The findings cover five aspects of the disaster – including the explosions on the unit; the resulting fire; evacuations; the flooding and sinking of the unit; and the safety systems of the MODU and its owner, Transocean. The findings, released Friday, do not include an analysis of what led to the loss of well control or other aspects of the investigation that fall under BOEMRE jurisdiction.
Although the events leading to the sinking of DEEPWATER HORIZON were set into motion by the failure to prevent a well blowout, the findings say that the investigation revealed numerous systems deficiencies, and acts and omissions by Transocean and its DEEPWATER HORIZON crew, that had an adverse impact on the ability to prevent or limit the magnitude of the disaster. These included poor maintenance of electrical equipment that may have ignited the explosion, bypassing of gas alarms and automatic shutdown systems that could prevent an explosion, and lack of training of personnel on when and how to shutdown engines and disconnect the MODU from the well to avoid a gas explosion and mitigate the damage from an explosion and fire. These deficiencies indicate that Transocean's failure to have an effective safety management system and instill a culture that emphasizes and ensures safety contributed to this disaster.
This investigation also revealed that the oversight and regulation of DEEPWATER HORIZON by its flag state, the Republic of the Marshall Islands (RMI), was ineffective in preventing this casualty. By delegating all of its inspection activities to "recognized organizations," without itself conducting on board oversight surveys, the RMI effectively abdicated its vessel inspection responsibilities. In turn, this failure illustrates the need to strengthen the system of U.S. Coast Guard oversight of foreign-flagged MODUs, which as currently constructed is too limited to effectively ensure the safety of such vessel
Download the report here
April 25, 2011