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L. BOP System Leaks..................................................................................... 151
M. ROV Interventions .................................................................................... 153
XIII. BOP Stack Conclusions ................................................................................ 155
A. Cause of the BOP Stack Failure................................................................. 155
B. BOP Stack Failure Contributing Causes .................................................. 155
C. BOP Stack Failure Possible Contributing Causes..................................... 155
XIV. Regulatory Findings ..................................................................................... 157
A. Permitting Process..................................................................................... 158

B. Well Activity Reports................................................................................ 161
C. Macondo Departures and Alternative Procedures.................................... 161
D. MMS Drilling Inspections ........................................................................ 162
E. Potential Incident of Noncompliance Guidelines ...................................... 162
F. Inspection Forms........................................................................................ 164
G. MMS Deepwater Horizon Inspections at MC 252 ................................... 164
H. Safe Drilling Margin................................................................................. 165
I. Well Control............................................................................................... 165
J. Subsea BOP Regulatory Requirements..................................................... 167
K. Regulatory Improvements ......................................................................... 172
L. Incidents of Non‐Compliance .................................................................... 173
XV. Policies and Practices of Involved Companies ......................................... 175
A. BP’s Policies and Practices........................................................................ 175
B. Transocean’s Practices and Procedures..................................................... 185
C. BP and Transocean Bridging Document................................................... 189
D. Stop Work Authority................................................................................. 189
XVI. Conclusions Regarding Involved Companies’ Practices......................... 191
XVII. Summary of Panel Conclusions.................................................................. 194
A. Well Design and Cementing...................................................................... 194
B. Flow Path................................................................................................... 195
C. Temporary Abandonment, Kick Detection, and Emergency Response..... 195
D. Ignition Source .......................................................................................... 197
E. Blowout Preventer ..................................................................................... 198
F. Company Practices .................................................................................... 199
XVIII. Conclusion ..................................................................................................... 200
XIX. Recommendations......................................................................................... 202
A. Well Recommendations.............................................................................. 202
B. Kick Detection and Response Recommendations ...................................... 203
C. Ignition Source Recommendations............................................................ 205
D. Blowout Preventer Recommendations....................................................... 206
E. Regulatory Agency Recommendations...................................................... 207
F. OCS Companies’ Practices Recommendations.......................................... 209

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