Control
Alarm Management
Alarm design, prioritisation, response, testing and assurance.
Newest 100 Documents
All 235 in search- 2026Sep
Shell Polymers Furnace Explosion and Fire — Furnace Explosion and Fire at Shell Polymers
Investigates the June 2025 furnace explosion and fire at Shell Polymers Monaca following coke-trap cleaning. Inadvertent opening of isolation valves allowed cracked gas to enter the firebox and ignite. The report examines reliance on administrative safeguards, safety instrumented system bypasses, alarm suppression and confusing valve interfaces, recommending engineered protection and improved interface design.
- 202619 Aug
Improvements Needed In Production Safety System Training
This alert reports offshore production safety training deficiencies identified through audits, written competency tests and fire drills. Findings include gaps in retained knowledge, certification, contractor training oversight and emergency preparedness. Operators and contractors are asked to consider reviewing training arrangements, verifying competence, improving lifesaving equipment familiarity and checking alarm audibility.
- 202613 Aug
Grounding and subsequent loss of the fishing vessel Silver Cloud II (WK 80)
Investigation of Silver Cloud II’s grounding and subsequent loss near Lochinver. The skipper fell asleep during a lone navigational watch, very likely through acute fatigue exacerbated by illness and inadequate rest. Analysis examines watch alarm limitations and crew abandonment; regular safety drills likely helped the three crew escape without injury.
- 20261 Jul
Mechanical Failure of LACT Pump Caused Fire
An offshore production facility fire followed LACT charge-pump misalignment after motor replacement. Excessive vibration loosened casing fasteners, allowing oil leakage; coupling failure caused further damage. The alert identifies omitted angular alignment and incorrect bolt torques, and recommends manufacturer-compliant installation, personnel training, review of post-installation surveillance and investigation of abnormal operation.
- 202627 May
Givaudan Sense Colour Explosion
Investigation of a fatal reactor explosion during caramel colouring manufacture in Louisville. A vent valve failed closed, accelerating sugar decomposition; cooling and emergency pressure relief capacity were inadequate. Calorimetry and component testing inform findings on reactive hazards, process safety implementation, operating limits, occupied-building siting and regulatory coverage gaps.
- 2026Apr
Emergency response systems save lives! — Process Safety Beacon, April 2026
This issue examines an ammonia release at a Virginia food processing facility where evacuees encountered the outdoor cloud and four employees were hospitalised. It highlights shortcomings in alarms, emergency shutdown use and release-specific planning, emphasising trained responders, regular drills, safe relief discharge locations and wind-dependent evacuation routes.
- 202626 Feb
Dow Louisiana Operations Explosions
Investigation of the Dow Plaquemine explosion examines work lights left inside a reflux drum during turnaround. Degraded light debris punctured a rupture disc, admitting ethylene oxide into air-containing relief piping. The report analyses vessel closure practices, loss of nitrogen inerting, inadequate monitoring and relief routing that enabled propagation into the drum.
- 2026Jan
D-PINCs (Operators Version - Jan 2026) — Drilling
A regulatory checklist for oil and gas drilling, linking numbered compliance questions to statutory authorities and enforcement actions. It addresses approvals, diverter configuration and testing, casing installation, cement placement, drilling-fluid management and monitoring. Further checks cover ventilation, gas detection, ignition prevention and retention of drilling and test records.
- 202525 Sep
Cuisine Solutions Ammonia Release
CSB investigates an ammonia refrigeration release at Cuisine Solutions in Sterling, Virginia, which injured workers during evacuation. Relief-valve testing and dispersion modelling examine overpressure, liquid aerosol and unsafe discharge. The initiating upset remains undetermined. Recommendations address relief-system assessment, process-data retention, ammonia alarms and emergency preparedness.
- 202517 Sep
Handling alarms on the bridge – a DP incident
During scrap-metal recovery, a DPO inadvertently selected an adjacent command while trying to silence an alarm, leaving the vessel in manual mode with 10 metres of uncontrolled movement. The flash examines alarm overload, a frozen panel and inconsistent silencing arrangements, emphasising interface design, procedural reinforcement and openness within a no-blame culture.
- 202517 Sep
UK HSE: oil company fined after serious failure of elevator
An IMCA safety flash describes three workers encountering water while descending in a lift on the FPF-1 platform for inspection work. They stopped the lift and returned safely without injury. Hardware failures, incorrect operating procedures and absent water alarms were identified; enforcement included a £300,000 fine and an improvement notice.
- 202519 Aug
UK HSE: Motion Compensated Gangways Auto-Retraction
This IMCA flash summarises UK HSE concerns about unplanned retraction of motion-compensated gangways following power or control-system failures. It explains why simultaneous alarms provide inadequate warning and outlines required reviews of gangway arrangements and automatic-function testing, alongside recommended technical risk assessment and rigorous assessment of operator overrides.
- 20251 Aug
BSEE Safety Alert - 504 - Malfunction of Rental Generator's Engine Air Shutoff System
A rental generator fire on an offshore platform followed a closed right-bank air flap, allowing unburnt diesel and excess oil to accumulate and ignite with heat from the operating left bank. The alert recommends considering improved maintenance checks, alarm verification, training and procurement assurance, including independent testing of each emergency air flap.
- 2025Aug
Motion Compensated Gangways Auto-retraction
HSE warns that power failures or control-system errors can trigger unexpected retraction of motion-compensated gangways, exposing users to falls and moving parts. The notice requires reviews of gangway arrangements, design and automatic-function testing, and calls for adequate advance warnings and rigorous assessment of operator overrides.
- 20253 Jul
Grounding and subsequent loss of the prawn trawler Sustain
Investigation into Sustain’s grounding in Loch Broom and subsequent constructive total loss. It examines the skipper’s accumulated sleep debt, overnight repairs, lone watchkeeping and navigation by eye using a magnetic-compass autopilot. Unimplemented risk controls, absent watch alarms and inadequate passage planning are analysed; the crew were evacuated unharmed.
- 202516 Apr
UK HSE: Risk of collision with offshore installations from attendant vessels
This safety flash summarises five vessel collisions with offshore installations and wind turbines reported in an HSE notice. Cases examine distracted watchkeeping, restricted visibility, dynamic positioning limitations and bridge communication. Recommendations address watchkeeping procedures, bridge resource management, alarm operation, attendant-vessel monitoring and consideration of sailing audits.
- 202513 Mar
Marathon Martinez Renewable Fuels Fire
Investigation of a renewable diesel startup fire at Martinez, California, following heater tube rupture. Low process flow and afterburning caused overheating, releasing diesel and hydrogen and seriously injuring an operator. The report examines valve alignment, instrumented safeguards, combustion monitoring, alarm responses, human factors and corporate oversight, with recommendations and comparisons to earlier incidents.
- 2025Mar
Risk of collision with offshore installations from attendant vessels
HSE safety notice examines five vessel collisions involving offshore installations and wind turbines. Cases highlight distracted watchkeeping, lost situational awareness, environmental conditions and poor bridge communication. Recommended reviews cover watchkeeping instructions, bridge resource management, navigational alarms and vessel monitoring, with consideration of sailing audits to identify operational bad practice.
- 202416 Jul
Emergency musters and drills
Two events highlight emergency alarm readiness and fire hazards at muster stations. A stuck emergency button delayed alarm activation during a drill, prompting questions about functional checks. In a separate event, a paper cup discarded with a burning cigarette butt in an ashtray caused smouldering and a small fire.
- 202424 Jun
BP - Husky Oregon Chemical Release and Fire
Investigates the fatal naphtha release and flash fire at the BP-Husky Toledo Refinery in Oregon, Ohio. Examines cascading process disturbances, vessel overflow, manual draining, misleading level indications and alarm overload. Recommendations address engineered overfill safeguards, abnormal-situation procedures, stop-work practice and alarm performance, alongside shortcomings in applying earlier incident lessons.
- 20243 Jun
Vessel collided with platform
A vessel waiting on weather collided with an unmanned, unlit platform while using joystick auto heading mode. Nobody was injured and damage was minor. The flash examines distracted watchkeeping, position monitoring and unset navigation alarms, and describes revised DP checklists, watchkeeping analysis and restrictions on non-watchkeeping duties.
- 2024May
CHIRP Superyacht FEEDBACK 6 (Summer 2024)
This superyacht incident digest examines watertight door failures, a starting battery explosion, a galley fire, unprotected window cleaning and steering loss. Commentary addresses alarm visibility, towing checks, battery maintenance, heat lamp safeguards, crew numbers and the independence of the designated person ashore.
- 2024May
Risk of serious injury from motion compensated gangways
This safety notice addresses serious injury risks during deployment and use of motion compensated gangways, including entrapment, shearing and falls from open walkway ends. It sets out expectations for risk assessment, timely audible and visible auto-retraction warnings, user and operator competence, and inspection and maintenance arrangements.
- 202422 Jan
LTI – forklift knocked spooler bar onto person’s leg
A reversing forklift struck a spooler bar resting on wooden chocks at a third-party yard, causing it to roll onto a worker’s leg. The flash discusses unsuitable bar provision, combined supervisory roles and ineffective sensor positioning. Actions addressed risk assessments, banksman use, collision-warning systems and reversing cameras.
- 202330 Nov
Grounding of general cargo vessel BBC Marmara
Investigation of BBC Marmara’s grounding at Eilean Trodday examines a sleeping watch officer, alcohol consumption, absent lookout and disabled bridge watch alarm. It analyses electronic passage planning, ineffective shipboard management and falsified records, alongside distracted coastguard monitoring. Recommendations address crew resources and coastguard cognitive performance.
- 202330 Nov
Yenkin-Majestic Resin Plant Vapor Cloud Explosion and Fire
Investigation of a fatal resin-plant explosion and fire following solvent vaporisation and release through an altered reactor manway. The report examines pressure-containment design, inadequate alteration assurance, agitator-dependent safeguards, alarm deficiencies and evacuation preparedness. Recommendations address low-pressure vessel guidance, safer process design and flame-resistant clothing.
- 202313 Nov
Failure of AHC cylinder causing oil leak to deck
An offshore vessel’s heave-compensated crane suffered a hydraulic cylinder failure during jumper installation. Worn seals allowed oil to accumulate behind the piston, leading to end-cover bolt failure. Approximately 150 litres remained contained aboard. Proposed actions address pressure alarms, seal inspections, return-filter checks and planned cylinder overhaul.
- 20238 Sep
Collision between cargo vessel Scot Carrier and split hopper barge Karin Høj with loss of 2 lives
Investigation of Scot Carrier’s collision with Karin Høj in the Baltic Sea, followed by the barge’s capsize, its master’s death and the mate’s presumed death. It examines distracted watchkeeping, alcohol consumption, absent lookouts, disabled navigation warnings, rescue delays and weaknesses in company oversight, while acknowledging uncertainty about the barge crew’s actions.
- 20236 Jul
Intercontinental Terminals Company (ITC) Tank Fire
Investigation of the March 2019 tank-farm fire at ITC’s Deer Park terminal, following a circulation-pump seal failure and butane-enriched naphtha release. The report examines pump maintenance, gas detection, emergency isolation, fire spread, containment failure and regulatory exemptions, with recommendations addressing mechanical integrity, tank-farm design and process safety management.
- 20237 Mar
Investigation of Subsea Leak Identifies the Use of Materials Susceptible to Hydrogen Embrittlement (update)
A subsea jumper leak released approximately 479 barrels of oil into the Gulf of Mexico. Investigation attributed fractured Inconel 718 flange studs to hydrogen embrittlement and identified procurement, quality assurance and change-management gaps. The alert recommends operators consider metallurgical evaluation, fastener torque documentation and improved subsea leak alarm monitoring.
- 2023Jan
Hydrogen Sulfide Release
This fatality alert describes hydrogen sulphide poisoning that killed a worker responding to a pump alarm and, later, his spouse at an oil production facility. It examines defective gas detection, missing detector-use policies, inadequate isolation arrangements and visitor access, alongside recommendations for lockout/tagout, ventilation assessment and detection-system assurance.
- 202221 Dec
Kuraray Pasadena Release and Fire
Investigation of an ethylene release and fire during reactor startup at Kuraray’s Pasadena plant, injuring 23 workers. It examines unsafe atmospheric pressure-relief discharge, disabled interlocks, alarm flooding, conflicting operating instructions and restricted flare use. Recommendations address safe discharge design, worker exclusion, operating limits, training and independent process safety assessment.
- 202226 Sep
American P&I Club: Vessel grounding – fatigue was a factor
A towing vessel pulling a deck barge grounded on a shoal after the Mate fell asleep on watch. The flash discusses disrupted rest, inaccurate work/rest records and unused ECDIS alarms. Lessons emphasise adequate rest, honest recording of working hours, assistance when struggling to remain alert and correct alarm settings.
- 202231 May
Surface decompression near-miss
A surface decompression near-miss involved an unintended chamber depth reduction from 12msw to 5msw following a SURDO2 dive. Divers remained symptom-free. The account identifies an incompletely closed exhaust valve and supervisor distraction, and describes revised operating responsibilities, venting and depth alarms, and camera monitoring.
- 20224 May
Maintenance and painting – two incidents
Two maintenance-related incidents involved a lifeboat brake mechanism and a crane high-hook alarm. Paint restricted moving components; a broken shackle affected lifeboat braking, while the crane hook block struck sheaves. Neither incident caused injury. Actions include post-maintenance operational checks, alarm testing, crane movement monitoring and dye penetration inspection.
- 202222 Mar
MAIB: Flooding, capsize and foundering of small vessel after issues with towing wires
This flash summarises a fishing boat loss involving hull damage from trawl doors while uncrossing towing wires, unnoticed flooding and capsize. It examines absent watertight subdivision, unheard bilge alarms and abandonment to a life raft. Lessons address reassessing changed operations, checking unattended spaces, wearing lifejackets and using emergency equipment.
- 20229 Feb
Flooding, capsize and sinking of prawn trawler Diamond D
Investigation of Diamond D’s flooding, capsize and sinking near Tynemouth on 16 August 2020. Hull damage from trawl doors was considered almost certain. The report examines crossed towing wires, reduced manning, unnoticed bilge alarms, pumping limitations and absent watertight subdivision, alongside liferaft abandonment and the successful rescue of both crew.
- 2022
MAIB Safety Digest 2/2022
A collection of marine accident lessons covering merchant ships, fishing vessels and recreational craft. Cases examine groundings, fires, towing and lifting failures, flooding, capsize and people overboard. Reproduced bulletins and flyers discuss blocked CO2 pilot hoses, vessel stability, flotation and distress alerting, alongside navigation, training and equipment checks.
- 202116 Dec
Grounding of chemical tanker Key Bora
Investigates Key Bora’s grounding near Kyleakin pier, Scotland, with hull damage and ballast tank flooding but no injury or pollution. Examines inaccurate survey data used for passage planning, ineffective ECDIS use, bridge resource management and deficiencies in pier safety governance, alongside subsequent actions and recommendations.
- 202120 Jul
Cargo tank explosion and fire on chemical tanker Stolt Groenland
Investigation of the Stolt Groenland explosion and fire at Ulsan examines runaway styrene polymerisation following heat transfer through an intermediate cargo tank. It analyses inhibitor depletion, stowage planning, unused temperature monitoring and alarms, and onboard remedial limitations. Fire response and missed learning from the separate Stolt Focus incident are also considered.
- 202117 Jun
Sikorsky S-92A Passed Close to Terrain in Degraded Visual Conditions
AAIB investigation of a Sikorsky S-92A serious incident near Shipston-on-Stour in degraded visual conditions. The helicopter passed within 28 ft of rising terrain without reported damage or injuries. Analysis examines manual flight, automation limitations, approach guidance, altitude alerts and crew intervention, leading to eight safety recommendations.
- 202113 Jun
Report - Error tolerance in dynamic positioning systems - November 2018
NOPSEMA examines inadvertent deactivation of dynamic positioning controls through incident database review, manufacturer consultation and a survey covering 28 Australian facilities. The report assesses double-press vulnerabilities, confirmation dialogues, alarms, protective covers and interface layouts, finding widespread additional safeguards while identifying gaps requiring further risk reduction.
- 20212 Jun
Grounding of general cargo vessel Kaami
Investigates Kaami’s grounding on Sgeir Graidach in the Little Minch, which caused extensive hull damage without injuries. Examines incomplete voyage planning, inappropriate electronic chart scales, disabled ECDIS safeguards, ineffective lookout integration and probable fatigue. Recommendations address second-navigator checks, navigational auditing and competence assurance.
- 202121 May
Aghorn Operating Inc. Waterflood Station Hydrogen Sulfide Release
This investigation summary examines a fatal hydrogen sulphide release at an Odessa waterflood station that killed an employee and his spouse. It identifies a broken pump plunger, while leaving failure timing unresolved, and examines detector nonuse, missing lockout procedures, inadequate ventilation, detection and alarm failures, and deficient site security.
- 202123 Apr
Failed Seal on Subsea Safety Valve Causes Leak
A subsea safety-valve seal failure allowed hydrocarbons into hydraulic lines at a Gulf of Mexico production platform, releasing an estimated three to 50 barrels of hydraulic fluid and oil. The alert describes ROV sampling and leak isolation, and recommends considering hydraulic-system monitoring, alarm configuration and pressure management during leaks and platform evacuation.
- 20218 Apr
Near miss: Vessel approach to wind turbine tower
Two near misses involved turbine nacelle movement during vessel approaches for offshore personnel transfer. Neither caused harm. The flash examines autonomous-mode selection, cable unwinding and alarm resetting, alongside inadequate warnings, verification, procedures and communication. It explains why turbine STOP mode is necessary for safe docking and transfer.
- 202130 Mar
Case study: Lone watchkeeping grounding at night
This flash examines Priscilla’s night-time grounding after drifting south of its planned track on autopilot. The watch officer spent about two hours watching mobile-phone videos without monitoring progress. Lessons emphasise attentive navigation, risk assessment before using a sole lookout, and configuring electronic navigation aids to warn of danger.
- 202126 Mar
The Offshore Management of Human Factors Inspection Guide
Inspection guidance for assessing human factors management in UKCS offshore oil and gas operations. It sets success criteria for critical task analysis, procedures, competence, fatigue, handovers, staffing, organisational change, interfaces and alarms. Qualitative analysis underpins quantitative assessment, while inspection scoring accounts for the scope inspected and cumulative risk gaps.
- 202123 Feb
Disabled audible alarm on fire alarm panel
Routine testing revealed a fire alarm panel giving a visual warning but no audible alarm. Inspection identified a disconnected cable, although how it became disconnected remained unknown. The flash records inadequate testing and maintenance oversight, and suggests members may wish to verify audible and visual alarm functions.
- 202122 Jan
Fire Damages a Platform’s Living Quarters and Nearby Areas
A Pacific Region platform fire damaged accommodation and nearby areas, with a cigarette filter suspected as the ignition source. Shared circuitry disabled general alarm and public announcement systems. The alert identifies smoking-area, combustible-storage and firefighting deficiencies, recommending operators consider redundant wiring, improved receptacles, hazard analysis and emergency drills.
- 202121 Jan
Risk-Based Inspections of Subsea Leak Detection Technology Reveals Gaps in System Processes
BSEE reviews three subsea oil leaks and inspection findings showing weaknesses in leak-detection procedures and management processes. Operators and contractors are asked to consider clearer alarm response responsibilities, personnel training, system testing, configuration change control and ROV surveys. The alert emphasises investigating abnormal flow and learning from previous detection failures.
- 202015 Oct
Safety warning about carbon monoxide poisoning after the loss of 2 lives on the motor cruiser Diversion
This bulletin presents initial findings following two carbon monoxide deaths aboard Diversion, moored on the River Ouse in York. A non-gas-tight heater exhaust silencer and loose connection allowed fumes into the cabin. Safety lessons address marine-approved heater components, professional inspection, servicing, carbon monoxide alarm selection and testing, and suspected poisoning.
- 202025 Aug
High potential near miss: Nitrogen hose failure during transfer of gas
A nitrogen transfer hose detached from its ferrule, releasing approximately 165,000 litres into a pipelay HPU room and reducing oxygen to approximately 17.4%. The degraded hose was absent from the hose register and maintenance regime. The flash recommends rated whip restraints and hose inspections, and records restricted-access signage and low-oxygen alarms.
- 2020Jul
Process interruptions: a threat to process safety — Process Safety Beacon, July 2020
This bulletin examines an explosion involving mononitrotoluene left in a shut-down vacuum distillation column. Leaking steam valves heated the material, leading to decomposition and a runaway reaction. It highlights shutdown isolation, detailed procedures, continued monitoring of process parameters and alarms, and repair or replacement of leaking block valves.
- 20201 Jun
Inadvertent activation of condensed aerosol fire extinguishing system leads to a fatality
An inadvertent partial discharge of a FirePro condensed aerosol extinguishing system during installation aboard Resurgam contributed to an apprentice’s death through inhalation of suppressant particles. The flash highlights underestimated exposure risks and MAIB recommendations for isolation during installation and maintenance, evacuation checks, warning alarms and enclosed-space rescue planning.
- 202021 May
Engineering and design information paper
This information paper explains how human factors can be integrated into offshore petroleum facility design to reduce error and support recovery. It examines control rooms, panels, software displays and alarm rationalisation, alongside maintainability, equipment accessibility and escape routes. Recommendations address human factors involvement throughout the project lifecycle.
- 202031 Mar
Safety Alert 380 - Subsea Jumper Failure Leads to Leak
BSEE describes a subsea jumper failure involving internal corrosion and mechanical stress from pipeline and PLET movement. The October 2017 leak released an estimated 16,000 barrels of oil and remained undetected for over 24 hours. Recommendations address operator training, improved leak detection, corrosion mitigation and verification of pipeline design tolerances.
- 202019 Mar
Collision between container vessel ANL Wyong and gas carrier King Arthur
Investigates the collision between ANL Wyong and King Arthur in dense fog, darkness and heavy shipping traffic. Examines bridge-team decision-making, AIS prioritisation over radar tracking, VHF distraction and shore traffic monitoring. Both vessels sustained damage without injury or pollution; recommendations address traffic services and AIS navigation-status descriptions.
- 202017 Mar
Trencher angle inadvertently altered
Accidental joystick activation during offshore trenching raised the cutting wheel and reduced cutting depth, unnoticed during a shift handover and computer reboot. No equipment or permanent material damage occurred. The flash examines interface design and alarm tolerances, describing revised alarm settings, cessation of trenching during handovers and joystick deactivation.
- 202010 Mar
Safety warning after inadvertent activation of condensed aerosol fire extinguishing system leads to a fatality
This bulletin addresses a fatal inadvertent discharge during installation of a FirePro condensed aerosol extinguishing system aboard Resurgam in Newlyn. Inhalation of concentrated suppressant particles significantly contributed to an apprentice’s death. Safety lessons cover isolation during installation and maintenance, discharge warnings, evacuation checks and enclosed-space rescue planning.
- 202016 Jan
Loss of cargo containers overboard from container ship CMA CGM G. Washington
This investigation examines the loss of 137 containers from CMA CGM G. Washington in the North Pacific. Parametric rolling was assessed as almost certain. Analysis addresses container strength, twistlocks and lashings, loading-computer limits, verified gross mass and ineffective use of motion decision support, with recommendations concerning software approval and cargo planning.
- 20192 Oct
Grounding of general cargo vessel Priscilla
Investigation of Priscilla’s grounding on Pentland Skerries examines uncorrected track deviation, an unsafe alternative route, distracted watchkeeping and inadequate navigational warnings. It analyses passage planning, ECDIS settings, lookout arrangements and coastguard intervention, using AIS reconstruction and bridge simulation. Significant hull damage occurred, without pollution or injury; periodic sleep remained possible rather than established.
- 20194 Sep
Listing of crew boat due to water ingress
A crew boat listed on its first voyage after dry-docking when water entered a starboard void space. The flash describes valve installation and gasket defects, a visual-only bilge alarm and a pump control in manual mode. It highlights absent post-drydock inspection and testing, and subsequent pre-sail checks.
- 201912 Jun
Pryor Trust Fatal Gas Well Blowout and Fire
Investigation of an Oklahoma gas-well blowout and fire that killed five workers in the driller’s cabin. It examines underbalanced drilling, tripping methods, missed influx indications, disabled alarms, procedural and change-management deficiencies, blocked escape routes and unsuccessful blowout-preventer closure. Recommendations address drilling regulation, barrier assurance, alarm design and operating practices.
- 20193 May
Unsafe actions and conditions – Inhibited alarm buttons
A vessel safety walk-round identified alarm acknowledgement and mute buttons held down with toothpicks and adhesive tape. The flash stresses the importance of prompt attention to visual and audible alarms for protecting people, equipment and vessels. The affected alarms were not fire alarms.
- 201925 Apr
Safety Alert 348 - Chemical Leak in Flying Lead Discovered by ROV
An ROV survey discovered a subsea paraffin-inhibitor leak from a hydraulic flying lead in the Gulf of Mexico. Outer-jacket damage compromised collapse resistance; loss of positive pressure resulted in collapse and tearing. BSEE recommends considering pressure-maintaining procedures, training, check valves, low-pressure alarms, inventory monitoring and regular ROV inspections.
- 2019Apr
MAIB Safety Digest 1/2019
A marine accident digest examining merchant, fishing and recreational vessel casualties. Cases address collisions, groundings, mooring equipment failures, fires, flooding and fatal water-entry accidents. Lessons discuss passage planning, equipment testing, alarm accuracy, emergency arrangements and risk assessment. A reproduced bulletin examines oxygen deficiency during refrigerated salt-water tank entry.
- 201913 Feb
High potential near miss: Dropped line pipe after vacuum lifter failed
A vacuum lifter lost suction while an excavator loaded line pipe onto a trailer, dropping the load from approximately 2 m in height. Personnel were clear. The flash discusses worn and partly replaced seals, a missing alignment tab, absent routine testing and maintenance information, and recommends daily integrity tests and alarm verification.
- 201831 Oct
Dragging anchor and subsequent collisions by general cargo vessel Celtic Spirit
Investigation of Celtic Spirit dragging anchor in heavy weather on the River Humber and colliding with two anchored vessels. It examines insufficient anchor cable, delayed recognition of movement, engine readiness and warning communications, alongside anchorage allocation. Fleet procedures and port arrangements were revised; no recommendations were made.
- 2018Oct
MAIB Safety Digest 2/2018
A collection of marine accident lessons covering merchant vessels, fishing boats and recreational craft. Cases examine navigation errors, flooding, machinery failures, fires, scalding, overboard emergencies and carbon monoxide poisoning. Discussion addresses electronic chart checks, alarm use, maintenance, risk assessment and practised emergency procedures, with appended rescue-line and yacht-keel safety bulletins.
- 201811 Sep
Unintentional release of carbon dioxide from fixed fire-extinguishing systems on ro-ro vessels Eddystone and Red Eagle
Investigation of unintended carbon dioxide discharges on Eddystone and Red Eagle examines leaking cylinder valves, system activation arrangements and maintenance deficiencies. Neither incident harmed anyone. The report analyses leakage alarms, pressure protection, valve testing and servicing, and recommends design reviews and improved survey assurance of safety devices.
- 201820 Jul
USCG: two alerts relating to gas releases
This flash summarises two US Coast Guard alerts: ethylene vapours triggering carbon monoxide alarms on an LNG carrier, and contaminated Gulf Coast bunker fuel causing fuel-system failures. It highlights gas-monitor cross-sensitivity, corrective action on alarms, and fuel contamination problems undetectable by standard ISO 8217 test methods.
- 201820 Jun
Grounding of general cargo vessel Ruyter
Investigation of Ruyter’s grounding at Rathlin Island examines an unattended bridge, disabled watch alarms and absent night lookout. It analyses alcohol consumption, inadequate company oversight and normalised departures from watchkeeping instructions. Hull damage caused flooding; the vessel refloated without assistance. Subsequent company action included random alcohol testing and crew reporting empowerment.
- 201822 Mar
Aircraft Accident Report 1/2018, G-WNSR High resolution
Investigation of G-WNSR’s loss of yaw control during landing at West Franklin. A failed tail rotor pitch change shaft bearing damaged the control servo; the initiating reason remained undetermined. The report examines missed HUMS warnings, software interfaces, maintenance review and crew decisions, documenting safety actions and recommendations. No injuries occurred.
- 201819 Mar
Catastrophic Engine Failure Resulting in A Fire on A Crew Transfer Vessel
This safety flash summarises an engine failure and fire aboard Windcat 8 following a big end bearing failure. Nobody was injured. Fixed firefighting proved ineffective because some engine-space vents remained open. MAIB recommendations address crew training for critical propulsion alarms and familiarity with fixed firefighting systems.
- 201730 Nov
Limitations of Monitors Hazard Alert
This hazard alert explains multi-gas monitor selection and use in oil and gas operations. It highlights hydrogen sulphide monitor limitations, unreliable flammable-gas detection under some atmospheric conditions, and misleading alarm cessation. Guidance covers sensor selection, calibration, bump testing, breathing-zone positioning and immediate evacuation following any alarm.
- 201725 Oct
Grounding of the ultra-large container vessel CMA CGM Vasco de Gama
Investigates the grounding of CMA CGM Vasco de Gama in Southampton’s Thorn Channel during pilotage. The analysis examines an unsuitable track for prevailing conditions and manoeuvring limitations, unclear bridge responsibilities, passage planning and underused electronic navigation aids. It records refloating without damage, injuries or pollution, and subsequent training and pilot-assessment measures.
- 201719 Oct
Grounding of bulk carrier Muros
Investigation of Muros’s grounding on Haisborough Sand examines an unapproved revised passage plan, electronic chart scale, disabled warning functions and reduced watchkeeper alertness. ECDIS replay and simulations explored route checking and safety-contour alarm behaviour. Rudder damage required towing for repair; no injuries or pollution occurred.
- 20175 Oct
Flooding in steering gear compartment
Heavy-weather water ingress through a worn towing pin/Karm fork seal flooded a vessel’s steering compartment and caused loss of steering. The flash describes delayed alarm escalation, broken bilge alarm float arms, pumping and equipment isolation. Lessons address alarm response, regular logged compartment inspections and checks of bilge sensor operation.
- 201713 Sep
Loss of control and grounding of ro-ro passenger ferry Hebrides
Investigation of Hebrides’ loss of propeller pitch control approaching Lochmaddy, followed by pontoon damage, grounding and pier contact. It examines actuator setscrew loosening, missing maintenance instructions, unimplemented control upgrades and difficulties coordinating emergency actions. Recommendations address propulsion-failure drills, contingency planning and handling manufacturers’ advice.
- 201726 Jul
Sinking of vivier creel boat Louisa with loss of 3 lives
Investigation of Louisa’s fatal foundering at anchor in Mingulay Bay examines probable hold flooding from a deck wash hose, disabled bilge warning and crew fatigue. Wreck examination and modelling accompany analysis of liferaft inflation failure, lifejacket performance, equipment servicing and delays in the distress-alert and rescue response.
- 201711 May
Carbon monoxide poisoning on board the motor cruiser Love for Lydia with the loss of 2 lives
Investigates two fatal carbon monoxide poisonings aboard Love for Lydia on Wroxham Broad. Uncatalysed petrol-engine exhaust spread beneath the canvas canopy into inadequately ventilated accommodation. Engine-running tests examined gas accumulation under different configurations, using gas monitors, domestic alarms and infrared imaging. Findings address ventilation, alarm reliability and recreational-craft regulatory gaps.
- 20173 Mar
Near-miss: Suspected high levels of CO₂ in diver breathing gas
Two saturation divers working at approximately 92 m experienced breathing difficulties associated with elevated carbon dioxide in reclaimed breathing gas. Saturated absorbent and apparently incorrect analyser calibration were identified. The dive was aborted without further ill effects. Learning focuses on alarm settings, operating manuals, safety-critical competence and contaminated-gas emergency arrangements.
- 201629 Nov
Be alarmed by all alarms
This flash relays USCG observations of repeated hydraulic-lock alarms during steering tests on two relatively new vessels. Crews acknowledged the alarms without investigating their causes; neither event caused a marine casualty. Recommendations address nuisance alarms through safety management systems and prohibit securing alarm acknowledgement buttons or switches.
- 201622 Nov
SPHL battery charging – build-up of hydrogen
Hydrogen accumulated in a self-propelled hyperbaric lifeboat cockpit during battery charging, and its ventilation system had no flow. The flash explains that fan alarms may not detect restricted vent pipes and identifies faulty lid seals as a potential problem. Recommended checks include polythene-bag airflow testing and weekly planned-maintenance verification.
- 201612 Sep
Safety Alert 323 - Subsea Flowline Failure Causes Pollution Incident and Delayed Detection Leads to Larger Spill Volume
A subsea flowline released production fluids while personnel interpreted alarms as slugging or plugging, delaying shut-in for several hours. With the failure cause still under investigation, BSEE recommends thorough alarm investigation, revised leak-detection escalation, monitoring of operating data, conditional ROV integrity checks and transient analysis of small-volume leaks.
- 20168 Aug
Safety warning after carbon monoxide poisoning on motor cruiser results in loss of 2 lives
This bulletin presents initial findings following fatal carbon monoxide poisoning aboard a motor cruiser on the Norfolk Broads. Exhaust from a running petrol engine entered through the aft canopy and spread into unventilated accommodation. It emphasises suitable carbon monoxide alarms, routine testing, ventilation and recognising poisoning symptoms.
- 201627 Jul
Flooding and sinking of wooden potter Majestic
Investigation of Majestic’s flooding and sinking off Shetland on 21 January 2016. The precise ingress source remained unknown, but seawater-system failure was considered probable. Analysis examines unheard wheelhouse bilge alarms, unused pumping capacity, emergency drills and lifejacket use. Both crew abandoned into a liferaft and were rescued without injury.
- 201627 Jun
Vessel loss of position while diving in close proximity to a hydrocarbon facility
A diving vessel drifted over 40 metres after inadvertent deselection of its surge control disabled automatic positioning. A diver noticed his umbilical becoming taut. The alert examines vulnerable console layout, absent confirmation and ineffective excursion feedback, highlighting interface design and safeguards against unintended deactivation.
- 201611 Apr
Fire and sinking of twin-rig prawn trawler Karinya
MAIB examines the fire and subsequent foundering of Karinya in the Moray Firth. The ignition source remained undetermined, although a cigarette was considered probable. Analysis addresses combustible cabin contents, inaudible fire alarms, rapid smoke spread, inaccessible lifejackets and radios, and the successful liferaft evacuation supported by regular emergency drills.
- 201615 Mar
Super Puma Sea Impact During Non-Precision Approach to Sumburgh
Investigation of G-WNSB’s sea impact during a non-precision approach to Sumburgh, with four passenger fatalities. It examines ineffective instrument monitoring, approach procedures and automation use through recorded flight data and human-performance studies. Survivability analysis addresses underwater escape, emergency breathing systems, flotation, liferaft deployment and rescue, alongside recommendations and subsequent safety action.
- 201519 Nov
Contact made by ro-ro passenger ferry Dover Seaways with a breakwater
This investigation examines Dover Seaways’ contact with Dover’s South Breakwater following an unintended transfer of steering control to a trackpilot. The transfer’s cause remained unidentified. It analyses bridge-team system knowledge, delayed stopping actions, ineffective anchor deployment and absent passenger warnings, recommending improved emergency training and procedures for timely warnings.
- 201519 Nov
Grounding of general cargo vessel Lysblink Seaways
Investigation of Lysblink Seaways’ grounding near Kilchoan on 18 February 2015. Alcohol impaired the sole watchkeeper’s situational awareness. The report examines absent lookouts, disabled bridge watch alarms, inadequately configured electronic chart safeguards, deficient passage planning and persistent safety-management non-compliance. It records fleet-wide corrective action and makes no recommendations.
- 201521 Oct
Caribbean Petroleum Corporation (CAPECO) Refinery Tank Explosion and Fire
Investigation of gasoline tank overfill at CAPECO’s petroleum terminal, followed by vapour-cloud ignition and multiple tank fires. It examines unreliable float-and-tape gauging, absent independent overfill safeguards, drainage valves, filling procedures and emergency preparedness. Comparisons with earlier incidents inform recommendations addressing regulatory gaps and automatic overfill protection.
- 20158 Oct
Fatal AW139 Accident During Departure in Darkness and Fog
An AAIB investigation examines the fatal AW139 departure near Gillingham Hall in darkness and fog. Recorded flight data and wreckage examination inform analysis of abnormal pitch, possible somatogravic illusion, crew co-ordination and automatic flight control use. The report also considers private-operation oversight, departure visibility requirements and two-pilot training.
- 20157 Oct
Disabled and Non-Functional Safety Devices Leads to Destruction of Derrick Board
A drilling alert describes elevators bending a derrick diving board as the drill string was lowered. The driller attempted to float the elevators but did not notice that they remained extended. The link-tilt warning light was non-functional, and the electronic anti-collision shutdown system had been manually switched off.
- 201521 Sep
Grounding and flooding of ferry – complacency
This safety flash summarises MAIB findings on Commodore Clipper’s grounding and flooding in the Channel Islands in July 2014. It highlights inadequate passage planning, overlooked tidal, squat and chart-data factors, complacency in repetitive ferry operations, delayed damage checks, ineffective electronic navigation settings and alarms, and deficiencies in port-authority risk assessment.
- 20156 Aug
Grounding and flooding of ro-ro ferry Commodore Clipper
Investigation of Commodore Clipper’s grounding near Guernsey examines inadequate passage planning, tidal effects, squat and survey uncertainty. It analyses ineffective ECDIS settings and alarms, bridge-team working, delayed damage assessment and shortcomings in pilotage safety management. Hull breaches caused flooding contained within double-bottom spaces; no injuries or pollution were reported.
- 2015Jul
2015-002 ST 220 Investigation of Loss of Well Control and Fire, Gulf of Mexico, July 23, 2013, South Timbalier Area Block 220, Well No. A-3 OCS-G 24980
BSEE investigates the South Timbalier A-3 blowout and subsequent fire during well completion on Hercules 265. It examines temperature-dependent brine density, seepage losses, kick recognition, shut-in procedures and unsuccessful BOP sealing. The report documents evacuation, depletion-relief drilling, regulatory findings and recommendations; the ignition source remains unknown.
- 201511 Mar
Horsehead Holding Company Fatal Explosion and Fire
An independent desk study examines the fatal Monaca zinc-refinery incident using CSB evidence and the author’s records. It proposes sump restriction, liquid-zinc backfilling and explosive decompression as the sequence, while acknowledging disputed analysis. Discussion covers distillation-column design, temperature trends, operating procedures, human factors and predictive warnings.