jeopardize the safety of the men and women work with state in and day out. why? we may never know the answer to that question. many of the individuals who made those decisions died in the explosion. others suffered severe medical injuries. others have asserted their fifth amendment right not to testify. we may never know. we do have some information. we have snippets from witnesses who walked in and out of the rig during those three hours. we have the data itself. i would like to go over in more detail what that data looks like and what information we have that might explain why the red croup and will site leaders came to this decision.

here is the set up. you have those three lines. you have the riser and the printer is label. the first thing that the crew is going to do after running the drill pipe in is to displace the mud on of these three lines. that is not terribly significant for us except to note that some point, they are going to use the kill line during the procedure. at this point, they are setting up the test. they are going to displace mud would see water. -- would seawater. this is the first thing to note at this point. the spacer.

the cure was unusual. -- spacer was unusual. bp wants to use some leftover materials. is significant volume of leftover materials. they were known as lost circulation materials. they are viscous fluids that you can actually put solid matter into that you send down to the well when there has been a lost circulation. that material can patch many of the holes and the formation. bp has some of the stuff lying around and wanted to get rid of it. here is the quirk -- its bp does not send this down into the well, it has to dispose of this as hazardous waste back on shore. there is an exception to that requirement for water based drilling fluid.

bp wants to send these materials down into the wild, circulate them back up to surface, where they can overboard them. there is no dispute that that was a decision that they made here. that is not a problem, but what is more problematic is nobody had used these combined materials before. the engineers said, it should be ok, but everybody acknowledges that they have not use these materials before. the other thing to keep in mind about this is that is very heavy. 16.5 lbs per gallon. that is almost twice the density of seawater. the seawater is pushing it back up during the displacement. when you have a lighter fluid trying to push a much heavier fluid, the concern is that heavier fluid will drop down into the lighter fluid.

keep at spacer in mind. the crew gets -- at that point, the proceeds this residual pressure leftover in the well. they go to plead its down. they open up the drill pipe. they do something unusual. they stopped at 1250. we are not entirely sure why they did that. the kill lion, which also has a pressure gauge, was there at 1250. the crew may have wanted to see if the drill pipe and kill line would equilibrate. they should be the same pressure.

12500 and one should be in 1250 on the other. at this point, they open up the kill line just to see if the pressures are equal. the pressure on the kill line goes down to 645. the pressure on the drill pipe goes up to 1400. it does not make sense given that these should be communicating with the same measure. the crew then tries to bleed down the pressure on the drill pipe. the fluid is coming out. they bleed down the pressure and they cannot get it below 250. they cannot get it to blow up to 60. this indicates that there is a leak somewhere in the well. it does not say where or what it is, but there is a leak. the crew shots back to the drill

pipe and the pressure goes back up again. they notice that if level -- the fluid level has been dropping. somebody walks over, put the flashlight down in to see if the fluid level has dropped. what they realize is that the printer is leaking. it was not closed quite enough. i list the crew has not solved one possible reason as to why there might be a leak. they go to try to test again. the crew of leads off the drill pipe and this time it goes all

-- goes down to zero. water is flowing. didn't close the drill pipe to watch what happens. the pressure jumps up again. this is starting not to make sense. there is slow coming up from the wild. what did they do? they decide we will try to bleed off the pressure on the drill pipe through the kill line per it did get a pressure down to zero. they shot it in again. the drill pipe pressure goes back up to 1400. at this point, there was a discussion. according to certain witnesses,

some of this is in dispute, the transocean -- croute explained why they were getting the 1400 in the drill pipe. they attributed it to something called the bladder a fact. -- a fact. a well site's leaders said about it. the mud in the riser would push and transmits pressure downhole, which would be seen on the drill pipe. what we know now is that everybody who has looked at this agrees, the bladder fact does not exist.

to the extent that it does not -- that it might exist, it would not explain the data that the crew was in and night. it would not explain why the pressure would keep coming back up. after these discussions, one of dpp leaders said, let's move the test to the kill line. the reason given was that when they submitted its application setting forth a temporary abandonment procedures, it indicated that it would run a negative pressure test on the kill line. one of the leaders said, let's run it to the killing. so they did. they opened it up and they get a little bit of flow, which then stops.

like i said before, everything then looked good. but they never reconcile the fact that there was that 1400 still on the drill pipe. the enduring mystery here is why on earth was there 1400 on the drill pipe and zero on the kill line? how can those two things possibly be reconciled? there are a number of possibilities that people have cited. one is a spacer. we all know that there was a leak in the printer and that spacer clicked down below. some of that could have gone into the kill line. the purpose of that is to actually clock materials. there is a possibility that clawed back to .

ogged that kill line. there is no good explanation for that difference. if you cannot explain the 1400, it is not a good-pressure test. why would these men not have realized that this is a bad negative pressure test? just to show you here, 1400 -- this is what it should have looked like in a perfect world. why would these men not have realized that this was a bad negative pressure test? nobody really in the industry or in government had set forth any procedures governing what the test is, how to conducted or how to interpret it. the mms had no regulations

governing procedures for conducting or interpreting a negative pressure test. the regulations requiring one of all. the crew that night, had they not conducted a negative pressure test, would of been violating the regulations. bp, while they require a negative pressure test, does not have any such procedures, nor does it train in particular procedures. it could be different on every single red, depending on what the team agrees to. transocean, they require a negative pressure test in these situations. they, too, have no set procedures and no training for their people. at least prior to this event.

it appears to us that at no point in time during the three hours that anyone on that floor called back to shore. to say, we're getting weird readings. there is a problem here can you help us out? it doesn't appear that anybody from bp did that. it does not appear that anyone from transocean did that. that is a concern that we raised for the commission. the parties have wanted us to assess blame on this. who is responsible? he signed off on the negative pressure test? bp has said that it was transocean response ability. -- responsibility. transocean has said that it is the responsibility of bp. that is not our job. we are not trying to assess

blame or fault or liability. the only plan we want to make is that those men had convinced themselves and agreed that this was a good-pressure test. there is no indication to any of us that anybody spoke up and said, there are problems. we should not go ahead. it is it o'clock at night and a crew -- is 8:00 and a crew is going to move on to the rest of the temporary abandonment procedure. once the crew green light to the negative pressure test, the next up was to displace the riser entirely. the deep water horizon is going

to be leaving. it will be taking its riser and it needs to get rid of that heavyweight mud. the next step would then have then to set the surface cement plug, that 300-foot 30-story building cement plug. once that was done, bp would .hen set the lockdown sleeve you will see that there is all this drill pipe hanging beneath it when it is being set. it needs 100,000 pounds of weight to be sacked. the way that bp chose to achieve that waite was to hang in 3,000 feet of drill pipe. because bp want to set it last, that is why it be needed to set the surface cement plug so deep.

they needed that 3,000 feet of space to accommodate the weight. finally, the crew would pull up the riser and blowout preventer and go on to the next job. at this point, i would like to make a few comments about the particular temporary abandonment procedure that bp chose and the sequence that they chose from getting to point a to point b period -- b. i will talk about two points here. we have talked a little bit about it already, but it is the removal of that 3,000 feet of heavyweight mud. that mud is exerting a force down on the bottom of the well.

it is helping out the cement job. it does not have enough force to hold the hydrocarbons and they want you pulled up and there is no heavyweight mud in the riser. but it helps. the more seawater you've removed, the more stress you are placing on the cement job. the decision to displaced that much mud with seawater was a decision to stress the cement dropped perhaps more than was necessary. it is a decision that puts a real premium on the test of the cement job, the-to pressure test. it eliminates >> there has been uniform testimony setting the plug 3,000 feet deep was not only unusual but unheard of. here is some testimony you can

look at. this second problem with these procedures, or something that introduced additional risks, is that bp chose to displace the mud from the riser before setting that cement plug. once the negative pressure test was passed, they plan would have the crew moves into displacement. what happens at this point is they bop is open. there is a straight shot to the bottom. this puts a large premium on the cement job at the bottom and the negative pressure test that tests the integrity at the bottom. if that cement job fails, the only thing you have is the blowout preventer.

the blowout preventer depends on a human on the rig. if a human does not notice there are problems here such that the bop should be shut in, then you have a problem. we believe bp in order to lessen the risk of the situation could have set the cement plug before displacing the riser to create a second barrier, or put in a mechanical plug. but to put in another barrier to flow during this time of the well. the last point i would like to make is a process. what is of additional concern to us is that the procedures for temporary abandonment were changing up until the last minute. on april 14 one of the engineers at bpa sends out the temporary

abandonment procedures. as of april 14 the procedure was to run your drill pipe down to 3,000 feet below sea level and set your plug. at that point it would have been a barrier. only once the barrier had been set with their be a negative pressure test. that is as of april 14. a barrier would be in place. fast-forward two days to april 16. the procedure has morphed. now the negative test is a first. then you go into 8,300 feet. it was a different type of negative pressure test. you monitor the well and then you set the plug. now they have moved putting in the barrier before the

displacement to after the displacement. let's fast-forward to april 20. this is the note sent by the engineers on the morning of april 20 setting forth what the abandonment procedures would be. you will see the surface cement plug is being sent last. there have been additional changes. they are displacing like we talked about, running the negative test and displacing. as it turns out, this is where the blowout occurred. before that cement plug was set. the process point is it is not clear to us why decisions on these procedures are changing in the last week before the blowout. it strikes us -- you have to change things on the fly

because drilling conditions change. this type of procedure does not appear to us should have been changing up until the last minute. this is a note from an april 28 interview of one of the pp leaders out there that evening -- one of the bp leaders. he said it was a different sequence. the team wanted to do something different. they decided we could do the displacement and negative test together. maybe trying to save time. at the end of the well they think about speeding up. it appeared that at least robert was not in on those conversations were told about

why these procedures might be changing. with that, i would like to go back to 8:00, at the time the crew was about to start displacing. >> we are running a little bit late. it is important ever want understand this. it is complicated stuff. i understand the commissioners want to keep going. >> we will take a short lunch break if necessary. >> i said earlier i want to be sure you don't confuse with what i said earlier. i said we see no instance where a decision making person sat there aware of safety risks and opted to give up safety for costs. there are people that made observations about what they thought others might be doing.

we do not say everything done was perfectly safe. we are saying people traded to save the $4. we studied the hell out of this. -- we are saying people traded time to save dollars. we have not seen that. you have to be sure you understand that. now we are going to kick detection. this is transocean's -- they have a volume this deck on how you operate a deep water. they say a kick is when oil gas gets in the wellboard. you will see him sitting in his chair as to continually monitor what is going on. if there is a kick, the driller

in to shuiut the well quickly. things really happen fast. what might be 3 barrels of gas by the time it gets to the surface, it is moving like hell. it is powerful beyond belief. he will see the impact of these gas influxes eroding away carbon steel. this really happens fast. this is the driller. he has a screen in front of him. he can choose what is to be on

that screen. the fact that he can choose what is on the screen is important because we don't know what was on the screen that night. because it went down with a rig. we will be asking questions as to what they think it showed, but we only have a secondary source as to what the evidence really was. here is a better chartres -- better shot of the screen. commissioner murray saw this. if you look here to the side there is another screen. that has -- a driller has the high tech data that is gone.

this is a subsidiary of halliburton. it is also available at bp's office. you could have seen this data there. there is nobody in the bp office that night. everybody has gone home. this is the data. the information as to what was happening when the cement job failed is here. this is the information. what we have done here is to move it sideways because every time bp display is this

information they take it sideways and expand it. that is because it is easier to see. here is drill pipe pressure. here is this information. this is a little complicated. we don't know anybody in the world saw this specific information. it was available in the alberta and schack. it was available in houston. we don't know anybody was looking at it because the driller had this information available but would have been looking at the screen. it is difficult witte -- what this information shows when we don't know anybody looked at it.

i try to imagine myself having been there for eight hours in that chair watching that stuff. is this a big deal? it turned sideways and spreads out. the drill pipe pressure is constant. it is increasing. it is subtle. if the trailer knows that they are displacing heavier fluids with lighter fluid to sea water, then maybe it makes this upward move more significant. one of the points we are going to make is that the system depends on the right person watching this information at the right time have enough knowledge about all the other activities to interpret it the right way

and to act very rapidly. it depends on people -- one person getting everything right at the right time. we have talked to a lot of people here about -- i cannot subpoena people and put them under oath. i wish i could. i think it is dan important. people in the industry have said of course we would have noticed that. i pressed them like i am pressing myself here. people begin to say i don't know about this first one. the second one is interesting because they turn off the pumps

totally to perform a test. now the drill pipe pressure is going up quite a bit. they have given us by lot of data and the useful explanations that can explain why some of this happened, but nobody can say the drill pipe pressure was not going up wendy pumps were off. most people we talked to say that should have been detected and somebody moved fast. the explosion occurred at 9:49. it can be closed in 47 seconds. we will be talking about this later, but when i looked at this

i said with all these skills people have isn't there a better way to display this information so that we have algorithms that point when things are heading in the wrong direction. this is unfair because i am talking about this. the data -- maybe the data was a lot clearer than this. maybe there was digital information that was easier to pick up. i would expect that the screen would be better because it is there rig, but i don't know that. it is a critical thing that would be good to know.

one of the issues -- we know there was a kick then and hydrocarbons were coming through that had not been abbreviated we know there was a leak. remember i told you earlier we would discuss where the leak occurred. did it come up? let's go to the next one. this is a hangar seal. they made this and these guys have some of the best engineers i have ever seen. they say there is no damage to the casing hangar seals at all. if they came up there would be some damage to the seal. remember i told you you would be

blown away by the power of this gas under pressure coming up through the riser? this is the way the inside of the casing looks. this stuff is so strong on the inside they have been totally blown away by the force of gas coming up. amazing the force of this. but the inside is totally eroded. bp agrees -- we are not sure about how the burden. they may say we don't know that come up but that is what we will be doing. we feel their view is that the leak came up the shoe.

if the flow had been -- you can see what that pressure will do in a big area. these holes would have been torn apart brand there has been a discussion here of what happened at the very end. transocean was good enough to prepare this slide for us which shows the activities that have been going on. the negative test took three hours. sean grimsley told you about the discussion. at 8:00 they deem it done wrong way. we have to keep repeating nobody thought they were taking a chance.

for one reason or another they convince themselves they faulty tests had succeeded. a critical point in this thing. we will not go through this at length. it shows the activities that were going on when they began displacing the rise in. when you take the sea water out of the riser and put in seawater, then there is less pressure at the bottom of the formation. we see the different activities going on. it will be up to the commission to decide if those were too many activities. if you should have rules about what activities are going on so everybody knows what is going on.

here is the taverna and date separator. remember it that the hydrocarbons come up here. the crew has a choice of sending the stuff coming up. mud is now on the floor because the pressure is pushing the mud up first. when gas comes up, that is really bad. the crew could send this stuff to the mud gas m separatorgasud sometimes -- mud gas separator. the mud gas separator is a relatively light weight piece of apparatus. it could not have withstood the pressure coming out from the bottom of the well. it did not and there is a question as to whether if the

crew had diverted it overboard, instead of sending it to the mud gas they sent it over board, would that have stopped the explosion? we have some information on the burgers. -- information on diverters. remember, gas is in the rise turnout. the issue is bp says the crew might have done better if they sent it overboard. time is happening rapidly. let's see what the existing knowledge was on diverters. this is the transocean document.

if there is rapid expansion of gas in the riser the diverter must be closed and diverted over court. if you look at the manual you are impressed by it. it is a safety experts dream. we will talk tomorrow about it because everything under the sun is covered. it is hard to see at a particular place somebody saying symptoms of that for this. people have tried like hell to get it, but it may be that when time is short there might have been different ways to make clear what should have been done. there was a report on diversion 1999-2006. the success rate was very high.

this is a point we covered before. we all know a little gas at the bottom is a lot of gas at the top. we can cut to the chase. let's just cut to the next slide. we are now going to the blowout. hydrocarbons' emerge on the brick -- emerged on the rig. that is where the initial explosion is. there has been talk of can you fireproof a rig?

production rates are a lot of attention is paid to every light fixture being sealed. drilling rigs are not as fire- protective. anybody with any engineering knows gas and air is perfect. it is a perfect substance for exposure. to an ordinary person, if you have huge volumes of flammable gas coming up into the riser at extremely high pressures, it is pretty likely something will happen. this is what happened. transocean tried its darndest to be sure that people will that problems could be caused when the wells are under balance.

transocean had to have an earlier problem in the north sea. i have agreed with transocean this slide accurately reflects what was learned from that explosion. transocean and they well operator analyze the event. hi vigilance is required when you have one barrier under ballots. the only barrier we had that night was the cement. it had failed the negative pressure test. people know there was one bear, and that called for heightened hyde vigilance while everybody -- people knew this was something you have to be careful. what is high vigilance?

should you have your hands somewhere? we all agreed that the -- that is a lesson they communicated to people. you have to recognize when the well is under balance. you have to have heightened vigilance. a lot of this depends on the right person with the right knowledge and experience seeing the right information and making a quick decision. finally, remember i showed you this information going up? i said the problem is it gets confusing that that is not what the driller was looking at. one would hope the driller was looking at information clearer than that.

transocean nail that they had to highlight -- transocean nknew they had to highlight. there were kick detectors. some were a subtle and again this is a wonderful observation, but how do you highlight it? these are some of the issues the commissioners will be dealing with. the last two hours. it is 8:02. bp is open. the negative pressure test is over. it has been wrongly interpreted ascessful when everybody agrees it was unsuccessful.

they begin to remove the heavy mud that allows hydrocarbons to come up. 50 minutes later bp calculates through some software which we have not unpacked yet. we have not figured it out. we assume it is sensible. i put up bp's conclusions most don't disagree with. the well is under ballots. 50 minutes of putting in the sea water to balance the well. that means if the cement job is failing the hydrocarbons will start entering the well. a little after that we get this subtle increase. the well is under bounced and symptoms are starting to show up

again. it is so easy to get confused. we don't know what the trailer was looking at. -- we don't know what they driller was looking at. bp is open. the cement is the only barrier. hydrocarbons are going to get up into the drill pipe. when they get up there is nothing you can do to stop that. 9:38, bp calculates that hydrocarbons are in the riser. bp is open. if you shut it down you still have a mile of risers full of hydrocarbons. they are going to come out on the creek. you are probably going to have a

big explosion. with that have solved some later problems? maybe. coming out on the floor. the hydrocarbons are coming up under enormous pressure. now the presenter is activated. that is that big tire that shows -- the transocean crew operated at 9:41. bp says this is the first action taken by the crew when they see the mud coming up. we don't know if that is accurate. there are disputes between bp and transocean as to who said what when.

there are disputes about who has responsibility for what. we sat down with everybody and we get a lot of arguments. this is where subpoena power would be helpful, because it will be hard to resolve those unless i can sit people down and cross examine them to find out what is believable and what is not believable. i have no reason to believe anyone said anything they don't believe. but people are at the kits. the annual per venter activate it. a nearby ship. you go out to these wells and there are ships working around them. it looks like a small community

out there. the drill crew does exactly the right thing. they say move back, something that is going on. gas comes out on the drill floor. you can see how fast this happens. eight minutes later the gas is up. the first explosion, a power loss, things happened fast. it is brings to life those last couple hours what was going on. you can see it is when the negative pressure test is wrongly concluded to have worked. they start removing the blood and pressure on the hydrocarbon is released. that is when everything starts going south. i said earlier we would give

this group our preliminary technical conclusions. when we began the afternoon i will say it does anybody want to comment on any of days. if they want to comment, find. not commenting does not mean they agree. they can submit a paper within five days with every kind of idea under the sun. if we ever get subpoena power we will use those to cross-examine people further. it would be the good thing to do. preliminary means we will change them if somebody gives us information that is wrong. i have told all the parties i will tell you what we are thinking so nobody is surprised. you have every chance to tell

us how we screwed up. this was exclusively through the casing. the cement may be contaminated and displaced by other materials. the annual space cement is what -- the hydrocarbons could not get in unless something happened. laboratory data should have prompted redesigned. we look at these differing results. we think maybe more time could have been spent getting consistent results. remember that most of the lab reports show that stuff works better if you stir it for 3 hours before you foam it.

yopu foam it and send it down the well. it may be that foaming it -- it gets the same scientific result as the first conditioning. we don't know that. the negative pressure test -- cement evaluation tools might have identified the failure. most operators would not have run the tools on that time. bp can see it in this report that maybe if they had done a risk assessment of all the things we showed the commission earlier maybe they would have run this instead of sending halliburton home. it probably would have shown some. negative pressure test

repeatedly showed the primary cement juppe had not isolated hydrocarbons. i think public sam sankar drove that -- i think sean grimsley drove that home. they treated the negative pressure test as a success. abandonment procedures introduced additional risks. sitting at 3,000 feet reduces the pressure at the bottom of the well. bp had good reasons for doing that. we feel -- i don't want to have anybody saying he missed something, tell us now. we think setting the temporary abandonment plug that low

introduced some additional risk. people have told us looking at this that the simultaneous activities and the nature of the monitoring equipment made detection more difficult. if there is something i am less certain about, -- you can argue endlessly over the effects of moving mud around. that is a preliminary conclusion we are prepared to make. the big indications which i showed you were clear enough that if observed would have allowed the crew to respond earlier. the irony is we don't know what the driller was looking at. i would hope the information would be at least as good as halliburton.

once the crew recognized the influx there were options that would have prevented them to lay the explosion. triggering the emergency disconnect earlier might have shot in the well and limited the impact of the explosion. there are issues as to whether the emergency disconnect would have worked. there is a lot of complexities of this. that is why we say it might have shot in the well. technical conclusions should have waived results. i'm sure you wanted to hear more about the bop. finally, it really is important that you distinguish what i am saying. as we stand here today we don't

see where a man or a group of men were making one of these decisions and they had in their minds that if we do it this way it will be safer, we will do it the cheap way instead of the safeway. we know that $1 million a day is a lot of money. the idea that the delay cost $1 million is overhanging on the heads of people. they don't want to risk their lives, so there is a complex matrix here. the matrix is they want to be efficient and don't want to waste money, but they don't want their bodies to get killed. i have been on a lot of breaks and i don't believe people sit there and say this is really

dangerous, but the guys will make more money. i think it is more complicated than that. what we are saying is human beings that made the decision -- we don't see a concrete situation where humans made a trade off of safety for dollars. thanks so much for your attention. we will be asking a number of questions of panels. >> thank you for that tour de force. we will resume at 1:30-30 minutes. see see you then.

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