NAE: Flawed decisions, poor oversight led to 2010 oil spill


A series of flawed decisions by companies working on BP’s failed Macondo well, poor oversight by federal regulators and a “misplaced trust” in emergency equipment guarding the site led to the lethal Deepwater Horizon disaster, the National Academy of Engineering concluded today.

The 136-page report by the NAE and the National Research Council broadly echoes the findings of other investigations into the 2010 oil spill by insisting that companies did not heed numerous warning signs as they worked on the Macondo well in the Gulf of Mexico last year.

“The lack of a strong safety culture … is evident in the multiple flawed decisions that led to the blowout,” according to the report by a 15-member panel of geophysics experts, petroleum engineers and scientists. “Industrial management involved with the Macondo well-Deepwater Horizon disaster failed to appreciate or plan for the safety challenges presented by the Macondo well.”

When the Macondo well blew out on April 20, 2010, it triggered a lethal explosion aboard the Deepwater Horizon drilling rig, killing 11 workers, injuring 16 others and unleashing the nation’s worst oil spill.

Donald Winter, the former secretary of the Navy who headed the 15-member NAE committee that investigated the oil spill, said major changes are needed to prevent a repeat of the disaster. Chief among them, he said, is paying greater attention — and adopting a broad, holistic approach — to managing risks and emphasizing safety in all stages of offshore drilling.

“Industry and regulators need to include a factual assessment of all the risks in deep-water drilling operations in their decisions and make the overall safety of the many complex systems involved a top priority,” Winter said.

Echoing the presidential commission that investigated the Deepwater Horizon disaster, the NAE panel insisted that the U.S. should remake its approach to regulating offshore drilling by following the lead of Norway, the United Kingdom and other countries that pair some proscriptive regulations with a performance-based approach that hinges on systematic risk management practices.

“The United States should fully implement a hybrid regulatory system that incorporates a limited number of prescriptive elements into a pro-active, goal-oriented risk management system for health, safety, and the environment,” the NAE committee said.

The panel noted that many of its recommendations dovetail with steps that have already been taken to boost oversight of the industry. But the group said Congress and the administration still need to provide “the funding and flexibility in hiring practices” that will allow offshore drilling regulators to go head-to-head with industry.

Interior Secretary Ken Salazar stressed that the government has already made many of the changes NAE recommended.

“The work we have done to implement rigorous new offshore drilling and safety rules and reform offshore regulation and oversight is in line with the recommendations of the committee and with our goals moving forward,” Salazar said in a statement.

Winter said the regulatory change was a step in the right direction but said it was unclear whether “it represents a transient response” to the Deepwater Horizon disaster. Even so, Winter insisted that it makes sense to continue offshore drilling now, though “further improvements” are needed.

“Given all the improvements that have already been made” including new regulations and technologies for containing runaway subsea wells, “we think that it is in fact a reasonable process to continue drilling at this time,” Winter said.

The NAE report called for major changes to the way emergency equipment known as blowout preventers are designed and used to help control surges of oil and gas at wells. Powerful pipe-cutting and closing rams on the BOP used at the Macondo well failed to successfully shear through drill pipe and seal off the well bore.

“BOP systems should be redesigned to provide robust and reliable cutting, sealing, and separation capabilities for the drilling environment to which they are being applied and under all foreseeable operating conditions of the rig on which they are installed,” the NAE concluded. At the same time, workers need to be better trained to operate the devices in emergencies.

Winter stressed that the BOP used at the Macondo well “was neither designed nor tested for the dynamic conditions that most likely existed (during) attempts to recapture well control.” And, he said, that was the case despite “numerous warnings about the potential failure of BOPs even before the Macondo well blowout.”

Overall, Winter said, the offshore drilling industry — and the crew working on the Macondo well — pinned too much trust on the blowout preventer.

“There was a level of confidence on the part of the crew that if anything didn’t work out right, they could count on the blowout preventer,” Winter said. There was, at the time, a “misplaced confidence that the blowout preventer could provide a guarantee, if you will, an insurance policy against a blowout.”

But Winter noted that blowout preventers — like parachutes on a plane — are only meant to be used as a final, last-ditch backup. In offshore drilling, “the primary means of well control is associated with design of the well itself,” Winter stressed.

The National Academy of Engineering pinned much of the blame for the disaster on the decision to proceed with temporarily abandoning the well — so it could be hooked up to a production facility later — even though workers at the site had not confirmed that cement barriers at the site were sound. Investigators separately concluded that negative pressure tests conducted on the cement applied at the site were misinterpreted.

“We viewed the decision to proceed with temporary abandonment … as being the pivotal decision that led to the eventual blowout of the well,” Winter told reporters today. “Up until that point in time, the team did have control of the well. Once they made the decision to basically disregard the results of the tests that were conducted … and to proceed to temporary abandonment, they set the course for the subsequent events.”

In preparing to temporarily abandon the well, BP chose to displace heavy drilling muds with lighter seawater — a move the NAE said was a “questionable decision” that may have left the well perilously vulnerable.

Throughout the Macondo project, companies working at the site, including well operator BP, drilling rig owner Transocean Ltd., and the cement contractor Halliburton Co., were outmatched by the risks of drilling and managing the well, the NAE said.

“The team was attempting to drill with a challenging well geology,” Winter said. “The approach they chose to seal the well failed to provide an adequate barrier.”

At the site, companies were forced to work within a slim drilling margin — the difference between the pore pressure exerted by oil and gas in the underground formation and the countervailing weight and pressure of drilling fluids at the site. If the downhole drilling mud pressure exceeds the forces exerted by the formation itself, it can cause cracks to develop.

The narrow drilling margin raised the risks associated with the Macondo project and put a premium on making sure the well was adequately secured.

In the weeks before the April 20, 2010 blowout, the Deepwater Horizon drilling team encountered unexpected kicks of hydrocarbon at the site and cases where drilling fluids were lost in the well — an indication that the formation had cracked.

BP said in a statement that the NAE’s conclusions “are consistent with the consensus which has emerged from every official investigation: that the Deepwater Horizon accident was complex and was the result of multiple causes, involving multiple parties.”

The National Academy of Engineering acknowledged some things may never truly be known, including the precise path of hydrocarbons to the surface, “since the requisite forensic evidence lies more than two miles beneath the seabed.” The 11 workers who perished in the disaster also may have shed light on pivotal decisions made onboard the rig.

Winter admitted that the information the panel could get “was constrained by the legal environment” surrounding the civil litigation tied to the oil spill and the multiple investigations into the incident, including the Justice Department’s criminal probe. But Winter said companies were generally cooperative and still provided some info to the panel. Houston-based Cameron, which made the blowout preventer used at the site, “provided some material but declined to make a presentation on the Deepwater Horizon BOP,” Winter said.

Winter complained that the NAE did not receive the results of additional testing of the blowout preventer, which was led by BP and conducted after a federal examination of the device was completed.

Check out this summary of the NAE’s conclusions and recommendations or view the report below.

NAE report on the Deepwater Horizon disaster

Jennifer Dlouhy

16 Responses

  1. Trail Tramp says:

    Good points Burrito-Boy. I failed to mention anything about setting plugs.

  2. Burrito-boy says:

    Years ago there was a pretty common saying in the oilfield.

    “While Dowell’s meeting, Halliburton’s treating”!

    Dowell got ripped regularly for holding “tailgate” safety meetings each day before work started. Not only by Big Red, but by Blue Junk and Western as well.

    In this instance, I think it would not have mattered whom the Contractors on the well were, or what the employees of those Contractors would or would not have said, as regards displacing the drilling mud with sea water, after or before the temporary cement plug was in place. Unless one of the Contractor employees present had a college degree of greater value than the BP hand onsite, any words of caution would have been disregarded out of hand because of the “BP Culture”. I say that, having worked for Atlantic Richfield for 12 years before the ARCO buyout by BP (the Macondo well is a former ARCO property), and having worked for Dowell for 10 years before I went to work at ARCO. There has been a steady and determined progression, in the oil & gas industry, from taking the “Word” of experienced hands as “Gospel”, to dismissing anything from anyone whom does not hold a college degree as “useless and uninformed” words. If you don’t have that piece of paper that you paid for handsomely, you are stupid, in most instances.

    I have worked on “Blow-outs” in Wyoming, Utah, California, Colorado, New Mexico and Texas. The ones where I was “On Location” at the moment of blow-out, will remain with me for the rest of my life. Whether it is 2 1/2 inch tubing stripping out of the well head, 7 5/8 buttress threaded casing used as tubing stripping out of the well head, or a fully cemented well casing, BOP and all, stripping out of the ground, blow-outs can be and are, very scarey to experience. Especially on land. When pipe and rig parts start falling around you, while mud, water and oil or natural gas is blowing into the atmosphere, people tend to freeze and forget.

    The best blow-outs that I worked on, were the ones that Red Adair and company responded to. Always damned good food when they were there, and “worker bees” were always treated with respect.

    I was in Canada waiting to enter a Shell facility, when news of the Deep Water Horizon explosion was broadcast on the facility PA system.

    Once I started hearing more of what transpired, it was obvious to me that several formerly “Standard” practices, regarding well shut-in, had to have been entirely dismissed (most likely to save those few extra cents). The first would have been the placement of either a drill-able bridge plug, or a retrievable bridge plug, below the P & A cement (with drilling mud left below the bridge plug to cover the formation), then a double set cement plug above the bridge plug, before circulating the remainder of the drilling mud out of the well.

    BP was willing to save 20 cents by circulating the mud out of the well before cement was placed, so I am willing to bet BP was also willing to save another 20 cents by not setting a bridge plug capable of containing the formation. After all, Management (at any corporation) has to be responsible to the investors for every penny spent on work completed. Why pay a few extra thousand dollars for something, that nobody really would ever know wasn’t there? Right?

    In this instance, it would have behooved BP to spend the extra thousands of dollars to make a few extra trips out of and back into “The Hole” placing a capable bridge plug, spotting sand above said bridge plug, then preparing the well casing for the temporary “Double Set” abandonment plugs.

    Had those “Formerly Standard” practices been used, WE would not have the pleasure of discussing the consequences of BP’s carelessness.

    Eeerrrr…….BP’s fiduciary responsibilities!

    Of course, I am not “College Educated”, therefore I have uttered (actually typed) completely useless drivel (actually numerical electrons) about something I am completely oblivious of.

    What could an old Dinosaur like me possibly understand about Shareholder Value??

  3. HaHA says:

    @Trail Tramp
    What generous words! Thank you.

    The idea was that we would tailor it to the layperson.

    Much of the criticism that we received on the hill had to do with the fact that Obama had created the commission and that there were other parallel investigations ongoing. I feel like each investigation’s perspective compliments public understanding as a whole… USCoastGuard/MMS, this NAE report, Presidential Commission report, and the continuing legal battles.

    It’s unfortunate that so many of our elected leaders dismissed/embraced the Commission’s findings due to ideological/political motivation without seriously addressing what was actually described in the report. Folks on the right stood up and delivered negative talking points and left the hearing, folks on the left did the opposite; however,there was practically ZERO constructive dialogue or effort to address the issues raised.

    As the second largest revenue generator for the gov’t behind income taxes, I feel like our oversight of federal oil and gas development should be top notch in order to promote effective, efficient, safe, and timely development. Our regulatory system delivers burdensome, complex regulation without results.

    Apparently that point was lost in the partisan, ideological quibbling that followed the publication of the presidential Commission’s report.

    I hope that this NAE report is well-received on both sides of the aisle and that our leaders can get together to LEAD, instead of following enviro/industry talking points.

  4. Trail Tramp says:

    @HaHa I watched all the hearings and read the Coast Guard report. No, I did not read the Presidents Oil Spill Commission Report, but from what I did read or hear of it, I must admit I was both surprised and impressed. In regards to the event, it seem fair, factual and presented in a manner most anyone could understand. The website is well done too. Some nice multimedia presentations. I ignored all the political stuff. At the risk of being branded a “socialist”, I do recommend the Oil Spill Commission website for lay persons who want to understand what happened.

  5. HaHA says:

    Trail Tramp, you must have read the presidential oil spill commission report as well?!
    It came to many similar conclusions… I had no idea you were a closet “socialist” as well.
    It’s too bad; now that I know you DO secretly support Obama, I can never trust anything you say again…

  6. Wayne Togo says:

    It is probably time for me to quit bothering with the news media, from Fox to NBC, print, radio and TV. I have a life-long history of reading, listening and watching the news.

    I now have the distinct impression that in virtually EVERY story, the media works to conceal and distort the facts. It is now too evident to deny that EVERY traditional media outlet directly sells their slant on current events … to the high bidder.

    The newspaper appears to do little besides ‘image-management’ for politicians, corporations and other payers.

    There are probably, now, sufficient, non-traditional sources for current events, to walk away.

    The news media now simply seems to be ‘in the way’.

  7. Trail Tramp says:

    There is fault, there is responsibility and there is legal responsibility. The three are not the same. BP is at fault for misinterpreting the negative test and not insuring they had a good cement job. As far as displacing the casing with seawater, you have to do that sooner or later. Either after drilling before the mud sets up, or later with the completion unit after the mud has set up. Transocean, and to a lesser degree Sperry-Sun, are at fault for not monitoring for pit gain during displacement. In hindsight, Transocean is at fault for diverting the kick to the gas buster instead of over board. You would hope the BOP would shear the pipe and shut in the well, but under blow out conditions, that is not a 100% certainty. The Coast Guard is at fault for allowing the rig to sink because of the water cannons, which led to the uncontrolled spill. If the fire had been left to burn, there was a chance the formation would bridge off and constrict the flow, or possibly a chance of activating the upper BOP. In terms of who is responsible, the operator, in this case BP, is always ultimately responsible for everything. That includes insuring that your contractors perform as required. As far as who is legally responsible, that’s up to the lawyers and the courts.

  8. olddispatcher says:

    I must say this is the first report of this kind I can remember reading that puts any blame on the Management. It is always ‘Operator Error’ and since in many of these cases the Operator is dead then that just takes care of everything. Things began to change in this area after the Bellingham Incident and two management types went to prison, but that was years ago and the lessons learned there are beginning to be forgotten.

    I also have to agree with Helen: Some companies have a culture of extreme safety and some have a culture of ‘Safety?’ and some are in-between. This culture comes from the top down and, if done right, is communicated to everyone just how committed the company is. Or is not.

    Concerned about the bottom line? Over the long haul the safest way is the cheapest way.

  9. Wayne Togo says:

    The operator is totally in charge. All legal precedent for all previous marine blowouts in USA history have held the operator SOLELY responsible. This is also in accordance with the jaded modern version of ‘The Golden Rule’, “He who has the gold, makes the rules.”

    BP has lots of political and media clout, so they can keep figuratively ‘muddying the water’ as well as fouling the Gulf.

    BP stooges, such as BHO and interested party comment writers, will continue to FLACK for BP.

    BP did it. BP ALONE is responsible.

  10. tacolover says:

    Agreed with Trail Tramp however BP getting the majority of blame may not be justifiable. I would think the decision to remove heavy fluids to replace with seawater would come from BP, Halliburton and Transocean. I realize BP is the customer and Halliburton and Transocean will try and do what BP says but if unsafe I would think they would not go ahead and replace fluids. I’ve been to offshore rigs and told Company Men no before, they don’t like it and they call the home office but I stand my ground. I don’t care how long they may make me sit in a boat.

  11. Wayne Togo says:

    BP, Wall Street, elected federal officials and major sectors of the energy business, particularly the nuclear power industry, are ‘sparing with the truth’, utterly ruthless and actively oppose the public interest.

    The behavior of these stakeholders is incompatible with sound public policy formation and their own continuation.

  12. Dr. Dave says:


    “In preparing to temporarily abandon the well, BP chose to displace heavy drilling muds with lighter seawater — a decision that the NAE said was a ‘questionable decision’ that may have left the well perilously vulnerable.
    “In the weeks before the April 20, 2010 blowout, the Deepwater Horizon drilling team encountered unexpected kicks of hydrocarbon at the site and cases where drilling fluids were lost in the well — an indication that the formation had cracked.”

    Calculating the difference in bottom hole pressure (BHP) with sea water versus drilling mud is a real eye opener. Drilling mud would have provided an increase of pressure on the order of 5,000 to 7,000 psi depending on its density.

    Having already experienced kicks, there is now no excuse for the increased risk. Using drilling mud may not have prevented the blow out, but it would have cut the flow almost in half which may have given the personnel enough time to recognize the problem and the well in on the surface instead of relying on the BOP.

  13. helen says:

    Richard is obviously ignorant of certain facts. Everyone in the industry has known for many years that BP is all talk and no action. Everything they do is smoke. The only company worse was Enron. Richard, most of the major oil companies are EXTREMELY safety conscious, both in the office and in the field. It’s not funny and it’s not just pretending. Lives can be lost any minute on a rig or a platform. The lives that can be lost are people many of us know and love. Try to put a little humanity into your posts in the future.

  14. Trail Tramp says:

    Pretty much the same thing that was said from day one…don’t be stupid.

  15. richard says:

    These are the details. The problem is that oil and gas companies can fold these disasters into their cost of doing business knowing there will be no real penalty, civil or, more importantly, criminal.