One that should come as no surprise: “This disaster was preventable had existing progressive guidelines and practices been followed. This catastrophic failure appears to have resulted from multiple violations of the laws of public resource development, and its proper regulatory oversight.”
The first DHSG progress report identified seven elements responsible for this disaster:
• Improper cement design (segmented discontinuous cement sheath).
• Flawed Quality Assurance and Quality Control (QA / QC) – no cement bond logs in critical sections of the well, ineffective oversight of operations.
• Bad decision making – removing the pressure barrier – displacing the drilling mud with sea water 8,000 feet below the drill deck.
• Loss of situational awareness – early warning signs not properly detected, analyzed or corrected (repeated major gas kicks, lost drilling tools, including evidence of damaged parts of the Blowout Preventer) during drilling and/or cementing, lost circulation, changes in mud volume and drill string weight).
• Improper operating procedures – premature off-loading of the drilling mud (weight material not available at critical time).
• Flawed design and maintenance of the final lines of defense – including the Blowout Preventers (BOPs) blind shear rams, hydraulic lines, and triggering equipment – and the Emergency Shutdown and Disconnect (ESD) systems.
In the case of the Deepwater Horizon’s BOPs, the first few days following the incident are very revealing and symptomatic of BP’s failed Safety Management System (SMS). The initial response by engineers was focused on trying to fully engage the rig’s single functional blind shear ram using Remote Operated Vehicles (ROVs). However, it did not work and, in fact, the BP engineers reportedly did not even have accurate information about how the BOPs had been previously modified and wasted precious time trying to activate the BOPs.