The well blew out because a number of separate risk factors, oversights, and outright mistakes combined to overwhelm the safeguards meant to prevent just such an event from happening. But most of the mistakes and oversights at Macondo can be traced back to a single overarching failure—a failure of management. Better management by BP, Halliburton, and Transocean would almost certainly have prevented the blowout...the root causes are systemic and, absent significant reform in both industry practices and government policies, might well recur...BP’s management process did not adequately identify or address risks created by late changes to well design and procedures...Halliburton and BP’s management processes did not ensure that cement was adequately tested...BP, Transocean, and Halliburton failed to communicate adequately...Transocean failed to adequately communicate lessons from an earlier near-miss to its crew...