ity into all its aspects. Operating companies should be held responsible and accountable for well design, well construction, and the suitability of the rig and associated safety equipment. Notwithstanding the above, the drilling contractor should be held responsible and accountable for the operation and safety of the offshore equipment. (Recommendations 5.1 and 6.20)

10. Industry should greatly expand R&D efforts focused on improving the overall safety of offshore drilling in the areas of design, testing, modeling, risk assessment, safety culture, and systems integration. Such efforts should encompass well design, drilling and marine equipment, human factors, and management systems. These endeavors should be conducted to benefit the efforts of industry and government to instill a culture of safety. (Recommendation 5.2)

11. Industry, BSEE, and other regulators should undertake efforts to expand significantly the formal education and training of personnel engaged in offshore drilling to support proper implementation of system safety. (Recommendations 5.3 and 6.23)

12. Industry, BSEE, and other regulators should improve corporate and industrywide systems for reporting safety-related incidents. Reporting should be facilitated by enabling anonymous or “safety privileged” inputs. Corporations should investigate all such reports and disseminate their lessons-learned findings in a timely manner to all their operating and decision-making personnel and to the industry as a whole. A comprehensive lessons-learned repository should be maintained for industrywide use. This information can be used for training in accident prevention and continually improving standards. (Recommendations 5.4 and 6.14)

13. Industry, BSEE, and other regulators should foster an effective safety culture through consistent training, adherence to principles of human factors, system safety, and continued measurement through leading indicators. (Recommendations 5.5 and 6.25)

On the basis of the available evidence, the committee has identified the principal causes of the incident, as summarized above and described in the report in greater detail. Certain factors, such as the complete hydrocarbon flow path, may never be definitively identified, since the requisite forensic evidence lies more than 2 miles beneath the seabed. Similarly, many questions concerning the Deepwater Horizon rig will remain unanswerable so long as it lies on the bottom of the Gulf of Mexico, with its equipment unavailable for inspection and data recorders unreadable. Furthermore, the loss of several of the workers involved in the pivotal decisions on the Deepwater Horizon limits inquiry into the causes and rationale involved in those decisions. Even so, the committee believes that it was able to identify and assess the principal direct and root causes of the incident and develop a series of recommendations that would provide suitable and cost-effective corrective actions, materially reducing the likelihood of a similar event in the future.



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