HORIZON

DEEPWATER
TronsoceonInternollncident Investigolion

llem
Invesfigcrlion
Iickel ReferenceNo.

EquipmenlAlerl Review
0000

DocumenlConflol
j Bob Walsh

Draft for review and comment

ofchangeprocess
I Inclusionof management

i Bill Ambrose

i Review and clarification of summary

02

OF INTEREST
QUISTPN/EVENT

Hove oll monufocluring equipment olerls been opplied/completed

per TO requiremenls on BOP

conlrols?

Scopc AND METHODOF INVESTIGATION

2.1.1

Scope

Aspecls Covered
rvebsites.
Downloadedall Equipmentalertsfor Cameronequipmentfrom CameronandTransocean
Reviewedall EmpacWO's and RMS jobs to detenninethe statusof all equipmentalerts.ContactedSubsea
supportfor possibleupdateof alerts that were not coveredin the maintenancemanagemenlsystem.

Aspecfs Nof-Covered

2.2

Mef hod ol lnvesfigolion

Revie,rvedexisting recordsfrom RMS, Ernpac,Sub-SeaDaily activiS report. as well as supplementaldata frotn
lvith TechnicalField Support.
ernailsandphoneconversations

2.3

Relerence Documenls

(markI pod Upgrade)

Cameron-X-9VBat
cts-01-c01(H|GHsHocK FLoWMETERS)
DesignFeatures)
CIS-01-C02(PBOF Connector/Cable

(PremiumValvesfor DrillingControlSystems)
CIS-01-C03
cis-01-c04(Pilot Operated Check Valve, 1 %" Upgrade)
(SolenoidValve (3lZWay)Valve Upgrade)
CIS-01-C05RevA01

CONFIDENTIAL- WORK IN PROGRESS

CONFIDENTIAL

5 roG
Exhibit No.

WorldwideCourt
Inc.

TRN-tNV-03353731

DEEPWATER
HORIZON
TronsoceonInlernolIncidenl Investigolion

(SolenoidValve(3/2Way)CabteUpgrade)
cis-01-c06
(EventLogger:Features& Upgrades)
CIS-01-C07
cls-O1-c08(standard
shuttleValvein cameroncontrolsystemsMarklll)
(Drilling
CIS-01-C09
ControlSystemTroubteshooting
Guide)
CIS-01-C10
(Unbalanced
ShuttleValvein CameronControlsystems)
CIS-01-C11
(Pressure
BiasedShutileValvefor ROVFunctions)
cls-01-c12(HighDragshuttleVatvein cameroncontrotsystemsMarkilt Upgrade)
cfs-04-001(18-314AnnularstripperPackerfor cameron18-314"
- 10,000psi Annular
BOP)
packing)
(Cameron
CIS-04-002
D/DlAnnularBlowoutPreventer
CI5-04-003(18-3/4"-5000
psi LowTemperature
AnnutarpackingElement)
CI5-96-002(ProperStorageof CameronElastomerProducts)
E8 831M (STROKELtMtT- MODEL 70 & HC COLLETCONNECTORS)

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

i EB 10717(StandardTestStump)
(H-4Connector
CamRingandDogs)
i f e TOZSS
EB 1A734(H-4 AX /X Gasket RetainerScrews)
i EB 119 D (PLASTICPACKTNG.TNSTRUCTTONS
FOR'F' PREVENTERGLANDS)

EB 124D (F' BLOWOUTPREVENTER

SH@TREMOVALTOOLS)
EB'126W (Storageand agingof rubbergoods)
EB 136 D (OPERATORHOOti-UpFOR'F',PREVENTER)

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

i EB 205 D (on useof checkvalvesto lockramsin posistion(1966))

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
F O R A C C E P T A N C EO F C A M E R O N , S S ' B O p )
i EB 465 D (F|ELDTESTTNGFOR ACCEPTANCEOF CAMERON,QRC' BOp,)

2
CONFIDENTIAL

CONFIDENTIAL_ WORK IN PROGRESS

TRN-lNV-03353732

HORIZON
DEEPWATER
TrqnsoceonlnlernolIncideni Investigofion

EB 503 D (LowerRiserPackageEmergencyRecoveryTool(ERT))
EB 521 D (SIORCSNUBBINGBLOWOUTPREVENTERS)
-- CAMEROND ANNULARBOP)
RECOMMENDATIONS
EB 527D (STRIPPING
RAM"U type")
EB 532 D ( DUALSTRINGCENTRALIZING
ANDMAINTENANCE)
RAMOPERATION
EB 533D (DUALSTRINGCENTRALIZING
Hydraulicbonnetboltand HydraulicBoltTensioner)
EB 537 D (Camerron
EB 538 D ( SHEARINGBLIND RAMS -- OPERATION,CARE, AND MAINTENANCE)

OF THECAMEROND ANNULARBOP)
OPERATION
EB 550 D (LOWTEMPERATURE
EB 552 D (RECOMMENDATIONSFOR FIELD,TESTINGOF THE CAMERON
ANNULAR)

DATA)
BORERAM-- ENGINEERING
EB 555 D (VARIABLE
EB 561W (Cadmiumplatingof nutsand bolts(1988)
EB 571 D (LARGEBORESHEARBONNETS)
AND USE OF SHUTTLEVALVE WITH S/ORC SNUBBING
EB 580 D (OPERATTON
BLOWOUTPREVENTERS)
EB 599 C (CANERON t-1l2" POD VALVE WITH QUICK DUMP 309s38-01
, -02 i
CAMERONY4" DUMP VALVE 309542-01)
EB 601 D (CANERONCOLLETCONNECTOR- SELF.LOCKINGDESIGN)

OF THE CAMERONHYDRAULICBONNETBOLTi
EB 603 D (SAFE OPERATTON
TENSTONER)
EB 608W (installation
of BOPPlugTypeTesterin "FMTB"BowlPreparation)

EB 637 D (ST-LOCKSEQUENCINGVALVE FOR T BOP)

EB 641 D ( STRIPPING(SNUBBING)PROCEDURETHROUGH CAMERON RAM-TYPE
BLOWOUT PREVENTERS)

BLINDRAMS)
i EB 648 D (H2SSHEARING
(1990))
Procedures
I EB 649C (SystemFlushing
i EB 650 C (RECOMMENDEDPR4CTICESFOR INSTALLATIONAND OPERATIONOF i

HOSEBUNDLES)
CONTROL
i BOPANDWORKOVER
FOR THE CASTLENUT i
EB 667 W (RECOMMEND
OPERATINGPROCEDURES
TIEDOWNSCREW)

|ryr:gtig:gj
y:'ft1*N9:":u.1t
q10? !:gl'!,dig
i *EB
I EB 679D ( DoesnotApply(1990)
EB 686 C (SEOUENCING OF FAILSAFE GATE VALVES ON SUBSEA BLOWOUT
PREVENTERSTACKS)

EB 687 C (CONTINUOUS
LATCH PRESSURECONTROLMODEL WC* COLLET
CONNECTORS)
EB 691 D (SHEARINGLIMITATIONSDUE TO INCREASEDPIPE STRENGTH)
EB 699 D ('D" SEAL --'D" SHAPEDSEAL)

CONFIDENTIAL_ WORK IN PROGRESS

CONFIDENTIAL

TRN-tNV-03353733

DEEPWATER
HORIZON
TronsoceonInternolIncidenl Invesligolion

EB 700D (CAMERON
DS SHEARTNG
BLTND
RAMS)
EB 701 D ( Recommended
Torquefor GradeB-7CapScrews)
EB 702D (Shearing
Capabilities
of CameronShearRams)
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 (INSPECTIONAND SERVICINGMODULARBOP CONTROLPOD STINGERS)

EB 783D (LOWTEMPERATURE
TESTTNG
OF VARTABLE
BORERAMS)
EB 798 D (GENERALINFORMATIONFOR CAMERONRAM BOPs)
EB 806 W (lnstallationand Operation Procedure for High Pressure Injection and Bleeder
fittings)

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

ANDTUBTNG
NtppLES)
i ee aosw ( HV-sHpruBtNGHEADADAeTERS
PROTECTOR
RUNNTNG
& RETRTEVAL
TOOL)
i EB 810W ( B.O.p.TESTER/BOWL
Ml11338)
i fA At+ W (ValveRemovalTool
i

pUMpS)
VALVE,HYDRAULIC
i EB 820C (DIRECTTONAL
PACK|NG|NJECTION
PORTS)
i EB 823W (PLASTIC
BOp ELASTOMERS)
i EB 833D( H|GHTEMPERATURE
y4"NpT BURTED
FORCHECKTNG
] E 8 8 41 W (PROCEDURE
CHECKVALVES)
1 EB 842M-Bl (SurfaceTreatmentfor ColletSegmentsandActuatorRings)
i EB 843 W ( MAXTMUMTEMPERATURERATINGOF K-2 AND K-6 SLtp AND SEAL)
HighSeparating
Forcesfor ColletConnectors
Operatedin
i EB 848 M, rev. Bl (Potential
I DeepWater.Connectors)
U, UUUM& TL)
i EB 851D, Rev.Cl (BonnetBoltTorquefor SealCarrierBOPBonnets:
i EB 852D (ShearRamProductLine)

Storageof T & TL BOPsEquippedwith"ST"and "Ram"Locks)

i fA ASOD (Long-Term

'

Connector
sealplacement)
i fS ASZC (%"DoubleRetractable

'.=F.B--9.:9""-9!.r':9]l'9"?iT'r*:j?:-|.ruy-U..]l-o-?.:
I EB 859D (Rev.D1)fr'ariableBoreRam& Flexpacker-Sealing& Hangoff)

t--

l_:

; EB 861 C WForm (CeramicSeal PlatesCameronPod)

i EB 862 D ( SHEARINGCAPABILITYOF THE CAMERON7-1t16")
EB 864 D (RecommendedFlangeBoll Torques)

CONFIDENTIAL- WORK IN PROGRESS

4

CONFIDENTIAL

TRN-tNV-03353734

HORIZON
DEEPWATER
IronsoceonInlernollncidenl lnvestigolion

SystemSurfaceTesting)
EB 865 G (Deadman/AMF
STORAGEOF D & DL ANNULARBOPS)
EB 868 D (LONG-TERM
for the EfficientOperation)
EB 870 D Rev.81 ( BOPControlSystemRecommendations
15MTL BOPSuperShearRamBonnets)
EB 874D withForm(18-314"
Pins)
EB 875D (18%" 15MTL BOPSuperShearRamRetainer
10MTL BOPDVSShearRamTopSeals)
EB 876D (18-314"
EB 882 D ( Choke and Kill ManifoldSystems )

18/o"15MPSIUllBlowoutPreventer)
EB 885D (Rev.A01)(Cameron
Maintenance
of BOP's)
EB 886 D Rev01 ( Preventive
EB 890 D (PeriodiclnspectionandAir Purging)
EB 891 D (AMF/Dead
BatteryReplacement)
BOPGaske)
i EB A950001(18-314"
of SubseaH-4Connectors)
I EB A960007(Lubrication
StuddedTop 10 & 15KH-4Connectors)
i EB H022(18-314"
Vgx-2,& VT-2(2nd)Generation
of WellheadGasket)
i EB H032202(VX-2,
I EB H970002( SocketHeadCap ScrewUsagein MaineEnvironments)
(H-4WellheadConnectorExcluderring)
I fA HSSOZS0
i EB-209D RevG2 (CupTester)
ER 2768(DeadmanBatteryLongevity(Life)Test)
I FSA4033322(H-4TestStumpHandling& LiftingHoleThreadProteclors)
i FSAA070008(VX-2Gaskets)
(H-4Wellheadconnectorhydrateprotection
H051195Hydrates
recommendations)
(Eliminationof CriticalSolenoidValve
HQS_OPS_ADV_435_026_Single_point_failureRev2
i SinglePointFailures)

I HQS_OPs_ADv_435_029sofl_shift
HQS_OPS_ADv_435_030_rev
1_Mux_Connectors

,I_9:-_ol_9_l1l?9_t-T-g:1Tr11T9,I3ter"_-!le_91.:3-11e,::
i HQS-HSE-AL-080
(BOPTESTTOOLFAILURE)

(FUNCTION
TESTSFORSUBSEABoP )
, nOS-OpS-ADV-07

(CameronSuperShear Rams)
HQS-OPS-ADV-401-005
HQS-OPS-ADV-401-006(Cameron Rams with ST-Locks)

(Cameron18 %" 10KColletConnectors)

HQS-OPS-ADV-405-002
(CameronTypeColletConnectors)
HQS-OPS-ADV-405-003
(Enhancement
HQS-OPS-ADV-405-004
for Corrosion
Resistance
)
HQS-OPS-ADV-413-003 (lmplementationof "Stuck Button"Alarm)

CONFIDENTIAL- WORK IN PROGRESS

CONFIDENTIAL

TRN-lNV-03353735

DEEPWATER
HORIZON
Ironsoceonlnlemol IncidentInvesligofion

HQS-OPS-ADV-434-001
(BOPFluidConcentration
Erro/')
HQS-OPS-ADV-435-026
(Elimination
of CriticalSolenoidValveSinglePointFailures)
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)

- SolenoidVent)
(BOPControlSystem
HQS-OPS-ADV-976-007
HQS-OPS-ADV-BOPR-01
0 (CameronST LockProblems)
HQS-OPS-AL-05
OPERAT|ON)
WELL CONTROLEQU|PMENT
(lnspection
HOS-OPS-EAL-401-04
of CameronShearRamBlocks)
HQS-OPS-EAL-413-01-Rev1(BOP CONTROL PANEL)

HQS-OPS-E
(MUX ConnectorFailuresoperatingprocidures)
AL-444-001
HQS-OPS-EAL-BOPR-005
(ReducedFatigueLifeOf PackerFor BOPRam)
I

(CAMEROND & DLANNULARTypE BOP'SOVERHAUL)

HQS-OPS-TIB-400-OH-01
3 FUNCTIOI,I
HYDRAULTC
LOCKS)
HQS-OPS-TIB-401-OH-04-Rev-1(CAMERON TYPE "T" RAM TYPE BOP'S WITH ST

locTgl.*_

._______

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

_ _. ** . _
(CAMERONHC COLLETCONNECTORS
HQS-OPS-T|B-405-OH-02
MAJOROVERHAU)
(CAMERONMODEL70 CONNECTORSMAJOROVERHAUL)
HQS-OPS-T|B-405-OH-03
(VETCO H4 CONNECTORS MAJOR OVERHAUL)
-HQS-OPS-T|B-405-OH-04
-- ; irsa1ffilA*;il.]";;;; ;*ti
! l

I
I

(INSTRUCTIONS
FORREBUILDING
CAMERON
CONTROLS,
i HQS-oPS-TlB-435-01Revl
] SOLENOID
VALVE)
i

(CameronSolenoidlnternalPressureTest)
I HQS-OPS-T|B-435-02

(BOPControlsystem
I HQS-OPS-T|B-BOPU-001
BallValveFailures)

(BlowOut Preventer(BOP)TestStumps)
I HQS-OPS-TIB-BOTS-001

(SubseaBOPMUXTrainingRequirements)
HQS-SS-2001-002

OnnO nnt
/ -^i^-^
^i-^..^^i
^-l
^^r^
^il..^^-^r^r\
-2003-003
( modemshbeing
podsall
usedand
upgraded)
I , JQS-SS-ADV
-2003-004(software)
HQS-SS-ADV
r UnO

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

OC

AnU

(HCColletConnector's
acluatorpiston)
, HOS-SS-ADV-2001-001
(SubseaEquipment
HQS-SS-ADV-2001-004
Survey)
(Cathodic
HOS-SS-ADV-2001-010
Protection
for Markll Pods)

l-,-

(REPLACESEAT MATERIALIN NEEDLEVALVE)

HQS-SS-ADV-2001-011

- WORKIN PROGRESS
CONFIDENTIAL
6

CONFIDENTIAL

TRN-tNV-03353736

HORIZON
DEEPWATER
ion
IronsoceonInternollncident Investigof

(Heatin BOPControlPanels)
HQS-SS-ADV-2001-012
3 (EventLoggerSofiware)
HQS-SS-ADV-2001-01
(CameronPressureVesselModifications
of Test& PurgePorts)
HQS-SS-ADV-2002-001
(Cameron:PressureTransducers)
HQS-SS-ADV-2002-002
(Cameron:BOPControlFluidMixingSystemRequirements
HQS-SS-ADV-2002-003
)
(OrderingMUXCables)
HQS-SS-ADV-2002-004
HQS-SS-ADV-2002-006(ShuttleValve Approval)

(PanelPowerDown/ PowerUp Indications)

HQS-SS-ADV-2002-0O7
(CameronPODs- %" SlideValveSpringReplacement)
HQS-SS-ADV-2002-008
HQS-SS-ADV-2002-01
0 (CameronControlPodSEMShroudRemoval)
(CameronControlPod5K SlideValves)
i HOS-SS-ADV-2002-011
(CameronMarkl& Markll PodCylinderTieRodReplacements)
HOS-SS-ADV-2002-012
(CameronMUXControls- Self-Audit)
i HOS-SS-ADV-2002-019
(Useof CameronFPRReporting
for CameronControlsEquipment)i
I HOS-SS-ADV-2002-14
(E-Connector
i HOS-SS-ADV-2003-001
)
_-_i-*_

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

(Corrosion
ResistantSealPlatesFor CameronPodValves)
i HOS-SS-AOV-2003-005
(CameronMUXControls- PLC's)
HQS-SS-ADV-2003-008
(PEPdigitalout Boards)
HQS-SS-ADV-2003-009

(SoftwareChangeson the CameronMUXSystem)

I HQS-SS-ADV-2003-04
MEMO-26-Sep-02(policiesfor dealingwith componentobsolescence)

(CameronRegulatorUpgrade- OrificeAddition)
OPT-ADV-435-003
(CameronControlsMonitoring
of OLM's)
i OPT-ADV-435-012
(CameronMUX24VDC SystemProtection
OPT-ADV-435-021
& Coordination)
OPT-ADV-435-022(Cameron ControlsMark | & Mark ll, STM and STBM Modifications)

I
t!

1'\DT

EAI

AAE

A4

/QI

IAQEA

D,1D

(Cameron
OPT-EAL-435-03
MUXPod)

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

A'^\NITD.\I

Q\

(MUX Cablesand Pod Hoses)

OPT-EAL-444-01

i
la

,: - - - - i
i !

)P1-EAL-447-01
(STlockIncidentcausedby incorrectdesignof the hydraulicsystem)
(BOPFLUIDCARE
oPT-EAL-994-01
insrructions)

CONFIDENTIAL- WORK IN PROGRESS

7

CONFIDENTIAL

TRN-tNV-03353737

DEEPWATER
HORIZON
Ironsoceon Inlernol Incident Investigolion

(BOPFluidContamination)
OPT-EAL-994-02
PA #006024(Fusesln SubseaArchitecture)
i PA #006044(CoolingKitsfor Driiler'sControtpanets)
PA #006104(ST-LockBrakeHub)
PA #006124(ST-Lock
Overhauling
Nut)
PA #1005(8 %'5/10,000psiTL BOPVariableBoreRamAssembty)
PAffi2A22(AtlasCylinderTie Rods)
PA#1204(Bearing
Overhauling
Nut,ST-Lock)
PA #1602(ShuttleValves)
PA #18020(LMRP& WELLHEAD
CONNECTOR
FUNCTTON
LOCKOUT)
PA #1802036(Deepwater
Connectors)
PA #1802058(18 y1" NOMTNAL
WEAR BUSHTNG
POTENT|AL
TO BLOCKBOp RAM I
cAVrTYl
i
PA #18040(PodSubseaElectronic
ModulePowerSupplies)

PA #20 (Hydraulic
BonnetBoltsTensioners
for CameronBOPHydraulicBonnetBolts)
PA #35 (CameronFalsifiedAPI Compliance
Documents)
; PA #38 (Subseaactuatedgate valves)

i pn *+OZO(ShuttleVatveCapscrews)
i PA#44 (Stingingopen ball checkvalve)
i PA #6020 (TL Super Shear Ram)
i PA #6024 (INSTALLINGTRANSFORMERS)

I PA #6040(ST-LockOperatingand PreventerMaintenance)

;_l1troglse::el":_Y:Y:31_Tl9el5lg:T:tl1Il9lpn
I

*AtO+(SuperShearRetainer
Pin)

- Optional
(Ramassembly
Ram-01-03
WearPads)
i SA-2072(18%" 15,000TL BOPwithRamLock)

i SA-2092(18314"15,000TL BOPSuperShear)

I
!I

r---'*-

"-

3/-n q, nnn/{n
e-A-252O
a-t6,rn
t ' l e %"
n n n TL
rr a
a \ D rwith
r r i + h Ramlock)
Damr naL\
(18
5,000/10,000
BOP

( Damageto RamBOPSealsFromInternalPressure)
i
i Tech_Hazard_Alertl
lssues)
i T010065(MuxCableConnector
i
-*_**_*,]
;*___**-**._*_-:*--"**
i
X_2341O2_01
(Handling
Rev2
Procedure
for
Connectors)
I
I
(HandlingProcedure.Dry MateableSubseaConnectionsSeaconMSS ,
X-065438-39
I
j
i Series)
I

CONFIDENTIAL- WORK IN PROGRESS

8

CONFIDENTIAL

TRN-tNV-03353738

HORIZON
DEEPWATER
Tronsoceon

Incidenl Investigoiion

(WaterBasedHydraulicFluidPurchaser's
Guide)
X-201678-01
(WaterBasedHydraulicFluidUser'sGuide)
X-201679-01

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

4
4.1

FrHorNes
ANDCoNctusroNs
toilureslDireclCouses
Of the 9 tlr,atcannot find if doneandthe 3 thatwerenot donethereare4 alertsthatcouldhavehadan effecton the
operationof theBOPduring theHorizonincident

4.2

ConfdbuloryFoclors/UndedyingCouses
Organizalional
People
Not all Transocean
thedecisiottto actis left up to therig.
alertsaremandatory
Environmenlal
Technical
Not all Transoceanalerts are mandatorythe decisionto act is left up to the rig. All alerts shouldbe
reviewedby TransoceanEngineeringand the decision to act or not act should be made at a level above
operationsmanger.

4.3

Polenliol leoming lor Ongoing Operolions

Fleet wide

high

TAEtEsAND FIGURES

CONFIDENTIAL- WORK IN PROGRESS

9

CONFIDENTIAL

TRN-tNV-03353739