Today (November 9), Co-Chairman William Reilly's issued an opening statement summarizing his feeling on the previous day's hearing and the Commissions investigation thus far. Co-Chairman Bob Graham's was expected to release a statement later today at the completion of the hearing. Co-Chairman Reilly said the presentations and examinations covered in the November 8 session uncovered a suite of bad decisions which he listed as follows: failed cement tests, premature removal of muds underbalancing the well, a negative pressure test that failed but was adjudged a success, apparent inattention, distraction or misreading of a key indicator that gas was rising toward the rig.
He said, "Our investigative team did not ascribe motive to any of those decisions and reported that they found no evidence that those flawed decisions were made to save money. They didn't rule out cost, just said they weren't prepared to attribute mercenary motives to men who cannot speak for themselves because they are not alive. But the story they told is ghastly: one bad call after another.
"Whatever else we learned and saw yesterday is emphatically not a culture of safety on that rig. I referred to a culture of complacency and speaking for myself, all these companies we heard from displayed it. And to me the fact that each company is responsible for one or more egregiously bad decision, we're closing in on the answer to the question I posed at the outset of yesterday's hearing, whether the Macondo disaster was a unique event, the result of special challenges and circumstances, or indicates something larger, a systemic problem in the oil and gas industry.
"BP, Halliburton and Transocean are major respected companies operating throughout the Gulf and the evidence is they are in need of top-to-bottom reform. We are aware of what appeared to be a rush to completion at Macondo, and one must ask whether the drive came from that made people determine they couldn't wait for sound cement, or the right centralizers. We know a safety culture must be led from the top, and permeate a company. The Commission is looking beyond the rig to the months and years before. BP has been notoriously challenged on matters of process safety. Other companies may not be so challenged and today we will hear from two whose reputations for safety and environmental protection are exemplary.
"They will tell us, I believe, that safety and efficiency reinforce one another, and that their safety cultures have contributed to their profitability. Both companies and their safety/risk management systems have received extensive examination by the Commission's staff in meetings I have attended. They are impressive. Nevertheless, their rigs have been shut down in the Gulf this summer because of the performance of other companies. This has led the Commission to learn from the nuclear industry which has an institute that promotes best practices, reinforces regulations, and polices the laggards. So if yesterday we heard from the laggards, today we hope to learn from the leaders -- companies which learned from their own crises and disasters and rose to become standard setters."
The Commission issued a summary listing of "Preliminary Conclusions Technical," along with extensive technical backup information. The summary is as follows:
- Flow path was exclusively through shoe track and up through casing.
- Cement (potentially contaminated or displaced by other materials) in shoe track and in some portion of annular space failed to isolate hydrocarbons.
- Pre-job laboratory data should have prompted redesign of cement slurry.
- Cement evaluation tools might have identified cementing failure, but most operators would not have run tools at that time. They would have relied on the negative pressure test.
- Negative pressure test repeatedly showed that primary cement job had not isolated hydrocarbons.
- Despite those results, BP and TO personnel treated negative pressure test as a complete success.
- BP's temporary abandonment procedures introduced additional risk.
- Number of simultaneous activities and nature of flow monitoring equipment made kick detection more difficult during riser displacement.
- Nevertheless, kick indications were clear enough that if observed would have allowed the rig crew to have responded earlier.
- Once the rig crew recognized the influx, there were several options that might have prevented or delayed the explosion and/or shut in the well.
- Diverting overboard might have prevented or delayed the explosion. Triggering the EDS prior to the explosion might have shut in the well and limited the impact of any explosion and/or the blowout.
- Technical conclusions regarding BOP should await results of forensic BOP examination and testing.
- No evidence at this time to suggest that there was a conscious decision to sacrifice safety concerns to save money.