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sought to ensure that the engine would not over‐speed after ingesting
                   combustible gases.   300

                          The design of engine shutdown mechanisms on dynamically‐positioned
                   rigs, such as the Deepwater Horizon, is different from the shutdown systems in
                                            301
                   moored or jack‐up rigs.   Instead of the single top‐level shutdown of all engines,
                   a dynamically‐positioned rig is typically designed to allow the rig to activate an
                   emergency disconnect system to separate from the wellhead and allow the rig to
                   escape the hazardous area in the event of an uncontrolled blowout or other
                   emergency.  This design also allows for continued use of the engines in an
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                   emergency such as a fire.   Manual activation of the emergency disconnect
                   system, required on a dynamically‐positioned rig, can add complexity to a rig
                   crew’s response to a well control event and can also create a possible ignition
                   source during the presence of free gas on the rig.

                                   2.    Testing of the Over‐Speed Devices


                          A representative of Wartsila, the manufacturer of the Deepwater Horizon
                   engines, told the Panel that all automatic stop devices should be function tested
                   at least once every 1,000 hours of engine operation and that the over‐speed trip
                   devices be checked every 2,000 hours.   He also stated that the Deepwater
                                                           303
                   Horizon engines were not configured to run on natural gas and that if they
                   ingested natural gas they would mechanically fail (but not explode).
                                                                                           304

                          The Panel found no evidence establishing whether, and how often, the
                   engine over‐speed devices and individual engine components were tested by the
                   American Bureau of Shipping (“ABS”).  ABS conducted yearly inspections of the
                   over‐speed devices during their continuous machinery surveys.  These yearly
                   inspections included an evaluation of approximately 20% of the over‐speed
                   devices on the rig, with the goal of inspecting all devices within a 5‐year period.

                   300  KMI_PI001156 RBS8D.  The driller was responsible for shutting in the engine air intake on the
                   Deepwater Horizon.  The driller’s other responsibilities included: drilling the well and knowing the
                   drilling operations; monitoring real time data of the well; insuring the safety of rig floor
                   personnel working in a confined space; investigating well flow issues and responding to well
                   control events; communicating with the Subsea Engineer; and activating the EDS if necessary.
                   301  A moored rig is held in place by cables attached to giant anchors; a jackup rig is towed onto
                   location and is supported by mechanical legs lowered to the seafloor.
                   302  KMI_PI001156 RBS8D.
                   303  BOEMRE interview of Bob Miller (Wartsila) (November 16, 2010).  An “overspeed trip device”
                   is a safety device that is designed to restrict the uncontrolled acceleration of the engine.
                   304  Id.


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