The joint investigation by the Bureau of Ocean Energy Management Regulation and Enforcement and the US Coast Guard said poor management and mistakes by BP and other parties were to blame.
The investigation found that rig owner Transocean and contractor Halliburton also played a part in the incident.
Volume 1 of the report, previously released on 22 April 2011, covers findings relating to the Deepwater Horizon mobile drilling unit. It covers the explosions, the resulting fire, the evacuations, the flooding and sinking of the drilling unit, and its safety systems and those of its owner, Transocean.
Volume II, published on 16 September, includes findings on the causes of the Macondo oil well blowout and the resulting explosion and fire aboard the Deepwater Horizon.
Almost five million barrels of oil leaked into the Gulf of Mexico over 87 days before the well was capped. Despite, the 11 deaths 115 people evacuated and survived.
The report said BP made a series of decisions that added risk and may have contributed to the ultimate failure of the installation of a cement seal the day before the explosion. The panel said BP failed to communicate these decisions and the increasing operational risks to Transocean.
Fire safety issues
The series of failures led to hydrocarbons travelling up a riser and igniting onboard Deepwater Horizon, resulting in the explosions. As a result, at around 9.45pm on 20 April 2010, Deepwater Horizon experienced a significant fire that lasted around 36, hours until the mobile drilling unit sank on 22 April.
The report said there was a ‘degree of complacency among the crew members and that personnel did not fully embrace the importance of fire brigade exercises’. It also found that the fire main system was not capable of operation after all electrical power was lost, because only electric motor driven fire pumps were provided.
It also pointed out that A-class fire barriers surrounding the drill floor were not effective in preventing the spread of the fire. A-class bulkheads are not tested for exposure to hydrocarbon fire sources.
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