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Committee on the Analysis of Causes of the Deepwater Horizon Explosion, Fire, and Oil Spill to Identify Measures to Prevent Similar Accidents in the Future Marine Board Board on Environmental Studies and Toxicology

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Insti- tute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This project was supported by Contract No. N10PC18384 between the National Academy of Sciences and the U.S. Department of the Interior. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-22138-2 International Standard Book Number-10: 0-309-22138-2 Additional copies of this report are available from The National Academies Press 500 Fifth Street, NW Box 285 Washington, DC 20055 800-624-6242 202-334-3313 (in the Washington metropolitan area) http://www.nap.edu Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the re- sponsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the Na- tional Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON THE ANALYSIS OF CAUSES OF THE DEEPWATER HORIZON EXPLOSION, FIRE, AND OIL SPILL TO IDENTIFY MEASURES TO PREVENT SIMILAR ACCIDENTS IN THE FUTURE Members DONALD C. WINTER (Chair), University of Michigan, Ann Arbor PAUL M. BOMMER, University of Texas at Austin CHRYSSOSTOMOS CHRYSSOSTOMIDIS, Massachusetts Institute of Technology, Cambridge DAVID E. DANIEL, University of Texas at Dallas THOMAS J. ECCLES, United States Navy, Washington, D.C. EDMUND P. GIAMBASTIANI, JR., United States Navy (retired), Warwick, Maryland DAVID A. HOFMANN, University of North Carolina at Chapel Hill ROGER L. MCCARTHY, McCarthy Engineering, Palo Alto, California NAJMEDIN MESHKATI, University of Southern California, Los Angeles KEITH K. MILLHEIM, Strategic Worldwide, LLC, The Woodlands, Texas (Resigned November 28, 2011, prior to completion of the committee’s report) M. ELISABETH PATÉ-CORNELL, Stanford University, Stanford, California ROBERT F. SAWYER, University of California at Berkeley JOCELYN E. SCOTT, DuPont Engineering, Facilities and Real Estate, Wilmington, Delaware ARNOLD F. STANCELL, Georgia Institute of Technology, Greenwich, Connecticut MARK D. ZOBACK, Stanford University, Stanford, California Staff RAYMOND A. WASSEL, Project Director v

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MARINE BOARD MICHAEL S. BRUNO (Chair), Stevens Institute of Technology, Hoboken, New Jersey THOMAS M. LESCHINE (Vice Chair), University of Washington, Seattle STEVEN R. BARNUM, Hydrographic Consultation Services, Suffolk, Virginia JERRY A. BRIDGES, Virginia Port Authority, Norfolk MARY R. BROOKS, Dalhousie University, Halifax, Nova Scotia, Canada JAMES C. CARD, Maritime Consultant, The Woodlands, Texas STEPHEN M. CARMEL, Maersk Line Limited, Norfolk, Virginia EDWARD N. COMSTOCK, Raytheon Company, Sudbury, Massachusetts STEPHAN TONI GRILLI, University of Rhode Island, Narragansett DOUGLAS J. GRUBBS, Crescent River Port Pilots Association, Metairie, Louisiana FREDERICK J. HARRIS, General Dynamics, San Diego, California JUDITH HILL HARRIS, City of Portland, Maine JOHN R. HEADLAND, Moffatt & Nichol Engineers, New York, New York JOHN M. HOLMES, Port of Los Angeles, San Pedro, California DONALD LIU, Marine Consultant, Willis, Texas RICHARD S. MERCIER, Texas A&M University, College Station EDMOND J. MORAN, JR., Moran Towing Corporation, New Canaan, Connecticut ALI MOSLEH, University of Maryland, College Park GEORGE BERRYMAN NEWTON, QinetiQ North America, Marstons Mills, Massachusetts PETER K. VELEZ, Shell International Exploration and Production, Inc., Houston, Texas JOHN WILLIAM WAGGONER, HMS Global Maritime, New Albany, Indiana TRANSPORTATION RESEARCH BOARD 2011 EXECUTIVE COMMITTEE OFFICERS NEIL J. PEDERSEN (Chair), Administrator, Maryland State Highway Administration (retired), Baltimore SANDRA ROSENBLOOM (Vice Chair), Professor of Planning, University of Arizona, Tucson C. MICHAEL WALTON (Division Chair for NRC Oversight), Ernest H. Cockrell Centennial Chair in Engineering, University of Texas, Austin ROBERT E. SKINNER, JR. (Executive Director), Transportation Research Board vi

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BOARD ON ENVIRONMENTAL STUDIES AND TOXICOLOGY Members ROGENE F. HENDERSON (Chair), Lovelace Respiratory Research Institute, Albuquerque, New Mexico PRAVEEN AMAR, Clean Air Task Force, Boston, Massachusetts TINA BAHADORI, American Chemistry Council, Washington, D.C. MICHAEL J. BRADLEY, M.J. Bradley & Associates, Concord, Massachusetts JONATHAN Z. CANNON, University of Virginia, Charlottesville GAIL CHARNLEY, HealthRisk Strategies, Washington, D.C. FRANK W. DAVIS, University of California, Santa Barbara RICHARD A. DENISON, Environmental Defense Fund, Washington, D.C. CHARLES T. DRISCOLL, JR., Syracuse University, New York H. CHRISTOPHER FREY, North Carolina State University, Raleigh RICHARD M. GOLD, Holland & Knight, LLP, Washington, D.C. LYNN R. GOLDMAN, George Washington University, Washington, D.C. LINDA E. GREER, Natural Resources Defense Council, Washington, D.C. WILLIAM E. HALPERIN, University of Medicine and Dentistry of New Jersey, Newark PHILIP K. HOPKE, Clarkson University, Potsdam, New York HOWARD HU, University of Michigan, Ann Arbor SAMUEL KACEW, University of Ottawa, Ontario, Canada ROGER E. KASPERSON, Clark University, Worcester, Massachusetts THOMAS E. MCKONE, University of California, Berkeley TERRY L. MEDLEY, E.I. du Pont de Nemours & Company, Wilmington, Delaware JANA MILFORD, University of Colorado at Boulder FRANK O’DONNELL, Clean Air Watch, Washington, D.C. RICHARD L. POIROT, Vermont Department of Environmental Conservation, Waterbury KATHRYN G. SESSIONS, Health and Environmental Funders Network, Bethesda, Maryland JOYCE S. TSUJI, Exponent Environmental Group, Bellevue, Washington Senior Staff JAMES J. REISA, Director DAVID J. POLICANSKY, Scholar RAYMOND A. WASSEL, Senior Program Officer for Environmental Studies ELLEN K. MANTUS, Senior Program Officer for Risk Analysis SUSAN N.J. MARTEL, Senior Program Officer for Toxicology EILEEN N. ABT, Senior Program Officer RUTH E. CROSSGROVE, Senior Editor MIRSADA KARALIC-LONCAREVIC, Manager, Technical Information Center RADIAH ROSE, Manager, Editorial Projects vii

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DEDICATION We dedicate this report to the memory of the eleven people who lost their lives on board the Deepwater Horizon on April 20, 2010. Jason Christopher Anderson Aaron Dale Burkeen Donald Neal Clark Stephen Ray Curtis Gordon Lewis Jones Roy Wyatt Kemp Karl Dale Kleppinger, Jr. Keith Blair Manuel Dewey Allen Revette Shane Michael Roshto Adam Taylor Weise viii

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Preface The blowout of the Macondo well on April 20, 2010, led to enormous consequences for the individuals involved in the drilling operations and for their families. Eleven workers on the Deepwater Horizon drilling rig lost their lives, and 16 others were seriously injured. There were also enormous consequences for the companies involved in the drilling operations, to the Gulf of Mexico en- vironment, and to the economy of the region and beyond. The flow continued for nearly 3 months before the well could be completely killed, during which time nearly 5 million barrels of oil spilled into the gulf. The economic conse- quences of the event were felt almost immediately and became more widespread over time. A moratorium on drilling activities was put in place throughout the gulf, and commercial fishing was halted in much of the region. The total eco- nomic impact is in the tens of billions of dollars. The long-term ecological im- pact will likely take many years to measure. This was truly a “spill of national significance,”1 and international efforts to learn from this disaster have been spurred. Shortly after the event, the National Academy of Engineering (NAE) and the National Research Council (NRC) were asked by the Secretary of the Inte- rior to form a committee to examine the probable causes of the Deepwater Hori- zon explosion, fire, and oil spill and to identify means for preventing similar harm in the future. The committee benefited from a focused and well-defined scope, which excluded several issues such as the extensive response and reme- diation efforts (see Appendix A). Nonetheless, NAE and NRC wanted to ensure that the committee had not only the requisite expertise appropriate to a deepwa- ter drilling accident but also the breadth needed to ensure that the root causes of the incident and appropriate corrective actions could be identified. Conse- quently, a committee of 15 members was assembled, which provided expertise in geophysics, petroleum engineering, marine systems, accident investigations, safety systems, risk analysis, human factors, and organizational behavior (see the biographical information at the end of this document). 1 Designation made by the Secretary of Homeland Security on April 29, 2010. ix

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x Preface The committee was able to take advantage of other investigations occur- ring at the same time, such as the Marine Board of Investigation (MBI), con- vened by the U.S. Coast Guard (USCG) and the Bureau of Ocean Energy Man- agement, Regulation, and Enforcement (BOEMRE—formerly the Minerals Management Service). Members of the committee observed the MBI hearings and reviewed documentation submitted to the board. Similarly, committee members observed hearings of the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling and the U.S. Chemical Safety Board. The committee conducted its own public meetings to hear presentations from regulators (USCG, BOEMRE, and the Republic of the Marshall Islands—the flag state), the American Petroleum Institute, the American Bureau of Shipping, and industry (see Appendix B). The information provided to the committee by industry was constrained by the legal environment generated by the MBI, the investigation of the De- partment of Justice, and the prospect of multiple matters of civil litigation in- volving tens of billions of dollars. However, some of the companies involved in the Deepwater Horizon incident participated in the committee’s public meetings and submitted material in writing, including several corporate investigative re- ports. BP, Halliburton, and Transocean provided information to the committee. Cameron, manufacturer of the Deepwater Horizon’s blowout preventer (BOP), provided some material but declined to make a presentation on the Deepwater Horizon BOP. The committee also benefited from good support by USCG, which facili- tated access to recovered items from Deepwater Horizon (lifeboats, riser, drill pipe, and BOP). The BOP assessment was greatly aided by the forensic work performed by Det Norske Veritas (DNV) and reported by DNV (2011a, 2011b). However, the committee was unable to obtain results of Phase 2 testing of the Deepwater Horizon BOP led by BP. The results are maintained under protective orders by the courts supervising related litigation matters. The committee received support from a number of industrial organizations that were not directly involved in the Macondo well–Deepwater Horizon inci- dent, which improved its understanding of the various standards and practices of the industry. Of note, Shell provided access both to its Real-Time Operations Center in Houston, Texas, and to the Deepwater Nautilus, the sister ship to Deepwater Horizon. Hydril similarly provided access to its BOP design, produc- tion, and test facilities. The committee also visited Wild Well Control School in Houston to improve its understanding of the training provided to drilling per- sonnel. In addition to the industry inputs provided through corporate channels, the committee was able to obtain inputs from industry personnel reflected in written summaries provided by the Society of Petroleum Engineers and the In- ternational Association of Drilling Contractors. The summaries were prepared with the prior understanding that none of the input would be attributed to spe- cific individuals. To obtain a better understanding of alternative regulatory ap- proaches, committee members visited the Petroleum Safety Authority of Nor-

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xi Preface way, SINTEF (Stiftelsen for Industriell og Teknisk Forskning), the Norwegian Oil Industry Association, and the U.K. Health and Safety Executive. The scope and depth of the information available to the committee enabled it to develop findings and informed observations concerning the probable causes (both direct and root causes) of the incident. The information also enabled the committee to develop a series of recommendations that it believes will reduce the likelihood and impact of any future well control incidents. This final report documents the major findings, observations, and recommendations developed by the committee during its study.2 The report does not attempt to assign responsi- bility for the incident to specific individuals or corporations, nor does it attempt to make a systematic assessment of the extent to which the parties involved complied with applicable regulations. Such matters were deemed to be appropri- ately addressed by the MBI. The committee notes that several of its recommendations reinforce steps already taken to strengthen regulatory practices in the aftermath of this incident. These are steps in the right direction, which need to be built on in a timely man- ner to ensure that the risks associated with this critical industry are minimized and that the public trust in both industry operations and regulatory processes is restored. Many challenges beyond those addressed in this report must be faced to revitalize the regulatory process. In particular, the administration and Con- gress will need to provide the funding and flexibility in hiring practices that will allow the Bureau of Safety and Environmental Enforcement (BSEE)3 to enhance its capability and capacity. There have been positive indications regarding industry’s recognition of the need for change, as well. Notable have been the formation and funding of additional response capabilities, such as the Marine Well Containment Com- pany. That said, the companies involved in the Macondo well–Deepwater Hori- zon incident have the added challenge of ensuring that positions taken to defend against civil liabilities and potential criminal charges do not inhibit their timely recognition of the need to change their internal processes and the manner in which the many parties to this industry (operating companies, drilling contrac- tors, and service companies) all work together. The need to maintain domestic sources of oil is great, but so is the need to protect the lives of those who work in this industry and to protect the Gulf of Mexico and the many other industries that depend on it. The oil and gas industry 2 The committee issued an interim letter report on November 16, 2010, which pre- sented preliminary findings and observations concerning key factors and decisions that may have contributed to the blowout of the Macondo well. The committee also provided a letter to BOEMRE on September 17, 2010, which identified potential approaches for use in conducting forensic analyses of the Deepwater Horizon BOP. 3 On October 1, 2011, BOEMRE split into two entities. BSEE is currently the federal entity responsible for safety and environmental oversight of offshore oil and gas opera- tions internal processes and the manner in which the many parties to this industry (operat- ing companies, drilling contractors, and service companies) work together.

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xii Preface is robust and capable of improving offshore drilling safety; it employs many experienced personnel and utilizes many impressive technologies. Similarly, there are many dedicated and capable individuals in the various regulatory agen- cies responsible for overseeing the industry who can make further safety im- provements. There is no reason why the diligent application of these multifold capabilities toward strengthening system safety should not significantly reduce the likelihood and consequences of any future loss of well control in the Gulf of Mexico. Donald C. Winter, Chair Committee on the Analysis of Causes of the Deepwater Horizon Explosion, Fire, and Oil Spill to Identify Measures to Prevent Similar Accidents in the Future

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Acknowledgments This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise in accordance with procedures ap- proved by NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that assist the authors and NRC in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confi- dential to protect the integrity of the deliberative process. We thank the follow- ing individuals for their review of this report: Benton F. Baugh, Radoil Inc., Houston, Texas; Robert Bea, University of California, Berkeley (emeritus); Mi- chael J. Burke, Tulane University, New Orleans, Louisiana; Vice Admiral James C. Card (USCG, retired), The Woodlands, Texas; Elmer Danenberger III, inde- pendent consultant, Reston, Virginia; Chan Gill, independent consultant, Avon- dale, Arizona; Richard Hartley, B&W Pantex, Amarillo, Texas; Trevor O. Jones, ElectroSonics Medical Inc., Cleveland, Ohio; Rear Admiral Malcolm MacKinnon III (U.S. Navy, retired), MSCL LLC, Alexandria, Virginia; Erik B. Nelson, independent consultant, Houston, Texas; Robin Pitblado, Det Norske Veritas (U.S.A.), Inc., Katy, Texas; Christopher Ranger, Ranger Consultants, Ltd., Ayrshire, Scotland; Frank J. Schuh, Drilling Technology, Inc., Plano, Texas; Richard Sears, Leading Energy Now, Houston, Texas; and A. Dan Tar- lock, Chicago Kent College of Law, Chicago, Illinois. Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the committee’s conclu- sions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Robert A. Frosch, Harvard University, Cambridge, Massachusetts, and by C. Michael Walton, University of Texas, Austin. Appointed by NRC, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully con- sidered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. xiii

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xiv Acknowledgments The work of the committee was assisted by three consultants. Michael Griffes, Alexandria, Virginia, and Peter Johnson, Washington, D.C., facilitated information-gathering activities. Stephen Kemp, Marine & Process Controls LLC, Whitmore Lake, Michigan, provided analysis of the Deepwater Horizon control and alarm systems. This project was overseen by the Marine Board, a component of the NRC’s Transportation Research Board (TRB), with support from the Board on Environ- mental Studies and Toxicology of the NRC’s Division on Earth and Life Studies. Raymond Wassel managed the study under the guidance of the committee and the supervision of Stephen Godwin, Director, Studies and Special Programs, TRB. Beverly Huey and Mirsada Karalic-Loncarevic provided scientific and tech- nical information. Norman Solomon edited the report; Jennifer Weeks prepared the prepublication manuscript, under the supervision of Javy Awan, Director of Publications, TRB. Radiah Rose assisted in preparing the prepublication manu- script and the final published version. Mark Hutchins and Orin Luke arranged meetings and provided logistical communications to the committee. In addition, Keri Schaffer helped with gathering and compiling background information.

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Abbreviations ABS American Bureau of Shipping ALARP as low as reasonably practicable AMF automatic mode function AoC acknowledgment of compliance API American Petroleum Institute ASRS Aviation Safety Reporting System BOEMRE Bureau of Ocean Energy Management, Regulation, and Enforcement BOP blowout preventer BSR blind shear ram BSEE Bureau of Safety and Environmental Enforcement CAIB Columbia Accident Investigation Board CCPS Center for Chemical Process Safety CDC Centers for Disease Control and Prevention CGD combustible gas detector CSB U.S. Chemical Safety Board CSR casing shear ram DHSG Deepwater Horizon Study Group DNV Det Norske Veritas DoD U.S. Department of Defense DOI U.S. Department of the Interior ECD equivalent circulating density EDS emergency disconnect system EIA U.S. Energy Information Administration EMW equivalent mud window EPA U.S. Environmental Protection Agency EPRI Electric Power Research Institute E&P exploration and production ESD emergency shutdown FAA Federal Aviation Administration FBI Federal Bureau of Investigation FS flag state GAO U.S. General Accounting Office xv

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xvi Abbreviations HSE Health and Safety Executive of the United Kingdom IACS integrated alarm and control system IADC International Association of Drilling Contractors IAEA International Atomic Energy Agency IBOP internal blowout preventer LCM lost circulation material LMRP lower marine riser package MBI Marine Board of Investigation MGS mud–gas separator MMS Minerals Management Service MODU mobile offshore drilling unit MUX multiplexer MWCC Marine Well Containment Company NAE National Academy of Engineering NEI Nuclear Energy Institute NOAA National Oceanic and Atmospheric Administration NPC National Petroleum Council NRC National Research Council NTSB National Transportation Safety Board OECD Organisation for Economic Cooperation and Development OIM offshore installation manager OLF Norwegian Oil Industry Association ppg pounds per gallon Presidential Commission National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling PSA Petroleum Safety Authority of Norway ROV remotely operated vehicle SEMS Safety and Environmental Management Systems SINTEF Stiftelsen for Industriell og Teknisk Forskning SPE Society of Petroleum Engineers SUBSAFE U.S. Navy’s Submarine Safety Program TSA Transportation Security Administration USCG U. S. Coast Guard U.S. NRC U.S. Nuclear Regulatory Commission VBR variable bore ram WCID well construction interface document

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Contents Summary............................................................................................................. 3 1 Introduction .............................................................................................. 10 Challenges in Designing and Constructing Offshore Wells, 11 Several Past Accidents Caused by Blowouts, 14 History of Macondo Well Before the Blowout, 14 Committee’s Approach to Its Task, 15 Other Investigations, 17 2 Well Design and Construction ................................................................. 19 Overview of the Macondo Well Plan, 19 Findings, 25 Observations, 39 Recommendations, 43 3 Blowout Preventer System ....................................................................... 45 BOP System for Deepwater Horizon, 45 Areas of Investigation, 52 Findings, 68 Observations, 73 Recommendations, 73 4 Mobile Offshore Drilling Units ................................................................ 75 Deepwater Horizon Rig, 75 Findings, 82 Observations, 85 Recommendations, 85 5 Industry Management of Offshore Drilling ............................................ 90 Safety Culture, 92 Recommendations, 104 xvii

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xviii Contents 6 Regulatory Reform ................................................................................. 111 Regulation of U.S. Offshore Drilling Before the Macondo Well Blowout, 112 DOI’s Safety and Environmental Management Systems, 114 Goal-Oriented Risk Management Regulatory Systems, 116 Recommendations, 120 7 Concluding Comments ........................................................................... 128 References ....................................................................................................... 130 APPENDICES A Statement of Task ..................................................................................... 136 B Public Agendas of the Committee on the Analysis of Causes of the Deepwater Horizon Explosion, Fire, and Oil Spill to Identify Measures to Prevent Similar Accidents in the Future ............................... 138 C Findings, Observations, and Recommendations ....................................... 142 D Calculating the Differential Pressure at the Start of the Negative Test and the Quality of Foam Cement ....................................... 166 Study Committee Biographical Information ............................................... 170 BOXES, FIGURES, AND TABLES BOX 1-1 Reports of Other Macondo Well–Deepwater Horizon Investigations, 18 FIGURES 2-1 Original wellbore architecture planned for Macondo well, 21 2-2 Final wellbore architecture for Macondo well, 22 2-3 Overburden stress, fracture gradients in the shale and sands, and pore pressure in the Macondo well, 23 2-4 Variation of pore pressure in the open hole section of the Macondo well expressed in pounds per gallon, 24 2-5 Planned cement location and likely cement location after pumping, 29 2-6 Calculated foam density versus depth during pumping, 30 2-7 Uncontaminated cement compressive strength tests (DP = differential pressure), 31

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xix Contents 2-8 Float collar with flapper valves and differential fill tube, 34 2-9 View inside casing hanger, 36 3-1 Deepwater Horizon BOP port side, 47 3-2 Sketch of intended nominal operation of BSR in the Macondo well, 48 3-3 Upper and lower shear blades crushing the drill pipe and beginning the shearing (or breaking) operation, 48 3-4 Macondo well blowout timeline, 60 3-5 Finite element analysis model of BSR blade surfaces and off-center drill pipe, 63 3-6 Progression of off-center BSR shear model, isometric view (top) and top view showing deformation of drill pipe outside of shearing blade surfaces (bottom), 65 4-1 Basic dimensions of the Deepwater Horizon rig while drilling, 76 4-2 Illustration of the main deck of the Deepwater Horizon, 80 5-1 Selected major petroleum mergers (1996–2002), 97 D-1 Well diagram, 166 TABLES 2-1 Chevron Data to Illustrate the Effect of Mud Contamination on Cement Compressive Strength, 33 6-1 Offshore Drilling Operations and Relevant Federal Agencies, 124

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