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Notes -
CSB reports are pretty fun, if morbid reads, especially since they're a lot more willing to point fingers (contrast NTSB).
I will caution that they tend to put a pretty heavy thumb on the scales to favor as wide-ranging a possible conclusion as available from the evidence: even their own videos make it sound more like BP (or Amaco's) process engineering played a much bigger role than the page count would. The report notes that there were previous incidents involving the blowdown system, but most of these were from before the 2004 budget cuts, and some were from before the merger. Counterfactuals are hard, but with that bad a process design, and that level of normalization of deviance, I'm not sure better trained or less tired staff would have done much more than changed the body count for whatever inevitable incident happened.
I'm currently reading a deposition where the head of safety at the facility freely admitted that he had never actually looked at 29 CFR 1910.119.
I also really appreciate the one victim's mother who hired her own lawyer seperate from the ones representing the other plaintiffs just so he could ask if they knew that one victim in particular and to berate them especially hard for their failures.
Ah, you've read deeper into the incident than I have, then. Apologies.
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