporaryandpermanentchangesto
organization,personnel,systems,process,procedures,equipment,products,
materialsofsubstances,andlawsandregulationscannotproceedunlessaMOC
processiscompleted.BPrequiredtheMOCprocesstoinclude:(1)arisk
assessmentconductedbyallaffectedbythechange;(2)aworkplanthat
includeddetailsregardingcontrolmeasurestobeimplementedforequipment,
facilities,process,operations,maintenance,inspection,training,personnel,
communication,anddocumentation;and(3)authorizationoftheworkplanby
responsibleperson(s). 437

Despitethecompanyscarefuldocumentationoftheimportanceand
necessityoftheMOCprocess,theMacondoteamdidnotusethisprocessto
manageimportantchangesoccurringindaytodaydrillingoperations.
ExamplesofMOCissuesthatwerenotproperlydocumentedorcompletedin
accordancewithBPpolicyduringdrillingoperationsincluded:

436 BPDWOP4.4.
437 Id.

179
DuringApril1419,2010,BPmadeanumberofcasingdesignchanges,but
correspondingMOCdocumentswereneverformallycompleted.Gregg
Walzagreedinhistestimonythatthiswasaclericalerror. 438

ThecasingdesignchangesfortheMacondowellweresubmittedtoMMS
forapprovalpriortocompletionoftheMOCprocess. 439

Thefollowingoperationalchangeswerenotsubjectedtothetypeofrisk
analysesrequiredbyBPsMOCpolicy:

(1) Rigprocedurechangessuchasreplacingtheviscousspacerwith
alostcirculationmaterial.The450barrellostcirculationmaterial
(MISWACOFormASetandFormASqueeze)withpolymer
viscosifierandweightingmaterialaddedwashighlythixotropic
(resistanttoinitiateflow)andviscous.Thiswouldleadtoa
resistancetoflowininthecolderkillline(locatedoutsidethe
riser),whichinturnwouldresultinthesuppressionofpressure
readingsusingthekilllineforthenegativetest.

(2) Thedecisionnottorunthecementbondloglackedaproperrisk
evaluationbecauseseveralfactorswerenotconsideredsuchas
therelativelysmallvolumeoffoamcementpumped,insufficient
centralizationofthecasing,andquestionableconversionofthe
floatcollar. 440

DavidSimstestifiedthat,during2010,BPwasintheprocessofconverting
fromapaperMOCprocesstoanelectronicprocess.Hecalledtheprocessa
gradual,painfulprocess. 441WhetherthemembersoftheMacondoteamwere
usingthepaperorelectronicprocess,thereisevidencethattheywerenot
followingBPscarefullycraftedpoliciesonoperationalchanges.Theteams
decisionmakingproceededwithfewornochecksandbalances.OnApril17,
justthreedaysbeforetheblowout,GuidestatedinanemailtoSims:

David,overthepastfourdaystherehas[sic]beensomanylastminute
changestotheoperationthattheWSLs[WellSiteLeaders]havefinally

438TestimonyofGreggWalz,JointInvestigationHearing,October7,2010,at128.
439Simstestimony,August26,2010at147.
440 BPdidnotappeartoignoretheMOCprocessinallofitsdecisions.Thepanelfoundevidence

thatthecasingdesignchangesfortheMacondowellweresubjecttoanMOCanalysis.
441Simstestimonyat165.

180
cometotheirwitsend.Thequoteisflyingbytheseatofourpants.More
over,wehavemadeaspecialboatorhelicopterruneveryday.Everybody
wantstodotherightthing,but,thishugelevelofparanoiafrom
engineeringleadershipisdrivingchaos.Thisoperationisnot
Thunderhorse.Brianhascalledmenumeroustimestryingtomakesense
ofalltheinsanity.Lastnightsemergencyevolvedaroundthe30bblsof
cementspacerbehindthetopplugandhowitwouldaffectanybond
logging(Idonotagreewithputtingthespacerabovetheplugtobegin
with).ThismorningBriancalledmeandaskedmyadviceabout
exploringopportunitiesbothinsideandoutsideofthecompany.Whatis
myauthority?Withtheseparationofengineeringandoperation,Idonotknow
whatIcanandcantdo.Theoperationisnotgoingtosucceedifwecontinuein
thismanner.(emphasisadded). 442

3. ManagementofChangePersonnelChanges

BPhadMOCpoliciesrelatedspecificallytopersonnelchanges.The
requirementsforpersonnelMOCswereidenticaltotherequirementsfor
operationalchange,requiringformalriskassessment,aworkplan,and
authorization.Thesepoliciesappliedtobothtemporaryandpermanentchanges
totheorganization.

NotwithstandingthedetailedpersonnelMOCrequirements,BPappears
tohavegivenlittleconsiderationtowhowouldtemporarilyreplaceSepulvado
aswellsiteleaderontherigduringtemporaryabandonmentprocedures.
SepulvadofirstnotifiedGuideonFebruary26ofhisupcomingwellcontrol
training(scheduledforApril19throughApril24). 443Sepulvadoreminded
GuideagainonApril11thatheneededtofindatemporaryreplacementwellsite
leaderwhileSepulvadowasoutfortraining..444

KaluzainformedGuideonApril12thathecouldcoverforSepulvado. 445
Duetohisanticipatedshorttenureontherig,Kaluzawasnotgivenallaccess
rightstopertinentinformationwithinBPsownsystem. 446Guideapprovedthe
replacementofSepulvadowithKaluzaonApril12withoutreviewingKaluzas
performanceevaluations.NooneprovidedKaluzawithadetailedbriefingon

442BPHZNMBI00255906.
443BPHZNMBI00171845.
444BPHZNMBI00171849.

445BPHZNMBI00171853.

446BPHZNMBI00171859.

181
problemsthathadbeenencounteredduringdrillingoperationsatMacondo;nor
washegivenanyMOCmaterials.SepulvadosentKaluzaashortemailonApril
16aboutrigoperationsthatwastheonlyinformationKaluzareceivedfrom
SepulvadopriortostartingaswellsiteleaderontheDeepwaterHorizon.

Kaluzahadfouryearsofdeepwaterdrillingexperience,butnoexperience
ontheDeepwaterHorizonandlimitedexperiencewithTransoceanoperations.
ThePanelconcludedthattherewasadequatetimeforGuidetofindamore
suitablereplacementforSepulvadoortoperformaMOCpriortothedate
KaluzatookSepulvadosplace.

4. JobTransitionandHandoverAssurance

BPrequiredemployeestocompleteajobtransitionandhandover
assuranceformpriortopermanenttransferfromonejobtoanother.Thestated
purposeofthisformwastoassureasafeandseamlessjobtransition,andBP
wassupposedtouseittocertifythatallaccountabilitiesandexpectationsare
clearandcommunicatedtoallinvolvedandthatallperformanceobligationsare
fulfilled. 447

Aspartofthejobhandoverprocess,BPrequiredthattheincumbent
andtherecipientreviewandsignacompletedformtocertifythetransferof
authority.BPsproceduresstatedthattheteamleadershouldsigntheform
indicatingthathandoveriscomplete(emphasisadded). 448Thejobtransition
andhandoverassuranceprocessstepscontradictedBPsowngoldenrulesof
safetybyleavingthereviewandsignatureoptional.ThePanelfoundevidence
thatthreeofthefivejobtransitionandhandoverassuranceformsconcerningthe
personnelchangesinthemonthsprecedingApril20werenotfullycompletedin
accordancewiththeinstructionsprovidedinthedocument. 449

447BPHZNMBI00190164.Theformincludedthefollowingsections:accountabilitiesand
expectations;transitionprocess;businessrisksandcriticalareasoffocus;health,safety,security
andenvironmentandcrisismanagement;informationtransfer;peopleandorganization;
performancemonitoringandreporting;externalrelationships;andcommunication.
448Id.

449Duringa2010reorganization,BPfailedtofollowitsMOCprocessinthefollowingways:

KevinLacywasreplacedbyPatOBryanandfouritemswerenotcheckedcompletedandnot
signed(BPHZNMBI00190161);BrettCocalestransitiontoengineeringwasnotcompleted(BP
HZNMBI00190128);andHarryThierenshandoverofwellsdirectorrolesandaccountabilitiesto
DaveRichwasnotcompleted(BPHZNMBI00190128).

182
5. CommunicationProblems

BPhadacommunicationplaninplacetoalleviatesomeoftheconfusion
aboutwhoshouldmakedecisionsconcerningrigoperationsandwhensuch
decisionsshouldbemade.AccordingtotheBPscommunicationplan,BPwas
responsibleforallofthedecisionsbeingmadeontheDeepwaterHorizon.

Thecommunicationplandepicteddirectlinesbetweenthewellsite
leadersandonshorepersonnel;andthereweremultipledailymeetingsbetween
BPpersonnelinHoustonandpersonnelontheDeepwaterHorizon.Nonetheless,
thePanelfoundevidencethatBPpersonnelinHoustondidnottransfercritical
informationtorigpersonnel.AsnotedpreviouslyinthisReport,this
communicationfailure,whichresultedintherigcrewbeingunawareof
increasingoperationalrisks,mayhavecreatedafalsesenseofsecurityamong
thoseontherig.

6. HealthandSafety

ThestatedgoalofBPssafetypolicywas[n]oaccidents,noharmto
peopleandnodamagetotheenvironment.AsreferencedearlierinthisReport,
BPssafetyrules(calledthegoldenrules)providedkeycontrolsand
procedureswithwhichtheworkforcemustcomply.BPsgoldenrulesalso
requiredidentifyingthehazardsandassessingtherisksassociatedwiththe
activitiesonaregularbasis.

KentWellstestifiedaboutBPssafetypolicies:

Well,soourbeliefaroundsafetyisthatweneedeveryonefeeling
responsiblefornotonlytheirownpersonalsafetybutthesafetyofthe
peoplearound.

Andsoourourpoliciesandourproceduresandourapproacharesortof
gearedtowardstryingtocreatethatsafetyculturesoitsnotwhereone
personistryingtodoit.Wetrytohaveeverybodythinkingaboutwhat
arethehazards,whatactivityarewegoingon.

Wehaveapolicyofstoppingthejob.Wehopefullymakesurethatevery
singleemployeeoutthereknowsthatatanypointtheycanstopthejob

183
whentheybelievetheresahazardthatwehaventaddressedortheresa
riskthatneedstobedealtwith. 450

NotwithstandingBPshealthandsafetypolicies,asdetailedearlierinthis
Report,thePanelfoundthatthecompanyconducteddrillingoperationsat
Macondoinamannerthatincreasedtherisksoftheproject.

7. FocusonCostSavings

ThePanelfoundevidencethatBPpersonnelwerecompensatedandtheir
performancereviewed,atleastinpart,basedupontheirabilitiestocontrolor
reducecosts.Atsomepointin2008,BPimplementedaneverydollarcounts
programthatwasfocusedonreducingcostsbyimprovingtheefficiencyof
drillingoperations. 451

Performanceevaluationsreflectedthiscostcuttingfocus.An
operationalperformancemeasureforBPdrillingpersonnelwasdeliveringa
wellwithcostsundertheauthorizedexpenditureamount.Therewasno
comparableperformancemeasureforoccupationalsafetyachievements.

ThePanelreviewedperformanceevaluationsconductedin2009of13BP
personnelinvolvedinMacondooperations.Theseindividualshadvarious
differentresponsibilitiesontheMacondoproject;however,theseevaluations
maynothavebeenreflectiveofeachpersonspositionsonApril20,2010,
particularlygiventhenumberofreorganizationsthatoccurredatBP.ThePanel
foundthat12ofthe13evaluationscompletedbyBPpersonnelcapturedcosts
savingsasaspecificperformancemeasure.

AsmentionedpreviouslyinthisReport,intheweeksleadinguptoApril
20,theBPMacondoteammadeaseriesofoperationaldecisionsthatreduced
costsandincreasedrisks.Forexample,whenconsideringthelockdownsleeve
installationontheMacondowellinJanuary2010,MarkHafleandMerrickKelley
reviewedthe$2.2millionofincrementalcostbenefittoBP.Haflediscussedthis
furtherwithSims,andtheyagreedthatBPshouldmoveforwardwiththelock
downsleeveinstallationaftersettingthesurfacecementplugandpriortothe
departureoftheDeepwaterHorizonfromtheMacondowell.Thisdecision

450 Wellstestimonyat18.
451 Guidetestimony,October7,2010,at14143.

184
affectedtheprocedureforthesettingofthesurfaceplug,thedisplacement,and
thenegativetestsequence. 452

Onthedayoftheblowout,aBPcontractorsuggestedmakingan
additionalwashrunduetohisconcernsaboutachievingasuccessfullead
impressiontoolimpression. 453Guiderespondedbysaying[w]ewillnever
knowifyourmilliondollarflushrunwasneeded.Howdoesthisgetustosector
leadership(?) 454

ThePanelfoundthatanumberofBPdecisionswerenotsubjectedtoa
formalriskassessmentprocess.Inaddition,thePanelfoundnoevidence
indicatingthat,atthetimeoftheblowout,BPhadinplaceanypolicyorpractice
toassesswhethersafeoperationswerebeingcompromisedtoachievecost
savings.

B. TransoceansPracticesandProcedures

1. SafetyRelatedPolicies

TransoceanwasresponsibleforthesafeoperationoftheDeepwater
Horizon.Thecompanyhastouteditscommitmenttosafetybypointingtowards
itscompanywidesafetymanagementprogramsandtheintensivetraining
regimenrequiredofitsrigcrews. 455

AccordingtoTransoceanshealthandsafetypolicystatement,each
employeehastheobligationtointerruptanoperationtopreventanincident
fromoccurring. 456During2010,Transoceanhadanarrayofacronymbased
safetyprogramsthatattemptedtoensuresaferigoperations(THINK,START,
CAKE,FOCUS,andTOFS).Transoceandesignedthesesafetyprogramstoallow
rigpersonneltoidentifyhazardsandstopworkwhennecessary.ThePanel
foundnoevidence,however,thatonApril20anyoneonboardtheDeepwater
Horizonidentifiedrisksthatwouldwarrantshuttingdownoperations.

TransoceansTHINKprogramwasdesignedtoincreaseawarenessof
safetyissuesthroughtaskplanning,hazardidentificationandassessmentofthe

452BPHZNMBI0097490.
453BPHZNMBI00258505.
454BPHZNMBI00258507.

455SeeSubmissionofTransoceantotheJIT(May13,2011),at1.

456BPHZNMBI00001604.

185
likelyconsequencesofapotentialincident.TheTHINKprogramattemptsto
reducerisksthroughpreventativeandmitigatingactions. 457Accordingto
Transoceandocuments,[t]heTHINKprocessremindspersonneltothinkabout
everythingtheydobeforeactuallydoingit....THINKisusedbythecompany
toformulateandcommunicatetheplan....TheTHINKPlanningProcessis
utilizedforRiskManagementofallactivitiesandtaskscarriedoutthroughout
thecompany. 458

TransoceansSTARTprogramwasarelatedprocessthatisdefinedas
See,Think,Act,Reinforce,andTrack.TransoceanstatedthattheSTART
processmonitor[ed]theoperationandreinforce[ed]safebehavior,while
correctinganyunsafeactsorconditions,[and]isvitaltoensurethatthe
necessarycontrolsremaininplaceduringimplementation....STARTisusedby
thecompanytomonitortheplanandrecognizewhentheplanisnolonger
suitable. 459

CAKESwasTransoceansprogramfortaskplanning.Theacronym
incorporatesdifferentrulesusingthewordscomply,authority,knowledge,
experience,andskills. 460TransoceansFOCUSapproachseekstomake
consistenttheexecutionofTHINKandSTARTacrosstheorganization. 461TOFS
(timeoutforsafety)wasTransoceansstatedpolicythatallowedtaskstobe
stopped(plannedorunplanned)toensuresafeoperations. 462

Noneofthesepolicieseliminatedconcernsaboutsomemembersofthe
Transoceancrew.ThePanelfoundevidencethatPaulJohnston,Transoceanrig
manager,questionedwhethertheTransoceanmembersoftheDeepwaterHorizon
crewwereadequatelypreparedtoindependentlyrecognizehazards.InaMarch
2010emailtoGuide,Johnson offeredacandidassessmentoftherigcrewand
theirabilities:

John,Ithoughtaboutthisalotyesterdayandaskedforinputfromtherig
andnoneofuscouldcomeupwithanythingwearenotalreadydoingor
havedoneinthepastwithlittlesuccess.Therewasacommontheme
fromallthough.Nothingtakestheplaceofsupervisorinvolvementtoask

457SeeSubmissionofTransoceantotheJIT(May13,2011),at2.
458BPHZNMBI00001764.
459BPHZNMBI00001626.

460BPHZNMBI00001769.

461BPHZNMBI00001627.

462BPHZNMBI00001770.

186
thatquestionofthehands,intheTHINKPlans,andtomakethemthink
forthemselvesandleadthemintherightdirectionbymentoringthem.
Youcantellthemwhatthehazardsare,butuntiltheygetusedto
identifyingthemtheirselves,theyareonlyfollowingyourlead.Ihavent
givenuponthisandifIhaveanepiphanyIwillsendyouanemail.
BelieveitornotwhenIamtroubledorstumpedItalkedwithmywifeas
sheisagoodlistenerandgetsmeheadedintherightdirection.Maybe
whatweneedisanewperspectiveonhazardrecognitionfromsomeone
outsidetheindustry. 463

JohnsonsassessmentwasreinforcedbyaMarch2010LloydsRegister
auditofTransocean,whichfoundthat[Rigcrews]dontalwaysknowwhat
theydontknow.Frontlinecrewsarepotentiallyworkingwiththemindsetthat
theybelievetheyarefullyawareofallthehazardswhenitishighlylikelythat
theyarenot. 464

TheLloydsauditalsoevaluatedtheDeepwaterHorizoninMarch2010and
foundthattherewasastrongteamcultureonboardDeepwaterHorizonandthe
levelsofmutualtrustevidentbetweenthecrewsmeansthattherigsafetyculture
wasdeemedtoberobust,largelyfair,andinclusive,whichwascontributingtoa
justculture. 465Thisauditfoundthattherigcrewsstrengthswereleadership,
theworkforcesinfluenceonsafety,theleveloftrustbetweentheteams,andthe
provisionofeffectiveresourcestosupportsafeoperations. 466

Butthesameauditfoundweaknesses,includingmanagementofchange
andthecomplexityofsomeriskmanagementprocedures.Whilethemajorityof
thecrewwascomfortablewithidentifyingandunderstandingthehazardsof
theirrespectivejobs,supervisorsandrigleadershipteamshadconcernsthat:

Theworkforcewasnotalwaysawareofthehazardstheywere
exposedto,relatingtoboththeirjobandtootherjobsbeingconducted
inthesame/adjoiningworkareas;
THINKPlansdidnotalwaysidentifyrelevantmajorhazardsrelatedto
thattask;

463BPHZNMBI00225048.
464TRNHCEC90501.
465TRNHCEC90579.

466Id.

187
Therisksposedbyidentifiedhazardswerenotfullyunderstoodand
thesubsequentcontrolmeasureswerenotalwaysappropriate;
Emerginghazardsduringtaskexecution,andhazardswithachanging
risklevel,werenotalwaysdetectedorfullyappreciated;and
Theydontknowwhattheydontknow. 467

Thisdifferenceinawarenessofhazardsclearlydemandedattention,as
frontlinecrewswerepotentiallyworkingwithamindsetthattheybelievedthey
werefullyawareofallthehazardswhenitislikelythattheywerenot.Ifacrew
isnotawareofrisksandhazards,itislesslikelytobeabletorecognizeunsafe
situationsandwillnottakeimmediateactionstomitigaterisks.

Takentogether,theauditsanddocumentaryevidencesuggestthatthe
DeepwaterHorizoncrewwasgenerallyeffectiveandsafetyconscious,butmay
nothavehadthetools,abilityoropportunitytoidentifyandmitigatehazards
associatedwithrigoperations.

2. Transocean21dayHitchPolicy

InSeptember2009,Transoceanreviseditsoffshoreemployeehitch
schedulefrom14to21days.Therevisiontotheworkscheduleswaspartially
duetoatransportationschedulethatwouldallowforfewerflightstoandfrom
thefacilities.Sevenofthe11individualswhodiedonboardtheDeepwater
Horizonhadbeenonboardformorethan19days.ThePanel,however,foundno
evidencethattheTransoceanhitchscheduleaffectedrigpersonnelsabilityto
performtheirduties.SeeAppendixN.

3. TransoceanIncentiveAwards

Transoceanhadmultiplebonusincentives,dependentuponlevelof
employment(rig,division,rigmanagers).Variablesofthebonusequations
were:safetyperformance;individualperformance;cashflowvalueadded;in
servicedailycost;rigdowntime;lostrevenue;andoverheadcost.

Rigemployeesbonusincentiveswerebasedon60%costrelateditems,
20%safetyperformanceand20%individualperformance.Divisionemployees
bonusincentiveswereweighedinthesameway:60%costrelateditems,20%
safetyperformanceand20%individualperformance.Rigmanagersbonus

467TRNHCEC90501.

188
incentiveswere50%discretionaryfactors,37.5%costrelateditemsand12.5%
safetyperformance.

ThePanelfoundnoevidencethatdecisionsbyTransoceanpersonnelto
deferrigmaintenanceand/ordowntimeweredirectlyrewardedwithanytype
ofbonuspayment.However,Transoceanspolicyofrewardingpersonnelbased
uponanumberofdifferentvariables(e.g.,downtime,lostrevenue,cashflow
valueadded)whentryingtomaintainsafeoperationsintroducedconflicting
prioritiesandcreatedrisksthatoperationaldecisionsmightcompromisesafety.

C. BPandTransoceanBridgingDocument

BPandTransoceandevelopedabridgingdocumentforoperations
associatedwithdeepwaterdrillinginNorthAmerica.Itoutlinesthe
responsibilityofbothpartiestoensurethathealthandsafetymanagement
systemsareinplace,andthatalloperationsaretobeconductedinasafemanner.
Butthebridgingdocumentdidnotincludeproceduresonwellcontrol,acrucial
topicforsafedrillingoperations. 468ThiswasinconsistentwithBPsprescribed
policiesforsafedrillingoperations. 469

D. StopWorkAuthority

TheDeepwaterHorizonhadmultiplestopworkpoliciesinplayontheday
oftheblowout.BP,TransoceanandHalliburtonpersonnelallhadcompany
specificpoliciestostopworktheydeemedtobeunsafe.

BPsgoldenrulesofsafetystate,[e]veryonewhoworksfororonbehalf
ofBPisresponsiblefortheirsafetyandthesafetyofthosearoundthem. 470
Transoceansstopworkauthoritystates,[e]achemployeehastheobligationto
interruptanoperationtopreventanincidentfromoccurring. 471Halliburtons
hazardobservationandcommunicationpolicystates[t]heHOCCardhasbeen
designedforusebyallemployeesregardlessoftheirpositionortheirtypeor

468ThePanellocatedstandalonewellcontrolmanualswithinBPandTransocean;however,but
nodocumentbridgingthetwomanualstogether.
469Section15.2.17ofBPsDWOPrequiresthatawellcontrolinterface/bridgingdocumentshall

bepreparedwiththeappropriatecontractortoensurethereisclearunderstandingof
responsibilitiesandwhichreferencedocumentsandprocedureswillbeusedinawellcontrol
situation.
470BPsGoldenRulesofSafety.

471BPHZNMBI00001604.

189
placeofwork.Thephilosophyofthecompanyisthataccidentscanbeprevented
bybreakingthechainofeventsthatfittogethertoformanaccident.

AllwitnesseswhotestifiedbeforethePanelstatedthattheywereawareof
thestopworkauthorityandtheirobligationstowardssafety.Nevertheless,no
stopworkauthoritywasimplementedonthedayoftheblowoutdespitethefact
thattherigcrewencounterednumerousanomaliesthatmighthavecausedsuch
authoritytobeinvoked.

190
XVI. ConclusionsRegardingInvolvedCompaniesPractices

BP,TransoceanandHalliburtoneachhadstopworkprograms.The
Panelfoundnoevidencetosuggestthattherigcrewmemberswereawareofthe
multipleanomaliesthatoccurredonApril1920.Thefailureoftherigcrewto
stopworkontheDeepwaterHorizonafterencounteringmultiplehazardsand
warningswasacontributingcauseoftheMacondoblowout.

ThePanelfoundnoevidencethatBPperformedaformalriskassessment
ofcriticaloperationaldecisionsmadeinthedaysleadinguptotheblowout.
BPsfailuretofullyassesstherisksassociatedwithanumberofoperational
decisionsleadinguptotheblowoutwasacontributingcauseoftheMacondo
blowout.

ManyofthedecisionsmadeleadinguptheDeepwaterHorizonblowout
includingthetimingoftheinstallationofthelockdownsleeve,theconducting
ofmultipleoperationsduringmuddisplacement,andtheuseoflostcirculation
materialpillsasspacerloweredthecostsofthewellandincreasedoperating
risks.Thesedecisionswerenotsubjectedtoaformalriskassessment.BPscost
ortimesavingdecisionswithoutconsideringcontingenciesandmitigation
werecontributingcausesoftheMacondoblowout.

Multipledecisions(thenumberofcentralizersrun,thedecisionnottorun
acementevaluation,thedecisionnottocirculateafullbottomsup,andothers)
wereindirectcontradictionwiththeDWOPguidancetokeepriskaslowas
reasonablypractical.BPsfailuretoensureallrisksassociatedwithoperations
ontheDeepwaterHorizonwereaslowasreasonablypracticablewasa
contributingcauseoftheMacondoblowout.

Asaprudentoperator,BPshouldhavecompletecontrolofoperationsand
issuessurroundingoperationsonitslease.ExamplesofitemsBPshouldhave
hadcontrolandresponsibilityoverare:

MaintenanceoftheDeepwaterHorizon;
Generalalarmconfigurationandoperation;
BOP5yearmajorinspectionrequirements;
BOPmodifications;and
Cementjob.

191
BPsfailuretohavefullsupervisionandaccountabilityovertheactivities
associatedwiththeDeepwaterHorizonwasacontributingcauseofthe
Macondoblowout.

AspartofBPsoperationsintegrityandriskmanagementprograms,BP
developedasystematic,riskbasedMOCtodocument,evaluate,approveand
communicatechangestofacilities,systems,process,procedures,organization,
andpersonnel.TheBPMOCprocessdidnotdocumentcertaincriticalchanges,
including:

DuringApril1419,2010,severalBPcasingdesignchangesoccurred,yet
multipleMOCdocumentswereneverofficiallycompletedduetoa
clericalerror.
ThesecasingdesignchangesfortheMacondowellweresubmittedto
MMSforapprovalpriortotheMOCbeingapproved,accordingto
testimonybySimsonAugust26,2010.
Duringareorganizationin2010,theresponsibilityshiftfromthedrilling
teamleader(DavidSims)tothedrillingengineeringteamleader(Gregg
Walz)wasnotproperlycompleted.
AMOCwasnotcompletedfortheoperationsdrillingengineer(Bret
Cocales)inregardtohistransfertotheBPdrillingengineerteam.
ExamplesofBPsfailuretoconductaproperriskanalysisinclude:
(1) NoformalMOCriskanalysisdocumentwascompletedforthe
wellsiteleadertransitionfromSepulvadotoKaluza.
(2) Rigprocedurechanges,suchasreplacingtheviscousspacer
withlostcirculationmaterial,werenotsubjectedtoaformal
riskanalysis.The450barrellostcirculationmaterial(MI
SWACOFormASetandFormASqueeze)withpolymer
viscosifierandweightingmaterialaddedwashighly
thyrotrophic(resistanttoinitiateflow)andviscous.Thiswould
leadtoaresistancetoflowinthecolderkillline(locatedoutside
theriser),resultinginthesuppressionofpressurereadings
usingthekilllineforthenegativetest.
(3) Thedecisionnottorunthecementbondloglackedaproper
riskevaluationbecauseseveralfactorswerenotconsidered,
suchastherelativelysmallvolumeoffoamcementpumped,
insufficientcentralizationofthecasingandquestionable
conversionofthefloatcollar.

192
BPsfailuretodocument,evaluate,approve,andcommunicatechanges
associatedwithDeepwaterHorizonpersonnelandoperationswasapossible
contributingcauseoftheMacondoblowout.

BPandTransoceanhadabridgingdocumentthatmergedtheirrespective
safetyprograms.Thebridgingdocumentdidnotaddresswellcontrol.BPand
Transoceanhadstandalonewellcontrolmanuals,andtherigcrewwastrained
andoperatedinaccordancewithTransoceansmanual.ThefailureofBPand
Transoceantoensuretheyhadacommon,integratedapproachtowellcontrol
wasapossiblecontributingcauseoftheMacondoblowout.

BPrequireditsemployeesandcontractorpersonnelwithwellcontrol
responsibilitiestobetrainedeverytwoyearsinwellcontrolinaccordancewith
BPsSubpartOplan.ThePanelfoundthatallpersonnelidentifiedwithinBPs
planweretrainedinaccordancewiththeBPSubpartOplan.Thecurrent
SubpartOruledoesnotidentifypersonnelwhoshouldhavetraininginwell
controloperations(includingmonitoringthewell)beyondthepersonnelwhoare
interfacingwiththeBOPstackanddrillflooroperations.Thefailureofthe
currentSubpartOruletoidentify(bydefinition)personnelwhoneedtobe
trainedinwellcontroloperations,specificallyinkickdetection,wasa
possiblecontributingcauseoftheMacondoblowout.

193
XVII. SummaryofPanelConclusions

A. WellDesignandCementing

ThePanelconcludedthatacombinationofcontamination,over
displacement,andpossiblynitrogenbreakoutoftheshoecementwerecausesof
theblowout.

Thedecisiontosettheproductioncasinginalaminatedsandshalezone
inthevicinityofahydrocarbonintervalwasacontributingcauseoftheblowout.

Withtheknownlossesexperiencedinthewell,BPsfailuretotake
additionalprecautions,suchasestablishingadditionalbarriersduring
cementing,wasacontributingcauseoftheblowout.

BPandHalliburtonsfailuretoperformtheproductioncasingcementjob
inaccordancewithindustryacceptedrecommendationsasdefinedinAPIRP65
wasacontributingcauseoftheblowout.

BPsdecisiontosetthefloatcollaracrossthehydrocarbonbearingzones
ofinterest,insteadofatthebottomoftheshoe,wasacontributingcauseofthe
blowout.

BPsfailuretoinformthepartiesoperatingonitsbehalfofallknownrisks
associatedwithMacondowelloperationswasacontributingcauseofthe
blowout.

BPsfailuretoappropriatelyanalyzeandevaluaterisksassociatedwith
theMacondowellinconnectionwithitsdecisionmakingduringthedays
leadinguptotheblowoutwasacontributingcauseoftheblowout.

BPsfailuretoplacecementontopofthewiperplugwasacontributing
causeoftheblowout.

BPsdecisiontouseafloatcollarthatwasnotsufficientlydebristolerant
wasapossiblecontributingcauseoftheblowout.

BPsdecisiontosetcasingintheproductionintervalwithknowndrilling
marginlimitsattotaldepthwasapossiblecontributingcauseoftheblowout.

194

ThefactthattheDeepwaterHorizoncrewmembersdidnothaveavailable
tothemaccurateandreliableflowlinesensorsduringcementingoperationsin
ordertodeterminewhethertheywereobtainingfullreturnswasapossible
contributingcauseoftheblowout.

VariousdecisionsbyBPandHalliburtonwithrespecttoplanningand
conductingtheMacondoproductioncasingcementjobwerepossible
contributingcausesoftheblowout.

ThefailureofBPswellsiteleadersandtheTransoceanDeepwaterHorizon
rigcrewtorecognizetherisksassociatedwithcementingoperationsproblems
thatoccurredbetweenApril19andApril20wasapossiblecontributingcauseof
theblowout.

B. FlowPath

ThePanelconcludedthathydrocarbonflowduringtheblowoutoccurred
throughthe97/8x7inchproductioncasingfromtheshoetrackasaresultof
floatcollarandshoetrackfailure.

C. TemporaryAbandonment,KickDetection,andEmergency
Response

ThefailureoftheDeepwaterHorizoncrew(includingBP,Transocean,and
SperrySunpersonnel)todetecttheinfluxofhydrocarbonsuntilthe
hydrocarbonswereabovetheBOPstackwasacauseofthewellcontrolfailure.

TheDeepwaterHorizoncrews(BPandTransocean)collective
misinterpretationofthenegativetestswasacauseofthewellcontrolfailure.

TheDeepwaterHorizoncrewsinabilitytoaccuratelymonitorpitlevels
whileconductingsimultaneousoperationsduringthecriticalnegativetestwasa
contributingcauseofthekickdetectionfailure.

BPsfailuretoperformanincidentinvestigationintotheMarch8,2010
wellcontroleventanddelayedkickdetectionwasapossiblecontributingcause
totheApril20,2010kickdetectionfailure.

195
BPsfailuretoinformthepartiesoperatingonitsbehalfofallknownrisks
associatedwiththeMacondowellproductioncasingcementjobwasapossible
contributingcauseofthekickdetectionfailure.

BPsuseofthelostcirculationmaterialpillsasaspacerintheMacondo
well,whichlikelyaffectedthecrewsabilitytoconductanaccuratenegativetest
onthekillline,wasapossiblecontributingcauseofthekickdetectionfailure.

TheoverallcomplacencyoftheDeepwaterHorizoncrewwasapossible
contributingcauseofthekickdetectionfailure.

MarkHaflesfailuretoinvestigateorresolvethenegativetestanomalies
notedbyDonaldVidrinewasapossiblecontributingcauseofthekickdetection
failure.

Thefailureofthewellsiteleaderstocommunicatewellrelatedissues
withthemanagersonboardtheDeepwaterHorizonwasapossiblecontributing
causeofthekickdetectionfailure.

BPsfailuretogetcompleteandfinalnegativetestprocedurestotherigin
atimelyfashionwasapossiblecontributingcauseofthekickdetectionfailure.

TheDeepwaterHorizoncrewshesitancetoshutintheBOPimmediately
wasapossiblecontributingcauseofthekickdetectionfailure.

BPsfailuretoconductthefirstofthetwonegativetestswasapossible
contributingcauseofthekickdetectionfailure.

TherigcrewsdecisiontobypasstheSperrySunflowmeterwhile
pumpingthespaceroverboardwasapossiblecontributingcauseofthekick
detectionfailure.

ThefailureofBPsandTransoceanswellcontroltrainingandMMS
requirementstoaddresssituations,suchasnegativetestsanddisplacement
operations,wasapossiblecontributingcauseofthewellcontrolfailure.

Thedecisiontousethemudgasseparatorduringthewellcontrolevent
wasacontributingcauseoftheresponsefailure.

196
TheambiguitywithintheTransoceanwellcontrolmanualonwhentouse
thediverterandnotthemudgasseparatorwasacontributingcauseofthe
responsefailure.

ThefailureofthepersonnelontheDeepwaterHorizonbridgemonitoring
thegasalarmstonotifytheDeepwaterHorizoncrewintheenginecontrolroom
aboutthealarmssothattheycouldtakeactionstoshutdowntheengineswasa
contributingcauseoftheresponsefailure.

Therigfloorcrewsinabilitytodeterminethelocationofthekickin
relationtotheBOPandthevolumeofhydrocarbonscomingtotheriginamatter
ofsecondswasapossiblecontributingcauseoftheresponsefailure.

Therigcrewsfailuretoinitiatetheemergencydisconnectsystemuntil
afterthehydrocarbonswerehadrisenabovetheBOPstackwasapossible
contributingcauseoftheresponsefailure.

Theinhibitedgeneralalarmsystemwasapossiblecontributingcauseof
theresponsefailure.

Transoceansfailuretotrainthemarinecrewtohandleseriousblowout
eventswasapossiblecontributingcauseoftheresponsefailure.

D. IgnitionSource

Themostprobableignitionsourcewaseitherengineroomnumber3or
engineroomnumber6.

Thecatastrophicfailureofthemudgasseparatorcreatedapossible
ignitionsourcewiththegasplumereleasedontotherigfromthewell.

Thelocationoftheairintakesforthenumber3andnumber6engine
roomswasacontributingcauseoftheDeepwaterHorizonexplosion.

Thefailureoftheoverspeeddevicestoinitiateshutdownoftheengines
wasacontributingcauseoftheDeepwaterHorizonexplosion.

FleytasfailuretoinstructtheDeepwaterHorizonengineroomcrewto
initiatetheemergencyshutdownsequenceafterreceiving20gasalarms

197
indicatingthehighestlevelofgasconcentrationwasacontributingcauseinthe
DeepwaterHorizonexplosion.

Theclassificationofengineroomsnumber3andnumber6asnon
classifiedareaswasapossiblecontributingcauseoftheDeepwaterHorizon
explosion.

Thefailuretoidentifytherisksassociatedwithlocatingtheairintakeof
engineroom3incloseproximitytothedrillfloorwasapossiblecontributing
causeoftheDeepwaterHorizonexplosion.

Theabsenceofemergencyshutdowndevicesthatcouldbeautomatically
triggeredinresponsetohighgaslevelsontherigwasapossiblecontributing
causeoftheDeepwaterHorizonexplosion.

ThefailureofABSandTransoceantodocumentwhichdeviceswere
testedtoensurealldevicesaretestedisapossiblecontributingcauseofthe
DeepwaterHorizonexplosion.

TheDPMODUoperatingphilosophywhenconsideringtheperformance
ofanEmergencyShutdown(ESD)isapossiblecontributingcauseofthe
DeepwaterHorizonexplosion.

E. BlowoutPreventer

ThePanelconcludedthatthefailureoftheBOPtoshearthedrillpipeand
sealthewellborewascausedbythephysicallocationofthedrillpipenearthe
insidewallofthewellbore,whichwasoutsidetheblindshearramcutting
surfaceduringactivationonApril20orApril22.

Theelasticbucklingofthedrillpipeforcedthedrillpipetothesideofthe
wellboreandoutsideoftheBSRcuttingsurface,andwasacontributingcauseof
theBOPfailure.

Theforcesgeneratedbytheflowfromthewelland/orforcesgeneratedby
theweightofthedrillpipeledtotheelasticbucklingofthedrillpipeandwasa
possiblecontributingcauseoftheBOPfailure.

198
F. CompanyPractices

ThefailureofthecrewtostopworkontheDeepwaterHorizonafter
encounteringmultiplehazardsandwarningswasacontributingcauseofthe
Macondoblowout.

BPsfailuretofullyassesstherisksassociatedwithanumberof
operationaldecisionsleadinguptotheblowoutwasacontributingcauseofthe
Macondoblowout.

BPscostortimesavingdecisionswithoutconsideringcontingenciesand
mitigationwerecontributingcausesoftheMacondoblowout.

BPsfailuretoensureallrisksassociatedwithoperationsontheDeepwater
Horizonwereaslowasreasonablypracticablewasacontributingcauseofthe
Macondoblowout.

BPsfailuretohavefullsupervisionandaccountabilityovertheactivities
associatedwiththeDeepwaterHorizonwasacontributingcauseoftheMacondo
blowout.

BPsfailuretodocument,evaluate,approve,andcommunicatechanges
associatedwithDeepwaterHorizonpersonnelandoperationswasapossible
contributingcauseoftheMacondoblowout.

ThefailureofBPandTransoceantoensuretheyhadacommon,
integratedapproachtowellcontrolwasapossiblecontributingcauseofthe
Macondoblowout.

ThefailureofthecurrentSubpartOruletoidentify(bydefinition)
personnelwhoneedtobetrainedinwellcontroloperations,specificallyinkick
detection,wasapossiblecontributingcauseoftheMacondoblowout.

199
XVIII. Conclusion

AsdetailedinthisReport,theblowoutattheMacondowellonApril20,
2010wastheresultofaseriesofdecisionsthatincreasedriskandanumberof
actionsthatfailedtofullyconsiderormitigatethoserisks.Whileitisnot
possibletodiscernwhichprecisecombinationofthesedecisionsandactionsset
theblowoutinmotion,itisclearthatincreasedvigilanceandawarenessbyBP,
TransoceanandHalliburtonpersonnelatcriticaljuncturesduringoperationsat
theMacondowellwouldhavereducedthelikelihoodoftheblowoutoccurring.

BPwelldesignerssetthecasinginalocationthatcreatedadditionalrisks
ofhydrocarboninflux.Evenknowingthis,BPdidnotsetadditionalcementor
mechanicalbarriersinthewell.BPmadetwoadditionalsignificantdecisions
thatfurtherincreasedrisksfirst,itdecidedtohavetheDeepwaterHorizoncrew
installalockdownsleeveaspartofthetemporaryabandonmentprocedure.
Second,BPdecidedtousealostcirculationmaterialasspacer,whichrisked
clogginglinesusedforwellintegritytests.

BPpersonnelandTransoceanpersonnelfailedtoconductanaccurate
negativetesttoassesstheintegrityoftheproductioncasingcementjob.The
DeepwaterHorizonrigcrew,therefore,performedtemporaryabandonment
procedureswhileunawareofthefailedcementjobbeneaththemandthe
loominginfluxofhydrocarbons.Unfortunately,therigcrewthenlimiteditskick
detectionabilitiesbydecidingtobypasstheSperrySunflowmeterwhen
displacingfluidfromthewelloverboard.

TheDeepwaterHorizonrigcrewmissedsignsofakickandthuswas
delayedinreactingtothewellcontrolsituation.Oncetheflowreachedtherig
floor,thecrewclosedtheupperannularanduppervariableboreramand
divertedtheflowtothemudgasseparator.Themudgasseparatorcouldnot
handlethevolumeoftheblowoutandexplosionsfollowed.Additionally,
forensicanalysisbyDNVstronglysuggeststhatbythetimeacrewmemberon
thebridgeactivatedtheemergencydisconnectsystem,theexplosionshad
damagedtheDeepwaterHorizonsmultiplexcableandhydrauliclines,which
renderedinoperabletheBOPstacksblindshearrams.

Theforceoftheblowout,andpossiblytheforcefromdrillpipeinthe
riser,buckledthedrillpipeandplaceditinapositionwhereitcouldnotbe
completelyshearedbytheblindshearramblades.Asaresult,theblindshear

200
ram,whenactivatedoneitherApril20orApril22,couldnotshearthedrillpipe
andsealthewellbore.FlowfromtheMacondowellcontinuedfor87daysafter
theblowout,spewingalmost5millionbarrelsofoilintotheGulfofMexico.

InthefollowingsectionofthisReport,thePanelmakesrecommendations
toimprovethesafetyofoffshorewelloperations.Recommendedchangesto
regulatoryrequirementsandoversightaremadeinthefollowingareas:well
design(particularlyforhighflowpotentialwells),wellintegritytesting,kick
detectionandresponse,rigconfiguration,blowoutpreventers,andremotely
operatedvehicles.

201
XIX. Recommendations

A. WellRecommendations

1. TheAgencyshouldconsiderpromulgatingregulationsthatrequirethe
negativepressuretestingofwellswherethewellborewillbeexposedto
negativepressureconditions,suchaswhentheBOPandriserare
disconnectedfromthewellheadduringpermanentortemporary
abandonmentprocedures.Allsubseawellswillexperienceanegative
pressureconditionwhentheBOPandriseraredisconnectedfromthe
wellheadateithertemporaryorpermanentabandonmenttime.While
operationsarebeingconductedonawell,themudweightexertedonthe
formationisfromtherigtotheformation.PriortounlatchingtheBOP,
themudintheriserisdisplacedwithseawaterinpreparationoftherigto
moveoffoflocation.Thisreducestheeffectivemudweightonthe
formationshouldacementplugnotsetproperly. 472HadtheDeepwater
Horizoncrewinterpretedthenegativetestproperly,theblowoutmayhave
beenaverted.

2. TheAgencyshouldconsiderincorporatingintheCodeofFederal
Regulation(CFR)partsofAPIRecommendedPractice(RP)65,parts1and
2;TheAgencyshouldalsoconsidersupplementingtheCFRtorequire
compliancewithspecificAPIRP65requirementsrelatingtoamongother
things:aminimumholediameterof3.0inchesgreaterthanthecasing
outerdiameter;ratholemuddensitygreaterthancement;andmud
conditioningvolumegreaterthanoneannularvolume.Currently,the
CFRonlyrequiresadesignatedoperatortoprovideawrittenstatementon
howitevaluatedthebestpracticesincludedinAPIRP65. 473

3. TheAgencyshouldresearchandconsider,withaNoticetoLessees(NTL),
definingthetermsafedrillingmargin(s)in30CFR250.414(c),which
refersto[p]lannedsafedrillingmarginbetweenproposeddrillingfluid
weightsandtheestimatedporepressures.Thedefinitionshouldbe
expandedtoencompassporepressure,fracturegradientandmudweight.
ThisexpandeddefinitionwouldbebeneficialtoBOEMREandindustry.

472Thisrequirementwasincorporatedintotheregulationswiththeinterimfinalruleeffective
October14,2010.
473API65Part2wasincorporatedintotheregulationswiththeinterimfinalruleeffective

December2010.Thisrecommendationistoincorporatespecificswithintheregulations.

202

4. TheAgencyshouldconsiderpromulgatingregulationsthatrequireat
leasttwobarriers(onemechanicalandonecementbarrier)forawellthat
isundergoingtemporaryabandonmentprocedures. 474Asseeninthis
eventtheonlybarrierbetweentherigandtheformationwasacement
plugintheshoetrack.Havingacementplugandanadditional
mechanicalbarrierwouldaddanincreasedsafetyfactor.Whilethe
Macondowelldidhavedualfloatvalves,thePaneldoesnotbelievethat
floatvalvesshouldbeconsideredamechanicalbarrier. 475

5. TheAgencyshouldconsiderrevising30CFR250.420(b)(3),whichis
includedintheInterimFinalRule,toclarifythatafloatcollar/valveisnot
tobeconsideredtobeamechanicalbarrier.Floatcollarsaredesigned
topreventthecementfromutubingbackintotheworkstring;theyare
notdesignedtokeeptheformationpressuresfromcomingupthe
wellbore.AdualfloatvalvewasusedintheMacondowell.Clarifying
thelimitationsofthefloatcollarwouldpreventoperatorsfromrelyingon
adevicenotdesignedspecificallyforpressurecontainment. 476

6. TheAgencyshouldresearchandconsiderdefininglostreturns,partial
returns,fullreturns,andcementvolumemarginwithin30CFR
250.428.Asseeninthisevent,lostreturnsplayedalargerolein
accuratelydeterminingholestabilityandcementplacement.However,
theregulationsdonotdefinewhatisconsideredlostreturns.

B. KickDetectionandResponseRecommendations

1. TheAgencyshouldconsiderissuingaSafetyAlertsimilartoSafetyAlert
284thataddresseshowthemovementoffluidacrosstherigcanlimitthe
monitoringcapabilitiesofrigpersonnel.AsdiscussedintheReport,the
multiplesimultaneousoperationsinvolvingfluidmovementthatwere

474Thisrecommendationwasincorporatedintotheregulationswiththeinterimfinalrule
effectiveOctober14,2010.
475Thisrecommendationwasincorporatedintotheregulationswiththeinterimfinalrule

effectiveOctober14,2010.
47630CFR250.420wasrevisedwiththeinterimfinalruletorequiretwobarriers.Thisrevision

allowsfortheuseofadualfloatvalveoronefloatvalveandamechanicalbarrierinadditionto
thecement.ThePanelrecommendsthattheagencyshouldnotallowtheuseoffloatvalvesasa
mechanicalbarrier.

203
underwayontheDeepwaterHorizonpriortotheblowoutincreasedthe
difficultyofmonitoringthewellbore.

2. TheAgencyshouldconsiderresearchingwhatmeteraccuracyis
acceptable,aswellastheplacementofflowmetersforthepurposeofkick
detection.Flowmetersareaccuratewithin510%.Placementofthese
metersiscriticalsothatthewellcanbeaccuratelymonitoredandthe
vesselmotioneffectminimized.

3. TheAgencyshouldconsiderrevisingtheincidentreportingruleat30CFR
250.188tocapturewellkickincidents,similartotheMarch8,2010,
Macondowellcontrolevent.Undercurrentregulations,operatorsare
onlyrequiredtoreportlossesofwellcontrolandarenotrequiredto
reportwellcontroleventssuchaskicks.Thereportingoftheseevents
wouldallowtheAgencytotrackthemandevaluatetrendsthatmay
indicateproblemswithaspecificoperatororcontractor.

4. TheAgencyshouldconsiderworkingwithindustrytodevelopa
standardizednegativetestprocedurewithinterpretationguidance.As
discussedinthisReport,BPconsideredseveralnegativetestprocedures
withoutspecificinterpretationguidance.Ifinterpretationguidancehad
beenprovidedtotherigcrew,theearlysignalsofthewellflowingmay
havebeendetectedandtheblowoutaverted.

5. TheAgencyshouldconsiderresearchingtheeffectofwaterdepthonkick
detectionandresponsetimesincomparisontoshallowwater.Prompt
kickdetectioniscriticalindeepwateroperationswithasubseaBOPstack.
Itisimperativethattherigcrewdetectwellflowbeforethehydrocarbons
riseabovetheBOPstack.Ifthekickisnotdetecteduntilafterthe
hydrocarbonsriseabovetheBOPstack,thenwellcontrolresponseoptions
areseverelylimitedandtherisksofablowoutaresignificant.

6. TheAgencyshouldconsiderpromulgatingaregulationat30CFR
250.416thatallowsforthelimiteduseofmudgasseparator(MGS)
systems.TheAgencyshouldconsiderincludingtherequirementsinAPI
RP96Ainthisregulation.MGSsystemsaredesignedtocirculateout
kicksinacontrolledmannerbutarenotdesignedtohandlealarge
volumeofuncontrolledflow.Operatorsmusthaveproceduresinplaceto
guidetherigcrewsuseoftheMGSsystems,andrigcrewsmustbe

204
trainedontheseprocedures.Inparticular,rigcrewsneedguidanceon
whentodiverttheflowoverboard.

7. TheAgencyshouldreviewitsproceduresforanalyzingthewellactivity
reportstodetermineiftheoperatorisaccuratelyreportingsignificant
anomalies(e.g.,ballooning,lostreturns,wellboreintegrityfailures).
Currently,therequirementsforthewellactivityreportsincludereporting
ofsignificantwelleventsincluding,forexample,lostreturns,kick
occurrence,andwellboreintegrityfailure.UndercurrentAgency
procedures,theengineerreviewsthecurrentapprovedprocedureand
comparesittothewellactivityreporttoensurethattheoperatoris
complyingwiththeapprovedpermit.

8. TheAgencyshouldclarifythewellboremonitoringregulationscontained
in30CFR250.401(c)toaddresspotentialkickdetectionfailures,likethe
onesthatoccurredattheMacondowell.Thisprovisioncurrentlystates
thatanoperatorshould[e]nsurethatthetoolpusher,operators
representative,oramemberofthedrillingcrewmaintaincontinuous
surveillanceontherigfloorfromthebeginningofdrillingoperationsuntil
thewelliscompletedorabandoned,unlessyouhavesecuredthewell
withblowoutpreventers(BOPs),bridgeplugs,cementplugs,or
packers.TheAgencyshouldclarifythemeaningofthetermmemberof
thedrillingcrew,whichistoobroadanddoesnotaddressspecific
requirementsforsurveillanceofthewell.TheAgencyshouldalsoclarify
themeaningofthephrasesecuredthewell,whichdoesnotaddresshow
theeffectivenessofdifferentcementbarriersshouldbeevaluatedand
monitored.

C. IgnitionSourceRecommendations

1. TheAgencyshouldconsiderincludingintheSafetyAlertdiscussionson
designconsiderationsofexistingandplannedairintakelocations,
operatingphilosophywhenconductingdesignhazardanalysesofMobile
OffshoreDrillingUnits(MODUs),inspectionandtestingdocumentation
ofallsafetydevicesforengineshutdown,andperformanceofsitespecific
safetyanalysesofsafetydevicestoensurethatsystemsalignwith
operatingphilosophy.

205
2. TheAgencyshouldconsiderconductingunannouncedinspectionsofall
enginecompartmentairintakelocationsforallMODUsoperatingonthe
OCStodeterminetheextentofpossibleproblems.

3. TheAgencyshouldperformanauditofmudgasseparatorventing
systemsforallMODUsoperatingontheOCStoensurethatadequate
proceduresareinplaceforproperuse.

4. TheAgencyshouldconsiderworkingwiththeUnitedStatesCoastGuard
toevaluatepotentialregulatoryreformsregardingairintakelocationsand
theinspectionanddocumentationofengineoverspeeddevices.

D. BlowoutPreventerRecommendations

1. TheAgencyshouldevaluateresearchonBOPstacksequencingand
centralizationandshouldconsiderincludingintheSafetyAlerta
recommendationtolesseesusingasubseaBOPstacktocentralizethedrill
pipebymeansotherthantheannularpreventerpriortoactivatingthe
blindshearram(BSR).

2. TheAgencyshouldconsiderpromulgatingregulationsthatrequire
operators/contractorstohavethecapabilitytomonitortheSEMbattery(s)
fromthedrillingrig.TheSEMbattery,asdescribedinthisReport,isvery
importantfortheactivationoftheautomaticmodefunction
(AMF/deadman)system.Ifthebatteryisweak,thesystemmaynot
functionasitwasdesigned.HavingthecapabilitytomonitortheSEM
batterystatusfromtherigwouldhelpensuresufficientbatterypower
existstoexecutethesystem.

3. TheAgencyshouldconsiderresearchingthedesignoptionsonMODUs
thatcouldprotectMUXlinesduringanexplosionincident.AstheReport
indicated,theinitialexplosionsmostlikelydamagedordestroyedthe
MUXlines,thusrenderingtherigBOPcontrolsysteminoperable.Had
thesystemremainedintactandoperable,personnelmayhavebeenableto
activateanyBOPfunctionsequence.

4. TheAgencyshouldconsiderresearchingthestandardizationofRemote
OperatingVehicle(ROV)interventionpanels,ROVintervention
capabilities,andmaximumclosingtimeswhenusinganROV.Onthe
DeepwaterHorizon,numerousattemptsweremadetoactivatetheBOP

206
usingmultipleROVs.Duringtheseattempts,itwasdiscoveredthatthe
ROVpumpoutputswereincapableofgeneratingthevolumeneededto
shiftshuttlevalvesandactivatetheBOPfunctions.Insum,theROVs
pumpsdidnothavethesamepressureandfluidflowastheaccumulator
systemthattypicallyoperatestheBOPstack.Additionally,theROVs
werenotalwaysequippedwiththenecessaryhotstabsneededtoconnect
totherigspecificBOPstack.Further,theramclosingtimesare
significantlyextendedwhenusinganROV,creatingtheopportunityfor
ramerosionduetotheuncontrolledflowofwellborefluidsandsolids
acrossthecuttingandsealingsurfacesoftheramblocks.

5. TheAgencyshouldconsiderresearchingtheeffectsofaflowingwellon
theabilityofasubseaBOPtoshearpipe.

6. TheAgencyshouldconsiderresearchingablindshearramdesignthat
incorporatesanimprovedpipecenteringshearram.

E. RegulatoryAgencyRecommendations

1. TheAgencyshouldconsiderrevising30CFR250.443(g)toreferto[a]
wellheadassemblywitharatedworkingpressurethatexceedsthe
maximumanticipatedwellheadpressure,ratherthansurfacepressure,as
theregulationcurrentlyreads.

2. TheAgencyshouldconsiderrevisingtheregulationsat30CFR
250.450(e)todefineBOPtestingproblemsorirregularities.BPsdaily
operationsreportsnotedthatapilotleakexistedononeofthecontrol
podsoverthecourseof17days.Thisleakexistedduringatimewhenthe
requiredBOPfunctionandpressuretestingoccurred.Operatorsshould
berequiredtoreportirregularities,suchasthistypeofleak,tothe
Agency.

3. TheAgencyshouldconsiderdefiningthetermproperlyfunctioningin
30CFR250.451(d),whichstates,inpart,thatifthelesseeencountersa
BOPcontrolstationorpodthatdoesnotfunctionproperly,itmust
[s]uspendfurtherdrillingoperationsuntilthatstationorpodis
operable.TheAgencyshouldalsoconsiderdefiningthetermproper
operationunder30CFR250.442(d),whichstates,[t]heBOPsystem
mustincludeanoperabledualpodcontrolsystemtoensureproperand
independentoperationsoftheBOPsystem.AsindicatedinthisReport,

207
therewereBOPcontrolsystemhydraulicleakswerenotedinthedaily
operationsreport;however,theydidnotimpedetheclosingabilityofthe
annularorrampreventers.Theseleaksdidrequiretheplacementofthe
BOPcontrolsintotheblock/neutral/ventpositioninordertostopor
slowthehydraulicleak.TheAgencyneedstodetermineifapodwith
hydraulicleaksofthisnatureisanoperablepodand/oris
function[ing]properly.

4. TheAgencyshouldconsiderpromulgatingregulationsthatwouldrequire
designatedoperatorstoreportleaksassociatedwithBOPcontrolsystems
ontheIADCdailyreport,inthewellactivityreport,andtothedistrict
drillingengineer.ThiswouldensurethattheAgencyisawareoftheleak
andcouldeitherrequiretheoperatortosuspendoperationsandfixthe
leakordeterminethattheleakwillnotaffecttheoperationoftheBOP
systemandallowoperationstocontinue.

5. TheAgencyshouldconsiderrevisingthedefinitionofwellcontrolat30
CFR250.1500toreadasfollows:Wellcontrolmeansdrilling,well
completion,wellworkover,andwellservicingoperations.Itincludes
measures,practices,proceduresandequipment,suchasfluidflow
monitoring,toensuresafe,accidentfree,andpollutionfreedrilling,
completion,andworkoveroperationsaswellastheinstallation,repair,
maintenance,andoperationofsurfaceandsubseawellcontrol
equipment.Thisrevisionwouldestablishminimumexpectationsfor
whoshouldbetrainedfortheirrolesinmonitoringandmaintainingwell
controlatalltimes.Thisnewdefinitionwouldencompassmudloggersas
wellassubseaengineersandanyonewhohastheresponsibilityfor
monitoringthewelland/ormaintainingthewellcontrolequipment.As
discussedintheReport,themudloggerplayedacriticalroleinmonitoring
thewellalongwiththedrillerandassistantdriller.BP,however,didnot
identifythemudloggerasapersonneedingwellcontroltrainingora
personresponsibleformonitoringthewellforkickdetection.

6. TheAgencyshouldconsiderexpanding30CFR250.446toinclude
documentationandrecordkeepingrequirementsformajor(35year)
inspectionsasrequiredbyBOEMREsadoptionofAPIRP53,which
identifieswhatmajorinspectionsandmaintenanceshouldbeperformed.
However,APIRP53doesnotindicatethenecessaryrecordsneededto
documentthatthemajorinspectionswereperformed.Thisrecordkeeping

208
wouldallowBOEMREinspectorstoreviewthemajorBOPinspection
recordstoensuretheywereperformedasrequired.

7. TheAgencyshouldconsiderresearchingthebestBOPstackconfiguration
tominimizeunsupportedpipeinordertoreducethelikelihoodofelastic
bucklingofdrillpipe.

8. TheAgencyshouldconsiderresearchingtheneedtorequirethirdparty
surveysofthedrillingpackagesonrigsoperatingontheOCS.

9. TheAgencyshouldconsiderresearchingtheneedforacomplete
independent,acousticallycontrolledsystemforsubseaBOPs.Thiswould
eliminatethesituationwhichoccurredinthiseventwheretheMUXlines
seemedtobedamagedintheexplosionandrenderedthesurface
operationoftheBOPinoperative.Havingacompleteindependentcontrol
systemwouldaddanadditionalsafeguardforoperatingtheBOPstack.

10. TheAgencyshouldconsiderresearchingtheneedforacompletely
independentBOPsystem(shortstack)inlieuof,orinadditionto,the
independentcontrolsystemdiscussedinRecommendation9.Thisgives
therigatrulyindependent,redundant,androbustsystemunlikean
acousticsystemoranyothersecondarysystem.TheDeepwaterHorizon
BOPstackhadredundantelements,buttheseelementsreliedupona
numberofthesamecomponentstofunction.Acompletelyindependent
BOPcontrolsystemprovidestrueredundancyandrobustness.

11. TheAgencyshouldconsiderpromulgatingregulationsthatwouldrequire
realtime,remotecaptureofBOPfunctiondata.Thiswouldbebeneficial
inpostaccidentsourcecontrolandsubsequentinvestigations.Havingthe
datathatshowwhichramshavebeenactivatedwouldhelpanalyze
interventionoptions.DuringtheMacondosourcecontrolresponseand
ROVinterventionattempts,BPandTransoceandidnotknowwhichrams
mayhavebeenactivatedandcriticaltimewasspenttryingtofunctiona
ramthathadalreadybeenactivated.

F. OCSCompaniesPracticesRecommendations

TheAgencyshouldconsiderworkingwithindustryorganizationsto
revisitthecorewellcontroltrainingcurriculumusedbymostcompaniesand

209
trainingproviders.Ataminimum,wellcontroltrainingshouldencompassthe
followingadditionalsubjects:

1. Understandingthedifferentoptionsindeepwaterwellcontrol
whenworkingfromeitheramooredMODUoradynamically
positionedMODU;

2. Theimportanceoffluidflowmonitoringandearlykickdetectionin
deepwaterwells;

3. Wellboreanomalies/hazardsrecognitionandmitigations;

4. Recognitionoflimitedwellcontroloptionswhenwellborefluids
aredetectedabovetheBOPstack;

5. Useofthediverterandlimiteduseofthemudgasseparatorina
wellcontrolevent;and

6. Incorporationoftheemergencydisconnectfunctionintowell
controloptions.ThePanelfoundthatbythetimethehydrocarbons
reachedtherigflooritmighthavebeentoolatetoattemptto
controltheflow.Abetteroptioninthesecasesmaybeto,inthese
cases,immediatelyactivatetheemergencydisconnectfunctionto
disconnectfromthewellandstopfurtherhydrocarbonflow.

210
Dedication

OnApril20,2010,elevenpeoplelosttheirlivesonboardtheTransocean
DeepwaterHorizon.ThemembersofthisPanelinvestigationteamdedicatethis
Reporttothememoryofthefollowingindividuals:

JasonChristopherAnderson

AaronDaleBurkeen

DonaldNealClark

StephenRayCurtis

GordonLewisJones

RoyWyattKemp

KarlDaleKleppinger,Jr.

KeithBlairManuel

DeweyAllenRevette

ShaneMichaelRoshto

AdamTaylorWeise

Withourfindingsandrecommendations,wehopetoimproveoffshore
safetyandpreventthereoccurrenceofatragiceventliketheMacondoblowout.

211
Acknowledgement

WiththesupportofthecrewoftheDamonBankstonandtheRamblin
Wreck,115survivorswereabletoevacuatetheDeepwaterHorizonandbe
immediatelyrescuedwithoutfurtherincident.

Iftheaforementionedcrewsdidnotquicklydirectthesearchandrescue
mission,assistinmuster,providechangesofclothes,andcoordinatemedical
attentionandtransferofinjuredpersonnel,thedeathtollcouldhavebeenhigher.

TheDamonBankstonandRamblinWreckcrewsdisplayedvalor,leadership,
andempathytowardstheirfellowmarinersonboardtheDeepwaterHorizonata
timeofperil.Thewellbeingofthe115survivorsisdirectlyattributabletotheir
actions.

Further,BOEMRErecognizestheeffortsofcrewswithinthevicinityof
MC252inrespondingtotheDeepwaterHorizonblowout.Theseindividualswere
thefirstrespondersonthesceneandprovidedadmirableassistancetotheir
fellowoffshoreemployees.

AliceG.McCall JoeGriffin OceanInterventionIII


Beesting KatrinaFagan PatTillman
BoaSubC KobeChouest Reliance
CExpress LaneyChouest ResolvePioneer
C.Enforcer MaxChouest SailFish
CPacer MissAddison SeaExpress
FastCajun MonicaAnn SeacorLee
GeoSearcher Sydney SeacorVanguard
GloriaB.Callais MSCFamilia SeacorWashington
GulfPrincess Norbert

212

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