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Macondo: The Gulf Oil Disaster. Chief Counsel\'s Report 2011

Agency Publisher: National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling
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Examines the relevant facts and circumstances concerning the root causes of the British Petroleum's (BP) April 20, 2010, Macondo well blowout and oil spill disaster from the investigative team under the Chief Counsel of the National Commission on the BP Deep Water Horizon Oil Spill and Offshore Drilling. Offers the American public and policymakers additional details and evidentiary documentation describing the technical, managerial, and regulatory causes of the blowout and oil spill and sets forth the conclusions of the investigation.

The Macondo well blowout cost the lives of 11 men and began a catastrophe that sank BP's Deepwater Horizon drilling rig and spilled over 4 million barrels of crude oil into the Gulf of Mexico.  The spill disrupted an entire region’s economy, damaged fisheries and critical habitats, and brought vividly to light the risks of deepwater drilling for oil and gas – the latest frontier in the national energy supply.  Soon after, President Barack Obama appointed a seven-member Commission to investigate the disaster, analyze its causes and effects, and recommend the actions necessary to minimize such risks in the future.

The Commission’s report, supplemented by this Chief Counsel’s Report, offers the American public and policymakers alike the fullest account available of what happened in the Gulf and why, and proposes actions –changes in company behavior, reform of government oversight, and investments in research and technology –required as industry moves forward to meet the nation’s energy needs.

What the investigation makes clear, above all else, is that management failures, not mechanical failings, were the ultimate source of the disaster.  In clear, precise, and unflinching detail, this Report lays out the confusion, lack of communication, disorganization, and inattention to crucial safety issues and test results that led to the deaths of 11 men and the largest offshore oil spill in our nation’s history.

The wealth of materials in this book offers new details and technical documentation in support of the Commission’s final report—Deep Water: The Gulf Oil Disaster and the Future of Offshore Drilling, Report to the President, January 2011.

While an an important companion publication to the Final Report of the Commission, this report nevertheless stands on its own as well – a durable contribution to our understanding of the importance of responsible management systems and state-of-the art practices, and the dire consequences when they fail.

Table of Contents


Executive Summary of findings

            Technical Findings

            Management Findings

            Regulatory Findings

Chapter 1/Scope of Investigation and Methodology

            Nature of Report

            Scope of Investigation and Report

            Structure of the Report

Chapter 2/Drilling for Oil in Deepwater

            Oil and Gas in Deepwater

            How to Drill a Deepwater Well

Chapter 3/ Background on the Macondo Well, the Deepwater Horizon, and the Companies Involved

            The Macondo Well

            The Deepwater Horizon

            Companies and Individuals Involved in the Macondo Blowout

Chapter 4/Technical Findings

            Underlying Technical Causes

            Underlying Management Causes

Chapter 4.1/Flow Path

            Potential Flow Paths

Forensic Evidence Suggests That Hydrocarbons Did Not Flow up the Annulus and Through the Seal Assembly

Hydrobarbons Appear to Have Flowed Into and up the Production Casing

Technical Findings

Chapter 4.2/Well Design

            Deepwater Well Design

            The Macondo Well Design

            Drilling the Macondo Well

            Technical Findings

            Mangement Findings

Chapter 4.3/Cement

            Well Cementing

            Preparing for the Macondo Cement Job

            Designing the Macondo Cement Job

            Planning for and Installing Centralizers at Macondo

            Float Collar Installation and Conversion at Macondo

            Pre-Cementing Wellbore Conditioning at Macondo

            Cementing Process at Macondo

            The Float Check at Macondo

            Cement Evaluation at Macondo

            Technical Findings

            Management Findings

Chapter 4.4/Foamed Cement Stability

            Foamed Cement

            Foamed Cement at Macondo

            Technical Findings

            Management Findings

Chapter 4.5/Temporary Abandonment

            Temporary Abandonment

            Temporary Abandonment at macondo

            Technical Findings

            Management findings

Chapter 4.6/Negative Pressure Test

            Well Integrity Test

            Negative Pressure Test at Macondo

            Technical Findings

            Management Findings

Chapter 4.7/Kick Detection

            Well Monitoring and Kick Detention

            Well Monitoring at Macondo

            Technical Findings

            Management Findings

Chapter 4.8/Kick Response

            Well control Equipment

            Kick Response at Macondo

            Technical Findings

            Management Findings

Chapter 4.9/The Blowout Preventer

            Blind Shear Rams

            Blind Shear Ram Activation at Macondo

            ROV Hot Stab Activation at Macondo

            Automatic Blind Shear Ram Activation at Macondo

Potential Reasons the Blind Shear Ram Failed to Seal

BOP Recertification

Technical Findings

Management Findings

Chapter 4.10/Maintenance

            Transocean’s Rig Management System

            Competing Interests Between Drilling and Maintenance

            Lack of Onshore Maintenance

            Maintenance Audits and Inspections

            Maintenance Findings

Chapter 5/Overarching Failures and Management









Chapter 6/Regulatory Observations

            MMS Background

            MMS Regulations Did Not Address Many Key Risk Factors for the Blowout

            BOP Recertification

            Ethical Considerations


Appendix A/Blowout Investigation Team

Appendix B/Commission Staff

Appendix C/Acronyms

Appendix D/Chevron Laboratory Report Cover Letter

Appendix E/Nile and Kaskida

            Schedule when Deepwater Horizon Arrived at Macondo

            Request to Suspend Operations at Kaskida


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National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling
2011: 387 p.; ill.
Key Phrases:
Commission on the British Petroleum Deepwater Horizon Oil Spill, April 20, 2009
Oil Spills
British Petroleum Deepwater Horizon Oil Spill
Petroleum Industry
Macondo Well
Gulf of Mexico
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