BP Disaster A failure To Learn From Previous "Near Misses"

Nov 16: An interim report of preliminary findings from a committee of the National Academy of Engineering (NAE) and National Research Council (NRC) of the National Academy of Sciences (NAS) indicates that the numerous technical and operational breakdowns that contributed to the Deepwater Horizon oil rig explosion and spill from the Macondo well in the Gulf of Mexico suggest "the lack of a suitable approach for managing the inherent risks, uncertainties, and dangers associated with deepwater drilling operations and a failure to learn from previous 'near misses.'" The events also suggest insufficient checks and balances for critical decisions impacting the schedule for "abandoning" the exploratory well -- or sealing it in transition to production -- and for considering well safety. The NAS evaluation seem to provide confirmation of many of the same findings of the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling established by the President [See WIMS 11/9/10].

 

    Donald Winter, former secretary of the Navy, professor of engineering practice at the University of Michigan, and chair of the study committee said, "Important decisions made to proceed toward well abandonment despite several indications of potential hazard suggest an insufficient consideration of risks. It's also important to note that these flawed decisions were not identified or corrected by BP and its service contractors, or by the oversight process employed by the U.S. Minerals Management Service and other regulatory agencies."

 

    According to the report -- Interim Report on Causes of the Deepwater Horizon Oil Rig Blowout and Ways to Prevent Such Events -- it may not be possible to definitively establish which mechanisms caused the blowout and explosion, given the deaths of 11 witnesses on board, the loss of the oil rig and important records, and the difficulty in obtaining reliable forensics information from the Macondo well. Nevertheless, the committee believes it has been able to develop a good understanding of a number of key factors and decisions that may have contributed to the blowout of the well.

 

    The report cites numerous decisions that apparently contributed to the accident, beginning with continuing abandonment operations at the Macondo site despite several tests that indicated that the cement put in place after the installation of a long-string production casing was not an effective barrier to prevent gases from entering the well. The decision to accept the test results as satisfactory without review by adequately trained shore-based engineering or management personnel suggests a lack of discipline and clearly defined responsibilities. In addition, several clear failures in monitoring of the well appear to have contributed to its blowout; available data show hydrocarbons entered the well undetected for almost an hour before the first explosion. Timely and aggressive action to control the well was not taken, and for unknown reasons, hydrocarbons were funneled through equipment that vented them directly above the rig floor rather than overboard. These conditions made ignition "most likely," according to the report.  Finally, the blowout preventer did not seal the well once activated.

 

    Of particular concern is the lack of a systems approach to integrate the multiple factors impacting well safety, to monitor the overall margins of safety, and to assess various decisions from a well integrity and safety perspective. The report also notes that a previous loss of hydrocarbon circulation in the Macondo well more than a month before the accident presented an opportunity to take actions to mitigate future risks. 

 

    Several questionable decisions also were made about the cementing process prior to the accident, including attempting to cement across multiple hydrocarbon and brine zones in the deepest part of the well in a single operational step, making a hydraulic fracture in a low-pressure zone more likely; using a long-string production casing instead of a liner over the uncased section of the well; and deciding that only six centralizers were needed to ensure an even spacing between the formation rock and the casing, even though modeling results suggested that more centralizers would have been necessary. The type and volume of cement used to prepare for well abandonment and the time provided for the cement to cure may also have impacted the well's integrity [See WIMS 10/29/10].

 

    According to a release, for its final report, due in the summer of 2011, the NAS committee will examine ways to establish practices and standards to foster a culture of safety and methods to ensure that schedule and cost decisions do not compromise safety. The committee will assess the extent to which there are gaps, redundancies, and uncertainties in responsibilities of multiple agencies and professional societies overseeing deepwater drilling operations, and it will consider the merits of an independent technical review to provide operation checks and balances by enforcing standards and reviewing deviations. 

 

    The committee also notes that the Macondo well's blowout preventer was only recently recovered and is undergoing forensic analyses. The committee will evaluate possible causes for the failure of the blowout preventer once key data are made available.  Data on maintenance, testing, operating procedures, and reliability of alarms and other safety systems on the Deepwater Horizon rig will also be examined; testimony at other hearings indicate that various alarms and safety systems failed to operate as intended.

 

    Secretary of the Interior (DOI) Ken Salazar commented on the interim report saying, "I appreciate the rigorous work the experts on the NAE and NRC team have undertaken to understand the root causes of the Deepwater Horizon oil spill. Their independent, science-based analysis of what went wrong in the lead up to the blowout will help guide our continuing efforts to raise the bar for safety and oversight of offshore oil and gas operations, and will be of assistance to other ongoing investigations. I look forward to receiving the team's final report and to the additional insight and recommendations they will be providing us over the coming months."

    Bureau of Ocean Management, Regulation and Enforcement (BOEMRE) Director Michael Bromwich also commented saying, "The interim report by the NAE and NRC team raises important questions they will be exploring further in their ongoing review. Their work will help guide our continuing efforts to strengthen standards and oversight and underscores the importance of our ongoing efforts to build a strong and independent agency with the resources, training, and expertise to provide aggressive oversight of offshore oil and gas operations. I appreciate the time and expertise the NAE and NRC team are providing as we work towards ensuring that offshore energy production is conducted in a manner that protects human life and the environment."

    Also reacting to the report were Representatives Henry Waxman (D-CA) and Edward Markey (D-MA) the Chair of the House Energy and Commerce Committee and the Energy and Environment Subcommittee, respectively. The representatives issued a release saying that "in light of another report highlighting the systemic failures that led to the BP Deepwater Horizon disaster," the Chairmen believe the new BP CEO Bob Dudley should testify publicly about the changes BP has made to improve the safety of its operations.

Access a release from NAS (click here). Access the complete report and appendices (click here). Access the review committees website with additional information (click here). Access a release from DOI (click here). Access the Oil Spill Commission website for a additional background information (click here). Access a release from Waxman and Markey with links to their letters (click here).