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 The risks posed by identified hazards were not fully understood and
the subsequent control measures were not always appropriate;
 Emerging hazards during task execution, and hazards with a changing
risk level, were not always detected or fully appreciated; and
 “They don’t know what they don’t know.”
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This difference in awareness of hazards clearly demanded attention, as
frontline crews were potentially working with a mindset that they believed they
were fully aware of all the hazards when it is likely that they were not. If a crew
is not aware of risks and hazards, it is less likely to be able to recognize unsafe
situations and will not take immediate actions to mitigate risks.

Taken together, the audits and documentary evidence suggest that the
Deepwater Horizon crew was generally effective and safety‐conscious, but may
not have had the tools, ability or opportunity to identify and mitigate hazards
associated with rig operations.

2. Transocean 21‐day Hitch Policy

In September 2009, Transocean revised its offshore employee hitch
schedule from 14 to 21 days. The revision to the work schedules was partially
due to a transportation schedule that would allow for fewer flights to and from
the facilities. Seven of the 11 individuals who died onboard the Deepwater
Horizon had been onboard for more than 19 days. The Panel, however, found no
evidence that the Transocean hitch schedule affected rig personnel’s ability to
perform their duties. See Appendix N.

3. Transocean Incentive Awards

Transocean had multiple bonus incentives, dependent upon level of
employment (rig, division, rig managers). Variables of the bonus equations
were: safety performance; individual performance; cash flow value added; in‐
service daily cost; rig downtime; lost revenue; and overhead cost.

Rig employees’ bonus incentives were based on 60% cost‐related items,
20% safety performance and 20% individual performance. Division employees’
bonus incentives were weighed in the same way: 60% cost related items, 20%
safety performance and 20% individual performance. Rig managers’ bonus

467 TRN‐HCEC 90501.

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