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    THEBUREAUOFOCEANENERGYMANAGEMENT,

    REGULATIONANDENFORCEMENT

    REPORTREGARDINGTHECAUSESOFTHEAPRIL20,2010

    MACONDOWELLBLOWOUT

    September14,2011

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    i

    TABLEOFCONTENTS

    ExecutiveSummary................................................................................................1

    I. Introduction ..................................................................................................... 10

    A. TheInvestigation ......................................................................................... 10

    B. BackgroundRegardingDeepwaterDrillingintheGulfofMexico ............ 13

    C. CompaniesInvolvedintheMacondoWell .................................................. 16

    D. TheDeepwaterHorizon ............................................................................... 18

    E. TheMacondoWell ....................................................................................... 19

    F. TheBlowout ................................................................................................. 23

    II. WellDesign...................................................................................................... 25

    A. CostoftheMacondoWell ............................................................................ 25

    B. DrillingMargin........................................................................................... 27

    C. CasingProgram ........................................................................................... 31

    D. MudProgramandType .............................................................................. 32

    E. MudLosses .................................................................................................. 33

    F. WellBallooning ........................................................................................... 34

    G. PlannedandActualTotalDepth ................................................................. 34

    H. DesigningtheProductionCasingLongStringversusLiner................... 36

    III. Cementing ........................................................................................................ 40

    A. CementingProcess....................................................................................... 40

    B. CementDesignandModeling ..................................................................... 41

    C. GasFlowPotential....................................................................................... 46

    D. Centralizers .................................................................................................. 47E. FloatCollar .................................................................................................. 49

    F. CementingtheMacondoProductionCasing .............................................. 53

    G. IndustryStandardsforCementing.............................................................. 57

    IV. PossibleFlowPaths ........................................................................................ 61

    V. ConclusionsonWellDesign,Cementing,andFlowPath ........................ 68

    A. CauseoftheFailureoftheCementBarrier.................................................. 68

    B. ContributingCausesoftheCementBarrierFailure ................................... 68

    C. PossibleContributingCausesoftheCementBarrierFailure ..................... 70

    D. FlowPathCause .......................................................................................... 73

    VI. ChallengesattheMacondoWell .................................................................. 75

    A. KicksandStuckDrillPipe .......................................................................... 75

    B. SchedulingConflictsandCostOverruns .................................................... 78

    C. PersonnelChangesandConflicts ................................................................ 79

    D. SafetyStanddown....................................................................................... 83

    VII. TemporaryAbandonmentoftheMacondoWell ....................................... 85

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    A. InstallingtheLockDownSleeve ................................................................. 85

    B. SettingtheCementPlug.............................................................................. 86

    C. TheUseofLostCirculationMaterialasSpacer .......................................... 87

    D. WellIntegrityTesting ................................................................................. 88

    VIII. KickDetectionandRigResponse................................................................. 98

    A. KickDetectionMethodsandResponsibilities.............................................. 98

    B. MultipleSimultaneousOperationsThatHamperedtheCrewsAbilityto

    DetectKicks ................................................................................................. 99

    C. RigFloorResponse .................................................................................... 103

    D. TheUseoftheMudGasSeparator ............................................................ 104

    E. ActivityontheBridge................................................................................ 106

    F. EmergencyDisconnectSystem.................................................................. 107

    IX. ConclusionsonTemporaryAbandonment,KickDetection,andthe

    EmergencyResponse................................................................................... 109

    A. KickDetectionandResponseFailureCause ............................................. 109B. KickDetectionFailureContributingCauses ............................................ 109

    C. KickDetectionFailurePossibleContributingCauses .............................. 110

    D. ResponseFailureContributingCauses ..................................................... 112

    E. ResponseFailurePossibleContributingCauses ....................................... 113

    X. IgnitionSource(s)andExplosions .............................................................. 115

    A. MainEnginesandEngineSwitchGearRooms ........................................ 115

    B. MudGasSeparator .................................................................................... 119

    C. OtherPossibleIgnitionSources ................................................................ 122

    XI. Conclusionson

    Ignition

    Source

    and

    Explosion........................................ 125A. IgnitionSources ......................................................................................... 125

    B. ContributingCausesoftheExplosion ....................................................... 125

    C. PossibleContributingCausesoftheExplosion ......................................... 126

    D. OtherPossibleIgnitionSources ................................................................ 127

    XII. TheDeepwaterHorizonBOPStack............................................................... 129

    A. DesignandConfiguration ......................................................................... 129

    B. ControlandPowerSystems....................................................................... 132

    C. EmergencyDisconnectSystem.................................................................. 133

    D. AutomaticModeFunction(Deadman) ................................................. 134

    E. AutoshearFunction ................................................................................... 134

    F. ForensicExaminationoftheBOP ............................................................. 135

    G. ExaminationMethodsUsedbyDNV........................................................ 137

    H. DNVsForensicExaminationFindings .................................................... 138

    I. EvaluationofOtherPossibleFailures ....................................................... 142

    J. StudiesEvaluatingtheReliabilityofBOPs .............................................. 144

    K. MaintenanceoftheDeepwaterHorizonBOP ........................................... 146

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    iii

    L. BOPSystemLeaks ..................................................................................... 151

    M. ROVInterventions .................................................................................... 153

    XIII. BOPStackConclusions ................................................................................ 155

    A. CauseoftheBOPStackFailure................................................................. 155

    B. BOPStackFailureContributingCauses .................................................. 155

    C. BOPStackFailurePossibleContributingCauses..................................... 155

    XIV. RegulatoryFindings ..................................................................................... 157

    A. PermittingProcess..................................................................................... 158

    B. WellActivityReports ................................................................................ 161

    C. MacondoDeparturesandAlternativeProcedures .................................... 161

    D. MMSDrillingInspections ........................................................................ 162

    E. PotentialIncidentofNoncomplianceGuidelines ...................................... 162

    F. InspectionForms........................................................................................ 164

    G. MMSDeepwaterHorizonInspectionsatMC252 ................................... 164

    H. SafeDrillingMargin ................................................................................. 165I. WellControl............................................................................................... 165

    J. SubseaBOPRegulatoryRequirements ..................................................... 167

    K. RegulatoryImprovements ......................................................................... 172

    L. IncidentsofNonCompliance .................................................................... 173

    XV. PoliciesandPracticesofInvolvedCompanies ......................................... 175

    A. BPsPoliciesandPractices ........................................................................ 175

    B. TransoceansPracticesandProcedures ..................................................... 185

    C. BPandTransoceanBridgingDocument................................................... 189

    D. StopWork

    Authority ................................................................................. 189

    XVI. ConclusionsRegardingInvolvedCompaniesPractices......................... 191

    XVII.SummaryofPanelConclusions.................................................................. 194

    A. WellDesignandCementing...................................................................... 194

    B. FlowPath ................................................................................................... 195

    C. TemporaryAbandonment,KickDetection,andEmergencyResponse ..... 195

    D. IgnitionSource .......................................................................................... 197

    E. BlowoutPreventer ..................................................................................... 198

    F. CompanyPractices .................................................................................... 199

    XVIII.Conclusion ..................................................................................................... 200

    XIX. Recommendations......................................................................................... 202

    A. WellRecommendations.............................................................................. 202

    B. KickDetectionandResponseRecommendations ...................................... 203

    C. IgnitionSourceRecommendations ............................................................ 205

    D. BlowoutPreventerRecommendations ....................................................... 206

    E. RegulatoryAgencyRecommendations ...................................................... 207

    F. OCSCompaniesPracticesRecommendations.......................................... 209

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    Dedication .............................................................................................................211

    Acknowledgement...............................................................................................212

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    1

    ExecutiveSummary

    Atapproximately9:50p.m.ontheeveningofApril20,2010,whilethe

    crewoftheDeepwaterHorizonrigwasfinishingworkafterdrillingtheMacondo

    exploratorywell,

    an

    undetected

    influx

    of

    hydrocarbons

    (commonly

    referred

    to

    as

    akick)escalatedtoablowout. Shortlyaftertheblowout,hydrocarbonsthat

    hadflowedontotherigfloorthroughamudgasventlineignitedintwo

    separateexplosions. Flowinghydrocarbonsfueledafireontherigthat

    continuedtoburnuntiltherigsankonApril22. Elevenmendiedonthe

    DeepwaterHorizonthatevening. Overthenext87days,almostfivemillion

    barrelsofoilweredischargedfromtheMacondowellintotheGulfofMexico.1

    AfteranextensiveinvestigationconductedbytheJointInvestigation

    TeamoftheBureauofOceanEnergyManagement,RegulationandEnforcement

    (BOEMRE)(formerlytheMineralsManagementServiceorMMS)andthe

    UnitedStatesCoastGuard,theBOEMREpanelofinvestigators(thePanel)has

    identifiedanumberofcausesoftheMacondoblowout.

    ThePanelfoundthatacentralcauseoftheblowoutwasfailureofa

    cementbarrierintheproductioncasingstring,ahighstrengthsteelpipesetina

    welltoensurewellintegrityandtoallowfutureproduction. Thefailureofthe

    cementbarrierallowedhydrocarbonstoflowupthewellbore,throughtheriser

    andontotherig,resultingintheblowout. Theprecisereasonsforthefailureof

    theproductioncasingcementjobarenotknown. ThePanelconcludedthatthefailurewaslikelydueto:(1)swappingofcementanddrillingmud(referredtoas

    fluidinversion)intheshoetrack(thesectionofcasingnearthebottomofthe

    well);(2)contaminationoftheshoetrackcement;or(3)pumpingthecementpast

    thetargetlocationinthewell,leavingtheshoetrackwithlittleornocement

    (referredtoasoverdisplacement).

    ThelossoflifeattheMacondositeonApril20,2010,andthesubsequent

    pollutionoftheGulfofMexicothroughthesummerof2010weretheresultof

    poor

    risk

    management,

    last

    minute

    changes

    to

    plans,

    failure

    to

    observe

    and

    respondtocriticalindicators,inadequatewellcontrolresponse,andinsufficient

    1Thisestimateisbaseduponpressurereadings,data,andanalysisconductedbyU.S.scientific

    teamscommissionedbytheNationalIncidentCommander. See

    http://www.doi.gov/news/pressreleases/USScientificTeamsRefineEstimatesofOilFlowfrom

    BPWellPriortoCapping.cfm.

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    emergencybridgeresponsetrainingbycompaniesandindividualsresponsible

    fordrillingattheMacondowellandfortheoperationoftheDeepwaterHorizon.

    BP,asthedesignatedoperatorunderBOEMREregulations,was

    ultimatelyresponsibleforconductingoperationsatMacondoinawaythat

    ensuredthesafetyandprotectionofpersonnel,equipment,naturalresources,

    andtheenvironment. Transocean,theowneroftheDeepwaterHorizon,was

    responsibleforconductingsafeoperationsandforprotectingpersonnelonboard.

    Halliburton,asacontractortoBP,wasresponsibleforconductingthecementjob,

    and,throughitssubsidiary(SperrySun),hadcertainresponsibilitiesfor

    monitoringthewell. CameronwasresponsibleforthedesignoftheDeepwater

    Horizonblowoutpreventer(BOP)stack.

    Atthetimeoftheblowout,therigcrewwasengagedintemporary

    abandonmentactivitiestosecurethewellafterdrillingwascompletedandbeforetheDeepwaterHorizonleftthesite. InthedaysleadinguptoApril20,BP

    madeaseriesofdecisionsthatcomplicatedcementingoperations,added

    incrementalrisk,andmayhavecontributedtotheultimatefailureofthecement

    job. Thesedecisionsincluded:

    Theuseofonlyonecementbarrier. BPdidnotsetanyadditionalcementor

    mechanicalbarriersinthewell,eventhoughvariouswellconditions

    createddifficultiesfortheproductioncasingcementjob.

    Thelocationoftheproductioncasing. BPdecidedtosetproductioncasingin

    alocationinthewellthatcreatedadditionalriskofhydrocarboninflux.

    Thedecisiontoinstallalockdownsleeve. BPsdecisiontoincludethesetting

    ofalockdownsleeve(apieceofequipmentthatconnectsandholdsthe

    productioncasingtothewellheadduringproduction)aspartofthe

    temporaryabandonmentprocedureatMacondoincreasedtherisks

    associatedwithsubsequentoperations,includingthedisplacementof

    mud,thenegativetestsequenceandthesettingofthesurfaceplug.

    Theproductioncasingcementjob. BPfailedtoperformtheproduction

    casingcementjobinaccordancewithindustryaccepted

    recommendations.

    ThePanelconcludedthatBPfailedtocommunicatethesedecisionsand

    theincreasingoperationalriskstoTransocean. Asaresult,BPandTransocean

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    personnelonboardtheDeepwaterHorizonontheeveningofApril20,2010,did

    notfullyidentifyandevaluatetherisksinherentintheoperationsthatwere

    beingconductedatMacondo.

    OnApril20,BPandTransoceanpersonnelonboardtheDeepwaterHorizon

    missedtheopportunitytoremedythecementproblemswhenthey

    misinterpretedanomaliesencounteredduringacriticaltestofcementbarriers

    calledanegativetest,whichseekstosimulatewhatwilloccuratthewellafterit

    istemporarilyabandonedandtoshowwhethercementbarrier(s)willhold

    againsthydrocarbonflow.

    Therigcrewconductedaninitialnegativetestontheproductioncasing

    cementjobthatshowedapressuredifferentialbetweenthedrillpipeandthekill

    line,whichisahighpressurepipeleadingfromtheBOPstacktotherigpumps.

    Thiswasaseriousanomalythatshouldhavealertedtherigcrewtopotentialproblemswiththecementbarrierorwiththenegativetest. Aftersome

    discussionamongmembersofthecrewandasecondnegativetestonthekill

    line,therigcrewexplainedthepressuredifferentialawayasabladdereffect,a

    theorythatlaterprovedtobeunfounded. Around7:45p.m.,afterobservingfor

    30minutesthattherewasnoflowfromthekillline,therigcrewconcludedthat

    thenegativetestwassuccessful. Atthispoint,therigcrewmostlikely

    concludedthattheproductioncasingcementbarrierwassound.

    Thecement

    in

    the

    shoe

    track

    barrier,

    however,

    had

    in

    fact

    failed,

    and

    hydrocarbonsbegantoflowfromtheMacondoreservoirintothewell. Despitea

    numberofadditionalanomaliesthatshouldhavesignaledtheexistenceofakick

    orwellflow,thecrewfailedtodetectthatthewellwasflowinguntil9:42p.m.

    Bythenitwastoolatethewellwasblowingdrillingmudupintothederrick

    andontotherigfloor. Ifmembersoftherigcrewhaddetectedthehydrocarbon

    influxearlier,theymighthavebeenabletotakeappropriateactionstocontrol

    thewell. TherewereseveralpossiblereasonswhytheDeepwaterHorizoncrew

    didnotdetectthekick:

    Therigcrewhadexperiencedproblemsinpromptlydetectingkicks. TheDeepwaterHorizoncrewhadexperiencedakickonMarch8,2010thatwent

    undetectedforapproximately30minutes. BPdidnotconductan

    investigationintothereasonsforthedelayeddetectionofthekick.

    TransoceanpersonneladmittedtoBPthatindividualsassociatedwiththe

    March8kickhadscrewedupbynotcatchingthekick. Tenofthe11

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    individualsondutyonMarch8,whohadwellcontrolresponsibilities,

    werealsoondutyonApril20.

    Simultaneousrigoperationshamperedtherigcrewswellmonitoringabilities.

    Therigcrewsdecisiontoconductsimultaneousoperationsduringthe

    criticalnegativetests includingdisplacementoffluidstotwoactivemud

    pitsandcleaningthepitsinpreparationtomovetherig complicated

    wellmonitoringefforts.

    Therigcrewbypassedacriticalflowmeter. Atapproximately9:10p.m.,the

    rigcrewdirectedfluiddisplacedfromthewelloverboard,which

    bypassedtheSperrySunflowmeter,whichisacriticalkickdetectiontool

    thatmeasuresoutflowfromthewell. TheDeepwaterHorizonwas

    equippedwithotherflowmeters,butthePanelfoundnoevidencethat

    thesemeterswerebeingmonitoredpriortotheblowout.

    Oncethecrewdiscoveredthehydrocarbonflow,itsenttheflowtoamud

    gasseparator,apieceofequipmentnotdesignedtohandlehighflowrates. The

    mudgasseparatorcouldnothandlethevolumeofhydrocarbons,andit

    dischargedagasplumeabovetherigfloorthatignited.

    ThePanelfoundevidencethattheconfigurationoftheDeepwaterHorizon

    generalalarmsystemandtheactionsofrigcrewmembersonthebridgeofthe

    rigcontributed

    to

    a

    delay

    in

    notifying

    the

    entire

    crew

    of

    the

    presence

    of

    very

    highgaslevelsontherig. TransoceanhadconfiguredtheDeepwaterHorizons

    generalalarmsystemininhibitedmode,whichmeantthatthegeneralalarm

    wouldnotautomaticallysoundwhenmultiplegasalarmsweretriggeredin

    differentareasontherig. Asaresult,personnelonthebridgewereresponsible

    forsoundingofthegeneralalarm. Personnelonthebridgewaited

    approximately12minutesafterthesoundingoftheinitialgasalarmstosound

    thegeneralalarm,eventhoughtheyhadbeeninformedthatawellcontrol

    problemwasoccurring. Duringthisperiod,therewereapproximately20

    alarmsindicatingthehighestlevelofgasconcentrationindifferentareasonthe

    rig.

    TheDeepwaterHorizonsBOPstack,amassive,360tondeviceinstalledat

    thetopofthewell,wasdesignedtoallowtherigcrewtohandlenumeroustypes

    ofwellcontrolevents. However,onApril20,theBOPstackfailedtosealthe

    welltocontaintheflowofhydrocarbons. Theexplosionslikelydamagedthe

    DeepwaterHorizonsmultiplexcablesandhydrauliclines,renderingthecrew

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    5

    unabletoactivatetheBOPstack. TheBOPstackwasequippedwithan

    automaticmodefunction,whichuponactivationwouldtriggertheblindshear

    ram(BSR),twometalblockswithbladesontheinsideedgesthataredesignedto

    cutthroughthedrillpipeandsealthewellduringawellcontrolevent.

    ThePanelconcludedthatthereweretwopossiblewaysinwhichtheBSR

    mighthavebeenactivated:(1)onApril20,bytheautomaticmodefunction,

    immediatelyfollowinglossofcommunicationwiththerig;or(2)onApril22,

    whenaremotelyoperatedvehicletriggeredtheautoshearfunction,whichis

    designedtoclosetheBSRifthelowermarineriserpackagedisconnectsfromthe

    restoftheBOPstack. RegardlessofhowtheBSRwasactivated,itdidnotseal

    thewell.

    AforensicexaminationoftheBOPstackrevealedthatelasticbucklingof

    thedrillpipehadforcedthedrillpipeupagainstthesideofthewellboreandoutsidethecuttingsurfaceoftheBSRblades. Asaresult,theBSRdidnot

    completelyshearthedrillpipeanddidnotsealthewell. Thebucklingofthe

    drillpipe,whichlikelyoccurredatornearthetimewhencontrolofthewellwas

    lost,wascausedbytheforceofthehydrocarbonsblowingoutofthewell;bythe

    weightofthe5,000feetofdrillpipelocatedintheriserabovetheBOPforcingthe

    drillpipedownintotheBOPstack;orbyacombinationofboth. Asaresultof

    thefailureoftheBSRtocompletelycutthedrillpipeandsealthewell,

    hydrocarbonscontinuedtoflowaftertheblowout.

    PriortotheeventsofApril20,BPandTransoceanexperiencedanumber

    ofproblemswhileconductingdrillingandtemporaryabandonmentoperations

    atMacondo. Theseproblemsincluded:

    Recurringwellcontroleventsanddelayedkickdetection. Atleastthree

    differentwellcontroleventsandmultiplekicksoccurredduring

    operationsatMacondo. OnMarch8,ittooktherigcrewatleast30

    minutestodetectakickinthewell. ThedelayraisedconcernsamongBP

    personnelabouttheDeepwaterHorizoncrewsabilitytopromptlydetect

    kicksandtakeappropriatewellcontrolactions. Despitethesepriorproblems,BPdidnottakestepstoensurethattherigcrewwasbetter

    equippedtodetectkicksandtohandlewellcontrolevents. AsofApril20,

    TransoceanhadnotcompleteditsinvestigationintotheMarch8incident.

    Schedulingconflictsandcostoverruns. Atthetimeoftheblowout,

    operationsatMacondoweresignificantlybehindschedule. BPhad

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    6

    initiallyplannedfortheDeepwaterHorizontomovetoBPsNilewellby

    March8,2010. Inlargepartasaresultofthisdelay,asofApril20,BPs

    Macondooperationsweremorethan$58millionoverbudget.

    Personnelchangesandconflicts. BPexperiencedanumberofproblems

    involvingpersonnelwithresponsibilityforoperationsatMacondo. A

    reorganizationthattookplaceinMarchandApril2010changedtheroles

    andresponsibilitiesofatleastnineindividualswithsomeresponsibility

    forMacondooperations. Inaddition,thePanelfoundevidenceofa

    conflictbetweentheBPdrillingandcompletionsoperationsmanagerand

    theBPwellsteamleaderandevidenceofafailuretoadequatelydelineate

    rolesandresponsibilitiesforkeydecisions.

    Atthetimeoftheblowout,bothBPandTransoceanhadextensive

    proceduresinplaceregardingsafedrillingoperations. BPrequiredthatitsdrillingandcompletionspersonnelfollowadocumentedandauditablerisk

    managementprocess. ThePanelfoundnoevidencethattheBPMacondoteam

    fullyevaluatedongoingoperationalrisks,nordiditfindevidencethatBP

    communicatedwiththeTransoceanrigcrewaboutsuchrisks.

    Transoceanhadanumberofdocumentedsafetyprogramsinplaceatthe

    timeoftheblowout. Nonetheless,thePanelfoundevidencethatTransocean

    personnelquestionedwhethertheDeepwaterHorizoncrewwasadequately

    preparedto

    independently

    identify

    hazards

    associated

    with

    drilling

    and

    other

    operations.

    EveryoneonboardtheDeepwaterHorizonwasobligatedtofollowthe

    TransoceanstopworkpolicythatwasinplaceonApril20,whichprovided

    that[e]achemployeehastheobligationtointerruptanoperationtopreventan

    incidentfromoccurring. DespitethefactthatthePanelidentifiedanumberof

    reasonsthattherigcrewcouldhaveinvokedstopworkauthority,noindividual

    ontheDeepwaterHorizondidsoonApril20.

    ThePanelfoundevidencethatBPand,insomeinstances,itscontractorsviolatedthefollowingfederalregulations:

    30CFR250.107BPfailedtoprotecthealth,safety,property,andthe

    environmentby(1)performingalloperationsinasafeandworkmanlike

    manner;and(2)maintainingallequipmentandworkareasinasafe

    condition;

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    30CFR250.300BP,Transocean,andHalliburton(SperrySun)failedto

    takemeasurestopreventtheunauthorizedreleaseofhydrocarbonsinto

    theGulfofMexicoandcreatingconditionsthatposedunreasonablerisk

    topublichealth,life,property,aquaticlife,wildlife,recreation,navigation,

    commercialfishing,orotherusesoftheocean;

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

    takenecessaryprecautionstokeepthewellundercontrolatalltimes;

    30CFR250.420(a)(1)and(2)BPandHalliburtonfailedtocementthe

    wellinamannerthatwouldproperlycontrolformationpressuresand

    fluidsandpreventthereleaseoffluidsfromanystratumthroughthe

    wellboreintooffshorewaters;

    30CFR250.427(a)BPfailedtousepressureintegritytestandrelated

    holebehaviorobservations,suchasporepressuretestresults,gascut

    drillingfluid,andwellkickstoadjustthedrillingfluidprogramandthe

    settingdepthofthenextcasingstring;

    30CFR250.446(a)BPandTransoceanfailedtoconductmajor

    inspectionsofallBOPstackcomponents;and

    30CFR250.1721(a)BPfailedtoperformthenegativetestprocedures

    detailedinanapplicationforapermittomodifyitsplans.

    AlthoughthePanelfoundnoevidencethatMMSregulationsineffecton

    April20,2010wereacauseoftheblowout,thePanelconcludedthatstronger

    andmorecomprehensivefederalregulationsmighthavereducedthelikelihood

    oftheMacondoblowout. Inparticular,thePanelfoundthatMMSregulationsin

    placeatthetimeoftheblowoutcouldbeenhancedinanumberofareas,

    including:cementingproceduresandtesting;BOPconfigurationandtesting;

    wellintegrity

    testing;

    and

    other

    drilling

    operations.

    In

    addition,

    the

    Panel

    found

    thattherewereanumberofwaysinwhichtheMMSdrillinginspections

    programcouldbeimproved. Forexample,thePanelconcludedthatdrilling

    inspectionsshouldevaluateemergencydisconnectsystemsand/orotherBOP

    stacksecondarysystemfunctions. BOEMREhasalreadyimplementedmanyof

    theseimprovements.

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    8

    ThisReportsetsforthindetailthePanelsinvestigativefindings,

    conclusions,andrecommendations. ThePanelsfindingsandconclusionsare

    presentedinthefollowingsubjectareas:welldesign;cementing;possibleflow

    paths;temporaryabandonmentoftheMacondowell;kickdetectionandrig

    response;ignitionsourceandexplosion;thefailureoftheDeepwaterHorizon

    blowoutpreventer;regulatoryfindingsandconclusions;andcompanypractices.

    ThisReportconcludeswiththePanelsrecommendations,whichseekto

    improvethesafetyofoffshoredrillingoperationsinavarietyofdifferentways:

    Welldesign. Improvedwelldesigntechniquesforwellswithhighflow

    potential,includingincreasingtheuseofmechanicalandcementbarriers,

    willdecreasethechancesofablowout.

    Wellintegritytesting. Betterwellintegritytestpractices(e.g.,negativetestpractices)willallowrigcrewstoidentifypossiblewellcontrolproblemsin

    atimelymanner.

    Kickdetectionandresponse. Theuseofmoreaccuratekickdetectiondevices

    andothertechnologicalimprovementswillhelptoensurethatrigcrews

    candetectkicksearlyandmaintainwellcontrol. Bettertrainingalsowill

    allowrigcrewstoidentifysituationswherehydrocarbonsshouldbe

    divertedoverboard.

    Rigengineconfiguration(airintakelocations). Assessmentandtestingof

    safetydevices,particularlyonrigswhereairintakelocationscreate

    possibleignitionsources,maydecreasethelikelihoodofexplosionsand

    fatalitiesintheeventofablowout.

    Blowoutpreventers. ImprovementsinBOPstackconfiguration,operation,

    andtestingwillallowrigcrewstobebetterabletohandlewellcontrol

    events.

    Remotelyoperatedvehicles(ROVs). StandardizationofROVinterventionpanelsandinterventioncapabilitieswillallowforimprovedresponse

    duringablowout.

    ThePanelbelievesthattheadoptionoftheproposedrecommendations

    willimprovethesafetyofoffshoreoperationsandwillhelptoreducethe

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    9

    likelihoodoftheoccurrenceofanothertragiceventsimilartotheMacondo

    blowout.

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    10

    I. Introduction

    A.

    TheInvestigation

    OnApril

    27,

    2010,

    the

    Secretaries

    of

    the

    Department

    of

    Homeland

    Security

    andtheDepartmentoftheInteriorconvenedajointinvestigationofthe

    explosionandsinkingofthemobileoffshoredrillingunitDeepwaterHorizon2by

    theBureauofOceanEnergyManagement,RegulationandEnforcement

    (BOEMRE)andtheUnitedStatesCoastGuard(USCG). TheConvening

    OrderdirectedtheJointInvestigationTeam(JIT)toissueajointreportwithin

    ninemonths. ThisdeadlinewasextendedtoallowtheJITtocompletethe

    investigation.

    OnApril29,2010,anMMSAssociateDirectorappointedtheMMS(now

    BOEMRE)membersoftheJIT.3 ThisReportisbasedontheinvestigativerecord

    developedbytheJITandcontainsthePanelsfindingsandconclusions.

    BOEMREsInvestigationsandReviewUnit(IRU),inclosecoordinationwith

    thePanel,hadasubstantialroleinthedraftingandpreparationoftheReport.4

    TheConveningOrderprovidesthatrelevantstatutesandregulations

    relatingtoboththeUSCGandBOEMREgoverntheJITandthattheJITspublic

    hearingsbeconductedinaccordancewiththeUSCGsrulesandprocedures

    relatingtoMarineBoardsofInvestigation. Undertheserules,theJITwas

    requiredto

    formally

    designate

    certain

    companies

    and

    individuals

    involved

    with

    theDeepwaterHorizonoperationatthetimeoftheblowoutaspartiesininterest

    (PIIs)andalsoretainedtheauthoritytodesignateotherPIIsatitsdiscretion.

    TheJITdesignatedthefollowingentitiesandindividualsasPIIs:BP,Transocean,

    Halliburton,MISWACO,Weatherford,AnadarkoPetroleum,MOEXUSACorp.,

    DrilQuip,JimmyHarrell(Transocean),CurtKuchta(Transocean),Douglas

    HaroldBrown(Transocean),SteveBertone(Transocean),MikeWilliams

    2Joint

    Department

    of

    the

    Interior

    and

    Department

    of

    Homeland

    Security

    Statement

    of

    Principles

    andConveningOrderRegardingInvestigationintotheMarineCasualty,Explosion,Fire,

    Pollution,andSinkingofMobileOffshoreDrillingUnitDeepwaterHorizon,withLossofLifein

    theGulfofMexico,April2122,2010(theConveningOrder). ByorderoftheSecretaryofthe

    Interior,datedJune18,2010,BOEMREreplacedtheformerMineralsManagementService

    (MMS)astheUnitedStatesoffshoreresourcemanagerandsafetyauthority.3PanelmembersincludedDavidDykes(cochair),GlynnBreaux,JohnMcCarroll,Kirk

    Malstrom,andJasonMathews.4IRUmembersincludedMichaelFarber,LisaScanlon,andKishanNair.

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    11

    (Transocean),PatrickOBryan(BP),andRobertKaluza(BP).5 UndertheMarine

    Boardrulesandothergoverningauthorities,thePIIspossessedcertainrights

    relatingtotheinvestigation.6

    UndertheConveningOrder,theJITwasgiventhefullinvestigative

    authorityofboththeDepartmentoftheInteriorandtheDepartmentof

    HomelandSecurity.7 TheJITheldsevenpublichearingsandheardtestimony

    frommorethan80witnesses.8 Threewitnesseswhosetestimonywassoughtby

    theJITinvokedtheirFifthAmendmentrightsagainstselfincriminationand

    refusedtotestifyduringtheJIThearings,andtwootherwitnessesclaimedthey

    wereunabletotestifyformedicalreasons.9 Inadditiontothepublichearings,

    BOEMREinvestigatorsalsoconductedinterviewsofmorethan25individuals

    throughouttheinvestigation.

    TheJITcollectedandreviewedlargevolumesofelectronicandwrittenmaterial,includingdata,emailsandotherrecordsrelatedtothePIIsequipment,

    managementsystems,supervisionofemployeesandcontractors,

    communications,performanceandtrainingofpersonnel,relevantcompany

    policiesandpractices,andworkenvironment. TheJITissuedmorethan90

    subpoenasfordocumentsandotherinformationandcollectedover400,000

    pagesofevidence.

    Duringthecourseoftheinvestigation,theJITcommissionedseveral

    entitiesand

    qualified

    individuals

    to

    conduct

    expert

    analyses

    of

    evidence.

    Dr.

    JohnSmith,apetroleumengineerwithPetroleumConsultingLLC,reviewed

    5AttherequestoftheRepublicoftheMarshallIslands,theJITdesignateditasaSubstantially

    InterestedState. TheDeepwaterHorizonwasaforeignflaggedvesselthat,atthetimeofthe

    blowout,wasflaggedundertheRepublicoftheMarshallIslands.6See46U.S.C.6303;46CFR.4.0310,4.0735,4.0915.7ConveningOrder,at1.8RetiredUnitedStatesDistrictJudgeWayneAndersen,whoservedwithoutcompensation,

    joinedtheJITinAugust2010topresideoversubsequenthearings. BOEMREisgratefulforJudge

    Andersens

    assistance

    during

    the

    hearings

    and

    in

    meetings

    with

    counsel

    for

    the

    PIIs.

    9BrianMorelandRobertKaluzaeachinvokedhisFifthAmendmentRightsandrefusedtotestify

    duringJIThearings. Aftertestifyingatonehearing,MarkHafleinvokedhisFifthAmendment

    Rightsandrefusedtotestifyasecondtime. Throughhisattorney,DonaldVidrineclaimedthat

    hecouldnottestifyduetomedicalreasons. EachofthesefourindividualswasaBPemployeeat

    thetimeoftheblowoutandcontinuestobeemployedbyBP. Inaddition,twoTransocean

    witnessesdeclinedtocooperatewiththeinvestigation,citingtechnicalreasonsfortheirdecisions

    nottotestify. Transoceandeclinedtoencouragethesewitnessestocooperatewiththe

    investigation.

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    12

    wellconditiondatacollectedbySperrySunduringthetemporaryabandonment

    procedureandreportspreparedbytheInternationalAssociationofDrilling

    Contractors(IADC)tohelpreconstructandidentifykeyissuesduringthe24

    hoursimmediatelypriortotheblowout. KeystoneEngineeringconducteda

    casingbuoyancyanalysis.10 OilfieldTestingandConsultingconductedacement

    blendanalysisonsamplesprovidedbyHalliburton. DetNorskeVeritas

    (DNV)conductedtheforensicexaminationoftheDeepwaterHorizonsBOP

    stackandsectionsofdrillpipeandprovidedaforensicanalysisreportdetailing

    theinformationandconclusionsdevelopedbasedonthisexamination.11 These

    expertreportsareattachedasappendicestothisReport.

    Thepurposeofthisinvestigationwastoidentifythecausesofthe

    Macondoblowoutandissuerecommendationsinordertoreducethelikelihood

    ofasimilareventinthefuture. Throughoutthisreport,thePanelclassifiesthe

    factorsthatcontributedtotheblowoutinthefollowingcategories:

    Causesarethosefactorsthatmostimmediatelyandproximatelycaused

    theblowout;thatmostdirectlyledtothecircumstancesunderlyingthe

    blowout;orthatallowedtheblowouttohappen. Butforthesefactors,

    therewouldnothavebeenablowout. Thesefactorsmaybespecific

    eventsorconditionsthatexistedinthewellorontherigatthetimeofthe

    blowout.

    Contributing

    Causesare

    those

    factors

    that

    alone

    would

    not

    have

    led

    to

    theblowout,butthatweresignificantincontributingtotheeventsor

    conditionsthatgaverisetotheblowout. Forafactortobeclassifiedasa

    contributingcauseofanevent,theremustbecompellingevidence

    supportingboththeexistenceofthefactorandthatitmaterially

    contributedtotheoccurrenceorseverityoftheevent.

    PossibleContributingCausesarethosefactorsthateitherwereminor

    contributingcausesoftheblowoutorforwhichtheevidencesuggeststhe

    factorscontributingroleintheblowoutisweakerorlesscompelling.

    10Thecasingbuoyancyanalysisevaluatedwhethertheproductioncasingfloatedupthewellbore

    aresultoftheblowout.11

    Asdiscussedinmoredetaillaterinthisreport,aBOPstackisalargedevicethatsitsontopofa

    wellandisdesignedtoassistrigcrewsinmaintainingcontrolofthewell. VariousBOPstack

    componentscanbemanuallyorautomaticallyoperatedtosealthewellandprotectagainsta

    blowout. ThecentralissueinvestigatedbytheJITregardingtheDeepwaterHorizonBOPwaswhy

    theBOPfailedtostoptheflowofhydrocarbonsfromtheMacondowell.

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    B. BackgroundRegardingDeepwaterDrillingintheGulfof

    Mexico

    Thegoalofdeepwaterdrillingoperationsistolocateandextractoiland

    gas(collectivelyreferredtoashydrocarbons)fromreservoirslocatedbeneath

    theseafloor. Insomereservoirs,thehydrocarbonsbecometrappedbeneath

    impermeablerock;whenthishappens,thehydrocarbonsseepintosurrounding

    porousrock. Drillingoperationsseektopenetratetheimpermeablerocktogetto

    hydrocarbonbearingreservoirsorpayzones.

    TheGulfofMexicoishometoalargenumberofhydrocarbonreservoirs.

    Since1947,morethan50,000wellshavebeendrilledintheU.S.GulfofMexico.

    Approximately97%oftheoilproducedontheU.S.OuterContinentalShelf

    (OCS)isproducedintheU.S.GulfofMexico. Therearecurrentlynearly7,000activeleasesintheU.S.GulfofMexico,64%ofwhichareindeepwater.12

    Since1995,deepwaterdrillingactivityhasincreasedsignificantlyinthe

    Gulf. In2001,U.S.deepwateroffshoreoilproductionsurpassedshallowwater

    offshoreoilproductionforthefirsttime. AsofMay2010,operatorsdrilled

    approximately700wellsinwaterdepthsequaltoorgreaterthan5,000feet,the

    approximatedepthoftheMacondowell.13 Deepwaterreservoirscanyieldahigh

    volumeofoilandgas. Productionratesfordeepwaterwellsaretypicallymuch

    higherthan

    in

    shallow

    water

    wells.

    Theinitialwellorwellsdrilledintoaformationarereferredtoas

    exploratorywells,whichanoperatordrillstodeterminewhetherareservoir

    containssufficientvolumesofhydrocarbonstowarrantinvestmentinthe

    12SeeDepartmentofInterior,IncreasedSafetyMeasuresforEnergyDevelopmentontheOuter

    ContinentalShelf,(May27,2010). Althoughthereisnosingleaccepteddefinitionof

    deepwater,acommonuseofthetermistorefertolocationswherethewaterdepthisatleast

    1,000feet.

    13Id.Operatorsarethepersonsthelessee(s)designatesashavingcontrolormanagementofoperationsontheleasedareaoraportionthereof. Anoperatormaybealessee,theMMS

    approveddesignatedagentofthelessee(s),ortheholderofoperatingrightsunderanMMS

    approvedoperatingrightsassignment. Lesseemeansapersonwhohasenteredintoalease

    withtheUnitedStatestoexplorefor,develop,andproducetheleasedminerals. Thetermlessee

    alsoincludestheMMSapprovedassigneeofthelease,andtheownerortheMMSapproved

    assigneeofoperatingrightsforthelease. 30CFR250.105.

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    installationofequipmentrequiredforproduction. Atthisstage,theoperator

    mayhavelimitedinformationaboutthegeologicalcharacteristicsofthereservoir

    andsurroundingformations. Suchinformation,includingdataaboutthe

    surroundingformations,porepressures,14reservoirconfigurationandreservoir

    volumes,isdevelopedduringtheexploratorydrillingoperationandmayleadto

    changesinthedrillingplanandwelldesignastheoperationproceeds.

    Onceanoperatorfinishesdrillinganexploratorywellandperformingits

    initialevaluationofthewell,ittypicallysealsthewellbypumpingcementand

    installingmechanicalplugs. Thisprocedureiscommonlyreferredtoas

    pluggingandabandoningthewell. Iftheoperatorbelievesthatiteventually

    willbeabletoproducehydrocarbonsfromtheexploratorywell,itmaychooseto

    performtemporaryabandonmentprocedures,whichareproceduresthatallow

    thedrillingrigtomoveoffofthewellsothattheoperatorcanreturnatalater

    datetocompletethewellandprepareitforproduction.

    Atypicaldeepwaterwellisdrilledusingthefollowingprocess:

    Adrillingrigmovesonthelocationofthewell. Manyrigsoperatingin

    deepwateraredynamicallypositioned,whichmeansthattheyarenot

    mooredtotheseafloorbutinsteadholdtheirpositionoverthewell

    throughacombinationofsatellitetechnologyanddirectionalthruster

    activity. TheDeepwaterHorizonwasadynamicallypositionedrig.

    Theriglowersdrillpipe(alsoknownasadrillstring)withadrillbit

    attachedtoitsend. Thedrillbitboresintotheseafloorandthesubsea

    formationtomakeahole. Thatholeisreferredtoasthewellbore.

    Theriginstalls,orsets,alargediameterpipeknownascasinginto

    thewellboretoestablishabarrierbetweenthewellboreandthe

    surroundingformationandtoensurethatcontinueddrillingdoesnot

    resultinthecollapseofthewellbore. Theinitialcasingthatissetinthe

    wellboreiscalledconductorcasing.

    Therigthenusesthemarineriserorriser,whichisalargepipethat

    surroundsthedrillpipe,tolowerthesubseaBOPstackontothewell.

    ThesubseaBOPislatchedtothewellheadontheconductorcasing.

    14Porepressureisthepressureoffluidswithintheporesofareservoir.

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    Asdrillingprogresses,therigsetsadditionalcasings(sectionsofpipe)

    thatareslightlysmallerindiameterthantheholecreatedbythedrillbit.

    Thecombinationofcasingsisreferredtoasthecasingstring. The

    casingsarebondedintoplaceusingcement. Thecasingstringmaintains

    theintegrityofthewellborebyprotectingthesidesofthewellborefrom:

    (1)pressureexertedfromthedrillingmud;(2)collapseoftheholealready

    drilled;and(3)influxoffluidsfromthesurroundingformation.

    Theoutermostcasingnearthetopofthewellcanbeuptofourfeetin

    diameter,andtheinnermoststringofcasingnearthebottomofthewell

    canbelessthansixinchesindiameter. Thesizeoftheinitialandfinal

    casing,thetypesofcasing,andthetypeofcementusedaredetermined

    bytheprofileofthewellbeingdrilled,includingfactorssuchaswell

    depth,temperatures,andwellpressures. Oncethewellisinproduction,

    hydrocarbonsareextractedthroughatubingstringthatisrundownthroughthemiddleoftheproductioncasingstring.

    Duringdrilling,therigcrewpumpsafluid,calleddrillingmudor

    muddownthedrillpipeandthroughthedrillbitnozzles. Althoughthefluid

    isreferredtoasmud,itisactuallyacomplexsystemcomprisedofcomponents

    thataredesignedinlightof,andtailoredto,avarietyofwellconditions. The

    mudsprimaryfunctionistoassistdrillcrewsinmaintainingwellcontrol.

    Drillingmudexertshydrostaticpressureinthedrillpipeandannulus(thespace

    betweenthe

    drill

    pipe

    and

    the

    walls

    of

    the

    casing

    strings

    or

    open

    hole)

    that

    is

    equaltoorgreaterthanthepressuresencounteredinthewellbore,thereby

    keepingthewellbalancedandundercontrol. Drillingmudalsocoolsthedrill

    bitandliftscuttingstothesurfaceasthemudiscirculatedduringdrilling.15 By

    closelymonitoringwellpressure,rigcrewsmaintainthewellborefluidpressure

    sothatitisequaltoorslightlygreaterthanthepressuresfromtheformation.

    Thistypeofpressurebalanceisreferredtoasanoverbalancedcondition. By

    contrast,awellisinanunderbalancedconditionwhentheformationpressures

    exceedthewellboredrillingfluidpressures. Rigcrewsrelyuponanumberof

    indicatorstotrackfluidpressures.16

    15Operatorsroutinelyrelyupondrillingmudsupplierstoprovideassistancewithchoosingan

    appropriatedrillingmud. Drillingrigcrewsincludemudloggerswhomonitordrillingmud,

    wellborepressures,andotherdata.16Thisprocessofmonitoringwellpressuresisreferredtoasmeasurementwhiledrilling.

    Operatorsalsoroutinelyrelyupondrillingmudsupplierstoprovideassistancewithchoosingan

    appropriatedrillingmudandtoprovidemudloggersontherigtomonitordrillingmud,

    wellborepressures,andotherdata.

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    16

    Cementingisanimportantfactorinwelldesignandtheexecutionofa

    safedrillingprogram. Aftereachcasingstringisset,cementispumpeddown

    thedrillstring,outthebottomofthecasingandbackupintotheannularspace.

    Thecementreinforcesthecasingstringandsealsofftheannularspace,

    preventinghydrocarbonsfromflowingthroughthespace. Aproperlycemented

    annularspaceissaidtohaveachievedzonalisolation. Operatorsoftenwork

    withcontractorsthatpossessspecificcementingexpertisetodeveloptheoptimal

    typeofcementforaparticulardrillingoperation. Cementingcompaniesalsocan

    helpmodeldifferentanticipatedwellconditionstohelpdrillingengineersto

    designasuccessfulcementjob. Thereareanumberofdifferentteststhatcanbe

    performedtoassessthequalityofacementjob.

    Duringthedrillingprocess,pocketsofoil,naturalgas,orwaterthatare

    encounteredinporouslayersoftheformationcanexertpressureintothewellborethatmaysuddenlyforcemudbackupthewellborewithconsiderable

    forcethisiscommonlyreferredtoasakick. Tohandlekicksandtomaintain

    wellcontrol,drillingcrewsusevariousmechanisms,including,underextreme

    circumstances,activationoftheBOPstackanddiverters. Ifakickoverwhelms

    thecontrolmechanisms,ablowouttheuncontrolledflowofhydrocarbons

    throughthewellborecanoccur.

    C.

    CompaniesInvolvedintheMacondoWell

    BPandTransoceanweretheprimarycompaniesinvolvedindrillingthe

    Macondowell. BPwasthemajorityowneranddesignatedoperatorofthelease.

    BPidentifiedtheprospectanddesignedandplannedthewell. Transoceanwas

    thedrillingcontractorengagedbyBPtodrilltheMacondowellandprovidethe

    DeepwaterHorizon,adynamicallypositioned,mobileoffshoredrillingunit(DP

    MODU),aswellasthedrillingpersonnel.

    BPisaglobaloilandgascompanyheadquarteredinLondon,England.

    BPoperatesinmorethan80countriesandisinvolvedinoilandgas

    exploration,production,andrefining,aswellastheoperationofservicestationsworldwide. BPholdsmorethan500activeleasesin

    theGulfofMexico,morethananyotherlessee. From2005through

    2009,BPwastheleadingproducerofoilandgasintheGulfofMexico,

    producing559,336,436barrelsofoiland846,352,047MCF(thousand

    cubicfeet)ofgasduringthatperiod.

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    17

    Transoceanistheworldslargestoffshoredrillingcontractor. Basedin

    Switzerland,Transoceanownsmorethan140drillingrigsandoperates

    inthemajoroffshoreoilandgasfieldsintheworld. Transoceanhas

    grownsubstantiallythroughaseriesofcorporateacquisitions,

    includingtheacquisitionofReading&BatesFalcon(R&BFalcon)in

    2000andGlobalSantaFein2007. TransoceanownedtheDeepwater

    Horizonrig,whichwasunderalongtermleasetoBPatthetimeofthe

    Macondoblowout. TheleaseagreementrequiredTransoceanto

    manageandoperatetheDeepwaterHorizononbehalfofBP.

    Offshoredrillingoperationsarecomplexandnormallyinvolvethework

    ofmanydifferentspecialists. InadditiontoBP,theleaseholderandthe

    designatedoperatoroftheMacondowell,andTransocean,thefollowing

    companiesalsohadsignificantrolesintheoperation:

    Halliburton,whichprovidesproductsandservicestotheenergy

    industryworldwideandisoneoftheworldslargestcementing

    contractorstotheoilandgasindustry,providedcementplanning,

    products,andservicesatMacondo.

    AnadarkoE&PCompanyLP,AnadarkoPetroleumCorporationand

    MOEXwereBPspartnersintheMacondowell. AnadarkoE&P

    CompanyLPowned22.5%,andAnadarkoPetroleumCorporation

    owned2.5%.

    17Both

    Anadarko

    companies

    are

    U.S.

    oil

    and

    gas

    explorationcompanies.18 MOEXOffshore2007,aJapaneseoil

    explorationfirm,owneda10%shareofthewell.19 Thecompanies

    sharedinBPscoststodrilltheMacondowellandwouldhaveshared

    inanyprofitsfromthewell.

    Cameron,whichisaTexasbasedmanufacturerofoilandgaspressure

    controlequipment,manufacturedtheDeepwaterHorizonsBOPstack.

    MISWACO,whichprovidesdrillingsuppliesandservices

    worldwide,developedthemudprogramandprovideddrillingmudandpersonneltooperatetheDeepwaterHorizonrigsmudsystem.

    17BP-HZN-MBI-00192559.18BPHZNMBI00177777.19Id.

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    18

    Schlumberger,whichprovidesoilfieldservicesthroughouttheworld,

    providedwellloggingservicesfortheMacondowell.

    SperryDrilling(SperrySun),asubsidiaryofHalliburtonthat

    providesdrillingdatasystemsandpersonneltothedrillingindustry,

    equippedtheDeepwaterHorizonwithSperrydatasensorsandSperry

    mudloggerstomonitorandevaluatewellconditiondata. The

    DeepwaterHorizonwasalsooutfittedwithTransoceanpaddleflow

    meterstomonitorflow.

    Weatherford,whichprovidesavarietyofdrillingservicesand

    components,providedthecasing,casingcentralizers,andfloat

    conversionequipmentusedontheDeepwaterHorizon.

    D.

    TheDeepwater

    Horizon

    TheDeepwaterHorizonwasadeepwater,columnstabilized,semi

    submersibleDPMODU,designedtodrillsubseawellsforoilandgas

    explorationanddevelopment. TheDeepwaterHorizonwasbuiltforR&BFalcon

    (whichlaterbecamepartofTransocean)byHyundaiHeavyIndustriesinUlsan,

    SouthKorea. ConstructionstartedinDecember1998,andtherigwasdelivered

    onFebruary23,2001,afterTransoceanacquiredR&BFalcon. Atthetimeofthe

    blowout,theDeepwaterHorizonwasregisteredinMajuro,MarshallIslands,and

    leasedto

    BP.

    TheDeepwaterHorizonsdayrateatthetimeoftheblowoutwas$533,495

    andtherigstotalestimateddailyoperatingcostswereapproximately$1

    million.20 Asiscommonintheindustry,underitscontractwithBP,Transocean

    wasallowedaspecificamountoftime(inthiscase,uptotwentyfourhoursper

    calendarmonth)formechanicaldowntimetoperformmaintenanceandrepairs

    withamaximumaccumulationof12daysofdowntimeperyear.21 Transocean

    wasnotpaiditsdayrateiftherigwasnotoperationalduetoequipmentrepairs

    fortimeperiodsbeyondthisallotment.22

    20TRNUSCG_MMS00040941.21TRNUSCG_MMS00040482.22Id.

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    19

    E. TheMacondoWell

    BPacquiredLeaseOCSG32306inanMMSCentralGulfofMexicolease

    saleonMarch19,2008. Thisleasecovers5,760acresandextendsfor10years,

    beginningonJune1,2008. BPisthedesignatedleaseoperatorandshares

    ownershipoftheleasewithAnadarkoandMOEX.

    TheMacondowellislocatedapproximately48milesfromthenearest

    shoreline,114milesfromtheshippingsupplypointofPortFourchon,Louisiana,

    and154milesfromtheHouma,Louisianahelicopterbase. BPbegandrillingthe

    Macondowell(referredtoasspuddingthewell)onOctober7,2009,using

    TransoceansMarianasrig. AftertheMarianassustaineddamageduring

    HurricaneIdainNovember2009,BPmovedtheDeepwaterHorizontothe

    Macondowell. TheDeepwaterHorizoncrewresumeddrillingoperationsat

    MacondoinFebruary2010.

    BPandTransoceanexperiencedseveralchallengesindrillingthe

    Macondowell. InOctober2009,thewellexperiencedakickduringdrilling

    operations.23 ThedrillingcrewexperiencedanotherkickonMarch8,2010. Asa

    resultoftheMarch8kick,thedrillpipebecamestuckinthewellbore,andtherig

    crewcouldnotpullthepipefree.24 Thecrew,therefore,hadtoseverthedrill

    pipeanddrillabypassaroundtheportionofthewellwiththestuckpipe.25 The

    wellalsoexperiencedseverallostreturnincidentsduringdrilling,when

    drillingmud

    pumped

    down

    the

    wellbore

    did

    not

    return

    to

    the

    surface

    as

    expectedbecausesomevolumeofthemudflowedintoandwaslostinthe

    formation.26 Lostreturnsarenotuncommonandcanoccurforavarietyof

    reasons,suchasafractureintheformationordrillinginoverbalanced

    conditions.27 Becauseoftheseandotherchallenges,onApril20,2010,the

    Macondowellwasabout38daysbehindscheduleandapproximately$58

    millionovertheoriginalbudget.28

    23MC252WellActivityReport,10/25/2009.24IADCReports,3/8/10 3/12/10.25Abypassisasecondarywellboredrilledawayfromtheoriginalhole. Itisnotuncommonfor

    anoperatortodrillabypasswhileexperiencingproblemsduringthedrillingofawell.26IADCReports,3/8/10 3/12/10.27AsdiscussedthroughouttheReport,thelostreturnsattheMacondowellwereofnotebecause

    oftheirfrequencyandbecausetheyoccurredalongwithotheranomalies.28BPHZNMBI00125958;BPHZNMBI0019553;BPMBHZN00192599.

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    Despitetheseproblems,byApril14,theDeepwaterHorizoncrew

    successfullydrilledtotheM56sand,oneofthehydrocarbonbearingzones

    thatBPgeologistsandengineershadtargetedforthewell.29 Althoughthe

    originalwellplanwastodrillapproximately1,800additionalfeet,theBPdrilling

    teaminHoustonoptedtostopdrillingthewellatatotaldepthof18,360feet

    becauseBPbelievedthewellhadreachedthebaseofthetargetreservoirandthat

    ithadrunoutofdrillingmargin.30 Inotherwords,BPconcludedthatitcouldno

    longersafelydrillintotheformationwithoutcreatinganunderbalancedwell(if

    themudwastoolight)orriskingfracturingtheformationandthreateningwell

    integrity(ifthemudwastooheavy). BPplannedtorunproductioncasingand

    temporarilyabandonMacondobysealingitwithasurfacecementplugsothat

    anotherrigcouldreturntothewelllaterandtakethestepsnecessarytocomplete

    thewellforproduction.

    OnApril19,theDeepwaterHorizoncrewrantheproductioncasingstringintothewell.31 BPsengineeringteamhadengagedinsignificantdebateoverthe

    appropriatedesignofthecasingtoruninthefinalwellsection. Therewas

    additionaldebateamongBPpersonnelaboutthenumberofcentralizers,which

    arepiecesofequipmentusedtokeepthecasingcenteredinthewell,touseon

    thefinalcasingstring. Thecrewpumpedcementintotheannulusandintothe

    shoetrack,thesectionofthecasingbetweenthebottomofthewellandthefloat

    valveinstalledinthewell(alargevalvedesignedtoallowfluidstoflowdown

    thewellwhilepreventingfluidsfromflowingbackupthewellboreduring

    cementingoperations).

    Thepurposeofthecementjobwastoestablishanisolationbarrieracross

    thehydrocarbonzoneatthebottomofthewellsothathydrocarbonscouldnot

    enterthewell. InthelatehoursofApril19andintothemorningofApril20,the

    rigcrewandBPscementcontractor,Halliburton,pumpedcementintothe

    Macondowelltoisolatethehydrocarbonzones.32 BasedondataprovidedbyBP,

    Halliburtondesigned the cement slurry, whichisamixtureofcement,waterand

    29BPHZNMBI00126338.30Id. AsdiscussedindetaillaterinthisReport,drillingmarginisthedifferencebetweenthe

    weightofthemudusedtodrillrelativetotheporepressuresandthefracturegradientofthe

    formation. Commonindustrypracticeistouseadrillingmarginof0.5ppgmudweightunder

    thefracturegradient.31IADCReport4/19/10.32HalliburtonPostJobCementReport,BPHZNCEC011406.

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    assorteddryandliquidadditives.33 After BP approved the design, Halliburtonbegan pumping the cement.

    Inadditiontocementing,theprocessofpreparingawellfortemporary

    abandonmentincludesfurtherprocedurestosecurethewellsothattherigsBOP

    stackandrisercanberemovedastherigpreparestomoveoffthelocation. BP

    engineersinHoustondevelopedtemporaryabandonmentprocedures(different

    fromtheMMSapprovedprocedure)fortheMacondowellthatincludedthe

    followingsteps:performingapositivepressuretest;34displacingmudinthewell

    from8,367feettothewellhead;performinganegativepressuretest;35settinga

    300footcementpluginthewellapproximately3,300feetbelowtheseafloorand

    settingalockdownsleevetolockthefinalcasingintoplace.36 BPengineers

    changedtheorderofthesestepsseveraltimesinthedaysbeforethetemporary

    abandonment.

    Duringallwellactivities,includingtemporaryabandonment,crew

    membersmonitorvarioussensorsontherigthatshowfluidvolumesandwell

    pressures.37 Thesesensorsproviderealtimedatatothecrew,whichmonitors

    andanalyzesthedataonelectronicdisplaystoidentifypotentialkicks,among

    otherthings. Earlykickdetectioniscriticaltomaintainingwellcontrol.

    OnApril20,thecrewconductedteststoevaluatetheintegrityofthe

    productioncasingcementjob. ThetestswerebasedonMMSapproved

    procedures

    that

    a

    BP

    drilling

    engineer

    had

    sent

    to

    the

    rig

    that

    morning.38

    The

    crewfirstconductedapositivepressuretesttoevaluatewhetherthewellcasing

    couldsustainpressureexertedonitfromtheinsideofthewellandreceived

    favorableresults.39 Onthesameafternoon,thecrewcirculatedmudupfromthe

    33Additivesareusedtotailorthecementtotheneedsofawell. Forexample,aweighting

    materialmightbeaddedtoacementslurrywhenahigherdensitycementisneeded.34Apositivepressuretestisconductedbypumpingfluidintothewellaftersealingtheblind

    shearrams. Therigcrewmonitorsthewelltodeterminewhetherpressuresinthewellremain

    static.35

    A

    negative

    pressure

    test

    seeks

    to

    create

    conditions

    that

    simulate

    what

    will

    occur

    when

    the

    well

    isabandoned. Therigcrewdisplacesdrillingmudwithotherfluids,resultinginthewellbore

    beingunderbalancedagainsttheformationpressures. Therigcrewthenmonitorspressuresand

    flowtodeterminetheintegrityofthebarrierbeingtested.36BPHZNMBI00129108. EachofthesestepsisdiscussedindetailinSectionIofthefindings

    andconclusionsinthisReport.37Fluidincludesanyfluid(mud,spacer,seawater)comingoutofthewelloracrosstherig.38BPHZNMBI00021237.39BPHZNMBI00136947.

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    well,andpumpedtherecoveredmudontotheDamonBankston,avesselworking

    alongsidetheDeepwaterHorizonatMacondo. Becauseofthemovementofthe

    mud,itwasdifficultforthecrewtotrackfluidvolumesinthewellboreandin

    themudpitsontherig.40

    Next,crewmembersturnedtoconductingnegativepressuretestsonthe

    well,whichwouldgivethecrewinformationaboutwhethertheproduction

    casingcementjobwascapableofkeepinghydrocarbonsoutofthewellbore. The

    crewrantwoseparatenegativetestsusingdifferentproceduresforeachtest.

    Justpriorto8:00p.m.onApril20,theBPwellsiteleaderondutyontherig,

    DonaldVidrine,andTransoceancrewmembersconcludedthatthesecond

    negativetestshowedthatthefinalcementjobwassuccessful.41 Vidrinealso

    calledMarkHafle,aBPengineerinHouston,around8:50p.m.todiscussthe

    surfaceplug. Duringthiscall,Vidrinedescribedtheresultsofthenegativetests.

    HaflequestionedVidrineabouttheresultsofthenegativetest,buthechosenottoinvestigatefurtherbyaccessingandreviewingtheavailablerealtimedata.

    Instead,HaflechosetorelyuponVidrinesassurancethattherigcrewhad

    successfullyperformedanegativetest.42

    DuringtheeveningofApril20,theDeepwaterHorizoncrewcontinued

    withthetemporaryabandonmentprocedurebyopeningtheBOPandpumping

    seawaterdownthedrillpipetodisplacemudandaspacerfromtheriser.43

    Duringthesewellactivities,thewellexperiencedsignificantchangesinpressure.

    Personnelresponsible

    for

    monitoring

    the

    condition

    of

    the

    well,

    however,

    did

    not

    recognizethesechangesassignsofakick. Thecrewmembersshutdownthe

    wellaround9:15p.m.toperformasheentestonthespacerthattheyplannedto

    sendoverboardasitwasdisplacedfromthewell.44 Thedecisiontosendthe

    displacedspaceroverboardrenderedSperrySunpersonnelunabletomeasure

    returnsononeoftherigsflowmeters. Duetotheplacementoftheflowmeters,

    40BPHZNMBI00021238.41TestimonyofJimmyHarrell,JointInvestigationHearing,May27,2010,at9091;Testimonyof

    MilesEzell,JointInvestigationHearing,May28,2010,at279282.42

    BP

    HZN

    BLY00125470.

    43Spacerreferstomaterialthatrigcrewspumpintoawelltoseparatethedrillingmudfrom

    seawater. Displacementofmudandspacerarepartofthetemporaryabandonmentprocedures

    discussedindetailinSectionIVofthefindingsandconclusions.44SperrySunrigdata,April20,2010. Thecrewperformedasheentesttoconfirmthatallofthe

    oilbasedmudhadbeendisplacedfromtheriser. Asheentestisintendedtoindicatethe

    presenceoffreeoilwhendrillingfluid,drilledcuttings,deckdrainage,welltreatmentfluids,

    completionandworkoverfluids,producedwaterorsandorexcesscementslurryaredischarged

    intooffshorewaters.

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    theSperrySuncrewcouldonlymeasurereturnssenttothemudpitsandcould

    notmeasureflowvolumessentoverboard.45

    F.

    TheBlowout

    OnApril20,2010,ataround9:40p.m.,powerfulpressuresfromthewell

    causedmudtoflowupfromthewell. Mudspilledontherigfloorasthewell

    begantoblowout. Thecrewrespondedtothesituationbydivertingtheflowto

    themudgasseparator,partofthedivertersystemtowhichthecrewcoulddirect

    fluidscomingupfromthewell.46 Atthistime,crewmemberslikelyrealizedthat

    theyhadlostcontrolofthewellandattemptedtoregaincontrolofthewellby

    activatingtheBOPstacksupperannularpreventerandtheuppervariablebore

    ram.47

    Themudgasseparator,towhichthecrewhaddivertedflowfromthewell,wasquicklyoverwhelmedandfailed,causingagasplumetofilltherig

    floor. Thegasquicklyignited,causingthefirstexplosionontherigat9:49p.m.

    Approximatelytensecondslater,asecondlargerexplosionoccurredandthefire

    onboardtherigspreadrapidly. Shortlyafterthesecondexplosion,theriglost

    powerandexperiencedatotalblackout.

    Atapproximately9:56p.m.,therigssubseaengineerattemptedto

    activatetheBOPstacksemergencydisconnectsystemfromtheBOPpanelonthe

    rigsbridge.

    The

    emergency

    disconnect

    system

    is

    designed

    to

    activate

    the

    BOP

    stacksblindshearramanddisconnecttherigslowermarineriserpackage

    (LMRP)fromthewell. TheBOPpanelapparentlyindicatedthatthe

    emergencydisconnectsystemwasactivated,buttherigremainedconnectedto

    thewellandhydrocarbonscontinuedtoflowuncontrolledfromthewell.48

    Aboutfourminutesaftertheattempttoactivatetheemergencydisconnect

    system,personnelontheDeepwaterHorizonsbridgemanuallysoundedthe

    generalalarmandmadeamustercallforpersonneltogatheratdesignated

    45

    Testimony

    of

    Joseph

    Keith,

    Joint

    Investigation

    Hearing,

    December

    7,

    2010,

    at

    135.

    46Themudgasseparator,andtherigcrewsdecisiontouseittohandletheinfluxof

    hydrocarbonsfromthewell,isdiscussedindetailinSectionVDofthefindingsandconclusions.47DNV,ForensicExaminationofDeepwaterHorizonBlowoutPreventer,March20,2001,(DNV

    Report)at4. AsdiscussedinlaterinthisReport,theupperannularpreventerandtheupper

    variableboreramaretwoBOPstackcomponentsthatareusedbyrigcrewsinwellcontrol

    events. Neithercomponent,however,isdesignedtoshearthedrillpipeandcompletelysealthe

    welltheblindshearramontheBOPstackisdesignedtoperformthesefunctions.48TestimonyofChrisPleasant,JointInvestigationHearing,May28,2010,at123.

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    lifeboatstations. Personnel,includingcrewmembers,contractorsandvisiting

    executivesfromBPandTransocean,evacuatedtherigontwolifeboatsandalife

    raft. Atleastsixpeoplejumpedfromtherigintothewater.

    At10:00p.m.,theDamonBankston,whichpriortotheexplosionshadbeen

    directedbytheDeepwaterHorizontomove500metersawayfromtherig,

    receiveddistresscallsfromtheDeepwaterHorizonandprepareditsfastrecovery

    craftforlaunchandrescueofthosewhohadabandonedtherig. TheDamon

    Bankstonretrievedsixpeoplefromthewaterandrecoveredanother108people

    fromthetwolifeboatsandliferaft. Uncontrollablefirescontinuedtoblazeon

    theDeepwaterHorizon,andtherigsankonthemorningofApril22.

    Elevenmendiedasaresultoftheblowoutandsixteenotherswere

    injured. EstimatesarethattheMacondowellspilledclosetofivemillionbarrels

    ofoilintotheGulfofMexicoduring87daysbetweentheblowoutandwhenthewellwassuccessfullycappedonJuly15,2010. Aftermonthsofadditional

    interventionwork,thewellwaspermanentlysealedonSeptember19,2010.

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    II. WellDesign

    Welldesignisafundamentalandimportantphaseofoffshoredrilling

    operations. Operatorsmustconsidersitespecificfactors,includingflows,

    pressurizedformation

    flows,

    reservoir

    natural

    gas

    and

    oil

    type,

    reservoir

    lithology(formationcharacteristics),reservoirstructure,andtheanticipated

    volumeofhydrocarbonstodeterminethebestwaytodrilltothetargetreservoir

    andtoconfigurecasingtoallowproductionfromthewell. Duringthedesign

    process,engineersuseallavailabledatatodetermineplannedtotaldepth

    (sometimesreferredtoasTD)ofthewell,casingpointselections,required

    casingspecifications,casingpressureratings,cementslurrydesign,mudweight,

    andriskfactorsparticulartothewell.49

    Developmentwellsaretypicallydesignedanddrilledbasedinparton

    datafromnearbywells,referredtoasoffsetwelldata. Inthecaseofexploratory

    wells,suchasMacondo,operatorshavelimitedoffsetwelldataavailable,

    makingitmoredifficulttoanticipatewellconditionspriortothespudofthe

    well. Asaresult,designprocessesinexploratorywellsaresubjecttochange.

    Operatorstypicallydealwithwelldesignchangesduringdrillingoperations

    throughdocumentedmanagementofchangeprocesses,whichareintendedto

    aidpersonnelinsystematicallyidentifyingandmitigatingtherisksassociated

    withthechanges.

    TheBP

    well

    engineering

    team

    and

    the

    BP

    subsurface

    team

    were

    involved

    indevelopingtheMacondowelldesign. Theteamsreferredtovarious

    documentsandmanualswhiledesigningtheMacondowell,includingBPs

    internalcasingdesignmanual,drillingwelloperationspolicy(DWOP),

    advancedguidelinesfordeepwaterdrillingandotherguidance.50

    A.

    CostoftheMacondoWell

    BPexceededitsoriginalcostestimatesfordrillingtheMacondowell. To

    obtainadditionalfundsandcontinuedparticipationfromitspartnersinthe

    Macondoproject,BPsubmittedtoAnadarkoE&PCompanyLPandAnadarko

    PetroleumCorporation(collectivelyAnadarko)andMOEXseveral

    49Casingpointisthedepthatwhichdrillingaparticularwellborediameterwillendsothat

    casingofagivensizecanberunandcemented.50BPHZNMBI000010362.

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    26

    AuthorizationsforExpenditures(AFEs),whichincludedwrittendescriptions

    oftheprojectandcostestimatesforproposedwellactivitiesandoperations.51

    UndertheiroperatingagreementwithBP,AnadarkoandMOEXcould

    choosetoparticipateintheactivitiesandoperationsdescribedintheAFEand

    therebycommittothefundingnecessarytocontinuetheoperation;theycould

    proposeanalternativeoperatingplan;ortheycouldendtheirparticipationinthe

    Macondoproject.52

    BPsubmittedtoAnadarkoandMOEXaninitialAFEfortheMacondo

    wellinAugust2009,estimatingthatthetotalcostsofthewellwouldbeabout

    $96.1million. BothAnadarkoandMOEXapprovedtheoperationand

    expenditures.53 BPsoughtitsfirstsupplementalAFEforapprovalofan

    additional$27.9millioninJanuary2010,whichthepartnersacceptedinFebruary

    2010.54 InMarch2010,BPsoughtauthorizationforanadditional$27million,explainingthatithadexceededthefirstsupplementalAFEduetounexpected

    lostcirculationandwellcontrolevents.55 AnadarkoandMOEXapprovedthe

    expenditureandofferednoalternativeoperatingplan.56

    OnApril14,afterBPhaddrilledtotheMacondowellsrevisedtarget

    depth,itsoughtafinalAFEfor$3.5milliontofundsettingtheproductioncasing

    inconnectionwiththetemporaryabandonmentofthewell. Anadarkoand

    MOEXapprovedtheAFEanddidnotproposeanyalternativeoperatingplan.57

    Intotal,

    the

    companies

    allocated

    $154.5

    million

    to

    drilling

    the

    Macondo

    exploratorywell,anamountwellinexcessoftheoriginalestimatedcostof

    $96.16millionandthenottoexceedcostof$139.5million.

    UndertheiroperatingagreementwithBP,AnadarkoandMOEXhad

    accessto,andinfactreviewed,dataandfilesrelatedtotheMacondowellthatBP

    madeavailabletothemthroughsharedwebsites. ThePanelfoundnoevidence,

    otherthanreviewingthisinformationandapprovingtheAFEs,indicatingthat

    51BPHZNMBI000173275.52BPHZNMBI00173275.53BPHZNMBI00192546,BPHZNMBI00192549.54BPHZNMBI00192552,BPHZNMBI00192553.55BPHZNMBI00192557.56BPHZNMBI00192558.57BPHZNMBI00192559,BPHZNMBI00192561.

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    27

    AnadarkoorMOEXweredirectlyinvolvedindecisionsrelatedtothedesignor

    drillingoftheMacondowell.58

    B.

    DrillingMargin

    Drillingengineersmustdesignawelltomanageporepressureand

    fracturegradientsatdifferentwelldepths. Porepressureisthepressureexerted

    byfluidsintheporespaceoftheformationbeingdrilled. Fracturepressureis

    thepointatwhichpressureexertedbythedrillingfluidinthewellwouldcause

    thesurroundingformationtofracture. Thefracturegradientplot,expressedasa

    calculatedequivalentmudweight,isacurvethatshowsthewellsestimated

    fracturegradientbydepth. Duringwelldesign,engineerstypicallyusea

    graphicalrepresentationoftheestimatedporepressure,mudweight,and

    fracturegradient,whichtogetherdefinetheappropriatedrillingmargins.

    Drillingengineersconductaleakofftesttodeterminethestrengthor

    fracturepressureoftheopenformation. Thistestisusuallyconducted

    immediatelyafterdrillingpastthecementedcasingshoeinthewell.59 During

    thetest,thewellisshutinandfluidispumpedintothewellboretogradually

    increasethepressurethattheformationexperiences. Atacertainpressure,fluid

    pumpedintothewellwillentertheformation,orleakoff,bymovingthrough

    permeablepathsintherockorbycreatingaspacebyfracturingtherock. Ifthe

    pressureisincreasedbeyondtheformationfracturepoint,fracturingofthe

    formationcan

    occur.

    The

    results

    of

    the

    leak

    off

    test

    dictate

    the

    maximum

    pressureormudweightthatmaybeappliedtothewellduringdrilling

    operationsbeforetheformationcanbeexpectedtotakefluid.

    BOEMREregulationsrequirethat[w]hiledrilling,youmustmaintainthe

    safedrillingmarginidentifiedintheapprovedAPD[ApplicationforPermitto

    Drill]. Whenyoucannotmaintainthissafedrillingmargin,youmustsuspend

    drillingoperationsandremedythesituation.60 Safedrillingmargincanbe

    maintainedbyensuringthatthemudweightremainsbetweenthekick

    toleranceorkickmargin,whichistypically0.5poundspergallon(ppg)

    58DataobtainedfromHalliburtonshowedthatrepresentativesofAnadarkoandMOEX

    periodicallyreviewedinformationrelatedtotheMacondowellduringdrilling.59Thecasingshoeisashortsteelcollarthatistypicallyattachedtothebottomofthecasing

    string. Ithelpstoestablishproperpositioningofthecasingstringinthewellbore.6030CFR250.427(b). BOEMREregulationsdonotspecifywhatasafedrillingmarginis.

    Theremaybeinstanceswhereasafedrillingmargincanbemaintainedoutsidethekickor

    swabmargins.

    http://www.glossary.oilfield.slb.com/Display.cfm?Term=formationhttp://www.glossary.oilfield.slb.com/Display.cfm?Term=formation
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    belowthefracturegradient,andtheswabmargin,whichistypically0.2ppg

    abovetheporepressure. Inshort,themudmustbeheavyenoughtocontrolthe

    porepressureandensurethattheformationfluids(includinghydrocarbons)do

    notenterthewellbore,whilenotsoheavythatitfracturestheformation.61

    BOEMREregulationsrequireoperatorstoprovidevariousdatatothe

    Agencydemonstratingthattheoperatorismaintainingasafemargin. For

    example,operatorsmustshow,inasinglegraphicplot,porepressures,mud

    weightsandfracturegradientsforthefullextentofthewell.62 Theplotteddata

    reflectsforecasteddatabasedon3Dseismicandoffsetwelldata.63 When

    operatorsencounterunexpectedpressuresthatdifferfromtheirforecasts,

    applicableregulationsrequiretheoperatortoreviseitscasingdesignandapply

    totheAgencyforapprovalofthemodification.64

    ThefinalestimatedMacondowellporepressure,mudweight,andfracturegradientplotsubmittedtoMMSonMarch26isshownatFigure1. The

    verticalaxisofFigure1showsthedepthofthewell. Thehorizontalaxisshows

    themudweight. TheredlinedepictsBPsplannedmudweight,whichwas

    designedtobebetweenthekickmarginandtheswabmarginidentifiedin

    Figure1.

    61Maintainingmudweightinthisrangeisanindustryacceptedpracticebutisnotspecifically

    requiredbyBOEMREregulations.6230CFR250.413and414.63Offsetwelldataaredataobtainedfromwellsthataredrilledinanareaclosetothetarget

    well.6430CFR250.427(b).

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    Figure1MacondoWellPorePressureFractureGradientPlot65

    AsseeninFigure2,theformationintegritytestatthe97/8inchlinershoe

    locatedat17,168feetyieldedresultsof15.98ppg(asidentifiedintheIADCdaily

    reports,whicharecompletedbytherigcrewtodocumentdailyoperations)and

    16.22ppg(identifiedinBPsDailyOperationReport). ThePanelfoundthatthis

    integritytestmayhavecreateduncertaintybecause(1)itwas1.0ppghigherthan

    anticipatedand(2)therewasapossibilitythatthetestresultsdidnotreflecta

    truetestoftheformationbelowthe97/8inchlinershoe. Althoughthisfracture

    gradienttestwasquestionable,BPchosenottoretestthefracturegradientatthe

    shoeanddecidedtodrillahead. AfterdrillingtheM57Csandinterval,BP

    65API608174116901,March26APD(RevisedBypass)fortheMacondoWell.

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    30

    conductedaGeotapsurveytodeterminethesandporepressure. Thesandpore

    pressurewasdeterminedtobe14.15ppg. BPalsoconvertedthisporepressure

    toanestimatedfracturegradientof15.0ppg. Theopenholesectiondrilled

    utilizedasurfacemudweightrangeof14.114.5ppg,whichallowedforasafe

    drillingmargintobemaintainedbetweenporepressureandfracturegradient.

    Throughoutthisinterval,however,BPencounteredmultipleproblems

    associatedwithbothlostreturnsandregressingporepressures(1.9ppg

    difference)between17,001and18,066feet. BPlostapproximately4,000barrels

    (bbls)ofmudintheproductionopenholeinterval. BPutilizedlosscirculation

    materialinthisintervaltoattempttocontroltheselosses.

    Figure2 DrillingmargindatafromIADCreportsandBPDailyReports

    BPcontinueddrillinguntilitconcludedithadrunoutofdrillingmargin

    betweenmudweightandformationporepressure. RobertBodek,BPGeological

    Operations

    Coordinator,

    emailed

    Michael

    Bierne,

    another

    BP

    employee,

    on

    April

    13,2010,andexplainedthereasonswhyBPconcludedthatithadrunoutof

    drillingmarginat18,360feet. Hesaidthattheteamdecidedtostopdrilling

    becauseithadbecomeawellintegrityandsafetyissue.66 Theemailalsostates:

    Wehadonemajorproblemhowever:thesandthatwetooktheinitial

    GeoTappressureinwasmeasuredat14.15ppg. Theabsoluteminimum

    surfacemudweightwecouldusetocovertheporepressureinthissand

    was14.0ppg. Thiswouldgiveusapproximatelya14.2ppgESDoverthe

    aforementionedsand. Ifweweretodrillaheadwitha14.0surfacemud

    weight/14.2ESD,ourequivalentcirculatingdensity(ECD)wouldbeapproximately14.414.5ppg. Wehadalreadyexperiencedstaticlosses

    witha14.5ppgESD! Itappearedasifwehadminimal,ifany,drilling

    margin... Drillingaheadanyfurtherwouldunnecessarilyjeopardizethe

    wellbore. Havinga14.15ppgexposedsand,andtakinglossesina12.6

    66BPHZNMBI00126338.

    Date Depth MW Losses PP Remarks Hydrocarbon Zones

    2-Apr 17,007 - 17,321 14.3 17,168 FIT 16.22 PPG 17,684 - 17,693 M-57C 14.1 PPG

    3-Apr 17,321 - 17,835 14.5 233 bbls 17,723 - GeoTap 14.15 ppg (PP) 17,786 - 17,791 M-56A 13.1 PPG

    3-Apr 17,835 - 17,909 14.34-Apr 17,909 - 18,195 14.3 12.58 @ 18,089 Schematic - 12.6 ppg at 18,066 18,061 - 18,223 M-56E 12.6 PPG

    4-Apr 18,215 - 18,250 14.4 639 bbls

    Lost full returns

    5-Apr 18,260 14.0 1263 - Total

    6-Apr 14.0 1586 - Total

    7-Apr 14.0

    8-Apr 14.0

    9-Apr 18,360 14.0 called TD

    Open Hole Interval below 9 7/8-in Liner @ 17,168 - FIT 15.98 PP 13.9

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    ppgreservoirinthesameholesectionhadforcedourhand. Wehad

    simplyrunoutofdrillingmargin.

    C.

    CasingProgram

    Casingprogramsdescribethenumberandsizesofthecasingstringstobe

    setinthewellboreandarebaseduponporepressureandfracturegradientplots.

    Casingprogramsaredesignedbasedonanumberoffactors,includingburstand

    collapsepressures,67tensilestrength,68drillbitsize,anticipatedhydrocarbon

    flow,andhydrocarbontype. BPoriginallydesignedtheMacondowellto

    includesevencasingstringstoreachthetargetwelldepth. However,basedon

    theactualconditionsencounteredduringdrilling,BPusedninecasingstringsto

    reachtotaldepth.

    Conditionsencounteredduringdrillingcandrivechangesincasingprograms. Forexample,circulationlosseventsoccurredintheopenholesection

    oftheMacondowell. Lostcirculationisthelossofdrillingfluids(suchas

    drillingmudandspacer)intotheformation. Thislossofdrillingfluidis

    observedduringthecirculationofdrillingfluids. Whenlessfluidisreturnedup

    thewellannulusthanwaspumpedintothewellthroughthedrillstring,this

    meansalossofdrillingfluidlostreturnshasoccurred. Theselostreturns

    wereafactorinBPsdecisiontolimitthewelltotaldepthto18,360feet(shortof

    the20,200feetoriginallyplanned)andalsoledBPtorevisethewellscasing

    designprogram

    to

    account

    for

    mud

    weight

    and

    fracture

    gradient

    drilling

    margin

    issues. Specifically,BPmodifieditscasingprogramseveraltimesbecauseof:(1)

    awellcontroleventinMarch2010thatresultedinthedrillpipebecomingstuck;

    (2)changesinporepressureestimates;and(3)wellballooning.69 AfterBP

    reviseditscasingprogram,itsubmittedarevisedApplicationforPermittoDrill

    toMMSforapproval.70

    67Burstpressureisthetheoreticalinternalpressuredifferentialatwhichajointofcasingwillfail.

    Collapsepressureisthepressureatwhichatubeorvesselwillcatastrophicallydeformasaresult

    of

    differential

    pressure

    between

    the

    outside

    and

    the

    inside

    of

    the

    tube

    or

    vessel.

    Schlumberger

    OilfieldGlossary.68Tensilestrengthistheforceperunitcrosssectionalarearequiredtopullasubstanceapart.

    SchlumbergerOilfieldGlossary.69Ballooning,inwhichtheformationabsorbsdrillingmudwhiletherigspumpsareactivated

    andthenreleasesthemudbackintothewellwhenthepumpsarenotactive,canbe

    misinterpretedasakick.70MMSapproved:BPsApplicationforPermittoBypass,whichaddedanadditionalcasing

    string,onMarch15,2010;BPsRevisedApplicationforPermittoBypass,whichaddedaliner,on

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    D. MudProgramandType

    Drillingmudprovideshydrostaticpressure pressureexertedbyafluid

    atequilibriumduetotheforceofgravity topreventformationfluidsfrom

    enteringthewellbore.Drillingmudalsokeepsthedrillbitcoolandcleanduring

    drilling,carriesdrilledcuttingsoutofthewellandsuspendsthedrillcuttings

    wheneverdrillingispaused.

    Operatorshavemultipleoptionsforthetypeofmudtouseduringthe

    drillingofawell,includingoilbasedmud,syntheticoilbasedmudandwater

    basedmud. Dependingonreservoirconditions,operatorsassesswhichmud

    typeismostappropriateforthespecificwellbeingdrilled.

    FortheMacondowell,BPchoseasyntheticoilbasedinvertmudsystem,asysteminwhichsyntheticoilinthemudremainsinacontinuousfluidphasein

    thelowerholesectionsofthewell. BPchosethissystemforseveralreasons:(1)

    toenhancetheabilitytomaintainconsistentfluidpropertiesindependentofthe

    temperatureandpressureconditionsofthewell;(2)toimproveholecleaning

    andminimizebaritesag,controlofpressurespikes,andgaininggelstrengths;71

    and(3)todealwithotherproblemsthatresultwhenbalancingequivalent

    circulatingdensity(ECD).72 Inselectingthesyntheticoilbasedmud,BPalso

    soughttoreducefluidlossinordertominimizeformationdamagewhile

    maintaininga

    higher

    drilling

    efficiency.

    Syntheticoilbasedmud,suchasthetypeBPusedintheMacondowell,

    hasmanypositivefeaturesasdescribedabove. However,thistypeofmudalso

    presentsrisksrelatingtoitseffectonthecrewsabilitytoaccuratelydetect

    naturalgasinflux(kicks)intothewell. Arecentstudyofdrillingfluidmixtures

    andwellcontrolfoundthatdrillersmighthaveahardertimedetectingkicks

    March26,2010;andBPsRevisedApplicationforPermittoBypass,whichincludedaproduction

    casing,onApril15,2010.71

    Society

    of

    Professional

    Engineers,

    SPE

    116013

    PA

    Studyof

    the

    PVT

    Properties

    of

    GasSynthetic

    DrillingFluidMixturesAppliedtoWellControl(2009). Baritesagisthesettlingofbariteparticles

    (orotherweightingmaterials),whichcanresultinfluctuationsindrillingfluiddensity. When

    thisoccursindrillingmud,themudlosesitsintegrityandcanonlybeatemporarybarrierinthe

    well. Gaining,orprogressive,gelstrengthstypicallyrequirehigherpumppressurestobreak

    circulation.72ECDisthetotaleffectivepressurethatacolumnofdrillingmudexertsonaformationasthe

    mudiscirculatedthroughthedrillstringandbackupthewellbore,accountingforfrictional

    forcesthroughoutthecirculatorysystem.

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    whenusingsyntheticoilbasedmud. Thestudystatedthatanimportantaspect

    thatshouldbeaddressedwhendrillingwithasyntheticfluidisthepeculiarities

    concernedwithwellcontrol. Becauseofthesolubilityofformationgasinoil

    basedfluids,itcouldbecompletelydissolvedinthemudatbottomhole

    temperatureandpressureconditions,makingkickdetectionverydifficult.73

    ThePanelfoundnoevidencethatBPandMISWACOdiscussedwhether

    theuseofsyntheticoilbasedmudwouldaffecttherigcrewsabilitytodetect

    kicksduringdrillingoperationsatMacondo. Evenso,thePanelfoundno

    evidencethatthespecificmudprogramusedbyBPandMISWACOwasacause

    oftheblowout.

    E. MudLosses

    Throughout

    the

    drilling

    of

    the

    Macondo

    well,

    BP

    experienced

    multiple

    incidentswheremudwaslostintotheformation. Whilethelossofmudduring

    drillingoperationsisnotuncommon,itisakeyindicatortodrillingengineers

    thattheymustmonitorthewellcloselytoensurethatwellandformation

    integrityarebeingmaintainedproperly. Abnormalpressurezonesidentifiedas

    aresultofmudlosseventsoftenleaddrillingengineerstochangethewelldesign

    andcasingsettingpoints.

    BPdrilledtheMacondowelltoameasureddepthof18,360feet. Thecrew

    seta97/8inchlinerinplaceat17,168feetmeasureddepthpriortodrillingthe

    productionsection,whichwasthefinalsectionofthewell. Thelastsectionwasdifficulttodrillduetoadecreaseinthefracturegradientatthebottomofthe

    wellbore. ThisconditionrequiredBPtocarefullyselectthecorrectmudweight

    necessarytomaintainoverbalancerelativetotheformationwhileavoidingfluid

    lossestothewell.

    AccordingtoIADCdailyreports,thewellexperiencedmudlossesof

    approximately3,000bblsacrossthehydrocarbonzonesofinterestduringthe

    drillingoftheproductioncasingopenholesection. Thecrewcontrolledthese

    losseswith

    the

    addition

    of

    lost

    circulation

    material

    (LCM)

    pills

    and

    a

    relatively

    smallquantity(lessthan200bbls)ofaspecialblendofdrillingfluid,whichhelp

    retardthelossofmudintofracturesandhighlypermeableformations. Fromthe

    timetheDeepwaterHorizonmovedontolocationatMacondo,atotalof

    73Id.

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    approximately15,500bblsofdrillingfluidswerelostduringdrilling,running

    casingandcementingoperations.74

    F.

    WellBallooning

    Wellballooningisacommonphenomenoninwhichtheformation

    absorbsdrillingmudwhiletherigspumpsareactivatedandthenreleasesthe

    mudbackintothewellwhenthepumpsarenotactive. Wellballooningis

    significantbecauseitcanmimicakick. Rigcrewscanthereforemisscriticalkick

    indicatorsiftheymistakenlybelievethatballooningisoccurringinthewell.

    MudloggingdatafortheMacondowelldemonstratedthattheproduction

    casingzonestartedballooningbetween17,530feetand17,761feet. Thedaily

    IADCreportsalsoshowthatthewellflowedbackduringflowchecksfollowing

    mudlossatthosedepths.

    G.

    PlannedandActualTotalDepth

    Indesigningawell,engineerscalculateaplannedtotaldepthofthewell.

    BPsFebruary2009ExplorationPlanestimatedthewelldepthatapproximately

    20,200feettrueverticaldepth. Duetoanarroweddrillingmargin,BPultimately