Control
Human-Centred Design
Design of interfaces and systems to support human performance.
Newest 100 Documents
All 105 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.
- 20254 Dec
BSEE Safety Alert - 510 - Blackout and Weather-Driven EDS Incidents Underscore the Need for Stronger Operational Discipline
This alert examines two emergency disconnects on a dynamically positioned drillship: a blackout during damper maintenance involving the wrong control panel, and loss of position during severe weather. Both resulted in pollution. Recommendations invite operators to consider clearer controls, competence verification, closed-loop communication and proactive weather-related operational adjustments.
- 202527 Oct
Injury after fall from vertical ladder
A crew member carrying a fire patrol device lost grip while climbing a vertical ladder and suffered a minor eyebrow cut after striking a steel bund. The flash examines inadequate ladder design and routine-task risk awareness, identifying possible ladder extensions, anti-slip paint, carrying aids and pre-task discussions.
- 20252 Oct
Dropped object due to over-ridden limit switch
A vessel crane operator bypassed limit switches while raising the hook for an overboarding lift. A mini beacon struck the clump weight and fell to the deck; a restraint and sensor cable also parted. Nobody was injured. The flash examines knuckle-boom configuration, override decisions, safety-system verification and safer equipment design.
- 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.
- 202521 Aug
Serious injury to a passenger on the sea safari rigid inflatable boat Lundy Explorer
Investigates a passenger’s permanent spinal injury during wave-induced slamming aboard Lundy Explorer at Ilfracombe. Examines forward jockey seating, passenger bracing, safety briefings, sea-condition decisions and regulatory gaps. Records restrictions on forward-seat use and recommends improved operating procedures and risk assessments within a safety management system.
- 20253 Jul
LTI: Hand injury during capstan maintenance
A crew member suffered a serious hand injury while greasing a vessel capstan when rotation trapped his hand between an underside wire clamp and the deck. The flash examines difficult access and grease-gun design, describing grease-point extensions, clamp removal, revised maintenance procedures and wider inspections for line-of-fire hazards.
- 20259 Jun
BSEE Safety Alert 501-BSEE Identifies Bypassed Safety Device Deficiencies
BSEE inspections of five production platforms identified poorly documented safety-device bypasses, non-operational data historians and overly broad maintenance bypasses. Findings included pressure protection disabled during startup and unreverted ladder-logic changes. Recommendations address bypass logs, electronic records, interface visibility, construction changes and verification of procedural compliance.
- 20254 Jun
LTI: Back injury in Confined Space (Tank Entry)
A worker injured their lower back after losing hand grip while exiting a confined compartment feet-first through a lightening hole during planned maintenance. The flash examines access ergonomics and gaps in risk assessment, describing additional grab handles, possible platforms under investigation and a review of confined-space entry procedures.
- 2025
CHIRP Maritime FEEDBACK 80 (Autumn 2025)
This maritime incident digest examines unsafe pilot transfers, an obstructed escape hatch, incorrect antenna labelling, pest infestation and unsafe fumigation, an unmanned survey vessel capsize, and an enclosed-space inspection injury. Commentary emphasises practical design validation, operational limits, crew welfare and confirmed communication between teams.
- 2024Nov
Risk of exposure of laboratory staff to biological agents due to missing clinical information
This safety notice addresses infection risks in clinical and veterinary diagnostic laboratories when specimen requests lack relevant clinical information. It describes exposures involving Hazard Group 3 agents and calls for better request forms, staff training, sample-processing procedures, linked patient specimens and IT systems that make updated clinical details accessible to laboratory staff.
- 202425 Sep
Laceration to right index finger
A crew member sustained a right index finger laceration while closing a workshop-container door on a vessel’s deck. Wind and vessel movement accelerated the closure, trapping the finger. Lessons address safer work-area design, door pinch points and awareness of surrounding conditions; heavy-duty automatic door closers were installed.
- 202413 Jun
Collision between fishing vessel Kirkella and pusher tug Shovette
Investigation of Kirkella’s collision with Shovette in Hull following propulsion control transfer with mismatched pitch levers. The tug partially sank and released about 7,000 litres of diesel. The report examines control interfaces, absent interlocks, handover procedures and safety management, recording interim checks and requested system modifications.
- 202314 Dec
Heavy contact between the high-speed passenger craft Seadogz and a navigation buoy with loss of 1 life
Investigation of Seadogz’s fatal collision with a navigation buoy in Southampton Water. It examines skipper workload and visibility, chart plotter accessibility, passenger seating and handhold protection, lifejacket effectiveness, and operator oversight. Recommendations address passenger protection, inconsistent regulatory guidance and port assessment of high-speed commercial passenger operations.
- 202330 Oct
Serious LTI – Person struck in rigging accident
A rigger suffered multiple serious injuries when rigging fell from a hatch cover during vessel loading. The flash examines oversized rigging, misleading drawings, missed radio instructions and fast thinking. Lessons address crew-aware design, positive confirmation of communications and end-user involvement in developing procedures.
- 202315 Sep
Safety warning issued following a serious passenger injury during a rigid inflatable boat ride
This interim safety bulletin examines a sea safari passenger’s spinal fracture and permanent paralysis after a RIB slammed into a wave trough. It highlights increased injury risk in forward seats, regardless of speed, and strongly advises operators to review risk assessments and briefings addressing seat use, handholds, posture and stability.
- 20233 Aug
Unexpected descent and ascent of mattress lifting frame
A mattress handling frame descended and abruptly ascended near divers during crane operations in active heave compensation mode. No injuries or damage occurred. The flash identifies controller-lock software interactions, obsolete operating manuals and inadequate familiarisation, with actions addressing revision control, operator briefings and protection of the controller-lock button.
- 202312 Jun
MAIB: Who is in control?
A ferry nearly grounded after confusion over transfer of propulsion control between bridge consoles. The crew regained control by zeroing the joysticks and repeating the command sequence. The flash highlights poorly visible control displays, unambiguous console indications, careful consideration of modifications and familiarity with documented recovery procedures.
- 202311 Jan
Lost ROV incident
An ROV became trapped in a platform jacket during routine inspection in strong tidal current. Tether damage interrupted power and telemetry; subsequent recovery failed and the vehicle was lost. The flash identifies inadequate recovery procedures, understaffing and premature beacon battery exhaustion, and records procedural revisions and a current display added to the pilot interface.
- 202214 Jul
IOGP: Squeezed hand due to unintentional activation of winch
A crewman’s hand was squeezed between a railing and structure after he grabbed a rope moved by unintended auxiliary winch activation. The flash identifies workplace design, unidentified operational risk, incomplete role descriptions and training gaps, and recommends design improvements, disconnecting redundant levers, competence assurance and task-specific risk communication.
- 202216 Jun
Person overboard from single-handed creel fishing vessel Saint Peter with loss of 1 life
Investigates the fatal overboard accident involving Saint Peter’s lone skipper during creel shooting near Torness Point. Probable rope entanglement, cold-water shock and inability to reboard are examined. The report analyses deck separation, flotation, boarding arrangements and distress signalling, finding that the inflated flotation device prevented drowning but did not ensure survival.
- 20225 May
Person overboard from motor cruiser Diamond Emblem 1 with loss of 1 life
Investigates a fatal overboard accident involving a self-drive hire cruiser on the River Bure. Embankment impact threw a passenger into the water, where rope and propeller entanglement caused injuries and drowning. Analysis examines dual-helm controls, labelling, stern protection, handover competence, risk assessment and regulatory oversight.
- 202222 Mar
MSF: Contact between Vessel and Offshore Installation
A standby vessel struck an offshore installation after watchkeeping distractions and an accidental change to emergency steering prevented forward movement being arrested. The hull was dented but not holed. The flash discusses failure to follow existing procedures, switch functionality, lookout duties, passage planning and emergency scenario training.
- 2022Feb
CHIRP Maritime FEEDBACK 66 (February 2022)
This maritime incident digest examines accommodation ladder failure, unsafe floating-armoury conditions, personnel falls, defective workboat lifting eyes, berthing errors, a fatal tug-line incident and a hydraulic motor fire. Commentary addresses maintenance, securing arrangements, bridge resource management, mooring briefings, human-centred deck design and collision-avoidance communication.
- 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.
- 20201 Dec
Labeling, Removing, Storing and Installing Hatch Covers
A slickline helper suffered fatal injuries after the wrong well hatch cover was lifted on a Gulf of Mexico facility, exposing an opening through which he fell approximately 90 feet. The alert recommends hatch identification, specific procedures, practical training and hazard review, and suggests mechanical handling to reduce proximity to openings.
- 202010 Nov
Main crane hoist wire damage
A crane hoist wire was damaged by rubbing against a knuckle aperture after the operator disengaged automatic knuckle control to activate heave compensation. The flash describes subsea wire cutting, onboard re-socketing and downtime, alongside familiarisation constraints, ignored alarms and recommendations to improve the operator interface and reinforce adherence to manufacturer instructions.
- 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.
- 202021 May
Procedures and instructions information paper
This information paper examines how procedure quality and workforce compliance influence human reliability. It covers task analysis, worker involvement, readable layouts, workplace trials, learning-focused training and timely approval of deviations. It also discusses risk-based reviews and management of change, emphasising the limitations of administrative controls and investigation of non-compliance rather than automatic discipline.
- 202028 Apr
Near miss: Dropped clump weight
A clump weight fell approximately 30 m to the deck, landing around a metre from a rigger after unintended tugger winch activation pulled rigging against a sheave and released a wedge socket connection. The flash examines control positioning, changed rigging arrangements, risk assessment and management of change.
- 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.
- 202012 Feb
Safety Alert 376 - Rig Floorman Pinned by Moving Equipment
A rig floorman suffered a major lost-time injury when an Iron Roughneck control panel pinned him against a guide roller assembly after its travel switch failed to return to neutral. BSEE recommends considering design and layout changes, checking control functionality, evaluating proximity switches and delineating unsafe operating areas.
- 202030 Jan
Near miss during helicopter operations
A crew member removed a helideck access chain during helicopter boarding and passed beneath the tail rotor despite a shouted warning. No injury occurred. The flash examines passenger judgement, access supervision and ineffective readiness checks, and recommends clearer boarding routes, passenger briefings and consideration of human factors in safety-system design.
- 20209 Jan
Fall on board fishing vessel Artemis with loss of 1 life
Investigates the skipper’s fatal fall through a wheelhouse hatch aboard Artemis in Kilkeel harbour. The report examines altered access arrangements, a near-vertical ladder without handrails and alcohol impairment. The precise initiating event remained uncertain. Recommendations address access design, drug and alcohol policies, and fishermen’s work agreements.
- 201912 Nov
Near miss: Emergency stop pressed accidentally
A vessel’s port azimuth thruster stopped during dynamic positioning when a passing crew member accidentally struck its emergency stop with his elbow. The vessel safely withdrew from the 500m zone. The flash identifies ineffective switch guarding and calls for similar emergency stop buttons across vessels to be identified and replaced.
- 201923 Aug
Accidental activation of emergency stop during saturation diving operations
Accidental operation of unprotected emergency-stop buttons stopped both lubricating-oil pumps and tripped a vessel’s starboard Voith Schneider propulsion during saturation diving. The vessel maintained position and divers were safely recovered without injury. Lessons address button covers, situational awareness, shipboard familiarisation, and more thorough job safety analysis and toolbox talks for routine engine-space maintenance.
- 201916 Jul
High potential near miss: Dropped object during piggyback drilling operations
A safety flash describes inadvertent sample-winch activation during piggyback drilling. An 11 kg overshot snagged on a ladder safety hoop, separated from its wire and fell approximately 8 m, without injury or damage. Lessons address console ergonomics, design risk assessment, familiarisation assessment and preventive maintenance documentation.
- 201928 May
High potential near miss – unsecured sheave
This safety flash describes a vessel near miss in which inadvertent control activation moved a power swivel, changing a tagline’s orientation and opening a sheave gate. A 40 kg assembly remained suspended above crew. Lessons address console design, sheave installation standards, operator visibility and clearer responsibilities across overlapping operations.
- 201928 May
Partial pressure of oxygen (PPO₂) getting low in bell
During saturation diving at approximately 147 msw, oxygen partial pressure fell in a bell and the main oxygen bottle was subsequently found empty. The flash describes breathing-mix purging, BIBS use and recovery, followed by changes to oxygen make-up responsibilities, panel positioning, valve configuration and buffer-tank connections.
- 201913 May
Diver fatality during subsea lifting operations – update
This fatal diving incident update examines secondary life support activation after a trapped umbilical interrupted primary breathing gas during subsea spool relocation. Delayed completion of two-stage activation accelerated gas depletion. It reports equipment testing, refresher training and drills, and a decision to replace two-stage systems with single-stage activation.
- 20195 Apr
Latent trip hazards
Two crew injuries in vessel machinery spaces involved an exposed support gusset and uneven walkways. The flash links latent hazards to vessel design and engineering changes, recommends human factors in design and management of change, and describes a fleet-wide hazard hunt followed by rectification or scheduled maintenance.
- 201912 Mar
Galley safety – rice cooker smouldering
An unused rice cooker was likely activated unintentionally through controls exposed to passing pedestrians. With no rice or liquid present, heat accumulated and its rubber seal smouldered. No injury or major outcome resulted. Lessons address unplugging equipment during prolonged disuse, protective barriers and area inspections.
- 201810 Sep
Dropped object: first aid injury during ROV maintenance
During ROV maintenance aboard a vessel in port, a tooling tray guide arm fell onto a technician working underneath. The flash identifies inadequate task-specific risk assessment, poor communication and unsafe removal design. A design improvement eliminated the need to work beneath the equipment.
- 20183 Jan
MGPI Processing, Inc. Toxic Chemical Release
This case study investigates an incorrect sulfuric acid delivery connection to a sodium hypochlorite tank at MGPI in Atchison, Kansas, producing a chlorine-containing cloud. It examines unloading equipment design, pipe identification, procedure compliance, training, remote shutdown, control-room ventilation and escape respirator access, alongside community emergency planning and subsequent preventive changes.
- 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.
- 201718 Sep
ExxonMobil Baton Rouge Refinery Chemical Release and Fire
This safety bulletin examines an isobutane release and fire at ExxonMobil’s Baton Rouge refinery that seriously injured four workers. It analyses plug valve gearbox removal, pressure-retaining bolt arrangements, design ambiguity and organisational practices. Lessons address safer valve designs, human-factors hazard analysis, written removal procedures and operator training.
- 20178 Feb
Collision between pure car carrier City of Rotterdam and ro-ro freight ferry Primula Seaways
Investigates the River Humber collision between City of Rotterdam and Primula Seaways. Ergonomic assessment and bridge simulation examine the pilot’s relative motion illusion through an off-axis window. Findings address bridge resource management, speed reduction and vessel traffic service intervention, with corrective measures concerning centreline references, radio access and training.
- 201619 Dec
Some Ergonomic Issues of DP Vessel Controls
This safety alert examines accidental disengagement of dynamic positioning on a semisubmersible drilling rig and delayed recognition of manual control. It identifies inadequate button protection and unclear mode displays, and calls for operators to review control ergonomics, alert crews to weaknesses and make appropriate improvements.
- 2016Sep
Manual handling - Manual Handling Operations Regulations 1992 - Guidance on Regulations
Guidance explains duties under the Manual Handling Operations Regulations and an ergonomic approach to preventing musculoskeletal injury. It covers avoiding hazardous handling, assessing unavoidable tasks, mechanical assistance, workplace and load design, training and handling techniques. Assessment methods include initial filters, MAC, V-MAC, RAPP and ART, with limitations on their use.
- 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.
- 20166 May
First aid injury: Person struck by wire under tension
A crew member suffered minor abrasions when a slack tagging wire became taut during preparations to transfer an inline tee between vessels. The flash examines constant-tension winch operation, control-panel design, supervision and training deficiencies, and presents recommendations on equipment testing, risk assessment, staffing and emergency-stop placement.
- 20154 Jun
Accident to skipper of scallop dredger Ronan Orla with loss of 1 life
MAIB investigates fatal winch entanglement during single-handed scallop dredge recovery aboard Ronan Orla off north Wales. The exact snagging mechanism remained inconclusive. Analysis examines poor winch condition, inaccessible controls, absent emergency stops and lone-working risks, with recommendations addressing safety training and fishing-vessel self-certification.
- 20155 Mar
Contact made by passenger vessel Millennium Diamond with Tower Bridge
This investigation examines Millennium Diamond’s contact with Tower Bridge on 4 June 2014, injuring ten passengers and crew. It analyses distraction during VHF replay, wheelhouse ergonomics, ineffective public-address warnings and unexpected pier closure. Recommendations address equipment layout, holding areas and boatmaster training; unsecured catering equipment is also examined.
- 201516 Jan
Unplanned release of 960 litres of hydraulic oil
During vessel transit between piling locations, unintended crane control activation lowered a suspended hammer, tightening its hydraulic umbilical until the coupling parted and the restraint chain snapped. The release totalled 960 litres of hydraulic oil. Identified measures addressed crane inactivity, communications, hose isolation, ROV observation and potential pollution-reduction arrangements.
- 20143 Oct
Near-miss: Engine room flooding
A ballasting near-miss flooded a vessel’s engine room after rapid valve closure created a pressure shock that displaced a sea-strainer cover. Inadequate communication and departure from the manufacturer’s procedure worsened events. Lessons include vessel-specific procedures, clearer valve displays and interlocks preventing simultaneous pump and valve operation.
- 2014Jan
Contact made by ro-ro passenger ferry Sirena Seaways with berth
Investigation of Sirena Seaways striking a berth at Harwich International Port on 22 June 2013. It examines inadvertent selection of controllable pitch propeller back-up control, misleading console indications, inadequate testing and crew familiarity, and subsequent flooding response. No injuries or pollution occurred; procedural and interface improvements are discussed.
- 2013Nov
Workplace health, safety and welfare. Workplace (Health, Safety and Welfare) Regulations 1992. Approved Code of Practice and guidance
This Approved Code of Practice reproduces the Workplace Regulations and explains workplace health, safety and welfare requirements. It covers maintenance, ventilation, temperature, lighting, cleanliness, workstation suitability, floors, vehicle routes and welfare facilities. Guidance distinguishes legal duties from recommendations and addresses accessibility, fall prevention and safe window cleaning.
- 2013Mar
Are your signs and labels confusing? — Process Safety Beacon, March 2013
This bulletin examines how missing or confusing equipment labels and signs can undermine safe plant work. It recommends repairing unreadable labels, matching identification to plant procedures and using consistent chemical names. Label corrections should use proper replacements, with consideration of a management of change review.
- 201318 Jan
First aid injury: Contact with spinning spooler arm
A technician sustained light bruising when a spooler handle spun during crane recovery of a hydraulic grapple and pipe section aboard a vessel. Heave tightened hydraulic hoses with insufficient slack. The flash examines body positioning and gaps in task assessment, highlighting automatic spooling and changes to recovery risk assessment.
- 2013Jan
Drill-floor machinery and tubular-handling safety
Guidance for users, suppliers and integrators addresses automated drilling machinery and tubular handling. It explains system-wide hazard identification through HAZOP, FMEA, FMECA and collision or contention matrices, alongside safety-function specification and integrity assessment. Fifteen incident examples illustrate shortcomings in design, protective systems, software management and operator interfaces.
- 2012Sep
A guide to the integrity, workplace environment and miscellaneous aspects of the Offshore Installations and Wells (Design and Construction etc.) Regulations 1996
HSE guidance explains offshore installation integrity duties across the asset life cycle, alongside workplace and accommodation requirements. It addresses design hazards, operational limits, periodic integrity assessment and reporting significant threats. Workplace provisions cover ergonomic layout, ventilation, lighting, safe access, sanitary facilities and accommodation hygiene.
- 2012Jun
Contact made by ro-ro cargo ferry Clipper Point with quay and 2 berthed ships
Investigates Clipper Point’s contacts during manoeuvring at Heysham on 24 May 2011. The report examines wind effects, unavailable bow-thruster capacity, limited tug assistance, bridge teamwork and console control transfer. It identifies weaknesses in operational limits, training, contingency planning and port risk assessment.
- 2012May
Failure of controllable pitch propeller on general cargo vessel Saffier resulting in contact with berthed tug Svitzer Ferriby
Investigation of Saffier’s contact with an unmanned berthed tug at Immingham following excessive astern propeller pitch. Incorrect feedback calibration escaped post-repair testing, while unfamiliarity with backup controls and delayed emergency action worsened the event. Recommendations address full-range propulsion checks, emergency drills and clearer backup-control identification.
- 2012Mar
Derailment of hatch-lid gantry crane on dry cargo vessel Blue Note
Investigation of Blue Note’s hatch-lid gantry crane derailment alongside in Londonderry, which left three crewmen with minor injuries. Incomplete engagement of the port hooks was considered the most likely cause. The report examines hook visibility, spreader adjustment, wheel-bolt fatigue, unsafe riding practices, maintenance, risk assessment and crew competence.
- 201225 Jan
Lost time incident (LTI): Laceration to finger
A crewman aboard a dive support vessel sustained a serious finger laceration while opening an aft bell moon pool door. A replacement spring made the retaining hook too stiff for foot operation, prompting hand use. Unaddressed modification risks and subsequent rope-operated, hands-free changes are described.
- 2012
Engineering a Safer World: Systems Thinking Applied to Safety
A practitioner-focused book explaining safety through systems theory and constraint enforcement rather than component reliability alone. It develops STAMP, STPA hazard analysis and CAST accident analysis, using varied cases and design examples. Guidance addresses human–automation interaction, safety-guided engineering, operational feedback, organisational responsibilities, management of change and safety culture.
- 201123 Dec
Diver helmet hat light
A diver helmet light inadvertently activated on the surface overheated without cooling, causing a fire in a diving bell aboard a dive support vessel. No injuries occurred, but equipment sustained extensive damage. The flash describes emergency response, guarded replacement switches and a revised light design incorporating thermistor protection.
- 201123 Dec
Near-miss: Diver loss of gas
A diver’s gas supply became restricted when a bellman lost his footing during bell heave and knocked the supply valve towards closed. The diver used bailout gas and the bellman restored the main supply; no injuries occurred. The flash describes valve-handle repositioning, overlooked ergonomic hazards, team briefing and regular emergency drills.
- 2011Oct
Collision between prawn trawlers Sapphire II and Silver Chord, resulting in Sapphire II sinking
Investigation of the collision between fishing vessels Silver Chord and Sapphire II on 12 January 2011. Sapphire II flooded and foundered within ten minutes. The report examines unattended wheelhouses, restricted forward visibility, radar use and single-handed fishing, alongside risk assessments, navigational watchkeeping guidance and subsequent visibility improvements.
- 201113 Jun
Technical Report - Offshore petroleum facility accomodation
This informational technical report synthesises good practice for offshore petroleum living quarters. It addresses cabin layouts, privacy, communal spaces, acoustic insulation, vibration isolation, artificial lighting and indoor air quality. Recommendations cover design modelling, vendor specifications and commissioning checks, with application to new facilities and practicable improvements to existing accommodation.
- 20108 Apr
Inadvertent opening of circuit breakers
An engineer inadvertently opened a vessel’s essential-services circuit breaker while checking a crane breaker, causing downtime and project delays without injury, damage or loss of position keeping. The flash examines unclear switchboard indications, ineffective supervision, unrestricted access and incomplete competence assurance, alongside revised standing orders and familiarisation arrangements.
- 200915 Dec
Safety Alert 284 - Diverter Flow Event
A semi-submersible completion operation experienced expanding formation gas in the riser and diverter discharge. The investigation established no specific cause, identifying possible packer communication, omitted reverse circulation and fluid-monitoring difficulties. Recommendations address brine pills, pressure monitoring, BOP sweeping, consideration of further circulation or bullheading, piping documentation and display scaling.
- 200910 Nov
Tumble dryer fire onboard a vessel
A diving bell bottom hatch jammed during recovery after a detached hydraulic pipe ferrule caused oil loss and disabled its operating system. Manual attempts failed, and divers were recovered successfully through another bell. Corrective actions included valve interlocking, visual alignment indication, revised procedures, training and reviews of failure analysis and maintenance.
- 2009Jun
DOE Human Performance Improvement Handbook, Volume 1
This DOE handbook explains human performance through individual behaviour, workplace conditions and organisational influences. It combines error prevention with layered control assurance, examining cognitive limitations, investigation, operating-experience learning and safety culture. Leadership practices, just culture and performance improvement methods are developed through conceptual models and illustrative accident accounts.
- 20083 Dec
Accidental shutdown of main engines
During vessel transit, rolling pressed a crew member against a flexible Perspex guard, activating emergency shutdown buttons and cutting power to both fuel pumps. Main engines were unavailable for 35 minutes. The flash discusses protective-cover suitability, two-action activation and accessible control placement, with temporary guard strengthening pending permanent replacement.
- 2007
Testing of TEMPSC release gear
Guidance addresses testing release mechanisms on suspended totally enclosed motor propelled survival craft. It explains fatal accident risks from inadequate securing and recommends reviewing test frequency and methods, confirming securing arrangements, reducing attachment errors and monitoring compliance. In situ testing requires suitable hang-off pendants or alternative securing measures.
- 200531 May
Safety Alert 231 - Human Engineering Factors Result in Increasing Number of Riser Disconnects
This alert reviews accidental and emergency riser disconnects in deepwater operations, highlighting human error, hydraulic connection mistakes and station-keeping failures. It recommends reviewing existing requirements for deliberate sequential disconnection, protected controls and documented subsea function testing. An accompanying table summarises eleven events involving drilling and production risers.
- 2005May
Uncontrolled decent of lifeboat during release gear test on Royal Fleet Auxiliary vessel Fort Victoria with 2 people injured
Investigates two injuries during an on-load lifeboat release test aboard RFA Fort Victoria at Falmouth ship repair yard. The boat fell about 1.2 m before striking water. Analysis examines test procedures, risk assessment, unclear command, crew experience, restraint accessibility and impact transmission, alongside subsequent procedural changes and design recommendations.
- 200429 Dec
Safety Alert 224 - Erroneous Activation of Dump Valve Causes Loss of 165 bbls of Oil-Based Mud
Drilling personnel operated a dump valve using an incorrect line schematic, releasing 165 barrels of synthetic oil-based drilling fluid and cuttings overboard, including 96 barrels of oil. The alert examines an overlooked handwritten correction and recommends correcting plumbing and schematics immediately, while considering a downstream master dump valve.
- 20031 Jun
Jet pump incidents
A worker twisted their left knee while racking jet hose alone on top of a jet pump after colleagues were reassigned to tend a diver. The flash highlights equipment access, adequate deck space, unsuitable working platforms, two-person hose handling and job safety analysis addressing body mechanics.
- 200229 May
Safety Alert 200 - Subsea Equipment Failure Leads to Deepwater GOM Pollution
An incorrectly seated replacement choke was expelled during restart of a deepwater subsea oil well, releasing crude oil and gas. The alert examines unsuccessful ROV visual verification, delayed shut-in and confusing monitoring displays. Recommendations address pre-job emergency discussions, visually verifiable intervention equipment and clearer control-room systems with reduced need for safety-system bypasses.
- 2002Feb
Grounding of stern trawler Lomur
This investigation examines Lomur’s grounding on Hoe Skerry while returning to Scalloway on 14 June 2001. The skipper fell asleep on watch after inadequate rest. Analysis addresses inshore fishing routines, crew numbers, visual navigation, autopilot reliance and watch-alarm arrangements. Recommendations concern manning, risk assessment, wheelhouse practices and alarm-reset positioning.
- 2001Jul
Contact made by ro-ro passenger ferry P&OSL Aquitaine with quay resulting in several injuries
Investigation of P&OSL Aquitaine’s impact with a Calais berth, injuring 180 passengers and 29 crew. Damaged pump vanes caused loss of port propeller pitch control. The report examines hydraulic diagnostics, bridge monitoring, fault communication and casualty response, recommending reviews of pressure monitoring, indicator visibility and accessible troubleshooting manuals.
- 2001May
Person overboard from potter Girl Alice with loss of 1 life
This investigation examines the loss overboard of Girl Alice’s lone skipper during crab and lobster potting off south-east Scotland. The precise cause remains unknown. It discusses shooting pots, delayed alarm raising, buoyancy equipment and inaccessible engine controls, recommending that advice on controls near the pot-hauling position be included in any leaflet reprint.
- 200129 Jan
Safety Alert 192 - Water Survival Craft
This revised alert describes an offshore operator’s study finding that survival-craft design assumptions did not match the average size of its Gulf of Mexico workers. Field trials confirmed seating limitations. The operator reconfigured some seating and reduced selected craft capacities; a corresponding examination of liferafts found no similar problem.
- 1999
Reducing error and influencing behaviour
Guidance on reducing human error through ergonomic design, usable procedures and organisational improvements. It distinguishes errors from violations, examines fatigue, shift handovers and safety culture, and explains human reliability assessment. Eighteen intervention case studies demonstrate practical changes, emphasising workforce participation and controls beyond reliance on individual behaviour.
- 19943 Mar
Safety Alert 11 - Crane/helicopter Operations
An alert describes a crane boom swinging in line with a helideck while a helicopter idled before take-off on a Pacific offshore platform. It reiterates crane shutdown, boom securing and operators leaving cabs, recommends arrival announcements, and attaches guidance on pilot–operator coordination, crane visibility and warning indicators.
- Undated
Drill-Pipe Joint Dropped During Knuckle-Boom Crane Lift
BSEE investigates a drill-pipe joint dropped during a knuckle-boom crane lift on the Holstein Spar Rig. The pipe fell approximately 13 feet onto the rack before entering the Gulf of Mexico. Analysis identified incorrect gripping and abrupt boom stopping; planned improvements included gripping-force indicators and additional operator training. No injuries were reported.
- Undated
Uncontrolled Crane Boom Movement During Tote-Tank Lifting
An investigation examines uncontrolled crane boom movement during tote-tank lifting aboard the Superior Champion. It identifies adjustment beyond safe operating limits as the probable cause and discusses possible hydraulic-control problems, crane placement and an earlier event not reported to office staff. Recommendations address communication, pressure relief and engine kill-switch accessibility.
- Undated
Drilling Mud Discharge Following Loss of Slip Joint Seal Pressure
Investigation of a 223.3-barrel synthetic-based drilling mud discharge into the Gulf of Mexico from West Sirius. A hydraulic supply valve left closed after maintenance deprived the telescopic slip joint seals of pressure. The report discusses startup procedure failures, a failed pressure alarm, valve identification improvements and additional alarm-response requirements.
- Undated
Paraffin-Solvent Fire During Gravity Transfer at Unmanned Platform
An investigation into a paraffin-solvent fire during gravity transfer at unmanned platform PL 11-F. Overfilling occurred while the crane operator was away and the shut-off valve was inaccessible. Solvent ignited on pump exhaust. Both workers escaped into the water and were rescued; nearby boats extinguished the fire.
- Undated
Oil Spill Following Production Surges and Oil Carryover
Investigation of an estimated 3.5-barrel oil spill at MP 299 FP on 18 July 2006. The report attributes oil carryover to production surges and identifies leaking valves, difficult level observation and limited operator familiarity as contributing factors. Corrective actions address backflow prevention, vessel operating levels, sight-glass visibility and shift experience.
- Undated
Crane Boom Damaged During Positioning Above Steel Plate
An investigation describes damage to a platform crane while positioning its boom above a steel plate. A manual override valve stuck in the override position allowed contact with the boom stops and bending of the boom. Merit recommended valve modifications, pre-use inspections, personnel instruction and a boom watch person.
- Undated
Compressor Crankcase Explosion Burns Operators During Restart
Investigates a compressor crankcase explosion during restart that burnt two operators with redirected hot oil. The report identifies leaking piston-rod packing, engine backfire and a failed pneumatic relay among the causes. Recommendations address crankcase relief doors, flame arrestors, downward oil deflection, control-station positioning and crew safety discussions.
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Arm Injury During Pipe Laydown Following Accidental Trolley Activation
An investigation examines an arm injury during pipe laydown after inadvertent activation of a Cat Walk Machine trolley control. It identifies accidental control activation and the absence of a trolley movement alarm. Reported changes include removing an unused control lever and appointing a flagger; alarm reconfiguration remained under discussion.
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Vessel Strikes Platform After Anchor Recovery
Investigation of M/V Fred striking Platform F after recovering its last anchor. The report attributes the collision to the pilot diverting attention from the vessel’s path, with failed platform lighting probably contributing. It discusses bow-light switch placement, bridge staffing and possible radar use, and records damage to both assets.
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Inadvertent Blind Shear Ram Activation During Casing Pressure Test Preparations
An investigation examines inadvertent blind shear ram activation during preparations for a casing pressure test. A sheared drill-pipe joint dropped 500 feet into the wellbore, without personnel injury. The report discusses control protection, human error and possible lack of experience, alongside planned procedural changes involving two competent people and verbal confirmation.
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Human and organisational factors in well control audit report
This multinational audit examines human and organisational influences on well control across operators, drilling contractors and service companies. Common interview questionnaires assess interfaces, competence, procedures and company coordination. Findings highlight variable bridging documents, limited incident learning and well-control indicators, alongside generally clear displays and assurance of driller shut-in authority.
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Incorrect painter release hook connection causing rescue boat to fall from ro-ro passenger ferry Pride of Bilbao with 2 people injured
Investigates a rescue boat falling during recovery alongside a berth in Cherbourg, injuring two crewmen, one seriously. Examination and tests established incorrect attachment of the forward suspension ring to the painter hook. The report analyses davit and hook behaviour, recovery instructions, lifejacket performance and possible modifications preventing incorrect connections.
- Undated
Parting of mooring line between shuttle tanker Randgrid and monobuoy resulting in discharge of 12 tonnes of crude oil
Investigation of Randgrid’s mooring release at the Tetney monobuoy during cargo discharge. Accidental operation of chain stopper controls released the chafing chain; the pickup-rope lashing subsequently failed and discharge hoses broke away. An estimated spill of about 12 tonnes occurred without injury. Recommendations address control design, alarms and bridge procedures.