Here are links to the various reports:

http://www.oilspillcommission.gov/sites/default/files/documents/1%20Safety%20Culture%20Final.pdf

http://www.oilspillcommission.gov/sites/default/files/meeting5/Preliminary_Conclusions.pdf

http://www.oilspillcommission.gov/sites/default/files/meeting5/Master_Presentation_v2.pdf

Very interesting!