The report on the BP oil rig disaster - familiar lessons, familiar root causes

The Report to the President of USA by the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling has been released.
I have summarized the key points from the investigation report:

"The final moments:
Down in the engine control room, Chief Mechanic Douglas Brown, an Army veteran employed by Transocean, was filling out the nightly log and equipment hours. He had spent the day fixing a saltwater pipe in one of the pontoons. First, he noticed an “extremely loud air leak sound.” Then a gas alarm sounded, followed by more and more alarms wailing. In the midst of that noise, Brown noticed someone over the radio. “I heard the captain or chief mate, I’m not sure who, make an announcement to the standby boat, the Bankston, saying we were in a well-control situation.” The vessel was ordered to back off to 500 meters. Now Brown could hear the rig’s engines revving. “I heard them revving up higher and higher and higher. Next I was expecting the engine trips to take over. . . . That did not happen. After that the power went out.” Seconds later, an explosion ripped through the pitch-black control room, hurtling him against the control panel, blasting away the floor.
Brown fell through into a subfloor full of cable trays and wires. A second huge explosion roared through, collapsing the ceiling on him. All around in the dark he could hear people screaming and crying for help.
Steve Bertone, the rig’s chief engineer, had been in bed, reading the first sentence of his book, when he noticed an odd noise. “As it progressively got louder, it sounded like a freight train coming through my bedroom and then there was a thumping sound that consecutively got much faster and with each thump, I felt the rig actually shake.” After a loud boom, the lights went out. He leapt out of bed, opening his door to let in the emergency hall light so he could get dressed. The overhead public-address system crackled to life: “Fire. Fire. Fire.”
Root Causes (failures in industry):
BP’s management process did not adequately identify or address risks created by late changes to well design and procedures. BP did not have adequate controls in place to ensure that key decisions in the months leading up to the blowout were safe or sound from an engineering perspective. While initial well design decisions undergo a serious peer review process155 and changes to well design are subsequently subject to a management of change (MOC) process,156 changes to drilling procedures in the weeks and days before implementation are typically not subject to any such peer-review or MOC process. At Macondo, such decisions appear to have been made by the BP Macondo team in ad hoc fashion without any formal risk analysis or internal expert review. This appears to have been a key causal factor of the blowout.
Halliburton and BP’s management processes did not ensure that cement was adequately tested. Halliburton had insufficient controls in place to ensure that laboratory testing was performed in a timely fashion or that test results were vetted rigorously in-house or with the client. In fact, it appears that Halliburton did not even have testing results in its possession showing the Macondo slurry was stable until after the job had been pumped. It is difficult to imagine a clearer failure of management or communication.
BP, Transocean, and Halliburton failed to communicate adequately. Information appears to have been excessively compartmentalized at Macondo as a result of poor communication. BP did not share important information with its contractors, or sometimes internally even with members of its own team. Contractors did not share important information with
BP or each other. As a result, individuals often found themselves making critical decisions without a full appreciation for the context in which they were being made (or even without recognition that the decisions were critical).
Transocean failed to adequately communicate lessons from an earlier near-miss to its crew. Transocean failed to adequately communicate to its crew lessons learned from an eerily similar near-miss on one of its rigs in the North Sea four months prior to the Macondo blowout. On December 23, 2009, gas entered the riser on that rig while the crew was displacing a well with seawater during a completion operation. As at Macondo, the rig’s crew had already run a negative-pressure test on the lone physical barrier between the pay zone and the rig, and had declared the test a success.163 The tested barrier nevertheless
failed during displacement, resulting in an influx of hydrocarbons. Mud spewed onto the rig floor—but fortunately the crew was able to shut in the well before a blowout occurred.Nearly one metric ton of oil-based mud ended up in the ocean. The incident cost Transocean 11.2 days of additional work and more than 5 million British pounds in expenses.
Decision making processes at Macondo did not adequately ensure that personnel fully considered the risks created by time- and money-saving decisions. Whether purposeful or not, many of the decisions that BP, Halliburton, and Transocean made that increased the risk of the Macondo blowout clearly saved those companies significant time (and money)".

For those of you who are interested in reading the complete report, here is the link. (File is large, be patient...)