Study Group Report Amounts to an Indictment: BP Was “Geared Toward a Trip-and-Fall Compliance Mentality”


With relatively little fanfare, a key independent oil spill study group has filed its “final” report – a riveting, meticulously detailed account of what most likely went wrong on the Deepwater Horizon rig and an indictment of the attitudes and industrial cultures identified as the fundamental cause of the disaster.

While it’s not part of the technical analysis, it’s indicative of the “Deepwater Horizon Study Group” (DHSG) sensitivities that the report begins with “in memorial” pages to both the people who lost their lives last April and to “the environment.” BP could learn a thing or two there – remember when CEO Robert Dudley recently apologized, he said “sorry” to the industry, not the families of the workers or the people of the Gulf who’ve had their lives turned upside down. A bunch of classy guys, those BP execs.

The DHSG was formed last May by the Center for Catastrophic Risk Management at the University of California, Berkeley. The DHSG is “…an international group (64 members) of experienced professionals, experts, and scholars who have extensive experience in offshore oil and gas facilities and operations, drilling and reservoir engineering, geology, accident investigations, management, organizational behavior, government regulatory affairs, legislative-legal processes, marine ecology and environmental science, and risk assessment and management.”

The study group’s latest report notes:

…available evidence indicates the Macondo well blowout most probably was initiated with a breach in the well structure at its bottom — some 18,000 ft below the sea surface and approximately 13,000 ft below the seafloor. The Deepwater Horizon drill crew was in the final hours of preparing the well for later production and for temporary abandonment.

Undetected, a large quantity of hydrocarbons entered the bottom of the well as it was being prepared for temporary abandonment. Multiple tests failed to disclose the breach or the ingress of hydrocarbons into the well. Due to the displacement inside the well of the upper 8,300 ft of heavy drilling fluids with lighter seawater, there were large reductions in pressures inside the well that allowed substantial quantities of gases to evolve from the hydrocarbons.

But the tick-tock of the mechanical process is perhaps less interesting than the root organizational causes outlined by the DHSG, which says:

…while this particular disaster involves a particular group of organizations, the roots of the disaster transcend this group of organizations. This disaster involves an international industry and its governance.

This disaster was preventable if existing progressive guidelines and practices had been followed — the Best Available and Safest Technology. BP’s organizations and operating teams did not possess a functional Safety Culture. Their system was not propelled toward the goal of maximum safety in all of its manifestations but was rather geared toward a trip-and-fall compliance mentality rather than being focused on the Big-Picture.

The report notes that the industry cannot possibly be expected to police itself, asserting that: “…a capable and productive industry needs equally capable and productive government — governance. It is clear that the predecessor of the Department of Interior’s Bureau of Ocean Energy Management, Regulation and Enforcement (BOEMRE), the U.S. Minerals Management Service (MMS) was not able to keep abreast of developments associated with ultra hazardous hydrocarbon exploration and production projects.”

In short, along with detailed timelines and reviews, the group says that such deep-water drilling can be done with acceptable risks only if the actual culture improves.

The final report and other documents can be found at:

Documents the group developed during the investigation are available for search and downloading at:

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Stuart H. Smith is an attorney based in New Orleans fighting major oil companies and other polluters.
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