CONTACTS 

SUBJECTS
Little Inconsequential Details Case Study Have Major Impact on Perfo

0503 -
0503 -    ..
0504 - Summary/Objective
0505 -
050501 - Follow up
050502 -
050503 -
050504 -
050505 -
050507 -  ..
0506 -
0507 -
0508 - Progress
0509 -
050901 - Ignoring Little Mistakes Multiplies into Catastrophy
050902 -
050903 - British Petroleum oil rig, the Deepwater Horizon, exploded in the Gulf
050904 - of Mexico, causing loss of life, billions of dollars in loss of
050905 - property, loss of energy production, and severe environmental damage
050906 - due to a very little bubble of gas that excaped at the bottom of the
050907 - well, and multiplied over the distance of 1 mile into catastrophy at
050908 - the surface. ref SDS 0 T56K
050910 -  ..
050911 - Case study shows BP's catastrophy from ignoring a very small mistake,
050912 - reflects Aristotle's rule that the least deviation in the beginning is
050913 - multipled later a thousand times, reviewed in NWO. ref OF 10 JV3G
050915 -         ..
050916 -    1.  Space shuttle Challenger explodes on
050917 -        take-off because defective
050918 -        Thiokol O ring joint
050919 -        seals................................ 921021 0800, ref SDS 1 4499
050921 -         ..
050922 -    2.  Oil tanker lost at sea due to small change
050923 -        in specifications to expedite work
050924 -        and save money....................... 940611 0838, ref SDS 2 8239
050926 -         ..
050927 -    3.  World Trade Center bombed by terrorists on
050928 -        930226 causing 6 deaths, thousands injured,
050929 -        and $500M in property damage; HBO movie
050930 -        dramatized FBI management would not pay
050931 -        $500 for informant, Salem, and ignored
050932 -        intelligence rather than take
050933 -        action in time to prevent
050934 -        calamity............................. 980423 2123, ref SDS 3 MV6L
050935 -        HBO movie dramatized terrorists
050936 -        threat in 1993, that "Next time
050937 -        we'll bring them both
050938 -        down"................................ 980423 2123, ref SDS 3 L75L
050940 -         ..
050941 -    4.  Health care medical mistakes 300% worse than
050942 -        automobile, airplane, train deaths because
050943 -        correcting small communication mistakes
050944 -        seems like unnecessary overkill
050945 -        until somebody gets
050946 -        killed............................... 990912 0926, ref SDS 4 0001
050948 -         ..
050949 -    5.  Mars landing exploded into $200M loss
050950 -        because little deviation in trajectory
050951 -        multiplied into huge
050952 -        mistake.............................. 991001 1657, ref SDS 5 0001
050954 -         ..
050955 -    6.  Wheels with small wobble from slight error
050956 -        in bolt specifications create small vibration
050957 -        that nobody sees nor feels for many trips
050958 -        over thousands of miles at high speed
050959 -        eventually causes disaterous
050960 -        train wreck.......................... 010725 1217, ref SDS 6 HF4L
050962 -         ..
050963 -    7.  World Trade Center destroyed by terrorist
050964 -        attacks over 2,000 killed, $200 billion
050965 -        property damage, because small intelligence
050966 -        mistakes added up to collosal
050967 -        failure.............................. 010911 1304, ref SDS 7 I64N
050969 -         ..
050970 -    8.  Space Shuttle Columbia explodes on re-entry
050971 -        from space of minor loss of insulation
050972 -        foam on external fuel
050973 -        tank................................. 030201 1656, ref SDS 8 0001
050975 -         ..
050976 -    9.  BP oil rig Deepwater Horizon explodes causing
050977 -        loss of life, $billions of property, energy
050978 -        production, environmental damage because
050979 -        small bubble of gas at bottom of the
050980 -        well multiplied into huge
050981 -        calamity at surface.................. 100508 0801, ref SDS 0 T56K
050982 -
050983 -
050984 -
050985 -
050986 -
0510 -

SUBJECTS
BP Oil Rig Deepwater Horizon Owner Transocean Offshore Drilling Plat

0703 -
070401 -  ..
070402 - Deepwater Horizon Exploded Small Gas Bubble Got Really Big
070403 -
070404 - Reuters reports today interviews with members of the crew on the BP
070405 - oil rig, Deepwater Horizon, that exploded 100420...
070406 -
070407 -    1.  APNewsBreak: Bubble of methane triggered rig blast
070409 -         ..
070410 -        May 8, 2010
070411 -
070412 -              http://news.yahoo.com/s/ap/20100508/ap_on_bi_ge/us_gulf_oil_spill;_ylt=A2KIKvyaeeVL8tEAdyes0NUE;_ylu=X3oDMTNocmU4cWJtBGFzc2V
070414 -         ..
070415 -    2.  By NOAKI SCHWARTZ and HARRY R. WEBER,
070416 -        Associated Press Writers Noaki Schwartz
070417 -        And Harry R. Weber, Associated Press Writers 1 min ago
070419 -         ..
070420 -    3.  ON THE GULF OF MEXICO - The deadly blowout of an oil rig in the
070421 -        Gulf of Mexico was triggered by a bubble of methane gas that
070422 -        escaped from the well and shot up the drill column, expanding
070423 -        quickly as it burst through several seals and barriers before
070424 -        exploding, according to interviews with rig workers conducted
070425 -        during BP's internal investigation.
070427 -         ..
070428 -    4.  While the cause of the explosion is still under investigation,
070429 -        the sequence of events described in the interviews provides the
070430 -        most detailed account of the April 20 blast that killed 11
070431 -        workers and touched off the underwater gusher that has poured
070432 -        more than 3 million gallons of crude into the Gulf.
070434 -         ..
070435 -    5.  Portions of the interviews, two written and one taped, were
070436 -        described in detail to an Associated Press reporter by Robert
070437 -        Bea, a University of California Berkeley engineering professor
070438 -        who serves on a National Academy of Engineering panel on oil
070439 -        pipeline safety and worked for BP PLC as a risk assessment
070440 -        consultant during the 1990s. He received them from industry
070441 -        friends seeking his expert opinion.
070443 -         ..
070444 -    6.  A group of BP executives were on board the Deepwater Horizon
070445 -        rig celebrating the project's safety record, according to the
070446 -        transcripts.  Meanwhile, far below, the rig was being converted
070447 -        from an exploration well to a production well.
070449 -         ..
070450 -    7.  Based on the interviews, Bea believes that the workers set and
070451 -        then tested a cement seal at the bottom of the well.  Then they
070452 -        reduced the pressure in the drill column and attempted to set a
070453 -        second seal below the sea floor.  A chemical reaction caused by
070454 -        the setting cement created heat and a gas bubble which
070455 -        destroyed the seal.
070457 -         ..
070458 -    8.  Deep beneath the seafloor, methane is in a slushy, crystalline
070459 -        form.  Deep sea oil drillers often encounter pockets of methane
070460 -        crystals as they dig into the earth.
070462 -         ..
070463 -    9.  As the bubble rose up the drill column from the high-pressure
070464 -        environs of the deep to the less pressurized shallows, it
070465 -        intensified and grew, breaking through various safety barriers,
070466 -        Bea said.
070468 -         ..
070469 -   10.  "A small bubble becomes a really big bubble," Bea said. "So the
070470 -        expanding bubble becomes like a cannon shooting the gas into
070471 -        your face."
070473 -         ..
070474 -   11.  Up on the rig, the first thing workers noticed was the sea
070475 -        water in the drill column suddenly shooting back at them,
070476 -        rocketing 240 feet in the air, he said.  Then, gas surfaced.
070477 -        Then oil.
070479 -         ..
070480 -   12.  "What we had learned when I worked as a drill rig laborer was
070481 -        swoosh, boom, run," Bea said. "The swoosh is the gas, boom is
070482 -        the explosion and run is what you better be doing."
070484 -         ..
070485 -   13.  The gas flooded into an adjoining room with exposed ignition
070486 -        sources, he said.
070488 -         ..
070489 -   14.  "That's where the first explosion happened," said Bea, who
070490 -        worked for Shell Oil in the 1960s during the last big northern
070491 -        Gulf of Mexico oil well blowout. "The mud room was next to the
070492 -        quarters where the party was.  Then there was a series of
070493 -        explosions that subsequently ignited the oil that was coming
070494 -        from below."
070496 -         ..
070497 -   15.  According to one interview transcript, a gas cloud covered the
070498 -        rig, causing giant engines on the drill floor to run too fast
070499 -        and explode.  The engines blew off the rig and set "everything
070500 -        on fire," the account said.  Another explosion below blew more
070501 -        equipment overboard.
070503 -         ..
070504 -   16.  BP spokesman John Curry would not comment Friday night on
070505 -        whether methane gas or the series of events described in the
070506 -        internal documents caused the accident.
070508 -         ..
070509 -   17.  "Clearly, what happened on the Deepwater Horizon was a tragic
070510 -        accident," said Curry, who is based at an oil spill command
070511 -        center in Robert, La. "We anticipate all the facts will come
070512 -        out in a full investigation."
070514 -         ..
070515 -   18.  The BP executives were injured but survived, according to one account. Nine
070516 -        rig crew on the rig floor and two engineers died.
070518 -         ..
070519 -   19.  "The furniture and walls trapped some and broke some bones but
070520 -        they managed to get in the life boats with assistance from
070521 -        others," said the transcript.
070523 -         ..
070524 -   20.  The reports made Bea, the 73-year-old industry veteran, cry.
070526 -         ..
070527 -   21.  "It sure as hell is painful," he said. "Tears of frustration
070528 -        and anger."
070530 -         ..
070531 -   22.  On Friday, a BP-chartered vessel lowered a 100-ton
070532 -        concrete-and-steel vault onto the ruptured well, an important
070533 -        step in a delicate and unprecedented attempt to stop most of
070534 -        the gushing crude fouling the sea.
070536 -         ..
070537 -   23.  "We are essentially taking a four-story building and lowering
070538 -        it 5,000 feet and setting it on the head of a pin," BP
070539 -        spokesman Bill Salvin told The Associated Press.
070541 -         ..
070542 -   24.  Underwater robots guided the 40-foot-tall box into place in a
070543 -        slow-moving drama.  Now that the contraption is on the
070544 -        seafloor, workers will need at least 12 hours to let it settle
070545 -        and make sure it's stable before the robots can hook up a pipe
070546 -        and hose that will funnel the oil up to a tanker.
070548 -         ..
070549 -   25.  "It appears to be going exactly as we hoped," Salvin said on
070550 -        Friday afternoon, shortly after the four-story device hit the
070551 -        seafloor. "Still lots of challenges ahead, but this is very
070552 -        good progress."
070554 -         ..
070555 -   26.  By Sunday, the box the size of a house could be capturing up to
070556 -        85 percent of the oil.
070558 -         ..
070559 -   27.  The task became increasingly urgent as toxic oil crept deeper
070560 -        into the bays and marshes of the Mississippi Delta.
070562 -         ..
070563 -   28.  A sheen of oil began arriving on land last week, and crews have
070564 -        been laying booms, spraying chemical dispersants and setting
070565 -        fire to the slick to try to keep it from coming ashore.  But
070566 -        now the thicker, stickier goo - arrayed in vivid, brick-colored
070567 -        ribbons - is drawing ever closer to Louisiana's coastal
070568 -        communities.
070570 -         ..
070571 -   29.  There are still untold risks and unknowns with the containment
070572 -        box:  The approach has never been tried at such depths, where
070573 -        the water pressure is enough to crush a submarine, and any
070574 -        wrong move could damage the leaking pipe and make the problem
070575 -        worse.  The seafloor is pitch black and the water murky, though
070576 -        lights on the robots illuminate the area where they are
070577 -        working.
070579 -         ..
070580 -   30.  If the box works, another one will be dropped onto a second,
070581 -        smaller leak at the bottom of the Gulf.
070583 -         ..
070584 -   31.  At the same time, crews are drilling sideways into the well in
070585 -        hopes of plugging it up with mud and concrete, and they are
070586 -        working on other ways to cap it.
070588 -         ..
070589 -   32.  Investigators looking into the cause of the explosion have been
070590 -        focusing on the so-called blowout preventer.  Federal
070591 -        regulators told The Associated Press Friday that they are going
070592 -        to examine whether these last-resort cutoff valves on offshore
070593 -        oil wells are reliable.
070595 -         ..
070596 -   33.  Blowouts are infrequent, because well holes are blocked by
070597 -        piping and pumped-in materials like synthetic mud, cement and
070598 -        even sea water.  The pipes are plugged with cement, so fluid
070599 -        and gas can't typically push up inside the pipes.
070601 -         ..
070602 -   34.  Instead, a typical blowout surges up a channel around the
070603 -        piping.  The narrow space between the well walls and the piping
070604 -        is usually filled with cement, so there is no pathway for a
070605 -        blowout.  But if the cement or broken piping leaves enough
070606 -        space, a surge can rise to the surface.
070608 -         ..
070609 -   35.  There, at the wellhead of exploratory wells, sits the massive
070610 -        steel contraption known as a blowout preventer.  It can snuff a
070611 -        blowout by squeezing rubber seals tightly around the pipes with
070612 -        up to 1 million pounds of force.  If the seals fail, the
070613 -        blowout preventer deploys a last line of defense: a set of rams
070614 -        that can slice right through the pipes and cap the blowout.
070616 -         ..
070617 -   36.  Deepwater Horizon was also equipped with an automated backup
070618 -        system called a Deadman.  It should have activated the blowout
070619 -        preventer even if workers could not.
070621 -         ..
070622 -   37.  Based on the interviews with rig workers, none of those
070623 -        safeguards worked.
070624 -
070625 -        **********************************************
070627 -         ..
070628 -   38.  Associated Press writers Cain Burdeau, Vicki Smith and Ray
070629 -        Henry in Louisiana, Jeff Donn in Boston, Michael Graczyk in
070630 -        Houston and Noaki Schwartz in Los Angeles contributed to this
070631 -        report.
070632 -
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070634 -
070635 -
070636 -
070637 -
0707 -