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A. Installing the Lock‐Down Sleeve................................................................. 85
B. Setting the Cement Plug.............................................................................. 86
C. The Use of Lost Circulation Material as Spacer.......................................... 87
D. Well Integrity Testing ................................................................................. 88
VIII. Kick Detection and Rig Response................................................................. 98
A. Kick Detection Methods and Responsibilities.............................................. 98
B. Multiple Simultaneous Operations That Hampered the Crew’s Ability to
Detect Kicks ................................................................................................. 99

C. Rig Floor Response .................................................................................... 103
D. The Use of the Mud Gas Separator............................................................ 104
E. Activity on the Bridge................................................................................ 106
F. Emergency Disconnect System.................................................................. 107
IX. Conclusions on Temporary Abandonment, Kick Detection, and the
Emergency Response................................................................................... 109
A. Kick Detection and Response Failure Cause ............................................. 109
B. Kick Detection Failure Contributing Causes ............................................ 109
C. Kick Detection Failure Possible Contributing Causes .............................. 110
D. Response Failure Contributing Causes ..................................................... 112
E. Response Failure Possible Contributing Causes ....................................... 113
X. Ignition Source(s) and Explosions.............................................................. 115
A. Main Engines and Engine Switch Gear Rooms........................................ 115
B. Mud Gas Separator.................................................................................... 119
C. Other Possible Ignition Sources ................................................................ 122
XI. Conclusions on Ignition Source and Explosion........................................ 125
A. Ignition Sources......................................................................................... 125
B. Contributing Causes of the Explosion....................................................... 125
C. Possible Contributing Causes of the Explosion......................................... 126
D. Other Possible Ignition Sources ................................................................ 127
XII. The Deepwater Horizon BOP Stack............................................................... 129
A. Design and Configuration......................................................................... 129
B. Control and Power Systems....................................................................... 132
C. Emergency Disconnect System.................................................................. 133
D. Automatic Mode Function (“Deadman”) ................................................. 134
E. Autoshear Function................................................................................... 134
F. Forensic Examination of the BOP ............................................................. 135
G. Examination Methods Used by DNV........................................................ 137
H. DNV’s Forensic Examination Findings.................................................... 138
I. Evaluation of Other Possible Failures ....................................................... 142
J. Studies Evaluating the Reliability of BOPs .............................................. 144
K. Maintenance of the Deepwater Horizon BOP........................................... 146

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