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The most blame for the country’s biggest oil spill falls on BP, federal investigators said.

In a report that may be pivotal in the multibillion-dollar legal battles to come and could set the stage for criminal charges, the Coast Guard and the federal offshore oil regulator wrote BP was to blame for 21 of 35 contributing causes to the Macondo well blowout, and shared blame for 8 more.

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The explosion, 11 deaths and spill “were the result of poor risk management, last-minute changes to plans, failure to observe and respond to critical indicators, inadequate well control response, and insufficient emergency bridge response training by companies and individuals responsible for drilling at the Macondo well and for the operation of the Deepwater Horizon” drilling rig, the report said.

Of particular note was the cement seal put in place the day before the explosion in the Gulf of Mexico.

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The cement’s failure to maintain the integrity of the well was the central cause of the blowout.

BP worked with Halliburton to design the cement job. Because the well was over budget, “BP sought to minimize these losses by reducing the volume of cement it pumped into the well” and they skipped a key analysis recommended by a Halliburton engineer, according to the report.

In the days leading up to the disaster, the panel wrote, BP made “decisions that complicated cementing operations, added incremental risk, and may have contributed to the ultimate failure of the cement job.”

The details were contained in the final report from an investigative team of the U.S. Coast Guard and the Bureau of Ocean Energy Management Regulation and Enforcement. The panel held hearings in the year following the April 20, 2010, disaster.

After BP's Deepwater Horizon rig exploded causing a giant oil leak last year in the Gulf of Mexico, it became clear no device to cap a heavily leaking oil well existed.

After BP's Deepwater Horizon rig exploded causing a giant oil leak last year in the Gulf of Mexico, it became clear no device to cap a heavily leaking oil well existed.

Other investigations have spread around the blame rather evenly, faulting misreadings of key data, the failure of the blowout preventer to stop the flow of oil to the sea and other shortcomings by executives, engineers and rig crew members.

The federal joint investigation team laid considerable blame on BP’s shoulders, saying BP made decisions blindly, without assessing risk, and in some cases skipping internal processes the company relied on to evaluate the potential dangers of decisions.

The report said the decisions included using only one cement barrier and BP’s choice to set the production casing in a location in the Macondo well that created additional risk of influx of oil or gas. The casing is a steel pipe placed in a well to maintain its integrity.

The panel said BP failed to communicate these decisions and the “increasing operational risks” to rig owner Transocean.

“BP, as the designated operator under BOEMRE regulations, was ultimately responsible for conducting operations at Macondo in a way that ensured the safety and protection of personnel, equipment, natural resources, and the environment,” the panel concluded.

In the report’s 57 findings about the disaster, only one person — BP engineer Mark Hafle — is mentioned by name. The report said Hafle’s failure to investigate or resolve anomalies detected during a critical test possibly contributed to the failure of the crew to detect the initial influx of gas and oil. Hafle also chose not to run a cement log, a test that evaluates the quality of the cement job, in violation of BP procedures, the report found.

Hafle — a key decision maker on the doomed rig — refused to testify before the federal panel in August 2010, citing his constitutional right against self-incrimination.

BP said in a statement that the British company accepts the report’s conclusion that the accident was the result of multiple causes involving multiple parties. BP did not address the report’s specific conclusions about the cement.

“From the outset, BP acknowledged its role in the accident and has taken concrete steps to further enhance safety and risk management throughout its global operations, including the implementation of new voluntary standards and practices in the Gulf of Mexico that exceed current regulatory requirements and strengthen the oversight of contractors,” BP said. “We continue to encourage other parties to acknowledge their roles in the accident and make changes to help prevent similar accidents in the future.”

Transocean said the report “finally puts to rest all previous allegations that improper maintenance of the blowout preventer contributed to the tragedy.”

Halliburton said the report “accurately places responsibility on BP”, which it said was responsible for all the operational decisions in the contributing causes.

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