Deepwater Horizon Case Slides

Deepwater Horizon Oil Spill:Figuring out the mess

Evan Harvey, Spenser Schwabe, Robert Slack, Brandon Swartwood, Katie White 1

Outline

1. Introduction

2. Phenotype Description

3. Genotype Description

4. Conclusion

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The Predecessor - Exxon Valdez

When and Where?

March 24, 1989

William Sound, Alaska

When?What Happened?

Exxon Valdez tanker struck a reef spilling 11 million gallons of crude oil

Results

Thousands of miles of pristine waters damaged killing marine mammals, fish, seabirds, etc.

$2.1 Billion in costs

Introduction Phenotype Genotype Conclusion 3

Exxon Valdez Recommendations

● Exxon Operations Integrity Management System (OIMS)○ Rigorous 11-point inspection designed to identify management and hazard risks○ Monitors, benchmarks, and measures aspects of safety performance

○ Since implementation Exxon has received 10/10 rating from GovernanceMetrics International


Deepwater Horizon Oil Rig

● $350 million to build by Transocean

● Cost $1 million per day to operate● Maiden voyage 2001● Backlog of rig maintenance● Deepwater Horizon rig replaces

previous Macondo well rig● Meant to be an exploratory vessel● Temporary Abandonment


Macondo Oil Well and BP

● Many modifications were being made due to increasing knowledge of the geologic features

● 6 weeks behind schedule● Over $58 million over budget


Outline

1. Introduction



4. Conclusion

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What Happened

April 20, 2010

● 11 crew died● Many injured● Over 4 million barrels of oil emptied into the Gulf


Lost Circulation Event

April 9, 2010

● Began to reach pay zone of hydrocarbon bearing rock● Pressure exerted by drilling exceeded strength of formation● Test were performed on the well● It was determined that at least 50 million barrels of oil and gas were present

and it was worth proceeding● Needed to prepare the well for further production by inserting either a casing

or liner


Long String Casing vs. LinerLong String Casing

● Single, continuous wall of steel that is cemented to formation

● Took less time to install● Original models showed that this could not

be cemented reliably so switched to liner

Liner

● Engineers often choose this option after circulation event

● More barriers to flow of gas up annular space

● Shorter string of casing, hangs lower in well, anchored next to higher string

● BP resisted this and had in-house engineers confirm Halliburton engineers conclusion

● Cost $7-$10 million more


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Centralizers on Long String Casing

● Centralizers help keep the drill pipe centered as casing is installed● BP design originally called for 16 or more centralizers● Halliburton engineers performed calculations and created models and

simulations that suggested at least 21 were needed○ Only had 6 on the rig

● Alternative option was to incorporate “slip on” centralizers but BP did not trust these

● BP’s team ignored Halliburton’s recommendations and only installed 6 centralizers for the sake of time


Centralizers (Cont.)

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Cementing Process

“Bottoms Up”

● Pump enough drilling mud to bring mud from the bottom of the well back to the top at the rig

● Test for presence of hydrocarbons before cementing● To completely circulate mud:

○ 6 - 12 hours○ 2,760 barrels

● BP finished in 30 minutes○ Only 350 barrels of mud


Cementing Process (Cont.)

Low pumping rate

● Pumped cement at low rate of 4 barrels per minute● Feared that increasing rate would increase risk of lost returns


Cementing Process (Cont.)

Low volume

● They limited amount of cement they pumped down well● More cement reduces risk of:

○ Contamination○ Errors in placement

● Only pumped 60 barrels of cement○ BP did not satisfy their own guidelines for the height of the cement column


Cement Bond Log

● Tests integrity of the cement job● BP elected to not perform this test

○ This occurred the morning of the explosion, 12 hours prior


Temporary Abandonment

● Remove Deepwater Horizon riser and blowout preventer● Procedures emailed to team the day that they would be performed


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Pressure Tests

Check integrity of well and make sure there are no leaks

● Positive Test○ Evaluates ability of casing in well to hold in pressure

● Negative Test○ Also checks integrity of casing○ Checks integrity of bottom hole cement job as well


Positive Pressure Test

● Similar to pumping air into a bike tire to see if it will leak● Pump fluids into well to build up pressure and see if it holds● Pumped in pressure at 250 psi

○ Held for 5 minutes

● Increased pressure to 2,500 psi○ Held for 30 minutes


Timeline

7:30AM Decision not to perform cement bond log test

10:43AM Temporary abandonment procedures sent to crew

12:00PM Positive pressure test

5:00PM Negative pressure test

12:00AM 10:00AM 5:00PM

12:40AM Cement job complete

7:00AM

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Negative Pressure Test

● Isolate well by replacing drilling mud with seawater because it exerts less pressure

○ Checks that hydrocarbons will not leak into well when the pressure is changed

● “Spacer” is pumped into well to separate mud from seawater○ Used a new spacer they weren’t familiar with and had not tested

● Negative pressure test is performed when mud is displaced above blowout preventer

● Pressure must stay at 0 psi after drill pipe is closed in order for it to be successful


Negative Pressure Test (Cont.)

● Drill pipe on rig is opened to release pressure from inserting the spacer

○ Pressure should reach 0 psi

● Pressure only reached 266 psi and then jumped to up to 1,260 psi

● Annular preventer leaking?



● Performed test a second time○ Pressure reached 0 psi but jumped back up when pipe was closed

● Third attempt → Same result● BP Wellsite Leader (Don Vidrine) insisted running test again while

monitoring the kill line○ Kill line pressure should be identical to drill pipe pressure



● Kill line pressure = 0 psi● Drill pipe pressure = 1,400 psi● Wellsite leaders and crew did NOT reconcile this discrepancy● Declared test a success


Timeline (Cont.)

Should have been monitoring for kicks

8:00PM BP concluded negative pressure tests success

8:02PM Annular preventer opened to begin displacing mud and spacer from riser

8:00PM

Crew had to reroute mud returning to rig to active pits

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Monitoring for Kicks

● Kicks are any unplanned influxes of gas or fluid● Monitor volume of mud flow to and from pits● Monitor volume of fluid to and from well● Monitor rate of flow of fluid in and out of well● Visual flow checks

○ Cameras setup to observe flow in and out of well

● Monitor drill pipe pressure

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Monitoring for Kicks (Cont.)

● 9:01 pm - Drill pipe pressure began increasing (red line)

● 9:08 pm - Pump turned off to perform “sheen” test but pressure kept increasing

● 9:14 pm - Pumps turned back on


Monitoring for Kicks (Cont.)● Pressure increase unnoticed until 9:30 pm● Crew tried to bleed off the pressure but it increased again● Began decreasing at 9:39 pm

○ This meant hydrocarbons were pushing up drilling mud, up casing and into well

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Timeline (Cont.)

9:40PM 9:45PM

Rerouted mud to diverter system rather than overboard, into sea

9:50PM

9:49PMEXPLOSION

9:40PM-9:43PMDrilling mud spewing on rig floor

9:41PM Closed annular preventer to shut in well but gas was already above BOP

9:46PM Attempted to activate blind shear ram

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http://www.youtube.com/watch?v=FCVCOWejlag

Outline

1. Introduction



4. Conclusion

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Root Causes

● Whitehouse Report○ “The root causes are systemic and, absent significant reform in both industry practices and

government policies, might well recur.”

● Robert Bea○ UC Berkeley Engineer

○ Worked on previous disasters: Nasa Columbia launch, Exxon Valdez, Hurricane Katrina levee break

○ “There is one common thread to these disasters. They are system disasters. They are caused by human and organizational malfunctions.”


Man-Made

Disaster Theory

Root Causes

1. Decision Making2. Organizational Culture3. Scheduling/Budget 4. Failures of Government to provide effective regulatory oversight 5. Communication issues


Decision Making

Decision to use Long String Casing after lost circulation event

● This design provided few barriers to gas flow● The liner would have taken extra time and cost $7 - $10 million more


Drift Toward Failure

Decision Making (Cont.)

● Halliburton models called for 21 centralizers● Halliburton informed BP that using only 6 centralizers could lead to “severe

gas flow problems”● Put cement job at risk for channeling to occur and leading to failure● BP team members decided to ignore these models and only install 6


Breakdown at Boundaries

Cognitive Tunneling

Decision Making (Cont.)● Gregory Walz gave go ahead to order additional centralizers● John Guide expressed in email he was not pleased with Walz’s decision

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Deference to ExpertiseFragmented

Problem Solving

Decision Making (Cont.)● Brian Morel and Brett Cocales also involved in decision to ignore Halliburton● BP did not want to waste time so only installed 6 centralizers

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Overconfidence Bias


Did NOT fully circulate the drilling mud

● Would allow them to test drilling mud for presence of gas, eliminate debris, and prevent contamination of the cement

● Up to 12 hours to complete

Decided NOT to perform cement bond log test

● Even after Halliburton warned them about potential gas flow problems● Would have taken 9 - 12 hours● Tested integrity of the cement seal




Decision to not install lockdown sleeve

● Only 2 barriers to gas flow○ Cement seal at bottom of well○ Seal at the wellhead at the seafloor

● Due to BP electing to install Single String Casing




Negative Pressure Test

● Assumed problem was with kill line● Failed to investigate discrepancy between kill line pressure and drill pipe

pressure● Declared test a success anyways


Lack of Sensitivity to Operations

No Preoccupation with Failure

Generating a Limited Number of

Hypotheses

Lack of Vigilance

Monitoring for kicks

● Monitor volume of mud flow● Monitor volume of fluid flow● Monitor rate of flow● Perform visual flow checks● Monitor pressure

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Displacing mud and spacer from riser

● Routing mud to active pitsAttention to

Limited Number of Cues

Alarm Sounding stuffs

Something about how crew tried to manually activate emergency disconnect system and light was on signifying that they had when in fact nothing happened

Automated system in BOP failed

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Kick Test Monitoring

● Individuals sit in front of the alarms for 12 hours at a time● Simultaneous activities and other monitoring responsibilities.

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Decisions were made that valued money over safety



Decision Making (cont.)

BP incidents in the Gulf of Mexico preceding the Deepwater Horizon accident

1996-2009

79 incidents

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Organizational Culture

● 46% of the crew surveyed reported felt that some of the workforce feared reprisals for reporting unsafe situations

Introduction Phenotype Genotype Conclusion

Pathological

Culture

48

Organizational Culture (cont.)

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Breakdown at Boundaries


Insert Bob Bea quote about how it’s similar to NASA’s culture… faster, better, etc



BP was criticized for neglecting to “address human performance issues and organizational factors which, in any major accident investigation, constitute major contributing factors,” He added that BP’s investigation also ignored factors such as fatigue, long shifts, and the company’s poor safety culture

- Najmedin Meshkati

Introduction Phenotype Genotype Conclusion

No Preoccupation

with Failure

51

Scheduling

As of April 20, BP and the Macondo well were almost six weeks behind schedule


Budget

More than $58 million over budget


Government Regulatory Failures


Poor Communication

● Transocean experienced a near miss eerily similar to the Deepwater Horizon incident four months prior in the North Sea

● Mud spewed onto the rig floor, but crew was able to seal the well before a blowout occurred

● PowerPoint and advisory were created to require standard well control but neither made it to Deepwater Horizon

● Had the rig crew known about this incident and had been trained, events at Macondo could have turned out very differently


Lack of communication between management and crew


Swiss Cheese Model

Holes:

● Well casing● Centralizers● No further tests on foam cement● Not completing “Bottoms Up” process● Not completing cement bond log test● Missed kick detection● Blind shear ram failure due to pipe buckling● Overlooking models● Time pressures

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Sequence of Events Model

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Aftermath of the accident

● Spilled for 87 days● Estimated 210,000,000 gallons of oil spilled● Impacted 68,000 square miles of ocean● More than 8,000 birds, sea turtles, and marine mammals found injured or

dead within 6 months after the spill● 16,000 miles of coastline affected● Cost BP up to $60 billion in legal and cleanup ● July 15, 2010 BP says oil spill has stopped

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Effects on Environment

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Effects on Surrounding Businesses

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Resulting Costs

● Estimate of $32 billion to cover cleanup, legal costs, fines, and other costs○ $14 billion to contain and clean up the spill○ $5.4 billion to settle 60,800 claims to date with individuals and business affected by the spill

○ $4 billion for criminal penalties and fines, including payments to the National Fish and Wildlife Foundation

○ $525 million to settle civil charges with the S.E.C that it misled investors about the flow rate of oil from the well during the spill

○ $236 million to revitalize tourism in Gulf Coast states

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Results of court proceedings?

•A federal grand jury returned an indictment charging the two highest-ranking BP supervisors on board the Deepwater Horizon on the day of the explosion with 23 criminal counts•The two men were charged with seaman’s manslaughter and involuntary manslaughter for each of the 11 men killed•Also charged of criminal violation of the clean water act

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Legal changes

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Recommendations

Just some ideas:

● Redundancy● De-coupling● New leadership

○ Organizational decision making○ Stress safety!

● Simulation training● Coordination between technical expertise and authority

○ Managers, contractors, and crew

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Documents

Deepwater Horizon Case Slides