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There are a few possibleexplanationsfor why the crew did neither: . First, they may not have recognizedthe severity of the situation, though that seems unlikely given th amount of mud that spewdfiom the rig floor. Second,they did not have much time to act. The explosion occurred roughly six to ight minutes after mud first emergedonto the rig floor Finalll., and perhapsmost significantly, the rig crew had not been trained adequately how to respond to such an emergencysituation. In the future, well-control training should include simulations and drills for such emergencies-inciuding the momentous decisionto engagethe blind shear rams or trigger the EDS

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The Root Causes: Failures in lndustry and Government Overarching Management Failures Industry by
Whatevcr irreducible uncertainty may persist regarding the precisecontribution to the blowout of eachof sweral potentially immediate causes,no such uncertainty exists about the blowout's root causes.The blowout was not the product of a seriesof aberrational decisionsmade by rogue industry or government officials that cor.rldnot hav been anticipated or er?ectedto occur again. Rather,the root causesare systemic and, absent significant reform in both industry practicesand government policies,might well rcur The misstepswere rooted in systemic failures by industry managemmt (extendingbeyond BP to contractors that servemany in the industry), and also by failures of government to providceffective reguldtoryoversightoI offshoredrilling The most significant failure at Macondo and the clear rool causeof th blowout-was a failure of industry management Most, if not ail, of the failures at Macondo can be traced back lo r.rnderlyingfailures of managemcnt and communication. Better management of within RP and other companies,better communication within decisionmakingprocesses and between BP and its contractors, and efTective training of key engineeringand rig personnelwould have preventcdthe Macondo incident. BP and other operators must have effectivesystems in place for integrating the various corporate cLrltures,internal procedures,and decisionmakingprotocols of the many different contractors involved in drilling a deepwaterwell. RP .r DtanagcnitntIt (rL'cs,; Dt)tarhqrntct' idctrtity ot addrcss ri;ks ct catctl by latc diLl .lnDges to wdl dtsigu tltd prot edr/ftr. BP did not have adequatecontrols in place to ensur that key decisionsin the months leading up to the blowout were safeor sound from an engineeringperspective. While initial well design decisionsundergo a serious peerrwiew processr'5and changesto wll design are subsequently srrbjectto a management of change (MOC) process,rs6 changesto drilling procduresin the weeks and days before implementation are typically 1?r)tsubjct any such peer-reviewor MOC process At to Macondo, such decisionsappear to have been made by the BP Macondo team in ad hrrr-

fashion without any formal risk analysis or internal expert review.rsT This appearsto have beena key causal factor of the blowout. A few obvious e\amples, such as the last-minute confusion regarding whether to run six or 21 centralizers,hawealready been highlighted Another clear example is provided by the temporary abandonment procedureused at Macondo. As discussed earlier,that procedure changeddramatically and repeatedlyduring the week leading up to the blowout. As of April 12, the plan was to set the cement plug in seawaterless than l,OOOfeet below the mud line after setting the lockdown slewe. 1i,vodays latet Morel sent an e rnail in which the procedurewas to set th cement plug in mud before displacing the riser with seawater By April 20, the plan had morphd into the one set forth in the "Ops Note"r the crw would remove 3,300 feet of mud from below the mud line and set the cement plug after the riser had beendisplaced. There is no readily discerniblereasonwhy these temporary abandonment procedurescould not have been more thoroughly and rigorously vetted earlier in the design process.rs3 lt does not appear that the changesio the temporary abandonmnt procedureswent through any sort of formal review at all. jlallibtD'ton and Bl>'s t:nar'tagrruttit pr(rr'c-slrs rrrrf clsrt-!: th,lt rctlicnt r,'a5 a.lcquatclv drd tc-rLJ. Halliburton had insufficient controls in place to ensurethat laboratory testing was performed in a timely fashion or that test results were vetted rigorously in-house or with the client. In fact, it appearsthat Halliburton did not evn have testing results in its possession showing the Macondo slurry was stable until allcr thejob had beenpumped. It is difficult to imagine a clearerfailure of management or communication. The story of the foam stability tests may illuminate management problems within BPas well. By early April, BP team members had recognizedthe importance of timely cement testing.r5! Ar.rdby mid-April, BP's team had identified conccrns regarding the timeliness of Halliburton's testing processr'r' But despitetheir recognition that final changesto the cement design (made to accommodatetheir concernsabout lost returns) might increasethe risks of foam instability,r6r BP personncl do not appar to have insisted that Ilalliburton complete its foam stability tsts-let alone rport the rsults to BP for review-before ordcringprimdry ccmentingto hcgin BI n.1r1soccttt, and HalliburtoD Ltil*l to t'tttt ttutictttc adcqrlattlJ:.Information appearsto have been sxcessively compartmentalized at Macondo as a rcsult of poor communication BP did not sharimportant information rvith its contractors, or sometimesinternally even with members of its own team. Contractors did not share important information with BP or eachothr. As a result, individuals often Found themselvesmaking critical decisions without a full appreciation for the context in u/hich they were being made (or even without recognition that the decisions n,c.rc critical). For example,many BP and Halliburton employeeswere aware of the difficulty of the primary cementjob. But those issueswere for the most part n()t communicated to the rig crew that conductedthe negative-pressure test and monitored the well. It appearsthat