To date, the best blow-by-blow account of what happened on April 20 on the Deepwater Horizon and what led up to the catastrophe appeared on May 27 and 28 in the Wall Street Journal. The second installment, "There Was 'Nobody in Charge,' " is particularly absorbing--reminiscent in a way of Titanic eyewitness testimony and, to anybody familiar with the work of Malcolm Gladwell, of what he's had to say about "mitigation."
A technical term in the field of management and industrial organization, mitigation refers to the tendency of people working in highly hierarchical situations or cultures to minimize problems when addressing superiors. The situation on Deepwater Horizon appears to have been one in which workers had a hierarchical mentality but didn't really know who was at the top of the totem poll--the worst of all possible Gladwellian worlds.
Both the Journal and a somewhat similar account that appeared later in The New York Times, "At Issue in the Gulf: Who Was in Charge?," tell the story of a young woman in the control room who realized minutes into the accident that the rig had neglected to call for help. When she sent out an SOS on her own authority, and was immediately reprimanded by her boss for doing so. As people around then were jumping into life boats or into the water, she apologized to him.
The Gladwell syndrome may be somewhat academic, but not the details of what led up to the tragedy, as spelled out in the preliminary Times story and the first installment of the Journal's investigation, "BP Decisions Set Stage for Disaster." As Attorney General Holder's people look into criminal charges, the president calls for a top-level shake-up at BP, and lawyers prepare all manner of class action suits against the oil company, there will be plenty to work with. Among the details in the two newspapers' accounts:
--BP cut short a procedure designed to detect gas in the well and skipped a quality test normally used to evaluate cement around the pipe
--Halliburton advised BP to install 21 devices to make sure the pipe was properly centered in the well before starting to cement, but BP installed only 5, ignoring Halliburton's written warning that without all the devices there could be "a SEVERE gas flow problem"
--in the weeks before the disaster, there had been repeated "gas kicks," and the blowout preventer was found to be leaking
--almost a year before the disaster, BP engineers had expressed misgivings about the kind of casings the company was planning to use in the well
--rather than install two pipes, one within the other, which is widely considered best practice, BP installed only one
--before cementing, BP cut short the normal practice of circulating drilling mud through the well, which enables workers to check whether excess gas is leaking into the well
--BP did not properly test the final cementing, and even though Schlumberger technicians were on board the Deepwater Horizon and available to do the testing, BP sent them packing 12 hours before the rig exploded
On April 20, the Deepwater Horizon's work was running a month and a half behind schedule, and a great deal of evidence suggests that BP was cutting corners, hoping to reduce losses and get the well producing. Delays, according to the Times, already had cost the company about $21 million.