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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
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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
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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
ISM Code Section 4 130
ISM Code Section 5 131
ISM Code Section 6 136
ISM Code Section 7 140
ISM Code Section 8 168
ISM Code Section 9 183
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ISM Code Section 10 192
ISM Code Section 11 198
ISM Code Section 12 201
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
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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
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Report of Captain Andrew Mitchell Page 6 of 154
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.
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Executive Summary and Conclusions
1. This Report is the result of a detailed examination and assessment of the Transocean Safety
Management System (SMS), in particular how it was applied on board the DEEPWATER HORIZON
in 2010. It identifies two major non-conformities2 with the requirements of the ISM Code.3
2. Through a Drilling Contract signed in 1998, 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).
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Report of Captain Andrew Mitchell Page 8 of 154
organisational structure with properly trained marine crew onboard the DEEPWATER HORIZON
and the major loss of life, personal injury, and pollution would most probably have been averted.
This Report sets out my opinion on this matter.
4. In 2004, Transocean prepared the DEEPWATER HORIZON “Major Accident Hazard Risk
Assessment” (MAHRA) 7 and in 2008 the Operations Integrity Case (OIC). 8 Both of these
documents identified a “Reservoir blowout ” and “Hydrocarbons in formation (including gas), loss
of containment” as major hazards. Further, in 2009 Transocean recognised in its Annual Report
that its operations were subject to the “usual hazards inherent in drilling of oil and gas wells”
and identified blow outs, loss of well control, fires, personal injuries, environmental damage and
failure to retain key personnel as hazards which had the potential to have a serious effect on
their business.9 Having recognised these hazards, and despite having procedures in place to
mitigate the risk, Transocean failed to effectively implement the very procedures which may
have prevented the disaster which occurred on April 20, 2010.
5. The Republic of the Marshall Islands (RMI), the flag Administration, by not recognising the
DEEPWATER HORIZON as a Dynamically Positioned (DP) ship, improperly facilitated the
implementation of a confusing dual command structure in which the Master was prevented from
exercising his statutory right of overriding authority and responsibility with respect to safety and
pollution prevention.
6. Det Norske Veritas (DNV), by not following its own procedures, also facilitated 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)
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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.
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Report of Captain Andrew Mitchell Page 10 of 154
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
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• 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.
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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
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“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
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• 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
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40MDL Exhibit 4644: DWH Emergency Response Manual: Section 9
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• 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
39MDL Exhibit 4644: DWH Emergency Response Manual: Section 7
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• The DWH Emergency Response Manual indicates that the only person with the
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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
41MDL Exhibit 4644: DWH Emergency Response Manual: Section 12
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
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• 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)
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• “ 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)
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57National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling Report, Ch. 4, p. 114
Report of Captain Andrew Mitchell Page 19 of 154
56MDL Exhibit 5173: Cameron EDS, MUX BOP Control System for DWH
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protect the crew, the vessel, and the environment. This constitutes major non-conformity with
the ISM Code and contributed significantly to the outcome of events on April 20, 2010.
24. Transocean was able to continue in its failure to clearly state the 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
65MDL Exhibit 3163: DNV Guidance for Auditors to the ISM Code, pp. 24
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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
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environment . . . . The OIM has the authority to implement any action he deems necessary
to gain control of an emergency or to prevent the potential for an emergency to arise.” He
is “disciplinary superior to the Senior Tool Pusher .” The job description also requires the
OIM to hold a certificate of competency as a Master Mariner STCW II/2 (unlimited).70
• Stena Drilling, which in the OIM job description states the qualifications as “STCW Master
Mariner with Class 1 Deck/Master Foreign Going (unlimited), GMDSS revalidated,
Management of Offshore Emergencies” and in roles and responsibilities “co-ordinate the
activities of the departments under the control of the Barge Master, Chief Engineer, Senior
Toolpusher, Catering Manager, including all Operator and Service Company Supervisors.”71
70See Appendix 8: Maersk Drilling OIM Job Description
71Stena Drilling Job Description of the OIM
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28. Major non-conformity #2 ISM Code Section 6 – Resources and Personnel
It is a requirement of the ISM Code Section 6.1.1 that the Master be properly qualified for
command. There is no evidence that the OIM, nominated as the person in charge and in
command of the DEEPWATER HORIZON during “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
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Master. He was, however, not qualified to be the Master of the DEEPWATER HORIZON under
international or flag State requirements.
33. RMI has requirements for Merchant Marine Personnel Qualification which outlines the
qualifications and experience personnel must have before undertaking marine examinations
under the regime of the RMI.74
• Section 4.5 specifically addresses “Service Requirements for MODU Deck Officers
Examinations - for MODUs” but clearly notes that MODU certification does not permit
service on board self-propelled MODUs such as the DEEPWATER HORIZON.
•
Section 4.5.3 lists the requirements for “Master Offshore Installation Manager ”, 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)
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leading Members of IMO, will have adopted these Recommendations which are applicable to
DEEPWATER HORIZON. Relevant sections include:
2.1.8 the OIM is the competent person appointed by the company as the person in charge
who has complete and ultimate command of the unit and to whom all personnel on
board are responsible;
2.1.13 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
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38. To be “ properly qualified for command ” of the DEEPWATER HORIZON required the Master, and
OIM in the case of the DEEPWATER HORIZON, not only to hold statutory certification but also to
have received training identified by Transocean as that required to support the safety
management system.82 The training records of Kuchta83 and Harrell84 show them to have each
attended a considerable number of courses during their employment with Transocean. Despite
this, Curt Kuchta had not received critical training on Major Emergency Management, nor had he
received any training in the operation of the EDS system.
39. The Transocean OIC states that “the OIM and the Master are both required to complete Major
Emergency Management (MEM) training which includes assessment as PIC ” and “training
requirements for the Master include completion of the MEM course and assessment/qualification
as PIC .”85 It was the responsibility of the Rig Manager Performance (RMP) to “ensure key rig
personnel are trained, competent and licensed in all safety critical areas
including …..Management of Major Emergency Training, Well Control…..”86
The lessons of the MEM course included:
• Understanding the philosophical differences between normal and major emergency
management;
• Pro-active planning;
• Understanding the principles of command, control and communication; and
• Development of the discipline of implementation of the 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
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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
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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.
96MDL Exhibit 1471: Interoffice Correspondence - Internal ISM Audit, March 15, 2010
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Summary
44. The MAHRA and OIC for the DEEPWATER HORIZON developed by Transocean in 2004 and 2008,
respectively, demonstrate that Transocean recognised that the marine department, not only the
drilling crew, plays a critical role in mitigation of major accident hazards for which the
DEEPWATER HORIZON was at risk. Transocean failed, however, to implement the procedures
that would ensure that “emergency response training and drills” were carried out and that the
marine department, specifically the Master, would have the “ Ability to move off station” at the
time in the blowout scenario when the last clear chance to avoid catastrophe could be taken.
45. As a Master Mariner, OIM, and Chairman of the working groups that developed the standards by
which IACS Societies acting as Recognised Organisations carry out ISM compliance audits on
behalf of flag Administrations, I conclude that Transocean was not operating the DEEPWATER
HORIZON safely and in compliance with the requirements of the ISM Code in that there was
objective evidence of major non-conformity with ISM Code Sections 5 and 6.
46. Evidence shows that there was confusion of command and a lack of training and competence of
the Master and OIM created by an improper, unclear, and confusingly divided command.Confusion on the bridge of the DEEPWATER HORIZON delayed the last clear chance to avoid a
catastrophic explosion and loss of the installation, as well as the consequent deaths and resulting
major pollution. A clear, unqualified, unambiguous command structure with the Master in
charge at all times would make more probable an appropriate emergency response when it
mattered the most.
47. The long standing practices at Transocean had placed the Master “in a box” with little
responsibility, authority or training. From there Transocean expected that he would be capable
and prepared to instantly assume command of an escalating major emergency situation with no
knowledge of what had gone before or what had gone wrong. Transocean expected, despite
contradictory and confusing guidance, that the crew would somehow understand the point at
which command of the ship had transitioned from the OIM to the Master.
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48. The DEEPWATER HORIZON was drilling one of deepest wells in the deepest water. When a major
emergency struck on April 20, 2010, its Master did not have a clear and unambiguous mandate
from Transocean to unequivocally and immediately assume command authority, he did not have
the knowledge to assess the deteriorating situation nor the competence to operate the EDS
without any delay. This failure by Transocean to comply with international maritime standards,
regulations, and practices led to avoidable tragedy.
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Annex A: The ISM Code
Background to the ISM Code
49. The sinking of the Titanic in 1912 was the event which triggered the process leading eventually
to the development of the ISM Code. This sinking, probably the first major marine casualty to
gain world attention, resulted through public and hence governmental pressure in the formation
of an international body to address “maritime safety.” Now known as the IMO, this body
developed, and its members adopted, the International Convention for the Safety of Life at Sea
(SOLAS) Convention. The IMO remit was stated as "to provide machinery for cooperation among
Governments in the field of governmental regulation and practices relating to technical matters
of all 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
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prevention. In recognition of the complexity of the marine industry, the Preamble to the ISM
Code states “the ISM Code [is] expressed in broad terms so that it can have wide spread
interpretations” and “recognising that no two shipping companies are the same . . . the Code is
based on general principles and 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
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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.
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61. The Document of Compliance (DOC)99 is issued to the Company to certify that the safety
management system of the Company has been audited and that it complies with the
requirements of the ISM Code for a specific ship type. The certificate is valid for a period of up to
five years subject to successful annual verifications at the Company premises.
62. The Safety Management Certificate (SMC)100 is issued to a ship to certify that the safety
management system of the ship has been audited and that it complies with the requirements of
the ISM Code, following verification that the DOC for the Company is applicable for the ship type.
The certificate is valid for a period of up to five years subject to at least one successful
intermediate verification. An SMC cannot be issued without a valid DOC for the appropriate ship
type being in place.
99E.g. MDL Exhibit 953 and Annex J
100E.g. MDL Exhibit 1776 and Annex K
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Annex B: Enforcement of the ISM Code
Flag Administrations
63. The responsibility for the enforcement of the ISM Code belongs to the signatories to the SOLAS
Convention: the flag Administrations. Administrations enact the requirements of SOLAS IX and
the ISM Code through their own legislation. In the case of the Marshall Islands this is through
Marine Notice No. 2-011-13 as amended and specific to MODUs in the Mobile Offshore Drilling
Unit Standards Part III - M. In the case of the United States this is through 33 C.F.R. Part 96 –
Rules for the Safe Operation of Vessels and Safety Management Systems. In both cases it is clear
that the ISM Code applied to Transocean and the DEEPWATER HORIZON in April 2010.
64. Recognising the need for uniform implementation of the ISM Code by the Administrations, The
IMO in 1995 adopted “Guidelines on Implementation of the ISM Code” through Resolution
A.788(19). These were amended by A.913(22) and adopted in November 2001 which state in the
Introduction that “effective enforcement by Administrations must include verification that the
safety management system complies with the requirements as stipulated in the ISM Code as well
as verification of compliance with mandatory rules and regulations.”
65. The Guidelines lay out the process of verifying compliance with the ISM Code, the certification
process, the standards on ISM Code certification arrangements, and the competence of auditors.
They also provide for Administrations to appoint Recognised Organisations (RO) to issue DOCs
and SMCs on their behalf.
Recognised Organisations
66. While several Administrations issue ISM certification themselves, the majority do not. They have
neither the technical knowledge, nor the resources, to carry out their responsibilities under UNCLOS
Article 94 and SOLAS and so delegate to Recognised Organisations (RO). IMO Resolution A.739 (18)
1993, “Guidelines for the Authorization of Organisations Acting on behalf of the Administration” and
IMO Resolution A.789 (19) 1995, “Requirement to be a Recognised Organisation” lay down
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minimum requirements for ROs. The major classification societies, those forming the International
Association of Classification Societies (IACS), have been found to meet these Requirements by the
majority of Administrations, including RMI, and act as their ROs. In the case of Transocean, DNV
acted as the RO for the RMI.
67. The RO is responsible and accountable to the flag Administration for the work that it carries out on
its behalf. The RO carries out its work in accordance with the IMO Resolutions and any guidelines
and additional requirements provided by the Administration.
68. There are currently more than 50 organisations that offer classification services to the industry.
Many of these are small and have limited technical ability. However the leading thirteen societies,
including Det Norske Veritas (DNV), form IACS, which has strict criteria for membership. These
include:
• ability to develop, apply, maintain, regularly up-date and publish its own set of classification
rules in the English language,
• ability to survey ships under construction in accordance with its rules and statutory IMO and
flag State requirements,
• have sufficient international coverage by exclusive surveyors,
• have independence from ship-owning, ship-building and other commercial interests which
could undermine the 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.
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Port State Control
70. In recognition of the fact that in some cases it may be difficult for the Administration to exercise
full and continuous control over some ships entitled to fly its flag, there is provision in SOLAS for
the inspection of foreign ships in national ports to verify that the condition of the ship and its
equipment comply with the requirements of international regulations and that the ship is
manned and operated in compliance with these rules. However the primary responsibility for
ships' standards rests with the flag State, with port State control providing a "safety net" to catch
substandard ships.
71. IMO adopted Resolution A.882(21), “ Amendments to the Procedures for Port State Control ”
(A.787(19)) in November 1999. This Resolution contained an amendment at 3.7, providing
Guidelines for port State control related to the ISM Code. This empowers PSCO to examine the
ISM certificates on board a ship and, if clear grounds are established, to carry out a more
detailed inspection based on an 11 point checklist. Deficiencies identified are communicated to
the flag State and may result in detention.
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Annex C: The ISM Code and other Rules, Regulations, Codes, Guidelines and Standards
72. ISM Code 1.2.3.1 requires that the safety management system should ensure “compliance with
mandatory rules and regulations.” Primarily these are the rules and regulations promulgated by
the Organisation (e.g. MODU Code), the applicable flag State and also classification societies (as
the requirement to maintain a ship in class is a SOLAS requirement). They may be supplemented
by requirements from the port State, the coastal State or a Government in whose exclusive
economic zone the ship may be operating.
73. ISM Code 1.2.3.2 requires that the safety management system should ensure “applicable codes,
guidelines and standards recommended by the Organisation, Administrations, classification
societies and maritime industry organisations are taken into account .” Where such
requirements are not implemented, it is incumbent on the company to demonstrate why they
were not and what, if any, equivalency has been adopted.
74. ISM Code 1.2.2.2 requires the Company to “assess all identified risks to its ships, personnel and
the environment and establish appropriate safeguards.” This means all the risks on board the
ship, there are no exclusions provided for. In the case of the MODU this will include the drilling
operation, the operations of any contractors and the inter face with support vessels.
75. It is clear from the above that the scope of the SMS shall address all operations on board MODUs,
such as the DEEPWATER HORIZON, and as such, all operations shall be subject to audit during
DOC and SMC ISM audits.
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Annex D: The ISM Code Verification
The External Audit Process
76. The following process is that followed by an IACS society acting as an RO implementing IACS PR 9
and PR 10.
77. ISM verification audits may only be carried out by personnel who meet the competence
requirements stated in the Appendix to Resolution A.913(22), paragraphs 3.2 and 3.3, as
expanded in IACS PR 10 and detailed in the 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
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• 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
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Reporting the Audit Findings
81. Audit findings are conveyed in a report as observations, non-conformity or major non-conformity against compliance with the requirements of the ISM Code and Company requirements. By its
nature, an audit106 is a sampling process, it is not an inspection.107
82. An observation is a statement of fact substantiated by objective evidence. An observation will
be raised by an auditor when a finding has the potential to become a non-conformity in the
future, if no action is taken by the Company.
83. A non-conformity means an observed situation where objective evidence indicates the 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
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• The immediate action needed to prevent recurrence of the non-conformity at the location
• Longer term action, known as preventive action arising from identification of the root causes,
to prevent recurrence of the non-conformity in other locations in the company. This will
generally involve an amendment to the management system.
86. On receipt of the corrective action plan from the Company, the RO will, having considered its
adequacy, accept or reject the plan. The effectiveness of the action taken will be assessed at the
next scheduled audit and the non-conformity will be closed out. When all non-conformity is
closed out, the Audit is considered “closed.”
87. Should the Company not take corrective action within the agreed time schedule; the RO will
consider this to be a reason for which the SMC or DOC may become invalid. If it is considered
that by not taking corrective action poses a serious threat to the safety of personnel and ships, or
is a serious risk to the environment and includes the lack of effective and systematic
implementation of a requirement of the ISM Code, the RO will raise a major non-conformity. In
all cases the flag Administration will be informed of the circumstances.
The Internal Audit Process
88. Section 12 of the ISM Code requires companies to carry out internal audits of their SMS on an
annual basis. The Code is not prescriptive as to how this will be done but all sections of the Code
should be addressed and corrective actions identified should be followed up in a timely manner.
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Annex E: A Typical SMS for a Company operating a MODU
Organisation for effective HSE management
89. The ISM Code states “the cornerstone of good safety management is commitment from the top.”
This requires the CEO and other senior managers to be personally involved in safety
management at the appropriate level, providing support to the Designated Person, a statutory
requirement of the ISM Code.108 The management of safety must be integrated into all company
activities and its implementation the responsibility of operational managers. Health, safety and
environmental specialists may form a support group, but must be advisors and auditors,
providing confidence to management that the SMS is being implemented effectively.
Scope of the SMS
90. Apart from the statutory requirement for the SMS to ensure compliance with mandatory Rules
and Regulations and that applicable Codes shall be taken into account, the overarching
requirement is that the company shall “assess all identified risks to its ships, personnel and the
environment and establish appropriate safeguards.” This process of risk assessment
encompasses all activities on the MODU: marine and drilling related activities and those activities
of specialist Third Party contractors. It follows that the SMS shall address all activities on the
MODU.
Bridging Documents
91. The Company has the non-delegable duty to provide a safe place of work for its employees
through its safety management system. However, the oil majors contracting the MODU will have
their own SMS and may require specific input to individual operations. This is allowed for
through the Bridging Document where the two 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
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which takes precedence and is the controlling document. This must be clearly recorded to avoid
confusion at a later date.
92. Likewise, the SMS of a Third Party contractor employed by the Company or the oil major to work
on the MODU will be compared and a Bridging Document created to identify additional
requirements and key responsibilities.
93. All Bridging Document form part of the SMS and are subject to audit by the RO.
Structure of the SMS
94. There is no prescriptive structure for an SMS. It will depend entirely on the size and complexity
of the Company and in many cases, its geographical spread. Generally the more complex the
company, the more complex the SMS. Some large international companies have a single SMS
implemented through several divisions and multiple offshore locations, the approach taken by
Transocean. Other companies break their operation into smaller entities and multiple DOCs to
simplify implementation of the SMS.
95. A typical SMS may comprise three levels; corporate policy, company procedures, local work
instructions. The policies provide management commitment to stated objectives, the company
procedures describe what must be done to achieve the objectives, and the work instructions
state how this is to be achieved in the work place. Supporting these are many third party
documents such as nautical publications, equipment manufacturers instructions, classification
society records, builders drawings.
Content of the SMS
96. The ISM Code was developed primarily for conventional ship types trading internationally but
also applies to other minority ship types, MODU being one of them. The SMS shall ensure the
Company meets the requirements of ISM 1.2 Objectives, and in so doing addresses each section
of the Code. Standardized interpretations of the sections have been adopted by the marine
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industry, but where specific interpretations for MODUs are required I have given my opinion in
the following paragraphs.
97. ISM Code Section 5: 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
109MDL Exhibit 3163: DNV Guidance for Auditors to the ISM Code, pp. 24
11046 C.F.R. 109.107
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subject making the position of Master synonymous with that of OIM111 requiring him to have
marine qualifications and oil industry training.112
ISM 6.1.2 requires the Master to be fully conversant with the 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
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management, making decisions based on expert advice. In other words, while it is very sensible
to combine the role of OIM and Master in one person, it is also possible to have a Master who is
primarily a mariner but who is trained in well control and drilling at a basic level but does not
directly manage drilling operations, while there is a drilling superintendent in charge of the
drilling operation.
100. Section 8: Emergency Preparedness
The requirement is to “identify potential emergency shipboard situations and establish
procedures to respond to them.” This includes all situations which may occur on the MODU
whether marine or drilling related; there are no exceptions. 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
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measures aimed at promoting reliability of such equipment and systems .” Such equipment and
systems on a MODU include DP systems, well control, fire and gas detection systems, power
generation and should be prioritised in the maintenance systems (ISM 10.4).
103. Section 11: Documentation
The simplistic requirement is to maintain a companywide document control system providing
valid, up to date documents for the operation of the fleet. There is no prescriptive method by
which this has to be achieved but considering the diverse scope of documents required for a
fleet of MODUs, an effective system is essential.
104. Section 12: Company Verification, Review and Evaluation
Internal audits shall “verify whether safety and pollution activities comply with the safety
management system.” Having established that the ISM Code and SMS applies to all activities on
the MODU then the scope of the audits shall address all activities on board.
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Annex F: The SMS implemented by Transocean
Structure of the Transocean Company Management System (CMS)
105. Transocean implements a complex CMS, its structure being based on the eight core management
functions of the Company. The system is formatted in 3 Levels, albeit Level 1 is subdivided. It is
distributed in electronic format as E-docs.
• Level 1 comprises the Company Management System Manual which is the lead document.
It defines management expectations and requirements.
•
Level 1A comprises the corporate department policies and procedures which define 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
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System Management and Review Team (SMART) process.115 While the process is valid, it is
complex and takes 16 pages to describe. The ability to affect change in a reasonable timescale is
questioned. This may be immaterial as Rose said “it is not revised that often, it would not change
any substance of it if there was (sic). It would probably be a minor revision to organisation or
something, or titles.”116 Despite this he then went on to admit the organisation chart shown in
the CMS Manual was out of date.117
107. Complex and detailed management systems satisfy the management need to inform employees,
the converse being that it may not be implemented on the rig floor. This may be the case at
Transocean and specific areas are addressed later in this Report. Comments such as “it is
designed by a load of college people who 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.
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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
123Rose Deposition, p. 45
124MDL Exhibit 939: Transocean ISM/ISPS MODU Handbook, Forward and Section 2.5.1
125MDL Exhibit 929: Lloyd’s Register Safety Management and Safety Culture/Climate Review (March 16, 2010)
126Canducci Deposition, p. 92
127MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 2.4
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112. The main Transocean documents which I consider are required to comply with the ISM Code are
shown in Annex Q. Those considered necessary by Transocean are circled in red. The difference is
due to the narrow interpretation of the requirements of the ISM Code by Transocean. Notably,
Well Control and BOP Operations are excluded. For some reason not identified, the Marine
Compliance Manual, Lifting Operations, and the Level 3 DEEPWATER HORIZON documents,
Bridge Procedures, and Operations Manual are also excluded.
113. Due to a lack of a clear definition of the Transocean SMS, it is unclear what the DNV auditor,
David McKay, considered to be the SMS. At the Annual DOC Audit 2007,
128
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
130MDL Exhibit 1768 and Annex N: DNV Transocean 2009 DOC Audit (April 16, 2009)
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)
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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
137Canducci Deposition, p. 609
138MDL Exhibit 956: DWH – BP CMID Audit Work List September 2009
139MDL Exhibit 955: Winslow Email, August 17, 2009
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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
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141MDL Exhibit 925: Transocean Company Management System Manual, Section 2.3, 2.4
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Annex G Content and the implementation of the Transocean SMS
120. The Transocean SMS described in the Health and Safety Policies and Procedures Manual section
2.4 is shown in summary below:
CMS 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
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document, I consider it would be difficult for operational personnel to identify the company
safety objectives.
ISM Section 2: Safety and Environmental Protection Policy
122. Transocean had two Policies in place: the Health and Safety Policy Statement and the
Environmental Policy Statement.142 They were signed by the correct personnel, had appropriate
content and described in the barest form, through the use of acronyms such as FIRST, THINK,
START and FOCUS, how the safety objectives were to be met. 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)
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• 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
150Rose Deposition, p. 238
151Rose Deposition, p. 238
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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)
154Rose Deposition, p. 412
155MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 1.2
156bis
157Canducci Deposition, p. 585
158Canducci Deposition, p. 92
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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
159Canducci Deposition, p. 301
160Canducci Deposition, p. 495
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
163Canducci Deposition, p. 36
164See Annex O and MDL Exhibit 946: Notification of Corporate DP 9, March 2010
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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)
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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
173MDL Exhibit 1768 and Annex N: DNV Transocean 2009 DOC Audit (April 16, 2009)
174Rose Deposition, p. 485
175MDL Exhibit 1471: Interoffice Correspondence - Internal ISM Audit, March 15, 2010
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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).
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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)
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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
186MDL Exhibit 929: Lloyd’s Register Safety Management and Safety Culture/Climate Review (March 16, 2010)
187MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 4.2.1, page 174
188Rose Deposition, p. 257
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192MDL Exhibit 925: Company Management System Manual, 5.5 (pages 138 – 153)
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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
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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)
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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:
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151. Permit to Work: (section 4.2.2): This critical control mechanism, the failure of which is common
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in the industry, is described over 19 pages. It addresses the many situations, in which a PTW is
required but confuses the control mechanisms of the PTW with the details of doing the job, e.g.
entry to confined spaces, which is a safety critical topic in itself. Significantly the PTW process is
managed by the OIM with the Toolpusher as his designee. There is no management input from
the Master.
152. Client and Subcontractor Personnel and Equipment: (section 4.2.3): recognised for many years
as a major contributor to incidents offshore is described over 5 pages. While addressing
personnel and equipment it does not address the key element of bridging documents and
interfaces with TO and others.
153. Dropped Objects: (section 4.2.5): a safety critical consideration on an offshore installation
described over 20 pages. The key precautions are lost in pages of text which establish a
“Dropped Objects Steering Committee” with its own unique identity.
154. Safety Meetings: (sections 2.2 and 4.4.2): a hierarchy of committees and meetings is established
in these sections. They comprise:
Onshore HSE Meetings
• Corporate QHSE Steering Committee – 2 times per year
• Division QHSE Steering Committee – 2 times per year
Installation HSE Meetings
• QHSE Steering Committee Meeting - periodic
• Departmental Meeting - weekly
•
General HSE meeting - periodic
• Daily Operation Meeting - daily
• Pre-Tour Meeting – every 21 days
• Pre-task meeting – as required
The requirements are comprehensive and prescriptive, requiring considerable administration in
paper or electronic format. Follow up on actions is through the FOCUS system. The HSE
department acts in in support of the operational line. Significantly, on the installation the OIM,
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and not the Master, is the focusThe only example of implementation of the procedure194 shows
the meeting in question was well attended, apart from the lack of field personnel which was
actioned, addresses many topics in detail and appears to meet the procedural requirements.
Performance and Operations Policies and Procedures Manual: (MDL Exhibit 1474)
Issue 1, Rev 00, 04.19.2010
155. This document provides the Transocean policies concerning:
• planning an operation
• carrying out an operation
•
associated marine operations• maintaining the asset
It states the Transocean position with regard to the management of risk, which client
requirements may impose upon a Transocean asset, specifically to ensure that:
• “all operation and maintenance activities do not conflict with the Company conformity
Management System Policies and 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
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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
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misquote from the ISM Code, concerning compliance with mandatory rules and regulations.
Other than that, it is a re-print extracts from the ISM and ISPS Codes and DNV documentation.
DWH Operations Manual: (MDL Exhibit 671)
Rev 02, December 2004
160. This is the document required by the MODU Code Chapter 14. Its purpose is to provide
“guidance for the safe operation of the unit for both normal and envisaged emergency
conditions to the satisfaction of the Administration.” It is DEEPWATER HORIZON-specific and is a
Level 3 document. It was Approved by ABS as Rev.1 in 2002 and, following review, was 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
201MDL Exhibit 1449: Health and Safety Policies and Procedures Manual, Section 2.4
202MDL Exhibit 5037: DWH Bridge Procedures Guide
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time containing much the same information. Both these documents are a non-conformity with
the ISM Code.
163. Notwithstanding the foregoing, the document contains valuable information. It could be
construed to be a cross between an update of the Operations Manual and Master Standing
Orders. However, assuming it was issued in 2007, 5 years after DEEPWATER HORIZON came into
operation, it may or may not have represented reflect current practice in 2010.
164. What it does do, is to provide a window on what really happened in the marine department of
the DEEPWATER HORIZON, regardless of the Transocean procedures which existed. It 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
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incident escalating does not appear to have been considered and surprisingly there is no
reference to EDS.
167. Due to the complexity of the CMS, this document was written to provide a simplified reference,
based on actual practice, to personnel new to DEEPWATER HORIZON or minimal experience.
ISM Section 8: Emergency Preparedness
168. The requirement is to identify potential emergency shipboard scenarios, establish procedures to
respond to them ashore and on board and implement drills and exercise program. 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
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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
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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.
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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.”
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181. Nowhere does the document address the responsibilities associated with activating the EDS
system, addressing it simply as “Move Off Location” in 10.4.2.
182. Having two documents in a management system addressing the same topic is bad practice. They
will seldom, if ever, be congruent, creating unnecessary confusion, leading to non-conformity.
This document, as presented and noted previously, is a non-conformity with the ISM Code.
ISM Section 9: Reports and Analysis of Non-Conformities, Accidents and Hazardous
Occurrences
183. The reporting of incidents and their subsequent investigation is addressed in the Health and
Safety Policies and Procedures Manual Section 4.6.3. In common with other procedures, the
wording is long winded and complex and it is not easy to identify the key points of the process
without extensive use or training. While the procedure applies to onshore as well as offshore,
only offshore is commented on here.
184. All “incidents” are required to be reported to the OIM and on to the Rig Manager through the
Global Management System (GMS). The involvement of the Divisional and Corporate HSE
departments appears to be restricted to reviewing reports, ensuring follow is carried out and
identifying lessons learned.
185. It would appear the emphasis is on reporting incidents which have resulted in personal injury.
These are categorized by the industry standard definitions and subject to analysis through a
severity matrix to provide a potential injury severity rating. As with all statistics, it is not difficult
to facilitate the results, particularly with the introduction in 1985 of the Restricted Work Case
(RWC). This category allows considerable flexibility to avoid reporting a Lost Time Incident (LTI)
which is a high visibility KPI in safety management. DEEPWATER HORIZON had just achieved
seven years without a reported LTI.
186. “Near Hits” and “Serious Near Hits” (defined as “hazardous occurrences” in the ISM Code,
otherwise known as “near misses”) are reported verbally and through the Daily Operations
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Report. “Loss of Containment” is reported through the Environmental Procedures, while
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.
207Rose Deposition, p. 368
208Canducci Deposition, p. 52
209bis page 485
210MDL Exhibit 1479: Rose deposition: Operation Event Report
211MDL Exhibit 673 Operations Policies and Procedures Manual, Section 2.3
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These are classed as “mandatory sources of opportunity ” which include SMART plans, PMAA
action plans, follow up from Regulatory Audits, follow up from HSE meetings and action plans
from incident investigations. There are “discretionary sources of opportunity ” such as complex
action plans which are required to be followed up. It is not known whether FOCUS is used for
this purpose.
191. In conclusion, Transocean theoretically has the requirements of the ISM Code in place albeit
complex, and it is not easy to understand the detail. I have not seen any records of
implementation and hence cannot comment on the efficacy of the process. Significantly there is
no formal role for the Master in the process or supporting procedures. This again, is non-
conformity with the ISM Code. It is of concern that there are two parallel systems in place and
that both do not feed into the Divisional and Corporate HSE departments where global lessons
are identified and disseminated.
ISM Section 10: Maintenance of the Ship and Equipment
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Annex H: Extract from DEEPWATER HORIZON MAHRA
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Annex I: Extract from DEEPWATER HORIZON OIC
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Annex J: Document of Compliance (DOC) issued to Transocean Offshore Deepwater Drilling Inc.
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Annex J (continued): DOC reverse side
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Annex K: Safety Management Certificate (SMC) issued to DEEPWATER HORIZON
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Annex L: Transocean Organisation for Safety and Environmental Management
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Annex M: Exhibit 5483: DNV DEEPWATER HORIZON SMC Audit May 2002
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Annex N: Exhibit 1768: DNV Transocean DOC audit April 2009
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Annex O: Exhibit 946: Notification of corporate DP March 9, 2010
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Annex P: Analysis of Transocean Company Management System and the ISM Code
Sections of the ISM Code
1 2 3 4 5 6 7 8 9 10 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
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Annex Q: Transocean Management System relevant to the ISM Code
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Annex R: Transocean Risk Management Processes
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Annex S: Non-Conformity with the ISM Code
The following non-conformities, defined as “an observed situation where objective evidence indicates
non-fulfilment of a specified requirement ” exist with the ISM Code.235 More objective evidence exists in
the appropriate Annex.
Section 1: Meeting the Objectives of the ISM Code
The documentation and information identified in the Health and Safety Policies and Procedures Manual
section 2.4, as that being required to comply with the ISM Code, MDL Exhibit 1449: Health and Safety
Policies and Procedures Manual, does not address the objectives of the ISM Code as defined in sections
1.2.2.2 and 1.2.3.236
Section 4: Training and Competence of Designated Persons
There is no objective evidence that Transocean recognised the IMO document MSC-MEPC.7/Circ.6
“Guidance on the qualifications, training and experience necessary for undertaking the role of Designated
Person under the provision of the ISM Code” as being required to support the safety management system
as required by ISM Code 6.5. Further there is no objective evidence that any of the nominated DPs
received such training.
Section 10.1: Outstanding maintenance routines
There is overwhelming objective evidence from external audits that the RMS II maintenance system
contained errors due the migration of the system from the previous system, EMPAC. Further, records
indicate that REMS II was not being implemented in accordance with instructions in that work orders
were being closed out before they were complete, maintenance history files were incomplete,
procedures for maintaining safety critical software were not implemented and safety critical work
routines were overdue.
235MDL Exhibit 938: ISM Code, Section 1.1.9
236MDL Exhibit 938: ISM Code
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Section 11.1: Out of date and uncontrolled documentation
There is objective evidence from Transocean internal audits 2004 to 2010, Approvals of documents,including safety critical documents such as Emergency Response Team contacts list, being retained
current. Further two DEEPWATER HORIZON level 3 documents are incomplete, do not represent the
current status, exist in an un-approved format and are not approved.
Section 12: Inadequate internal ISM Audits
The ISM Internal Audit process described in the Performance Monitoring Audit and Assessment
Procedures (PMAA) (HQS-CMS-PR-02 issued 12.31.08) does not comply with the requirements of the ISM
Code section 12.1 in that the scope of the annual audit as defined in section 4.3 and contained in the ISM
internal Audit Checklist / Report does not address all safety and pollution prevention activities in TO
ashore or onboard DEEPWATER HORIZON or any MODU to which the DOC applies. Further, objective
evidence of audits carried out shows the process to be ineffective in meeting the intent of the ISM Code.
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Appendix 1: Experience Profile of Captain Andrew Mitchell
Practical experience relevant to the ISM Code
A deck officer with Shell Tankers Limited for 19 years gained in-depth experience of international ship
operations and the handling of oil cargoes of all categories.
The manager within the Shell Exploration Health and Safety (HSE) Department responsible for the
introduction of the elements of safety management, initiating the “you cannot manage what you cannot
measure” philosophy, in the Shell offshore environment.
An Independent consultant employed by oil majors and offshore service companies to develop safety
management systems, to audit compliance, and provide appropriate training courses.
The 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,
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startup and early operation of the installation and later the Production Supervisor and OIM on Auk Alpha
production platform.
The manager in Shell Expro reporting to the Operations Director responsible for the introduction of a safety
management system into the North Sea onshore and offshore operation. This involved daily intervention
with senior management onshore, OIMs, Supervisors and crew offshore.
The manager in the Shell Expro HSE department responsible for the Contractor safety management program,
working with Service companies employed on Shell offshore installations to meet the HSE Standards
established by Shell Expro, and a team member of the major incident investigation group.
An Independent consultant employed by oil majors and offshore Service companies to develop safety
management systems, to audit compliance, to provide training courses, and mentor management teams.
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Oil Companies and Service companies employed by as a consultant
Amerada Hess 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
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Marine Industry positions held
• Chairman of the International Association of Classification Societies (IACS) Working Group
on the ISM Code from 1997 to 2002.
• Chairman of the IACS Working Group on the International Ship and Port Facility Security
Code (ISPS) Working Group from 2002 to 2006.
• Chairman of the International Ship Managers’ Association (ISMA) Audit Committee from
1998 to 2003.
• IACS Representative to the International Maritime Organisation (IMO) on the ISM and ISPS
Codes from 1997 to 2006.
• IACS Representative to the International Labour Organisation (ILO) on the Maritime Labour
Convention 2006.
• UK Representative to the ISO Standards Working Group on Intermodal Security and ISO
28000.
• IACS Representative to the International Council of Chemical Associations Working Group
on the “Responsible Care” initiative.
• Chair and member of many working groups comprising flag Administrations, major shipping
companies and Classification societies on the further development and implementation of
management and audit systems in the marine industry.
• Member of the Nautical Institute IMO Committee.
• Visiting lecturer on safety management at Cranfield University.
• External Examiner, Doctor of Professional Studies, Middlesex University.
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Professional legal experience
2007 m.v. Erika – High Court of Paris
Loss of 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
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Appendix 2: Glossary of Terminology
Administration A signatory to the SOLAS Convention, sometimes referred to as the flag
Administration or the flag State.
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 )
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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
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Appendix 3: The International Safety Management (ISM) Code 2002
Preamble
1 The purpose of this Code is to provide an international standard for the safe management and
operation of ships and for pollution prevention.
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.
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1.1.4 "Safety management system" means a structured and documented system enabling
Company personnel to implement effectively the Company safety and environmental 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
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.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.
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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.
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6.5 The Company should establish and maintain procedures for identifying any training which
may be required in support of the safety management system and ensure that such training is
provided for all personnel concerned.
6.6 The Company should establish procedures by which the ship's personnel receive relevant
information on the safety management system in a working language or languages understood
by them.
6.7 The Company should ensure that the ship's personnel are able to communicate effectively in
the execution of their duties related to the safety management system.
7 DEVELOPMENT OF PLANS FOR SHIPBOARD OPERATIONS
The Company should establish procedures for the preparation of plans and instructions,including checklists as appropriate, for key shipboard operations concerning the safety of the
ship and the prevention of pollution. The various tasks involved should be defined and assigned
to qualified personnel.
8 EMERGENCY PREPAREDNESS
8.1 The Company should establish procedures to identify describe and respond to potential
emergency shipboard situations.
8.2 The Company should establish programs for drills and exercises to prepare for emergency
actions.
8.3 The safety management system should provide for measures ensuring that the Company's
organisation can respond at any time to hazards, accidents and emergency situations involving
its ships.
9 REPORTS AND 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.
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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.
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12.5 The results of the audits and reviews should be brought to the attention of all personnel
having responsibility in the area involved.
12.6 The management personnel responsible for the area involved should take timely corrective
action on deficiencies found.
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Appendix 4: The Applicability of the ISM Code to MODU Operations
1. For SOLAS to apply to a ship, the ship is required to be propelled by mechanical means (see
SOLAS Part A Regulation 3(a)(iii)).
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.
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Appendix 5: UNCLOS Part VII, Section 1, Article 94 paragraph 4(b)
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Appendix 6: Analysis of Industry Norm on “Dual Command Structure”
According to ODS-Petrodata the offshore drilling fleet today is 811 units. This includes all the types shown below.
The companies shown are the top 11 and between them operate more than 50% of marine drilling units.
Accuracy is +/- 5% as different databases give different information
Those operating a single command structure
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.
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Appendix 7: Pride Drilling DP Rigs Organization Chart
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Appendix 8: Maersk Drilling OIM Job Description
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Appendix 9: Consideration Materials
Beg Bates 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
TRN-MDL-02865459 TRN-MDL-02865602 DWH Operations Integrity Case Section 4
TRN-MDL-02865603 TRN-MDL-02865615 DWH Operations Integrity Case Section 5
TRN-MDL-02865616 TRN-MDL-02865637 DWH Operations Integrity Case Section 6
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-BLY00246391 BP-HZN-BLY00246394 Daily Drilling Report No. 02
BP-HZN-BLY00246395 BP-HZN-BLY00246397 Daily Drilling Report No. 03
BP-HZN-BLY00246399 BP-HZN-BLY00246403 Daily Drilling Report No. 04
BP-HZN-BLY00246404 BP-HZN-BLY00246406 Daily Drilling Report No. 05
BP-HZN-BLY00242668 BP-HZN-BLY00242670 Daily Drilling Report No. 06
BP-HZN-BLY00242671 BP-HZN-BLY00242675 Daily Drilling Report No. 07
BP-HZN-BLY00265911 BP-HZN-BLY00265914 Daily Drilling Report No. 08
BP-HZN-BLY00265915 BP-HZN-BLY00265919 Daily Drilling Report No. 09
BP-HZN-BLY00265920 BP-HZN-BLY00265923 Daily Drilling Report No. 10
BP-HZN-BLY00265924 BP-HZN-BLY00265927 Daily Drilling Report No. 11BP-HZN-BLY00265928 BP-HZN-BLY00265931 Daily Drilling Report No. 12
BP-HZN-BLY00251267 BP-HZN-BLY00251271 Daily Drilling Report No. 13
BP-HZN-BLY00251272 BP-HZN-BLY00251276 Daily Drilling Report No. 14
BP-HZN-BLY00251277 BP-HZN-BLY00251280 Daily Drilling Report No. 15
BP-HZN-BLY00251281 BP-HZN-BLY00251285 Daily Drilling Report No. 16
BP-HZN-BLY00251590 BP-HZN-BLY00251593 Daily Drilling Report No. 17
BP-HZN-BLY00251586 BP-HZN-BLY00251589 Daily Drilling Report No. 18
BP-HZN-BLY00251582 BP-HZN-BLY00251585 Daily Drilling Report No. 19
ABSDWH001251 ABSDWH001254 American Bureau of Shipping Certificate of
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Beg Bates End Bates Description
Classification - DWH
BP-HZN-BLY00251577 BP-HZN-BLY00251581 Daily Drilling Report No. 20
BP-HZN-BLY00246606 BP-HZN-BLY00246610 Daily Drilling Report No. 21
BP-HZN-2179MDL00254876 BP-HZN-2179MDL00254880 Daily Drilling Report No. 22
BP-HZN-2179MDL00254824 BP-HZN-2179MDL00254828 Daily Drilling Report No. 23
BP-HZN-2179MDL00254829 BP-HZN-2179MDL00254834 Daily Drilling Report No. 24
BP-HZN-2179MDL00254835 BP-HZN-2179MDL00254840 Daily Drilling Report No. 24
BP-HZN-2179MDL00254841 BP-HZN-2179MDL00254846 Daily Drilling Report No. 25
BP-HZN-2179MDL00254847 BP-HZN-2179MDL00254850 Daily Drilling Report No. 27
BP-HZN-2179MDL00254851 BP-HZN-2179MDL00254855 Daily Drilling Report No. 28
BP-HZN-2179MDL00254861 BP-HZN-2179MDL00254865 Daily Drilling Report No. 29
BP-HZN-2179MDL00254856 BP-HZN-2179MDL00254860 Daily Drilling Report No. 30
BP-HZN-2179MDL00254930 BP-HZN-2179MDL00254934 Daily Drilling Report No. 31BP-HZN-2179MDL00254925 BP-HZN-2179MDL00254929 Daily Drilling Report No. 32
BP-HZN-2179MDL00254885 BP-HZN-2179MDL00254888 Daily Drilling Report No. 33
BP-HZN-2179MDL00254881 BP-HZN-2179MDL00254884 Daily Drilling Report No. 34
BP-HZN-2179MDL00254872 BP-HZN-2179MDL00254875 Daily Drilling Report No. 35
BP-HZN-2179MDL00254866 BP-HZN-2179MDL00254868 Daily Drilling Report No. 36
BP-HZN-2179MDL00254869 BP-HZN-2179MDL00254871 Daily Drilling Report No. 37
BP-HZN-2179MDL00254790 BP-HZN-2179MDL00254793 Daily Drilling Report No. 38
BP-HZN-2179MDL00254794 BP-HZN-2179MDL00254797 Daily Drilling Report No. 39
BP-HZN-2179MDL00254798 BP-HZN-2179MDL00254801 Daily Drilling Report No. 40
BP-HZN-2179MDL00254802 BP-HZN-2179MDL00254805 Daily Drilling Report No. 41
BP-HZN-2179MDL00254806 BP-HZN-2179MDL00254809 Daily Drilling Report No. 42
BP-HZN-2179MDL00254810 BP-HZN-2179MDL00254812 Daily Drilling Report No. 43BP-HZN-2179MDL00254813 BP-HZN-2179MDL00254816 Daily Drilling Report No. 44
BP-HZN-2179MDL00254817 BP-HZN-2179MDL00254820 Daily Drilling Report No. 45
BP-HZN-2179MDL00254821 BP-HZN-2179MDL00254823 Daily Drilling Report No. 46
BP-HZN-2179MDL00254889 BP-HZN-2179MDL00254892 Daily Drilling Report No. 47
BP-HZN-2179MDL00254893 BP-HZN-2179MDL00254896 Daily Drilling Report No. 48
BP-HZN-2179MDL00254897 BP-HZN-2179MDL00254900 Daily Drilling Report No. 49
BP-HZN-2179MDL00254901 BP-HZN-2179MDL00254904 Daily Drilling Report No. 50
BP-HZN-2179MDL00254905 BP-HZN-2179MDL00254985 Daily Drilling Report No. 51
BP-HZN-2179MDL00254909 BP-HZN-2179MDL00254912 Daily Drilling Report No. 52
BP-HZN-2179MDL00254913 BP-HZN-2179MDL00254916 Daily Drilling Report No. 53
BP-HZN-2179MDL00254917 BP-HZN-2179MDL00254920 Daily Drilling Report No. 54
BP-HZN-2179MDL00254921 BP-HZN-2179MDL00254924 Daily Drilling Report No. 55
TRN-MDL-00507922 TRN-MDL-00507922 HS Sect 4-2.1 THINK Planning Process.doc
TRN-MDL-00380823 TRN-MDL-00380826 Morning Report
BP-HZN-BLY00101523 BP-HZN-BLY00101528 Daily Drilling Report No. 01
BP-HZN-2179MDL00060757 BP-HZN-2179MDL00060761 Daily Drilling Report No. 02
BP-HZN-2179MDL00060766 BP-HZN-2179MDL00060770 Daily Drilling Report No. 03
BP-HZN-2179MDL00060774 BP-HZN-2179MDL00060778 Daily Drilling Report No. 04
BP-HZN-2179MDL00060782 BP-HZN-2179MDL00060786 Daily Drilling Report No. 05
BP-HZN-2179MDL00060790 BP-HZN-2179MDL00060794 Daily Drilling Report No. 06
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BP-HZN-2179MDL00060799 BP-HZN-2179MDL00060803 Daily Drilling Report No. 07
BP-HZN-2179MDL00060807 BP-HZN-2179MDL00060811 Daily Drilling Report No. 08
BP-HZN-2179MDL00060815 BP-HZN-2179MDL00060819 Daily Drilling Report No. 09
BP-HZN-2179MDL00060823 BP-HZN-2179MDL00060828 Daily Drilling Report No. 10
BP-HZN-2179MDL00060833 BP-HZN-2179MDL00060836 Daily Drilling Report No. 11
BP-HZN-2179MDL00060840 BP-HZN-2179MDL00060844 Daily Drilling Report No. 12
BP-HZN-2179MDL00060848 BP-HZN-2179MDL00060852 Daily Drilling Report No. 13
BP-HZN-2179MDL00060857 BP-HZN-2179MDL00060860 Daily Drilling Report No. 14
BP-HZN-2179MDL00060864 BP-HZN-2179MDL00060868 Daily Drilling Report No. 15
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
BP-HZN-2179MDL00060872 BP-HZN-2179MDL00060875 Daily Drilling Report No. 16
BP-HZN-2179MDL00060879 BP-HZN-2179MDL00060882 Daily Drilling Report No. 17BP-HZN-2179MDL00060886 BP-HZN-2179MDL00060889 Daily Drilling Report No. 18
BP-HZN-2179MDL00060893 BP-HZN-2179MDL00060897 Daily Drilling Report No. 19
BP-HZN-2179MDL00060901 BP-HZN-2179MDL00060903 Daily Drilling Report No. 20
BP-HZN-2179MDL00060907 BP-HZN-2179MDL00060909 Daily Drilling Report No. 21
BP-HZN-2179MDL00060913 BP-HZN-2179MDL00060915 Daily Drilling Report No. 22
BP-HZN-2179MDL00060919 BP-HZN-2179MDL00060921 Daily Drilling Report No. 23
BP-HZN-2179MDL00060925 BP-HZN-2179MDL00060928 Daily Drilling Report No. 24
BP-HZN-2179MDL00060932 BP-HZN-2179MDL00060934 Daily Drilling Report No. 25
BP-HZN-2179MDL00060938 BP-HZN-2179MDL00060940 Daily Drilling Report No. 26
BP-HZN-2179MDL00060944 BP-HZN-2179MDL00060946 Daily Drilling Report No. 27
BP-HZN-2179MDL00060950 BP-HZN-2179MDL00060952 Daily Drilling Report No. 28
BP-HZN-2179MDL00060956 BP-HZN-2179MDL00060958 Daily Drilling Report No. 29BP-HZN-2179MDL00060762 BP-HZN-2179MDL00060765 Daily Drilling Report No. 30
BP-HZN-2179MDL00060771 BP-HZN-2179MDL00060773 Daily Drilling Report No. 31
BP-HZN-2179MDL00060779 BP-HZN-2179MDL00060781 Daily Drilling Report No. 32
BP-HZN-2179MDL00060787 BP-HZN-2179MDL00060789 Daily Drilling Report No. 33
BP-HZN-2179MDL00060795 BP-HZN-2179MDL00060798 Daily Drilling Report No. 34
BP-HZN-2179MDL00060804 BP-HZN-2179MDL00060806 Daily Drilling Report No. 35
BP-HZN-2179MDL00060812 BP-HZN-2179MDL00060814 Daily Drilling Report No. 36
BP-HZN-2179MDL00060820 BP-HZN-2179MDL00060822 Daily Drilling Report No. 37
BP-HZN-2179MDL00060829 BP-HZN-2179MDL00060832 Daily Drilling Report No. 38
BP-HZN-2179MDL00060837 BP-HZN-2179MDL00060839 Daily Drilling Report No. 39
BP-HZN-2179MDL00060845 BP-HZN-2179MDL00060847 Daily Drilling Report No. 40
BP-HZN-2179MDL00060853 BP-HZN-2179MDL00060856 Daily Drilling Report No. 41
BP-HZN-2179MDL00060861 BP-HZN-2179MDL00060863 Daily Drilling Report No. 42
BP-HZN-2179MDL00060869 BP-HZN-2179MDL00060871 Daily Drilling Report No. 43
BP-HZN-2179MDL00060876 BP-HZN-2179MDL00060878 Daily Drilling Report No. 44
BP-HZN-2179MDL00060883 BP-HZN-2179MDL00060885 Daily Drilling Report No. 45
BP-HZN-2179MDL00060890 BP-HZN-2179MDL00060892 Daily Drilling Report No. 40
BP-HZN-2179MDL00060898 BP-HZN-2179MDL00060900 Daily Drilling Report No. 01
BP-HZN-2179MDL00060904 BP-HZN-2179MDL00060906 Daily Drilling Report No. 02
BP-HZN-2179MDL00060910 BP-HZN-2179MDL00060912 Daily Drilling Report No. 03
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BP-HZN-2179MDL00060916 BP-HZN-2179MDL00060918 Daily Drilling Report No. 04
BP-HZN-2179MDL00060922 BP-HZN-2179MDL00060924 Daily Drilling Report No. 05
BP-HZN-2179MDL00060929 BP-HZN-2179MDL00060931 Daily Drilling Report No. 06
BP-HZN-2179MDL00060935 BP-HZN-2179MDL00060937 Daily Drilling Report No. 07
BP-HZN-2179MDL00060941 BP-HZN-2179MDL00060943 Daily Drilling Report No. 08
BP-HZN-2179MDL00060947 BP-HZN-2179MDL00060949 Daily Drilling Report No. 09
BP-HZN-2179MDL00060953 BP-HZN-2179MDL00060955 Daily Drilling Report No. 10
BP-HZN-2179MDL00060959 BP-HZN-2179MDL00060961 Daily Drilling Report No. 11
BP-HZN-2179MDL00060962 BP-HZN-2179MDL00060964 Daily Drilling Report No. 12
BP-HZN-2179MDL00060965 BP-HZN-2179MDL00060967 Daily Drilling Report No. 13
BP-HZN-2179MDL00060968 BP-HZN-2179MDL00060970 Daily Drilling Report No. 14
BP-HZN-2179MDL00251184 BP-HZN-2179MDL00251187 Daily Drilling Report No. 15
BP-HZN-2179MDL00251188 BP-HZN-2179MDL00251191 Daily Drilling Report No. 16BP-HZN-2179MDL00251192 BP-HZN-2179MDL00251196 Daily Drilling Report No. 17
BP-HZN-2179MDL00251197 BP-HZN-2179MDL00251200 Daily Drilling Report No. 18
BP-HZN-2179MDL00251201 BP-HZN-2179MDL00251204 Daily Drilling Report No. 19
BP-HZN-2179MDL00251205 BP-HZN-2179MDL00251208 Daily Drilling Report No. 20
BP-HZN-2179MDL00251209 BP-HZN-2179MDL00251212 Daily Drilling Report No. 21
BP-HZN-2179MDL00251213 BP-HZN-2179MDL00251217 Daily Drilling Report No. 22
BP-HZN-2179MDL00251218 BP-HZN-2179MDL00251221 Daily Drilling Report No. 23
BP-HZN-2179MDL00251222 BP-HZN-2179MDL00251226 Daily Drilling Report No. 24
BP-HZN-2179MDL00251227 BP-HZN-2179MDL00251230 Daily Drilling Report No. 25
BP-HZN-2179MDL00251231 BP-HZN-2179MDL00251234 Daily Drilling Report No. 26
BP-HZN-2179MDL00251235 BP-HZN-2179MDL00251238 Daily Drilling Report No. 27
BP-HZN-2179MDL00251239 BP-HZN-2179MDL00251242 Daily Drilling Report No. 28BP-HZN-2179MDL00251243 BP-HZN-2179MDL00251246 Daily Drilling Report No. 29
BP-HZN-2179MDL00251247 BP-HZN-2179MDL00251250 Daily Drilling Report No. 30
BP-HZN-2179MDL00251251 BP-HZN-2179MDL00251255 Daily Drilling Report No. 31
BP-HZN-2179MDL00251256 BP-HZN-2179MDL00251259 Daily Drilling Report No. 32
BP-HZN-2179MDL00251260 BP-HZN-2179MDL00251265 Daily Drilling Report No. 33
BP-HZN-2179MDL00251266 BP-HZN-2179MDL00251270 Daily Drilling Report No. 34
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
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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
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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
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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
TRN-MDL-00359569 TRN-MDL-00359570 MDL Dep. Ex. 0946: Email attaching updated
Corporate Designated Persons
TRN-MDL-00351629 TRN-MDL-00351632 MDL Dep. Ex. 0947: Email attaching updated
Declaration of DPA and CSO-ISM/ISPS Rigs
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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"
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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
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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
Policies and Procedures Manual
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
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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
Policies and Procedures Manual
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
MDL Dep. Ex. 1518: Agreed 30(b)(6) Deposition
Notice of Transocean Defendants (With 30(b)(5)
Document Requests)
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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
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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
TRN-HCEC-00116104 TRN-HCEC-00116105 MDL Dep. Ex. 1772: Safety Management
Certificate
TRN-HCEC-00118108 TRN-HCEC-00118109 MDL Dep. Ex. 1773: Safety Management
Certificate
TRN-HCEC-00116109 TRN-HCEC-00116109 MDL Dep. Ex. 1774: Safety Management
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
TRN-HCEC-00116107 TRN-HCEC-00116178 MDL Dep. Ex. 1784: International Ship Security
Shipboard Verification Statement of Compliance
TRN-HCEC-00116173 TRN-HCEC-00116174 MDL Dep. Ex. 1785: ISPS Code Certification
Renewal Ship Security Verification Report
TRN-HCEC-00116175 TRN-HCEC-00116178 MDL Dep. Ex. 1786: International Ship Security
Certificate
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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"
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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
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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
Audit Work List September 2010
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
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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
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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
Audit Work List September 2009
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
MDL Dep. Ex. 3426: Deepwater Horizon - BP CMID
Audit Work List September 2009
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MDL Dep. Ex. 3427: Deepwater Horizon - BP CMID
Audit Work List September 2009
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
MDL Dep. Ex. 3504: Agreed 30(b)(6) Deposition
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
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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
NONE NONE MDL Dep. Ex. 4251: Image of Deepwater Horizon
explosion
NONE NONE MDL Dep. Ex. 4252: Image of Deepwater Horizon
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
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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
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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"
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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
TRN-MDL-01941195 TRN-MDL-01941199 MDL Dep. Ex. 4646: Deepwater Horizon
Emergency Response Manual - Emergency
Disconnect Procedure - General
TRN-MDL-01941200 TRN-MDL-01941200 MDL Dep. Ex. 4647: Deepwater Horizon
Emergency Response Manual - Emergency
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
TRN-MDL-01941212 TRN-MDL-01941213 MDL Dep. Ex. 4649: Deepwater Horizon
Emergency Response Manual - Emergency
Disconnect Procedure - Emergency Disconnect
Activation - Cementing (Hanger Landed in
Wellhead)
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TRN-MDL-01941214 TRN-MDL-01941215 MDL Dep. Ex. 4650: Deepwater Horizon
Emergency Response Manual - EmergencyDisconnect Procedure - Emergency Disconnect
Activation - Cement (Setting Plugs)
TRN-MDL-01941216 TRN-MDL-01941217 MDL Dep. Ex. 4651: Deepwater Horizon
Emergency Response Manual - Emergency
Disconnect Procedure - Emergency Disconnect
Activation - Well Control
TRN-MDL-01941219 TRN-MDL-01941219 MDL Dep. Ex. 4652: Deepwater Horizon
Emergency Response Manual - Emergency
Disconnect Procedure - Emergency Disconnect
Sequence
TRN-MDL-01941220 TRN-MDL-01941224 MDL Dep. Ex. 4653: Deepwater Horizon
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
TRN-MDL-01967636 TRN-MDL-01967639 MDL Dep. Ex. 4683: Deepwater Horizon
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
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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
TRN-MDL-01597604 TRN-MDL-01597626 MDL Dep. Ex. 5037: Deepwater Horizon
Watchstanding and Dynamic Positioning Bridge
Procedures Guide
MDL Dep. Ex. 5038: Transocean DP Vessel Drift-off
and Watch Circle Program Deepwater Horizon
Operating Draft
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
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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
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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
TRN-INV-02806139 TRN-INV-02806139 MDL Dep. Ex. 5420: Email from J. MacDonald to D.
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
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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
TRN-MDL-02070856 TRN-MDL-02070857 MDL Dep. Ex. 5446: Deepwater Horizon
Emergency Response Manual - Emergency
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
TRN-INV-00000720 TRN-INV-00000724 MDL Dep. Ex. 5451: Transocean Interviewing Form
of Nathan Carroll
TRN-INV-00000992 TRN-INV-00000997 MDL Dep. Ex. 5452: Transocean Interviewing Form
of Michael Cutrer
TRN-INV-00001205 TRN-INV-00001210 MDL Dep. Ex. 5453: Transocean Interviewing Form
of Michael Dicello
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TRN-INV-00001246 TRN-INV-00001252 MDL Dep. Ex. 5454: Transocean Interviewing Form
of Mike Dow
TRN-INV-00001748 TRN-INV-00001752 MDL Dep. Ex. 5455: Transocean Interviewing Form
of Daivd Hackney
TRN-INV-00002645 TRN-INV-00002652 MDL Dep. Ex. 5456: Transocean Interviewing Form
of Yancy Keplinger
TRN-INV-00002988 TRN-INV-00002995 MDL Dep. Ex. 5457: Transocean Interviewing Form
of Mike Mayfield
TRN-INV-00003298 TRN-INV-00003305 MDL Dep. Ex. 5458: Transocean Interviewing Form
of Paul Meinhart
TRN-INV-00003543 TRN-INV-00003548 MDL Dep. Ex. 5459: Transocean Interviewing Form
of James Musgrove
TRN-INV-00004126 TRN-INV-00004130 MDL Dep. Ex. 5460: Transocean Interviewing Form
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
TRN-INV-03073902 TRN-INV-03073904 MDL Dep. Ex. 5465: Email from J. MacDonald to D.
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
TRN-MDL-02865451 TRN-MDL-02865458 MDL Dep. Ex. 5473: Deepwater Horizon
Operations Integrity Case, Section 1 (Introduction
and Table of Contents)
TRN-MDL-02865347 TRN-MDL-02865450 MDL Dep. Ex. 5474: Deepwater Horizon
Operations Integrity Case, Section 2 - HSE
Managment
TRN-MDL-02865459 TRN-MDL-02865602 MDL Dep. Ex. 5475: Deepwater HorizonOperations Integrity Case - Risk Management
TRN-MDL-02865603 TRN-MDL-02865637 MDL Dep. Ex. 5476: Deepwater Horizon
Operations Integrity Case Emergency Response
TRN-MDL-02865616 TRN-MDL-02865637 MDL Dep. Ex. 5477: Deepwater Horizon
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
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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
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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
TRN-MDL-01175982 TRN-MDL-01175982 MDL Dep. Ex. 5634: Email from S. Newman to L.
McMahan re: Update
TRN-MDL-02754126 TRN-MDL-02754126 MDL Dep. Ex. 5635: Email from S. Newman to L.
McMahan, et al. re: Operational Concerns re
Shutting in the Well
MDL Dep. Ex. 5642: Transocean: Positioned to
Lead Proxy Statment and 2009 Annual Report
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
TRN-MDL-02764790 TRN-MDL-02764792 MDL Dep. Ex. 5653: Email from S. Newman to L.
McMahan re: weekly OER Executive Review 2009
Week 02
MDL Dep. Ex. 6000: Tony Hayward Speech
Transcription -- Stanford, YouTube,
"Entrepreneurial Spirit Needed"
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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
MDL Dep. Ex. 6008: United States of America v. BP
Exploration (Alaska) Inc.
MDL Dep. Ex. 6009: Interview in article format
titled: Alaskan Oil Pipeline Leak Raises
Environmental Concerns
MDL Dep. Ex. 6010: United States of America v. BP
America Inc.
MDL Dep. Ex. 6011: Lessons from Grangemouth: A
Case History
MDL Dep. Ex. 6012: Investigation Report -
Refinery Explosion and Fire - Key issues: 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
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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
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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
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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
8/3/2019 Mitchell Capt Andrew
http://slidepdf.com/reader/full/mitchell-capt-andrew 150/150
Beg Bates End Bates Description
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