Mitchell Capt Andrew

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In the Matter of DEEPWATER HORIZON

Report Regarding

Transocean’s Safety Management System and the ISM Code

Captain Andrew Mitchell

October 17, 2011



Report of Captain Andrew Mitchell Page 2 of 154

CONTENTS

Paragraph

Qualifications and Experience of Captain Andrew Mitchell

Executive Summary and Conclusions 1 - 9

Major Non-Conformity with the ISM Code 10 – 43

Major Non-Conformity #1: ISM Code Section 5 14

Major Non-Conformity #2: ISM Code Section 6 28

Summary 44 – 48




Annex A The ISM Code

Paragraph

49 - 62

Background to the Code 49 Objectives of the Code 55

The Safety Management System (SMS) 57

DOC and SMC Certificates 59

Annex B Enforcement of the ISM Code

Flag Administrations 63

63 - 70

Recognised Organisations 66

Port State Control 70

Annex C The ISM Code and other Rules, Regulations,

Codes, Guidelines and Standards 71 - 75

Annex D The ISM Code verification process

The External Audit Process 76

76 - 88

Reporting the Audit Findings 81

Follow Up and Close Out of the Audit 85

The Internal Audit Process 88

Annex E A Typical SMS for a Company operating a MODU

Organisation for effective safety management 89

89 - 104

Scope of the SMS 90

Bridging Documents 91

Structure of the SMS 94

Content of the SMS 96

Annex F The SMS implemented by Transocean

Structure of the Transocean CMS 105

105 - 118

The Major Accident Hazard Risk Assessment 108

The Operations Integrity Case 109

Scope of the Transocean SMS 111

Bridging Documents 114

Annex G Content and the implementation of the Transocean SMS 120 - 208

ISM Code Section 1 121ISM Code Section 2 122

ISM Code Section 3 123













Annex H Extract from DEEPWATER HORIZON MAHRA

Annex I Extract from DEEPWATER HORIZON OIC

Annex J Document of Compliance (DOC) issued to Transocean Offshore Deepwater Drilling Inc.

Annex K Safety Management Certificate (SMC) issued to DEEPWATER HORIZON

Annex L Transocean Organisation for Safety and Environmental Management

Annex M Exhibit 5483: DNV DEEPWATER HORIZON SMC audit May 2002

Annex N Exhibit 1768: DNV Transocean DOC audit April 2009

Annex O Exhibit 946: Notification of corporate DP March 9, 2010

Annex P Analysis of Transocean Company Management System and the ISM Code

Annex Q Transocean Management System relevant to the ISM Code

Annex R Transocean Risk Management Processes

Annex S Non-Conformity with the ISM Code




Appendix 1 Experience profile of Andrew Mitchell

Appendix 2 Glossary of Terminology

Appendix 3 ISM Code 2002

Appendix 4 Applicability of the ISM Code to MODU Operations

Appendix 5 UNCLOS Part VII, Section 1, Article 94 paragraph 4(b)

Appendix 6 Analysis of Industry norm on “Dual Command Structure”

Appendix 7 Pride Drilling DP Rigs Organisation Chart

Appendix 8 Maersk Drilling OIM Job Description

Appendix 9 Reliance Exhibits

Appendix 10 Consideration Exhibits




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 Shell’s 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 theLloyd’s

Register Group, and as a Principal Surveyor, I was responsible from 1994 forconsultancy 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 Lloyd’s Register Headquarters in London as a

Senior Principal Surveyor and Manager to establish the infrastructure and procedures to allow Lloyd’s

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 Lloyd’s 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.

1See Annex B, paragraphs 67-70 for more detailed information on IACS and the leading recognized organizations.




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, BP’s 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

2MDL Exhibit 938 and Appendix 3: International Safety Management Code and Guidelines on Implementation of

the ISM Code, Section 1.1.103

MDL Exhibit 938: International Safety Management Code and Guidelines on Implementation of the ISM Code;

Appendix 3: The ISM Code 20024

MDL Exhibit 4271: BP – Transocean Drilling Contract (1998)5

MDL Exhibit 948: BP-Transocean HSE Management System Bridging Document6

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).




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 Transocean’s

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

7MDL Exhibit 2187: DWH Major Accident Hazard Risk Assessment (MAHRA) ( 29 August 2004)

8MDL Exhibits 5473, 5474, 5475, 5476 & 5477: DWH Operations Integrity Case, Sections 1, 2, 4, 5, & 6.

9Transocean 2009 Annual Report at AR-16, AR-17

10MDL Exhibit 5483 and Annex M: DNV DWH Audit Report (05.16.2002)

11MDL Exhibit 1768 and Annex N: DNV Transocean 2009 DOC Audit (04.16.2009)




reason why the DEEPWATER HORIZON’s 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 Master’s 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 non-

conformity 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.




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 Master’s Responsibility and Authority

• ISM Code 6 Resources and Personnel

13. Other non-conformities also existed in the following areas:15

• ISM Code 1.2 Meeting the objectives of the ISM Code

• ISM Code 4 Training and competence of Designated Persons

• ISM Code 10.1 Outstanding maintenance routines

12Annex D: ISM Code verification process

13MDL Exhibit 953 and Annex J: Document of Compliance Issued to Transocean

14MDL Exhibit 1776 and Annex K: Safety Management Certificate Issued to Transocean

15See Annex S




• ISM Code 11.1 Out of date and uncontrolled documentation

• ISM Code 12 Inadequate internal ISM audits

These are discussed in Annex S to this Report.




Major Non-Conformity #1: ISM Code Section 5 – Master’s 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 SOLAS

17

and subject tocompliance with the ISM Code from July 1, 2002.18 This is confirmed by RMI as the flag

Administration of DEEPWATER HORIZON.19

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 responsibility ”23 and will “issue appropriate

orders and instructions in a clear and simple manner.”24 U.S. requirements for MODUs state that

16SOLAS Part A, Regulation 3(a) (iii)

17SOLAS Chapter IX Regulation 1 (8)

18SOLAS Chapter IX Regulation 2 (1.3)

19Marshall Islands Guidance MI-293: Mobile Offshore Drilling Unit Standards: Part IV (M) and Part V (L)

20COLREG 1972: Rule 3 (i)

21MDL Exhibit 3749: DWH Bridge Procedures Guide, p. 29

22UNCLOS 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 5.224

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 Master’s job description where it states the Master reports to the OIM;28

• The OIM’s job description where it states the Master reports to the OIM;29

• The DWH Emergency Response Manual’s 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

2546 C.F.R. 109.107: Designation of master or person in charge

26MDL Exhibit 939: Transocean ISM/ISPS MODU Handbook, Forward

27bis Section 2: page 8

28TRN-INV-00463941: Transocean Master Job Description; MDL Exhibit 942: Transocean Master Job Description

29TRN-INV-00463832: Transocean OIM Job Description

30MDL Exhibit 4644: DWH Emergency Response Manual: Section 1

31MDL Exhibit 4644: DWH Emergency Response Manual: Forward & Section 1

32MDL 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, Transocean’s CEO, addresses the “Rig Chain of

Command ” and stated “t he 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 systemdocumentation 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 tothe OIM, including that of maintaining emergency equipment. This is in conflict with

Master’s Job Description.36

33MDL Exhibit 960: DWH Station Bill

34MDL Exhibit 5643: Integration Memo, November 20, 2007

35TRN-INV-00463941: Transocean Master Job Description; MDL Exhibit 942: Transocean Master Job Description

36TRN-MDL-00046974: Emergency Management Procedures Manual





• The DWH Emergency Response Manual’s 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 ship’s 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.

37MDL Exhibit 4644: DWH Emergency Response Manual: Forward & Section 1

38MDL Exhibit 4644: DWH Emergency Response Manual: Forward




• 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,

Transocean’s 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 Transocean’s 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 OIC’s 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


42MacDonald Deposition, p. 168.

43MDL Exhibit 671: DWH Operations Manual: Section 2.1

44MDL Exhibit 671: DWH Operations Manual: Section 2.2

45MDL Exhibit 671: DWH Operations Manual: Section 10.4.1

46MDL Exhibit 5474: DWH Operations Integrity Case, Section 2: DWH Organization Chart

47MDL 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 “Safet y ” 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

“Isn’t 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 “f uc k it….let’ s leave”

• “Dave Young [Chief Mate] came and told the Captain ‘ we have an uncontrollable fire’ . The

Captain told Dave to ‘ calm down’ ”

48MDL Exhibit 5474: DHW Operations Integrity Case, Section 2.2.1.5: MODU organization

49MDL Exhibit 5434: E-mail from Kriedemann to Rispoli (04.08.2010)

50MDL Exhibit 5435: E-mail Young to MacDonald (05.07.2008)

51MDL Exhibit 4472: Transocean Interview with Fleytas (06.24.2010)




• “ Andrea took instructions from the Chief mate”

David Young Chief Mate52

• “So w ho 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.”. . . “W ho was in charge during an

emergency?”. . . “Mast er is in charge for an emergency situation.”

• “ Okay. . . who deter mines that it ’ s 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 y ou 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 can’t speak for i f

they knew the Master wa s 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 di stress”

• “Jimmy [Harrell] gave Chris [Pleasant] permission to activate [EDS]”

52Young Deposition, pp. 196-198

53Testimony of Jimmy Harrell to the Joint Marine Board of Investigation

54MDL Exhibit 4365: Transocean interview with Bertone (06.24.2010)





57National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling Report, Ch. 4, p. 114


56MDL Exhibit 5173: Cameron EDS, MUX BOP Control System for DWH




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 Master’s 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 Master’s 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 DNV’s 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

58MDL Exhibit 1726: RMI DWH Minimum Safe Manning Certificate

59MDL Exhibit 1787: RMI Letter to the Joint Marine Board of Investigation, September 14, 2010.

60MDL Exhibit 5483 and Annex M: DNV ISM Code Certification Ship Audit Report, DWH, May 16, 2002

61MDL Exhibit 1777: DNV Survey Report Intermediate ISM Audit, June 29, 2005

62IACS Procedural Requirement No. 9

63MDL Exhibit 1768 and Annex N: DNV Transocean 2009 DOC Audit (April 16, 2009)

64MDL 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 Master’s 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 leastduring an internal ISM audit.66 The “ primary objective of the audit was to assess conformity of

the Company ’s 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 Master’s 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 Master’s 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

66MDL Exhibit 1471: Interoffice Correspondence - Internal ISM Audit, March 15, 2010

67MDL Exhibit 1471: Interoffice Correspondence - Internal ISM Audit,March 15, 2010

68See Appendix 6: “Analysis of industry norm on dual command structure.”

69See Appendix 7: Pride Drilling DP Rigs Organization Chart




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

70See Appendix 8: Maersk Drilling OIM Job Description

71Stena Drilling Job Description of the OIM




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 “t he 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 andcoastal state regulation that the DEEPWATER HORIZON was a ship and specifically a self-

propelled and dynamically positioned MODU. As such, compliance with the ISM Code was

mandatory under the regulation of RMI.

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 responsibility ” 73

and so “during the day-to day operation

of the MODU” while the DEEPWATER HORIZON was underway in DP, he was effectively the

72MDL Exhibit 938 and Appendix 3: ISM Code, Section 6.1.1

73MDL Exhibit 939: Transocean ISM/ISPS MODU Handbook, Section 2




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 ”, interestingterminology 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

74Marshall Islands Guidance MI-118: Requirements for Merchant Marine Personnel Certification

75Marshall Islands Guidance MI-325: Guidelines for MODU Officer’s Examinations

76International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW) 1978, as

amended77

International Maritime Organization’s Resolution A.891(21) adopted on 25 November 1999, Recommendations

on Training of Personnel on Mobile Offshore Units (MOUs)




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 the Maritime crew comprises amongst others, the OIM;

3.1 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 amember 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, RMI’s MI-118 states that “MODU certification does not permit service aboard

self-propelled vessels.” 81

DEEPWATER HORIZON was a self-propelled MODU and Harrell’scertification was not valid on this ship.

78MDL Exhibit 3751: Kuchta USCG Licence

79MDL Exhibit 3753: Kuchta RMI Licence

80MDL Exhibit 3802: Harrell RMI Licence

81RMI MI-118




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 installation’s 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.

82MDL Exhibit 938 & Appendix 3: ISM Code, Section 6.5

83MDL Exhibit 3747: Kuchta Training Record

84MDL Exhibit 3804: Harrell Training Record

85MDL Exhibit 5476: Operations Integrity Case, Section 5.3.1.2; MDL Exhibit 5474: Operations Integrity Case,

Section 2.3.10.286

TRN-MDL-01159705: Slide 46: Rig Manager Performance Training Marine Module87

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 brid ge?” “Chaos,

mayhem…I was hearing shouts, directions being yelled that weren’t 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”

David Young, Chief Mate, told Transocean’s 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, . . . I’m 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

88Brown Deposition, pp. 90, 98, 100

89MDL Exhibit 5461: Transocean Interview of David Young, Chief Mate.

90MDL Exhibit 5476: DWH Operations Integrity Case, Section 5.3.1.2

91MDL Exhibit 4644: DWH Emergency Response Manual, Vol. 1, Section 12.2

92MacDonald Deposition, pp. 192-193

93Keeton Deposition, pp. 470 & 471

94Keplinger Deposition, p. 150

95IADC 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 Transocean’s own training matrix, including those

in emergency response and Health, Safety, and Environment.96

42. The DEEPWATER HORIZON had two Masters and PICs. Neither were properly qualified for

command:

•

Harrell had no statutory certification in compliance with international or RMI regulations tobe 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 installation’s 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, majorpollution and the eventual loss of the DEEPWATER HORIZON.





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.




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.




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 ki nds…..” 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




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 obj ectives”.

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.

97See Appendix 4 (The applicability of the ISM Code to MODU operations)

98MDL Exhibit 938 and Appendix 3: ISM Code Section 1.2




The Safety Management System (SMS)

57. The Company is required to achieve its objectives through the development, implementationand 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.




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.

99E.g. MDL Exhibit 953 and Annex J

100E.g. MDL Exhibit 1776 and Annex K




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




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 society’s 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.




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.




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.




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 RO’s own procedures. In the case of Transocean andthe 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,

101McKay Deposition

102The 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 1.1.7104

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.

105See Annex K: SMC issued to DEEPWATER HORIZON




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 non-

fulfilment 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:

106An examination of records to check and verify their accuracy through a sampling process.

107To examine items carefully and critically, especially for flaws using a checklist




• 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.




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 SMS’s are compared and any “gaps” or additional

requirements are identified. Regardless, it is the SMS of the Company operating the MODU

108MDL Exhibit 938 and Appendix 3: ISM Code, Section 4




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




industry, but where specific interpretations for MODUs are required I have given my opinion in

the following paragraphs.

97. ISM Code Section 5: Master’s 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 Company’s 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 Code”109 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

Operator’s contractual requirements, including the conditions imposed in the Bridging Document,

are fulfilled through the Company management system. The Master is responsible to manage

the Operator’s expectations; the Company Man cannot override the Master’s 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


11046 C.F.R. 109.107




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 Company’s 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

111International Maritime Organization’s Resolution A.891(21) adopted on 25 November 1999, Recommendations

on Training of Personnel on Mobile Offshore Units (MOUs) 2.1.8112

bis 4.1, 4.2, 5.2, 5.3, 5.4, 6.2




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. The shipboard emergency

procedures must fit seamlessly with the onshore support. 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: Reports & Analysis of Non-Conformities, Accidents, and Hazardous

Occurrences 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.




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 theexpectations and requirements for each core function in the company.

• Level 1B comprises the corporate department support documentation. These provide

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

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

113MDL Exhibit 925: HQS-CMS-GOV: Company Management System Manual, Section 5.2

114Exhibit 938: Appendix 3: ISM Code 12.2




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 d on’t know about the operation” and “written for the

courtroom and not the oilfield ”118 are extreme but have some truth.

Major Accident Hazard Risk Assessment (MAHRA)

108. 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

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

115MDL Exhibit 925 Company Management System Manual, Section 5.1

116Rose Deposition, p. 46

117bis page 48

118MDL Exhibit 929: Lloyd’s Register Safety Management and Safety Culture/Climate Review (March 16, 2010)

119MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 4.2.1

120MDL Exhibit 2187: DWH Major Accident Hazard Risk Assessment (MAHRA) ( 29 August 2004)

121MDL Exhibits 5473, 5474, 5475, 5476 & 5477: DWH Operations Integrity Case, Sections 1, 2, 4, 5, & 6.




identified, and that within Transocean’ s 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 Manager ……to ensure the

ISM Code is implemented correctly ” states that the “CMS is considered a SMS.”124

• The Lloyd’s 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 inAnnex P.

122MDL Exhibits 5473: OIC Section 1: Introduction


124MDL Exhibit 939: Transocean ISM/ISPS MODU Handbook, Forward and Section 2.5.1


126Canducci Deposition, p. 92

127MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 2.4




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

2008

129

and 2009

130

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, BP’s 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

128MDL Exhibit 1766: Transocean DOC Audit 2007

129MDL Exhibit 1767: Transocean DOC Audit 2008


131MDL Exhibit 1777: DWH Intermediate SMC Audit 2005

132MDL Exhibit 1778: DWH Renewal SMC Audit 2007

133McKay Deposition, p. 144

134MDL 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 thecontractual requirement that “Contractor shall have the primary responsibility for the safety of

all its operati ons,” 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 “let’s get a game plan together” when communicating with his managers.139 It was

135MDL Exhibit 948: BP-Transocean HSE Management System Bridging Document

136MDL Exhibit 948: BP-Transocean HSE Management System Bridging Document


138MDL Exhibit 956: DWH – BP CMID Audit Work List September 2009

139MDL 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.

140MDL Exhibit 4271: BP – Transocean Drilling Contract (1998), Section 3.4



141MDL Exhibit 925: Transocean Company Management System Manual, Section 2.3, 2.4


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 HSE HRM OPS Job

Descrip.

Emergcy

Manual

E-

Docs ISM GOV PR-02 PP-01 PP-02 PR-01 PP-01 PP-01 PR-01 HB-03 HB-05

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 Codein 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




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. They meet the minimum

requirements of the ISM Code.

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:

142bis Section 2.2 (and reproduced in HQS-HSE-PP-01 and PP-02)

143See Annex L: Transocean Organization for Safety and Environmental Management

144MDL Exhibit 925: Transocean Company Management System Manual, Section 1.3

145MDL 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 Transocean’s consultant, Lloyd’s 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 function”150 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

146Newman Deposition, p. 274

147Annex L: Transocean Organization for Safety and Environmental Management

148Newman Deposition, p. 275

149MDL Exhibit 5643: Integration Memo, November 20, 2007






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 system”158 and “it was not under my umbrella … . . for me to audit the asset

152TRN-MDL-01159705:Rig Manager Performance Training Marine Module

153MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 1.2 (page 4 of 8)



156bis






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 Canducci’s statements above. In my opinion Mr. Canducci was not

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.

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 confusion

162

andwhich did so when Canducci, as a Divisional DP, stated “I don’t 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



161Exhibit 1449: HQS-HSE-PP-01: Health and Safety Policies and Procedures Manual: section 1.2

162See Annex L: Transocean Organization for Safety and Environmental Management


164See 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: Master’sResponsibility 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……f or 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 vessel…and 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 self-

propelled MODU. The former requires a Master at all times; the latter only requires aMaster when the MODU was underway.

165IMO MSC-MEPC.7/Circ.6, October 2007

166Moore Deposition, p. 89

167Appendix 5: UNCLOS Part VII, Section 1, Article 94 paragraph 4(b)




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

135. 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 level ”174 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.

168MDL Exhibit 938 and Appendix 3: ISM Code, Section 5.2

169bis 5.1.1

170MDL Exhibit 939: Transocean ISM/ISPS MODU Handbook, Section 2.4.3

171MDL Exhibit 1726: RMI MSMC for DEEPWATER HORIZON

172MDL Exhibit 5483 and Annex M: DNV ISM Code Certification Ship Audit Report, DWH, May 16, 2002







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 Harrell’s 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

176MDL Exhibit 938 and Appendix 3: ISM Code Section 6.1.1

177MDL Exhibit 3753: RMI Certificates

178MDL Exhibit 3747: Kuchta Training Record; MDL Exhibit 3750: Kuchta Training Certificates; MacDonald

Deposition, pp. 180-184179

MDL Exhibit 3802: RMI Certificates180

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

processes, implementation may not be effective. There is no evidence of Kuchta or Harrell

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,

182MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 4.1.1

183Annex R: Transocean Risk Management Processes

184MDL 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 OIC ”185 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 Lloyd’s 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 don’ t know what they don’t know ”186(In

the LR Report, 100% of the DEEPWATER HORIZON workforce stated they understood the hazards

associated with their jobs.) Lloyd’s 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 don’t 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

185bis page 173


187MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 4.2.1, page 174




192MDL Exhibit 925: Company Management System Manual, 5.5 (pages 138 – 153)


numerical targets 189 which brought the program into disrepute and possibly devalued its

potential. Lloyd’s 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 somebody’s 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 Lloyd’s

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 don’t

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 y ou’re made to feel

like a dumb ass”191

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 Lloyd’s 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.” It is highly unusual for

exemptions to be provided for at all, let alone granted verbally.

189bis page 348

190TRN-HCEC-0090593: Lloyd’s Register Culture Survey

191TRN-HCEC-0090662: Lloyd’s Register Culture Survey



147. Lloyd’s Register identified an initiative by the DEEPWATER HORIZON Rig Manager, Paul Johnson,

193MDL Exhibit 925: Company Management System Manual, 5.5 (pages 138 – 153)


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 Lloyd’s 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 “i t’s like

you’ve 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:



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,




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 Procedures”195

• “review site specific information for items that increase the risk or complexity of the

operati on…..these are to be planned according to Transocean policy and procedure

requirements”196

• “only Transocean personnel are authorized and permitted to operate installation

equipment ”197

• “the MoC is to be used to safely implement and monitor any changes in the drilling

program”198

• “detailed communication on individual activities ..will be clearly communicated ..using the

THINK planning process”199

194MDL Exhibit 945: Corporate QHSE Steering Committee Meeting Minutes September 2, 2010.

195MDL Exhibit 1474: Performance and Operations Policies and Procedures, Section 2.1 (4.2.1)

196bis 4.3

197bis 4.3.3

198bis 4.3.7

199bis 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 keysections 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

200Exhibit 1449: HQS-HSE-PP-01: Health and Safety Policies and Procedures Manual: Section 2.4




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 re-

Approved 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


202MDL Exhibit 5037: DWH Bridge Procedures Guide




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 clearlystates 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 Master’s 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

203MDL Exhibit 3749: DWH Bridge Procedures Guide

204Keplinger deposition: 09.12.2011: page 136

205Young deposition: page 267

206Exhibit 3749: Harrell: DWH Bridge Procedures Guide: TRN-MDL-00533235




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. Transoceanaddressed 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 Master’s 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 ship’s 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 any kick situation

Level 2 analysis of Level 1 indicates available equipment may not control the well

Level 3 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




B “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 Master’s 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 iscorrect. 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 précised 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 wasnot 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.”




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




Report. “Loss of Containment” is reported through the Environmental Procedures, while

property damage is reported via an “Operational Event Report.” The process is over

complicated, providing opportunities for high potential near misses to avoid investigation.

187. “Unsafe Observations” are carried out through the START process.

188. 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

“Operation Event Report .” 210 The procedure is outlined in the Operations Policies and

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.



209bis page 485

210MDL Exhibit 1479: Rose deposition: Operation Event Report

211MDL 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




Annex H: Extract from DEEPWATER HORIZON MAHRA




Annex I: Extract from DEEPWATER HORIZON OIC




Annex J: Document of Compliance (DOC) issued to Transocean Offshore Deepwater Drilling Inc.




Annex J (continued): DOC reverse side




Annex K: Safety Management Certificate (SMC) issued to DEEPWATER HORIZON




Annex L: Transocean Organisation for Safety and Environmental Management




Annex M: Exhibit 5483: DNV DEEPWATER HORIZON SMC Audit May 2002




Annex N: Exhibit 1768: DNV Transocean DOC audit April 2009




Annex O: Exhibit 946: Notification of corporate DP March 9, 2010




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 11 12HQS-CMS-GOV

section 1

section 2

section 3

section 5

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




Annex R: Transocean Risk Management Processes




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.

235MDL Exhibit 938: ISM Code, Section 1.1.9

236MDL Exhibit 938: ISM Code




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.




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 Lloyd’s 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 Lloyd’s 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.



Report of Captain Andrew Mitchell Page 100 of

Oil Companies and Service companies employed by as a consultant

Amerada Hess Asco Service CompanyBP Exploration UK Deutag Drilling

Enterprise Oil KCA Drilling

Marathon Lasmo Nova Scotia

MSR Noble Drilling

Shell Canada Prosafe Offshore Limited

Shell UK Exploration and Production Santa Fe Drilling

Total 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 Sedco 707

Nordic Apollo Sedco 714

Treasure Finder Galaxy 1

Safe Caledonia Rowan Gorilla III




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.




Professional legal experience

2007 m.v. Erika – High Court of Paris

Loss of shipRetained by RINA SpA and Paris attorneys

Expert Witness in marine management systems and audit.

2009 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

2010 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

2011 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




Appendix 2: Glossary of Terminology

Administration A signatory to the SOLAS Convention, sometimes referred to as the flag

Administration or the flag State.

ABS American Bureau of Shipping (a classification Society)

Audit 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 company’s HSE

policy and objectives.

Classification: Compliance with a classification society’s rules on construction and other items.

CMS Transocean Company Management System

Company 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).

Designated Person 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

DNV Det Norske Veritas (a classification Society )

DOC Document of Compliance (as required by the ISM Code)

EDS Emergency Disconnect Sequences

FOCUS Formulate, Organise, Communicate, Undertake, Summarize improvement

process

HAZOP Hazard and Operability Study

HAZID Hazard Identification Study

IACS International Association of Classification SocietiesIADC International Association of Drilling Contractors

IMO International Maritime Organisation (an Agency of the United Nations)

ISM Code International Management Code for the Safe Operation of Ships and for Pollution

Prevention 2010

ISPS Code International Ship and Port Facility Security Code 2002

LR Lloyds Register (a classification Society )




MAHRA Major Accident Hazard Risk Assessment

MEM Major Emergency Management

MoC Management of Change

MODU Mobile Offshore Drilling Unit (SOLAS Chapter IX, Regulation 1.7)

OIC Operations Integrity Case

PIC Person In Charge (33 C.F.R. 146.5 and 46C.F.R. 109.107))

PMAA Performance Monitoring Audit and Assessment

RMI The Republic of the Marshall Islands (the flag State of the DEEPWATER HORIZON)

RO Recognised Organisation (IMO Resolution A.739 (18) 1993)

SMART System Management and Review TeamSMC Safety Management Certificate (as required by the ISM Code)

SMS Safety Management System (as required by the ISM Code)

SOLAS Convention IMO Safety of Life at Sea Convention 1974 as amended

START See, Think, Act, Reinforce, Track (a workplace observation program)

TOFS Time Out For Safety

TRA Task Risk Assessment

TSTP Task Specific THINK Procedure




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.

2 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.

3 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.

4 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.

5 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.

6 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.




1.1.4 "Safety management system" means a structured and documented system enabling

Company personnel to implement effectively the Company safety and environmental protectionpolicy.

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




.2 that applicable codes, guidelines and standards recommended by the Organisation,

Administrations, classification societies and maritime industry organisations are takeninto 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 theenvironment 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-PROTECTIONPOLICY

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.




4 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.

5 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 shore-

based 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.

6 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.




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 ANALYSIS OF NON-CONFORMITIES, ACCIDENTS AND HAZARDOUS

OCCURRENCES

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 pollution-

prevention 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.




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.




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)).

2. 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 .”

3. 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.

4. SOLAS Chapter IX Regulation 3(1) requires that the company and the MODU shall comply with

the requirements of the ISM Code.

5. 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).

6. The ISM Code is therefore mandatory on self-propelled MODUs greater than 500 gt from 1 July

2002.

7. This is confirmed in Marshall Islands “Mobile Offshore Drilling Unit Standards” (MI-293) Part IV

(M) and Part V (L)

8. 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)).

9. 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.

10. 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.




Appendix 5: UNCLOS Part VII, Section 1, Article 94 paragraph 4(b)




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

Name Total Rigs MODU DP MODU Moored Drill Ship Jack UpMODUs and Drillships only

In Command Qualification

ENSCO 74 13 7 7 47 Captain/OIM not stated

Seadrill 71 10 2 7 45 OIM Master

Diamond Offshore 53 9 27 4 13 OIM/Master not stated

Odjefell Drilling 11 4 3 4 0 OIM Master

Songa Offshore 4 1 3 0 0 Master/OIM Master

Stena Drilling 12 6 2 4 0 OIM Master

Ocean Rig 6 4 0 2 0 OIM Master

Maersk Drilling 31 7 1 4 19 OIM Master

262 54 45 32 124

Those operating a dual command structure

Transocean 142 11 40 23 68 OIM and

Master

OIM

Master

Noble Drilling 74 15 2 10 47 Ass Rig Mgr

and Captain

OIM

Master

Atwood Oceanics 14 4 2 0 8 OIM (see note 3) OIM

230 30 44 33 123

Note 1 Figures include new buildings in the next 24 months

Note 2 In command titles are those used by the relevant Companies

Note 3 It is assumed that there is a “Master”

Note 4: 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.




Appendix 7: Pride Drilling DP Rigs Organization Chart




Appendix 8: Maersk Drilling OIM Job Description










Appendix 9: Consideration Materials

Beg Bates End Bates Description

TRN-MDL-01159660 TRN-MDL-01159803 Rig Manager Performance Training Marine

Module

CAM_CIV_0105569 CAM_CIV_0105576 Emergency Disconnect Sequences, Mux BOP

Control System for "Deepwater Horizon" R&B

Falcon

TRN-INV-00463832 TRN-INV-00463834 OIM Job Description-Transocean (2001)

TRN-INV-00463941 TRN-INV-00463943 Master Job Description-Transocean (2001)

ABSDWH003385 ABSDWH003393 American Bureau of Shipping Class Survey Report

ABSDWH011842 ABSDWH011842 Marshall Islands Letter - ABS Authorizations

TRN-MDL-00552586 TRN-MDL-00553017 DWH 2005 ISM Internal DP Audit.doc

TRN-MDL-00514434 TRN-MDL-00514442 Letter from Captain Brent Young, Master of DWH,

to John MacDonald, Transocean Marine

Operations Superintendent

TRN-MDL-01021471 TRN-MDL-01021491 DWH ISM Installation Audit Checklist/Report

06.30.2009

TRN-MDL-02865451 TRN-MDL-02865458 DWH Operations Integrity Case Section 1




ABSDWH003894 ABSDWH003901 American Bureau of Shipping Class Survey Report

TRN-MDL-00694329 TRN-MDL-00694351 Transocean NAR ISM Installation Audit, 2009

TRN-INV-00629642 TRN-INV-00629642 HQS-HSE-ADV-21 Dropped Objects Procedures

and Responsibilities

BP-HZN-BLY00264376 BP-HZN-BLY00264379 Daily Drilling Report No. 01










BP-HZN-BLY00265924 BP-HZN-BLY00265927 Daily Drilling Report No. 11BP-HZN-BLY00265928 BP-HZN-BLY00265931 Daily Drilling Report No. 12








ABSDWH001251 ABSDWH001254 American Bureau of Shipping Certificate of





Classification - DWH



BP-HZN-2179MDL00254876 BP-HZN-2179MDL00254880 Daily Drilling Report No. 22









BP-HZN-2179MDL00254930 BP-HZN-2179MDL00254934 Daily Drilling Report No. 31BP-HZN-2179MDL00254925 BP-HZN-2179MDL00254929 Daily Drilling Report No. 32























TRN-MDL-00507922 TRN-MDL-00507922 HS Sect 4-2.1 THINK Planning Process.doc

TRN-MDL-00380823 TRN-MDL-00380826 Morning Report




















TRN-MDL-00507923 TRN-MDL-00507925 ABS Class Survey Audit - 02/14/10

TRN-MDL-00509616 TRN-MDL-00509617 ABS Class Survey Audit 2-14-10.xls


































































TRN-INV-00032770 TRN-INV-00032787 DAR-DWH-Safety

TRN-MDL-00460393 TRN-MDL-00460393 Horizons maintenance EMPAC.xls

TRN-INV-00094173 TRN-INV-00094682 Transocean Health and Safety Policies and

Procedures Manual, December 15, 2009

TRN-INV-01700334 TRN-INV-01700917 Transocean Environmental Management System

Manual, September 30, 2007

TRN-INV-02820382 TRN-INV-02820387 Excerpt of Transocean Human Resources Policies

and Procedures: Required Training.

TRN-MDL-00366063 TRN-MDL-00366372 Marine_Compliance_Procedures_-

_SMART_Review[1].pdf

TRN-INV-00778224 TRN-INV-00778227 TO Investigation Ticket re Command

TRN-INV-02844490 TRN-INV-02844491 HQS-HSE-ADV-28 - Health and Safety Manual

Update.pdf

TRN-MDL-00272650 TRN-MDL-00272675 Deepwater Horizon Annual Survey Inspection

Reports.pdf





000007 000024 Det Norske Veritas - Audit Programme

BP-HZN-2179MDL00259138 BP-HZN-2179MDL00259677 BP-Transocean Drilling Contract for DWH, 1998

TRN-HCEC-00006018 TRN-HCEC-00006211 Master Register Emergency Response Manual Vol

2 of 2

TRN-HCEC-00011573 TRN-HCEC-00011573 HSE Advisory Ref. No. HQS-HSE-ADV-25

TRN-HCEC-00116167 TRN-HCEC-00116174 Det Norske Veritas - Survey Report (2007),

TRN-HCEC-00116167 TRN-HCEC-00116178 DNV DWH Survey Report for Renewal ISM Audit

and Renewal Scope ISPS Audit, 2007.

TRN-INV-00435113 TRN-INV-00435114 HSE_Advisory_Prompt Card.pdf

TRN-INV-00499943 TRN-INV-00499944 Transocean HSE Advisory: Manoverboard -

Handrail Failure.

TRN-INV-00655432 TRN-INV-00655433 Transocean HSE Advisory: Think Risk Assessment

Prompt Card, July 16, 2008

TRN-MDL-00027238 TRN-MDL-00027239 DNV Safety Management Certificate for DWH

issued May 16, 2007

TRN-MDL-00027240 TRN-MDL-00027262 DWH ISM Installation Audit Checklist/Report

04.08.2008

TRN-MDL-00027263 TRN-MDL-00027280 Transocean ISM Installation Audit

Checklist/Report, July 15, 2004

TRN-MDL-00027956 TRN-MDL-00027979 Transocean ISM Installation Audit

Checklist/Report, June 28, 2007

TRN-MDL-00027981 TRN-MDL-00027991 DNV Survey Report for Intermediate ISM Audit of

DWH, 2005

TRN-MDL-00033918 TRN-MDL-00033998 Kuchta Personnel File

TRN-MDL-00039040 TRN-MDL-00039046 NAR Regional Office ISM Audit 2009.pdf

TRN-MDL-00039054 TRN-MDL-00039062 NAR Regional Office ISM Audit 2008.pdf

TRN-MDL-00046974 TRN-MDL-00047024 Transocean Emergency Management Procedures

Manual

TRN-MDL-00144432 TRN-MDL-00144432 ISM Certification May 2007

TRN-MDL-00144510 TRN-MDL-00144521 2007-05-15 DNV Renewal ISM Audit

TRN-MDL-00286651 TRN-MDL-00286654 2010 Internal Audit Report

TRN-MDL-00447009 TRN-MDL-00447012 Transocean Health, Safety, and Environment

Assessment Manual Think Planning Process

TRN-MDL-00518415 TRN-MDL-00518433 DNV Audit

TRN-MDL-00522719 TRN-MDL-00522741 Transocean DWH ISM Installation Audit Checklist

and Report, April 2008

TRN-MDL-00542768 TRN-MDL-00542778 Transocean HSE Performance Meeting Slide

TRN-USC_MMS-00027263 TRN-USC_MMS-00027280 DWH ISM Installation Audit Checklist/Report

07.13.2004

TRN-USCG_MMS-00027956 TRN-USCG_MMS-00027979 DWH ISM Installation Audit Checklist/Report

06.28.2007

TRN-USCG_MMS-00027980 Det Norske Veritas- Safety Management

Certificate issued 2007-07-11

TRN-USCG_MMS-00043659 TRN-USCG_MMS-00043661 Det Norske Veritas - ISM Certification,

TRN-USCG_MMS-00043662 TRN-USCG_MMS-00043664 Det Norske Veritas - Survey Report (Preliminary)

2009





TRN-HCJ-00128051 TRN-HCJ-00128052 Det Norske Veritas- Safety Management

Certificate issued 2007-07-11

TRN-MDL-00032700 TRN-MDL-00033035 Transocean Company Management System

Manual, November 2009

TRN-MDL-00273633 TRN-MDL-00273896 Performance and Operations Policies and

Procedures.PDF

TRN-MDL-00364423 TRN-MDL-00364428 Horizon-2009-Mar 8.pdf

TRN-MDL-01160394 TRN-MDL-01160407 Excerpt of DWH Emergency Response Manual,

Emergency Notification

TRN-MDL-01288444 TRN-MDL-01288685 2009 Transocean PMAA Findings - Corrective

Actions

TRN-MDL-02071217 TRN-MDL-02071217 2009 Transocean DWH Emergency Response

Manual Approval Page, 2009

TRN-MDL-02353887 TRN-MDL-02353893 Curt Kuchta LicenseTRN-MDL-024696448 TRN-MDL-024696449 2009-03-20 Internal Transocean Memo re Marine

Integrity Message

TRN-MDL-02496571 TRN-MDL-02496577 2008-01-21 Transocean internal memo: Marine

Integrity Management Survey

TRN-USCG-MMS-00027186 TRN-USCG-MMS-00027216 ISM Internal Audit Report, 2007

BP-HZN-2179MDL00141787 BP-HZN-2179MDL001423999 MDL Dep. Ex. 0671: DWH Operations Manual, v. 1

& 2

TRN-HCEC-00004639 TRN-HCEC-00004726 MDL Dep. Ex. 0673: Transocean Operations

Policies and Procedures Manual

TRN-MDL-00287334 TRN-MDL-00287334 MDL Dep. Ex. 0916: Conference call to discuss

Deepwater Horizon events.

TRN-MDL-00293187 TRN-MDL-00293196 MDL Dep. Ex. 0917: Email attaching pictures of the Deep Water Horizon going down

TRN-MDL-00286537 TRN-MDL-00286537 MDL Dep. Ex. 0918: North America Division, QHSE

Management Diagram

TRN-MDL-00359569 TRN-MDL-00359570 MDL Dep. Ex. 0919: Email attaching updated

corporate designated persons sheet.

TRN-MDL-00286528 TRN-MDL-00286528 MDL Dep. Ex. 0920: North America Division, Direct

Reports Hierarchy

TRN-MDL-00129825 TRN-MDL-00129830 MDL Dep. Ex. 0921: Email attaching AMU Ballast

Questionnaire

TRN-MDL-00294981 TRN-MDL-00295106 MDL Dep. Ex. 0922: Email attaching BP Audit

Working Copy, DWH Follow Up Audit Report, Rig

Move Work List attaching BP Audit; DeepwaterHorizon Follow UP Audit Report 17 March 2010

TRN-MDL-00038591 TRN-MDL-00038677 MDL Dep. Ex. 0923: Rig Condition Assessment-

Deepwater Horizon

TRN-MDL-00287195 TRN-MDL-00287200 MDL Dep. Ex. 0924: Email attaching Rig

Leadership Engagement-Houma-Mar. 29-31 and

Houma Schedule attaching DW Wells Leadership

TRN-MDL-00032700 TRN-MDL-00033035 MDL Dep. Ex. 0925: Transocean - Company

Management System Manual





TRN-MDL-00273897 TRN-MDL-00273900 MDL Dep. Ex. 0926: Operations Advisory: Loss of

Well Control During Upper Completion

TRN-MDL-00039463 TRN-MDL-00039544 MDL Dep. Ex. 0927: Performance Monitoring

Audit and Assessment Procedures

BP-HZN-MBI 00044258 BP-HZN-MBI 00044261 MDL Dep. Ex. 0928: Email attaching NAM Safety

Expectations

TDD006-000505 TDD-006-000697 MDL Dep. Ex. 0929: Consulting Services Lloyd's

Register EMEA Aberdeen Energy

BP-HZN-OIG00039700 BP-HZN-OIG00039705 MDL Dep. Ex. 0930: MI Cleanup

TRN-MDL-00301009 TRN-MDL-00301009 MDL Dep. Ex. 0931: Notification of Dropped

Object

TRN-MDL-00291896 TRN-MDL-00291907 MDL Dep. Ex. 0932: Lloyd's Register Safety

Management Systems and Safety Culture/Climate

Reviews: Deepwater HorizonTRN-MDL-00077298 TRN-MDL-00077325 MDL Dep. Ex. 0933: RMS II Morning Report, Righ:

Deepwater Horizon

TRN-MDL-00039081 TRN-MDL-00039085 MDL Dep. Ex. 0934: QHSE Steering Committee

Meeting Minutes

TRN-MDL-0002721 TRN-MDL-0002723 MDL Dep. Ex. 0935: NAR ISM Installation Audit for

Deepwater Horizon

TRN-MDL-00040723 TRN-MDL-00040741 MDL Dep. Ex. 0936: Exhibit "D" HSSE

Requirements

TRN-MDL-00351151 TRN-MDL-00351152 MDL Dep. Ex. 0937: Transocean Results of HSSE

Common Inspection Document (CMID) Audit,

August 3, 2009

MDL Dep. Ex. 0938: International SafetyManagement Code and Guidelines on

Implementation of the ISM Code

TRN-MDL-00033216 TRN-MDL-00033281 MDL Dep. Ex. 0939: Transocean ISM/ISPS MODU

Handbook

MDL Dep. Ex. 0940: Ad Title: Make the Right Move

TRN-MDL-00351317 TRN-MDL-00351322 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

TRN-USCG_MMS-00043662 TRN-USCG_MMS-00043664 MDL Dep. Ex. 0943: Survey Report: 2009 Annual

ISM DOC AuditTRN-MDL-00273305 TRN-MDL-00273632 MDL Dep. Ex. 0944: Marine Compliance

Procedures

TRN-MDL-00364450 TRN-MDL-00364457 MDL Dep. Ex. 0945: QHSE Steering Committee

Meeting Minutes


Corporate Designated Persons


Declaration of DPA and CSO-ISM/ISPS Rigs





BP-HZN-BLY00076260 BP-HZN-BLY00076264 MDL Dep. Ex. 0948: BP-GoM TODDI NAM, HSE

Management System Bridging Document

BP-HZN-2179MDL00293151 BP-HZN-2179MDL00293165 MDL Dep. Ex. 0949: E&P Segment Recommended

Practice, Applying Control of Work On Drilling &

Completion Operational Sites

BP-HZN-BLY00115468 BP-HZN-BLY00115468 MDL Dep. Ex. 0950: Terms of Reference-Self

Assessment Process, BP GoM D&C HSSE

BP-HZN-MBI 00109884 BP-HZN-MBI 00109893 MDL Dep. Ex. 0951: Improving Control of Work

within Drilling & Completions

BP-HZN-BLY00165701 BP-HZN-BLY00165704 MDL Dep. Ex. 0952: Operations Department Alert,

Deepwater DP Rigs Subsea Well Control

Equipment Operation, Mainenance and Testing

TRN-MDL-0000488930 TRN-MDL-0000488931 MDL Dep. Ex. 0953: Document of Compliance

Issued to TransoceanTRN-MDL-00351222 TRN-MDL-00351222 MDL Dep. Ex. 0954: Results fo BP Gulf of Mexico

HSSE Audit conducted on August 3, 2009

TRN-MDL-00351151 TRN-MDL-00351152 MDL Dep. Ex. 0955: Email attaching Transocean

Inc. results of HSSE audit conducted August 3,

2009

TRN-MDL-00129254 TRN-MDL-00129277 MDL Dep. Ex. 0956: Deepwater Horizon-BP CMD

Audit Work List September 2009

TRN-MDL-00351153 TRN-MDL-00351221 MDL Dep. Ex. 0957: Contractor HS&E

Management System Assessment (Common Audit

Process Report)

TRN-MDL-00106485 TRN-MDL-00106487 MDL Dep. Ex. 0958: Service Loop Fire HQS-HSE-AL-

108TRN-MDL-00294807 TRN-MDL-00294808 MDL Dep. Ex. 0959: Email re Corporate QHSE

Incident Review 4/16/2010 attaching Corporate

QHSE Incident Review Apr. 16

TRN-MDL-00364219 TRN-MDL-00364220 MDL Dep. Ex. 0960: Email attaching DWH Station

Bill

TRN-MDL-00143899 TRN-MDL-00143943 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.KMI-MDL-001287 KMI-MDL-001287 MDL Dep. Ex. 0995: Kongsberg Confirmation

Purchase Order Invoice

KMI-MDL-001288 KMI-MDL-001350 MDL Dep. Ex. 0996: Kongsberg Simrad Quotation

No. 1452-7R&B Falcon Report

KMI-MDL-002090 KMI-MDL-002091 MDL Dep. Ex. 0997: E-mail from Jan Roger

Hellerud to Hans Alan Pedersen re: "RSS-

8D/Request for ESD Design Philosophy"

KMI-MDL-000645 KMI-MDL-000663 MDL Dep. Ex. 0998: Safety System Design

Philosophy RBS8D Project "Deepwater Horizon"





with Revision History

KMI-MDL-018781 KMI-MDL-018781 MDL Dep. Ex. 0999: Service Report for

RBF/Transocean for Deepwater Horizon

KMI-MDL-019864 KMI-MDL-019871 MDL Dep. Ex. 1100: Transocean Engineering

Recommendation for DWH: Engine Room

Ventilation Controls

KMI-MDL-001094 KMI-MDL-001143 MDL Dep. Ex. 1101: Konsberg RBS8D Safety

Systems: Functional Design Specification for

Emergency ShutDown System

KMI-MDL-002602 KMI-MDL-002647 MDL Dep. Ex. 1102: Konsberg Safety Philosophy

ESD, PSD and F&G AIM Safe

KMI-MDL-021669 KMI-MDL-021693 MDL Dep. Ex. 1103: Konsberg Maritime Inc.'s

("KMI") Response to Information Request byRepublic of Marshall Islands

KMI-MDL-002780 KMI-MDL-002817 MDL Dep. Ex. 1104: RBS8D Vessel Fire & Gas I/O

List Spreadsheet

KMI-MDL-021551 KMI-MDL-021609 MDL Dep. Ex. 1105: Hyundai Heavy Industries

Drawing (Title: Cause & Effect Matrix) Request

Form

KMI-MDL-010010 KMI-MDL-000827 MDL Dep. Ex. 1106: Konsberg ESD and K&G Safety

Images for K-Safe Product.

KMI-MDL-003884 KMI-MDL-003919 MDL Dep. Ex. 1107: Konsberg Simrad ESD and

F&G Matrix User Manual for the Deepwater

Horizon

KMI-MDL-001776 KMI-MDL-001833 MDL Dep. Ex. 1108: Konsberg Quotation: DP &Navigation SVC/SSS XP Mid-Life Upgrade

KMI-MDL-001249 KMI-MDL-001264 MDL Dep. Ex. 1109: Konsberg Maritime Safety

System (ESD and F&G) Overview of KM Safety

System.

KMI-MDL-000664 KMI-MDL-000698 MDL Dep. Ex. 1110: Konsberg ESD Deepwater

Horizon Operator Manual

KMI-MDL-000699 KMI-MDL-000739 MDL Dep. Ex. 1111: Konsberg Fire & Gas

Deepwater Horizon Operator Manual

KMI-MDL-000885 KMI-MDL-001093 MDL Dep. Ex. 1112: Konsberg and R&B Falcon

Integrated Automation & Control Sustem

Deepwater Horizon Functional Design

SpecificationKMI-MDL-002337 KMI-MDL-002356 MDL Dep. Ex. 1113: Konsberg "AIM Safe - The

complete Safety solution" Presentation Slide

KMI-MDL-000481 KMI-MDL-000500 MDL Dep. Ex. 1114: Module Tools - Excerpt

KMI-MDL-001542 KMI-MDL-001566 MDL Dep. Ex. 1115: Konsberg Safety System

Presentation

MDL Dep. Ex. 1116: Konsberg Service Report

Work Description for Deepwater Horizon.

KMI-MDL-001265 KMI-MDL-001286 MDL Dep. Ex. 1117: R&B Falcon Correspondence

to Konsberg re: Purchase Order





TRN-HCEC-00027279 TRN-HCEC-00027295 MDL Dep. Ex. 1118: R&B Falcon Safety System

Design Philosophy RBS8D Project "DeepwaterHorizon"

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

TRN-MDL-00023807 TRN-MDL-00023808 MDL Dep. Ex. 1120: Training History List Profile

KMI-MDL-009896 KMI-MDL-009900 MDL Dep. Ex. 1121: Dynamic Positioning

Conference - The DP Simulator Training Concept

TRN-MDL-00427057 TRN-MDL-00427058 MDL Dep. Ex. 1177: Table of Contents oon

Transocean Subsea Maintenance PhilosophyTRN-MDL-00406377 TRN-MDL-00406380 MDL Dep. Ex. 1351: BP Performance Review - Rig

Solicit Feedback

CAM-DOI-000000249 CAM-DOI-000000250 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.

TRN-MDL-00688525 TRN-MDL-00688542 MDL Dep. Ex. 1354: Presentation: "Macondo As I

See It"

TRN-MDL-00546475 TRN-MDL-00546476 MDL Dep. Ex. 1355: Email from D. Winslow to B.

Sannan re: "FW: Negative test Procedure"

BP-HZN-2179MDL00259139 BP-HZN-2179MDL00259159 MDL Dep. Ex. 1356: Drilling Contract - RBS-8D -Semisubmersible Drilling Unit - Vastar Resources,

Inc. and R & B Falcon Drilling Co.

TRN-MDL-00541805 TRN-MDL-00541805 MDL Dep. Ex. 1357: Email from T. Shackelford to

D. Winslow re: "Re: Marianas"

TRN-MDL-00542932 TRN-MDL-00542936 MDL Dep. Ex. 1358: Email from D. Winslow to K.

Adamson re: "RE: Horizon Plan forward"

TRN-MDL-00541813 TRN-MDL-00541815 MDL Dep. Ex. 1359: Email from T. Shackelford to

D. Winslow, P. Calligeros, et al.

BP-HZN-BLY00052571 BP-HZN-BLY00052578 MDL Dep. Ex. 1360: Transocean Change Proposal

TRN-MDL-00046464 TRN-MDL-00046973 MDL Dep. Ex. 1449: Transocean Health and Safety


TRN-MDL-00048160 TRN-MDL-00048520 MDL Dep. Ex. 1453: DWH Emergency ResponseManual-Vol. 1

TRN-MDL-00286767 TRN-MDL-00287162 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)

TRN-MDL-00653993 TRN-MDL-00654039 MDL Dep. Ex. 1459: Achieving the Vision Through

Motivated People, Performance Excellence and





Asset Integrity

TRN-MDL-00649010 TRN-MDL-00650592 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)

BP-HZN-2179MDL00621653 BP-HZN-2179MDL00621654 MDL Dep. Ex. 1462: Summary of Daily Activities

TRN-USCG_MMS-00032704 TRN-USCG_MMS-00032723 MDL Dep. Ex. 1467: Overview: Introduction to the

Company Management System

TRN-USCG_MMS-00039081 TRN-USCG_MMS-00039084 MDL Dep. Ex. 1471: Interoffice Correspondencefrom S. Sutherland and M. Bachand to J. Moore

re: Internal ISM Audit

TRN-MDL-00606649 TRN-MDL-00606655 MDL Dep. Ex. 1473: Day 1 Operational Guidance

TRN-MDL-00607004 TRN-MDL-00607267 MDL Dep. Ex. 1474: Performance and Operations


TRN-MDL-00655523 TRN-MDL-00655592 MDL Dep. Ex. 1475: Assistant Driller, OJT Module

MDL Dep. Ex. 1476: Request for Engineering

Assistance (REA) Well-Specific Planning Sheet

TRN-MDL-00606601 MDL Dep. Ex. 1477: Request for Exemption

TRN-MDL-00606602 TRN-MDL-00606603 MDL Dep. Ex. 1478: Task Risk Assessment

Worksheet

MDL Dep. Ex. 1479: Operation Event Report-Format for Well Control Event

TRN-MDL-00648543 TRN-MDL-00648567 MDL Dep. Ex. 1480: Transocean Performance

Review

TRN-MDL-00635387 MDL Dep. Ex. 1481: U.S. Coastal State Regulation

Compliance

TRN-MDL-00030501 TRN-MDL-00030537 MDL Dep. Ex. 1482: RGIT - Certificate in Offshore

Management

TRN-MDL-00122507 TRN-MDL-00122531 MDL Dep. Ex. 1483: Area Command Operating

Guide

TRN-MDL-00498732 TRN-MDL-00498734 MDL Dep. Ex. 1484: DWH VBR Middle Pipe Ram

Closure Procedure Rev A

TRN-MDL-00645098 MDL Dep. Ex. 1485: MMS QuestionTRN-MDL-00645097 MDL Dep. Ex. 1486: RE: MMS Question

TRN-MDL-00606514 MDL Dep. Ex. 1487: Well Schematic

BP-HZN-CEC041475 BP-HZN-CEC041596 MDL Dep. Ex. 1488: Amendment No.38 to Drilling

Contract No.980249 between BP America

Production Company and Transocean Holdings

LLC


Notice of Transocean Defendants (With 30(b)(5)

Document Requests)





MDL Dep. Ex. 1519: Rig Crew and Onshore

Organizational Charts

TRN-OIG-00258937 TRN-OIG-00258940 MDL Dep. Ex. 1520: Operations Advisory re Loss of

Well Control During Upper Completion

BP-HZN-2179MDL00161670 BP-HZN-2179MDL00161670 MDL Dep. Ex. 1521: Ops Note

TRN-MDL-00273270 TRN-MDL-00273271 MDL Dep. Ex. 1523: Monitoring well control

integrity of mechanical barriers

BP-HZN-2179MDL00351644 BP-HZN-2179MDL00351645 MDL Dep. Ex. 1524: Permit to Work

TRN-MDL-00273272 TRN-MDL-00273280 MDL Dep. Ex. 1525: Sedco 711 Well Control

Incident

BP-HZN-CEC020166 BP-HZN-CEC020166 MDL Dep. Ex. 1526: Temporary Abandonment

Procedure

BP-HZN-CEC029558 BP-HZN-CEC029560 MDL Dep. Ex. 1527: Incident Report- Drift Off and

Emergency Riser Disconnect

TRN-HCEC-00063449 TRN-HCEC-00063488 MDL Dep. Ex. 1528: Deepwater Horizon- Subsea

Equipment Condition Audit

BP-HZN-2179MDL00643468 BP-HZN-2179MDL00643481 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

TRN-MDL-00285606 TRN-MDL-00285607 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 HorizonMDL Dep. Ex. 1725: Certificado de Seguridad de

Tripulacion Minima Minimum Safe Manning

Certificate

TRN-MDL-00618614 TRN-MDL-00618614 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

TRN-MDL-00077298 TRN-MDL-00077325 MDL Dep. Ex. 1729: RMS II Morning Report- Rig:

Deepwater Horizon

MDL Dep. Ex. 1730: Recorded Coast GaurdInterview Cover Page

TRN-MDL-00692632 TRN-MDL-00692632 MDL Dep. Ex. 1731: Watertight Door Inspection

TRN-MDL-00034938 TRN-MDL-00034938 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

TRN-MDL00507823 TRN-MDL-00027981 MDL Dep. Ex. 1758: Deepwater Horizon Focus

Report

TRN-MDL-00286668 MDL Dep. Ex. 1759: ISM Installation Audit





Checklist/Report

TRN-MDL-00799316 TRN-MDL-00799318 MDL Dep. Ex. 1762: Email from M. Wright to L.

McMahan with 4/28/10 DWH Event Log

TRN-MDL-00121329 TRN-MDL-00121354 MDL Dep. Ex. 1763: Gulf of Mexico Strategic

Performance System Concept Risk Review

TRN-USCG_MMS-00059294 TRN-USCG_MMS-00059301 MDL Dep. Ex. 1764: ISM Code Certification

Company Audit Report

TRN-USCG_MMS-00059341 TRN-USCG_MMS-00059344 MDL Dep. Ex. 1765: Audit Programme

TRN-USCG_MMS-00059318 TRN-USCG_MMS-00059321 MDL Dep. Ex. 1766: Audit Program

TRN-USCH_MMS-00059290 TRN-USCH_MMS-00059293 MDL Dep. Ex. 1767: Audit Programme

TRN-USCG_MMS-00059325 TRN-USCG_MMS-00059333 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

TRN-HCEC-00116082 TRN-HCEC-00116085 MDL Dep. Ex. 1770: Vessel Summary Report-

"Deepwater Horizon"

TRN-HCEC-00116103 TRN-HCEC-00116105 MDL Dep. Ex. 1771: Safety Management

Certificate


Certificate


Certificate


Certificate

TRN-USCH_MMS-00043710 TRN-USCH_MMS-00043710 MDL Dep. Ex. 1775: Safety Management

CertificateTRN-HCO-00128051 TRN-HCO-00128052 MDL Dep. Ex. 1776: Safety Management

Certificate

TRN-USCG_MMS-00027982 TRN-USCG_MMS-00027991 MDL Dep. Ex. 1777: DNV Survey Report-

Intermediate ISM Audit 2005

TRN-HCEC-00116167 TRN-HCEC-00116171 MDL Dep. Ex. 1778: Survey Report- Renewal ISM

Audit and Renewal Scope ISPS Audit

MDL Dep. Ex. 1779: Document of Compliance

TRN-MDL-00468930 TRN-MDL-00468931 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- TheUnited States of America

TRN-HCEC-00116106 TRN-HCEC-00116106 MDL Dep. Ex. 1783: International Ship Security

Plan (SSP) Statement of Compliance


Shipboard Verification Statement of Compliance

TRN-HCEC-00116173 TRN-HCEC-00116174 MDL Dep. Ex. 1785: ISPS Code Certification

Renewal Ship Security Verification Report


Certificate





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

TRN-MDL-00302127 TRN-MDL-00302132 MDL Dep. Ex. 1790: Survey Report- Initial ISM and

ISPS Audits

TRN-MDL-00302146 TRN-MDL-00302155 MDL Dep. Ex. 1791: Survey Report- Initial ISM and

ISPS Audits

TRN-MDL-00302156 TRN-MDL-00302160 MDL Dep. Ex. 1792: Survey Report- Initial

ISM/ISPS Audit

TRN-MDL-00302182 TRN-MDL-00302192 MDL Dep. Ex. 1793: Survey Report Initial ISM and

ISPS AuditsTRN-MDL-00420097 TRN-MDL-00420155 MDL Dep. Ex. 1794: Common Marine Inspection

Document

TRN-MDL-00420038 TRN-MDL-00420096 MDL Dep. Ex. 1795: GMID Annex ( BP

Requirements for Modus) with Guidance Notes

BP-HZN-CEC060931 BP-HZN-CEC060931 MDL Dep. Ex. 1819: Organizational Chart

BP-HZN-2179MDL01122681 BP-HZN-2179MDL01122682 MDL Dep. Ex. 1820: Email from Neil Cramond to

Cindi Skelton

BP-HZN-2179MDL01122683 BP-HZN-2179MDL01122726 MDL Dep. Ex. 1821: BP Gulf of Mexico / SPU GoM

Marine Function / Marine Vessel Operations

Team Report

BP-HZN-CEC035380 BP-HZN-CEC035422 MDL Dep. Ex. 1822: BP CMID Annex (BP

Requirements for MODUS) with Guidance NotesBP-HZN-2179MDL01106466 BP-HZN-2179MDL01106501 MDL Dep. Ex. 1823: BP Group Standards Marine

Operations

BP-HZN-2179MDL00984912 BP-HZN-2179MDL00984913 MDL Dep. Ex. 1824: BP GoM Function 2010

Activity Prioritization

BP-HZN-2179MDL00984928 BP-HZN-2179MDL00984928 MDL Dep. Ex. 1825: GoM SPU Gap Closure Status

Chart

BP-HZN-2179MDL01127713 BP-HZN-2179MDL01127714 MDL Dep. Ex. 1826: Email from Neil Cramond to J.

Skelton, H. Thierens: Initial Incident Summary

BP-HZN-2179MDL01137477 BP-HZN-2179MDL01137491 MDL Dep. Ex. 1827: Email from A. Rodriguez to N.

Cramond re: GP 10-40 Drilling Rig Audits & Rig

Acceptance

BP-HZN-2179MDL01115530 BP-HZN-2179MDL01115549 MDL Dep. Ex. 1828: Email from Neil Cramond toN. Cramond, T. Endicott, et al. re: "Simplifying

Communication re Safety"

BP-HZN-2179MDL01131227 BP-HZN-2179MDL01131232 MDL Dep. Ex. 1829: Email from T. Endicott to N.

Cramond re: "P1 - Horizon Audit Findings update

and IM Risk rankings"

BP-HZN-2179MDL00340255 BP-HZN-2179MDL00340256 MDL Dep. Ex. 1830: Email from A. Rodriguez to J.

Guide, M. Sepulvado, et al. re: "Updated audit

tracking sheet for DW Horizon"





BP-HZN-CEC041034 BP-HZN-CEC041035 MDL Dep. Ex. 1831: Email from B. Cocales to DWH

OIM, P. Johnson, et al. re: "Audit ReportDocuments - DWH Sept 2009"

BP-HZN-2179MDL00033637 BP-HZN-

2179MDL00033638[3]

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"

BP-HZN-2179MDL00347967 BP-HZN-2179MDL00347968 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.

BP-HZN-2179MDL01122823 BP-HZN-2179MDL01122826 MDL Dep. Ex. 1835: Email from R. Malone to S.

Bond, N. Cramond, and D. Clarkson

BP-HZN-2179MDL01114974 BP-HZN-2179MDL01114980 MDL Dep. Ex. 1836: Email from T. Endicott to N.Cramond

BP-HZN-2179MDL00002012 BP-HZN-2179MDL00002013 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

BP-HZN-CEC041288 BP-HZN-CEC041346 MDL Dep. Ex. 1839: IMCA Common Marine

Inspection DocumentBP-HZN-2179MDL01130999 BP-HZN-2179MDL01131006 MDL Dep. Ex. 1840: Email from N. Cramond to E.

dan re: "SIMOPS Review" with BP Marine SIMOPS

Assurance Review Attachment

BP-HZN-2179MDL01114934 BP-HZN-2179MDL01114973 MDL Dep. Ex. 1841: Email from N. Cramond to T.

Davolt re: "FW: Approved - Doc No. 2200-T2-DO-

PR-4039 - Ops Note 02" with BP Macondo Top Kill

Procedures Manual

BP-HZN-2179MDL01134676 BP-HZN-2179MDL01134676 MDL Dep. Ex. 1842: Email from N. Cramond to R.

Singh re: "Some Thoughts"

BP-HZN-2179MDL01094903 BP-HZN-2179MDL01094905 MDL Dep. Ex. 1843: Email from N. Cramond to M.

Bowman and P. Singh re: "RE: INFO (Confidential):

GOM GRASP Operations"

BP-HZN-2179MDL00620074 BP-HZN-2179MDL00620081 MDL Dep. Ex. 1949: Gulf of Mexico SPU Risk

Management SEEAC Brief

BP-HZN-MBL00052735 BP-HZN-MBL00052738 MDL Dep. Ex. 1950: Email from J Skelton to P

Lockwood and R Sepulvado et al; 2008/2009

Continuous Improvement Plan- Deepwater

Horizon

BP-HZN-2179MDL00353304 BP-HZN-2179MDL00353305 MDL Dep. Ex. 1951: Email from J Guide to B

Cocales and K Daigle; FW: Deepwater Horizon Rig

Audit





BP-HZN-OIG00002240 BP-HZN-OIG00002243 MDL Dep. Ex. 1952: Email from M Sepulvado to J

Guide; FW: Deepwater Horizon Rig Audit

BP-HZN-MBL00072280 BP-HZN-MBL00072281 MDL Dep. Ex. 1953: Email from A Frazelle to I

Little and P Hill et al

BP-HZN-2179MDL00301434 BP-HZN-2179MDL00301434 MDL Dep. Ex. 1954: Email from B Cocales to J

Guide

BP-HZN-MBL00059311 BP-HZN-MBL00059312 MDL Dep. Ex. 1955: Email from B Morel to J Guide

BP-HZN-MBL00059313 BP-HZN-MBL00059314 MDL Dep. Ex. 1956: Email from B Morel to J

Guide; FW: Cost Saving Ideas

BP-HZN-2179MDL00248210 BP-HZN-2179MDL00248210 MDL Dep. Ex. 1957: Email from D Maxie to B

Cocales and T Haygood et al; Losses Total

BP-HZN-MBL00110606 BP-HZN-MBL00110607 MDL Dep. Ex. 1958: Email from I Little to D Sims

and J Guide; Macondo Update

CAM_CIV_0013074 CAM_CIV_0013074 MDL Dep. Ex. 2094: Certificate of Compliance:Customer Transocean Offshore

CAM_CIV_0013008 CAM_CIV_0013008 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

MODUSA 000088 MDL Dep. Ex. 2165: Rig Condition Assessment-

Deepwater Horizon

MDL Dep. Ex. 2166: J.Mansfield ltr to Hymel

TRN-MDL-00374741 TRN-MDL-00374770 MDL Dep. Ex. 2167: Deepwater Horizon-BP CMID


TO-JM Med 000048 TO-JM Med 000050 MDL Dep. Ex. 2169: Details of neurosurgicalopinion re J.Mansfield.

TO-JM Med 000057 TO-JM Med 000058 MDL Dep. Ex. 2170: Letter re Opthalmic

Evaluation of J.Mansfield

TO-JM Med 000059 MDL Dep. Ex. 2171: Ltr re Follow-Up Neurological

Examination of J.Mansfield.

TO-JM Med 000067 MDL Dep. Ex. 2172: Clinical Notes re J.Mansfield,

Prosthodontics

TO-JM Med 000071 MDL Dep. Ex. 2173: Office Consultation Notes re

J.Mansfield.

TO-JM Med 000073 TO-JM Med 000087 MDL Dep. Ex. 2174: Neuropsychological

Evaluation of J.Mansfield

TO-JM Med 000088 TO-JM Med 000095 MDL Dep. Ex. 2175: Medical Evaluation andSummary of J.Mansfield

TO-JM Med 000096 MDL Dep. Ex. 2176: Neurological Office

Consultation Notes re J.Mansfield

TO-JM Med 000098 TO-JM Med 000125 MDL Dep. Ex. 2177: Physical Medical Information

and Documents re J.Mansfield

TO-JM Med 000128 MDL Dep. Ex. 2178: Office Consultation Notes re

J.Mansfield

TO-JM Med 000129 MDL Dep. Ex. 2179: Discharge Note for

J.Mansfiled from Day One Physical Therapy and





Wellness

TO-JM Med 000131 TO-JM Med 000165 MDL Dep. Ex. 2180: Forensic Psychiatric

Consultation re J.Mansfield

TRN-MDL-00047535 TRN-MDL-00047554 MDL Dep. Ex. 2187: DWH Major Accident Hazard

Risk Assessment (MAHRA) (29 August 2004)

TRN-HCJ-00027084 TRN-HCJ-00027372 MDL Dep. Ex. 3075: Deepwater Horizon: Licensing

Information

TRN-MDL-00272650 TRN-MDL-00272653 MDL Dep. Ex. 3076: Republic of the Marshall

Islands Maritime Administrator

MODUSI010000087 MODUSI010000091 MDL Dep. Ex. 3077: Rig Condition Assessment -

Deepwater Horizon

MDL Dep. Ex. 3149: Peter Bjerager Curriculum

VitaeTRN-MDL-01075563 TRN-MDL-01075604 MDL Dep. Ex. 3152: Transocean-DNV Fleet

Agreement (2005-2010) for Periodical Class and

Statutory Surveys

DNV-SUPPL-000189 DNV-SUPPL-000208 MDL Dep. Ex. 3154: DWH HAZARD Report for

Transocean

DNV-SUPPL-000209 DNV-SUPPL-000230 MDL Dep. Ex. 3155: Deepwater Horizon HAZID

(Rev C) Chart

DNV-SUPPL-000231 DNV-SUPPL-000244 MDL Dep. Ex. 3156: Deepwater Horizon HAZID

(Rev C) Chart

DNV-SUPPL-000245 DNV-SUPPL-000269 MDL Dep. Ex. 3157: Det Norske Veritas Deepwater

Horizon HAZARD Report, Rev. 0

DNV-SUPPL-000270 DNV-SUPPL-000287 MDL Dep. Ex. 3158: Det Norske Veritas HAZARDReport Chart

DNV-SUPPL-000288 DNV-SUPPL-000300 MDL Dep. Ex. 3159: Det Norske Veritas Report

Chart re Evacuation/Escape

DNV-SUPPL-000301 DNV-SUPPL-000315 MDL Dep. Ex. 3160: Report Chart re Accident

Scenario: Visiting Vessel Collision

3438 3441 MDL Dep. Ex. 3161: Det Norske Veritas Non-

Conformity and Finding Note

25 34 MDL Dep. Ex. 3162: ISM Certification Guidance for

Planning of Periodical Company Audits

35 91 MDL Dep. Ex. 3163: DNV Guidance for Auditors to

the ISM Code: Maritime Management Systems

99 100 MDL Dep. Ex. 3164: Appendix H3 Guide: CompanyAudit Guide

244 259 MDL Dep. Ex. 3165: Email from H. Samadpour to

D. McKay re "Transocean's Safety Management

System"

TRN-MDL-00041202 MDL Dep. Ex. 3244: List of technical information

MDL Dep. Ex. 3245: Email re

Recommendation/Report

MODUSA 000343 MODUSA 000344 MDL Dep. Ex. 3246: Email re Follow-up to DWH

Asseyt Mgr Close-out





MODUSA 01 2 009667 MODUSA 01 2 009746 MDL Dep. Ex. 3247: Report of Survey, Deepwater

Horizon

MODUSI 01 2 009517 MODUSI 01 2 009575 MDL Dep. Ex. 3248: Report of Survey, Deepwater

Horizon

TRN-MDL-01120767 TRN-MDL-01120777 MDL Dep. Ex. 3259: Subsea Maintenance

Philosophy Family 400

TRN-MDL-01084397 TRN-MDL-01084397 MDL Dep. Ex. 3271: Email from J. Canducci to P.

Smith re: NAM Data attaching Transocean awards

and Safety in Excellence Milestones

TRN-MDL-01084353 TRN-MDL-01084367 MDL Dep. Ex. 3272: Email from I. Ajayi to P. Smith

attaching Deepwater Horizon Summary

TRN-MDL-00648560 TRN-MDL-00648559 MDL Dep. Ex. 3278: Performance and Asset

Organization Chart

TRN-MDL-01119375 TRN-MDL-01119381 MDL Dep. Ex. 3279: Email from P. Smith to R.Turlak

TRN-MDL-00519065 TRN-MDL-00519127 MDL Dep. Ex. 3400: Deepwater Horizon Technical

Rig Audit - January 2005

BP-HZN-CEC035543 BP-HZN-CEC035585 MDL Dep. Ex. 3401: CMID Annex (BP

Requirements for MODU) Guidance Notes

MODUSI 01 1010533 MODUSI 01 1 010550 MDL Dep. Ex. 3402: Transocean Rig Assessment:

Rig Condition Environmental Scorecard

BP-HZN-CEC035317 BP-HZN-CEC035379 MDL Dep. Ex. 3403: Common Marine Inspection

Documents

BP-HZN-CEC035317 BP-HZN-CEC035379 MDL Dep. Ex. 3404: Common Marine Inspection

Document

TRN-MDL-00478589 TRN-MDL-00478652 MDL Dep. Ex. 3405: Deepwater Horizon Follow UpRig Audit, Marine Assurance Audit and Out of

Service Period - September 2009

BP-HZN-2179MDL01131229 BP-HZN-2179MDL01131232 MDL Dep. Ex. 3406: Email from J. Guide to M.

Perez re: "FW: Deepwater Horizon Rig Audit"

BP-HZN-2179MDL01257480 BP-HZN-2179MDL01257486 MDL Dep. Ex. 3407: Email from I. Little to H.

Thierens and J. Guide re: "Fw: BP Audit"

BP-HZN-2179MDL00340659 BP-HZN-2179MDL00340659 MDL Dep. Ex. 3410: Deepwater Horizon - BP CMID

Audit Work List - September 2009

BP-HZN-2179MDL00028730 BP-HZN-2179MDL00028730 MDL Dep. Ex. 3412: Deepwater Horizon - BP CMID


BP-HZN-2179MDL00028731 BP-HZN-2179MDL00028731 MDL Dep. Ex. 3413: Observation Chart

TRN-MDL-00297882 TRN-MDL-00297882 MDL Dep. Ex. 3414: Deepwater Horizon - BP CMIDAudit Work List September 2009

MDL Dep. Ex. 3415: Observation Chart

TRN-MDL-00667435 TRN-MDL-00667436 MDL Dep. Ex. 3416: Email from Rig_DWH

Maintenance to Horizon Captain re: "FW: Latest

copy of BP Rig audit Jan 2005" with Attachment

MODUSI019008332 MODUSI019008360 MDL Dep. Ex. 3417: Deepwater Horizon Rig

Hardware Assessment Report









TRN-MDL-01175932 MDL Dep. Ex. 3501: Email re What are we going to

do different

TRN-MDL-01175869 TRN-MDL-01175873 MDL Dep. Ex. 3502: Email re Hanger Lock Down

TRN-MDL-01323431 TRN-MDL-01323432 MDL Dep. Ex. 3503: Email re Negative Test While

Displacing, attaching same


Notice fo Transocean Defendants (With 30(b)(6)

Document Requests)

TRN-MDL-01293200 TRN-MDL-01293262 MDL Dep. Ex. 3505: Email re 711 WC Incident,

attaching powerpoint of same

BP-HZN-2179MDL00270393 BP-HZN-2179MDL00270394 MDL Dep. Ex. 3506: Email re Way Forward with

Transocean on CoWTRN-MDL-01180030 MDL Dep. Ex. 3507: Email re SQA Information

BP-HZN-BLY00076260 BP-HZN-BLY00076264 MDL Dep. Ex. 3508: BP Gulf of Mexico Transocean

Offshore Deepwater Drilling Inc. North America

HSE Management System Bridging Document

TRN-MDL-00607000 TRN-MDL-00607035 MDL Dep. Ex. 3509: Email re Performance and

Operations Policies and Procedures Manual for

SMART Review, attaching same

TRN-MDL-00453590 TRN-MDL-00453709 MDL Dep. Ex. 3510: Email re Audit Report

Documents-DWH Sept 2009, attaching DWH Sept

2009 Audit Findings

TRN-MDL-01227613 TRN-MDL-01227619 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

TRN-HCEC-00064428 TRN-HCEC-00064445 MDL Dep. Ex. 3745: C. Robert Kuchta Sworn

Statement

TRN-HCJ-00121110 TRN-HCJ-00121110 MDL Dep. Ex. 3746: US Coast Guard Witness

Statement: Curt Kuchta

TRN-USCG_MMS-00023845 TRN-USCG_MMS-00023991 MDL Dep. Ex. 3747: Transocean Training History:

Kuchta

MDL Dep. Ex. 3748: Employee Chart

TRN-MDL-00533207 TRN-MDL-00533274 MDL Dep. Ex. 3749: Transocean Deepwater

Horizon Bridge Procedures Guide

TRN-USCG_MMS-00033918 TRN-USCG_MMS-00036918 MDL Dep. Ex. 3750: Transocean CompletionsNotification 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





TRN-HCJ-00006423 TRN-HCJ-00006431 MDL Dep. Ex. 3754: Deepwater Horizon

Emergency Response Manual: Vol. 1 of 2

BP-HZN-MBI00011579 BP-HZN-MBI00011580 MDL Dep. Ex. 3755: Excerpt from Operations

Manual for the Deepwater Horizon re

Organization and Responsibilities

NONE NONE MDL Dep. Ex. 4245: Biography of Bill Ambrose on

the National Commission on the BP Deepwater

Horizon Oil Spill and Drilling website

NONE NONE MDL Dep. Ex. 4246: Agreed 30(b)(6) Deposition

Notice of Transocean Defendants (With 30(b)(5)

Document Requests)

NONE NONE MDL Dep. Ex. 4247: Letter sent via email re

Deepwater Horizon MDL No. 2179

NONE NONE MDL Dep. Ex. 4248: Macondo Well Incident,Transocean Investigation Report, Volume 1

BP-HZN-2179MDL01027524 BP-HZN-2179MDL01027525 MDL Dep. Ex. 4249: Email re Macondo update and

forward plan awareness

NONE NONE MDL Dep. Ex. 4250: Image of Deepwater Horizon

explosion


explosion


explosion

TRN-INV-00446562 TRN-INV-00446564 MDL Dep. Ex. 4253: 2008 Maintenance Update

from B. Trahan, DWH Rig Manager

NONE NONE MDL Dep. Ex. 4254: Daily Drilling ReportTRN-INV-01143129 TRN-INV-01143189 MDL Dep. Ex. 4255: Email re Risler Unloading Well

Control Events

NONE NONE MDL Dep. Ex. 4256: Transocean's 10 Worst Kicks -

2009

TRN-USCG_MMS-00042958 TRN-USCG_MMS-00043221 MDL Dep. Ex. 4258: Transocean Report titled

"Performance and Operations, Policies and

Procedures"

TRN-INV-01144395 TRN-INV-01144395 MDL Dep. Ex. 4259: Email re Deepwater Horizon

flow indicator

TRN-INV-01155156 TRN-INV-01155160 MDL Dep. Ex. 4260: Email re Transocean

Deepwater Horizon - Mud Flow Transmitter

Documentation RequestTRN-INV-00016752 TRN-INV-00016763 MDL Dep. Ex. 4261: Lloyd's Register Safety

Management Systems and Safety Culture/Climate

Reviews: Deepwater Horizon

TRN-INV-01798151 TRN-INV-01798153 MDL Dep. Ex. 4262: Email re Investigation Team

Bi-Weekly update

TRN-INV-01639748 TRN-INV-01639756 MDL Dep. Ex. 4263: Transocean memo re

Investigation of Negative Test and Riser

Displacement Procedures (Preliminary Report)

MDL Dep. Ex. 4265: Well Advisor Handbook





MDL Dep. Ex. 4266: Email re MDL 2179 - Opticem

Modeling

TRN-INV-01021316 TRN-INV-01021316 MDL Dep. Ex. 4268: Excerpt from Transocean

website re DWH Investigation

BP-HZN-MB100021460 BP-HZN-MB100021999 MDL Dep. Ex. 4271: Drilling Contract, RBS-8D,

Semisubmersible Drilling Unit, Vastar Resources,

Inc. and R&B Falcon Drilling Co.

BP-HZN-IIT-0008871 BP-HZN-IIT-0008929 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

TRN-INV-00000296 TRN-INV-00000306 MDL Dep. Ex. 4365: Transocean InterviewingForm: Stephen Bertone

TRN-HCEC-00090493 TRN-HCEC-00090685 MDL Dep. Ex. 4366: Safety Management and

Safety Culture/Climate Review

BP-HZN-2179MDL02936720 BP-HZN-2179MDL02936723 MDL Dep. Ex. 4375: Annual Individual

Performance Assessment

Not Legible Not Legible MDL Dep. Ex. 4376: Email from A. Rodriguez to J.

Guide re: Deepwater Horizon audit

BP-HZN-2179MDL01270743 BP-HZN-2179MDL01270920 MDL Dep. Ex. 4377: Email from A. Rodriguez to M.

Sepulvado, et al. re: DW Horizon's Rig audit and

CMID

BP-HZN-2179MDL01114980 BP-HZN-2179MDL01114981 MDL Dep. Ex. 4378: Email from A. Rodriguez to J.

Guide, et al. attaching Deepwater Horizon's RigAudit close out report status

BP-HZN-2179MDL01137477 BP-HZN-2179MDL01137491 MDL Dep. Ex. 4379: Email from A. Rodriguez to N.

Cramond re: GP 10-40 Drilling Rig Audits & Rig

Acceptance

TRN-HCJ-00128069 TRN-HCJ-00128074 MDL Dep. Ex. 4458: Passport for Fleytas, Andrea

from Republic of the Marshall Islands

TRN-MDL-01598152 TRN-MDL-01598184 MDL Dep. Ex. 4459: Transocean Dynamic

Positioning Operator, OJT Module

TRN-MDL-01593467 TRN-MDL-01593477 MDL Dep. Ex. 4460: Deepwater Horizon ADPO

Familiarization/OJT Program

TRN-MDL-01601026 TRN-MDL-01601030 MDL Dep. Ex. 4461: Rig Specific OJT, Answers to

ADPO Theory testTRN-USCG_MMS_00035826 TRN-USCG_MMS_00035826 MDL Dep. Ex. 4462: Network file for Personnel

Training for Andrea Anasette

TRN-USCG_MMS-00035808 TRN-USCG_MMS-00035808 MDL Dep. Ex. 4463: Certificate for Attending a 4

day Dynamic Positioning, Advanced DP Power

Simulaton Course

TRN-USCG_MMS-00035812 TRN-USCG_MMS-00035812 MDL Dep. Ex. 4464: Certificate for Attending a 5

day Dynamic Positioning Basic Operator Course

TRN-USCG_MMS-00035815 TRN-USCG_MMS-00035816 MDL Dep. Ex. 4465: Certificate for the Dynamic

Positioning Operator OJT Course





NONE NONE MDL Dep. Ex. 4466: List of personnel names and

corresponding rig

NONE NONE MDL Dep. Ex. 4467: List of personnel, job titles

and applicable rigs

TRN-MDL-01603842 TRN-MDL-01603843 MDL Dep. Ex. 4468: Handover Notes

TRN-HCJ-00120898 TRN-HCJ-00120899 MDL Dep. Ex. 4469: US Coast Guard, Witness

Statement, Investigations Department

TRN-INV-00800577 TRN-INV-00800578 MDL Dep. Ex. 4470: Report re Rig Explosion injury

and evacuation for Fleytas, Andrea

NONE NONE MDL Dep. Ex. 4471: Transcript of the Testimony of

the Joint United States Coast Guard/ Bureau of

Ocean Energy Management Investigation

TRN-INV-00001465 TRN-INV-00001474 MDL Dep. Ex. 4472: Transocean Interviewing Form

- Andrea FleytasBP-HZN-2179MDL01248950 BP-HZN-2179MDL01248950 MDL Dep. Ex. 4600: Certificate Veritas: David

Hackney

TRN-INV-00710371 TRN-INV-00710371 MDL Dep. Ex. 4601: Transocean Training List

History Profile

BP-HZN-MB100021445 BP-HZN-MB100021446 MDL Dep. Ex. 4602: Description of Master position

on Transocean's website

TRN-MDL-00527083 TRN-MDL-00527083 MDL Dep. Ex. 4603: Transocean, Deepwater

Horizon chart of abandonment stations and chain

of command

TRN-MDL-01608127 TRN-MDL-01608127 MDL Dep. Ex. 4604: Drillship organizational chart

NONE NONE MDL Dep. Ex. 4605: Command Group - Bridge

TRN-INV-00001748 TRN-INV-00001766 MDL Dep. Ex. 4606: Interviewing Form forHackney, David

TRN-MDL-01604104 TRN-MDL-01604134 MDL Dep. Ex. 4607: Deepwater DP Management,

DP Familiarisation, Course Notes

TRN-INV-00467935 TRN-INV-00467937 MDL Dep. Ex. 4608: Email re FRC

Recommendations

BP-HZN-IIT-0008871 BP-HZN-IIT-0008930 MDL Dep. Ex. 4609: Deepwater Horizon, Follow

Up Rig Audit, Marine Assurance, Audit and Out of

Service Period, September 2009

TRN-INV-01854295 TRN-INV-01854299 MDL Dep. Ex. 4620: Deepwater Horizon Weekly

Ops/Eng Meeting re Subsea Issues, Transit,

Equipment, Rig Inspector, and Thruster Repair

TRN-INV-01266391 TRN-INV-01266398 MDL Dep. Ex. 4621: Email from D. Williams to W.Stringfellow et al. re RE: DSP - DTL Shuttle Valves

RMR

TRN-MDL-01960318 TRN-MDL-01960320 MDL Dep. Ex. 4625: Email from H. Valdez to S.

Woelfel et al.

TRN-MDL-01990701 TRN-MDL-01990702 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"





TRN-MDL-01956053 TRN-MDL-01956054 MDL Dep. Ex. 4630: Transocean NAM EOM Injury

and Event Logs for July 2008 - Safety Statistics andOverview

TRN-INV-00002585 TRN-INV-00002605 MDL Dep. Ex. 4631: John Keeton Interviewing

Form

TRN-MDL-01938654 TRN-MDL-01938655 MDL Dep. Ex. 4632: Email from K. Corser to D.

Ruedelhuber

TRN-MDL-01938641 TRN-MDL-01938642 MDL Dep. Ex. 4633: Juno Term of Reference for

Investigation

TRN-MDL-01965612 TRN-MDL-01965622 MDL Dep. Ex. 4634: MRO Justification Sheet -

2009 Budget for Horizon re Other Drillfloor

TRN-MDL-01934635 TRN-MDL-01934636 MDL Dep. Ex. 4635: Email from J. Kent to J. Keeton

et al. re Multiple Issues on the Rig

TRN-MDL-01949530 TRN-MDL-01949532 MDL Dep. Ex. 4638: Deepwater Horizon TaskSpecific Think Procedure

TRN-MDL-01995506 TRN-MDL-01995515 MDL Dep. Ex. 4639: DWH Task Specific Index

TRN-MDL-01995569 TRN-MDL-01995570 MDL Dep. Ex. 4640: Deepwater Horizon Task

Specific Think Procedure re Negative Flow Test

Using Choke and Kill Lines

TRN-MDL-01965043 TRN-MDL-01965043 MDL Dep. Ex. 4641: Deepwater Horizon Well

Specific Operating Guidelines

MDL Dep. Ex. 4641: Well Specific Operating

Guidelines, Mississippi Canyon 948 (Freedom)

TRN-MDL-01967887 TRN-MDL-01967913 MDL Dep. Ex. 4642: Riser Analysis

TRN-MDL-02009493 TRN-MDL-02009494 MDL Dep. Ex. 4643: Email from J. Keeton to DSP et

al.TRN-MDL-02070578 TRN-MDL-02070931 MDL Dep. Ex. 4644: Deepwater Horizon

Emergency Response Manual - Volume 1 of 2

TRN-MDL-02070932 TRN-MDL-02071196 MDL Dep. Ex. 4645: Deepwater Horizon

Emergency Response Manual - Volume 2 of 2


Emergency Response Manual - Emergency

Disconnect Procedure - General



Disconnect Procedure - Emergency Disconnect

Activation

TRN-MDL-01941201 TRN-MDL-01941202 MDL Dep. Ex. 4648: Deepwater HorizonEmergency Response Manual - Emergency

Disconnect Procedure - Dynamic Positioning/DP

Standby Conditions




Activation - Cementing (Hanger Landed in

Wellhead)






Emergency Response Manual - EmergencyDisconnect Procedure - Emergency Disconnect

Activation - Cement (Setting Plugs)




Activation - Well Control




Sequence


Emergency Response Manual - EmergencyDisconnect Procedure - Appendix 1: Emergency

Disconnect (EDS) Sequence

MDL Dep. Ex. 4654: Excerpt from Jonathan Keeton

Transcript on 08/17/2011 re Weekly EDS Drills

TRN-MDL-02009260 TRN-MDL-02009262 MDL Dep. Ex. 4655: Email from DSP, OIM to J.

Keeton re RE: BOP Emergency System Testing -

Standard Procedures

TRN-MDL-02009493 TRN-MDL-02009494 MDL Dep. Ex. 4663: Email from J. Keeton to DSP,

OIM re FW: HSE and DT Stats

TRN-MDL-00542891 TRN-MDL-00542901 MDL Dep. Ex. 4676: Transocean HSE Performance

Meeting

TRN-MDL-01953367 TRN-MDL-01953367 MDL Dep. Ex. 4677: Email from D. Winslow to J.Keeton et al.

TRN-MDL-01953368 TRN-MDL-01953378 MDL Dep. Ex. 4678: BP HSE Performance Meeting

TRN-MDL-01973942 TRN-MDL-01973942 MDL Dep. Ex. 4679: Email from D. Sims to J.

Keeton re FW: Deepwater Horizon Audit Report

TRN-MDL-01973943 TRN-MDL-01974024 MDL Dep. Ex. 4680: Deepwater Horizon Technical

Rig Audit - January 2008

TRN-MDL-01979905 TRN-MDL-01979905 MDL Dep. Ex. 4681: Email from J. Skelton to J.

Keeton et al. re Deepwater Horizon Audit Report

January 2008.doc

TRN-MDL-01967635 TRN-MDL-01967635 MDL Dep. Ex. 4682: Email from J. Keeton to J. Kent


Emergency Response Manual - EmergencyDisconnect Procedure - Appendix 1: Emergency

Disconnect (EDS) Sequence

TRN-MDL-01533488 TRN-MDL-01533493 MDL Dep. Ex. 4684: Email from G. Coltrin to J.

Keeton et al.

TRN-MDL-00607004 TRN-MDL-00607004 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





CAM_CIV_003283 CAM_CIV_003287 MDL Dep. Ex. 4687: Cameron Well Control

Equipment - Periodic Inspection/Recertification

TRN-MDL-00119247 TRN-MDL-00119248 MDL Dep. Ex. 4688: Email from Deepwater

Horizon, Formen to

[email protected] et al.

TRN-MDL-00885690 TRN-MDL-00885690 MDL Dep. Ex. 4689: Email from J. Kent to B.

Trahan

TRN-MDL-01851695 MDL Dep. Ex. 4911: OIM-Master Relationship

TRN-INV-00002645 TRN-INV-00002652 MDL Dep. Ex. 5032: Interviewing Form re Yancy J.

Keplinger by P. Roller and J. MacDonald

TRN-MDL-02411791 TRN-MDL-02411792 MDL Dep. Ex. 5033: Email from DWH, DPOperator

to DWH, Captain re "DWH PIC Letter" with Letter

TRN-USCG_MMS-00036708 TRN-USCG_MMS-00036751 MDL Dep. Ex. 5034: Y. Keplinger Personnel

Training File Report from NAR.OPS.RigCentral.comTRN-MDL-01587834 TRN-MDL-01587836 MDL Dep. Ex. 5035: Email from rig_DWH,captain

to DWH Chief Mate, DWH Marine, and DWH

Maintenance

TRN-MDL-01587341 TRN-MDL-01587346 MDL Dep. Ex. 5036: Personal Letter from M. Dow

to Y. Keplinger


Watchstanding and Dynamic Positioning Bridge

Procedures Guide

MDL Dep. Ex. 5038: Transocean DP Vessel Drift-off

and Watch Circle Program Deepwater Horizon

Operating Draft

BP-HZN-MBI00167544 BP-HZN-MBI00167545 MDL Dep. Ex. 5039: Safety Drill ReportTRN-MDL-01585758 TRN-MDL-01585761 MDL Dep. Ex. 5040: Superior Offshore Solutions

LLC Daily Report #3 re Deepwater Horizon

TRN-MDL-01597103 TRN-MDL-01597103 MDL Dep. Ex. 5041: Transocean Task Specific

Think Procedure Chart

TRN-HCEC-00010352 TRN-HCEC-00010676 MDL Dep. Ex. 5042: Transocean Deepwater

Horizon Failure Modes Effects and Critically

Analysis

TRN-MDL-02412174 TRN-MDL-02412176 MDL Dep. Ex. 5043: Letter from N. Roche to Y.

Keplinger

TRN-MDL-01586886 TRN-MDL-01586891 MDL Dep. Ex. 5044: Letter from M. Dow to Y.

Keplinger

TRN-MDL-01586100 TRN-MDL-01586104 MDL Dep. Ex. 5045: Deepwater Horizon MarineCrew Task Specific Think Procedures

TRN-MDL-02420138 TRN-MDL-02420138 MDL Dep. Ex. 5046: Email from DWH DPOperator

to DWH Captain re "Katie's Handover Notes - 19

February 2010"

TRN-MDL-02420139 TRN-MDL-02420141 MDL Dep. Ex. 5047: Macondo Handover Notes

41 42 MDL Dep. Ex. 5048: Letter from K. Trosclair

Bourgeois to Dr. J. Steen re Yancy Keplinger/"Left

Shoulder Pain"

TRN-MDL-02247359 TRN-MDL-02247364 MDL Dep. Ex. 5122: Master’s Responsibilities





CAM_CIV_0105569 CAM_CIV_0105576 MDL Dep Ex. 5173: Cameron EDS, MUX BOP

MDL Dep. Ex. 5285: Sperry Drilling Services -

Surface Data Logging

HAL_0696735 HAL_0696736 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

HAL_0606676 HAL_0606677 MDL Dep. Ex. 5288: Email from R. Sweatman to T.

Roth re: Conversation with Jeff Moss of Exxon

Mobil

HAL_0699897 HAL_0699898 MDL Dep. Ex. 5289: Mud Logging Report

HAL_1060808 HAL_1060809 MDL Dep. Ex. 5290: Email from J. Grier to A.

Scardino, et al. re: Statement awareness of

Halliburton's response to BP

HAL_0984480 HAL_0984481 MDL Dep. Ex. 5291: Email from J. Bement to I.Mitchell and R. Dirksen re: SDL monitoring

attaching image

HAL_0643366 HAL_0643368 MDL Dep. Ex. 5292: Email from J. Grable to R.

Russell, et al. re: Evaluate programs of Process

Excellence

HAL_1228396 HAL_1228401 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

HAL_1228429 HAL_1228430 MDL Dep. Ex. 5294: Email from T.

Probert/Halliburton Communications to

Halliburton Managers and Supervisors re"Halliburton's 2011 Service Quality Strategy"

HAL_1228332 HAL_1228333 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

HAL_1228479 HAL_1228480 MDL Dep. Ex. 5296: Email from J. Prestidge to N.

Buck re "RE: Sperry Drilling - Service Quality in the

Drilling Equipment Maintenance world!"

HAL_1228404 HAL_1228405 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"

HAL_1228406 HAL_1228428 MDL Dep. Ex. 5298: Halliburton 2011 ServiceQuality Strategy

HAL_1228196 HAL_1228221 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

TRN-MDL-00048168 MDL Dep. Ex. 5299: Transocean’s Deepwater

Horizon Organization Chart.pptx (from TO

Emergency Response Manual

MDL Dep. Ex. 5338: DWH Well Specific Operating





Guidelines, Dorado

TRN-INV-01122946 TRN-INV-01122949 MDL Dep. Ex. 5417: Deepwater Horizon

Investigation Chart

TRN-INV-00000228 TRN-INV-00005245 MDL Dep. Ex. 5418: Interviewing Form of Sean

Bayer

TRN-INV-02806138 TRN-INV-02806138 MDL Dep. Ex. 5419: Email from J. MacDonald to D.

hart re: Scheduled Interviews Represented by

Lawyers


Hart re: Statement

TRN-MDL-02733584 TRN-MDL-02970752 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 chartabout rig events

TRN-INV-00000228 TRN-INV-00000232 MDL Dep. Ex. 5423: Interviewing Form of Sean

Bayer

TRN-INV-02803304 TRN-INV-02803306 MDL Dep. Ex. 5424: Email from D. Hart to J.

MacDonald re: Scheduled Interviews Represented

by Lawyers

TRN-INV-00000658 TRN-INV-00000663 MDL Dep. Ex. 5425: Interviewing Form of Stanley

Carden

TRN-INV-00000664 TRN-INV-00000695 MDL Dep. Ex. 5426: Image of Deepwater Horizon

Rig General Arrangements

TRN-INV-00002238 TRN-INV-00002244 MDL Dep. Ex. 5427: Interview Form of William

JerniganTRN-MDL-02521307 TRN-MDL-02521307 MDL Dep. Ex. 5428: Email from J. MacDonald to J.

Judkins, et al. re: Interview Notes

TRN-INV-02392449 TRN-INV-02392449 MDL Dep. Ex. 5429: Email from S. Watson to J.

Judkins and J. MacDonald re: Michael Dicello -

Interview Draft

TRN-MDL-02865450 TRN-MDL-02865450 MDL Dep. Ex. 5430: Diagram of Transocean

Management System - HSE management

TRN-MDL-02865410 TRN-MDL-02865410 MDL Dep. Ex. 5431: Exerpt of report entitled

Transocean Management system - HSE

management

TRN-MDL-02865365 TRN-MDL-02865367 MDL Dep. Ex. 5432: HSE performance in order to

motivate personnel to take a proactive roleTRN-MDL-02865605 TRN-MDL-02865605 MDL Dep. Ex. 5433: Exerpt of report entitled

Operations Integrity Case - Emergency Response

TRN-INV-02983283 TRN-INV-02983286 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

TRN-MDL-02721029 TRN-MDL-02721030 MDL Dep. Ex. 5435: Email from Rig DWH, Captain

to J. MacDonald re: Optical Gyros - Technical

Information Bulletin attaching HQS OPS TIB





TRN-MDL-02722323 TRN-MDL-02722328 MDL Dep. Ex. 5436: Marine Compliance

Procedures - Personnel Designation of OIM andPIC

TRN-MDL-02723284 TRN-MDL-02723286 MDL Dep. Ex. 5437: Email from Hgr,

BargeSupervisor to J. MacDonald re: Watertight

Integrity and Compliance attaching Pump Rm.

Blank

TRN-INV-02963910 TRN-INV-02963912 MDL Dep. Ex. 5438: Email from J. MacDonald to

M. Lindsley, et al. re: Nautical Institute Proposals

TRN-MDL-02521321 TRN-MDL-02521322 MDL Dep. Ex. 5439: Email from J. MacDonald to D.

Hart and A. Nordholm re: Share Point

Investigation Tickets #246 - #250

TRN-INV-02642862 TRN-INV-02642862 MDL Dep. Ex. 5440: Email from D. Reudelhuber to

S. Walker and J. MacDonald re: DeepwaterHorizon attaching DWH Weekly Drill Reports

TRN-INV-026442863 TRN-INV-026442901 MDL Dep. Ex. 5441: Weekly Drill Report

TRN-INV-02642902 TRN-INV-02642943 MDL Dep. Ex. 5442: Weekly Drill Report

TRN-MDL-02526400 TRN-MDL-02526400 MDL Dep. Ex. 5443: Email from D. Reudelhuber to

S. Walker and J. MacDonald re: Deepwater

horizon attaching Dwh Safety Drill Reports March

TRN-INV-03485220 TRN-INV-03485224 MDL Dep. Ex. 5444: Email from J. MacDonald to A.

Rose, et al. re: LA times Story - URGENT &

CONFIDENTIAL attaching Panamanian Manning

letter

TRN-INV-03540868 TRN-INV-03540869 MDL Dep. Ex. 5445: Letter from M Canada to N.

Smith re: Transocean propose common wordingon the Minimum Manning Certificates for the

MODU



Disconnect Procedure

TRN-MDL-02702988 TRN-MDL-02703001 MDL Dep. Ex. 5447: Chapter 6 - Summary of

Conclusions - Deepwater casualty

TRN-MDL-02703711 TRN-MDL-02703711 MDL Dep. Ex. 5448: Email from W. Weaver to A.

Rose re: Marine Board Conclusions and

Recommendations attaching Macondo Conclusion

Survey; Macondo Recommendations Survey

TRN-INV-00000248 TRN-INV-00000253 MDL Dep. Ex. 5449: Transocean Interviewing Formof Rex Beard

TRN-INV-00000594 TRN-INV-00000598 MDL Dep. Ex. 5450: Transocean Interviewing form

of Jonathan Camacho


of Nathan Carroll


of Michael Cutrer


of Michael Dicello






of Mike Dow


of Daivd Hackney


of Yancy Keplinger


of Mike Mayfield


of Paul Meinhart


of James Musgrove


of Nathaniel RocheTRN-INV-00005239 TRN-INV-00005245 MDL Dep. Ex. 5461: Transocean Interviewing Form

of David Young

TRN-MDL-02703795 TRN-MDL-02703798 MDL Dep. Ex. 5462: Email from J. MacDonald to

M. LaBella attaching Rig Awareness Manual

TRN-MDL-02703799 TRN-MDL-02703817 MDL Dep. Ex. 5463: Rig Awarness Training

TRN-MDL-02703881 TRN-MDL-02703943 MDL Dep. Ex. 5464: Rig Awareness Training - Rig

Operations


Hart re: Questions attaching Horizon EER

Questions - Offshore Personnel

TRN-MDL-02726350 TRN-MDL-02726367 MDL Dep. Ex. 5468: Deepwater Horizon Incident -

Internal Investigation update - Interim ReportTRN-INV-02494856 TRN-INV-02494857 MDL Dep. Ex. 5469: HSE Alert - Verification of

Ability to Respond to an Emergency

TRN-HCJ-00004903 TRN-HCJ-00004903 MDL Dep. Ex. 5472: Exerpt of Health and Safety

Policies and Procedures Manual - Safety Policies,

Procedures and Documentation


Operations Integrity Case, Section 1 (Introduction

and Table of Contents)


Operations Integrity Case, Section 2 - HSE

Managment

TRN-MDL-02865459 TRN-MDL-02865602 MDL Dep. Ex. 5475: Deepwater HorizonOperations Integrity Case - Risk Management


Operations Integrity Case Emergency Response


Operations Integrity Case Performance

Monitoring

TRN-MDL-00655132 TRN-MDL-00655156 MDL Dep. Ex. 5478: Email from A. Rose to S.

Newman re: Meeting Presentations - GSF and

Total attaching QHSE group for GSF





TRN-MDL-00547497 TRN-MDL-00547526 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

TRN-MDL-02833303 TRN-MDL-02833582 MDL Dep. Ex. 5481: Email from A. Rose to J.

Moore re: Rig Visit Assignement attaching PMAA

Criteria Standard; PMAA Procedures Manual -

Section

TRN-MDL-02834327 TRN-MDL-02834345 MDL Dep. Ex. 5482: Lloyd's Register Safety

Management System and Safety Culture/Climate

Reviews Closing Meeting

TRN-MDL-02830621 TRN-MDL-02830629 MDL Dep. Ex. 5483: DWH ISM Code CertificationShip Audit Report (DNV, 2002)

TRN-MDL-02832154 TRN-MDL-02832188 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

TRN-INV-00018567 TRN-INV-00018600 MDL Dep. Ex. 5485: Corporate Emergency

Response Plan

TRN-MDL-02827465 TRN-MDL-02827484 MDL Dep. Ex. 5486: Engineering & Technical

Support HSE Meeting

TRN-MDL-02831737 TRN-MDL-02831741 MDL Dep. Ex. 5487: Letter from D. Dickman to B.

Poskaitis re: U.S. Coastal State RegulationCompliance

TRN-INV-01463636 TRN-INV-01463640 MDL Dep. Ex. 5488: Deepwater Horizon Accident

Investigation Report Review

HCG161-040009 HCG161-040017 MDL Dep. Ex. 5571: Department of Homeland

Security United States Coast Gaurd - Certificate of

Compliance

TRN-INV-02265384 TRN-INV-02265385 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

HCG037-010037 HCG037-010038 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

DHCIT_TPY-0169122 DHCIT_TPY-0169123 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

DHCIT_TPY-0169130 DHCIT_TPY-0169131 MDL Dep. Ex. 5585: Activity Summary Report -

MODU is in very good condition, Good Crew

participation





TRN-INV-00003875 TRN-INV-00003887 MDL Dep Ex. 5629: Transocean Interview Form: C.

Pleasant.

TRN-MDL-01293817 TRN-MDL-01293819 MDL Dep. Ex. 5633: Email from S. Newman to L.

McMahan re: Ops Brief


McMahan re: Update


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

TRN-MDL-00606649 TRN-MDL-00606655 MDL Dep. Ex. 5643: Integration Memo from

Executive Vice Presidents of Performance to

Business Unit Senior Vice Pres. re: Day 1operational guidance

MDL Dep Ex. 5643: Integration Memo, Nov. 20,

2007.

TRN-MDL-02865347 TRN-MDL-02865450 MDL Dep. Ex. 5644: Transocean Management

System - HSE Management

TRN-MDL-02493368 TRN-MDL-02493372 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

TRN-HCEC-00100941 TRN-HCEC-00100951 MDL Dep. Ex. 5646: Email from gmsproject to S.

Newman re: Daily Executive Notification -

Incidents 4/12/2010TRN-MDL-02506723 TRN-MDL-02506745 MDL Dep. Ex. 5647: Well Control Events Statistics

2005 - 2006 - 2007

TRN-MDL-02506721 TRN-MDL-02506722 MDL Dep. Ex. 5648: Email from M. Pathak to S.

Newman re: 2007 Well Control Analysis

TRN-INV-00760054 TRN-INV-00760101 MDL Dep. Ex. 5649: Annual Report - 2009 Well

Control Events & Statistics 2005 to 2009

TRN-INV-01143039 TRN-INV-01143059 MDL Dep. Ex. 5650: EAU Incident Investigation

Report

TRN-INV-01215566 TRN-INV-01215567 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; Exampledisplacement charts

TRN-INV-00003563 TRN-INV-00003566 MDL Dep. Ex. 5652: Interviewing Form of Steven

Newman


McMahan re: weekly OER Executive Review 2009

Week 02

MDL Dep. Ex. 6000: Tony Hayward Speech

Transcription -- Stanford, YouTube,

"Entrepreneurial Spirit Needed"





MDL Dep. Ex. 6001: House of Representatives

Verbatim Transcript of June 17, 2010 - Committeeon 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 IndependentPanel to Review U.S. Refinery Safety


Exploration (Alaska) Inc.

MDL Dep. Ex. 6009: Interview in article format

titled: Alaskan Oil Pipeline Leak Raises

Environmental Concerns


America Inc.

MDL Dep. Ex. 6011: Lessons from Grangemouth: A

Case History

MDL Dep. Ex. 6012: Investigation Report -

Refinery Explosion and Fire - Key issues: SafetyCulture, 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 AnnualGeneral Meeting 2010: Speeches - Tony Hayward

MDL Dep. Ex. 6018: 2010 Drilling Excellence Plan

BP-HZN-2179MDL00369620 BP-HZN-2179MDL00369643 MDL Dep. Ex. 6019: Gulf of Mexico SPU - Drilling

and Completions The Way We Work

BP-HZN-2179MDL00306832 BP-HZN-2179MDL00306837 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





BP-HZN-2179MDL003405 BP-HZN-2179MDL003405 MDL Dep. Ex. 6140: Email from N. Wong to H.

Thierens and J. Sprague re: Deepwater HorizonRig Audit

BP-HZN-BLY-00356689 BP-HZN-BLY-00356691 MDL Dep. Ex. 6141: Email from N. Wong to I. Little

re: Horizon Rig Audit Updates and path forward

BP-HZN-BLY00360479 BP-HZN-BLY00360479 MDL Dep. Ex. 6142: Feedback via teleconference

BP-HZN-2179MDL00353304 BP-HZN-2179MDL00353305 MDL Dep. Ex. 6143: Email from J. Guide to B.

Cocales and K. Daigle re: Deepwater Horizon Rig

Audit

BP-HZN-2179MDL01160382 BP-HZN-2179MDL01160384 MDL Dep. Ex. 6144: Email from S. haden to N.

Wong re: Deepwater Horizon Rig Audit

BP-HZN-BLY00367395 BP-HZN-BLY00367395 MDL Dep. Ex. 6149: Safety Alert on the Deepwater

Horizon Explosion

BP-HZN-BLY00367395 BP-HZN-BLY00367395 MDL Dep. Ex. 6150: Safety Alert on the Deepwaterhorizon Explosion and Fire Resulting in multiple

Fatalities

TRN-USCG_MMS-00043818 TRN-USCG_MMS-00043819 MDL Dep. Ex. 7117: Well Control Procedures and

Responsibilities: Well Control Procedures

TRN-MDL-00868018 TRN-MDL-00868020 MDL Dep. Ex. 7118: Transocean- Section 1- Well

Control Procedure and Responsibilities

TRN-MDL-00868024 TRN-MDL-00868025 MDL Dep. Ex. 7119: Transocean- Section 3 - Well

Control Principles

TRN-MDL-00868026 TRN-MDL-00868029 MDL Dep. Ex. 7120: Transocean- Section 4 -

Preparation & Prevention

TRN-MDL-00868030 TRN-MDL-00868033 MDL Dep. Ex. 7121: Transocean- Section 5 -

Actions Upon Taking A KickTRN-MDL-0086808 TRN-MDL-0086812 MDL Dep. Ex. 7122: Transocean- Drilling

Deepwater Wells

TRN-MDL-00867646 TRN-MDL-00867701 MDL Dep. Ex. 7123: Deepwater Horizon HAZID-

Report for Transocean Offshore Deepwater

Drilling Inc.

MDL Dep. Ex. 7124: Incident Title- Transocean

S711

BP-HZN-MBI00021460 BP-HZN-MBI00021999 MDL Dep. Ex. 4271: Drilling Contract RBS-80

Submersible Drilling Unit, Vastar Resources Inc.

and R&B Falcon Drilling Co.

TRN-INV-03455358 TRN-INV-03455362 2010-09-07 Venable response to RMI letter

LREMEA-MDL 000001 LREMEA-MDL 000889 Lloyd's Register EMEA Document ProductionTRN-HCEC-00116082 TRN-HCEC-00116085 DNV Vessel Summary Report for DWH, April 26,

2010

TRN-HCEC-00116088 TRN-HCEC-00116088 DNV ISM Code/ISO Certification Observation, May

15, 2007

TRN-USCG_MMS-00030803 TRN-USCG_MMS-00030823 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





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 transcriptWong, 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 transcriptHackney, 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





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

TRN-MDL-00635387 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/Public-

Report-1076.html






Republic of the Marshall Islands DEEPWATER

HORIZON_Marine Casualty InvestigationReport.pdf

Transocean 2009 Annual Report

Reliance Exhibit List to Webster Report

2011-09-23 Transocean Disclosure of Non-

Retained Expert Witness Not Required to Provide

a Written Report

2011-09-23 Transocean’s 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 DescriptionStena 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 Officer’s Examinations