BP 2010 Annual Report Download - page 39
Download and view the complete annual report
Please find page 39 of the 2010 BP annual report below. You can navigate through the pages in the report by either clicking on the pages listed below, or by using the keyword search tool below to find specific information within the annual report.
Businessreview
Business review
Internalinvestigationandreport
BP’sinvestigationfoundthatnosinglefactorcausedtheMacondowell
tragedy;rather,itconcludedthatdecisionsmadeby‘multiplecompanies
andworkteams’contributedtotheaccidentwhicharosefrom‘acomplex
andinterlinkedseriesofmechanicalfailures,humanjudgments,
engineeringdesign,operationalimplementationandteaminterfaces.’
Thereport–basedonafour-monthinvestigationledbyBP’shead
ofSafetyandOperationsandconductedindependentlybyateamofover
50technicalandotherspecialistsdrawnfrominsideBPandexternally–
foundthat:
• Theannuluscementbarrier–andinparticularthecementslurrythat
wasused–atthebottomoftheMacondowellfailedtocontain
hydrocarbonswithinthereservoir,asitwasdesignedtodo.The
annuluscementprobablyexperiencednitrogenbreakoutandmigration,
allowinggasandliquidstoenterthewellboreannulus.Theinvestigation
teamconcludedthattherewereweaknessesincementdesignand
testing,qualityassuranceandriskassessment.
• TheshoetrackbarriersatthebottomoftheMacondowellfailedto
containhydrocarbonsastheyweredesignedtodo,allowing
hydrocarbonstoowuptheproductioncasing.Theshoetrackbarriers
consistedoftwobarriersintheshoetrack:thecementintheshoe
trackandtheoatcollar.BP’sinvestigationteamidentiedanumberof
potentialfailuremodesthatcouldexplainhowboththeshoetrack
cementandtheoatcollarallowedhydrocarboningressintothe
productioncasing,buthasnotdeterminedwhichofthesefailure
modesoccurred.
• Theresultsofthenegativepressuretestwereincorrectlyacceptedby
BPandTransocean,althoughwellintegrityhadnotbeenestablished.
• Overa40-minuteperiod,theTransoceanrigcrewfailedtorecognize
andactontheinuxofhydrocarbonsintothewelluntilthe
hydrocarbonshadpassedthroughtheBOPandintotheriserandwere
rapidlyowingtothesurface.
• Wellcontrolresponseactionsfailedtoregaincontrolofthewell.The
rstwellcontrolactionsweretoclosetheBOPanddiverter,routing
theuidsexitingtherisertoamudgasseparatorratherthantothe
overboarddiverterline.Ifuidshadbeendivertedoverboard,rather
thantothemudgasseparator,theremayhavebeenmoretime
torespond,andtheconsequencesoftheaccidentmayhave
beenreduced.
• Diversionofthehydrocarbonstothemudgasseparatorresultedingas
ventingontotherig.Thedesignofthemudgasseparatorsystem
alloweddiversionoftherisercontentstothemudgasseparatorvessel
althoughthewellwasinahigh-owcondition.Thisoverwhelmedthe
mudgasseparatorsystem,resultingingasventingontotherig.This
increasedthepotentialforthegastoreachanignitionsource.
• Theowofgasintotheengineroomsthroughtheventilationsystem
createdapotentialforignitionthattherig’sreandgassystemdid
notprevent.
• Evenaftertheexplosionandrehaddisableditscrew-operated
controls,therig’sBOPontheseabedshouldhaveactivated
automaticallytosealthewell.Butitfailedtooperate,probablybecause
criticalcomponentswerenotworking.Throughareviewofrigaudit
ndingsandmaintenancerecords,theinvestigationteamfound
indicationsofpotentialweaknessesinthetestingregimeand
maintenancemanagementsystemfortheBOP.
Theinvestigationteamdevelopedaseriesofrecommendationsbasedon
theabovendings.Theserecommendationscovercontractoroversightand
assurance,riskassessment,wellmonitoringandwell-controlpractices,
integritytestingpracticesandBOPsystemmaintenance.Thereportmakes
thefollowingrecommendations,amongothers:
Procedures and engineering technical practices
• Updateandclarifycurrentpracticestoensurethataclearand
comprehensivesetofcementingguidelinesandassociatedEngineering
TechnicalPractices(ETPs)areavailableascontrolledstandards.
• ReviewandupdaterequirementsforsubseaBOPconguration.
• Updatetherelevanttechnicalpracticestoincorporatecertainimproved
designrequirementsforsubseawellheads.
• ReviewandupdateETPsregardingnegative-pressuretesting.
• Clarifyandstrengthenstandardsforwell-controlandwell-integrity
incidentreportingandinvestigation.
• ProposetotheAmericanPetroleumInstitutethedevelopmentofa
recommendedpracticefordesignandtestingoffoamcementslurries
inhigh-pressure,high-temperatureapplications.
• Reviewandassesstheconsistency,rigourandeffectivenessofthe
currentriskmanagementandmanagementofchangeprocesses
practisedbyDrillingandCompletions(D&C).
Capability and competency
• Reassessandstrengthenthecurrenttechnicalauthority’sroleinthe
areasofcementingandzonalisolation.
• EnhanceD&Ccompetencyprogrammestodeepenthecapabilitiesof
personnelinkeyoperationalandleadershippositionsandaugment
existingknowledgeandprociencyinmanagingdeepwaterdrilling
andwells.
• Developanadvanceddeepwaterwell-controltrainingprogrammethat
supplementscurrentindustryandregulatorytrainingandembeds
lessonslearnedfromtheGulfofMexicoincident.
• EstablishBP’sin-houseexpertiseintheareasofsubseaBOPsandBOP
controlsystemsthroughthecreationofacentralexpertteam,including
adenedsegmentengineeringtechnicalauthorityroletoprovide
independentassuranceoftheintegrityofdrillingcontractors’BOPsand
BOPcontrolsystems.
• RequestthattheInternationalAssociationofDrillingContractorsreview
andconsidertheneedtodevelopaprogrammeforformalsubsea
engineeringcerticationofpersonnelwhoareresponsibleforthe
maintenanceandmodicationofdeepwaterBOPsandcontrolsystems.
Audit and verication
• StrengthenBP’srigauditprocesstoimprovetheclosureand
vericationofauditndingsandactionsacrossBP-ownedand
BP-contracteddrillingrigs.
Process safety performance management
• EstablishD&Cleadingandlaggingindicatorsforwellintegrity,well
controlandrigsafetycriticalequipment.
• Requiredrillingcontractorstoimplementanauditableintegrity
monitoringsystemtocontinuouslyassessandimprovetheintegrity
performanceofwell-controlequipmentagainstasetofestablished
leadingandlaggingindicators.
Cementing services assurance
• Conductanimmediatereviewofthequalityoftheservicesprovidedby
allcementingserviceproviders.Conrmthatadequateoversightand
controlsareinplacewithintheserviceprovider’sorganizationandBP.
Well-control practices
• Assessandconrmthatessentialwell-controlandwell-monitoring
practices,suchaswellmonitoringandshut-inprocedures,areclearly
denedandrigorouslyappliedonallBP-ownedandBP-contracted
offshorerigs.
BPAnnualReportandForm20-F2010 37