21.b (CD) Lessons Learned From Macondo

PresentationtoOceanEnergySafetyAdvisoryCommittee
April18,2011
April 18 2011
LESSONS LEARNED FROM MACONDO
Sean C. Grimsley, Bartlit Beck Herman Palenchar & Scott LLP

DeputyChiefCounsel
TheNationalCommissionontheDeepwaterHorizonOilSpillandOffshoreDrilling
21.b(CD) Lessons Learned from Macondo

Background
WhatHappened
WhatHappened HighLevel
RootCauses Background
ThoughtsforCommittee

The Commission Executive Order
Sec.3. Mission.TheCommissionshall:
(a) examinetherelevantfactsandcircumstancesconcerningthe
rootcausesoftheDeepwaterHorizonoildisaster;
...
(c) submitafinalpublicreporttothePresidentwithitsfindingsand
submit a final public report to the President with its findings and
optionsforconsiderationwithin6monthsofthedateofthe
Commissionsfirstmeeting.

Task of Chief Counsels Investigative Team
Investigateandidentifyrootcausesofthe
blowout
Otherstaffinvestigatedcontainmentandresponse
DidnotinvestigateBOPfailurepostexplosionand
blowout
Presentpreliminaryfindingsathearingon
November 89,
November8 9,2010
2010
AssistinpreparingCommissionsFinalReport
Prepare and submit Chief CounselssReport
PrepareandsubmitChiefCounsel Report
detailingfindingsonrootcausesofblowout

Two Reports Containing Findings on Root Cause of Blowout
CommissionsReport
ReleasedJanuary11,2011
Chapter4setsoutCommissionsfindingsregardingroot
causes
ChiefCounselsReport
ReleasedFebruary17,2011
More detailed explanation of findings contained in
Moredetailedexplanationoffindingscontainedin
Chapter4oftheCommissionsReport
Containssomeadditionalinformationnotavailableat
timeCommissionsReportwritten confirmedfindings

Background
RootCauses What Happened:

WhatHappened:
HighLevel

The Macondo Well

What Happened High Level
1. Bottomholecementwastheonlyactivebarrierwhenblowout
occurred
Mudremoved(underbalanced)andBOPwasopen
Mud removed (underbalanced) and BOP was open
BPchosenottoputadditionalbarriersinplacepriortodisplacementof
mudfromtheriser

occurred
mudfromtheriser
2. Bottomholecementjobfailed
Unusuallytrickycementjob manyriskfactors
Foamed cement slurry was likely unstable as well
Foamedcementslurrywaslikelyunstableaswell

occurred
mudfromtheriser
3. Nobodydetectedfailureuntiltoolate
Misinterpretedthenegativepressuretest
Misinterpreted the negative pressure test
Failedtodetectinfluxduringdisplacement

occurred
mudfromtheriser
3. Nobodydetectedfailureuntiltoolate
Misinterpretedthenegativepressuretest
Misinterpreted the negative pressure test HumanJudgment
Human Judgment
Failedtodetectinfluxduringdisplacement HumanJudgment

Background
WhatHappened
RootCauses RootCauses
Root Causes
ListsofRecommendations

BPs View of the Blowout
Failure of Management

Overview of Management Failures
1. Absenceofresponsibility
Diffusedecisionmaking
Diffusedecisionmaking withinBPandbetweencontractors
Ineffective communication
Ineffectivecommunication
Lackofleadership

Lackofleadership
2. Setting
Settingpeopleup
peopleupforfailure
forfailure
Overreliance
Overrelianceonhumanjudgment
on human judgment
Inadequateinstructionanduntimelyprocedures
Inadequatetrainingandproceduresforemergencysituations
Poor management of staffing
Poormanagementofstaffing
Poormanagementof

Lackofleadership
2. Setting
Settingpeopleup
peopleupforfailure
forfailure
Overreliance
on human judgment
Poormanagementof
3. Inadequateriskassessment
Adhocandtunnelvisiondecisionmakingduringcriticaloperations
P bl
Problemswithsafetymetricsandprocesssafety
ih f i d f
Focusonefficiencybiasesdecisionstowardcostsavings

Lackofleadership
2. Setting
Settingpeopleup
peopleupforfailure
forfailure
Overreliance
on human judgment
Poormanagementof
P bl
ih f i d f

Some of the Companies Involved at Macondo
Surfacedata
Riganddrilling
logging
Cementing Blowoutpreventer
Drilling mud
Drillingmud ROVsupport
pp
Welland
cementlogging
tl i Centralizers,
Centralizers
floatcollar,
shoetrack
Wellhead,casinghangers

Onshore Organizational Chart

Rig Crew Organizational Chart

Cement Job: Example of Problems with
Decentralized Decision-Making
Numerousdifferentriskfactorsassociatedwith
cementjob
cement job
Little to no communication of those risks to

Littletonocommunicationofthoserisksto
individuals/contractorsconductingthenegative
p
pressuretestormonitoringwellaftercementjob
g j
Resultedinlookingatriskstheyknewaboutone
atatimeratherthancollectivelyasagroup

Recommendation: Make Clear Who is Responsible
Muchfingerpointingafterevent saying
someoneelseresponsible
someone else responsible
Make clear entity responsible for critical

Makeclearentityresponsibleforcritical
decisionsandoperations

Did Not Communicate Lessons Learned From Other Events
drillcrewdidnotconsiderwellcontrolasarealistic
eventduringthedisplacementoperationasthe
[d
[downholebarrier]hadbeensuccessfullytested
h l b i ]h db f ll t t d
testedbarrierscanfailandriskawarenessandcontrol
measuresneedtobeimplemented
standardwellcontrolpracticesmustbemaintained
p
throughoutthelifeofthewell
specifyoperationsthatinduceunderbalanceconditions
specify operations that induce underbalance conditions
April14,2010Advisory
inthewellbore

Did Not Communicate Lessons Learned From Other Events
Itsinthedatabase
April14,2010Advisory

Recommendation: Create Centralized System for
Communicating Lessons Learned and Best Practices
Createcentralized,industrywidesystemfor
alertingallplayerstolessonslearnedandnear
alerting all players to lessons learned and near
misses
Keepbettertrackofproceduresusedbydifferent
companiesinordertofacilitatestudyand
p y
identificationofbestpractices

Lackofleadership
2. Setting
Settingpeopleup
peopleupforfailure
forfailure
Overreliance
on human judgment
Poormanagementof
P bl
ih f i d f

The Macondo Well

Barriers to Hydrocarbon Escape
ActiveBarriers
Mud(drillingfluid)
Testedphysicalbarriers
Bottomholecement
Cement plugs and other up hole mechanical barriers
Cementplugsandotherupholemechanicalbarriers
ClosedBOP
ContingentBarriers
C i B i
OpenBOP dependsonhumanjudgment
Untested physical barriers testsoftendependonhuman
Untestedphysicalbarriers tests often depend on human
judgment(e.g.,negativepressuretest)

Single Physical Barrier During Displacement:
Placed Unnecessary Reliance on Human Judgment

Inadequate Focus on Technology
Oneofbiggestsurprisesinwholeinvestigation
Antiquatedsensors,datapresentationandvery
f
fewautomatedsafetysystemsorchecks
t t d f t t h k
Appearstolagbehindotherindustrieswhen
comestosafetyrelatedtechnologies(e.g.,
airline industry) particularly where no drilling
airlineindustry)particularlywherenodrilling
efficiencypayoff

Example: How Driller Sees Data

Recommendation: Eliminate Human Judgment as Much as
Possible Where Mistake Could Have Huge Consequences
Requireredundant
Require redundant dumb
dumb safetybarriers
safety barriers for
for
instancemusthaveatleasttwoactivebarriers
whenunderbalanced
Incentivizedevelopmentoftechnologyto
eliminate reliance on human judgment where
eliminaterelianceonhumanjudgmentwhere
possible

Lackofleadership
2. Setting
Settingpeopleup
peopleupforfailure
forfailure
Overreliance
on human judgment
Poormanagementof
P bl
ih f i d f

Evolution of Temporary Abandonment Procedure
April14EMailFrom April14 April16 April20

MoreltoR.Sepulvado MorelEMail MMSPermit OpsNote
Run in hole
to 8,367'
Set 300'
cement plug in mud
BARRIER
Negative pressure test with

base oil to wellhead
Displace mud in well and

riser from 6,000' with
seawater
Set lockdown sleeve
Privileged&Confidential

April16Applicationfor April14 April16 April20

PermittoDrillSenttoMMS MorelEMail MMSPermit OpsNote
Negative pressure test to

Trip
Run in hole
seawater gradient
to 8,367'
(with base oil to wellhead)
Set 300'
cement
cement
plug
plug
in in
seawater
mud Trip in hole
to 8,367'
BARRIER

base oil to wellhead
seawater

Monitor well for 30 minutes
to ensure no flow
seawater
Set 300'
cement plug in seawater
BARRIER
Set lockdown sleeve Set lockdown sleeve

April20OperationsNote April14 April16 April20

FromMoreltoRig MorelEMail MMSPermit OpsNote

Run in hole Trip in hole
seawater gradient
to 8,367' to 8,367'
Set 300'
Displace mud with
cement plug in mud Trip in hole seawater from 8,367' to
to 8,367'
BARRIER above wellhead (BOP)

Negative pressure test with seawater to depth 8,367'
base oil to wellhead rather than with base oil to
seawater
wellhead
Displace mud in
Monitor well for 30 minutes riser
Displace
with seawater
mud in
to ensure no flow riser with seawater
seawater Blowout
Set 300' Set 300'

cement plug in seawater cement plug in seawater
BARRIER BARRIER
Set lockdown sleeve Set lockdown sleeve Set lockdown sleeve

April28Interview April14 April16 April20

ofBobKaluza MorelEMail MMSPermit OpsNote

Run in hole Trip in hole
seawater gradient
to 8,367' to 8,367'
Set 300'
Displace mud with
cement plug in mud Trip in hole seawater from 8,367' to
to 8,367'
BARRIER above wellhead (BOP)

Negative pressure test with seawater to depth 8,367'
base oil to wellhead rather than with base oil to
seawater
wellhead
Displace mud in
Monitor well for 30 minutes riser with seawater
to ensure no flow
seawater Blowout
Set 300' Set 300'

cement plug in seawater cement plug in seawater
BARRIER BARRIER
Set lockdown sleeve Set lockdown sleeve Set lockdown sleeve

Recommendation: Require Earlier Submission of
Procedures for Approval
BPdidnotsubmittemporaryabandonmentplan
with original permit requests didnotdevelop
withoriginalpermitrequests did not develop
untillast10daysbeforeblowout
Requiringearliersubmissionwouldallowgreater
l b ld ll
timeforagencyreviewandforcecompaniesto
develop procedures before last minute
developproceduresbeforelastminute

Recommendation: Require Strict Adherence to
Approved Procedures
BPalteredthetemporaryabandonmentprocedure
from those approved by MMS saidbelievedwas
fromthoseapprovedbyMMS said believed was
saferproceduresononeedtoresubmit
Requiringstrictadherencetoapprovedprocedures
dh d d
willpreventadhocdecisionmakingandforce
companies to do real risk assessment
companiestodorealriskassessment

Lackofleadership
2. Setting
Settingpeopleup
peopleupforfailure
forfailure
Overreliance
on human judgment
Poormanagementof
P bl
ih f i d f

Inadequate Training on Low Probability Emergency Events
WellControlHandbook

Recommendation: Require and Approve Training, Procedures
and Drills for Various Potential Emergencies
Requirethatcompaniestrainanddrillforvarious
emergency scenarios such as blowout
emergencyscenarios,suchasblowout
Requirecompaniestosubmitemergency
proceduresandtrainingplans

Lackofleadership
2. Setting
Settingpeopleup
peopleupforfailure
forfailure
Overreliance
on human judgment
Poormanagementof
P bl
ih f i d f

Major Process Safety Gaps at BP
BPsStageGateProcess
Robustriskanalysis/peerreviewduringdesignstage
Little to no risk analysis/no peer review during execute stage
Littletonoriskanalysis/nopeerreviewduringexecutestage
BUTmajorproceduralandotherdecisionsmade
BPactuallyputoffcertaindesigndecisionsuntilexecutestage
Resultsinadhoc decisionmakingonkeydecisions
Noformalstructureforevaluatingriskorpeerreview
D ii
Decisionsoftenonepersonontheflywithoutfullinformation
ft th fl ith t f ll i f ti
Centralizerdecision
Temporaryabandonmentprocedures
Inadequatepostexecutionauditforevaluatingdecisionsthat
increaseriskoflowprobability,highconsequenceevent

No Formal Risk Assessment of
Temporary Abandonment Procedures
April1516,2010Emails

Recommendation: Require Robust Internal Risk Assessment
Procedures Throughout All Phases of Well
Ensurecompanieshaveriskassessmentregimes
that do not have gaps in critical areas particularly
thatdonothavegapsincriticalareas particularly
processsafety
Failuretoadheretoownriskassessment
l dh k
procedurescouldberegulatoryviolation hardto
know how to enforce/check
knowhowtoenforce/check

Background
WhatHappened
ParticularFailures ThoughtsforCommittee
Thoughts for Committee

Some Thoughts for Committee
MakeClearWhoisResponsible
EliminateHumanJudgmentasMuchasPossibleWhereMistake
CouldHaveHugeConsequences
Could Have Huge Consequences
IncentivizeInvestmentinSafetyRelatedTechnology
Create Centralized System for Communicating Lessons Learned
CreateCentralizedSystemforCommunicatingLessonsLearned
andBestPractices
RequireEarlierSubmissionofandStrictAdherencetoProcedures
RequireandApproveTraining,ProceduresandDrillsforVarious
PotentialEmergencies
RequireRobustInternalRiskAssessmentProcedures
R i R b tI t l Ri k A tP d
ThroughoutAllPhasesofWell

Background
WhatHappened
ParticularFailures Questions?

21.b (CD) Lessons Learned From Macondo

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PresentationtoOceanEnergySafetyAdvisoryCommittee

LESSONS LEARNED FROM MACONDO

Sean C. Grimsley, Bartlit Beck Herman Palenchar & Scott LLP

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

RootCauses What Happened:

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

Little to no communication of those risks to

21.b(CD) Lessons Learned from Macondo

Make clear entity responsible for critical

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo

April14EMailFrom April14 April16 April20

Negative pressure test with

Displace mud in well and

Set lockdown sleeve

21.b(CD) Lessons Learned from Macondo

April16Applicationfor April14 April16 April20

Negative pressure test to

Displace mud in well and

Displace mud in well and

Set lockdown sleeve Set lockdown sleeve

21.b(CD) Lessons Learned from Macondo

April20OperationsNote April14 April16 April20

Negative pressure test to

Negative pressure test with

Set 300' Set 300'

Set lockdown sleeve Set lockdown sleeve Set lockdown sleeve

21.b(CD) Lessons Learned from Macondo

April28Interview April14 April16 April20

Negative pressure test to

Negative pressure test with

Set 300' Set 300'

Set lockdown sleeve Set lockdown sleeve Set lockdown sleeve

21.b(CD) Lessons Learned from Macondo

21.b(CD) Lessons Learned from Macondo