My experience has been that there is a 30 to 40% time / cost reduction, 100% awareness of quality on an asset, and harmony when a operation is carried out transparently, and with care by all participants.  Such a practice of team participation and learning, continuous improvement, wasn't possible  until the Internet and digital multimedia database, satellite technology arrived, but it is here now. 

I express an example here from my personal experience hopefully to justify the way we map out the way forward.   When I'm positioned in an operation as senior engineer / company man,  I spend hours with all the various parties involved during the planning, so that I can see what they know, their behavior when collaborating, etc.,  and then put them in control of that part of the operation, but simultaneously align them with what the other groups are doing.  Basically its a 5 week induction process and my time on the rig supervising is letting the team tell me how things are going, which I can verify watching all the data in a planned vs actual format.  I don't believe this is a desired process in  current industry culture.

What I've observed across the project coordination aspect of the industry, is that there is a lot of telling,  by one type of thinker,  and they do tend to demand it be done.

I don't see the colors system that is causing the problem, its the way its being used by project managers.    I must disagree with you that one should have to tell anyone on a drilling operation what to do.  There should have been two people shutting in the well (possibly one).  The mud logger calls the driller to say stuff is happening.  Its the signals that should be automatically driving the driller to shut in.  Then the driller advises the tool pusher and company man that the well is shut in, what the pit gain and  pressures were (although they all have a monitor now days including the manager in his home to see the actions so no one should even need to phone)  The project coordination culture needs to become of seeing the outcome and learning why the action was taken as driven by the data trends.  When its run like the space ship captain in Avatar, there will be loss control.
  The oil industry managers and management systems have created robots.  In many ways the root cause is linked to the outcomes of the Piper Alpha inquiry.  The case studies and check lists were set up and done by management / engineering prior to the operations, which is fine but two things happened;

One -   "engineering" , "exploration / geology", "management" do the well planning through meetings of various disciplines, putting the range of conclusions and evidence on the company server in pdf format, PowerPoint, Excel, Word files,  and processing conclusions from the knowledge and engineering issues with probability and 3D seismic interpretations, then  paste conclusions into a linear type of plan, again on paper.   This is then shared to the participants and each digests their role and double checks the 90 revenue.  There is a precursory look at capability and a people selection process to be on the job based on availability and possibly past experience, with a focus to minimize the cost and maximize the returns.  Final launch is a prespud meeting which states the way things will be done.

Point being, its a telling culture from disjointed disciplines rather than asking, so limited holistic learning by a team and hazard awareness initiatives have gaps in it.

Secondly, the team that is on the rig got there by competing.  The selection process for building the team is thru' competitive, secretive presentations where lowest price is a dominant factor.  The original qualification is not to request submissions from groups  not considered capable so limited hazard awareness discussion during the selection process.  This is in a climate where each tenderer took the basic services and bid them as low as possible, and keeps the "possible" needs in another package called the price book so that the unexpected can bring revenue that meets company profit goals. 

Point being, everyone is heading off to the rig with instructions from management of what to do based on what they learned through a competitive, secretive selection process and the first "team learning process" is in a one or two day prespud meeting prior to start up, and many of the second tour assignees may never had any of the induction for the issues that might be encountered on the well.

CONCLUSION
Step one is to verify the culture of how the well plan was created, the contractors and various disciplines / operating team / consumables were selected and inducted for the operations.

Step two is to look at how the decisions were taken based on the data.  For example, what were the operating signals used to choose the mud weight and casing setting depths.  This will allow everyone to see the gaps and the cultural and best practices issues.  Who learned what or was it just following a program.  What drills were conducted, who called the drills, what types of responses were there, how were they recorded for well history and lessons learned for all involved.

The reason the catastrophe occurred is that "gas" got into the annulus of the last casing string run and cemented.  The gas being there has nothing to do with the quality of the cement used.  Theoretically if there was never a swab or underbalance, gas should never be in the well bore. The complexities of the operating process and geological conditions created an artificial pressure in the well and a gas bubble in the annulus which brought its bottom hole pressure to the surface and created an environment that when beyond the casing's capability. 

There is nothing else.   The regulations, the redundant systems, the equipment is all fine.  It was the culture and mental disorientation of the team on the well that has led to the loss control. 

The last well I supervised in Indonesia (45 deg deviated subsea well) with a 9.3 ppg mud when in the history of the operator the lowest mud weight was 10.5 ppg for hole stability, oil base mud in all cases, I went to bed as a wiper trip was to be made.  I mentioned to the driller to pull one stand fast.  I woke up in the morning with a report that there was gas bubbling out over the bell nipple after the wiper trip so they had raised the mud weight to 9.6 ppg after getting the office's ok.  In the end there was a whole lot of learning achieved when I showed the mud log of the swab action and after the wiper trip how the gas came to surface after so many pump strokes, and raising the mud weight wasn't the appropriate action, it was to avoid swabbing.  

Point being, if people on the location don't understand the well system then they can't see the hazards and can't learn best practices.  Cultures of ruling from top down and do as you are told ends up creating the loss control because just one gap in understanding catches the dictator. 

There can be no learning from such catastrophes until all of the hazards and actions are transparent to individuals, in a culture of best practices that bring reliability and sustainability to the life cycle of a community.

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