Internal medicine training programs in hospitals have what are called morbidity and mortality conferences—known as M&Ms. The reviews usually take place after unexpectedly poor patient outcomes—like deaths, for instance—and investigate what medical errors might have been made that contributed to the failure. M&Ms are dreaded by medical residents—imagine the worst job review you’ve ever had, times a thousand—but they’re a necessary part of a doctor’s education. The only way to ensure a mistake isn’t repeated is to ensure that you know why it happened in the first place.
That was the task of the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, a panel of independent experts appointed by the President with the task of figuring out just what went wrong on that drilling rig on April 20, leading to a disaster that spilled some 4 million barrels of oil into the Gulf of Mexico. After months of work, the panel has finished its final report, which will be released next week, but today the commission published an advance chapter that focuses on the immediate mistakes aboard the Deepwater Horizon in the days and weeks before the accident. (Download a PDF of the chapter here.) The result is a laundry list of errors by, both large and small, in the weeks leading up to the explosion, by both BP (which owned the rig, though it didn’t directly control the drilling) and Halliburton (the energy services company responsible for cementing the well). But more than that, the commission found that there were root failures—by both industry and by government regulators—that ultimately made an avoidable accident all but inevitable. As the report concluded:
The blowout was not the product of a series of aberrational decisions made by rogue industry or government officials that could not have been anticipated or expected to occur again. Rather, the root causes are systemic and, absent significant reform in both industry practices and government policies, might well recur.
The panel didn’t attempt to assign blame for the accident to specific companies or individuals; indeed, given the sheer number of things that went wrong aboard the Deepwater Horizon, we’ll never know exactly what might have been the final cause. But there’s no shortage of candidates, as the report details:
- BP decided to long string design in its well casing, which increased the difficulty of obtaining a reliable cementing job on the well—which was one of the primary causes of the Macondo well blowout.
- BP decided to use only six centralizers on its string, when safety would have called for using an additional 15.
- Halliburton never told BP that tests of the foam cement slurry that would be used on the final stages of the drilling process indicated that the mixture was unstable, and never reviewed the data itself. In fact, Halliburton personnel appeared to have modified the conditions of the test to assure that they would obtain a successful outcome, rather than fixing the mixture. As the report records: “If true, Halliburton pumped foam cement into the well at a time when all available test data showed the cement would be, in fact, unstable.”
- BP’s engineering team did not appear to conduct a formal, disciplined risk analysis on the final cementing jobs—despite mounting evidence of problems with the well.
- Personnel aboard the Deepwater Horizon failed to respond to a number of signs that a well blowout was imminent until it was too late.
- There were repeated communication failures between BP, Halliburton and Transocean (the company that ran the rig)—and within those companies as well. Data that could have revealed serious threats to the rig never made it to the right personnel.
But those are just the immediate causes. Deeper—and more worrying—are the root failures of industry and government that the report highlights:
The most significant failure at Macondo—and the clear root cause of the blowout—was a failure of industry management. Most, if not all, of the failures at Macondo can be traced back to underlying failures of management and communication. Better management of decisionmaking processes within BP and other companies, better communication within and between BP and its contractors, and effective training of key engineering and rig personnel would have prevented the Macondo incident. BP and other operators must have effective systems in place for integrating the various corporate cultures, internal procedures, and decisionmaking protocols of the many different contractors involved in drilling a deepwater well.
The commission’s report also notes in detail that—purposefully or not—nearly every one of the decisions made by BP, Halliburton and Transocean saved those companies time and money. And what’s scarier is that under the existing regulations, nearly all of those cost-cutting decisions were perfectly legal—indicating that the Deepwater Horizon was a regulatory failure as well. Unless systematic changes are made in the way the country drills for oil and gas—and regulates that practice—this could happen again:
Notwithstanding [the risks of drilling], the accident of April 20 was avoidable. It resulted from clear mistakes made in the first instance by BP, Halliburton, and Transocean, and by government officials who, relying too much on industry’s assertions of the safety of their operations, failed to create and apply a program of regulatory oversight that would have properly minimized the risks of deepwater drilling. It is now clear that both industry and government need to reassess and change business practices to minimize the risks of such drilling.
With a Republican-controlled House looking to free business from regulation—including the oil and gas industry—that reformation will only get harder. But the commission report should remind us—just in case we’ve forgotten—that those changes may be a matter of life or death. That’s something any student doctor could tell you.