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Little Inconsequential Details Case Study Have Major Impact on Perfo

0503 -
0503 -    ..
0504 - Summary/Objective
0505 -
050501 - Follow up ref SDS 9 0000.
050502 -
050503 -
050504 -
050505 -
050507 -  ..
0506 -
0507 -
0508 - Progress
0509 -
050901 - Deepwater Horizon Exploded Small Gas Bubble Got Really Big
050902 -
050903 - Follow up ref SDS 9 BT9M.
050904 -
050905 - On 100508, Reuters reported investigation of British Petroleum oil
050906 - rig, the Deepwater Horizon, that exploded in the Gulf of Mexico on
050907 - 100420, ref SDS 9 BT9M, causing loss of life, billions of dollars
050908 - destroying the drilling platform, loss of energy production, and
050909 - severe environmental damage, now indicates huge problems were caused
050910 - by a very little bubble of gas escaping at the bottom of the well.
050911 - This mistake was not corrected, because investing time and money to
050912 - fix a small mistake seemed like unnecessary overkill.  The mistake at
050913 - the bottom of the well, then compounded over the distance of 1 mile
050914 - into a huge catastrophy at the surface. ref SDS 9 T56K
050916 -  ..
050917 - Case study on 100508, ref SDS 9 VK5K, shows BP's catastrophy from
050918 - ignoring a very small mistake, reflects Aristotle's rule that the
050919 - least deviation in the beginning is multipled a thousand times, cited
050920 - in NWO. ref OF 1 JV3G
050921 -
050923 -  ..
050924 - Ignoring Warnings Fundamental Mistake
050925 - Wicked Problems Send Mixed Signals Presenting Management Dilemma
050926 -
050927 - The Wall Street Journal reports today on 100526 that engineers ignored
050928 - early warnings in order to continue work, and this "fundamental
050929 - mistake," ref SDS 0 7O4I, allowed a small problem to explode into
050930 - castrophy, reported on 100508 0801. ref SDS 9 BT9M
050932 -  ..
050933 - Reporting today relates inconclusive test results could have been
050934 - interpreted as showing a 'very large abnormality' in the well which
050935 - required immediate correction, but was actually interpreted as a
050936 - successful test, and so no corrective action was taken. ref SDS 0 7P6T
050937 -
050938 -    1.  The Wall Street Journal
050939 -
050940 -        May 25, 2010
050941 -         ..
050942 -        BP Cites Crucial "Mistake"
050943 -
050944 -        'Very Large Abnormality' in the Well Wasn't Heeded Hours
050945 -        Before Fatal Explosion
050946 -
050947 -        By STEPHEN POWER
050949 -         ..
050950 -    2.  Oil giant BP PLC told congressional investigators that a
050951 -        decision to continue work on an oil well in the Gulf of Mexico
050952 -        after a test warned that something was wrong may have been a
050953 -        "fundamental mistake," according to a memo released by two
050954 -        lawmakers Tuesday.
050956 -         ..
050957 -    3.  The document describes a wide array of mistakes in the fateful
050958 -        final hours aboard the Deepwater Horizon-but the main
050959 -        revelation is that BP now says there was a clear warning sign
050960 -        of a "very large abnormality" in the well, but work proceeded
050961 -        anyway.
050963 -         ..
050964 -    4.  The rig exploded about two hours later.
050966 -         ..
050967 -    5.  The congressional memo outlines what the lawmakers say was a
050968 -        briefing for congressional staff by BP officials early
050969 -        Tuesday. Company representatives provided a preliminary report
050970 -        on their internal investigation of the April 20 disaster,
050971 -        which killed 11 workers and continues to spill thousands of
050972 -        barrels of oil daily into the Gulf of Mexico.
050974 -         ..
050975 -    6.  The new developments come as President Barack Obama, working
050976 -        to tame a political storm over the spill, is expected to
050977 -        announce Thursday that the government will impose tougher
050978 -        safety requirements and more rigorous inspections on off-shore
050979 -        drilling operations.
050981 -         ..
050982 -    7.  According to the memo, BP identified several other mistakes
050983 -        aboard the rig, including possible contamination of the cement
050984 -        meant to seal off the well from volatile natural gas and the
050985 -        apparent failure to monitor the well closely for signs that
050986 -        gas was leaking in, the congressmen wrote in their
050987 -        post-meeting memo. An immense column of natural gas, erupting
050988 -        from the oil well, fueled the fireball that destroyed the rig.
050990 -         ..
050991 -    8.  A BP spokesman declined to comment on the memo's specific
050992 -        statements. He said the company had identified "what we
050993 -        believe to be a series of underlying failures" that caused the
050994 -        accident.
050996 -         ..
050997 -    9.  Although the memo identifies some of the problems that led to
050998 -        these mistakes, it doesn't identify who made the key
050999 -        decisions. Most of the work aboard the rig was performed by
051000 -        employees of Transocean Ltd., the rig's owner and operator,
051001 -        and other contractors, but BP had managers aboard the rig to
051002 -        supervise the work at the time of the accident.
051004 -         ..
051005 -   10.  A Transocean spokesman said in response to the memo: "A well
051006 -        is constructed and completed the same way a house is built-at
051007 -        the direction of the owner and the architect. And in this
051008 -        case, that's BP."
051010 -         ..
051011 -   11.  The memo sheds new light on a key test performed hours before
051012 -        the explosion that has been a focus of congressional
051013 -        investigations. BP previously told investigators that a
051014 -        "negative pressure" test, which checks for leaks in the well,
051015 -        was inconclusive at best and "not satisfactory" at worst.
051017 -         ..
051018 -   12.  But in the meeting Tuesday, BP went further, saying the
051019 -        results were an "indicator of a very large abnormality" but
051020 -        that workers-unnamed in the memo-decided by 7:55 p.m. that the
051021 -        test was successful after all. That may have been a
051022 -        "fundamental mistake," BP's investigator said in the meeting,
051023 -        according to the memo. Reps. Henry Waxman (D., Calif.) and
051024 -        Bart Stupak (D., Mich.) wrote the memo, which was made public
051025 -        Tuesday.
051027 -         ..
051028 -   13.  After that, workers began to remove the heavy drilling fluid,
051029 -        called "mud" in the industry, that provides pressure to
051030 -        prevent any gas that seeps into the well from rising to the
051031 -        surface.
051033 -         ..
051034 -   14.  The memo also describes a breakdown in communication aboard
051035 -        the rig in the hours leading up to the explosion that made it
051036 -        tough for workers to monitor how much mud was coming out of
051037 -        the well-a key measure of whether gas is leaking in, according
051038 -        to the memo.
051040 -         ..
051041 -   15.  BP identified "several concerns" related to the cementing
051042 -        process used on the well, the memo indicated. The cement work
051043 -        that was supposed to hold back gas "failed," the memo said,
051044 -        allowing gas into the well.
051046 -         ..
051047 -   16.  Halliburton, Co., the cementing contractor on the rig, said it
051048 -        followed BP's instructions. "As a contractor, Halliburton made
051049 -        recommendations regarding the contract services provided,"
051050 -        said Halliburton spokeswoman Cathy Mann. "However, ultimately,
051051 -        the responsibility for what operations to conduct lies with
051052 -        the well owner, and Halliburton is obligated to act at the
051053 -        direction of the well owner."
051055 -         ..
051056 -   17.  The congressional inquiry by Mr Waxman, chairman of the House
051057 -        Energy and Commerce Committee, and Mr Stupak, a senior member
051058 -        of the panel, has focused on the actions of the various
051059 -        companies and their workers on the day of the accident.
051060 -        Inquiries by other congressional panels have tended to focus
051061 -        more on the actions of regulators or the general policies of
051062 -        the companies.
051064 -         ..
051065 -   18.  Separately on Tuesday, Democrats and Republicans jousted on
051066 -        Capitol Hill over how much money oil companies should have to
051067 -        pay for oil-spill damages, but agreed that the current $75
051068 -        million limit was too low.
051070 -         ..
051071 -   19.  BP, which is responsible for stopping and cleaning up the
051072 -        giant spill, has said it would pay "all legitimate claims"
051073 -        from the spill. Some Democrats fear that the company might
051074 -        find a way to avoid some liability.
051076 -         ..
051077 -   20.  Speaking to a Senate panel, Associate Attorney General Thomas
051078 -        Perrelli said the limit should be removed entirely for
051079 -        deepwater drilling, arguing that the government needs to
051080 -        "ensure that there is no arbitrary cap on corporate
051081 -        responsibility for a similar major oil spill."
051083 -         ..
051084 -   21.  The agency that oversees the offshore oil industry, the
051085 -        Minerals Management Service, again came in for criticism. On
051086 -        Tuesday the Interior Department's inspector general published
051087 -        a report saying employees at the Lake Charles, La., office of
051088 -        the MMS accepted sporting-event tickets, lunches and other
051089 -        gifts from oil and natural-gas companies. The report also said
051090 -        employees used government computers to view pornography.
051092 -         ..
051093 -   22.  It wasn't immediately clear how many MMS staffers were
051094 -        implicated in the inspector general's report, which said that
051095 -        "all of the conduct chronicled in this report occurred prior
051096 -        to 2007."  In a written statement, Interior Secretary Ken
051097 -        Salazar said that some employees cited in the report have
051098 -        resigned, been terminated or been referred for prosecution. He
051099 -        said that any remaining staffers accused of questionable
051100 -        behavior in the inspector general's report would be placed on
051101 -        administrative leave pending the outcome of a personnel
051102 -        review.
051104 -         ..
051105 -   23.  On Wednesday, Secretary Salazar is to testify before the House
051106 -        Natural Resources Committee on his plan to overhaul the MMS.
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