Mitchell Capt Andrew

In the Matter of DEEPWATER HORIZON
Report Regarding Transoceans Safety Management System and the ISM Code
Captain Andrew Mitchell October 17, 2011
CONTENTS
Paragraph
Qualifications and Experience of Captain Andrew Mitchell Executive Summary and Conclusions Major Non-Conformity with the ISM Code Major Non-Conformity #1: ISM Code Section 5 Major Non-Conformity #2: ISM Code Section 6 Summary 14 28 44 48 1-9 10 43
Report of Captain Andrew Mitchell
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Paragraph
Annex A
The ISM Code Background to the Code Objectives of the Code The Safety Management System (SMS) DOC and SMC Certificates Enforcement of the ISM Code Flag Administrations Recognised Organisations Port State Control The ISM Code and other Rules, Regulations, Codes, Guidelines and Standards The ISM Code verification process The External Audit Process Reporting the Audit Findings Follow Up and Close Out of the Audit The Internal Audit Process A Typical SMS for a Company operating a MODU Organisation for effective safety management Scope of the SMS Bridging Documents Structure of the SMS Content of the SMS The SMS implemented by Transocean Structure of the Transocean CMS The Major Accident Hazard Risk Assessment The Operations Integrity Case Scope of the Transocean SMS Bridging Documents
49 - 62 49 55 57 59 63 - 70 63 66 70
Annex B
Annex C
71 - 75 76 - 88 76 81 85 88 89 - 104 89 90 91 94 96 105 - 118 105 108 109 111 114 120 - 208
Annex D
Annex E
Annex F
Annex G
Content and the implementation of the Transocean SMS ISM Code Section 1 121 ISM Code Section 2 122 ISM Code Section 3 123 ISM Code Section 4 130 ISM Code Section 5 131 ISM Code Section 6 136 ISM Code Section 7 140 ISM Code Section 8 168 ISM Code Section 9 183
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ISM Code Section 10 ISM Code Section 11 ISM Code Section 12
192 198 201
Annex H Annex I Annex J Annex K Annex L Annex M Annex N Annex O Annex P Annex Q Annex R Annex S
Extract from DEEPWATER HORIZON MAHRA Extract from DEEPWATER HORIZON OIC Document of Compliance (DOC) issued to Transocean Offshore Deepwater Drilling Inc. Safety Management Certificate (SMC) issued to DEEPWATER HORIZON Transocean Organisation for Safety and Environmental Management Exhibit 5483: DNV DEEPWATER HORIZON SMC audit May 2002 Exhibit 1768: DNV Transocean DOC audit April 2009 Exhibit 946: Notification of corporate DP March 9, 2010 Analysis of Transocean Company Management System and the ISM Code Transocean Management System relevant to the ISM Code Transocean Risk Management Processes Non-Conformity with the ISM Code
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Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 Appendix 8 Appendix 9 Appendix 10
Experience profile of Andrew Mitchell Glossary of Terminology ISM Code 2002 Applicability of the ISM Code to MODU Operations UNCLOS Part VII, Section 1, Article 94 paragraph 4(b) Analysis of Industry norm on Dual Command Structure Pride Drilling DP Rigs Organisation Chart Maersk Drilling OIM Job Description Reliance Exhibits Consideration Exhibits
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Curriculum Vitae
I am a Class 1 Master Mariner with 19 years sea service with Shell Tankers from 1962, followed by four years as an Offshore Installation Manager with Shell (UK) Exploration and Production in the North Sea. In 1986, I transferred to Production Operations where I led the development and introduction of safety management systems into Shells offshore operations and later, in the Shell corporate Health and Safety Department, led the implementation of the Shell contractor safety management program. Leaving Shell, I established a consultancy in Aberdeen, specializing in the development, implementation and auditing of safety management systems in the oil and gas industry world-wide. This company was acquired by the Lloyds Register Group, and as a Principal Surveyor, I was responsible from 1994 for consultancy projects assisting shipping Companies to comply with ISO 9002, as applied to the marine industry prior to the ISM Code. In 1997, I moved to the Lloyds Register Headquarters in London as a Senior Principal Surveyor and Manager to establish the infrastructure and procedures to allow Lloyds Register to act as a Recognised Organisation for the issue of ISM certification on behalf of flag Administrations. This role was subsequently expanded to include the ISPS Code and ILO Maritime Labor Convention 2006, the international security and welfare Standards. I chaired the International Association of Classification Societies (IACS) working groups that developed the auditing and competence requirements for the interpretation and verification of the ISM Code and these other Codes and Conventions.1 Through this position, I led the IACS input to the International Maritime Organisation (IMO) on the implementation of the ISM and ISPS Codes in close liaison with the major flag Administrations. I retired from Lloyds Register in 2006 to be a marine consultant and to undertake diverse marine projects associated with maritime management systems. I serve as a member of the Nautical Institute International Maritime Organisation Committee; I am a visiting lecturer on safety management at Cranfield University and an external examiner for Doctorates of Professional Studies at Middlesex University.
My full experience profile is included as Appendix 1.
See Annex B, paragraphs 67-70 for more detailed information on IACS and the leading recognized organizations.
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Executive Summary and Conclusions

1. This Report is the result of a detailed examination and assessment of the Transocean Safety Management System (SMS), in particular how it was applied on board the DEEPWATER HORIZON in 2010. It identifies two major non-conformities2 with the requirements of the ISM Code.3 2. Through a Drilling Contract signed in 1998, BPs predecessor engaged a MODU,4 later to be known as DEEPWATER HORIZON. The Contract required that the Contractor shall have the primary responsibility for the safety of all its operations . . . the Contractor shall place the highest priority on safety while performing the work. BP had reason to be confident that the risks associated with the DEEPWATER HORIZON drilling Macondo 252 were being managed effectively by Transocean, given: Specific health, safety and environmental requirements specified in Exhibit D of the Contract; The additional requirements in the BP-Transocean HSE Management Systems Bridging Document;5 Regular audits conducted by BP and third parties;6 and The fact that DEEPWATER HORIZON achieved seven years without recording a lost time injury. 3. However, Transocean failed to comply with sections of the International Safety Management (ISM) Code. The Master of the DEEPWATER HORIZON was incapable by virtue of the Transocean command structure and inadequate training to make the right decisions at critical times. As a consequence of these major non-conformities with the ISM Code, the Emergency Disconnect System (EDS) was not operated in a timely manner. Had Transocean fully complied with these sections of the ISM Code, it would have had a more coherent, clear, and understandable
2
MDL Exhibit 938 and Appendix 3: International Safety Management Code and Guidelines on Implementation of the ISM Code, Section 1.1.10 3 MDL Exhibit 938: International Safety Management Code and Guidelines on Implementation of the ISM Code; Appendix 3: The ISM Code 2002 4 MDL Exhibit 4271: BP Transocean Drilling Contract (1998) 5 MDL Exhibit 948: BP-Transocean HSE Management System Bridging Document 6 E.g., MDL Exhibit 937: Transocean Results of HSSE Common Inspection Document (CMID) Audit (08.03.2009); Cramond Deposition, p. 330; Wong Deposition, pp. 28-30; Odom Deposition, p. 185-186, 188; MDL Exhibit 1827: BP GP 10-40: Drilling Rig Audits and Rig Acceptance, 8.1.b (June 11, 2008); MDL Exhibit 961: DWH CMID Annex (BP Requirements for MODUS), at 2 (September 2009).
Report of Captain Andrew Mitchell Page 7 of 154
organisational structure with properly trained marine crew onboard the DEEPWATER HORIZON and the major loss of life, personal injury, and pollution would most probably have been averted. This Report sets out my opinion on this matter.
4.
In 2004, Transocean prepared the DEEPWATER HORIZON Major Accident Hazard Risk Assessment (MAHRA) 7 and in 2008 the Operations Integrity Case (OIC). 8 Both of these documents identified a Reservoir blowout and Hydrocarbons in formation (including gas), loss of containment as major hazards. Further, in 2009 Transocean recognised in its Annual Report that its operations were subject to the usual hazards inherent in drilling of oil and gas wells and identified blow outs, loss of well control, fires, personal injuries, environmental damage and failure to retain key personnel as hazards which had the potential to have a serious effect on their business.9 Having recognised these hazards, and despite having procedures in place to mitigate the risk, Transocean failed to effectively implement the very procedures which may have prevented the disaster which occurred on April 20, 2010.
5.
The Republic of the Marshall Islands (RMI), the flag Administration, by not recognising the DEEPWATER HORIZON as a Dynamically Positioned (DP) ship, improperly facilitated the implementation of a confusing dual command structure in which the Master was prevented from exercising his statutory right of overriding authority and responsibility with respect to safety and pollution prevention.
6.
Det Norske Veritas (DNV), by not following its own procedures, also facilitated Transoceans implementation of a confusing dual command structure on the DEEPWATER HORIZON. It
identified as early as 2002 that the responsibilities and authorities of the Master and the OIM as stated in the Transocean SMS were in conflict.10 This was identified again in 2009,11 but by April 2010, Transocean had taken no action. Had DNV considered the 2002 non-conformity as a
7 8
MDL Exhibit 2187: DWH Major Accident Hazard Risk Assessment (MAHRA) ( 29 August 2004) MDL Exhibits 5473, 5474, 5475, 5476 & 5477: DWH Operations Integrity Case, Sections 1, 2, 4, 5, & 6. 9 Transocean 2009 Annual Report at AR-16, AR-17 10 MDL Exhibit 5483 and Annex M: DNV DWH Audit Report (05.16.2002) 11 MDL Exhibit 1768 and Annex N: DNV Transocean 2009 DOC Audit (04.16.2009)
reason why the DEEPWATER HORIZONs SMC may become invalid in 2005, notifying RMI and so ensuring Transocean complied with the requirements of ISM Code Section 5, the explosion and fire, loss of life and the ship and the subsequent pollution would have been avoided.
7.
This Report describes in detail the major non-conformities against Sections 5 and 6 of the ISM Code. It provides the background to the ISM Code highlighting the history which initiated its development and the subsequent responsibilities of the Maritime Administrations in its implementation and verification. It provides an interpretation of the ISM Code for MODUs and comments on the SMS being implemented by Transocean in April 2010 based on the objective evidence available.
8.
This Report is prepared by Global Marine Associates of which I am the Director.
I am
recompensed at the rate of GBP 160 per hour for my services. I reserve the right to amend this Report should additional information be received.
Conclusion
9.
By failing to make the Masters role and authority clear on board the DEEPWATER HORIZON and failing to properly train the marine crew, Transocean failed to operate the DEEPWATER HORIZON in compliance with the requirements of the ISM Code. There is objective evidence of major nonconformity with ISM Code Sections 5 and 6 and this, together with further non-conformity in the management system, were causative of the explosion, fire, tragic loss of life and the installation, and the subsequent pollution which occurred.
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Major Non-Conformity with the ISM Code
10.
ISM Code Part A section 1.1.10 defines a major non-conformity as an identifiable deviation that poses a serious threat to the safety of personnel or the ship or a serious risk to the environment that requires immediate corrective action and includes the lack of effective and systematic implementation of a requirement of this Code. A major non-conformity may be identified in the Company during a Document of Compliance (DOC) audit or on board during a Safety Management Certificate (SMC) audit.12
11.
Compliance with the ISM Code is signified through the issue of two certificates, one to the Company, one to the ship. These are detailed in ISM Code Part B Certification and Verification. The DOC is issued to the Company to certify that the safety management system of the Company has been audited and that it complies with the requirements of the ISM Code for a specific ship type.13 The SMC is issued to a ship to certify that the safety management system of the ship has been audited and that it complies with the requirements of the ISM Code, following verification that the DOC for the Company is applicable for the ship type.14 ISM Code Part B sections 13.5 and 13.9 states that the DOC or SMC should be withdrawn by the Administration if there is evidence of major nonconformities with this Code.
12.
On April 20, 2010 two major non-conformities existed in the Transocean SMS in the following areas: ISM Code 5 ISM Code 6 Masters Responsibility and Authority Resources and Personnel
13.
Other non-conformities also existed in the following areas:15 ISM Code 1.2 ISM Code 4 ISM Code 10.1 Meeting the objectives of the ISM Code Training and competence of Designated Persons Outstanding maintenance routines
12 13
Annex D: ISM Code verification process MDL Exhibit 953 and Annex J: Document of Compliance Issued to Transocean 14 MDL Exhibit 1776 and Annex K: Safety Management Certificate Issued to Transocean 15 See Annex S
ISM Code 11.1 ISM Code 12
Out of date and uncontrolled documentation Inadequate internal ISM audits
These are discussed in Annex S to this Report.
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Major Non-Conformity #1: ISM Code Section 5 Masters Authority and Responsibility
14.
The command structure described in the Transocean ISM/ISPS MODU Handbook (HQS-HSE-HB-02 issued 12.19.08) section 2.4.3 and in other controlling documents, and as implemented on the DEEPWATER HORIZON did not establish that the Master had overriding authority and responsibility to make decisions with respect to safety and pollution prevention.
15.
DEEPWATER HORIZON, as a ship propelled by mechanical means, had to comply with the requirements of the International Convention for the Safety of Life at Sea (SOLAS) Convention 1974 as amended.16 DEEPWATER HORIZON was a MODU as defined by SOLAS17 and subject to compliance with the ISM Code from July 1, 2002.18 Administration of DEEPWATER HORIZON.
19
This is confirmed by RMI as the flag
16.
DEEPWATER HORIZON was not only self-propelled but was operating in dynamic positioning (DP) mode at Macondo 252. By definition she was underway by virtue of the fact that she was not at anchor, made fast to the shore or aground.20 This was confirmed by the Master.21
17.
The United Nations Convention on the Law of the Sea (UNCLOS) requires that each ship is in charge of a Master.22
18.
Under maritime regulation, the Master is in command of his ship at all times, including during emergency situations, with overriding authority and responsibility23 and will issue appropriate orders and instructions in a clear and simple manner.24 U.S. requirements for MODUs state that
16 17
SOLAS Part A, Regulation 3(a) (iii) SOLAS Chapter IX Regulation 1 (8) 18 SOLAS Chapter IX Regulation 2 (1.3) 19 Marshall Islands Guidance MI-293: Mobile Offshore Drilling Unit Standards: Part IV (M) and Part V (L) 20 COLREG 1972: Rule 3 (i) 21 MDL Exhibit 3749: DWH Bridge Procedures Guide, p. 29 22 UNCLOS Part VII, Section 1, Article 94 , paragraph 4(b). Both UNCLOS and the ISM Code make no differentiation between the differing modes in which the ship may operate. 23 MDL Exhibit 938 and Appendix 3: ISM Code 5.2 24 bis ISM Code 5.1.3
the owner of a unit or his agent shall designate an individual to be the master or person in charge [PIC] of the unit.25 19. The Transocean interpretation of this requirement with regard to overriding responsibility is to appoint two PICs. The Transocean command structure is described in the Transocean ISM/ISPS Handbook, a management resource for the Rig manager . . . to ensure the ISM Code . . . is implemented correctly, where it states that:26 the Master is the overall responsible person on the MODU when it is underway and/or moving to another location the OIM is the overall responsible person for the day to day operation of the MODU while it is drilling Further, both positions are charged with ensuring the implementation of the safety policies and procedures.27
This command structure and reporting relationship is also described in: The Masters job description where it states the Master reports to the OIM;28 The OIMs job description where it states the Master reports to the OIM;29 The DWH Emergency Response Manuals organisation chart, which shows the Master as just one of the Department Heads reporting to the OIM;30 DWH Emergency Response Manual, which states in its forward that the organisation chart defines the specific emergencies and in which the organisation chart states that the OIM is the PIC while the vessel is in drilling mode and the Master is the PIC in underway mode.31 The DEEPWATER HORIZON Operations Manual Vol 1 of 2 where it confusingly re-states the dual command structure, noting that there can only be one person in charge (PIC) at one time, but states the Master has overriding authority.32
25 26
46 C.F.R. 109.107: Designation of master or person in charge MDL Exhibit 939: Transocean ISM/ISPS MODU Handbook, Forward 27 bis Section 2: page 8 28 TRN-INV-00463941: Transocean Master Job Description; MDL Exhibit 942: Transocean Master Job Description 29 TRN-INV-00463832: Transocean OIM Job Description 30 MDL Exhibit 4644: DWH Emergency Response Manual: Section 1 31 MDL Exhibit 4644: DWH Emergency Response Manual: Forward & Section 1 32 MDL Exhibit 671: DWH Operations Manual, Vol 1 of 2: Section 2.1
The DEEPWATER HORIZON station bill, where the Master is listed as being in command during emergencies.33
A memo approved by Steve Newman, Transoceans CEO, addresses the Rig Chain of Command and stated the Offshore Installation Manager will remain overall responsible for the health, safety and welfare of all persons and all activities conducted onboard their respective rig. The OIM is authorized and obligated to take whatever actions he considers necessary to prevent injury, loss of life, damage to equipment/structure and/or loss of rig and well operation integrity.34
20.
The way that Transocean describes the command structure in the management system documentation is confusing and ambiguous, with many conflicting statements about when and whether the Master is appointed as the PIC during emergency situations, without clearly determining: What an emergency situation is; When it occurs; How the change of command will take place; and Who is in command at what time.
This is evidenced by: The Transocean Job Description for Master shows the Master reporting to the OIM but also exercise[ing] overriding authority and discretion to take whatever action is required for the safety of the crew, vessel, and protection of the environment.35 This is in inherently
contradictory, but also in conflict with the the Integration Memo approved by Mr. Newman and other manuals discussed here. The Transocean Emergency Management Procedures Manual assigns all responsibilities to the OIM, including that of maintaining emergency equipment. Masters Job Description.36 This is in conflict with
33 34
MDL Exhibit 960: DWH Station Bill MDL Exhibit 5643: Integration Memo, November 20, 2007 35 TRN-INV-00463941: Transocean Master Job Description; MDL Exhibit 942: Transocean Master Job Description 36 TRN-MDL-00046974: Emergency Management Procedures Manual
The DWH Emergency Response Manuals organisation chart shows the OIM in command. The Forward to the manual explicitly states that the organisation chart found on the following page will be used to define each of the specific emergencies, and as this manual deals with emergency scenarios, the assumption is that the OIM is in command at such times.37
The DWH Emergency Response Manual states in the Forward that change of command will be noted in the ships logbook, showing reason and time of change but offers no guidance on how or when this will be achieved.38
The DWH Emergency Response Manual states in the Well Control/Shallow Gas Blowout section that at level 3 (an uncontrolled blow out) the OIM Advises Master to Initiate Abandon Unit. 39 This appears to suggest that the OIM is still in command during an uncontrolled blowout emergency requiring evacuation of the vessel. Several instructions for various positions on the vessel in blow outs instruct that the person will execute a task when so ordered by the OIM/Master without specifying which one would be in command to give such orders under which circumstances. Other instructions provide that the person will execute certain procedures when directed by the OIM. The CCR will execute certain duties when the OIM/Master orders Abandon Unit while the Chief Engineer will prepare[] for Abandon Unit if so ordered by the Master and the RSTT/Medic will continue his duties until ordered to evacuate by the Master, making it unclear who is in charge during the type of emergency that might lead to an Abandon Unit order.
The DWH Emergency Response Manual states in the Hydrogen Sulphide section that the OIM is in overall command of gas control activities and the master is to be informed of the situation.40 At a level 3 gas emergency (an undefined term) the OIM advises the master that EDS will be initiated and to move away from site and implement Abandon Unit procedures. This again indicates that the OIM continues to be in command during an emergency requiring emergency disconnect of the rig from the well and/or an abandoning of the vessel.
MDL Exhibit 4644: DWH Emergency Response Manual: Forward & Section 1 MDL Exhibit 4644: DWH Emergency Response Manual: Forward 39 MDL Exhibit 4644: DWH Emergency Response Manual: Section 7 40 MDL Exhibit 4644: DWH Emergency Response Manual: Section 9
38
37
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The DWH Emergency Response Manual indicates that the only person with the responsibility to activate the EDS is the driller.41 No alternate is nominated.
The DWH Emergency Response Manual authorises 5 persons (Master, Mate, OIM, Toolpusher, and DPO) to order a red status during an emergency and effectively order EDS, because the Driller must EDS when a red status is achieved. This has the potential to
considerably confuse the command structure in an emergency. Captain John McDonald, Transoceans Marine Operations Manager responsible for marine operations, including the DWH, had a different understanding of who had authority to activate the EDS that is much broader than Transoceans manuals and procedures. It included the Captain, the DPOs, OIM, Toolpushers, Drillers, Assistant Drillers, and Subsea Engineers.42 The DWH Operations Manual in its Organisation section states the OIM can request the Master to assume the role of PIC at any time and the Master must not refuse.43 The DWH Operations Manual states that the Master advises the OIM of possible actions to take during emergency situations.44 This indicates that the Master still must report to the OIM before action is taken, even during emergencies. DWH Operations Manual, in the section on Uncontrolled Escape of Hydrocarbons, makes no differentiation between the responsibilities of the OIM and the Master and puts them both in overall command of the response to the incident.45 The DWH Operations Integrity Case (OIC) organisation chart shows all personnel, without exception, as subordinate to the OIM.46 The DWH OICs Marine Operation section states that ultimate responsibility for the safety of the installation and personnel remains with the OIM and the Installation owners at all times.47 The DWH OIC MODU organisation section states in DWH the OIM has overall responsibility for the command, activity co-ordination and control of management . . . while the Master provides marine support to the industrial operation.48
41 42
MDL Exhibit 4644: DWH Emergency Response Manual: Section 12 MacDonald Deposition, p. 168. 43 MDL Exhibit 671: DWH Operations Manual: Section 2.1 44 MDL Exhibit 671: DWH Operations Manual: Section 2.2 45 MDL Exhibit 671: DWH Operations Manual: Section 10.4.1 46 MDL Exhibit 5474: DWH Operations Integrity Case, Section 2: DWH Organization Chart 47 MDL Exhibit 5474: DWH Operations Integrity Case, Section, 2.3.10.1
An e-mail from Sven Kriedemann, Master of the Transocean drillship Deepwater Discovery, to his Marine Superintendent confirms the confusion with the dual command structure. When questioning the content of a letter from Transocean to the flag State, Kriedemann asks, The NOTICE OF PERSON IN CHARGE is mentioning that the Master (PIC) has got the legal overriding authority in situations involving safety. It is not clear if Safety is meant in times of Operation and Emergencies, or only Emergencies . . . Basically, what is my function, acting as advisor, or am I responsible for deciding, am I accountable or not?49 It is such questions that Kuchta may have been asking himself on the night of April 20, 2010.
An e-mail from Brent Young, Master of the DWH, to his Manager in Marine Operations asks Isnt the Master part of the rig staff? when questioning why in an e-mail from him, rig staff had been defined as OIM / Maintenance Supervisor.50
21.
It is not surprising that the crew of the DEEPWATER HORIZON on April 20, 2010 were confused, resulting in (1) a total breakdown of the command structure, (2) delays in sounding the General Alarm, (3) personnel taking action they were not authorised to take, and finally, (4) the critical delay in activating the Emergency Disconnect Sequence (EDS) that resulted in explosions, the total loss of the installation, and a consequent uncontrolled flow of well fluid.
Evidence of confusion of the DEEPWATER HORIZON crew includes the following: Andrea Fleytas, Dynamic Positioning Officer (DPO)51
She took it upon herself to activate the MAYDAY and GMDSS alarms. She told the Captain that she had issued the distress signal. The captain turned to her and cursed and said did I give you authority to do that?
. . . one minute before the distress signal was sent, Captain Kuchta wanted permission from Jimmy Harrell [OIM] to disconnect the EDS The captain was told they could not start anything. He replied fuck it.lets leave Dave Young [Chief Mate] came and told the Captain we have an uncontrollable fire. The Captain told Dave to calm down
48 49
MDL Exhibit 5474: DHW Operations Integrity Case, Section 2.2.1.5: MODU organization MDL Exhibit 5434: E-mail from Kriedemann to Rispoli (04.08.2010) 50 MDL Exhibit 5435: E-mail Young to MacDonald (05.07.2008) 51 MDL Exhibit 4472: Transocean Interview with Fleytas (06.24.2010)
Andrea took instructions from the Chief mate
David Young Chief Mate52

So who is in charge of the vessel?. . . The OIM . . . From the time you came on watch to the time you evacuated the vessel? . . . Yes. . . .to sort of review the Chain of Command. . ., the Captain or the Master of the DEEPWATER HORIZON was in charge in every way while the ship was underway from one drilling--one well location to another well location?. . .Yes.. . .While the the DEEPWATER HORIZON was drilling and latched onto the well, both the Captain and the OIM were in charge of different aspects of the DP positioned vessel at that time, correct?. . . They were in charge of different aspects of the vessel, yes.. . . They were each in command of something?. . . Yes.. . . Who was in charge during an emergency?. . . Master is in charge for an emergency situation. Okay. . . who determines that its an emergency? . . . any event that would deem the general alarm being sounded would be considered an emergency . . . did you deem the point in time when you pushed the button for the General Alarm that at that point it was an emergency . . . we were in an emergency situation when I hit the General Alarm, yes. . . .when you and/or the DPO sounded the general alarm, was that the point in time when everybody on the ship would know the Captain was in charge?. . . I cant speak for if they knew the Master was in charge.
Jimmy Harrell, OIM53 normally it would be a driller, toolpusher or the OIM to do the EDS yes . . . it would eliminate confusion if the OIM and the Master were the same person
Stephen Bertone, Maintenance Supervisor54 . . . walked in on Capt. Kuchta yelling at Andrea Fleytas. Curt was screaming at her asking why she had activated the EDS and saying they were not in distress Jimmy [Harrell] gave Chris [Pleasant] permission to activate [EDS]
52 53
Young Deposition, pp. 196-198 Testimony of Jimmy Harrell to the Joint Marine Board of Investigation 54 MDL Exhibit 4365: Transocean interview with Bertone (06.24.2010)
Chris Pleasant, Subsea Engineer55 Chris went to the Bridge, the captain said we are not EDS . . . Chris said FU . . . Chris hit the EDS.
22.
The delay in activation of the Emergency Disconnect Sequence (EDS) had significant consequences. The EDS, after which the well is shut in and the LMRP disconnected from the BOP, is designed to be completed in 26 or 51 seconds depending on the mode activated, EDS 1 or EDS 2.56 Several accounts demonstrate there was some 4 to 8 minutes between the blow out reaching the drill floor and the first explosion.57 Had the EDS been initiated at any time in that period, one or all of the explosions may have been avoided and there would have been potentially no or less loss of life, no loss of the ship and no subsequent pollution.
23.
The command structure implemented by Transocean placed the Master of the DEEPWATER HORIZON in a situation where he was unable to carry out his legal responsibilities effectively. He did not have the authority to implement the safety and environmental protection policy of the company in connection with all activities on his ship. He did not have the responsibility to motivate the crew, as he was not in command for the large majority of the time. He did not have the authority to issue appropriate orders and instructions in a clear and simple manner due to confused and contradictory statements in the management system. He did not have the responsibility to verify that specified requirements were being observed, as he had no authority over a large area of the installation. He did not have the single point, overall responsibility to report to shore based management.
Simply, the Master of the DEEPWATER HORIZON did not have overriding authority and responsibility from Transocean to take the decisive action he needed to take on April 20, 2010 to
55 57
MDL Exhibit 5629: Transocean Interview with Pleasant (05.20.2010) National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling Report, Ch. 4, p. 114
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56
MDL Exhibit 5173: Cameron EDS, MUX BOP Control System for DWH
57
National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling Report, Ch. 4, p. 114
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protect the crew, the vessel, and the environment. This constitutes major non-conformity with the ISM Code and contributed significantly to the outcome of events on April 20, 2010.
24.
Transocean was able to continue in its failure to clearly state the Masters authority when RMI, in the Safe Manning Certificate it issued,58 did not consider the DEEPWATER HORIZON as a Dynamically Positioned ship and hence one not requiring a Master when on location. Not surprisingly, following the incident, RMI admitted that this was a clerical error.59
25.
Similarly, DNV was complicit in justifying the dual command structure over the period of its certification of the DEEPWATER HORIZON from 2002 to 2010. The Masters overriding authority and responsibility is an absolute requirement of the ISM Code Section 5.2. At the Initial SMC audit of the DEEPWATER HORIZON in May 2002, the DNV auditor identified that the authority and responsibilities of the Master and OIM were in conflict and raised a non-conformity with ISM Code Section 3.2, requiring action to be taken by August 2002.60 There is no evidence of
corrective action being taken by Transocean within the agreed timescale, nor mention of it in the DEEPWATER HORIZON 2005 SMC Intermediate audit.61 At this time, DNV should have considered this as a reason for which the SMC may become invalid and notified the flag State, RMI.62 In 2009 at the Transocean DOC audit, Lead Auditor David McKay raised an observation regarding lack of clear compliance with ISM Code 5.1 noting that this finding had been previously observed.63 David McKay had very clear guidance from DNV on the interpretation of this
requirement of the ISM Code.64 DNVs guidance stated that it is a common misconception that the overriding authority of the Master applies to emergencies only. . . . the overriding authority of the Master is not limited to emergency situations. It applies to all circumstances affecting safety and pollution prevention.65 Considering this Guidance and recognising that a non-conformity had been raised in 2002, McKay should have raised a non-conformity in 2009 and escalated it to
58 59
MDL Exhibit 1726: RMI DWH Minimum Safe Manning Certificate MDL Exhibit 1787: RMI Letter to the Joint Marine Board of Investigation, September 14, 2010. 60 MDL Exhibit 5483 and Annex M: DNV ISM Code Certification Ship Audit Report, DWH, May 16, 2002 61 MDL Exhibit 1777: DNV Survey Report Intermediate ISM Audit, June 29, 2005 62 IACS Procedural Requirement No. 9 63 MDL Exhibit 1768 and Annex N: DNV Transocean 2009 DOC Audit (April 16, 2009) 64 MDL Exhibit 3163: DNV Guidance for Auditors to the ISM Code, pp. 24 65 MDL Exhibit 3163: DNV Guidance for Auditors to the ISM Code, pp. 24
a major non-conformity at the 2010 audit if Transocean had continued not to take corrective action. Through Transocean taking no corrective action in 2002, through DNV ignoring this in 2005 and through DNV only raising an observation in 2009, Transocean was able to maintain its dual command structure on DEEPWATER HORIZON. Had DNV issued a major non-conformity in 2005 and notified RMI, it is possible that the outcome of April 20, 2010 would have been different.
26.
Transocean knew that its statements of the Masters authority aboard its vessels were not clear and this was out of compliance with the ISM Code. Its own Corporate Designated Person for compliance with the ISM Code, Jimmy Moore, was made aware of the DNV observation at least during an internal ISM audit.66 The primary objective of the audit was to assess conformity of the Companys Management System against the requirements contained in the ISM Code. The Report reiterated the previously-documented DNV observation, DNV Observation: No clear and absolute indication of the Masters overriding authority and responsibility. The Report also stated that the Operations Performance and Marine Support groups are revising their departmental manuals. They were aware of the requirement to define the Masters overriding authority and responsibility and plan to include this change in the new versions.67
27.
It is worth noting that by implementing a dual command structure, Transocean is out of step with its industry peers.68 An overwhelming majority of Companies operating MODUs implement a single command structure in compliance with the ISM Code. Examples include: Pride Drilling (part of Ensco) shows in its DP Rigs organisation chart that the Master/OIM is the most senior person on board to whom all report.69 Maersk Drilling, which in its job description for the OIM states the OIM is shipmaster, holds the highest authority on board and manages all aspects of the offshore operation . . . Management is exercised in close consultation with the Barge Engineer, Maintenance Supervisor, Toolpusher and the Clients representative . . . The OIM is overall responsible for the safety of all personnel on board and for safeguarding the integrity of the MODU and the
66
MDL Exhibit 1471: Interoffice Correspondence - Internal ISM Audit, March 15, 2010 MDL Exhibit 1471: Interoffice Correspondence - Internal ISM Audit,March 15, 2010 68 See Appendix 6: Analysis of industry norm on dual command structure. 69 See Appendix 7: Pride Drilling DP Rigs Organization Chart
67
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environment . . . . The OIM has the authority to implement any action he deems necessary to gain control of an emergency or to prevent the potential for an emergency to arise. He is disciplinary superior to the Senior Tool Pusher. The job description also requires the OIM to hold a certificate of competency as a Master Mariner STCW II/2 (unlimited).70 Stena Drilling, which in the OIM job description states the qualifications as STCW Master Mariner with Class 1 Deck/Master Foreign Going (unlimited), GMDSS revalidated, Management of Offshore Emergencies and in roles and responsibilities co-ordinate the activities of the departments under the control of the Barge Master, Chief Engineer, Senior Toolpusher, Catering Manager, including all Operator and Service Company Supervisors.71
70 71
See Appendix 8: Maersk Drilling OIM Job Description Stena Drilling Job Description of the OIM
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28.
Major non-conformity #2 ISM Code Section 6 Resources and Personnel It is a requirement of the ISM Code Section 6.1.1 that the Master be properly qualified for command. There is no evidence that the OIM, nominated as the person in charge and in
command of the DEEPWATER HORIZON during the day to day operation of the MODU while it is drilling, was qualified in compliance with RMI requirements and IMO recommendations. Further the Master of the DEEPWATER HORIZON had not been properly trained by Transocean and was therefore not appropriately prepared or capable on April 20, 2010 to take the decisive action necessary to handle the emergency.
29.
It has already been established that within the meaning of applicable international, national and coastal state regulation that the DEEPWATER HORIZON was a ship and specifically a selfpropelled and dynamically positioned MODU. mandatory under the regulation of RMI. As such, compliance with the ISM Code was
30.
It has also been established that Transocean implemented a dual command structure on board the DEEPWATER HORIZON nominating two PICs, delegating authority and responsibility to the Master and the OIM, at differing times under differing circumstances.
31.
The OIM was nominated as being in command and the PIC, during the day-to-day operation of the MODU whilst it was drilling. The OIM was, therefore, in command of DEEPWATER HORIZON for the large majority of the time. The Master was nominated as being in command and the PIC, not only when the MODU was underway and/or moving to another location, but he was also brought out of the box to manage emergency situations as and when they occurred.
32.
ISM Code section 6.1.1 requires that the Company should ensure that the master is properly qualified for command.72 The OIM was not a Master according to accepted marine practice, but Transocean had given him overall responsibility73 and so during the day-to day operation of the MODU while the DEEPWATER HORIZON was underway in DP, he was effectively the
72 73
MDL Exhibit 938 and Appendix 3: ISM Code, Section 6.1.1 MDL Exhibit 939: Transocean ISM/ISPS MODU Handbook, Section 2
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Master. He was, however, not qualified to be the Master of the DEEPWATER HORIZON under international or flag State requirements.
33.
RMI has requirements for Merchant Marine Personnel Qualification which outlines the qualifications and experience personnel must have before undertaking marine examinations under the regime of the RMI.74 Section 4.5 specifically addresses Service Requirements for MODU Deck Officers Examinations - for MODUs but clearly notes that MODU certification does not permit service on board self-propelled MODUs such as the DEEPWATER HORIZON. Section 4.5.3 lists the requirements for Master Offshore Installation Manager, interesting terminology potentially combining the two positions. The prequalification service is clearly drilling rig oriented, requiring service on the drill floor or as Barge Supervisor but in any case having completed training in well control. There is no requirement for any marine training linked to the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW Convention) or the STCW Code, the competence requirements for merchant marine officers. RMI Guidelines for MODU Officers
Examinations contains the syllabus for OIM and other positions.75
34.
The Standards for Certification and Watchkeeping (STCW Code) adopted by all flag Administrations, including RMI, provides in Regulation II/2 the mandatory minimum requirements for Master and chief mate on ships of 3000 gross tonnage or more.76 This is the qualification required by the Master of the DEEPWATER HORIZON.
35.
IMO Resolution A.891(21), Recommendations on Training of Personnel on Mobile Offshore Units (MOUs), provides an international standard for training complementary to that required by the STCW Code.77 The recommendations are offered without prejudice to any rights of the coastal States who may wish to impose additional requirements. It is to be expected that RMI, as
74 75
Marshall Islands Guidance MI-118: Requirements for Merchant Marine Personnel Certification Marshall Islands Guidance MI-325: Guidelines for MODU Officers Examinations 76 International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW) 1978, as amended 77 International Maritime Organizations Resolution A.891(21) adopted on 25 November 1999, Recommendations on Training of Personnel on Mobile Offshore Units (MOUs)
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leading Members of IMO, will have adopted these Recommendations which are applicable to DEEPWATER HORIZON. Relevant sections include: 2.1.8 the OIM is the competent person appointed by the company as the person in charge who has complete and ultimate command of the unit and to whom all personnel on board are responsible; 2.1.13 3.1 the Maritime crew comprises amongst others, the OIM; every company employing personnel assigned to MOUs has responsibility for ensuring that the standards set out in the document are given full and complete effect; 4.1 all maritime crew members should meet the requirements of the STCW Convention.
The description of the OIM is coincident with that of the ship Master. The OIM is nominated as a member of the marine crew and as such shall have appropriate marine qualifications in compliance with the STCW Code. My interpretation of the intent is that the OIM and the Master are the same person and shall hold a certificate of competency as Master as defined in STCW Regulation II/2.
36.
Curt Kuchta, the Master of the DEEPWATER HORIZON, was certificated to be Master. He held: Master any gross tons upon oceans issued by the USCG valid to January 9, 201278 Master License issued by RMI no limitations valid to January 9, 2012,79 and OIM License issued to RMI valid to January 9, 2012.
37.
Jimmy Harrell, the OIM of the DEEPWATER HORIZON, was not qualified to be Master. He held: OIM License issued by RMI (presumed valid but not legible) endorsed MODU only; 80 Barge Supervisor issued by RMI (presumed valid but not legible) endorsed MODU only
As noted above, RMIs MI-118 states that MODU certification does not permit service aboard self-propelled vessels. 81 DEEPWATER HORIZON was a self-propelled MODU and Harrells
certification was not valid on this ship.
78 79
MDL Exhibit 3751: Kuchta USCG Licence MDL Exhibit 3753: Kuchta RMI Licence 80 MDL Exhibit 3802: Harrell RMI Licence 81 RMI MI-118
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38.
To be properly qualified for command of the DEEPWATER HORIZON required the Master, and OIM in the case of the DEEPWATER HORIZON, not only to hold statutory certification but also to have received training identified by Transocean as that required to support the safety management system.82 The training records of Kuchta83 and Harrell84 show them to have each attended a considerable number of courses during their employment with Transocean. Despite this, Curt Kuchta had not received critical training on Major Emergency Management, nor had he received any training in the operation of the EDS system.
39.
The Transocean OIC states that the OIM and the Master are both required to complete Major Emergency Management (MEM) training which includes assessment as PIC and training requirements for the Master include completion of the MEM course and assessment/qualification as PIC.85 It was the responsibility of the Rig Manager Performance (RMP) to ensure key rig personnel are trained, competent and licensed in all safety critical areas including ..Management of Major Emergency Training, Well Control..86 The lessons of the MEM course included: Understanding the philosophical differences between normal and major emergency management; Pro-active planning; Understanding the principles of command, control and communication; and Development of the discipline of implementation of the installations Emergency Response Plan. There is no record of Curt Kuchta ever having attended this critical training or of him ever being assessed competent as a PIC,87 the responsibilities of which had been assigned to him from the day he was appointed Master of the DEEPWATER HORIZON in June 2008.
82 83
MDL Exhibit 938 & Appendix 3: ISM Code, Section 6.5 MDL Exhibit 3747: Kuchta Training Record 84 MDL Exhibit 3804: Harrell Training Record 85 MDL Exhibit 5476: Operations Integrity Case, Section 5.3.1.2; MDL Exhibit 5474: Operations Integrity Case, Section 2.3.10.2 86 TRN-MDL-01159705: Slide 46: Rig Manager Performance Training Marine Module 87 MDL Exhibit 3747: Kuchta Training Record; MDL Exhibit 3750: Kuchta Training Certificates; MacDonald Deposition, pp. 180-184
The result of this was described by Doug Brown:88 How would you describe what was going on as a whole on the bridge? mayhemI was hearing shouts, directions being yelled that werent being enacted [at the lifeboats] no order, no control, no one in charge. Everybody just in a state of panic [at the lifeboats] chaotically pushing and shoving, not following the training that we did have for manning the lifeboats Chaos,
David Young, Chief Mate, told Transoceans Marine Operations Manager after the incident that Captain Kuchta was flustered at the rafts.89
40.
The OIC also requires that, in connection with response to emergency training, OIMs, Toolpushers, Drillers, Assistant Drillers, Derrickhands, Pumphands, and Floorhands attend Well Control Training at the required appropriate level.90 Masters, including Kuchta, nominated as the PICs during emergency situations were not included in those nominated to attend Well Control training. Further the DWH Emergency Response Manual, Vol. 1, required that weekly EDS drills be conducted.91 John MacDonald, the Transocean Marine Operations Manager, confirmed this and stated records of the drills were in the IADC Daily Drilling Report.92 Keeton, the DEEPWATER HORIZON Performance Manager, did not know if the requirement for EDS drills had been complied with and confirmed that he had not required them to be carried out.93 Yancy Keplinger, the senior Dynamic Positioning Officer, when asked whether weekly EDS drills were conducted, answered, I think so, . . . Im not 100% sure.94 Significantly the IADC Drilling Reports for 30 days prior to April 20, 2010 show that no EDS drills took place in that period.95
88 89
Brown Deposition, pp. 90, 98, 100 MDL Exhibit 5461: Transocean Interview of David Young, Chief Mate. 90 MDL Exhibit 5476: DWH Operations Integrity Case, Section 5.3.1.2 91 MDL Exhibit 4644: DWH Emergency Response Manual, Vol. 1, Section 12.2 92 MacDonald Deposition, pp. 192-193 93 Keeton Deposition, pp. 470 & 471 94 Keplinger Deposition, p. 150 95 IADC Daily Drilling Reports Nos. 03-34, March 20, 2010 to April 20, 2010
41.
Overall it is not the number of courses attended, but the right courses, that is key to ensuring that those responsible for the safety of the vessel, crew, and environment are properly qualified. The Transocean internal ISM audit in March 2010 recorded several instances in which personnel were not receiving the training required under Transoceans own training matrix, including those in emergency response and Health, Safety, and Environment.96
42.
The DEEPWATER HORIZON had two Masters and PICs. command:
Neither were properly qualified for
Harrell had no statutory certification in compliance with international or RMI regulations to be Master of the DEEPWATER HORIZON. Indeed, what qualification he did have were not valid on the DEEPWATER HORIZON.
Kuchta did have the required statutory certification, but Transocean failed him by not providing the essential MEM training identified in the OIC and assessing him competent to fill the position of PIC. Further, Transocean failed in that it did not identify the fact that Masters would be better equipped to manage emergency scenarios involving Well Control if they received appropriate training.
With training in Major Emergency Management and Well Control and involvement in weekly EDS drills, Captain Kuchta would have been better prepared to recognise the escalating situation on April 20, 2010, to take early and decisive action to operate the EDS which could have saved the DEEPWATER HORIZON and prevented the more serious release of hydrocarbons into the Gulf of Mexico that ensued as a result of the installations sinking.
43.
Simply, the Master and the OIM of the DEEPWATER were not properly qualified for command. This constitutes major non-conformity with the ISM Code, which resulted in loss of life, major pollution and the eventual loss of the DEEPWATER HORIZON.
96
MDL Exhibit 1471: Interoffice Correspondence - Internal ISM Audit, March 15, 2010
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Summary
44.
The MAHRA and OIC for the DEEPWATER HORIZON developed by Transocean in 2004 and 2008, respectively, demonstrate that Transocean recognised that the marine department, not only the drilling crew, plays a critical role in mitigation of major accident hazards for which the DEEPWATER HORIZON was at risk. Transocean failed, however, to implement the procedures that would ensure that emergency response training and drills were carried out and that the marine department, specifically the Master, would have the Ability to move off station at the time in the blowout scenario when the last clear chance to avoid catastrophe could be taken.
45.
As a Master Mariner, OIM, and Chairman of the working groups that developed the standards by which IACS Societies acting as Recognised Organisations carry out ISM compliance audits on behalf of flag Administrations, I conclude that Transocean was not operating the DEEPWATER HORIZON safely and in compliance with the requirements of the ISM Code in that there was objective evidence of major non-conformity with ISM Code Sections 5 and 6.
46.
Evidence shows that there was confusion of command and a lack of training and competence of the Master and OIM created by an improper, unclear, and confusingly divided command. Confusion on the bridge of the DEEPWATER HORIZON delayed the last clear chance to avoid a catastrophic explosion and loss of the installation, as well as the consequent deaths and resulting major pollution. A clear, unqualified, unambiguous command structure with the Master in charge at all times would make more probable an appropriate emergency response when it mattered the most.
47.
The long standing practices at Transocean had placed the Master in a box with little responsibility, authority or training. From there Transocean expected that he would be capable and prepared to instantly assume command of an escalating major emergency situation with no knowledge of what had gone before or what had gone wrong. Transocean expected, despite contradictory and confusing guidance, that the crew would somehow understand the point at which command of the ship had transitioned from the OIM to the Master.
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48.
The DEEPWATER HORIZON was drilling one of deepest wells in the deepest water. When a major emergency struck on April 20, 2010, its Master did not have a clear and unambiguous mandate from Transocean to unequivocally and immediately assume command authority, he did not have the knowledge to assess the deteriorating situation nor the competence to operate the EDS without any delay. This failure by Transocean to comply with international maritime standards, regulations, and practices led to avoidable tragedy.
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Annex A: The ISM Code
Background to the ISM Code
49.
The sinking of the Titanic in 1912 was the event which triggered the process leading eventually to the development of the ISM Code. This sinking, probably the first major marine casualty to gain world attention, resulted through public and hence governmental pressure in the formation of an international body to address maritime safety. Now known as the IMO, this body developed, and its members adopted, the International Convention for the Safety of Life at Sea (SOLAS) Convention. The IMO remit was stated as "to provide machinery for cooperation among Governments in the field of governmental regulation and practices relating to technical matters of all kinds.. Consequently, for more than 70 years, SOLAS addressed only technical items including ship construction, ship stability, lifesaving appliances and fire protection.
50.
Following large unexplained ship losses in the 1980s and particularly the capsize of the Herald of Free Enterprise in March 1987, it became clear that a technically sound ship was not necessarily a safe ship. At the conclusion of the Herald of Free Enterprise Enquiry, Lord Justice Sheen
commented, A full investigation into the circumstances of a disaster leads inexorably to the conclusion that underlying cardinal faults lay higher up in the company. He found staggering complacency on the part of the company and remarked from top to bottom, the body corporate was infected with the disease of sloppiness.
51.
This prompted the IMO to follow the lead of other industry sectors, such as Oil and Gas, to introduce safety management systems to identify and minimise risk in operations. In 1988, the IMO adopted Resolution A.647 (16), Guidelines on Management for the Safe Operation of Ships and for Pollution Prevention, followed by Resolution A.680(17) and subsequently Resolution A.741(18) International Management Code for the Safe Operation of Ships and for Pollution Prevention (The ISM Code) in November 1993.
52.
The ISM Code is based on the principles of quality management as expressed in ISO 9002:1987 (as amended) providing a management framework, but with a focus on safety and pollution
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prevention. In recognition of the complexity of the marine industry, the Preamble to the ISM Code states the ISM Code [is] expressed in broad terms so that it can have wide spread interpretations and recognising that no two shipping companies are the same . . . the Code is based on general principles and objectives.
53.
The ISM Code primarily applies to all ships, including MODUs, which trade internationally and are over 500 gt. It had a mandatory implementation over a period of four years; passenger ships, tankers and high speed craft to comply by July 1998 and the remainder by July 2002. DEEPWATER HORIZON fell into this latter group.97 To date, approximately 6,500 companies and more than 50,000 ships have been certificated as being in compliance with the ISM Code.
54.
The ISM Code has been amended and re-issued twice since its introduction, the 2002 Edition being in force in April 2010.
Objectives of the Code98
55.
The objectives of the ISM Code are to ensure safety of life at sea, prevention of human injury or loss of life, and avoidance of damage to the environment, in particular to the marine environment and property.
56.
Following from this, the safety management objectives of the Company should, inter alia: provide for safe practices in ship operation and safe working environment, establish safeguards against all identified risks, continuously improve safety management skills of personnel ashore and onboard ships, including preparing for emergencies related to both safety and environmental protection.
97 98
See Appendix 4 (The applicability of the ISM Code to MODU operations) MDL Exhibit 938 and Appendix 3: ISM Code Section 1.2
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The Safety Management System (SMS) 57. The Company is required to achieve its objectives through the development, implementation and maintenance of a safety management system (SMS) which includes the following functional requirements: a safety and environmental policy; instructions and procedures to ensure compliance with relevant international and flag State legislation; defined levels of authority and lines of communication between, and amongst, shore and shipboard personnel; procedures for reporting accidents and non-conformities with the provisions of this Code; procedures to prepare for and respond to emergencies; and procedures for internal audits ad management reviews.
58.
In meeting the above requirements the safety management system should ensure: compliance with mandatory rules and regulations that applicable codes, guidelines and standards recommended by the IMO, Administrations, classification societies and maritime industry organisations are taken into account
DOC and SMC Certificates
59.
SOLAS Chapter IX, Regulation 4 details the requirement to issue certification by the Administration, while Regulation 6 requires the Administration to verify proper functioning of the ships safety management system.
60.
Compliance with the ISM Code is signified through the issue of two certificates, one to the Company, one to the ship. These are detailed in ISM Code Part B Certification and Verification. This was the first time that SOLAS has imposed requirements on a Company, up to this time SOLAS had only applied to ships.
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61.
The Document of Compliance (DOC)99 is issued to the Company to certify that the safety management system of the Company has been audited and that it complies with the requirements of the ISM Code for a specific ship type. The certificate is valid for a period of up to five years subject to successful annual verifications at the Company premises.
62.
The Safety Management Certificate (SMC) 100 is issued to a ship to certify that the safety management system of the ship has been audited and that it complies with the requirements of the ISM Code, following verification that the DOC for the Company is applicable for the ship type. The certificate is valid for a period of up to five years subject to at least one successful intermediate verification. An SMC cannot be issued without a valid DOC for the appropriate ship type being in place.
99
100
E.g. MDL Exhibit 953 and Annex J E.g. MDL Exhibit 1776 and Annex K
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Annex B: Enforcement of the ISM Code
Flag Administrations
63.
The responsibility for the enforcement of the ISM Code belongs to the signatories to the SOLAS Convention: the flag Administrations. Administrations enact the requirements of SOLAS IX and the ISM Code through their own legislation. In the case of the Marshall Islands this is through Marine Notice No. 2-011-13 as amended and specific to MODUs in the Mobile Offshore Drilling Unit Standards Part III - M. In the case of the United States this is through 33 C.F.R. Part 96 Rules for the Safe Operation of Vessels and Safety Management Systems. In both cases it is clear that the ISM Code applied to Transocean and the DEEPWATER HORIZON in April 2010.
64.
Recognising the need for uniform implementation of the ISM Code by the Administrations, The IMO in 1995 adopted Guidelines on Implementation of the ISM Code through Resolution A.788(19). These were amended by A.913(22) and adopted in November 2001 which state in the Introduction that effective enforcement by Administrations must include verification that the safety management system complies with the requirements as stipulated in the ISM Code as well as verification of compliance with mandatory rules and regulations.
65.
The Guidelines lay out the process of verifying compliance with the ISM Code, the certification process, the standards on ISM Code certification arrangements, and the competence of auditors. They also provide for Administrations to appoint Recognised Organisations (RO) to issue DOCs and SMCs on their behalf.
Recognised Organisations
66.
While several Administrations issue ISM certification themselves, the majority do not. They have neither the technical knowledge, nor the resources, to carry out their responsibilities under UNCLOS Article 94 and SOLAS and so delegate to Recognised Organisations (RO). IMO Resolution A.739 (18) 1993, Guidelines for the Authorization of Organisations Acting on behalf of the Administration and IMO Resolution A.789 (19) 1995, Requirement to be a Recognised Organisation lay down
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minimum requirements for ROs. The major classification societies, those forming the International Association of Classification Societies (IACS), have been found to meet these Requirements by the majority of Administrations, including RMI, and act as their ROs. In the case of Transocean, DNV acted as the RO for the RMI.
67.
The RO is responsible and accountable to the flag Administration for the work that it carries out on its behalf. The RO carries out its work in accordance with the IMO Resolutions and any guidelines and additional requirements provided by the Administration.
68.
There are currently more than 50 organisations that offer classification services to the industry. Many of these are small and have limited technical ability. However the leading thirteen societies, including Det Norske Veritas (DNV), form IACS, which has strict criteria for membership. These include: ability to develop, apply, maintain, regularly up-date and publish its own set of classification rules in the English language, ability to survey ships under construction in accordance with its rules and statutory IMO and flag State requirements, have sufficient international coverage by exclusive surveyors, have independence from ship-owning, ship-building and other commercial interests which could undermine the societys impartiality.
69.
Recognising the need for uniform implementation of the ISM Code certification requirements when acting as ROs, IACS formed a working group (chaired by the Author) to develop mandatory Procedural Requirements. These requirements, known as PRs, address the ISM audit process and issue of certificates (PR 09) and the competence of auditors (PR 06 and PR 10). In addition two more PRs, PR 17 Reporting by Surveyors of Deficiencies relating to Possible SMS Failures and PR 18 Transfer of SMS Certification, are also relevant. These PRs form the basis of
individual ROs mandatory procedures, which are approved by the Administration prior to authorisation to act on their behalf.
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Port State Control
70.
In recognition of the fact that in some cases it may be difficult for the Administration to exercise full and continuous control over some ships entitled to fly its flag, there is provision in SOLAS for the inspection of foreign ships in national ports to verify that the condition of the ship and its equipment comply with the requirements of international regulations and that the ship is manned and operated in compliance with these rules. However the primary responsibility for ships' standards rests with the flag State, with port State control providing a "safety net" to catch substandard ships.
71.
IMO adopted Resolution A.882(21), Amendments to the Procedures for Port State Control (A.787(19)) in November 1999. This Resolution contained an amendment at 3.7, providing
Guidelines for port State control related to the ISM Code. This empowers PSCO to examine the ISM certificates on board a ship and, if clear grounds are established, to carry out a more detailed inspection based on an 11 point checklist. Deficiencies identified are communicated to the flag State and may result in detention.
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Annex C: The ISM Code and other Rules, Regulations, Codes, Guidelines and Standards
72.
ISM Code 1.2.3.1 requires that the safety management system should ensure compliance with mandatory rules and regulations. Primarily these are the rules and regulations promulgated by the Organisation (e.g. MODU Code), the applicable flag State and also classification societies (as the requirement to maintain a ship in class is a SOLAS requirement). They may be supplemented by requirements from the port State, the coastal State or a Government in whose exclusive economic zone the ship may be operating.
73.
ISM Code 1.2.3.2 requires that the safety management system should ensure applicable codes, guidelines and standards recommended by the Organisation, Administrations, classification societies and maritime industry organisations are taken into account. Where such
requirements are not implemented, it is incumbent on the company to demonstrate why they were not and what, if any, equivalency has been adopted.
74.
ISM Code 1.2.2.2 requires the Company to assess all identified risks to its ships, personnel and the environment and establish appropriate safeguards. This means all the risks on board the ship, there are no exclusions provided for. In the case of the MODU this will include the drilling operation, the operations of any contractors and the inter face with support vessels.
75.
It is clear from the above that the scope of the SMS shall address all operations on board MODUs, such as the DEEPWATER HORIZON, and as such, all operations shall be subject to audit during DOC and SMC ISM audits.
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Annex D: The ISM Code Verification
The External Audit Process
76.
The following process is that followed by an IACS society acting as an RO implementing IACS PR 9 and PR 10.
77.
ISM verification audits may only be carried out by personnel who meet the competence requirements stated in the Appendix to Resolution A.913(22), paragraphs 3.2 and 3.3, as expanded in IACS PR 10 and detailed in the ROs own procedures. In the case of Transocean and the DEEPWATER HORIZON, David McKay, the DNV Lead Auditor, was a marine surveyor, with no marine qualifications and no formal training in drilling operations.101
78.
At the first part of the initial company audit for the issue of a DOC, the Document Review, the auditor will verify that the SMS documentation complies with the objectives of the ISM Code and is applicable to the ship type(s) which the company operates. At the Initial Audit he will establish through sampling,102 objective evidence,103 and interviewing company personnel that the SMS is effectively implementing the company safety and environmental protection policy and objectives. Objective evidence will include records of personnel, training, shipboard maintenance, emergency provisions, internal audits and inspections. A successful audit will result in the issue of a DOC on behalf of the Administration.104
79.
At the Initial SMC shipboard audit the auditor, following an opening meeting, will first interview the Master to verify that: the Company has a valid DOC for the applicable ship type, that the ship is maintained in compliance with the requirements of a classification society,
101 102
McKay Deposition The auditor will review sufficient objective evidence to provide him with a level of confidence to make a decision on the level of compliance with a stated requirement or procedure. It is not a quantative process. 103 MDL Exhibit 938 and Appendix 3: ISM Code, Section 1.1.7 104 See Annex J: DOC issued to Transocean
that the ship is in compliance with mandatory rules and regulations and that all statutory certificates are valid, that applicable codes, guidelines and standards recommended by the IMO, the Administrations and maritime industry organisations have been taken into account. He will establish through walking around the ship, interviewing personnel and sampling objective evidence that the SMS is being implemented effectively onboard. Objective evidence will
include records of competence, maintenance, and emergency exercises, and follow up on internal audits and inspections. A successful audit will result in the issue of a SMC on behalf of the Administration.105
80.
In addition to the Initial and Renewal audits, there is a requirement for Annual verification audits of the company and Intermediate audits of the ship. These take place as determined by the Code and verify that the SMS continues to be implemented effectively and that it is still applicable to the relevant ship type.
In the office the auditor will typically review objective evidence related to management control processes, such as incident, near miss, and defect reporting; preventive and corrective action; safety meeting minutes; management review meeting minutes etc.; and all the objective evidence which shows the relationship and communications between the ships and the management ashore is secure.
On the ship the auditor will seek to verify that the day to day requirements of the SMS are being complied with and that the communication link, specifically to the DP and senior company management is working.
105
See Annex K: SMC issued to DEEPWATER HORIZON
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Reporting the Audit Findings 81. Audit findings are conveyed in a report as observations, non-conformity or major non-conformity against compliance with the requirements of the ISM Code and Company requirements. By its nature, an audit106 is a sampling process, it is not an inspection.107 82. An observation is a statement of fact substantiated by objective evidence. An observation will be raised by an auditor when a finding has the potential to become a non-conformity in the future, if no action is taken by the Company. 83. A non-conformity means an observed situation where objective evidence indicates the nonfulfilment of a specified requirement in the SMS or the ISM Code. The auditor will require corrective action to be taken within a stated period of time dependant on the severity of the non-conformity. This is generally up to three months from the date of the audit. 84. A major non-conformity means an identifiable deviation that poses a serious threat to the safety of personnel or the ship or a serious risk to the environment that requires immediate corrective action and includes the lack of effective and systematic implementation of a requirement of the ISM Code.
Major non-conformity raised on a ship will result in detention and generally results in an Additional audit of the Company. Should the related findings in the company be judged to be systematic and the lack of effective implementation of a requirement of the ISM Code, immediate corrective action will be required. If this action is not taken to the satisfaction of the auditor and within the required time scale a recommendation will be made to the Administration to withdraw the DOC. Withdrawal of the DOC results in the withdrawal of all associated SMCs.
Follow Up and Close out of the Audit 85. It is the responsibility of the Company to identify the corrective action and advise the RO. Corrective action will generally take two forms:
106 107
An examination of records to check and verify their accuracy through a sampling process. To examine items carefully and critically, especially for flaws using a checklist
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The immediate action needed to prevent recurrence of the non-conformity at the location Longer term action, known as preventive action arising from identification of the root causes, to prevent recurrence of the non-conformity in other locations in the company. This will generally involve an amendment to the management system.
86.
On receipt of the corrective action plan from the Company, the RO will, having considered its adequacy, accept or reject the plan. The effectiveness of the action taken will be assessed at the next scheduled audit and the non-conformity will be closed out. When all non-conformity is closed out, the Audit is considered closed.
87.
Should the Company not take corrective action within the agreed time schedule; the RO will consider this to be a reason for which the SMC or DOC may become invalid. If it is considered that by not taking corrective action poses a serious threat to the safety of personnel and ships, or is a serious risk to the environment and includes the lack of effective and systematic implementation of a requirement of the ISM Code, the RO will raise a major non-conformity. In all cases the flag Administration will be informed of the circumstances.
The Internal Audit Process
88.
Section 12 of the ISM Code requires companies to carry out internal audits of their SMS on an annual basis. The Code is not prescriptive as to how this will be done but all sections of the Code should be addressed and corrective actions identified should be followed up in a timely manner.
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Annex E: A Typical SMS for a Company operating a MODU
Organisation for effective HSE management
89.
The ISM Code states the cornerstone of good safety management is commitment from the top. This requires the CEO and other senior managers to be personally involved in safety management at the appropriate level, providing support to the Designated Person, a statutory requirement of the ISM Code.108 The management of safety must be integrated into all company activities and its implementation the responsibility of operational managers. Health, safety and environmental specialists may form a support group, but must be advisors and auditors, providing confidence to management that the SMS is being implemented effectively.
Scope of the SMS
90.
Apart from the statutory requirement for the SMS to ensure compliance with mandatory Rules and Regulations and that applicable Codes shall be taken into account, the overarching requirement is that the company shall assess all identified risks to its ships, personnel and the environment and establish appropriate safeguards. This process of risk assessment encompasses all activities on the MODU: marine and drilling related activities and those activities of specialist Third Party contractors. It follows that the SMS shall address all activities on the MODU.
Bridging Documents
91.
The Company has the non-delegable duty to provide a safe place of work for its employees through its safety management system. However, the oil majors contracting the MODU will have their own SMS and may require specific input to individual operations. This is allowed for through the Bridging Document where the two SMSs are compared and any gaps or additional requirements are identified. Regardless, it is the SMS of the Company operating the MODU
108
MDL Exhibit 938 and Appendix 3: ISM Code, Section 4

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which takes precedence and is the controlling document. This must be clearly recorded to avoid confusion at a later date.
92.
Likewise, the SMS of a Third Party contractor employed by the Company or the oil major to work on the MODU will be compared and a Bridging Document created to identify additional requirements and key responsibilities.
93.
All Bridging Document form part of the SMS and are subject to audit by the RO.
Structure of the SMS
94.
There is no prescriptive structure for an SMS. It will depend entirely on the size and complexity of the Company and in many cases, its geographical spread. Generally the more complex the company, the more complex the SMS. Some large international companies have a single SMS implemented through several divisions and multiple offshore locations, the approach taken by Transocean. Other companies break their operation into smaller entities and multiple DOCs to simplify implementation of the SMS.
95.
A typical SMS may comprise three levels; corporate policy, company procedures, local work instructions. The policies provide management commitment to stated objectives, the company procedures describe what must be done to achieve the objectives, and the work instructions state how this is to be achieved in the work place. Supporting these are many third party
documents such as nautical publications, equipment manufacturers instructions, classification society records, builders drawings.
Content of the SMS
96.
The ISM Code was developed primarily for conventional ship types trading internationally but also applies to other minority ship types, MODU being one of them. The SMS shall ensure the Company meets the requirements of ISM 1.2 Objectives, and in so doing addresses each section of the Code. Standardized interpretations of the sections have been adopted by the marine
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industry, but where specific interpretations for MODUs are required I have given my opinion in the following paragraphs.
97.
ISM Code Section 5:
Masters Responsibility and Authority:
ISM 5.2 requires the Company to establish in the safety management system that the master has the overriding authority and the responsibility to make decisions with respect to safety and pollution prevention and request the Companys assistance as may be necessary. The term overriding implies a single point of command. The term safety applies to all operations, the Code does not provide for exceptions. With this being the case the Master has single point
responsibility for all operations on board the MODU at all times. This is supported by DNV Guidance for Auditors to the ISM Code109 and encapsulates the USCG requirement for a Person in Charge (PIC) during emergencies.110 How, in an organisational sense, this is achieved is the responsibility of the Company to demonstrate to the flag State. It is recognized that the drilling operation, ballasting, DP are all complex activities requiring specialised personnel to ensure a safe operation. The Master may be qualified to undertake such responsibilities or he may
manage a team, or teams, reporting to him. However, it must be clear from the organisation chart that the Master is in command at all times and the Company will be required to demonstrate the efficacy of the organisational arrangements.
In the majority of cases there will be a Company Man resident onboard to ensure that the Operators contractual requirements, including the conditions imposed in the Bridging Document, are fulfilled through the Company management system. The Master is responsible to manage the Operators expectations; the Company Man cannot override the Masters authority.
98.
ISM Code Section 6:
Resources and Personnel
ISM 6.1 requires the Master to be properly qualified for command. This term requires the master to have the formal qualifications required by the flag State supported by any additional qualifications required by the Coastal State or that the company may have identified through risk assessment or industry standards. IMO Resolution A.891(21) provides specific guidance on the
109 110
MDL Exhibit 3163: DNV Guidance for Auditors to the ISM Code, pp. 24 46 C.F.R. 109.107
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subject making the position of Master synonymous with that of OIM111 requiring him to have marine qualifications and oil industry training.112
ISM 6.1.2 requires the Master to be fully conversant with the Companys SMS which will encapsulate all activities on board to a greater or lesser degree. There will be no operation carried out in which the Master does not have some knowledge or influence over.
ISM 6.1.3 requires that the Master be given the necessary support to safely perform his duties. This shall be through the MODU departmental organisation and access to onshore support as and when required. Drilling and associated activities are specialised operations requiring
experienced, competent personnel. The SMS should ensure that such personnel are competent to accepted industry standards. The remainder of this section of the Code has a clear translation into MODU operation requiring competent personnel on board as defined in A.891(21) and adopted by the flag State, supplemented by any additional training identified through risk assessment.
99.
Section 7:
Shipboard Operations
The requirement is to establish procedures, plans and instructions. Here the emphasis is on the term key shipboard operations linked to the requirement in ISM 1.2.2.2 to assess all identified risks, resulting in procedures, plans and instructions for all MODU operations as being within the SMS.
Dependant on the organisational setup, the procedures are owned by the department head that has the responsibility to implement them through delegation to competent subordinates. For example, the drilling procedures will be owned by the toolpusher, whoever is organisationally head of that department. However this responsibility does not detract from the overriding responsibility of the Master to coordinate all activities on the MODU. There is no requirement for the Master to have the detailed technical knowledge; his role is that of co-ordination and
111
International Maritime Organizations Resolution A.891(21) adopted on 25 November 1999, Recommendations on Training of Personnel on Mobile Offshore Units (MOUs) 2.1.8 112 bis 4.1, 4.2, 5.2, 5.3, 5.4, 6.2
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management, making decisions based on expert advice. In other words, while it is very sensible to combine the role of OIM and Master in one person, it is also possible to have a Master who is primarily a mariner but who is trained in well control and drilling at a basic level but does not directly manage drilling operations, while there is a drilling superintendent in charge of the drilling operation. 100. Section 8: Emergency Preparedness
The requirement is to identify potential emergency shipboard situations and establish procedures to respond to them. This includes all situations which may occur on the MODU whether marine or drilling related; there are no exceptions. procedures must fit seamlessly with the onshore support. The shipboard emergency It is obvious that specialised
procedures will be applicable to downhole incidents and the responsibility to implement will remain with those with the expert domain knowledge. However the ultimate and overriding responsibility rests singularly with the Master to take action based upon his knowledge and experience and advice taken from others.
101.
Section 9: Occurrences
Reports
& Analysis
of Non-Conformities, Accidents, and Hazardous
This is a key element in achieving the ISM Code objective of continuous improvement. The procedures shall address all non-conformities, accidents and hazardous occurrences on board and ensure that the root causes are correctly identified and preventive action fed back into the management system.
102.
Section 10:
Maintenance of the Ship and Equipment
ISM section 10.1 requires that the company should establish procedures to ensure the ship is maintained in conformity with the provisions of the relevant rules and regulations . . . . These include the requirements of the MODU Code and hence the requirement is to maintain both marine and drilling equipment under the ISM Code.
ISM 10.3 specifically requires the identification of equipment and technical systems, the sudden operational failure of which may result in hazardous situations . . . and provide for specific
measures aimed at promoting reliability of such equipment and systems. Such equipment and systems on a MODU include DP systems, well control, fire and gas detection systems, power generation and should be prioritised in the maintenance systems (ISM 10.4).
103.
Section 11:
Documentation
The simplistic requirement is to maintain a companywide document control system providing valid, up to date documents for the operation of the fleet. There is no prescriptive method by which this has to be achieved but considering the diverse scope of documents required for a fleet of MODUs, an effective system is essential.
104.
Section 12:
Company Verification, Review and Evaluation
Internal audits shall verify whether safety and pollution activities comply with the safety management system. Having established that the ISM Code and SMS applies to all activities on the MODU then the scope of the audits shall address all activities on board.
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Annex F: The SMS implemented by Transocean
Structure of the Transocean Company Management System (CMS)
105.
Transocean implements a complex CMS, its structure being based on the eight core management functions of the Company. The system is formatted in 3 Levels, albeit Level 1 is subdivided. It is distributed in electronic format as E-docs. Level 1 comprises the Company Management System Manual which is the lead document. It defines management expectations and requirements. Level 1A comprises the corporate department policies and procedures which define the expectations and requirements for each core function in the company. Level 1B comprises the corporate department support documentation. additional support in achieving the requirements specified in Level 1A. Level 2 are Division or Unit documents deemed necessary to address local specific requirements. Level 3 are Rig specific documents which describe the activities required to safely execute work to meet corporate, client and regulatory requirements. The structure, naming convention and relationship between the documents is described in the Level 1 document.113 These provide
106.
The style of the management system is one of providing detailed information through a vast library of documents on a myriad of topics. It is organised under headings which, to many readers, will give no idea of where to find specific items, e.g. Travel is contained under
Implementing and Monitoring. Some sections, while containing sound information, read like a text book, e.g. Management Principles. There is repetition between documents, e.g. Management of Change. Other documents contain conflicting and confusing information, e.g. references to the Master and OIM. Periodic review is required and essential.114 Change to the management system is formally captured, reviewed, communicated and executed through the
113 114
MDL Exhibit 925: HQS-CMS-GOV: Company Management System Manual, Section 5.2 Exhibit 938: Appendix 3: ISM Code 12.2
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System Management and Review Team (SMART) process.115 While the process is valid, it is complex and takes 16 pages to describe. The ability to affect change in a reasonable timescale is questioned. This may be immaterial as Rose said it is not revised that often, it would not change any substance of it if there was (sic). It would probably be a minor revision to organisation or something, or titles.116 Despite this he then went on to admit the organisation chart shown in the CMS Manual was out of date.117
107.
Complex and detailed management systems satisfy the management need to inform employees, the converse being that it may not be implemented on the rig floor. This may be the case at Transocean and specific areas are addressed later in this Report. Comments such as it is designed by a load of college people who dont know about the operation and written for the courtroom and not the oilfield118 are extreme but have some truth.
Major Accident Hazard Risk Assessment (MAHRA) As a requirement of the Health and Safety Policies and Procedures Manual 4.2.1 (4.7),119 Transocean in 2004 prepared the DEEPWATER HORIZON MAHRA.120 The objective was to
108.
demonstrate that major hazards have been identified; the risk associated with the hazards has been qualitatively assessed, and that preventive and mitigating controls necessary to reduce the risk to as low as reasonably practicable (ALARP) have been identified.
Operations Integrity Case (OIC) 109. As a further requirement of the Health and Safety Policies and Procedures Manual 4.2.1 (4.7), Transocean in 2008 prepared a DEEPWATER HORIZON OIC.121 This demonstrates and provides assurance that risks associated with hazards relevant to operation of the MODU have been
115 116
MDL Exhibit 925 Company Management System Manual, Section 5.1 Rose Deposition, p. 46 117 bis page 48 118 MDL Exhibit 929: Lloyds Register Safety Management and Safety Culture/Climate Review (March 16, 2010) 119 MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 4.2.1 120 MDL Exhibit 2187: DWH Major Accident Hazard Risk Assessment (MAHRA) ( 29 August 2004) 121 MDL Exhibits 5473, 5474, 5475, 5476 & 5477: DWH Operations Integrity Case, Sections 1, 2, 4, 5, & 6.
identified, and that within Transoceans management system controls for those risks have been identified and evaluated [and] are effectively managed.122
110.
From the sections of the MAHRA and OIC which I have seen, I have no criticism of the method and systematic processes employed to identify hazards, quantify residual risk and state mitigating controls to achieve ALARP. They follow standard formats and industry guidance and commit Transocean from the highest level of management to implementing detailed processes and procedures. Unfortunately the controls were poorly implemented.
Scope of the Transocean SMS
111.
There is a level of uncertainty as to what comprised the Transocean SMS in 2010. There is a family of documents with the generic indicator, HQS-HSE-XX-XXX, however: Adrian Rose stated that the CMS defines which documents form the Safety Management System.123 The definition could not be identified. The ISM/ISPS Handbook as a management resource for the Rig Managerto ensure the ISM Code is implemented correctly states that the CMS is considered a SMS.124 The Lloyds Register Report confirms that the crew considered that the SMS consisted only of the Health and Safety Policy and Procedures manual and found it vague and ambiguous and interpretation is often required.125 Gerald Canducci, the Transocean division Designated Person for ISM for the DEEPWATER HORIZON, excluded one section of the ISM Code from the SMS by stating maintenance of equipment is outside the safety management system.126 The Health and Safety Policies and Procedures Manual lists the sections of the management system considered as meeting the requirements of the ISM Code.127 They are analysed in Annex P.
122 123
MDL Exhibits 5473: OIC Section 1: Introduction Rose Deposition, p. 45 124 MDL Exhibit 939: Transocean ISM/ISPS MODU Handbook, Forward and Section 2.5.1 125 MDL Exhibit 929: Lloyds Register Safety Management and Safety Culture/Climate Review (March 16, 2010) 126 Canducci Deposition, p. 92 127 MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 2.4
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112.
The main Transocean documents which I consider are required to comply with the ISM Code are shown in Annex Q. Those considered necessary by Transocean are circled in red. The difference is due to the narrow interpretation of the requirements of the ISM Code by Transocean. Notably, Well Control and BOP Operations are excluded. For some reason not identified, the Marine Compliance Manual, Lifting Operations, and the Level 3 DEEPWATER HORIZON documents, Bridge Procedures, and Operations Manual are also excluded.
113.
Due to a lack of a clear definition of the Transocean SMS, it is unclear what the DNV auditor, David McKay, considered to be the SMS. At the Annual DOC Audit 2007,128 2008129 and 2009130 he interviewed representatives from the HSE Department, Human Resources, Engineering, Maintenance, Operations and Marine Support. Nowhere does the audit documentation state the scope of the audit other than to say it was to assess the ability of the SMS to meet the requirements of the ISM Code. On the DEEPWATER HORIZON at the Intermediate ISM Audit 2005131 and the Renewal SMC Audit on DWH 2007132 McKay excluded the drilling operation. In his deposition he agreed he had received no formal training in drilling operations, well control issues or operational equipment and that drilling is not part of your ISM audit.133
114.
Where drilling is seen to be a standalone operation independent of the marine operation, the result is an incorrect interpretation of the ISM Code.
Bridging Documents
115.
Through the Drilling Contract signed in 1998, BPs predecessors engaged a MODU later to be known as DEEPWATER HORIZON.134 In section 17.1 it states Contractor shall have the primary responsibility for the safety of all its operations, shall take all measures necessary or proper to
128 129
MDL Exhibit 1766: Transocean DOC Audit 2007 MDL Exhibit 1767: Transocean DOC Audit 2008 130 MDL Exhibit 1768 and Annex N: DNV Transocean 2009 DOC Audit (April 16, 2009) 131 MDL Exhibit 1777: DWH Intermediate SMC Audit 2005 132 MDL Exhibit 1778: DWH Renewal SMC Audit 2007 133 McKay Deposition, p. 144 134 MDL Exhibit 4271: BP Transocean Drilling Contract (1998)
protect the personnel and facilities and, in addition, shall observe all safety rules and regulations of any governmental agency having jurisdiction over operations conducted hereunder. Contractor shall place the highest priority on safety while performing the work. Exhibit D of this contract amplifies the HSE requirements through 13 additional BP requirements.
116.
In June 2005 the BP-Transocean HSE Management Systems Bridging Document was issued, the latest revision being issued October 2008.135 This appears to be a generic document addressing all BP-Transocean activities in the Gulf of Mexico, including the DEEPWATER HORIZON. In
Purpose and Scope it is stated that TODDI NAM [Transocean] has an HSE management system that provides the framework through which all operations are conducted, confirming the contractual requirement that Contractor shall have the primary responsibility for the safety of all its operations, including those on the DEEPWATER HORIZON.
117.
The scope of the BP additional requirements (section 2) and the limited amendments (section 4.0) indicate the confidence that BP had at that time in the Transocean management system and the safety culture which existed to manage the risk inherent in delivering the Terms of the Contract. Section 3 appoints a Core and Extended Steering Team comprising both BP and
Transocean senior staff to resolve BP/TODDI NAM gaps in the HSE system and to review and implement new programs, and section 4 indicates that this team made changes in 2006 and 2008.136 Disappointingly, Gerald Canducci at his deposition, stated that he had had no practical involvement in the current document other than to extend it when it came to its termination.137 118. The confidence of BP in the Transocean management system and safety culture is evidenced through the results of the September 2009 CMID Audit findings and the quick response by Transocean in preparing an Action List138 supported by Daun Winslow, the Operations Manager, stating lets get a game plan together when communicating with his managers.139 It was
135 136
MDL Exhibit 948: BP-Transocean HSE Management System Bridging Document MDL Exhibit 948: BP-Transocean HSE Management System Bridging Document 137 Canducci Deposition, p. 609 138 MDL Exhibit 956: DWH BP CMID Audit Work List September 2009 139 MDL Exhibit 955: Winslow Email, August 17, 2009
further strengthened through DEEPWATER HORIZON achieving seven years operation with no lost time injury cases reported.
119.
It was a requirement of the Drilling Contract that Transocean would ensure that similar HSE standards were applied by their sub-contractors when carrying out work under the prime contract.140 To facilitate this it would be normal for Transocean, as the prime contractor, to have developed Bridging Documents with their key specialist contractors, e.g. the providers of marine support vessels. I have been unable to identify such documents. With this being the case there is the possibility that individual contractors employed on, or in connection with, DEEPWATER HORIZON were working as individuals with potentially safety critical interfaces not identified.
140
MDL Exhibit 4271: BP Transocean Drilling Contract (1998), Section 3.4

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Annex G
Content and the implementation of the Transocean SMS
120.
The Transocean SMS described in the Health and Safety Policies and Procedures Manual section 2.4 is shown in summary below:
CMS ISM GOV PR-02 PP-01
HSE PP-02 PR-01
HRM PP-01 PP-01 PR-01
OPS HB-03 HB-05
Job Descrip.
Emergcy Manual
EDocs
1 2 3 4 5 6 7 8 9 10 11 12 Each section of the ISM Code is now addressed to identify the level of compliance with the Code in the documents identified and the level of implementation from the objective evidence supplied.
ISM Section 1:
General
121.
Transocean has encapsulated the overall company objectives, including safety objectives, within four leadership principles, eight management principles and three personal principles.141 It has set performance standards, requiring performance to be measured relative to the black line. While the principle is theoretically sound and good background information, much of the content belongs in the classroom and not in documents to be implemented in working locations, where clear, easily understood documents are required. Without specific training on the
141
MDL Exhibit 925: Transocean Company Management System Manual, Section 2.3, 2.4
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document, I consider it would be difficult for operational personnel to identify the company safety objectives.
ISM Section 2:
Safety and Environmental Protection Policy
122.
Transocean had two Policies in place: the Health and Safety Policy Statement and the Environmental Policy Statement.142 They were signed by the correct personnel, had appropriate content and described in the barest form, through the use of acronyms such as FIRST, THINK, START and FOCUS, how the safety objectives were to be met. requirements of the ISM Code. They meet the minimum
ISM Section 3:
Company Responsibilities and Authority
123.
Transocean, by its very size and geographical spread, operates a complex organisation which is mirrored in their organisation for safety.143 General Management responsibilities are defined in the CMS.144
124.
Transocean in April 2010 was led by Steve Newman, previously the COO who was appointed CEO in March 2010. His HSE responsibilities are listed and clearly make him ultimately responsible for the health, safety and welfare of all personnel working at Company installations, facilities and offices.145 His specific responsibilities include personal involvement in attending corporate HSE meetings and participating in reviews of HSE performance ensuring that effective HSE plans are in place to achieve the Company Vision. As COO, his HSE responsibilities had included reviewing critical incident reports, ensuring adequate HSE resources were available to support operations and approving HSE plans. Clearly, Steve Newman had for some time been the highest level of management in Transocean. Despite this, he appears vaguely involved in HSE in two key areas:
142 143
bis Section 2.2 (and reproduced in HQS-HSE-PP-01 and PP-02) See Annex L: Transocean Organization for Safety and Environmental Management 144 MDL Exhibit 925: Transocean Company Management System Manual, Section 1.3 145 MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 1.2 (1.1)
He does not differentiate between the leader in our QHSE function and Designated Person (DP).146 Confusingly in Transocean, the Corporate HSE Director and the Corporate DP are one and the same person but the two functions have very different reporting relationships to the CEO.147 Steve Newman was correct in saying the leader of the QHSE function did not report to him but the ISM Code section 4 requires that the DP have access to the CEO. As CEO he should be very clear about the position and duties of the DP.
He did not appear to understand the meaning of management review of the SMS, considering it as the activity carried out by Transoceans consultant, Lloyds Register.148 As CEO this is an activity he should leading.
It could be construed that Steve Newman as COO and CEO did not fully understand his HSE responsibilities or organisation nor consider the ramifications of the policy he was making. At the time of the Transocean and Global Santa Fe merger he stated in a memo with regard to Rig Chain of Command that the offshore installation manager will remain overall responsible for the health, safety, and welfare of all persons and all activities conducted on board their respective rig. The OIM is authorized and obligated to take whatever actions he considers
necessary to prevent injury, loss of life, damage to equipment, structure and/or loss of rig and well operation integrity.149 This is the very situation which resulted in delays in activation of the EDS on DEEPWATER HORIZON and is a major non-conformity with the ISM Code.
125.
Transocean has a philosophy that reporting goes through a line management function150 and Health and Safety responsibilities in HQS-HSE-PP-01151 reflects this. I understand this to mean that all decisions concerning safety and environmental management are taken by line managers from the Corporate to the Rig level as shown in Annex L. This is an industry norm, particularly in the oil and gas industry. The benefit is that operational and safety responsibilities are integrated; the down side is that operational personnel may have little knowledge of the subject or become commercially orientated, both of which have a negative influence on safety. No evidence other
146 147
Newman Deposition, p. 274 Annex L: Transocean Organization for Safety and Environmental Management 148 Newman Deposition, p. 275 149 MDL Exhibit 5643: Integration Memo, November 20, 2007 150 Rose Deposition, p. 238 151 Rose Deposition, p. 238
than the Rig Managers training course has been identified to demonstrate that shore managers have attended safety management training.152
126.
Integrated within the safety responsibility chain is the global group called all company personnel. Amongst their responsibilities is .not to participate in an unsafe act and to prevent an unsafe act or condition from causing an incident .and take action to correct any unsafe behaviour or condition.153 When written it is likely that the focus of this statement was potential physical occurrences and was supported by the STOP and TOFS initiatives. However it is equally applicable to potentially inadequate procedures or work instructions.
127.
To support the safety is a line management responsibility philosophy, Transocean operated a two-tier safety function. The corporate QHSE function headed up by Jimmy Moore (prior to April 20, 2010), reporting to Adrian Rose, the Vice President HSE, who in turn reported to the CEO, was stated as being independent of [the line.], its role being the oversight of the safety performance, safety management system, approval of the safety policies and procedures.154 This was reflected in the departmental responsibilities155 and is what would be expected of a corporate department. However, with such high level responsibilities, it is possible that Moore and Rose had become separated from the rigs and the reality of the offshore operation.
128.
The Divisional QHSE department for the NAM Division was headed up by Gerald Canducci and was represented on the DEEPWATER HORIZON by a Rig Safety Training Coordinator (RSTC) who reported to the OIM. While the specific responsibilities of the Division HSE manager are stated,156 there is little guidance on the role of the Division HSE department. It would be expected that the support provided to the Division would be of a practical nature but Canducci stated that he did not supply . . . expertise for drilling,157 maintenance is outside the safety management system158 and it was not under my umbrella . . for me to audit the asset
152 153
TRN-MDL-01159705:Rig Manager Performance Training Marine Module MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 1.2 (page 4 of 8) 154 Rose Deposition, p. 412 155 MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 1.2 156 bis 157 Canducci Deposition, p. 585 158 Canducci Deposition, p. 92
management and operations crowd,159 while admitting the drilling or the industrial function of the vessel also comes within the ISM Code.160 The HSE support for global operations is stated,161 but it is not specific as to who provides what, the interpretation of which can result in the confusion witnessed by Canduccis statements above. competent to hold the position of Division HSE manager. 129. Based on the information provided, the organisation for safety and environmental management in Transocean was complex, with long lines of communication, duplication of effort and un-clear responsibilities. Significantly the HSE function appears to distance itself from providing practical support in the drilling, marine and maintenance operations, restricting itself to approving documents, basic training, inspection and audit. In my opinion Mr. Canducci was not
ISM Section 4:
Designated Person(s)
130.
The company is required to appoint a Designated Person (DP), or more than one, if required. The intent is to provide a single line of communication from any crew member to the highest level of authority in the Company. In meeting this requirement Transocean appointed DPs and deputies at both corporate and divisional level which had the potential to cause confusion162 and which did so when Canducci, as a Divisional DP, stated I dont know exactly what they did when referring to the corporate DPs.163 In March 2009, the DEEPWATER HORIZON was notified of the corporate DPs, not Divisional DPs,164 when it was stated that contact with the DP is to be made when the need is identified by MODU management. This does not meet the intent of the ISM Code, in that DPs provide a communication link for all employees unhindered by MODU management. Through having a VP HSE, Transocean had the opportunity to establish a single, high visibility, independent DP with direct access to the CEO. Instead they choose to confuse the issue and possibly reduce the effectiveness of the DP position. In addition it could not be
identified that any of the four DPs had received training in compliance with the Guidance
159 160
Canducci Deposition, p. 301 Canducci Deposition, p. 495 161 Exhibit 1449: HQS-HSE-PP-01: Health and Safety Policies and Procedures Manual: section 1.2 162 See Annex L: Transocean Organization for Safety and Environmental Management 163 Canducci Deposition, p. 36 164 See Annex O and MDL Exhibit 946: Notification of Corporate DP 9, March 2010
promulgated by the IMO in 2007.165 As a minimum this is an observation at the Company DOC audit and potentially a non-conformity with the ISM Code if the DP position is found to be ineffective. The confusion of combining the Corporate DP position with that of Director HSE was illustrated by Moore, the Corporate DP, when he implied that he was only responsible to review the audits of the ISM rigs.166 As Director of HSE he would be responsible for all rigs.
ISM Section 5:
Masters Responsibility and Authority
131.
In considering the interpretation of this section of the Code there is relevant legislation: It is the duty of the flag State to ensure that each ship is in the charge of a Master and officers who possess appropriate qualifications for the type of the ship.167 SOLAS Chapter IX Regulation 2, paragraph 1.3, identifies a mobile offshore drilling unit (MODU) as a ship type to which the ISM Code applies no later than 1 July 2002. It makes no differentiation as to whether the MODU is self-propelled, dynamically positioned (DP), conducting drilling operations or in transit. US Code of Federal Regulations 46 C.F.R. 10.107 defines underway as applied to a MODU when the MODU is not in an on-location or laid up status. On location means that the MODU is bottom bearing or moored with anchors. US Code of Federal Regulations 46 C.F.R. 10.107 defines OIM as equivalent to a master on a conventional vesseland is the person designated .to be in complete and ultimate command of the unit. Republic of the Marshall Islands (RMI) in MI-293 Part V section L made self-propelled MODUs of 500 gross tons and larger subject to the ISM Code. RMI in Marine Notice No. 7-038-2 differentiated between a DP Vessel and a selfpropelled MODU. The former requires a Master at all times; the latter only requires a Master when the MODU was underway.
165 166
IMO MSC-MEPC.7/Circ.6, October 2007 Moore Deposition, p. 89 167 Appendix 5: UNCLOS Part VII, Section 1, Article 94 paragraph 4(b)
Page 60 of 154
132.
From the information above there would appear to be consensus that the ISM Code applies to MODUs, that a DP MODU is underway at all times and one person shall be in ultimate command of the MODU. Whether that person is titled Master or OIM is irrelevant provided that he
possesses appropriate qualifications.
133.
With specific reference to the ISM Code, it gives the Master overriding authority and responsibility to make decisions with regard to safety and pollution prevention.168 In addition it places the responsibility for implementing the safety and environmental protection policy of the Company on the master. 169 Hence there is an absolute responsibility on the Master to
implement the SMS as certificated by the flag Administration.
134.
Transocean however chose to place the responsibility for the implementation of the SMS on both the OIM and the Master,170 differentiating between underway and/or moving to another location and the day to day operation of the MODU while it is drilling. On the DEEPWATER HORIZON this established a dual command structure which was in effect supported by the issuance of the RMI Minimum Safe Manning Certificate which specified that a Master was not required when the ship was on location/field move.171 This situation was identified by DNV, as RO for RMI, in 2002 as a non-conformity172 and in 2009 as an observation at the Company DOC audit.173 There was no correction action by Transocean, nor follow up by DNV on either occasion. In his deposition Adrian Rose stated that by definition an observation is a very low level174 implying the observation would not be actioned. However, Moore was aware of the observation 175 and determined that action was being taken but was not complete.
135.
168 169
MDL Exhibit 938 and Appendix 3: ISM Code, Section 5.2 bis 5.1.1 170 MDL Exhibit 939: Transocean ISM/ISPS MODU Handbook, Section 2.4.3 171 MDL Exhibit 1726: RMI MSMC for DEEPWATER HORIZON 172 MDL Exhibit 5483 and Annex M: DNV ISM Code Certification Ship Audit Report, DWH, May 16, 2002 173 MDL Exhibit 1768 and Annex N: DNV Transocean 2009 DOC Audit (April 16, 2009) 174 Rose Deposition, p. 485 175 MDL Exhibit 1471: Interoffice Correspondence - Internal ISM Audit, March 15, 2010
ISM Section 6:
Resources and Personnel
136.
This section requires the master to be properly qualified for command.176 In the case of the MODU, this is addressed by the IMO in Resolution A.891(21). The definition of OIM in 2.1.8 reflects that in 46 C.F.R. 10.107 but, significantly, the Resolution states in 2.1.13 that the OIM is part of the marine crew and in 4.1 for self-propelled MODUs, that all maritime crew members should meet the requirements of the STCW Convention. Specialised training for the OIM is provided at ISM Code Section 6.2. The majority of this section, other than specific references to MODUs, is the training associated with STCW A-II/2, Mandatory minimum requirements for certification of masters and mates, while 6.2.2.11 requires appreciation of drilling and maintenance..of wells.
137.
It has been established that the DEEPWATER HORIZON had in effect two Masters. Curt Kuchta was certificated for command of the DEEPWATER HORIZON by RMI,177 but had not received the Company training for Major Emergency Management, had not been assessed competent as a PIC, and hence was not properly qualified for command.178 Jimmy Harrell held certification as an OIM and Barge Master 179 issued by RMI. MI-118, Requirements for Merchant Marine Personnel Certification, states, however, that MODU certification does not permit service aboard self-propelled vessels. Jimmy Harrells qualifications were endorsed MODU only and therefore not valid on DEEPWATER HORIZON.
138.
Transocean had in place a Worldwide Training Matrix but this has not been sighted. Further basic HSE training based on specific section of the SMS is addressed in a Table of HSE training.180 In 2007 DNV raised an observation on the DEEPWATER HORIZON to record the fact that a number of personnel on board had not been trained in accordance with the Training Matrix.181
176 177
MDL Exhibit 938 and Appendix 3: ISM Code Section 6.1.1 MDL Exhibit 3753: RMI Certificates 178 MDL Exhibit 3747: Kuchta Training Record; MDL Exhibit 3750: Kuchta Training Certificates; MacDonald Deposition, pp. 180-184 179 MDL Exhibit 3802: RMI Certificates 180 MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 4.1.3 (4.1) 181 MDL Exhibit 1778: DNV DWH SMC Renewal Audit (5.16.2007).
139.
Familiarization for new personnel ashore and off shore is a mandatory requirement of the ISM Code and something Companies generally do well. Transocean has a comprehensive procedure,182 administered by the RSTC, covering the expected items. However it is totally focused around the OIM; with no mention whatsoever of the Master, even on the Welcome Onboard Card. The OIM is named as the Person in Charge even when providing information on emergency situations.
ISM Section 7:
Shipboard Operations
Risk Management Processes
140.
This section of the Code is linked to paragraph 1.2.2.2, the emphasis being to provide a safe place of work through the identification of risk and its mitigation through processes and procedures. Transocean had several comprehensive processes and procedures in place183 and they are described in detail in the CMS and the HSE Policies and Procedures Manual184 with a degree of overlap. Theoretically and together they meet the intent of the Code, but the manner in which they are presented in the documents is long and complex, and I believe not easily understood. Unless personnel at all levels have received comprehensive training in the There is no evidence of Kuchta or Harrell
processes, implementation may not be effective. attending any relevant courses.
141.
The prime risk identification processes are THINK, Task Risk Assessment, MAHRA, the Safety Case and the OIC. They are hierarchical dependant on an increasing severity of risk and are supported by hazard identification and hazard operability studies which are common in the industry.
142.
THINK, supported by PLAN and CAKES, is the process which impacts on the day to day operation. CAKES is the logic process through which employees (personal, supervisory or management) decide on the level of THINK plan to use and thus it is possible to take the verbal option and avoid a written THINK plan thereby negating detailed consideration of the risk. TSTP,
182 183
MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 4.1.1 Annex R: Transocean Risk Management Processes 184 MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 4.2.1 (page 165 185)
otherwise known as Job Safety Analysis, is a standard within the industry, and in Transocean they are required for all hazardous operations as determined by the OIC185 and form Level 3 SMS documents. When they are fully and correctly implemented and made time specific they are the key to practical safety management. The THINK process is verified through THINK Reviews carried out by the Rig Manager. However Lloyds Register, in its Report expressed the concern of Transocean managers that processes were perceived to be over complex, stating that employees were not always sure of the hazards they were exposed to, THINK plans did not always identify major hazards, hazards identified were not fully understood, hazards with a changing risk level were not fully appreciated and they dont know what they dont know186 (In
the LR Report, 100% of the DEEPWATER HORIZON workforce stated they understood the hazards associated with their jobs.) Lloyds summed this up with crews are potentially working with a
mindset that they believe they are fully aware of all the hazards when it is highly likely that they are not. This is a common problem, and it is my belief that despite the good intent, the
effectiveness of the THINK process is reduced through an overzealous approach by Transocean resulting in complex procedures, a lack of understanding of risk management by offshore staff and, more importantly, an attitude of we have always done it this way which is prevalent in the marine and offshore industries.
143.
Following on from THINK in the hierarchy of risk is Task Risk Assessment. This process is to be invoked in defined situations187 but Adrian Rose defined it as being used when they dont have the experience and skills normally to operate that job.188 This qualitative process requires training and understanding to be effective and is unlikely to be successfully carried out by offshore personnel alone.
144.
START, a workplace observation program and industry standard otherwise known as STOP, is designed to provide the opportunity for the involvement of all workers. Implemented correctly it has considerable value but success relies totally upon an understanding by all of what is trying to be achieved and a will to be involved. In order to drive the initiative, Transocean introduced
185 186
bis page 173 MDL Exhibit 929: Lloyds Register Safety Management and Safety Culture/Climate Review (March 16, 2010) 187 MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 4.2.1, page 174 188 Rose Deposition, p. 257
numerical targets 189 which brought the program into disrepute and possibly devalued its potential. Lloyds Register identified a further 8 problems, all of which are congruent with my personal experience. They are summed up in as soon as you put a gun to somebodys head, is he ever gonna be your buddy again?190
145.
Time Out For Safety (TOFS) is another industry standard which relies, to an even greater extent than START, on human element factors. A hierarchical structure with a we have always done it this way attitude in a commercially driven environment, does not lend itself to stopping work on what may be perceived to be uninformed comment. This was confirmed by the Lloyds Register Report, which stated that 46.3% of the crew on DEEPWATER HORIZON were uncomfortable with calling a TOFS when unsafe situations occur, possibly because crew dont want to question a direct superior because they control their future. One comment summed up TOFS by saying you think you are doing right by saying something, and then youre made to feel like a dumb ass191
146.
The Management of Change (MoC) procedure, located in the CMS, is to be invoked when a change to a written plan is required.192 A non-exhaustive list of 20 examples of change
triggering the MOC procedure is listed. As a process it is complete, if complex, requiring a rigorous TRA. Comments received by Lloyds Register was contradictory: some felt that MoC was handled well and they were involved, while others said they make the changes, we have to deal with them for whatever reason.
Significantly the MoC procedure is used when an exemption from a Transocean procedure is sought if a new or revised plan does not comply with the CMS. A strict authorisation process is provided, but approval [for an exemption] may be granted verbally in urgent situations; required documentation must be completed within seven days. exemptions to be provided for at all, let alone granted verbally. It is highly unusual for
189 190
bis page 348 TRN-HCEC-0090593: Lloyds Register Culture Survey 191 TRN-HCEC-0090662: Lloyds Register Culture Survey 192 MDL Exhibit 925: Company Management System Manual, 5.5 (pages 138 153)
147.
Lloyds Register identified an initiative by the DEEPWATER HORIZON Rig Manager, Paul Johnson, called Back to Basics. Apparently this was to bring a structured approach [to the THINK process] to take the rig from a situation of confusion and frustration to a more participative, communicative process based on consultation and shared understanding. 193 This further supports the analysis that the risk management processes in Transocean and implemented on DEEPWATER HORIZON, were not operating as intended.
148.
The many detailed procedures supporting the risk management process are held in multiple documents classified as Manuals, Procedures and Handbooks. Highlights of these documents are discussed below.
Company Management System Manual: (MDL Exhibit 925) Issue 4, Rev 05, 11.30.2009 149. As the name suggests, it is the top level document providing management principles, policies, and expectations. It is complex, containing both overview and extremely detailed information. Much of it has little relevance to day to day operation and that which has, e.g. MoC, is not easily identified. Section 6, subsections 1, 2, 3 and 4 contain important health, safety, environmental, operations and human resources one line policies as Level 1A documents.
Health and Safety Policies and Procedures Manual: (MDL Exhibit 1449) Issue 03, Rev 07, 12.15.2009 150. This is the document seen by the majority as the SMS and contains very detailed, prescriptive information in 862 pages aimed at all levels in the Company. However it is indexed and written in a manner which is not compatible with the majority of its users, the rig worker. Comments noted by Lloyds Register on the DEEPWATER HORIZON included it is written in legalise. It is generic and vague and it leaves the door open for many different interpretations and its like youve got to go to class to understand it. It is very comprehensive and does contain the
information required, but the potential weakness will be in its implementation through its very size and presentation. Examples are discussed below:
193
MDL Exhibit 925: Company Management System Manual, 5.5 (pages 138 153)
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151.
Permit to Work: (section 4.2.2): This critical control mechanism, the failure of which is common in the industry, is described over 19 pages. It addresses the many situations, in which a PTW is required but confuses the control mechanisms of the PTW with the details of doing the job, e.g. entry to confined spaces, which is a safety critical topic in itself. Significantly the PTW process is managed by the OIM with the Toolpusher as his designee. There is no management input from the Master.
152.
Client and Subcontractor Personnel and Equipment: (section 4.2.3): recognised for many years as a major contributor to incidents offshore is described over 5 pages. While addressing
personnel and equipment it does not address the key element of bridging documents and interfaces with TO and others.
153.
Dropped Objects: (section 4.2.5): a safety critical consideration on an offshore installation described over 20 pages. The key precautions are lost in pages of text which establish a Dropped Objects Steering Committee with its own unique identity.
154.
Safety Meetings: (sections 2.2 and 4.4.2): a hierarchy of committees and meetings is established in these sections. They comprise: Onshore HSE Meetings Corporate QHSE Steering Committee 2 times per year Division QHSE Steering Committee 2 times per year
Installation HSE Meetings QHSE Steering Committee Meeting - periodic Departmental Meeting - weekly General HSE meeting - periodic Daily Operation Meeting - daily Pre-Tour Meeting every 21 days Pre-task meeting as required
The requirements are comprehensive and prescriptive, requiring considerable administration in paper or electronic format.
Follow up on actions is through the FOCUS system.
The HSE
department acts in in support of the operational line. Significantly, on the installation the OIM,
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and not the Master, is the focusThe only example of implementation of the procedure194 shows the meeting in question was well attended, apart from the lack of field personnel which was actioned, addresses many topics in detail and appears to meet the procedural requirements.
Performance and Operations Policies and Procedures Manual: (MDL Exhibit 1474) Issue 1, Rev 00, 04.19.2010 155. This document provides the Transocean policies concerning: planning an operation carrying out an operation associated marine operations maintaining the asset
It states the Transocean position with regard to the management of risk, which client requirements may impose upon a Transocean asset, specifically to ensure that: all operation and maintenance activities do not conflict with the Company conformity Management System Policies and Procedures195 review site specific information for items that increase the risk or complexity of the operation..these are to be planned according to Transocean policy and procedure requirements196 only Transocean personnel are authorized and permitted to operate installation equipment197 the MoC is to be used to safely implement and monitor any changes in the drilling program198 detailed communication on individual activities ..will be clearly communicated ..using the THINK planning process199
194 195
MDL Exhibit 945: Corporate QHSE Steering Committee Meeting Minutes September 2, 2010. MDL Exhibit 1474: Performance and Operations Policies and Procedures, Section 2.1 (4.2.1) 196 bis 4.3 197 bis 4.3.3 198 bis 4.3.7 199 bis 4.4
156.
It is apparent that Transocean accepts the fact that while they are implementing client programs, they do so through their own procedures, using the risk management processes to identify and mitigate risks to their ship, personnel and the environment. This is entirely in line with ISM Code requirements, other than the fact that the Master, the person with the legal responsibility for implementing the processes, does not have the authority to do so.
Marine Compliance Procedures: (MDL Exhibit 944) Issue 1, Rev 00, 07.28.2010 157. This document is dated after the DEEPWATER HORIZON incident and as it is Issue No.1, it is assumed that no equivalent document was in place at the time of the incident. There are 12 key sections missing from the Exhibit supplied, it could be construed that these relate directly to the DEEPWATER HORIZON incident. The procedures contain what would be expected in such a document. An exception to this is the statement that the Master, as the senior marine person on board, reports to the directly to the OIM. In addition, in Section 3.3 (4.2) a distinction is drawn between DP Operations and underway operations which is erroneous. It is also worthy of note that this document, while addressing marine matters, is not considered by Transocean200 to be addressing any requirement of the ISM Code!
Well Control Handbook: (MDL Exhibit 1454) Issue 03, Rev 01, 03.31.2009 158. Whilst clearly within the remit of personnel skilled in well control operations, I consider this document to be part of the SMS. Risk to the ship, personnel and the environment identified through THINK, TRA etc. is mitigated through implementation of these procedures.
ISM/ISPS MODU Handbook: (MDL Exhibit 939) Issue 01, Rev 00, 12.19.2008 159. This document is an information-only source for Transocean Rig Managers on the ISM and ISPS Codes. It includes an incorrect quote from SOLAS concerning the definition a MODU, which attempts to support the Transocean philosophy concerning the dual command structure and a
200
Exhibit 1449: HQS-HSE-PP-01: Health and Safety Policies and Procedures Manual: Section 2.4
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misquote from the ISM Code, concerning compliance with mandatory rules and regulations. Other than that, it is a re-print extracts from the ISM and ISPS Codes and DNV documentation.
DWH Operations Manual: (MDL Exhibit 671) Rev 02, December 2004 160. This is the document required by the MODU Code Chapter 14. Its purpose is to provide
guidance for the safe operation of the unit for both normal and envisaged emergency conditions to the satisfaction of the Administration. It is DEEPWATER HORIZON-specific and is a Level 3 document. It was Approved by ABS as Rev.1 in 2002 and, following review, was reApproved in December 2004 and issued by Transocean. 161. It is stated that it has been complied with reference to Transocean documents and hence describes the inadequate dual command structure. This is reflected through Section 2,
Organization and Responsibilities, and places the OIM in charge of supply boats (6.3.2) and helicopter operations (9.7.2). The section concerning maintenance is missing. With other
Transocean documents having been subject to regular revision and this having not been revised since 2004, there is no confidence that this document represents current modus operandi. This is a non-conformity with the ISM Code. This document is not referenced by Transocean as being relevant to the ISM Code.201
DWH Bridge Procedures Guide: (MDL Exhibit 3749) No version or issue date given 162. This preface in this document would indicate that it has been developed on board the DEEPWATER HORIZON as a guide based on best practice and lessons learned. Having stated that it states that it does not supersede company standards but yet it it publishes procedure, deviations from which may sometimes be justified. In some areas it is conversational, do
yourself a favour and climb to the crown . . . enjoy the view. It is controlled electronically by the Master but as issued in paper format it displays no corporate identity, no revision date, is not in the accepted company format and therefore cannot be considered to be part of the Company SMS. There was an earlier uncontrolled version of this document202 developed at an unknown
201 202
MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 2.4 MDL Exhibit 5037: DWH Bridge Procedures Guide
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time containing much the same information. Both these documents are a non-conformity with the ISM Code.
163.
Notwithstanding the foregoing, the document contains valuable information.
It could be
construed to be a cross between an update of the Operations Manual and Master Standing Orders. However, assuming it was issued in 2007, 5 years after DEEPWATER HORIZON came into operation, it may or may not have represented reflect current practice in 2010.
164.
What it does do, is to provide a window on what really happened in the marine department of the DEEPWATER HORIZON, regardless of the Transocean procedures which existed. It clearly states in the Fire and Gas System, Outputs Common section that during normal operations, we override all Outputs Common from the SVC. This is to prevent false alarms and further we typically have all the beacons and audible alarm outputs overridden. 203 Keplinger, when
questioned, did not deny this204 and David Young, the Chief Mate, confirmed it was correct.205 The result of doing this is that following any fire or gas alarm on the Bridge, the beacons and alarms will have to be manually activated by removing overrides. It is most likely that this was the status of the Fire and Gas Panel at the time of the incident.
165.
The section Watchstanding Practices is a set of Masters Standing Orders. Under the section Navigation Lights, it states that the ship is underway when latched to the BOP but not making way.206 This confirms that from the Masters point of view the DEEPWATER HORIZON was a ship, and therefore should be under the command of a Master at all times.
166.
The document goes on to provide guidance on confined space entry, DP Procedures, power management, boat and fire drills, relationships with the drill floor etc. The section on Well Control and High Gas appears to establish an almost informal procedure concerning action to be taken by the Bridge when a kick is taken associated with high gas. The situation of a well control
203 204
MDL Exhibit 3749: DWH Bridge Procedures Guide Keplinger deposition: 09.12.2011: page 136 205 Young deposition: page 267 206 Exhibit 3749: Harrell: DWH Bridge Procedures Guide: TRN-MDL-00533235
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incident escalating does not appear to have been considered and surprisingly there is no reference to EDS.
167.
Due to the complexity of the CMS, this document was written to provide a simplified reference, based on actual practice, to personnel new to DEEPWATER HORIZON or minimal experience.
ISM Section 8:
Emergency Preparedness
168.
The requirement is to identify potential emergency shipboard scenarios, establish procedures to respond to them ashore and on board and implement drills and exercise program. Transocean addressed these requirements through several documents:
Emergency Management Procedures Manual
Issue 01, Rev 00, 10.31.2007 169. This document provides guidance on the content of offshore installation and onshore Emergency Response Manuals. There is a requirement to develop Office and Facility manuals at Corporate and Division level, but the content is brief. These are not shown in the CMS nor have they been sighted.
170.
For offshore it lists the scenarios which must be considered, and these are reflected in the DWH Level 3 document described below. Responsibilities are all assigned to the OIM including that for maintenance of emergency response equipment which is in conflict with other documents including the Masters job description. The list of emergency drills required to be carried does not include any related to well control nor is there any reference to the Master as PIC nor when he should assume command.
DWH Emergency Response Manual Volume 1 (Exhibit 4644) Issue 02, Rev 06, 08.31.2008 171. This document is specific to the DEEPWATER HORIZON, and in compliance with ISM 8.1 identifies 16 emergency scenarios. Each scenario is dealt with in detail, assigning responsibilities to key
people. While the document was current in 2010, it is worthy of note that the DPs nominated were incorrect.
172.
In compliance with 46 C.F.R. 109.107, a PIC is nominated. The organisation chart clearly shows all personnel reporting to the OIM but in addition notes under the heading PIC: Underway Mode: Master in Charge Drilling Mode: OIM is in charge As this is the Emergency Response Manual it is assumed that this refers to emergency scenarios. However this is in direct conflict with the DWH Bridge Procedures Guide which states that DEEPWATER HORIZON is "underway" at all times. Further, it is required that the change of command will be noted in the ships log book, showing reason and time of change. Significantly, the document does not define a procedure for the change of command, nor at what stage in an escalating emergency does it occur. This is most likely the scenario on the night of the incident when it was abundantly clear that confusion arose.
173.
Of the 16 scenarios listed, only two are specifically drilling related. Section 7 - Well Control/Shallow Gas Blow Out The levels of well control emergencies are listed here: Level 1 Level 2 Level 3 any kick situation analysis of Level 1 indicates available equipment may not control the well an uncontrolled well (blowout)
Actions associated with level 1 and 2 are focused on the driller and the OIM. Only when the situation has escalated to level 3 does the OIM advise the Master to Abandon [the] Unit. Section 9 Hydrogen Sulphide The procedure places the OIM in overall command of gas control activities with the Master being informed of the situation. There are no specific duties listed for the Master. If required, partial evacuation is ordered by the OIM. This is contrary to information elsewhere, where it states only the Master has the authority to evacuate personnel. At a level 3 gas emergency, an undefined term, the OIM advises the master: A EDS will be initiated and to move away from site and
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implement Abandon Unit procedures
174.
The remaining scenarios are general ship emergencies, although peculiar to MODUs operating in an area where hurricanes can be expected. The Masters responsibilities generally indicate that he is the PIC, although this is not always clearly identified.
175.
The subject of abandon ship and EDS are addressed in detail. Section 10 Abandon Ship/Evacuation The decision to abandon the MODU is stated as that of the Master and that he should make this decision following consultation with the OIM and the Senior Client Representative which is correct. However, it is not stated how or when this responsibility is assumed.
Section 12 Emergency Disconnect Procedure This the most detailed section of the manual, organised in 9 drilling related scenarios, providing detailed responsibilities by job description for the two DP alert states, red and yellow. The DP standby condition may be commanded by any one of the following individuals, OIM, Toolpusher, Master, Mate and DP Operator. These conditions are prcised below Yellow: prepare to disconnect vessel position keeping performance is deteriorating/unstable risk of well control situation outside normal operational criteria Red: disconnect vessel cannot maintain position imminent risk of danger due to deteriorating well control situation In all the scenarios the person nominated with the responsibility to activate the EDS is the Driller.
Most likely in recognition of the criticality of the EDS system and the number of variables dependent on the drilling acidity at the time, section 12.2 requires EDS drills to be executed weekly. All emergency drills held on the drill floor are recorded in the Daily IADC Drilling Report. Examination of these for the 30 days prior to April 20 2010 shows that whilst well control drills were held on an approximate weekly basis, there is no record of an EDS drill having taken place, leaving a critical system untested.
176.
In conclusion, the decision to prepare to disconnect and to disconnect appears to be defined but there is no formal course of action if the driller is unable, for whatever reason, to activate the EDS. The situation is further confused by the fact that in an escalating well control situation, when does a controlled well become an uncontrolled well, and at what point does the Master become the PIC? It is these two facts that caused the confusion on the DEEPWATER HORIZON delaying the activation of the EDS. DWH Emergency Response Manual Volume 2 (MDL Exhibit 4645) Issue 02, Rev 06, 08.31.2008
177.
This document is required to comply with 33 C.F.R. 155 and forms a NonTank Vessel Response Plan under the Oil Pollution Act of 1990 approved by the USCG. It was originally issued in 02.15.2005 and last updated 06.16 2008 to reflect detailed contact changes at TO Despite regular updates, the version sighted did not indicate the correct DP nor Rig Manager.
178.
It appoints Marine Response Alliance as the selected Contractor for five vessels including DEEPWATER HORIZON. The contracted services include Lightering, towing, salvage and
firefighting on a renewable annual contract. Significantly on the night of the incident, MRA was not contacted and an alternate was used.
179.
An annual drill followed by a Plan review is required. I have sighted no evidence that either was carried out.
DWH Operations Manual (MDL Exhibit 671) Rev 02, December 2004 180. In sections 9 and 10, this document, in general, mirrors the DWH Emergency Response Manual Volume 1. It continues the confusion between the responsibilities of the Master and the OIM and in section 10.4, when addressing Uncontrolled Escape of Hydrocarbons, it assigns critical responsibilities to IM/Master. Further in 2.2 under The Master, it states that [the Master] advises the OIM of possible actions to take during an emergency situation.
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181.
Nowhere does the document address the responsibilities associated with activating the EDS system, addressing it simply as Move Off Location in 10.4.2.
182.
Having two documents in a management system addressing the same topic is bad practice. They will seldom, if ever, be congruent, creating unnecessary confusion, leading to non-conformity. This document, as presented and noted previously, is a non-conformity with the ISM Code.
ISM Section 9:
Reports and Analysis of Non-Conformities, Accidents and Hazardous Occurrences
183.
The reporting of incidents and their subsequent investigation is addressed in the Health and Safety Policies and Procedures Manual Section 4.6.3. In common with other procedures, the wording is long winded and complex and it is not easy to identify the key points of the process without extensive use or training. While the procedure applies to onshore as well as offshore, only offshore is commented on here.
184.
All incidents are required to be reported to the OIM and on to the Rig Manager through the Global Management System (GMS). The involvement of the Divisional and Corporate HSE
departments appears to be restricted to reviewing reports, ensuring follow is carried out and identifying lessons learned.
185.
It would appear the emphasis is on reporting incidents which have resulted in personal injury. These are categorized by the industry standard definitions and subject to analysis through a severity matrix to provide a potential injury severity rating. As with all statistics, it is not difficult to facilitate the results, particularly with the introduction in 1985 of the Restricted Work Case (RWC). This category allows considerable flexibility to avoid reporting a Lost Time Incident (LTI) which is a high visibility KPI in safety management. DEEPWATER HORIZON had just achieved seven years without a reported LTI.
186.
Near Hits and Serious Near Hits (defined as hazardous occurrences in the ISM Code, otherwise known as near misses) are reported verbally and through the Daily Operations
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Report.
Loss of Containment is reported through the Environmental Procedures, while The process is over
property damage is reported via an Operational Event Report.
complicated, providing opportunities for high potential near misses to avoid investigation. 187. 188. Unsafe Observations are carried out through the START process. Reported incidents are investigated via the industry standard investigation process known as Kelvin TOP-SET which has three levels of investigation dependent on the severity or potential severity of the personal injury. Transocean personnel leading investigations at any level must have received TOP-SET training, but Adrian Rose implied that despite this, not all root causes were being identified and the training was being reviewed.207 There is no evidence that either Kuchta or Harrell had received this training. 189. Significantly, there is a parallel reporting system in existence. Gerald Canducci stated that Well Control events are not part of the Safety Management System,208 and hence they are outside the remit of the HSE department. This was confirmed when Canducci stated that he was unaware of the incident on the Sedco 711,209 the results of which may have impacted on the DEEPWATER HORIZON. Such events are reported to the Operations Group through an The procedure is outlined in the Operations Policies and Operation Event Report. 210
Procedures Manual211 and the detail is in Field Operations Manual HQS-OPS-HB-05 which I have not sighted. The process does not reference the HSE department and Canducci confirmed this disconnection by stating that Advisories from the Well Operations group did not come through the HSE department and hence he did not monitor them.
190.
Follow up on recommendations arising from incident reporting is through the FOCUS improvement process. It is basically a database which uses systematic steps to develop
improvement and action plans using data from a variety of sources known in Transocean as opportunities. The end objective is to ensure improvement opportunities are closed out.
207 208
Rose Deposition, p. 368 Canducci Deposition, p. 52 209 bis page 485 210 MDL Exhibit 1479: Rose deposition: Operation Event Report 211 MDL Exhibit 673 Operations Policies and Procedures Manual, Section 2.3
These are classed as mandatory sources of opportunity which include SMART plans, PMAA action plans, follow up from Regulatory Audits, follow up from HSE meetings and action plans from incident investigations. There are discretionary sources of opportunity such as complex action plans which are required to be followed up. It is not known whether FOCUS is used for this purpose.
191.
In conclusion, Transocean theoretically has the requirements of the ISM Code in place albeit complex, and it is not easy to understand the detail. I have not seen any records of
implementation and hence cannot comment on the efficacy of the process. Significantly there is no formal role for the Master in the process or supporting procedures. This again, is non-
conformity with the ISM Code. It is of concern that there are two parallel systems in place and that both do not feed into the Divisional and Corporate HSE departments where global lessons are identified and disseminated.
ISM Section 10:
Maintenance of the Ship and Equipment
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Annex H: Extract from DEEPWATER HORIZON MAHRA
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Annex I: Extract from DEEPWATER HORIZON OIC
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Annex J: Document of Compliance (DOC) issued to Transocean Offshore Deepwater Drilling Inc.
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Annex J (continued): DOC reverse side
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Annex K: Safety Management Certificate (SMC) issued to DEEPWATER HORIZON
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Annex L: Transocean Organisation for Safety and Environmental Management
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Annex M: Exhibit 5483: DNV DEEPWATER HORIZON SMC Audit May 2002
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Annex N: Exhibit 1768: DNV Transocean DOC audit April 2009
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Annex O: Exhibit 946: Notification of corporate DP March 9, 2010
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Annex P: Analysis of Transocean Company Management System and the ISM Code Sections of the ISM Code 1 2 3 4 5 6 7 8 9 10 HQS-CMS-GOV
section 1 section 2 section 3 section 5
11
12
HQS-CMS-PR-02
all
HQS-HSE-PP-01
introduction section 1 section 2 section 3 section 4
HQS-HSE-PP-02
section 2 section 4 section 5
HQS-HSE-PR-01
all
HQS-HRM-PP-01
section 2 section 6
HQS-OPS-PP-01
section 2 section 3 section 4
HQS-OPS-PR-01
section 2 section 3
HQS-OPS-HB-03
section 1
HQS-OPS-HB-05
section 3
Job Descriptions Emerg. Resp. Manual e-docs

Annex Q: Transocean Management System relevant to the ISM Code
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Annex R: Transocean Risk Management Processes
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Annex S: Non-Conformity with the ISM Code The following non-conformities, defined as an observed situation where objective evidence indicates non-fulfilment of a specified requirement exist with the ISM Code.235 More objective evidence exists in the appropriate Annex.
Section 1: Meeting the Objectives of the ISM Code The documentation and information identified in the Health and Safety Policies and Procedures Manual section 2.4, as that being required to comply with the ISM Code, MDL Exhibit 1449: Health and Safety
Policies and Procedures Manual, does not address the objectives of the ISM Code as defined in sections
1.2.2.2 and 1.2.3.236 Section 4: Training and Competence of Designated Persons There is no objective evidence that Transocean recognised the IMO document MSC-MEPC.7/Circ.6 Guidance on the qualifications, training and experience necessary for undertaking the role of Designated Person under the provision of the ISM Code as being required to support the safety management system as required by ISM Code 6.5. Further there is no objective evidence that any of the nominated DPs received such training.
Section 10.1: Outstanding maintenance routines There is overwhelming objective evidence from external audits that the RMS II maintenance system contained errors due the migration of the system from the previous system, EMPAC. Further, records indicate that REMS II was not being implemented in accordance with instructions in that work orders were being closed out before they were complete, maintenance history files were incomplete, procedures for maintaining safety critical software were not implemented and safety critical work routines were overdue.
235 236
MDL Exhibit 938: ISM Code, Section 1.1.9 MDL Exhibit 938: ISM Code
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Section 11.1: Out of date and uncontrolled documentation There is objective evidence from Transocean internal audits 2004 to 2010, Approvals of documents, including safety critical documents such as Emergency Response Team contacts list, being retained current. Further two DEEPWATER HORIZON level 3 documents are incomplete, do not represent the current status, exist in an un-approved format and are not approved.
Section 12: Inadequate internal ISM Audits The ISM Internal Audit process described in the Performance Monitoring Audit and Assessment Procedures (PMAA) (HQS-CMS-PR-02 issued 12.31.08) does not comply with the requirements of the ISM Code section 12.1 in that the scope of the annual audit as defined in section 4.3 and contained in the ISM internal Audit Checklist / Report does not address all safety and pollution prevention activities in TO ashore or onboard DEEPWATER HORIZON or any MODU to which the DOC applies. Further, objective evidence of audits carried out shows the process to be ineffective in meeting the intent of the ISM Code.
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Appendix 1: Experience Profile of Captain Andrew Mitchell Practical experience relevant to the ISM Code
A deck officer with Shell Tankers Limited for 19 years gained in-depth experience of international ship operations and the handling of oil cargoes of all categories.
The manager within the Shell Exploration Health and Safety (HSE) Department responsible for the introduction of the elements of safety management, initiating the you cannot manage what you cannot measure philosophy, in the Shell offshore environment. An Independent consultant employed by oil majors and offshore service companies to develop safety management systems, to audit compliance, and provide appropriate training courses. The Lloyds Register Principal Surveyor responsible for marine management system consultancy and for carrying out management system audits against ISO 9002 as applied to the marine industry prior to the ISM Code. The Lloyds Register Senior Principal Surveyor and Manager in London responsible for the development of the infrastructure to allow the Society to act as a Recognised Organisation for the issue of ISM certification. Chaired the IACS working group developing the Procedural Requirements on the ISM Code for member societies and lead the IACS input to the IMO on the implementation of the ISM Code.
Practical experience relevant to the Offshore Industry
A Shell Tankers deck officer working in cooperation with Shell (UK) Exploration and Production (Shell Expro), involved in the design, trials and early implementation of offtake systems for oil tankers in the North Sea. The methods developed were subsequently adopted worldwide.
The marine advisor to the Shell Expro Fulmar Project responsible for marine input into the conversion of a VLCC, the Medora, to an offshore installation, the Fulmar FSU. This became, and still is, one of the largest FSUs in service. Subsequently the Offshore Installation Manager (OIM) responsible for the commissioning,
startup and early operation of the installation and later the Production Supervisor and OIM on Auk Alpha production platform.
The manager in Shell Expro reporting to the Operations Director responsible for the introduction of a safety management system into the North Sea onshore and offshore operation. This involved daily intervention with senior management onshore, OIMs, Supervisors and crew offshore.
The manager in the Shell Expro HSE department responsible for the Contractor safety management program, working with Service companies employed on Shell offshore installations to meet the HSE Standards established by Shell Expro, and a team member of the major incident investigation group. An Independent consultant employed by oil majors and offshore Service companies to develop safety management systems, to audit compliance, to provide training courses, and mentor management teams.
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Oil Companies and Service companies employed by as a consultant Amerada Hess BP Exploration UK Enterprise Oil Marathon MSR Shell Canada Shell UK Exploration and Production Total Asco Service Company Deutag Drilling KCA Drilling Lasmo Nova Scotia Noble Drilling Prosafe Offshore Limited Santa Fe Drilling Schlumberger Sedco Forex Stena Drilling Stolt Offshore Trafalgar House Offshore Services Weir Group Wood Group
Production Platforms audited as a Shell employee and consultant Auk Alpha Brent Alpha, Bravo, Charlie, Delta Cormorant Alpha, North Dunlin Alpha Fulmar Alpha and FSU FA Platform Jack-Ups, MODUs, FPSOs, FSUs, Accommodation platforms audited as a consultant Emerald Producer Nordic Apollo Treasure Finder Safe Caledonia Sedco 707 Sedco 714 Galaxy 1 Rowan Gorilla III
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Marine Industry positions held
Chairman of the International Association of Classification Societies (IACS) Working Group on the ISM Code from 1997 to 2002.
Chairman of the IACS Working Group on the International Ship and Port Facility Security Code (ISPS) Working Group from 2002 to 2006.
Chairman of the International Ship Managers Association (ISMA) Audit Committee from 1998 to 2003.
IACS Representative to the International Maritime Organisation (IMO) on the ISM and ISPS Codes from 1997 to 2006.
IACS Representative to the International Labour Organisation (ILO) on the Maritime Labour Convention 2006.
UK Representative to the ISO Standards Working Group on Intermodal Security and ISO 28000.
IACS Representative to the International Council of Chemical Associations Working Group on the Responsible Care initiative.
Chair and member of many working groups comprising flag Administrations, major shipping companies and Classification societies on the further development and implementation of management and audit systems in the marine industry.
Member of the Nautical Institute IMO Committee. Visiting lecturer on safety management at Cranfield University. External Examiner, Doctor of Professional Studies, Middlesex University.
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Professional legal experience 2007 m.v. Erika High Court of Paris Loss of ship Retained by RINA SpA and Paris attorneys Expert Witness in marine management systems and audit. m.v. Viking Islay Sheffield High Court, UK 3 counts of manslaughter against ship master Retained by Crown Chambers and NUMAST Expert Witness and advisor to Queens Counsel on the ISM Code and safety management systems m.v. Athos 1 District Court of Philadelphia, USA Environmental pollution Retained by Holman, Fenwick Willan (Montgomery, McCraken, Walker and Rhoads) Expert Witness in ISM Code and statutory audit practice MODU Deepwater Horizon New Orleans Explosion, fire, loss of life and ship and pollution Retained by Kirkland and Ellis, Chicago, USA Expert in the ISM Code and interpretation for MODUs
2009
2010
2011
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Appendix 2: Glossary of Terminology Administration A signatory to the SOLAS Convention, sometimes referred to as the flag Administration or the flag State. American Bureau of Shipping (a classification Society) A systematic, independent evaluation to determine whether or not the SMS and its implementation comply with planned arrangements and whether or not the system is implemented effectively and is suitable to fulfil the companys HSE policy and objectives. Compliance with a classification societys rules on construction and other items. Transocean Company Management System The owner or manager of the ship who has agreed to take over all the duties and responsibilities imposed by the ISM Code (ISM 1.1.2). A position required by ISM Code paragraph 4 to provide a link between the company and those on board. Also responsible to the highest level of authority to monitor safety aspects of each ship Det Norske Veritas (a classification Society) Document of Compliance (as required by the ISM Code) Emergency Disconnect Sequences Formulate, Organise, Communicate, Undertake, Summarize improvement process Hazard and Operability Study Hazard Identification Study International Association of Classification Societies International Association of Drilling Contractors International Maritime Organisation (an Agency of the United Nations) International Management Code for the Safe Operation of Ships and for Pollution Prevention 2010 ISPS Code LR International Ship and Port Facility Security Code 2002 Lloyds Register (a classification Society)
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ABS Audit
Classification: CMS Company
Designated Person
DNV DOC EDS FOCUS
HAZOP HAZID IACS IADC IMO ISM Code
MAHRA MEM MoC MODU OIC PIC PMAA RMI RO SMART SMC SMS SOLAS Convention START TOFS TRA TSTP
Major Accident Hazard Risk Assessment Major Emergency Management Management of Change Mobile Offshore Drilling Unit (SOLAS Chapter IX, Regulation 1.7) Operations Integrity Case Person In Charge (33 C.F.R. 146.5 and 46C.F.R. 109.107)) Performance Monitoring Audit and Assessment The Republic of the Marshall Islands (the flag State of the DEEPWATER HORIZON) Recognised Organisation (IMO Resolution A.739 (18) 1993) System Management and Review Team Safety Management Certificate (as required by the ISM Code) Safety Management System (as required by the ISM Code) IMO Safety of Life at Sea Convention 1974 as amended See, Think, Act, Reinforce, Track (a workplace observation program) Time Out For Safety Task Risk Assessment Task Specific THINK Procedure
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Appendix 3: The International Safety Management (ISM) Code 2002 Preamble 1 The purpose of this Code is to provide an international standard for the safe management and operation of ships and for pollution prevention. The Assembly adopted resolution A.443(XI), by which it invited all Governments to take the necessary steps to safeguard the shipmaster in the proper discharge of his responsibilities with regard to maritime safety and the protection of the marine environment. The Assembly also adopted resolution A.680(17), by which it further recognised the need for appropriate organisation of management to enable it to respond to the need of those on board ships to achieve and maintain high standards of safety and environmental protection. Recognising that no two shipping companies or shipowners are the same, and that ships operate under a wide range of different conditions, the Code is based on general principles and objectives. The Code is expressed in broad terms so that it can have a widespread application. Clearly, different levels of management, whether shore-based or at sea, will require varying levels of knowledge and awareness of the items outlined. The cornerstone of good safety management is commitment from the top. In matters of safety and pollution prevention it is the commitment, competence, attitudes and motivation of individuals at all levels that determines the end result.
PART A - IMPLEMENTATION 1 GENERAL 1.1 Definitions
The following definitions apply to parts A and B of this Code. 1.1.1 "International Safety Management (ISM) Code" means the International Management Code for the Safe Operation of Ships and for Pollution Prevention as adopted by the Assembly, as may be amended by the Organisation. 1.1.2 "Company" means the owner of the ship or any other organisation or person such as the manager, or the bareboat charterer, who has assumed the responsibility for operation of the ship from the shipowner and who, on assuming such responsibility, has agreed to take over all duties and responsibility imposed by the Code. 1.1.3 "Administration" means the Government of the State whose flag the ship is entitled to fly.
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1.1.4 "Safety management system" means a structured and documented system enabling Company personnel to implement effectively the Company safety and environmental protection policy. 1.1.5 "Document of Compliance" means a document issued to a Company which complies with the requirements of this Code. 1.1.6 "Safety Management Certificate" means a document issued to a ship which signifies that the Company and its shipboard management operate in accordance with the approved safety management system. 1.1.7 "Objective evidence" means quantitative or qualitative information, records or statements of fact pertaining to safety or to the existence and implementation of a safety management system element, which is based on observation, measurement or test and which can be verified. 1.1.8 "Observation" means a statement of fact made during a safety management audit and substantiated by objective evidence. 1.1.9 "Non-conformity" means an observed situation where objective evidence indicates the non-fulfilment of a specified requirement. 1.1.10 "Major non-conformity" means an identifiable deviation that poses a serious threat to the safety of personnel or the ship or a serious risk to the environment that requires immediate corrective action and includes the lack of effective and systematic implementation of a requirement of this Code. 1.1.11 "Anniversary date" means the day and month of each year that corresponds to the date of expiry of the relevant document or certificate. 1.1.12 "Convention" means the International Convention for the Safety of Life at Sea, 1974, as amended. 1.2 Objectives
1.2.1 The objectives of the Code are to ensure safety at sea, prevention of human injury or loss of life, and avoidance of damage to the environment, in particular to the marine environment and to property. 1.2.2 Safety management objectives of the Company should, inter alia: .1 provide for safe practices in ship operation and a safe working environment; .2 establish safeguards against all identified risks; and .3 continuously improve safety management skills of personnel ashore and aboard ships, including preparing for emergencies related both to safety and environmental protection. 1.2.3 The safety management system should ensure: .1 compliance with mandatory rules and regulations; and
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.2 that applicable codes, guidelines and standards recommended by the Organisation, Administrations, classification societies and maritime industry organisations are taken into account. 1.3 Application
The requirements of this Code may be applied to all ships. 1.4 Functional requirements for a safety management system
Every Company should develop, implement and maintain a safety management system which includes the following functional requirements: .1 a safety and environmental-protection policy; .2 instructions and procedures to ensure safe operation of ships and protection of the environment in compliance with relevant international and flag State legislation; .3 defined levels of authority and lines of communication between, and amongst, shore and shipboard personnel; .4 procedures for reporting accidents and non-conformities with the provisions of this Code; .5 procedures to prepare for and respond to emergency situations; and .6 procedures for internal audits and management reviews. 2 SAFETY AND ENVIRONMENTAL-PROTECTION POLICY 2.1 The Company should establish a safety and environmental-protection policy which describes how the objectives given in paragraph 1.2 will be achieved. 2.2 The Company should ensure that the policy is implemented and maintained at all levels of the organisation, both ship-based and shore-based. 3 COMPANY RESPONSIBILITIES AND AUTHORITY 3.1 If the entity who is responsible for the operation of the ship is other than the owner, the owner must report the full name and details of such entity to the Administration. 3.2 The Company should define and document the responsibility, authority and interrelation of all personnel who manage, perform and verify work relating to and affecting safety and pollution prevention. 3.3 The Company is responsible for ensuring that adequate resources and shore-based support are provided to enable the designated person or persons to carry out their functions.
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DESIGNATED PERSON(S) To ensure the safe operation of each ship and to provide a link between the Company and those on board, every Company, as appropriate, should designate a person or persons ashore having direct access to the highest level of management. The responsibility and authority of the designated person or persons should include monitoring the safety and pollution-prevention aspects of the operation of each ship and ensuring that adequate resources and shore-based support are applied, as required.
MASTER'S RESPONSIBILITY AND AUTHORITY 5.1 The Company should clearly define and document the master's responsibility with regard to: .1 implementing the safety and environmental-protection policy of the Company; .2 motivating the crew in the observation of that policy; .3 issuing appropriate orders and instructions in a clear and simple manner; .4 verifying that specified requirements are observed; and .5 reviewing the safety management system and reporting its deficiencies to the shorebased management. 5.2 The Company should ensure that the safety management system operating on board the ship contains a clear statement emphasizing the master's authority. The Company should establish in the safety management system that the master has the overriding authority and the responsibility to make decisions with respect to safety and pollution prevention and to request the Company's assistance as may be necessary.
RESOURCES AND PERSONNEL 6.1 The Company should ensure that the master is: .1 properly qualified for command; .2 fully conversant with the Company's safety management system; and .3 given the necessary support so that the master's duties can be safely performed. 6.2 The Company should ensure that each ship is manned with qualified, certificated and medically fit seafarers in accordance with national and international requirements. 6.3 The Company should establish procedures to ensure that new personnel and personnel transferred to new assignments related to safety and protection of the environment are given proper familiarization with their duties. Instructions which are essential to be provided prior to sailing should be identified, documented and given. 6.4 The Company should ensure that all personnel involved in the Company's safety management system have an adequate understanding of relevant rules, regulations, codes and guidelines.
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6.5 The Company should establish and maintain procedures for identifying any training which may be required in support of the safety management system and ensure that such training is provided for all personnel concerned. 6.6 The Company should establish procedures by which the ship's personnel receive relevant information on the safety management system in a working language or languages understood by them. 6.7 The Company should ensure that the ship's personnel are able to communicate effectively in the execution of their duties related to the safety management system. 7 DEVELOPMENT OF PLANS FOR SHIPBOARD OPERATIONS The Company should establish procedures for the preparation of plans and instructions, including checklists as appropriate, for key shipboard operations concerning the safety of the ship and the prevention of pollution. The various tasks involved should be defined and assigned to qualified personnel. 8 EMERGENCY PREPAREDNESS 8.1 The Company should establish procedures to identify describe and respond to potential emergency shipboard situations. 8.2 The Company should establish programs for drills and exercises to prepare for emergency actions. 8.3 The safety management system should provide for measures ensuring that the Company's organisation can respond at any time to hazards, accidents and emergency situations involving its ships. 9 REPORTS AND OCCURRENCES ANALYSIS OF NON-CONFORMITIES, ACCIDENTS AND HAZARDOUS
9.1 The safety management system should include procedures ensuring that non-conformities, accidents and hazardous situations are reported to the Company, investigated and analysed with the objective of improving safety and pollution prevention. 9.2 The Company should establish procedures for the implementation of corrective action. 10 MAINTENANCE OF THE SHIP AND EQUIPMENT 10.1 The Company should establish procedures to ensure that the ship is maintained in conformity with the provisions of the relevant rules and regulations and with any additional requirements which may be established by the Company.
10.2 In meeting these requirements the Company should ensure that: .1 inspections are held at appropriate intervals; .2 any non-conformity is reported, with its possible cause, if known; .3 appropriate corrective action is taken; and .4 records of these activities are maintained. 10.3 The Company should establish procedures in its safety management system to identify equipment and technical systems the sudden operational failure of which may result in hazardous situations. The safety management system should provide for specific measures aimed at promoting the reliability of such equipment or systems. These measures should include the regular testing of stand-by arrangements and equipment or technical systems that are not in continuous use. 10.4 The inspections mentioned in 10.2 as well as the measures referred to in 10.3 should be integrated into the ship's operational maintenance routine. 11 DOCUMENTATION 11.1 The Company should establish and maintain procedures to control all documents and data which are relevant to the safety management system. 11.2 The Company should ensure that: .1 valid documents are available at all relevant locations; .2 changes to documents are reviewed and approved by authorized personnel; and .3 obsolete documents are promptly removed. 11.3 The documents used to describe and implement the safety management system may be referred to as the Safety Management Manual. Documentation should be kept in a form that the Company considers most effective. Each ship should carry on board all documentation relevant to that ship. 12 COMPANY VERIFICATION, REVIEW AND EVALUATION 12.1 The Company should carry out internal safety audits to verify whether safety and pollutionprevention activities comply with the safety management system. 12.2 The Company should periodically evaluate the efficiency of and, when needed, review the safety management system in accordance with procedures established by the Company. 12.3 The audits and possible corrective actions should be carried out in accordance with documented procedures. 12.4 Personnel carrying out audits should be independent of the areas being audited unless this is impracticable due to the size and the nature of the Company.
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12.5 The results of the audits and reviews should be brought to the attention of all personnel having responsibility in the area involved. 12.6 The management personnel responsible for the area involved should take timely corrective action on deficiencies found.
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Appendix 4: The Applicability of the ISM Code to MODU Operations
1.
For SOLAS to apply to a ship, the ship is required to be propelled by mechanical means (see SOLAS Part A Regulation 3(a)(iii)). Both SOLAS Chapter IX Regulation 1(8) and the MODU Code 2001 1.3.1 define the MODU as a vessel capable of engaging in drilling operations for the exploration for or exploitation of resources beneath the sea-bed such as liquid or gaseous hydrocarbons, sulphur or salt. SOLAS Chapter IX Regulation 2(1.3) makes the application of SOLAS Chapter IX applicable to MODUs of 500 gross tonnage and upwards from 1 July 2002. SOLAS Chapter IX Regulation 3(1) requires that the company and the MODU shall comply with the requirements of the ISM Code. The accepted definition of self-propelled is that the MODU is able to transit from one geographical location to another unassisted by outside resource (e.g. tugs). The ISM Code is therefore mandatory on self-propelled MODUs greater than 500 gt from 1 July 2002. This is confirmed in Marshall Islands Mobile Offshore Drilling Unit Standards (MI-293) Part IV (M) and Part V (L) When in DP mode, the MODU is still deemed to be underway as it is not at anchor, or made fast to the shore, or aground (Colreg 1972 Rule 3 (i)). The MODU Code 2001 in 1.13.11 seeks to define mode of operation by differentiating between operating conditions, severe storm conditions and transit conditions. The ISM Code makes no such differentiation. The ISM Code applies to the self-propelled MODU during all phases of its operation, on transit between geographical locations, while in DP over a well and alongside a shore facility. The ISM Code makes no exceptions.
2.
3.
4.
5. 6.
7.
8.
9.
10.
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Appendix 5: UNCLOS Part VII, Section 1, Article 94 paragraph 4(b)
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Appendix 6: Analysis of Industry Norm on Dual Command Structure

According to ODS-Petrodata the offshore drilling fleet today is 811 units. This includes all the types shown below. The companies shown are the top 11 and between them operate more than 50% of marine drilling units. Accuracy is +/- 5% as different databases give different information Those operating a single command structure
MODUs and Drillships only In Command ENSCO Seadrill Diamond Offshore Odjefell Drilling Songa Offshore Stena Drilling Ocean Rig Maersk Drilling 74 71 53 11 4 12 6 31 262 13 10 9 4 1 6 4 7 54 7 2 27 3 3 2 0 1 45 7 7 4 4 0 4 2 4 32 47 45 13 0 0 0 0 19 124 Captain/OIM OIM OIM/Master OIM Master/OIM OIM OIM OIM Qualification not stated Master not stated Master Master Master Master Master
Name
Total Rigs
MODU DP
MODU Moored
Drill Ship
Jack Up
Those operating a dual command structure

OIM and Master Noble Drilling Atwood Oceanics 74 14 230 15 4 30 2 2 44 10 0 33 47 8 123 Ass Rig Mgr and Captain OIM (see note 3)
Transocean
142
11
40
23
68
OIM Master OIM Master OIM
Note 1 Note 2 Note 3 Note 4:
Figures include new buildings in the next 24 months In command titles are those used by the relevant Companies It is assumed that there is a Master Masters hold a certificate of competence issued by an Administration following compliance with STCW Regulation II/2
Conclusion: Out of 84 DP MODUs identified from the top 11 companies, 64% have a single command structure. Out of 73 DP MODUs identified (excluding Transocean) of the remaining top 10 companies, 74% have a single command structure.
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Appendix 7: Pride Drilling DP Rigs Organization Chart
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Appendix 8: Maersk Drilling OIM Job Description
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Appendix 9: Consideration Materials

Beg Bates TRN-MDL-01159660 CAM_CIV_0105569 End Bates TRN-MDL-01159803 CAM_CIV_0105576 Description Rig Manager Performance Training Marine Module Emergency Disconnect Sequences, Mux BOP Control System for "Deepwater Horizon" R&B Falcon OIM Job Description-Transocean (2001) Master Job Description-Transocean (2001) American Bureau of Shipping Class Survey Report Marshall Islands Letter - ABS Authorizations DWH 2005 ISM Internal DP Audit.doc Letter from Captain Brent Young, Master of DWH, to John MacDonald, Transocean Marine Operations Superintendent DWH ISM Installation Audit Checklist/Report 06.30.2009 DWH Operations Integrity Case Section 1 DWH Operations Integrity Case Section 4 DWH Operations Integrity Case Section 5 DWH Operations Integrity Case Section 6 American Bureau of Shipping Class Survey Report Transocean NAR ISM Installation Audit, 2009 HQS-HSE-ADV-21 Dropped Objects Procedures and Responsibilities Daily Drilling Report No. 01 Daily Drilling Report No. 02 Daily Drilling Report No. 03 Daily Drilling Report No. 04 Daily Drilling Report No. 05 Daily Drilling Report No. 06 Daily Drilling Report No. 07 Daily Drilling Report No. 08 Daily Drilling Report No. 09 Daily Drilling Report No. 10 Daily Drilling Report No. 11 Daily Drilling Report No. 12 Daily Drilling Report No. 13 Daily Drilling Report No. 14 Daily Drilling Report No. 15 Daily Drilling Report No. 16 Daily Drilling Report No. 17 Daily Drilling Report No. 18 Daily Drilling Report No. 19 American Bureau of Shipping Certificate of
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TRN-INV-00463832 TRN-INV-00463941 ABSDWH003385 ABSDWH011842 TRN-MDL-00552586 TRN-MDL-00514434
TRN-INV-00463834 TRN-INV-00463943 ABSDWH003393 ABSDWH011842 TRN-MDL-00553017 TRN-MDL-00514442
TRN-MDL-01021471 TRN-MDL-02865451 TRN-MDL-02865459 TRN-MDL-02865603 TRN-MDL-02865616 ABSDWH003894 TRN-MDL-00694329 TRN-INV-00629642 BP-HZN-BLY00264376 BP-HZN-BLY00246391 BP-HZN-BLY00246395 BP-HZN-BLY00246399 BP-HZN-BLY00246404 BP-HZN-BLY00242668 BP-HZN-BLY00242671 BP-HZN-BLY00265911 BP-HZN-BLY00265915 BP-HZN-BLY00265920 BP-HZN-BLY00265924 BP-HZN-BLY00265928 BP-HZN-BLY00251267 BP-HZN-BLY00251272 BP-HZN-BLY00251277 BP-HZN-BLY00251281 BP-HZN-BLY00251590 BP-HZN-BLY00251586 BP-HZN-BLY00251582 ABSDWH001251
TRN-MDL-01021491 TRN-MDL-02865458 TRN-MDL-02865602 TRN-MDL-02865615 TRN-MDL-02865637 ABSDWH003901 TRN-MDL-00694351 TRN-INV-00629642 BP-HZN-BLY00264379 BP-HZN-BLY00246394 BP-HZN-BLY00246397 BP-HZN-BLY00246403 BP-HZN-BLY00246406 BP-HZN-BLY00242670 BP-HZN-BLY00242675 BP-HZN-BLY00265914 BP-HZN-BLY00265919 BP-HZN-BLY00265923 BP-HZN-BLY00265927 BP-HZN-BLY00265931 BP-HZN-BLY00251271 BP-HZN-BLY00251276 BP-HZN-BLY00251280 BP-HZN-BLY00251285 BP-HZN-BLY00251593 BP-HZN-BLY00251589 BP-HZN-BLY00251585 ABSDWH001254
Beg Bates
End Bates
Description Classification - DWH Daily Drilling Report No. 20 Daily Drilling Report No. 21 Daily Drilling Report No. 22 Daily Drilling Report No. 23 Daily Drilling Report No. 24 Daily Drilling Report No. 24 Daily Drilling Report No. 25 Daily Drilling Report No. 27 Daily Drilling Report No. 28 Daily Drilling Report No. 29 Daily Drilling Report No. 30 Daily Drilling Report No. 31 Daily Drilling Report No. 32 Daily Drilling Report No. 33 Daily Drilling Report No. 34 Daily Drilling Report No. 35 Daily Drilling Report No. 36 Daily Drilling Report No. 37 Daily Drilling Report No. 38 Daily Drilling Report No. 39 Daily Drilling Report No. 40 Daily Drilling Report No. 41 Daily Drilling Report No. 42 Daily Drilling Report No. 43 Daily Drilling Report No. 44 Daily Drilling Report No. 45 Daily Drilling Report No. 46 Daily Drilling Report No. 47 Daily Drilling Report No. 48 Daily Drilling Report No. 49 Daily Drilling Report No. 50 Daily Drilling Report No. 51 Daily Drilling Report No. 52 Daily Drilling Report No. 53 Daily Drilling Report No. 54 Daily Drilling Report No. 55 HS Sect 4-2.1 THINK Planning Process.doc Morning Report Daily Drilling Report No. 01 Daily Drilling Report No. 02 Daily Drilling Report No. 03 Daily Drilling Report No. 04 Daily Drilling Report No. 05 Daily Drilling Report No. 06
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BP-HZN-BLY00251577 BP-HZN-BLY00246606 BP-HZN-2179MDL00254876 BP-HZN-2179MDL00254824 BP-HZN-2179MDL00254829 BP-HZN-2179MDL00254835 BP-HZN-2179MDL00254841 BP-HZN-2179MDL00254847 BP-HZN-2179MDL00254851 BP-HZN-2179MDL00254861 BP-HZN-2179MDL00254856 BP-HZN-2179MDL00254930 BP-HZN-2179MDL00254925 BP-HZN-2179MDL00254885 BP-HZN-2179MDL00254881 BP-HZN-2179MDL00254872 BP-HZN-2179MDL00254866 BP-HZN-2179MDL00254869 BP-HZN-2179MDL00254790 BP-HZN-2179MDL00254794 BP-HZN-2179MDL00254798 BP-HZN-2179MDL00254802 BP-HZN-2179MDL00254806 BP-HZN-2179MDL00254810 BP-HZN-2179MDL00254813 BP-HZN-2179MDL00254817 BP-HZN-2179MDL00254821 BP-HZN-2179MDL00254889 BP-HZN-2179MDL00254893 BP-HZN-2179MDL00254897 BP-HZN-2179MDL00254901 BP-HZN-2179MDL00254905 BP-HZN-2179MDL00254909 BP-HZN-2179MDL00254913 BP-HZN-2179MDL00254917 BP-HZN-2179MDL00254921 TRN-MDL-00507922 TRN-MDL-00380823 BP-HZN-BLY00101523 BP-HZN-2179MDL00060757 BP-HZN-2179MDL00060766 BP-HZN-2179MDL00060774 BP-HZN-2179MDL00060782 BP-HZN-2179MDL00060790
BP-HZN-BLY00251581 BP-HZN-BLY00246610 BP-HZN-2179MDL00254880 BP-HZN-2179MDL00254828 BP-HZN-2179MDL00254834 BP-HZN-2179MDL00254840 BP-HZN-2179MDL00254846 BP-HZN-2179MDL00254850 BP-HZN-2179MDL00254855 BP-HZN-2179MDL00254865 BP-HZN-2179MDL00254860 BP-HZN-2179MDL00254934 BP-HZN-2179MDL00254929 BP-HZN-2179MDL00254888 BP-HZN-2179MDL00254884 BP-HZN-2179MDL00254875 BP-HZN-2179MDL00254868 BP-HZN-2179MDL00254871 BP-HZN-2179MDL00254793 BP-HZN-2179MDL00254797 BP-HZN-2179MDL00254801 BP-HZN-2179MDL00254805 BP-HZN-2179MDL00254809 BP-HZN-2179MDL00254812 BP-HZN-2179MDL00254816 BP-HZN-2179MDL00254820 BP-HZN-2179MDL00254823 BP-HZN-2179MDL00254892 BP-HZN-2179MDL00254896 BP-HZN-2179MDL00254900 BP-HZN-2179MDL00254904 BP-HZN-2179MDL00254985 BP-HZN-2179MDL00254912 BP-HZN-2179MDL00254916 BP-HZN-2179MDL00254920 BP-HZN-2179MDL00254924 TRN-MDL-00507922 TRN-MDL-00380826 BP-HZN-BLY00101528 BP-HZN-2179MDL00060761 BP-HZN-2179MDL00060770 BP-HZN-2179MDL00060778 BP-HZN-2179MDL00060786 BP-HZN-2179MDL00060794
Beg Bates BP-HZN-2179MDL00060799 BP-HZN-2179MDL00060807 BP-HZN-2179MDL00060815 BP-HZN-2179MDL00060823 BP-HZN-2179MDL00060833 BP-HZN-2179MDL00060840 BP-HZN-2179MDL00060848 BP-HZN-2179MDL00060857 BP-HZN-2179MDL00060864 TRN-MDL-00507923 TRN-MDL-00509616 BP-HZN-2179MDL00060872 BP-HZN-2179MDL00060879 BP-HZN-2179MDL00060886 BP-HZN-2179MDL00060893 BP-HZN-2179MDL00060901 BP-HZN-2179MDL00060907 BP-HZN-2179MDL00060913 BP-HZN-2179MDL00060919 BP-HZN-2179MDL00060925 BP-HZN-2179MDL00060932 BP-HZN-2179MDL00060938 BP-HZN-2179MDL00060944 BP-HZN-2179MDL00060950 BP-HZN-2179MDL00060956 BP-HZN-2179MDL00060762 BP-HZN-2179MDL00060771 BP-HZN-2179MDL00060779 BP-HZN-2179MDL00060787 BP-HZN-2179MDL00060795 BP-HZN-2179MDL00060804 BP-HZN-2179MDL00060812 BP-HZN-2179MDL00060820 BP-HZN-2179MDL00060829 BP-HZN-2179MDL00060837 BP-HZN-2179MDL00060845 BP-HZN-2179MDL00060853 BP-HZN-2179MDL00060861 BP-HZN-2179MDL00060869 BP-HZN-2179MDL00060876 BP-HZN-2179MDL00060883 BP-HZN-2179MDL00060890 BP-HZN-2179MDL00060898 BP-HZN-2179MDL00060904 BP-HZN-2179MDL00060910
End Bates BP-HZN-2179MDL00060803 BP-HZN-2179MDL00060811 BP-HZN-2179MDL00060819 BP-HZN-2179MDL00060828 BP-HZN-2179MDL00060836 BP-HZN-2179MDL00060844 BP-HZN-2179MDL00060852 BP-HZN-2179MDL00060860 BP-HZN-2179MDL00060868 TRN-MDL-00507925 TRN-MDL-00509617 BP-HZN-2179MDL00060875 BP-HZN-2179MDL00060882 BP-HZN-2179MDL00060889 BP-HZN-2179MDL00060897 BP-HZN-2179MDL00060903 BP-HZN-2179MDL00060909 BP-HZN-2179MDL00060915 BP-HZN-2179MDL00060921 BP-HZN-2179MDL00060928 BP-HZN-2179MDL00060934 BP-HZN-2179MDL00060940 BP-HZN-2179MDL00060946 BP-HZN-2179MDL00060952 BP-HZN-2179MDL00060958 BP-HZN-2179MDL00060765 BP-HZN-2179MDL00060773 BP-HZN-2179MDL00060781 BP-HZN-2179MDL00060789 BP-HZN-2179MDL00060798 BP-HZN-2179MDL00060806 BP-HZN-2179MDL00060814 BP-HZN-2179MDL00060822 BP-HZN-2179MDL00060832 BP-HZN-2179MDL00060839 BP-HZN-2179MDL00060847 BP-HZN-2179MDL00060856 BP-HZN-2179MDL00060863 BP-HZN-2179MDL00060871 BP-HZN-2179MDL00060878 BP-HZN-2179MDL00060885 BP-HZN-2179MDL00060892 BP-HZN-2179MDL00060900 BP-HZN-2179MDL00060906 BP-HZN-2179MDL00060912
Description Daily Drilling Report No. 07 Daily Drilling Report No. 08 Daily Drilling Report No. 09 Daily Drilling Report No. 10 Daily Drilling Report No. 11 Daily Drilling Report No. 12 Daily Drilling Report No. 13 Daily Drilling Report No. 14 Daily Drilling Report No. 15 ABS Class Survey Audit - 02/14/10 ABS Class Survey Audit 2-14-10.xls Daily Drilling Report No. 16 Daily Drilling Report No. 17 Daily Drilling Report No. 18 Daily Drilling Report No. 19 Daily Drilling Report No. 20 Daily Drilling Report No. 21 Daily Drilling Report No. 22 Daily Drilling Report No. 23 Daily Drilling Report No. 24 Daily Drilling Report No. 25 Daily Drilling Report No. 26 Daily Drilling Report No. 27 Daily Drilling Report No. 28 Daily Drilling Report No. 29 Daily Drilling Report No. 30 Daily Drilling Report No. 31 Daily Drilling Report No. 32 Daily Drilling Report No. 33 Daily Drilling Report No. 34 Daily Drilling Report No. 35 Daily Drilling Report No. 36 Daily Drilling Report No. 37 Daily Drilling Report No. 38 Daily Drilling Report No. 39 Daily Drilling Report No. 40 Daily Drilling Report No. 41 Daily Drilling Report No. 42 Daily Drilling Report No. 43 Daily Drilling Report No. 44 Daily Drilling Report No. 45 Daily Drilling Report No. 40 Daily Drilling Report No. 01 Daily Drilling Report No. 02 Daily Drilling Report No. 03
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Beg Bates BP-HZN-2179MDL00060916 BP-HZN-2179MDL00060922 BP-HZN-2179MDL00060929 BP-HZN-2179MDL00060935 BP-HZN-2179MDL00060941 BP-HZN-2179MDL00060947 BP-HZN-2179MDL00060953 BP-HZN-2179MDL00060959 BP-HZN-2179MDL00060962 BP-HZN-2179MDL00060965 BP-HZN-2179MDL00060968 BP-HZN-2179MDL00251184 BP-HZN-2179MDL00251188 BP-HZN-2179MDL00251192 BP-HZN-2179MDL00251197 BP-HZN-2179MDL00251201 BP-HZN-2179MDL00251205 BP-HZN-2179MDL00251209 BP-HZN-2179MDL00251213 BP-HZN-2179MDL00251218 BP-HZN-2179MDL00251222 BP-HZN-2179MDL00251227 BP-HZN-2179MDL00251231 BP-HZN-2179MDL00251235 BP-HZN-2179MDL00251239 BP-HZN-2179MDL00251243 BP-HZN-2179MDL00251247 BP-HZN-2179MDL00251251 BP-HZN-2179MDL00251256 BP-HZN-2179MDL00251260 BP-HZN-2179MDL00251266 TRN-INV-00032770 TRN-MDL-00460393 TRN-INV-00094173 TRN-INV-01700334 TRN-INV-02820382 TRN-MDL-00366063 TRN-INV-00778224 TRN-INV-02844490 TRN-MDL-00272650
End Bates BP-HZN-2179MDL00060918 BP-HZN-2179MDL00060924 BP-HZN-2179MDL00060931 BP-HZN-2179MDL00060937 BP-HZN-2179MDL00060943 BP-HZN-2179MDL00060949 BP-HZN-2179MDL00060955 BP-HZN-2179MDL00060961 BP-HZN-2179MDL00060964 BP-HZN-2179MDL00060967 BP-HZN-2179MDL00060970 BP-HZN-2179MDL00251187 BP-HZN-2179MDL00251191 BP-HZN-2179MDL00251196 BP-HZN-2179MDL00251200 BP-HZN-2179MDL00251204 BP-HZN-2179MDL00251208 BP-HZN-2179MDL00251212 BP-HZN-2179MDL00251217 BP-HZN-2179MDL00251221 BP-HZN-2179MDL00251226 BP-HZN-2179MDL00251230 BP-HZN-2179MDL00251234 BP-HZN-2179MDL00251238 BP-HZN-2179MDL00251242 BP-HZN-2179MDL00251246 BP-HZN-2179MDL00251250 BP-HZN-2179MDL00251255 BP-HZN-2179MDL00251259 BP-HZN-2179MDL00251265 BP-HZN-2179MDL00251270 TRN-INV-00032787 TRN-MDL-00460393 TRN-INV-00094682 TRN-INV-01700917 TRN-INV-02820387 TRN-MDL-00366372 TRN-INV-00778227 TRN-INV-02844491 TRN-MDL-00272675
Description Daily Drilling Report No. 04 Daily Drilling Report No. 05 Daily Drilling Report No. 06 Daily Drilling Report No. 07 Daily Drilling Report No. 08 Daily Drilling Report No. 09 Daily Drilling Report No. 10 Daily Drilling Report No. 11 Daily Drilling Report No. 12 Daily Drilling Report No. 13 Daily Drilling Report No. 14 Daily Drilling Report No. 15 Daily Drilling Report No. 16 Daily Drilling Report No. 17 Daily Drilling Report No. 18 Daily Drilling Report No. 19 Daily Drilling Report No. 20 Daily Drilling Report No. 21 Daily Drilling Report No. 22 Daily Drilling Report No. 23 Daily Drilling Report No. 24 Daily Drilling Report No. 25 Daily Drilling Report No. 26 Daily Drilling Report No. 27 Daily Drilling Report No. 28 Daily Drilling Report No. 29 Daily Drilling Report No. 30 Daily Drilling Report No. 31 Daily Drilling Report No. 32 Daily Drilling Report No. 33 Daily Drilling Report No. 34 DAR-DWH-Safety Horizons maintenance EMPAC.xls Transocean Health and Safety Policies and Procedures Manual, December 15, 2009 Transocean Environmental Management System Manual, September 30, 2007 Excerpt of Transocean Human Resources Policies and Procedures: Required Training. Marine_Compliance_Procedures__SMART_Review[1].pdf TO Investigation Ticket re Command HQS-HSE-ADV-28 - Health and Safety Manual Update.pdf Deepwater Horizon Annual Survey Inspection Reports.pdf
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Beg Bates 000007 BP-HZN-2179MDL00259138 TRN-HCEC-00006018 TRN-HCEC-00011573 TRN-HCEC-00116167 TRN-HCEC-00116167 TRN-INV-00435113 TRN-INV-00499943 TRN-INV-00655432 TRN-MDL-00027238 TRN-MDL-00027240 TRN-MDL-00027263 TRN-MDL-00027956 TRN-MDL-00027981 TRN-MDL-00033918 TRN-MDL-00039040 TRN-MDL-00039054 TRN-MDL-00046974 TRN-MDL-00144432 TRN-MDL-00144510 TRN-MDL-00286651 TRN-MDL-00447009 TRN-MDL-00518415 TRN-MDL-00522719 TRN-MDL-00542768 TRN-USC_MMS-00027263 TRN-USCG_MMS-00027956 TRN-USCG_MMS-00027980 TRN-USCG_MMS-00043659 TRN-USCG_MMS-00043662
End Bates 000024 BP-HZN-2179MDL00259677 TRN-HCEC-00006211 TRN-HCEC-00011573 TRN-HCEC-00116174 TRN-HCEC-00116178 TRN-INV-00435114 TRN-INV-00499944 TRN-INV-00655433 TRN-MDL-00027239 TRN-MDL-00027262 TRN-MDL-00027280 TRN-MDL-00027979 TRN-MDL-00027991 TRN-MDL-00033998 TRN-MDL-00039046 TRN-MDL-00039062 TRN-MDL-00047024 TRN-MDL-00144432 TRN-MDL-00144521 TRN-MDL-00286654 TRN-MDL-00447012 TRN-MDL-00518433 TRN-MDL-00522741 TRN-MDL-00542778 TRN-USC_MMS-00027280 TRN-USCG_MMS-00027979
Description Det Norske Veritas - Audit Programme BP-Transocean Drilling Contract for DWH, 1998 Master Register Emergency Response Manual Vol 2 of 2 HSE Advisory Ref. No. HQS-HSE-ADV-25 Det Norske Veritas - Survey Report (2007), DNV DWH Survey Report for Renewal ISM Audit and Renewal Scope ISPS Audit, 2007. HSE_Advisory_Prompt Card.pdf Transocean HSE Advisory: Manoverboard Handrail Failure. Transocean HSE Advisory: Think Risk Assessment Prompt Card, July 16, 2008 DNV Safety Management Certificate for DWH issued May 16, 2007 DWH ISM Installation Audit Checklist/Report 04.08.2008 Transocean ISM Installation Audit Checklist/Report, July 15, 2004 Transocean ISM Installation Audit Checklist/Report, June 28, 2007 DNV Survey Report for Intermediate ISM Audit of DWH, 2005 Kuchta Personnel File NAR Regional Office ISM Audit 2009.pdf NAR Regional Office ISM Audit 2008.pdf Transocean Emergency Management Procedures Manual ISM Certification May 2007 2007-05-15 DNV Renewal ISM Audit 2010 Internal Audit Report Transocean Health, Safety, and Environment Assessment Manual Think Planning Process DNV Audit Transocean DWH ISM Installation Audit Checklist and Report, April 2008 Transocean HSE Performance Meeting Slide DWH ISM Installation Audit Checklist/Report 07.13.2004 DWH ISM Installation Audit Checklist/Report 06.28.2007 Det Norske Veritas- Safety Management Certificate issued 2007-07-11 Det Norske Veritas - ISM Certification, Det Norske Veritas - Survey Report (Preliminary) 2009
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TRN-USCG_MMS-00043661 TRN-USCG_MMS-00043664
Beg Bates TRN-HCJ-00128051 TRN-MDL-00032700 TRN-MDL-00273633 TRN-MDL-00364423 TRN-MDL-01160394 TRN-MDL-01288444 TRN-MDL-02071217 TRN-MDL-02353887 TRN-MDL-024696448 TRN-MDL-02496571 TRN-USCG-MMS-00027186 BP-HZN-2179MDL00141787 TRN-HCEC-00004639 TRN-MDL-00287334 TRN-MDL-00293187 TRN-MDL-00286537 TRN-MDL-00359569 TRN-MDL-00286528 TRN-MDL-00129825 TRN-MDL-00294981
End Bates TRN-HCJ-00128052 TRN-MDL-00033035 TRN-MDL-00273896 TRN-MDL-00364428 TRN-MDL-01160407 TRN-MDL-01288685 TRN-MDL-02071217 TRN-MDL-02353893 TRN-MDL-024696449 TRN-MDL-02496577 TRN-USCG-MMS-00027216 BP-HZN-2179MDL001423999 TRN-HCEC-00004726 TRN-MDL-00287334 TRN-MDL-00293196 TRN-MDL-00286537 TRN-MDL-00359570 TRN-MDL-00286528 TRN-MDL-00129830 TRN-MDL-00295106
Description Det Norske Veritas- Safety Management Certificate issued 2007-07-11 Transocean Company Management System Manual, November 2009 Performance and Operations Policies and Procedures.PDF Horizon-2009-Mar 8.pdf Excerpt of DWH Emergency Response Manual, Emergency Notification 2009 Transocean PMAA Findings - Corrective Actions 2009 Transocean DWH Emergency Response Manual Approval Page, 2009 Curt Kuchta License 2009-03-20 Internal Transocean Memo re Marine Integrity Message 2008-01-21 Transocean internal memo: Marine Integrity Management Survey ISM Internal Audit Report, 2007 MDL Dep. Ex. 0671: DWH Operations Manual, v. 1 &2 MDL Dep. Ex. 0673: Transocean Operations Policies and Procedures Manual MDL Dep. Ex. 0916: Conference call to discuss Deepwater Horizon events. MDL Dep. Ex. 0917: Email attaching pictures of the Deep Water Horizon going down MDL Dep. Ex. 0918: North America Division, QHSE Management Diagram MDL Dep. Ex. 0919: Email attaching updated corporate designated persons sheet. MDL Dep. Ex. 0920: North America Division, Direct Reports Hierarchy MDL Dep. Ex. 0921: Email attaching AMU Ballast Questionnaire MDL Dep. Ex. 0922: Email attaching BP Audit Working Copy, DWH Follow Up Audit Report, Rig Move Work List attaching BP Audit; Deepwater Horizon Follow UP Audit Report 17 March 2010 MDL Dep. Ex. 0923: Rig Condition AssessmentDeepwater Horizon MDL Dep. Ex. 0924: Email attaching Rig Leadership Engagement-Houma-Mar. 29-31 and Houma Schedule attaching DW Wells Leadership MDL Dep. Ex. 0925: Transocean - Company Management System Manual
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TRN-MDL-00038591 TRN-MDL-00287195
TRN-MDL-00038677 TRN-MDL-00287200
TRN-MDL-00032700
TRN-MDL-00033035
Beg Bates TRN-MDL-00273897 TRN-MDL-00039463 BP-HZN-MBI 00044258 TDD006-000505 BP-HZN-OIG00039700 TRN-MDL-00301009 TRN-MDL-00291896
End Bates TRN-MDL-00273900 TRN-MDL-00039544 BP-HZN-MBI 00044261 TDD-006-000697 BP-HZN-OIG00039705 TRN-MDL-00301009 TRN-MDL-00291907
Description MDL Dep. Ex. 0926: Operations Advisory: Loss of Well Control During Upper Completion MDL Dep. Ex. 0927: Performance Monitoring Audit and Assessment Procedures MDL Dep. Ex. 0928: Email attaching NAM Safety Expectations MDL Dep. Ex. 0929: Consulting Services Lloyd's Register EMEA Aberdeen Energy MDL Dep. Ex. 0930: MI Cleanup MDL Dep. Ex. 0931: Notification of Dropped Object MDL Dep. Ex. 0932: Lloyd's Register Safety Management Systems and Safety Culture/Climate Reviews: Deepwater Horizon MDL Dep. Ex. 0933: RMS II Morning Report, Righ: Deepwater Horizon MDL Dep. Ex. 0934: QHSE Steering Committee Meeting Minutes MDL Dep. Ex. 0935: NAR ISM Installation Audit for Deepwater Horizon MDL Dep. Ex. 0936: Exhibit "D" HSSE Requirements MDL Dep. Ex. 0937: Transocean Results of HSSE Common Inspection Document (CMID) Audit, August 3, 2009 MDL Dep. Ex. 0938: International Safety Management Code and Guidelines on Implementation of the ISM Code MDL Dep. Ex. 0939: Transocean ISM/ISPS MODU Handbook MDL Dep. Ex. 0940: Ad Title: Make the Right Move MDL Dep. Ex. 0941: Transocean MMS/USCG RIC Inspection Summary Report: Deepwater Horizon MDL Dep. Ex. 0942: Transocean Career Center, North American Offshore Fleet, Current Job Openings-Master Job Description MDL Dep. Ex. 0943: Survey Report: 2009 Annual ISM DOC Audit MDL Dep. Ex. 0944: Marine Compliance Procedures MDL Dep. Ex. 0945: QHSE Steering Committee Meeting Minutes MDL Dep. Ex. 0946: Email attaching updated Corporate Designated Persons MDL Dep. Ex. 0947: Email attaching updated Declaration of DPA and CSO-ISM/ISPS Rigs
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TRN-MDL-00077298 TRN-MDL-00039081 TRN-MDL-0002721 TRN-MDL-00040723 TRN-MDL-00351151
TRN-MDL-00033216
TRN-MDL-00033281
TRN-MDL-00351317
TRN-MDL-00351322
TRN-USCG_MMS-00043662 TRN-MDL-00273305 TRN-MDL-00364450 TRN-MDL-00359569 TRN-MDL-00351629
TRN-USCG_MMS-00043664 TRN-MDL-00273632 TRN-MDL-00364457 TRN-MDL-00359570 TRN-MDL-00351632
Beg Bates BP-HZN-BLY00076260 BP-HZN-2179MDL00293151
End Bates BP-HZN-BLY00076264 BP-HZN-2179MDL00293165
Description MDL Dep. Ex. 0948: BP-GoM TODDI NAM, HSE Management System Bridging Document MDL Dep. Ex. 0949: E&P Segment Recommended Practice, Applying Control of Work On Drilling & Completion Operational Sites MDL Dep. Ex. 0950: Terms of Reference-Self Assessment Process, BP GoM D&C HSSE MDL Dep. Ex. 0951: Improving Control of Work within Drilling & Completions MDL Dep. Ex. 0952: Operations Department Alert, Deepwater DP Rigs Subsea Well Control Equipment Operation, Mainenance and Testing MDL Dep. Ex. 0953: Document of Compliance Issued to Transocean MDL Dep. Ex. 0954: Results fo BP Gulf of Mexico HSSE Audit conducted on August 3, 2009 MDL Dep. Ex. 0955: Email attaching Transocean Inc. results of HSSE audit conducted August 3, 2009 MDL Dep. Ex. 0956: Deepwater Horizon-BP CMD Audit Work List September 2009 MDL Dep. Ex. 0957: Contractor HS&E Management System Assessment (Common Audit Process Report) MDL Dep. Ex. 0958: Service Loop Fire HQS-HSE-AL108 MDL Dep. Ex. 0959: Email re Corporate QHSE Incident Review 4/16/2010 attaching Corporate QHSE Incident Review Apr. 16 MDL Dep. Ex. 0960: Email attaching DWH Station Bill MDL Dep. Ex. 0961: DWH CMID Annex (BP Requirements for MODUS) with Guidance Notes MDL Dep. Ex. 0993: Notice of 30(b)(6) Video Deposition of Kongsberg Maritine Inc. Pursuant to the Federal Rules of Civil Procedure. MDL Dep. Ex. 0994: Dynamic Positioning 2011 Conference Website. MDL Dep. Ex. 0995: Kongsberg Confirmation Purchase Order Invoice MDL Dep. Ex. 0996: Kongsberg Simrad Quotation No. 1452-7R&B Falcon Report MDL Dep. Ex. 0997: E-mail from Jan Roger Hellerud to Hans Alan Pedersen re: "RSS8D/Request for ESD Design Philosophy" MDL Dep. Ex. 0998: Safety System Design Philosophy RBS8D Project "Deepwater Horizon"
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BP-HZN-BLY00115468 BP-HZN-MBI 00109884 BP-HZN-BLY00165701
BP-HZN-BLY00115468 BP-HZN-MBI 00109893 BP-HZN-BLY00165704
TRN-MDL-0000488930 TRN-MDL-00351222 TRN-MDL-00351151
TRN-MDL-00129254 TRN-MDL-00351153
TRN-MDL-00129277 TRN-MDL-00351221
TRN-MDL-00106485 TRN-MDL-00294807
TRN-MDL-00106487 TRN-MDL-00294808
TRN-MDL-00364219 TRN-MDL-00143899
TRN-MDL-00364220 TRN-MDL-00143943
KMI-MDL-001287 KMI-MDL-001288 KMI-MDL-002090
KMI-MDL-000645
KMI-MDL-000663
Beg Bates
End Bates
Description with Revision History
KMI-MDL-018781 KMI-MDL-019864
KMI-MDL-001094
KMI-MDL-001143
KMI-MDL-001265
KMI-MDL-001286
MDL Dep. Ex. 0999: Service Report for RBF/Transocean for Deepwater Horizon MDL Dep. Ex. 1100: Transocean Engineering Recommendation for DWH: Engine Room Ventilation Controls MDL Dep. Ex. 1101: Konsberg RBS8D Safety Systems: Functional Design Specification for Emergency ShutDown System MDL Dep. Ex. 1102: Konsberg Safety Philosophy ESD, PSD and F&G AIM Safe MDL Dep. Ex. 1103: Konsberg Maritime Inc.'s ("KMI") Response to Information Request by Republic of Marshall Islands MDL Dep. Ex. 1104: RBS8D Vessel Fire & Gas I/O List Spreadsheet MDL Dep. Ex. 1105: Hyundai Heavy Industries Drawing (Title: Cause & Effect Matrix) Request Form MDL Dep. Ex. 1106: Konsberg ESD and K&G Safety Images for K-Safe Product. MDL Dep. Ex. 1107: Konsberg Simrad ESD and F&G Matrix User Manual for the Deepwater Horizon MDL Dep. Ex. 1108: Konsberg Quotation: DP & Navigation SVC/SSS XP Mid-Life Upgrade MDL Dep. Ex. 1109: Konsberg Maritime Safety System (ESD and F&G) Overview of KM Safety System. MDL Dep. Ex. 1110: Konsberg ESD Deepwater Horizon Operator Manual MDL Dep. Ex. 1111: Konsberg Fire & Gas Deepwater Horizon Operator Manual MDL Dep. Ex. 1112: Konsberg and R&B Falcon Integrated Automation & Control Sustem Deepwater Horizon Functional Design Specification MDL Dep. Ex. 1113: Konsberg "AIM Safe - The complete Safety solution" Presentation Slide MDL Dep. Ex. 1114: Module Tools - Excerpt MDL Dep. Ex. 1115: Konsberg Safety System Presentation MDL Dep. Ex. 1116: Konsberg Service Report Work Description for Deepwater Horizon. MDL Dep. Ex. 1117: R&B Falcon Correspondence to Konsberg re: Purchase Order
Page 127 of 154
Beg Bates TRN-HCEC-00027279
End Bates TRN-HCEC-00027295
Description MDL Dep. Ex. 1118: R&B Falcon Safety System Design Philosophy RBS8D Project "Deepwater Horizon" MDL Dep. Ex. 1119: Correspondence from J.D. Sipes re: "Guide for Electrical Installation on Merchant Vessels and Mobile Offshore Drilling Units" MDL Dep. Ex. 1119: Navigation and Vessel Inspection Circular No. 2-89 MDL Dep. Ex. 1120: Training History List Profile MDL Dep. Ex. 1121: Dynamic Positioning Conference - The DP Simulator Training Concept MDL Dep. Ex. 1177: Table of Contents oon Transocean Subsea Maintenance Philosophy MDL Dep. Ex. 1351: BP Performance Review - Rig Solicit Feedback MDL Dep. Ex. 1352: Preventive Maintenance of Cameron Blowout Preventers (BOPs) MDL Dep. Ex. 1353: Chief Counsel's Report (2011) - National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling. MDL Dep. Ex. 1354: Presentation: "Macondo As I See It" MDL Dep. Ex. 1355: Email from D. Winslow to B. Sannan re: "FW: Negative test Procedure" MDL Dep. Ex. 1356: Drilling Contract - RBS-8D Semisubmersible Drilling Unit - Vastar Resources, Inc. and R & B Falcon Drilling Co. MDL Dep. Ex. 1357: Email from T. Shackelford to D. Winslow re: "Re: Marianas" MDL Dep. Ex. 1358: Email from D. Winslow to K. Adamson re: "RE: Horizon Plan forward" MDL Dep. Ex. 1359: Email from T. Shackelford to D. Winslow, P. Calligeros, et al. MDL Dep. Ex. 1360: Transocean Change Proposal MDL Dep. Ex. 1449: Transocean Health and Safety Policies and Procedures Manual MDL Dep. Ex. 1453: DWH Emergency Response Manual-Vol. 1 MDL Dep. Ex. 1454: Well Control Handbook MDL Dep. Ex. 1457: Website Article RE: Adrian P. Rose, Transocean Vice President, Special Projects MDL Dep. Ex. 1458: Agreed 30(b)(6) Deposition Notice of Transocean Defendants (with 30(b)(6) Document Requests) MDL Dep. Ex. 1459: Achieving the Vision Through Motivated People, Performance Excellence and
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TRN-MDL-00023807 KMI-MDL-009896 TRN-MDL-00427057 TRN-MDL-00406377 CAM-DOI-000000249
TRN-MDL-00023808 KMI-MDL-009900 TRN-MDL-00427058 TRN-MDL-00406380 CAM-DOI-000000250
TRN-MDL-00688525 TRN-MDL-00546475 BP-HZN-2179MDL00259139
TRN-MDL-00688542 TRN-MDL-00546476 BP-HZN-2179MDL00259159
TRN-MDL-00541805 TRN-MDL-00542932 TRN-MDL-00541813 BP-HZN-BLY00052571 TRN-MDL-00046464 TRN-MDL-00048160 TRN-MDL-00286767
TRN-MDL-00541805 TRN-MDL-00542936 TRN-MDL-00541815 BP-HZN-BLY00052578 TRN-MDL-00046973 TRN-MDL-00048520 TRN-MDL-00287162
TRN-MDL-00653993
TRN-MDL-00654039
Beg Bates
End Bates
Description Asset Integrity
TRN-MDL-00649010
TRN-MDL-00650592
BP-HZN-2179MDL00621653 TRN-USCG_MMS-00032704 TRN-USCG_MMS-00039081
BP-HZN-2179MDL00621654 TRN-USCG_MMS-00032723 TRN-USCG_MMS-00039084
TRN-MDL-00606601 TRN-MDL-00606602
TRN-MDL-00606603
TRN-MDL-00648543 TRN-MDL-00635387 TRN-MDL-00030501 TRN-MDL-00122507 TRN-MDL-00498732 TRN-MDL-00645098 TRN-MDL-00645097 TRN-MDL-00606514 BP-HZN-CEC041475
TRN-MDL-00648567
BP-HZN-CEC041596
MDL Dep. Ex. 1460: Email from C. Jacobson to A. Bobillier and T. Bonno MDL Dep. Ex. 1461: United States Coast Guard: Report of Investigation into the Circumstances Surrounding the Explosion, Fire, Sinking and Loss of Eleven Crew Members Aboard the Mobile Offshore Drilling Unit Deepwater Horizon (Volume 1) MDL Dep. Ex. 1462: Summary of Daily Activities MDL Dep. Ex. 1467: Overview: Introduction to the Company Management System MDL Dep. Ex. 1471: Interoffice Correspondence from S. Sutherland and M. Bachand to J. Moore re: Internal ISM Audit MDL Dep. Ex. 1473: Day 1 Operational Guidance MDL Dep. Ex. 1474: Performance and Operations Policies and Procedures Manual MDL Dep. Ex. 1475: Assistant Driller, OJT Module MDL Dep. Ex. 1476: Request for Engineering Assistance (REA) Well-Specific Planning Sheet MDL Dep. Ex. 1477: Request for Exemption MDL Dep. Ex. 1478: Task Risk Assessment Worksheet MDL Dep. Ex. 1479: Operation Event ReportFormat for Well Control Event MDL Dep. Ex. 1480: Transocean Performance Review MDL Dep. Ex. 1481: U.S. Coastal State Regulation Compliance MDL Dep. Ex. 1482: RGIT - Certificate in Offshore Management MDL Dep. Ex. 1483: Area Command Operating Guide MDL Dep. Ex. 1484: DWH VBR Middle Pipe Ram Closure Procedure Rev A MDL Dep. Ex. 1485: MMS Question MDL Dep. Ex. 1486: RE: MMS Question MDL Dep. Ex. 1487: Well Schematic MDL Dep. Ex. 1488: Amendment No.38 to Drilling Contract No.980249 between BP America Production Company and Transocean Holdings LLC MDL Dep. Ex. 1518: Agreed 30(b)(6) Deposition Notice of Transocean Defendants (With 30(b)(5) Document Requests)
Page 129 of 154
Beg Bates
End Bates
Description MDL Dep. Ex. 1519: Rig Crew and Onshore Organizational Charts MDL Dep. Ex. 1520: Operations Advisory re Loss of Well Control During Upper Completion MDL Dep. Ex. 1521: Ops Note MDL Dep. Ex. 1523: Monitoring well control integrity of mechanical barriers MDL Dep. Ex. 1524: Permit to Work MDL Dep. Ex. 1525: Sedco 711 Well Control Incident MDL Dep. Ex. 1526: Temporary Abandonment Procedure MDL Dep. Ex. 1527: Incident Report- Drift Off and Emergency Riser Disconnect MDL Dep. Ex. 1528: Deepwater Horizon- Subsea Equipment Condition Audit MDL Dep. Ex. 1721: Drilling Rig Audits and Rig Acceptance- BP Group Engineering Technical Practices MDL Dep. Ex. 1722: Deepwater Horizon - BP CMID Audit Work List MDL Dep. Ex. 1723: US Coast Gaurd Witness/ Investigator Statement Form MDL Dep. Ex. 1724: Statement of Douglas Harold Brown- Chief Mechanic/Acting Second Engineer of the Deepwater Horizon MDL Dep. Ex. 1725: Certificado de Seguridad de Tripulacion Minima Minimum Safe Manning Certificate MDL Dep. Ex. 1726: DWH Minimum Safe Manning Certificate MDL Dep. Ex. 1727: Court Reporter copy of court testimony MDL Dep. Ex. 1728: Resume application for Chief Mechanic position MDL Dep. Ex. 1729: RMS II Morning Report- Rig: Deepwater Horizon MDL Dep. Ex. 1730: Recorded Coast Gaurd Interview Cover Page MDL Dep. Ex. 1731: Watertight Door Inspection MDL Dep. Ex. 1732: R&B Falcon certifies Doug Brown- Safety Management System MDL Dep. Ex. 1733: Emails Between J. Kent, DWH Rig Manager, and DWH Subsea Supervisor MDL Dep. Ex. 1758: Deepwater Horizon Focus Report MDL Dep. Ex. 1759: ISM Installation Audit
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TRN-OIG-00258937 BP-HZN-2179MDL00161670 TRN-MDL-00273270 BP-HZN-2179MDL00351644 TRN-MDL-00273272 BP-HZN-CEC020166 BP-HZN-CEC029558 TRN-HCEC-00063449 BP-HZN-2179MDL00643468
TRN-OIG-00258940 BP-HZN-2179MDL00161670 TRN-MDL-00273271 BP-HZN-2179MDL00351645 TRN-MDL-00273280 BP-HZN-CEC020166 BP-HZN-CEC029560 TRN-HCEC-00063488 BP-HZN-2179MDL00643481
TRN-MDL-00285606
TRN-MDL-00285607
TRN-MDL-00618614
TRN-MDL-00618614
TRN-MDL-00077298
TRN-MDL-00077325
TRN-MDL-00692632 TRN-MDL-00034938
TRN-MDL-00692632 TRN-MDL-00034938
TRN-MDL00507823 TRN-MDL-00286668
TRN-MDL-00027981
Beg Bates
End Bates
Description Checklist/Report MDL Dep. Ex. 1762: Email from M. Wright to L. McMahan with 4/28/10 DWH Event Log MDL Dep. Ex. 1763: Gulf of Mexico Strategic Performance System Concept Risk Review MDL Dep. Ex. 1764: ISM Code Certification Company Audit Report MDL Dep. Ex. 1765: Audit Programme MDL Dep. Ex. 1766: Audit Program MDL Dep. Ex. 1767: Audit Programme MDL Dep. Ex. 1768: DNV Survey Report- 2009 Annual ISM DOC Audit of Transocean MDL Dep. Ex. 1769: Survey Report- ISM Code DOC Annual Audit MDL Dep. Ex. 1770: Vessel Summary Report"Deepwater Horizon" MDL Dep. Ex. 1771: Safety Management Certificate MDL Dep. Ex. 1772: Safety Management Certificate MDL Dep. Ex. 1773: Safety Management Certificate MDL Dep. Ex. 1774: Safety Management Certificate MDL Dep. Ex. 1775: Safety Management Certificate MDL Dep. Ex. 1776: Safety Management Certificate MDL Dep. Ex. 1777: DNV Survey ReportIntermediate ISM Audit 2005 MDL Dep. Ex. 1778: Survey Report- Renewal ISM Audit and Renewal Scope ISPS Audit MDL Dep. Ex. 1779: Document of Compliance MDL Dep. Ex. 1780: Document of Compliance- The Republic of the Marshall Islands MDL Dep. Ex. 1781: Document of Compliance- The United States of America MDL Dep. Ex. 1782: Document of Compliance- The United States of America MDL Dep. Ex. 1783: International Ship Security Plan (SSP) Statement of Compliance MDL Dep. Ex. 1784: International Ship Security Shipboard Verification Statement of Compliance MDL Dep. Ex. 1785: ISPS Code Certification Renewal Ship Security Verification Report MDL Dep. Ex. 1786: International Ship Security Certificate
Page 131 of 154
TRN-MDL-00799316 TRN-MDL-00121329 TRN-USCG_MMS-00059294 TRN-USCG_MMS-00059341 TRN-USCG_MMS-00059318 TRN-USCH_MMS-00059290 TRN-USCG_MMS-00059325
TRN-MDL-00799318 TRN-MDL-00121354 TRN-USCG_MMS-00059301 TRN-USCG_MMS-00059344 TRN-USCG_MMS-00059321 TRN-USCH_MMS-00059293 TRN-USCG_MMS-00059333
TRN-HCEC-00116082 TRN-HCEC-00116103 TRN-HCEC-00116104 TRN-HCEC-00118108 TRN-HCEC-00116109 TRN-USCH_MMS-00043710 TRN-HCO-00128051 TRN-USCG_MMS-00027982 TRN-HCEC-00116167
TRN-HCEC-00116085 TRN-HCEC-00116105 TRN-HCEC-00116105 TRN-HCEC-00118109 TRN-HCEC-00116109 TRN-USCH_MMS-00043710 TRN-HCO-00128052 TRN-USCG_MMS-00027991 TRN-HCEC-00116171
TRN-MDL-00468930
TRN-MDL-00468931
TRN-HCEC-00116106 TRN-HCEC-00116107 TRN-HCEC-00116173 TRN-HCEC-00116175

TRN-HCEC-00116106 TRN-HCEC-00116178 TRN-HCEC-00116174 TRN-HCEC-00116178
Beg Bates
End Bates
Description MDL Dep. Ex. 1787: Letter from B Bubar to D Dykes and H Nguyen MDL Dep. Ex. 1788: The Republic of The Marshall Islands- Mobile Offshore Drilling Unit Standards MDL Dep. Ex. 1789: Minimum Safe Manning Requirements for Vessels MDL Dep. Ex. 1790: Survey Report- Initial ISM and ISPS Audits MDL Dep. Ex. 1791: Survey Report- Initial ISM and ISPS Audits MDL Dep. Ex. 1792: Survey Report- Initial ISM/ISPS Audit MDL Dep. Ex. 1793: Survey Report Initial ISM and ISPS Audits MDL Dep. Ex. 1794: Common Marine Inspection Document MDL Dep. Ex. 1795: GMID Annex ( BP Requirements for Modus) with Guidance Notes MDL Dep. Ex. 1819: Organizational Chart MDL Dep. Ex. 1820: Email from Neil Cramond to Cindi Skelton MDL Dep. Ex. 1821: BP Gulf of Mexico / SPU GoM Marine Function / Marine Vessel Operations Team Report MDL Dep. Ex. 1822: BP CMID Annex (BP Requirements for MODUS) with Guidance Notes MDL Dep. Ex. 1823: BP Group Standards Marine Operations MDL Dep. Ex. 1824: BP GoM Function 2010 Activity Prioritization MDL Dep. Ex. 1825: GoM SPU Gap Closure Status Chart MDL Dep. Ex. 1826: Email from Neil Cramond to J. Skelton, H. Thierens: Initial Incident Summary MDL Dep. Ex. 1827: Email from A. Rodriguez to N. Cramond re: GP 10-40 Drilling Rig Audits & Rig Acceptance MDL Dep. Ex. 1828: Email from Neil Cramond to N. Cramond, T. Endicott, et al. re: "Simplifying Communication re Safety" MDL Dep. Ex. 1829: Email from T. Endicott to N. Cramond re: "P1 - Horizon Audit Findings update and IM Risk rankings" MDL Dep. Ex. 1830: Email from A. Rodriguez to J. Guide, M. Sepulvado, et al. re: "Updated audit tracking sheet for DW Horizon"
Page 132 of 154
TRN-MDL-00302127 TRN-MDL-00302146 TRN-MDL-00302156 TRN-MDL-00302182 TRN-MDL-00420097 TRN-MDL-00420038 BP-HZN-CEC060931 BP-HZN-2179MDL01122681 BP-HZN-2179MDL01122683
TRN-MDL-00302132 TRN-MDL-00302155 TRN-MDL-00302160 TRN-MDL-00302192 TRN-MDL-00420155 TRN-MDL-00420096 BP-HZN-CEC060931 BP-HZN-2179MDL01122682 BP-HZN-2179MDL01122726
BP-HZN-CEC035380 BP-HZN-2179MDL01106466 BP-HZN-2179MDL00984912 BP-HZN-2179MDL00984928 BP-HZN-2179MDL01127713 BP-HZN-2179MDL01137477
BP-HZN-CEC035422 BP-HZN-2179MDL01106501 BP-HZN-2179MDL00984913 BP-HZN-2179MDL00984928 BP-HZN-2179MDL01127714 BP-HZN-2179MDL01137491
BP-HZN-2179MDL01115530
BP-HZN-2179MDL01115549
BP-HZN-2179MDL01131227
BP-HZN-2179MDL01131232
BP-HZN-2179MDL00340255
BP-HZN-2179MDL00340256
Beg Bates BP-HZN-CEC041034
End Bates BP-HZN-CEC041035
Description MDL Dep. Ex. 1831: Email from B. Cocales to DWH OIM, P. Johnson, et al. re: "Audit Report Documents - DWH Sept 2009" MDL Dep. Ex. 1832: Email from A. Rodriguez to J. Guide, B. Cocales, et al. re: "Deepwater Horizon's Rig Audit close out report status" MDL Dep. Ex. 1833: Email from D. Porter to H. Thierens re: "FW: LoWC Review with Neil Shaw on 9/25" MDL Dep. Ex. 1834: Email from N. Cramond to N. Cramond, N. Cameron, et al. MDL Dep. Ex. 1835: Email from R. Malone to S. Bond, N. Cramond, and D. Clarkson MDL Dep. Ex. 1836: Email from T. Endicott to N. Cramond MDL Dep. Ex. 1837: Email from A. Rodriguez to P. Johnson, J. Guide, and B. Cocales re: "RE: Audits Reviewed and Updated" MDL Dep. Ex. 1838: United States Coast Guard Report of Investigation into the Circumstances Surrounding the Explosion, Fire, Sinking and Loss of Eleven Crew Members Aboard to Mobile Offshore Drilling Unit Deepwater Horizon in the Gulf of Mexico April 20 - 22, 2010; Volume I MDL Dep. Ex. 1839: IMCA Common Marine Inspection Document MDL Dep. Ex. 1840: Email from N. Cramond to E. dan re: "SIMOPS Review" with BP Marine SIMOPS Assurance Review Attachment MDL Dep. Ex. 1841: Email from N. Cramond to T. Davolt re: "FW: Approved - Doc No. 2200-T2-DOPR-4039 - Ops Note 02" with BP Macondo Top Kill Procedures Manual MDL Dep. Ex. 1842: Email from N. Cramond to R. Singh re: "Some Thoughts" MDL Dep. Ex. 1843: Email from N. Cramond to M. Bowman and P. Singh re: "RE: INFO (Confidential): GOM GRASP Operations" MDL Dep. Ex. 1949: Gulf of Mexico SPU Risk Management SEEAC Brief MDL Dep. Ex. 1950: Email from J Skelton to P Lockwood and R Sepulvado et al; 2008/2009 Continuous Improvement Plan- Deepwater Horizon MDL Dep. Ex. 1951: Email from J Guide to B Cocales and K Daigle; FW: Deepwater Horizon Rig Audit
Page 133 of 154
BP-HZN-2179MDL00033637
BP-HZN2179MDL00033638[3] BP-HZN-2179MDL00347968
BP-HZN-2179MDL00347967
BP-HZN-2179MDL01122823 BP-HZN-2179MDL01114974 BP-HZN-2179MDL00002012
BP-HZN-2179MDL01122826 BP-HZN-2179MDL01114980 BP-HZN-2179MDL00002013
BP-HZN-CEC041288 BP-HZN-2179MDL01130999
BP-HZN-CEC041346 BP-HZN-2179MDL01131006
BP-HZN-2179MDL01114934
BP-HZN-2179MDL01114973
BP-HZN-2179MDL01134676 BP-HZN-2179MDL01094903
BP-HZN-2179MDL00620074 BP-HZN-MBL00052735
BP-HZN-2179MDL00620081 BP-HZN-MBL00052738
BP-HZN-2179MDL00353304
BP-HZN-2179MDL00353305
Beg Bates BP-HZN-OIG00002240 BP-HZN-MBL00072280 BP-HZN-2179MDL00301434 BP-HZN-MBL00059311 BP-HZN-MBL00059313 BP-HZN-2179MDL00248210 BP-HZN-MBL00110606 CAM_CIV_0013074 CAM_CIV_0013008
End Bates BP-HZN-OIG00002243 BP-HZN-MBL00072281 BP-HZN-2179MDL00301434 BP-HZN-MBL00059312 BP-HZN-MBL00059314 BP-HZN-2179MDL00248210 BP-HZN-MBL00110607 CAM_CIV_0013074 CAM_CIV_0013008
Description MDL Dep. Ex. 1952: Email from M Sepulvado to J Guide; FW: Deepwater Horizon Rig Audit MDL Dep. Ex. 1953: Email from A Frazelle to I Little and P Hill et al MDL Dep. Ex. 1954: Email from B Cocales to J Guide MDL Dep. Ex. 1955: Email from B Morel to J Guide MDL Dep. Ex. 1956: Email from B Morel to J Guide; FW: Cost Saving Ideas MDL Dep. Ex. 1957: Email from D Maxie to B Cocales and T Haygood et al; Losses Total MDL Dep. Ex. 1958: Email from I Little to D Sims and J Guide; Macondo Update MDL Dep. Ex. 2094: Certificate of Compliance: Customer Transocean Offshore MDL Dep. Ex. 2095: Certificate of Compliance: Transocean Offshore MDL Dep. Ex. 2162: Job Description, First Assistant Engineer MDL Dep. Ex. 2163: Training History List Profile MDL Dep. Ex. 2165: Rig Condition AssessmentDeepwater Horizon MDL Dep. Ex. 2166: J.Mansfield ltr to Hymel MDL Dep. Ex. 2167: Deepwater Horizon-BP CMID Audit Work List September 2010 MDL Dep. Ex. 2169: Details of neurosurgical opinion re J.Mansfield. MDL Dep. Ex. 2170: Letter re Opthalmic Evaluation of J.Mansfield MDL Dep. Ex. 2171: Ltr re Follow-Up Neurological Examination of J.Mansfield. MDL Dep. Ex. 2172: Clinical Notes re J.Mansfield, Prosthodontics MDL Dep. Ex. 2173: Office Consultation Notes re J.Mansfield. MDL Dep. Ex. 2174: Neuropsychological Evaluation of J.Mansfield MDL Dep. Ex. 2175: Medical Evaluation and Summary of J.Mansfield MDL Dep. Ex. 2176: Neurological Office Consultation Notes re J.Mansfield MDL Dep. Ex. 2177: Physical Medical Information and Documents re J.Mansfield MDL Dep. Ex. 2178: Office Consultation Notes re J.Mansfield MDL Dep. Ex. 2179: Discharge Note for J.Mansfiled from Day One Physical Therapy and
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MODUSA 000088
TRN-MDL-00374741 TO-JM Med 000048 TO-JM Med 000057 TO-JM Med 000059 TO-JM Med 000067 TO-JM Med 000071 TO-JM Med 000073 TO-JM Med 000088 TO-JM Med 000096 TO-JM Med 000098 TO-JM Med 000128 TO-JM Med 000129
TRN-MDL-00374770 TO-JM Med 000050 TO-JM Med 000058
TO-JM Med 000087 TO-JM Med 000095
TO-JM Med 000125
Beg Bates
End Bates
Description Wellness
TO-JM Med 000131 TRN-MDL-00047535 TRN-HCJ-00027084 TRN-MDL-00272650 MODUSI010000087
TO-JM Med 000165 TRN-MDL-00047554 TRN-HCJ-00027372 TRN-MDL-00272653 MODUSI010000091
TRN-MDL-01075563
TRN-MDL-01075604
DNV-SUPPL-000189 DNV-SUPPL-000209 DNV-SUPPL-000231 DNV-SUPPL-000245 DNV-SUPPL-000270 DNV-SUPPL-000288 DNV-SUPPL-000301 3438 25 35 99 244
DNV-SUPPL-000208 DNV-SUPPL-000230 DNV-SUPPL-000244 DNV-SUPPL-000269 DNV-SUPPL-000287 DNV-SUPPL-000300 DNV-SUPPL-000315 3441 34 91 100 259
TRN-MDL-00041202
MODUSA 000343
MODUSA 000344
MDL Dep. Ex. 2180: Forensic Psychiatric Consultation re J.Mansfield MDL Dep. Ex. 2187: DWH Major Accident Hazard Risk Assessment (MAHRA) (29 August 2004) MDL Dep. Ex. 3075: Deepwater Horizon: Licensing Information MDL Dep. Ex. 3076: Republic of the Marshall Islands Maritime Administrator MDL Dep. Ex. 3077: Rig Condition Assessment Deepwater Horizon MDL Dep. Ex. 3149: Peter Bjerager Curriculum Vitae MDL Dep. Ex. 3152: Transocean-DNV Fleet Agreement (2005-2010) for Periodical Class and Statutory Surveys MDL Dep. Ex. 3154: DWH HAZARD Report for Transocean MDL Dep. Ex. 3155: Deepwater Horizon HAZID (Rev C) Chart MDL Dep. Ex. 3156: Deepwater Horizon HAZID (Rev C) Chart MDL Dep. Ex. 3157: Det Norske Veritas Deepwater Horizon HAZARD Report, Rev. 0 MDL Dep. Ex. 3158: Det Norske Veritas HAZARD Report Chart MDL Dep. Ex. 3159: Det Norske Veritas Report Chart re Evacuation/Escape MDL Dep. Ex. 3160: Report Chart re Accident Scenario: Visiting Vessel Collision MDL Dep. Ex. 3161: Det Norske Veritas NonConformity and Finding Note MDL Dep. Ex. 3162: ISM Certification Guidance for Planning of Periodical Company Audits MDL Dep. Ex. 3163: DNV Guidance for Auditors to the ISM Code: Maritime Management Systems MDL Dep. Ex. 3164: Appendix H3 Guide: Company Audit Guide MDL Dep. Ex. 3165: Email from H. Samadpour to D. McKay re "Transocean's Safety Management System" MDL Dep. Ex. 3244: List of technical information MDL Dep. Ex. 3245: Email re Recommendation/Report MDL Dep. Ex. 3246: Email re Follow-up to DWH Asseyt Mgr Close-out
Page 135 of 154
Beg Bates MODUSA 01 2 009667 MODUSI 01 2 009517 TRN-MDL-01120767 TRN-MDL-01084397
End Bates MODUSA 01 2 009746 MODUSI 01 2 009575 TRN-MDL-01120777 TRN-MDL-01084397
Description MDL Dep. Ex. 3247: Report of Survey, Deepwater Horizon MDL Dep. Ex. 3248: Report of Survey, Deepwater Horizon MDL Dep. Ex. 3259: Subsea Maintenance Philosophy Family 400 MDL Dep. Ex. 3271: Email from J. Canducci to P. Smith re: NAM Data attaching Transocean awards and Safety in Excellence Milestones MDL Dep. Ex. 3272: Email from I. Ajayi to P. Smith attaching Deepwater Horizon Summary MDL Dep. Ex. 3278: Performance and Asset Organization Chart MDL Dep. Ex. 3279: Email from P. Smith to R. Turlak MDL Dep. Ex. 3400: Deepwater Horizon Technical Rig Audit - January 2005 MDL Dep. Ex. 3401: CMID Annex (BP Requirements for MODU) Guidance Notes MDL Dep. Ex. 3402: Transocean Rig Assessment: Rig Condition Environmental Scorecard MDL Dep. Ex. 3403: Common Marine Inspection Documents MDL Dep. Ex. 3404: Common Marine Inspection Document MDL Dep. Ex. 3405: Deepwater Horizon Follow Up Rig Audit, Marine Assurance Audit and Out of Service Period - September 2009 MDL Dep. Ex. 3406: Email from J. Guide to M. Perez re: "FW: Deepwater Horizon Rig Audit" MDL Dep. Ex. 3407: Email from I. Little to H. Thierens and J. Guide re: "Fw: BP Audit" MDL Dep. Ex. 3410: Deepwater Horizon - BP CMID Audit Work List - September 2009 MDL Dep. Ex. 3412: Deepwater Horizon - BP CMID Audit Work List September 2009 MDL Dep. Ex. 3413: Observation Chart MDL Dep. Ex. 3414: Deepwater Horizon - BP CMID Audit Work List September 2009 MDL Dep. Ex. 3415: Observation Chart MDL Dep. Ex. 3416: Email from Rig_DWH Maintenance to Horizon Captain re: "FW: Latest copy of BP Rig audit Jan 2005" with Attachment MDL Dep. Ex. 3417: Deepwater Horizon Rig Hardware Assessment Report MDL Dep. Ex. 3426: Deepwater Horizon - BP CMID Audit Work List September 2009
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TRN-MDL-01084353 TRN-MDL-00648560 TRN-MDL-01119375 TRN-MDL-00519065 BP-HZN-CEC035543 MODUSI 01 1010533 BP-HZN-CEC035317 BP-HZN-CEC035317 TRN-MDL-00478589
TRN-MDL-01084367 TRN-MDL-00648559 TRN-MDL-01119381 TRN-MDL-00519127 BP-HZN-CEC035585 MODUSI 01 1 010550 BP-HZN-CEC035379 BP-HZN-CEC035379 TRN-MDL-00478652
BP-HZN-2179MDL01131229 BP-HZN-2179MDL01257480 BP-HZN-2179MDL00340659 BP-HZN-2179MDL00028730 BP-HZN-2179MDL00028731 TRN-MDL-00297882
BP-HZN-2179MDL01131232 BP-HZN-2179MDL01257486 BP-HZN-2179MDL00340659 BP-HZN-2179MDL00028730 BP-HZN-2179MDL00028731 TRN-MDL-00297882
TRN-MDL-00667435
TRN-MDL-00667436
MODUSI019008332
MODUSI019008360
Beg Bates
End Bates
Description MDL Dep. Ex. 3427: Deepwater Horizon - BP CMID Audit Work List September 2009 MDL Dep. Ex. 3501: Email re What are we going to do different MDL Dep. Ex. 3502: Email re Hanger Lock Down MDL Dep. Ex. 3503: Email re Negative Test While Displacing, attaching same MDL Dep. Ex. 3504: Agreed 30(b)(6) Deposition Notice fo Transocean Defendants (With 30(b)(6) Document Requests) MDL Dep. Ex. 3505: Email re 711 WC Incident, attaching powerpoint of same MDL Dep. Ex. 3506: Email re Way Forward with Transocean on CoW MDL Dep. Ex. 3507: Email re SQA Information MDL Dep. Ex. 3508: BP Gulf of Mexico Transocean Offshore Deepwater Drilling Inc. North America HSE Management System Bridging Document MDL Dep. Ex. 3509: Email re Performance and Operations Policies and Procedures Manual for SMART Review, attaching same MDL Dep. Ex. 3510: Email re Audit Report Documents-DWH Sept 2009, attaching DWH Sept 2009 Audit Findings MDL Dep. Ex. 3511: Email re SQA's for DWH MDL Dep. Ex. 3744: USCG/MMS Marine Board of Investigation Transcript re Captain Curt Kuchta on May 27, 2010 MDL Dep. Ex. 3745: C. Robert Kuchta Sworn Statement MDL Dep. Ex. 3746: US Coast Guard Witness Statement: Curt Kuchta MDL Dep. Ex. 3747: Transocean Training History: Kuchta MDL Dep. Ex. 3748: Employee Chart MDL Dep. Ex. 3749: Transocean Deepwater Horizon Bridge Procedures Guide MDL Dep. Ex. 3750: Transocean Completions Notification GOM: Environmental Leadership Training MDL Dep. Ex. 3751: Merchant Mariner Credential MDL Dep. Ex. 3752: Excerpt of MBI re Curt Kuchta MDL Dep. Ex. 3753: Certificate re Endorsement Attesting to the Recognition of the Provision of International Training from the Republic of the Marshall Islands
Page 137 of 154
TRN-MDL-01293200 BP-HZN-2179MDL00270393 TRN-MDL-01180030 BP-HZN-BLY00076260
TRN-MDL-01293262 BP-HZN-2179MDL00270394
BP-HZN-BLY00076264
TRN-MDL-00607000
TRN-MDL-00607035
TRN-MDL-00453590
TRN-MDL-00453709
TRN-MDL-01227613
TRN-MDL-01227619
TRN-HCEC-00064428 TRN-HCJ-00121110 TRN-USCG_MMS-00023845
TRN-HCEC-00064445 TRN-HCJ-00121110 TRN-USCG_MMS-00023991
TRN-MDL-00533207 TRN-USCG_MMS-00033918
TRN-MDL-00533274 TRN-USCG_MMS-00036918
Beg Bates TRN-HCJ-00006423 BP-HZN-MBI00011579
End Bates TRN-HCJ-00006431 BP-HZN-MBI00011580
Description MDL Dep. Ex. 3754: Deepwater Horizon Emergency Response Manual: Vol. 1 of 2 MDL Dep. Ex. 3755: Excerpt from Operations Manual for the Deepwater Horizon re Organization and Responsibilities MDL Dep. Ex. 4245: Biography of Bill Ambrose on the National Commission on the BP Deepwater Horizon Oil Spill and Drilling website MDL Dep. Ex. 4246: Agreed 30(b)(6) Deposition Notice of Transocean Defendants (With 30(b)(5) Document Requests) MDL Dep. Ex. 4247: Letter sent via email re Deepwater Horizon MDL No. 2179 MDL Dep. Ex. 4248: Macondo Well Incident, Transocean Investigation Report, Volume 1 MDL Dep. Ex. 4249: Email re Macondo update and forward plan awareness MDL Dep. Ex. 4250: Image of Deepwater Horizon explosion MDL Dep. Ex. 4251: Image of Deepwater Horizon explosion MDL Dep. Ex. 4252: Image of Deepwater Horizon explosion MDL Dep. Ex. 4253: 2008 Maintenance Update from B. Trahan, DWH Rig Manager MDL Dep. Ex. 4254: Daily Drilling Report MDL Dep. Ex. 4255: Email re Risler Unloading Well Control Events MDL Dep. Ex. 4256: Transocean's 10 Worst Kicks 2009 MDL Dep. Ex. 4258: Transocean Report titled "Performance and Operations, Policies and Procedures" MDL Dep. Ex. 4259: Email re Deepwater Horizon flow indicator MDL Dep. Ex. 4260: Email re Transocean Deepwater Horizon - Mud Flow Transmitter Documentation Request MDL Dep. Ex. 4261: Lloyd's Register Safety Management Systems and Safety Culture/Climate Reviews: Deepwater Horizon MDL Dep. Ex. 4262: Email re Investigation Team Bi-Weekly update MDL Dep. Ex. 4263: Transocean memo re Investigation of Negative Test and Riser Displacement Procedures (Preliminary Report) MDL Dep. Ex. 4265: Well Advisor Handbook
Page 138 of 154
NONE
NONE
NONE
NONE
NONE NONE BP-HZN-2179MDL01027524 NONE NONE NONE TRN-INV-00446562 NONE TRN-INV-01143129 NONE TRN-USCG_MMS-00042958
NONE NONE BP-HZN-2179MDL01027525 NONE NONE NONE TRN-INV-00446564 NONE TRN-INV-01143189 NONE TRN-USCG_MMS-00043221
TRN-INV-01144395 TRN-INV-01155156
TRN-INV-01144395 TRN-INV-01155160
TRN-INV-00016752
TRN-INV-00016763
TRN-INV-01798151 TRN-INV-01639748
TRN-INV-01798153 TRN-INV-01639756
Beg Bates
End Bates
Description MDL Dep. Ex. 4266: Email re MDL 2179 - Opticem Modeling MDL Dep. Ex. 4268: Excerpt from Transocean website re DWH Investigation MDL Dep. Ex. 4271: Drilling Contract, RBS-8D, Semisubmersible Drilling Unit, Vastar Resources, Inc. and R&B Falcon Drilling Co. MDL Dep. Ex. 4362: Deepwater Horizon Follow Up Rig Audit, Marine Assurance Audit and Out of Service Period September 2009 MDL Dep. Ex. 4363: Resume Guidlines for Maintenance Supervisor MDL Dep. Ex. 4364: Plaintiff's Original Complaint MDL Dep. Ex. 4365: Transocean Interviewing Form: Stephen Bertone MDL Dep. Ex. 4366: Safety Management and Safety Culture/Climate Review MDL Dep. Ex. 4375: Annual Individual Performance Assessment MDL Dep. Ex. 4376: Email from A. Rodriguez to J. Guide re: Deepwater Horizon audit MDL Dep. Ex. 4377: Email from A. Rodriguez to M. Sepulvado, et al. re: DW Horizon's Rig audit and CMID MDL Dep. Ex. 4378: Email from A. Rodriguez to J. Guide, et al. attaching Deepwater Horizon's Rig Audit close out report status MDL Dep. Ex. 4379: Email from A. Rodriguez to N. Cramond re: GP 10-40 Drilling Rig Audits & Rig Acceptance MDL Dep. Ex. 4458: Passport for Fleytas, Andrea from Republic of the Marshall Islands MDL Dep. Ex. 4459: Transocean Dynamic Positioning Operator, OJT Module MDL Dep. Ex. 4460: Deepwater Horizon ADPO Familiarization/OJT Program MDL Dep. Ex. 4461: Rig Specific OJT, Answers to ADPO Theory test MDL Dep. Ex. 4462: Network file for Personnel Training for Andrea Anasette MDL Dep. Ex. 4463: Certificate for Attending a 4 day Dynamic Positioning, Advanced DP Power Simulaton Course MDL Dep. Ex. 4464: Certificate for Attending a 5 day Dynamic Positioning Basic Operator Course MDL Dep. Ex. 4465: Certificate for the Dynamic Positioning Operator OJT Course
Page 139 of 154
TRN-INV-01021316 BP-HZN-MB100021460
TRN-INV-01021316 BP-HZN-MB100021999
BP-HZN-IIT-0008871
BP-HZN-IIT-0008929
TRN-INV-00000296 TRN-HCEC-00090493 BP-HZN-2179MDL02936720 Not Legible BP-HZN-2179MDL01270743
TRN-INV-00000306 TRN-HCEC-00090685 BP-HZN-2179MDL02936723 Not Legible BP-HZN-2179MDL01270920
BP-HZN-2179MDL01114980
BP-HZN-2179MDL01114981
BP-HZN-2179MDL01137477
BP-HZN-2179MDL01137491
TRN-HCJ-00128069 TRN-MDL-01598152 TRN-MDL-01593467 TRN-MDL-01601026 TRN-USCG_MMS_00035826 TRN-USCG_MMS-00035808
TRN-HCJ-00128074 TRN-MDL-01598184 TRN-MDL-01593477 TRN-MDL-01601030 TRN-USCG_MMS_00035826 TRN-USCG_MMS-00035808
Beg Bates NONE NONE TRN-MDL-01603842 TRN-HCJ-00120898 TRN-INV-00800577 NONE
End Bates NONE NONE TRN-MDL-01603843 TRN-HCJ-00120899 TRN-INV-00800578 NONE
Description MDL Dep. Ex. 4466: List of personnel names and corresponding rig MDL Dep. Ex. 4467: List of personnel, job titles and applicable rigs MDL Dep. Ex. 4468: Handover Notes MDL Dep. Ex. 4469: US Coast Guard, Witness Statement, Investigations Department MDL Dep. Ex. 4470: Report re Rig Explosion injury and evacuation for Fleytas, Andrea MDL Dep. Ex. 4471: Transcript of the Testimony of the Joint United States Coast Guard/ Bureau of Ocean Energy Management Investigation MDL Dep. Ex. 4472: Transocean Interviewing Form - Andrea Fleytas MDL Dep. Ex. 4600: Certificate Veritas: David Hackney MDL Dep. Ex. 4601: Transocean Training List History Profile MDL Dep. Ex. 4602: Description of Master position on Transocean's website MDL Dep. Ex. 4603: Transocean, Deepwater Horizon chart of abandonment stations and chain of command MDL Dep. Ex. 4604: Drillship organizational chart MDL Dep. Ex. 4605: Command Group - Bridge MDL Dep. Ex. 4606: Interviewing Form for Hackney, David MDL Dep. Ex. 4607: Deepwater DP Management, DP Familiarisation, Course Notes MDL Dep. Ex. 4608: Email re FRC Recommendations MDL Dep. Ex. 4609: Deepwater Horizon, Follow Up Rig Audit, Marine Assurance, Audit and Out of Service Period, September 2009 MDL Dep. Ex. 4620: Deepwater Horizon Weekly Ops/Eng Meeting re Subsea Issues, Transit, Equipment, Rig Inspector, and Thruster Repair MDL Dep. Ex. 4621: Email from D. Williams to W. Stringfellow et al. re RE: DSP - DTL Shuttle Valves RMR MDL Dep. Ex. 4625: Email from H. Valdez to S. Woelfel et al. MDL Dep. Ex. 4626: Email from OIM to J. Keeton MDL Dep. Ex. 4629: Beacon: Transocean in the Spotlight - Spring 2009, Issue 1 - "Deepwater Horizon Six Years Safety in Excellence"
Page 140 of 154
TRN-INV-00001465 BP-HZN-2179MDL01248950 TRN-INV-00710371 BP-HZN-MB100021445 TRN-MDL-00527083
TRN-INV-00001474 BP-HZN-2179MDL01248950 TRN-INV-00710371 BP-HZN-MB100021446 TRN-MDL-00527083
TRN-MDL-01608127 NONE TRN-INV-00001748 TRN-MDL-01604104 TRN-INV-00467935 BP-HZN-IIT-0008871
TRN-MDL-01608127 NONE TRN-INV-00001766 TRN-MDL-01604134 TRN-INV-00467937 BP-HZN-IIT-0008930
TRN-INV-01854295
TRN-INV-01854299
TRN-INV-01266391
TRN-INV-01266398
TRN-MDL-01960318 TRN-MDL-01990701
TRN-MDL-01960320 TRN-MDL-01990702
Beg Bates TRN-MDL-01956053
End Bates TRN-MDL-01956054
Description MDL Dep. Ex. 4630: Transocean NAM EOM Injury and Event Logs for July 2008 - Safety Statistics and Overview MDL Dep. Ex. 4631: John Keeton Interviewing Form MDL Dep. Ex. 4632: Email from K. Corser to D. Ruedelhuber MDL Dep. Ex. 4633: Juno Term of Reference for Investigation MDL Dep. Ex. 4634: MRO Justification Sheet 2009 Budget for Horizon re Other Drillfloor MDL Dep. Ex. 4635: Email from J. Kent to J. Keeton et al. re Multiple Issues on the Rig MDL Dep. Ex. 4638: Deepwater Horizon Task Specific Think Procedure MDL Dep. Ex. 4639: DWH Task Specific Index MDL Dep. Ex. 4640: Deepwater Horizon Task Specific Think Procedure re Negative Flow Test Using Choke and Kill Lines MDL Dep. Ex. 4641: Deepwater Horizon Well Specific Operating Guidelines MDL Dep. Ex. 4641: Well Specific Operating Guidelines, Mississippi Canyon 948 (Freedom) MDL Dep. Ex. 4642: Riser Analysis MDL Dep. Ex. 4643: Email from J. Keeton to DSP et al. MDL Dep. Ex. 4644: Deepwater Horizon Emergency Response Manual - Volume 1 of 2 MDL Dep. Ex. 4645: Deepwater Horizon Emergency Response Manual - Volume 2 of 2 MDL Dep. Ex. 4646: Deepwater Horizon Emergency Response Manual - Emergency Disconnect Procedure - General MDL Dep. Ex. 4647: Deepwater Horizon Emergency Response Manual - Emergency Disconnect Procedure - Emergency Disconnect Activation MDL Dep. Ex. 4648: Deepwater Horizon Emergency Response Manual - Emergency Disconnect Procedure - Dynamic Positioning/DP Standby Conditions MDL Dep. Ex. 4649: Deepwater Horizon Emergency Response Manual - Emergency Disconnect Procedure - Emergency Disconnect Activation - Cementing (Hanger Landed in Wellhead)
Page 141 of 154
TRN-INV-00002585 TRN-MDL-01938654 TRN-MDL-01938641 TRN-MDL-01965612 TRN-MDL-01934635 TRN-MDL-01949530 TRN-MDL-01995506 TRN-MDL-01995569
TRN-INV-00002605 TRN-MDL-01938655 TRN-MDL-01938642 TRN-MDL-01965622 TRN-MDL-01934636 TRN-MDL-01949532 TRN-MDL-01995515 TRN-MDL-01995570
TRN-MDL-01965043
TRN-MDL-01965043
TRN-MDL-01941200
TRN-MDL-01941200
TRN-MDL-01941201
TRN-MDL-01941202
TRN-MDL-01941212
TRN-MDL-01941213
Description MDL Dep. Ex. 4650: Deepwater Horizon Emergency Response Manual - Emergency Disconnect Procedure - Emergency Disconnect Activation - Cement (Setting Plugs) MDL Dep. Ex. 4651: Deepwater Horizon Emergency Response Manual - Emergency Disconnect Procedure - Emergency Disconnect Activation - Well Control MDL Dep. Ex. 4652: Deepwater Horizon Emergency Response Manual - Emergency Disconnect Procedure - Emergency Disconnect Sequence MDL Dep. Ex. 4653: Deepwater Horizon Emergency Response Manual - Emergency Disconnect Procedure - Appendix 1: Emergency Disconnect (EDS) Sequence MDL Dep. Ex. 4654: Excerpt from Jonathan Keeton Transcript on 08/17/2011 re Weekly EDS Drills MDL Dep. Ex. 4655: Email from DSP, OIM to J. Keeton re RE: BOP Emergency System Testing Standard Procedures MDL Dep. Ex. 4663: Email from J. Keeton to DSP, OIM re FW: HSE and DT Stats MDL Dep. Ex. 4676: Transocean HSE Performance Meeting MDL Dep. Ex. 4677: Email from D. Winslow to J. Keeton et al. MDL Dep. Ex. 4678: BP HSE Performance Meeting MDL Dep. Ex. 4679: Email from D. Sims to J. Keeton re FW: Deepwater Horizon Audit Report MDL Dep. Ex. 4680: Deepwater Horizon Technical Rig Audit - January 2008 MDL Dep. Ex. 4681: Email from J. Skelton to J. Keeton et al. re Deepwater Horizon Audit Report January 2008.doc MDL Dep. Ex. 4682: Email from J. Keeton to J. Kent MDL Dep. Ex. 4683: Deepwater Horizon Emergency Response Manual - Emergency Disconnect Procedure - Appendix 1: Emergency Disconnect (EDS) Sequence MDL Dep. Ex. 4684: Email from G. Coltrin to J. Keeton et al. MDL Dep. Ex. 4685: Excerpts from Transocean Performance and Operations Policies and Procedures Manual re OPS Planning and Reporting MDL Dep. Ex. 4686: Well Advisor
Page 142 of 154
TRN-MDL-01941216
TRN-MDL-01941217
TRN-MDL-01941219
TRN-MDL-01941219
TRN-MDL-01941220
TRN-MDL-01941224
TRN-MDL-02009260
TRN-MDL-02009262
TRN-MDL-02009493 TRN-MDL-00542891 TRN-MDL-01953367 TRN-MDL-01953368 TRN-MDL-01973942 TRN-MDL-01973943 TRN-MDL-01979905
TRN-MDL-02009494 TRN-MDL-00542901 TRN-MDL-01953367 TRN-MDL-01953378 TRN-MDL-01973942 TRN-MDL-01974024 TRN-MDL-01979905
TRN-MDL-01967635 TRN-MDL-01967636
TRN-MDL-01967635 TRN-MDL-01967639
TRN-MDL-01533488 TRN-MDL-00607004
TRN-MDL-01533493 TRN-MDL-00607004
Beg Bates CAM_CIV_003283 TRN-MDL-00119247
End Bates CAM_CIV_003287 TRN-MDL-00119248
Description MDL Dep. Ex. 4687: Cameron Well Control Equipment - Periodic Inspection/Recertification MDL Dep. Ex. 4688: Email from Deepwater Horizon, Formen to Driller@dwh.rig.deepwater.com et al. MDL Dep. Ex. 4689: Email from J. Kent to B. Trahan MDL Dep. Ex. 4911: OIM-Master Relationship MDL Dep. Ex. 5032: Interviewing Form re Yancy J. Keplinger by P. Roller and J. MacDonald MDL Dep. Ex. 5033: Email from DWH, DPOperator to DWH, Captain re "DWH PIC Letter" with Letter MDL Dep. Ex. 5034: Y. Keplinger Personnel Training File Report from NAR.OPS.RigCentral.com MDL Dep. Ex. 5035: Email from rig_DWH,captain to DWH Chief Mate, DWH Marine, and DWH Maintenance MDL Dep. Ex. 5036: Personal Letter from M. Dow to Y. Keplinger MDL Dep. Ex. 5037: Deepwater Horizon Watchstanding and Dynamic Positioning Bridge Procedures Guide MDL Dep. Ex. 5038: Transocean DP Vessel Drift-off and Watch Circle Program Deepwater Horizon Operating Draft MDL Dep. Ex. 5039: Safety Drill Report MDL Dep. Ex. 5040: Superior Offshore Solutions LLC Daily Report #3 re Deepwater Horizon MDL Dep. Ex. 5041: Transocean Task Specific Think Procedure Chart MDL Dep. Ex. 5042: Transocean Deepwater Horizon Failure Modes Effects and Critically Analysis MDL Dep. Ex. 5043: Letter from N. Roche to Y. Keplinger MDL Dep. Ex. 5044: Letter from M. Dow to Y. Keplinger MDL Dep. Ex. 5045: Deepwater Horizon Marine Crew Task Specific Think Procedures MDL Dep. Ex. 5046: Email from DWH DPOperator to DWH Captain re "Katie's Handover Notes - 19 February 2010" MDL Dep. Ex. 5047: Macondo Handover Notes MDL Dep. Ex. 5048: Letter from K. Trosclair Bourgeois to Dr. J. Steen re Yancy Keplinger/"Left Shoulder Pain" MDL Dep. Ex. 5122: Masters Responsibilities
Page 143 of 154
TRN-MDL-00885690 TRN-MDL-01851695 TRN-INV-00002645 TRN-MDL-02411791 TRN-USCG_MMS-00036708 TRN-MDL-01587834
TRN-MDL-00885690
TRN-INV-00002652 TRN-MDL-02411792 TRN-USCG_MMS-00036751 TRN-MDL-01587836
TRN-MDL-01587341 TRN-MDL-01597604
TRN-MDL-01587346 TRN-MDL-01597626
BP-HZN-MBI00167544 TRN-MDL-01585758 TRN-MDL-01597103 TRN-HCEC-00010352
BP-HZN-MBI00167545 TRN-MDL-01585761 TRN-MDL-01597103 TRN-HCEC-00010676
TRN-MDL-02412174 TRN-MDL-01586886 TRN-MDL-01586100 TRN-MDL-02420138
TRN-MDL-02412176 TRN-MDL-01586891 TRN-MDL-01586104 TRN-MDL-02420138
TRN-MDL-02420139 41
TRN-MDL-02420141 42
TRN-MDL-02247359
TRN-MDL-02247364
Beg Bates CAM_CIV_0105569
End Bates CAM_CIV_0105576
Description MDL Dep Ex. 5173: Cameron EDS, MUX BOP MDL Dep. Ex. 5285: Sperry Drilling Services Surface Data Logging MDL Dep. Ex. 5286: Email from R. Vargo to J. Miller re: Cement Top attaching TOC Review MDL Dep. Ex. 5287: Top of Cement simulations MDL Dep. Ex. 5288: Email from R. Sweatman to T. Roth re: Conversation with Jeff Moss of Exxon Mobil MDL Dep. Ex. 5289: Mud Logging Report MDL Dep. Ex. 5290: Email from J. Grier to A. Scardino, et al. re: Statement awareness of Halliburton's response to BP MDL Dep. Ex. 5291: Email from J. Bement to I. Mitchell and R. Dirksen re: SDL monitoring attaching image MDL Dep. Ex. 5292: Email from J. Grable to R. Russell, et al. re: Evaluate programs of Process Excellence MDL Dep. Ex. 5293: Email from J. Lewis to A. Briston, C. Perez, et al. re "Release of 2010 Pil White Paper" with Halliburton White Paper Attachment MDL Dep. Ex. 5294: Email from T. Probert/Halliburton Communications to Halliburton Managers and Supervisors re "Halliburton's 2011 Service Quality Strategy" MDL Dep. Ex. 5295: Email from N. Buck to J. Prestidge re "Sperry Drilling - Service Quality in the Drilling Equipment Maintenance world!" with Roadmap Attachment MDL Dep. Ex. 5296: Email from J. Prestidge to N. Buck re "RE: Sperry Drilling - Service Quality in the Drilling Equipment Maintenance world!" MDL Dep. Ex. 5297: Email from B. Murphy to D. Wood, G. Taylor, J. Vagher, et al. re "FW: Halliburton's 2011 Service Quality Strategy" MDL Dep. Ex. 5298: Halliburton 2011 Service Quality Strategy MDL Dep. Ex. 5299: Email from J. Prestidge to R. Shuman, R. Grisinger, G. Badrashini, et al. re "HSE and SQ for 2011" with Halliburton 2011 Service Quality Attachment MDL Dep. Ex. 5299: Transoceans Deepwater Horizon Organization Chart.pptx (from TO Emergency Response Manual MDL Dep. Ex. 5338: DWH Well Specific Operating
Page 144 of 154
HAL_0696735
HAL_0696736
HAL_0606676
HAL_0606677
HAL_0699897 HAL_1060808
HAL_0699898 HAL_1060809
HAL_0984480
HAL_0984481
HAL_0643366
HAL_0643368
HAL_1228396
HAL_1228401
HAL_1228429
HAL_1228430
HAL_1228332
HAL_1228333
HAL_1228479
HAL_1228480
HAL_1228404
HAL_1228405
HAL_1228406 HAL_1228196
HAL_1228428 HAL_1228221
TRN-MDL-00048168
Beg Bates
End Bates
Description Guidelines, Dorado MDL Dep. Ex. 5417: Deepwater Horizon Investigation Chart MDL Dep. Ex. 5418: Interviewing Form of Sean Bayer MDL Dep. Ex. 5419: Email from J. MacDonald to D. hart re: Scheduled Interviews Represented by Lawyers MDL Dep. Ex. 5420: Email from J. MacDonald to D. Hart re: Statement MDL Dep. Ex. 5421: Email from B. Breaux to S. Wells, et al. re: 05112010 1400 Operations Action Plan MDL Dep. Ex. 5422: Exerpt from Share Point chart about rig events MDL Dep. Ex. 5423: Interviewing Form of Sean Bayer MDL Dep. Ex. 5424: Email from D. Hart to J. MacDonald re: Scheduled Interviews Represented by Lawyers MDL Dep. Ex. 5425: Interviewing Form of Stanley Carden MDL Dep. Ex. 5426: Image of Deepwater Horizon Rig General Arrangements MDL Dep. Ex. 5427: Interview Form of William Jernigan MDL Dep. Ex. 5428: Email from J. MacDonald to J. Judkins, et al. re: Interview Notes MDL Dep. Ex. 5429: Email from S. Watson to J. Judkins and J. MacDonald re: Michael Dicello Interview Draft MDL Dep. Ex. 5430: Diagram of Transocean Management System - HSE management MDL Dep. Ex. 5431: Exerpt of report entitled Transocean Management system - HSE management MDL Dep. Ex. 5432: HSE performance in order to motivate personnel to take a proactive role MDL Dep. Ex. 5433: Exerpt of report entitled Operations Integrity Case - Emergency Response MDL Dep. Ex. 5434: Email from W. Weaver to A. Rispoli and J. Brekke re: POB 4-8-2010 - Day Visitor exceeding the Max POB attaching image MDL Dep. Ex. 5435: Email from Rig DWH, Captain to J. MacDonald re: Optical Gyros - Technical Information Bulletin attaching HQS OPS TIB
Page 145 of 154
TRN-INV-01122946 TRN-INV-00000228 TRN-INV-02806138
TRN-INV-01122949 TRN-INV-00005245 TRN-INV-02806138
TRN-INV-02806139 TRN-MDL-02733584
TRN-INV-02806139 TRN-MDL-02970752
TRN-INV-00000228 TRN-INV-02803304
TRN-INV-00000232 TRN-INV-02803306
TRN-INV-00000658 TRN-INV-00000664 TRN-INV-00002238 TRN-MDL-02521307 TRN-INV-02392449
TRN-INV-00000663 TRN-INV-00000695 TRN-INV-00002244 TRN-MDL-02521307 TRN-INV-02392449
TRN-MDL-02865450 TRN-MDL-02865410
TRN-MDL-02865450 TRN-MDL-02865410
TRN-MDL-02865365 TRN-MDL-02865605 TRN-INV-02983283
TRN-MDL-02865367 TRN-MDL-02865605 TRN-INV-02983286
TRN-MDL-02721029
TRN-MDL-02721030
Description MDL Dep. Ex. 5436: Marine Compliance Procedures - Personnel Designation of OIM and PIC MDL Dep. Ex. 5437: Email from Hgr, BargeSupervisor to J. MacDonald re: Watertight Integrity and Compliance attaching Pump Rm. Blank MDL Dep. Ex. 5438: Email from J. MacDonald to M. Lindsley, et al. re: Nautical Institute Proposals MDL Dep. Ex. 5439: Email from J. MacDonald to D. Hart and A. Nordholm re: Share Point Investigation Tickets #246 - #250 MDL Dep. Ex. 5440: Email from D. Reudelhuber to S. Walker and J. MacDonald re: Deepwater Horizon attaching DWH Weekly Drill Reports MDL Dep. Ex. 5441: Weekly Drill Report MDL Dep. Ex. 5442: Weekly Drill Report MDL Dep. Ex. 5443: Email from D. Reudelhuber to S. Walker and J. MacDonald re: Deepwater horizon attaching Dwh Safety Drill Reports March MDL Dep. Ex. 5444: Email from J. MacDonald to A. Rose, et al. re: LA times Story - URGENT & CONFIDENTIAL attaching Panamanian Manning letter MDL Dep. Ex. 5445: Letter from M Canada to N. Smith re: Transocean propose common wording on the Minimum Manning Certificates for the MODU MDL Dep. Ex. 5446: Deepwater Horizon Emergency Response Manual - Emergency Disconnect Procedure MDL Dep. Ex. 5447: Chapter 6 - Summary of Conclusions - Deepwater casualty MDL Dep. Ex. 5448: Email from W. Weaver to A. Rose re: Marine Board Conclusions and Recommendations attaching Macondo Conclusion Survey; Macondo Recommendations Survey MDL Dep. Ex. 5449: Transocean Interviewing Form of Rex Beard MDL Dep. Ex. 5450: Transocean Interviewing form of Jonathan Camacho MDL Dep. Ex. 5451: Transocean Interviewing Form of Nathan Carroll MDL Dep. Ex. 5452: Transocean Interviewing Form of Michael Cutrer MDL Dep. Ex. 5453: Transocean Interviewing Form of Michael Dicello
Page 146 of 154
TRN-MDL-02723284
TRN-MDL-02723286
TRN-INV-02963910 TRN-MDL-02521321
TRN-INV-02963912 TRN-MDL-02521322
TRN-INV-02642862
TRN-INV-02642862
TRN-INV-026442863 TRN-INV-02642902 TRN-MDL-02526400
TRN-INV-026442901 TRN-INV-02642943 TRN-MDL-02526400
TRN-INV-03485220
TRN-INV-03485224
TRN-INV-03540868
TRN-INV-03540869
TRN-MDL-02070856
TRN-MDL-02070857
TRN-MDL-02702988 TRN-MDL-02703711
TRN-MDL-02703001 TRN-MDL-02703711
TRN-INV-00000248 TRN-INV-00000594 TRN-INV-00000720 TRN-INV-00000992 TRN-INV-00001205
TRN-INV-00000253 TRN-INV-00000598 TRN-INV-00000724 TRN-INV-00000997 TRN-INV-00001210
Beg Bates TRN-INV-00001246 TRN-INV-00001748 TRN-INV-00002645 TRN-INV-00002988 TRN-INV-00003298 TRN-INV-00003543 TRN-INV-00004126 TRN-INV-00005239 TRN-MDL-02703795 TRN-MDL-02703799 TRN-MDL-02703881 TRN-INV-03073902
End Bates TRN-INV-00001252 TRN-INV-00001752 TRN-INV-00002652 TRN-INV-00002995 TRN-INV-00003305 TRN-INV-00003548 TRN-INV-00004130 TRN-INV-00005245 TRN-MDL-02703798 TRN-MDL-02703817 TRN-MDL-02703943 TRN-INV-03073904
Description MDL Dep. Ex. 5454: Transocean Interviewing Form of Mike Dow MDL Dep. Ex. 5455: Transocean Interviewing Form of Daivd Hackney MDL Dep. Ex. 5456: Transocean Interviewing Form of Yancy Keplinger MDL Dep. Ex. 5457: Transocean Interviewing Form of Mike Mayfield MDL Dep. Ex. 5458: Transocean Interviewing Form of Paul Meinhart MDL Dep. Ex. 5459: Transocean Interviewing Form of James Musgrove MDL Dep. Ex. 5460: Transocean Interviewing Form of Nathaniel Roche MDL Dep. Ex. 5461: Transocean Interviewing Form of David Young MDL Dep. Ex. 5462: Email from J. MacDonald to M. LaBella attaching Rig Awareness Manual MDL Dep. Ex. 5463: Rig Awarness Training MDL Dep. Ex. 5464: Rig Awareness Training - Rig Operations MDL Dep. Ex. 5465: Email from J. MacDonald to D. Hart re: Questions attaching Horizon EER Questions - Offshore Personnel MDL Dep. Ex. 5468: Deepwater Horizon Incident Internal Investigation update - Interim Report MDL Dep. Ex. 5469: HSE Alert - Verification of Ability to Respond to an Emergency MDL Dep. Ex. 5472: Exerpt of Health and Safety Policies and Procedures Manual - Safety Policies, Procedures and Documentation MDL Dep. Ex. 5473: Deepwater Horizon Operations Integrity Case, Section 1 (Introduction and Table of Contents) MDL Dep. Ex. 5474: Deepwater Horizon Operations Integrity Case, Section 2 - HSE Managment MDL Dep. Ex. 5475: Deepwater Horizon Operations Integrity Case - Risk Management MDL Dep. Ex. 5476: Deepwater Horizon Operations Integrity Case Emergency Response MDL Dep. Ex. 5477: Deepwater Horizon Operations Integrity Case Performance Monitoring MDL Dep. Ex. 5478: Email from A. Rose to S. Newman re: Meeting Presentations - GSF and Total attaching QHSE group for GSF
Page 147 of 154
TRN-MDL-02726350 TRN-INV-02494856 TRN-HCJ-00004903
TRN-MDL-02726367 TRN-INV-02494857 TRN-HCJ-00004903
TRN-MDL-02865451
TRN-MDL-02865458
TRN-MDL-02865347
TRN-MDL-02865450
TRN-MDL-00655132
TRN-MDL-00655156
Description MDL Dep. Ex. 5480: Email from J. Canducci to M. Wright, et al. re: Corporate QHSE Incident Review - April 1, 2010 attaching Corporate QHSE Incident Review Apr 1; Actinia - DSC - Potential Dropped object; Safety Vision Review 2010 Clear Agreement Document MDL Dep. Ex. 5481: Email from A. Rose to J. Moore re: Rig Visit Assignement attaching PMAA Criteria Standard; PMAA Procedures Manual Section MDL Dep. Ex. 5482: Lloyd's Register Safety Management System and Safety Culture/Climate Reviews Closing Meeting MDL Dep. Ex. 5483: DWH ISM Code Certification Ship Audit Report (DNV, 2002) MDL Dep. Ex. 5484: Email from S. Hopkins to J. Moore re: ISM Audit Reports - DWH Flag State Inspection Reports attaching DNV Annual Verification Audit; DNV Annual Corporate ISM Audit MDL Dep. Ex. 5485: Corporate Emergency Response Plan MDL Dep. Ex. 5486: Engineering & Technical Support HSE Meeting MDL Dep. Ex. 5487: Letter from D. Dickman to B. Poskaitis re: U.S. Coastal State Regulation Compliance MDL Dep. Ex. 5488: Deepwater Horizon Accident Investigation Report Review MDL Dep. Ex. 5571: Department of Homeland Security United States Coast Gaurd - Certificate of Compliance MDL Dep. Ex. 5572: Transocean MMS/USCG RIG Inspection Summary Report Deepwater Horizon MDL Dep. Ex. 5575: Letter from the USCG to the Republic of the Marshall Islands Regarding MODU Code Equivalence MDL Dep. Ex. 5576: Congressional Staff, DHS, OMB & Other Misc Q&As - Regulation/Policy to Allow CG to Issue 2 YR Certificate to DH MODU MDL Dep. Ex. 5584: Activity Summary Report Attended MODU in company with POC CWO Carrera and LT Mike Franklin to conduct renewal examination for CoC MDL Dep. Ex. 5585: Activity Summary Report MODU is in very good condition, Good Crew participation
Page 148 of 154
TRN-MDL-02833303
TRN-MDL-02833582
TRN-MDL-02834327
TRN-MDL-02834345
TRN-MDL-02830621 TRN-MDL-02832154
TRN-MDL-02830629 TRN-MDL-02832188
TRN-INV-00018567 TRN-MDL-02827465 TRN-MDL-02831737
TRN-INV-00018600 TRN-MDL-02827484 TRN-MDL-02831741
TRN-INV-01463636 HCG161-040009
TRN-INV-01463640 HCG161-040017
TRN-INV-02265384
TRN-INV-02265385
HCG037-010037
HCG037-010038
DHCIT_TPY-0169122
DHCIT_TPY-0169123
DHCIT_TPY-0169130
DHCIT_TPY-0169131
Beg Bates TRN-INV-00003875 TRN-MDL-01293817 TRN-MDL-01175982 TRN-MDL-02754126
End Bates TRN-INV-00003887 TRN-MDL-01293819 TRN-MDL-01175982 TRN-MDL-02754126
Description MDL Dep Ex. 5629: Transocean Interview Form: C. Pleasant. MDL Dep. Ex. 5633: Email from S. Newman to L. McMahan re: Ops Brief MDL Dep. Ex. 5634: Email from S. Newman to L. McMahan re: Update MDL Dep. Ex. 5635: Email from S. Newman to L. McMahan, et al. re: Operational Concerns re Shutting in the Well MDL Dep. Ex. 5642: Transocean: Positioned to Lead Proxy Statment and 2009 Annual Report MDL Dep. Ex. 5643: Integration Memo from Executive Vice Presidents of Performance to Business Unit Senior Vice Pres. re: Day 1 operational guidance MDL Dep Ex. 5643: Integration Memo, Nov. 20, 2007. MDL Dep. Ex. 5644: Transocean Management System - HSE Management MDL Dep. Ex. 5645: Email from B. Sannan to S. Newman and L. McMahan re: Daily Executive Notification - NPT 29 Oct 2008 attaching explanation from the Rig manager MDL Dep. Ex. 5646: Email from gmsproject to S. Newman re: Daily Executive Notification Incidents 4/12/2010 MDL Dep. Ex. 5647: Well Control Events Statistics 2005 - 2006 - 2007 MDL Dep. Ex. 5648: Email from M. Pathak to S. Newman re: 2007 Well Control Analysis MDL Dep. Ex. 5649: Annual Report - 2009 Well Control Events & Statistics 2005 to 2009 MDL Dep. Ex. 5650: EAU Incident Investigation Report MDL Dep. Ex. 5651: Email from L. McMahan to M. Robichaux and B. Ambrose re: Presidential Commission Report - Chapter 4 Comments attaching HQS OPS ADV Integrity; Example displacement charts MDL Dep. Ex. 5652: Interviewing Form of Steven Newman MDL Dep. Ex. 5653: Email from S. Newman to L. McMahan re: weekly OER Executive Review 2009 Week 02 MDL Dep. Ex. 6000: Tony Hayward Speech Transcription -- Stanford, YouTube, "Entrepreneurial Spirit Needed"
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TRN-MDL-00606649
TRN-MDL-00606655
TRN-MDL-02865347 TRN-MDL-02493368
TRN-MDL-02865450 TRN-MDL-02493372
TRN-HCEC-00100941
TRN-HCEC-00100951
TRN-MDL-02506723 TRN-MDL-02506721 TRN-INV-00760054 TRN-INV-01143039 TRN-INV-01215566
TRN-MDL-02506745 TRN-MDL-02506722 TRN-INV-00760101 TRN-INV-01143059 TRN-INV-01215567
TRN-INV-00003563 TRN-MDL-02764790
TRN-INV-00003566 TRN-MDL-02764792
Beg Bates
End Bates
Description MDL Dep. Ex. 6001: House of Representatives Verbatim Transcript of June 17, 2010 - Committee on Energy and Commerce, Subcommittee on Oversight and Investigations MDL Dep. Ex. 6002: Leading from the top in BP MDL Dep. Ex. 6003: Speech - Working Safely - a continuous journey MDL Dep. Ex. 6004: Exxon's Tillerson blames BP for Gulf oil spill MDL Dep. Ex. 6005: OT: BP Fined $15.5 Million in Dumping of Toxic Waste in Alaska MDL Dep. Ex. 6006: United States of America v. BP Products North America Inc. MDL Dep. Ex. 6007: BP to Appoint Independent Panel to Review U.S. Refinery Safety MDL Dep. Ex. 6008: United States of America v. BP Exploration (Alaska) Inc. MDL Dep. Ex. 6009: Interview in article format titled: Alaskan Oil Pipeline Leak Raises Environmental Concerns MDL Dep. Ex. 6010: United States of America v. BP America Inc. MDL Dep. Ex. 6011: Lessons from Grangemouth: A Case History MDL Dep. Ex. 6012: Investigation Report Refinery Explosion and Fire - Key issues: Safety Culture, Regulatory Oversight, Process Safety Metrics, Human Factors MDL Dep. Ex. 6013: 2006 BPXA GPB OTL Incidents BP America Inc. Final Report MDL Dep. Ex. 6014: BP boss warns of shake-up after dreadful results MDL Dep. Ex. 6015: Speech in article format entitled - Tony Hayward's speech at the 2008 Annual General Meeting MDL Dep. Ex. 6016: BP Press Release: BP AGM Speech- Tony Hayward MDL Dep. Ex. 6017: BP Press Release - BP Annual General Meeting 2010: Speeches - Tony Hayward MDL Dep. Ex. 6018: 2010 Drilling Excellence Plan MDL Dep. Ex. 6019: Gulf of Mexico SPU - Drilling and Completions The Way We Work MDL Dep. Ex. 6020: D&C HSSE Organizational Change - August 09 MDL Dep. Ex. 6022: Horizon, Issue Three 2008: A Better Record on Safety and Environment
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Beg Bates BP-HZN-2179MDL003405
End Bates BP-HZN-2179MDL003405
Description MDL Dep. Ex. 6140: Email from N. Wong to H. Thierens and J. Sprague re: Deepwater Horizon Rig Audit MDL Dep. Ex. 6141: Email from N. Wong to I. Little re: Horizon Rig Audit Updates and path forward MDL Dep. Ex. 6142: Feedback via teleconference MDL Dep. Ex. 6143: Email from J. Guide to B. Cocales and K. Daigle re: Deepwater Horizon Rig Audit MDL Dep. Ex. 6144: Email from S. haden to N. Wong re: Deepwater Horizon Rig Audit MDL Dep. Ex. 6149: Safety Alert on the Deepwater Horizon Explosion MDL Dep. Ex. 6150: Safety Alert on the Deepwater horizon Explosion and Fire Resulting in multiple Fatalities MDL Dep. Ex. 7117: Well Control Procedures and Responsibilities: Well Control Procedures MDL Dep. Ex. 7118: Transocean- Section 1- Well Control Procedure and Responsibilities MDL Dep. Ex. 7119: Transocean- Section 3 - Well Control Principles MDL Dep. Ex. 7120: Transocean- Section 4 Preparation & Prevention MDL Dep. Ex. 7121: Transocean- Section 5 Actions Upon Taking A Kick MDL Dep. Ex. 7122: Transocean- Drilling Deepwater Wells MDL Dep. Ex. 7123: Deepwater Horizon HAZIDReport for Transocean Offshore Deepwater Drilling Inc. MDL Dep. Ex. 7124: Incident Title- Transocean S711 MDL Dep. Ex. 4271: Drilling Contract RBS-80 Submersible Drilling Unit, Vastar Resources Inc. and R&B Falcon Drilling Co. 2010-09-07 Venable response to RMI letter Lloyd's Register EMEA Document Production DNV Vessel Summary Report for DWH, April 26, 2010 DNV ISM Code/ISO Certification Observation, May 15, 2007 Transocean ISM Installation Audit Checklist/Report, July 10, 2003 Canducci, Jerry deposition transcript, Vol. 1 & 2 Simonsen, Jan (Kongsberg) deposition transcript Winslow, Daun deposition transcript, Vol. 1 & 2
Page 151 of 154
BP-HZN-BLY-00356689 BP-HZN-BLY00360479 BP-HZN-2179MDL00353304
BP-HZN-BLY-00356691 BP-HZN-BLY00360479 BP-HZN-2179MDL00353305
BP-HZN-2179MDL01160382 BP-HZN-BLY00367395 BP-HZN-BLY00367395
BP-HZN-2179MDL01160384 BP-HZN-BLY00367395 BP-HZN-BLY00367395
TRN-USCG_MMS-00043818 TRN-MDL-00868018 TRN-MDL-00868024 TRN-MDL-00868026 TRN-MDL-00868030 TRN-MDL-0086808 TRN-MDL-00867646
TRN-USCG_MMS-00043819 TRN-MDL-00868020 TRN-MDL-00868025 TRN-MDL-00868029 TRN-MDL-00868033 TRN-MDL-0086812 TRN-MDL-00867701
BP-HZN-MBI00021460
BP-HZN-MBI00021999
TRN-INV-03455358 LREMEA-MDL 000001 TRN-HCEC-00116082 TRN-HCEC-00116088 TRN-USCG_MMS-00030803
TRN-INV-03455362 LREMEA-MDL 000889 TRN-HCEC-00116085 TRN-HCEC-00116088 TRN-USCG_MMS-00030823
Beg Bates
End Bates
Description Rose, Adrian deposition transcript, Vol. 1 & 2 Cramond, Neil deposition transcript Ezell, Miles R. deposition transcript Durkan, Alaric (Kongsberg) deposition transcript Brown, Douglas deposition transcript Guide, John deposition transcript Sepulvado, Murray deposition transcript Mansfield, James deposition transcript Millsap, Kristofer deposition transcript Sepulvado, Murray deposition transcript McKay, David deposition transcript Hayward, Anthony deposition transcript Vol.1 & 2 Cameron, David deposition transcript Wong, Norman deposition transcript Vol. 1 & 2 Kent, James deposition transcript Vol. 1 & 2 Schneider, Alan deposition transcript Haynie, William deposition transcript Smith, Newton Pharr deposition transcript Vol. 1 &2 McMahan, Larry desposition transcript Vol. 1 & 2 DNV 30(b)(6)-Thompson, Neil deposition transcript DNV 30(b)(6)-Bjerager, Peter deposition transcript DNV 30(b)(6)-Kenney, Gary deposition transcript Kuchta, Curtis Robert deposition transcript Hackney, David deposition transcript Bertone, Stephen deposition transcript Ambrose, Billy Dean, deposition transacript, Vols. 1&2 Fleytas, Andrea deposition transcript (non-injury) Rodriguez, Angel deposition transcript Keplinger, Yancy deposition transcript Young, David deposition transcript MacDonald, John deposition transcript Newman, Steve deposition transcript Odom, Michael deposition transcript Keeton, Jonathan deposition transcript Moore, Jimmy deposition transcript MBI testimony of Michael Saucier (MMS) Regional Supervisor Field Operations MBI testimony of Captain Vern B Gifford (USCG) Chief of Prevention at MSU Port Arthur MBI testimony of Lt. Com. Michael Odom (USCG) Chief of Prevention Division
Page 152 of 154
Beg Bates
End Bates
Description MBI testimony of Lt. Barbara Wilk (USCG) Marine Safety Unit MBI testimony of Captain Thomas Heinen (MI) Deputy Commissioner of Maritime Affairs MBI testimony of Brian Bubar (MI) Deputy Commissioner of Maritime Affairs MBI testimony of John Forsyth (ABS) Assistant Chief Surveyor MBI testimony of Douglas Brown (Transocean) Chief Mechanic on DH MBI testimony of Captain Carl Smith (Court Expert to Enquiry) Ex Captain & OIM MBI testimony of Adrian Rose (Transocean) VP of QHSE MBI testimony of Steve Tink (BP) HSE Manager MBI testimony of David McKay (DNV) Marine Surveyor MBI testimony of Arinjit Roy (ABS) Surveyor MBI testimony of Jimmy Harrell (Transocean) Offshore Installation Manager MBI testimony of Captain Curt Kuchta (Transocean) Master DH MBI testimony of Captain Vern Gifford (USCG) Chief of Prevention Division MBI testimony of John Gislair MBI testimony of Michael Wright (Transocean) TO Command Centre Coordinator 20/04/10 MBI testimony of Jerry Canducci (Transocean) Designated TO person for NA Division BP CounterComplaint, Cross Complaint and Third Party Complaint Against Transocean DWH ISM Annual Installation Internal audit checklist rev 05.doc Transocean Interview of Chris Pleasant Response to USCG Draft Report By Transocean Offshore Deepwater Drilling Inc. and Transocean Holdings LLC MODU Code 2001 - Publicly available Report to the President, National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling http://www.deepwater.com/fw/main/PublicReport-1076.html
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TRN-MDL-00635387
Beg Bates
End Bates
Description Republic of the Marshall Islands DEEPWATER HORIZON_Marine Casualty Investigation Report.pdf Transocean 2009 Annual Report Reliance Exhibit List to Webster Report 2011-09-23 Transocean Disclosure of NonRetained Expert Witness Not Required to Provide a Written Report 2011-09-23 Transoceans Rule 26(a)(2)(C) Disclosures Expert Report of Jeff Wolfe 2011-09-23 Expert report of R. Scates and J. Roberts Maersk Drilling OIM/Master Job Description Stena Drilling Job Description for OIM MDL Dep. Ex. 3802: Jimmy Harrell RMI Licence. MDL Dep. Ex. 3804: Training Record for Jimmy Harrell. Expert Report of E. G. Webster Marshall Islands Guidance MI-118: Requirements for Merchant Marine Personnel Certification Marshall Islands Guidance MI-325: Guidelines for MODU Officers Examinations Marshall Islands Guidance MI-293: Mobile Offshore Drilling Unit Standards: Part IV (M) and Part V (L) International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW) 1978, as amended International Maritime Organizations Resolution A.891(21) adopted on 25 November 1999, Recommendations on Training of Personnel on Mobile Offshore Units (MOUs)
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Mitchell Capt Andrew

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In the Matter of DEEPWATER HORIZON

Captain Andrew Mitchell October 17, 2011

Report of Captain Andrew Mitchell

Report of Captain Andrew Mitchell

ISM Code Section 10 ISM Code Section 11 ISM Code Section 12

192 198 201

Report of Captain Andrew Mitchell

Report of Captain Andrew Mitchell

My full experience profile is included as Appendix 1.

Report of Captain Andrew Mitchell

Executive Summary and Conclusions

This Report is prepared by Global Marine Associates of which I am the Director.

Report of Captain Andrew Mitchell

Major Non-Conformity with the ISM Code

ISM Code 11.1 ISM Code 12

Out of date and uncontrolled documentation Inadequate internal ISM audits

These are discussed in Annex S to this Report.

Report of Captain Andrew Mitchell

This is confirmed by RMI as the flag

Report of Captain Andrew Mitchell

Andrea took instructions from the Chief mate

David Young Chief Mate52

Report of Captain Andrew Mitchell

Report of Captain Andrew Mitchell

Report of Captain Andrew Mitchell

Report of Captain Andrew Mitchell

Report of Captain Andrew Mitchell

Examinations contains the syllabus for OIM and other positions.75

Report of Captain Andrew Mitchell

certification was not valid on this ship.

Report of Captain Andrew Mitchell

The DEEPWATER HORIZON had two Masters and PICs. command:

Neither were properly qualified for

Report of Captain Andrew Mitchell

Report of Captain Andrew Mitchell

Report of Captain Andrew Mitchell

Annex A: The ISM Code

Background to the ISM Code

Report of Captain Andrew Mitchell

Objectives of the Code98

Report of Captain Andrew Mitchell

DOC and SMC Certificates

Report of Captain Andrew Mitchell

Report of Captain Andrew Mitchell

Annex B: Enforcement of the ISM Code

Report of Captain Andrew Mitchell

Report of Captain Andrew Mitchell

Port State Control

Report of Captain Andrew Mitchell

Report of Captain Andrew Mitchell

Annex D: The ISM Code Verification

The External Audit Process

Report of Captain Andrew Mitchell

See Annex K: SMC issued to DEEPWATER HORIZON

Report of Captain Andrew Mitchell

The Internal Audit Process

Report of Captain Andrew Mitchell

Annex E: A Typical SMS for a Company operating a MODU

Organisation for effective HSE management

Scope of the SMS

MDL Exhibit 938 and Appendix 3: ISM Code, Section 4

Report of Captain Andrew Mitchell

Structure of the SMS