The BP internal investigation team did not identify any single action or inaction that caused this accident; it was rather a complex and interlinked series of mechanical failures, human judgments, engineering design, operational implementation and team interfaces that came together to allow the initiation and escalation of the accident. Multiple companies, work teams and circumstances were involved over time. A series of recommendations were developed by the internal investigation team to address each of the key findings and to enable the prevention of similar accidents in the future. These recommendations are summarised as follows:
Implementation of Drilling and Well Operations Practice and Operating Management System
1. Procedures and Engineering Technical Practices
a. Review current practices to ensure that a clear and comprehensive set of cementing guidelines and associated Engineering Technical Practices (ETPs) are available as controlled standards.
b. Review ETP covering well control to clarify requirements for subsea blowout preventer (BOP) configuration
c. Update technical practices to consider load conditions for negative-pressure tests in the casing design assessment for subsea wells and to standardize the installation of the locking mechanism of the casing hanger seal assembly to the high-pressure housing for subsea wellheads.
d. Review ETP covering work with pressure to include negative pressure testing.
e. Clarify standards for well control and well integrity incident reporting and investigation. Ensure that all incidents are rigorously investigated and that close-outs of corrective actions are completed effectively.
f. Propose to the American Petroleum Institute the development of a recommended practice for the design and testing of foam cement slurries in high-pressure, high-temperature applications.
g. Review the consistency, rigor and effectiveness of the current risk management and management of change (MOC) processes practiced by Drilling and Completions (D&C)
2. Capability and Competency
a. Reassess the Technical Authority’s (TA) role in the areas of cementing and zonal isolation. Ensure adequate TA coverage to support all the D&C global operations.
b. Enhance D&C competency programs to deepen the capabilities of personnel in key operational and leadership positions and augment existing knowledge and proficiency in managing deepwater drilling and wells operations.
c. Develop an advanced deepwater well control training program that supplements current industry and regulatory training. Training outcomes would be the development of greater response capability and a deeper understanding of the unique well control conditions that exist in deepwater drilling.
d. Establish BP's in-house expertise in the areas of subsea BOPs and BOP control systems through the creation of a central expert team, including a defined segment engineering technical authority (SETA) role to provide independent assurance of the integrity of drilling contractors' BOPs and BOP control systems. A formalized set of authorities and accountabilities for the SETA role should be defined.
e. Request that the International Association of Drilling Contractors review and consider the need to develop a program for formal subsea engineering certification of personnel who are responsible for the maintenance and modification of deepwater BOPs and control systems
3. Audit and Verification
a. Strengthen BP's rig audit process to improve the closure and verification of audit findings and actions across BP-owned and BP-contracted drilling rigs.
4. Process Safety Performance Management
a. Establish D&C leading and lagging indicators for well integrity, well control and rig safety critical equipment.
b. Require drilling con tractors to implement an auditable integrity monitoring system to continuously assess and improve the integrity performance of well control equipment against a set of established leading and lagging indicators.
Contractor and Service Provider Oversight and Assurance
1. Cementing Services Assurance
a. Conduct an immediate review of the quality of the services provided by all cementing service providers. Confirm that adequate oversight and controls are in place within the service provider's organization and BP.
2. Well Control Practices
a. Assess and confirm that essential well control and well monitoring practices, such as well monitoring and shut-in procedures, are clearly defined and rigorously applied on all BP-owned and BP-contracted offshore rigs (consider extending to selected onshore rigs such as those for high-pressure, high-temperature, extended reach drilling IERDJ and sour service applications).
3. Rig Process Safety
a. Require hazard and operability (HAZOP) reviews of the surface gas and drilling fluid systems for all BP-owned and BP-contracted drilling rigs. Include a HAZOP review as an explicit check for rig acceptance and rig audit. Phase 1 should address offshore rigs. Phase 2 should address selected onshore rigs such as those for high-pressure, high-temperature, ERD and sour services applications.
b. Include in the HAZOP reviews a study of all surface system hydrocarbon vents, reviewing suitability of location and design.
4. BOP Design and Assurance
a. Establish minimum levels of redundancy and reliability for BP's BOP systems. Require drilling contractors to implement an auditable risk management process to ensure that their BOP systems are operated above these minimum levels.
b. Strengthen BP's minimum requirements for drilling contractors' BOP testing, including emergency systems.
c. Strengthen BP's minimum requirements for drilling contractors' BOP maintenance management systems.
d. Define BP's minimum requirements for drilling contractors' MOCs for subsea BOPs.
e. Develop a clear plan for ROV intervention (independent of the rig-based ROV) as part of the emergency BOP operations in each of BP's operating regions, including all emergency options for shearing pipe and sealing the wellbore.
f. Require drilling contractors to implement a qualification process to verify that shearing performance capability of BSRs is compatible with the inherent variations in wall thickness, material strength and toughness of the rig drill pipe inventory.
g. Include testing and verification of conformance with above Recommendations in the rig audit process.