USCG Deepwater Horizon Investigation Report REVIEW

Since last Friday’s release of the USCG report into the Deepwater Horizon disaster, gCaptain staff has been looking over the report to see what the Coast Guard had to say.  There were many different “findings” based on speculation, or what “might have happened”, but few real solid conclusions.

We would like to highlight a few of these statements and call it as we see it.

The following are excerpts from the report, gCaptain commentary is in bold:

“Although the events leading to the sinking of DEEPWATER HORIZON were set into motion by the failure to prevent a well blowout, 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,” [no specific equipment mentioned in this report except for “dirty shale shaker motor starters” – which, like everything else in the shaker room, is generally covered in dirt and mud half the time]

“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.”  [The bypassing of alarms issue is discussed later in this commentary.  Considering the crew was unable to disconnect from the well, shutting down the engines via ESD may not have seemed a logical option considering further damage to the riser and wellhead connection as well as shutdown of some emergency systems, including the fire pump, would likely have resulted]

“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 report does not indicate anything about Transocean’s corporate culture.  The report fails to mention any details about the START program (a proactive safety management program recognized by the entire industry), or the THINK process (a risk and process management program used by every employee on every job they do).  It also doesn’t mention the two week Health and Safety (TOPS) course each employee is required to participate in before going offshore.]

“Failure to Use the Diverter Line: When the drilling crew directed the uncontrolled well flow through the MGS, the high pressure exceeded the system’s capabilities and caused gas to discharge on the Main Deck.  Alternatively, the crew could have directed the well flow through a “diverter line” designed to send the flow over the side of the MODU.  Although the diverter line also may have failed under the pressure, had it been used to direct the flow overboard, the majority of the flammable gas cloud may have formed away from the Drill Floor and the MODU, reducing the risk of an onboard explosion.”

This was an “environmental” call. No one wants to send oil into the water and the rig crew, apparently, didn’t think the blowout was as bad as it was. Either that or, because the AD was new, he didn’t know how to line it up properly. But we’ll never know the answer to this.

“Bypassed Systems: A number of gas detectors were bypassed or inoperable at the time of the explosions.  According to the chief electronics technician, it was standard practice to set certain gas detectors in “inhibited” mode, such that gas detection would be reported to the control panel but no alarm would sound, to prevent false alarms from awakening sleeping crew members.”

These gas detectors are not inhibited from working as designed, they will just not set off the general alarm if triggered.  Places like the welding shop where smoke exists, or even staterooms where steam from the shower might be mistaken by the sensor as smoke are “inhibited”.  The bridge still sees the alarm on their control panel, it just doesn’t trigger the general alarm. See https://gcaptain.com/critical-alarms-are-they-being-monitored-inhibited-or-both?16487

“Key Investigative Findings: The DEEPWATER HORIZON crew did not follow its own emergency procedures for  notifying the crew of an emergency and taking steps to prepare for evacuation.  For example, contrary to standard procedure, the crew failed to sound the general alarm after two gas detectors activated.  This failure may be attributable to the presence of the BP and Transocean executives onboard, which had also prevented key personnel from attending to the well control issues immediately prior to the blowout.  A senior drilling crew member acknowledged that if he and the master had not been conducting a tour for the company executives, he would have been on the Drill Floor while key tests were being conducted.”

This is not a “finding”, this is someone’s opinion.  Also, the executives had nothing to do with the crew “attending to the well control issues immediately prior to the blowout”.   One of the executives noticed that the drill crew was working on something that didn’t look right, offered his assistance, but in the end, the drill crew member told this executive he was confident he could take care of things.

“Although DEEPWATER HORIZON conducted a number of emergency drills, it never conducted drills on how to respond to a well blowout that leads to the need to abandon ship.”

They also never trained for a subsea collision with a submarine that leads to a triage causality and space men dropping from the moon.  So what. There are only so many contingencies one can plan for. That being said, it is BS that the rig floor and “Companymen” were regularly excused from drills.  But then again, that had little to do with this incident as no fire was ever fought.

“Transocean never developed a salvage plan for DEEPWATER HORIZON.  The only document it generated, an introductory guidance document, did not designate a specific person on scene to direct response vessels and did not warn of the possible impact of downflooding on the stability and buoyancy of the MODU.”

Valid statement. Although the USCG took over OSC at 2310 on the night of the disaster, the USCG is only responsible for rescue, unlike the Navy, they have no trained firefighters and are not set up (or tasked with) any salvage ops except extracting people…. certainly not blow-out fires. The USCG representative as OSC should have made this clear and directed Transocean to develop a salvage plan.

“Poor Maintenance Record: Two recent audits of DEEPWATER HORIZON found numerous maintenance deficiencies that could impact safety, including problems with firefighting, electrical, and watertight integrity systems.  In particular, the audits found that, contrary to the manufacturer’s guidelines which called for inspection and certification of the blowout preventer (BOP) every three to five years, Transocean did not arrange to have the DEEPWATER HORIZON BOP recertified for over ten years.

In addition, key BOP parts had “significantly surpassed the recommended recertification period” and needed to be replaced.”

API RP 53 governs this “requirement”, however RP stands for “recommended practice” not “required practice” and it references back to the BOP owners manual, which doesn’t specifically indicate a required maintenance schedule to remain in compliance.

“History of Safety Incidents: In 2008, DEEPWATER HORIZON had two significant incidents which could have seriously affected the safety of the vessel or the environment – a loss of power that jeopardized the MODU’s ability to maintain its position above the well and the flooding of a compartment resulting from a failure to close valves.  Neither of these incidents was properly investigated and addressed.”

Internal investigation reports and after action reviews were carried out in both cases and sent out to the Fleet to capture lessons learned.  Since then, Transocean has adopted the Kelvin TOPSET investigation process, an highly effective and industry accepted practice for accident investigation and root cause analysis.

“Emergency Preparedness: Transocean failed to require that systems and personnel emphasize maximum emergency preparedness.   As discussed above, Transocean allowed the DEEPWATER HORIZON crew to inhibit or bypass gas alarms and automatic shutdown systems, and it did not require robust emergency drills.”

gCaptain agrees with the fact that Transocean emergency drills could likely have been significantly more robust in nature, but they did drill every Sunday and performed these drills as required.  Recommendations may include working with the USCG and the US Navy to come up with a new damage control training program and new system of evaluating the effectiveness of weekly drills.  The gas alarm is a totally separate issue, and should not be included in this finding.  Again, see https://gcaptain.com/critical-alarms-are-they-being-monitored-inhibited-or-both?16487

“The JIT recommends that the Commandant:

Require and coordinate expanded ISM Code examinations of all Transocean vessels that are subject to the ISM Code and that engage in oil and gas drilling activities on the U.S. OCS;  Work with the RMI to require an immediate annual verification of the safety management system of the main and North American offices of Transocean;”

What about all the other drilling companies operating in the GoM?  Are they going to be examined too?  Transocean sure isn’t perfect, but they are better than many out there. Why does this report ignore the other operators which run their rigs and crews into the ground?

“The DEEPWATER HORIZON crew bypassed an automatic shutdown system designed to prevent flammable gas from reaching ignition sources.

Another such location was the Drill Shack, which housed the blowout preventer (BOP) control panel.  The chief electrician testified that if the access door to the Drill Shack was held open for an extended period of time the work station would “lose purge.”  Because the BOP control panel was kept separate under a positive pressure, if the BOP control panel doors were opened causing it to “lose purge,” it would automatically shut down electrical power, requiring the panel to be cleared and restarted.  As a result, the crew had set the positive pressure feature of the BOP control panel in a continuously bypassed condition to avoid unnecessary shutdown of the system.  The chief electrician had been told by a crew member that it had “been in bypass for five years” and that “the entire fleet runs them in bypass.”97  With the positive pressure feature bypassed, any flammable gases that entered the BOP control panel could be exposed to unguarded ignition sources without an automatic power shutdown.”

Commentary from a former Transocean Subsea Engineer:

“Most BOP control panels built for the Driller’s cabins are equipped with purge systems due to the location of the panel being so close to well center. The bypass mode disables the automatic shut down function and is used mainly for maintenance. On the newer rigs the entire Drill shack is purged so that individual components do not have to be purged. I’ve never been on the Horizon, but I would suspect that the Drillers cabin was purged. If so, then the BOP control panel would not require a purge system and could be kept in the bypass mode. The comment from the Chief Electrician about the entire fleet running the purge systems in bypass is not correct. I know this for a fact because I have always kept mine in auto, even with a purged Drill shack. As a matter of fact, Transocean has a corporate PM to test the functionality of the purge system in the BOP control panel every so often. Also this is something that the MMS used to check during their monthly inspections, whether or not the purge controller is in auto or bypass.”

gCaptain Commentary:

Even if the BOP control panel was in bypass, there were certainly other ignition sources within the drill shack such as computers and TV screens, but they were all protected via the purge system.  The point this Electronics Technician is trying to make is moot.

It is recommended that Marine Safety Unit Morgan City coordinate with the Republic of the Marshall Islands (RMI) to consider, based on this report, whether and to what extent action should be taken against (the) Captain(‘s) mariner license.

gCaptain has been told by RMI, on the record, that they are considering no action against Captain Kuchta’s license. Were mistakes made by him and the OIM? Yes, but it is much easier to analyze these events from a court room than to live them and one fact remains clear… they successfully led the safe evacuation of 115 persons that night.

The Coast Guard’s current guidance for inspectors performing MODU Certificate of Compliance examinations and the casework process contained in the Coast Guard Marine Information for Safety and Law Enforcement database system do not provide inspectors with a sufficient level of detail for documenting and entering examination activities. Only the main categories of inspected systems are provided. As a result, it is impossible to understand which specific systems were satisfactorily examined by the Coast Guard.

This does not mention a primary cause of oversight failures: the historic lack of cooperation between USCG and MMS investigators nor does it recommend the strengthening of bond between the two organizations in the future. This is a major oversight in our opinion.

There is no evidence that any consideration was given prior to abandonment of the MODU to trying to determine the condition or location of crew members who may have been injured or trapped, except for the chief mate’s independent attempt to organize the rescue of the starboard crane operator, only to be driven back by subsequent explosions. It was not until the safety of DAMON B. BANKSTON was reached that a full accounting of the crew was undertaken by those in charge.

In our interviews with survivors we heard repeatedly that the bridge team, OSMIC, and Engine Room team’s concern for, and attempt, to locate the missing people. A full muster was organized and conducted at the lifeboats but failed to accurately account for the missing once panicked crew members started jumping overboard. There are systems that might have faired better (T-Card, electronic mustering, etc) but none of these where mentioned by the CG report and it was only due to the clear thinking and organization of the radio operator that a muster was taken on the Bankston.

The STCW does not adequately establish standards and competencies for officers-in-charge of emergency procedures to operate lifesaving appliances that serve liferafts.

Our interviews with survivors showed that the “officers” had intimate knowledge of the liferafts and lifesaving appliances. But who the “officers where is also not clear. The officer on watch did not hold an unlimited license and there is no mention of the difference between an Unlimited Chief Engineer and a MODU Chief Engineer (the Horizon had the later).

The inflatable liferafts on DEEPWATER HORIZON served by launching appliances did not provide adequate protection for occupants under the circumstances. The exposure to extreme heat due to the proximity of the fire to the launching area, combined with the lack of a water spray system, placed them at greater risk during the evacuation.

The report fails to discuss the fact that having a davit launched liferaft made it possible to load a stretcher and saved, at least, one life. It also does not suggest other evacuation systems that might have been useful like inflatable slides nor does it suggest heat testing of inflatable devices or shielding as the raft passes below main deck on it’s way to the waterline.

Masters, officers, particular ratings and special personnel assigned to MODUs are not required to receive specialized training for crowd control, crisis management or human behavior. Such training could have helped minimize the chaos and confusion surrounding the muster and evacuation of DEEPWATER HORIZON.

Transocean has led the industry in providing Major Emergency Management classes to it’s employees. These classes are highly effective but they were not reviewed by the CG Investigators nor was any recommendation to require emergency management training industry-wide. This is a major oversight of the report.

The quantity and location of rescue boats provided on MODUs should align with the “widely separated location” philosophy adopted for lifeboats. The location of a secondary rescue boat at the alternate lifeboat location would increase the availability of a rescue boat

We would have worded this “All MODU’s must have, at least, one properly shielded fast rescue boat near the accommodations.”

The overall fire-fighting effort lacked central coordination. As a result, large volumes of water were directed toward the MODU without careful consideration of the potential effects of water entering the hull. Although improved coordination likely would not have suppressed the fire, an unknown portion of the fire-fighting water (that which did not drain overboard or vaporize) contributed to the reduction of stability and freeboard of DEEPWATER HORIZON.

No mention is made of the fact that the water directed toward the hull served another purpose: to shield the ROV boats attempting to shut in the BOP. There is also no recommendation for developing better emergency coordination centers & procedures among drilling contractors.

The crew onboard DEEPWATER HORIZON and Transocean employees failed to identify the potential consequences of their decisions regarding deferred maintenance and the loss of situational awareness regarding the overall safety of the MODU.

Everyone who has worked aboard ships knows full well that the crew is usually fully aware of the safety deficiencies on their own rigs and our interviews highlight the fact that Deepwater Horizon crew members knew the problems the rig faced. Many of these problems were to be fixed at the upcoming shipyard interval and, yes, some where ignored by management.  To blame the crew for the deficiencies is simply not accurate.

The international standards and Coast Guard regulations for dynamic positioned vessels do not properly address the current design, operation and manning found aboard these vessels.

The Coast Guard has essentially ignored Dynamic Positioning since its inception. Stating that the current regs don’t “properly address” DP is an understatement… the regulations don’t exist.

It is recommended that Commandant work with the IMO to develop a symbol for “knife” and require the placement of a label to identify its location in all lifesaving appliances requiring the tool.

Considering crews are not generally allowed to carry knives, is another sign really the best solution to this problem?

The Coast Guard’s current guidance for inspectors performing MODU Certificate of Compliance examinations and the casework process contained in the Coast Guard Marine Information for Safety and Law Enforcement database system do not provide inspectors with a sufficient level of detail for documenting and entering examination activities.

Certainly a valid point but there is no mention of coordinating the computer systems of class, flag and coastal states nor is there mention of creating a single database that the USCG and MMS can share.

The A-class fire barriers surrounding the Drill Floor were not effective in preventing the spread of the fire. A-class bulkheads are not tested for exposure to hydrocarbon fire sources.

This is also a valid point but there is no mention as to what should be done aboard the hundreds of existing rigs currently using A60 doors. What specific action are they suggesting?

A fixed deluge system for the protection of these areas would not place the fire brigade members in jeopardy and could be rapidly activated upon gas detection to mitigate the effects of a possible explosion.

Fixed deluge systems are certainly important but the design, reserve capacity and location of deluge systems are also of primary concern as the “fire brigade” is not the only ones needing protection. Also, why did they not consider regulations for the location of emergency gear lockers and how they are protected in general?

The proximity and operational capabilities of the offshore supply vessel DAMON B. BANKSTON were critical to the successful evacuation of the one hundred-fifteen survivors of this casualty.

The Coast Guard certainly got this one right but, again, what are they suggesting? What capabilities did the Damon Bankston have that other boats should be required to install, what other lessons where learned from the Bankston’s service that night?

Unfortunately this report is not as well developed as we had hoped, maybe the Marshall Islands report – expected to be released in about 4 weeks – will be more thoroughly thought out. We were also hoping to write a list of the important items the Coast Guard missed however, it appears that would require several more pages of analysis.  One last thought, why was BP not mentioned in this report?

And, for what it’s worth, Transocean’s (NYSE:RIG) stock has dropped over 5% since Monday due to the USCG’s report…  I don’t know about you, but we’re feeling bullish.

(This report was written by Rob Almeida and John Konrad with the confidential assistance of USCG, RMI and Transocean employees)

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