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likely consequences of a potential incident. The THINK program attempts to
457
reduce risks through preventative and mitigating actions. According to
Transocean documents, “[t]he THINK process reminds personnel to think about
everything they do before actually doing it.”. . . ”THINK is used by the company
to formulate and communicate the plan.”. . .“The THINK Planning Process is
utilized for Risk Management of all activities and tasks carried out throughout
458
the company.”

Transocean’s “START” program was a related process that is defined as
“See, Think, Act, Reinforce, and Track.” Transocean stated that the START
process “monitor[ed] the operation and reinforce[ed] safe behavior, while
correcting any unsafe acts or conditions, [and] is vital to ensure that the
necessary controls remain in place during implementation. . . . START is used by
the company to monitor the plan and recognize when the plan is no longer
suitable.”
459

“CAKES” was Transocean’s program for task planning. The acronym
incorporates different rules using the words comply, authority, knowledge,
460
experience, and skills. Transocean’s “FOCUS” approach seeks to make
461
consistent the execution of THINK and START across the organization. TOFS
(time out for safety) was Transocean’s stated policy that allowed tasks to be
462
stopped (planned or unplanned) to ensure safe operations.

None of these policies eliminated concerns about some members of the
Transocean crew. The Panel found evidence that Paul Johnston, Transocean rig
manager, questioned whether the Transocean members of the Deepwater Horizon
crew were adequately prepared to independently recognize hazards. In a March
2010 email to Guide, Johnson offered a candid assessment of the rig crew and
their abilities:

John, I thought about this a lot yesterday and asked for input from the rig
and none of us could come up with anything we are not already doing or
have done in the past with little success. There was a common theme
from all though. Nothing takes the place of supervisor involvement to ask

457 See Submission of Transocean to the JIT (May 13, 2011), at 2.
458 BP‐HZN‐MBI00001764.
459 BP‐HZN‐MBI00001626.
460 BP‐HZN‐MBI00001769.
461 BP‐HZN‐MBI00001627.
462 BP‐HZN‐MBI00001770.

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