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to the mud gas separator. Transocean’s well control manual did not clearly state
to go to the diverter if the flow event is unknown. The ambiguity within the
Transocean well control manual on when to use the diverter and not the mud
gas separator was a contributing cause of the response failure.

At approximately 9:48 p.m., several of the gas alarms sounded. Within
minutes, approximately 20 gas alarms were sounding, the result of extremely
high levels of gas concentration. Yancy Keplinger, the senior dynamic
positioning officer, went to the video monitor and saw large amounts of mud
being ejected. Shortly afterwards, Andrea Fleytas, the dynamic positioning
officer, got a call from the rig floor, which informed her that there was a “well
control problem.” Fleytas told the Panel she received a phone call from the
engine room, but she never told the engine room personnel to perform an
emergency shutdown. The initial explosion occurred approximately 30 seconds
to a minute after the first gas alarm. At approximately 10:00 p.m., the general
alarm and fire alarm on the Deepwater Horizon sounded and the rig began to list
to one side. Only then did Keplinger make an announcement to muster and
prepare to evacuate. Personnel were not told to evacuate until approximately
twelve minutes after the first gas alarm went off. The failure of the personnel
on the Deepwater Horizon bridge monitoring the gas alarms to notify the
Deepwater Horizon crew in the engine control room about the alarms so that
they could take actions to shut down the engines was a contributing cause of
the response failure.

E. Response Failure Possible Contributing Causes

The crew was unaware of the volume of the hydrocarbon influx associated
with the blowout. The rig floor crew’s inability to determine the location of
the kick in relation to the BOP stack and the volume of hydrocarbons coming
to the rig in a matter of seconds was a possible contributing cause of the
response failure.

The Panel found no evidence that Jason Anderson, Transocean driller,
who was identified in the Transocean procedures as the individual who should
initiate the emergency disconnect system, attempted to do so once the
hydrocarbons were past the stack. There is evidence that the rig crew activated
the upper annular and upper variable bore ram when the hydrocarbons were
past the stack. There is also evidence that Chris Pleasant, Transocean subsea
engineer, attempted to activate the emergency disconnect system some time after
the explosions had disabled communications with the BOP stack. The rig crew’s

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