HORIZON DEEPWATER

Internollncident Investigolion Tronsoceon

llem Invesfigcrlion Iickel ReferenceNo. DocumenlConflol

Draft for review and comment

EquipmenlAlerl Review 0000

j Bob Walsh

ofchangeprocess I Inclusionof management 02 i Review and clarification of summary i Bill Ambrose

OF QUISTPN/EVENT INTEREST per TO requiremenls on BOP

Hove oll monufocluring equipment olerls been opplied/completed conlrols?

OF Scopc AND METHOD INVESTIGATION 2.1.1 Scope

Aspecls Covered rvebsites. from Cameron Transocean and equipment alertsfor Cameron Downloaded Equipment all Subsea alerts.Contacted Reviewedall EmpacWO's and RMS jobs to detenninethe statusof all equipment managemenl system. supportfor possibleupdateof alerts that were not coveredin the maintenance

Aspecfs Nof-Covered

2.2

Mef hod ol lnvesfigolion data frotn Daily activiS report. as well as supplemental Revie,rved existing recordsfrom RMS, Ernpac,Sub-Sea lvith ernailsandphoneconversations TechnicalField Support.

2.3

Relerence Documenls

(markI pod Upgrade) Cameron-X-9VBat sHocK FLoWMETERS) cts-01-c01(H|GH

(PBOF Connector/Cable DesignFeatures) CIS-01-C02

(Premium Control Systems) Valves Drilling for CIS-01-C03

cis-01-c04(Pilot Operated Check Valve, 1 %" Upgrade) (Solenoid Valve (3lZWay) Valve Upgrade) CIS-01-C05RevA01

CONFIDENTIAL WORK IN PROGRESS

5 roG
Exhibit No.

CONFIDENTIAL

WorldwideCourt
Inc.

TRN-tNV-03353731

DEEPWATER HORIZON
Tronsoceon InlernolIncidenl Investigolion

(Solenoid cis-01-c06 Valve(3/2Way) CabteUpgrade) (EventLogger: CIS-01-C07 Features Upgrades) & (standard cls-O1-c08 shuttle Valve cameron in controlsystems Marklll) (Drilling CIS-01-C09 Control System Troubteshooting Guide) CIS-01-C10 (Unbalanced Shuttle Valvein Cameron Controlsystems) CIS-01-C11 (Pressure Biased Shutile Valve ROVFunctions) for cls-01-c12(HighDragshuttle Vatve cameron in controt systems Markilt Upgrade) cfs-04-001 (18-314 Annular stripperPackerfor cameron18-314" 10,000psi Annular BOP) packing) (Cameron Annular CIS-04-002 D/Dl Blowout Preventer packingElement) (18-3/4"-5000 LowTemperature CI5-04-003 psi Annutar CI5-96-002 (Proper Storage Cameron of Elastomer Products)
E8 831M (STROKELtMtT- MODEL 70 & HC COLLETCONNECTORS)

EB 015W (onwellhead year equipment (1981)) EB 046D (F|ELD REPLACEMENT ,SS- BOp BONNET OF BOLTS) EB 096W (on 1/4checkvalves)

(Standard i EB 10717 TestStump) (H-4 CamRingandDogs) i f e TOZSS Connector

EB 1A734(H-4 AX /X Gasket RetainerScrews) TNSTRUCTTONS i EB 119 D (PLASTICPACKTNG. FOR'F' PREVENTERGLANDS)

EB 124D (F' BLOWOUT PREVENTER SH@TREMOVAL TOOLS) EB'126 (Storage agingof rubber goods) W and
EB 136 D (OPERATORHOOti-UpFOR'F',PREVENTER)

j EB 160D ( SKEWED FACEVERSUS FLATFACERAMPACKERS FoR'U'Bops) OUTLET AVA|LAB|LIT\1 i EB 191D ('U'BOp S|DE
I EB 195 D (USE OF RAM PACKERStN RAMS OF DTFFERENT STZES)

(1966)) i EB 205 D (on useof checkvalves lockramsin posistion to

g_gll_E_r g_9ll-E-g-I_ol_i__E_B_?19_D_q_E-y9_?F_lgg
i EB241M OHE PIN CONNECTOR)

_;

I E B 4 6 4 D ( F | E L DT E S T T N G O R A C C E P T A N C E F C A M E R O N , S S ' B O p ) F O i EB 465 D (F|ELDTESTTNG FOR ACCEPTANCEOF CAMERON,QRC' BOp,)

2 CONFIDENTIAL

_ CONFIDENTIAL WORK IN PROGRESS

TRN-lNV-03353732

HORIZON DEEPWATER
ion lnlernolIncideni Investigof Trqnsoceon

Tool(ERT)) Recovery Emergency RiserPackage EB 503 D (Lower PREVENTERS) BLOWOUT SNUBBING EB 521 D (SIORC -- CAMERON ANNULAR BOP) D RECOMMENDATIONS EB 527D (STRIPPING RAM CENTRALIZING "U type") EB 532 D ( DUALSTRING AND RAM STRING CENTRALIZING OPERATION MAINTENANCE) EB 533D (DUAL Bolt bonnet boltand Hydraulic Tensioner) Hydraulic EB 537 D (Camerron
CARE, AND MAINTENANCE) EB 538 D ( SHEARINGBLIND RAMS -- OPERATION,

BOP) D OF OPERATION THECAMERON ANNULAR EB 550 D (LOWTEMPERATURE

EB 552 D (RECOMMENDATIONSFOR FIELD,TESTINGOF THE CAMERON ANNULAR)

DATA) BORERAM-- ENGINEERING EB 555 D (VARIABLE plating nutsand bolts(1988) of EB 561W (Cadmium BORESHEARBONNETS) EB 571 D (LARGE AND USE OF SHUTTLEVALVE WITH S/ORC SNUBBING EB 580 D (OPERATTON BLOWOUT PREVENTERS)
EB 599 C (CANERON t-1l2" POD VALVE WITH QUICK DUMP 309s38-01 -02 i , 4" CAMERONY DUMP VALVE 309542-01) DESIGN) EB 601 D (CANERONCOLLETCONNECTOR SELF.LOCKING

BONNETBOLTi OF EB 603 D (SAFE OPERATTON THE CAMERONHYDRAULIC TENSTONER) BowlPreparation) EB 608W (installation BOPPlugTypeTesterin "FMTB" of
EB 637 D (ST-LOCKSEQUENCINGVALVE FOR T BOP) PROCEDURETHROUGH CAMERON RAM-TYPE EB 641 D ( STRIPPING(SNUBBING) BLOWOUT PREVENTERS)

RAMS) BLIND i EB 648 D (H2SSHEARING (1990)) Procedures Flushing I EB 649C (System

AND OPERATIONOF i i EB 650 C (RECOMMENDEDPR4CTICESFOR INSTALLATION

HOSEBUNDLES) CONTROL i BOPANDWORKOVER FOR THE CASTLENUT i EB 667 W (RECOMMEND OPERATING PROCEDURES TIEDOWN SCREW)

|ryr:gtig:gj y:'ft1*N9:":u.1t q10 i *EB ? !:gl'!,dig

I EB 679D ( DoesnotApply(1990)
EB 686 C (SEOUENCING OF FAILSAFE GATE VALVES ON SUBSEA BLOWOUT PREVENTERSTACKS)

CONTROLMODEL WC* COLLET EB 687 C (CONTINUOUS LATCH PRESSURE CONNECTORS)

DUE TO INCREASED PIPE STRENGTH) EB 691 D (SHEARING LIMITATIONS EB 699 D ('D" SEAL --'D" SHAPEDSEAL)

_ CONFIDENTIAL WORK IN PROGRESS

CONFIDENTIAL

TRN-tNV-03353733

DEEPWATER HORIZON
Tronsoceon InternolIncidenl Invesligolion

EB 700D (CAMERON SHEARTNG DS BLTND RAMS) EB 701 D ( Recommended Torque GradeB-7CapScrews) for EB 702D (Shearing Capabilities Cameron of Shear Rams) i EB 707c (FA|LcLosE AND FA|LopEN coNTRoLS FoR GATEVALVES) E8722 c (BoP Fluid(1989)) LtNEQUTCK-DTSCONNECT COUpLtNGS) i EB72s C (PTLOT
E8729 C (INSPECTION AND SERVICINGMODULARBOP CONTROLPOD STINGERS)

EB 783D (LOWTEMPERATURE TESTTNG VARTABLE OF BORERAMS)

EB 798 D (GENERALINFORMATION FOR CAMERONRAM BOPs) EB 806 W (lnstallationand Operation Procedure for High Pressure Injection and Bleeder fittings)

EB 807W ( lnstallation Procedure TypeMS-1Secondary for seals)

ruBtNGHEAD ADAeTERS TUBTNG AND NtppLES) i ee aosw ( HV-sHp

TESTER/BOWL PROTECTOR RUNNTNGRETRTEVAL & TOOL) i EB 810W ( B.O.p. RemovalTool Ml11338) i fA At+ W (Valve pUMpS) VALVE, HYDRAULIC i EB 820C (DIRECTTONAL PACK|NG |NJECTION PORTS) i EB 823W (PLASTIC BOp i EB 833D( H|GHTEMPERATURE ELASTOMERS) y4" FOR ] E 8 8 41 W (PROCEDURE CHECKTNG NpT BURTED CHECK VALVES) Treatment ColletSegments Actuator for and Rings) 1 EB 842M-Bl (Surface TEMPERATURE RATINGOF K-2 AND K-6 SLtp AND SEAL) i EB 843 W ( MAXTMUM HighSeparating Forces ColletConnectors for Operated in i EB 848 M, rev. Bl (Potential I DeepWater.Connectors) Bolt for BOPBonnets: UUUM& TL) U, i EB 851D, Rev.Cl (Bonnet Torque SealCarrier RamProduct Line) i EB 852D (Shear
i

D Storage T & TL BOPsEquipped of with"ST"and "Ram"Locks) i fA ASO (Long-Term C Retractable Connector placement) seal i fS ASZ (%"Double

'

'.=F.B--9.:9""-9!.r':9]l'9"?iT'r*:j?:-|.ruy-U..]l-o-?.:
I EB 859D (Rev. D1)fr'ariable BoreRam& FlexpackerSealing Hangoff) &
; EB 861 C WForm (CeramicSeal PlatesCameronPod) OF i EB 862 D ( SHEARINGCAPABILITY THE CAMERON7-1t16") EB 864 D (Recommended FlangeBoll Torques)

t-4

l_:
CONFIDENTIAL

CONFIDENTIAL WORK IN PROGRESS

TRN-tNV-03353734

HORIZON DEEPWATER
IronsoceonInlernollncidenl lnvestigolion

Testing) SystemSurface EB 865 G (Deadman/AMF BOPS) OF STORAGE D & DL ANNULAR EB 868 D (LONG-TERM for Operation) System Recommendations the Efficient EB 870 D Rev.81 ( BOPControl Shear RamBonnets) 15M EB 874D withForm(18-314" TL BOPSuper Pins) ShearRamRetainer EB 875D (18%" 15MTL BOPSuper 10M EB 876D (18-314" TL BOPDVSShearRamTopSeals)
EB 882 D ( Choke and Kill ManifoldSystems )

Preventer) 18/o"15MPSIUllBlowout EB 885D (Rev. A01)(Cameron Maintenance BOP's) of EB 886 D Rev01 ( Preventive lnspection Air Purging) and EB 890 D (Periodic Replacement) EB 891 D (AMF/Dead Battery (18-314" BOPGaske) i EB A950001 (Lubrication Subsea H-4Connectors) of I EB A960007 Studded Top 10 & 15KH-4Connectors) i EB H022(18-314" Gasket) Vgx-2,& VT-2(2nd)Generation Wellhead of i EB H032202(VX-2, ( I EB H970002 SocketHeadCap ScrewUsagein MaineEnvironments) (H-4 Excluder ring) Connector I fA HSSOZS0 Wellhead D i EB-209 RevG2 (CupTester) (Life)Test) ER 2768(Deadman Battery Longevity I FSA4033322(H-4TestStumpHandling Lifting & HoleThreadProteclors) (VX-2Gaskets) i FSAA070008 protection (H-4 H051195Hydrates Wellhead connector hydrate recommendations)
(Eliminationof CriticalSolenoidValve HQS_OPS_ADV_435_026_Single_point_failureRev2 i SinglePointFailures)

I HQS_O Ps_ADv_435_029sofl_shift HQS_OPS_ADv_435_030_rev ux_Con 1_M nectors i HQS-HSE-AL-080 (BOPTESTTOOLFAILURE)

,I_9:-_ol_9_l1l?9_t-T-g:1Tr11T9,I3ter"_-!le_91.:3-11e,::
l I (FUNCTION TESTS FORSUBSEA BoP ) , nOS-OpS-ADV-07
(CameronSuperShear Rams) HQS-OPS-ADV-401-005 (Cameron Rams with ST-Locks) HQS-OPS-ADV-401-006

(Cameron %" 10KColletConnectors) HQS-OPS-ADV-405-002 18 (Cameron HQS-OPS-ADV-405-003 TypeColletConnectors) (Enhancement Corrosion HQS-OPS-ADV-405-004 for Resistance )
HQS-OPS-ADV-41 3-003 (lmplementation "Stuck Button"Alarm) of

CONFIDENTIAL WORK IN PROGRESS

CONFIDENTIAL

TRN-lNV-03353735

DEEPWATER HORIZON
Ironsoceonlnlemol IncidentInvesligofion

HQS-OPS-ADV-434-001 FluidConcentration (BOP Erro/') HQS-OPS-ADV-435-026 (Elimination Critical of Solenoid ValveSinglePointFailures) HQS-OPS-ADV-435-028 (Subsea Transducer Modutes (STM) Transducer/Battery Modules) and Subsea

HQS-OPS-ADV-435-028 (MUX control system equipped with subsea Transducer Modules)

(BOP HQS-OPS-ADV-976-007 ControlSystemSolenoid Vent) HQS-OPS-ADV-BOPR-01 0 (Cameron LockProblems) ST HQS-OPS-AL-05 EQU|PMENT OPERAT|ON) WELL CONTROL (lnspection Cameron HOS-OPS-EAL-401-04 of ShearRamBlocks)
HQS-OPS-EAL-41 3-01-Rev1(BOP CONTROL PANEL)

HQS-OPS-E (M AL-444-001 UX Connector iluresoperating procid res) Fa u HQS-OPS-EAL-BOPR-005 (Reduced Fatigue Of Packer BOPRam) Life For
I

(CAMERON & DLANNULAR HQS-OPS-TIB-400-OH-01 D TypE BOP'SOVERHAUL) 3 FUNCTIOI,I HYDRAULTC LOCKS)

(CAMERON TYPE "T" RAM TYPE BOP'S WITH ST HQS-OPS-TIB-401-OH-04-Rev-1

locTgl.*_

._______

(Preventing HQS-OPS-T|B-405-01 Internal.C-orrosion of VetcoH4)

_ _. ** . _ (CAMERON COLLET HQS-OPS-T|B-405-OH-02 HC CONNECTORS MAJOROVERHAU)

(CAMERONMODEL70 CONNECTORS HQS-OPS-T|B-405-OH-03 MAJOROVERHAUL) (VETCO H4 CONNECTORS MAJOR OVERHAUL) HQS-OPS-T|B-405-OH-04 - -- ; irsa1ffi lA*;il.]";;;; ;*ti
! l

I I I I I I I I '--------*"""'i i
I
i

(INSTRUCTIONS REBUILDING FOR CAMERON CONTROLS i HQS-oPS-TlB-435-01Revl , ] SOLENOID VALVE) i (Cameron Solenoid lnternal Pressure Test) I HQS-OPS-T|B-435-02 (BOP I HQS-OPS-T|B-BOPU-001 Controlsystem BallValve Failures) (Blow (BOP) I HQS-OPS-TIB-BOTS-001 Out Preventer TestStumps) (Subsea HQS-SS-2001-002 BOPMUXTraining Requirements)
OnnO nnt / ^i^-^ h ^-l -2003-003-modems^ i - ^ . . ^ ^usedand^ ^ r ^ all. upgraded) ( pods^ i l . ^ ^ - ^ r ^ r \ beingi I , JQS-SS-ADV -2003-004 (software) HQS-SS-ADV r UnO OC AnU

i , : i

(HC piston) Connector's acluator , HOS-SS-ADV-2001-001 Collet (Subsea HQS-SS-ADV-2001-004 Survey) Equipment (Cathodic HOS-SS-ADV-2001-010 Protection Markll Pods) for
(REPLACESEAT MATERIALIN NEEDLEVALVE) HQS-SS-ADV-2001-011

l-,I

- WORKIN PROGRESS CONFIDENTIAL

6

CONFIDENTIAL

TRN-tNV-03353736

HORIZON DEEPWATER
ion IronsoceonInternollncident Investigof

(Heat Panels) HQS-SS-ADV-2001-012 in BOPControl Sofiware) 3 (EventLogger HQS-SS-ADV-2001-01 (Cameron of Pressure VesselModifications Test& PurgePorts) HQS-SS-ADV-2002-001 (Cameron: Pressure Transducers) HQS-SS-ADV-2002-002 (Cameron: System Requirements FluidMixing BOPControl HQS-SS-ADV-2002-003 ) (Ordering MUXCables) HQS-SS-ADV-2002-004
(ShuttleValve Approval) HQS-SS-ADV-2002-006

(Panel / HQS-SS-ADV-2002-0O7 PowerDown PowerUp Indications) (Cameron PODs- %" SlideValveSpringReplacement) HQS-SS-ADV-2002-008 Removal) Control PodSEMShroud HQS-SS-ADV-2002-01 0 (Cameron (Cameron Control Pod5K SlideValves) i HOS-SS-ADV-2002-011 (Cameron RodReplacements) Markl& Markll PodCylinderTie HOS-SS-ADV-2002-012 (Cameron MUXControls Self-Audit) i HOS-SS-ADV-2002-019 (Use FPRReporting Cameron for Controls Equipment)i I HOS-SS-ADV-2002-14 of Cameron (E-Connector i HOS-SS-ADV-2003-001 )
_-_i-*_

(PressureBalancedOil Filled Cables (PBOF)) HQS-SS-ADV-2003-002

(Corrosion Resistant SealPlates Cameron For PodValves) i HOS-SS-AOV-2003-005 (Cameron HQS-SS-ADV-2003-008 MUXControls PLC's) (PEP HQS-SS-ADV-2003-009 digital Boards) out

(Software Changes the Cameron on MUXSystem) I HQS-SS-ADV-2003-04

(policiesfor dealingwith componentobsolescence) MEMO-26-Sep-02

(Cameron OPT-ADV-435-003 Regulator Upgrade Orifice Addition) (Cameron Controls Monitoring OLM's) of i OPT-ADV-435-012 (Cameron OPT-ADV-435-021 MUX24VDC System Protection Coordination) &
(Cameron ControlsMark | & Mark ll, STM and STBM Modifications) OPT-ADV-435-022 I

I t!

!,'..-^.*.-.---'-.-..-'^*'..."',.-....,.*,--]'|-I-:
I
l

1'\DT

EAI

AAE

A4

/QI

IAQEA

D,1D

A'^\NITD.\I

Q\

(Cameron OPT-EAL-435-03 MUXPod)

(MUX Cablesand Pod Hoses) OPT-EAL-444-01

i
la
i !

,----: i

)P1-EAL-447-01 lockIncident (ST caused incorrect by design the hydraulic of system) (BOP oPT-EAL-994-01 FLUIDCARE insrructions)

CONFIDENTIAL WORK IN PROGRESS 7

CONFIDENTIAL

TRN-tNV-03353737

DEEPWATER HORIZON
Ironsoceon Inlernol Incident Investigolion

(BOPFluidContamination) OPT-EAL-994-02 (Fuses Subsea PA #006024 ln Architecture) panets) (Cooling for Driiler's Kits Controt i PA #006044 (ST-Lock PA #006104 BrakeHub) (ST-Lock PA #006124 Overhauling Nut) PA #1005(8 %'5/10,000 TL BOPVariable psi BoreRamAssembty) PAffi2A22(Atlas Cylinder Rods) Tie (Bearing PA#1204 Overhauling ST-Lock) Nut, PA #1602(Shuttle Valves) (LMRP WELLHEAD PA #18020 & CONNECTOR FUNCTTON LOCKOUT) (Deepwater PA #1802036 Connectors) (18 PA #1802058 y1" NOMTNAL WEAR BUSHTNG POTENT|AL BLOCKBOp RAM I TO cAVrTYl i (PodSubsea PA #18040 Electronic Module Power Supplies)

PA #20 (Hydraulic Bonnet BoltsTensioners Cameron for BOPHydraulic BonnetBolts) PA #35 (Cameron Falsified Compliance API Documents)
; PA #38 (Subseaactuatedgate valves)

(Shuttle VatveCapscrews) i pn *+OZO

open ball checkvalve) i PA#44 (Stinging i PA #6020 (TL Super Shear Ram) TRANSFORMERS) i PA #6024 (INSTALLING

I PA #6040(ST-Lock Operating Preventer and Maintenance)

;_l1troglse::el":_Y:Y:31_Tl9el5lg:T:tl1Il9lpn
I *AtO+(Super Shear Retainer Pin) (Ramassembly Optional Ram-01-03 WearPads) (18 TL i SA-2072 %" 15,000 BOPwithRamLock) I
I !

(18 15,000 BOPSuper TL Shear) i SA-2092 314"

( Damage RamBOPSealsFromInternal to Pressure) i i Tech_Hazard_Alertl (MuxCable Connector lssues) i T010065 i -*_**_*,] ;*___**-**._*_-:*--"** i Rev2 Procedure Connectors) for I X_2341O2_01 (Handling I (Handling X-065438-39 Procedure. Dry Mateable SubseaConnections SeaconMSS , I j i Series) I

r---'*-

"-

ea-t6,rn t'le 3/-n q, nnn/{n n n n TL BOP with D a m r n a L \ r -A-252O(18 %" 5,000/10,000r a a \ D r r r i + h Ramlock)

CONFIDENTIAL WORK IN PROGRESS 8

CONFIDENTIAL

TRN-tNV-03353738

HORIZON DEEPWATER
Tronsoceon
Incidenl Investigoiion

(WaterBasedHydraulic Guide) FluidPurchaser's X-201678-01 (WaterBasedHydraulic FluidUser's Guide) X-201679-01

oF Summanv lNVEsrlGATroN
Of the 248 alerts that rvere located78 rverecomplete,43 do not apply to the Horizon, ll2 rverefor information purposes, were not done, I is post Horizon incident and thereare 9 that can not find if done. 3

4 4.1

FrHorNes CoNctusroNs AND toilureslDireclCouses that Of the 9 tlr,at not find if doneandthe 3 thatwerenot donethereare4 alerts couldhavehadan effecton the can operation theBOPduring theHorizonincident of

4.2

ConfdbuloryFoclors/UndedyingCouses Organizalional People Not all Transocean aremandatory decisiott actis left up to therig. the to alerts
Environmenlal Technical the decisionto act is left up to the rig. All alerts shouldbe Not all Transocean alerts are mandatory reviewedby Transocean Engineeringand the decision to act or not act should be made at a level above manger. operations

4.3

Polenliol leoming lor Ongoing Operolions

Fleet wide

high

TAEtEs AND FIGURES

CONFIDENTIAL WORK IN PROGRESS 9

CONFIDENTIAL

TRN-tNV-03353739