Page 202 - test2

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.

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.

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

The rig crew’s failure to initiate the emergency disconnect system until
after the hydrocarbons were had risen above the BOP stack was a possible
contributing cause of the response failure.

The “inhibited” general alarm system was a possible contributing cause of
the response failure.

Transocean’s failure to train the marine crew to handle serious blowout
events was a possible contributing cause of the response failure.

D. Ignition Source

The most probable ignition source was either engine room number 3 or
engine room number 6.

The catastrophic failure of the mud gas separator created a possible
ignition source with the gas plume released onto the rig from the well.

The location of the air intakes for the number 3 and number 6 engine
rooms was a contributing cause of the Deepwater Horizon explosion.

The failure of the over‐speed devices to initiate shutdown of the engines
was a contributing cause of the Deepwater Horizon explosion.

Fleytas’ failure to instruct the Deepwater Horizon engine room crew to
initiate the emergency shutdown sequence after receiving 20 gas alarms

197