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This report is dedicated to the 11 men who lost their lives on the Deepwater Horizon rig on April 20, 2010 and to their families, in hope that this report will help minimize the chance of another such disaster ever happening again.

Jason Anderson

Aaron Dale Burkeen

Donald Clark

Stephen Curtis

Gordon Jones

Roy Wyatt Kemp

Karl Dale Kleppinger, Jr.

Blair Manuel

Dewey Revette Shane Roshto

Adam Weise

Dedication

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Acknowledgements We wish to acknowledge the many individuals and organizations, government officials and agencies alike that offered their views and insights to the Commission. We would especially like to express our gratitude to the Coast Guard’s Incident Specific Preparedness Review (ISPR) for allowing Commission staff to participate in its interviews and discussions, which was invaluable to the preparation of this report. (A copy of the Coast Guard’s ISPR report can be found at the Commission’s website at www.oilspillcommission. gov). We would also like to thank Chevron for performing the cement tests that proved so critical to our investigation into the Macondo well blowout.

We also thank the Department of Energy, which served as our supporting agency, and all of the Department employees whose assistance was so essential to the success and functioning of the Commission. In particular, we would like to thank Christopher Smith, Deputy Assistant Secretary for Oil and Natural Gas, who acted as the Commission’s Designated Federal Officer, as well as Elena Melchert, Petroleum Engineer in the Office of Oil and Gas Resource Conservation, who served as the Committee Manager.

But most importantly, we are deeply grateful to the citizens of the Gulf who shared their personal experiences as Commissioners traveled in the region, providing a critical human dimension to the disaster and to our undertaking, as well as the many people who testified at the Commission’s hearings, provided public comments, and submitted statements to our website. Together, these contributions greatly informed our work and led to a better report. Thank you one and all.

Copyright, Restrictions, and Permissions Notice Except as noted herein, materials contained in this report are in the public domain. Public domain information may be freely distributed and copied. However, this report contains illustrations, photographs, and other information contributed by or licensed from private individuals, companies, or organizations that may be protected by U.S. and/or foreign copyright laws. Transmission or reproduction of items protected by copyright may require the written permission of the copyright owner.

When using material or images from this report we ask that you credit this report, as well as the source of the material as indicated in this report.] Permission to use materials copyrighted by other individuals, companies or organizations must be obtained directly from those sources.

This report contains links to many Web sites. Once you access another site through a link that we provide, you are subject to the use, copyright and licensing restrictions of that site. Neither the Government nor the National Commission on the BP/Deepwater Horizon Oil Spill and Offshore Drilling (Commission) endorses any of the organizations or views represented by the linked sites unless expressly stated in the report. The Government and the Commission take no responsibility for, and exercise no control over, the content, accuracy or accessibility of the material contained on the linked sites.

Cover Photo: © Steadfast TV ISBN: 978-0-16-087371-3

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Deep Water The Gulf Oil Disaster and the Future of Offshore Drilling

Report to the President

National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling

January 2011

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Commission Members

Bob Graham, Co-Chair

Cherry A. Murray

Donald F. Boesch

Fran Ulmer

Frances Beinecke

William K. Reilly, Co-Chair

Terry D. Garcia

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Table of Contents Foreword

PART I: The Path to Tragedy Chapter 1 “Everyone involved with the job…was completely satisfied….” The Deepwater Horizon, the Macondo Well, and Sudden Death on the Gulf of Mexico Chapter 2 “Each oil well has its own personality” The History of Offshore Oil and Gas in the United States

Chapter 3 “It was like pulling teeth.” Oversight—and Oversights—in Regulating Deepwater Energy Exploration and Production in the Gulf of Mexico

PART II: Explosion and Aftermath: The Causes and Consequences of the Disaster Chapter 4 “But, who cares, it’s done, end of story, [we] will probably be fine and we’ll get a good cement job.” The Macondo Well and the Blowout

Chapter 5 “You’re in it now, up to your neck!” Response and Containment Chapter 6 “The worst environmental disaster America has ever faced.” Oiling a Rich Environment: Impacts and Assessment Chapter 7 “People have plan fatigue . . . they’ve been planned to death” Recovery and Restoration

PART III: Lessons Learned: Industry, Government, Energy Policy Chapter 8 “Safety is not proprietary.” Changing Business as Usual Chapter 9 “Develop options for guarding against, and mitigating the impact of, oil spills associated with offshore drilling.” Investing in Safety, Investing in Response, Investing in the Gulf Chapter 10 American Energy Policy and the Future of Offshore Drilling

Endnotes

Appendices Appendix A: Commission Members Appendix B: List of Acronyms Appendix C: Executive Order Appendix D: Commission Staff and Consultants Appendix E: List of Commission Meetings Appendix F: List of Staff Working Papers

Index

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21

55

87 89

129

173

197

215 217

249

293

307

356 358 359 362 365 366

368

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Photo: Susan Walsh, Associated Press

Foreword The explosion that tore through the Deepwater Horizon drilling rig last April 20, as the rig’s crew completed drilling the exploratory Macondo well deep under the waters of the Gulf of Mexico, began a human, economic, and environmental disaster.

Eleven crew members died, and others were seriously injured, as fire engulfed and ultimately destroyed the rig. And, although the nation would not know the full scope of the disaster for weeks, the first of more than four million barrels of oil began gushing uncontrolled into the Gulf—threatening livelihoods, precious habitats, and even a unique way of life. A treasured American landscape, already battered and degraded from years of mismanagement, faced yet another blow as the oil spread and washed ashore. Five years after Hurricane Katrina, the nation was again transfixed, seemingly helpless, as this new tragedy unfolded in the Gulf. The costs from this one industrial accident are not yet fully counted, but it is already clear that the impacts on the region’s natural systems and people were enormous, and that economic losses total tens of billions of dollars.

On May 22, 2010, President Barack Obama announced the creation of the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling: an independent, nonpartisan entity, directed to provide a thorough analysis and impartial judgment. The President charged the Commission to determine the causes of the disaster, and to improve the country’s ability to respond to spills, and to recommend reforms to make offshore energy production safer. And the President said we were to follow the facts wherever they led.

This report is the result of an intense six-month effort to fulfill the President’s charge.

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From the outset, the Commissioners have been determined to learn the essential lessons so expensively revealed in the tragic loss of life at the Deepwater Horizon and the severe damages that ensued. The Commission’s aim has been to provide the President, policymakers, industry, and the American people a clear, accessible, accurate, and fair account of the largest oil spill in U.S history: the context for the well itself, how the explosion and spill happened, and how industry and government scrambled to respond to an unprecedented emergency. This was our first obligation: determine what happened, why it happened, and explain it to Americans everywhere.

As a result of our investigation, we conclude:

• The explosive loss of the Macondo well could have been prevented.

• The immediate causes of the Macondo well blowout can be traced to a series of identifiable mistakes made by BP, Halliburton, and Transocean that reveal such systematic failures in risk management that they place in doubt the safety culture of the entire industry.

• Deepwater energy exploration and production, particularly at the frontiers of experience, involve risks for which neither industry nor government has been adequately prepared, but for which they can and must be prepared in the future.

• To assure human safety and environmental protection, regulatory oversight of leasing, energy exploration, and production require reforms even beyond those significant reforms already initiated since the Deepwater Horizon disaster. Fundamental reform will be needed in both the structure of those in charge of regulatory oversight and their internal decisionmaking process to ensure their political autonomy, technical expertise, and their full consideration of environmental protection concerns.

• Because regulatory oversight alone will not be sufficient to ensure adequate safety, the oil and gas industry will need to take its own, unilateral steps to increase dramatically safety throughout the industry, including self-policing mechanisms that supplement governmental enforcement.

• The technology, laws and regulations, and practices for containing, responding to, and cleaning up spills lag behind the real risks associated with deepwater drilling into large, high-pressure reservoirs of oil and gas located far offshore and thousands of feet below the ocean’s surface. Government must close the existing gap and industry must support rather than resist that effort.

• Scientific understanding of environmental conditions in sensitive environments in deep Gulf waters, along the region’s coastal habitats, and in areas proposed for more drilling, such as the Arctic, is inadequate. The same is true of the human and natural impacts of oil spills.

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We reach these conclusions, and make necessary recommendations, in a constructive spirit: we aim to promote changes that will make American offshore energy exploration and production far safer, today and in the future.

More broadly, the disaster in the Gulf undermined public faith in the energy industry, government regulators, and even our own capability as a nation to respond to crises. It is our hope that a thorough and rigorous accounting, along with focused suggestions for reform, can begin the process of restoring confidence. There is much at stake, not only for the people directly affected in the Gulf region, but for the American people at large. The tremendous resources that exist within our outer continental shelf belong to the nation as a whole. The federal government’s authority over the shelf is accordingly plenary, based on its power as both the owner of the resources and in its regulatory capacity as sovereign to protect public health, safety, and welfare. To be allowed to drill on the outer continental shelf is a privilege to be earned, not a private right to be exercised.

“Complex Systems Almost Always Fail in Complex Ways” As the Board that investigated the loss of the Columbia space shuttle noted, “complex systems almost always fail in complex ways.” Though it is tempting to single out one crucial misstep or point the finger at one bad actor as the cause of the Deepwater Horizon explosion, any such explanation provides a dangerously incomplete picture of what happened—encouraging the very kind of complacency that led to the accident in the first place. Consistent with the President’s request, this report takes an expansive view.

Why was a corporation drilling for oil in mile-deep water 49 miles off the Louisiana coast? To begin, Americans today consume vast amounts of petroleum products—some 18.7 million barrels per day—to fuel our economy. Unlike many other oil-producing countries, the United States relies on private industry—not a state-owned or -controlled enterprise—to supply oil, natural gas, and indeed all of our energy resources. This basic trait of our private-enterprise system has major implications for how the U.S. government oversees and regulates offshore drilling. It also has advantages in fostering a vigorous and competitive industry, which has led worldwide in advancing the technology of finding and extracting oil and gas.

Even as land-based oil production extended as far as the northern Alaska frontier, the oil and gas industry began to move offshore. The industry first moved into shallow water and eventually into deepwater, where technological advances have opened up vast new reserves of oil and gas in remote areas—in recent decades, much deeper under the water’s surface and farther offshore than ever before. The Deepwater Horizon was drilling the Macondo well under 5,000 feet of Gulf water, and then over 13,000 feet under the sea floor to the hydrocarbon reservoir below. It is a complex, even dazzling, enterprise. The remarkable advances that have propelled the move to deepwater drilling merit comparison with exploring outer space. The Commission is respectful and admiring of the industry’s technological capability.

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But drilling in deepwater brings new risks, not yet completely addressed by the reviews of where it is safe to drill, what could go wrong, and how to respond if something does go awry. The drilling rigs themselves bristle with potentially dangerous machinery. The deepwater environment is cold, dark, distant, and under high pressures—and the oil and gas reservoirs, when found, exist at even higher pressures (thousands of pounds per square inch), compounding the risks if a well gets out of control. The Deepwater Horizon and Macondo well vividly illustrated all of those very real risks. When a failure happens at such depths, regaining control is a formidable engineering challenge—and the costs of failure, we now know, can be catastrophically high. In the years before the Macondo blowout, neither industry nor government adequately addressed these risks. Investments in safety, containment, and response equipment and practices failed to keep pace with the rapid move into deepwater drilling. Absent major crises, and given the remarkable financial returns available from deepwater reserves, the business culture succumbed to a false sense of security. The Deepwater Horizon disaster exhibits the costs of a culture of complacency.

The Commission examined in great detail what went wrong on the rig itself. Our investigative staff uncovered a wealth of specific information that greatly enhances our understanding of the factors that led to the explosion. The separately published report of the chief counsel (a summary of the findings is presented in Chapter 4) offers the fullest account yet of what happened on the rig and why. There are recurring themes of missed warning signals, failure to share information, and a general lack of appreciation for the risks involved. In the view of the Commission, these findings highlight the importance of organizational culture and a consistent commitment to safety by industry, from the highest management levels on down.*

But that complacency affected government as well as industry. The Commission has documented the weaknesses and the inadequacies of the federal regulation and oversight, and made important recommendations for changes in legal authority, regulations, investments in expertise, and management.

The Commission also looked at the effectiveness of the response to the spill. There were remarkable instances of dedication and heroism by individuals involved in the rescue and cleanup. Much was done well—and thanks to a combination of good luck and hard work, the worst-case scenarios did not all come to pass. But it is impossible to argue that the industry or the country was prepared for a disaster of the magnitude of the Deepwater Horizon oil spill. Twenty years after the Exxon Valdez spill in Alaska, the same blunt response technologies—booms, dispersants, and skimmers—were used, to limited effect. On-the-ground shortcomings in the joint public-private response to an overwhelming spill like that resulting from the blowout of the Macondo well are now evident, and demand public and private investment. So do the weaknesses in local, state, and federal coordination revealed by the emergency. Both government and industry failed to anticipate and prevent this catastrophe, and failed again to be prepared to respond to it.

*The chief counsel’s investigation was no doubt complicated by the lack of subpoena power. Nonetheless, Chief Counsel Bartlit did an extraordinary job building the record and interpreting what he learned. He used his considerable powers of persuasion along with other tools at his disposal to engage the involved companies in constructive and informative exchanges.

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If we are to make future deepwater drilling safer and more environmentally responsible, we will need to address all these deficiencies together; a piecemeal approach will surely leave us vulnerable to future crises in the communities and natural environments most exposed to offshore energy exploration and production.

The Deepwater Drilling Prospect The damage from the spill and the impact on the people of the Gulf has guided our work from the very beginning. Our first action as a Commission was to visit the Gulf region, to learn directly from those most affected. We heard deeply moving accounts from oystermen witnessing multi-generation family businesses slipping away, fishermen and tourism proprietors bearing the brunt of an ill-founded stigma affecting everything related to the Gulf, and oil-rig workers dealing with mounting bills and threatened home foreclosures, their means of support temporarily derailed by a blanket drilling moratorium, shutting down all deepwater drilling rigs, including those not implicated in the BP spill.

Indeed, the centrality of oil and gas exploration to the Gulf economy is not widely appreciated by many Americans, who enjoy the benefits of the energy essential to their transportation, but bear none of the direct risks of its production. Within the Gulf region, however, the role of the energy industry is well understood and accepted. The notion of clashing interests—of energy extraction versus a natural-resource economy with bountiful fisheries and tourist amenities—misses the extent to which the energy industry is woven into the fabric of the Gulf culture and economy, providing thousands of jobs and essential public revenues. Any discussion of the future of offshore drilling cannot ignore these economic realities.

But those benefits have imposed their costs. The bayous and wetlands of Louisiana have for decades suffered from destructive alteration to accommodate oil exploration. The Gulf ecosystem, a unique American asset, is likely to continue silently washing away unless decisive action is taken to start the work of creating a sustainably healthy and productive landscape. No one should be deluded that restoration on the scale required will occur quickly or cheaply. Indeed, the experience in restoring other large, sensitive regions—the Chesapeake Bay, the Everglades, the Great Lakes—indicates that progress will require coordinated federal and state actions, a dedicated funding source, long-term monitoring, and a vocal and engaged citizenry, supported by robust non-governmental groups, scientific research, and more.

We advocate beginning such an effort, seriously and soon, as a suitable response to the damage and disruption caused by the Deepwater Horizon emergency. It is a fair recognition not only of the costs that energy exploitation in the Gulf has, for decades, imposed on the landscape and habitats—and the other economic activities they support—but also of the certainty that Americans will continue to develop the region’s offshore energy resources.

For the simple fact is that the bulk of our newly discovered petroleum reserves, and the best prospects for future discoveries, lie not on land, but under water. To date, we have

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made the decision as a nation to exploit the Gulf ’s offshore energy resources—ruling much of the Florida, Atlantic, and Pacific coasts out of bounds for drilling. The choice of how aggressively to exploit these resources, wherever they may be found, has profound implications for the future of U.S. energy policy, for our need to understand and assure the integrity of fragile environmental resources, and for the way Americans think about our economy and our security. Although much work is being done to improve the fuel- efficiency of vehicles and to develop alternative fuels, we cannot realistically walk away from these offshore oil resources in the near future. So we must be much better prepared to exploit such resources with far greater care.

The Commission and Its Work While we took a broad view of the spill, it could not be exhaustive. There is still much we do not know—for instance, the blowout preventer, the last line of defense against loss of well control, is still being analyzed; and the Deepwater Horizon itself, after its explosive destruction, remained out of reach during our investigation. The understandable, immediate need to provide answers and concrete suggestions trumped the benefits of a longer, more comprehensive investigation. And as we know from other spills, their environmental consequences play out over decades—and often in unexpected ways. Instead, the Commission focused on areas we thought most likely to inform practical recommendations. Those recommendations are presented in the spirit of transforming America into the global leader for safe and effective offshore drilling operations. Just as this Commission learned from the experiences of other nations in developing our recommendations, the lessons learned from the Deepwater Horizon disaster are not confined to our own government and industry, but relevant to rest of the world.

We wish we could say that our recommendations make a recurrence of a disaster like the Macondo blowout impossible. We do not have that power. No one can eliminate all risks associated with deepwater exploration. But when exploration occurs, particularly in sensitive environments like the Gulf of Mexico or the Arctic, the country has an obligation to make responsible decisions regarding the benefits and risks.

The report is divided into three sections.

Chapters 1 through 3 describe the events of April 20th on the Deepwater Horizon, and, more important, the events leading up to it in the preceding decades—especially how the dramatic expansion of deepwater drilling in the Gulf was not met by regulatory oversight capable of ensuring the safety of those drilling operations.

Chapters 4 through 7 lay out the results of our investigation in detail, highlighting the crucial issues we believe must inform policy going forward: the specific engineering and operating choices made in drilling the Macondo well, the attempts to contain and respond to the oil spill, and the impacts of the spill on the region’s natural resources, economy, and people—in the context of the progressive degradation of the Mississippi Delta environment.

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Chapters 8 through 10 present our recommendations for reforms in business practices, regulatory oversight, and broader policy concerns. We recognize that the improvements we advocate all come with costs and all will take time to implement. But inaction, as we are deeply aware, runs the risk of real costs, too: in more lost lives, in broad damage to the regional economy and its long-term viability, and in further tens of billions of dollars of avoidable clean-up costs. Indeed, if the clear challenges are not addressed and another disaster happens, the entire offshore energy enterprise is threatened—and with it, the nation’s economy and security. We suggest a better option: build from this tragedy in a way that makes the Gulf more resilient, the country’s energy supplies more secure, our workers safer, and our cherished natural resources better protected.

Our Thanks and Dedication We thank President Obama for this opportunity to learn thoroughly about the crisis, and to share our findings with the American public. We deeply appreciate the effort people in the affected Gulf regions made to tell us about their experiences, and the time and preparation witnesses before the Commission dedicated to their presentations. We have come to respect the seriousness with which our fellow Commissioners assumed our joint responsibilities, and their diverse expertise and perspectives that helped make its work thorough and productive. On their behalf, we wish to recognize the extraordinary work the Commission’s staff—scientists, lawyers, engineers, policy analysts, and more— performed, under demanding deadlines, to make our inquiries broad, deep, and effective; and we especially highlight the leadership contributions of Richard Lazarus, executive director, and Fred Bartlit, chief counsel. Together, they have fulfilled an extraordinary public service.

Finally, to the American people, we reiterate that extracting the energy resources to fuel our cars, heat and light our homes, and power our businesses can be a dangerous enterprise. Our national reliance on fossil fuels is likely to continue for some time—and all of us reap benefits from the risks taken by the men and women working in energy exploration. We owe it to them to ensure that their working environment is as safe as possible. We dedicate this effort to the 11 of our fellow citizens who lost their lives in the Deepwater Horizon explosion.

Bob Graham, Co-Chair

William K. Reilly, Co-Chair

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Part I

The Path to Tragedy

On April 20, 2010, the 126 workers on the BP Deepwater Horizon

were going about the routines of completing an exploratory

oil well—unaware of impending disaster. What unfolded would

have unknown impacts shaped by the Gulf region’s distinctive

cultures, institutions, and geography—and by economic forces

resulting from the unique coexistence of energy resources,

bountiful fisheries and wildlife, and coastal tourism. The oil and

gas industry, long lured by Gulf reserves and public incentives,

progressively developed and deployed new technologies, at

ever-larger scales, in pursuit of valuable energy supplies in

increasingly deeper waters farther from the coastline. Regulators,

however, failed to keep pace with the industrial expansion and

new technology—often because of industry’s resistance to more

effective oversight. The result was a serious, and ultimately

inexcusable, shortfall in supervision of offshore drilling that

played out in the Macondo well blowout and the catastrophic oil

spill that followed. Chapters 1 through 3 describe the interplay

of private industry and public oversight in the distinctive Gulf

deepwater context: the conditions that governed the deployment

of the Deepwater Horizon and the drilling of the Macondo well.

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Chapter One 11

The Deepwater Horizon, the Macondo Well, and Sudden Death on the Gulf of Mexico

At 5:45 a.m. on Tuesday, April 20, 2010, a Halliburton Company cementing engineer sent an e-mail from the rig Deepwater Horizon, in the Gulf of Mexico off the Louisiana coast, to his colleague in Houston. He had good news: “We have completed the job and it went well.”1

Outside in the Gulf, it was still dark—beyond the glare of the floodlights on the gargantuan rig, the four decks of which towered above the blue-green water on four huge white columns, all floating on massive pontoons. The oil derrick rose over 20 stories above the top deck. Up on the bridge on the main deck, two officers monitored the satellite- guided dynamic positioning system, controlling thrusters so powerful that they could keep the 33,000-ton Deepwater Horizon centered over a well even in high seas. The rig’s industrial hum and loud mechanical noises punctuated the sea air as a slight breeze blew in off the water. The crew worked on

Chapter One

“Everyone involved with the job . . . was completely satisfied. . .”

Pride of the Transocean fleet of offshore drilling rigs, Deepwater Horizon rides calmly on station 40 miles off the Louisiana coast. The $560-million-dollar rig, under lease to BP, was putting the finishing touches on the oil company’s 18,000-foot-deep Macondo well when it blew out and escaping methane gas exploded. Eleven workers died in the inferno. According to the government’s estimates, by the time the well was sealed months later, over 4 million barrels of oil had spilled into the Gulf. < Photo courtesy of Transocean

National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling2

the well bore, aiming always to keep the pressure inside the well balancing the force exerted by the surrounding seabed.2

By the time the Halliburton engineer had arrived at the rig four days earlier to help cement in the two-and-a-half-mile-deep Macondo well, some crew members had dubbed it “the well from hell.”3 Macondo was not the first well to earn that nickname;4 like many deepwater wells, it had proved complicated and challenging. As they drilled, the engineers had to modify plans in response to their increasing knowledge of the precise features of the geologic formations thousands of feet below. Deepwater drilling is an unavoidably tough, demanding job, requiring tremendous engineering expertise.

BP drilling engineer Brian Morel, who had designed the Macondo well with other BP engineers including Mark Hafle, was also on board to observe the final stages of work at the well.5 In an April 14 e-mail, Morel had lamented to his colleagues, “this has been [a] nightmare well which has everyone all over the place.”6 BP and its corporate partners on the well, Anadarko Petroleum and MOEX USA, had, according to government reports, budgeted $96.2 million and 51 days of work to drill the Macondo well in Mississippi Canyon Block 252.7 They discovered a large reservoir of oil and gas, but drilling had been challenging.

As of April 20, BP and the Macondo well were almost six weeks behind schedule and more than $58 million over budget.8 The Deepwater Horizon was not originally meant to drill Macondo. Another giant rig, the Marianas, had initiated work on the well the previous October.9 Drilling had reached more than 9,000 feet below the ocean surface (4,000 feet below the seabed), with another 9,000 feet to go to “pay zone” (the oil and gas reservoir), when Hurricane Ida so battered the rig on November 9 that it had to be towed in for repair.

Both Marianas and Deepwater Horizon were semisubmersible rigs owned by Transocean, founded in Louisiana in 1919 as Danciger Oil & Refining Co. and now the world’s largest contractor of offshore drilling rigs.10 In 2009, Transocean’s global fleet produced revenues of $11.6 billion.11 Transocean had consolidated its dominant position in the industry in November 2007 by merging with rival GlobalSantaFe.12

Deepwater Horizon, built for $350 million,13 was seen as the outstanding rig in Transocean’s fleet; leasing its services reportedly cost as much as $1 million per day. Since Deepwater Horizon’s 2001 maiden voyage to the Gulf, it had been under contract to London-based BP (formerly known as British Petroleum). By 2010, after numerous acquisitions, BP had become the world’s fourth-largest corporation (based on revenue)14 producing more than 4 million barrels of oil daily from 30 countries.* Ten percent of BP’s output came from the Gulf of Mexico, where BP America (headquartered in Houston) was the largest producer. But BP had a tarnished reputation for safety. Among other BP accidents, 15 workers died in a 2005 explosion at its Texas City, Texas, refinery; in 2006, there was a major oil spill from a badly corroded BP pipeline in Alaska.

* * * * *A barrel equals 42 gallons.

National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling Chapter One 33

Deepwater Horizon had arrived at the Macondo lease site on January 31, at 2:15 p.m. It was 55 degrees, chilly and clear—the night of a full moon. About 126 people were aboard: approximately 80 Transocean employees, a few BP men, cafeteria and laundry workers, and a changing group of workers contracted for specialized jobs. Depending on the status of the well, these might include Halliburton cementers, mud loggers from Sperry Sun (a Halliburton subsidiary), mud engineers from M-I SWACO (a subsidiary of Schlumberger, an international oilfield services provider), remotely operated vehicle technicians from Oceaneering, or tank cleaners and technicians from the OCS Group. The offices and living quarters were on the two bottom decks of the rig. Helicopters flew in and out regularly with workers and supplies, landing on the top-deck helipad, and service ships made regular visits.

At its new Macondo assignment, Deepwater Horizon floated in 4,992 feet of water just beyond the gentle slope of the continental shelf in the Mississippi Canyon.15 The seabed far below was near-freezing, visible to the crew only via cameras mounted on the rig’s subsea remotely operated vehicle. Another two and a half miles below the seabed was the prize BP sought: a large reservoir of oil and gas from the Middle Miocene era trapped in a porous rock formation at temperatures exceeding 200 degrees.16 These deepwater hydrocarbon fields, buried far below the seabed—not just in the Gulf, but in other oil-rich zones around the world, too—were the brave new oil frontier. The size of some deepwater fields was so huge that the oil industry had nicknamed those with a billion barrels or more “elephants.”17

Drilling for oil had always been hard, dirty, dangerous work, combining heavy machinery and volatile hydrocarbons extracted at high pressures. Since 2001, the Gulf of Mexico workforce—35,000 people, working on 90 big drilling rigs and 3,500 production platforms—had suffered 1,550 injuries, 60 deaths, and 948 fires and explosions.18

The rig never slept. Most workers on Deepwater Horizon, from BP’s top “company man” down to the roustabouts, put in a 12-hour night or day shift, working three straight weeks on and then having three weeks off. Rig workers made good money for the dangerous work and long stints away from home and family. Top rig and management jobs paid well into six figures.

On the morning of April 20, Robert Kaluza was BP’s day-shift company man on the Deepwater Horizon. On board for the first time, he was serving for four days as a relief man for Ronald Sepulvado, a veteran well-site leader on the rig. Sepulvado had flown back to shore April 16 for a required well-control class.19

During the rig’s daily 7:30 a.m. operations conference call to BP in Houston, engineer Morel discussed the good news that the final cement job at the bottom of the Macondo well had gone fine.20 To ensure the job did not have problems, a three-man Schlumberger team was scheduled to fly out to the rig later that day, able to perform a suite of tests to examine the well’s new bottom cement seal.21

National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling4

According to the BP team’s plan, if the cementing went smoothly, as it had, they could skip Schlumberger’s cement evaluation. Generally, the completion rig would perform this test when it reopened the well to produce the oil the exploratory drilling had discovered. The decision was made to send the Schlumberger team home on the 11:00 a.m. helicopter, thus saving time and the $128,000 fee. As BP Wells Team Leader John Guide noted, “Everyone involved with the job on the rig site was completely satisfied with the [cementing] job.”22

At 8:52 a.m., Morel e-mailed the Houston office to reiterate: “Just wanted to let everyone know the cement job went well. Pressures stayed low, but we had full returns on the entire job…We should be coming out of the hole [well] shortly.” At 10:14 a.m., David Sims, BP’s new drilling operations manager in charge of Macondo, e-mailed to say, “Great job guys!”

* * * *

The rest of the day would be devoted to a series of further tests on the well—positive- and negative-pressure tests—in preparation for “temporary abandonment.”* During the positive-pressure test, the drill crew would increase the pressure inside the steel casing and seal assembly to be sure they were intact. The negative-pressure test, by contrast, would reduce the pressure inside the well in order to simulate its state after the Deepwater Horizon had packed up and moved on. If pressure increased inside the well during the negative-pressure test, or if fluids flowed up from the well, that would indicate a well integrity problem—a leak of fluids into the well. Such a leak would be a worrisome sign that somewhere the casing and cement had been breached—in which case remedial work would be needed to reestablish the well’s integrity.

At 10:43 a.m., Morel, about to leave the rig on the helicopter with the Schlumberger team, sent a short e-mail laying out his plan for conducting the day’s tests of the well’s integrity and subsequent temporary abandonment procedures. Few had seen the plan’s details when the rig supervisors and members of the drill team gathered for the rig’s daily 11:00 a.m. pre-tour meeting in the cinema room. “Basically [we] go over what’s going to be taking place for today on the rig and the drill floor,” said Douglas Brown, chief mechanic.23

During the rig meeting, the crew on the drill floor was conducting the Macondo well’s positive-pressure test.24 The positive-pressure test on the casing was reassuring, a success.25 There was reason for the mood on the rig to be upbeat. Ross Skidmore, a subsea engineer explained, “When you run the last string of casing, and you’ve got it cemented, it’s landed out, and a test was done on it, you say, ‘This job, we’re at the end of it, we’re going to be okay.’”26

At noon, the drill crew began to run drill pipe into the well in preparation for the negative- pressure test later that evening.27 By now, it was a sunny afternoon. Transocean’s top men on the rig, Jimmy Harrell and Captain Curt Kuchta, were standing together near the helipad, watching a helicopter gently land. Kuchta had come in from New Orleans just

* Temporary abandonment describes the process, after successful exploration, for securing the well until the production platform can be brought in for the purpose of extracting the oil and gas from the reservoir.

National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling Chapter One 55

that morning to begin his three-week hitch. Harrell was the top Transocean man on the rig when—as now—the well was “latched up.” Captain Kuchta, who had served on the Deepwater Horizon since June 2008, was in command when the vessel was “unlatched” and thus once again a maritime vessel. 28

The helicopter landed, the doors opened, and four Houston executives stepped out to begin their 24-hour “management visibility tour.”29 Harrell and Kuchta greeted the VIPs.30 Two were from Transocean: Buddy Trahan, vice president and operations manager for assets, and Daun Winslow, a one-time assistant driller who had worked his way up to operations manager. BP’s representatives were David Sims, the new drilling operations manager (he had sent the congratulatory e-mail about the cement just that morning), and Pat O’Bryan, vice-president for drilling and completions, Gulf of Mexico Deepwater.31

At about 4:00 p.m., Harrell began his escorted tour of the Deepwater Horizon for the VIPs.32 He was joined by Chief Engineer Steve Bertone, on board since 2003, and senior toolpusher Randy Ezell, another top man on the rig. 33 Like Harrell, Ezell was an offshore veteran. He had worked for 23 years with Transocean34 and was now the senior man in charge of the drilling floor. He had been on the rig for years. If any people knew this rig, they were Harrell, Bertone, and Ezell; they showed the VIPs around.

At 5:00 p.m., the rig crew, including toolpusher Wyman Wheeler, began the negative- pressure test.35 After bleeding pressure from the well, the crew would close it off to check whether the pressure within the drill pipe would remain steady. But the pressure repeatedly built back up. As the crew conducted the test, the drill shack grew crowded.36 The night crew began arriving to relieve the day shift, and Harrell brought the VIPs through as part of their tour.37

“There was quite a few people in there,” said Transocean’s Winslow. “I tapped Dewey Revette on the shoulder. He was the driller master. I said, ‘Hey, how’s it going, Dewey? You got everything under control here?’

“And he said, ‘Yes, sir.’

“And there seemed to be a discussion going on about some pressure or a negative test. And I said to Jimmy [Harrell] and Randy Ezell, ‘Looks like they’re having a discussion here. Maybe you could give them some assistance.’ And they happily agreed to that.”38 Bertone took over the tour, wandering on to look at the moon pool, down toward the pontoons and the thrusters.39

The two shifts continued to discuss how to proceed. It was about 6:00 p.m. Jason Anderson, a tool pusher, turned to Ezell and said, “Why don’t you go eat?”40

Ezell had originally planned to attend a meeting with the VIPs at 7:00 p.m. He replied, “I can go eat and come back.”41

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Anderson was from Bay City, Texas, and had been on the rig since it was built; he was highly respected as a man who understood the finer points of deepwater well control. This was his final shift on the Deepwater Horizon: he had been promoted to teaching in Transocean’s well-control school, and he was scheduled to fly out the next day. He told Ezell, “Man, you ain’t got to do that. I’ve got this. Don’t worry about it. If I have any problems at all with this test I’ll give you a call.”42

“I knew Jason well,” said Ezell, “I’ve worked with him for all those years, eight or nine years….He was just like a brother. So I had no doubt that if he had any indication of any problem or difficulty at all he would have called me. So I went ahead and ate. I did attend the meeting with the dignitaries.”43

Wheeler was “convinced that something wasn’t right,” recalled Christopher Pleasant, a subsea supervisor. Wheeler couldn’t believe the explanations he was hearing. But his shift was up.44

Don Vidrine, the company man coming on the evening shift, eventually said that another negative test had to be done.45 This time the crew members were able to get the pressure down to zero on a different pipe, the “kill line,” but still not for the drill pipe, which continued to show elevated pressure.46 According to BP witnesses, Anderson said he had seen this before and explained away the anomalous reading as the “bladder effect.”47 Whether for this reason or another, the men in the shack determined that no flow from the open kill line equaled a successful negative-pressure test.48* It was time to get on with the rest of the temporary abandonment process. Kaluza, his shift over, headed off duty.49

At 7:00 p.m., after dinner, the VIPs had gathered in the third floor conference room with the rig’s leadership. According to BP’s Patrick O’Bryan, the Deepwater Horizon was “the best performing rig that we had in our fleet and in the Gulf of Mexico. And I believe it was one of the top performing rigs in all the BP floater fleets from the standpoint of safety and drilling performance.” O’Bryan, at his new job just four months, was on board in part to learn what made the rig such a stand-out.50 Despite all the crew’s troubles with this latest well,51 they had not had a single “lost-time incident” in seven years of drilling.52

The Transocean managers discussed with their BP counterparts the backlog of rig maintenance. A September 2009 BP safety audit had produced a 30-page list of 390 items requiring 3,545 man-hours of work.53 The managers reviewed upcoming maintenance schedules and discussed efforts to reduce dropped objects and personal injuries: on a rig with cranes, multiple decks, and complicated heavy machinery, errant objects could be deadly.54

Around 9:00 p.m., Transocean’s Winslow proposed they all go visit the bridge, which had not been part of their earlier tour. According to David Sims, the bridge was “kind of an impressive place if you hadn’t been there…[l]ots of screens…lots of technology.”55 The four

* The precise content of this particular conversation is disputed and is considered more fully in Chapter 4.

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men walked outside. The Gulf air was warm and the water calm as glass. Beyond the glare of the rig’s lights, the night sky glimmered with stars.

* * * *

After concluding that the negative-pressure test was successful, the drilling crew prepared to set a cement plug56 deep in the well—3,000 feet below the top of the well. 57 They reopened the blowout preventer and began pumping seawater down the drill pipe to displace the mud and spacer* from the riser (the pipe that connected the rig to the well assembly on the seafloor below).58 When the spacer appeared up at the surface, they stopped pumping because the fluid had to be tested to make sure it was clean enough to dump it in the Gulf, now that it had journeyed down into the well and back. By 9:15 p.m., the crew began discharging the spacer overboard.59

* * * *

Inside the bridge, Captain Kuchta welcomed visitors Sims, O’Bryan, Trahan, and Winslow.60 The two dynamic-positioning officers, Yancy Keplinger and Andrea Fleytas, were also on the bridge.61 Keplinger was giving the visitors a tour of the bridge while Fleytas was at the desk station.62 The officers explained how the rig’s thrusters kept the Deepwater Horizon in place above the well, showed off the radars and current meters, and offered to let the visiting BP men try their hands at the rig’s dynamic-positioning video simulator.63

Winslow watched as the crew programmed in 70-knot winds and 30-foot seas, and hypothetically put two of the rig’s six thrusters out of commission. Then they put the simulator into manual mode and let Sims work the hand controls to maintain the rig’s location. Keplinger was advising about how much thrust to use. Winslow decided it was a good moment to go grab a quick cup of coffee and a smoke. He walked down to the rig’s smoking area, poured some coffee, and lit his cigarette.64

* * * *

Senior Toolpusher Randy Ezell left the evening meeting with BP feeling pleased at their praise “on how good a job we had done…How proud they were of the rig.” He stopped in at the galley to get a beverage before continuing to his office. At 9:20, he called Anderson up on the rig floor and asked, “‘How did your negative test go?’”65

Anderson: “It went good. . . . We bled it off. We watched it for 30 minutes and we had no flow.” Ezell: “What about your displacement? How’s it going?” Anderson: “It’s going fine. . . . It won’t be much longer and we ought to have our spacer back.”

* As described more fully in Chapter 4, a “spacer” is a liquid that separates drilling mud used during the drilling operations from the seawater that is pumped in to

displace the mud once drilling is complete.

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Ezell: “Do you need any help from me?” Anderson: “No, man. . . . I’ve got this. . . . Go to bed. I’ve got it.” Ezell concluded: “Okay.”66

Ezell walked to his cabin. He had worked with Anderson since the rig came from the shipyard. He had complete confidence in him. “Jason was very acute on what he did. . . he probably had more experience as far as shutting in for kicks than any individual on the Deepwater Horizon.” So Ezell prepared for bed, called his wife, and then turned off the lights to watch a bit of TV before going to sleep.67

* * * *

Up on the bridge, O’Bryan was taking his turn on the simulator.68 Sims had stepped to the opposite side of the bridge when he felt a distinct high-frequency vibration.69

Captain Kuchta looked up and remarked “What’s that?” He strode to the port-side door and opened it.70 Outside, O’Bryan could see the supply vessel Bankston glistening with what looked like drilling mud.71 The captain shut the door “and told everybody to stay inside.”72 Then there began a hissing noise.73

* * * *

BP’s Vidrine had headed back to his office to do paperwork. He had been there about 10 to 15 minutes when the phone rang. It was Anderson, who reported “they were getting mud back and were diverting to the gas buster.” Vidrine grabbed his hard hat and started for the drill floor. By the time he got outside, “[t]here was mud and seawater blowing everywhere, there was a mud film on the deck. I decided not to continue and came back across.”74

* * * *

Down in Ezell’s cabin, he was still watching TV when his phone rang. It was assistant driller Steve Curtis calling, also from the rig floor. “We have a situation. …The well is blown out. . . . We have mud going to the crown.” Ezell was horrified. “Do y’all have it shut in?”75

Curtis: “Jason is shutting it in now. . . Randy, we need your help.” Ezell: “Steve, I’ll be—I’ll be right there.”76

He put on his coveralls, pulled his socks on, and opened the door to go across the hall to his office for his boots and hard hat. Once in the hall, “a tremendous explosion... blew me probably 20 feet against a bulkhead, against the wall in that office. And I remember then that the lights went out, power went out. I could hear everything deathly calm.”77

* * * *

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Up on the main deck, gantry crane operator Micah Sandell was working with the roustabouts. “I seen mud shooting all the way up to the derrick. . . . Then it just quit. . . I took a deep breath thinking that ‘Oh, they got it under control.’ Then all the sudden the. . . mud started coming out of the degasser. . . so strong and so loud that it just filled up the whole back deck with a gassy smoke. . . loud enough. . . it’s like taking an air hose and sticking it in your ear. Then something exploded. . . that started the first fire...on the starboard side of the derrick.”78

Sandell jumped up and turned off the crane cab’s air conditioner, worried that the gas would come in. “And about that time everything in the back just exploded at one time. It. . . knocked me to the back of the cab. I fell to the floor. . . put my hands over my head and I just said, ‘No, God, no.’ Because I thought that was it.”79 Then the flames pulled back from his crane and began to shoot straight up, roaring up and over the 20-story derrick.80

* * * *

Down in the engine control room, Chief Mechanic Douglas Brown, an Army veteran employed by Transocean, was filling out the nightly log and equipment hours. He had spent the day fixing a saltwater pipe in one of the pontoons. First, he noticed an “extremely loud air leak sound.” Then a gas alarm sounded, followed by more and more alarms wailing. In the midst of that noise, Brown noticed someone over the radio. “I heard the captain or chief mate, I’m not sure who, make an announcement to the standby boat, the Bankston, saying we were in a well-control situation.”81 The vessel was ordered to back off to 500 meters. 82

Now Brown could hear the rig’s engines revving. “I heard them revving up higher and higher and higher. Next I was expecting the engine trips to take over. . . . That did not happen. After that the power went out.” Seconds later, an explosion ripped through the pitch-black control room, hurtling him against the control panel, blasting away the floor. Brown fell through into a subfloor full of cable trays and wires. A second huge explosion roared through, collapsing the ceiling on him. All around in the dark he could hear people screaming and crying for help.83

Dazed and buried in debris, he pulled himself out of the subfloor hole. In front of him appeared Mike Williams, chief electronic technician, blood pouring from a wound on his forehead, crawling over the rubble, screaming that he had to get out.84

* * * *

Steve Bertone, the rig’s chief engineer, had been in bed, reading the first sentence of his book, when he noticed an odd noise. “As it progressively got louder, it sounded like a freight train coming through my bedroom and then there was a thumping sound that consecutively got much faster and with each thump, I felt the rig actually shake.”85 After a loud boom, the lights went out.86 He leapt out of bed, opening his door to let in the emergency hall light so he could get dressed.87 The overhead public-address system crackled to life: “Fire. Fire. Fire.” 88

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The air smelled and tasted of some kind of fuel. A second explosion roared through, flinging Bertone across his room. He stood up, pulled on his coveralls, work boots, and hard hat, and grabbed a life vest. Out in the hall, clogged with debris from blown-out walls and ceilings, four or five men stood in shock. Bertone yelled to them to go out by the port forward or starboard forward spiral staircases and report to their emergency stations. He ran toward the bridge.89

He went to the portside back computer, the dynamic positioning system responsible for maintaining the rig’s position. “I observed that we had no engines, no thrusters, no power whatsoever. I picked up the phone which was right there and I tried calling extension 2268, which is the engine control room. There was no dial tone whatsoever.” It was then that Bertone looked out to the bridge’s starboard window. “I was fully expecting to see steel and pipe and everything on the rig floor.” “When I looked out the window, I saw fire from derrick leg to derrick leg and as high as I could see. At that point, I realized that we had just had a blowout.”90

Fleytas hit the general alarm.91 The alarm went off: “Report to emergency stations and lifeboats.” The rig crew heard: “This is not a drill. This is not a drill.”92 Fleytas, realizing that the rig had not yet issued a Mayday call, sent it out.93 Out in the dark of the Gulf, three friends on the 31-foot Ramblin’ Wreck were out on the water for a day of tuna fishing.94 Around 9:45 p.m., Bradley Shivers trained his binoculars at a brilliant light in the distance and realized it must be an oil rig on fire.95 On their radio, they heard, “Mayday, Mayday, Mayday, this is the Deepwater Horizon. We are on fire.”96 At that moment they “heard and felt a concussive sonic boom.”97 The Ramblin’ Wreck headed to the scene, their first tuna outing of the year cut short. 98

Bertone was now back to his station on the bridge, thinking, “The engines should be starting up because in approximately 25 to 30 seconds two engines start up, come online. . . . There was still no power of any kind. No engines starting; no indication of engines starting.”99

At that moment, the water-tight door to his left banged open and he heard someone say, “The engine room ECR [engine control room] and pump room are gone. They are all gone.” Bertone turned around, “What do you mean gone?” The man speaking was so coated in blood Bertone had no idea who he was. Then he recognized the voice. It was Mike Williams. Bertone saw how badly lacerated Williams’s forehead was, grabbed a roll of toilet paper from the bathroom, pressed it on the wound to staunch the bleeding, and ordered, “Hold this here.”100

Then he went back to his station and looked at his screen. “There was still nothing, no engines starting, no thrusters running, nothing. We were still [a] dead ship.”101

He heard the water-tight door slam again and saw another man soaked in blood, holding a rag to his head, repeating, “I’m hurt. I’m hurt bad, Chief. I’m hurt real bad.” It was the voice of Brent Mansfield, a Transocean marine engineer. Bertone pulled back Mansfield’s

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hand holding a rag, saw the head wound, and ran over to the bridge door and yelled down to the life-vessel area, “We need a medic up here now.”102

* * * *

After the explosion, Randy Ezell lay buried under the blown-out walls and ceilings of the toolpusher’s office. The room was dark and smoky, the debris atop him so heavy he could barely move. On the third try, adrenalin kicked in. “I told myself, ‘Either you get up or you’re going to lay here and die.’” Pulling hard on his right leg, he extricated it and tried to stand up. “That was the wrong thing to do because I immediately stuck my head into smoke. . . .I dropped back down. I got on my hands and knees and for a few moments I was totally disoriented.” He wondered which way the door was. He felt air. He crawled through the debris toward the door and realized the “air” was methane. He could feel the droplets. He was crawling slowly atop the rubble in the pitch-black hall when he felt a body.103

Ezell then saw a bobbing beam of light. Stan Carden, the electrical supervisor, came round the corner. Carden had a light that bounced off shattered walls and collapsed ceilings in the pitch-black corridor, giving glimpses into rooms on each side wrecked by the power of the blast.104 Stumbling into what was left of the hall was Offshore Installation Manager Jimmy Harrell, who had been in the shower when the rig exploded;105 he had donned coveralls, and now was groping his way out of what was left of his room. “I think I’ve got something in my eyes,” Harrell said. He had no shoes. “I got to see if I can find me some shoes.”106