Summary of Macondo Inquiries

OIL & GAS
SUMMARY OF
MACONDO INQUIRIES
SAFER, SMARTER, GREENER
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Summary of Macondo Inquiries
SUMMARY OF
MACONDO INQUIRIES
Background
DNV GL is one of the largest advisory, verification and certification companies serving the global
oil and gas, energy and maritime industries. Our corporate purpose is to safeguard life, property
and the environment and one way we do this is to distill diverse information of importance and to
share this publicly. This report which summarizes the many Macondo investigations is an example
of this. There have been over 20 major inquiries and many have quite different key lessons and
recommendations. It can be difficult for people in the industry to have an overview of what
recommendations were made and by whom. This report provides a short summary of each
investigation and highlights important points it makes. Further investigation reports are likely,
especially on the long-term environmental impacts, but DNV GL feels that this current summary
would be timely.
The Macondo Event and Major Investigations
Given the significance of the event and the potential for other
events associated with deepwater drilling where response
is difficult, there have been multiple investigations and
lessons-learned exercises. DNV GL has reviewed 21 major
investigations and this report attempts to summarize these
impartially but there was necessarily some selection involved
and we apologize in advance to the many authors if we might
have inadvertently missed some points. Clearly no single
investigation provides a full overview of needed actions.
The Deepwater Horizon (DWH) drilling rig was operating on

the Macondo prospect 90 miles south of Louisiana at a depth
of 5000ft. It suffered a major blowout event on April 20, 2010
that led immediately to 11 fatalities and 17 seriously injured,
to the rig sinking 36 hours later, and thereafter to a prolonged
subsea release of gas and crude oil. A massive intervention was
organized by multiple US Government agencies, BP, and many
organizations, including DNV GL. The release was capped and
the discharge halted on July 15th and by mid-September, a
relief well intercepted the Macondo well and permanently
sealed it with cement. The spill was estimated by the US
Government to be 5 million barrels the largest recorded
offshore blowout event.
Transocean
The Deepwater Horizon drill rig (from National

Commission Chief Counsels Report)
Type: Deepwater, dynamically positioned,
semi-submersible mobile offshore drilling unit
Constructed: Hyundai Heavy Industries, Korea
Completed: 2001
Cost: $560 million
Length: 112 m (367 ft)
Beam: 78 m (256 ft)
Gross Tons: 32,588
Persons on Board: 126
Flag state: Marshall Islands
Classification: ABS A1, Column Stabilized Drilling
Unit; AMS; ACCU; DPS-3
Figure 1. Deepwater Horizon Rig features
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Table 1. Major Macondo Investigation reports summarized in this study

(Numbers refer to the following sections, a full Table of Acronyms appears at the end of the document)
No. Author
Title
Release Date
1
DWH Commission

National Commission on the BP Deepwater Horizon Oil Spill and Offshore Jan 2011
Drilling Main Report and multiple topic papers
DWH Commission
Chief Counsels Report
Feb 2011
BP
DWH Accident Investigation Report
Sep 2010
Transocean
Macondo Well Incident: Transocean Investigation Reports, Vol. I and II
Jun 2011
5
USCG

Report of Investigation into the Circumstances Surrounding the Explosion, Apr 2011
Fire, Sinking and Loss of Eleven Crew Members Aboard the Mobile
Offshore Drilling Unit DWH Vol.1 (MISLE 3721503)
BOEMRE
JIT - BOEMRE Final Report regarding Macondo Well Blowout
Sep 2011
Republic of the
Marshall Islands
Deepwater Horizon Marine Casualty Investigation Report
Aug 2011
Adm Thad Allen
Incident Commanders Report
Oct 2010
9
DNV GL

Forensic Examination of Deepwater Horizon Blowout Preventer,

Vol. I and II (Appendices).
Mar 2011
10
Chemical Safety Board
Investigation Report (Vols 1-2)
Jun 2014
11

Center for Catastrophic Risk

Management (UC Berkeley)
Final Report on the Investigation of the Macondo Well Blowout
Mar 2011
12

National Academy
of Engineering
Macondo Well-Deepwater Horizon Blowout: Lessons for Improving

Offshore Drilling Safety
2012
13
National Research Council
Ecosystem Services Approach to DWH
2013
14

US District Court
Eastern Louisiana
Court Judgment
Sep 2014
15

Norway Petroleum
Safety Authority
Interim report DWH Accident
Jun 2011
16

Norway Petroleum
Safety Authority
PSAs Concluding report on its follow-up for the DWH accident
Feb 2014
17
OGP
Getting it Right
Jan 2013
18
OLF
DWH Lessons Learned and Follow-up
Jun 2012
19
SINTEF
Report on DWH (A19148)
May 2011
20
UK HSL
DWH Fire & Explosion Issues
Apr 2014
21

US Transportation
Research Board
Evaluating the Effectiveness of Offshore Safety and Environmental

Management Systems (Special Report 309)
2012
Table 3 in the Conclusions summarizes the topic areas addressed in the findings and recommendations of each inquiry.
1) National Commission BP Deepwater Horizon Oil Spill

The National Commission was
established by President Obama
soon after the event with a mandate
to report within 6 months. The
Commission was chaired by Bob
Graham and William K. Reilly, along
with 5 other members and supported
by a chief counsel and technical team.
The main report was issued in
January 2011 and was structured
into 3 main sections: I) Path to the
Tragedy, II) Explosion and Aftermath, and III) Lessons Learned
for Industry, Government, and Energy Policy. The Commission
had an extensive support staff to collect and analyze evidence,
but their report was one of the first published and thus many
technical features were still unknown and were addressed in
later reports. The Commission staff issued 21 working papers

on specific engineering and regulatory topics to aid the
Commissions understanding of the issues and current practices.
Links to these papers are available at the IADC website.
In Part I, the history of development of drilling in the Gulf of
Mexico (GoM) and particularly in deepwater was summarized,
along with the technical challenges. The development of
offshore regulations from the late 1970s was summarized along
with the potential conflict of interest within the Minerals
Management Service (MMS) which issued leases and
collected revenue from drilling activities, but which also
regulated offshore safety. Potential overlaps with USCG
regulations of offshore facilities are resolved through a
memorandum. The Commission highlighted the prescriptive
nature of MMS regulations and a lack of resources to enable
the MMS and its staff to keep up with rapid developments and
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to carry out its inspection activities. This ultimately led to a

departure from the normal standards of excellence the nation
expects. Specifically, these deficiencies led to an inadequate
review and permitting of the Macondo well, and for BPs
inadequate Oil Spill Response Plan. The Commission contrasted
this situation to regulatory developments in Norway and UK
after major accidents where they adopted risk-based
performance regulations, complementing prescription. The
MMS had been pushing for a formal safety and environmental
management approach (SEMS), but this was subject to much
industry and internal government opposition. SEMS was
mandated soon after the Macondo event.
In Part II, the causes and consequences of the disaster were
reviewed. Many aspects of the Macondo well involved
compromises affecting safety; and in accumulation they gave
rise to a high risk well. The well cementing job was difficult
and the subsequent pressure tests were misinterpreted by the
drilling team. As they replaced heavy drilling mud with lighter
seawater, a well kick event commenced but was not recognized
immediately. Soon gas appeared on the rig, and the drill team
diverted flow to the mud-gas separator and shut a BOP annular
ram (Figure 2), but these actions were too late and soon
afterwards a major explosion and fire occurred, killing 11
people and injuring 17 others. The BOP did not stop the
flow and questions remained as to when the shear rams were
actuated. The commission identified several errors by the Drill
Team, but went much wider to consider root causes due to
failures in the companies involved, the industry and
government. The Commission listed nine decisions taken in the
weeks preceding, mostly to save time all of which increased
risk. This accumulation of additional risk was not assessed.
Similarly, the MMS failed to pose any significant challenges to
BPs proposed abandonment procedure. The response activities
were also summarized, and they document how the response
increased in scale as the magnitude of the event was
recognized. USCG Commandant Thad Allen was selected as
National Incident Commander and he controlled a response
that involved up to 45,000 people from government agencies,
the oil industry, local populations and fishermen. Technical
changes to the BOP had been made by Transocean but this was
not recognized for 10 days and this affected interventions.
Efforts to minimize the impact of the spill included closing
fishing areas, use of dispersants, and deploying a containment
dome. The initial well release rate was significantly
underestimated and this meant dispersant injection was
insufficient to be fully effective. The containment dome failed
due to accumulation of hydrates formed at the cold
temperatures prevailing and these blocked the collection
system. Further interventions included a top kill and a junk shot
these also failed. Surface interventions offshore booms and
berms protecting islands were tried with some success. Offshore
oil skimmed by booms was collected when possible or burned.
But use of dispersants continued and that caused controversy.
A capping stack installed above the BOP was successful in
stopping the release of oil on July 15th and this allowed a static
kill followed by cementing by Aug 4th. The relief well was
completed in mid-September and cement injected to
permanently seal the well. The Commission documented the
many environmental, social and economic impacts. A six month
Moratorium was declared on new deepwater drilling on
May 30, 2010.

Figure 2. BOP design
Part III addressed lessons learned for industry, government

and for energy policy and contained the Commission
recommendations. The report emphasized safety culture as a
key factor for enhancing safety and discussed culture issues
affecting BP, its contractors, and the GoM industry generally.
The Commission also identified a conflict of interest in API,
which serves as coordinator for industry expertise and
standards, but also acts as the industry chief lobbyist. API
standards were characterized as lowest common denominator
rather than best practice standards, and since these standards
underpin the Department of Interior regulations, the whole regulatory system was compromised. The opposition to
regulations for a SEMS program was a quoted example; API
preferred a voluntary system. The Commission gave other
examples of lessons learned from the nuclear Navy, the Exxon
Valdez, Shell, and Bhopal. The experience in the civilian nuclear
industry and its use of INPO (Institute of Nuclear Power
Operations) to carry out regular demanding audits and
assessments was suggested as a possible model for the O&G
industry. The Commission also addressed spill containment and
response requirements and liability issues. Two new industry
cooperatives the Marine Well Containment Company and
Helix were mentioned as necessary solutions but with a need
to address long term R&D challenges. Commission
recommendations were grouped into nine areas (A G):
A. Improving the Safety of Offshore Operations (A1-A5)

DOI should develop a blend of risk management and
prescriptive regulations; it should adopt a safety case like
approach for specific installations; it should adopt selected
best practices from international approaches; Congress
should separate the safety and revenue aspects of MMS;
and ensure adequate finances
B. Safeguarding the Environment (B1-B3)
Environmental analysis, transparency and consistency must
be improved; interagency environmental cooperation to be
enhanced; and lease fees should pay for these extra costs
C. Strengthening Oil Spill Response, Planning,
and Capacity (C1-C6)
DOI should carry out oil spill risk analysis and implement
better response strategies; EPA and USCG should develop
better plans for major oil spills including State and local
agencies; there needs to be adequate R&D funding; the
control and use of dispersants should be enhanced; and
the use of shore berms should be discouraged
D. Advancing Well-Containment Capabilities (D1-D3)
Government must enhance its expertise in source control
technologies, and be able to estimate release volumes more
accurately; Operators must enhance their oil spill response
plans; demonstrate that their wells have provide adequate
diagnostics and that well design mitigates risks to well
integrity after a blowout event
E. Overcoming the Impacts of the Deepwater Horizon Spill
and Restoring the Gulf (E1-E7)
USCG to provide timely access to scientists during a spill
event; compensation for remediation needs to be
transparent; EPA to assure that human health issues are
addressed; efforts are needed to restore consumer
confidence; 80% of revenue from penalties should be
directed to restoration; government to assure that
restoration is carried out on a strong footing; and better
holistic management of the OCS areas including
monitoring and planning
F. Ensuring Financial Responsibility (F1-F4)
The $75m liability cap must be increased; payouts per
incident should be increased; the DOI should enhance
auditing and evaluation of offshore risks; and the claims
payment system should be reviewed and enhanced
G. Promoting Congressional Engagement to Ensure
Responsible Offshore Drilling (G1-G2)
Congressional oversight capabilities should be enhanced;
ensure adequate funding is directed to relevant
government agencies.
The Commission concluded that deepwater resources are key to
future US oil supply security and these must be managed better.
These ideas need to be applied to areas beyond the GoM OCS
such as Alaska and to address the challenges of the Arctic.
PAGE 5
2) National Commission Chief Counsels report

The Chief Counsels report
complements the Commissions main
report and contains significantly more
technical details. This report focuses
on the direct technical and
managerial causes of the accident
and does not address response
activities or environmental, social or
economic impacts. Main chapters deal
with deepwater drilling topics and the
Macondo well, deepwater well design,
cementing, the temporary abandonment, the negative pressure
test, kick detection and response, and the blowout preventer
and its maintenance. Many findings are made on technical
and management issues, but the report does not make
recommendations these are presented in the Commission
main report (1). But the findings do highlight important issues
and lessons learned.
The specific technical findings presented align with knowledge
at the time the well design issues, the abandonment process,
cementing failure, the faulty pressure tests, replacement of
heavy mud with seawater, and failure to recognize the kick and
to respond sufficiently quickly. The report was based mainly
on their own investigations, witness interviews and company
statements, and included some recovered equipment from the
seabed; but this was before the DNV GL forensic investigation
(9) and the CSB investigation (10) which better explained the
reasons for the BOP failure. The report included a very detailed
and well-illustrated explanation of deepwater well design issues
and explained some of the reasons for the specific design
selected by BP and also some of the risks it created for
example the cementing challenges involved with the long
production string used.
It is not possible to list all the findings identified in this lengthy
report, but some main findings are presented. The use of a long
production casing made the cementing job more difficult and
the use of rupture disks to prevent annular pressure build-up
compromised later containment efforts as these were believed
to have failed inwards. BP selected the long-term benefits of
using the long string without adequate assessment of the
short-term risks. The report was clear that the cement job failed
but there were several possible reasons and it was not
possible to select amongst these. Contributory factors may have
included the limited number of pipe centralizers used, the low
pre-cementing mud circulation, the low volume of cement used,
and some other factors. Management findings focused on BPs
systems that did not force the Macondo team to identify and
evaluate all cementing risks; and changes to the well plan that
were not adequately assessed. The BP team did not assess
contractor data in sufficient detail and made too simple an
analysis of well data as an indicator of cementing success.
Similar detailed analysis with technical and management
findings applied to foamed cement stability, temporary
abandonment, the negative pressure test, kick detection and
response, and the BOP and its maintenance was presented.
A final chapter dealt with overarching failures of management.
The Chief Counsels team observed at least the following
management failures: (1) ineffective leadership at critical times;
(2) ineffective communication and siloing of information; (3)
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failure to provide timely procedures; (4) poor training and

supervision of employees; (5) ineffective management and
oversight of contractors; (6) inadequate use of technology;
and (7) failure to appropriately analyze and appreciate risk.
Ultimately, the companies placed undue reliance on timely
intervention and human judgment, in light of their failure to
provide individuals with the information, tools, and training
necessary to be effective.
The Chief Counsels report emphasized the influence of costs
the DWH rig was chartered at $533K/day and was the largest
expense of the well. Many decisions were taken both onshore
and offshore that saved time, but increased risk and these risks
were not assessed. Examples include: BP did not run a cement
evaluation log, nor did it perform further well integrity tests
after the unexpected results of the negative pressure test, it did
not install additional barriers during temporary abandonment,
nor did it elect to install the surface cement plug closer to the
wellhead. The BP incentive system focused on cost savings and
encouraged top quartile performance. Safety was also an
important factor in the incentive program but this measured
occupational safety, not major accident well safety. However, the
report admitted this would have been difficult to measure.
The report addressed regulatory deficiencies, but these mirror
the findings in the Commission main report and they are not
repeated here.
The Chief Counsels report concluded: the blowout occurred
in large part because the companies diffused knowledge,
responsibility for, and ownership of safety among themselves
and among groups of people. The people onshore and on the
rig had a false sense of security. They did not recognize the
need for individual leadership in addressing the multiple anomalies and uncertainties that they observed. Instead, they relied
on many ambiguous dotted line relationships within
and between the companies and personnel involved.
3) BP Report: Deepwater Horizon Accident Investigation Report
The BP team commenced their
investigation very soon after the
blowout event. They focused on the
direct technical causes of the incident
and did not address management
related issues or alternative risk
management strategies that might
have been employed nor the
sequence of emergency actions
immediately after the explosion.
As with the Commission report, the
authors provided a clear description of the technology
employed for deepwater drilling and showed key safety
provisions. They identified a sequence of eight key barriers that
failed and permitted the accident to occur. These are shown in
the Swiss Cheese barrier diagram format in Figure 3.
Figure 3. Barrier failures leading to DWH blowout event
The eight barrier failures identified by BP and shown

in Figure 3 were:
1) The annulus cement barrier did not isolate the hydrocarbons
2) The shoe track barriers did not isolate the hydrocarbons
3) The negative-pressure test was accepted although well
integrity had not been established
4) Influx was not recognized until hydrocarbons were
in the riser
5) Well control response actions failed to regain control
of the well
6) Diversion to the mud gas separator resulted in gas
venting onto the rig
7) The fire and gas system did not prevent
hydrocarbon ignition
8) The BOP emergency mode did not seal the well
The BP team made recommendations in eight areas that would
apply to BP and to its contractors:
1) Procedures and technical practices
Update practices related to cementing, well control, well
design, negative-pressure testing, review risk management
and management of change processes as practices by
drilling teams, and recommend that API develop a
recommended practice for foam cement
2) Capability and competency
Strengthen the BP Technical Authority role for cementing
and zonal isolation, and enhance personnel competency in
key operational and leadership roles, develop an advanced
deepwater well control training program, establish in-house
expertise on subsea BOPs and BOP control systems, request
IADC to consider a certification program for personnel who
maintain deepwater BOPs
3) Audit and verification
Strengthen BPs audit and verification program on BP owned
and contracted drilling rigs
4) Process safety performance management
Establish leading and lagging indicators for well integrity,
well control and safety critical equipment, require drilling
contractors to implement an auditable integrity
monitoring system,
5) Cementing services assurance
Review immediately the quality of services provided by
cementing contractors
6) Well control practices

Confirm that essential well control and monitoring practices
are clearly defined and rigorously applied offshore and at
high hazard onshore wells
7) Rig process safety
Require HAZOP studies on key parts of the surface gas and
drilling fluid systems, including all surface system vents
8) BOP design and assurance
Establish minimum levels of reliability for BOP systems,
develop ROV intervention strategies, and for contractors
strengthen minimum requirements for BOP tests,
maintenance management systems and MOC processes,
and to develop a qualification process verifying shearing
performance for all types of drill pipe in use
4) Transocean: Macondo Well Incident
The Transocean investigation
is presented in Vol 1 with
supporting appendices in
Vol 2. The report had three
main objectives to establish
1) how the reservoir fluids
reached the rig floor, 2) why
the BOP failed to stop the
flow, and 3) how did the fluids ignite. The Transocean report did
not make specific recommendations. Their main conclusion was:
The Macondo incident was the result of a succession of
interrelated well design, construction, and temporary
abandonment decisions that compromised the integrity of the
well and compounded the risk of its failure. Their findings were
summarized into four main categories:
1) Risk management and communications
BP was responsible for all planning and design details, and
it approved the work of all contractors. It failed to assess,
manage and communicate risks and these failures led the
Transocean drill team to make faulty actions on the
assumption that the cement job had been successful.
2) Well design and construction
The Macondo well was difficult with a narrow margin of pore
pressure to fracture pressure and the well had experienced
both lost circulation and kick events. Rather than change its
long-string production casing design BP decided to adopt
a complex nitrogen foam cement with little margin for error.
This was poorly installed and not tested adequately and the
cement may have been compromised.
3) Risk assessment and process safety
Halliburton and BP failed to test the cement adequately
given the risks and test data showing the cement might not
have been stable. BP generated five different abandonment
procedures over an eight day period and the final plan
called for an unnecessary displacement of the mud. There
was no documented management of changes and risks were
not assessed.
4) Operations
The negative pressure test was incorrectly approved by all
present, including BP. When mud was displaced the well
became underbalanced and hydrocarbons entered the well
PAGE 7
through the faulty cement. None of the drill team detected

the influx. Data analysis shows the influx was occurring
but it is unknown if the team was aware of this data. The
DNV GL forensic examination (9) showed the BOP
functioned but failed to seal the well due to the drill pipe
bowing outside of the shear ram cutting zone
Following the ignition and initial blast, 115 staff mustered
and safely evacuated, assisted by the presence of an
offshore supply vessel
BP made several changes from its initial well plan: reduced
the target depth of the well; considered changes to the well
casing; used a lower circulating rate than the parameters
specified to convert the float collar; reduced cement density
with nitrogen foam; used a lesser quantity of cement than
that specified in BP procedures; and decided not to perform
a complete bottoms-up circulation before cementing.
5) USCG JIT - Vol.1 Report into the Deepwater Horizon
(Ref: 3721503)
This investigation was
conducted under a
Memorandum of Agreement
with BOEMRE. That agency
was responsible for incidents
related to drilling, production,
and pipeline operations, and
USCG was responsible for
fatalities/injuries, property loss, vessel safety systems, and
environmental damage. The USCG also coordinated data
requests for this report with the Flag State Republic of the
Marshall Islands. To aid their work, a Joint USCG-BOEMRE
Investigation Roadmap was developed. This defined interested
parties, the 7 public hearings, and the various safety activities
that would be reviewed. The USCG aspects relevant here are: 1)
the explosions, 2) the fire, 3) the evacuation, 4) the flooding and
sinking of the MODU, and 5) the safety systems of the
Deepwater Horizon and its owner-operator, Transocean. The
USCG concluded there were multiple systems deficiencies
on-board the vessel contributing to the event. These included
poor maintenance of electrical equipment that may have ignited
the explosion, bypassing of gas alarms and automatic shutdown
systems that could prevent an explosion, and lack of training of
personnel on when and how to shutdown engines and
disconnect the MODU from the well to avoid a gas explosion
and to mitigate the damage from an explosion and fire. These
deficiencies indicated that Transoceans failure to have an
effective safety management system and instill a culture that
emphasized and ensured safety contributed to this disaster. The
USCG also was critical of the oversight from the Flag State (RMI).
They had delegated all of its inspection activities to recognized
organizations and thus in the view of the USCG it had
abdicated its inspection responsibilities.
The report summarized detailed findings on each of the five
aspects for which the USCG was responsible. Regarding
explosions they found multiple problems with safety systems
for example gas detectors did not automatically actuate safety
systems and many were bypassed to avoid false alarms. There
was insufficient protection of staff from blast loads. There was
some organizational confusion between the OIM and the Master
that may have affected actuation of the Emergency Disconnect
PAGE 8
System. The firewater system was electrically powered and the

explosions rendered the power system inoperative a diesel
fire pump would have helped. The A-Class bulkheads (a lesser
standard than H-Class) did not prevent the spread of fire as they
were not designed for the heat experienced. Several practical fire
protection recommendations were made to address observed
deficiencies. The evacuation was affected by the intense fires and
some staff could not reach the two available lifeboats and had to
jump. A lack of proper drills and heat protection of the area meant
that one liferaft was improperly launched, with a line still attached
to the rig. Several recommendations were made to enhance
practice drills, to protect launch areas from heat exposure, and to
address the need for fast rescue craft. Firefighting was not well
coordinated as the initial focus was towards saving lives. This
meant that excess water may have been applied from responding
vessels and when combined with known prior violations of
watertight integrity, may have contributed to the sinking. The
USCG identified several deficiencies in compliance to the ISM
Code. The BOP was recertified after 10 years rather than every
3-5 years, there had been two prior serious incidents but neither
was properly investigated, and there were deficiencies in Master
and crew training, and these gaps in emphasizing safety led to
staff bypassing important gas alarms.
The USCG made a large number of detailed recommendations
related to its areas of responsibilities (these are listed in Table
2). Some were made to IMO and others to Congress to amend
local regulations. Flag states need to enhance their own
inspection activities and to audit recognized organizations
acting on their behalf in this case ABS and DNV GL.
Ref
Recommendation summary
1A

Labelling of rated electrical equipment in

hazardous areas.
1B

Guidance on design of detection and

alarm systems.
1C

Guidance on fire and explosion strategies

for units with DP.
1D
Specification of minimum explosion design loads.
1E
Explosion risk analysis for each existing facility.
1F/G

Control of location of ventilation inlets. Shut down

of ventilation in the event of gas detection.
2A
Fire pumps to be self-contained.
2B

H-60 rated separation between drill floor and

adjacent accommodation areas.
2C

Guidelines on engineering evaluations

of fire partitions.
2D
Fixed deluge or monitors provided for drill floor.
2E

Fire risk analysis to supplement the prescriptive

requirements of the MODU code.
3A

Standards for maximum radiant heat allowable at

muster stations and lifeboat stations.
operational details of the Deepwater Horizon, a timeline of

the event, a synopsis of audits and ISM non-compliances, and
results of surveys.
6) BOEMRE Report into Causes of Macondo Well Blowout
The BOEMRE investigation
was carried out as part of
the Joint Investigation Team
(JIT) with USCG. It focused
on BOEMRE responsibilities,
especially the drilling activity
and the cause of the blowout.
The introduction provided a
little background on deepwater drilling in GoM and the
Deepwater Horizon drilling activities, but this was less
educative than in the Presidential Commission Chief
Counsels report which had appeared 7 months prior and thus
had no need to be repeated. The report provided an analysis
of the available drilling margin, the casing program, and
various mud issues. It also covered casing design issues around
a long string vs. a liner system and discussed key factors in the
selection. A third option would have been to abandon the well
without setting any production casing, as BP had done in other
narrow margin GoM wells, and BOEMRE noted this might have
made sealing the well easier.
The BOEMRE report provided a good discussion on
cementing approaches and particularly the nitrified (i.e. foamed)
cement slurry as was used. Nitrified cement is less dense than
unfoamed cement and therefore exerts less pressure on the
formation. However, the use of foamed cement creates the risk
of nitrogen breakout and hence a non-uniform density. Overall,
it still remains a viable option, but requires greater care.
The Halliburton OptiCem model was used for the well, with
30-40 model runs trialing different options. BOEMRE identified
a number of faults with the model parameters used. They noted
that BP did not query the model parameters nor did it share
the results with Transocean and cementing was critical to well
integrity. There was also an issue with centralizers. There were
only 6 on-board and the Halliburton cementing model
suggested 21 were needed. BP located 15 additional
centralizers and these were delivered to the rig, but these
would have taken longer to install and they were not used.
BOEMRE concluded however that the lesser number of
centralizers did not cause the blowout event. The float collar
suffered a blockage problem during conversion. There is doubt
that conversion actually occurred properly and this would affect
cement effectiveness. BP could have used a more debris
tolerant design, but BOEMRE could not establish exactly what
caused the blockage.
BOEMRE then developed about a dozen contributing causes
to the blowout mostly ascribed to BP failings. They also
considered alternative flow paths but decided that the primary
flow path was through the 9 x 7 production casing from the
shoe track as a result of float collar and shoe track failures.
Table 2. Summary of USCG Recommendations related to fire & explosion
Although the report focused on deficiencies, a final section did

commend the heroic actions of staff onboard the Deepwater
Horizon, the Damon B Bankston, and the Ramblin Wreck
vessels. Detailed appendices provided design and
BOEMRE then examined multiple technical challenges and

organizational issues (schedule and personnel changes and
conflicts, cost overruns) and the details of the actual
abandonment process including the failed negative pressure
test. They then addressed reasons why the Transocean team
might have failed to recognize the kick, the later flawed drill
floor response, and the failure to activate the emergency
disconnect system which would have actuated the shear rams.
Possible ignition sources were discussed.
The reasons for the BOP failure to seal the well referred mainly
to the DNV GL Forensic examination (9). BP company policies
were a contributing factor.
BOEMRE did review regulatory processes and how these may
have contributed to the event. However in most instances they
concluded these had no contribution to the blowout event.
A final section provided 41 recommendations and was divided
into six sections (with recommendations counts in each): wells
(6), kick detection and response (8), ignition source (4), BOP (6),
regulatory agency (11), and OSC Companies (6).
Some of the more significant recommendations included:
require the negative pressure testing of wells where
appropriate
require at least two barriers (one mechanical and one
cement barrier) for a well that is undergoing temporary
abandonment procedures, and to clarify that a float collar/
valve is not to be considered to be a mechanical barrier.
revise the incident reporting rule at 30 CFR 250.188 to
capture well kick incidents
enhance BOP operation and intervention
expand 30 CFR 250.446 to include documentation and
record keeping requirements for major (3-5 year) inspections
as required by BOEMREs adoption of API RP 53
Note, there was no recommendation regarding safety and
environmental management systems as BOEMRE had already
decided by this time to require adoption of SEMS based
on API RP 75.
7) Marshall Islands Registry DWH Marine Casualty
Investigation Report
The Flag State for the DWH
was the Republic of the
Marshall Islands. Under
international conventions, the
Flag State must report the
causal factors of all serious
and very serious marine
casualties. Therefore the
Marshall Islands issued a report to the IMO on 17 Aug 2011
outlining its findings with respect to the accident. The focus of
this report was to identify non-compliances with relevant
international regulations, including the United Nations
Convention on the Law of the Sea, 1983 (UNCLOS), the
International Convention for the Safety of Life at Sea, 1974, as
amended (SOLAS), and the Code of the International Standards
and Recommended Practices for a Safety Investigation into A
Marine Casualty or Marine Incident.
The report provided a detailed timeline of the incident including
witness statements. The report then addressed the functioning
of the safety and other equipment and human and
organizational factors. There were instances of unclear
command and control, evacuation systems that did not function
well (as power had been lost), and the Emergency Disconnect
PAGE 9
System did not function as intended. All inspections required by

Flag State and USCG were in place and classification surveys by
ABS were current. The vessel complied with its Minimum Safe
Manning Certificate and all marine crew and officer positions
were held by staff holding appropriate credentials. The vessel
sank due to damages sustained in the explosion and this led
to its listing. Further ingress of fluids caused greater listing and
once the deck reached the sea surface, further ingress occurred
and the vessel sank.
The report concluded that the causal factors were: deviations
from standards of well control engineering; deviation from the
well abandonment plans submitted to and approved by the
Minerals Management Service; and failure to react to multiple
indications that a well control event was in progress.
The report also identified a number of non-causal factors.
These included:
Better communications between the Flag State and the
coastal state on inspections might have increased awareness
of safety issues
The DWH structure withstood the explosion sufficient to
allow evacuation of most staff, but the power failure affected
any possible fire response but that would have been futile
due to the damage and hydrocarbon leak
The Emergency Disconnect System did not function as
intended
There was evidence of confusion in chain-of-command
during the emergency but this was not a causal factor
Rapid evacuation., although not as planned, is a testament to
the robustness of the regulatory system and the redundancy
of life saving equipment
The report contained 17 recommendations, but the Marshall
Islands highlighted four: enhanced communications between
the Flag State and the Coastal State; IMO should review the
MODU code related to aspects of this incident; there should be
better definition of responsibilities of the Master and OIM
especially during emergencies; and better procedures for
actuating the Emergency Disconnect System.
8) Adm Thad Allen: Incident Commanders Report
Once the scale of the incident was
established, the event was declared
to be a Spill of National Significance
and Thad Allen, then Commandant of
the USCG, was declared the National
Incident Commander. These were the
first applications of these terms and
the event tested existing laws
and regulations very hard. The Oil
Pollution Act (OPA 90) and the
National Contingency Plan (NCP 40
CFR Part 300) provided the guiding regulations but there was
overlap with a Homeland Presidential Directive for domestic
incidents. Allen recommended these two documents need to be
reconciled before another emergency occurs.
The NCP had been deployed successfully for thousands of spill
events over the past 20 years. However, it started to break down
during the Deepwater Horizon spill as some aspects were not
accepted by the public or by state officials notably the role of
the responsible party (here BP) was not understood and some
PAGE 10
states/local authorities did not accept federal authority. There

was concern that BP would not sufficiently prioritize the
environment over its shareholder interest. Allen stressed that the
Federal Government directs and oversees the response the
responsible party must implement these instructions. Adm Allen
and the Federal On-Scene Coordinator issued many directives
to BP, and BP provided the resources and capabilities as
required by law, but he notes that BP and its subcontractors
often executed these without direct government supervision.
State and local actions were in many cases outside the NCP
structure and this was partly due to the 9/11 attacks that resulted
in substantial emergency resources having been channeled to
these bodies. Adm Allen concluded unequivocally that the NCP
is a sound framework and allowed for the needed
discretion and freedom of action to address contingencies
during the response.
The response involved 47,000 people, 120 aircraft controlled
from a dedicated air center, a fleet of 6,500 vessels (more
vessels than the D-Day landing in Normandy), and boosted
manufacture of booms from around a thousand feet/week to
over a quarter million feet/week. Figure 4 from BP shows the
scale of response efforts.
9) DNV GL Forensic Examination of Deepwater Horizon BOP

The Justice Department
commissioned DNV (now DNV
GL) to carry out a forensic
examination of the Transocean
BOP recovered from the sea
floor once the well had been
killed. The objectives were to
determine the performance of
the BOP system during the well control event, any failures that
may have occurred, the sequence of events leading to failure(s)
of the BOP and the effects, if any, of a series of modifications to
the BOP stack that BP and Transocean officials implemented.
The BOP was transported to NASAs Michoud facilities in
Louisiana where tests were conducted. A detailed set of tests
was agreed amongst the interested parties. This included the
ST Locks, Choke and Kill Valves, the five rams on the lower BOP,
the HP accumulator, and the hydraulic and electronic circuits
of the AMF/Deadman and autoshear systems. Drill pipe was
recovered from inside the BOP, from the riser, and from the sea
floor these segments were matched together to determine the
failure mode.
The report was designed to support legal proceedings, if
required, and thus contains a very detailed set of information
with 149 figures and 30 tables. The equipment examined is
shown in Figure 5.
Figure 4. Massive scale of response to spill event
The National Incident Commander (NIC) concluded that the

Oil Pollution Act of 1990 and the NCP provided a sound basis
for response and any changes should not change its
fundamental governance structure. But many changes were
required. There must be better integration of all necessary
government agencies before there is an emergency, actions
are needed to de-conflict and reconcile the role of the NIC, the
NIC must have adequate authorities to execute the role
properly and work with the National Response Team (15 relevant
federal agencies), and the private sector must be encouraged
to develop modern oil spill response capabilities, matching the
challenges of deepwater activities.
Figure 5. BOP and associated equipment
Selected conclusions on the event include:

Evidence supports that the Upper VBRs were closed at
21:56 prior to the EDS activation on April 20, 2010 (the date
of the accident)
Forces from the flow of the well induced a buckling
condition on the portion of drill pipe between the Upper
Annular and Upper VBRs
The portion of the drill pipe located between the shearing
blade surfaces of the Blind Shear Rams was off center and
held in this position by buckling forces
As the BSRs (Blind Shear Rams) closed, this portion of the
drill pipe became trapped between the ram block faces,
preventing the blocks from fully closing and sealing
(Figure 6)
Trapping of the drill pipe between the ram faces would have
taken place regardless of which means initiated BSR closure
(AMF/Deadman or Autoshear)
When the drill pipe was sheared on April 29, 2010, using the
CSRs (Casing Shear Rams), the well flow pattern changed
to a new exit point through the open drill pipe at the CSRs
expanded to flow up the entire wellbore to the BSRs and
through the gap along the entire length of the block faces.
Drill pipe properly

centered in BSR
Drill pipe buckled beyond

BSR cutting zone
Figure 6. Location of drill pipe inside BSR and its effect on BSR
cutting ability
The DNV GL report made a number of detailed

recommendations to industry regarding BOP design and
operation issues. These included:
Study of elastic buckling of drill pipe as this is what
prevented the BSR from functioning properly
Study of the shear blade surfaces of shear rams as they
could not shear the off-center drill pipe
Study of well control procedures or practices as the timing
of the closure of the Upper Annular and the Upper VBRs
contributed to the drill pipe buckling and moving off center
Better testing of back-up control systems as some system
components did not perform as intended
Better processes to prevent common mode failure of
back-up control systems
Provide better means to verify the operation or state of
various components of BOPs in an emergency
Study of the effectiveness of Remotely Operated Vehicle
interventions
Stipulating requirements for back-up control system
Performance as now for primary control functions
10) CSB Investigations (Vols 1-2)
The US Chemical Safety Board,
which is well known for its
onshore investigations,
undertook an investigation into
the Macondo offshore event at
the request of Congress. They
issued two reports in June
2014. Vol 1 addressed the
relationship between the parties involved and described the
many technical challenges associated with the drilling at
Macondo. Vol 2 is much more detailed and this focused on the
CSB technical findings on the Deepwater Horizon BOP and its
ongoing management as a safety critical element (SCE). The
report presented the technical evidence carefully with many
detailed figures and tables. The CSB noted that two further
reports (Vols 3-4) will be issued addressing human factors issues
and organizational issues. The CSB Vol 2 report contained many
photographs and diagrams to explain the relatively complex sys-
PAGE 11
tems around the BOP and their analysis, which involved

additional BOP function tests, went beyond prior investigations
by the National Commission and others.
Vol 2 had five main objectives: 1) to review the BOP reliability
issues; 2) to account for drill pipe buckling inside the BOP; 3)
to explore possible barriers (hardware, operational and
organizational) to prevent such accidents; 4) to outline a
management system for SCEs; and 5) to identify regulatory
enhancements related to SCEs.
The CSB participated in some of the forensic examinations of
the BOP and carried out its own additional tests. They
identified gaps in BOP effectiveness due to when it might be
actuated either manually or by one of the automatic systems.
Although the DWH BOP contained multiple redundant systems
designed to achieve a very high reliability, the CSB identified
many deficiencies in components of this system. The CSB found
evidence of miswiring of two systems (one each in the blue and
yellow control pods see Figure 7). This drained one battery
making the blue pod inoperative on the day, and the yellow pod
miswiring would have prevented its operation as well except a
battery failure in it allowed the yellow pod to actuate the BSR. A
separate issue identified in (9) and accepted by the CSB was the
buckling of the drill pipe inside the BOP and this prevented the
BSR knife edge from cutting through the pipe. The CSB noted
that while the BOP was frequently tested for operational
function, these deeper latent individual component failures
could not be identified by those system-level tests. However,
the BOP manufacturer recommended tests that would have
identified the component failures. Changes in testing protocols
post-Macondo by the industry have improved, but not
eliminated, AMF/deadman failure to actuate the BOP.
Figure 7. Example of BOP miswiring*
*Note: Photograph of Y103 wire arrangement from Phase II

testing with pins 1 and 4 connected to white wires and 2 and 3
connected to black wires. (Right) Schematic of correct
arrangement of wires, with pins 1 and 3 connected to white
wires and 2 and 4 connected to black wires.
The CSB noted several opportunities to improve US regulations.
These should include risk based concepts with a focus on major
accident events; that safeguards for such accidents be based
on a sound philosophy; that there should be an explicit target
for risk reduction (e.g. ALARP); and that SCEs be identified and
managed through life to attain defined performance standards.
The report addressed a number of specific faults for the BOP,
but the CSB decided not to make detailed BOP design
recommendations, rather to focus on a higher level on issues
PAGE 12
relating to all Safety Critical Elements. These include that BSEE

should develop regulations requiring SCEs to be identified
and performance standards defined for each, and that risks be
reduced to an ALARP target level. SCEs should be monitored
through life; that there should be an independent verification
scheme for these; and deficiencies identified be documented
and corrected. The CSB recommended that API support this
process by developing guidance documents for identifying
SCE and reducing risks to ALARP. More specifically also, the API
should revise Blowout Preventer Equipment System for Drilling
Wells (API Standard-53, 4th edition) to establish additional
component level tests to supplement the current system
level tests.
11) Center for Catastrophic Risk Management (UC Berkeley)
A group of experienced risk
management and
organizational specialists
resides at the UC Berkeley
Management and this includes
members who developed the
high reliability organization
model. The Center formed an investigation team to assess this
accident the Deepwater Horizon Study Group. The final report
was issued in March 2011, and this was preceded by 3 progress
reports. The study group addressed both technical and
organizational causes. The report contained a useful deepwater
drilling technology overview and provided a clear description
of the technical and organizational failings. They made multiple
findings and recommendations.
In the three progress reports the Center concluded: 1) this
disaster was preventable had existing progressive guidelines
and practices been followed; 2) the failures (to contain, control,
mitigate, plan, and clean-up) appear to be deeply rooted in a
multi-decade history of organizational malfunction and
shortsightedness; and 3) thus, as a result of a cascade of
deeply flawed failure and signal analysis, decision-making,
communication, and organizational - managerial processes,
safety was compromised to the point that the blowout occurred
with catastrophic effects. At the time of the Macondo blowout,
BPs corporate culture remained one that was embedded in
risk-taking and cost-cutting.
Key findings in the Center final report included:
Deepwater exploration and production poses greater risks
than are commonly understood
Risks can be orders of magnitude greater than in shallow
waters and to be ALARP much greater precautions are
necessary than displayed at Macondo
Ongoing developments should be at a measured pace and
require deployment of BAST technologies (Best Available
and Safest Technologies)
A step change process is required matching BAST
technologies with high reliability type organizations and
collaborative industry government relations.
The Center recommendations included:
Develop technology systems between government and
industry to develop high hazard wells sustainably
Develop institutions capable of effective risk assessment
and management of high hazard wells
Implement such risk based systems in the context of high

reliability organizations and capable of responding to major
blowout events
Utilize validation projects to show such characteristics.
12) National Academy of Engineering
The National Academy of
Engineering convened a
review panel of 15 experts in
response to a request from the
Department of Interior.
Their report included main
sections on well design and
construction, the BOP system,
MODUs, industry management of offshore drilling, and
regulatory oversight; each of these with multiple findings,
observations and recommendations.
Appendix C in the report grouped together all 38 findings, 23
observations, and 68 recommendations. While these are all
important, space does not permit listing all of these here,
however the Summary chapter highlighted the most important
and those 13 recommendations are listed here:
1) Develop guidelines for drilling and completion that address
credible risks and safety margins
2) Tests should be defined with acceptance criteria for primary
cement and mechanical barriers
3) BOP systems need to provide reliable cutting, sealing and
separation, with suitable maintenance and training
4) Instrumentation / expert systems should warn of loss of well
control with automatic functions if response is delayed
5) Consequences of loss of well control should be mitigated by
access to well capping and containment capabilities
6) US regulations should be updated to be a hybrid of
prescription with proactive goal-setting
7) BSEE should identify and approve safety critical points in
well construction and abandonment
8) A single US agency should have responsibility for an
integrated approach to system safety for offshore drilling
9) Operating companies should have ultimate responsibility for
well integrity and the drilling contractor for equipment
10) Industry should carry out more R&D on all aspects of drilling
safety including design, equipment, human factors, and
management
11) There needs to be formal education and training of offshore
staff to properly implement system safety
12) Develop industry-wide systems for incident reporting,
including confidential reporting, and share lessons
learned openly
13) Enhance safety culture through training, addressing human
factors, system safety, and leading indicators
13) National Research Council Ecosystem Services

Approach to DWH (2013)
The NRC team adopted a newer approach to damage
assessment and restoration by means of an ecosystem services
approach. This focused not on the natural resources themselves,
but on the valuable goods and services these resources supply
to people. At the current stage, the team could only assess four
case studies for ecosystem services. The aim is to support
agencies in their duties under the Oil Pollution Act of 1990 to
make the environment and the public whole.
Wetlands: The Committee identified that 1100 miles of coastal

salt marsh were affected during the event. Only some limited
areas are not expected to recover. Some areas where root
systems have died are being converted from marshland to open
water, and subsequent storm activity resulted in additional
erosion. However, where roots and rhizomes survived, little or
no long term impairment is expected. A complicating factor is
significant and ongoing losses of wetlands due to many
other factors.
Fisheries: Fisheries in the GoM provide some of the most
important and lucrative services through the production of
seafood, industrial fish products, and recreational fishing.
Fishery closures ordered by NOAA in the aftermath of the spill
resulted in decreased fishery landings of up to 20% of the GoM
total in 2010.
The committee also examined marine mammals (blue nose
dolphins) and the deep Gulf of Mexico ecosystem but no
direct conclusions were offered on either of these.
14) US District Court Eastern Louisiana Judgment

(Sept 4 2014)
While this judgment by Judge Barbier is not an inquiry like
the others it does represent a detailed examination of the
evidence with several key findings. Unlike inquiries, it is subject
to appeal and findings may be subject to change. This court was
assigned responsibility for most federal cases under a
judgment for multi-district litigation.
The Court ruling reviewed the accident sequence in some
detail, but focused primarily on technical issues and human
errors involved. It assessed the well design options, the faults
with the float collar conversion, cement placement and
composition problems, and the misinterpretation of the
negative pressure test. The Court reviewed the kick event
and the failure of the AMF and some BOP functions due to
maintenance problems. Finally the emergency response was
reviewed. However, the Court did not address
organizational factors.
The Court found that the discharge of oil was the result of BPs
gross negligence and willful misconduct. This is an
important finding as the fine per barrel of oil discharged is
normally $1,100 but this is nearly quadrupled in the case of
gross negligence. In this context ordinary negligence is a
failure to exercise the degree of care that someone of ordinary
prudence would have exercised in the same circumstances,
whereas gross negligence is an extreme departure from the care
required under the circumstances or a failure to exercise even
slight care. The Court further finds that BPs conduct was
reckless. Transoceans conduct was negligent. Halliburtons
conduct was also negligent. In assigning percentage liability
the split was as follows: BP 67%, Transocean 30%, and
Halliburton 3%. Although BPs conduct warranted the imposition
of punitive damages under general maritime law, BP cannot be
held liable for such damages under Fifth Circuit precedent.
PAGE 13
15) Norway PSA Interim Report DWH

The Petroleum Safety
Authority is the safety
regulator for offshore
developments in Norway. It
established an internal review
team after the Macondo event,
but considered also Montara
(2009), Snorre A (2004) and
Gullfaks C (2010) events and that work generated an interim
report in 2011. The extensive report is in Norwegian, but there
is a short English summary which contains its key findings. Some
lessons for Norwegian Operators are listed here.
The full report provided a detailed description of the accident
with numerous figures explaining the drilling strategy, the BOP
design and the formation of the gas cloud and explosion on the
rig. Following chapters then discuss various issues identified and
from these the PSA extracted lessons for Norwegian offshore
industry. There are a large number of lessons.
The PSA does not believe that the Macondo accident challenged
the critical philosophies underpinning the Norwegian regulatory
system such as the division of responsibility for regulatory
compliance and the demand for systematic and risk-based
compliance with functional requirements. But it did challenge
whether the PSA is continuously improving the way it seeks to
influence safety. An overall observation was that industry needs
to significantly improve how it manages major accident risk and
that safety culture must be enhanced.
The PSA addressed lessons specific for Macondo-style drilling
and well operations, but also for major accidents offshore in
general. The PSA noted the Macondo accident did not arise due
to some new causal mechanism unique to deepwater GoM or
to the companies involved, thus its lessons were relevant to the
management of major accident risks on the Norwegian
Continental Shelf.
The need for effective barrier management covering all barrier
elements is emphasized. There should be an integrated
approach to well barriers, including the principle of two
independent and tested well barriers as well as barrier
monitoring. The DWH accident confirms the importance of
defining the ambition level of performance standards for
barrier elements and ongoing monitoring of these. In Norway,
the effects of cold climate and aging facilities are important in
this regard. The BOP may need to have an associated SIL level
to ensure its reliability.
The DWH accident has highlighted the need for an effective
capping and containment capability. Furthermore there is a
need for better training of key staff in dealing with emergencies.
Better systems are needed for disconnection from the well, and
for enhanced ignition controls especially related to air intakes
of power generators. Maintenance of the BOP was an issue and
the PSA reemphasized the need to maintain safety
critical equipment.
The PSA highlighted that offshore safety needs a systems
perspective complex systems fail in complex ways and
simplistic solutions are not likely to be effective. There needs
to be a program to develop better tools for managing major
PAGE 14
accident risk, especially related to decision support. These

would provide information on uncertainties, highlight safety
critical priority areas, and prompt robust solutions.
Initiatives are needed to enhance safety culture and the
development of a culture of accountability. Companies need to
demonstrate their commitment to safety by participating actively
in standards development.
The PSA should enhance safety by fostering strong and
competent players. It could do this by making safety
performance an important factor in awarding licenses,
assessing company financial capacity, and determining whether
management of major accidents are properly considered in
company planning. The PSA concluded it needs to continue to
support research into various topics related to major accident
risks, both technical and social.
Finally, the costs associated with the DWH have exceeded
the cost of all previous accidents and this leads to a need to
assess financial incentives and how these impact safety
decisions, the quality of information characterizing major
accident risks and how such risks might be priced, and how
audits might address this.
16) Norway PSA Concluding report on DWH accident
The Interim Report was
issued in 2011 and the PSA
decided that a follow-up
report was justified in 2014
addressing new information
that appeared after the Interim
Report. The central findings
did not change, but extra
emphasis was given in several areas, and some recent changes
are documented.
The original work concluded that the Macondo accident did not
challenge the central principles used in Norway for systematic
risk-based compliance with functional requirements (i.e. a
goal-based regulatory system under-pinned by thorough risk
assessment). The PSA studied well control events on the
Norwegian Continental Shelf and identified four main challenges:
the need for a stronger commitment to technical measures
to improve safety
a bigger commitment to planning, barrier management and
better-adapted risk analyses
paying greater attention to major accident risk more
investigation of incidents
creating operational parameters for good collaboration in
the operator/supplier hierarchy.
In the area of risk assessment, the PSA noted that the DWH
accident demonstrated a need for better risk management and
processes which lead to more robust solutions and operations.
The impression may be that awareness of major accident risk
and robust solutions/operations has increased, but the PSA
concluded that the industry still has a further way to go in
adopting a more proactive approach to managing risk.
Barrier management has been a PSA focus area for several
years, but there is an ongoing need to maintain industry
commitment to barrier management and to link this to overall
risk management. Finally, with respect to safety culture and

organization, the DWH accident highlighted the need for
companies to be open to the unknown and pay attention to
signals of vulnerability. The Interim PSA report called for
development of tools and data to assess accident costs from a
social perspective. The PSA initiated a several projects including
Culture and system for learning and this produced
communication and audit tools. The Norwegian industry has
initiated several projects relating to safety culture,
organization and management. The NORSOK D-010 standard
for well control has been updated, including key performance
indicators and change management.
BOP equipment is the subject of ongoing work by IADC and
OGP, and PSA is awaiting the results of this. The PSA quoted
OGP as believing that the BOP as an isolated system has a SIL
rating of 3, but this drops to 2 when connected to the wellhead,
and maintaining this SIL level over the BOP lifetime poses a
challenge. PSA agreed with BSEEs four main expectations for
the BOP:
that shear rams have the capacity to cut the equipment
being run into the well through the BOP
that the BOP is maintained as a critical safety system
that real-time condition monitoring is established by
instrumenting the BOP
that requirements are developed for the competence of BOP
maintenance personnel.
Capping and containment was an area of concern in 2011, but
this has been adequately addressed in recent years with the
formation of international consortia to provide for capping and
containment equipment. For example, the OGP Subsea Well
Response Project (17) has established equipment depots in
international locations Stavanger, Singapore, South Africa and
soon in Brazil, and this is suitable for water depths up to 3000m
(10,000ft). This is matched with the expertise needed to operate
the equipment. Access to such equipment and expertise before
drilling commences has been proposed in new regulations. The
PSA recommended that industry conducts a full scale test of this
equipment in Norway.
17) OGP Offshore Safety Getting it Right
After Macondo, the OGP
(International Association of
Oil & Gas Producers based
in London) quickly established
the Global Industry Response
Group. This had a mandate
to improve well incident
prevention, intervention and
response capabilities. The team involved 100 specialists from
20 companies working on these three topics. A series of reports
were produced with numerous recommendations.
In the area of prevention four areas required work and OGP
reports progress in all four areas:
Creation of an industry-wide well control incident database
Assessment of BOP reliability and potential for improvement
Improved training and competence and more attention to
human factors
Development of international standards for well design and
operations management
In the area of intervention there has been tangible progress. This

resulted in the creation of the Subsea Well Response Project
(SWRP). This included capping stacks and dispersant toolboxes
available in four international locations and suitable for air transport.
Finally, related to Oil Spill Response a Joint Industry Project
has been initiated involving 18 member companies to build on
the lessons from Macondo. This is investigating optimal use of
dispersants, including in sensitive arctic environments, in-situ
burning procedures, and development of Recommended
Practices on environmental risk assessment, and response
resource planning. The JIP developed 19 separate work
packages and many of these have completed their work and
documentation is available on the oilresponseproject.org
website. This work has converted many recommendations into
practical guidance documents for industry.
18) OLF DWH Lessons Learned and Follow-up
The Norwegian Oil
Industry Association (OLF),
now renamed Norwegian
Oil and Gas Association, in
collaboration with NOFO (the
Norwegian Clean Seas
Association for Operating
Companies) carried out a
review of the DWH incident, compared regulations in the US
and Norway, and made recommendations to enhance
Norwegian operations and engineering standards. The group
commissioned DNV GL to review regulatory differences
between the USA and Norway. They concluded that the
Norwegian Continental Shelf is characterized by robust
legislation and safe operations, however, opportunities exist for
further improvements in prevention, intervention and response.
Figure 8. Recommendation count and types from 10 major Macondo inquiries
PAGE 15
The group made 45 recommendations for improvements,

summarized below.
Prevention: The focus for improvement is to enhance the
Norwegian NORSOK drilling standards (D-001: drilling
facilities and D-010: well integrity in drilling and well
operations). Specific recommendations addresed critical
cementing jobs, lockdown requirements for tubing and casing
hangers, negative pressure testing, fluid displacement
requirements, well control exercises, BOP backup control
systems, and enhanced BOP testing requirements.
Enhancement to well management systems, process safety, and
teamwork and communications were also proposed. Action on
drill crew expertise is being addressed by OGP (17).
Intervention and Response: Capping and containment is being
addressed through the OGP SWRP Project (17). The Macondo
unified command system proved to be effective and is now
considered a best practice approach and it is recommended
for Norway. There are lessons to be learned about protecting
workers from chemical exposure during a response through
protective equipment and training. OLF commissioned the
Norwegian Institute for Water Research to assess the
environmental impact to fisheries and of dispersant usage.
Fortunately, environmental damage from DWH was less than
expected and the use of in-situ burning and underwater use
of dispersants was considered beneficial. There remain gaps
in knowledge regarding Corexit dispersant and its potential to
delay natural degradation of oil. While fisheries have recovered,
there were very large costs to the fishing industry due to an
extensive closure of the resource.
OLF provided a useful summary of recommendations related to
well control and response issues (Figure 8).
PAGE 16
19) SINTEF Report on DWH (A19148, May 2011)

SINTEF is a large
independent, non-commercial
research group
headquartered in Trondheim
Norway. It was commissioned
by the PSA to summarize
lessons learned and provide
recommendations for the
industry in order to reduce the likelihood of a similar accident
to occur in the Norwegian petroleum activity. Its report, mostly
in Norwegian, but with an English Executive Summary contains
much useful analysis of the Macondo event and of other
offshore accidents.
SINTEF developed a very detailed timeline integrating inputs
from BP, UC Berkeley, USCG and the National Commission and
its Chief Counsels reports (all summarized above). The diagram
showed time steps across the page with the key players down
the page here covering BP, Transocean and Halliburton with
each having onshore and offshore players. The diagram (Figure
9, in Norwegian) covered 3 pages and mapped the interactions
between all the players very clearly. This diagram highlighted
the communication problems and SINTEF described the
process of offshore drilling into complex reservoirs as a
continuous process of problem-solving and this created a
need to interact and make decisions in an environment of
increasing complexity and uncertainty. SINTEF reviewed 134
recommendations from all the DWH reports issued by April
2011, as well as recommendations from the Montara and Snorre
A blowouts and the Gullfaks well incident.
Figure 9. Extract of SINTEF timeline of event
SINTEF makes 13 recommendations to the industry and 5 to the

authorities (in the Executive Summary in English). In overview,
the industry list included: 1) the cement barrier; 2) strategies for
two independent and tested barriers; 3) to evaluate whether
BOPs with a single shear ram are acceptable; 4) better design
guidance for diverters; 5) enhance safety instructions relating to
watertight integrity; 6) manage driller maintenance backlogs; 7)
enhance blowout control strategies; 8) enhance organizational
and individual awareness of early warnings of loss of control; 9)
enhance competency and working environment for drilling staff;
10) enhance communications between players offshore and
onshore; 11) develop new methods for operational risk
evaluation and decision making; 12) develop safety
management strategies to ensure compliance and resilience;
and 13) facilitate sharing of lessons learned globally.
The recommendations to the authorities included: 1) consider
requiring better redundancy in BOP e.g. double shear rams;
2) confirm performance standards exist on safety critical drilling
well operations; 3) revise the stability code with respect to
watertight integrity; 4) maintain a focus on maintenance
activities; and 5) build better well control knowledge in
the regulator.
20) UK Health & Safety Laboratory - DWH Fire & Explosion

Issues (Apr 2014)
The HSE requested the HSL to
study fire & explosion issues
related to the Macondo event.
HSL relied on several key
investigations including the
BOEMRE, USCG, BP,
Transocean, and RMI reports
(all summarized above). The
HSL focus was on technical issues related to fire and explosion.
Based on their analysis, the HSL made several recommendations:
Control of ignition sources across the rig in the event of
blowout should be considered in ALARP demonstrations
Substantial reductions in risk can be achieved by improving
the reliability of detection systems and simplifying or
eliminating reliance on human responses
Preventing the ingestion of gas into large spaces deep within
the rig should be a priority
If there is a residual risk of gas accumulation in internal spaces,
the consequences of explosion should be considered. The risks
of explosions venting through vulnerable areas of the rig should
be minimized; this may involve strengthening some internal
partitions and/or providing explosion relief to the outside.
The HSL report summarized fire and explosion related
recommendations in other Macondo investigations and found
that these generally matched UK offshore recommendations.
Some later chapters worked through examples of mitigations
of ignition likelihood, flammable gas dispersion, and
explosion damage.
21) US Transportation Research Board Evaluation
of SEMS Systems
BSEE (BOEMRE at the time) requested that the Transportation
Research Board assist them shift their focus from inspection of
hardware compliance matters to a broader focus on safety and
environmental management activities as these have greater
influence on accidents. The request related to implementation
of SEMS-I which was based on API RP 75 an element based
management system, similar to OSHA PSM requirements
onshore, and which was developed in the early 1990s. While
the work was underway, extra requirements related to SEMS-II
were promulgated in Sept 2011 (e.g. including stop work and
ultimate work authorities, employee participation, external
certification of SEMS programs, and job safety assessment).
The Committee believed that a good SEMS program does
contribute to a positive safety culture in the workforce. Culture
was defined as the intrinsic value of the importance of safety,
not as an exercise to convince people to comply with
regulations and procedures. This aligns well with the Nuclear
Regulatory Commission view on safety culture and BSEE
published this as guidance for the offshore industry.
The Committee addressed nine different means to assess SEMS
effectiveness (e.g. inspections, audits, peer reviews, KPIs, etc.).
They concluded all of these could have some value at
various times in assessing effectiveness. They also surveyed other management system assessment programs managed by the
USCG, OSHA, Mine Safety and Health Administration,
California State Lands Commission, the Center for Offshore
Safety (an API group), the UK HSE, and Norway PSA.
PAGE 17
Their overall conclusions were:

1) To encourage a positive safety culture, assessment should
focus on attitudes and actions, not paperwork
2) Complying with all elements of SEMS is not sufficient on its
own to create a culture of safety
3) The operator and its top management must own the
SEMS program
4) SEMS must be dynamic and evolve with the hazards as they
change in offshore developments
5) BSEE can have a positive or negative influence on safety
culture by the way it measures SEMS
6) A holistic combination of methods is needed to evaluate and
ensure continuous improvement of SEMS
7) BSEE must not dictate solutions to achieve safe operations,
the operator needs to develop these
8) Competent BSEE inspectors should be present routinely
offshore to verify SEMS
9) BSEE inspectors need to spend sufficient time offshore to
identify problems in an operators safety culture
10) Audits alone are insufficient to improve safety
11) BSEE driven audits are a regulatory requirement, but an
operators own audit program is fundamental
12) BSEE must ensure the quality of audits carried out
13) Such audits must have sufficient qualified personnel and
time availability
14) Qualified auditors have different skills and competencies to
qualified inspectors
15) BSEE is in a unique position to combine audit and inspection
reports and to generate best practices and trends
The Committee made a number of other observations on how
BSEE might encourage a culture of safety. These included many
suggestions on audit procedures, key performance indicators,
whistleblower /anonymous reporting programs, and ensuring
an adequate budget.
Conclusions
There have been many investigations into the Macondo
accident and these have addressed several different aspects of
the accident. Some investigations took a purely technical cause
perspective whereas others emphasized more compliance with
regulations or addressed organizational or human causes. Early
investigations provided very detailed tutorials on deepwater
drilling challenges. An indication of the range of
recommendations is shown in Table 3 and a more specific focus
on technical recommendations appears in the OLF Figure 8.
Many of the key recommendations have been adopted in one
form or another. The USA has seen major changes to the MMS
regulator, now BSEE and BOEM, with an updated style of
operation emphasizing goal-based safety and increased
inspector staff to allow greater presence offshore. BSEE has
issued new requirements for drilling safety, for BOP
recertification, negative pressure tests, and professional
engineer sign-offs on casing and cement, and a requirement to
estimate worst case blowout events. API and IADC have worked
on an interface requirement between lessee and contractor, and
several new API standards have been developed. SEMS I and
SEMS II have been implemented with the Center for Offshore
Safety defining the protocols and approving third party audit
service providers. BSEE has provided guidance on safety
culture and is working with another federal agency to
PAGE 18
No. Title
Prevention

BOP Design
& Operation
Contain &
Respond
Management US
& culture
Regulatory
International
Regulatory
1
DWH Commission Main
X X X X X
2
DWH Chief Counsels report
3
BP Investigation X X X
4
Transocean Investigation
X X X
5
USCG
X X X X X
6
BOEMRE
X X X X
7
Republic of the Marshall
X X X X X
Islands
8
Adm Thad Allen Report X X
9
DNV GL Forensic Investigation
10
X X X X
11
X X X X X

Management (UC Berkeley)
12
National Academy of
X X X X X
Engineering
13
National Research Council X
14

US District Court
X
X
Eastern Louisiana
15
Norway Petroleum Safety
X X X X X

Authority Interim
16
Norway Petroleum Safety
X X X X X

Authority Final
17
OGP
X X X X
18
OLF
X X X X
19
SINTEF
X X X X
20
UK HSL X
21
US Transportation X
X

Research Board
Table 3. Range of Findings and Recommendations
implement a confidential reporting system. BSEE has

established the Ocean Energy Safety Institute to research
several longer term problems (e.g. risk, reliability data, BAST).
USCG has issued guidance on additional fire and explosion
assessments it would like to see. There have been consortia
established in the USA and by OGP at 4 international locations
to provide emergency response support. There have been
standards updates for drilling and well control by API and by
NORSOK, and they have made their safety standards freely
available. Detailed assessments of fire and explosion lessons
have been made and these are starting to find their way
into designs.
The National Commission (1) co-chairs maintain a website
(oscaction.org) monitoring progress on implementation of their
recommendations. They have issued 3 annual progress reports
up to 2014. Generally they conclude that industry and the
Executive Branch have done a good job implementing
recommendations, but Congress lags.
Environmental findings of long term damage are too soon to be

available, but initial indications are that the damage is less than
might have been feared.
There have been changes overseas. The EU has decided to
adopt a safety case approach (similar to that in the UK) for all
offshore developments in the EU, and Australia expanded
coverage of its regulator (NOPSEMA) to address drilling and
environmental impacts to achieve close to a single offshore
regulator. The UK and Norway both believe their goal-setting
approach was not challenged by the Macondo accident, but
that many detailed aspects of drilling safety did need
enhancement and HSE, PSA and OGP are working on
these issues.
There are some important recommendations for the US
regulatory system which have not yet been adopted. These
include suggestions to adopt a safety case approach with a
greater focus on risk assessment with a risk target, and to
nominate safety critical items with defined performance
standards. It is not yet known if these will be adopted, or
perhaps addressed in some other equivalent manner.
Table of Acronyms
ALARP
AMF
API
BAST
BOEMRE
BOP
BSEE
BSR
CFR
CSB
CSR
DOI
DWH
EDS
EPA
GoM
HP
HSE
HSL
IADC
IMO
INPO
ISM
JIP
JIT
MMS
MOC
MODU
NCP
NIC
OCS
OGP
OLF
OIM
OSHA
PSA
PSM
RMI
ROV
RP
SCE
SEMS
SIL
USCG
VBR
As Low As Reasonably Practicable

Automatic Mode Function
American Petroleum Institute
Best Available and Safest Technologies
Bureau of Ocean Energy Management, Regulation and Enforcement
Blowout Preventer
Bureau of Safety and Environmental Enforcement
Blind Shear Ram
Code of Federal Regulations
Casing Shear Ram
Department of Interior
Deepwater Horizon Rig
Emergency Disconnect System
Environmental Protection Agency
Gulf of Mexico
High Pressure
Health and Safety Executive (UK)
Health & Safety Laboratory (UK)
International Association of Drilling Contractors
International Maritime Organization
Institute of Nuclear Power Operations
International Safety Management Code
Joint Industry Project
Joint Investigation Team (USCG / BOEMRE)
Minerals Management Service
Management of Change
Mobile Offshore Drilling Unit
National Contingency Plan
National Incident Commander
Outer Continental Shelf
International Association of Oil & Gas Producers
Norwegian Oil and Gas Association
Offshore Installation Manager
Occupational Safety and Health Administration
Petroleum Safety Authority (Norway)
Process Safety Management
Republic of Marshall Islands
Remotely Operated Vehicle
Recommended Practice
Safety Critical Element
Safety and Environmental Management System
Safety Integrity Level (ISO 61511)
United States Coast Guard
Variable Bore Ram
PAGE 19
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