Report of Investigation into the Circumstances Surrounding the Explosion, Fire, Sinking and Loss of Eleven Crew Members Aboard the Mobile Offshore Drilling Unit Deepwater Horizon In the Gulf of Mexico, April 20-22, 2010 (Volume 1)   [open pdf - 20MB]

This report examines the various causal factors surrounding the explosion, fire, sinking, and loss of crew members onboard the mobile offshore drilling unit (MODU) Deepwater Horizon in the Gulf of Mexico between April 20-22, 2010. "The Joint Investigation Team (JIT) comprised of members from the U.S. Coast Guard and Bureau of Ocean Energy Management, Regulation and Enforcement (BOEMRE) examined five aspects of this disaster relating to areas of responsibility of the U.S. Coast Guard: the explosions, the fire, the evacuation, the flooding and sinking of the MODU, and the safety systems of DEEPWATER HORIZON and its owner-operator, Transocean. Although the events leading to the sinking of DEEPWATER HORIZON were set into motion by the failure to prevent a well blowout, the investigation revealed numerous systems deficiencies, and acts and omissions by Transocean and its DEEPWATER HORIZON crew, that had an adverse impact on the ability to prevent or limit the magnitude of the disaster. [...] This report covers the areas under the cognizance of the U.S. Coast Guard investigated by the [JIT]. It includes USCG JIT recommendations to enhance the safety and effective oversight of foreign-flagged MODUs operating on the U.S. [Outer Continental Shelf]. Many of these recommendations are for the Commandant of the Coast Guard to work with the International Maritime Organization (IMO) to amend its MODU Code, which is intended to provide guidance to flag state administrations in promulgating their own regulations."

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United States Coast Guard: http://homeport.uscg.mil/
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Listed on May 4, 2011 [Critical Releases]